HA-1-targeted T cell receptor (TCR) T cell therapy for recurrent leukemia after hematopoietic stem cell transplantation

Relapse is the leading cause of death after allogeneic hematopoietic stem cell transplantation (HCT) for leukemia. T cells engineered by gene transfer to express T cell receptors (TCR; TCR-T) specific for hematopoietic-restricted minor histocompatibility (H) antigens may provide a potent selective anti-leukemic effect post-HCT. We conducted a phase I clinical trial employing a novel TCR-T product targeting the minor H antigen HA-1 to treat or consolidate treatment of persistent or recurrent leukemia and myeloid neoplasms. The primary objective was to evaluate the feasibility and safety of administration of HA-1 TCR-T post-HCT. CD8+ and CD4+ T cells expressing the HA-1 TCR and a CD8-co-receptor were successfully manufactured from HA-1 disparate HCT donors. One or more infusions of HA-1 TCR-T following lymphodepleting chemotherapy were administered to nine HCT recipients who had developed disease recurrence post-HCT. TCR-T cells expanded and persisted in vivo after adoptive transfer. No dose-limiting toxicities occurred. Although the study was not designed to assess efficacy, four patients achieved or maintained complete remissions following lymphodepletion and HA-1 TCR-T, with one ongoing at >2 years. Single-cell RNA sequencing of relapsing/progressive leukemia after TCR-T therapy identified upregulated molecules associated with T cell dysfunction or cancer cell survival. HA-1 TCR-T therapy appears feasible and safe and shows preliminary signals of efficacy. This clinical trial is registered at clinicaltrials.gov as NCT03326921.

Antiviral cellular therapy for enhancing T-cell reconstitution before or after hematopoietic stem cell transplantation (ACES): a two-arm, open label phase II interventional trial of pediatric patients with risk factor assessment

Viral infections remain a major risk in immunocompromised pediatric patients, and virus-specific T cell (VST) therapy has been successful for treatment of refractory viral infections in prior studies. We performed a phase II multicenter study (NCT03475212) for the treatment of pediatric patients with inborn errors of immunity and/or post allogeneic hematopoietic stem cell transplant with refractory viral infections using partially-HLA matched VSTs targeting cytomegalovirus, Epstein-Barr virus, or adenovirus. Primary endpoints were feasibility, safety, and clinical responses (>1 log reduction in viremia at 28 days). Secondary endpoints were reconstitution of antiviral immunity and persistence of the infused VSTs. Suitable VST products were identified for 75 of 77 clinical queries. Clinical responses were achieved in 29 of 47 (62%) of patients post-HSCT including 73% of patients evaluable at 1-month post-infusion, meeting the primary efficacy endpoint (>52%). Secondary graft rejection occurred in one child following VST infusion as described in a companion article. Corticosteroids, graft-versus-host disease, transplant-associated thrombotic microangiopathy, and eculizumab treatment correlated with poor response, while uptrending absolute lymphocyte and CD8 T cell counts correlated with good response. This study highlights key clinical factors that impact response to VSTs and demonstrates the feasibility and efficacy of this therapy in pediatric HSCT.

The computer-assisted interview In My Shoes – a successful method to capture children’s perspectives

Background

Child mental health problems are considered the second highest cause of burden of disease in Europe and the Americas. Children’s own opinions and experiences are pivotal in addressing these problems. However, including young children as active informants in health research and practice not only requires a well-trained and highly qualified workforce, but also valid methods that enhance and support children’s self-expression. The aim was to investigate preschool aged children’s experiences in two health and welfare contexts using the interactive computer-assisted interview In My Shoes (IMS).

Methods

Interviews were conducted using IMS in three studies encompassing 43 children aged 3-6 years old. The setting for the first and second study was Child Health Centres and the third setting was families entering the Triple P group parenting programme. Qualitative content analysis was performed.

Results

The IMS interview aided preschool aged children to report on the factual, emotional and physical aspects of their experiences within a health care context. In addition, IMS helped young children verbalise unique information on negative interplay within their families, especially experiences of negative parenting including verbal and physical child abuse. The successes with IMS are likely related to the structured and systematic approach, that it is pictorial-based and emotion-focused, as well as the interactive, collaborative and triadic conversation between the child, the interviewer and the computer.

Conclusions

The interactive computer-assisted interview IMS, is a suitable and valid method for aiding young children to provide unique and extensive information about different aspects of their experiences and lives. We urge professionals and researchers to systematically include the young children’s own perspectives to better tailor and evaluate interventions on all levels to improve children’s health and wellbeing.

Key messages

• Young children’s own perspectives on their health and wellbeing are pivotal to better tailor and evaluate interventions.

• The interactive computer-assisted interview In My Shoes is a suitable and valid method to capture children’s voices.

Naive T-Cell Depletion to Prevent Chronic Graft-Versus-Host Disease

PURPOSE

Graft-versus-host disease (GVHD) causes morbidity and mortality following allogeneic hematopoietic cell transplantation. Naive T cells (TN) cause severe GVHD in murine models. We evaluated chronic GVHD (cGVHD) and other outcomes in three phase II clinical trials of TN-depletion of peripheral blood stem-cell (PBSC) grafts.

METHODS

One hundred thirty-eight patients with acute leukemia received TN-depleted PBSC from HLA-matched related or unrelated donors following conditioning with high- or intermediate-dose total-body irradiation and chemotherapy. GVHD prophylaxis was with tacrolimus, with or without methotrexate or mycophenolate mofetil. Subjects received CD34-selected PBSC and a defined dose of memory T cells depleted of TN. Median follow-up was 4 years. The primary outcome of the analysis of cumulative data from the three trials was cGVHD.

RESULTS

cGVHD was very infrequent and mild (3-year cumulative incidence total, 7% [95% CI, 2 to 11]; moderate, 1% [95% CI, 0 to 2]; severe, 0%). Grade III and IV acute GVHD (aGVHD) occurred in 4% (95% CI, 1 to 8) and 0%, respectively. The cumulative incidence of grade II aGVHD, which was mostly stage 1 upper gastrointestinal GVHD, was 71% (95% CI, 64 to 79). Recipients of matched related donor and matched unrelated donor grafts had similar rates of grade III aGVHD (5% [95% CI, 0 to 9] and 4% [95% CI, 0 to 9]) and cGVHD (7% [95% CI, 2 to 13] and 6% [95% CI, 0 to 12]). Overall survival, cGVHD-free, relapse-free survival, relapse, and nonrelapse mortality were, respectively, 77% (95% CI, 71 to 85), 68% (95% CI, 61 to 76), 23% (95% CI, 16 to 30), and 8% (95% CI, 3 to 13) at 3 years.

CONCLUSION

Depletion of TN from PBSC allografts results in very low incidences of severe acute and any cGVHD, without apparent excess risks of relapse or nonrelapse mortality, distinguishing this novel graft engineering strategy from other hematopoietic cell transplantation approaches.

Incidence of venous thromboembolic events not related to vascular catheters in a prospective cohort of critically ill children

The risk for venous thromboembolism (VTE) is considered to be low in the general paediatric intensive care unit (PICU) population, and pharmacological thromboprophylaxis is not routinely used. PICU patients considered at high-risk of VTE could possibly benefit from pharmacological thromboprophylaxis, but the incidence of VTE in this group of patients is unclear. This was an observational, prospective study at a tertiary multi-disciplinary paediatric hospital. We used comprehensive ultrasonography screening for VTE in critically ill children with multiple risk factors for VTE. Patients admitted to PICU ≥ 72 h and with ≥ two risk factors for VTE were included. Patients receiving pharmacological thromboprophylaxis during their entire PICU stay were excluded. The primary outcome of the study was VTEs not related to the use of a CVC. Ultrasonography screening of the great veins was performed at PICU discharge. Seventy patients with median (interquartile range) 3 (2-4) risk factors for VTE were evaluated. Median age was 0.3 years (0.03-4.3) and median PICU length of stay 9 days (5-17). Regarding the primary outcome, no symptomatic VTEs occurred and no asymptomatic VTEs were found on ultrasonography screening, resulting in an incidence of VTEs not related to a vascular catheter of 0% (95% CI: 0-5.1%).

CONCLUSION

Our results indicate that VTEs not related to a vascular catheter are a rare event even in a selected group of severely ill small children considered to be at high risk of VTE.

WHAT IS KNOWN

• Children in the PICU often have several risk factors for venous thromboembolism (VTE). • The incidence of VTE in PICU patients is highly uncertain, and there are no evidence-based guidelines regarding VTE prophylaxis.

WHAT IS NEW

• This study found an incidence of VTEs not related to a vascular catheter of 0% (95% CI: 0-5.1%). • This indicates that such VTE events are rare even in PICU patients with multiple risk factors for VTE.

Outcomes of pediatric patients with therapy-related myeloid neoplasms

Long-term outcomes after allogeneic hematopoietic cell transplantation (HCT) for therapy-related myeloid neoplasms (tMNs) are dismal. There are few multicenter studies defining prognostic factors in pediatric patients with tMNs. We have accumulated the largest cohort of pediatric patients who have undergone HCT for a tMN to perform a multivariate analysis defining factors predictive of long-term survival. Sixty-eight percent of the 401 patients underwent HCT using a myeloablative conditioning (MAC) regimen, but there were no statistically significant differences in the overall survival (OS), event-free survival (EFS), or cumulative incidence of relapse and non-relapse mortality based on the conditioning intensity. Among the recipients of MAC regimens, 38.4% of deaths were from treatment-related causes, especially acute graft versus host disease (GVHD) and end-organ failure, as compared to only 20.9% of deaths in the reduced-intensity conditioning (RIC) cohort. Exposure to total body irradiation (TBI) during conditioning and experiencing grade III/IV acute GVHD was associated with worse OS. In addition, a diagnosis of therapy-related myelodysplastic syndrome and having a structurally complex karyotype at tMN diagnosis were associated with worse EFS. Reduced-toxicity (but not reduced-intensity) regimens might help to decrease relapse while limiting mortality associated with TBI-based HCT conditioning in pediatric patients with tMNs.

Hematopoietic Cell Transplantation after CD19 Chimeric Antigen Receptor T Cell-Induced Acute Lymphoblastic Lymphoma Remission Confers a Leukemia-Free Survival Advantage

Consolidative hematopoietic cell transplantation (HCT) after CD19 chimeric antigen receptor (CAR) T cell therapy is frequently performed for patients with refractory/ relapsed B cell acute lymphoblastic leukemia (B-ALL). However, there is controversy regarding the role of HCT following remission attainment. We evaluated the effect of consolidative HCT on leukemia-free survival (LFS) in pediatric and young adult subjects following CD19 CAR T cell induced remission. We evaluated the effect of consolidative HCT on LFS in pediatric and young adult subjects treated with a 41BB-CD19 CAR T cell product on a phase 1/2 trial, Pediatric and Young Adult Leukemia Adoptive Therapy (PLAT)-02 (ClinicalTrials.gov identifier NCT02028455), using a time-dependent Cox proportional hazards statistical model. Fifty of 64 subjects enrolled in PLAT-02 phase 1 and early phase 2 were evaluated, excluding 14 subjects who did not achieve remission, relapsed, or died before day 63 post-CAR T cell therapy. An improved LFS (P = .01) was observed in subjects who underwent consolidative HCT after CAR T cell therapy versus watchful waiting. Consolidative HCT improved LFS specifically in subjects who had no prior history of HCT, with a trend toward significance (P = .09). This benefit was not evident when restricted to the cohort of 34 subjects with a history of prior HCT (P = .45). However, for subjects who had CAR T cell functional persistence of 63 days or less, inclusive of those with a history of prior HCT, HCT significantly improved LFS outcomes (P = .01). These data support the use of consolidative HCT following CD19 CAR T cell-induced remission for patients with no prior history of HCT and those with short functional CAR T cell persistence.

Impact of T Cell Repertoire Diversity on Mortality Following Cord Blood Transplantation

Introduction

Cord blood transplantation (CBT) recipients are at increased risk of mortality due to delayed immune recovery (IR). Prior studies in CBT patients have shown that recovery of absolute lymphocyte count is predictive of survival after transplant. However, there are no data on the association of T-cell receptor (TCR) and clinical outcomes after CBT. Here we retrospectively performed TCR beta chain sequencing on peripheral blood (PB) samples of 34 CBT patients.

Methods

All patients received a total body irradiation based conditioning regimen and cyclosporine and MMF were used for graft versus host disease (GvHD) prophylaxis. PB was collected pretransplant on days 28, 56, 80, 180, and 1-year posttransplant for retrospective analysis of IR utilizing high-throughput sequencing of TCRβ rearrangements from genomic DNA extracted from PB mononuclear cells. To test the association between TCR repertoire diversity and patient outcomes, we conducted a permutation test on median TCR repertoire diversity for patients who died within the first year posttransplant versus those who survived.

Results

Median age was 27 (range 1–58 years) and most of the patients (n = 27) had acute leukemias. There were 15 deaths occurring between 34 to 335 days after transplant. Seven deaths were due to relapse. Rapid turnover of T cell clones was observed at each time point, with TCR repertoires stabilizing by 1-year posttransplant. TCR diversity values at day 100 for patients who died between 100 and 365 days posttransplant were significantly lower than those of the surviving patients (p = 0.01).

Conclusions

Using a fast high-throughput TCR sequencing assay we have demonstrated that high TCR diversity is associated with better patient outcomes following CBT. Importantly, this assay is easily performed on posttransplant PB samples, even as early as day 28 posttransplant, making it an excellent candidate for early identification of patients at high risk of death.

Assessment tools for screening the mental health of refugee minors: from preschool to adolescence

The high number of asylum seekers in Sweden highlighted the need to develop and evaluate structured assessment tools for children and adolescents. In a series of studies, we aimed to explore the utility of (i) the Strengths and Difficulties Questionnaire with a trauma supplement of six items (SDQ-T) for preschool children; (ii) the Children's Revised Impact of Events Scale (CRIES-8) with unaccompanied refugee adolescents; and (iii) the Refugee Health Screener (RHS-13) with refugee adolescents. Parents of two- to six-year-olds (N = 61) were asked to complete the SDQ-T, and refugee adolescents were asked to complete the CRIES-8 (N = 208) and, in a separate study, the RHS-13 (N = 29) during the routine health checks. Focus-group interviews were conducted with the nurses who used the SDQ-T. The nurses felt the SDQ-T contributed to a more structured and informative conversation about the child's mental health. The SDQ total difficulties showed good internal consistency (α=.82). A significant proportion of children scored above the clinical cut-off and SDQ scores correlated with the number of post-traumatic stress symptoms measured using the trauma supplement (rho=.29). The findings suggest the SDQ-T is a useful tool in this clinical setting. The CRIES-8 was feasible to use, showed good internal consistency and its factor structure was confirmed. However, an independent assessment of test-retest reliability (N = 48) and longitudinal invariance (N = 284) indicated potential instability. It could be the CRIES-8 does not perform well when used with the unaccompanied refugee adolescent population over time, or that PTSD symptoms are less stable within this group given the multiple stressors in everyday life related to acculturation stress, family separation and living arrangements. The RHS showed excellent internal consistency (α=.96) and correlated with symptoms of post-traumatic stress disorder (r=.41).

Using a simple direct-to-consumer marketing strategy to increase participation in parenting programs

Low participation in evidence-based parenting programs not only presents a major challenge for population trials where a minimum level of intervention exposure is necessary to detect population-level impact, but also undermines the incorporation of these programs into routine practice settings. As part of a large population trial, we aimed to increase participation in a series of parenting seminars by using a simple direct-to-consumer marketing strategy, i.e., redesigning the program flyer.

We captured parents' attention by affirming that “parenting is not always easy”, highlighted the potential benefits of participation, clarified what participation entailed, and addressed some of the common barriers such as the stigma associated with participation in parenting programs. Because fathers and mothers were shown to have different needs, we tailored the flyers to mothers and fathers separately.

Testing the flyers on a small sample of parents showed that both mothers and fathers perceived the flyers as relevant. As expected, mothers were more likely to express interest in the program when they saw the flyer which focused on benefits related to dealing with child behavioural problems and featured a mother-child dyad, while fathers preferred the flyer which highlighted the benefits related to dealing with emotional problems, and featured a father-child dyad.

Next, following the same procedure that was used to deliver the original flyers over the first 18 months of the project, we used the new flyers to inform parents about the upcoming seminars over the next 24 months. The preliminary results showed that although the average number of parents participating in each seminar had initially decreased from about seven to four, after the introduction of the new flyers, the number increased consistently and reached an average of nine parents during the last 6-month period.

The results shows that program uptake can be increased using simple direct-to-consumer marketing strategies.

Strengths and Difficulties Questionnaire (SDQ) as an assessment tool for measuring emotional and behavioural problems in young children

Evaluation of new initiatives to tackle mental health problems in children requires instruments that are both valid and reliable. One such instrument is the Strengths and Difficulties Questionnaire (SDQ), an assessment tool for child emotional and behavioural problems. The instrument was developed by Goodman in the 1990's and is being used worldwide in both clinical settings and research projects.

However, previous studies on the SDQ have mainly focused on school-aged children and adolescents. We know very little about the usefulness of the SDQ for measuring preschool children's mental health problems. Using data from a large number of parents and preschool teachers of children aged 3-5 (> 11 000 questionnaires), we tested the psychometric properties of the SDQ, examined the inter-rater agreement and provided cut-off points.

The original five-factor model of the SDQ was supported and it was shown to be a reliable instrument in the hands of mothers, fathers and preschool teachers. We also found significant, albeit poor, agreement (ICC) between parent and teacher ratings and good agreement between parents' ratings. Teachers reported lower levels of problems compared to parents. Compared to girls, boys were generally reported to have more problems. Thus, we provided separate cut-offs for each age group, gender and rater category.

The results suggest that SDQ can reliably be used for measuring emotional and behavioural problems in young children in community settings. They also suggest that parent and teacher reports are complementary; hence, reports from both types of informants should be considered when using the SDQ as a method to identify mental health problems within the child health services. However, inter-rater agreement between mothers and fathers was good, meaning that it may be sufficient to obtain data from a single parent informant.

Prognosis of relapse after hematopoietic cell transplant (HCT) for treatment of leukemia or myelodysplastic syndrome (MDS) in children

We studied 232 consecutive children transplanted between 1990 and 2011 with relapse after first hematopoietic cell transplant (HCT). Kaplan-Meier survival and hazard ratios for mortality were calculated for factors known at time of relapse using Cox proportional hazards models. The median (range) age at time of first HCT was 10.9 (0.5-20.9) years, time to relapse was 6.1 (0.2-89.5) months after HCT, and age at relapse was 11.7 (0.7-23.6) years. The 3-year overall survival (OS) after relapse was 13% (95% confidence interval (CI): 9%, 18%).The median (range) follow-up for the 18 surviving patients was 7.2 (3.0-24.4) years after relapse. The remaining 214 died after a median of 3 months (0.02-190.4). OS was not significantly different for patients with ALL as compared to AML. Fifty-one patients proceeded to second transplant of whom nine survive. Factors associated with improved survival included late relapse (>12 months), ALL in first CR at the time of first transplant and chemotherapy-based first conditioning regimens. These results can be used to counsel patients at the time of relapse after first transplant and as a baseline for comparison as to the effectiveness of newer therapies which are greatly needed for treatment of post-transplant relapse.

Cord blood transplantation: rewind to fast forward

The utilization of cord blood as a source of stem cells for transplantation has decreased in recent years. Although cord blood transplantation (CBT) is an established practice for the treatment of adult and pediatric patients with hematological malignancies, the high acquisition cost of CB units along with high transplant-related mortality due to delayed hematopoietic recovery and immune reconstitution have contributed to the slowing in widespread adoption of CBT. Strategies aimed to enhance speed of engraftment and ongoing clinical trials are investigating ways to make CBT more widely available. Meanwhile, the recent clinical data suggest that the choice of CBT might be preferable for patients with pre-transplant minimal residual disease. We review here the background data on the utilization of CB for the treatment of hematological malignancies, and discuss the current challenges and future directions in the field of CBT.

Cord-Blood Transplantation in Patients with Minimal Residual Disease

BACKGROUND

The majority of patients in need of a hematopoietic-cell transplant do not have a matched related donor. Data are needed to inform the choice among various alternative donor-cell sources.

METHODS

In this retrospective analysis, we compared outcomes in 582 consecutive patients with acute leukemia or the myelodysplastic syndrome who received a first myeloablative hematopoietic-cell transplant from an unrelated cord-blood donor (140 patients), an HLA-matched unrelated donor (344), or an HLA-mismatched unrelated donor (98).

RESULTS

The relative risks of death and relapse between the cord-blood group and the two other unrelated-donor groups appeared to vary according to the presence of minimal residual disease status before transplantation. Among patients with minimal residual disease, the risk of death was higher in the HLA-mismatched group than in the cord-blood group (hazard ratio, 2.92; 95% confidence interval [CI], 1.52 to 5.63; P=0.001); the risk was also higher in the HLA-matched group than in the cord-blood group but not significantly so (hazard ratio, 1.69; 95% CI, 0.94 to 3.02; P=0.08). Among patients without minimal residual disease, the hazard ratios were lower (hazard ratio in the HLA-mismatched group, 1.36; 95% CI, 0.76 to 2.46; P=0.30; hazard ratio in the HLA-matched group, 0.78; 95% CI, 0.48 to 1.28; P=0.33). The risk of relapse among patients with minimal residual disease was significantly higher in the two unrelated-donor groups than in the cord-blood group (hazard ratio in the HLA-mismatched group, 3.01; 95% CI, 1.22 to 7.38; P=0.02; hazard ratio in the HLA-matched group, 2.92; 95% CI, 1.34 to 6.35; P=0.007). Among patients without minimal residual disease, the magnitude of these associations was lower (hazard ratio in the HLA-mismatched group, 1.28; 95% CI, 0.51 to 3.25; P=0.60; hazard ratio in the HLA-matched group, 1.30; 95% CI, 0.65 to 2.58; P=0.46).

CONCLUSIONS

Our data suggest that among patients with pretransplantation minimal residual disease, the probability of overall survival after receipt of a transplant from a cord-blood donor was at least as favorable as that after receipt of a transplant from an HLA-matched unrelated donor and was significantly higher than the probability after receipt of a transplant from an HLA-mismatched unrelated donor. Furthermore, the probability of relapse was lower in the cord-blood group than in either of the other groups.

Infusion of a non-HLA-matched ex-vivo expanded cord blood progenitor cell product after intensive acute myeloid leukaemia chemotherapy: a phase 1 trial

BACKGROUND

The intensive chemotherapy regimens used to treat acute myeloid leukaemia routinely result in serious infections, largely due to prolonged neutropenia. We investigated the use of non-HLA-matched ex-vivo expanded cord blood progenitor cells to accelerate haemopoietic recovery and reduce infections after chemotherapy.

METHODS

We enrolled patients with a diagnosis of acute myeloid leukaemia by WHO criteria and aged 18-70 years inclusive at our institution (Fred Hutchinson Cancer Research Center) into this phase 1 trial. The primary endpoint of the study was safety of infusion of non-HLA-matched expanded cord blood progenitor cells after administration of clofarabine, cytarabine, and granulocyte-colony stimulating factor priming. The protocol is closed to accrual and analysis was performed per protocol. The trial is registered with ClinicalTrials.gov, NCT01031368.

FINDINGS

Between June 29, 2010, and June 26, 2012, 29 patients with acute myeloid leukaemia (19 newly diagnosed, ten relapsed or refractory) were enrolled. The most common adverse events were fever (27 [93%] of 29 patients) and infections (25 [86%] of 29 patients). We observed one case of acute infusional toxicity (attributed to an allergic reaction to dimethyl sulfoxide) in the 29 patients enrolled, who received 42 infusions of expanded progenitor cells. The following additional serious but expected adverse events were observed (each in one patient): grade 4 atrial fibrillation, grade 4 febrile neutropenia, lung infection with grade 4 absolute neutrophil count, colon infection with grade 4 absolute neutrophil count, grade 4 changed mental status, and one death from liver failure. No unexpected toxicity or graft-versus-host disease was observed. There was no evidence of in-vivo persistence of the expanded progenitor cell product in any patient beyond 14 days or induced alloimmunisation.

INTERPRETATION

Infusion of the expanded progenitor cell product seemed safe and might provide a promising treatment method for patients with acute myeloid leukaemia.

FUNDING

Biomedical Advanced Research and Development Authority in the US Department of Health and Human Services and Genzyme (Sanofi).

Angiopoietin-like proteins stimulate HSPC development through interaction with notch receptor signaling

Angiopoietin-like proteins (angptls) are capable of ex vivo expansion of mouse and human hematopoietic stem and progenitor cells (HSPCs). Despite this intriguing ability, their mechanism is unknown. In this study, we show that angptl2 overexpression is sufficient to expand definitive HSPCs in zebrafish embryos. Angptl1/2 are required for definitive hematopoiesis and vascular specification of the hemogenic endothelium. The loss-of-function phenotype is reminiscent of the notch mutant mindbomb (mib), and a strong genetic interaction occurs between angptls and notch. Overexpressing angptl2 rescues mib while overexpressing notch rescues angptl1/2 morphants. Gene expression studies in ANGPTL2-stimulated CD34(+) cells showed a strong MYC activation signature and myc overexpression in angptl1/2 morphants or mib restored HSPCs formation. ANGPTL2 can increase NOTCH activation in cultured cells and ANGPTL receptor interacted with NOTCH to regulate NOTCH cleavage. Together our data provide insight to the angptl-mediated notch activation through receptor interaction and subsequent activation of myc targets.

137Cs in fungal sporocarps in relation to vegetation in a bog, pine swamp and forest along a transect

In this study, we estimated the relative importance of vegetation and fungi for radiocesium uptake and biological retention in adjacent bog, pine swamp, and forest. The measurements for (137)Cs activity concentration in sporocarps (i.e. fruitbodies of fungi) and vegetation along a bog to forest transect were combined with complementary published data to calculate estimates. Aboveground vegetation comprised 17.7% of the total fallout-derived radiocesium in the system in bog, 16.5% in pine swamp, and 40.6% in forest. In fungal sporocarps grown along a gradient, (137)Cs activity comprised <0.001% of the total radiocesium for peat bog, <0.02% for pine swamp, and 0.11% for forest. Total (137)Cs activity in sporocarps increased along the gradient due to increased production of sporocarps in the presence of trees from 0.006 (bog), 0.097 (pine swamp) and 0.67 (forest) g dwt m(-2). Based on calculation of the total vegetation biomass and through relationships between fungal biomass in sporocarps and as mycelia in soil, the total (137)Cs activity located in fungi was estimated as 0.1% in bog, 2% in pine swamp, and 11% in forest. An analysis of the time-dependency of (137)Cs in the sporocarps in forest between 1990 and 2011 suggested an ecological half-life for (137)Cs between 8 and 13 years. Although fungi comprised a relatively small fraction of the total radiocesium in the systems, its activity decreased slowly with time, and ecological residence time for (137)Cs in sporocarps of fungi was long, suggesting they will continue to contribute to the accumulation and cycling of this radionuclide in forest.

Correlations between potassium, rubidium and cesium ((133)Cs and (137)Cs) in sporocarps of Suillus variegatus in a Swedish boreal forest

An analysis of sporocarps of ectomycorrhizal fungi Suillus variegatus assessed whether cesium ((133)Cs and (137)Cs) uptake was correlated with potassium (K) or rubidium (Rb) uptake. The question was whether intraspecific correlations of Rb, K and (133)Cs mass concentrations with (137)Cs activity concentrations in sporocarps were higher within, rather than among, different fungal species, and if genotypic origin of sporocarps within a population affected uptake and correlation. Sporocarps (n = 51) from a Swedish forest population affected by the fallout after the Chernobyl accident were studied. The concentrations were 31.9 ± 6.79 g kg(-1) for K (mean ± SD, dwt), 0.40 ± 0.09 g kg(-1) for Rb, 8.7 ± 4.36 mg kg(-1) for (133)Cs and 63.7 ± 24.2 kBq kg(-1) for (137)Cs. The mass concentrations of (133)Cs correlated with (137)Cs activity concentrations (r = 0.61). There was correlation between both (133)Cs concentrations (r = 0.75) and (137)Cs activity concentrations (r = 0.44) and Rb, but the (137)Cs/(133)Cs isotopic ratio negatively correlated with Rb concentration. Concentrations of K and Rb were weakly correlated (r = 0.51). The (133)Cs mass concentrations, (137)Cs activity concentrations and (137)Cs/(133)Cs isotopic ratios did not correlate with K concentrations. No differences between, within or, among genotypes in S. variegatus were found. This suggested the relationships between K, Rb, (133)Cs and (137)Cs in sporocarps of S. variegatus is similar to other fungal species.

Respondent burden and patient-perceived validity of the PDQ-39

OBJECTIVES

To evaluate the respondent burden and patient-perceived content validity of the Parkinson's disease (PD)-specific health status questionnaire PDQ-39, and the linguistic validity of its revised Swedish version.

MATERIALS AND METHODS

Eighteen PD patients completed the revised Swedish version of the PDQ-39. Respondent burden was assessed by recording the time taken to complete the questionnaire. Content and linguistic validity was evaluated qualitatively.

RESULTS

Patients with mild, moderate and advanced PD needed a mean time of 9.5, 11.3 and 20.1 min, respectively, to complete the PDQ-39. One-third of the patients identified irrelevant items and 50% identified important health-related areas that were missing. Revisions had eliminated previous linguistic problems with the Swedish PDQ-39.

CONCLUSIONS

Undue respondent burden challenged the appropriateness of the PDQ-39 among patients with more advanced disease. Overall content validity was acceptable but compromised by lack of important content areas. Observations supported the linguistic validity of the revised Swedish PDQ-39.

Prevalence of spinal cord injury in Helsinki

STUDY DESIGN

Retrospective register-based epidemiological study.

OBJECTIVE

To estimate the prevalence rate of persons with spinal cord injury (SCI) with special reference to ASIA Impairment Grade A-D.

SETTING

Helsinki, Finland.

METHODS

Cases were identified using the registers of the Kapyla Rehabilitation Centre, Helsinki University Central Hospital and the local organization for the disabled. Local health centres were informed about the study, residential service houses were contacted, and announcements were published in patient magazines.

RESULTS

A regional population was found to have a prevalence rate of 28/100,000 inhabitants with SCI (ASIA Impairment Scale A-D).

CONCLUSION

The prevalence rate in this study is consistent with the data published in other Nordic countries.

SPONSORSHIP

The Finnish Cultural Foundation.

Bladder management in persons with spinal cord lesion

STUDY DESIGN

Cross-sectional clinical descriptive prevalence study.

OBJECTIVE

To evaluate the methods of self-reported bladder management, the frequency of urinary tract infection (UTI) and subjective disturbance of bladder problems of all those individuals with traumatic spinal cord lesion (SCL) living in Helsinki area.

SETTING

: Helsinki, Finland.

METHODS

A total of 152 persons with SCL were found in the Helsinki area (546 000 inhabitants). A structured questionnaire was sent to all subjects and they were invited to a clinical visit.

RESULTS

The final study-group consisted of 129 (85%) subjects. They were defined into seven specific subgroups of bladder management: 14 (11%) subjects in the normal voiding group, 15 (12%) in the controlled voiding group, 16 (12%) in the clean intermittent catheterization (CIC) group, 30 (23%) in the mixed group, 31 (24%) in the suprapubic tapping group, 16 (12%) in the compression or straining group and seven (5%) in the catheter or conduit group. The frequency of UTI was highest in the mixed group. The bladder management was a biggest bother to the subjects in the compression or straining group.

CONCLUSIONS

This prevalence study assesses the self-reported bladder management methods in all the persons with traumatic SCL in the Helsinki area. The subjects who used CIC and other methods for bladder management had more problems than others. These subjects might manage better by using either CIC or suprapubic tapping as the only method for bladder emptying.

Life situation of spinal cord-injured persons in Central Finland

STUDY DESIGN

Individual interview and questionnaire of a regional spinal cord-injured (SCI) population.

OBJECTIVE

Local health care centres are mainly responsible for the SCI patients health care and rehabilitation after initial hospitalization in Finland. The purpose of the present study was to study aspects of the SCI patients life situation and their opinion of the health care services after 1 year since the injury.

SETTING

Regional study in Central Finland.

METHODS

Subjects were individually interviewed in their homes using a semi-structured questionnaire, the Functional Independence Measure (FIM) and the Beck Depression Inventory (BDI).

RESULTS

The female/male ratio was 1:4. The mean age at the time of injury was 34 years in female and 40 in male. Traffic accidents accounted for 46% of the injuries. In all, 48 subjects (63%) used electrical or manual wheelchair or both. Most subjects regarded their living conditions as good having enough personal assistance in their everyday life. Only 10% of the subjects were employed. Half of the subjects had had out-patient physiotherapy, but no other therapies after 1 year since the injury. More than half of the subjects were dissatisfied with the current health care services. Many had experienced complications after the initial hospitalization, especially urinary tract infections, decubitus ulcers and neurogenic-type pain. FIM classified well according to the disability groups. The motor complete tetraplegic group had the lowest mean scores (63) and the recovered group the highest ones (122). There was no association between the FIM and the BDI results. There was a correlation between the BDI and the subject's age at the time of the injury and the year of the injury. The older the subjects were when injured, the higher were the BDI scores, that is, they had more depressive symptoms. Those injured in the 1990s had the highest BDI scores. Nearly one-third of the subjects had mild, moderate or severe depression.

CONCLUSIONS

The reported medical complications, depression and dissatisfaction with the health care services support a life-long care for SCI patients in Jyväskylä Central hospital, not in the local health care centres. The psychological services, for example, prevention and treatment of depression, in particular, require more attention.

Parental tracking in the postfire wood decay ascomycete Daldinia loculata using highly variable nuclear gene loci

The origin of the male and female gametes involved in fertilization events within a local population of the postfire wood decay ascomycete Daldinia loculata was investigated by genotyping the mycelia growing in the wood and the sexual ascospores, using three highly variable nuclear gene loci. The study was conducted in a geographically isolated burned forest site in southern Sweden. An intensive sampling was performed by collecting stromata containing ascospores and wood samples containing mycelia. In total, from 32 mapped burned birches, cultures of 22 haploid genets from decayed wood and six ascospores from each of 19 stromata were isolated and analysed. In 80% of the investigated burned branches, only one genet was found. From the analysis of the ascospore genotypes, we detected 30 fertilization events and 60% of them were the result of mating between conidia (clonal propagules) acting as male gametes and the genets in the branches representing the female gametes. The male parents producing the conidia were detected within the same local population as the female parents in 27% of the fertilization events and originated either from the same branch or from different trees located at 0.5-36 m away from the female parents. In 33% of the fertilization events, conidia originated from three male parents that were not found within the local population sampled. These parents could be anywhere inside or outside the sampled area. For the remaining fertilization events, we could not rule out the ascospores or the conidia as fertilizing propagules. No strong evidence for fertilization by recombinant propagules (ascospores) was detected in this study. The pyrophilous insect species associated with conidia of D. loculata are suggested to be essential vectors for the realization of the sexual cycle of this fungal species. By feeding on the conidia and flying between nearby trees inhabiting wood decay mycelia, these insects allow the transfer of conidia and therefore the opposite mating types to meet within a localized burned forest site.

Genetic differentiation in Eurasian populations of the postfire ascomycete Daldinia loculata

The genetic population structure of the postfire ascomycete Daldinia loculata was studied to test for differentiation on a continental scale. Ninety-six samples of spore families, each comprising mycelia from six to 10 spores originating from single perithecia, were sampled from one Russian and six Fennoscandian forest sites. Allelic distribution was assayed for six nuclear gene loci by restriction enzyme analyses of polymerase chain reaction (PCR)-amplified gene fragments. In addition, the full sequence of the gene fragment was analysed for a subset of haploid single-ascospore isolates in a multiallelic approach. A third data set was generated by using arbitrary-primed PCR with the core sequence of the phage M13 as primer. Although there was a reduction in heterozygosity in the total population from what would have been expected at random mating, the levels of genetic differentiation among the Eurasian subpopulations of D. loculata were low. All subpopulations were found to be in Hardy-Weinberg equilibrium and gametic equilibrium was observed between all investigated nuclear gene loci. The results obtained by the different markers were consistent; we confirmed low levels of genetic differentiation among the Eurasian subpopulations of D. loculata. The differentiation did not increase with distance; the Russian subpopulation, sampled more than 7000 km from the Fennoscandian subpopulations, was only moderately differentiated from the others (FST = 0.00-0.14). In contrast, one of the Swedish populations was the most highly differentiated from the others, with FST and GST values of 0.10-0.16. The results suggest that D. loculata consists of a long-lived background Eurasian population of latent mycelia in nonburned forests, established by sexual ascospores dispersed from scattered burned forest sites. Local differentiation is probably due to founder effects of populations in areas with low fire frequency. A tentative life cycle of D. loculata is presented.

Diversity and abundance of resupinate thelephoroid fungi as ectomycorrhizal symbionts in Swedish boreal forests

Resupinate thelephoroid fungi (hereafter called tomentelloid fungi) have a world-wide distribution and comprise approximately 70 basidiomycete species with inconspicuous, resupinate sporocarps. It is only recently that their ability to form ectomycorrhizas (EM) has been realized, so their distribution, abundance and significance as mycobionts in forest ecosystems is still largely unexplored. In order to provide baseline data for future ecological studies of tomentelloid fungi, we explored their presence and abundance in nine Swedish boreal forests in which the EM communities had been analysed. Phylogenetic analyses were used to compare the internal transcribed spacer of nuclear ribosomal DNA (ITS rDNA) sequence data obtained from mycobionts on single ectomycorrhizal tips with that obtained from sporocarps of identified tomentelloid fungi. Five species of Tomentella and one species of Pseudotomentella were identified as ectomycorrhizal fungi. The symbiotic nature of Tomentella bryophila, T. stuposa, T. badia and T. atramentaria is demonstrated for the first time. T. stuposa and Pseudotomentella tristis were the most commonly encountered tomentelloid fungi, with the other species, including T. sublilacina, only being recorded from single stands. Overall, tomentelloid fungi were found in five of the studies, colonizing between 1 and 8% of the mycorrhizal root tips. Two of the five sites supported several tomentelloid species. Tomentelloid fungi appear to be relatively common ectomycorrhizal symbionts with a wide distribution in Swedish coniferous forests. The results are in accordance with accumulating data that fungal species which lack conspicuous sporocarps may be of considerable importance in EM communities.

Pregnancy results from a vibrator application, electroejaculation, and a vas aspiration programme in spinal-cord injured men

In an infertility treatment programme for spinal-cord injured men, vibrator application was primarily used in cases of upper motor neurone lesion and electroejaculation in men with lower lesions, or when vibrator application failed to induce ejaculation. Spermatozoa were obtained by these methods from 29 out of 35 men who desired infertility treatment. No ejaculate was obtained from six men. Three of these men plus two others with very poor sperm quality with electroejaculation underwent micro-surgical sperm aspiration from the vas deferens for invitro fertilization (IVF), and spermatozoa were obtained from all of them. Thus it was possible to obtain spermatozoa from almost every spinal-cord injured man who had ongoing spermatogenesis using these three methods. Insemination was the primary infertility treatment used with all the couples where there was successful ejaculation. In all, 12 pregnancies resulted from home vaginal inseminations, eight from intrauterine inseminations, two from IVF with ejaculated spermatozoa, and two from IVF with spermatozoa aspirated from the vas. Three couples had children from donor inseminations (not counted in the results); 12 are still in the programme. From 24 pregnancies, 22 children have now been born to 18 couples out of the original 35 (51%), and there were four abortions. Hence, overall, infertility treatment of spinal-cord injured men has given good results.

Factors influencing the outcome of thyrostatic drug therapy in Graves' disease

In patients with Graves' disease, thyrostatic drug treatment may induce definitive remission without the need of more aggressive measures such as surgery or radioiodine. Following drug therapy, however, relapses often occur. In the present study, a multivariate analysis of pretreatment variables was performed, in order to identify individuals running a high risk of an unfavourable outcome of thyrostatic drug therapy. We studied 109 consecutive patients with a mean age of 38 years, range 20-70, over a mean follow-up period of 5.3 years after cessation of therapy. The analysis showed that goitre size, age, thyroid hormone levels, HLA-DR 3 haplotype, and TSH receptor antibody levels were of prognostic significance, whereas HLA-B8 haplotype, a lymphocytic infiltrate at fine needle biopsy, thyroglobulin, and microsomal antibodies had no such value. In particular, patients characterized by young age, large goitre and high hormone values were found to be associated with an unfavourable course.

Anejaculation following spinal cord injury does not induce sperm-agglutinating antibodies

Antisperm antibodies were tested for by the MAR-test and the tray agglutination test in 16 men with spinal cord injury. None of these men could ejaculate without artificial methods. Seven men ejaculated externally by vibrator stimulation or electroejaculation, while seven exhibited retrograde ejaculation; in two cases no semen was obtained. Sperm density in the external ejaculations was high (average = 405 x 10(6)/ml), with 10-45% motility. None of these 16 men had antisperm antibodies. This result indicates that anejaculation and sperm retention in men with spinal cord injury, even of 30 years duration, does not result in antisperm antibody formation.

The interaction of migration, income, and employment in Sweden

A common approach in migration studies is to explain interregional migration by single-equation models. Such models are likely to suffer from simultaneous-equation bias when used in studies attempting to analyze migration over a long period of time. In this study, a simultaneous-equation appraoch is applied, which takes account of the interdependence between migration and income and employment changes. The four-equation model is estimated for 70 labor market areas in Sweden.