Large-scale real-life analysis of survival and usage of therapies in multiple myeloma

Survival in multiple myeloma has improved significantly in recent years, especially in young patients. We reviewed the evolution of the survival of patients with MM in three groups based on age at MM diagnosis over three time periods between 1999 and 2020 at our 12 de Octubre Hospital institution (H12O). Then, to confirm our results, we used data from TriNetx, a global health research platform that includes patients from Europe to US. Finally, we analysed differences in the patterns of treatment between networks across the world. Kaplan‒Meier analysis was used to estimate survival probabilities, and between-group differences were tested using the log-rank test and hazard ratio. For patients from H12O, the median OS was 35.61, 55.59 and 68.67 months for the 1999-2009, 2010-2014 and 2015-2020 cohorts, respectively (p = 0.0001). Among all patients included in the EMEA network, the median OS was 20.32 months versus 34.75 months from 1999-2009 versus 2010-2014. The median OS from the 2010-2014 versus 2015-2020 time cohorts was 34.75 months versus 54.43 months, respectively. In relation to the US cohort, the median OS from before 2010 versus 2010-2014 was not reached in either time cohort and neither when comparing the 2010-2014 versus 2015-2019 time cohorts. Bortezomib is the most commonly used drug in the EMEA cohort, while lenalidomide is the most commonly used drug in the US cohort. This large-scale study based on real-world data confirms the previous finding that MM patients have increased their survival in the last two decades.

[What about the weekend effect? Impact of the day of admission on in-hospital mortality, length of stay and cost of hospitalization]

INTRODUCTION

There is no agreement on the existence of the weekend effect in healthcare or, if it exists, on its possible causes. The objective of the study was to evaluate the differences in healthcare outcomes between patients admitted on weekdays or weekends in a high-complexity hospital.

METHODS

Observational and retrospective study of patients admitted between 2016 and 2019 in a public hospital with more than 1300 beds. Hospitalization episodes were classified according to whether admission took place between Friday at 3:00 p.m. and the following Monday at 8:00 a.m. (weekend admission) or not (admission on weekdays). Mortality, length of stay and associated costs were compared, applying their respective risk-adjustment models.

RESULTS

Of the total 169,495 hospitalization episodes analyzed, 48,201 (28.44%) corresponded to the weekend, presenting an older age (54.9 years vs. 53.9; P<.001), a higher crude mortality rate (5.22% vs. 4.59%; P<0.001), and a longer average length of stay (7.42 days vs. 6.74; P<.001), than those admitted on weekdays. The median crude cost of stay was lower (€731.25 vs. €850.88; P<0.001). No significant differences were found when applying the adjustment models, with a risk-adjusted mortality ratio of 1.03 (0.99-1.08) vs. 0.98 (0.95-1.01), risk-adjusted length of stay of 1.002 (0.98-1.005) vs. 0.999 (0.997-1.002) and risk-adjusted cost of stay of 0.928 (0.865-0.994) vs. 0.901 (0.843-0.962).

CONCLUSION

The results of the study reveal that the assistance provided during the weekends does not imply worse health outcomes or increased costs. Comparing the impact between hospitals will require a future homogenization of temporal criteria and risk adjustment models.

Lymphocyte Apoptosis and Thrombocytopenia in Spleen during Classical Swine Fever: Role of Macrophages and Cytokines

Thirty-two Large White X Landrace pigs, 4 months old, were inoculated with the classical swine fever (CSF) or hog cholera virus strain “Alfort” in order to identify the mechanism responsible for the lymphopenia and thrombocytopenia observed in the spleen during the experimental induction of disease, by immunohistochemical and ultrastructural techniques. Results showed a progressive depletion of splenic lymphoid structures and evidence of platelet aggregation processes. Lymphoid depletion was due to lymphocyte apoptosis, which could not be ascribed to the direct action of the virus on these cells; direct virus action could play only a secondary role in the death of these cells. Absence of severe tissue and endothelial damage, together with moderate procoagulant cytokine levels in the serum, suggest that these pathologies can be ruled out as the cause of platelet aggregation and thrombocytopenia in CSF. Monocyte/macrophages were the main target cells for the CSF virus, and they exhibited phagocytic and secretory activation leading to the synthesis and release of tumor necrosis factor α, which proved to be the chief mediator, followed by IL-6, IL-1α, and C1q complement component. In view of their characteristics, TNF-α and, to a lesser extent, IL-1α and IL-6 appear to be the major cytokines involved in the pathogenesis of lymphocytopenia and thrombocytopenia; a clear spatial and temporal relationship was observed between these two phenomena.

Comparative analysis of cellular immune responses and cytokine levels in sheep experimentally infected with bluetongue virus serotype 1 and 8

Protective immunity in sheep with bluetongue virus (BTV) infection as well as the role of BTV-induced cytokines during immune response remains unclear. Understanding the basis immunological mechanisms in sheep experimentally infected with serotypes 1 and 8 (BTV-1 and -8) was the aim of this study. A time-course study was carried out in order to evaluate cell-mediated immune response and serum concentrations of cytokines (IL-1β, TNFα, IL-12, IFNγ, IL-4 and IL-10) with inflammatory and immunological functions. Depletion of T cell subsets (mainly CD4(+), γδ and CD25(+)) together with the absence of cytokines (IFNγ and IL-12) involved in the regulation of cell-mediated antiviral immunity at the first stage of the disease suggested that both BTV-1 and BTV-8 might impair host's capability against primary infections which would favor viral replication and spreading. However, cellular immune response and cytokines elicited an immune response in sheep that efficiently reduced viremia in the final stage of the experiment. Recovery of T cell subsets (CD4(+) and CD25(+)) together with a significant increase of CD8(+) T lymphocytes in both infected groups were observed in parallel with the decrease of viremia. Additionally, the recovery of CD4(+) T lymphocytes together with the significant increase of IL-4 serum levels at the final stage of the experiment might contribute to humoral immune response activation and neutralizing antibodies production against BTV previously described in the course of this experiment. These results suggested that both cellular and humoral immune response may contribute to protective immunity against BTV-1 and BTV-8 in sheep. The possible role played by IL-10 and CD25(+) cells in controlling inflammatory and immune response in the final stage of the experiment has also been suggested.

Effects of Preinfection With Bovine Viral Diarrhea Virus on Immune Cells From the Lungs of Calves Inoculated With Bovine Herpesvirus 1.1

The aim of this work was to study the interstitial aggregates of immune cells observed in pulmonary parenchyma of calves preinfected with bovine viral diarrhea virus and challenged later with bovine herpesvirus 1. In addition, the intent of this research was to clarify the role of bovine viral diarrhea virus in local cell-mediated immunity and potentially in predisposing animals to bovine respiratory disease complex. Twelve Friesian calves, aged 8 to 9 months, were inoculated with noncytopathic bovine viral diarrhea virus genotype 1. Ten were subsequently challenged with bovine herpesvirus 1 and euthanized at 1, 2, 4, 7, or 14 days postinoculation. The other 2 calves were euthanized prior to the second inoculation. Another cohort of 10 calves was inoculated only with bovine herpesvirus 1 and then were euthanized at the same time points. Two calves were not inoculated with any agent and were used as negative controls. Pulmonary lesions were evaluated in all animals, while quantitative and biosynthetic changes in immune cells were concurrently examined immunohistochemically to compare coinfected calves and calves challenged only with bovine herpesvirus 1. Calves preinfected with bovine viral diarrhea virus demonstrated moderate respiratory clinical signs and histopathologic evidence of interstitial pneumonia with aggregates of mononuclear cells, which predominated at 4 days postinoculation. Furthermore, this group of animals was noted to have a suppression of interleukin-10 and associated alterations in the Th1-driven cytokine response in the lungs, as well as inhibition of the response of CD8+ and CD4+ T lymphocytes against bovine herpesvirus 1. These findings suggest that bovine viral diarrhea virus preinfection could affect the regulation of the immune response as modulated by regulatory T cells, as well as impair local cell-mediated immunity to secondary respiratory pathogens.

Quantification and determination of spread mechanisms of bovine viral diarrhoea virus in blood and tissues from colostrum-deprived calves during an experimental acute infection induced by a non-cytopathic genotype 1 strain

To detect and monitor the sequential changes in virus levels, a reverse transcription quantitative real-time polymerase chain reaction assay using a TaqMan probe was carried out on frozen blood and tissues samples collected from calves experimentally infected with a non-cytopathic Bovine viral diarrhoea virus (BVDV) genotype 1 strain. Blood samples were collected among days 1-14 post-inoculation (p.i). On day 3 p.i, viral RNA was detected in blood samples from six of the eight inoculated animals. Viral RNA was detected in all remaining inoculated animals between 5 and 12 days p.i. The levels of viral RNA increased along the experiment, with a maximal peak between 6 and 9 days p.i. Analysis of virus load in tissues collected from calves euthanized on days 3, 6, 9 and 14 p.i displayed that BVDV was detected on day 3 p.i, being especially abundant in tonsils and ileocaecal valve, highlighting the role of tonsils as the main earliest viral replication sites as well as the principal source for virus spread to other lymphoid tissues and visceral organs. Coinciding with the highest viraemia levels, the highest viral loads were recorded at 9 days p.i. in tonsils, ileal lymph nodes, distal ileum and spleen, showing the main role of these secondary lymphoid organs in the pathogenic mechanisms of BVDV. However, virus levels in the liver and lung increased only towards the end of the infection. This fact could influence in the appearance of bovine respiratory diseases because of the capacity of BVDV for enhancing susceptibility to secondary infections.

Response of proinflammatory and anti-inflammatory cytokines in calves with subclinical bovine viral diarrhea challenged with bovine herpesvirus-1

The aim of this work was to investigate the susceptibility of calves infected with bovine viral diarrhea virus (BVDV) against secondary infections. For this purpose, the profile of cytokines implicated in the immune response of calves experimentally infected with a non-cytopathic strain of BVDV type-1 and challenged with bovine herpesvirus 1.1 (BHV-1.1) was evaluated in comparison with healthy animals challenged only with BHV-1.1. The immune response was measured by serum concentrations of cytokines (IL-1β, TNFα, IFNγ, IL-12, IL-4 and IL-10), acute phase proteins (haptoglobin, serum amyloid A and fibrinogen) and BVDV and BHV-1.1 specific antibodies. BVDV-infected calves displayed a great secretion of TNFα and reduced production of IL-10 following BHV-1 infection, leading to an exacerbation of the inflammatory response and to the development of more intense clinical symptoms and lesions than those observed in healthy animals BHV-1-inoculated. A Th1 immune response, based on IFNγ production and on the absence of significant changes in IL-4 production, was observed in both groups of BHV-1-infected calves. However, whereas the animals inoculated only with BHV-1 presented an IFNγ response from the start of the study and high expression of IL-12, the BVDV-infected calves showed a delay in the IFNγ production and low levels of IL-12. This alteration in the kinetic and magnitude of these cytokines, involved in cytotoxic mechanisms responsible for limiting the spread of secondary pathogens, facilitated the dissemination of BHV-1.1 in BVDV-infected calves.

Characterization of apoptosis pathways (intrinsic and extrinsic) in lymphoid tissues of calves inoculated with non-cytopathic bovine viral diarrhoea virus genotype-1

Previous studies have shown that activation of effector caspase-3 is associated with the apoptosis of lymphocytes occurring during infection with bovine viral diarrhoea virus (BVDV); however, the regulation of the apoptosis pathways that induce cell death via activation of effector caspase-3 has not yet been clarified. The aim of this study was to examine immunohistochemically the expression of cleaved caspase (CCasp)-8 (initiator caspase of the extrinsic pathway), CCasp9 (initiator caspase of the intrinsic pathway) and Bcl-2 (an anti-apoptotic marker) in gut-associated lymphoid tissue (GALT) of the ileum from calves inoculated with a non-cytopathic strain of BVDV genotype-1. CCasp8 had similar expression to that of CCasp3. In interfollicular T-cell areas there was moderate apoptosis and evidence of moderate activation of initiator caspase-8. In B-cell follicles there was marked lymphocyte apoptosis and evidence of intense caspase-8 activation, highlighting the potentially major role of the extrinsic pathway in lymphocyte apoptosis in the GALT during BVDV infection. Additionally, there was a significant decrease in the number of CCasp9(+) cells from the start of the experiment and this was linked to inactivation of caspase-9. Therefore, the intrinsic pathway may play only a minor role in the induction of lymphocyte apoptosis. Finally, the observed overexpression of Bcl-2 protein could play a major role in protecting lymphocytes in the T-cell areas against apoptosis, while low levels of Bcl-2 expression could be associated with the follicular lymphocyte apoptosis occurring during BVDV infection.

Cytokine Expression in Paraffin Wax-embedded Tissues from Conventional Calves

The cross-reactivity of antibodies against human tumour necrosis factor (TNF)alpha, interleukin (IL)-1alpha, IL-1beta and porcine IL-6, and the distribution of immunolabelled cells were evaluated on paraffin wax-embedded tissues from five healthy calves. The tissues were fixed in 10% buffered formalin or Bouin's solution and processed for structural studies and immunohistochemical studies by the avidin-biotin-peroxidase technique. Bouin's solution proved to be the more suitable fixative and Tween 20 the most effective antigen unmasking technique for increasing detectable antigenicity. Constitutive expression of TNFalpha, IL-1alpha, IL-1beta and IL-6 by different cell populations, mainly macrophage-like cells, was detected. Lymphoid organs displayed a higher presence of immunolabelled cells than did lung, liver or kidney. TNFalpha and IL-1alpha appeared as the predominant cytokines, especially in the gut-associated lymphoid tissue of the ileum and in the regional mesenteric lymph nodes. The results will facilitate investigation of the role of these cytokine-producing cells in inflammatory disease processes in calves.

Atoxoplasma spp. Infection in Captive Canaries (Serinus canaria)

Clinical signs, histopathological and ultrastructural findings associated with Atoxoplasma spp. natural infection in captive canaries (Serinus canaria) are described. Intracytoplasmic Atoxoplasma-like protozoa were found in the liver and lung. In the liver, protozoa were found in hepatocytes and Kupffer's cells and were associated with granulomatous hepatitis and a marked bile duct hyperplasia. An usual finding was the presence of infected mononuclear cells adhered to the endothelium of the blood vessels in lung. The diagnosis was confirmed by ultrastructural examination of reprocessed paraffin-embedded tissues.

The Role of B Cells in the Immune Response to Pestivirus (Classical Swine Fever Virus)

Pigs inoculated with the Alfort 187 isolate of classical swine fever (CSF) virus were used to study the immunological mechanisms associated with the humoral immune response in the disease. Quantitative and qualitative changes in the B-cell population (lambda light chain [C-lambda]-positive, immunoglobulins [Ig]-M-positive, and IgG-positive were demonstrated in the spleen, thymus and ileocaecal lymph node. Blood and serum samples were used to examine changes in leucocytes, albumin/globulin ratios and specific antibodies against CSF virus titration. Despite the lymphoid depletion shown by infected animals, an increase in B cells and potentially immunoglobulin-producing C-lambda+ plasma cells was observed in the lymphoid organs from the onset of disease. The increase in C-lambda+ B cells was matched by a parallel increase in IgM+ cells, which attained peak values from 7 days post-inoculation (dpi), while IgG+ cells increased from 11 dpi onwards. The enhanced biosynthetic capacity of these cells may have been linked to the initiation of a humoral response to CSF virus, and to the progressive decline in the albumin/globulin ratios of inoculated animals. Activation, proliferation and differentiation of B cells coincided with the presence of viral antigen, and with an intense phagocytic and biosynthetic activity of monocytes-macrophages and T lymphocytes. The previously reported increase of cytokine (TNFalpha, IL-1alpha and IL-6) production by monocytes-macrophages, and the release of IL-2, IL-4 and IFNgamma by T lymphocytes, may play a role in the initiation of the humoral immune response in CSF. These changes may have influenced the late appearance of virus-specific antibodies in the study, as well as the progressive increase of immunoglobulins.

Expression of proinflammatory cytokines by hepatic macrophages in acute classical swine fever

Fourteen pigs were inoculated with the 'Alfort 187' strain of classical swine fever (CSF) virus and killed in pairs at 2, 4, 7, 9, 11, 14 or 17 days post-inoculation for histopathological, ultrastructural and immunohistochemical examination. For the latter method, the antibodies used were those against viral antigen Gp55, porcine myeloid marker SWC3, IL-1alpha, IL-6, TNF-alpha and Factor VIII-related antigen. Activation and increase in the number of hepatic macrophages was observed following viral detection in liver, as well as an increase in IL-1alpha and IL-6 production, mainly by Kupffer cells. Maximum detection of viral antigen was observed in the middle stage of the experiment coinciding with overexpression of the three cytokines studied, with IL-6 production by interstitial macrophages prominent at the end. Additionally, the labelling of platelets for Factor VIII-related antigen and the ultrastructural study of the sinusoids revealed activation and aggregation of thrombocytes close to Kupffer cells at the beginning of the infection. The liver seems to play a prominent role in the origin of the thrombocytopenia that occurs in CSF and contributes to the overexpression of proinflammatory cytokines considered responsible for the disorders observed during the course of the disease.

Immunohistochemical Detection of the Expression of Pro-inflammatory Cytokines by Ovine Pulmonary Macrophages

The aim of this study was to determine the expression of three proinflammatory cytokines by pulmonary macrophages of sheep in paraffin wax-embedded tissue. Samples of lung from seven healthy sheep were fixed by immersion in either 10% neutral buffered formalin, acetic formalin, paraformaldehyde-lysine-periodate or Bouin's solution and processed for structural and immunohistochemical studies. The expression of interleukin (IL)-1alpha, IL-6 and tumour necrosis factor (TNF)-alpha by pulmonary intravascular macrophages (PIMs) and alveolar macrophages (AMs) was detected by the avidin-biotin-peroxidase (ABC) technique. Bouin's solution proved to be the most suitable fixative and Tween 20 the most effective pretreatment for increasing permeability. Constitutive expression of IL-1alpha, IL-6 and TNF-alpha by both macrophage populations was detected. The number of PIMs expressing IL-1alpha (the predominant cytokine in ovine lung) was higher than that of AMs, while the expression of IL-6 was greater in AMs. No differences between PIMS and AMs were found in respect of TNF-alpha expression. The evaluation of cytokine expression represents a valuable tool for studying the pathogenesis of disease in the ovine lung.