Single-cell multiomic dissection of response and resistance to chimeric antigen receptor T cells against BCMA in relapsed multiple myeloma

Markers that predict response and resistance to chimeric antigen receptor (CAR) T cells in relapsed/refractory multiple myeloma are currently missing. We subjected mononuclear cells isolated from peripheral blood and bone marrow before and after the application of approved B cell maturation antigen-directed CAR T cells to single-cell multiomic analyses to identify markers associated with resistance and early relapse. Differences between responders and nonresponders were identified at the time of leukapheresis. Nonresponders showed an immunosuppressive microenvironment characterized by increased numbers of monocytes expressing the immune checkpoint molecule CD39 and suppressed CD8+ T cell and natural killer cell function. Analysis of CAR T cells showed cytotoxic and exhausted phenotypes in hyperexpanded clones compared to low/intermediate expanded clones. We identified potential immunotherapy targets on CAR T cells, like PD1, to improve their functionality and durability. Our work provides evidence that an immunosuppressive microenvironment causes resistance to CAR T cell therapies in multiple myeloma.

Cellular dynamics following CAR T cell therapy are associated with response and toxicity in relapsed/refractory myeloma

B-cell maturation antigen (BCMA)-targeting chimeric antigen receptor (CAR) T cells revolutionized the treatment of relapsed/refractory multiple myeloma (RRMM). However, data on cellular (CAR) T cell dynamics and the association with response, resistance or the occurrence of cytokine release syndrome (CRS) are limited. Therefore, we performed a comprehensive flow cytometry analysis of 27 RRMM patients treated with Idecabtagene vicleucel (Ide-cel) to assess the expansion capacity, persistence and effects on bystander cells of BCMA-targeting CAR T cells. Additionally, we addressed side effects, like cytokine release syndrome (CRS) and cytopenia. Our results show that in vivo expansion of CD8+ CAR T cells is correlated to response, however persistence is not essential for durable remission in RRMM patients. In addition, our data provide evidence, that an increased fraction of CD8+ T cells at day of leukapheresis in combination with successful lymphodepletion positively influence the outcome. We show that patients at risk for higher-grade CRS can be identified already prior to lymphodepletion. Our extensive characterization contributes to a better understanding of the dynamics and effects of BCMA-targeting CAR T cells, in order to predict the response of individual patients as well as side effects, which can be counteracted at an early stage or even prevented.

Steady-state versus chemotherapy-based hematopoietic cell mobilization after anti-CD38-based induction therapy in newly diagnosed multiple myeloma

BACKGROUND

The incorporation of anti-CD38 monoclonal antibodies (mAb) in induction regimens of newly diagnosed transplant-eligible multiple myeloma (MM) patients has been established as a new standard. However, the optimal strategy of stem cell mobilization in this context is not yet clear.

STUDY DESIGN AND METHODS

From May 2020 till September 2022, we retrospectively reviewed patients receiving anti-CD38 mAb-based induction therapy followed by stem cell mobilization either in a steady-state protocol (SSM) using 10 μg/kg granulocyte colony-stimulating factor (G-CSF) for 5 days or in a chemotherapy-based protocol (CM) using 1-4 g/m2 cyclophosphamide and G-CSF.

RESULTS

Overall, 85 patients (median age 61 years) were included in the analysis. In total, 90 mobilization attempts were performed, 42 with SSM and 48 with CM. There was no significant difference in the median concentration of CD34+ cells in peripheral blood (PB) prior to apheresis between SSM and CM (61/μL vs. 55.4/μL; p = .60). Cumulative CD34+ yields did not differ between the groups with median of 6.68 and 6.75 × 106 /kg body weight, respectively (p = .35). The target yield (≥4 × 106 CD34+ cells/kg body weight) was reached in 88% (CM) and 86% (SSM), with a high proportion even after a single apheresis session (76% vs. 75%). Plerixafor was found to be more frequently used in SSM (52%) than in CM (23%; p < .01). A total of 83 patients underwent autologous transplantation and all were engrafted.

CONCLUSIONS

Stem cell collection in patients undergoing anti-CD38-based induction therapy is feasible with either CM or SSM, although SSM more frequently requires plerixafor.

Analysis of stem cell collections in adult patients with Ewing sarcoma

BACKGROUND

Ewing sarcoma is one of the most frequent soft-tissue tumors in pediatric patients. The current treatment protocols recommend stem cell apheresis (SCA) after completion of the second course of induction therapy with vincristine, ifosfamide, doxorubicine, and etoposide (VIDE). The feasibility of SCA and graft compositions in adult patients with Ewing sarcoma have not been previously analyzed.

METHODS AND MATERIALS

The authors analyzed 29 stem cell collections of 19 adult patients (9 male, 10 female) at a median age of 27 (range 19-53) years mobilized after VIDE (n = 17), cyclophosphamide/topotecan (n = 1) or vincristine, dactinomycin and ifosfamide (n = 1) chemotherapy. All patients were mobilized with filgrastim 5 μg/kg twice daily from day +7 of chemotherapy. The collections were performed if CD34+ cell count in peripheral blood was >10/μL. The target yields were ≥4×10⁶ CD34+ cells/kg body weight.

RESULTS

Median CD34+ cells/μL in peripheral blood before SCA were 45.8 (range 6.7-614.4)/μL. The median cumulative yields were 10.6 (range 1.5-38.8) CD34+ cells/kg body weight and ≥2×10⁶ in all but two patients (89%). CD34, CD3, and CD56 yields in collections after the third VIDE and after later courses did not differ. Four patients underwent high-dose therapy with autologous transplantation, and all were engrafted.

DISCUSSION

Stem cell mobilization is feasible in most Ewing sarcoma patients. Additionally, the present study's data suggest that it is safe to postpone stem cell collection to a later VIDE chemotherapy cycle if medically indicated.

Case Report: Large Granular Lymphocyte Leukemia (LGLL)-A Case Series of Challenging Presentations

Large granular lymphocyte leukemia (LGLL) represents a rare group of diseases with considerable difficulties in their correct diagnostic workup and therapy. The major challenges lie in their distinction from reactive (including autoimmune) lymphoproliferations. Moreover, monoclonal LGL proliferative diseases are in fact a heterogeneous group of disorders, as recognized by the three subtypes in the current WHO classification. It distinguishes two chronic forms (the focus of this case series), namely T-LGLL and chronic lymphoproliferative disorders of Natural Killer cells (CLPD-NK) as well as aggressive NK-cell leukemia. In the clinical routine, the variable presentations and phenotypes of T-LGLL and CLPD-NK are underappreciated. The relevant differential diagnoses range from benign reactive T-cell expansions to other mature T-cell leukemias to highly aggressive γδ-lymphomas. T-LGLL or CLPD-NK patients suffer from a wide variety of symptoms often including, but not limited to, cytopenias or classical autoimmune phenomena. They receive treatments ranging from mere supportive measures (e.g. antibiotics, growth factors, transfusions) over strategies of immunosuppression up to anti-leukemic therapies. The diagnostic pitfalls range from recognition of the subtle T-cell proliferation, repeated establishment of monoclonality, assignment to a descript immunophenotypic pattern, and interpretations of molecular aberrancies. Here, we report a series of selected cases to represent the spectrum of LGLL. The purpose is to raise awareness among the scientifically or practically interested readers of the wide variety of clinical, immunological, and phenotypic features of the various forms of LGLL, e.g. of T-cell type, including its γδ forms or those of NK-lineage. We highlight the characteristics and courses of four unique cases from two academic centers, including those from a prospective nationwide LGLL registry. Each case of this instructive catalogue serves to transport a key message from the areas of (chronic inflammatory) contexts in which LGLL can arise as well as from the fields of differential diagnostics and of various treatment options. Implications for optimization in these areas are discussed.

Reasons for failure of total temporomandibular joint replacement: a systematic review and meta-analysis

The aim of this study was to evaluate the revision rate after total alloplastic temporomandibular joint replacement (TMJR) and determine whether there is a higher risk of revision surgery with stock or custom-fitted prostheses (the two most current TMJR prosthesis types). A systematic review was performed, with a search of PubMed, Google Scholar, and the Cochrane Library in November 2020. Overall, 27 articles were included in this study, describing Biomet and TMJ Concepts prostheses and including postoperative data on complications requiring a return to the operating room. A total of 2247 prostheses were analysed: 1350 stock Biomet prostheses and 897 custom-fitted TMJ Concepts and custom-fitted Biomet prostheses. The global revision rate was 1.19 per 100 prosthesis-years. The most common reason for revision was heterotopic bone formation. Stock prostheses appeared to have a lower risk of revision compared to custom prostheses: rate ratio 0.52 (95% confidence interval 0.33-0.81, P-value 0.003). Regarding causes of revision, the only significant difference between the types of devices was a higher rate of heterotopic bone formation for custom-made prostheses (P = 0.001). The results of this study revealed a low revision rate post TMJR revision, with stock devices even less prone to such risk. Nevertheless, these results can be explained by the fact that custom-made prostheses are more likely to be used for cases in which the anatomy is significantly abnormal or there is a history of multiple joint surgeries, which carry a greater risk of complications and heterotopic bone formation.

Stem-cell mobilization of healthy sibling donors with pegfilgrastim-A prospective open-label phase II trial (EudraCT no: 2005-004971-39)

BACKGROUND

Pegfilgrastim is a covalently bound conjugate of filgrastim and mono-methoxypolyethylene glycol with a longer half-life.

STUDY DESIGN AND METHODS

We report on phase II prospective monocentric trial examining the feasibility of stem cell mobilization with 12 mg single dose pegfilgrastim in related donors. The objectives were to determine the optimal collection day, defined as CD34+ concentration in peripheral blood (PB) >50 cells/μl, the number of donors collected with single leukapheresis, and the peak level of pegfilgrastim in donor-serum. Furthermore, the cell composition of grafts was assessed and compared to published data.

RESULTS

The results included about 28 matched related donors. The median pegfilgrastim serum level remained >200 ng/mL for 48 hours before declining, with the maximal measured concentration of 259.49 ng/ml 24 h after application. The median white blood cell count and CD34 count in PB peaked on day four with 52.6 (range 22.8-85.0) Gpt/l and 66.25 (range 22.9-136.6) cells/μl, respectively. A CD34+ count >50 cells/μl on day four was detected in 75% of donors. 79% of the donors underwent a single collection. Conventional filgrastim was administered additionally in two donors, due to insufficient CD 34+ concentration in PB. 89% of donors showed CD34+ yields ≥4 (median 6.5, range 4.6-14.5) × 10/kg body weight of the recipient. All grafts were administered without rejections.

DISCUSSION

The results of this trial showed that stem cell mobilization with pegfilgrastim is a feasible, and attractive option. This is the first trial presenting the kinetics of pegfilgrastim serum levels in healthy donors.

Salvage Therapy With Polatuzumab Vedotin, Bendamustine, and Rituximab Prior to Allogeneic Hematopoietic Transplantation in Patients With Aggressive Lymphomas Relapsing After Therapy With Chimeric Antigen Receptor T-Cells-Report on Two Cases

Up to 60% of patients with aggressive B-cell lymphoma who receive chimeric antigen receptor (CAR) T-cell therapy experience treatment failure and subsequently have a poor prognosis. Allogeneic hematopoietic stem cell transplantation (alloHSCT) remains a potentially curative approach for patients in this situation. Induction of a deep response prior to alloHSCT is crucial for long-term outcomes, but the optimal bridging strategy following relapse after CAR T-cell therapy has not yet been established. Polatuzumab vedotin, an antibody drug conjugate targeting CD79b, is a novel treatment option for use in combination with rituximab and bendamustine (Pola-BR) in relapsed or refractory disease. Patients: We report two heavily pretreated patients with primary refractory diffuse large B-cell lymphoma (DLBCL) and primary mediastinal B-cell lymphoma (PMBCL) respectively who relapsed after therapy with CAR T-cells with both nodal and extranodal manifestations of the disease. After application of three courses of Pola-BR both patients achieved a complete metabolic remission. Both patients underwent alloHSCT from a human leukocyte antigen (HLA)-mismatched donor following conditioning with busulfan and fludarabine and are disease free 362 days and 195 days after alloHSCT respectively. We conclude that Pola-BR can be an effective bridging therapy before alloHSCT of patients relapsing after CAR T-cell therapy. Further studies will be necessary to define the depth and durability of remission of this salvage regimen before alloHSCT.

Two rare cases of bronchus-associated lymphoid tissue lymphoma successfully treated with rituximab-bendamustine

BALT lymphoma is a rare B-NHL with a favorable prognosis. We here report on two patients with nonspecific symptoms: one showed as major symptom severe thrombocytopenia and the other dyspnea and dry cough, thereby suggesting an inflammatory focus in the lungs. There is no standard of care established yet. Both patients were successfully treated with rituximab and bendamustine. Thus, combined immunochemotherapy should be considered as first-line therapy as in other MALT lymphomas, if the treatment/eradication of an underlying chronic inflammatory disorder/trigger factor can be excluded.

Case Report: Allogeneic Stem Cell Transplantation Following Induction With CPX-351 in Patients With Acute Myeloid Leukemia Is Feasible

Acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) and treatment-related acute myeloid leukemia (tAML) after chemotherapy or radiation therapy for other neoplasms are associated with poor outcomes. CPX-351, a dual-drug liposomal encapsulation of daunorubicin and cytarabine, has been shown to improve outcomes in AML-MRC and tAML compared with standard 7+3 regimens. Here we report the cases of four consecutive patients with AML-MRC or tAML who received CPX-351 as outpatient induction therapy immediately followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT). Two patients received allo-HSCT in remission (one in complete remission and one in partial remission) and two patients received allo-HSCT in aplasia (one at 11 days and one at 52 days after the start of induction therapy with CPX-351). With a median follow-up of 188 days after allo-HSCT, all but one patient are alive and two are in remission. Further studies will help define and expand the role of CPX-351 in the treatment of AML-MRC and tAML, especially in patients expected to undergo allo-HSCT.

Clinical Challenges and Consequences of Measurable Residual Disease in Non-APL Acute Myeloid Leukemia

The ability to detect residual levels of leukemic blasts (measurable residual disease, MRD) has already been integrated in the daily routine for treatment of patients with chronic myeloid and acute lymphoblastic leukemia. In acute myeloid leukemia (AML), a variety of mostly retrospective studies have shown that individuals in AML remission who tested positive for MRD at specific time-points or had increasing MRD levels are at significantly higher risk of relapse and death compared to MRD-negative patients. However, these studies differ with respect to the "MRD-target", time-point of MRD determination, material analyzed, and method applied. How this probably very valuable MRD information in individual patients may be adapted in the daily clinical routine, e.g., to separate patients who need more aggressive therapies from those who may be spared additional-potentially toxic-therapies is still a work-in-progress. With the exception of MRD assessment in acute promyelocytic leukemia (APL), the lack of randomized, prospective trials renders MRD-based decisions and clinical implications in AML a difficult task. As of today, we still do not have proof that early intervention in MRD-positive AML patients would improve outcomes, although this is very likely. In this article, we review the current knowledge on non-APL AML MRD assessment and possible clinical consequences.

Mutations in the TLR3 signaling pathway and beyond in adult patients with herpes simplex encephalitis

Herpes simplex encephalitis (HSE) in children has previously been linked to defects in type I interferon production downstream of Toll-like receptor (TLR)3. In the present study, we used whole-exome sequencing to investigate the genetic profile of 16 adult patients with a history of HSE. We identified novel mutations in IRF3, TYK2 and MAVS, molecules involved in generating innate antiviral immune responses, which have not previously been associated with HSE. Moreover, data revealed mutations in TLR3, TRIF, TBK1 and STAT1 known to be associated with HSE in children but not previously described in adults. All discovered mutations were heterozygous missense mutations, the majority of which were associated with significantly decreased antiviral responses to HSV-1 infection and/or the TLR3 agonist poly(I:C) in patient peripheral blood mononuclear cells compared with controls. Altogether, this study demonstrates novel mutations in the TLR3 signaling pathway in molecules previously identified in children, suggesting that impaired innate immunity to HSV-1 may also increase susceptibility to HSE in adults. Importantly, the identification of mutations in innate signaling molecules not directly involved in TLR3 signaling suggests the existence of innate immunodeficiencies predisposing to HSE beyond the TLR3 pathway.

Amino acid supplementation is anabolic during the acute phase of endotoxin-induced inflammation: A human randomized crossover trial

BACKGROUND & AIMS

Inflammation is catabolic and causes muscle loss. It is unknown if amino acid supplementation reverses these effects during the acute phase of inflammation. The aim was to test whether amino acid supplementation counteracts endotoxin-induced catabolism.

METHODS

Eight young, healthy, lean males were investigated three times in randomized order: (i) normal conditions (Placebo), (ii) endotoxemia (LPS), and (iii) endotoxemia with amino acid supplementation (LPS + A). Protein kinetics were determined using phenylalanine, tyrosine, and urea tracers. Each study day consisted of a four-hour non-insulin stimulated period and a two-hour hyperinsulinemic euglycemic clamp period. Muscle biopsies were collected once each period.

RESULTS

Endotoxin administration created a significant inflammatory response (cytokines, hormones, and vital parameters) without significant differences between LPS and LPS + A. Whole body protein breakdown was elevated during LPS compared with Placebo and LPS + A (p < 0.05). Whole body protein synthesis was higher during LPS + A than both Placebo and LPS (p < 0.003). Furthermore, protein synthesis was higher during LPS than during Placebo (p < 0.02). Net muscle phenylalanine release was markedly decreased during LPS + A (p < 0.004), even though muscle protein synthesis and breakdown rates did not differ significantly between interventions. LPS + A increased mammalian target of rapamycin (mTOR) phosphorylation (p < 0.05) and eukaryotic translation factor 4E-binding protein 1 (4EBP1) phosphorylation (p = 0.007) without activating AMPK or affecting insulin signaling through Akt. During insulin stimulation net muscle phenylalanine release and protein degradation were further reduced.

CONCLUSIONS

Amino acid supplementation in the acute phase of inflammation reduces whole body and muscle protein loss, and this effect is associated with activation of mTOR and downstream signaling to protein synthesis through mTORC1, suggesting a therapeutic role for intravenous amino acids in inflammatory states.

CLINICAL TRIAL REGISTRY

The Central Denmark Region Ethics Commitee (1-10-71-410-12) www.clinicaltrials.gov (identification number NCT01705782).

Elucidating functional heterogeneity in hematopoietic progenitor cells: a combined experimental and modeling approach

A detailed understanding of the mechanisms maintaining the hierarchical balance of cell types in hematopoiesis will be important for the therapeutic manipulation of normal and leukemic cells. Mathematical modeling is expected to make an important contribution to this area, but the iterative development of increasingly accurate models will rely on repeated validation using experimental data of sufficient resolution to distinguish between alternative model scenarios. The multipotent hematopoietic progenitor FDCP-Mix cells maintain a hierarchy from self-renewal to post-mitotic differentiation in vitro and are accessible to detailed analysis. Here, we report the development of a combined mathematical modeling and experimental approach to study the principles underlying heterogeneity in FDCP-Mix cultures. We adapt a single-cell based model of hematopoiesis to the conditions of cell culture and describe an association between proliferative history and phenotype of FDCP-Mix cells. While data derived from population studies are incapable of distinguishing between three mechanistically different model scenarios, statistical analysis of single cell tracking data provides a resolution sufficient to select one of them. This scenario favors differences between granulocytic and monocytic lineage with respect to their proliferative behavior and death rates as a mechanistic explanation for the observed heterogeneity. Our results demonstrate the power of a combined experimental/modeling approach in which single cell fate analysis is the key to revealing regulatory principles at the cellular level.

Pretreatment long interspersed element (LINE)-1 methylation levels, not early hypomethylation under treatment, predict hematological response to azacitidine in elderly patients with acute myeloid leukemia

Background

Epigenetic modulations, including changes in DNA cytosine methylation, are implicated in the pathogenesis and progression of acute myeloid leukemia (AML). Azacitidine is a hypomethylating agent that is incorporated into RNA as well as DNA. Thus, there is a rationale to its use in patients with AML. We determined whether baseline and/or early changes in the methylation of long interspersed element (LINE)-1 or CDH13 correlate with bone marrow blast clearance, hematological response, or survival in patients with AML treated with azacitidine.

Methods

An open label, phase I/II trial was performed in 40 AML patients (median bone marrow blast count was 42%) unfit for intensive chemotherapy treated with azacitidine 75 mg/m²/day subcutaneously for 5 days every 4 weeks. Bone marrow mononuclear cell samples were taken on day 0 (pretreatment) and day 15 during the first treatment cycle; LINE-1 and CDH13 methylation levels were quantified by methylation-specific, semiquantitative, real-time polymerase chain reaction.

Results

Treatment with azacitidine significantly reduced LINE-1 but not CDH13 methylation levels over the first cycle (P < 0.0001). Absolute LINE-1 methylation levels tended to be lower on day 0 (P = 0.06) and day 15 of cycle 1 (P = 0.03) in patients who went on to achieve subsequent complete remission, partial remission or hematological improvement versus patients with stable disease. However, the decrease in LINE-1 methylation over the first treatment cycle did not correlate with subsequent response (P = 0.31). Baseline methylation levels of LINE-1 or CDH13 did not correlate with disease-related prognostic factors, including cytogenetic risk, relapsed/refractory AML, or presence of NPM1 or FLT3 mutations. No correlation was observed between LINE-1 or CDH13 methylation levels and overall survival.

Conclusion

Analysis of baseline LINE-1 methylation levels may help identify elderly AML patients who are most likely to respond to azacitidine therapy.

Experimental infection of wild-caught European rabbits (Oryctolagus cuniculus) with Sarcoptes scabiei from a naturally infected wild rabbit

Scabies was recently reported for the first time in the European wild rabbit, Oryctolagus cuniculus (Lagomorpha: Leporidae). We experimentally exposed 10 seronegative wild-caught rabbits to skin from a mangy wild rabbit. Serological, physiological, parasitological and histopathological changes were recorded. Three rabbits developed antibodies at 2-5 weeks post-infection (w.p.i.), two of which then developed lesions at 7 w.p.i. One of these had a small area of alopecia on the hind limb that healed naturally within 1 week; the other developed more extensive lesions restricted to the hind limbs (as typically observed in wild rabbits) that lasted until the rabbit died (12.5 w.p.i.). The third rabbit died of trauma 5 w.p.i. before developing any lesions. Antibodies in the healed rabbit disappeared from serum at 8 w.p.i., whereas antibody levels in the sick rabbit increased until its death. Disseminated intravascular coagulation and hepatic necrosis, probably arising from a concomitant infection with rabbit haemorrhagic disease virus, were the likely final cause of death in this rabbit. The mangy rabbit that served as a donor died of a multifocal fibrinosuppurative pneumonia that may have been secondary to the skin bacterial pyoderma.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Delayed processing of bone marrow samples reveals a prognostic pattern of NME mRNA expression in cytogenetically normal acute myeloid leukemia

Improvements in the therapy of cytogenetically normal acute myeloid leukemia (CN-AML) will depend largely on the characterization of functional subtypes identified by prognostic markers. Exposing leukemic cells to stress ex vivo may reveal relevant phenotypic markers not apparent in freshly explanted cells. Here, we assess the prognostic relevance of expression of the nucleoside diphosphate kinase genes NME1 and NME2 in a cohort of 78 patients with CN-AML aged < 60 years using archived mononuclear cell samples originally prepared from bone marrow either directly (n = 25) or following 2-3 days of transport (n = 53). The stress conditions arising during transport resulted in the development of a prognostic pattern of NME mRNA with maintenance of high NME2 mRNA being a strong indicator of increased event-free survival independent of FLT3-internal tandem duplication. Prospective analysis of CN-AML bone marrow (n = 7) confirmed that NME1 mRNA is always decreased during storage, while NME2 mRNA is either decreased or maintained. We conclude that ex vivo stress can reveal novel prognostic markers.

Evaluation of single and double centrifugation tube methods for concentrating equine platelets

The aim of this study was to evaluate single and double centrifugation tube methods for concentrating equine platelets. Whole blood samples were collected from clinically normal horses and processed by use of single and double centrifugation tube methods to obtain four platelet concentrates (PCs): PC-A, PC-B, PC-C, and PC-D, which were analyzed using a flow cytometry hematology system for hemogram and additional platelet parameters (mean platelet volume, platelet distribution width, mean platelet component concentration, mean platelet component distribution width). Concentrations of transforming growth factor beta 1 (TGF-beta(1)) were determined in all the samples. Platelet concentrations for PC-A, PC-B, PC-C, and PC-D were 45%, 44%, 71%, and 21% higher, respectively, compared to the same values for citrated whole blood samples. TGF-beta(1) concentrations for PC-A, PC-B, PC-C, and PC-D were 38%, 44%, 44%, and 37% higher, respectively, compared to citrated whole blood sample values. In conclusion, the single and double centrifugation tube methods are reliable methods for concentrating equine platelets and for obtaining potentially therapeutic TGF-beta(1) levels.

[Workload, gender and age among personnel with reported sudden lifting injuries]

INTRODUCTION

In 1996 the Danish Parliament passed a new Act on industrial injuries, including the so-called sudden lifting injuries. This type of lifting injury had been experienced in some industries in connection with lifting situations causing sudden pain in the back. Less frequently, other regions of the body may be affected. This study is a distribution of a sample of reported industrial injuries of this type in groups according to types of lifts. The study also includes a comparison with parameters from the Danish Work Environment Cohort Study.

MATERIAL AND METHODS

The sample consisted of a total of 482 cases of back injuries. Of these, 346 cases were distributed according to six categories of manual lifting work and to age and gender. The rest, 136 cases, were excluded for technical reasons.

RESULTS

In the distribution, 8% of the cases were in jobs with many heavy lifts, 66% of the cases were in jobs with moderate daily lifted weights or in jobs with only few or light lifts. Approximately 25% of cases concerned employees performing patient transfers. The distribution contained more men than the Danish Work Environment Cohort Study, and the persons in the cases were slightly older than this reference population.

DISCUSSION

Altogether, this study points towards an occurrence of sudden lifting injuries among employees performing certain types of manual lifting work. The industrial injuries cases may have been subject to some selection.

Work-related eye symptoms and respiratory symptoms in female cleaners

A prospective study was conducted in order to describe the incidence of eye symptoms, nose or throat symptoms, asthma and bronchitis among cleaners compared with former cleaners and according to the 'use of sprayers'. In 1989 and in 1991 questionnaire-based studies were conducted among female cleaners employed at Danish nursing homes, schools and offices. A cohort of 1,011 females was followed over two years. At baseline in 1989, the average age was 45 years and the average of seniority was 10 years. Overall, the cleaners tended to have the same or higher risk of developing respiratory symptoms compared to former cleaners. The 'use of sprayers' during the follow-up period was associated with an increased risk of eye and respiratory symptoms.

Relation between job strain and myocardial infarction: a case-control study

OBJECTIVES

To study the influence of different job related and socioeconomic factors for development of myocardial infarction (MI).

METHOD

The study was a case-control study of 76 male wage earners who had been admitted to hospital with MI. As a control group 176 male wage earners not admitted to hospital who were residents of the same county were used. Both groups were interviewed with an extensive questionnaire on job related conditions. Several indices on job related psychosocial factors were established in accordance with Karasek's job strain model as well as the extension of the model, the isostrain model.

RESULTS

The most significant findings were consistent with Karasek's job strain model in that mean with a high degree of demand combined with a low degree of control at work had a significantly increased odds ratio (OR) 95% confidence interval (95% CI) of 2.1 (1.2 to 3.8) for MI after adjustment for age compared with men with a low degree of demand and a high degree of control at work. Further adjustment for smoking, socioeconomic status, employment sector, job category, and social network did not affect the OR substantially (OR 2.3 (1.2 to 4.4)). Other factors significantly associated to MI were job category (blue collar workers v white collar workers, OR 2.8 (1.6 to 5.8)), and employment sector (private v public, OR 3.1 (1.8 to 6.1)).

CONCLUSIONS

Thus, the study confirmed the job strain model as well as the well known association between socioeconomic status and risk of MI, whereas the finding of an increased risk among employees in the private sector has not previously been described.

Cancer incidence in urban bus drivers and tramway employees: a retrospective cohort study

OBJECTIVE

To investigate the risk of cancer associated with exposure to air pollution among bus drivers and tramway employees.

METHODS

A retrospective cohort study of 18,174 bus drivers or tramway employees in Copenhagen in the period 1900-94. Data on employment were obtained from company files. Information on cancer was obtained from the Danish Cancer Registry.

RESULTS

Findings showed that bus drivers or tramway employees had an increased risk of all malignant neoplasms (standardised incidence ratio (SIR) 1.24, 95% confidence interval (95% CI) 1.19 to 1.30). The relative risk was significantly increased for both men and women (SIR 1.24, 95% CI 1.19 to 1.30 and 1.28, 1.06 to 1.53, respectively). People employed for < 3 months had no increased risk of cancer (1.04, 0.81 to 1.31). For men who were employed for > 3 months the risk of lung cancer (1.6, 1.5 to 1.8), laryngeal cancer (1.4, 1.0 to 1.9), kidney cancer (1.6, 1.3 to 2.0), bladder cancer (1.4, 1.2 to 1.6), skin cancer (1.1, 1.0 to 1.2), pharyngeal cancer (1.9, 1.2 to 2.8), rectal cancer (1.2, 1.0 to 1.5) and liver cancer (1.6, 1.2 to 2.2) was significantly increased. For women employed for > 3 months the risk of lung cancer was significantly increased (2.6, 1.5 to 4.3).

CONCLUSION

This cohort study shows that bus drivers and tramway employees are at an increased risk of developing several types of cancer. This might be due to the exposure to air pollution during working hours or to other risk factors, primarily smoking.

A new polymorphic restriction site in the human 11 beta-hydroxysteroid dehydrogenase type 2 gene

The 11 beta-hydroxysteroid dehydrogenase type II enzyme (11 beta HSD2) inactivates glucocorticoids in the kidney and thus prevents glucocorticoids from occupying the non-selective mineralocorticoid receptor in epithelial tissues. Mutations in the HSD11B2 gene have been found to cause the syndrome of apparent mineralocorticoid excess, a rare autosomal recessive disease characterized by severe hypertension. Thus, this locus could also be an ideal candidate involved in the etiology of primary hypertension. We identified a polymorphism in exon 3 characterized by a GAG to GAA transition at codon 178, with the loss of an Alu I restriction site and analysed it in an association study using end-stage renal disease patients, diabetic or essential hypertensive patients and control subjects. Two-hundred and eighty nine subjects and patients were analysed; the genotype was determined by amplification of genomic DNA and subsequent digestion with Alu I restriction enzyme. The prevalence of the Alu I allele was 8.6% in healthy control subjects (n = 116). This prevalence was lower (chi 2 P = 0.035 vs. controls) than the 18.0% in a group of renal transplant patients (n = 61). The corresponding values for patients with diabetes mellitus (n = 25), hypertension (n = 41) and patients on dialysis (n = 46) were 4.0%, 4.8% and 4.3%, respectively. There was no correlation between blood pressure and the marker in non-ESRD subjects. These data indicate the presence of a polymorphic marker in exon 3 of the HSD11B2 gene; this marker is associated with end-stage renal disease but not with essential hypertension in humans.

Work environment and low back pain: the influence of occupational activities

OBJECTIVES

To find associations between the prevalence of low back pain and occupational activities.

METHODS

Interviews of a random sample of 5185 19-59 year old Danish employees analysed by logistic regression.

RESULTS

Increased risks of low back pain were found for "vibration affecting the whole body" (odds ratio (OR) = 1.28), "physically hard work" (OR = 1.28), "frequently twisting or bending" (OR = 1.71), "standing up" (OR = 1.20), and "concentration demands" (OR = 1.28). In the analysis of dose-response relations between low back pain and the risk factors, the one year period prevalence increased with increasing exposure time during a working day to each of the risk factors. The prevalence proportion ratio for those reporting to be exposed for most of the working time were 1.30 for vibrations affecting the whole body, 1.54 for physically hard work, 1.48 for frequently twisting or bending, 1.29 for standing up, and 1.13 for concentration demands. These associations seemed to be stronger in the subset of subjects who worked for 37 hours or more per week. The population attributable fractions were 15.1% for frequently twisting or bending, 15.0% for standing up, 7.6% for concentration demands, and 4.4% for physically hard work.

CONCLUSION

Vibrations affecting the whole body, physically hard work, frequently twisting or bending, standing up, and concentration demands proved to be risk factors for the occurrence of low back pain, even after controlling for age, sex, educational level, and duration of employment in a specific occupation.

Occupation and risk for the occurrence of low-back pain (LBP) in Danish employees

Using data from a nation-wide cross-sectional survey in 1990 a study examining the risk for occurrence of LBP in various specific occupations was made among 5,185 Danish employees aged 19-59 years old. After adjusting for the confounding effects of age and gender we found significantly increased risks of LBP in three out of nine major occupational categories. They were 'health care and social work' (OR = 1.52, 95% Cl = 1.28-1.80), 'mining, quarrying and construction work' (OR = 1.97, 95% Cl = 1.41-2.74) and 'manufacturing and machine operation work' (OR = 1.21, 95% Cl = 1.05-1.40). Among 39 second-level occupational categories the highest risks were observed among persons employed in 'building construction work' (OR = 1.97, 95% Cl = 1.41-2.74), 'social work, child day care work and psychological work' (OR = 1.64, 95% Cl = 1.32-2.05). Skilled and unskilled manual workers had an increased risk of LBP.

National survey on the use of chemicals in the working environment: estimated exposure events

OBJECTIVES

To obtain knowledge about the use and distribution of hazardous chemicals in Danish industry. This knowledge is used to regulate the occupational environment and prevent hazardous exposure.

METHODS

A national survey on the use of chemicals was carried out in 1989 in a stratified sample of 1448 Danish businesses. 13,000 different chemical products were reported. Information on components in the chemical products was obtained from the Danish product register data base (PROBAS) and by inquiries to suppliers and manufacturers. At the end of the study the composition of about 9400 of the products was known. A model was developed to estimate national numbers of chemical exposure events as a supplement to data on weights of chemicals used.

RESULTS

Data are presented for 36 chemical substances with chronic toxic effects and high estimated national numbers of exposure events for the industry groups included in the survey. Seven of the 36 substances are carcinogens, 17 are reproductive toxicants, 12 are allergens, and 18 are neurotoxicants according to listings of chronic toxicants used by the Danish authorities. The largest national number of exposure events was estimated for the industry groups manufacture of fabricated metal products, and personal services, cleaning, and hair dressing. These should have special attention in further preventive work.

CONCLUSIONS

This survey on the use of chemicals is the first nationwide investigation in Denmark to delineate the use of all chemicals. The data have been used in a project to review occupational hazards in general in Danish industry. In the future, the data may be used as a basis for measuring chemical substitution, developing chemical safety, and as reference for more specific investigations and for follow up studies. Also job exposure matrices based on actual use of chemical products can be constructed.

Interferon gamma signals via a high-affinity multisubunit receptor complex that contains two types of polypeptide chain

Signaling by interferon gamma (IFN-gamma) requires two structurally related cell surface proteins: a ligand-binding polypeptide, known as the IFN-gamma receptor (IFN-gamma R), and an accessory factor. However, it is not known whether IFN-gamma forms a ternary complex with the IFN-gamma R and accessory factor to initiate signaling. Here we demonstrate complex formation between IFN-gamma and the two proteins, both in solution and at the cell surface. We observe complexes containing ligand, two molecules of IFN-gamma R (designated the IFN-gamma R alpha chain), and one or two molecules of accessory factor (designated the IFN-gamma R beta chain). Transfected cells expressing both IFN-gamma R chains bind IFN-gamma with higher affinity than do cells expressing alpha chain alone. Anti-beta-chain antibodies prevent the beta chain from participating in the ligand-receptor complex, reduce the affinity for IFN-gamma, and block signaling. Soluble alpha- or beta-chain extracellular domains also inhibit function. These results demonstrate that IFN-gamma signals via a high-affinity multisubunit complex that contains two types of receptor chain and suggest a potential approach to inhibiting specific actions of IFN-gamma by blocking the association of receptor subunits.

Employment status, non-daytime work and gastric ulcer in men

BACKGROUND

An excess risk of gastric ulcer (GU) (ICD-8: 531) has formerly been found in shift workers and ex-shiftworkers but little is known about the risk of GU associated with other forms of non-daytime work. This study deals with associations between non-daytime work and GU.

METHODS

A fixed cohort of 122,116 men in occupations in which at least 20% had non-daytime work and a reference group of 593,281 men in occupations with daytime work only, was followed in the National Inpatient Register for first discharges with GU as the principal diagnosis.

RESULTS

For men with daytime work only we found a steep inverse association between GU and employment status. Men in occupational groups with late evening work had a standardized hospitalization ratio (SHR) of 236 (90% confidence interval [Cl]: 184-299), groups working in rosters covering 24-hour services had an SHR of 147 (90% Cl: 116-183). A slightly raised risk of 114 (90% Cl: 101-128) was found in groups having other forms of non-daytime work. For all men in groups with non-daytime work we found a significant SHR of 130 (90% Cl: 118-142).

CONCLUSION

We conclude that both low employment status and non-daytime work are associated with an increased risk of GU.

Prevalence of objective eye manifestations in people working in office buildings with different prevalences of the sick building syndrome compared with the general population

A cross-sectional clinical epidemiological study was carried out among 169 office workers in four Copenhagen town halls with different prevalences of the sick building syndrome. The results were compared with those in 112 subjects randomly selected from the general population. Biomicroscopic eye manifestations, such as premature break-up of the precorneal tear film, absence of foam at the inner eye canthus and epithelial damage of the bulbar conjunctiva, were investigated together with self-reported eye complaints. Although intercorrelated, the objective eye manifestations independently were statistically associated with self-reported eye complaints in office workers. The prevalence of the objective eye manifestations was significantly elevated in office workers compared with the general population and most pronounced for the buildings with a high prevalence of the sick building syndrome (P < 0.001). In the general population, subjects with a non-industrial occupation, including office workers, had a significantly higher prevalence of objective eye manifestations than those with an industrial occupation (P = 0.03), but the prevalence was still significantly lower than that among the office workers in buildings with a high prevalence of the sick building syndrome (P < 0.001). Since possible confounders were found not to explain the difference in prevalence of objective eye manifestations and complaints among the two populations, it is concluded that the office environment (buildings and/or type of office work) promotes these objective changes accompanied by self-reported complaints.

An ultraviolet-spectrophotometric method with 2-cyanoacetamide for the determination of the enzymatic degradation of reducing polysaccharides

A rapid, facile, and sensitive uv-spectrophotometric assay has been developed for the determination of the enzymatic degradation of polysaccharides that generates reducing sugars. The assay was carried out with 2-cyanoacetamide in a single test tube. The solution was left at pH 9 by the addition of borate buffer within 5 min. Measurement of the reaction mixture at 274 nm allows a simple determination up to 600 mumol/liter of reducing sugars. The coefficient of variation was less than 2% on all measurements. The assay was developed with pectin and polygalacturonic acid from apples and has been compared with the Somogyi-Nelson method. The new assay was then exemplarily used for the determination of the enzymatic hydrolysis products of pectin from cotton.

Occupation and hospitalization with ischaemic heart diseases: a new nationwide surveillance system based on hospital admissions

A cohort of all people in Denmark aged 20-59 years on 1 January 1981 was followed up for four years for emigration, death and hospital admission for ischaemic heart disease (IHD) as the primary diagnosis. The data set allows tabulation of rates of hospitalization by occupation, position and industry. Well-known classic associations for IHD have been reproduced. Examples are: male bus drivers had a standardized hospitalization ratio (SHR) of 136; for male urban bus drivers SHR = 143, male taxi drivers SHR = 168, fishermen SHR = 129, men occupied in hotels and restaurants SHR = 140, women in hotels and restaurants SHR = 157. The consistency with previous findings is an argument that new significant associations should be treated as substantiated hypotheses if no selection bias is known. Examples of groups at significant excess risk of IHD are those self-employed in the textile industry, self-employed hairdressers, foremen in the construction industry, bakers, medical and industrial laboratory technicians, telephone assistants and unskilled tube and sheet workers in shipyards.