POS0869 CYTOKINES IN SYSTEMIC SCLEROSIS RELATED INTERSTITIAL LUNG DISEASE AND IDIOPATHIC PULMONARY FIBROSIS

Background

Immune pathways have been implicated in both systemic sclerosis (SSc)-related interstitial lung disease (ILD) and idiopathic pulmonary fibrosis (IPF). Determination of blood cytokine differences in these two disorders need to be elucidated to better understand potential biological processes and common pathogenic pathways.

Objectives

This study compared 87 circulating cytokine levels amongst healthy controls and both SSc-ILD and IPF. There was also exploration of the association between cytokine levels and disease progression based on the annualized rate of decline of forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO).

Methods

Levels of 87 plasma cytokines were measured using commercial panels for consecutive SSc-ILD, IPF, and healthy individuals recruited at a Canadian tertiary-care center. Pulmonary function tests were performed as clinically indicated every 3-12 months. Cytokine levels are compared using the Wilcoxon rank sum test for two samples pairwise. The association between differentially expressed cytokines with both percent predicted annualized FVC and DLCO change was assessed within each disease group using multiple linear models adjusted for age, sex, baseline FVC, and immunosuppressive or anti-fibrotic treatment at sampling. Correction for multiplicity of testing was by Holm’s method.

Results

There were 19 healthy controls, 40 SSc-ILD, and 17 IPF participants with clinical features shown in Table 1. Eotaxin-1 and interleukin 6 (IL-6) were significantly elevated in both SSc-ILD and IPF compared to healthy controls (Figure 1). SSc-ILD had significantly lower soluble epidermal growth factor receptor (sEGFR) and higher levels of both soluble tumor necrosis factor receptor type II (sTNFRII) and soluble vascular endothelial growth factor receptor-1 (sVEGFR1) compared to healthy controls. IPF cases were distinguished from healthy controls by significantly higher monocyte chemoattractant protein-1 (MCP-1) and monokine induced by gamma interferon (MIG, also known as CXCL9) levels. No significant association was found for any of the cytokines with ILD progression based on annualized rates of either FVC or DLCO change.

Table 1.

Baseline patient characteristics stratified by disease groups

Healthy control(n = 19)SSc-ILD(n = 40)IPF(n = 17)Age, year51 ± 1956 ± 1273 ± 7Male, count (%)6 (32)12 (30)12 (71)Disease duration, yearNA6.41 (7.81)1.76 (2.14)Ever smoker, count (%)2 (11)19 (48)14 (82)•4 (82)oker0.4 [0, 1]11 [4, 29]19 [11, 35]Treatment presence, count (%)NA16 (40)7 (41)Baseline FVC %NA80 ± 2285 ± 21Baseline DLCO %NA51 ± 1749 ± 11Annualized FVC % changeNA-1.7 ± 8.2-6.2 ± 13.6Annualized DLCO % changeNA-0.5 ± 6.2-7.8 ± 18.6

The number (%), mean ± standard deviation, and median [interquartile range] are shown. Disease duration is defined as time of ILD first seen on HRCT in IPF and time from first non-Raynaud’s phenomenon in SSc-ILD. Treatment includes presence of ILD therapies: nintedanib, pirfenidone, mycophenolate mofetil, azathioprine, rituximab. FVC = forced vital capacity, DLCO = diffusing capacity for carbon monoxide

Figure 1.

Notched box plots of cytokine differences between disease groups. All cytokine levels are shown on a log scale. Overlap of notches indicates lack of a statistically significant difference in medians in a pairwise comparison. P-values are for SSc-ILD or IPF compared to healthy controls using Wilcoxon rank sum two-sample test corrected for multiple testing using Holms method.

Conclusion

Differences in seven circulating cytokines between healthy controls with both SSc-ILD and IPF show evidence of systemic cytokine activation. All seven cytokines have a role in immune cell extravasation and pro-fibrotic signaling, which provides further evidence of immune pathways involved in pulmonary fibrosis. Further studies will be pursued of longitudinal change of these biomarkers for halting or slowing disease progression and improving response to treatment.

Disclosure of Interests

Boyang Zheng: None declared, Kevin Keen Grant/research support from: Merck Canada Inc, Marvin Fritzler Shareholder of: Abbott Laboratories; Roche Holdings; Abcellera; Moderna, Speakers bureau: For diagnostic company: Werfen, Consultant of: For diagnostic company: Werfen; Aesku, Employee of: Medical Director of Mitogen Diagnostics, Christopher Ryerson Speakers bureau: Boehringer Ingelheim, Hoffmann-La Roche, Consultant of: Boehringer Ingelheim, Hoffmann-La Roche, Veracyte, Astra Zeneca, Grant/research support from: Boehringer Ingelheim, Hoffmann-La Roche, Pearce Wilcox Speakers bureau: Vertex, Valeo, Boehringer, Beth Whalen: None declared, Basak Sahin: None declared, Haiyan Hou Employee of: Mitogen Diagnostics, Penny Latham Employee of: Eve technologies, Mei Feng Zhang Employee of: Mitogen diagnostics, Iris Yao: None declared, James Dunne: None declared

How is family health history discussed in routine primary healthcare? A qualitative study of archived family doctor consultations

OBJECTIVES

Family health history underpins genetic medicine. Our study aimed to explore language and patterns of communication relating to family health history observed in interactions between general practitioners (GPs) and their patients within routine primary care consultations.

DESIGN

Secondary analysis of patient and GP routine consultation data (n=252).

PARTICIPANTS

Consultations that included 'family health history' were eligible for inclusion (n=58).

PRIMARY OUTCOMES

A qualitative inductive analysis of the interactions from consultation transcripts.

RESULTS

46/58 conversations about family health history were initiated by the GP. Most discussions around family history lasted for between approximately 1 to 2 min. Patients were invited to share family health history through one of two ways: non-specific enquiry (eg, by asking the patient about 'anything that runs in the family'); or specific enquiry where they were asked if they had a 'strong family history' in relation to a particular condition, for example, breast cancer. Patients often responded to either approach with a simple no, but fuller negative responses also occurred regularly and typically included an account of some kind (eg, explaining family relationships/dynamics which impeded or prevented the accessibility of information).

CONCLUSIONS

Family health history is regarded as a genetic test and is embedded in the sociocultural norms of the patient from whom information is being sought. Our findings highlight that it is more complex than asking simply if 'anything' runs in the family. As the collection of family health history is expected to be more routine, it will be important to also consider it from sociocultural perspectives in order to help mitigate any inequities in how family history is collected, and therefore used (or not) in a person's healthcare. Orientating an enquiry away from 'anything' and asking more specific details about particular conditions may help facilitate the dialogue.

Worsening pulmonary outcomes during sex reassignment therapy in a transgender female with cystic fibrosis (CF) and asthma/allergic bronchopulmonary aspergillosis: a case report

Background

Cystic Fibrosis (CF) is a hereditary pulmonary and extra-pulmonary disease that occurs equally in men and women. However, a difference in morbidity and mortality rates between the sexes has been long documented. Similarly, a sex-disparity in disease severity has been reported in asthma as well. Studies done to date point to estrogen as a possible cause of this sex disparity in pulmonary outcomes in both conditions.

Case presentation

Here, we describe a case of a patient with CF and asthma/allergic bronchopulmonary aspergillosis (ABPA) undergoing sex reassignment therapy (male-to-female) and the negative impact it had on her lung function and frequency of pulmonary exacerbations in the context of increasing doses of exogenous estrogen.

Conclusions

This case raises the possibility of a link between estrogen and worsening pulmonary outcomes and the need for further studies into transgender individuals with CF and/or asthma/ABPA as well as those undergoing high dose estrogen therapy for other indications.

Including Digital Sequence Data in the Nagoya Protocol Can Promote Data Sharing

The Nagoya Protocol (NP), a legal framework under the Convention on Biological Diversity (CBD), formalises fair and equitable sharing of benefits arising from biological diversity. It encompasses biological samples and associated indigenous knowledge, with equitable return of benefits to those providing samples. Recent proposals that the use of digital sequence information (DSI) derived from samples should also require benefit-sharing under the NP have raised concerns that this might hamper research progress. Here, we propose that formalised benefit-sharing for biological data use can increase willingness to participate in research and share data, by ensuring equitable collaboration between sample providers and researchers, and preventing exploitative practices. Three case studies demonstrate how equitable benefit-sharing agreements might build long-term collaborations, furthering research for global benefits.

Baseline characteristics and comorbidities in the CAnadian REgistry for Pulmonary Fibrosis

Background

The CAnadian REgistry for Pulmonary Fibrosis (CARE-PF) is a multi-center, prospective registry designed to study the natural history of fibrotic interstitial lung disease (ILD) in adults. The aim of this cross-sectional sub-study was to describe the baseline characteristics, risk factors, and comorbidities of patients enrolled in CARE-PF to date.

Methods

Patients completed study questionnaires and clinical measurements at enrollment and each follow-up visit. Environmental exposures were assessed by patient self-report and comorbidities by the Charlson Comorbidity Index (CCI). Baseline characteristics, exposures, and comorbidities were described for the overall study population and for incident cases, and were compared across ILD subtypes.

Results

The full cohort included 1285 patients with ILD (961 incident cases (74.8%)). Diagnoses included connective tissue disease-associated ILD (33.3%), idiopathic pulmonary fibrosis (IPF) (24.7%), unclassifiable ILD (22.3%), chronic hypersensitivity pneumonitis (HP) (7.5%), sarcoidosis (3.2%), non-IPF idiopathic interstitial pneumonias (3.0%, including idiopathic nonspecific interstitial pneumonia (NSIP) in 0.9%), and other ILDs (6.0%). Patient-reported exposures were most frequent amongst chronic HP, but common across all ILD subtypes. The CCI was ≤2 in 81% of patients, with a narrow distribution and range of values.

Conclusions

CTD-ILD, IPF, and unclassifiable ILD made up 80% of ILD diagnoses at ILD referral centers in Canada, while idiopathic NSIP was rare when adhering to recommended diagnostic criteria. CCI had a very narrow distribution across our cohort suggesting it may be a poor discriminator in assessing the impact of comorbidities on patients with ILD.

Management of organic impurities in small molecule medicinal products: Deriving safe limits for use in early development

Management of organic non-mutagenic impurities (NMIs) in medicinal products is regulated by the ICH Q3A, B and C guidelines that are applicable at late stages of clinical development (Phase III onwards) and as a consequence there is no guidance for the assessment and control of NMIs in early clinical trials. An analysis of several key in vivo toxicology databases supports the ICH Q3A defined concept that a lifetime dose to 1 mg/day of a NMI would not represent a safety concern to patients. In conjunction with routine (Q)SAR approaches, this 1 mg/day value could be used as a universal qualification threshold for a NMI during any stage of clinical development. This analysis also proposes that modification of this 1 mg/day dose using an established methodology (i.e. Modified Haber's Law) could support 5 mg/day or 0.7% (whichever is lower) as an acceptable limit for a NMI in a drug substance or product in early clinical studies (<6 months). Given the controlled nature of clinical development and the knowledge that most toxicities are dose and duration dependent, these proposed NMI limits provide assurance of patient safety throughout clinical development, without the requirement to commission dedicated in vivo toxicology impurity qualification studies.

Extreme ultraviolet spectroscopy diagnostics of low-temperature plasmas based on a sliced multilayer grating and glass capillary optics

New extreme ultraviolet (EUV) spectroscopic diagnostics of relatively low-temperature plasmas based on the application of an EUV spectrometer and fast EUV diodes combined with glass capillary optics is described. An advanced high resolution dispersive element sliced multilayer grating was used in the compact EUV spectrometer. For monitoring of the time history of radiation, filtered fast EUV diodes were used in the same spectral region (>13 nm) as the EUV spectrometer. The radiation from the plasma was captured by using a single inexpensive glass capillary that was transported onto the spectrometer entrance slit and EUV diode. The use of glass capillary optics allowed placement of the spectrometer and diodes behind the thick radiation shield outside the direction of a possible hard x-ray radiation beam and debris from the plasma source. The results of the testing and application of this diagnostic for a compact laser plasma source are presented. Examples of modeling with parameters of plasmas are discussed.

Predictors of pulmonary exacerbations in patients with cystic fibrosis infected with multi-resistant bacteria

BACKGROUND

This study examined characteristics of adult and adolescent patients with cystic fibrosis (CF) to determine factors associated with an increased risk of pulmonary exacerbations.

METHODS

249 patients with CF infected with multidrug resistant bacteria were recruited and prospectively followed for up to 4.5 years until they experienced a pulmonary exacerbation severe enough to require intravenous antibiotics. Multivariable regression analyses were used to compare the characteristics of patients who experienced an exacerbation with those who did not.

RESULTS

124 of the 249 patients (50%) developed a pulmonary exacerbation during the first year and 154 (62%) experienced an exacerbation during the 4.5 year study period. Factors predictive of exacerbations in a multivariable survival model were younger age (OR 0.98, 95% CI 0.96 to 0.99), female sex (OR 1.45, 95% CI 1.07 to 1.95), lower forced expiratory volume in 1 second (FEV(1)) (OR 0.98, 95% CI 0.97 to 0.99), and a previous history of multiple pulmonary exacerbations (OR 3.16, 95% CI 1.93 to 5.17). Chronic use of inhaled corticosteroids was associated with an increased risk of exacerbation (OR 1.92, 95% CI 1.00 to 3.71) during the first study year.

CONCLUSIONS

Patients who experience pulmonary exacerbations are more likely to be younger, female, using inhaled steroids, have a lower FEV(1), and a history of multiple previous exacerbations. It is hoped that knowledge of these risk factors will allow better identification and closer monitoring of patients who are at high risk of exacerbations.

Adoptive immunotherapy with donor lymphocyte infusions and interleukin-2 after high-dose therapy and autologous stem cell rescue for multiple myeloma

In an attempt to induce a graft-versus-myeloma effect, we administered donor lymphocyte infusions (DLI) after high-dose therapy with autologous stem cell transplant rescue to seven patients with refractory or relapsed multiple myeloma. High-dose therapy consisted of melphalan, idarubicin and etoposide (days -9 to -6) followed by autologous stem cell infusion on day 0. DLI (five of seven donors with two or three HLA antigens mismatched) were administered on days +1, +5 and +10 along with IL-2 (from day +1 through +12). Six of the seven patients developed acute graft-versus-host disease (GVHD), which resolved spontaneously, coincidentally with autologous hematopoietic reconstitution. One patient failed to engraft and received a second autologous graft. One patient died from complications of a pulmonary hemorrhage after experiencing GVHD. With a minimum follow-up of 38 months, five patients remain without disease progression in complete remission or with minimal residual disease. In this setting, DLI/IL-2 is biologically active resulting in GVHD. A graft-versus-myeloma effect is suggested by the improved outcome of our small cohort of high-risk patients. The use of partially mismatched related donors makes this approach potentially available to nearly all patients.

Early microdose drug studies in human volunteers can minimise animal testing: Proceedings of a workshop organised by Volunteers in Research and Testing

Testing the safety and efficacy of a successful human medicine involves many laboratory animals, which can sometimes be subjected to considerable suffering and distress. Also, it is necessary to extrapolate from the test species to humans. UK and European legislation requires that Replacement, Reduction and Refinement of animal procedures (the Three Rs) are implemented wherever possible. Over the last decade, there has been substantial progress with applying in vitro and in silico methods to both drug efficacy and safety testing. This paper is a report of the discussions and recommendations arising from a workshop on the role that might be played by human volunteer studies in the very early stages of drug development. The workshop was organised in November, 2001 by Volunteers in Research and Testing, a group of individuals in the UK which launched an initiative in 1994 to identify where and how human volunteers can participate safely in biomedical studies to replace laboratory animals. It was considered that conducting pre-Phase I very low dose human studies (sub-toxic and below the dose threshold for measurable pharmacological or clinical activity) could enable drug candidates to be assessed earlier for in vivo human pharmacokinetics and metabolism. Moreover, accelerator mass spectrometry (AMS), nuclear magnetic resonance (NMR) spectroscopy and positron emission tomography (PET) are potentially useful spectrometric and imaging methods that can be used in conjunction with such human studies. Some, limited animal tests would still be required before pre-Phase I microdose studies, to take account of the potential risk posed by completely novel chemicals. The workshop recommended that very early volunteer studies using microdoses should be introduced into the drug development process in a way that does not compromise volunteer safety or the scientific quality of the resulting safety data. This should improve the selection of drug candidates and also reduce the likelihood of later candidate failure, by providing in vivo human ADME data, especially for pharmacokinetics and metabolism, at an earlier stage in drug development than is currently the case.

Decision-making about breast cancer susceptibility testing: how similar are the attitudes of physicians, nurse practitioners, and at-risk women?

PURPOSE

To determine what consumers and providers would want to discuss about breast cancer susceptibility testing (BCST) and their preferred role in testing decisions.

METHODS

We surveyed 426 at-risk women, 143 nurse practitioners, and 296 physicians in five specialties in Maryland.

RESULTS

All groups believe it is important to discuss how the chance of breast cancer can be reduced and what the chances are of getting breast cancer if the test is positive. Both provider groups attributed more importance than consumers to discussing whether cancer can occur if the test is negative. Discussing the risk of depression and anxiety was more important to providers than consumers. Eighty-two percent of women would want their providers to make a recommendation about testing, but only 43% of nurse practitioners and 68% of physicians would do so. Eighteen percent of physicians underestimated the importance of informed consent for testing and 34% of discussing the risk of insurance discrimination. Fewer than 6% of women, if found to have a mutation, would be likely to undergo prophylactic mastectomy, whereas 12% of nurse practitioners and 34% of physicians would be likely to recommend such surgery. One third of respondents in all three groups supported testing a 13-year old daughter of a mutation-carrier.

CONCLUSION

Physicians should place greater value on informed consent and discussing practical aspects of testing, and physicians and nurse practitioners should pay more attention to the limitations of testing children, insurance discrimination, and consumers' desire for provider recommendations. In light of the limited discordance between nurse practitioners and consumers, nurse practitioners can play an increasing role in education and counseling about BCST.

A comparison of conventional metaphase analysis of Giemsa-stained chromosomes with multi-colour fluorescence in situ hybridization analysis to detect chromosome aberrations induced by daunomycin

Chromosome aberrations induced by daunomycin, a widely used positive control compound for in vitro cytogenetics assays, were identified by multi-colour fluorescence in situ hybridization with probes for chromosomes 1, 2 and 3. The frequency and distribution of aberration types were compared to conventional metaphase analysis of Giemsastained chromosomes from parallel human lymphocyte cultures. Multi-colour chromosome painting was a more sensitive method for detecting daunomycin-induced chromosome aberrations compared with conventional metaphase analysis because: (i) a higher level of statistical significance was achieved at low doses; and (ii) the increases in aberration frequencies compared with controls were greater. The majority of exchanges identified by Giemsastaining were unstable and were likely to lead to cell death. In contrast, those detected by FISH were mostly stable exchanges which may be transmitted to cell progeny. Multicolour FISH using whole chromosome probes may provide an elegant solution to the problem of identifying non-lethal, heritable exchange events. The benefit of this technique is the quantification of a cytogenetic endpoint directly associated with carcinogenesis.

High-dose tumor necrosis factor alpha produces an impairment of hamster diaphragm contractility. Attenuation with a prostaglandin inhibitor

We have investigated the influence of the cytokine tumor necrosis factor alpha (TNF alpha), an important mediator of sepsis, on in vitro hamster diaphragm contractility. Costal diaphragm strips were excised and mounted on an experimental apparatus consisting of a force transducer and servomotor. Preparations were randomized to incubation in one of the following solutions: (1) indomethacin 10(-6) M (n = 5); (2) TNF alpha (0.1 ng/ml) (n = 5); (3) TNF alpha (500 ng/ml) (n = 5); and (4) TNF alpha (500 ng/ml) plus indomethacin (10(-6)) (n = 5). Baseline contractile parameters measured at optimal length included twitch and tetanic tension, half relaxation time, time to peak tension, force frequency response (10-80 Hz), and fatigability to response to repetitive stimulation. After 90-min incubation in one of the solutions, an identical stimulation protocol was repeated. Initial twitch and tetanus parameters were similar between groups. Maximal twitch tension and tetanic tension decreased significantly, as did tetanic stimulations at 10-80 Hz in the TNF group (500 ng/ml) (p < 0.05). Coincubation with indomethacin decreased but did not completely abolish changes in diaphragm function caused by the higher dose of TNF. There were no significant changes in twitch or tetanus parameters, or in response to repetitive stimulation after incubation in the lower dose TNF group (0.1 ng/ml). We conclude that TNF causes impairment of in vitro diaphragm contractility at high incubation concentrations of TNF and that this effect can be partially blocked by prostaglandin synthetase inhibition. No significant deleterious effect on in vitro contractility was detected at concentrations of TNF similar to serum levels in human sepsis.

Extended harvest times are not necessary for the detection of in vitro clastogens in regulatory cytogenetics studies

The choice of harvest time in in vitro cytogenetics assays is a critical factor in determining the sensitivity of the assay for detecting clastogenic potential. As yet there is no harmonization of regulatory requirements in this aspect. It has been suggested that the use of extended harvest times can improve the sensitivity of detecting some chemicals which either induce cell cycle delay or produce lesions which induce chromosome aberrations at divisions subsequent to the first post-treatment mitosis. The incidence of such chemicals encountered in the routine testing of chemicals for regulatory submissions is not known. Therefore a large database of 550 chemicals tested in nine laboratories using standard regulatory protocols, including a late harvest time, was assessed for the incidence of chemicals uniquely positive only at a delayed harvest time. The number of such chemicals was very low ( < 0.2%) and the chromosome damage induced by these chemicals may not result from direct genotoxic mechanisms. Based on these data it is recommended that there is no need to include an extended harvest time in in vitro cytogenetics assays except where it might help to resolve an equivocal result.

The effect of PHA stimulation on lymphocyte sub-populations in whole-blood cultures

Although lymphocytes in phytohaemagglutinin (PHA)-stimulated whole blood cultures are routinely used to assess genotoxin-induced chromosome damage, very little information is available on the effect of PHA on the various cell populations present, and there appear to be no data for the protocols used in routine genotoxicity assays. In this study, we used flow cytometric analysis to examine the size/complexity of the white blood cell (WBC) population and the expression of key antigenic markers by the lymphocytes over a 96-h period following PHA stimulation. The changes in the WBC population are complex, and would seem to represent different populations dying out, remaining static or starting to divide. The initial decrease seen in overall cell numbers probably reflects death of the neutrophil and monocyte populations. The subsequent increase in cell numbers appears to be due to division of the lymphocytes and, by 96 h post-stimulation, they comprise about half the total cell number and, as expected, > 90% are activated T-cells; it seems reasonable to assume that these represent the target cells in genotoxicity assays. Although we do not suggest that these findings should alter the routine conduct of clastogenicity assays using PHA-stimulated whole-blood cultures, they indicate that such tests are empirical and that closer investigation will only confirm their relatively imprecise nature.

Spontaneous pulmonary hemorrhage after thrombolytic therapy for acute myocardial infarction

We report a case of 63-year-old man who developed massive pulmonary hemorrhage following intravenous streptokinase for acute myocardial infarction. Pulmonary hemorrhage was diagnosed by the triad of hemoptysis, a drop in hematocrit, and a new unilateral infiltrate on chest radiograph. This diagnosis was confirmed by autopsy findings. Pulmonary hemorrhage has rarely been reported following thrombolytic therapy. We believe that pulmonary hemorrhage is a rare but a potentially life-threatening complication of thrombolytic therapy and should be considered in the differential diagnosis of pulmonary infiltrates or falling hemoglobin after thrombolytic therapy for acute myocardial infarction with no obvious site of bleeding.

Evaluation of pyrazole and ethanol induced S9 fraction in bacterial mutagenicity testing

A major constitutive enzyme in the liver of the uninduced rat is cytochrome P450-2E1. This isozyme has been shown to metabolize a number of carcinogens, including low molecular weight nitrosamines and a number of compounds normally regarded as non-mutagenic in the Ames test, e.g. aniline, urethane and benzene. Using the standard induction procedures [Aroclor 1254 or a combination of phenobarbitone (PB) and beta-naphthoflavone (beta-NF)] the level of CYP2E1 in rat liver is actually suppressed and it has been suggested that this may account for the negative findings with these compounds in the Ames test. S9 fractions were prepared from rats pre-treated with pyrazole or ethanol (inducers of CYP2E1) and then used in the Ames test (or pre-incubation modification) with urethane, acetaminophen, aniline, benzene, procarbazine and N-nitrosopyrrolidine. Both pyrazole and ethanol induced S9 were superior to PB/beta-NF-S9 and uninduced-S9 for the activation of N-nitrosopyrrolidine, a known CYP2E1 substrate. However, there was no evidence of mutagenic activity with urethane, aniline, benzene, procarbazine or acetaminophen. As these compounds have demonstrated genotoxicity in vivo, additional important metabolic pathways must be required which are not present in rat liver S9 fraction.

Report of the Association of British Pharmaceutical Industries Collaborative Study Group. Collaborative study to evaluate the inter/intra laboratory reproducibility and phenotypic stability of Salmonella typhimurium TA97a and TA102

A collaborative trial was carried out to determine the intra/interlaboratory variability of Salmonella typhimurium strains TA102 and TA97a with regard to spontaneous revertant frequency and in response to four model mutagens (cumene hydroperoxide and bleomycin for strain TA102, and 4-nitrophenylenediamine and 4-aminoantipyrine for strain TA97a). A secondary objective of the trial was to monitor the stability of the strains after storage for up to 8 months and identify any technical problems associated with their use. Thirteen different laboratories participated in the trial, all receiving identical stock cultures of the bacterial strains and samples from the same batch of mutagenic compound. A standard protocol was followed and two independent experiments were carried out within 1 month of receipt of the strains/compounds (phase I), and again after a period of 6-8 months (phase II). Comparative studies with the standard strain TA100 after treatment with 4-nitrophenylenediamine were carried out as part of phase II. Overall, both strains gave acceptably consistent results in different laboratories and are considered useful for screening purposes when used under standardized conditions. One major source of interlaboratory variability identified for TA102 appears to be the sensitivity of different types of automatic colony counter for detecting the micro-colony revertants that this strain produces.

Breast self-examination proficiency and training effects: women at increased risk of breast cancer

While breast self-examination (BSE) frequency has received extensive research attention, proficiency has been less frequently addressed. Moreover, BSE proficiency among women at increased risk has not been adequately examined. Assessment of BSE proficiency is critical in determining the value of BSE with mammography and clinical breast examination in the early detection of breast cancer. BSE proficiency was assessed in 101 first-degree relatives of breast cancer patients. Participants were stratified by BSE frequency and randomized to one of two training techniques (MammaCare or concentric circle). BSE performance was assessed at baseline and at three follow-up visits at 4-month intervals. Proficiency was assessed by verbal description, a projected grid observational method, and lump detection ability on two breast models. BSE frequency was also assessed, in addition to BSE confidence, knowledge of breast cancer, risk perception, and worry related to breast cancer development. At baseline, proficiency was poor and correlations were not significant across assessment modalities. Significant improvement occurred on self-report measures, lump detection ability (true positives) on both models, and the projected grid. Improvement occurred across both training groups by the first follow-up, with no changes at subsequent visits. Both training techniques significantly improved BSE proficiency and were viewed positively by participants.

Monocyte inflammatory mediators impair in vitro hamster diaphragm contractility

Sepsis has been shown to impair ventilatory muscle function. To determine whether this can be attributed to direct effects of inflammatory mediators on muscle fibers, we carried out in vitro studies on hamster costal diaphragm. Baseline measurements included supramaximal peak twitch (Pt) and tetanic tension (Po), twitch half relaxation time (1/2RT) and time-to-peak tension (TTP), and force frequency response (15 to 80 Hz). Fatigability was evaluated using 60-Hz stimulations at a duty cycle of 0.4 until tension fell to 50% of baseline. Preparations were then incubated in one of the following for 60 min: (1) Krebs solution (n = 5), (2) nonstimulated monocyte supernatant (n = 5), or (3) lipopolysaccharide-stimulated monocyte supernatant (n = 5). Baseline Pt, Po, 1/2RT, TTP, force frequency response, and fatigue profile were similar between groups. After incubation there was a significant fall in Pt (mean +/- SD, 538 +/- 65 to 288 +/- 13 g/cm2, p < 0.05) and Po (1,268 +/- 132 to 921 +/- 64 g/cm2, p < 0.05) in the LPS group, with no change in the other groups. There was no change in TTP; however, 1/2RT was lower in the LPS-stimulated group after incubation (p < 0.05). There was a rightward shift in the force frequency response for the LPS-stimulated group (p < 0.05). When normalizing for initial Po, there was no significant change in the time to fatigue for any of the three groups. This study demonstrated that monocyte secretory products impair diaphragmatic contractility in vitro by a direct effect on muscle fibers.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitivity of Salmonella typhimurium TA97a to the type of agar used for preparation of Vogel-Bonner plates

Recent problems with the supply of Difco bacto agar have forced some laboratories to evaluate alternative agars for use in the Salmonella/microsome assay. This led to the independent observation in two laboratories (Boots and Glaxo) that Salmonella typhimurium TA97a is sensitive to certain types of agar that may be used to prepare Vogel-Bonner minimal medium plates. A programme of work was, therefore, undertaken to investigate this phenomenon; 9-aminoacridine hydrochloride (at Boots) and 4-nitro-o-phenylenediamine (at Glaxo) were tested against TA1537 and TA97a using Vogel-Bonner plates prepared with a number of different agars. Three agars (Lab M, Difco Bi-tek and Beckton Dickinson granulated) were identified which, although supporting normal growth of TA1537 revertant colonies, gave much reduced control counts and responses to the mutagens with TA97a. One agar, Becton Dickinson grade A, gave poor responses with TA1537 but produced satisfactory results with TA97a. In contrast to the Vogel-Bonner plates, varying the type of agar used in the top agar overlays had little effect on the responses obtained. On the basis of these comparisons, Becton Dickinson purified agar was selected as a suitable alternative to Difco bacto and it was concluded that laboratories using agars other than these, or purchasing pre-poured plates without specifying the type of agar, should be made aware of potential problems with TA97a.

Investigations into the induction of aneuploidy and polyploidy in mammalian cells by the anti-tussive agent noscapine hydrochloride

Noscapine, a non-narcotic, centrally-acting anti-tussive drug induces polyploidy in Chinese hamster CHL cells; further studies were carried out to investigate whether similar effects could be induced in other rodent cells (Chinese hamster V79) and in human lymphocytes. In both cases, large increases in the frequency of polyploid cells were induced at test concentrations ranging from 15 to 120 micrograms/ml after 24 and 48 h continuous treatment in the absence of S9 mix. In addition, spindle damage was observed in V79 cells and human skin fibroblasts after 24 h treatment with test concentrations of 30 and 60 micrograms/ml. Furthermore, after treatment of human skin fibroblasts there was a marked increase in the proportion of cells containing chromosomes which had become dislocated from the spindle. Treatment of the mouse/human hybrid cell line R3-5 induced a significant increase in the number of 6-thioguanine resistant colonies and it was confirmed cytogenetically that these colonies had arisen due to loss of human chromosome 2. From these experiments it can be concluded that noscapine induces polyploidy in both rodent and human somatic cells, and that this could arise through a direct effect upon spindle structure and/or function. The aneugenic properties of noscapine are less certain and further work is required in this area. Exposure to the drug through its therapeutic use (15mg up to four times daily) could exceed, at least locally within the gastrointestinal (GI) tract, the concentration range shown to be active in these in vitro studies. An immediate topical hazard might exist within the buccal cavity and GI tract, but further confirmation of these in vitro results are required using suitable in vivo systems before definite conclusions can be made regarding any potential hazard associated with the administration of this drug.

Oxygen cost of inspiratory loading: resistive vs. elastic

We measured the O2 cost of breathing (VO2resp) against external inspiratory elastic (E) and resistive loads (R) when end-expiratory lung volume, tidal volume, breathing frequency, work rate, and pressure-time product were matched in each of six pairs of runs in six subjects. During E, peak inspiratory mouth pressure was 65.7 +/- 1.8% (SD) of the maximum at functional residual capacity. However, during resistive runs, peak inspiratory mouth pressure was 41.1 +/- 2.8% of the maximum at functional residual capacity. In 36 paired runs, where both work rate and pressure-time product were within 10%, VO2resp for E was less than for R (81 and 96 ml/min, respectively; P less than 0.01). During loaded and unloaded breathing with the same tidal volume, we measured the changes in anteroposterior diameter of the lower rib cage in five subjects. In four subjects we also recorded the electromyograms of several fixator and stabilizing muscles. During E and R, the change in anteroposterior diameter of the lower rib cage was -116 +/- 5 and -45 +/- 4% (SE), respectively, of the unloaded value (P less than 0.01), indicating greater deformation during E. Although the peak electromyographic activity was 72 +/- 16% greater during E (P less than 0.01), there was no difference between the loads for area under the electromyogram time curve (P greater than 0.05). However, the time to 50% peak activity was less during R (P less than 0.02). We conclude that, even when work rate and pressure-time product are matched, VO2resp during R is greater than that during E. This difference may be due to preferential recruitment of faster and less efficient muscle fibers.

Comparison of Salmonella typhimurium TA102 with Escherichia coli WP2 tester strains

In 1982, Levin et al. published a paper describing a new Salmonella typhimurium strain, TA102, for detecting mutagenic agents that react preferentially with AT base pairs. This strain has an AT base pair at the critical mutation site within the hisG gene, which is located on a multicopy plasmid, pAQ1; the chromosomal copy of the hisG gene has been deleted. It also has an intact excision repair system, thus facilitating the detection of cross-linking agents, and carries the mutator plasmid, pKM101. Although TA102 has been shown to be reverted by certain mutagenic agents that are not detected in the usual battery of strains (TA1535, TA1537, TA1538, TA98 and TA100), there has been a general reluctance within the field to include TA102 as one of the standard screening strains. This may in part result from the difficulties which have been experienced in many laboratories in maintaining the strain, and in obtaining reproducible spontaneous and induced revertant counts. At Glaxo we routinely include certain Escherichia coli strains in our microbial test battery, and were aware that some of the genetic features offered by TA102 were already being covered by these strains. For example, E.coli WP2 (pKM101) has an AT base pair at the critical mutation site within the trpE gene, is excision proficient (and thus will detect cross-linking agents) and carries the pKM101 plasmid to enhance error-prone repair. From the published literature it was apparent that a number of the 'TA102 specific' mutagens could be detected in E.coli e.g. neocarzinostatin, UV and 8-MOP plus UV.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term follow-up of symptoms, pulmonary function, respiratory muscle strength, and exercise performance after botulism

Respiratory muscle weakness occurs commonly at presentation in patients with botulism. Although clinical improvement occurs over several months, symptoms such as fatigue and dyspnea persist in many patients in the long term. To determine whether continued respiratory muscle weakness might contribute to these symptoms, we compared lung function tests, respiratory muscle strength, and exercise performance in 13 patients 2 years after type B botulism. We found that residual symptoms including dyspnea and fatigue were common in botulism patients at 2 years postintoxication. Lung function tests had returned to normal in all patients. Maximal inspiratory and expiratory pressures were similar between botulism patients and control subjects. Evaluation of individual results showed evidence of inspiratory muscle weakness in four of 13 patients with botulism (Plmax less than 65% predicted). Maximal oxygen consumption and maximal workload during exercise were reduced in botulism patients in comparison to control subjects. During exercise, botulism patients had a more rapid and shallow breathing pattern and a higher dyspnea score at a given minute ventilation in comparison to control subjects. Reasons for premature exercise termination in botulism patients were multifactorial. Although respiratory muscle weakness may have been contributory in some patients, most appeared to be limited by reduced cardiovascular fitness, leg fatigue, or reduced motivation.

Concentrated drinking water extracts, which cause bacterial mutation and chromosome damage in CHO cells, do not induce sex-linked recessive lethal mutations in Drosophila

Concentrated extracts prepared from chlorinated drinking water samples were tested for their ability to induce sex-linked recessive lethal mutations in Drosophila melanogaster. Adult flies were allowed to feed on sucrose solutions prepared using neat or half-strength water extract. The drinking water extracts used for this study were also tested in bacterial fluctuation assays using Salmonella typhimurium TA100 and TA98 and in an in vitro cytogenetic assay using CHO cells. Although the water extracts gave positive results in both of these in vitro tests, there was no evidence of mutagenic activity in the Drosophila studies.

Phrenic nerve function and its relationship to atelectasis after coronary artery bypass surgery

Atelectasis following coronary artery bypass surgery (CAB) occurs in the majority of patients. To determine the importance of operative variables in the development of postoperative atelectasis and the incidence of phrenic nerve injury caused by topical cold cardioplegic solution, we studied 57 patients (53 male, four female) undergoing CAB. Their mean age, +/- SD, was 58 +/- 13 years. Transcutaneous stimulation was used to evaluate phrenic nerve function preoperatively and postoperatively in 52 patients. An unequivocal paresis of the phrenic nerve was documented in five patients. In an additional 27 patients, the amplitude of the compound diaphragm action potential was reduced postoperatively. However, methodologic limitations did not allow the conclusion that this was secondary to a phrenic axonal degeneration. Discriminant analysis of intraoperative variables showed more severe atelectasis with a larger number of grafts, with a longer operative and bypass time, when the pleural space was entered, when a right atrial drain and a cardiac insulating pad were not used, and with a lower body temperature. It is concluded that phrenic paresis may occur after CAB and topical cold cardioplegia, but that other factors must explain the atelectasis found in the majority of patients.

The effects of processing techniques on the mechanical properties of bone-anterior cruciate ligament-bone allografts. An experimental study in goats

There has been a growing interest in the use of allografts as ACL substitutes. Allografts are often freeze dried to increase shelf storage time and sterilized with ethylene oxide. This study was conducted to determine the effect of a specific ethylene oxide sterilization procedure and freeze drying process on the initial mechanical properties of femur-ACL-tibia preparations. Twelve knees (stifle joints) from six mature goats were divided into two groups (one knee of pair to each group). Knees were cleaned of all soft tissue except for the anterior cruciate, posterior cruciate, and collateral ligaments. Group 1 was sterilized with ethylene oxide (simulating clean procurement) then freeze dried. Group 2 was freeze dried only (simulating sterile procurement). The knees were rehydrated and then tested in tension to failure to determine their structural mechanical properties. The ethylene oxide-freeze dried specimens (Group 1) had a mean maximum load before failure of 2059 +/- 273 newtons (N) (+/- SE) which was not statistically different than the maximum load of the freeze dried specimens (Group 2) of 2023 +/- 214 N. The average strength of Group 1 and 2 combined was not significantly different than a third group of 12 normal femur-ACL-tibia controls which had an average maximum force of 2403 +/- 133 N. No significant differences between the groups were observed for stiffness, energy to maximum strength, or elongation to maximum force. It appears the freeze dry processing, with or without ethylene oxide sterilization, using the procedure we used, has, at most, a small effect on the initial mechanical properties of the preparations.(ABSTRACT TRUNCATED AT 250 WORDS)

Airway involvement in ulcerative colitis

Two patients with ulcerative colitis developed progressive obstructive pulmonary disease. In one, the abnormality was a sclerosing peribronchiolitis confined to small airways, while the other demonstrated a large airway fibrotic obliterative bronchitis. A review of airway involvement in ulcerative colitis and a discussion of the possible similarity to another extraintestinal manifestation of ulcerative colitis, sclerosing cholangitis, are presented.

Mutagenic activity of concentrated drinking water samples

Concentrated drinking water extracts prepared by adsorption onto XAD-2 resin have been tested for their ability to induce chromosome damage in mammalian cells. Extracts prepared from drinking waters derived from upland and lowland sources have been found to induce chromosome aberrations in Chinese hamster ovary (CHO) cells and human lymphocytes in vitro. Although the identity of the compounds responsible for this activity is unknown, they are generated when the water is chlorinated and appear to bind readily to exogenous protein. When groups of mice were dosed orally with a concentrated water extract, however, no evidence of clastogenic activity in bone marrow cells was apparent. The absence of an in vivo effect may indicate that the mutagenic compounds failed to reach the bone marrow. The possibility that genetic damage could be induced in the cells first encountered in the body after ingestion (i.e., cells in the esophagus, stomach, and intestinal tract) is not precluded by this result. The relevance of these findings in evaluating the potential health hazard of mutagenic compounds in drinking water is discussed.

Giant intraarticular loose bodies of the knee. Cases demonstrate spectrum of the lesion

Synovial chondromatosis is a well-known, well-described clinical and histopathologic entity. Occasionally, loose bodies in the knee joint can continue to grow and become large enough to impinge on joint motion. Extremely large synovial chondromata are relatively rare in the knee joint and have only been described in singular case reports in the orthopaedic literature. We describe two cases representing the spectrum of this disease process occurring in the popliteal fossa, simulating bony and/or soft tissue neoplasm. Case 1 demonstrates a large ossified chondroma, while Case 2 demonstrates a large chondroma without much calcification and with no ossification present. Because of the rarity of these lesions, preoperative staging studies, including CT scan, bone scan, and angiography, are usually warranted to help in the preoperative planning. Open biopsy with adequate tissue sampling is necessary to make an accurate histopathologic diagnosis. Once diagnosis is made, local excision for removal of the mechanical block to motion results in "cure"; local recurrence has not been noted.

Synthesis of 1,6-diaminopyrene from 1,6-dinitropyrene and its S9 dependent mutagenicity to S. typhimurium

1,6-Dinitropyrene elicits a potent mutagenic response in a range of microorganisms in the absence of auxiliary metabolism (S9 mix). This activity is considered to be dependent upon nitroreductase enzymes endogenous to the marker organism producing electrophilic species from one or both of the nitro groups. In order to evaluate this suggestion 1,6-diaminopyrene has been synthesised, characterized and found to elicit a mutagenic response in strain TA98 of Salmonella typhimurium, but only when evaluated in the presence of S9 mix. The active dose-range of the diamino compound was 10(4) times higher than that of the parent dinitro compound.

The clastogenic activity of dinitropyrenes in a rat-liver epithelial cell line

The ability of 1,6-dinitropyrene and 1,8-dinitropyrene to induce chromosome aberrations has been examined in a rat epithelial cell line (RL4). Both compounds were found to be potent clastogenic agents in these cells, inducing predominantly chromatid type abberations. The number of aberrant metaphases was dose-related up to 1.25 micrograms/ml, after which the response showed a plateau at a frequency of around 60%. The number of chromatid gaps per 100 cells also increased linearly with concentration from 3.5 in the control cultures up to 117 with 1,6-DNP (1.25 micrograms/ml) and 98 with 1,8-DNP (2.5 micrograms/ml), indicating that the induction of chromatid gaps was a valid and sensitive measure of chromosome damage in this cell line. The fact that a positive result as obtained in RL4 cells implies that these cells contain enzyme systems which are capable of converting dinitropyrenes to a mutagenic form.