Posttransplant MRD and T-cell chimerism status predict outcomes in patients who received allografts for AML/MDS

Allogeneic stem-cell transplant allows for the delivery of curative graft-versus-leukemia (GVL) in patients with acute myeloid leukemia/myelodysplasia (AML/MDS). Surveillance of T-cell chimerism, measurable residual disease (MRD) and blast HLA-DR expression may inform whether GVL effectiveness is reduced. We report here the prognostic impact of these biomarkers in patients allografted for AML/MDS. One hundred eighty-seven patients from FIGARO, a randomized trial of reduced-intensity conditioning regimens in AML/MDS, were alive and relapse-free at the first MRD time-point and provided monitoring samples for flow cytometric MRD and T-cell chimerism, requested to month+12. Twenty-nine (15.5%) patients had at least 1 MRD-positive result posttransplant. MRD-positivity was associated with reduced overall survival (OS) (hazard ratio [HR], 2.18; P = .0028) as a time-varying Cox variable and remained significant irrespective of pretransplant MRD status in multivariate analyses (P < .001). Ninety-four patients had sequential MRD with T-cell chimerism results at months+3/+6. Patients with full donor T-cell chimerism (FDTC) had an improved OS as compared with patients with mixed donor T-cell chimerism (MDTC) (adjusted HR=0.4; P = .0019). In patients with MDTC (month+3 or +6), MRD-positivity was associated with a decreased 2-year OS (34.3%) vs MRD-negativity (71.4%) (P = .001). In contrast, in the group with FDTC, MRD was infrequent and did not affect the outcome. Among patients with posttransplant MRD-positivity, decreased HLA-DR expression on blasts significantly reduced OS, supporting this as a mechanism for GVL escape. In conclusion, posttransplant MRD is an important predictor of the outcome in patients allografted for AML/MDS and is most informative when combined with T-cell chimerism results, underlining the importance of a GVL effect in AML/MDS.

ALL-RIC trial protocol: a comparison of reduced dose total body irradiation (TBI) and cyclophosphamide with fludarabine and melphalan reduced intensity conditioning in adults with acute lymphoblastic leukaemia (ALL) in complete remission

INTRODUCTION

The usage of a T-cell depleted, reduced intensity conditioning (RIC) approach to haematopoietic cell transplantation (HCT) in adult patients with acute lymphoblastic leukaemia (ALL) over 40 years of age and in first complete remission (CR) has resulted in encouraging rates of event-free and overall survival in a population of adults with high risk disease. However, relapse rates remain high-with disease progression being the major cause of treatment failure. Using different, more powerful conditioning approaches is the logical next step in examining the role of RIC allogeneic HCT in adult ALL.

METHODS AND ANALYSIS

The ALL-RIC trial is a two-arm, phase II, multicentre, randomised clinical trial in adult patients with ALL in first or second CR, who are undergoing allogeneic HCT. Comparison of a novel RIC transplant conditioning regimen using reduced-dose total body irradiation (TBI), cyclophosphamide and alemtuzumab, is made against a standardised RIC approach using fludarabine, melphalan and alemtuzumab. The primary outcome of the study is disease-free survival at 3 years, defined as time from randomisation to the first of either relapse or death from any cause. Patients who are still alive and progression-free at the end of the trial will be censored at their last date known to be alive. Secondary outcomes include overall survival and non-relapse mortality.

ETHICS AND DISSEMINATION

The protocol was approved by the East Midlands-Leicester Central Research Ethics committee (18/EM/0112). Initial approval was received on 12 June 2018. Current protocol version (V.6.0) approval obtained on 18 November 2019. The Medicines and Healthcare products Regulatory Agency (MHRA) also approved all protocol versions. The results of this trial will be disseminated through national and international presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

EudraCT Number: 2017-004800-23.ISRCTN99927695.

Azacitidine for the treatment of steroid-refractory chronic graft-versus-host disease: the results of the phase II AZTEC clinical trial

Chronic graft-versus-host disease (cGvHD) is a major cause of non-relapse morbidity and mortality following allogeneic stem cell transplant. Over half of patients with moderate or severe cGvHD fail to respond adequately to first-line treatment with systemic steroids, and although a range of second-line options have been employed, a lack of prospective evidence means there is no standard of care. The AZTEC trial is a prospective, single-arm, phase II study investigating the safety and activity of azacitidine for the treatment of cGvHD in patients who are resistant to, or intolerant of, systemic steroid therapy. The co-primary outcomes were treatment tolerability, and activity measured as objective response according to modified National Institutes of Health criteria. Fourteen patients were recruited to the first stage of the trial, of whom seven completed the planned six cycles of azacitidine 36 mg/m2 days 1-5 per 28-day cycle. Azacitidine was tolerated by 13/14 patients, and 7/14 showed an objective response. Clinical responses were mirrored by improvements in patient-reported cGvHD symptoms and quality of life. AZTEC demonstrates that azacitidine is a safe and promising option for the treatment of cGvHD, and continued evaluation in the second stage of this phase II efficacy study is supported.

Augmented Reduced-Intensity Regimen Does Not Improve Postallogeneic Transplant Outcomes in Acute Myeloid Leukemia

PURPOSE

Reduced-intensity conditioning (RIC) regimens have extended the curative potential of allogeneic stem-cell transplantation to older adults with high-risk acute myeloid leukemia (AML) and myelodysplasia (MDS) but are associated with a high risk of disease relapse. Strategies to reduce recurrence are urgently required. Registry data have demonstrated improved outcomes using a sequential transplant regimen, fludarabine/amsacrine/cytarabine-busulphan (FLAMSA-Bu), but the impact of this intensified conditioning regimen has not been studied in randomized trials.

PATIENTS AND METHODS

Two hundred forty-four patients (median age, 59 years) with high-risk AML (n = 164) or MDS (n = 80) were randomly assigned 1:1 to a fludarabine-based RIC regimen or FLAMSA-Bu. Pretransplant measurable residual disease (MRD) was monitored by flow cytometry (MFC-MRD) and correlated with outcome.

RESULTS

There was no difference in 2-year overall survival (hazard ratio 1.05 [85% CI, 0.80 to 1.38] P = .81) or cumulative incidence of relapse (CIR) (hazard ratio 0.94 [95%CI, 0.60 to 1.46] P = .81) between the control and FLAMSA-Bu arms. Detectable pretransplant MFC-MRD was associated with an increased CIR (2-year CIR 41.0% v 20.0%, P = .01) in the overall trial cohort with a comparable prognostic impact when measured by an unsupervised analysis approach. There was no evidence of interaction between MRD status and conditioning regimen intensity for relapse or survival. Acquisition of full donor T-cell chimerism at 3 months abrogated the adverse impact of pretransplant MRD on CIR and overall survival.

CONCLUSION

The intensified RIC conditioning regimen, FLAMSA-Bu, did not improve outcomes in adults transplanted for high-risk AML or MDS regardless of pretransplant MRD status. Our data instead support the exploration of interventions with the ability to accelerate acquisition of full donor T-cell chimerism as a tractable strategy to improve outcomes in patients allografted for AML.

Combination Lenalidomide and Azacitidine: A Novel Salvage Therapy in Patients Who Relapse After Allogeneic Stem-Cell Transplantation for Acute Myeloid Leukemia

PURPOSE

Salvage options for patients who relapse after allogeneic stem-cell transplantation (allo-SCT) for acute myeloid leukemia (AML) and myelodysplasia (MDS) remain limited, and novel treatment strategies are required. Both lenalidomide (LEN) and azacitidine (AZA) possess significant antitumor activity effect in AML. Administration of LEN post-transplantation is associated with excessive rates of graft-versus-host disease (GVHD), but AZA has been shown to ameliorate GVHD in murine transplantation models. We therefore examined the tolerability and activity of combined LEN/AZA administration in post-transplantation relapse.

PATIENTS AND METHODS

Twenty-nine patients who had relapsed after allo-SCT for AML (n = 24) or MDS (n = 5) were treated with sequential AZA (75 mg/m² for 7 days) followed by escalating doses of LEN on days 10 to 30. Dose allocation and maximum tolerated dose (MTD) estimation were guided by a modified Bayesian continuous reassessment method (CRM).

RESULTS

Sequential AZA and LEN therapy was well tolerated. The MTD of post-transplantation LEN, in combination with AZA, was determined as 25 mg daily. Three patients developed grade 2 to 4 GVHD. There was no GVHD-related mortality. Seven of 15 (47%) patients achieved a major clinical response after LEN/AZA therapy. CD8+ T cells demonstrated impaired interferon-γ/tumor necrosis factor-α production at relapse, which was not reversed during LEN/AZA administration.

CONCLUSION

We conclude LEN can be administered safely post-allograft in conjunction with AZA, and this combination demonstrates clinical activity in relapsed AML/MDS without reversing biologic features of T-cell exhaustion. The use of a CRM model delivered improved efficiency in MTD assessment and provided additional flexibility. Combined LEN/AZA therapy represents a novel and active salvage therapy in patients who had relapsed post-allograft.

Investigation on the electron flux to the wall in the VENUS ion source

The long-term operation of high charge state electron cyclotron resonance ion sources fed with high microwave power has caused damage to the plasma chamber wall in several laboratories. Porosity, or a small hole, can be progressively created in the chamber wall which can destroy the plasma chamber over a few year time scale. A burnout of the VENUS plasma chamber is investigated in which the hole formation in relation to the local hot electron power density is studied. First, the results of a simple model assuming that hot electrons are fully magnetized and strictly following magnetic field lines are presented. The model qualitatively reproduces the experimental traces left by the plasma on the wall. However, it is too crude to reproduce the localized electron power density for creating a hole in the chamber wall. Second, the results of a Monte Carlo simulation, following a population of scattering hot electrons, indicate a localized high power deposited to the chamber wall consistent with the hole formation process. Finally, a hypervapotron cooling scheme is proposed to mitigate the hole formation in electron cyclotron resonance plasma chamber wall.

Development status of a next generation ECRIS: MARS-D at LBNL

To demonstrate a Mixed Axial and Radial field System (MARS) as the best magnet scheme for future ECRISs, MARS-D, a demonstrative ECRIS using a NbTi MARS magnet is progressing at Lawrence Berkeley National Laboratory. An optimized MARS design can use either NbTi or Nb3Sn coils with reduced engineering complexities to construct the needed high-field magnets. The optimized magnet design could enhance MARS-D to a next generation ECRIS by producing minimum-B field maxima of 5.6 T axially and 3.2 T radially for operating frequencies up to 45 GHz. In-progress test winding has achieved a milestone demonstrating the fabrication feasibility of a MARS closed-loop coil.

Haplotype analysis finds linkage disequilibrium in the IL-12 gene in patients with HCV

HCV is a major cause of liver disease worldwide. IL-12 plays an essential role in the balance of T helper 1 (Th1) differentiation versus a T helper 2 (Th2) driven response from its naïve precursor. Linkage disequilibrium measures the degree to which alleles at two loci are associated and the non-random associations between alleles at two loci. Haplotypes of the three IL-12B loci studied were determined in the patient cases and the normal healthy control subjects. The frequency of the 12 possible IL-12B haplotypes on the 3 loci was determined in subjects heterozygous at only one of the loci within the studied haplotype. Haplotype frequencies were compared between the patient groups and controls (n = 49) to determine if any preferential combination of markers occurred using chi-squared and applying the Bonferroni correction. 45 HCV RNA negative patients; 88 HCV RNA positive patients; and 15 uninfected cases at high risk of HCV infection (EU) were studied. The haplotype "C" SNP of the 3'UTR with the "E" 4 bp deletion of the intron 4 region was in linkage disequilibrium (χ(2)  = 45.15, P < 0.001, 95% CL). The haplotype analysis of the insertion allele of the promoter with the deletion allele of the intron 4("E") IL-12B polymorphism showed linkage disequilibrium (χ(2)  = 5.64, P = 0.02). Linkage disequilibrium of polymorphisms is reported in the IL-12 gene in patients with HCV infection and contributes to the understanding of patient genotype and expected production of IL-12, responding to infection.

AKR1B10 is induced by hyperglycaemia and lipopolysaccharide in patients with diabetic nephropathy

Aldose reductase family member B10 (AKR1B10) belongs to the aldo-keto reductase gene superfamily and is closely related to aldose reductase (AKR1B1). It has been shown that AKR1B10 is present in many of the same human tissues as AKR1B1. The objective of this study was to investigate whether AKR1B10 has a role in diabetic nephropathy (DN) by investigating its response to high glucose and inflammation, both of which have been associated with the development and progression of DN. Expression levels of AKR1B10 were determined in peripheral blood mononuclear cells (PBMCs) obtained from 25 patients with type 1 diabetes and nephropathy, 25 without DN and 25 normal healthy controls that were exposed to high glucose (25 mM D-glucose) and also the inflammatory stressor lipopolysaccharide (LPS, 10 μm). Under high glucose and LPS conditions, there was a significant increase in the expression of AKR1B10 in the PBMCs from patients with DN compared to those without DN and the normal controls. In conclusion, these results suggest that AKR1B10 may have an important role in the development and progression of DN.

Production of high intensity 48Ca for the 88-Inch Cyclotron and other updates

Recently the Versatile ECR for NUclear Science (VENUS) ion source was engaged in a 60-day long campaign to deliver high intensity (48)Ca(11+) beam to the 88-Inch Cyclotron. As the first long term use of VENUS for multi-week heavy-element research, new methods were developed to maximize oven to target efficiency. First, the tuning parameters of VENUS for injection into the cyclotron proved to be very different than those used to tune VENUS for maximum beam output of the desired charge state immediately following its bending magnet. Second, helium with no oxygen support gas was used to maximize the efficiency. The performance of VENUS and its low temperature oven used to produce the stable requested 75 eμA of (48)Ca(11+) beam current was impressive. The consumption of (48)Ca in VENUS using the low temperature oven was checked roughly weekly, and was found to be on average 0.27 mg/h with an ionization efficiency into the 11+ charge state of 5.0%. No degradation in performance was noted over time. In addition, with the successful operation of VENUS the 88-Inch cyclotron was able to extract a record 2 pμA of (48)Ca(11+), with a VENUS output beam current of 219 eμA. The paper describes the characteristics of the VENUS tune used for maximum transport efficiency into the cyclotron as well as ongoing efforts to improve the transport efficiency from VENUS into the cyclotron. In addition, we briefly present details regarding the recent successful repair of the cryostat vacuum system.

Development of a new superconducting Electron Cyclotron Resonance Ion Source for operations up to 18 GHz at LBNL

A new superconducting Electron Cyclotron Resonance Ion Source (ECRIS) is under development at LBNL to harness the winding techniques of a closed-loop sextupole coil for the next generation ECRIS and to enhance the capability of the 88-in. cyclotron facility. The proposed ECRIS will use a superconducting closed-loop sextupole coil to produce the radial field and a substantial portion of the axial field. The field strengths of the injection, central and extraction regions are adjusted by a three solenoids outside the closed-loop sextupole coil. In addition to maintaining the typical ECRIS magnetic field configuration, this new source will also be able to produce a dustpan-like minimum-B field to explore possible ECRIS performance enhancement. The dustpan-like minimum-B field configuration has about the same strengths for the maximum axial field at the injection region and the maximum radial pole fields at the plasma chamber walls but it can be substantially lower at the extraction region. The dustpan-like minimum-B will have a field maximum Bmax ≥ 2.6 T for operations up to 18 GHz with a ratio of Bmax/Bres ≥ 4 and higher ratios for lower frequencies. The field maxima of this new source can reach over 3 T both at the injection and the plasma chamber walls which could also support operation at 28 GHz. The source will be built of cryogen-free with the magnets directly cooled by cryo-coolers to simplify the cryostat structure. The source design features will be presented and discussed.

A mode converter to generate a Gaussian-like mode for injection into the VENUS electron cyclotron resonance ion source

A number of superconducting electron cyclotron resonance (ECR) ion sources use gyrotrons at either 24 or 28 GHz for ECR heating. In these systems, the microwave power is launched into the plasma using the TE01 circular waveguide mode. This is fundamentally different and may be less efficient than the typical rectangular, linearly polarized TE10 mode used for launching waves at lower frequencies. To improve the 28 GHz microwave coupling in VENUS, a TE01-HE11 mode conversion system has been built to test launching HE11 microwave power into the plasma chamber. The HE11 mode is a quasi-Gaussian, linearly polarized mode, which should couple strongly to the plasma electrons. The mode conversion is done in two steps. First, a 0.66 m long "snake" converts the TE01 mode to the TE11 mode. Second, a corrugated circular waveguide excites the HE11 mode, which is launched directly into the plasma chamber. The design concept draws on the development of similar devices used in tokamaks and stellerators. The first tests of the new coupling system are described below.

Hydrogen sulfide induces heme oxygenase-1 in human kidney cells

Hydrogen sulfide (H2S) has been shown to have a potential protective role in a number of disease states including diabetes and various kidney disorders; however, the mechanisms involved are still unclear. The aim of this study was to investigate if H2S effects the expression of the antioxidant enzyme heme oxygenase-1 (HO-1) in human kidney cells. Human mesangial cells and human podocytes were cultured at normal physiological glucose concentration (5.5 mM) and then treated with different H2S donors for a 24-h period. Protein was then extracted from the cells, and the expression levels of HO-1 determined by Western blotting. There was a significant increase in HO-1 expression after treatment with the H2S donors in both mesangial and podocyte cells. These results suggest that H2S has a role in the regulation of HO-1 expression, and the ability to upregulate this antioxidant enzyme maybe a potential mechanism by which H2S exerts its protective effects.

CD81 sequence and susceptibility to hepatitis C infection

Several cell surface molecules have hepatitis C virus (HCV) binding properties and may serve as receptors facilitating viral entry into cells. The large extracellular loop (LEL) of CD81 has been shown to bind the HCV envelope protein E2 with several critical residues for the CD81-HCV-E2 interaction. It was hypothesised that variation in the CD81 LEL sequence may modify susceptibility to HCV infection. HCV RNA negative patients with spontaneous viral clearance (RNA -ve); HCV RNA positive cases, who are affected chronically (RNA +ve); and patients at high risk of HCV infection, exposed but uninfected patients (EU) were studied. Genomic DNA was extracted from whole blood samples and four exons of the CD81 LEL gene were amplified by PCR and sequenced. The cDNA derived from CD81 (≈700 bp) was sequenced following RNA extraction from peripheral blood mononuclear cells. Patients, who are RNA positive, RNA negative, and exposed uninfected were sequenced for four DNA sections (A, B, C, and D). Sixty-two (43M:19F) patients, from all the patient cohorts, were sequenced and compared for the C section alone (which encompasses the important binding region of the molecule for envelope protein) including 21 (14M:7F) HCV RNA negative, 15 (10M:5F) HCV RNA positive and 26 (20M:6F) exposed uninfected and no sequence differences were observed. The entire CD81 sequence from cDNA was obtained in 23 cases-11 RNA -ve, 5 RNA +ve and 7 EU. In 7 of the 23 cases, the nucleotides were confirmed with the genomic sequence (4 RNA -ve and 3 EU cases). No sequence variation was found in any of the patients studied by either method, including gene sections encoding the residues most important for CD81-HCV E2 binding. The LEL of CD81 is a molecule that is highly conserved. No differences in nucleotide sequence influencing susceptibility to, or outcome of HCV infection or evidence of methylation of the gene were found.

Recent progress on the superconducting ion source VENUS

The 28 GHz Ion Source VENUS (versatile ECR for nuclear science) is back in operation after the superconducting sextupole leads were repaired and a fourth cryocooler was added. VENUS serves as an R&D device to explore the limits of electron cyclotron resonance source performance at 28 GHz with its 10 kW gryotron and optimum magnetic fields and as an ion source to increase the capabilities of the 88-Inch Cyclotron both for nuclear physics research and applications. The development and testing of ovens and sputtering techniques cover a wide range of applications. Recent experiments on bismuth demonstrated stable operation at 300 eμA of Bi(31+), which is in the intensity range of interest for high performance heavy-ion drivers such as FRIB (Facility for Rare Isotope Beams). In addition, the space radiation effects testing program at the cyclotron relies on the production of a cocktail beam with many species produced simultaneously in the ion source and this can be done with a combination of gases, sputter probes, and an oven. These capabilities are being developed with VENUS by adding a low temperature oven, sputter probes, as well as studying the RF coupling into the source.

Concept for a fourth generation electron cyclotron resonance ion source

A fourth generation electron cyclotron resonance ion source with an operating frequency between 40 and 56 GHz has the potential to quadruple the heavy-ion beam currents and provide a cost effective upgrade path for heavy ion drivers in use or in the planning stage at radioactive beam facilities. Design studies show it is feasible to produce the required magnetic fields in the plasma chamber, 7 T axially and 4 T in the radial direction with a magnetic structure using commercially available Nb(3)Sn superconducting materials. In this paper we describe the design of such a magnet structure including a 3D analysis of the Lorentz forces generated by the magnetic fields and the necessary clamping structure to stabilize the conductor against these forces.

Polymorphisms of myo-inositol oxygenase gene are associated with Type 1 diabetes mellitus

Myo-inositol oxygenase (MIOX) is the first and rate-limiting enzyme in myo-inositol (MI) metabolism pathway. The increase in MIOX enzyme activity is in proportion to serum glucose concentrations and may be responsible for the MI depletion found in the diabetic complications. The aim was to investigate whether single nucleotide polymorphisms (SNPs) in the MIOX gene are associated with Type 1 diabetes mellitus (T1D) and its complications. Four hundred thirty Caucasian patients with T1D were recruited: 172 patients had diabetic nephropathy, 140 had diabetic retinopathy/neuropathy, 118 patients had diabetes for ≥20 years without microvascular complications and 224 were normal controls. Three SNPs, rs761745 (C/T), and rs2232873 (A/G) in the promoter and rs1055271 (C/G) in the 3'-untranslated were genotyped commercially. The frequencies of the CC genotype (0.36 vs. 0.44; P=.034) and C allele (0.60 vs. 0.68; P=.011) of rs761745 were significantly lower in patients with T1D compared with normal controls. Patients with T1D had a decreased frequency of the combination genotypes of CC (rs761745), GG (rs2232873) and GC (rs1055271) compared with the normal controls (0.13 vs. 0.22, P=.0027, Pc=0.014). The haplotypes with C/G/G and C/G/C were less common in patients with T1D compared to normal controls (0.59 vs. 0.70, P=.021) and the haplotypes with T/G/C and T/G/G ware more common in patients with T1D compared to normal controls (0.37 vs. 0.26; P=.021). In summary, our results demonstrated that the polymorphism (rs761745) in the promoter region of MIOX gene may be associated with the development of T1D in our studied population.

Is inflammation a common retinal-renal-nerve pathogenic link in diabetes?

The global diabetes burden is predicted to rise to 380 million by 2025 and would present itself as a major health challenge. However, both Type 1 and Type 2 diabetes increase the risk of developing micro-vascular complications and macro-vascular complications which in turn will have a devastating impact on quality of life of the patients and challenge health services Worldwide. The micro-vascular complications that affect small blood vessels are the leading cause of blindness (diabetic retinopathy) in the people of the working-age, end-stage renal disease (diabetic nephropathy) the most common cause of kidney failure today, and foot amputation (diabetic neuropathy) in patients with Type 1 and Type 2 diabetes. It is accepted that hyperglycemia is a major causative factor for the development of these complications, there is also growing evidence for the role of inflammation. Here we discuss low-grade inflammation as a common retinal-renal-nerve pathogenic link in patients with Type 1 and Type 2 diabetes. This review summarizes evidence showing a link between circulating and locally produced inflammatory biomarkers, such as cell adhesion molecules (vascular adhesion cell molecule-1, VCAM-1; intracellular adhesion molecule-1, ICAM-1), pro-inflammatory cytokines (interleukin-6, IL-6; tumour necrosis factor-alpha, TNF-α; C-reactive protein, CRP) with the development and progression of diabetic micro-vascular complications.

Immune components of bovine colostrum and milk

Colostrum and milk provide a complete diet for the neonate. In ruminants, colostrum is also the sole source of initial acquired immunity for the offspring. Milk therefore plays an important role in mammalian host defense. In colostrum, the concentration of immunoglobulins is particularly high, with IgG being the major immunoglobulin class present in ruminant milk, in contrast to IgA being the major immunoglobulin present in human milk. Immunoglobulins are transported into mammary secretions via specialized receptors. In addition to immunoglobulins, both colostrum and milk contain viable cells, including neutrophils and macrophages, which secrete a range of immune-related components into milk. These include cytokines and antimicrobial proteins and peptides, such as lactoferrin, defensins, and cathelicidins. Mammary epithelial cells themselves also contribute to the host defense by secreting a range of innate immune effector molecules. A detailed understanding of these proteins and peptides offers great potential to add value to the dairy industry. This is demonstrated by the wide-ranging commercial applications of lactoferrin derived from bovine milk. Knowledge of the immune function of milk, in particular, how the gland responds to pathogens, can be used to boost the concentrations of immune factors in milk through farm management practices and vaccination protocols. The latter approach is currently being used to maximize yields of bovine milk-derived IgA directed at specific antigens for therapeutic and prophylactic use. Increasingly sophisticated proteomics technologies are being applied to identify and characterize the functions of the minor components of milk. An overview is presented of the immune factors in colostrum and milk as well as the results of research aimed at realizing this untapped value in milk.

Social, neuroradiologic, medical, and neuropsychologic correlates of sexually aberrant behavior after traumatic brain injury: a controlled study

OBJECTIVE

To identify social, neuroradiological, medical, and neuropsychological correlates of sexually aberrant behavior (SAB) after traumatic brain injury (TBI).

DESIGN

A controlled study using a retrospective file review.

SETTING

A brain injury unit providing inpatient and outpatient rehabilitation services.

PARTICIPANTS

A sample of males (n = 25) exhibiting SABs and a control group (n = 25) matched for gender, severity of injury, age at injury, and time after injury.

MAIN OUTCOME MEASURES

A protocol that recorded data on demographic, injury, radiological, medical, and neuropsychological variables.

RESULTS

The SAB group had a significantly higher incidence of postinjury psychosocial disturbance in areas of nonsexual crime and failure to return to work than the matched TBI group. There were no significant differences between the two groups in the incidence of premorbid psychosocial disturbance or postinjury radiological, medical, or neuropsychological variables.

CONCLUSIONS

The study results caution against simplistic explanations of SAB as the product of damage to the frontal-lobe systems or premorbid psychosocial disturbance. Furthermore, the results suggest that a wide-ranging assessment of people with TBI who exhibit SABs is required, because results of neuropsychological examination alone cannot be considered conclusive. Future research into the etiology of SABs could examine additional factors such as lack of insight, lack of empathy, and premorbid history of family dysfunction.

Service utilization following traumatic brain injury

OBJECTIVES

To document service utilization by people with a traumatic brain injury at different times postinjury and to identify factors that predict service use.

DESIGN

Cross-sectional study design. Four groups of subjects were randomly selected from a regional database, according to their time postinjury: 6-18 months; 2-4 years; 6-9 years; and 10-17 years.

SUBJECTS

A total of 119 adults with a traumatic brain injury (TBI).

SETTING

Hospital and community-based clients in Sydney, Australia.

OUTCOME MEASURES

Glasgow Outcome Scale, Disability Rating Scale; Functional Independence Measure; Lidcombe Psychosocial Disability Scale; number, type, and frequency of services used in the previous 12 months.

RESULTS

Subjects in all four groups used a variety of services. The mean number of services used was 4.2, and there was only a moderate decline in service use over time. The use of medical and allied health services remained high in all four groups. Severity of injury, physical and cognitive disability, and psychosocial disability were all predictors of service utilization. Psychosocial disability was strongly associated with ongoing service utilization.

CONCLUSION

In this study, people with TBI used services well beyond the early stage of recovery. Psychosocial disability may be a better predictor of service use than physical and cognitive disability alone.

Measuring psychosocial recovery after traumatic brain injury: psychometric properties of a new scale

OBJECTIVES

To determine the psychometric properties of the Sydney Psychosocial Reintegration Scale (SPRS), an instrument developed to quantify disability and handicap in persons with traumatic brain injury (TBI).

DESIGN

Descriptive correlational study.

SETTING

Brain Injury Rehabilitation Unit and Brain Injury Outpatient Clinic.

PARTICIPANTS

Two samples, a "subacute" group (n = 20) and a "long-term" group (n = 40), were studied to examine responsiveness (subacute group), reliability, and validity (long-term group) of the SPRS.

MAIN OUTCOME MEASURE

The SPRS is a 12-item questionnaire measuring three domains of everyday living commonly disrupted after severe TBI: occupational activities, interpersonal relationships, and independent living skills.

PROCEDURE

Patients in the subacute group were rated with the SPRS by a clinician at admission to the rehabilitation unit and again three months later or at discharge from the unit (whichever occurred first). For individuals from the long-term group attending the outpatient clinic, a close relative was interviewed with the SPRS and other validating measures. The SPRS was readministered one month later.

RESULTS

Internal consistency of the SPRS was high (alpha coefficient = .90), as was agreement between raters and stability over a one-month period (r(i) = .95 and .90, respectively). Reliability and stability coefficients for the three domains of the scale were also high, ranging from.86 to.94 for reliability and.77 to.93 for stability. Preliminary evidence for construct validity was established with a number of standard instruments, with evidence of both convergent and discriminant construct validity from the Sickness Impact Profile (SIP). The SPRS was sensitive to group differences on the Glasgow Outcome Scale (GOS) and to changes occurring during the period of active recovery.

CONCLUSIONS

The results suggest that the SPRS has sound psychometric properties, being a reliable, stable, sensitive, and valid instrument. It is potentially useful in both clinical and research settings.

Sex offending as a psychosocial sequela of traumatic brain injury

OBJECTIVE

To describe the nature and extent of sexual offending after traumatic brain injury (TBI).

DESIGN

Retrospective file review.

SETTING

A brain injury unit providing inpatient and outpatient rehabilitation services.

PARTICIPANTS

A review of five years of admissions to the Brain Injury Rehabilitation Unit (N = 477) identified a sample of 29 males who committed 128 incidents of sex offending.

MAIN OUTCOME MEASURES

A protocol to record data on demographic, injury, radiological, and psychosocial variables and offending behaviors.

RESULTS

Of the total population of 445 clients with TBI, 6.5% (n = 29) were identified as having committed some form of sexual offense. Alcohol was a factor in only three (2.3%) of the incidents, and only two clients had a preinjury history of sexual offending. The most common offenses were the "touching" offenses, followed by exhibitionism and overt sexual aggression. Staff members were the most common targets of the offenses, followed by members of the general public, other people with TBI, and family members.

CONCLUSIONS

Sex offending is a significant clinical problem among a small minority of men after TBI. The absence of alcohol and preinjury histories of sexual offending suggest that the brain injury and contingent sequelae were a significant etiological factor underlying the offenses. A number of implications for the clinical management of clients with sexually aberrant behaviors is identified and discussed.

Linking public health education and practice: the Australian experience

The public health workforce in Australia is highly skilled, multifunctional, and drawn from a variety of backgrounds, including clinical practice and non-health areas. A wide range of activities is needed to meet the educational and training requirements of this workforce, including on the job inservice training, context specific continuing education programs and short courses, distance and self-directed learning packages, and postgraduate University level courses. The core components of public health today include: a social and political commitment to health, a shared responsibility between government and the public, and a multidisciplinary field of action. The challenge for those providing education and training for the public health workforce is to ensure graduates have the broad range of knowledge and skills needed in this climate. A system-wide approach to learning, where knowledge and skill development is related to the practices and settings of service and program delivery, will ensure strong links between education and practice.

Prolonged, severe behavioural disturbance following traumatic brain injury: what can be done?

At the end of 1994 the New South Wales Department of Health identified the need for a specialized unit for people with a brain injury who exhibited aggressive and violent behaviour at such a level that they could not be cared for in standard rehabilitation programmes and who were not mentally ill as defined by the Mental Health Act. An interim unit based on the principles of neurobehavioural rehabilitation was opened in the grounds of Lidcombe Hospital, and in January 1995 the first patient (SA) was admitted. Following intervention weekly aggression decreased from a peak of 159 incidents to zero after ten months. Other maladaptive behaviours also decreased markedly. Simultaneous attempts to improve adaptive behaviours were successful. At 11 months follow-up in the community, these gains were all noted to have been maintained. This article discusses the need for specialized units dealing with severe behavioural problems following head injury, presents the case of SA for illustrative purposes, and addresses some of the more common criticisms of such environments.

A non-aversive approach to reducing hospital absconding in a head-injured adolescent boy

Patients who abscond from hospital exclude themselves from therapy, and attempts to stop the person can quickly become confrontational with the inherent risk of aggression. Although information is available on absconding in psychiatric settings little is known about the type of person with a head injury who absconds, why such people do so, or how the problem might best be approached. This paper presents a non-aversive approach to hospital absconding in a head-injured adolescent male, discusses how his case relates to the psychiatric literature, and looks at the feasibility of adopting such interventions in general hospital wards.

Tackling the tobacco challenge: achieving 'healthy public policy' in tobacco control in Guernsey

Scientific evidence identifying smoking as the major cause of poor health and premature death in both industrialised and increasingly in developing countries is now overwhelming. Despite this, for a variety of reasons, there has been reluctance amongst many Governments including that of Britain, to take all logical action necessary to restrict and reduce smoking, especially amongst the young. The States of Guernsey in the Channel Islands has recently agreed to introduce an integrated package of measures designed specifically to make smoking less attractive and less accessible and less affordable to young people in an attempt to reduce the number of addicted adult smokers. These measures include a total ban of all public advertising of tobacco, apart from at point of sale, a substantial price rise followed by further price rises for a minimum period of five years, a raising of the minimum age for the purchase of tobacco from 16 to 18 years, an increase in the size and content of pack health warnings, and increased funding for specific nonsmoking health promotion activities. The various barriers to achieving these reforms are described.

Inpatient quality assurance by local analysis of uniform data set data

We constructed a data base in order to examine the profile of patients admitted to a 24 bed inpatient rehabilitation unit at Fairfield Hospital. Data were collected according to the Uniform Data Set for Medical Rehabilitation, and collated and analysed using the Clinical Reporting System database software and the Statistical Package for Interactive Data Analysis statistical software. Outcome data collected included the patients domicile before and after admission, the duration of stay, medical diagnoses before admission to and during the stay in the Rehabilitation Unit, as well as the Functional Independence Measure item scores at admission and discharge. Analysis of the first 100 patients in the data base indicated a duration of stay of 43 +/- 34 days with a right skew distribution. Scatter plots of age and duration of stay, and age and functional improvement showed no bias in the Unit concerning these parameters. The Wilcoxon rank sum test indicated a highly significant difference (P = 0) between entry and exit Functional Independence Measure scores, indicating that patients improved functionally in the unit. Eighty three patients returned home on discharge and only five required admission to a nursing home. With the data base, the course of patients whose performance lies outside the range of normal for the unit can be examined and factors identified which produce a prolonged stay or failure to progress.

Effects of oral ethinyl oestradiol and norethisterone on plasma copper and zinc complexes in post-menopausal women

Orally administered ethinyl oestradiol increased the plasma total copper concentration and reduced the albumin concentration in post-menopausal women. Approximately 80% of the increase in copper was due to a rise in caeruloplasmin-bound copper and 20% to an increase in the amount of copper bound per gram of albumin. The plasma total zinc concentration was reduced, due partly to the decrease in albumin concentration and partly to a reduction in the amount of zinc bound per gram of albumin. Norethisterone had no significant effect on plasma copper but it reduced plasma zinc and albumin, though to a lesser extent than ethinyl oestradiol. When administered sequentially with ethinyl oestradiol, norethisterone diminished the effects of the former on plasma copper, zinc and albumin.

Hypothesis. Biochemical changes at the menopause: possible role of the central nervous system

Some of the biochemical changes which occur at the menopause can be attributed to an increased rate of loss of bone but others cannot be explained in this way. Data, collected through literature search, are presented which suggest that the rise in plasma phosphate concentration at the menopause is not due primarily to increased breakdown of bone but rather to the following sequence of events: progesterone deficiency----respiratory hypoventilation----mild respiratory acidosis and hypoxia----compensatory metabolic alkalosis----altered carbohydrate metabolism----rise in plasma phosphate concentration. Increases in the concentration of many plasma constituents occur at the menopause, which appear to be due to fluid loss and haemoconcentration. A possible cause of these changes is a reduced secretion of vasopressin by the pituitary gland as a result of oestrogen deficiency. Increases in the fasting urinary excretion of phosphate, sodium and magnesium also occur at the menopause. These changes cannot be attributed to increased bone loss but could be due to the effects of oestrogen deficiency on circadian rhythms in the hypothalamus.

Increase in plasma lactate at the menopause and its relation to the "anion gap"

The mean plasma anion gap (Na + K + Ca + Mg)--(Cl + HCO3(-) + HPO4(2-) + protein), was significantly higher in post-menopausal women compared with pre-menopausal women (8.04 mEq/l compared with 7.03 mEq/l). This change was due, in part, to an increase in the plasma lactate concentration and to smaller increases in citrate and pyruvate concentrations. There were also changes in bicarbonate and chloride concentrations which suggested an increase pH of approximately 0.02 U. Together, these changes accounted for 46% of the increase in the "anion gap", leaving 54% unexplained. It is suggested that the rise in plasma lactate concentration may be due to mild alkalosis and that this change may account for the rise in plasma urate concentration which also occurs at the menopause.

The effect of ethinyl oestradiol on calcium and bone metabolism in peri- and postmenopausal women

The effects of ethinyl oestradiol on plasma and urinary calcium and other indices of bone turnover have been compared in peri- and postmenopausal women. In postmenopausal women ethinyl oestradiol caused significant decreases in the fasting plasma total and ionised calcium and phosphate concentrations, in alkaline phosphatase activity and in the fasting urinary Ca/Cr and OHPr/Cr ratios. Similar, but less marked, effects were observed in peri-menopausal women, with significant decreases in the fasting plasma phosphate and urinary Ca/Cr ratio. Small decreases in the plasma total and ionised calcium concentrations, in alkaline phosphatase activity and in the urinary OHPr/Cr ratio also occurred but were not statistically significant in our sample. Ethinyl oestradiol therefore appears to reduce bone loss in peri- as well as post-menopausal women, at least in the short term, but the effect is less pronounced in the former group.

Changes in plasma sodium concentration in women at the menopause

A significant increase in the mean plasma sodium concentration and in the fasting urinary Na/Cr ratio was observed in healthy women at the menopause. Both of these changes were reversed by administering oestrogens. None of the above effects appeared to be due to alterations in sodium intake or in renal glomerular function. The most likely cause of the increase in plasma sodium concentration at the menopause appeared to be a decrease in plasma volume since there were also significant increases in the mean plasma albumin and total protein concentrations.

Plasma electrolyte concentrations in women and the effects of oestrogen administration

Age-related changes in the concentrations of the main plasma electrolytes and in the urinary excretion of some of these ions have been examined in 436 pre-menopausal and 117 post-menopausal women. The main changes up to the menopause were decreases in the mean plasma potassium, calcium and total protein concentrations, accompanied by increases in the renal excretion of calcium and inorganic phosphate. The decrease in plasma total calcium concentration was completely accounted for by the fall in albumin and globulin concentrations. The main changes observed at the menopause were increases in plasma sodium, total calcium, inorganic phosphate and magnesium concentrations, an increase in the plasma "anion gap" and increases in the renal excretion of sodium, magnesium and inorganic phosphate. All these changes were reversed by treatment with ethinyl oestradiol. The causes and significance of some of these changes are discussed, particularly the menopausal rises in plasma sodium concentration and in the plasma "anion gap".

Measurement of the fasting urinary hydroxyproline: creatinine ratio in normal adults and its variation with age and sex

Conditions for the determination of the fasting urinary hydroxyproline: creatinine ratio (OHPr: Cr ratio) have been examined, using a resin-catalysed hydrolysis and automated colorimetric procedure for the determination of hydroxyproline. Feeding experiments with gelatin showed that hydroxyproline is rapidly absorbed and excreted in the urine and that a 12-hour (overnight) fast is sufficient to ensure correct and reproducible fasting OHPr: Cr ratios. The mean fasting OHPr: Cr ratio decreased slightly with increasing age in both men and premenopausal women but there was no significant difference between the sexes. There was, however, a significant increase in the mean ratio in postmenopausal women. The normal range of fasting OHPr: Cr ratios for men and premenopausal women was found to be 0.003--0.015.

A comparison of the effects of lactose and of two chemically modified waxy maize starches on mineral metabolism in the rat

Diets containing 30% by weight of waxy maize starch, lactose monohydrate, acetylated distarch phosphate (EEC No. 1414) or acetylated distarch adipate (EEC No. 1422) were fed to weanling female Specified Pathogen-Free Sprague-Dawley rats for 1 yr and to similar 9-month-old rats for 34 wk. Behaviour and general health were unaffected by the different diets and there were no diet-related differences in food consumption. AT the end of the experiment with 9-month-old rats the mean body weight of the animals receiving lactose was significantly lower than that of the controls receiving starch. The animals receiving the modified starches were slightly but not significantly heavier than the controls at the end of both experiments. The main treatment-related changes in rats on the three test diets were (1) caecal enlargement, (2) increased urinary excretion of calcium, (3) increased renal calcification as measured by chemical analysis of renal tissue obtained at autopsy and (4) increased medullary and pelvic nephrocalcinosis as assessed histopathologically. Acetylated distarch adipate had a slightly greater effect on the above parameters than acetylated distarch phosphate but both modified starches had less effect than lactose. The calcium content of the kidneys, as measured by chemical analysis or histopathology, increased with age, even in the animals receiving the control diet. This change may be due to excessively high concentrations of calcium and phosphorus in all the diets, including the control diet. Cortico-medullary mineral deposits were not a feature in these studies possibly because the diets were not deficient in magnesium. The importance of correct dietary formulation in long-term toxicity studies is emphasized.