Scientific conferences, socialization, and the Covid-19 pandemic: A conceptual and empirical enquiry

Since the 1970s social analysts have seen communication between scientists not solely as information exchange (the algorithmical model), but as a process of socialization into overlapping and mutually embedded scientific domains (the enculturational model). Under the algorithmical model, the impact of the Covid-19 shutdown on travel would be easily remedied by replacing face-to-face communication with online platforms. Conferences and similar gatherings are costly, elitist, and environmentally damaging, but under the enculturational model abandoning them could be disastrous for science, which depends on the development of cross-national trust and mutual agreements through face-to-face interaction and, in turn, disastrous for science's role in democracy. We explore the problem theoretically and empirically, arguing against recent proposals from some scientists for the wholesale and permanent replacement of conferences with remote communication.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION

Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI).

METHODS

PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded.

FINDINGS

Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05).

CONCLUSION

Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

Laryngopharyngeal reflux: is laparoscopic fundoplication an effective treatment?

INTRODUCTION

Laryngopharyngeal reflux (LPR) is difficult to diagnose and treat owing to uncertainty relating to the underlying pathology. The initial management of LPR includes lifestyle modifications and oral medications. In patients who have failed to respond to proton pump inhibitor (PPI) therapy, anti-reflux surgery is considered; laparoscopic fundoplication is the surgery of choice. The primary aim of this review is to identify whether fundoplication is effective in improving signs and symptoms of LPR. The secondary aim is to identify whether patients who have had a poor response to PPIs are likely to have symptom improvement with surgery. The objective of the study is to establish the effect of laparoscopic fundoplication on the reflux symptom index score (RSI).

METHODS

PubMed, Embase, Medline and Cochrane databases were used to search according to the PRISMA guidelines. Original articles assessing the efficacy of fundoplication in relieving symptoms of LPR were included. For each study, the efficacy endpoints and safety outcomes were recorded.

FINDINGS

Nine studies from 844 initial records met the inclusion criteria: one prospective case control study, one retrospective case-control study, four prospective case series and three retrospective case series involving 287 fundoplications. All nine studies found fundoplication to be effective in improving symptoms of LPR (p < 0.05).

CONCLUSION

Current evidence suggests laparoscopic fundoplication is an effective treatment for LPR and should be considered if medical management is unsuccessful.

Variation in pickleweed root-associated microbial communities at different locations of a saline solid waste management unit contaminated with petroleum hydrocarbons

The main purpose of this study was to explore the potential influences of pickleweed vegetation on the abundance, diversity and metabolic activities of microbial communities in four distinct areas of a petroleum-contaminated solid waste management unit (SWMU) located in Contra Costa County, northern California. The four areas sampled include two central areas, one of which is central vegetated (CV) and one unvegetated (UV), and two peripheral vegetated areas, one of which is located to the west side of the SWMU (V-West) and one located to the east side (V-East). Measurements were made of total petroleum hydrocarbons (TPH), polyaromatic hydrocarbons (PAH), soil physicochemical properties, and various aspects of microbial communities including metabolic activities, microbial abundances (PLFAs), diversity and composition based on amplicon sequencing. The peripheral V-East and V-West sites had 10-times lower electrical conductivity (EC) than that of the CV and UV sites. The high salinity levels of the CV and UV sites were associated with significant reductions in bacterial and fungal abundances (PLFA) when compared to V-East but not when compared to V-West. TPH levels of CV and UV were not significantly different from those of V-West but were substantially lower than V-East TPH (19,311 mg/kg of dry soil), the high value of which may have been associated with a pipeline that ran through the area. Microbial activities (in terms of soil respiration and the activities of three soil enzymes, i.e., urease, lipase, and phosphatase) were greatest in the vegetated sites compared to the UV site. The prokaryotic community was not diverse as revealed by the Shannon index with no significant variation among the four groups of samples. However, the fungal community of the peripheral sites, V-East and V-West had significantly higher OTU richness and Shannon index. Structure of prokaryotic communities inhabiting the rhizosphere of pickleweed plants at the three sites differed significantly and were also different from those found in the UV region of the central site according to pairwise, global PERMANOVA and ANOSIM analyses. The differences in OTU-based rhizosphere-associated bacterial and fungal communities’ composition were explained mainly by the changes in soil EC and pH. The results suggest that saline TPH-contaminated areas that are vegetated with pickleweed are likely to have increased abundances, diversity and metabolic activities in the rhizosphere compared to unvegetated areas, even in the presence of high salinity.

Groups and individuals: conformity and diversity in the performance of gendered identities

The nature and role of social groups is a central tension in sociology. On the one hand, the idea of a group enables sociologists to locate and describe individuals in terms of characteristics that are shared with others. On the other, emphasizing the fluidity of categories such as gender or ethnicity undermines their legitimacy as ways of classifying people and, by extension, the legitimacy of categorization as a goal of sociological research. In this paper, we use a new research method known as the Imitation Game to defend the social group as a sociological concept. We show that, despite the diversity of practices that may be consistent with self-identified membership of a group, there are also shared normative expectations - typically narrower in nature than the diversity displayed by individual group members - that shape the ways in which category membership can be discussed with, and performed to, others. Two claims follow from this. First, the Imitation Game provides a way of simultaneously revealing both the diversity and 'groupishness' of social groups. Second, that the social group, in the quasi-Durkheimian sense of something that transcends the individual, remains an important concept for sociology.

Evaluation of a primary course of H9N2 vaccine with or without AS03 adjuvant in adults: A phase I/II randomized trial

BACKGROUND

Avian influenza A H9N2 strains have pandemic potential.

METHODS

In this randomized, observer-blind study (ClinicalTrials.gov: NCT01659086), 420 healthy adults, 18-64years of age, received 1 of 10 H9N2 inactivated split-virus vaccination regimens (30 participants per group), or saline placebo (120 participants). H9N2 groups received 2 doses (days 0, 21) of 15µg hemagglutinin (HA) without adjuvant, or 1.9µgHA+AS03_A, 1.9µgHA+AS03_B, 3.75µgHA+AS03_A, or 3.75µgHA+AS03_B; followed by the same H9N2 formulation or placebo (day 182). AS03 is an adjuvant system containing α-tocopherol (AS03_A: 11.86mg; AS03_B: 5.93mg) and squalene in an oil-in-water emulsion. Immunogenicity (hemagglutination inhibition [HI] and microneutralization assays) and safety were assessed up to day 546.

RESULTS

All adjuvanted formulations exceeded regulatory immunogenicity criteria at days 21 and 42 (HI assay), with seroprotection and seroconversion rates of ≥94.9% and ≥89.8% at day 21, and 100% and ≥98.1% at day 42. Immunogenicity criteria were also met for unadjuvanted vaccine, with lower geometric mean titers. In groups administered a third vaccine dose (day 182), an anamnestic immune response was elicited with robust increases in HI and microneutralization titers. Injection site pain was reported more frequently with adjuvanted vaccines. No vaccine-related serious adverse events were observed.

CONCLUSIONS

All H9N2 vaccine formulations were immunogenic with a clinically acceptable safety profile; adjuvanted formulations were 4-8 times dose-sparing (3.75-1.9vs 15µgHA).

TRIAL REGISTRATION

Registered on ClinicalTrials.gov: NCT01659086.

Pediatric Patients Demonstrate Progressive T1-Weighted Hyperintensity in the Dentate Nucleus following Multiple Doses of Gadolinium-Based Contrast Agent

BACKGROUND AND PURPOSE

While there have been recent reports of brain retention of gadolinium following gadolinium-based contrast agent administration in adults, a retrospective series of pediatric patients has not previously been reported, to our knowledge. We investigated the relationship between the number of prior gadolinium-based contrast agent doses and increasing T1 signal in the dentate nucleus on unenhanced T1-weighted MR imaging. We hypothesized that despite differences in pediatric physiology and the smaller gadolinium-based contrast agent doses that pediatric patients are typically administered based on weighted-adjusted dosing, the pediatric brain would also demonstrate dose-dependent increasing T1 signal in the dentate nucleus.

MATERIALS AND METHODS

We included children with multiple gadolinium-based contrast agent administrations at our institution. A blinded reader placed ROIs within the dentate nucleus and adjacent cerebellar white matter. To eliminate reader bias, we also performed automated ROI delineation of the dentate nucleus, cerebellar white matter, and pons. Dentate-to-cerebellar white matter and dentate-to pons ratios were compared with the number of gadolinium-based contrast agent administrations.

RESULTS

During 20 years at our institution, 280 patients received at least 5 gadolinium-based contrast agent doses, with 1 patient receiving 38 doses. Sixteen patients met the inclusion/exclusion criteria for ROI analysis. Blinded reader dentate-to-cerebellar white matter ratios were significantly associated with gadolinium-based contrast agent doses (r_s = 0.77, P = .001). The dentate-to-pons ratio and dentate-to-cerebellar white matter ratios based on automated ROI placement were also significantly correlated with gadolinium-based contrast agent doses (t = 4.98, P < .0001 and t = 2.73, P < .02, respectively).

CONCLUSIONS

In pediatric patients, the number of prior gadolinium-based contrast agent doses is significantly correlated with progressive T1-weighted dentate hyperintensity. Definitive confirmation of gadolinium deposition requires tissue analysis. Any potential clinical sequelae of gadolinium retention in the developing brain are unknown. Given this uncertainty, we suggest taking a cautious stance, including the use, in pediatric patients, of higher stability, macrocyclic agents, which in both human and animal studies have been shown to be associated with lower levels of gadolinium deposition, and detailed documentation of dosing. Most important, a patient should not be deprived of a well-indicated contrasted MR examination.

Studies of Expertise and Experience

I describe the program of analysis of expertise known as 'Studies of Expertise and Experience', or 'SEE' and contrast it with certain philosophical approaches. SEE differs from many approaches to expertise in that it takes the degree of 'esotericity' of the expertise to be one of its characteristics: esotericity is not a defining characteristic of expertise. Thus, native language speaking is taken to be an expertise along with gravitational wave physics. Expertise is taken to be acquired by socialisation within expert communities. Various methods of analysis are described.

Occupational therapy for stroke patients at home

The provision of occupational therapy for stroke patients by the social services was examined in 327 patients who had been discharged from hospital. Two- thirds (64%) of the patients were referred to the social service occupational therapist (SSOT). The occupational therapist visited a median of seven days from referral, treated the patient twice and then closed the case.

The SSOT provided a range of equipment and adaptations to encourage independence in the community. Half of the patients visited received a bath- board and a quarter received an extra stair-rail to assist with mobility.

Patients who had been referred to the SSOT and who also received therapy from an experimental domiciliary rehabilitation team received significantly more grab handles than those who were referred to the SSOT and also treated by the hospital-based rehabilitation teams.

The SSOT provided a limited service to the group of stroke patients studied, mainly delivering equipment. The equipment was relatively cheap and may have been more appropriately administered by the hospital-based occupational therapist before the patient was discharged.

The Bread-Making Machine: Tacit Knowledge and Two Types of Action

We analyse Nonaka and Takeuchi's (1995) claim that a master baker's tacit knowledge was made explicit and incorporated into a home bread-making machine and its manual — the `knowledge capture' thesis. In order to test the claim, bread was made without and with a breadmaker and we carried out an analysis of the bread-making actions before and after mechanization. Based on the theory of action morphicity (Collins and Kusch 1998) it is shown that the machine only mimics the mechanical counterpart of just a few of certain special kinds of human bread-making actions. The remaining success of the machine and its manual is due to what other human actors bring to the mechanical bread-making scene; this way the breadmaker can be an adequate social prosthesis. Action mimicking, action substitution, and the contributions of these other human actors, who are not needed in the case of the master baker, explain why the machine and its manual do work. It is not a matter of the explication or incorporation of tacit knowledge, but of fitting a social prosthesis into a rearranged world.

A thousand words is worth a picture

In this response to Ribeiro and Lima's paper on interactional expertise, we argue that, by not incorporating the insights of constructivist social science, their analysis goes backwards rather than advancing the debate. We show that much of the evidence they present does not lead to the conclusions they draw. We also critically examine the idea of physical contiguity, which forms a central part of Ribeiro and Lima's position. We show that its meaning is ambiguous. We conclude by suggesting that more research on the nature and influence of physical contiguity would be interesting in its own right but that it would not bear on the notion of interactional expertise.

Expertise revisited, Part II: Contributory expertise

In Part I of this two part paper we tried to elicit the 'essence' of the notion of interactional expertise by looking at its origins. In Part II we will look at the notion of contributory expertise. The exercise has been triggered by recent discussion of these concepts in this journal by Plaisance and Kennedy and by Goddiksen.

Expertise revisited, Part I-Interactional expertise

In Part I of this two part paper we try to set out the 'essence' of the notion of interactional expertise by starting with its origins. In Part II we will look at the notion of contributory expertise. The exercise has been triggered by recent discussion of these concepts in this journal by Plaisance and Kennedy and by Goddiksen.

In vivo biocompatibility, clearance, and biodistribution of albumin vehicles for pulmonary drug delivery

The development of clinically acceptable albumin-based nanoparticle formulations for use in pulmonary drug delivery has been hindered by concerns about the toxicity of nanomaterials in the lungs combined with a lack of information on albumin nanoparticle clearance kinetics and biodistribution. In this study, the in vivo biocompatibility of albumin nanoparticles was investigated following a single administration of 2, 20, and 390 μg/mouse, showing no inflammatory response (TNF-α and IL-6, cellular infiltration and protein concentration) compared to vehicle controls at the two lower doses, but elevated mononucleocytes and a mild inflammatory effect at the highest dose tested. The biodistribution and clearance of ¹¹¹In labelled albumin solution and nanoparticles over 48 h following a single pulmonary administration to mice was investigated by single photon emission computed tomography and X-ray computed tomography imaging and terminal biodistribution studies. ¹¹¹In labelled albumin nanoparticles were cleared more slowly from the mouse lung than ¹¹¹In albumin solution (64.1 ± 8.5% vs 40.6 ± 3.3% at t = 48 h, respectively), with significantly higher (P < 0.001) levels of albumin nanoparticle-associated radioactivity located within the lung tissue (23.3 ± 4.7%) compared to the lung fluid (16.1 ± 4.4%). Low amounts of ¹¹¹In activity were detected in the liver, kidneys, and intestine at time points > 24 h indicating that small amounts of activity were cleared from the lungs both by translocation across the lung mucosal barrier, as well as mucociliary clearance. This study provides important information on the fate of albumin vehicles in the lungs, which may be used to direct future formulation design of inhaled nanomedicines.

Characterization of mouse monoclonal antibodies directed against Pseudomonas aeruginosa lipopolysaccharides

Mouse monoclonal antibodies that react with O-side chain specific, O-side chain cross-reactive, and core P. aeruginosa lipopolysaccharide determinants have been isolated. The monoclonals directed at O-side chain determinants are generally opsonophagocytic with human neutrophils and human complement. They also protect mice from intraperitoneal and intravenous challenge and protect in the burned rat model of infection.

Rejecting knowledge claims inside and outside science

Citizens, policy-makers and scientists all face the problem of assessing maverick scientific claims. Via a case study, I show the different resources available to experts and non-experts when they make these judgements and reflect upon what this means for technological decision-making in the public domain.

Actor and analyst: a response to Coopmans and Button

We question the logic of Coopmans and Button's critique of our analysis of expertise on three grounds. First, their critique depends on a clear distinction between actor and analysts that we show cannot be maintained. Second, we question their reticence to allow the use of taxonomies in the analysis of expertise, suggesting that it is contradicted by their own descriptions of expert work, and we accuse them of making a mistake in the way they relate commonsense to specialist skills. Finally, we express our puzzlement at the antiseptic-like precautions that some ethnomethodologists apply to analysts' categories, especially given that--as we show--analysts' categories sometimes provide a superior resource for understanding and can change the actors' world as well as describing it.

Safety and immunogenicity of an AS01-adjuvanted varicella-zoster virus subunit candidate vaccine against herpes zoster in adults >=50 years of age

BACKGROUND

An adjuvanted varicella-zoster virus glycoprotein E (gE) subunit vaccine candidate for herpes zoster is in development. In this trial we compared the safety, reactogenicity, and immunogenicity of the vaccine antigen combined with different adjuvant doses.

METHODS

This was a phase II, observer-blind, randomized, multinational study. Adults ≥50 years old were randomized 4:4:2:1 to be vaccinated at months 0 and 2 with gE combined with a higher (AS01B) or lower (AS01E) dose adjuvant, unadjuvanted gE, or saline. Following each dose, solicited events were recorded for 7 days and unsolicited adverse events for 30 days. Serious adverse events were collected for 1 year. Cell-mediated and humoral immune responses were assessed at baseline and following each dose.

RESULTS

No vaccine-related severe adverse events were reported. Solicited adverse events were generally mild to moderate and transient. For all gE-based vaccines, pain was the most common local symptom and fatigue the most common general symptom. Immune responses were significantly enhanced by AS01B and AS01E compared to unadjuvanted gE and were significantly stronger for gE/AS01B than for gE/AS01E.

CONCLUSIONS

AS01 improved the immunogenicity of gE while retaining acceptable safety and reactogenicity profiles. The enhancement of gE-specific cellular and humoral responses was adjuvant dose dependent.

CLINICAL TRIALS REGISTRATION

NCT00802464.

Sport-decision aids and the "CSI-effect": Why cricket uses Hawk-Eye well and tennis uses it badly

Technologies of visualisation and measurement are changing the relationship between spectators and match officials at sporting events. Umpires and referees find themselves under increasing scrutiny and sports governing bodies are experimenting with new technologies and additional "off-field" officials in order to preserve the legitimacy of decision-making. In this paper, we examine how technologies are being used in a number of sports, paying particular attention to the way in which uncertainty and indeterminacy are conveyed to viewers and spectators. The contrast between cricket and tennis is particularly instructive in this respect as the same technology is used in two very different ways. The paper concludes with a series of recommendations for implementing sports measurement technologies whilst preserving the traditions of individual sports and enriching technological culture.

Dose-sparing H5N1 A/Indonesia/05/2005 pre-pandemic influenza vaccine in adults and elderly adults: a phase III, placebo-controlled, randomized study

BACKGROUND

Highly pathogenic avian influenza H5N1 viruses remain a threat to human health, with potential to become pandemic agents.

METHODS

This phase III, placebo-controlled, observer-blinded study evaluated the immunogenicity, cross-reactivity, safety, and lot consistency of 2 doses of oil-in-water (AS03(A)) adjuvanted H5N1 A/Indonesia/05/2005 (3.75 μg hemagglutinin antigen) prepandemic candidate vaccine in 4561 adults aged 18-91 years.

RESULTS

Humoral antibody responses in the H5N1 vaccine groups fulfilled US and European immunogenicity licensure criteria for pandemic vaccines in all age strata 21 days after the second dose. At 6 months after the administration of the primary dose, serum antibody seroconversion rates continued to fulfill licensure criteria. Neutralizing cross-clade immune responses were demonstrated against clade 1 A/Vietnam/1194/2004. Consistency was demonstrated for 3 consecutive H5N1 vaccine lots. Temporary injection-site pain was more frequent with H5N1 vaccine than placebo (89.3% and 70.7% in the 18-64 and ≥65 years strata vs 22.2% and 14.4% in the placebo groups). Unsolicited adverse event frequency, including medically attended and serious events, was similar between groups through day 364.

CONCLUSIONS

In adults and elderly adults, AS03(A)-adjuvanted H5N1 candidate vaccine was highly immunogenic for A/Indonesia/05/2005, with cross-reactivity against A/Vietnam/1194/2004. Temporary injection site reactions were more frequent with H5N1 vaccine than placebo, although the H5N1 vaccine was well tolerated overall. Clinical Trials Registration. NCT00616928.

Language and practice

What are the relative contributions of language and physical practice to practical understanding? The resolution of a series of puzzles depends upon the answer. I argue that language is, and must be, more central than physical practice in individual acquisition of practical understanding. Only this makes it possible for there to be a sociology of scientific knowledge, for there to be scientific specialities, for there to be a division of labour in society and for there to be a society that is more than a set of narrow and isolated worlds. Physical practice remains central to human culture but its influence is at the collective level at which languages are formed, rather than the individual level at which practical abilities are acquired. Domain languages 'contain' practices, and it is from these that individuals draw much, usually most, of their practical understanding. Because the individual level and the domain level have not previously been distinguished, certain philosophical problems have been wrongly cast and mistakes have been made. Domains of practice/language are embedded within one another in fractal-like relationships, and this is how we can make sense of higher levels of coordinated action. The ideas of 'special interactional expert', 'practice language' and 'methodological interactionalism' are introduced.

Bicycling on the Moon: Collective Tacit Knowledge and Somatic-limit Tacit Knowledge

The idea of tacit knowledge plays an important role in many areas of academic debate, not least automation and its role in management. Here it is shown that tacit knowledge comes in two distinct types, with different causes and consequences. The first kind, ‘somatic-limit tacit knowledge’, has to do with the limitations of the human body and brain and has no consequences for encoding knowledge into machines. The second kind, ‘collective tacit knowledge’, is more ‘ontological’ than biological, having to do with its location in the social collectivity. Here the human body and brain’s unique capacity gives it special access to the tacit knowledge; known and foreseeable machines do not have this capacity.

Bilateral diaphragmatic paralysis and related respiratory complications in a patient with West Nile virus infection

The case report is presented of a patient with West Nile virus infection and ventilator dependent respiratory failure in whom bilateral diaphragmatic paralysis developed. If the prevalence of West Nile virus infection continues to rise, recognition of diaphragmatic paralysis and related respiratory complications will become increasingly important to the pulmonary/critical care physician.

Effect of declining owned-cat population on veterinary practices in Sydney

OBJECTIVES

To investigate relationships between declining owned-cat populations and cat-related clinical work and practice activities.

DESIGN

Sydney practitioners were interviewed, and practice records were examined, from small animal veterinary practices (n = 56) in Sydney. Using data that covered a 4 year period, the age distribution of cats was examined and associated trends in cat-related clinical work were analysed.

RESULTS

Important changes in the pet population attending veterinary practices were found, with 38.2% of respondents reporting a fall in cat desexings from 1996 to 2000.

CONCLUSIONS

While economic impact could not be determined, the qualitative data demonstrated that the majority of practices in the survey were active in the promotion of cat ownership. The study provides a useful model for future investigations. To facilitate this process and to enhance principals' knowledge of their practice's population dynamics, we advocate a minimum standard of data collection that records week-by-week activities and the deaths of pets.

Effect of preoperative radiotherapy on matrilysin gene expression in rectal cancer

Matrilysin, a member of matrix metalloproteinase family, is believed to play a significant role in the growth and proliferation of colon cancer cells. Overexpression of the matrilysin gene has been shown to correlate with Dukes' stage and increased metastatic potential in colorectal cancer. The aim of this study was to evaluate the effect of preoperative high-dose radiotherapy (25 Gy in five fractions over 5 days) on matrilysin (MMP-7) gene expression, in patients with resectable rectal cancer, by a quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). Biopsy samples of tumour (n=30) and distant normal mucosa (n=12) from 15 patients were obtained pre- and post-radiotherapy. Messenger (m)RNA was extracted from all of the tissue samples and reverse transcribed to double-stranded cDNA. Quantitative RT-PCR was performed to study the effect of preoperative radiotherapy on matrilysin gene expression in both the tumour and normal mucosal specimens. Matrilysin mRNA values were expressed relative to glyceraldehyde-3-phosphate dehydrogenase (GAPDH) for each sample. In 14 out of 15 cases, matrilysin mRNA was detected in the cancerous tissue. Although all six normal mucosal specimens expressed matrilysin mRNA, the levels were approximately 10-fold lower compared with those seen in the paired tumour samples. Preoperative radiotherapy led to a significant 6- to 7-fold increase (P=0.001) in the expression of matrilysin mRNA in rectal cancer tissue. In contrast, there was no significant change in the matrilysin mRNA expression of normal mucosal specimens post-radiotherapy. Preoperative high-dose radiotherapy upregulates matrilysin gene expression in rectal cancer. Matrilysin inhibition may be a useful preventive or therapeutic adjunct to radiotherapy in rectal cancer.

Orlistat in the long-term treatment of obesity in primary care settings

OBJECTIVE

To evaluate the long-term efficacy and tolerability within primary care settings of orlistat, a gastrointestinal lipase inhibitor, for the treatment of obesity.

DESIGN

Randomized, double-blind, placebo-controlled, multicenter study.

PARTICIPANTS

A group of 796 obese patients (body mass index, 30-44 kg/m2), treated with placebo 3 times a day (TID), 60 mg of orlistat TID, or 120 mg of orlistat TID, in conjunction with a reduced-energy diet for the first year and a weight-maintenance diet during the second year.

SETTING

Seventeen primary care centers in the United States.

MAIN OUTCOME MEASURES

Changes in body weight and obesity-related disease risk factors.

RESULTS

Patients treated with orlistat lost significantly more weight (7.08 +/- 0.54 and 7.94 +/- 0.57 kg for the 60-mg and 120-mg orlistat groups, respectively) than those treated with placebo (4.14 +/- 0.56 kg) in year 1 (P<.001) and sustained more of this weight loss during year 2 (P<.001). More patients treated with orlistat lost 5% or more of their initial weight in year 1 (48.8% and 50.5% of patients in the 60-mg and 120-mg groups, respectively) compared with placebo (30.7%; P<.001), and approximately 34% of patients in the orlistat groups sustained weight loss of 5% or greater over 2 years compared with 24% in the placebo group (P<.001). Orlistat produced greater improvements than placebo in serum lipid levels and blood pressure and was well tolerated, although treatment resulted in a higher incidence of gastrointestinal events.

CONCLUSIONS

This long-term study indicates that orlistat is an effective adjunct to dietary intervention in the treatment of obesity in primary care settings.

Toxicity and efficacy of defined doses of CD4(+) donor lymphocytes for treatment of relapse after allogeneic bone marrow transplant

Donor lymphocyte infusions (DLI) can induce remissions in patients who have relapsed after allogeneic bone marrow transplantation (BMT). However, DLI frequently also result in significant acute and/or chronic graft-versus-host disease (GVHD). Several clinical and experimental lines of evidence have suggested that CD8(+) T cells play a critical role in the pathogenesis of GVHD. To develop methods to reduce the incidence of GVHD associated with DLI, we administered defined numbers of CD4(+) donor T cells after ex vivo depletion of CD8(+) lymphocytes to 40 patients with relapsed hematologic malignancies after allogeneic BMT. Cohorts of patients received 0.3, 1.0, or 1.5 x 10(8) CD4(+) cells/kg. Overall, 12 of 38 patients (32%) evaluable for toxicity developed acute or chronic GVHD. However, 6 of 27 patients (22%) receiving 0.3 x 10(8) CD4 cells/kg developed GVHD compared with 6 of 11 patients (55%) who received >/=1.0 x 10(8) CD4 cells/kg (P = .07). Treatment-related mortality was low (3%), with 1 death related to infection in the setting of immunosuppression for GVHD. Disease responses after CD4(+) DLI were documented in 15 of 19 patients (79%) with early-phase chronic myelogenous leukemia (CML) relapse, 5 of 6 patients (83%) with relapsed multiple myeloma, and 1 patient with myelodysplasia. For patients with early-phase CML relapse, the Kaplan-Meier probability of achieving complete cytogenetic remission was 87% and the probability of complete molecular response was 78% at 1 year after DLI. The median time to complete cytogenetic response and molecular response in patients with CML was 13 weeks (range, 9 to 30 weeks) and 34 weeks (range, 10 to 56 weeks), respectively. The median time to response in patients with multiple myeloma was 26 weeks (range, 15 to 62 weeks). All patients in this trial who developed GVHD demonstrated tumor regression, but the presence of GVHD was not required for patients to achieve a response, because 48% of responding patients never developed evidence of GVHD. Two patients with CML who did not respond at dose level 1 subsequently achieved complete cytogenetic remission after a second infusion of CD8-depleted cells at dose level 2. In patients with evidence of mixed hematopoietic chimerism who achieved a complete remission after DLI, cytogenetic analysis of marrow cells also demonstrated conversion to complete donor hematopoiesis in all evaluable patients. These studies suggest that relatively low numbers of CD8-depleted donor lymphocytes are effective in inducing complete remissions in patients with stable-phase CML and multiple myeloma who have relapsed after allogeneic BMT. Because of the relatively low risk of toxicity associated with the infusion of defined numbers of CD4(+) donor cells, further studies can be undertaken in the setting of persistent minimal residual disease to prevent relapse after allogeneic BMT.

How to save distressed IDS-physician marriages: a case study

A hospital-driven IDS that encounters serious problems resulting from ownership of a physician practice should address those problems by focusing on three core areas: vision and leadership, effectiveness of operations, and physician compensation arrangements. If changes in these areas do not lead to improvements, the IDS may need to consider organizational restructuring. In one case study, a hospital-driven IDS faced the problem of owning a poorly performing MSO with a captive physician group. The IDS's governing board determined that the organization lacked effective communication with the physicians and that realization of the organization's vision would require greater physician involvement in organizational decision making. The organization is expected to undergo some corporate reorganization in which physicians will acquire an equity interest in the enterprise.

Why intracellular parasitism need not be a degrading experience for Mycobacterium

The success of mycobacteria as pathogens hinges on their ability to infect and persist within the macrophages of their host. However, activation of host macrophages by cytokines from a productive cellular immune response can stimulate the cells to kill their resident pathogens. This suggests that the interaction between host cell and microbe is in delicate balance, which can be tipped in favour of either organism. Biochemical analysis of mycobacterial vacuoles has shown them to be integral to the host cell's recycling endosomal system. As such they show limited acidification and hydrolytic activity despite possession of known lysosomal constituents such as cathepsins D, B and L, and LAMP 1. Even in established infections, they remain dynamic compartments accessible to several plasmalemma-derived constituents. Once the macrophage has been activated by IFN-gamma and TNF-alpha the vacuoles coalesce and acidify. This marks a distinct alteration in vacuole physiology and leads to stasis and death of the mycobacteria. Mycobacteria have developed several strategies to avoid this outcome. Most notably, live bacilli-induce sustained release of IL-6 from infected macrophages. IL-6 blocks the ability of both polyclonal primary T cells and T-cell hybridomas to respond to appropriate stimuli. Such an activity could render the centres of infection foci, such as granulomas, anergic and thus avoid release of macrophage-activating cytokines. This paper discusses both the mechanisms by which mycobacteria try to ensure their success as intracellular pathogens and the relevance of these strategies to the overall understanding of mycobacterial diseases.

Characterization of T cell repertoire in patients with graft-versus-leukemia after donor lymphocyte infusion

The clinical efficacy of donor lymphocyte infusions (DLI) in patients with relapsed chronic myelocytic leukemia after allogeneic bone marrow transplantation has been demonstrated in several recent studies. Although it is presumed that allogeneic T cells mediate this graft-versus-leukemia (GVL) effect, the influence of DLI on the T cell compartment of recipients has not been determined. To characterize the immunologic effects of DLI and to identify T cell changes selectively associated with the GVL response, we analyzed the T cell receptor (TCR) repertoire in four patients with relapsed chronic myelocytic leukemia who achieved a complete remission after infusion of CD4+ lymphocytes from HLA-identical sibling donors. Only one of the four patients developed clinically significant graft-versus-host disease (GVHD) after infusion of donor lymphocytes. TCR repertoire was examined after PCR amplification of 24 Vbeta gene subfamilies in serial samples obtained over a 1-yr period before and after DLI. Results were compared to 10 normal donors. Before DLI, all four patients were found to have abnormal TCR Vbeta repertoire in peripheral T cells, associated with a large number of clonal and oligoclonal patterns. Abnormal TCR patterns persisted for at least 3 mo after DLI, but thereafter gradually began to normalize. By 1 yr after DLI, all patients demonstrated almost complete normalization of Vbeta repertoire with polyclonal representation within almost all Vbeta gene subfamilies. We also examined changes in the TCR Vbeta repertoire associated with the disappearance of Ph+ cells. In each patient, we were able to identify the expansion of at least 1 Vbeta gene subfamily that coincided with the time of the cytogenetic response. In one patient who was studied in greater detail, CDR3 size analysis of serial samples after DLI indicated that these changes were associated with the appearance of clonal T cells. This finding was confirmed through CDR3 sequence analysis and use of CDR3 clone-specific oligonucleotide probes. A putative GVL clone identified by this technique was not detectable in either donor or patient T cells before DLI, but persisted in peripheral T cells for approximately 1 yr. These experiments therefore provide evidence for the clonal expansion of allogeneic T cells that may be selective mediators of antileukemia activity without also mediating graft-versus-host disease.

Administration of R24 monoclonal antibody and low-dose interleukin 2 for malignant melanoma

R24 is a monoclonal antibody that recognizes the disialoganglioside GD3 expressed on the surface of malignant melanoma cells. Once bound, it can mediate destruction of these cells through both complement-mediated lysis and antibody-dependent cellular cytotoxicity. Agents such as interleukin 2 (IL-2), which can augment effector cell function and promote destruction of antibody-coated tumor cells, might produce improved antitumor responses when combined with R24. In this series, we evaluated the combination of R24 and IL-2 in a Phase 1b study in patients with metastatic melanoma. Twenty-eight patients with metastatic melanoma were entered into the protocol at two institutions. Patients received 8 weeks of IL-2 by continuous i.v. infusion at a dose (4.5 x 10(5) Amgen units/m2/day) designed to selectively expand natural killer (NK) cells. In weeks 5 and 6, patients received R24 for a total of four doses. Twenty-four h after each R24 infusion, patients received a 2-h bolus dose of IL-2 to help promote activity of NK effectors against antibody-coated melanoma targets. Additional IL-2 boluses were administered in weeks 7 and 8. Doses were escalated through two bolus doses of R24 (5 or 15 mg/m2) and two bolus doses of IL-2 (2.5 or 5.0 x 10(5) units/m2). Although one patient experienced severe capillary leak syndrome during IL-2, therapy was otherwise well tolerated. At the higher dose level of R24, two of four patients experienced transient but severe abdominal and chest discomfort, necessitating dose reduction. One patient with ocular melanoma and liver metastases had a partial response. Two additional patients had minor responses. A dramatic increase in NK cell number was noted as a result of treatment, as was augmentation of cytolytic activity against cultured NK-sensitive targets. Antibody-dependent cellular cytotoxicity against cultured melanoma cells in the presence of exogenous R24 or in the presence of serum obtained from patients following R24 infusion also increased during treatment. Our experience indicates that R24 and low-dose IL-2 can be safely combined in patients with metastatic melanoma and that this combination can promote destruction of cultured melanoma cells. The clinical activity of this combination against ocular melanoma may merit further investigation.