Nonpharmacological interventions to reduce respiratory viral transmission: an evidence-based review with recommendations

BACKGROUND

Viral respiratory infections are a leading cause of worldwide mortality and exert the potential to cause global socioeconomic crises. However, inexpensive, efficacious, and rapidly deployable strategies to reduce viral transmission are increasingly important in the setting of an ongoing pandemic, though not entirely understood. This article provides a comprehensive review of commonly employed nonpharmacological interventions to interrupt viral spread and provides evidence-based recommendations for their use.

METHODOLOGY

A systematic review of three databases was performed. Studies with defined endpoints of subjects receiving one of five interventions (nasal washing, gargling, personal protective equipment (PPE), social distancing, and hand hygiene) were included. An evidence-based review of the highest level of evidence, with recommendations, was created in accordance with a previously described, rigorous, iterative process.

RESULTS

Fifty-four primary studies were included. The most commonly studied intervention was hand hygiene, followed by PPE, gargling, saline nasal washing, and social distancing.

CONCLUSIONS

Mask use and hand hygiene are strong recommendations for prevention of viral transmission. Donning gloves, gowns, and eye protection are a recommendation in healthcare settings. Saline nasal washing and gargling are options in selected populations. Although an aggregate level of evidence is not provided, the authors recommend social distancing.

Comprehensive Dual- and Triple-Feature Intersectional Single-Vector Delivery of Diverse Functional Payloads to Cells of Behaving Mammals

The resolution and dimensionality with which biologists can characterize cell types have expanded dramatically in recent years, and intersectional consideration of such features (e.g., multiple gene expression and anatomical parameters) is increasingly understood to be essential. At the same time, genetically targeted technology for writing in and reading out activity patterns for cells in living organisms has enabled causal investigation in physiology and behavior; however, cell-type-specific delivery of these tools (including microbial opsins for optogenetics and genetically encoded Ca2+ indicators) has thus far fallen short of versatile targeting to cells jointly defined by many individually selected features. Here, we develop a comprehensive intersectional targeting toolbox including 39 novel vectors for joint-feature-targeted delivery of 13 molecular payloads (including opsins, indicators, and fluorophores), systematic approaches for development and optimization of new intersectional tools, hardware for in vivo monitoring of expression dynamics, and the first versatile single-virus tools (Triplesect) that enable targeting of triply defined cell types.

Cortical Observation by Synchronous Multifocal Optical Sampling Reveals Widespread Population Encoding of Actions

To advance the measurement of distributed neuronal population representations of targeted motor actions on single trials, we developed an optical method (COSMOS) for tracking neural activity in a largely uncharacterized spatiotemporal regime. COSMOS allowed simultaneous recording of neural dynamics at ∼30 Hz from over a thousand near-cellular resolution neuronal sources spread across the entire dorsal neocortex of awake, behaving mice during a three-option lick-to-target task. We identified spatially distributed neuronal population representations spanning the dorsal cortex that precisely encoded ongoing motor actions on single trials. Neuronal correlations measured at video rate using unaveraged, whole-session data had localized spatial structure, whereas trial-averaged data exhibited widespread correlations. Separable modes of neural activity encoded history-guided motor plans, with similar population dynamics in individual areas throughout cortex. These initial experiments illustrate how COSMOS enables investigation of large-scale cortical dynamics and that information about motor actions is widely shared between areas, potentially underlying distributed computations.

Chou-Yang Model for Forward-Backward Multiplicity Correlations at 7 TeV using Generalized Multiplicity Distribution

The basis of the Chou-Yang model is made up of a stochastic and non-stochastic distribution and has been successful in describing forward-backward multiplicities.[1] This project examines data drawn from CERN’s 7 TeV run where we revist the Chou-Yang model’s components. It also approaches phenomenological descriptions for cluster sizes from forward-backward multiplicaity correlation strength by the E735 collaboration.[6] For the stochastic binomial component, it examines the variance of the charge asymmetry parameter z with regards to fixed total charged multiplicities n. The fitting of the Generalized Multiplicity distribution along with the linear least square fitting of the forward backward multiplicity is analysed. The parameters for the Generalized Multiplicity Distribution is presented along with an investigation on the cluster size r.[3] This serves as an extention to the work done by W.Y Wang’sWeighted GMD model at7TeV, however the nonweighted GMD model is used here.[7]

Intermittency in pseudorapidity space of pp collisions at √s $ \sqrt s $ = 7 TeV

The intermittency-type fluctuations in the pseudorapidity space of pp collisions at $ \sqrt s $ = 7 TeV done at the LHC is investigated, by analysing the scaling properties (exponents) of the factorial moments of the event multiplicity distributions in decreasing pseudorapidity bin size. It is found that the scaling behaviour persists in the $ \sqrt s $ = 7 TeV regime, indicating intermittent behaviour as observed previously in analyses done at lower energies [1,2]. Comparison is also made with the theoretical predictions of the Generalised Multiplicity Distribution (GMD) [3,4,6].

2012: A watershed year for Alzheimer's disease research

Despite negative topline phase 3 clinical trial results for bapineuzumab and solanezumab in mild to moderate AD, findings from these trials and recent advances suggest renewed optimism for anti-amyloid therapies. Aβ immunotherapy has now demonstrated its ability to engage CNS Aβ and modify downstream CNS biomarkers in bapineuzumab treated patients, and to show likely cognitive benefits in mild patients treated with solanezumab. The current availability of potent BACE inhibitors provides additional opportunities to test the value of reducing Aβ in the clinic. Trial enhancements, such as selecting and enriching for early stage AD, treating participants longer and using more sensitive composite endpoints may further improve our chances of demonstrating clinical efficacy and securing beneficial treatments for patients.

Prevalence, knowledge and care patterns for gastro-oesophageal reflux disease in United States minority populations

BACKGROUND

While there is evidence of ethnic variation in the prevalence of gastro-oesophageal reflux disease (GERD) symptoms, few population-based studies examine GERD symptom prevalence amongst the growing Hispanic minority in the US as well as Asians in the West.

AIM

To examine the prevalence, awareness and care patterns for GERD across different ethnic groups.

METHODS

A population-based, cross-sectional survey was fielded in English, Chinese and Spanish that assessed self-reported GERD prevalence, awareness and care patterns in four ethnic groups (Caucasian, African American, Asian, Hispanic).

RESULTS

A total of 1172 subjects were included for analysis: 34.6% experienced GERD symptoms at least monthly, 26.2% at least weekly and 8.2% at least daily. Statistically significant differences in raw prevalence rates between racial groups were found: 50% of Hispanics experienced heartburn at least monthly, compared with 37% of Caucasians, 31% of African Americans and 20% of Asians (P > 0.0001). Significant differences in knowledge and care-seeking patterns by ethnicity were also observed.

CONCLUSIONS

This study confirms the high prevalence of GERD symptoms in the US and introduces Hispanics as the ethnicity with the highest prevalence rate. Asians in the US have higher rates of symptoms than in the Far East. These data demonstrate a need for culturally appropriate education about GERD symptoms and treatment.

Randomized trial of adjunctive topiramate therapy in infants with refractory partial seizures

OBJECTIVE

To evaluate the efficacy and safety of adjunctive topiramate (sprinkle capsules or oral liquid) in reducing daily rates of partial-onset seizures (POS) in infants with refractory POS.

METHODS

In this double-blind, placebo-controlled, parallel-group, international study, infants (n = 149) with clinical or EEG evidence of refractory POS were randomly allocated (1:1:1:1) to receive adjunctive topiramate 5, 15, or 25 mg/kg/d or placebo for 20 days. The primary variable was the median percentage reductions in daily POS rate from baseline to final assessment as recorded on a 48-hour video-EEG.

RESULTS

Of the 149 infants (mean age 12 months) included in the intent-to-treat analysis set, 130 completed the study. Median percentage reduction from baseline in daily POS rate was not significantly different (p = 0.97) between topiramate 25 mg/kg (20.4%) and placebo (13.1%). Lower doses were not formally tested, but nominal p values for comparisons with placebo were not significant (15-mg/kg/d dose: p = 0.97; 5-mg/kg/d dose: p = 0.91). Treatment-emergent fever, diarrhea, vomiting, anorexia, weight decrease, somnolence, and viral infection occurred more frequently (> or = 10% difference) with topiramate than with placebo.

CONCLUSION

In infants aged 1-24 months, topiramate 5, 15, or 25 mg/kg/d was not effective as adjunctive treatment for refractory partial-onset seizures. No new safety concerns associated with topiramate use were noted.

CLASSIFICATION OF EVIDENCE

This interventional study provides Class I evidence that topiramate 5, 15, or 25 mg/kg/d compared with placebo does not significantly reduce seizure rates in infants aged 1 month to 2 years with refractory partial-onset seizures.

Randomized, placebo-controlled trial of rofecoxib in the acute treatment of migraine

OBJECTIVE

To investigate the clinical profile of rofecoxib, a long-acting (approximately 17-hour half-life) selective cyclo-oxygenase-2 inhibitor, for the acute treatment of migraine.

METHODS

A randomized, double-blind, placebo-controlled, parallel-group study was conducted. Patients age > or =18 treated a moderate or severe migraine headache with placebo (n = 182), rofecoxib 25 mg (n = 183), or rofecoxib 50 mg (n = 192). The primary efficacy measure was headache relief (mild or no pain) 2 hours after dose.

RESULTS

The proportions of patients with migraine headache relief at 2 hours after dose were 34.3% for placebo, 54.0% for rofecoxib 25 mg (p < 0.001 vs placebo), and 56.7% for rofecoxib 50 mg (p < 0.001 vs placebo). Rofecoxib 25 and 50 mg were superior to placebo in providing pain freedom at 2 hours, 24-hour sustained headache relief, and 24-hour sustained pain freedom; in reducing photophobia, phonophobia, nausea (50 mg only), and functional disability at 2 hours after dose; and in improving some quality-of-life scores over 24 hours. More patients on rofecoxib 50 mg reported adverse events (39.6%) than patients on rofecoxib 25 mg (26.8%) or placebo (23.6%) regardless of drug relatedness; however, the incidences of drug-related adverse events were similar between treatment groups. These adverse events were generally mild or moderate in severity. The most commonly reported adverse events were dry mouth, dizziness, somnolence, nausea, dyspepsia, paresthesia, and asthenia, with similar incidences between treatment groups.

CONCLUSION

Rofecoxib 25 and 50 mg were effective and generally well tolerated for the acute treatment of migraine attacks.

Unusual neurological presentation of neuroblastoma

Acute cerebellar ataxia and opsomyoclonus are presenting signs of occult neuroblastoma for a substantial proportion of paediatric patients. Cerebellar ataxia may be due to antibodies against the neuroblastoma cross-reacting with cerebellar tissue. This report is of a 26-month-old boy who presented with encephalitis-like features of ataxia, seizures, decreased consciousness, and involuntary movements. Magnetic resonance imaging of the brain and spine were normal 2 weeks after presentation. The child did not have the classical signs of opsoclonus or myoclonus at any stage of the disease but was found to have occult neuroblastoma. The late demyelinating changes seen on magnetic resonance imaging of the brain support an immunological basis for the paraneoplastic manifestations of occult neuroblastoma in this child. Occult neuroblastoma should be considered as one of the differential diagnoses for children presenting with persisting encephalitis-like features in the presence of normal neuroimaging findings.

MR nerve imaging in a prospective cohort of patients with suspected carpal tunnel syndrome

OBJECTIVES

To evaluate the reliability and diagnostic accuracy of high-resolution MRI of the median nerve in a prospectively assembled cohort of subjects with clinically suspected carpal tunnel syndrome (CTS).

METHODS

The authors prospectively identified 120 subjects with clinically suspected CTS from five Seattle-area clinics. All subjects completed a hand-pain diagram and underwent a standardized nerve conduction study (NCS). The reference standard for determining CTS status was a classic or probable hand pain diagram and NCS with a difference >0.3 ms between the 8-cm median and ulnar peak latencies. Readers graded multiple imaging parameters of the MRI on four-point scales. The authors also performed quantitative measurements of both the median nerve and carpal tunnel cross-sectional areas. NCS and MRI were interpreted without knowledge of the other study or the hand pain diagram.

RESULTS

Intrareader reliability was substantial to near perfect (kappa = 0.76 to 0.88). Interreader agreement was lower but still substantial (kappa = 0.60 to 0.67). Sensitivity of MRI was greatest for the overall impression of the images (96%) followed by increased median nerve signal (91%); however, specificities were low (33 to 38%). The length of abnormal signal on T2-weighted images was significantly correlated with nerve conduction latency, and median nerve area was larger at the distal radioulnar joint (15.8 vs 11.8 mm(2)) in patients with CTS. A logistic regression model combining these two MR variables had a receiver operating characteristic area under the curve of 0.85.

CONCLUSIONS

The reliability of MRI is high but the diagnostic accuracy is only moderate compared with a research-definition reference standard.

Phase III randomized trial of gabapentin in patients with amyotrophic lateral sclerosis

BACKGROUND

Preclinical and clinical studies of gabapentin in patients with ALS led the authors to undertake a phase III randomized clinical trial.

METHODS

Patients were randomly assigned, in a double-blinded fashion, to receive oral gabapentin 3,600 mg or placebo daily for 9 months. The primary outcome measure was the average rate of decline in isometric arm muscle strength for those with two or more evaluations.

RESULTS

Two hundred four patients enrolled, 196 had two or more evaluations, and 128 patients completed the study. The mean rate of decline of the arm muscle strength was not significantly different between the groups. Moreover, there was no beneficial effect upon the rate of decline of other secondary measures (vital capacity, survival, ALS functional rating scale, timed walking) nor was there any symptomatic benefit. In fact, analysis of the combined data from the phase II and III trials revealed a significantly more rapid decline of forced vital capacity in patients treated with gabapentin.

CONCLUSION

These data provide no evidence of a beneficial effect of gabapentin on disease progression or symptoms in patients with ALS.

Familial dyskinesia and facial myokymia (FDFM): a novel movement disorder

We describe here familial dyskinesia and facial myokymia (FDFM), a novel autosomal dominant disorder characterized by adventitious movements that sometimes appear choreiform and that are associated with perioral and periorbital myokymia. We report a 5-generation family with 18 affected members (10 males and 8 females) with FDFM. The disorder has an early childhood or adolescent onset. The involuntary movements are paroxysmal at early ages, increase in frequency and severity, and may become constant in the third decade. Thereafter, there is no further deterioration, and there may even be improvement in old age. The adventitious movements are worsened by anxiety but not by voluntary movement, startle, caffeine, or alcohol. The disease is socially disabling, but there is no intellectual impairment or decrease in lifespan. A candidate gene and haplotype analysis was performed in 9 affected and 3 unaffected members from 3 generations of this family using primers for polymorphic loci closely flanking or within genes of interest. We excluded linkage to 11 regions containing genes associated with chorea and myokymia: 1) the Huntington disease gene on chromosome 4p; 2) the paroxysmal dystonic choreoathetosis gene at 2q34; 3) the dentatorubral-pallidoluysian atrophy gene at 12p13; 4) the choreoathetosis/spasticity disease locus on 1p that lies in a region containing a cluster of potassium (K+) channel genes; 5) the episodic ataxia type 1 (EA1) locus on 12p that contains the KCNA1 gene and two other voltage-gated K+ channel genes, KCNA5 and KCNA6; 6) the chorea-acanthocytosis locus on 9q21; 7) the Huntington-like syndrome on 20p; 8) the paroxysmal kinesigenic dyskinesia locus on 16p11.2-q11.2; 9) the benign hereditary chorea locus on 14q; 10) the SCA type 5 locus on chromosome 11; and 11) the chromosome 19 region that contains several ion channels and the CACNA1A gene, a brain-specific P/Q-type calcium channel gene associated with ataxia and hemiplegic migraine. Our results provide further evidence of genetic heterogeneity in autosomal dominant movement disorders and suggest that a novel gene underlies this new condition.

Diagnosis of carpal tunnel syndrome: electrodiagnostic and magnetic resonance imaging evaluation

In clinically diagnosed CTS without symptoms or signs to suggest other disorders that can mimic CTS, it is unclear whether performing nerve conduction studies are cost-effective. An outcome study to determine whether nerve conduction studies are necessary for the diagnosis may help to clarify this issue. Even less evidence exists regarding the cost-effectiveness of imaging for CTS. MR imaging reliably depicts normal carpal tunnel anatomic details, including the median and ulnar nerves as well as their intraneural fascicular structure. It can also identify pathologic nerve compression and mass lesions that compress nerves such as ganglion cysts. Currently, MR imaging is probably most commonly used to image patients with ambiguous electrodiagnostic studies and clinical examinations. In the near future, MR diffusion-weighted imaging should be possible for peripheral nerves. As is the case with brain imaging, diffusion-weighted imaging of peripheral nerves is likely to be the most sensitive imaging modality for the detection of early nerve dysfunction. Electrodiagnostic studies are likely to remain the pivotal diagnostic examination in patients with suspected CTS for the foreseeable future. With advances in software and hardware, however, high-resolution MR imaging of peripheral nerves should become faster, less expensive, and probably more accurate, possibly paving the way for an expanded role in the diagnosis of this common syndrome.

Water harvesting techniques for small communities in arid areas

Limited water resources exist in numerous remote indigenous settlements around Australia. Indigenous people in these communities are still living in rudimentary conditions while their urban counterparts have full amenities, large scale water supplies and behavioral practices which may not be appropriate for an arid continent but are supported by extensive infrastructure in higher rainfall coastal areas. As remote indigenous communities continue to develop, their water use will increase, and in some cases, costly solutions may have to be implemented to augment supplies. Water harvesting techniques have been applied in settlements on a small scale for domestic and municipal purposes, and in the large, broadacre farm setting for productive use of the water. The techniques discussed include swales, infiltration basins, infiltration trenches and "sand dam" basins. This paper reviews the applications of water harvesting relevant to small communities for land rehabilitation, landscaping and flood control. Landscaping is important in these communities as it provides shelter from the sun and wind, reduces soil erosion and hence reduced airborne dust, and in some cases provides food and nutrition. Case studies of water harvesting systems applied in the Pilbara Region, Western Australia for landscaping around single dwellings in Jigalong and Cheeditha, in a permaculture garden in Wittenoon and at a college and carpark in Karratha are described.

Introduction of water conservation education packages: the opportunites and constraints affecting their success

The Remote Area Developments Group in the Institute for Environmental Science at Murdoch University developed a video and booklet education package on water conservation. The package was developed after research, review of current efforts in water conservation, and consultation with communities showed that there was a need in this area. The package was distributed to all communities within Western Australia. Several different workshops were conducted with Indigenous Environmental Health Workers from around Western Australia in remote areas and in the Perth Metropolitan communities using the package. This paper will briefly describe the opportunities and constraints that exist for water conservation in remote Aboriginal communities in Western Australia as well as give an evaluation of the education package based on workshops, trials and survey instrument. This paper will explain the conclusions that have been drawn from the study: that a broad delivery style is the most advantageous style for remote communities, allowing the facilitator to assess the best style of delivery.

Family poisoned by mercury vapor inhalation

Acute mercury vapor poisoning is an uncommon but potentially fatal toxicologic emergency. A case series is presented of a family who became exposed to mercury vapor as a result of home gold ore processing. The severity of the poisoning necessitated mechanical ventilation in three of the eight patients who were exposed. Despite aggressive management, two patients died, because their clinical course was dominated by irreversible pulmonary toxicity. The remaining survivors developed varying degrees of mercury toxicity. The pathophysiology, clinical presentation and current treatment guidelines for acute mercury vapor poisoning are emphasized.

B7-2-positive myeloma: incidence, clinical characteristics, prognostic significance, and implications for tumor immunotherapy

Deficiencies in B7:CD28 costimulation are considered to be one of the major causes of the failure to generate a tumor-specific immune response. Up-regulating the expression of the B7 molecules on malignant B cells has been shown to stimulate cytotoxic T cells. Plasma cells from patients with myeloma express a tumor-specific idiotype but lack CD80 (B7-1) and have a variable expression of CD86 (B7-2). This study has identified the incidence and clinical significance of high CD86 expression on plasma cells at diagnosis and studied the ability of trimeric human CD40 ligand (huCD40LT) to up-regulate the expression of the B7 family on malignant plasma cells. CD86 expression on plasma cells was increased in 54% of the patients studied at diagnosis (n = 35) and was associated with a significantly shorter survival (median, 28 versus 57 months; chi(2) = 4.6; P =.03) and a higher tumor load (patients with more than 50% bone marrow plasma cells, 47% versus 6%; chi(2) = 7.2; P =.005). CD86 expression was highest on immature and primitive plasma cells (CD38(++), CD45(+)) of both patients and controls and was associated with a CD40(+), CD20(+), CD19(-), CD138(+) phenotype. The shortened survival was associated with high CD86 only on mature (CD38(++), CD45(-)) plasma cells (chi(2) = 7.6; P =.006). There was no significant correlation between high CD86 and other known prognostic markers, including serum beta(2)-microglobulin, serum thymidine kinase, and labeling index. The addition of huCD40LT to short-term cultures up-regulated both CD80 and CD86 expression on B cells (CD19(+)) and CD80 on plasma cells (CD38(++)), but did not up-regulate CD86 expression on plasma cells. Thus, B7-2-positive myeloma consists of a subgroup of patients with a relatively poor prognosis, and CD40LT may be useful in immunotherapy protocols because it up-regulates CD80 expression on malignant plasma cells without inducing B7-2-positive myeloma. (Blood. 2000;96:1274-1279)

T-cell expansions in patients with multiple myeloma have a phenotype of cytotoxic T cells

The presence of T-cell clones in peripheral blood has been previously shown to be associated with a survival advantage in patients with multiple myeloma and suggests that the expanded T-cell populations may be involved in an anti-tumour response. We studied the T-cell receptor (TCR) repertoire of 38 patients with myeloma to identify and characterize the expanded T-cell populations by flow cytometry. T-cell expansions were found in 79% of the patients. The expansions occurred randomly among the 21 variable regions of the TCR beta chain (Vbeta) studied, representing 62% of the V-beta repertoire, and were stable during an 18-month follow-up. The phenotype of the expanded V-beta populations was predominantly CD8+, CD57+, CD28- and perforin+, which differed significantly from the other non-expanded Vbeta populations. The expression of the apoptosis markers Fas (CD95) and bcl-2 were similar between the expanded and non-expanded Vbeta populations. In conclusion, expanded T-cell populations were frequent in patients with myeloma, they remained unchanged during follow-up and had phenotypic characteristics of cytotoxic T cells. These data add further support to the concept that the T-cell expansions may have an immunoregulatory role in myeloma.

Electrodiagnostic features of hereditary neuropathy with liability to pressure palsies

OBJECTIVE

Because diagnosis of hereditary neuropathy with liability to pressure palsies (HNPP) frequently is missed or delayed, we looked for electrodiagnostic features that raise suspicion of the disorder by making comparisons with two more common diseases that mimic it electrophysiologically: chronic inflammatory demyelinating polyneuropathy (CIDP) and diabetic polyneuropathy.

METHODS

A retrospective review of the neuromuscular laboratory database was performed.

RESULTS

Nine HNPP subjects, 22 with CIDP and 49 with diabetic polyneuropathy. Of all the HNPP nerves studied, abnormally slow sensory nerve conduction velocity (SNCV) was found in 93%, prolonged distal motor latencies (DML) in 78%, slow motor nerve conduction velocity in 31%, and prolonged F-wave latencies in 90%. Mean SNCV for HNPP was 85.6%+/-10.6% of the lower limit of normal and significantly slower than for CIDP (114.3%+/-20.1%; p<0.0001) or diabetes (108.1%+/-14.8%; p<0.0001). Excluding the carpal tunnel site from the analysis did not alter this observation: Mean DML were more prolonged in HNPP, even without median nerve data in the analysis (118.5%+/-31.0% of the upper limit of normal), than in CIDP (103.2%+/-31.6%; p<0.05) or diabetes (86.3%+/-18.3%; p<0.0001). Mean HNPP motor nerve conduction velocity was within normal limits.

CONCLUSIONS

According to findings, hereditary neuropathy with liability to pressure palsies (HNPP) has a distinctive background polyneuropathy independent of superimposed entrapment neuropathy. It is characterized by diffuse sensory nerve conduction velocity (SNCV) slowing and prolongation of distal motor latencies with relatively infrequent and minor reduction of motor nerve conduction velocities. This indicates disproportionate distal conduction slowing in the disorder.

The expression of T cell related costimulatory molecules in multiple myeloma

Presentation of tumour antigen by malignant cells not expressing costimulatory molecules is considered to be a major cause of the failure of the host's immune response against tumours. This study has determined the expression of the B7 family of costimulatory molecules on malignant plasma cells and the expression of the counter receptor molecules, CD28 and CD152 (CTLA-4), on T cells of patients with multiple myeloma. CD28 expression was present on most CD4 cells but was lower on CD8 cells especially from those patients who also showed evidence of expanded T cell clones (median 40%. z=2.4; p<0.02). CD152 expression was increased in 50% (9/18) of patients with myeloma. CD80 (B7-1) expression was present on the plasma cells of only 1 of 27 samples but CD86 (B7-2) expression within the normal range was present on the plasma cells of 14 of 27 samples. Primitive plasma cells (CD38++ CD45++) had a higher expression of CD86 (median 78%) than mature plasma cells (CD38++ CD45-) (median 19%, z=3.7; p<0.01). Thus patients with expanded T cell clones have a downregulated T cell CD28 expression and lack B7-1 expression on their malignant plasma cells. These results are consistent with the concept that engagement of the T cell receptor by tumour antigen on B7-1 deficient malignant plasma cells would result in T cell anergy rather than productive immunity.

The prognostic significance of T cell receptor beta gene rearrangements and idiotype-reactive T cells in multiple myeloma

Clonal T cell populations with idiotype specificity are present in the peripheral blood of a proportion of patients with multiple myeloma. We have identified the presence of both T cell subpopulations with a specificity for autologous immunoglobin fragments and T cell receptor beta gene rearrangements in peripheral blood samples of patients with myeloma. T cell receptor beta gene rearrangements were detected in 38 of 119 patient samples (32%) and were more common in progressive disease (70%), than at diagnosis (25%) or in stable disease (23%). The 38 patients who had T cell receptor beta gene rearrangements detected at any time had a better overall survival (median not yet achieved) than the patients who never had rearrangements detected (median 45 months, n = 49; chi2 = 6.2, P < 0.01). All 12 patients with T cell receptor beta gene rearrangements at diagnosis are still alive whereas the median survival for 28 patients with a germline configuration at diagnosis was 40 months (chi2 = 5.8, P > 0.01). The presence of T cell receptor beta gene rearrangements even conferred a survival advantage during progressive disease (median survival 44 months vs 19 months; chi2 = 8.7, P < 0.003). Two colour flow cytometry with biotinylated autologous immunoglobulin fragments demonstrated idiotype-reactive T cells in the peripheral blood of five out of 15 patients all of whom had T cell gene rearrangements. The remaining 10 patients had neither idiotype-reactive T cells nor a detectable T cell receptor beta gene rearrangement in concurrent samples. Thus in patients with myeloma there was a good correlation between the presence of T cell receptor beta gene rearrangements and idiotype-reactive T cells. Patients with a rearranged T cell receptor beta gene had a significantly better prognosis.

Immunophenotypic analyses of cultured hemopoietic mast cells

Immunophenotypic analyses of immature stage (day 19-23), intermediate stage (day 28-32), mature stage (day 34-37), and older stage (day 42-44) human hemopoietic mast cells from colonies grown in semi-solid agar cultures were performed to study the ontogeny and identity of this cell type and its relationship to other leukocytes. Intermediate to mature stage mast cells were positive with the YB5.B8 mouse monoclonal antibody, (McAb) specific for human mast cells, whereas the reactivity of immature mast cells with this McAb was inconsistent and older cells were generally negative. Mast cells at all stages of maturation were strongly positive for IgE receptor sites and negative with the Bsp-1 McAb, specific for human basophils. Mast cells at all stages of maturation were also strongly positive with the monocyte McAbs RPA-M1 (CD11), positive with the monocyte McAb OKM5 and the monocyte/granulocyte McAbs BMA-210 and MY7 (CD13), strongly positive with the B-cell markers J5 (CD10) and anti-IgM, and positive with the plasma cell marker PCA-1 and to a lesser extent with the activated B-cell marker CD23. The mast cells were also strongly positive with anti-CD45 to the common leukocyte antigen and positive with an antibody to HLA-DR and an antibody to FVIIIC. They were negative for specific T-cell markers. The diversity of this phenotype supports the current concept that mast cells originate from the pluripotential progenitor cells in the bone marrow.

Identification and characterization of human hemopoietic mast cell colonies

Persisting mast cell colonies from human bone marrow and cord blood cells grown in semisolid agar cultures for over 56 days have been positively identified and characterized using morphology and cytochemistry. Mast cells demonstrated the following features: Cytoplasmic granules frequently contained the specific and characteristic papyrus rolls (transmission electron microscopy); mature cells were positive to the mouse monoclonal antibody YB5.B8 specific for human mast cells (raised against acute myeloid leukemia cells) and RPA-M1 specific for human monocytes but negative to the human basophil monoclonal antibody Bsp-1; morphologically the cells were large (diameter 20-25 micron), deeply basophilic, and contained granules that measured up to 2 micron in diameter (May-Grünwald-Giemsa stain); the presence of heparin by the thrombin clotting time and positive staining with toluidine blue and alcian blue; the presence of histamine by a positive fluorescent o-phthalaldehyde stain; the presence of IgE receptor sites with human IgE and a rabbit anti-human IgE second antibody; and a unique zone of lysis around mast cell colonies occurred when cultured on peripheral blood feeder layers in agar plates that was not present around monocytic, neutrophilic, or eosinophilic colonies under the same culture conditions. Our results identify the cells in persisting colonies as mast cells and describe some specific characteristics that distinguish these cells from basophils.

Post bone marrow transplant sera and persisting mast cell colonies

Serum samples were collected from eight recipients of allogeneic bone marrow transplants (BMT) following the normalization of peripheral blood counts. Three patients (11 samples) were in the early engraftment period (less than 6 months post-BMT) and still receiving cyclosporin A or methotrexate and the remaining five patients (18 samples) were in stable engraftment (12-84 months post-BMT) and not on immunosuppressive therapy. All post-BMT serum samples supported the growth of increased numbers of mast cell colonies in long-term agar cultures when compared with normal controls (p less than 0.025-0.005), irrespective of the time from BMT or the presence of clinical graft-versus-host disease (GVHD). In contrast, the numbers of neutrophil, monocyte and eosinophil colonies were equivalent in test and control groups. It is proposed that post-BMT sera contain higher levels of a mast cell stimulating activity(s) than does normal sera. Such increased levels might be associated with clinical or subclinical GVHD.

Persisting colonies in agar cultures containing serum from patients with CML in blastic transformation

Addition of serum from patients with chronic myeloid leukemia (CML) in both chronic phase and blastic transformation, to agar cultures of normal human marrow cells stimulated the growth of persisting colonies (day 35) containing either eosinophils or mast cells. Chronic phase serum stimulated an 800% increase in the total number of these colonies of which only 16% were mast cells. Serial studies using serum from 2 patients demonstrated that the proportion of mast cells increased during the progression to blastic transformation. The emergence of a greater proportion of persisting mast cell colonies and a decrease in absolute number of eosinophil colonies in agar cultures of normal marrow cells containing serum from patients with CML coincides with the emergence of blastic transformation and suggests that a significant change occurs in the absolute and relative concentration of hemopoietic growth factors in these patients.

Human bone marrow progenitor cells stimulated by cord blood

Agar cultures of human bone marrow cells stimulated by cord plasma or irradiated cord blood feeder layers demonstrated the presence of a multilineage hemopoietic growth factor in cord blood. When bone marrow cultures stimulated with giant cell tumor-conditioned medium (GCT-CM) were supplemented with this cord blood-derived growth factor, total colony numbers increased by more than 50% after day 23 and persisted in culture for approximately 40 days. Marrow cultures stimulated by the cord blood-derived growth factor formed colonies of neutrophils, monocyte-macrophages, eosinophils, mast cells, and a few colonies containing a mixed cell population. The results suggest that, while GCT-CM contains granulocyte-monocyte colony-stimulating factor (GM-CSF), cord blood contains a high concentration of a multilineage hemopoietic growth factor, which may be multi-CSF.

Stimulation of persisting colonies in agar cultures by sera from patients with CML and AML

Cord plasma contains colony-stimulating activity (CSA) which stimulates the in vitro clonal growth of neutrophils, eosinophils, macrophages, erythrocytes, and persisting mast cells in semisolid cultures. Analysis of day 35 colonies in agar cultures was found to be a suitable means of demonstrating this activity and discriminating between it and granulocyte-macrophage colony-stimulating factor (GM-CSF). Serum (10%) from patients with acute and chronic myeloid leukemia (AML and CML) was added to normal human bone marrow cultures to search for similar activity in these patient's serum. Although the number of colonies on day 12 (predominantly neutrophils and macrophages) was not significantly different from the number of colonies in cultures containing normal serum, the number of colonies increased 500% in cultures containing CML serum on day 35. Serum from patients with AML during regeneration also stimulated an increased number of colonies on day 35. Although both eosinophil and mast cell colonies were still present on day 35, only mast cell colonies persisted for 150 days. On day 35, cultures containing 10% CML serum contained predominantly eosinophil colonies (84%), whereas cultures containing AML serum contained predominantly mast cell colonies (76%). Although serum contains various CSFs, the specific factor which stimulates persisting mast cell colonies may be the human equivalent of murine persisting (P) cell-stimulating factor (Multi-CSF).

Plasma lactoferrin in patients with neutropenia

This study examines the role of plasma lactoferrin in the assessment of neutropenia. In particular, we have studied lactoferrin as an inhibitor of granulopoiesis and as an indicator of the size of the total blood granulocyte pool (TBGP). Plasma lactoferrin concentration was determined in a heterogeneous group of 30 patients with neutropenia. Serial plasma lactoferrin levels in a patient with cyclic neutropenia correlated with the cycles of the neutrophil count. Patients with splenomegaly had a grossly elevated lactoferrin:neutrophil ratio. Most chronic idiopathic neutropenia patients had no real clinical problems and a normal plasma lactoferrin level. The results provide further evidence to support the concept that plasma lactoferrin indicates the size of the TBGP and the lactoferrin: neutrophil ratio indicates the degree of granulocyte margination. There was no evidence to suggest that lactoferrin acting as a feedback inhibitor of granulopoiesis caused neutropenia in these patients.

An evaluation of serum erythropoietin estimation by a hemagglutination inhibition assay in the differential diagnosis of polycythemia

A commercially available hemagglutination inhibition assay kit for the measurement of erythropoietin (EPO) was evaluated for its usefulness in the differential diagnosis of the polycythemic states. Serum samples were obtained from patients with polycythemia rubra vera (active and controlled), secondary and relative polycythemia and from normal controls. Firstly, we found that the mean EPO level (+/- SD) of our normal controls (81 +/- 69 miu/ml) was higher than the manufacturer's quoted normal range (15-59 miu/ml) and that there was a significant spread of values (7-233 miu/ml). Secondly, within each patient subgroup studied, the spread of data points was so wide that interpretation of individual data points would be impossible. We conclude that this assay kit is of little value for serum EPO estimation and in the differential diagnosis of polycythemia.

An analysis of peripheral blood burst forming units-erythroid in the polycythaemic states

Peripheral blood burst forming units-erythroid (BFU-E) were measured by the plasma clot cell culture technique in patients with the various subtypes of polycythaemia and compared to normal. 10 patients with active polycythaemia rubra vera (PRV) were found to have a mean BFU-E level of 48 +/- 15.8 (SEM) per 5 X 10(5) cultured cells which was significantly different from normals (4 +/- 1.1, P less than 0.02), patients with controlled PRV (7 +/- 1.6, P less than 0.025), secondary polycythaemia (1 +/- 0.3, P less than 0.015) and relative polycythaemia (0, P less than 0.015). Burst forming units were found to fall to normal levels in patients with PRV with appropriate disease control and then to rise again in patients untreated for more than 18 months. Clinical aspects. Measurement of BFU-E levels from the peripheral blood could provide a useful adjunct from an accessible source in the differential diagnosis of polycythaemia as well as being of use in serial monitoring of patients with PRV.

The use of peripheral blood feeder layers as a source of GM-CSF for human bone marrow cultures

The use of peripheral blood feeder layers as a source of stimulus for colony formation by human granulocytic progenitor cells in semi-solid agar cell cultures was examined. Comparison with various conditioned media demonstrated that cultures stimulated by peripheral blood feeder layers produced the greatest number and largest colonies. The cell concentration in the feeder layers was more important than the total cell number. Feeder layer plates containing 2 X 10(5) cells at a concentration of 1 X 10(6) cells/ml proved to be just potent as the conventional feeder layer plates containing 1 x 10(6) cells/ml in 1 ml. Thus feeder layer plates can be more economical in terms of cell numbers than has previously been reported. By using a known panel of donors for the leukocytes, the number of sub-optimal batches of feeder layers was reduced. Addition of 1 microM adenosine 3':5'-cyclic-monophosphate or 10 micrograms/ml Li2CO3 to poor feeder layers enhanced their colony-stimulating ability.

In vitro clonogenic assays in selective neutropenia

Granulocyte-monocyte colony forming cell (GM-CFC) concentration and the proportion of GM-CFC in DNA synthesis (S) were determined in 43 patients with varying degrees of selective neutropenia, including 5 patients who were normal extremes (2.0-2.5 x 10(9) neutrophils/1), to study the diagnostic and prognostic significance of clonogenic assays and to determine the response of the committed myeloid stem cell to neutropenia. The proportion of GM-CFC in S proved to be a more useful parameter than the GM-CFC concentration. 75% of the patients with greater than 60% GM-CFC in S returned to normal within 1 month. Patients with less than 20% GM-CFC in S had at least a 10 times greater incidence of developing a malignant or autoimmune disease than the other 28 patients. The 11 patients with 41-51% in GM-CFC in S had greater than 1 x 10(9) neutrophils/1 and no significant clinical problems but all have remained mildly neutropenic for a long period. An indirect relationship existed between the degree of neutropenia and the proportion of GM-CFC in S (r = -0.70).

Studies on human cord blood progenitor cells

Analysis of agar cultures throughout a 56-day period determined the concentration and cell cycle status of at least 4 different subclasses of hemopoietic colony forming cells (CFC) in human cord blood (CB). Although the concentration of CFC in CB was not significantly different from bone marrow (BM) in day-12 cultures, neutrophil colonies reached their peak on about day 23 in CB cultures and on day 12 in BM cultures. This suggests that the CFC in CB are more primitive than those in BM. In CB cultures, colonies of small cells contained predominantly neutrophils on day 14 and eosinophils on day 35, while the late developing (day 35) colonies of large cells contained mast-cell-like cells (MCL).

Some properties of the colony forming cell in adult acute leukaemia

Variations in the concentration and physical characteristics of the bone marrow derived colony forming cell(CFC) have been studied in patients with acute leukaemia. Two-hundred-and-fifteen marrow samples from 83 patients provide the basis for this analysis. CFC concentration confirmed the clinical remission/relapse status and yielded some guidelines to prognosis in individual patients while the proportions of CFC in DNA synthesis also proved to be a most reliable indicator of disease status. In remission, CFC concentrations return to normal values whilst on presentation and in the relapse phase of acute leukaemia CFC numbers are reduced. Biophysical profiles of CFC established using albumin density gradient and velocity sedimentation studies also indicated the state of the leukaemic process in individual patients. By applying physical laws to the data obtained from such profiles, the mean volume, diameter, density and mass of CFC were calculated. CFC from leukaemic patients in relapse were up to twice the volume and mass although slightly less dense than CFC from normal patients. The reasons for these changes are explained and discussed.

Scanning electron and light microscope correlation of individual human bone marrow cells before and after culture in nutrient agar

This study was undertaken with the aim of identifying the different cell types found in human bone marrow by examining their surface morphology. In an attempt to obtain a homogeneous cell population, cells were both fractionated by discontinuous albumin density gradient centrifugation (DADGC) and selectively grown in nutrient agar. Both cell preparations underwent the critical point drying technique before examination under both the scanning electron microscope (SEM) and subsequently the light microscope (LM). When the SEM image of individual cells was compared with the corresponding LM image, it was not easy to identify the different cell types, because of the shrinkage and distortion that occurred during their preparation. The shrinkage observed under the SEM amounted to a 45% reduction in mean cell diameter. This shrinkage was confirmed by comparing the SEM and LM images of the same cell. Although shrinkage occurred throughout the dehydration sequence, critical point drying was responsible for a 25% reduction in mean cell diameter. Furthermore, direct observation under LM of fixed cells drying in air from ethanol, revealed visible contraction of the cell and distortion of the cell membrane. We assume that a similar morphological change occurred during critical point drying. We conclude that the shrinkage and distortion, caused by the dehydration process involved in SEM preparation, severely limit the value of a study of surface morphology by SEM in the identification of the different cell types found in human bone marrow.

The effect of cyclic AMP on human colony forming cell and colony stimulating factor production

The effect of cyclic AMP (cAMP) and related nucleotides on human colony forming cells (CFC) and those cells producing colony stimulating factor (CSF) was studied in vitro. When added at physiological concentrations (10(-2) to 1 micron), exogenous cAMP stimulated maximum colony formation in cultures without feeder layers. Related nucleotides stimulated colony formation to a lesser extent and in decreasing order of free energy. All nucleotides inhibited colony formation in concentrations above 1 micron. A velocity sedimentation cell separation technique was used to obtain cell fractions rich in CFC but poor in CSF-producing cells. Such fractions did not respond to cAMP stimulation. These studies suggest that exogenous cAMP stimulates human bone marrow to form colonies in vitro by increasing the release and/or production of endogenous CSF.

Effects of acidity, cations and alcoholic fractionation on absorption of heparin from gastrointestinal tract

Heparin was introduced into the stomach or duodenum of mice separately in doses of ca. 250 mg/kg. A slight anticoagulant effect in the systemic circulation was detected in whole blood clotting times and factor X inhibition. In contrast to most drugs, more heparin was absorbed from the stomach than from the intestine. Suppressing ionization of heparin by simultaneous administration of acid resulted in improved absorption of heparin from the small intestine. Heparin was separated with ethanol into five molecular weight fraction: I, 17 999; II, 13 i99; III, 10800, IV, 8 700; and V, 6 700. Each was introduced into the duodenum of mice with citric acid. The maximum hypocoagulability was produced with fraction IV. When administered in distilled water instead of in citric acid, this heparin fraction did not produce an anticoagulant effect. These studies demonstrated that improvement of heparin absorption from the gastrointestinal tract can be obtained by the combination of suppressing ionization and selecting molecular size.