25. Immunogenicity and Reactogenicity of COVID-19 mRNA Vaccines in Allogeneic Stem Cell Transplant Recipients

Background

Allogeneic stem cell transplant (SCT) recipients are at an increased risk of poor outcomes from COVID-19. While the mRNA-1273 (Moderna) and BNT162b2 (Pfizer) COVID-19 mRNA vaccines are highly immunogenic in the general population, the immune response in SCT recipients is poorly understood. We characterized the immunogenicity and reactogenicity of COVID-19 mRNA vaccines in a cohort of SCT patients.

Methods

We performed a prospective cohort study of 16 allogeneic SCT patients and 23 healthy controls. Blood samples for both cohorts were collected prior to first vaccination (baseline), at the time of second vaccination, and approximately 28 days post-second vaccination. Anti-Spike (S), anti-S1, anti-receptor binding domain (RBD), and anti-Nucleocapsid (N) IgG levels were measured quantitatively from plasma using a multiplexed single molecule array (Simoa) immunoassay. Reactogenicity was captured for the SCT cohort via a self-reported post-vaccination diary for 7 days after each dose.

Results

Demographics and SCT recipients’ characteristics are shown in Table 1. In the SCT cohort, we observed a significantly lower anti-S (p< 0.0001), S1 (p< 0.0001), and RBD (p< 0.0001) IgG responses as compared to healthy controls, both at the time of dose 2 and 28 days post-vaccine series (Fig 1). Overall, 62.5% of SCT recipients were responders after vaccine series completion, as compared to 100% of healthy controls (Fig 2). While no patients had a reported history of COVID-19 diagnosis, 2 patients in the SCT cohort had elevated anti-S IgG levels and 1 showed elevated anti-N at baseline.

10/16 participants in the SCT cohort completed at least one post-vaccination diary. Local and systemic reactions were reported by 67% and 22% of participants, respectively, after dose 1, and 63% and 50% after dose 2 (Figure 3). All reported events were mild.

Table 1: Demographics

Figure 1: Plasma IgG Titers

Anti-Spike (A), anti-S1 (B), anti-RBD (C), and anti-nucleocapsid (D) IgG titers were measured at baseline, time of second dose, and approximately 28 days after second vaccination. IgG levels were measured quantitatively using multiplexed single molecule array (Simoa) immunoassays, and are reported as Normalized Average Enzymes per Bead (AEB). Allogeneic stem cell transplant recipients (mauve) showed significantly lower anti-S, S1, and RBD IgG responses as compared to healthy controls (mint). Low titers of anti-N IgG demonstrates no history of COVID-19 natural infection during the course of the study.

Figure 3. Solicited Local and Systemic Adverse Events

10 allogeneic stem cell transplant recipients completed at least one diary for 7 days after vaccination. Reactions after dose 1 are shown in light blue, and reactions after dose 2 are shown in dark blue. Local reactions (A) were reported by 67% (6/9) of participants after dose 1, and 63% (5/8) after dose 2. Systemic reactions (B) were reported by 22% (2/9) of participants after dose 1, and 50% (4/8) after dose 2. All reported events were mild (Grade 1).

Conclusion

Among SCT recipients, mRNA COVID-19 vaccines were well-tolerated but less immunogenic than in healthy controls. Further study is warranted to better understand heterogeneous characteristics that may affect the immune response in order to optimize COVID-19 vaccination strategies for SCT recipients.

Figure 2: Response Rate to COVID-19 Vaccination

An internally validated threshold for responders was established using pre-pandemic sera from healthy adults. A positive antibody response was was defined as individuals with anti-Spike IgG levels above the 1.07 Normalized AEB threshold.

Disclosures

Amy Joyce, NP, Kadmon (Advisor or Review Panel member) Lewis A. Novack, MS, Lumicell Inc. (Scientific Research Study Investigator, Research Grant or Support)Precision Healing, Inc. (Scientific Research Study Investigator, Research Grant or Support) David Walt, PhD, Quanterix Corporation (Board Member, Shareholder) Robert Soiffer, MD, alexion (Consultant)gilead (Advisor or Review Panel member)jazz (Advisor or Review Panel member)juno/bms (Advisor or Review Panel member)kiadis (Board Member)precision bioscience (Consultant)Rheos (Consultant)takeda (Consultant) Nicolas C. Issa, MD, AiCuris (Scientific Research Study Investigator)Astellas (Scientific Research Study Investigator)GSK (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)

Period of Purple Crying Program for the Prevention of Abusive Head Trauma/Shaken Baby Syndrome

The Period of PURPLE Crying Program is an educational program delivered to parents of newborn children that aims to reduce the incidence of abusive head trauma/shaken baby syndrome1. The program was developed by a research-based, non-profit organisation and has already been implemented in many countries around the world. It educates parents on what to expect during the first few months of their newborn infant's life, allowing parents to become more informed and better prepared to care for their child. The recent surge in the number of cases of abusive head trauma in children during the COVID-19 pandemic has highlighted the need for greater resources being made available to parents. The Period of PURPLE Crying Program is one such resource that could be implemented in Ireland.

Tribes and tribulations: interdisciplinary eHealth in providing services for people with a traumatic brain injury (TBI)

Background

eHealth has potential for supporting interdisciplinary care in contemporary traumatic brain injury (TBI) rehabilitation practice, yet little is known about whether this potential is being realised, or what needs to be done to further support its implementation. The purpose of this study was to explore health professionals’ experiences of, and attitudes towards eHealth technologies to support interdisciplinary practice within rehabilitation for people after TBI.

Methods

A qualitative study using narrative analysis was conducted. One individual interview and three focus groups were conducted with health professionals (n = 17) working in TBI rehabilitation in public and private healthcare settings across regional and metropolitan New South Wales, Australia.

Results

Narrative analysis revealed that participants held largely favourable views about eHealth and its potential to support interdisciplinary practice in TBI rehabilitation. However, participants encountered various issues related to (a) the design of, and access to electronic medical records, (b) technology, (c) eHealth implementation, and (d) information and communication technology processes that disconnected them from the work they needed to accomplish. In response, health professionals attempted to make the most of unsatisfactory eHealth systems and processes, but were still mostly unsuccessful in optimising the quality, efficiency, and client-centredness of their work.

Conclusions

Attention to sources of disconnection experienced by health professionals, specifically design of, and access to electronic health records, eHealth resourcing, and policies and procedures related to eHealth and interdisciplinary practice are required if the potential of eHealth for supporting interdisciplinary practice is to be realised.

Change in public awareness of symptoms and perceived barriers to seeing a doctor following Be Clear on Cancer campaigns in England

Background:

English Be Clear on Cancer (BCOC) campaigns aim to promote early presentation of potential cancer symptoms by (i) giving information on symptoms to look out for, and (ii) emphasising the approachability of the general practitioner (GP). This study examined public awareness of the targeted symptoms and perceived approachability of the GP before and after the national bowel and lung campaigns.

Methods:

The Cancer Research UK Cancer Awareness Measure (CAM) was included in the Opinions and Lifestyle survey (known then as the ‘Opinions Survey') run by the Office for National Statistics in October and November 2010 and 2012. Change in awareness of symptoms and barriers to help-seeking related to those targeted in the campaigns between the 2010 and 2012 surveys, was compared with change in awareness of symptoms and barriers not targeted by the campaigns.

Results:

Recall of ‘persistent cough' or ‘hoarseness' as a sign of cancer increased from 18% in 2010 to 26% in 2012 (P<0.001), and ‘change in bowel/bladder habits' increased from 21% to 43% (P<0.01). Recognition of these symptoms (from a list of symptoms) also increased significantly (both P-values <0.01). Awareness of non-targeted symptoms did not increase (all P-values >0.02). Barriers to visiting the GP targeted in the campaign (the doctor would be difficult to talk to and being worried about wasting the doctor's time) did not change, although several non-targeted barriers reduced.

Conclusions:

BCOC campaigns run in England in 2012 were associated with increased public awareness of some key symptoms of lung and bowel cancer. Barriers to visiting the GP that were targeted in the campaign were not reduced, indicating that a different approach may be needed to shift public attitudes towards GPs.

A survey study of women's responses to information about overdiagnosis in breast cancer screening in Britain

BACKGROUND

There is concern about public understanding of overdiagnosis in breast cancer screening, and uncertainty about the likely impact on screening participation.

METHODS

In a population-based survey of 2272 women, we assessed understanding of overdiagnosis and screening intentions before and after exposure to an explanation of overdiagnosis, and one of the three information formats providing an estimate of the rate of overdiagnosis based on the findings of the UK Independent Review.

RESULTS

Subjective and objective comprehension of overdiagnosis was moderate across information formats (64% and 57%, respectively). Following overdiagnosis information, 7% of women showed a decrease in screening intention, with a stronger effect among women below screening age (<47 years), and receiving the estimate of the rate of overdiagnosis in a simple ratio format (one life saved to three overdiagnoses).

CONCLUSIONS

Brief written information on overdiagnosis was incompletely understood, but reduced breast screening intentions in a proportion of women, regardless of comprehension. Subjective comprehension was lower among women who had not yet reached screening age but the deterrent effect was higher.

Changing profile of the bovine rotavirus G6 population in the south of Ireland from 2002 to 2009

Bovine group A rotavirus is one of the main causes of neonatal diarrhoea in calves. This study examined the different G and P genotypes circulating in the bovine population, from 2002-2009, in the south of Ireland. Rotavirus positive bovine faecal samples (n=332) were collected from the Cork Regional Veterinary Laboratory, between 2002 and 2009 and subjected to RNA extraction, PAGE analysis, and G and P genotyping. Genotyping analysis identified G6, G10, P[5], and P[11] to be the predominant G and P genotypes in the present study, with G6 rotavirus responsible for 70-80% of rotavirus infections. The highest combination of G and P types found was G6 P[5], followed by G6 P[5+11] mixed infection. The prevalence of G6 and G10 has shifted over the years, with an increase in the amount of G10 P[11] being detected. Novel combinations (G6+G10P[11], G6+G10P[5+11] and G10P[5+11]) were also detected for the first time. In addition to this, sequence analysis of the VP7 RT-PCR amplicons has revealed that Irish G6 strains are falling within three different lineages, III-V. During this study, two samples, initially genotyped as G8P[11] were identified through sequence analysis as being true G6, lineage III with a high nucleotide identity to Hun4, a G6 human sample from Hungary. The increase in novel G and P type combinations, as well as changes seen in G6 samples could have an impact on rotavirus vaccination programmes, as the current vaccine available may not offer protection against all of these circulating types.

Perceived barriers to flexible sigmoidoscopy screening for colorectal cancer among UK ethnic minority groups: a qualitative study

OBJECTIVES

Evidence from existing UK screening programmes indicates disparities in uptake rates between UK ethnic minorities and the white majority population. The aim of this study was to explore barriers to the uptake of flexible sigmoidoscopy (FS) screening among UK ethnic minority populations. Specifically, beliefs about bowel cancer, perceived barriers to the test and ideas about ways to increase uptake were investigated.

METHODS

Nine focus groups were conducted with a total of 53 participants from African-Caribbean, Gujarati Indian, Pakistani and white British communities. The topic guide was based on the Health Belief Model. Discussions were subject to framework analysis.

RESULTS

Most participants expressed limited awareness of bowel cancer and cited this as a barrier to screening attendance. Anxiety regarding the invasiveness of the test, the bowel preparation and fear of a cancer diagnosis were common barriers across all ethnic groups. Language difficulties, failure to meet religious sensitivities and the expression of culturally influenced health beliefs were all discussed as specific barriers to uptake. Ethnically tailored health promotion and general practitioner involvement were recommended as ways of overcoming such barriers.

CONCLUSIONS

The study was the first attempt to qualitatively explore barriers to FS bowel cancer screening in UK ethnic minorities. Most barriers were shared by all ethnic groups but health educators should supplement approaches designed for the majority to incorporate the specific needs of individual minority groups to ensure equitable access.

Molecular characterisation and analysis of bovine rotavirus strains circulating in Ireland 2002–2004

One hundred and two faecal samples were collected from calves diagnosed with rotavirus infection, in the southern region of Ireland, from 2002 to 2004. Ninety one percent (n=93) were confirmed positive for rotavirus, using latex agglutination and enzyme linked immunosorbent assay (ELISA) methods. Determination of the G- and P-types was carried out using nested reverse transcriptase polymerase chain reaction (nRT-PCR). G6 was the most prevalent genotype, accounting for 80.6% (75/93), G10 accounted for 6.5% (6/93) and G6G10 mixed types accounted for 9.7% (9/93) of the collection. Rotavirus in three of the samples (3.2%) could not be characterised with any of the five G-specific primers used in this study. A subset of the positive samples (n=54) was examined for their P-type specificities, P[5] and P[11] accounted for 77.8% (42/54), and 9.3% (5/54), respectively. One P[1] genotype (1.9%) was found in the collection. P[5] and P[11] mixed genotypes accounted for 11% (6/54) of the study. The genotypes corresponded to the UK-like strain (G6P[5]) 57.4%, KN4-like strain (G6[P11]) 7.4%, B223-like strain (G10P[11]) and NCDV-like strain (G6P[1]) 1.9% each. The unusual combination of G10P[5] accounted for 7.4%, with mixed infections G6+G10P[5] and G6P[5]+P[11] representing 13% and 11%, respectively. This is the first time that the G- and P-types of bovine rotaviruses (BRVs) have been determined in Ireland, and this study contributes to a better understanding of the epidemiology of such viruses circulating in Ireland.

Impact of antibiotic restrictions: the pharmaceutical perspective

The development of new antibiotics is dependent on their performance in economic models that favour products with large markets, high levels of potential sales and low development risks. There is a trend toward more severe and more widespread market restrictions for the use of antibiotics, ostensibly to control resistance, though they may be enacted through the control of drug budgets. The restrictions reduce the potential earnings of new antibiotics. In addition, more stringent regulatory procedures increase development costs and risk. As a consequence, compared with drugs for other diseases, particularly chronic diseases, antibiotics perform poorly in economic decision models and are therefore less likely to be selected by pharmaceutical companies for continued development. Overall, this creates a conflict between the twin objectives of controlling resistance through antibiotic restriction and addressing resistance clinically through the introduction of new agents. Ultimately, this may lead to the accelerated loss of efficacy for currently available agents, as we become more dependent on them. Moreover, the new agents that we need to maintain our current levels of health will be lacking in pharmaceutical pipelines. Antibiotic resistance is inevitable; the development of new antibiotics is, however, under threat. Unless the market conditions can be economically rebalanced to encourage innovation and investment, or new models of pharmaceutical development can be applied to this area, the number of companies with active antibiotic research programmes will continue to fall. Just as we should not be complacent regarding the development of resistance, we should not be complacent in assuming that the antibiotics of tomorrow will be there when we need them.

Evidence for a chromosomally located third integron in Salmonella enterica serovar Typhimurium DT104b

Salmonella enterica serovar Typhimurium isolates of phage types DT104 and DT104b are frequently associated with multiple antimicrobial resistance. We describe the characterization of a class 1 integron containing dfrA1 and aadA1, genes from two Salmonella serovar Typhimurium DT104b isolates. Genetic mapping located the integron to the bacterial chromosome in each case.

Random amplification of polymorphic DNA versus pulsed field gel electrophoresis of SmaI DNA macrorestriction fragments for typing strains of vancomycin-resistant enterococci

Genetic typing of vancomycin-resistant enterococci (VRE) can be performed using a variety of methods, but comparative analyses of the quality of these methods are still relatively scarce. We here compare random amplification of polymorphic DNA (RAPD) analysis with pulsed field gel electrophoresis (PFGE) of DNA macrorestriction fragments as examples of two of the recent and well-accepted molecular typing methods. For the latter method, empirical guidelines for the interpretation of the DNA fingerprints have been proposed in the international literature. Based on our experimental analyses, we define similar criteria for RAPD fingerprinting. A collection of 100 strains of VRE, comprising Enterococcus faecium, Enterococcus faecalis, Enterococcus avium, Enterococcus gallinarum and Enterococcus casseliflavus, was assembled. Fifty isolates were Dutch, another 50 were isolated in the UK. Strains were selected on the basis of previously determined putative identity, close relatedness or uniqueness. The strains were analysed using well-standardised RAPD and PFGE protocols. Resulting fingerprints were interpreted with computerised methods involving band positioning and we show that typing of VRE by PFGE and RAPD generates highly congruent DNA fingerprint clustering. When the proposed international criteria for interpretation of PFGE fingerprints were applied in our case, 86% PFGE homology as discriminating value between close relatedness and uniqueness, a 75% homology cut-off for the comparison of the RAPD-generated DNA fingerprints revealed essentially identical strain clusters. As a spin-off it is revealed that strains from the different species can be efficiently discriminated, that strains from the UK and The Netherlands form separate clusters and that strains from veterinary origin can be identified separately as well.

Molecular characterization of Irish Salmonella enterica serotype typhimurium: detection of class I integrons and assessment of genetic relationships by DNA amplification fingerprinting

Salmonella enterica is among the principal etiological agents of food-borne illness in humans. Increasing antimicrobial resistance in S. enterica is a cause for worldwide concern. There is concern at present in relation to the increasing incidence of human infection with antimicrobial agent-resistant strains of S. enterica serotype Typhimurium, in particular of phage type DT104. Integrons appear to play an important role in the dissemination of antimicrobial resistance genes in many Enterobacteriaceae including S. enterica. In this study the antimicrobial susceptibilities and phage types of 74 randomly collected strains of S. enterica serotype Typhimurium from the Cork region of southern Ireland, obtained from human, animal (clinical), and food sources, were determined. Each strain was examined for integrons and typed by DNA amplification fingerprinting (DAF). Phage type DT104 predominated (n = 48). Phage types DT104b (n = 3), -193 (n = 9), -195 (n = 6), -208 (n = 3), -204a (n = 2), PT U302 (n = 1), and two nontypeable strains accounted for the remainder. All S. enterica serotype Typhimurium DT104 strains were resistant to ampicillin, chloramphenicol, streptomycin, Sulfonamide Duplex, and tetracycline, and one strain was additionally resistant to trimethoprim. All DT104 strains but one were of a uniform DAF type (designated DAF-I) and showed a uniform pattern of integrons (designated IP-I). The DT104b and PT U302 strains also exhibited the same resistance phenotype, and both had the DAF-I and IP-I patterns. The DAF-I pattern was also observed in a single DT193 strain in which no integrons were detectable. Greater diversity of antibiograms and DAF and IP patterns among non-DT104 phage types was observed. These data indicate a remarkable degree of homogeneity at a molecular level among contemporary isolates of S. enterica serotype Typhimurium DT104 from animal, human, and food sources in this region.

Molecular analysis of Pseudomonas aeruginosa: epidemiological investigation of mastitis outbreaks in Irish dairy herds

Pseudomonas aeruginosa is a pathogen in both humans and animals. This bacterium, most often associated with respiratory infections in cystic fibrosis patients, was found to be the causative agent in bovine mastitis outbreaks among 11 Irish dairy herds. Epidemiological findings suggested that the infection was spread to all herds by teat wipes that had been contaminated with this organism. Two molecular-typing strategies were used in an attempt to determine the genomic relationship(s), if any, of the P. aeruginosa strains isolated from the various herds and to verify whether the same strain was responsible for each outbreak. Thirty-six isolates from the mastitis outbreaks were tested and compared to fourteen clinical isolates from Cork University Hospital. With one exception, all outbreak-linked strains produced identical patterns when ribotyped with ClaI and PvuII enzymes. Eight of the clinical isolates gave the same ClaI ribotype pattern as the mastitis-causing strains. However, PvuII proved more discriminatory, with only the outbreak isolates producing identical patterns. Similar results were obtained with RW3A-primed DNA amplification fingerprinting, with all outbreak isolates except one displaying the same fingerprint array. The clinical strains produced several fingerprint patterns, all of which were different from those of the mastitis-causing isolates. Fine-resolution DNA fingerprinting with a fluorescence-labelled RW3A primer also identified a number of low-molecular-weight polymorphisms that would have remained undetected by conventional methods. These data support the view that the same P. aeruginosa strain was responsible for the mastitis outbreaks in all 11 herds.

Carcinoid-associated ectopic ACTH syndrome with variable response to octreotide

The case is presented of a 31-year-old woman who developed florid clinical and biochemical Cushing's syndrome due to metastatic hepatic carcinoid tumour from a probable pancreatic primary. Hypercortisolaemia was controlled with metyrapone and ketoconazole, but high doses of octreotide failed to affect plasma cortisol and urinary 5-hydroxyindole acetic acid (5HIAA) levels, or prevent rapid tumour growth. Hepatic polystyrene embolisation failed, and she was treated by liver transplantation with initial excellent results, and normalisation of cortisol and 5HIAA levels. Ten months later, however, she relapsed with bony and pelvic tumour recurrence, and high and symptomatic levels of cortisol and 5HIAA. At this time, octreotide in similar doses to those used previously appeared to normalise her biochemically, although she died soon after. This variable responsiveness to octreotide could be related to somatostatin receptor changes, or cyclical tumour secretion patterns.

[Treatment results in 588 patients with multiple trauma]

BACKGROUND

Ten to fifteen million wounded and 700,000 deaths each year, around the world, are the consequences of accidents, according to the World Health Organization. In Chile 2,269 deaths occur each year due to accidents. The successful treatment of these patients requires a schematized initial management, that is taught in the Advanced Trauma Life Support Course.

AIM

To review the results of trauma treatment using this model at Hospital del Trabajador in Santiago.

PATIENTS AND METHODS

A retrospective review of patients with trauma treated between 1984 and 1994. The severity of trauma was classified according to the Injury Severity Score.

RESULTS

Five hundred eighty eight patients (60 female) aged 35.4 +/- 14 years old were treated in the period. Vehicular accidents accounted for 62% of trauma. The most frequently injured corporal segments were limbs and pelvis in 79%, head and neck in 66% and thorax in 44%. There were 2.45 lesions per patient. Mortality was 8% and, among survivors, 79% had a complete recovery and were reintegrated to their usual activities. Fifteen percent of patients were severely injured. Among these, mortality was 28% and 43% of survivors had some sequel. Head injuries had a predominant role in mortality and post traumatic disabilities.

CONCLUSIONS

These results confirm the efficacy of Advanced Trauma Life Support system in the treatment of patients with multiple trauma.

A hospital outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae investigated by RAPD typing and analysis of the genetics and mechanisms of resistance

Between July and September 1997 a ceftazidime- and aminoglycoside-resistant strain of Klebsiella pneumoniae infected or colonized seven patients on three paediatric wards at Guy's Hospital in London. The patients were mostly neonates or infants recovering from cardiac surgery for congenital defects. The organism was probably introduced by an asymptomatic patient from Greece and the subsequent outbreak could largely be explained by person-to-person spread on individual wards and frequent transfers of patients between wards. The outbreak was controlled by patient isolation and attention to handwashing, and there were no fatalities. The organisms were non-typeable by serology but had a characteristic RAPD profile. They produced the extended spectrum beta-lactamase SHV-5 and the aminoglycoside-modifying enzymes AAC(6') + probably AAC(3)II, encoded on a conjugative plasmid of approximately 160 kb. Two other patients had multi-resistant klebsiellas, one of them an SHV-5 producer and one a TEM-5 producer, but these could be distinguished from each other and from the outbreak strain by serological and RAPD typing and by the genetics and mechanisms of their resistances. Three other multi-resistant enterobacteria were isolated during the outbreak: an Escherichia coli that had acquired the 160 kb resistance plasmid from the epidemic klebsiella, a Citrobacter isolated from one of the patients with the klebsiella but which did not produce SHV-5, and a TEM-5-producing Enterobacter. This outbreak illustrates the importance of screening patients from high-risk areas for multiply-resistant organisms on admission, and the value of bacterial typing and analysis of resistance mechanisms to define the epidemiology of hospital infection.

Application of RAPD and restriction enzyme analysis to the study of oral carriage of Candida albicans

The genetic similarity of nineteen isolates of Candida albicans from four patients were compared by restriction fragment length polymorphism (RFLP) using EcoRI or HinfI, which both detected five types, and by random amplification of polymorphic DNA (RAPD), which detected three types. Phenotypically unusual isolates also produced distinct patterns with both typing systems demonstrating the carriage of two groups of C. albicans as well as the presence of more than one type in some subjects. Methods of DNA preparation were compared for the production of reproducible patterns; including using the supernatant fluid of boiled intact or spheroplasted cells for RAPD, and DNA precipitated from chloroform extracted cell lysate for RFLP and RAPD. Consistent patterns were produced from the DNA precipitate by RAPD and after an additional precipitation by RFLP, thus removing the necessity for lengthy extraction procedures or the use of toxic chemicals for purification.

Home glucose monitoring in type 2 diabetes: is it a waste of time?

A cross-sectional study to assess home glucose monitoring practices was conducted in 200 non-insulin-treated diabetic patients consecutively attending our hospital clinic. Of the 200, 97 (48%) patients (Group 1) regularly monitored urine (n = 74), blood (n = 19) or both (n = 4); 103 (52%) patients (Group 2) performed no home monitoring. The two groups were similar in terms of age, sex, duration of diabetes and type of treatment. The prevalence of diabetic complications was also closely comparable and only peripheral neuropathy differed between the groups, being more common in Group 1 (n = 12) than Group 2 (n = 4); p < 0.05. There was also no significant difference between the HbA1 concentration (mean +/- SD) in Group 1 (9.7 +/- 2.2%) and Group 2 (9.4 +/- 2.0%). The mean frequency of home monitoring was four tests weekly, but only 21 (22%) kept a written record and 60 (62%) would never alter their treatment on the basis of their results. Almost a third of patients could not interpret the results of monitoring or give the normal range of values. Home glucose monitoring, particularly of urine, is widely practised in Type 2 diabetes, at considerable overall expense. However, convincing evidence of its value in helping patients improve their blood glucose control or preventing the complications of the disease is lacking.

An audit of the management and outcome of hospital inpatients with diabetes: resource planning implications for the diabetes care team

In order to assess the outcome of hospitalized diabetic patients in an urban health district the notes of a cohort identified from a survey of all inpatients on a single day in spring 1990 were reviewed. One hundred and ten cases were reviewed (8.4% of all inpatients); median age 73 years (range 26-99), 59 female. Fifty-five percent were medical patients (general or geriatric) and 16% were general surgical. Six remained inpatients after 6 months. Sixteen died, of whom 10 had macrovascular disease. Median length of stay was 22 days (2-300), significantly above the district average in all specialties (< 10 days). Of 15 patients with foot problems, 5 died and 3 had major amputations. Only 23% of all patients had documented evidence of screening for diabetic complications. The discharge diagnoses failed to acknowledge diabetes in 54 cases (including 10 deaths). Only 10% had formal advice from the diabetes team and subsequent audit revealed that metabolic management was commonly suboptimal in non-physician units. These data suggest that inpatient diabetes is costly and carries a high mortality. The incidence is substantially underestimated by conventional episode statistics. The evidence from this cohort of diabetic inpatients suggests that improved communication and recognition of the importance of diabetes could usefully contribute to the quality of care achieved.

Calcium regulation of prolactin gene expression: opposing effects of extracellular CaCl2 and Ca2+ ionophores

Previous studies have demonstrated that the high basal level of transcription of the rat PRL gene in pituitary tumor GH3 cells is dependent on [CA2+]e. In the present study, we have extended these findings by examining the effects of the Ca2+ ionophores, A23187 and ionomycin, on [Ca2+]i, and on PRL mRNA levels and glucose-regulated protein (GRP) mRNA levels in GH3 cells cultured in a low Ca2+, serum-free medium (SFM). Using digital imaging microscopy of individual Fura 2-loaded GH3 cells in SFM plus 0.4 mM CaCl2, extranuclear and nuclear [Ca2+] were both about 70 nM. Addition of 600 nM ionomycin increased these levels by 10-fold within minutes, and by about 45-fold after 120 min. As previously published, addition of 0.4 mM CaCl2 to GH3 cells cultured in SFM significantly increased PRL mRNA, and had little or no effect on GRP78 and GRP94 mRNA after 16 h. Addition of 0.4 mM CaCl2 plus 100 nM A23187 significantly increased GRP78 and GRP94 mRNA. Surprisingly, the Ca2+ ionophore significantly inhibited PRL gene expression below that obtained in 0.4 mM CaCl2 without A23187. This same pattern of stimulation of GRP78 gene expression, but inhibition of PRL gene expression, was observed with 125 and 600 nM ionomycin. Both Ca2+ ionophores had no effect on histone 3 mRNA, and A23187 depressed PRL gene expression at a concentration (50 nM) that did not affect protein synthesis. Although A23187 reproducibly lowered PRL mRNA levels, it slightly inhibited its degradation in cells in which RNA synthesis was blocked by actinomycin D.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of the phosphatidylcholine biosynthetic enzymes in rat liver during development

The activities of the enzymes of rat hepatic phosphatidylcholine biosynthesis have been measured as a function of development in the rat (term, 23 days). During the last 5 days of gestation, the specific activity of choline kinase was elevated almost fivefold (p less than 0.05). After parturition, choline kinase activity was reduced to adult values by the 5th postnatal day. Over 75% of the total CTP:phosphocholine cytidylyltransferase protein in prenatal liver was detected in the cytosolic fraction. On the day of birth, most of the cytidylyltransferase translocated to the microsomes so that the microsomal specific enzyme activity was 3.3-fold higher (p less than 0.01) and the cytosolic specific enzyme activity (measured in the presence of phospholipid) was 68% lower (p less than 0.001) than the day before parturition. CDPcholine:diacylglycerol cholinephosphotransferase activity (measured in the presence of diacylglycerol) increased 130-fold (p less than 0.001) during the last 5 days of gestation. On the 10th postnatal day, cholinephosphotransferase activity was 1.7-fold higher (p less than 0.001) than immediately after birth, but declined to adult values by the 19th day. Between the 5th day prior to parturition and the 10th postnatal day, phosphatidylethanolamine N-methyltransferase activity steadily increased 16-fold (p less than 0.001). The results are in agreement with the hypothesis that the increase in phosphatidylcholine in rat liver during the perinatal period is due to an increased synthesis of CDPcholine, which is a consequence of the translocation of the cytidylyltransferase from cytosol to the endoplasmic reticulum.