Donor screening for human T-cell lymphotrophic virus 1/2: changing paradigms for changing testing capacity

Organ Procurement and Transplant Network (OPTN) policy currently requires the testing of all potential organ donors for human T-cell lymphotrophic virus (HTLV)-1/2. Most Organ Procurement Organizations (OPO) use the Abbott HTLV-I/HTLV-II Enzyme Immunoassay (EIA). This assay will no longer be manufactured after December 31, 2009; the only commercially available FDA-licensed assay will be the Abbott PRISM HTLV-I/II assay which poses many challenges to OPO use for organ donor screening. As a result, screening donors for HTLV-1/2 in a timely manner pretransplant after December 31, 2009 will be challenging. The true incidence of HTLV-1 in United States (U.S.) organ donors is not well described but appears to be low ( approximately 0.03-0.5%). HTLV-1 is associated with malignancy and neurological disease; HTLV-2 has not been convincingly associated with disease in humans. Donors that are HTLV-1/2 seropositive are infrequently used despite most results being either false positive or resulting from HTLV-2 infection. There is urgent need to encourage the development of assays, instruments and platforms optimized for organ donors that can be used to screen for transmissible disease in donors; these must have appropriate sensitivity and specificity to identify all infections while minimizing organ loss through false positive testing.

Survival Outcomes in Women with Ipsilateral Breast Tumor Relapse: An Analysis of Cohorts Classified Clinically as 'True Recurrence' Versus 'New Primary'

Background:Ipsilateral breast tumor relapse (IBTR) can occur in ∼5-20% of women after breast conserving therapy. Two entities of IBTR have been described: "True Recurrence" (TR), suggested to be cases of regrowth of pre-malignant or malignant cells not completely eradicated by surgery or radiation therapy; and "New Primary" (NP), distinct in histology and located away from the index tumor. Whether these two entities have different prognoses is unclear. This study examined a method of IBTR classification using chart review with pre-defined decision rules to assess histology and tumor location and compared survival between two groups classified as either TR or NP.Methods:Between 1989-1999, 6020 women with newly diagnosed invasive breast cancer, pT1-T2, 0-3 positive nodes, M0, treated with breast conserving surgery with clear margins were referred to the BC Cancer Agency. Of these, 289 cases had pathologically-confirmed IBTR, defined as the first recurrence occurring in the ipsilateral breast. Retrospective chart review was performed to abstract clinical data related to the index tumor and the IBTR. A set of decision rules established a priori (figure 1) was applied to classify these cases as either TR or NP.Time to recurrence, distant-relapse free survival (DRFS), and overall survival (OS) were compared between the two cohorts using Kaplan-Meier and log-rank statistics.Results:Of 289 subjects, 131(45%) were classified as TR, 128 (44%) as NP, and 30 (10%) unclassified due to insufficient information. The distributions of age at diagnosis, age at recurrence, index tumor histology, T size, nodal status, grade, lymphovascular invasion, and estrogen receptor status were similar in the two cohorts, (all p >0.05). The mean time to recurrence was shorter in TR compared to NP patients (4.7 years vs. 6.3 years, p=0.001). Surgical treatment of IBTR differed in the two groups, with 76% mastectomy and 21% local excision only in the TR cohort, compared to 81% mastectomy and 16% local excision only in the NP cohort (p<0.001). Systemic therapy at the time of IBTR also differed in the two groups, with hormone therapy alone used more frequently in the TR compared to the NP cohort (42% vs. 38%, p<0.001); and a smaller proportion of the NP cohort receiving both chemotherapy and hormone therapy compared to the TR cohort (8% vs. 15%, p<0.001). In the TR and NP cohorts, 10-year DRFS were 57% vs. 61%, p=0.59; and 10-year OS were 45% vs. 53%, p=0.67.Conclusions:The median time to recurrence is significantly longer in patients with IBTR classified as 'new primary' compared to 'true recurrence'. Non-statistically significant trends for more favorable DRFS and OS were observed for patients with NP compared to TR tumors. The hypothesis that NP and TR tumors are distinct entities with different survival prognoses requires confirmation with pathology review and molecular analyses.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4116.

HER2 Amplification, Polysomy Status and Breast Cancer Survival in a Large Kaiser Permanente Case-Control Study: Assessment of HER2 by Quantitative Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) and Fluorescence In Situ Hybridization (FISH)

BackgroundPolysomy 17 is found in breast cancer and may complicate interpretation of HER2 results. HER2 status by FISH and quantitative RT-PCR were determined in a case-control study that quantitated HER2 mRNA levels in polysomy 17 patients and that examined breast cancer survival in tamoxifen (TAM) treated and untreated patients.MethodsA Kaiser Permanente nested case-control study was performed in node-negative breast cancer patients diagnosed from 1985-94 who were not treated with chemotherapy. Cases died of breast cancer prior to 2002; up to three controls were matched for each case, with a total of 568 unique patients. HER2 was measured by quantitative RT-PCR by Oncotype DX; pre-defined cutoffs ≥11.5 expression units (positive), ≥10.7 to <11.5 expression units (equivocal), and <10.7 expression units (negative) (each unit represents ∼2-fold change in expression). HER2 and polysomy were assessed by FISH (Vysis, Abbott); ratio > 2.2 (positive), 1.8 to 2.2 (equivocal), <1.8 (negative). Chromosome 17 polysomy was defined as a CEP 17 signal ≥3. Conditional logistic regression explored the association between the HER2/Polysomy subgroups and risk of breast cancer death.ResultsMedian age at dx was 59 yrs, 30.9% were TAM treated and median time to death was 59 months. 12% (67/568) of patients were HER2 positive by RT-PCR and 11% (60/568) were HER2 positive by FISH. By ASCO/CAP guidelines, concordance for HER2 by central FISH and central RT-PCR was 97% (95% CI: 96%, 99%). HER2 positivity by either method was weakly prognostic; HER2 positive patients had increased odds of dying from breast cancer compared to HER2 negative patients (by FISH (OR=1.95, 95% CI=1.19-3.19) and RT-PCR (OR=1.72, 95% CI=1.04-2.84)). Similar results were obtained in TAM-treated and untreated groups separately. Seventy-one (12.5%) patients showed polysomy 17. 33% of FISH positive patients were polysomy 17 (20/60) and 19 of the 20 were RT-PCR HER2 positive (Table). The majority of FISH negative polysomy 17 cases were RT-PCR HER2 negative (32/49) but rare cases (4/49) were RT-PCR HER2 positive. Compared to chromosome 17 eusomic patients, HER2 positive patients with polysomy 17 had 2.77 (95% CI: 1.21, 6.33) times the odds of dying from breast cancer; HER2 positive, chromosome 17 eusomic patients had 1.78 (95% CI: 0.97, 3.25) times the odds; and HER2 negative, polysomy 17 patients had 1.50 (95% CI: 0.83, 2.72) times the odds.Incidence of Polysomy 17 by HER2 Status (FISH and RT-PCR)HER2Central FISH positiveCentral FISH equivocalCentral FISH negativeTotal RT-PCRRT-PCR positive19/55 (35%)1/1 (100%)4/11 (36%)24/67 (36%)RT-PCR equivocal0/4 (0%)1/5 (20%)13/79 (17%)14/88 (16%)RT-PCR negative1/1 (100%)0/4 (0%)32/408 (8%)33/413 (8%)Total FISH20/60 (33%)2/10 (20%)49/498 (10%)71/568 (13%) ConclusionHER2 amplification with polysomy was common. FISH negative polysomy 17 cases were rarely RT-PCR HER2 positive. While differences were not statistically significant, HER2+/polysomy 17 patients tended to have the worst prognosis, followed by HER2+/eusomic, HER2-/polysomy 17, and HER2 negative eusomic pts whether HER2 status was measured by FISH or RT-PCR.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6004.

Induction of tolerogenic vs immunogenic dendritic cells (DCs) in the presence of GM-CSF is regulated by the strength of signaling from monophosphoryl lipid A (MPLA) in association with glutathione and fetal hemoglobin gamma-chain

Previous studies showed a fetal sheep liver extract (FSLE), in association with monophosphoryl lipid A, MPLA (a bioactive component of lipid A of LPS), could interact to induce the development of dendritic cells (DCs) which regulated production of Foxp3+ Treg. This interaction was associated with an altered gene expression both of distinct subsets of TLRs and of CD200Rs. Prior studies had suggested that major interacting components within FSLE were gamma-chain of fetal hemoglobin (Hgbgamma) and glutathione (GSH). We investigated whether differentiation/maturation of DCs in vitro in the presence of either GM-CSF or Flt3L to produce preferentially either immunogenic or tolerogenic DCs was itself controlled by an interaction between MPLA, GSH and Hgbgamma. At low (approximately 10 microg/ml) Hgbgamma concentrations, DCs developing in culture with GSH and MPLA produced optimal stimulation of allogeneic CTL cell responses in vitro (and enhanced skin graft rejection in vivo). At higher concentrations (>40 microg/ml Hgbgamma) and equivalent concentrations of MPLA and GSH, the DCs induce populations of Treg which can suppress the induction of allogeneic CTL and graft rejection in vivo. These different populations of DCs express different patterns of mRNAs for the CD200R family. Addition of anti-TLR or anti-MD-1 mAbs to DCs developing in this mixture (Hgbgamma+GSH+MPLA), suggests that one effect of (GSH+Hgbgamma) on MPLA stimulation may involve altered signaling through TLR4.

Viral nucleic acid testing (NAT) and OPO-level disposition of high-risk donor organs

The use of Public Health Service/Centers for Disease Control and Prevention (PHS/CDC) high-risk donor (HRD) organs remains controversial, especially in light of a recent high-profile case of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission. Nucleic acid testing (NAT), while more expensive and time consuming, reduces infectious risk by shortening the period between infection and detectability. The purpose of this study was to characterize HRDs and disposition of their organs by organ procurement organization (OPO), to measure NAT practices by OPO and to examine associations between NAT practices and use of HRD organs. We analyzed 29 950 deceased donors (2574 HRDs) reported to UNOS since July 1, 2004 and May 8, 2008. We then surveyed all OPO clinical directors about their use of NAT, average time to receive NAT results, locations where NAT is performed and percentage of the time NAT results are available for allocation decisions. In total, 51.7% of OPOs always perform HIV NAT, while 24.1% never do. A similar pattern is seen for HCV NAT performance, while the majority (65.6%) never perform HBV NAT. AIDS prevalence in an OPO service area is not associated with NAT practice. OPOs that perform HIV NAT are less likely to export organs outside of their region. The wide variation of current practice and the possibility that NAT would improve organ utilization support consideration for a national policy.

Differential control of the scapulothoracic muscles in humans

The control of the scapulothoracic muscles trapezius (Tr) and serratus anterior (SA) has been examined in normal human subjects. Electromyographic recordings were made from the SA and Tr muscles (upper trapezius UTr, lower trapezius LTr) using surface electrodes placed bilaterally. Magnetic stimulation of the motor cortex and electrical stimulation of peripheral nerves were used to examine their descending and reflex control. The average optimal site of cortical stimulation was found to be the same for SA, UTr and LTr (an approximate centre of gravity of -0.6 cm, 3.7 cm where the centre of gravity is expressed as the mean anterio-posterior position, the mean medio-lateral position). Some asymmetry in the cortical representation of UTr was found in each individual tested. Magnetic stimulation evoked bilateral MEPs in Tr (latency contralateral (c) UTr 8.5 +/- 1.6 ms, ipsilateral (i) UTr 19.0 +/- 2.7 ms) but only contralateral responses were evoked in SA (11.2 +/- 2.6 ms). Electrical stimulation of the long thoracic nerve at two sites was used to examine homonymous and heteronymous reflexes of SA, while electrical stimulation of cervical nerve of C3/4 was used to examine the heteronymous reflexes of Tr. Ipsilateral SA H reflexes were evoked at a latency of 9.9 +/- 0.8 ms (proximal site) and 10.8 +/- 1.2 ms (distal site). No group I reflexes were evoked from SA to its contralateral homologue. No group I reflexes were evoked between Tr and SA. Finally, cross-correlation of activity from the Tr muscle pairs and the SA muscle pair revealed that the motoneurones of the Tr muscles share some common presynaptic input whereas there was no detectable common presynaptic input to the SA muscle pair. This study extends and consolidates knowledge regarding the neural control of trapezius and for the first time explores the neural control of SA. The study demonstrates a contrasting bilateral control of Tr and SA. These patterns of connections are discussed in relation to the contrasting bilateral functional roles of these muscles.

Differential control of the scapulothoracic muscles in humans

The control of the scapulothoracic muscles trapezius (Tr) and serratus anterior (SA) has been examined in normal human subjects. Electromyographic recordings were made from the SA and Tr muscles (upper trapezius UTr, lower trapezius LTr) using surface electrodes placed bilaterally. Magnetic stimulation of the motor cortex and electrical stimulation of peripheral nerves were used to examine their descending and reflex control. The average optimal site of cortical stimulation was found to be the same for SA, UTr and LTr (an approximate centre of gravity of -0.6 cm, 3.7 cm where the centre of gravity is expressed as the mean anterio-posterior position, the mean medio-lateral position). Some asymmetry in the cortical representation of UTr was found in each individual tested. Magnetic stimulation evoked bilateral MEPs in Tr (latency contralateral (c) UTr 8.5 +/- 1.6 ms, ipsilateral (i) UTr 19.0 +/- 2.7 ms) but only contralateral responses were evoked in SA (11.2 +/- 2.6 ms). Electrical stimulation of the long thoracic nerve at two sites was used to examine homonymous and heteronymous reflexes of SA, while electrical stimulation of cervical nerve of C3/4 was used to examine the heteronymous reflexes of Tr. Ipsilateral SA H reflexes were evoked at a latency of 9.9 +/- 0.8 ms (proximal site) and 10.8 +/- 1.2 ms (distal site). No group I reflexes were evoked from SA to its contralateral homologue. No group I reflexes were evoked between Tr and SA. Finally, cross-correlation of activity from the Tr muscle pairs and the SA muscle pair revealed that the motoneurones of the Tr muscles share some common presynaptic input whereas there was no detectable common presynaptic input to the SA muscle pair. This study extends and consolidates knowledge regarding the neural control of trapezius and for the first time explores the neural control of SA. The study demonstrates a contrasting bilateral control of Tr and SA. These patterns of connections are discussed in relation to the contrasting bilateral functional roles of these muscles.

Education, training and support needs of Australian trained doctors and international medical graduates in rural Australia: a case of special needs?

INTRODUCTION

Little attention has been paid to issues relating to the education, training and support needs of Australian medical graduates and international medical graduates (IMGs) in rural practices. The focus continues to be on recruiting to rural areas. The aim of this article was to document the education, training and support needs of rural GPs.

METHODS

Cross-sectional surveys were made of rural GPs working in rural north-west New South Wales, Australia. The main outcome measures were the key factors influencing rural GPs to stay in rural practice.

RESULTS

Australian medical graduates and IMGs largely agree on key education, training and professional support needs. Continuing professional development, training opportunities, professional support and networking, as well as financial support are the doctors' shared top priority issues. Rural GPs satisfied with their current medical practice, intend to remain in rural practice for 40% longer than those who are not satisfied (11.5 years compared with 8.2 years). Rural GPs contented with their life as a rural doctor intend to remain in rural practice for 51% longer than those who are discontented (11.8 years compared with 7.8 years).

CONCLUSION

While there is merit in delivering specially designed initiatives to target groups, such as male or female GPs, registrars or GPs, our results support the notion that IMGs should not so much be considered to have special needs, but rather an integral part of the region's medical workforce.

An alteration in the levels of populations of CD4+ Treg is in part responsible for altered cytokine production by cells of aged mice which follows injection with a fetal liver extract

We have shown previously that a fetal sheep liver extract (FSLE) containing significant quantities of fetal ovine gamma globin chain (Hbgamma) and LPS injected into aged (>20 months) mice could reverse the altered polarization (increased IL-4 and IL-10 with decreased IL-2 and IFNgamma) in cytokine production seen from ConA stimulated lymphoid cells of those mice. The mechanism(s) behind this change in cytokine production were not previously investigated. We report below that aged mice show a >60% decline in numbers and suppressive function of both CD4(+)CD25(+)Foxp3(+) Treg and so-called Tr3 (CD4(+)TGFbeta(+)), and that their number/function is restored to levels seen in control (8-week-old) mice by FSLE. In addition, on a per cell basis, CD4(+)CD25(-)Treg from aged mice were >4-fold more effective in suppression of proliferation and IL-2 production from ConA-activated lymphoid cells of a pool of CD4(+)CD25(-)T cells from 8-week-old mice than similar cells from young animals, and this suppression by CD25(-)T cells was also ameliorated following FSLE treatment. Infusion of anti-TGFbeta and anti-IL-10 antibodies in vivo altered Treg development following FSLE treatment, and attenuated FSLE-induced alterations in cytokine production profiles.

Publish and perish: a case study of publication ethics in a rural community

BACKGROUND

Health researchers must weigh the benefits and risks of publishing their findings.

OBJECTIVE

To explore differences in decision making between rural health researchers and managers on the publication of research from small identifiable populations.

METHOD

A survey that investigated the attitudes of Australian rural general practitioners (GPs) to nurse practitioners was explored. Decisions on the study's publication were analysed with bioethical principles and health service management ethical decision-making models.

RESULTS

Response rate was 78.5% (62/79 GPs). 84-94% of GP responders considered it to be undesirable for nurse practitioners to initiate referrals to medical specialists (n=58), to initiate diagnostic imaging (n=56) and to prescribe medication (n=52). BIOETHICAL ANALYSIS: It was concluded that the principle of beneficence outweighed the principle of non-maleficence and that a valid justification for the publication of these results existed. DECISION-MAKING MODELS OF HEALTH SERVICE MANAGERS: On the basis of models of ethical decision making in health service management, the decisions of the area's health managers resulted in approval to publish this project's results being denied. This was because the perceived risks to the health service outweighed benefits. Confidentiality could not be ensured by publication under a regional nom de plume.

CONCLUSIONS

A conflict of interests between rural researchers and health managers on publication of results is shown by this case study. Researchers and managers at times owe competing duties to key stakeholders. Both weigh the estimated risks and benefits of the effect of research findings. This is particularly true in a rural area, where identification of the subjects becomes more likely.

Role of MIF and glutathione, in association with fetal ovine globin chain (Hbγ) and LPS, in induction of TNFα from cells of young and aged mice, and PBL from healthy human populations

Previous reports from our group have established that the fetal ovine gamma globin chain (Hbgamma) and LPS can synergize in the induction of pro-inflammatory cytokines, especially TNFalpha, from mouse and human leukocytes. A fetal sheep liver extract (FSLE) which was observed to have marked immunoregulatory properties in vivo and in vitro had independently been observed to contain significant amounts of each of these molecules. However, the biological activity of this extract (hereafter FSLE) was not explained solely by its content of Hbgamma and LPS, and independent analysis confirmed also the presence of migration inhibitory factor, MIF, and glutathione in FSLE. We have investigated whether MIF and the cellular anti-oxidant glutathione can further synergize with Hbgamma and LPS in TNFalpha induction from human cells in vitro, and mouse cells activated in vivo/in vitro. Our data show that indeed there is evidence for such a synergy. Treatment or mouse cells with FSLE produced an enhanced TNFalpha production which could be inhibited independently both by anti-Hbgamma and by anti-MIF, and optimally by a combination of these reagents.