Impact and utility of follicular lymphoma GELF criteria in routine care: an Australasian Lymphoma Alliance study

Follicular Lymphoma (FL) treatment initiation is largely determined by tumor burden and symptoms. In the pre-rituximab era, the Group d'Etude des Lymphomes Folliculaires (GELF) developed widely adopted criteria to identify high tumor burden FL patients to harmonize clinical trial populations. The utilization of GELF criteria (GELFc) in routine therapeutic decision-making is poorly described. This multicenter retrospective study evaluated patterns of GELFc at presentation and GELFc utilization in therapeutic decision-making in newly diagnosed, advanced stage rituximab-era FL. Associations between GELFc, treatment given, and patient survival were analyzed in 300 eligible cases identified between 2002-2019. 163 (54%) had ≥1 GELFc at diagnosis. The presence or cumulative number of GELFc did not predict PFS in patients undergoing watch-and-wait (WW) or those receiving systemic treatment. Of interest, in patients with ≥1 GELFc, 16/163 (10%) underwent initial watch-and-wait (comprising 22% of the watchand- wait cohort). In those receiving systemic therapy +/- radiotherapy, 74/215 (34%) met no GELFc. Our data suggest clinicians are using adjunctive measures to make decisions regarding treatment initiation in a significant proportion of patients. By restricting FL clinical trial eligibility only to those meeting GELFc, reported outcomes may not be applicable to a significant proportion of patients treated in routine care settings.

Clinical characteristics of Australian treatment-naïve patients with classical Hodgkin lymphoma from the lymphoma and related diseases registry

Comprehensive clinical characteristics of Australian patients with classical Hodgkin Lymphoma (cHL) have not previously been systematically collected and described. We report real-world data of 498 eligible patients from the first 5 years of the Lymphoma and Related Diseases Registry (LaRDR), including baseline characteristics, histologic subtype, and treatment patterns in first-line therapy. Patient demographics and distribution of histopathological subtypes of cHL are similar to reported international cohorts. Doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) was the most common therapy for both early and advanced-stage disease, and 48% of patients with the early-stage disease received radiotherapy. Treatment patterns are consistent with international guidelines. In comorbid patients ≥60 years of age with advanced-stage disease, there is greater variation in treatment. In patients with a recorded response, the objective response rate (ORR) was 96% in early-stage disease, and 88% in advanced-stage disease. Early progression-free survival data suggest Australian patients with cHL have good outcomes, similar to other international studies.

Management and Outcomes of Diffuse Large B-cell Lymphoma Post-transplant Lymphoproliferative Disorder in the Era of PET and Rituximab: A Multicenter Study From the Australasian Lymphoma Alliance

There are limited data on post-transplant lymphoproliferative disorder (PTLD) in the era of positron emission tomography (PET) and rituximab (R). Furthermore, there is limited data on the risk of graft rejection with modern practices in reduction in immunosuppression (RIS). We studied 91 patients with monomorphic diffuse large B-cell lymphoma PTLD at 11 Australian centers: median age 52 years, diagnosed between 2004 and 2017, median follow-up 4.7 years (range, 0.5-14.5 y). RIS occurred in 88% of patients. For patients initially treated with R-monotherapy, 45% achieved complete remission, rising to 71% with the addition of rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone (R-CHOP) for those not in complete remission. For patients initially treated with R-CHOP, the complete remission rate was 76%. There was no difference in overall survival (OS) between R-monotherapy and R-chemotherapy patients. There was no difference in OS for patients with systemic lymphoma (n = 68) versus central nervous system (CNS) involvement (n = 23) (3-y OS 72% versus 73%; P = 0.78). Treatment-related mortality was 7%. End of treatment PET was prognostic for patients with systemic lymphoma with longer OS in the PET negative group (3-y OS 91% versus 57%; P = 0.01). Graft rejection occurred in 9% (n = 4 biopsy-proven; n = 4 suspected) during the entire follow-up period with no cases of graft loss. RIS and R-based treatments are safe and effective with a low likelihood of graft rejection and high cure rate for patients achieving complete remission with CNS or systemic PTLD.

Outpatient autologous stem cell transplantation in Royal Hobart Hospital, Tasmania: a single-centre, retrospective review in the Australian setting

BACKGROUND

Several international centres have published their experiences with outpatient autologous stem cell transplantation (ASCT) as treatment of haematological malignancies.

AIM

In this single-centre retrospective review, we aim to examine the outcomes of outpatient autograft and review healthcare resource utilization in the pre-cytopenic period.

METHODS

Patients undergoing ASCT in Royal Hobart Hospital, Tasmania between 2008 and 2018 had their records reviewed and key outcomes data collected based upon whether they received inpatient/outpatient ASCT. An outpatient ASCT was defined as conditioning as an outpatient; patients could then be managed with an elective admission during the cytopenic period or admission only when clinically indicated.

RESULTS

Of 231 ASCTs performed, 135 (58%) were as outpatients ASCTs: 59 used carmustine-etoposide-cytarabine-melphalan-conditioning for lymphoma (BEAM-ASCT) and 76 used high dose melphalan for myeloma and amyloidosis (MEL-ASCT). Approximately one-third of patients undergoing outpatient ASCT were admitted electively during nadir period; the majority of patients required minimal interventions prior to this time. The most common causes for unplanned hospitalization (which occurred in 71 of the 89 planned outpatient transplants, 80%) were febrile neutropenia (39%) and mucositis (35%). Age was the only risk factor identified to increase risk of requiring unplanned hospitalization. Use of oral antibiotic prophylaxis reduced febrile neutropenia rates amongst melphalan-outpatient-ASCT. Outpatient-ASCTs led to significantly reduced inpatient bed-days and overall cost (approximately AUD $13000- $16,000) compared with inpatient autografts, with no significant differences in engraftment, rates of febrile neutropenia, intensive care admissions or mortality.

CONCLUSION

Outpatient autografts may save healthcare resources without compromising patient outcomes. This article is protected by copyright. All rights reserved.

Abstract CT133: Targeting BCL-2 and MCL-1 overcomes treatment resistance in relapsed and refractory non-Hodgkin lymphoma: Pre-clinical rationale and results from an open-label phase 1b study

Purpose: Treatment of patients with relapsed or refractory lymphoid neoplasms represents a significant clinical challenge, largely due to the genetic heterogeneity of these malignancies. Our study goal was to design a rational treatment strategy that simultaneously targets multiple disease drivers to provide safe, efficacious, and durable responses in patients with relapsed or refractory non-Hodgkin lymphoma (NHL).

Experimental procedures and data summary: Venetoclax is a selective BCL-2 inhibitor that induces apoptosis and is efficacious in chronic lymphocytic leukemia; however, single-agent efficacy in other lymphoid neoplasms is limited. Using pharmacologic and genetic studies, we identified the pro-survival BCL-2 protein family member MCL-1 as a venetoclax resistance factor in NHL cell lines. We found that the monomethyl auristatin E (MMAE) payload of the antibody-drug conjugate polatuzumab vedotin promotes MCL-1 degradation via the ubiquitin/proteasome system, thus providing a strong rationale for combination with venetoclax. Mechanistically, polatuzumab vedotin combined with venetoclax promoted apoptotic NHL cell death. In NHL animal models, venetoclax, polatuzumab vedotin, and the anti-CD20 antibody obinutuzumab, that activates targeted antibody- and complement-dependent cell cytotoxicity, produced durable tumor regressions. In a phase 1b clinical trial, 33 patients with relapsed or refractory follicular lymphoma were evaluable for response over 6 dose levels with 19 complete responses and 6 partial responses (overall response rate 76%). All patients (8 of 8) treated with the recommended phase 2 regimen (venetoclax 800mg + polatuzumab vedotin 1.8mg/kg + obinutuzumab 1000mg) achieved complete responses at end of induction. The median duration of follow-up for all dose levels was 17.7 months. This triplet combination was well-tolerated by most patients and had an expected and acceptable safety profile.

Conclusions: Our studies implicate MCL-1 as a key venetoclax resistance factor in NHL that can be overcome by polatuzumab vedotin, which promotes MCL-1 degradation. Pre-clinical NHL animal models and early clinical data confirmed that the combination of venetoclax, polatuzumab vedotin, and obinutuzumab is safe and promotes durable responses. Because MMAE and other anti-tubulin agents are likely not the only therapeutics that antagonize MCL-1, our study provides scientific rationale to pursue the broader strategy of identifying other therapeutics that similarly neutralize MCL-1 function. Such agents could be used in combination with venetoclax in other malignancies where MCL-1 is a venetoclax resistance factor. Our mechanism-based treatment regimen that directly targets oncogenic drivers in NHL patients may serve as a framework for treating other malignancies with complex etiologies.

Citation Format: Dhara N. Amin, Rajat Bannerji, Raghuveer Singh Mali, Jason Oeh, Eva Lin, Anuradha Zindal, MaryAnn Go, Shang-Fan Yu, Maxwell Krem, Chris Arthur, Uwe Hahn, Anna M. Johnston, Vinit G. Karur, Nadia Khan, Paula Marlton, Tycel Phillips, Giuseppe Gritti, John F. Seymour, Monica Tani, Sam Yuen Yuen, Scott Martin, Matthew T. Chang, Christopher M. Rose, Victoria C. Pham, Elizabeth A. Lasater, Andrew G. Polson, YiMeng Chang, Jamie Hirata, Lisa Musick, Deepak Sampath, Christopher R. Flowers, Ingrid E. Wertz. Targeting BCL-2 and MCL-1 overcomes treatment resistance in relapsed and refractory non-Hodgkin lymphoma: Pre-clinical rationale and results from an open-label phase 1b study [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr CT133.

Outcomes of stage I/II follicular lymphoma in the PET era: an international study from the Australian Lymphoma Alliance

Management practices in early-stage (I/II) follicular lymphoma (FL) are variable and include radiation (RT), systemic therapy, or combined modality therapy (CMT). There is a paucity of data regarding maintenance rituximab in this cohort. We conducted an international retrospective study of patients with newly diagnosed early-stage FL staged with positron emission tomography (PET)-computed tomography and bone marrow biopsy. Three hundred sixty-five patients (stage I, n = 221), median age 63 years, treated from 2005-2017 were included, with a median follow-up of 45 months. Management included watchful waiting (WW; n = 85) and active treatment (n = 280). The latter consisted of RT alone (n = 171) or systemic therapy (immunochemotherapy [n = 63] or CMT [n = 46]). Forty-nine systemically treated patients received maintenance rituximab; 72.7% of stage I patients received RT alone, compared to 42.6% with stage II (P < .001). Active therapies yielded comparable overall response rates (P = .87). RT alone and systemic therapy without maintenance rituximab yielded similar progression-free survival (PFS) (hazard ratio [HR], 1.32; 95% confidence interval [CI], 0.77-2.34; P = .96). Maintenance rituximab improved PFS (HR, 0.24; 95% CI, 0.095-0.64; P = .017). The incidence of transformation was lower with systemic therapy compared to RT or WW (HR, 0.20; 95% CI, 0.070-0.61; P = .034). Overall survival was similar among all practices, including WW (P = .40). In the largest comparative assessment of management practices in the modern era, variable practices each resulted in similar excellent outcomes. Randomized studies are required to determine the optimal treatment in early-stage FL.

Effect of Recombinant Zoster Vaccine on Incidence of Herpes Zoster After Autologous Stem Cell Transplantation: A Randomized Clinical Trial

IMPORTANCE

Herpes zoster, a frequent complication following autologous hematopoietic stem cell transplantation (HSCT), is associated with significant morbidity. A nonlive adjuvanted recombinant zoster vaccine has been developed to prevent posttransplantation zoster.

OBJECTIVE

To assess the efficacy and adverse event profile of the recombinant zoster vaccine in immunocompromised autologous HSCT recipients.

DESIGN, SETTING, AND PARTICIPANTS

Phase 3, randomized, observer-blinded study conducted in 167 centers in 28 countries between July 13, 2012, and February 1, 2017, among 1846 patients aged 18 years or older who had undergone recent autologous HSCT.

INTERVENTIONS

Participants were randomized to receive 2 doses of either recombinant zoster vaccine (n = 922) or placebo (n = 924) administered into the deltoid muscle; the first dose was given 50 to 70 days after transplantation and the second dose 1 to 2 months thereafter.

MAIN OUTCOMES AND MEASURES

The primary end point was occurrence of confirmed herpes zoster cases.

RESULTS

Among 1846 autologous HSCT recipients (mean age, 55 years; 688 [37%] women) who received 1 vaccine or placebo dose, 1735 (94%) received a second dose and 1366 (74%) completed the study. During the 21-month median follow-up, at least 1 herpes zoster episode was confirmed in 49 vaccine and 135 placebo recipients (incidence, 30 and 94 per 1000 person-years, respectively), an incidence rate ratio (IRR) of 0.32 (95% CI, 0.22-0.44; P < .001), equivalent to 68.2% vaccine efficacy. Of 8 secondary end points, 3 showed significant reductions in incidence of postherpetic neuralgia (vaccine, n=1; placebo, n=9; IRR, 0.1; 95% CI, 0.00-0.78; P = .02) and of other prespecified herpes zoster-related complications (vaccine, n=3; placebo, n=13; IRR, 0.22; 95% CI, 0.04-0.81; P = .02) and in duration of severe worst herpes zoster-associated pain (vaccine, 892.0 days; placebo, 6275.0 days; hazard ratio, 0.62; 95% CI, 0.42-0.89; P = .01). Five secondary objectives were descriptive. Injection site reactions were recorded in 86% of vaccine and 10% of placebo recipients, of which pain was the most common, occurring in 84% of vaccine recipients (grade 3: 11%). Unsolicited and serious adverse events, potentially immune-mediated diseases, and underlying disease relapses were similar between groups at all time points.

CONCLUSIONS AND RELEVANCE

Among adults who had undergone autologous HSCT, a 2-dose course of recombinant zoster vaccine compared with placebo significantly reduced the incidence of herpes zoster over a median follow-up of 21 months.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01610414.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone

BACKGROUND

Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting.

METHODS

Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015.

RESULTS

A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients.

CONCLUSIONS

EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

Use of 'rainy day' autologous haemopoietic stem cells: a single-institution experience over 10 years

BACKGROUND

High-dose chemotherapy and autologous haematopoietic stem cell transplantation is an important therapeutic modality in the treatment of many haematological malignancies. Generally, stem cells are collected close to the time of the transplant, but an alternative is to collect and cryopreserve cells at an early stage of the illness so they are available for later use ('rainy day harvesting'). Although this practice has been commonplace in Australia, there is little evidence to document eventual use of cells collected in this manner.

METHODS

We conducted an audit of indications for and eventual transplantation of 'rainy day' harvests performed at our institution over a 10-year period.

RESULTS

Although there was some variation across different disease groups, we found that only 14% of cells were transplanted. The median delay to transplantation was 19 months.

CONCLUSION

Together with recent advances in stem cell mobilisation techniques, results from this audit suggest that the practice may not be an effective use of limited health resources.

Characteristics of commercial pig farms in Great Britain and their use of antimicrobials

A mail survey of 1889 pig producers in Great Britain with more than 100 sows or more than 1000 pigs was carried out to investigate their use of antimicrobials and other health-related management practices. The response rate was 25.5 per cent. Antimicrobials were most commonly administered in feed. Depending on the production system, between 60 and 75 per cent of the farms had used antimicrobials in their weaner rations and 20 to 62 per cent had used them in their grower rations. Antimicrobial injections had been used on 59 per cent of the farms. The use of antimicrobials in pigs of different age groups was variously associated with the scale of production, membership of a quality assurance scheme, the use of vaccination and whether the farmer thought the farm environment could be improved. Half the respondents (49 per cent) indicated that they used growth promoters in their weaners, but fewer used these in their growers (45 per cent) and finishers (34 per cent). Although 63 per cent of the farmers felt that the continued use of antimicrobials for disease prevention was justified, only 21 per cent felt that their continued use as growth promoters was justified.

Use of a functional assay to diagnose protein S deficiency; inappropriate testing yields equivocal results

Inherited deficiency of protein S (PS) is a rare but accepted risk factor for venous thromboembolism. There is accumulating evidence that inherited PS deficiency may be associated with a variety of adverse obstetric events. Acquired PS deficiency may be caused by a variety of clinical states including normal pregnancy. We conducted a retrospective audit of the results of screening for PS deficiency through our reference laboratory. The majority of patients in this audit with significantly reduced (<50%) free functional PS levels had a major confounding factor likely to cause acquired PS deficiency, most frequently pregnancy. Recommendations for PS testing for the diagnosis of hereditary PS deficiency include deferring testing until at least 40 days post-partum. It appears that these recommendations are not being adhered to leading to difficulty in the interpretation of results.

Modulators of insulin action and their role in insulin resistance

Insulin is a key anabolic hormone that plays a crucial role in growth, differentiation and metabolism. Insulin action is initiated by the binding of the hormone to its tyrosine kinase cell surface receptor, leading to the multisite autophosphorylation of the receptor. This results in the activation of the receptor kinase and subsequent tyrosine phosphorylation of insulin receptor substrates, most of which are docking proteins for signaling molecules. For the last several years, our laboratory has been interested in the mechanisms that lead to the modulation of insulin signal transduction, and hence might be involved in insulin resistance found in obesity and type II diabetes. For this review, we have focused on three 'modulators' of insulin action: hyperinsulinemia, suppressor of cytokine signaling proteins and advanced glycation end products.

Modulation of insulin action

Insulin is a key hormone regulating the control of metabolism and the maintenance of normoglycaemia and normolipidaemia. Insulin acts by binding to its cell surface receptor, thus activating the receptor's intrinsic tyrosine kinase activity, resulting in receptor autophosphorylation and phosphorylation of several substrates. Tyrosine phosphorylated residues on the receptor itself and on subsequently bound receptor substrates provide docking sites for downstream signalling molecules, including adapters, protein serine/threonine kinases, phosphoinositide kinases and exchange factors. Collectively, those molecules orchestrate the numerous insulin-mediated physiological responses. A clear picture is emerging of the way in which insulin elicits several intracellular signalling pathways to mediate its physiologic functions. A further challenge, being pursued by several laboratories, is to understand the molecular mechanisms that underlie insulin action at the peripheral level, deregulation of which ultimately leads to hyperglycaemia and Type 2 diabetes. We review how circulating factors such as insulin itself, TNF-alpha, interleukins, fatty acids and glycation products influence insulin action through insulin signalling molecules themselves or through other pathways ultimately impinging on the insulin-signalling pathway. Understanding how the mechanism by which molecular insulin action is modulated by these factors will potentially provide new targets for pharmacological agents, to enable the control of altered glucose and lipid metabolism and diabetes.

Immune reconstitution in human immunodeficiency virus-infected children receiving highly active antiretroviral therapy: a cohort study

BACKGROUND

Highly active antiretroviral therapy (HAART) has brought about rapid declines in HIV-1 RNA concentrations and an increase in CD4+ counts in HIV-1-infected children. These changes are often accompanied by clinical improvement; however, the extent to which immune reconstitution occurs is not known.

DESIGN

We compared two cohorts (n = 35) of HIV-1-infected children to evaluate the effects of HAART on immune recovery. Cohort 1 (C1) included clinically well children receiving HAART with a CD4 >22% at study initiation. Before HAART all children had moderately to severely suppressed immune function by CDC criteria (CD4 <25%) or CDC Category B or C disease. Cohort 2 (C2) included children with no current or past evidence of immunosuppression based on CDC criteria (CD4 >25%) and no evidence of clinical disease. Children in C2 were receiving a non-HAART regimen.

METHODS

Immunophenotyping was performed to characterize CD4+ and CD8+ subsets with regard to maturation and activation. T cell rearrangement excision circles (TRECs) were measured to quantify recent thymic emigrants.

RESULTS

No difference was found in percent CD4+ or percent CD8+ T cells or maturation markers between C1 and C2. There was significantly less expression of activation markers in both CD4+ and CD8+ cells in C1. There was no difference in TREC production between C1 and C2.

CONCLUSION

Moderately to severely suppressed HIV-1-infected children receiving HAART are able to reconstitute their immune systems to a degree that is indistinguishable from that of stable, CDC Class A1 HIV-1-infected children with regard to CD4+ and CD8+ T cell subsets, expression of cellular maturation markers and TREC production.

Animals and antibiotics

The routine use of antibiotics as growth promoters is no longer acceptable, but there is a continuing requirement to treat infection occurring in herds or flocks and often it is necessary to treat all animals regardless of whether or not they are infected. To minimise the risk of the development of resistant strains the mode of treatment should be carefully considered in order to prevent the transfer of low levels of antibiotics to uninfected animals. Suitable veterinary input into the course of treatment should reduce the chance of transfer of resistant strains or resistance mechanisms to human strains of microorganisms.

Interstitial laser photocoagulation and interstitial photodynamic therapy of normal lung parenchyma in the pig

Interstitial laser photocoagulation (ILP) and interstitial photodynamic therapy (PDT) involve delivery of light to lesions in solid organs using thin fibres passed through needles inserted percutaneously under image guidance. In ILP, the laser energy heats the tissue, whereas in PDT it activates a previously administered photosensitising agent. This study looks at their potential for treating localised, small, peripheral lung cancers in patients unsuitable for surgery. Experiments were undertaken on nine normal pigs, up to four fibres being inserted into the lung parenchyma percutaneously under X-ray guidance (ILP: 2-3 W, 1000 q/fibre, from 805 nm diode laser, PDT, 100-200 J/fibre from 652 nm diode laser at 50-100 W, 3 days after 0.15 mg/kg mTHPC). Animals were killed from 3 days to 3 months later and the treated areas examined macroscopically and microscopically. Both techniques were well tolerated, producing well-defined, localised lesions, typically 3.5 x 2 x 2 cm using four fibres. Histology showed thermal coagulative necrosis after ILP and haemorrhagic necrosis after PDT. Early small haematomas and late cavitation were sometimes seen after ILP, but not after PDT. PDT lesions healed with preservation of larger arteries and bronchi in the treated area. A few small pneumothoraces were seen which resolved spontaneously, probably related to the chest wall puncture. It was concluded that ILP and PDT lesions of a size large enough to cover a small tumour can be made safely in the lung parenchyma, although healing was better after PDT. Pilot clinical studies with both techniques are now justified on carefully selected patients.

Development of delta(15)N stratification of NO(3)(-) in soil profiles

New evidence, obtained using a robust method for measuring the delta(15)N of NO(3)(-)-N in soil, is consistent with denitrification being the major determinant in the vertical distribution of NO(3)(-)-delta(15)N in soil profiles. These data also suggest that varying moisture regimes result in different effects of soil NO(3)(-)-N leaching on residual whole soil delta(15)N.

Predominant transgene expression in exocrine pancreas directed by the CMV promoter

The enhancer/promoter of the human cytomegalovirus gene encoding the major immediate-early protein (CMVp) is reputed to be one of the strongest and most promiscuous regulatory elements for directing transcription of heterologous genes in vitro. However, transgene expression under the promoter in adult transgenic mice is often more restricted. We selected a CMVp segment from position -350 to +59 to control expression of transgenes for two secretory fusion proteins. Expression was analyzed by immunohistology staining and quantified by Northern blot, Western blot, and ELISA of secretions from explanted tissues. In all six lines of transgenic mice, the highest expression of transgenes at the mRNA and protein level was observed in the exocrine tissue of the pancreas, although the levels of expression varied among the lines. The results indicate not only that CMVp is not a universal promoter in vivo but indeed that it can be relatively specific for the exocrine pancreas, where expression of the gene it controlled was consistently very high.

SPAK, a STE20/SPS1-related kinase that activates the p38 pathway

We have cloned a member of the STE20/SPS1 protein kinase family from a transformed rat pancreatic beta cell line. SPAK (STE20/SPS1-related, proline alanine-rich kinase) belongs to the SPS1 subfamily of STE20 kinases and is highly conserved between species. SPAK is expressed ubiquitously, although preferentially in brain and pancreas. Biochemical characterization of SPAK catalytic activity demonstrates that is a serine/threonine kinase that can phosphorylate itself and an exogenous substrate in vitro. SPAK is immunoprecipitated from transfected mammalian cells as a complex with another, as yet uncharacterized, serine/threonine kinase which is capable of phosphorylating catalytically-inactive SPAK and myelin basic protein in an in vitro kinase assay. SPAK specifically activates the p38 pathway in cotransfection assays. Like MST1 and MST2, SPAK contains a putative caspase cleavage site at the junction of the catalytic domain and the C-terminal region. Full-length SPAK is expressed in the cytoplasm in transfected cells, while a mutant corresponding to caspase-cleaved SPAK is expressed predominantly in the nucleus. The similarity of SPAK to other SPS1 family members, its ability to activate the p38 pathway, in addition to its putative caspase cleavage site, provide evidence that SPAK may act as a novel mediator of stress-activated signals. Oncogene (2000) 19, 4290 - 4297

Lupus anticoagulant in a patient with parvovirus B19 infection

We report the case of a patient who presented with a prodromal illness suggestive of viral infection, subsequently confirmed as parvovirus B19, who had a lupus anticoagulant present. Her IgG anti-cardiolipin antibody was normal (7.0 units/ml) but her IgM anti-cardiolipin was elevated (55 units/ml). These later returned to normal. Parvovirus B19 infection may be associated with the presence of lupus anticoagulant.

Animal health and food safety

Foods of animal origin have an important role in a balanced diet and must be safe for human consumption. Equally important is the need for the food to be perceived as safe by the consumer. Safe food of animal origin must be free from animal pathogens that infect man and from contamination by residues. While intensive farming practices have been linked with the rise in foodborne illness in humans, it is interesting to note that the rise has continued even when there has been a shift to less intensive farm production systems. While the production of meat, milk and eggs, regardless of new technology or changes in production methods, cannot be expected to achieve zero bacterial risk, there is the need to reduce the risk and, where possible, eliminate it at the 'on the farm stage'. The current use of the terms 'farm-to-table', 'stable-to-table' and 'plough-to-plate' clearly identifies the farm as one part of the production chain which must be considered in terms of food safety.

Lithium-associated clinical hypothyroidism. Prevalence and risk factors

BACKGROUND

Rates of, and risk factors for, lithium-associated clinical hypothyroidism are uncertain.

AIMS

To determine prevalence of and risk factors for clinical hypothyroidism in patients treated with lithium carbonate.

METHOD

Retrospective case-note review of 718 patients who had undergone serum lithium estimation during a 15-month period. Patients on thyroxine had a more detailed review.

RESULTS

The prevalence of clinical hypothyroidism during lithium treatment was 10.4%. The main risk factor was female gender (women 14% v. men 4.5%). Women were at highest risk during the first two years of lithium treatment, and women starting lithium aged 40-59 years had the greatest prevalence (> 20%). No equivalent risk factors emerged in men, although, like women, their prevalence of hypothyroidism was substantially higher than community rates.

CONCLUSIONS

The high rates of clinical hypothyroidism identified may call for a review of the drug information given to women, particularly to those starting lithium in middle age. Consideration should be given to screening for thyroid antibodies before treatment in high-risk cases. Monitoring of thyroid function should take into account gender, age and stage of lithium treatment.

Determination of farm-level risk factors for abnormalities observed during post-mortem meat inspection of lambs: a feasibility study

To investigate the feasibility of using information about the health and management of lambs on farms to predict the risk of gross abnormalities at post-mortem meat inspection, 6732 lambs from 30 different farms in Great Britain were followed through to slaughter in 1995/6. The farm-level data were collected during farm visits at the beginning of the study. Routine meat inspection findings for the lambs were obtained from the 10 participating abattoirs. The most common abnormalities found during post-mortem inspection were pneumonia/pleurisy (53% of cohorts), lungworm (40%), abscesses (30%), liver fluke (27%) and nephritis/nephrosis (27%). The farm-level risk factors associated with abnormalities at slaughter varied with the type of lesion. The most significant risk factor was the age of the lambs at slaughter. Lambs slaughtered at an older age were more likely to have an abnormality, especially pneumonia, abscesses and liver fluke. After age, environmental factors appeared to be better predictors of those cohorts that would have lesions at slaughter than health and disease control variables. However, a much larger study would be required to identify a set of farm-level factors that adequately discriminated between lambs with high and low risks of lesion at slaughter. At the end of the study, the farmers were informed of the meat inspection findings for their lambs and a third indicated that they would improve their animal husbandry as a result of the information.

Welfare implications of sheep ear tags

The damaging effects of ear tags used to identify sheep were studied by examining the ears of sheep after slaughter in three different abattoirs and the ears of sheep on a farm. In total, 1040 ears with tags were examined. There were six types of ear tag: metal 'Ketchum' style loop tags; two-piece rigid plastic tags; 'Allflex' style flexible plastic tags with a male and female part; golf tee-shaped plastic ear tags; one-piece rigid plastic loop tags; and one-piece flexible plastic tags with a flap. The metal loop tags and plastic loop tags caused the most lesions, and the majority of the severe lesions. Ear tags placed near to the tip of the ear appeared to cause more damage. Some of the Ketchum style metal tags and two-piece rigid plastic tags appeared to be relatively new, as if recently fitted. These tags were more often associated with ear lesions, particularly moderate or severe lesions. The Allflex style flexible plastic tags caused the fewest problems, and the golf tee-shaped plastic tags also caused significantly fewer problems than the other tags.

Differential mRNA display analysis of two related but functionally distinct rat insulinoma (RIN) cell lines: identification of CD24 and its expression in the developing pancreas

To identify genes that might play a role in growth and differentiation of pancreatic beta-cells, we have applied the technique of differential mRNA display to the lineage-related, but functionally distinct rat insulinoma (RIN) cell lines RIN-5AH and RIN-A12. Direct comparison of PCR-generated RIN-5AH and RIN-A12 cDNAs on DNA sequencing gels revealed 31 differentially expressed bands. By Northern blot hybridization, authentic differential expression was confirmed for three cDNAs derived from RIN-5AH cells and four cDNAs from RIN-A12 cells. Nucleotide sequences were determined for these cDNAs and database searches identified one known gene that encoded heat stable antigen CD24. Of the remaining six genes, three matched with established sequence tags from fetal tissue, and three were potentially novel. By RT-PCR analysis, five of the seven genes were expressed in normal fetal and/or adult pancreas. In a detailed survey of CD24 protein expression in the pancreas using the CD24-specific monoclonal antibody J11d, CD24 was predominantly expressed in ductal epithelial cells (E13.5-15.5), developing endocrine (alpha, beta and delta) and exocrine cells (E15.5-20.5) and mature exocrine and peripheral islet delta-cells post E20.5. The retention of CD24 expression in a large proportion of delta-cells but only in a minority of alpha- and beta-cells leads us to hypothesize that CD24 may mark a pool of precursor endocrine cells within adult islets.

Tuberculin skin testing among economically disadvantaged youth in a federally funded job training program

Low income, medically underserved communities are at increased risk for tuberculosis. Limited population-based national data are available about tuberculous infection in young people from such backgrounds. To determine the prevalence of a positive tuberculin skin test among economically disadvantaged youth in a federally funded job training program during 1995 and 1996, the authors evaluated data from medical records of 22,565 randomly selected students from over 100 job training centers throughout the United States. An estimated 5.6% of students had a documented positive skin test or history of active tuberculosis. Rates were highest among those who were racial/ethnic minorities, foreign born, and (among foreign-born students) older in age (p < 0.001). Weighted rates (adjusting for sampling) were 1.3% for white, 2.2% for Native American, 4.0% for black, 9.6% for Hispanic, and 40.7% for Asian/Pacific Islander students; rates were 2.4% for US-born and 32.7% for foreign-born students. Differences by geographic region of residence were not significant after adjusting for other demographic factors. Tuberculin screening of socioeconomically disadvantaged youth such as evaluated in this study provides important sentinel surveillance data concerning groups at risk for tuberculous infection and allows recommended public health interventions to be offered.

Isolation of NO(3)(-)-N as 1-phenylazo-2-naphthol (Sudan-1) for measurement of delta(15)N

The conversion of nitrate (NO(3)(-)) to 1-phenylazo-2-naphthol (Sudan-1) has been examined as a method for natural abundance measurement of delta(15)N of NO(3)(-). The reaction results in dilution of NO(3)(-)-N with only one reagent-derived N and the product is readily concentrated from dilute samples by reverse phase chromatography. There is systematic isotopic fractionation during the reaction, but this can be allowed for by analysing known NO(3)(-) standards along with each sample set. Sudan-1 prepared from surface water samples containing approximately 50 &mgr;g NO(3)(-)-N can be analysed by automated continuous flow isotope ratio mass spectrometry with a precision of 0.2 per thousand (one standard deviation) and the accuracy is not affected by interference from other nitrogenous species in the sample or reagents. Copyright 1999 John Wiley & Sons, Ltd.

Meat inspection: an overview of present practices and future trends

This is a review of meat inspection literature, its history, current concerns and needs for the future. The value and limitations of meat inspection are discussed, along with the possible modifications or changes that are being developed to modernize an increasingly outdated method of safeguarding public health. The potential of on-farm risk assessment of slaughter animals and the practical considerations that need to be overcome are outlined. The needs of the consumer and subsequent challenges to the meat and farming industry are proposed as the driving force behind the changes occurring in veterinary public health. The current risk to consumers, from such microbial pathogens as Salmonella, Escherichia coli O157:H7 and Campylobacter infection, are highlighted.

Welfare implications of identification of cattle by ear tags

The damage caused by ear tags used for identification was studied by examining the ears of normal beef cattle and cull cows after slaughter, and by comparing the effects of metal and polyurethane ear tags in calves which had been double-tagged in the same ear. Metal tags were associated with more damage to the ears than polyurethane tags, the difference being most marked in the young calves, in which slight changes were found in 36.6 per cent and severe changes in 9.8 per cent of ears. There was a high incidence of blood around the point of insertion of the metal tags at three weeks old, but with the polyurethane tags only one calf showed slight evidence of blood around the point of insertion. In the beef cattle fitted with metal tags, a slight reaction was recorded in 40 per cent, a moderate reaction in 17 per cent and significant changes were found in 12 per cent of ears. By comparison, 16 per cent of ears with polyurethane tags showed only a slight reaction, and 80 per cent of the polyurethane tags were considered to be a good fit, compared with 37 per cent of metal tags. More changes were observed in the ears of the cull cows, with 23.5 per cent of ears with polyurethane tags being free from damage, compared with only 2.9 per cent of ears with metal tags.

Abattoir observations of the weights of stomachs and their contents in pigs slaughtered at known times after their last feed

From 15 farms, 1242 pigs (range per farm 12-169) were sent for slaughter at known times after their last feed. The time of feeding, quantity and type of last feed, time of loading, time in transit, distance travelled, time in lairage and time of slaughter, were recorded. The mean +/- SD stomach weight and wet stomach contents weight were 0.68 +/- 0.12 and 0.55 +/- 0.45 kg, respectively. There were 148 stomachs (11.9%) with wet contents weights > 1 kg, nine > 2 kg but < 3 kg, and one weighed 3.04 kg. The means and ranges for times from last feed to loading interval, time in transport, and time in lairage were 13.6 (0-40), 3.1 (0.75-6.0) and 4.1 (2.1-12.5) h, respectively. The mean and range for distance travelled was 193.1 (43-320) km. Ten stomachs were collected at random from a further load of pigs from one farm. They had been fed 0.64 kg dry pellets and were slaughtered 18.5 h later. The mean and range for wet stomach contents weight was 0.87 kg (0.24-1.33). Samples were dehydrated and the mean calculated stomach dry matter content for the 10 pigs was 127.4 +/- 69.1 g.

Microbial contamination of dental unit waterlines: short- and long-term effects of flushing

The extensive microbial contamination of DUW in this study is consistent with that described in previous reports. Comparisons with other common public potable water sources emphasize the relatively high concentrations of microorganisms in DUW, and the low numbers of bacteria in most domestic water samples. Microscopic evidence of amebas and worms in DUW reinforces the need for further qualitative and quantitative studies of these contaminants of dental tubing biofilm. In most cases, flushing for two minutes reduced microbial concentrations in DUW. However, in a few cases, concentrations rose; in others, the reductions were negligible. Moreover, after 30 minutes of stasis, or use of the waterline in a routine dental procedure, microbial counts were frequently restored to preflush levels or higher. The longer-term ineffectiveness 30 minutes after flushing is understandable when the hydrodynamics of laminar flow of water in narrow-bore tubing are considered. Biofilm on the tubing wall remains intact during flushes and quickly generates more bacteria during stasis. Increased bacterial concentrations after flushing probably result from sloughing of biofilm from the tubing wall because of stretching and movement of the line during routine use. These two phenomena undermine the benefits of routine water flushes. It is a common belief that bacterial levels build to extremes during overnight or weekend stasis; we observed more variation in contamination levels during the workday than between overnight stasis and typical workday samples. The presence of hemolytic staphylococci and streptococci in water samples from lines that were supplied only from sterile water reservoirs adds to the growing evidence that part of the microbial flora in DUWLs may be derived from patients' mouths. Additional prophylactic measures to limit bacterial contamination in DUW should be implemented according to standard principles used in other medical fluid delivery devices.

Influence of the beta-agonist salbutamol on claw horn lesions and walking soundness in finishing pigs

The effects of feeding the beta-adrenergic agonist salbutamol to pigs at levels between 0.5 and 5.0 mg/kg feed for different periods were studied in six experiments. The feet and ability to walk of pigs weighing 30 to 100 kg were examined at intervals. False sand-crack, white-line and heel erosion lesions were classified as mild or severe, and corns and wall haemorrhages were also recorded. At each examination the pig was given a grade for the overall severity of its foot lesions. Salbutamol fed at 1.0 to 5.0 mg/kg feed, for as little as 21 to 28 days, increased the frequency (P < 0.05 to 0.001) and often the severity (P < 0.05) of the foot lesions, the higher doses tending to produce more severe lesions, and the overall foot grades deteriorated (P < 0.001). The effects on both sexes were similar. No changes were observed when 0.5 mg/kg was fed for 56 days. Despite the severity of many of the foot lesions, the pigs became lame in only one experiment. Electron microscopy indicated that salbutamol was interfering with horn production, but light microscopy revealed no changes in skin sections. These findings suggested that salbutamol was not directly affecting the function of keratinocytes. Supplementing the diet of the pigs with biotin and methionine did not delay, or prevent, the effects of salbutamol.