The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS)

OBJECTIVE

Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS.

METHODS

A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS.

RESULTS

The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance.

CONCLUSION

These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.

The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS)

OBJECTIVE

Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS.

METHODS

A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS.

RESULTS

The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance.

CONCLUSION

These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.

O-283 Evidence based management of endometriosis – what has changed since 2013?

In 2005, under the auspices of ESHRE, a group of international experts evaluated the existing best evidence and published the first European guideline on the management of endometriosis. This highly successful project was the first guideline by ESHRE and was adopted by many counties as their national standard. A second, fully-updated edition was presented in 2013.

For the new ESHRE Endometriosis Guideline, published in February 2022, all available evidence for twelve chosen topics was gathered by a senior research specialist. Subgroups comprised of patient representatives and experts in healthcare, reproductive science and epidemiology evaluated the data according to GRADE criteria. Each subgroup wrote a chapter and formulated their recommendations which were then presented by a representative to the core group. There, a provisional document was generated and made available for stakeholder review. The resulting comments were taken into account and where relevant incorporated into the final guideline document for which approval was sought and gained from the ESHRE Executive Committee.

35 PICO (Patients, Interventions, Comparison, Outcome) and seven narrative questions were addressed resulting in 78 Research Recommendations were formulated. Where sufficient scientific evidence was lacking and the Guideline Development Group (GDG) was of the opinion that an important topic needed to be highlighted Good Clinical Practice Points where created based on experts’ experience.

During the process of reviewing the literature it became apparent that large knowledge gaps of the best clinical approach to endometriosis exist. As a result, 30 research recommendations were also produced.

One of the main differences to the 2013 version of the ESHRE guidelines is that laparoscopy is no longer the gold standard for endometriosis per se as there exist sufficient data to support the use of transvaginal ultrasound performed by an experienced operator or MRI can equally identify or rule out ovarian and most of deep endometriosis. However, it is recognised by the GDG that the required imaging standards are not ubiquitously available and for peritoneal disease both sensitivity and specificity using either imaging modalities are still poor. As opposed to the 2013 recommendation, the GDG does not anymore recommend an ultralong protocol for the women with rASRM stage III/IV endometriosis to improve IVF success rates. Furthermore, gonadotropin releasing hormone antagonists seem to be effective in the treatment of endometriosis-associate pain and, where available, could be considered as second-line treatment.

Other changes were specific chapters on endometriosis in adolescents and in menopausal women as the GDG strongly felt that these groups are concerningly underrepresented in clinical care and research. Finally, a chapter focussing on the association of endometriosis with certain forms of cancer namely subgroups of ovarian cancer, breast and thyroid cancer was added to give both patients and clinicians a better insight into the current evidence of this complex topic.

The GDG hope that the new ESHRE Endometriosis Guideline will improve the clinical management of a highly prevalent and heterogenous disease and that the freely-available patient-friendly version of the guideline empowers symptomatic and asymptomatic women to seek the best available advice, support and treatment.

O-258 Nuclear magnetic resonance profiling of the vaginal metabolome in adverse early pregnancy outcomes

Study question

Is the vaginal metabolome predictive of early pregnancy outcomes?

Summary answer

The vaginal metabolome is moderately predictive of live normally-sited pregnancies when compared to a pregnancy with an adverse outcome.

What is known already

Approximately 15% of all pregnancies are lost in the first trimester and a further 1-2% are ectopic. To date, no non-invasive and clinically useful tests have been developed to differentiate live normally-sited pregnancies from non-viable and ectopic pregnancies. Metabolomics is the comprehensive analysis of small molecules in biological samples used to identify disease biomarkers. The vaginal metabolome has previously been shown to be predictive of later adverse pregnancy outcomes including preterm birth. In this study, we aimed to identify biomarkers of live normally-sited pregnancies when compared to non-viable intrauterine and ectopic pregnancies using NMR metabolomic profiling of vaginal swabs (LVS).

Study design, size, duration

This was a prospective cohort study (EXPEDITE). 222 pregnant women <10 weeks’ gestation with pain and/or bleeding were recruited over a period of 36 months at the Liverpool Women’s Hospital, a tertiary referral centre. Pregnancy outcomes were categorised according to ESHRE guidelines as live normally-sited pregnancy, miscarriage, tubal ectopic pregnancy or pregnancy of unknown location (PUL).

Participants/materials, setting, methods

Participants consented to self-collecting a LVS, which was extracted in acetonitrile and analysis by NMR spectroscopy; 1D 1H and 2D 1H-13C. Spectra were acquired at 25 °C on a 700 MHz spectrometer. Relative metabolite abundances underwent univariate and multivariate statistical analysis using MetaboAnalyst 5.0 and custom-built R scripts (p-value false discovery rate adjusted). Area under receiver operating characteristic curve (AUC) values were used to evaluate predictive models.

Main results and the role of chance

Our cohort of 222 women were categorised in to 100 (45 %) live normally-sited pregnancies, 29 (13 %) tubal ectopic pregnancies, 52 (23 %) miscarriages and 31 (14%) pregnancies of unknown location (PUL). Ten spectra from rare or uncertain pregnancy outcomes (e.g. molar pregnancy) were excluded. Univariate statistical analysis of all four groups identified isoleucine levels as significantly higher (p < 0.05) in live normally-sited pregnancies compared with all groups with adverse pregnancy outcome groups. Multivariate partial least squares discriminant analysis (PLS-DA) models of all groups failed to accurately predict pregnancy outcomes. To enhance the predictive models, miscarriage, tubal ectopic pregnancy and PUL groups were combined and compared to live normally-sited pregnancies. Univariate analysis revealed levels of several metabolites (including isoleucine, tyrosine and maltose) as significantly altered in live normally-sited pregnancies compared with all other outcomes. PLS-DA models demonstrated modest discrimination between live normally-sited pregnancies versus other outcomes (AUC = 0.75). In summary, this study has identified a vaginal metabolite profile and potential biomarkers associated with live normally-sited pregnancy in the first trimester.

Limitations, reasons for caution

The number of tubal ectopic pregnancies and PULs were relatively low compared to other outcomes. Additionally, several factors that may influence the vaginal metabolome, including infection and the vaginal microbiome, were not characterised in this study.

Wider implications of the findings

These findings may be useful in the development of diagnostic tests to confirm an intrauterine pregnancy and exclude potential life-threatening pregnancies. It is well established that the microbiome contributes to the vaginal metabolome. As such, our findings will inform future correlative studies of vaginal microbiome and metabolome in early pregnancy.

Trial registration number

NA

Prevalence of deep and ovarian endometriosis in early pregnancy: ultrasound diagnostic study

OBJECTIVE

To assess the prevalence and morphological appearance of deep endometriosis and ovarian endometrioma using pelvic ultrasound examination in women attending for an early pregnancy assessment.

METHODS

This was a prospective observational study set within a dedicated early pregnancy unit. The study included 1341 consecutive women who attended for an early pregnancy assessment for reassurance or because of suspected early pregnancy complications. All women underwent a transvaginal scan to assess the location and viability of their pregnancy. In addition, a detailed examination of pelvic organs was carried out to detect the presence of endometriosis and other gynecological abnormalities. Data analysis was performed using logistic regression and multivariable analysis.

RESULTS

The prevalence of deep endometriosis and/or ovarian endometrioma in women attending our early pregnancy unit was 4.9% (95% CI, 3.8-6.2%). In 33/66 (50.0% (95% CI, 37.9-62.1%)) women with endometriosis, this was a new diagnosis that was made during their early pregnancy scan. On multivariable analysis, the presence of endometriosis was strongly associated with a history of subfertility (odds ratio (OR), 3.15 (95% CI, 1.63-6.07)) and presence of a congenital uterine anomaly (OR, 5.69 (95% CI, 2.17-14.9)) and uterine fibroids (OR, 2.37 (95% CI, 1.31-4.28)). Morphological changes typical of decidualization were seen in 11/33 (33.3% (95% CI, 17.2-49.4%)) women with ovarian endometrioma and 18/57 (31.6% (95% CI, 19.5-43.7%)) women with deep endometriotic nodules.

CONCLUSIONS

Deep endometriosis and ovarian endometrioma were present in a significant proportion of women attending for early pregnancy assessment. The prevalence varied depending on a history of subfertility, and therefore is likely to differ significantly among populations, depending on their characteristics. Ultrasound is a useful tool for the detection of endometriosis in early pregnancy and the identification of women who may benefit from specialist antenatal care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

O-234 Using serum metabolomics to identify biomarkers of viable early, intrauterine pregnancy: an untargeted 1H NMR-based approach

Study question

Which metabolites are associated with a viable intrauterine pregnancy (VIUP) when compared to other early pregnancy outcomes (failed intrauterine and ectopic pregnancies)?

Summary answer

Serum levels of four metabolites (phenylalanine, alanine, glutamate and glutamine) were significantly altered in VIUPs compared to other early pregnancy outcomes.

What is known already

Around 10% of all intrauterine pregnancies are lost in the first trimester. A further 1-2% of pregnancies are located outside the endometrial cavity; these ectopic pregnancies are the leading cause of maternal mortality in the first trimester of gestation. Early miscarriages may also cause significant morbidity when bleeding or infection occurs. The symptoms of miscarriages and ectopic pregnancy are often similar (pain and bleeding), however, such symptoms are also common in VIUPs. To date, no biomarkers have been identified to differentiate VIUPs from non-viable and ectopic pregnancies.

Study design, size, duration

This is a prospective cohort study that included 332 pregnant women at less than ten weeks of gestation, who attended the early pregnancy assessment unit (EPAU) at Liverpool Women’s Hospital with pain and/or bleeding.

Participants/materials, setting, methods

Blood samples were collected from the 332 pregnant women prior to final clinical diagnosis of pregnancy outcome. Serum samples were subjected to NMR metabolomics profiling (14 spectra that did not meet the recommended minimum reporting standards were removed from subsequent analysis). 1D 1H-NMR spectra were acquired at 37 °C on a 700 MHz spectrometer. Relative metabolite abundances underwent statistical analysis using MetaboAnalyst 5.0 (p-value FDR adjusted).

Main results and the role of chance

Final pregnancy outcomes were as follows: one hydatidiform mole (0.3%), 48 ectopic pregnancies (14.4%), three pregnancies of unknown location (PULs, 0.9%), 78 failed pregnancies of unknown location (FPULs, 23.4%), 47 miscarriages (14.1%), two vanishing twin pregnancies (0.6%) and 153 VIUPs (45.8%). Due to small sample numbers, the hydatidiform mole, PULs and vanishing twin pregnancies were excluded from further analysis. To compare VIUPs to other pregnancy outcomes, ectopic pregnancies, FPULs and miscarriages were grouped together. Univariate analysis of serum metabolite concentrations identified four metabolites (phenylalanine, alanine, glutamate and glutamine) as significantly different in VIUPs compared to other pregnancy outcomes. Multivariate partial least squared discriminant analysis provided only weak correlation between the serum metabolome and pregnancy outcome. In summary, we have identified differences in the metabolome of women with VIUPs compared to other common pregnancy outcomes, which may provide diagnostic utility.

Limitations, reasons for caution

In this study, women with VIUPs presented with pain and/or bleeding. The presence of symptoms may influence the metabolome of this group versus VIUPs without symptoms, thus limiting the translation of our findings. Furthermore, environmental factors were not controlled (e.g. fasting status), making it likely that cohort heterogeneity was enhanced.

Wider implications of the findings

This study identifies a metabolite profile associated with VIUPs. These findings may be useful in the development of a diagnostic test to confirm VIUPs and thus exclude potentially life-threatening pregnancy outcomes. Such a test would be invaluable in clinical emergencies.

Trial registration number

NA

POS1313 PSYCHIATRIC DISORDERS IN JUVENILE IDIOPATHIC ARTHRITIS - A POPULATION-BASED COHORT STUDY

Background:

Juvenile idiopathic arthritis (JIA) may have substantial consequences for quality of life, for instance due to chronic pain, restriction of activities, concern about physical appearance, and treatment protocols that may limit interactions with peers. However, it remains unclear whether children and adolescents with JIA sow a higher incidence of psychiatric disorders compared with the general population.

Objectives:

To examine the incidence of psychiatric disorders during childhood in JIA patients in Sweden relative to general population controls.

Methods:

We performed a register- and population-based cohort study including new-onset JIA patients aged 0 to 17 years 1st January 2012 through 31st December 2017. Incident JIA patients were followed-up from the date of their 2nd JIA diagnosis. At this date, five sex-age-region matched individuals were sampled from the general population. Nine psychiatric disorders were defined with ICD-10 codes and associated drugs (ATC codes): psychotic disorders (ICD-10: F20-29; ATC: N05A), mood and anxiety disorders (F30-F43; N05B, N06A, R06AD01, R06AD02, N03AX16), sleeping disorders (F51; N05C, N03AE01), eating and personality disorders (F50, F60-61, F69), neuropsychiatric disorders (F70-F79, F84, F90; N06BA, C02AC02), substance misuse (F10-F19; N07B), suicide attempts (X60-X84, Y10-34) and death by suicide or substance abuse, and all these combined. The follow-up stopped at date of first outcome, migration, death, 18th birthday or end of the study period, whichever occurred first. Incidence rates were calculated and compared by Cox regression analyses, adjusted for age, sex, calendar year, patient’s and family’s history of psychiatric disorder, country of birth, parents’ education level, and comorbidities (IBD, obesity and celiac disease). In sensitivity analyses, we (1.) excluded children with a history of a psychiatric diagnosis at start of follow-up, and (2.) defined the psychiatric disorders based on ICD-10 codes only.

Results:

We identified 2224 JIA patients (64% girls, mean age: 9.8 years) and 10,264 matched controls. In the JIA cohort, 309 patients developed a psychiatric disorder (all outcomes combined) during 4998 person-years (pyrs), which corresponded to a crude incidence rate (IR) of 6.2 per 100 pyrs (95% confidence interval (CI): 5.5-6.9). The corresponding crude IR for the general population matched controls was 3.6 (3.4-3.9). Comparing these incidence rates resulted in a sex-age adjusted hazard ratio (HR) of 1.66 (95% CI: 1.46-1.89) and a fully adjusted HR of 1.68 (1.47-1.91). Considering specific outcomes, the IRs per 100 pyrs in the JIA population ranged from 0.1 (suicide attempt) to 3.7 (mood and anxiety disorders) (Table 1). No death from suicide was recorded. There was an overlap across the seven outcomes: among all individuals diagnosed with at least one of the psychiatric outcomes during follow-up, 58% were diagnosed with one outcome only, 25% with two and 19% with three or more outcome conditions. The Cox analyses of the 7 outcome groups demonstrated four statistically significant increased risks for psychotic, mood and anxiety, sleeping and neuropsychiatric disorders (Figure 1). The three latter outcomes were correlated to each other (with Cramer’s V coefficient between 0.3 and 0.5). The sensitivity analyses did not substantially modify these findings.

Conclusion:

The burden of psychiatric illness in individuals with JIA is increased compared to the general population.

Table 1.

Risk of psychiatric disorders in JIA patients and general population controls.

DisordersN events JIAN events controlsIR JIA (95% CI)IR controls (95% CI)All combined3099186.2 (5.5-6.9)3.6 (3.4-3.9)Psychotic25440.5 (0.3-0.7)0.2 (0.1-0.2)Mood1945343.7 (3.2-4.3)2.0 (1.9-2.2)Sleeping1483482.8 (2.4-3.3)1.3 (1.2-1.5)Neuropsychiatric1264422.4 (2.0-2.8)1.7 (1.5-1.9)Eating13550.2 (0.1-0.4)0.2 (0.2-0.3)Substance misuse14490.3 (0.2-0.4)0.2 (0.1-0.2)Suicide attempt7550.1 (0.1-0.3)0.2 (0.2-0.3)

IR: crude incidence rate per 100 person-years; CI: confidence interval

1 adjustment: see text.

Figure 1.

Disclosure of Interests:

Bénédicte Delcoigne: None declared, AnnaCarin Horne Consultant of: SOBI and Novartis, Soley Omarsdottir: None declared, Johan Reutfors: None declared, Johan Askling Consultant of: Abbvie, Astra-Zeneca, BMS, Eli Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi, and UCB. These entities have entered into agreements with Karolinska Institutet with JA as principal investigator, mainly in the context of safety monitoring of biologics via the ARTIS national safety monitoring system

Caesarean scar pregnancy in the UK: a national cohort study

OBJECTIVE

To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition.

DESIGN

A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS).

SETTING

86 participating Early Pregnancy Units.

POPULATION

All women diagnosed in the participating units with CSP between November 2013 and January 2015.

METHODS

Cohort study of women identified through the UKEPSS monthly mailing system.

MAIN OUTCOME MEASURES

Incidence, clinical outcomes and complications.

RESULTS

102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management.

CONCLUSIONS

Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up.

TWEETABLE ABSTRACT

Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.

Effect of single-dose dexamethasone on acute phase response following zoledronic acid: a randomized controlled trial

Zoledronic acid provokes an inflammatory reaction, or acute phase response, in some individuals. We examined whether treatment with dexamethasone could prevent this response. A single dose of dexamethasone 4 mg, given at the time of zoledronic acid infusion, did not influence the incidence or severity of the acute phase response.

INTRODUCTION

The potent bisphosphonate zoledronic acid (ZOL) is used to treat osteoporosis, Paget's disease, and hypercalcemia of malignancy. This medication can provoke an inflammatory reaction, known as the acute phase response (APR). We examined whether glucocorticoid treatment at the time of first exposure to ZOL prevents the development of APR.

METHODS

This double-blind, randomized, controlled trial assessed 40 adults receiving ZOL 5 mg intravenously for the first time. Participants received oral dexamethasone 4 mg (n = 20) or placebo (n = 20) at the time of ZOL infusion. Oral temperature was measured at baseline and three times a day for 3 days following infusion. Symptoms of APR were assessed via questionnaire at baseline then daily for 3 days and again at day 15 post-infusion. Use of rescue medications (paracetamol or ibuprofen) in the 3 days following infusion was evaluated. Primary outcome was between-group difference in temperature change from baseline.

RESULTS

There was no significant difference in temperature change (p = 0.95) or symptom score (p = 0.42) in the 3 days following ZOL between dexamethasone and placebo recipients. Eleven (55%) in the dexamethasone group and 10 (50%) placebo recipients experienced a temperature increase of ≥1 °C (p = 0.99). Seven (35%) in the dexamethasone group and 9 (45%) in the placebo group experienced an increase in symptom score of ≥3 points (p = 0.75). Thirteen (65%) dexamethasone recipients and 12 (60%) in the placebo group required rescue medications (p = 0.99). Dexamethasone was well-tolerated.

CONCLUSIONS

A single dose of dexamethasone 4 mg does not influence the incidence or severity of APR following first exposure to ZOL.

TRIAL REGISTRATION

ACTRN12615000794505.

Incidence of ocular side effects with intravenous zoledronate: secondary analysis of a randomized controlled trial

SUMMARY

This prospective study showed that the incidence of acute anterior uveitis, confirmed by ophthalmic examination, in patients receiving intravenous zoledronate infusions as part of a randomized controlled trial for fracture prevention is 1.1%.

INTRODUCTION

We prospectively investigated the incidence of ocular side effects after a single intravenous zoledronate infusion.

METHODS

In a secondary analysis of a double-blind, placebo-controlled trial in which early post-menopausal women (N=1054) with normal bone density or osteopenia were randomized to infusion of zoledronate 5 mg (N=703) or placebo (N=351), we analyzed significant adverse ocular events occurring within 3 months.

RESULTS

Fourteen participants reported ocular symptoms after the infusion. All were examined by an ophthalmologist and eight were diagnosed with acute anterior uveitis (AAU) and one with sectoral episcleritis. The incidence of AAU and episcleritis was 1.1% (95% CI 0.5-2.1) and 0.1% (95% CI 0.0-0.7), respectively, in the zoledronate group and 0% for both conditions in the placebo group (95% CI 0.0-0.8). The mean time from infusion to symptom onset for AAU was 3 days (range 2-4). Three cases were bilateral. AAU was mild-moderate in seven participants and severe in one. All affected eyes were treated with topical cyclopentolate 1% (to break, or minimize, posterior synechiae), and intensive, potent, topical corticosteroids with a tapering regime based on treatment response. The mean duration of topical corticosteroid was 26±10 days (range 17-44). The mean, best corrected visual acuity was 20/20 (range 20/20-20/40) at presentation, which remained unchanged after AAU resolution. None of the participants lost vision, and no long-term sequelae were reported at last follow-up (range 3-13 months post-infusion).

CONCLUSIONS

Prescribers should inform patients about the possibility of ocular side effects with zoledronate infusions and refer promptly to an ophthalmologist if symptoms develop.

Health status, late effects and long-term survivorship of allogeneic bone marrow transplantation: a retrospective study

BACKGROUND

Survival after allogeneic haemopoietic stem cell transplantation (allo-HSCT) has improved because of advancements in allo-HSCT. Allo-HSCT has been performed in Australia since the late 1970s. However, there are few published data about health problems of allo-HSCT survivors in Australia.

AIMS

Identify health issues in long-term survivors of allo-HSCT in an Australian centre to manage better and prevent long-term complications.

METHODS

The health records of all patients of allo-HSCT in a single centre from January 2000 to December 2007 and survived beyond 2 years were assessed.

RESULTS

Ninety-nine of the 200 allo-HSCT patients survived beyond 2 years, and the median time from allo-HSCT was 74 months. Twenty-eight per cent died at a median of 37 months after allo-HSCT because of relapsed malignancy (12%), stroke (1%), infection (3%), chronic graft versus host disease (9%), secondary malignancy (2%) and unknown cause (1%). Ninety-one per cent reported one or more chronic health conditions. Health issues were chronic graft versus host disease (70%); respiratory (66%), ophthalmic (40%), bone (33%), and renal (26%) problems; and malignancies (14% skin, 3% solid organ). Seventy-nine per cent resumed vocation at full or reduced capacity 2 years after allo-HSCT. Clinicians identified 40% with quality of life (QOL) issues, but survivors' self-reported QOL was comparable with the general Australian population.

CONCLUSION

This study shows that allo-HSCT patients are living with high burdens of chronic diseases that warrant lifelong surveillance and engagement with healthcare. Structured, multi-disciplinary care as recommended by published guidelines for allo-HSCT survivors may reduce long-term effects and improve their outcomes.

Bone density in healthy men after cessation of calcium supplements: 20-month follow-up of a randomized controlled trial

Bone density has been followed up for 20 months following completion of a trial which compared calcium 1,200 mg/day with placebo, in normal older men. Following cessation of calcium supplements, there is a small residual benefit in total body bone density, but not at the hip or spine.

INTRODUCTION

Calcium supplements, or supplements of calcium-rich foods, have a positive effect on bone mineral density (BMD). However, it is uncertain whether there are any residual benefits of calcium on BMD following cessation of supplementation.

METHODS

In a previously published study, 323 healthy men were randomized to receive elemental calcium 600 mg/day (n = 108), calcium 1,200 mg/day (n = 108), or placebo (n = 107) over 2 years. Consenting men from the placebo and calcium 1,200 mg/day groups (85 and 87, respectively) were followed over the next 1-2 years (mean 20 months), off trial medication.

RESULTS

In the core trial, BMD increased at all sites by 1.0-1.5% at 2 years in the group receiving calcium 1,200 mg/day, compared to the group receiving placebo. In post-trial follow-up, the calcium group has some residual benefit at the total body (0.41% above placebo; P = 0.04) but there was no significant between-group differences at other sites.

CONCLUSION

Following cessation of calcium supplements in healthy men, there is a small residual benefit in total body BMD, but not at the hip or spine. This is unlikely to confer a clinically significant dividend in terms of ongoing fracture prevention.

The Auckland calcium study: 5-year post-trial follow-up

Five years after completion of a randomised placebo-controlled trial of calcium supplements, there was no effect of calcium on total fracture incidence, a significant reduction in vertebral and forearm fractures and, in a subset, no effect on bone density. There was no increased risk of cardiovascular events after discontinuation of calcium.

INTRODUCTION

The Auckland calcium study was a 5-year randomised controlled trial of 1 g/day calcium citrate in 1,471 postmenopausal women. Calcium did not reduce total, vertebral or forearm fracture incidence, increased hip fracture incidence and had beneficial effects on bone mineral density (BMD). A secondary analysis raised concerns about the cardiovascular safety of calcium. The purpose of this study was to determine whether the effects of calcium on fracture incidence, BMD and cardiovascular endpoints persisted after supplement discontinuation.

METHODS

Approximately 5-years post-trial, we collected information on the 1,408 participants alive at trial completion from the national databases of hospital admissions and deaths. We contacted 1,174 women by phone, and from these we obtained information on medical events and post-trial calcium use. We undertook BMD measurements at 10 years in a selected subset of 194 women who took study medication for 5 years in the original trial, and did not take bone-active medications post-trial.

RESULTS

Over the 10-year period, there was no effect on total fracture (HR 0.90, 95% CI 0.75-1.07) or hip fracture incidence (1.40, 0.89-2.21), but significant reductions in forearm (0.62, 0.43-0.89) and vertebral fractures (0.52, 0.32-0.85) in those assigned to calcium. There were no between-group differences in BMD at 10 years at any site. The adverse cardiovascular outcomes observed in the 5-year trial did not persist post-trial.

CONCLUSION

Calcium supplementation for 5 years had no effect on total fracture incidence at 10 years. The positive benefits on BMD and the adverse cardiovascular effects did not persist once supplements were stopped.

Differing perceptions of intervention thresholds for fracture risk: a survey of patients and doctors

This survey suggests that patients are prepared to accept higher absolute fracture risk than doctors, before considering pharmacological therapy to be justified. Patients require that drug treatments confer substantial fracture risk reductions in order to consider long-term therapy.

INTRODUCTION

Absolute fracture risk estimates are now incorporated into osteoporosis treatment guidelines. At present, little is known about how patients regard fracture risk and its management. We set out to describe and compare the views of patients and doctors on the level of fracture risk at which drug treatment is justified.

METHODS

A cross-sectional survey was conducted on 114 patients referred for bone density measurement and 161 doctors whose practice includes management of osteoporosis. Participants were asked about fracture risk thresholds for pharmacological intervention.

RESULTS

The absolute risk of both major osteoporotic fracture and hip fracture at which drug treatment was considered by patients to be justifiable was higher than that reported by doctors [major osteoporotic fracture, median (interquartile range): patients, 50% (25 to 60); doctors, 10% (10 to 20); P < 0.0001; hip fracture: patients, 50% (25 to 60); doctors, 10% (5 to 20); P < 0.0001]. Patients required that a drug provide a median 50% reduction in relative risk of fracture in order to consider taking long-term therapy, irrespective of the treatment mode or dosing schedule. Among doctors, there was an inverse relationship between the number of osteoporosis consultations conducted each month and threshold of risk for recommending drug treatment (r = -0.22 and r = -0.29 for major osteoporotic fracture and hip fracture, respectively, P < 0.01 for both)

CONCLUSIONS

Patients are prepared to accept higher absolute fracture risk than doctors, before considering pharmacological therapy to be justified. Patients require that drug treatments confer substantial fracture risk reductions in order to consider long-term therapy.

153. COMBINATION METHOTREXATE AND EPIDERMAL GROWTH FACTOR RECEPTOR INHIBITION AS A NOVEL MEDICATION-BASED CURE OF ECTOPIC PREGNANCIES

Ectopic pregnancies are serious gynaecological emergencies that can cause fatal haemorrhage. Most are treated surgically. Given the placenta is heavily reliant on Epidermal Growth Factor Receptor (EGFR) signaling, we set out to develop a medication-based treatment of ectopics using combination gefitinib (EGFR inhibitor) and methotrexate (folate antagonist). Both drugs are well tolerated and available in tablet form. We used in vitro and in vivo approaches to test the ability of gefitinib and methotrexate to regress placental tissue, and to explore molecular mechanisms. In vitro assays included immunohistochemistry (EGFR staining) western blot (EGFR phosphorylation), cell viability assays (Cell-Titre Blue, LDH cytotoxicity assay, xCELLigence system), apoptosis assays (PCR, FACS of M30 antibody) and The Bioplex Platform (phosphorylation of the EGFR pathway). JEG-3 xenografts were used to assess regression of placental tissue in vivo, where serum hCG was also measured (ELISA). EGFR was highly expressed in placentae from ectopic pregnancies. Combination treatment was supra-additive in inducing cell death of placental tissue in vitro, with >70% cell death by 48 hours (Syncytialised BeWos, JEG-3 and 1st trimester trophoblast). This supra-additive effect was demonstrated in both end point assays (cell viability) and regular monitoring using The xCELLigence system. Gefitinib potently blocks EGFR phosphorylation in placental tissues in vitro (Western blot). Both drugs may be converging to inhibit Akt phosphorylation (Bioplex analysis). Combination treatment increases apoptosis (FACS of M30 antibody). In vivo, Gefitinib or MTX as single agents induced significant decrease in xenograft tumour volume in a dose dependent manner (n ≤ 5 mice per treatment). However, combining these drugs was supra-additive in decreasing xenograph tumour volume and weight. Serum hCG in mice was lowest with combination treatment. Combination gefitinib and methotrexate potently regresses placental tissue. It may be a novel therapeutic approach to cure ectopic pregnancies, potentially replacing surgery with tablets.

HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis

In HLH-94, the first prospective international treatment study for hemophagocytic lymphohistiocytosis (HLH), diagnosis was based on five criteria (fever, splenomegaly, bicytopenia, hypertriglyceridemia and/or hypofibrinogenemia, and hemophagocytosis). In HLH-2004 three additional criteria are introduced; low/absent NK-cell-activity, hyperferritinemia, and high-soluble interleukin-2-receptor levels. Altogether five of these eight criteria must be fulfilled, unless family history or molecular diagnosis is consistent with HLH. HLH-2004 chemo-immunotherapy includes etoposide, dexamethasone, cyclosporine A upfront and, in selected patients, intrathecal therapy with methotrexate and corticosteroids. Subsequent hematopoietic stem cell transplantation (HSCT) is recommended for patients with familial disease or molecular diagnosis, and patients with severe and persistent, or reactivated, disease. In order to hopefully further improve diagnosis, therapy and biological understanding, participation in HLH studies is encouraged.

Calcium supplementation does not affect CRP levels in postmenopausal women--a randomized controlled trial

INTRODUCTION

Epidemiological studies suggest that calcium supplementation may decrease the risk of cardiovascular disease.

METHODS

Since the inflammatory marker C-reactive protein (CRP) is a risk factor for cardiovascular disease, and CRP production is potentially responsive to parathyroid hormone, we measured high-sensitivity CRP at baseline and 12 months in a subset of healthy postmenopausal women participating in a randomized controlled trial of the effects of 1 g of calcium daily on the incidence of fractures.

RESULTS

At baseline, we found that CRP correlated positively with indices of body weight and fat and with bone mineral density (BMD) at the total body and total hip sites, but the associations between CRP and BMD were lost after adjustment for body weight. There were consistent associations between levels of CRP and markers of the metabolic syndrome (fat mass, plasma triglycerides, fasting glucose).

CONCLUSION

After 1 year of calcium supplementation, there was no difference between the groups in levels of CRP. We conclude that levels of CRP correlate with anthropometric and biochemical features of insulin resistance, but that they are neither predictive of BMD nor affected by 1 g of calcium supplementation in healthy postmenopausal women.

Haematopoietic stem cell transplantation in haemophagocytic lymphohistiocytosis

Haemophagocytic lymphohistiocytosis (HLH) poses major therapeutic challenges, and the primary inherited form, familial haemophagocytic lymphohistiocytosis (FHL), is usually fatal. We evaluated, including Cox regression analysis, survival in 86 children (29 familial) that received HLH-94-therapy (etoposide, dexamethasone, ciclosporin) followed by allogeneic stem cell transplantation (SCT) between 1995 and 2000. The overall estimated 3-year-survival post-SCT was 64% [confidence interval (CI) = +/-10%] (n = 86); 71 +/- 18% in those patients with a matched related donor (MRD, n = 24), 70 +/- 16% with a matched unrelated donor (MUD, n = 33), 50 +/- 24% with a family haploidentical donor (haploidentical, n = 16), and 54 +/- 27% with a mismatched unrelated donor (MMUD, n = 13). After adjustment for potential confounding factors, estimated odds ratios (OR) for mortality were 1.93 (CI =0.61-6.19) for MUD, 3.31 (1.02-10.76) for haploidentical, and 3.01 (0.91-9.97) for MMUD, compared with MRD. In children with active disease after 2-months of therapy (n = 43) the OR was 2.75 (1.26-5.99), compared with inactive disease (n = 43). In children with active disease at SCT (n = 37), the OR was 1.80 (0.80-4.06) compared with inactive disease (n = 49), after adjustment for disease activity at 2-months. Mortality was predominantly transplant-related. Most HLH patients survived SCT using MRD or MUD, and survival with partially mismatched donors was also acceptable. Patients that responded well to initial pretransplant-induction therapy fared best, but some persisting HLH activity should not automatically preclude performing SCT.

Effects of once-weekly oral alendronate on bone in children on glucocorticoid treatment

OBJECTIVES

To determine the effects of once-weekly oral alendronate on indices of bone size, density and resorption in children with chronic illness being treated with glucocorticoids.

METHODS

Twenty-two children with chronic illness treated with prednisone were randomized to receive 1 year's treatment with either once-weekly oral placebo or alendronate (1-2 mg/kg body weight) in a double-blind study. The main outcome measures were changes in lumbar spine and femoral shaft size and volumetric density (measured by dual energy X-ray absorptiometry) and N-telopeptide excretion (a marker of bone resorption).

RESULTS

Once-weekly alendronate was well tolerated, and there were no major adverse events. In both groups bone size and bone mineral content increased through growth. Volumetric bone density of the lumbar spine increased significantly in the alendronate group (P = 0.013), but not in the placebo group. There were no differences between the groups in growth in the cortical width of the femoral shaft, but the cross-sectional moment of inertia per unit length-a derived estimate of mechanical strength-increased significantly in the alendronate group (P = 0.014) but not in the placebo group. Urine N-telopeptide excretion was suppressed significantly in the alendronate group (P = 0.007) but not in the placebo group. Height velocity was positively correlated with changes in both lumbar spine area and the total width of the femoral shaft (P = 0.015, P = 0.026, respectively).

CONCLUSION

Once-weekly oral alendronate is well tolerated, suppresses bone resorption and may improve volumetric bone density at the lumbar spine and mechanical strength of the femoral shaft in children with chronic illness taking glucocorticoids. It does not affect bone growth. Larger controlled studies are needed to determine if these changes translate into reduced fracture incidence or greater peak bone mass. This study highlights the importance of differentiating between changes in bone size and changes in volumetric bone density in assessing bone in children, and also having control subjects in intervention studies.

Effects of hormone replacement therapy on bone mineral density in postmenopausal women with primary hyperparathyroidism: four-year follow-up and comparison with healthy postmenopausal women

BACKGROUND

Long-term treatment of patients with asymptomatic primary hyperparathyroidism remains controversial, but the presence of osteoporosis is regarded as an indication for parathyroidectomy. Hormone replacement therapy (HRT) is a possible alternative therapy in osteopenic postmenopausal women with the disorder, and results of short-term studies suggest a beneficial effect on bone mass comparable to that achieved by parathyroidectomy. Longer-term data are required to further assess the efficacy of this treatment in chronic stable primary hyperparathyroidism.

METHODS

We report the results of the extension from 2 to 4 years of a randomized, placebo-controlled trial of HRT in postmenopausal women with primary hyperparathyroidism. Of 23 postmenopausal women with primary hyperparathyroidism, 11 received active HRT with conjugated equine estrogen, 0.625 mg/d, and medroxyprogesterone acetate, 5 mg/d, and 12 received placebo. Bone mineral density was measured throughout the skeleton at 6-month intervals using dual-energy x-ray absorptiometry in these women and in 50 normocalcemic age-matched control subjects. None of the 23 patients withdrew during the extension period.

RESULTS

Changes in bone mineral density were more positive in those taking HRT than placebo, with the between-group differences at 4 years being 4.6% in the total body, 7.5% in the lumbar spine, 7.4% in the femoral neck, 8.2% in the femoral trochanter, 6.8% in the legs, and 7.0% in the forearm (P<.01). At skeletal sites composed predominantly of cortical bone, there was a progressive divergence of the 2 groups. Biochemical markers of bone turnover remained lower throughout the study in women taking HRT. When rates of bone loss were compared between the placebo group and healthy women of comparable age, bone loss tended to be more marked throughout the skeleton in women with hyperparathyroidism, but only in the total body and its legs subregion was this difference significant.

CONCLUSIONS

Hormone replacement therapy is efficacious in the long-term management of osteopenia in postmenopausal women with primary hyperparathyroidism and thus represents an important new therapeutic option for asymptomatic patients who do not have other indications for surgery. Bone loss seems to be accelerated in untreated primary hyperparathyroidism.

Dimeric inhibins in amniotic fluid, maternal serum, and fetal serum in human pregnancy

Using new specific and sensitive enzyme-linked immunosorbent assays for inhibin A and inhibin B, we measured these proteins in amniotic fluid (AF), maternal serum (MS), and umbilical cord serum in normal pregnancies. Inhibin A levels in AF rose from a median (10-90th percentile) level of 615 (158.2-1124.6) pg/mL at 14 weeks to 1336.0 (489.4-2084.1) pg/mL at 20 weeks, and inhibin B rose from 216.6 (67.4-554.6) to 1078.2 (439.3-2482.2) pg/mL over the same period. In MS, inhibin A levels fell from a median (10-90th percentile) level of 177.5 (101.4-290.7) pg/mL at 10 weeks to a nadir of 111.9 (59.5-200.3) pg/mL at 17 weeks, rising again to 180.3 (74.1-327.2) pg/mL at 20 weeks. No inhibin B was detectable in MS. In 47 pairs of matched samples (14-16 weeks gestation) there was no correlation of inhibin A levels in AF with those in MS (r = 0.19; P > 0.05). In 45 term umbilical cord serum samples, no dimeric inhibin was detectable in serum from female babies, but inhibin B was detectable in male sera; the median (10-90th percentile) concentration was 167.4 (111.2-224.8) pg/mL. These data suggest that for the gestation periods studied, although the placenta secretes inhibin A, another source, probably the fetal membranes, secretes both inhibin A and inhibin B. Further, the presence of inhibin B in male fetuses is consistent with a testicular origin, suggesting that inhibin B may be important in the development of the fetal hypothalamo-pituitary-testicular axis.

Structure and thermal stability of alprazolam and selected solvates

Five forms of the drug alprazolam have been identified by thermal analysis and X-ray powder diffraction (XRD). The single crystal X-ray structures of two of these species, a polymorph 1 and a dihydrate 2, were determined. The dihydrate crystallized from a solution of alprazolam in methanol containing traces of water. Species 3 and 4 are nonstoichiometric solvates with ethanol and acetonitrile, respectively. The differential scanning calorimetric curves for the solvates 2-4 are similar, showing a desolvation endotherm, followed by an exotherm associated with recrystallization, and a final endotherm for the fusion of alprazolam. The solvates 3 and 4 were shown to be isomorphous by XRD. The products of desolvation of 2-4 were identified by their XRD traces. Solvates 2 and 3 yield polymorph 1 on desolvation, whereas solvate 4 yields a different polymorph.

Telephone follow-up of patients discharged from the emergency department: how reliable?

As the result of the current emphasis on health care cost containment, outpatient management of entities previously in the domain of inpatient therapy is being proposed. The advocates of this approach stress the importance of telephone follow-up in patients chosen for outpatient therapy. Our objective was to determine the reliability of phone follow-up in patients discharged from the emergency department (ED). We attempted to contact by phone 250 consecutive children evaluated and discharged from Loyola University Medical Center Emergency Department. A maximum of six attempts per patient was made starting within 72 hours of the ED visit. Calls were placed to home, work, and contact numbers provided at the time of the ED visit, and messages were left on answering machines or with persons who answered the phone. The time needed to reach the guardian was calculated from the time of the first call until successful contact of the guardian. We were successful in contacting 68.4% of our study subjects. Patients with commercial insurance were contacted more often than those with other types of insurance. A mean of 1.61 +/- 1.09 calls were needed to reach the guardians who were successfully contacted, and the mean time required was 3.14 +/- 7.25 hours. Medical indication for telephone follow-up, as determined by the managing physician, did not influence our ability to reach the study subjects. In view of our moderate success rate in reaching patients discharged from the ED, we advocate caution in the implementation of outpatient strategies in the management of febrile children who are at high risk for life-threatening complications.

Structure and biological activities of a heparin-derived hexasaccharide with high affinity for basic fibroblast growth factor

We demonstrated previously that heparin-derived hexasaccharides are the smallest fragments of the polysaccharide with comparable basic fibroblast growth factor (bFGF)-modulating activity in vitro (Ishihara, M., Tyrrell, D.J., Stauber, G.B., Brown, S., Cousens, L., and Stack, R.J. (1993) J. Biol. Chem. 268, 4675-4683. In this report, a specific hexasaccharide having high affinity for recombinant human bFGF was isolated and its structure deduced by analysis of its reduced disaccharide products after treatment with nitrous acid at pH 1.5, and by 1H NMR spectroscopy. The hexasaccharide has the structure [IdoA(2-OSO3)alpha 1-4GlcNSO3(6-OSO3)alpha 1-4]2IdoA(2-OSO3)alpha 1-4 AManR(6-OSO3). The hexasaccharide effectively inhibits the binding of syndecan-transfected RO-12 UC cells to bFGF-coated wells (Ishihara, M., Tyrrell, D.J., Kiefer, M.C., Barr, P.J., and Swiedler, S.J. (1992) Anal. Biochem. 202, 310-315), prevents the binding of 125I-bFGF to confluent monolayers of adrenocortical endothelial (ACE) cells, and inhibits the bFGF-dependent proliferation of ACE cells. Unlike the heparin from which it was derived, however, the hexasaccharide cannot promote the binding of 125I-bFGF to a recombinant high affinity bFGF receptor (flg) or restore the bFGF-dependent proliferative response to ACE cells grown in the presence of 5 mM sodium chlorate. Collectively, these data indicate that a hexasaccharide can be as effective as heparin as an antagonist of bFGF-mediated cell mitogenesis.

1H NMR spectroscopic studies on the interactions between human plasma antithrombin III and defined low molecular weight heparin fragments

The effects of length and composition upon the antithrombin-binding properties of heparin have been investigated for two series of structurally related heparin oligosaccharides. Each series consists of a tetrasaccharide, hexasaccharide, and octasaccharide heparin fragment composed of alternating hexuronic acid (either iduronate 2-sulfate or glucuronate) and glucosamine 6,N-disulfate residues. These two series represent dominant structural motifs in intact heparin and differ from each other by the presence of a glucuronic acid in one series in place of an iduronate 2-sulfate residue penultimate to the reducing end of the fragment. Perturbations to the 1H resonances in the NMR spectrum of antithrombin upon binding of the two series of heparin fragments are compared to those generated by intact heparin binding, as well as to the effects of binding of a synthetic high-affinity pentasaccharide. All of the heparin fragments examined appear to bind to antithrombin at the same site. Three of the heparin fragments (hexasaccharide-2, octasaccharide-2, and octasaccharide-1) produce almost identical perturbations in the antithrombin 1H NMR spectrum compared to binding of intact heparin, including perturbations of resonances from tryptophan 49. This indicates that neither the glucuronic acid nor the trisulfated glucosamine residue (structural elements known to be part of the high-affinity heparin motif) are necessary for the majority of the conformational changes induced upon heparin fragment binding to antithrombin. However, the low anticoagulant activity of these fragments indicates that the changes in protein conformation upon fragment binding, as manifested by these 1H resonance perturbations, are not sufficient for catalytic activation of the inhibitor.(ABSTRACT TRUNCATED AT 250 WORDS)

1H-N.m.r. spectral assignments for two series of heparin-derived oligosaccharides

Six heparin-derived oligosaccharides, ranging in size from di- to octa-saccharide and forming two closely related series differing in structure by the substitution of an unsulfated D-glucuronate for a 2-sulfated L-iduronate residue, have been characterized by 2-dimensional 1H-n.m.r. spectroscopy. In addition to providing new data on hexa- and octa-saccharides, several important changes to previously published data have been found for the two tetrasaccharides. The D-glucuronic acid H-5 proton is assigned to a resonance in the same region as resonances for the H-3 and H-4 D-glucuronate protons, rather than downfield from these resonances as earlier reported. The presence of D-glucuronic acid in the heparin sequence of the series-1 fragments affects the positions of neighboring D-glucosamine resonances, in particular shifting the anomeric proton signal in the preceding D-glucosamine 0.1-0.2 p.p.m. downfield. Resonances from the reducing-end D-glucosamines differ from internal D-glucosamine resonances both in relative position and in the degree of chemical shift difference between the H-6 and H-6' protons. This work illustrates the usefulness of two-dimensional techniques in determining heparin structure and emphasizes the need for direct analysis, rather than assignment by comparison to model compounds.

The prevention of major depression in the elderly

Limited information is available regarding the relationship between elderly individuals and depression; but the clinician can anticipate problems in those who have had depression in the past, in those who are bereaved, in caretakers, and in patients with a number of other illnesses, including Alzheimer's disease, Parkinson's disease, Huntington's disease, stroke, alcoholism, and severe medical illness. Treatment may shorten the duration of the depression, limit long-term sequelae, and reduce the likelihood of suicide. More research with careful methodology would be helpful in clarifying directions for primary, secondary, and tertiary prevention.

The relationship of egg yolk and serum antibody. I. Infectious bursal disease virus

Eggs and serum samples were collected from hens every 2 weeks for 50 weeks from hens caged individually so that the yolk and serum samples could be paired. It was found that the antibody titer of the yolk sample regressed significantly (F = 403.3, df = 1/135, P less than 0.001) on the titer of the serum sample. This permitted the use of the yolk titer to predict the serum titer.