'Thank you for loving me': A qualitative study on perceptions of gratitude and their effects in palliative care patients and relatives

BACKGROUND

Empirical studies suggest that gratitude positively influence the quality of life of palliative patients and relatives. However, the literature is marked by a lack of conceptual clarity about what gratitude is and whether it can bring about individual and social benefits.

AIM

This paper explores how palliative care patients and relatives understand gratitude, how discursive representations of gratitude may affect their positions, perceptions and relations, and how to conceptualise gratitude in the palliative context.

DESIGN

We examine 33 gratitude letters written by patients and relatives and 25 semi-structured interviews conducted as part of a pilot gratitude intervention study. We use a qualitative approach, thematic analysis, within a conceptual framework of discourse analysis.

SETTINGS/PARTICIPANTS

Data were collected from 23 patients and 13 relatives recruited through three hospital palliative care services in French-speaking Switzerland.

RESULTS

Participants articulate gratitude in five ways: (1) appreciating others; (2) love; (3) need to reciprocate; (4) appreciating the little things; (5) solace amid serious illness. While some of these representations are sources of positive emotions and outlook, wellbeing and hope, others may confirm self-perceptions of powerlessness and burden. These results support a tridimensional conceptualisation of gratitude in palliative care as source of individual benefits, valuing closest relationships and moral obligation.

CONCLUSION

Our study suggests that gratitude is a key to a good (end of) life, whilst highlighting potential negative effects. It could help healthcare professionals to better understand what gratitude means to patients and relatives, which may facilitate awareness and fostering of gratitude in palliative care.

Posttraumatic growth in palliative care patients and its associations with psychological distress and quality of life

OBJECTIVES

Posttraumatic growth (PTG) refers to positive psychological changes resulting from individuals' inner struggles with traumatic events such as life-threatening illness. Although palliative care patients are confronted with their own mortality, little is known about their PTG experience. This study investigates whether PTG is an empirically relevant concept for palliative patients by assessing the prevalence and areas of growth, and examining associations with psychological distress and quality of life.

METHODS

Participants were recruited in Switzerland. Using validated questionnaires, we assessed PTG (Posttraumatic Growth Inventory, PTGI), psychological distress (Hospital Anxiety and Depression Scale), and quality of life (McGill-Quality of Life Questionnaire - Revised). We performed descriptive analyses, Spearman correlations, and linear regressions.

RESULTS

Fifty-five patients completed the PTGI, 44% of whom experienced no/low growth, 47% moderate growth, and 9% high/very high growth. Participants experienced the greatest positive changes in terms of appreciating life and relating to others. We found significant negative bivariate correlations between PTG and psychological distress (r = -0.33) and between PTG and depression (r = -0.47). Linear regressions showed that PTG is associated with depression (β = -0.468; p = 0.000), but not with anxiety or quality of life (adjusted R² = 0.219).

SIGNIFICANCE OF RESULTS

Over half of our patients experienced moderate to very high growth, indicating that PTG is an empirically relevant psychological process in palliative care. PTG is associated with lower levels of depression, possibly as those experiencing growth are more able to process past traumas and build a more positive outlook on one's life and self. By contrast, the relative independence of anxiety and PTG points to the likely coexistence of positive and negative psychological responses to trauma. The lack of association between PTG and quality of life points to the uniqueness of the PTG concept in capturing how people access deeper meaning and greater appreciation of life along the path toward posttraumatic self-reconstruction.

Abstract P6-17-17: Pertuzumab, trastuzumab, and docetaxel for HER2-positive early or locally advanced breast cancer in the neoadjuvant setting: Efficacy and safety analysis of a randomized phase III study in Asian patients (PEONY)

Background

Pertuzumab and trastuzumab (P and H; F. Hoffmann-La Roche Ltd, Basel, CH) bind to distinct HER2 subdomains and have complementary modes of anticancer activity in HER2-positive breast cancer (BC). A global Phase II study (NeoSphere) reported that neoadjuvant treatment with P+H+docetaxel (D) significantly increased breast pathologic complete response (bpCR) vs H+D in patients (pts) with early/locally advanced/inflammatory HER2-positive BC (Gianni et al. Lancet Oncol 2012). PEONY (NCT02586025), a randomized, multicenter, double-blind, placebo-controlled, Phase III trial conducted in an Asian population (mainland China, Taiwan, Korea, Thailand), primarily compared the efficacy, safety, and tolerability of P+H+D vs placebo (Pla)+H+D in the neoadjuvant setting. We present data from the primary analysis.

Methods

Pts with centrally confirmed HER2-positive early (T2–3, N0–1)/locally advanced (T2–3, N2 or N3; T4, any N) BC were randomized 2:1 to 4 cycles of P+H+D or Pla+H+D every 3 weeks, before surgery: P, 840 mg loading/420 mg maintenance doses (or Pla); H, 8 mg/kg loading/6 mg/kg maintenance; D, 75 mg/m2. Post-surgery, pts received 3 cycles of fluorouracil, epirubicin, and cyclophosphamide followed by 13 cycles of P+H or Pla+H for up to 1 year (total of 17 HER2-targeted therapy cycles). The primary endpoint was total pCR rate (tpCR; absence of any residual invasive cancer in the breast and lymph nodes [ypT0/is, ypN0]) assessed by independent review committee (IRC) when pts completed surgery with a tpCR assessment. Missing/invalid assessments were considered residual disease.

Results

A total of 329 pts were randomized: 219 to P, 110 to Pla. Baseline characteristics were well balanced. Most pts had early BC (69.6%) and were from mainland China (79.3%). In the intention-to-treat population, the tpCR rate by IRC was 39.3% in the P arm and 21.8% in the Pla arm; a clinically and statistically significant difference of 17.5% (95% CI 6.9–28.0; p=0.0014). The local pathologist-assessed tpCR rates were 39.3% and 20.9%, respectively. A consistent treatment benefit of P vs Pla was observed in subgroups. Incidences of grade ≥3 adverse events (Aes) were 48.6% in the P arm and 41.8% in the Pla arm. Of the most common grade 3 Aes (≥3% of pts), neutropenia was higher in the P arm (38.1% vs 32.7%). Of the most common any-grade Aes (≥5%), diarrhea was higher in the P arm (38.5% vs 16.4%). No heart failure (New York Heart Association Functional Classification III or IV) or significant left ventricular ejection fraction decline events (≥10 percentage points from baseline and to <50%) were observed during neoadjuvant therapy.

Conclusions

PEONY met its primary endpoint: P+H+D resulted in a clinically meaningful and statistically significant improvement in the tpCR rate by IRC vs Pla+H+D for the neoadjuvant treatment of HER2-positive early/locally advanced BC in Asian pts. Safety data were in line with the known P safety profile and generally comparable between treatment arms. Results were similar to NeoSphere, and confirm that P+H+D provides superior anticancer activity to H+D alone.

Citation Format: Shao Z, Pang D, Yang H, Li W, Wang S, Cui S, Liao N, Wang Y, Wang C, Chang Y-C, Wang H, Kang SY, Jiang Z, Li J, Zhou J, Althaus B, Mao Y, Eng-Wong J. Pertuzumab, trastuzumab, and docetaxel for HER2-positive early or locally advanced breast cancer in the neoadjuvant setting: Efficacy and safety analysis of a randomized phase III study in Asian patients (PEONY) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-17.

Most and Least Preferred Colours Differ According to Object Context: New Insights from an Unrestricted Colour Range

Humans like some colours and dislike others, but which particular colours and why remains to be understood. Empirical studies on colour preferences generally targeted most preferred colours, but rarely least preferred (disliked) colours. In addition, findings are often based on general colour preferences leaving open the question whether results generalise to specific objects. Here, 88 participants selected the colours they preferred most and least for three context conditions (general, interior walls, t-shirt) using a high-precision colour picker. Participants also indicated whether they associated their colour choice to a valenced object or concept. The chosen colours varied widely between individuals and contexts and so did the reasons for their choices. Consistent patterns also emerged, as most preferred colours in general were more chromatic, while for walls they were lighter and for t-shirts they were darker and less chromatic compared to least preferred colours. This meant that general colour preferences could not explain object specific colour preferences. Measures of the selection process further revealed that, compared to most preferred colours, least preferred colours were chosen more quickly and were less often linked to valenced objects or concepts. The high intra- and inter-individual variability in this and previous reports furthers our understanding that colour preferences are determined by subjective experiences and that most and least preferred colours are not processed equally.

Abstract P4-12-09: Results from a phase 2a study of trastuzumab emtansine, paclitaxel, and pertuzumab in patients with HER2-positive metastatic breast cancer

Introduction

The antibody-drug conjugate trastuzumab emtansine (T-DM1) combines the antitumor properties of trastuzumab (H) with the cytotoxic agent DM1 via a stable linker. T-DM1 prolonged PFS and OS vs standard therapy in a phase 3 study of patients (pts) with HER2-positive metastatic breast cancer (MBC) previously treated with H and a taxane. Preclinical data suggest synergy when T-DM1 is combined with paclitaxel (T) or pertuzumab (P). In the phase 1b study TDM4652g, the maximum tolerated doses of T-DM1 + T ± P were defined. Here we present results from the phase 2a expansion, which further explored feasibility and safety.

Methods

TDM4652g is a phase 1b/2a open-label study of pts with HER2-positive locally advanced or MBC. Pts had no prior T-DM1 or P, no baseline peripheral neuropathy (PN; phase 2a only), and had LVEF ≥50%. Pts in phase 2a were randomized to T-DM1 3.6 mg/kg q3w + T 80 mg/m2 qw ± P 840 mg loading dose [LD], then 420 mg q3w. The primary objective, feasibility, was assessed by the percent of evaluable pts receiving ≥12 doses of T within 15 weeks of cycle 1, day 1, and those receiving 12 consecutive weeks of T.

Results

Forty-four pts were enrolled (T-DM1 + T, n = 22; T-DM1 + T + P, n = 22); the data snapshot date was May 23, 2013. Median age was 52.5 years (range, 35–81); median number of prior agents for MBC was 6 (range, 0–12). 43 (98%) pts had previously received H, and 36 (82%) pts had received taxane therapy. Median dose intensities were T-DM1, 94% (range 54–105); T, 50% (range 9–100) and P, 100% (range 67–100). 2 pts were not evaluable for feasibility (progressive disease [PD] before receiving 12 doses of T). 21/42 (50%) pts received ≥12 doses of T within 15 weeks; 6/42 (14%) pts received 12 consecutive doses by week 12, and 33/42 (79%) pts received ≥8 doses within 12 weeks. Grade 3/4 adverse events (AEs) were reported for 18 (82%) and 17 (77%) pts in the T-DM1 + T and T-DM1 + T + P groups, respectively (see Table for AEs and best responses). Ten pts discontinued early due to PD (n = 6), PD-related death (n = 2), AEs (n = 1), or withdrawal from the study (n = 1). 21 pts discontinued T due to AEs, most commonly PN (n = 12).

Grade 3/4 AEs occurring in >1 patientAE, n (%)All patients (N = 44)TDM1 3.6 mg/kg q3w + T 80 mg/m2 qw (n = 22)TDM1 3.6 mg/kg q3w + T 80 mg/m2 qw + P 840 mg LD, 420 mg q3w (n = 22)Neutropenia10 (23)6 (27)4 (18)Peripheral neuropathy9 (20)3 (14)6 (27)Fatigue6 (14)3 (14)3 (14)Thrombocytopenia6 (14)5 (23)1 (5)Anemia3 (7)2 (9)1 (5)Abdominal pain2 (5)2 (9)0Decreased hemoglobin2 (5)1 (5)1 (5)Muscosal inflammation2 (5)1 (5)1 (5)Muscular weakness2 (5)02 (9)Nausea2 (5)1 (5)1 (5)Best response,* n (%)CR2 (5)1 (5)1 (5)CR confirmed1 (2)1 (5)0PR27 (61)13 (59)14 (64)PR confirmed8 (18)3 (14)5 (23)SD10 (23)6 (27)4 (18)PD3 (7)1 (5)2 (9)*At any time point with responses ordered CR>PR>SD>PD.

Conclusions

Overall, 50% of pts received ≥12 doses of T within 15 weeks. Adding P to the combination of T-DM1 + T did not appear to increase the incidence of grade 3/4 AEs. Data support further investigation of T-DM1 + T ± P in larger studies in early breast cancer. Final data from all phase 2a patients will be available for the full report.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-12-09.

Tolerance and immunogenicity of the simultaneous administration of virosome hepatitis A and yellow fever vaccines

BACKGROUND

The purpose of this study was to evaluate the tolerance and immunogenicity of a hepatitis A vaccine using immunopotentiating reconstituted influenza virosomes (IRIV) as adjuvant when administered simultaneously with a yellow fever vaccine (YFV).

METHOD

An open prospective trial with two parallel groups was conducted with 105 volunteers to study the effect of these vaccinations on the anti-hepatitis A virus (HAV) antibody response. Half of the volunteers (53) received one dose of IRIV-HAV vaccine (Epaxal) and one dose of live attenuated YFV (Stamaril) on the same day at two different sites. Fifty-six volunteers were given a single injection of IRIV-HAV as a control group. Anti-HAV titers were measured at days 14, 28, months 3, 12, 13, and 24 using a standardized test (Enzymun test Anti-HAV). Neutralizing yellow fever antibodies were measured at days 14 and 28 for the YFV recipients. Regarding vaccine tolerance, the volunteers were asked to record all their adverse reactions on a standard report sheet for the 6 days following the immunization.

RESULTS

Seroconversion rates for HAV were 88% after 14 days and 100% after 4 weeks. There was no statistically significant difference between the two groups every time the titers were checked (IRIV-HAV vs HAV only: D14: 81 vs 101; D28: 275 vs 368; M3: 153 vs 169; M12: 117 vs 226; geometrical mean titers (GMT) in mIU/mL). However, lower titers were found among male volunteers, and were not attributable to YFV administration. The seroconversion rates for YFV were 90% after 14 days and 96% after 4 weeks. No serious general side-effects and only mild local reactions were reported. The administration of a booster of IRIV-HAV at 12 months resulted in a 24-fold increase in GMT.

CONCLUSION

When needed, the simultaneous administration of the IRIV-HAV and YFV is immunogenic, safe and well-tolerated, as volunteers seroconverted to both antigens, with no cross-interference.

Immunogenicity of trivalent subunit versus virosome-formulated influenza vaccines in geriatric patients

The safety and immunogenicity of a commercial trivalent subunit influenza vaccine and an experimental virosome-formulated influenza vaccine were evaluated among geriatric patients in a double-blind, randomized manner. The virosome vaccine was produced by incorporating hemagglutinin (HA) into the membrane of liposomes composed of phosphatidylcholine. Both vaccines elicited a significant (P < 0.01) rise in the geometric mean anti-HA antibody titer to all three vaccine components 1 month after immunization. However, significantly (P < 0.005) more subjects vaccinated with the virosome preparation mounted a more than fourfold rise to the A/Singapore and A/Beijing strains compared with those who received subunit vaccine. The percentage of patients who attained protective levels (anti-HA titer > or = 40) of anti-A/Beijing antibody was also significantly (P < 0.005) higher in the virosome group. Subjects who possessed non-protective baseline antibody levels to the A/Singapore and A/Beijing strains were more likely (P < 0.005-0.030) to achieve protective levels after immunization with the virosome vaccine than with the subunit vaccine. Of particular clinical significance was the fact that 68.4% of subjects immunized with the virosome vaccine attained protective levels of antibody to all three vaccine components versus 38% for the subunit vaccine (P = 0.010).

Immunogenicity and protectivity of a new liposomal hepatitis A vaccine

In this study we investigated a new liposomal hepatitis A vaccine (Epaxal) developed by the Swiss Serum and Vaccine Institute clinically and immunologically using a one dose priming schedule and a booster injection after 1 year. This vaccine contains formalin inactivated hepatitis A virus particles attached to phospholipid vesicles together with influenza virus haemagglutinin. Two doses of the vaccine were administered at months 0 and 12 in 117 volunteers. Blood samples were drawn at days-7, 14 and 28 and after 6, 12 and 13 months, local and systemic reactions were monitored by means of questionnaires. Immunogenicity was evaluated as usual by the determination of anti-HAV from the collected sera using the ELISA technique. In order to evaluate the protective efficacy of the vaccine induced antibodies a sample of 25 sera mainly from vaccinees showing low ELISA titres was additionally analysed by means of a virus NT. The vaccine was excellently tolerable and highly immunogenic. Seroconversion evaluated by ELISA was 97 and 99%, respectively, 14 and 28 days after the first dose and 100% after the second dose. NT titres were well correlated with ELISA titres and showed similar seroconversion rates even in the early phase of immunization. The results of this study show that with two doses of the liposomal hepatitis A vaccine administered at months 0 and 12 early protection within 14 days and long lasting immunity can be achieved.

Immunogenicity and adverse effects of inactivated virosome versus alum-adsorbed hepatitis A vaccine: a randomized controlled trial

Immunogenicity and adverse effects of a novel inactivated hepatitis A vaccine based on virosomes (IRIV-HAV) was compared with a standard vaccine adsorbed to aluminium (Al-HAV). Seronegative volunteers (n = 301) were randomly allocated to one injection of IRIV-HAV or to two injections of Al-HAV, followed by a booster injection at 12 months. Two hundred and ninety-eight (99%) completed the first month and 215 (71%) could be evaluated at 1 year. Geometric mean antibody concentrations at days 0, 14 and at 12 months were similar in the two vaccine groups. Lower antibody concentrations were recorded with IRIV-HAV at day 28 (P < 0.0001) and at 13 months (P = 0.02). Seroconversion to protective antibody levels, however, was similar (98% at day 28, 94% at 12 months, 100% at 13 months). Local adverse effects were reported in 17% with IRIV-HAV but in 66% with Al-HAV (P < 0.0001) after the initial vaccination and in 32% and 42% following the booster vaccination (P = 0.05). In conclusion, IRIV-HAV may provide similar protection but cause less local adverse effects.

[Immune response to a single dose of a novel kind of hepatitis A vaccine following splenectomy]

BASIC PROBLEM AND OBJECTIVE

The immune response to parenteral antigens is reduced in persons without spleen. The seroconversion rate was measured after application of a new type of vaccine against hepatitis A (immunopotentiating reconstituted influenza virus virosome [IRIV]) in patients who had undergone a splenectomy after trauma.

PATIENTS AND METHODS

26 patients (23 men and 3 women, mean age 34.9 +/- 9.7 [25-65] years) with anti-hepatitis A virus (HAV) antibody titres < 20 mIU/ml (maximally 17 mIU/ml) were given a single dose of 0.5 ml of the IRIV hepatitis A vaccine 1 to 14 (mean 9.4) years after splenectomy. Immediately after the immunisation and 14 and 28 days afterwards anti-HAV titres were determined. A titre rise to < 20 mIU/ml was counted as seroconversion. At the first and last titre measurement immunoglobulins, neopterin and beta-microglobulin levels were also measured as additional markers.

RESULTS

The seroconversion rate was 69.2% (18/26) after 14 days (geometric titre mean: 39 mIU/ml) and rose to 88.5% (23/26) after 28 days (geometric titre mean 74 mIU/ml). Seroconversion occurred in the three nonresponders after a second dose of the vaccine. All measurements of the immunological markers were within normal limits.

CONCLUSION

A single dose of a new type of vaccine against hepatitis A confers adequate protection even in those persons who had a splenectomy.

Safety and immunogenicity of a V3 loop synthetic peptide conjugated to purified protein derivative in HIV-seronegative volunteers

OBJECTIVES

To develop a peptide-based model for a preventive vaccine for HIV-1 infection.

DESIGN

Phase I trial in HIV-1-seronegative volunteers.

PARTICIPANTS

Adult healthy subjects HIV-1-antibody-seronegative in an enzyme-linked immunosorbent assay, screened for tuberculin [purified protein derivative (PPD)] reactivity with 2 tuberculin units PPD-administered intradermally.

INTERVENTIONS

Submicrogram doses of a PPD conjugate with a peptide of the primary neutralizing domain (PND) of HIV-1MN (PPD-MN-PND) were administered intradermally to tuberculin skin-test-positive and -negative volunteers.

RESULTS

Antibodies to the MN-PND were measured after two immunizations in 10 out of 11 PPD skin-test-positive volunteers. After the fourth immunization high-affinity antibodies were detected, which persisted for over 1 year. High titers of MN-PND-specific immunoglobulin (Ig) G and IgA were detected in the serum and saliva of all volunteers tested. Serum antibodies were cross-reactive with PND peptide from some other HIV-1 strains but neutralized only the HIV-1MN prototype. Human leukocyte antigen (HLA)-B7-restricted MN-PND-specific cytotoxic T lymphocytes (CTL) were also detected.

CONCLUSIONS

The PPD-MN-PND vaccine at submicrogram doses is safe and immunogenic in PPD skin-test-positive healthy adult volunteers. Long lasting humoral immune responses in the serum and saliva were possibly accompanied by HLA-B7-restricted CTL responses. This is a vaccine prototype that can be rapidly and inexpensively modified to include other peptide epitopes. It is especially suitable for use in a worldwide multibillion Bacillus Calmette-Guérin (BCG)-primed or tuberculosis-exposed population at risk for HIV-1 infection.

Inactivated virosome hepatitis A vaccine

Immunopotentiating reconstituted influenza virosomes (IRIV) are efficient carrier systems for small virion particles such as hepatitis A virus (HAV). We evaluated immunogenicity and tolerability of an IRIV-HAV vaccine and the effectiveness of a booster by immunising 104 healthy HAV seronegative volunteers. A single dose was highly immunogenic, since 98% of volunteers had seroconverted after 2 weeks. Anti-HAV titres remained high, with 100% seroconversion rate 1 year later, when the booster was given. The vaccine was effective, with a 22-fold increase in geometric mean titres 1 month later. No serious adverse reactions were observed.

Time course of hepatitis A antibody production after active, passive and active/passive immunisation: the results are highly dependent on the antibody test system used

Two commercially available automated test systems for hepatitis A antibody, HAVAB IMX (Abbott) and ENZYMUN Anti-HAV (Boehringer) were evaluated in a study of active, passive and active/passive immunisation against hepatitis A. The inactivated hepatitis A vaccine Epaxal Berna and the hepatitis A immunoglobulin preparation Globuman were products of the Swiss Serum and Vaccine Institute. Although both hepatitis A antibody test kits were standardised with the same international WHO standard hepatitis A immunoglobulin preparation, divergent results were obtained for the level of circulating hepatitis A antibody after vaccination. One month after the vaccination the mean geometric antibody titres were 315 mIU/ml after active, 253 mIU after active/passive and 22 mIU after passive immunisation when measured with the Enzymun assay. In the same sera 70 mIU/ml after active, 60 mIU after active/passive and 18 mIU after passive immunisation could be detected with the IMX test. Antibody avidity studies could not explain the differences obtained by the two test methods. The neutralization test is the standard method for the estimation of protection against hepatitis A. This test is not suitable for large series of serum samples, and enzyme immunoassays are indispensable for vaccination studies. To be suitable for monitoring antibody development in phase I and II clinical trials as well as in postmarketing studies, EIA tests for hepatitis A antibodies must be commercially available and of known sensitivity. The Enzymun anti-HAV test developed by Boehringer Mannheim (Germany) offers the possibility to measure antibody titres around the protective level of 20 mIU/ml which is reached by the passive immunisation with immunoglobulin preparations or within two weeks after active vaccination with an inactivated hepatitis A vaccine. The Abbott IMX test system is more useful for the detection of natural infections by the hepatitis A virus.

Immunopotentiating reconstituted influenza virus virosome vaccine delivery system for immunization against hepatitis A

Hepatitis A virus (HAV) was purified from MRC-5 human diploid cell cultures, inactivated with formalin, and evaluated for safety and immunogenicity in humans. Three vaccine formulations were produced: (a) a fluid preparation containing inactivated HAV, (b) inactivated HAV adsorbed to Al(OH)3, and (c) inactivated HAV coupled to novel immunopotentiating reconstituted influenza virosomes (IRIV). IRIV were prepared by combining phosphatidylcholine, phosphatidylethanolamine, phospholipids originating from the influenza virus envelope, influenza virus hemagglutinin, and neuraminidase. The HAV-IRIV appeared as unilamellar vesicles with a diameter of approximately 150 nm when viewed by transmission electron microscopy. Upon intramuscular injection, the alum-adsorbed vaccine was associated with significantly (P < 0.01) more local adverse reactions than either the fluid or IRIV formulations. 14 d after a single dose of vaccine, all the recipients of the IRIV formulation seroconverted (> or = 20 mIU/ml) versus 30 and 44% for those who received the fluid and alum-adsorbed vaccines, respectively (P < 0.001). The geometric mean anti-HAV antibody titer achieved after immunization with the IRIV-HAV vaccine was also significantly higher (P < 0.005) compared with the other two vaccines.

Safety and immunogenicity of a booster dose of Vibrio cholerae CVD 103-HgR live oral cholera vaccine in Swiss adults

Adult volunteers received a booster dose (4 x 10(8) CFU) of attenuated Vibrio cholerae CVD 103-HgR oral vaccine 15 or 24 months after primary immunization. The immune response was modest, presumably due to rapid clearance of the vaccine strain by a primed immune system.

[Does isolated TSH elevation need treatment? Study of risk factors for the development of manifest hypothyroidism]

Isolated elevations of basal TSH levels are frequently observed in the general population. In a prospective study we analyzed the spontaneous evolution of thyroid function over time in such patients. The mean observation period was 5.4 (0.5-12) years. During the follow-up period 20% of these patients developed overt hypothyroidism. The risk of developing hypothyroidism was determined primarily by the initial TSH value and an additive effect was found for the thyroid antibodies and the thyroidal reserve (delta-T3) after TRH stimulation (Cox proportional hazard model). The cumulative risk for overt hypothyroidism after 10 years was only 22% for a mean TSH level of 12 mU/l for patients with negative thyroid antibodies and a good thyroidal reserve (low-risk), but increased to 63% for patients with positive antibodies and impaired T3 reserve (high-risk). Therefore, patients with isolated elevation of TSH can be divided into two subgroups according to the results of TSH, antibody status and T3 reserve: (1) In the "low-risk group" with good prognostic factors the patients should be followed up by periodic laboratory testing only (TSH, FT4, every 2-3 years). (2) In the "high-risk group" with clearly abnormal parameters, however, frequent controls are mandatory (every 6-12 months) or treatment with thyroxine may be indicated.

Randomized double-blind placebo controlled trial to evaluate the safety and immunogenicity of the live oral cholera vaccine strain CVD 103-HgR in Swiss adults

A randomized, double-blind, placebo controlled trial was conducted in 50 healthy Swiss adults to assess the safety and immunogenicity of the live oral attenuated cholera vaccine candidate strain Vibrio cholerae CVD 103-HgR (classical, Inaba). A single dose of 5 x 10(8) viable CVD 103-HgR organisms, administered in a buffered liquid formulation, was well tolerated as compared with individuals who received an equivalent amount of heat-killed Escherichia coli K-12 placebo. Eighty-eight percent of subjects receiving CVD 103-HgR mounted a significant (greater than fourfold) rise in Inaba vibriocidal titre while 68% did so for the heterologous Ogawa serotype. The magnitude of the vibriocidal antibody response (as measured by peak geometric mean titre and by fold-rise in titre over baseline) was greater for the homologous Inaba serotype. Nineteen out of 25 volunteers (76%) responded with a significant (p less than 0.05) rise in serum antitoxin levels. No vaccinee who received the E. coli K-12 placebo mounted a significant rise in either vibriocidal or antitoxin antibody levels. These results corrobrate the safety and immunogenicity of CVD 103-HgR in healthy adult volunteers.

[Carbimazole therapy in Basedow's disease: therapy results in individual dosage adjustment]

We analyzed the results of 85 treatments with carbimazol in 71 patients with Graves' disease. The initial dose ranged from 45 to 60 mg/day, which was gradually reduced to the lowest possible maintenance dose; the mean treatment period was 17 months. All patients achieved euthyroid function after 12 weeks at the latest. Normalization of the pituitary TSH-reserve occurred late (after 6-12 months in most cases). 60% of the patients treated for the first time (n = 58) and 59% of the whole group remained in remission. The maintenance dose of carbimazol had no effect on the rate of remission. It is interesting to note that in 66% of the patients a very low dose (less than or equal to 5 mg/day) was fully effective and resulted in a remission rate of 54%. Therefore, the dose should always be reduced individually. Relapses occurred within the first year after the end of treatment in 77% of the cases, but were also observed after 2-3 years. Hence follow-up should be continued after cessation of therapy.

Assessment of antithyroglobulin and antimicrosomal autoantibodies in patients with autoimmune thyroid disease: comparison of haemagglutination assay, enzyme-linked immunoassay and radioligand assay

Four different assay systems for detection of antithyroglobulin (T-Ab) and thyroid antimicrosomal autoantibodies (M-Ab) were evaluated: two passive haemagglutination assays (PHA), an enzyme-linked immunoassay (ELISA) and a radioligand assay (RLA). Antibody levels measured with these methods correlated well (T-Ab: r = 0.72 to 0.88; M-Ab: r = 0.63 to 0.84; p less than 0.0001). However, when the results of the measured samples were classified as normal, slightly elevated and pathological, only 40-50% of the samples showed congruous results in all tests; 60-70% agreed in PHA and ELISA, whereas 80 to 90% corresponded in the two PHAs. RLA and ELISA gave more frequently positive results for T-Ab and negative results for M-Ab than the PHAs. Despite the lower sensitivity of the quantitative methods for M-Ab detection, they depicted more readily small changes after thyroxine treatment than the PHAs. We suggest that differences in autoantibody levels found with different methods may be due to autoantibody heterogeneity.

[Study of the long-term effects of amiodarone on thyroid function using ultrasensitive TSH measurements. Preliminary report]

The results of a prospective study of basal ultrasensitive TSH concentrations in patients during long-term treatment over 12 months with amiodarone are reported. 2 patients (3%) developed hypothyroidism, whereas no case of hyperthyroidism was observed. A significant increase in FT4 with a simultaneous decrease in T3 was demonstrated at every periodic investigation during amiodarone therapy. In most patients ultrasensitive TSH values stayed within the normal range and showed no significant alteration during treatment. A slow decline in TSH during therapy was observed in a subgroup of patients with completely euthyroid initial TSH concentrations. This TSH decrease reached statistical significance after 12 months' therapy. FT4 showed pathological results in 35% of all determinations at any time during the study, T3 in 27%, and TSH in only 17%. In conclusion, a new steady-state of thyroid tests is attained during treatment with amiodarone and most patients maintain a euthyroid function state. Assessment of ultrasensitive TSH can be recommended as a primary screening test for evaluation of thyroid function in patients under amiodarone therapy.

[Therapy resistance of amiodarone-induced hyperthyroidism]

The case of a 77-year-old patient who suffered from clinically severe and persistent hyperthyroidism induced by amiodarone is described. Amiodarone-associated hyperthyroidism is a rare (1-5%) but potentially severe complication. Its treatment presents a serious problem. The newer forms of treatment of this specific type of hyperthyroidism with prednisone and perchlorate are described. Under a combined therapy with thionamide drugs, prednisone and perchlorate euthyroidism could be achieved only after months. We propose a simple diagnostic procedure during amiodarone therapy based on the determination of basal ultrasensitive TSH enabling early recognition of amiodarone-associated hyperthyroidism. Thus, with well defined cardiac criteria for therapy with amiodarone as well as early assessment of thyroid dysfunction the incidence of this potentially severe complication can be reduced.

HLA-DR3 and DRw6: prognostic factors for the incidence of hypothyroidism in Graves' disease after radioiodine treatment

Several studies demonstrated a relationship between HLA-B8 and -DR3 and the early course of thyroid function after treatment of thyrotoxicosis. However, the association between certain DR antigens and the outcome of thyroid function years after radioiodine treatment for Graves' disease remains unclear. We therefore determined the HLA pattern in 2 groups of female patients with different severity of hypothyroidism. From a total of 45 patients, 27 had developed pre-clinical hypothyroidism (normal serum levels of T4, FT4 and T3, normal or elevated basal TSH levels, but an exaggerated TSH response to TRH, Group A). Mean follow-up was 111 months (range 36-360 months) for this group. Eighteen patients had become overtly hypothyroid (T4 and FT4 levels in the hypothyroid range and an elevated basal TSH concentration, group B) after a mean interval of 51 months (range: 4-132 months) following treatment. Eighty-seven healthy blood donors served a controls. Positive plasma antibody titres (tanned red cell haemagglutination technique) were observed in 67% of all patients with a preponderance in group B (83% versus 56% in group A, n.s.). The whole group of Graves' disease patients showed the antigens B8, DR3 and Drw6 in 37.8%, 33.3% and 35.6%, respectively (P less than 0.02, less than 0.05, and less than 0.04 vs controls). In patients with pre-clinical hypothyroidism there was a significantly increased prevalence of antigen B8 (P less than 0.01) and DR3 (P less than 0.05) compared to the control group. In contrast, the overt hypothyroid group showed an augmented frequency of HLA-DRw6 (P less than 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Diffuse peritonitis and chronic ascites due to infection with Chlamydia trachomatis in patients without liver disease: new presentation of the Fitz-Hugh-Curtis syndrome

Two women were admitted for increasing abdominal pain, vaginal discharge, and severe or moderate chronic ascites. Diffuse peritonitis without evidence of liver disease was found in both cases, and in one the ascites and vaginal discharge contained Chlamydia trachomatis. Both patients responded to doxycycline, and this and the laboratory findings pointed strongly to C trachomatis as the aetiological agent. C trachomatis may cause severe peritoneal infections with chronic ascites formation in the absence of liver disease in women with the Fitz-Hugh-Curtis syndrome. Prompt diagnosis and antibiotics lead to rapid cure.

Non-ferritin, non-heme iron pools in rat tissues

Concentrations of intracellular, low molecular weight (LMW) and desferrioxamine B (DF) chelatable Fe, in tissues of normal, Fe-deficient and Fe-loaded female rats, were determined. Ice cold, high speed supernatants were rapidly fractionated on Ultrogel AcA202 or by filter centrifugation. After correction for residual blood and DF effects on Fe proteins, liver, kidney, heart and spleen contained 3-8 micrograms/g LMW Fe, brain 20 micrograms/g, with DF; two-thirds of this was detected without DF. There was little variation with Fe status. MW standardization and fractionation on Sephadex G-25 indicated components of apparent MW 13,000, 1400 and 350; the latter two were rapidly labeled with in vivo 59Fe.

[Evaluation of the optimal thyroxine dose with the TRH test for replacement and suppression therapy]

53 patients with overt hypothyroidism (group 1), 17 patients with "preclinical hypothyroidism" (group 2), 22 patients with a euthyroid goiter (group 3) and 13 patients who had undergone total elimination of the thyroid gland for thyroid cancer (group 4) were treated with thyroxine. Basal levels of T4, T3, TSH and the TSH-response to 40 mg oral TRH were measured during treatment. For replacement therapy in hypothyroid patients of group 1 and 2 the dose was adjusted until the TSH response to TRH was within the normal range (3.5-38 mU/l). In groups 3 and 4 the thyroxine dose was increased to suppress the TSH response to TRH in the presence of euthyroid T4 and T3 levels (suppressive dose). Average thyroxine replacement doses were 128 micrograms per day in overt hypothyroidism and 101 micrograms/day in preclinical hypothyroidism. Suppressive doses of thyroxine were on average 119 micrograms/day in patients with euthyroid goiter and 183 micrograms thyroxine per day in patients with total thyroid ablation. In all 4 groups of patients a wide interindividual variation of the optimal thyroxine dose was found.

[Profile of autoimmune antibodies in idiopathic hypothyroidism and hypothyroidism following radio-iodine treatment in Basedow's disease: comparison with a group of normal subjects from the female population of Switzerland]

Prevalence of thyroid microsomal antibodies (MCHA) and thyroglobulin antibodies (TGHA), as well as frequency of other autoantibodies (parietal cell antibodies [PZA], adrenal antibodies [NNA], islet cell antibodies [IZA], smooth muscle antibodies [SMA], mitochondrial antibodies [MitA] and antibodies to nuclear antigens [ANF]), are reported for three different female groups in Switzerland in 91 euthyroid controls (group A), in 58 patients with idiopathic hypothyroidism (group B) and in 55 patients with hypothyroidism after administration of radioactive iodine for Graves' disease (group C). Prevalence of MCHA in the three groups was 14.5%, 90%, and 72%, respectively, and TGHA were positive in 6.5%, 56%, and 28%, respectively. Simultaneous occurrence of both thyroid antibodies and their appearance in higher titers were significantly more frequent in group B than in the other two groups. Goitrous forms of idiopathic hypothyroidism show higher MCHA titers than the atrophic forms. There was no association between thyroid antibodies and the presence of endocrine ophthalmopathy in group C. PZA were frequently found in groups B and C (26% and 13.6%, respectively; 4.7% in controls). The higher frequency of other autoantibodies was even more pronounced for ANF (52.1% in group B, 29.7% in group C, and 12.5% in controls). NNA and SMA were also more frequent, but not to a statistically significant degree. Two patients (both in group B) had positive islet cell antibodies. MitA were equally distributed in the three groups. These results suggest a relatively high proportion of asymptomatic autoimmune thyroiditis in the female population of Switzerland, with possible progression to overt hypothyroidism. Determinations of PZA and NNA are mandatory in both Graves' disease and idiopathic hypothyroidism. Cases with positive PZA must be closely monitored in view of the association with autoimmune atrophic gastritis and pernicious anemia.(ABSTRACT TRUNCATED AT 250 WORDS)