Dissecting the Mechanisms Underlying the Cytokine Release Syndrome (CRS) Mediated by T-Cell Bispecific Antibodies

PURPOSE

Target-dependent TCB activity can result in the strong and systemic release of cytokines that may develop into cytokine release syndrome (CRS), highlighting the need to understand and prevent this complex clinical syndrome.

EXPERIMENTAL DESIGN

We explored the cellular and molecular players involved in TCB-mediated cytokine release by single-cell RNA-sequencing of whole blood treated with CD20-TCB together with bulk RNA-sequencing of endothelial cells exposed to TCB-induced cytokine release. We used the in vitro whole blood assay and an in vivo DLBCL model in immunocompetent humanized mice to assess the effects of dexamethasone, anti-TNFα, anti-IL6R, anti-IL1R, and inflammasome inhibition, on TCB-mediated cytokine release and antitumor activity.

RESULTS

Activated T cells release TNFα, IFNγ, IL2, IL8, and MIP-1β, which rapidly activate monocytes, neutrophils, DCs, and NKs along with surrounding T cells to amplify the cascade further, leading to TNFα, IL8, IL6, IL1β, MCP-1, MIP-1α, MIP-1β, and IP-10 release. Endothelial cells contribute to IL6 and IL1β release and at the same time release several chemokines (MCP-1, IP-10, MIP-1α, and MIP-1β). Dexamethasone and TNFα blockade efficiently reduced CD20-TCB-mediated cytokine release whereas IL6R blockade, inflammasome inhibition, and IL1R blockade induced a less pronounced effect. Dexamethasone, IL6R blockade, IL1R blockade, and the inflammasome inhibitor did not interfere with CD20-TCB activity, in contrast to TNFα blockade, which partially inhibited antitumor activity.

CONCLUSIONS

Our work sheds new light on the cellular and molecular players involved in cytokine release driven by TCBs and provides a rationale for the prevention of CRS in patients treated with TCBs. See related commentary by Luri-Rey et al., p. 4320.

Does the built environment influence location- and trip-based sedentary behaviors? Evidence from a GPS-based activity space approach of neighborhood effects on older adults

OBJECTIVE

Evidence on the influence of built environments on sedentary behaviors remains unclear and is often contradictory. The main limitations encompass the use of self-reported proxies of sedentary time (ST), the scarce consideration of the plurality of sedentary behaviors, and environmental exposures limited to the residential neighborhood. We investigated the relationships between GPS-based activity space measures of environmental exposures and accelerometer-based ST measured in total, at the place of residence, at all locations, and during trips.

METHODS

This study is part of the CURHA project, based on 471 older adults residing in Luxembourg, who wore a GPS receiver and a tri-axial accelerometer during 7 days. Daily ST was computed in total, at the residence, at all locations and during trips. Environmental exposures included exposure to green spaces, walking, biking, and motorized transportation infrastructures. Associations between environments and ST were examined using linear and negative binomial mixed models, adjusted for demographics, self-rated health, residential self-selection, weather conditions and wear time.

RESULTS

Participants accumulated, on average, 8 h and 14 min of ST per day excluding sleep time. ST spent at locations accounted for 83 % of the total ST. ST spent at the residence accounted for 87 % of the location-based ST and 71 % of the total ST. Trip-based ST represents 13 % of total ST, and 4 % remained unclassified. Higher street connectivity was negatively associated with total ST, while the density of parking areas correlated positively with total and location-based ST. Stronger associations were observed for sedentary bouts (uninterrupted ST over 20 and 30 min).

CONCLUSION

Improving street connectivity and controlling the construction of new parking, while avoiding the spatial segregation of populations with limited access to public transport, may contribute to limit ST. Such urban planning interventions may be especially efficient in limiting the harmful uninterrupted bouts of ST among older adults.

Abstract LB558: Single cell profiling of PBMCs reveals correlates of clinical response to glofitamab

Glofitamab is a novel CD20-targeted bispecific T cell-engaging antibody that has demonstrated significant clinical efficacy in aggressive forms of Non-Hodgkin Lymphoma (aNHL). Despite significant clinical efficacy in aNHL (Hutchings et al. JCO 2021), some patients only achieve a partial response or progress upon treatment. To investigate the cellular and molecular factors that correlate with clinical activity of glofitamab, we applied CyTOF, single cell RNA and TCR sequencing to study PBMCs collected at baseline and at cycle 2 of treatment from patients with aNHL. Our cohort included 9 patients with complete response (CR) and 9 patients with progressive disease (PD) status (response assessed at cycle 3) recruited during dose escalation of glofitamab in a Ph1 clinical trial (NP30179).

We identified a higher proportion of CD4 T cells and a lower proportion of monocytes in CR versus PD patients. Complementary to changes in cell proportions, we explored the covariation of genes across single cells to isolate co-regulated processes and identified several gene expression programs associated with the response status, of which some were shared between two or more cell types while others were cell type-specific. Focusing on the T cell compartment, we further identified subtypes of CD8 and CD4 T cells enriched in either CR or PD patients, and used topic modeling, a computational approach that excels in settings of continuous phenotypes, to contrast the transcriptional state of T cells in CR patients compared to PD patients at baseline and on treatment. Interestingly, we found CR patients to exhibit a less exhausted CD8 T cell population at baseline, confirming our previous observations using tumor bulk RNA sequencing data. Moreover, we observed that hyper-expanded clonotypes were generally enriched in the CD8 T cell compartment, and that the clonal cells had a stronger cytotoxic phenotype compared to non-clonal T cells. This observation was further corroborated when looking at TCR diversity. Indeed, we observed that distinct T cell populations exhibited differences in TCR diversity, with exhausted CD8 T cells showing decreased clonal diversity. Finally, to better understand the changes in CD8 T cells, we performed trajectory inference and observed that the position of individual cells along the pseudotime varied largely according to timepoint and response status. This analysis further allowed us to identify the expression dynamic of numerous markers of T cell exhaustion, as well as transcription factors associated with progenitor and self-renewing state.

Notwithstanding the limited sample size and patient heterogeneity, our analysis provides a deep characterization of the cellular and molecular features associated with response to glofitamab using peripheral biomarkers. As glofitamab is being evaluated in a number of clinical trials either as a single agent or in combination, our dataset and findings can help broaden the understanding of its mode of action, and might be relevant for patient enrichment and monitoring response.

Citation Format: Sina Nassiri, Lucas Habegger, Petra Gerber, Vinko Tosevski, Tamara Hüsser, Emilio Yanguez, Sylvia Herter, Martin Weisser, Koorosh Korfi, Pablo Umana, Emily Piccione, Ann-Marie Bröske, Marina Bacac. Single cell profiling of PBMCs reveals correlates of clinical response to glofitamab [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB558.

Bottle Fermented Sparkling Wine: Cork or Crown Closures During the Second Fermentation?

Bottle-fermented sparkling wine producers are continuously striving to increase quality and produceniche products. One production tool that could be used is a cork closure instead of a crown cap closureduring the second fermentation and maturation on yeast lees. Anecdotal evidence suggests that thisleads to stylistic differences in the wine. Six pairs of South African bottle-fermented sparkling wines(Méthode Cap Classique), closed by either a cork or crown cap, were investigated. Analyses includedbottle pressure, infrared spectroscopy, phenolic acids, sensory attributes and CO2 kinetics. Generally,there were differences between the cork-closed and crown-capped wines. Cork-closed wines tended tohave lower pressure compared to crown-capped wines, albeit still well within legal requirements. Otherdifferences were evident in the infrared spectral data and in the polyphenol profile of the analysed wines.Levels of gallic, caftaric, caffeic and p-coumaric acids could be used collectively as marker compounds todifferentiate between cork-closed and crown-capped wines. The effect of the cork was also evident in thesensory attributes and CO2 kinetics. Cork-closed wines were judged to have smaller bubbles and a longeraftertaste. It was also shown that the cork-closed wines tended to lose CO2 from the glass slower after beingpoured than their crown-capped counterparts. The data tentatively support the anecdotal evidence thatcork can be used during the second fermentation and maturation on the yeast lees to change the style ofbottle-fermented sparkling wine.

Ästhetische Behandlungen mit Fillern und das Management von Nebenwirkungen

Medizinisch-ästhetische Behandlungen sind für die tägliche dermatologische Praxis von zunehmender Bedeutung. Als zentraler Bestandteil eines multimodalen Therapiekonzeptes sind dermale und Volumenfiller aus der modernen ästhetischen Therapie nicht mehr wegzudenken. Wegweisende Erkenntnisse zum Alterungsprozess des Gesichtes und zur Sicherheit und Spezifika der verschiedenen Typen von Füllstoffen der vergangenen Jahre bieten heute differenzierte Anwendungsmöglichkeiten von Volumenaugmentation bis hin zu Hydratation oder Kollageninduktion. Gleichsam sind aber auch der Markt an verfügbaren Injektionsprodukten und die verschiedenen Indikationen und Injektionstechniken nahezu unüberschaubar. Schließlich werden wir in der Praxis immer wieder mit Komplikationen nach unsachgemäßer Anwendung oder den Langzeitkomplikationen von in Deutschland längst nicht mehr verfügbaren Füllstoffen konfrontiert und auch bei regelhafter Injektion sind Nebenwirkungen nicht ausgeschlossen. Die vorliegende Arbeit soll einen Überblick über die am Markt verfügbaren aber auch relevanten historischen bzw. obsoleten Filler und ferner über mögliche Komplikationen und deren Management geben. Ferner finden sich persönliche Bewertungen zu besonderen Indikationen bzw. Injektionstechniken.

Weight loss prior to bariatric surgery: an updated review of the literature

BACKGROUND AND AIMS

Prior to bariatric surgery, a preoperative weight-reducing regimen is usually adhered to in most centers. The clinical effects of such a regimen are yet to be determined.

MATERIAL AND METHODS

We reviewed the current literature by searching in PubMed for publications reporting clinical effects resulting from a preoperative weight loss regimen prior to bariatric surgery published from January 1, 1995 to April 30, 2014.

RESULTS

In total, we identified 23 original publications and 2 review articles which met all inclusion criteria. These were included and fully analyzed with regard to effects of preoperative weight loss. In general, for parameters such as operating time and intraoperative complications including blood loss and recovery, inconsistent data were reported. Most studies included low number of patients and with heterogenic designs, and the results could not form the base for recommendations. However, for outcomes such as postoperative complications and weight development over time, data from large-scale studies and randomized controlled trials suggest beneficial effects following adherence to weight loss prior to bariatric surgery.

CONCLUSION

Although a large amount of data in the current literature on the effects of weight loss prior to bariatric surgery are inconsistent for many outcome parameters, recently published results regarding effects on postoperative complications and weight development over time strongly suggest that such a regimen should be recommended. Whether a certain degree of weight loss should be mandatory before being accepted for bariatric surgery is, however, still controversial.

Improved physiological properties of gravity-enforced reassembled rat and human pancreatic pseudo-islets

Previously we demonstrated the superiority of small islets vs large islets in terms of function and survival after transplantation, and we generated reaggregated rat islets (pseudo-islets) of standardized small dimensions by the hanging-drop culture method (HDCM). The aim of this study was to generate human pseudo-islets by HDCM and to evaluate and compare the physiological properties of rat and human pseudo-islets. Isolated rat and human islets were dissociated into single cells and incubated for 6-14 days by HDCM. Newly formed pseudo-islets were analysed for dimensions, morphology, glucose-stimulated insulin secretion (GSIS) and total insulin content. The morphology of reaggregated human islets was similar to that of native islets, while rat pseudo-islets had a reduced content of α and δ cells. GSIS of small rat and human pseudo-islets (250 cells) was increased up to 4.0-fold (p < 0.01) and 2.5-fold (p < 0.001), respectively, when compared to their native counterparts. Human pseudo-islets showed a more pronounced first-phase insulin secretion as compared to intact islets. GSIS was inversely correlated to islet size, and small islets (250 cells) contained up to six-fold more insulin/cell than large islets (1500 cells). Tissue loss with this new technology could be reduced to 49.2 ± 1.5% in rat islets, as compared to the starting amount. With HDCM, pseudo-islets of standardized size with similar cellular composition and improved biological function can be generated, which compensates for tissue loss during production. Transplantation of small pseudo-islets may represent an attractive strategy to improve graft survival and function, due to better oxygen and nutrient supply during the phase of revascularization. Copyright © 2014 John Wiley & Sons, Ltd.

Juggling revisited - a voxel-based morphometry study with expert jugglers

Juggling is a highly interesting tool to investigate neuroplasticity associated with motor-learning. Several brain-imaging studies have reported changes in regional brain morphology in visual association cortices in individuals learning how to juggle a three-ball cascade. However, to our knowledge there are no studies that investigated expert jugglers, looking for specific features in regional brain morphology related to this highly specialized skill. Using T1-weighted images and voxel-based morphometry we investigated in a cross-sectional study design 16 expert jugglers, able to juggle at least five balls and an age- and gender-matched group of non-jugglers. We hypothesized that expert jugglers would show higher gray matter density in regions involved in visual motion perception and eye-hand coordination. Images were pre-processed and analyzed using SPM8. Age was included in the analyses as covariate of no interest. As compared to controls jugglers displayed several clusters of higher, regional gray matter density in the occipital and parietal lobes including the secondary visual cortex, the hMT+/V5 area bilaterally and the intraparietal sulcus bilaterally. Within the jugglers group we also found a correlation between performance and regional gray matter density in the right hMT+/V5 area. Our study provides evidence that expert jugglers show increased gray matter density in brain regions involved in visual motion perception and eye-hand coordination, i.e. brain areas that have previously been shown to undergo dynamic changes in terms of gray matter increases in subjects learning a basic three-ball cascade. The extent to which transient increases in beginners and the differences in experts and non-experts are based on the same neurobiological correlates remains to be fully elucidated.

Nutrient balances for improving the use-efficiency of non-renewable resources: experiences from Switzerland and Southeast Asia

Simple nutrient balances can be a valuable tool to assess and visualize whether farming systems are in equilibrium or not with respect to nutrient inputs and outputs. Thus, they can raise awareness about environmental risks of agricultural production, and especially intensive livestock production. They are also a valuable tool for policy development and implementation processes. In this paper, we discuss how a nutrient-balance approach can help to improve the awareness of different stakeholders about the ecological impacts of agriculture and the efficient use of nutrients. While the example from Switzerland demonstrates the potential ecological benefits of compulsory nutrient balancing, the examples from Asia demonstrate how a combination of nutrient balancing and geographic information system (GIS) was used to identify hot-spots with respect to insufficient and excessive P input, and we will discuss a nutrient-balance method developed to improve nutrient management in the rapidly growing intensive livestock-production sector.

[Nasal polyps and osteolyses]

A 38-year-old man presented with a 2-month history of progressive leg pain. An x-ray film of both tibial bones showed multiple osteolysis. At the same time, nasal polyps were present. A biopsy of the tibial bone remained unclear. A carcinoma was not found. A biopsy of the nasal polyps revealed a Rosai-Dorfman-Destombes disease.

[Diabetes]

In 2004, a new insulin analogue was launched, Detemir insulin (Levemir). Detemir insulin is a long acting insulin and has a lower within-subject variability in comparison with other insulins. The recently published results of the CARDS study (atorvastatin treatment) also emphasize the need for a more aggressive attitude toward cardiovascular risk in diabetics even if LDL-cholesterol values are not particularly elevated. We will end this short review discussing the future of the inhibitor of GLP-1 degradation which in addition to a modest hypoglycaemic effect seems to be able to prevent apoptosis of insulin producing beta cells.

Routine experimental system for defining conditions used in photodynamic therapy and fluorescence photodetection of (non-) neoplastic epithelia

A common method to induce enhanced short-term endogenous porphyrin synthesis and accumulation in cell is the topical, systemic application of 5-aminolevulinic acid or one of its derivatives. This circumvents the intravenous administration of photosensitizers normally used for photodynamic therapy (PDT) of fluorescence photodetection. However, in the majority of potential medical indications, optimal conditions with respect to the porphyrin precursor or its pharmaceutical formulation have not yet been found. Due to ethical restrictions and animal right directives, the number of available test objects is limited. Hence, definition and use of nonanimal test methods are needed. Tissue and organ cultures are a promising approach in replacing cost intensive animal models in early stages of drug development. In this paper, we present a tissue culture, which can among others be used routinely to answer specific questions emerging in the field of photodynamic therapy and fluorescence photodetection. This technique uses mucosae excised from sheep paranasal sinuses or pig bladder, which is cultured under controlled conditions. It allows quasiquantitative testing of different protoporphyrin IX precursors with respect to dose-response curves and pharmacokinetics, as well as the evaluation of different incubation conditions and/or different drug formulations. Furthermore, this approach, when combined with the use of electron microscopy and fluorescence-based methods, can be used to quantitatively determine the therapeutic outcome following protoporphyrin IX-mediated PDT.

Cardiovascular parameters telemetrically measured during pregnancy, parturition, and lactation in a common marmoset (Callithrix jacchus)

Here we present the first report of heart rate, blood pressure, and locomotive activity of a female common marmoset (Callithrix jacchus) that was moving freely in its home cage during gestation, parturition, and lactation. We collected the data by using a miniaturized telemetry and data-acquisition system (Data Sciences, St. Paul, MN) that had been adapted for marmosets (1). The parameters were recorded continually from 12 days before to 15 days after parturition. Parturition lasted about 3.5 h, during which marked changes in heart rate, systolic blood pressure, and diastolic blood pressure occurred. To obtain control values, we again measured these parameters for 13 days during a "physiologically neutral" phase (4 months after parturition), when the female was neither pregnant nor lactating. Heart rate was 200% higher, systolic blood pressure was 25% higher, and diastolic blood pressure was 75% higher during parturition than during the neutral phase.

Retention of Teflon particles in hamster lungs: a stereological study

The significance of aerosols in medicine is increased when the distribution of inhaled aerosols in the different respiratory tract compartments and their interaction with lung structures are known. The aim of this study was to investigate the retention of the hydrophobic Teflon spheres used in human beings so as to analyze their regional distribution and to study their interaction with lung structures at the deposition site. Six intubated and anesthetized Syrian Golden hamsters inhaled aerosols of Teflon particles with an aerodynamic diameter of 5.5 microns by continuous negative-pressure ventilation adjusted to slow breathing. Lungs were fixed by intravascular perfusion within 21 minutes after inhalation was started, and tissue samples were taken and processed for light and electron microscopy. The stereological (fractionator) analysis revealed that particle retention was the greatest in alveoli (72.4%), less in intrapulmonary conducting airways (22.9%), and the least in extrapulmonary mainstem bronchi (0.3%) and trachea (4.4%). Particles were found submerged in the aqueous lining layer and in close vicinity to epithelial cells. In intrapulmonary conducting airways, 21.5% of Teflon particles had been phagocytized by macrophages. This study with highly hydrophobic Teflon particles clearly demonstrates that for spheres of this size, surface tension and line tension forces rather than the particles' surface free energy are decisive for the displacement of particles into the aqueous phase by surfactant. It was this displacement that enabled subsequent interaction with macrophages. Refined knowledge of particle retention may help us to better understand the biological response to inhaled particles.

Metabolic effects of temocapril in hypertensive patients with diabetes mellitus type 2

Compared with other angiotensin-converting enzyme (ACE) inhibitors, the elimination of temocapril is less dependent on renal function. To investigate the metabolic and antihypertensive effects of temocapril in diabetic hypertensives, 30 patients with diabetes mellitus type 2 and mild to moderate hypertension [diastolic blood pressure (BP) 90-115 mm Hg] and without azotemia (plasma creatinine < 180 microM) were evaluated in a prospective randomized double-blind placebo-controlled study. After a 4-week placebo run-in, they received temocapril, 20 mg daily (n = 19), or placebo (n = 11) for 6 weeks. Insulin sensitivity index (SI), determined by the Minimal Model method of Bergman, serum lipoproteins, plasma renin activity, fibrinogen, and microalbuminuria were assessed at the end of the placebo run-in phase and the double-blind treatment phases. Temocapril but not placebo administration produced a significant decrease in supine BP (152/92+/-5/3 vs. 162/98+/-5/2 mm Hg; p < 0.01) and increase in plasma renin (p < 0.05). Variation of SI during temocapril treatment did not reach statistical significance (0.95+/-0.2 before vs. 1.44+/-0.4 x 10(-4)/min/mU/L after treatment). During administration of temocapril or placebo, no significant changes in fasting plasma glucose, insulin, and serum levels of total triglycerides, cholesterol, lipoprotein cholesterol fractions, or fibrinogen were observed. Microalbuminuria decreased significantly on temocapril treatment (49+/-10 vs. 79+/-17 mg/24 h; p < 0.01) but not on placebo. These findings demonstrate that in hypertensive patients with diabetes mellitus type 2, short-term treatment with temocapril is neutral to insulin sensitivity, lipoprotein metabolism, and fibrinogen, and significantly reduces microalbuminuria.

Confidentiality and the courts

There is a general belief that, once in the witness box, doctors are compelled to reveal confidential information about their patients if asked by counsel. Where no issue of public interest is involved, a medical witness should ask the court to rule in its inherent discretion that the information sought is confidential and privileged.

[Thyroid and pregnancy]

Functional disorders of the thyroid, in particular hypothyroidism, can be the cause of reduced fertility in women. These dysfunctions may also increase the frequency of spontaneous miscarriage and/or fetal malformations. It is important to know the physiological adaptation-mechanisms of the thyroid in this special situation in order to understand and to diagnose such malformations and miscarriages. After a review of the physiology the most frequently observed thyroid disorders of mother and fetus during pregnancy are mentioned. Diagnostic methods and therapeutic measures are described. Finally a frequently misdiagnosed disorder of the thyroid, manifesting itself within the months following a delivery is presented: the postpartal thyroiditis.

Determination of the disulphide bonding pattern in proteins by local and global analysis of nuclear magnetic resonance data. Application to flavoridin

This paper describes a new method for the elucidation of the disulphide bonding pattern in a protein from an initial set of unrefined nuclear magnetic resonance solution structures. The use of both local and global proton-proton nuclear Overhauser enhancement (NOE) distance information for the identification of the disulphide bridge network in cysteine-rich polypeptides was investigated by statistical analysis of the crystal structures of a selected group of proteins. There are six different types of inter-cysteine proton-proton distances which can potentially be used for the prediction of disulphide links. The uniqueness and the extent to which disulphide bonds could be identified by these distances was evaluated. Only NOEs between C beta H/C beta H and C alpha H/C beta H were shown to have positive predictive values for the characterization of disulphide links. Contrarily, the observation of an NOE between C alpha H and NH is a strong indication for the absence of a disulphide bridge between the two residues. The global analysis of the nuclear magnetic resonance data starts with the calculation of an initial set of conformers. First, pairing weights wij were assigned to all putative cysteine pairs in the protein according to a Gaussian-type distribution function from the C beta-C beta interatomic distances. In a second step, all conceivable disulphide patterns were formed by an exhaustive combinatorial enumeration. Statistical weights were then assigned to all patterns from the weights of the participating cysteine pairs. This method was validated with protein crystal structures deposited in the Brookhaven Protein Data Bank having three or more cysteine residues. It was then used to determine the previously unknown disulphide bonding pattern of the 12 cysteine residues of flavoridin.

Lymphoproliferative disorders in an IL-7 transgenic mouse line

A high incidence of severe lymphoproliferative disease was observed in a newly generated strain of mice carrying murine IL-7 as a transgene under the control of the E alpha (MHC class II) promoter. An analysis of the cells from lesions in these mice shows the selective expansion of cells at an early stage of B cell development and, more interestingly, expansion of cells phenotypically identical to the recently reported bipotent (B/macrophage) stem cell populations described in midgestation embryonic liver. Such cells can be propagated (and remain dependent upon) bone marrow feeder cell lines obtained from IL-7 transgenic mice. A molecular analysis of fresh and cultured cells reveals that the lesions are oligoclonal, or in rare cases monoclonal, and include clones of cells with unrearranged Ig heavy chain loci. These data suggest that IL-7 acts at multiple stages of B cell development. Furthermore cell lines derived from IL-7 transgenic mice may provide a novel source of rare factor-dependent bipotent stem cells.

Gender differences in a type 2 (non-insulin-dependent) diabetic population with respect to apolipoprotein E phenotype frequencies

Apolipoprotein E polymorphism was examined in an Italian population of Type 2 (non-insulin-dependent) diabetic patients. There were significant differences (p < 0.05) in allele frequencies between male and female patients due to an under-representation of the E4 allele in the female group. No differences in allele frequencies were noted when non-diabetic male and female control subjects were compared. Both control groups exhibited similar allele distributions to that of male diabetic patients, but were significantly different (p < 0.05) from female diabetic patients. A closer examination of the female diabetic population revealed that under-representation of the E4 allele was principally confined to patients aged 60 years or older. This subgroup showed a significantly different (p < 0.05) allele frequency profile from control subjects (both men and women) and diabetic men, whereas this was not observed in the younger diabetic women (< or = 59 years). The results are consistent with the suggestion that the E4 allele may be a particular risk factor for female diabetic patients.

[Semiautomatic insulin injection equipment (pens)]

To the best of our knowledge, a good glycaemic control must be advised to avoid or delay the degenerative complications of diabetes, bearing in mind an increased risk of hypoglycaemias. Among other techniques, a treatment consisting of multiple injections (basal-bolus concept) is one way to achieve a good control. Although this form of treatment is rather restrictive (frequent blood glucose determinations), the use of pens makes it more acceptable. A fully informed and cooperative patient is a prerequisite before considering this particular type of insulin therapy which, however, is usually not very helpful for older diabetics. It is a misconception to think that every patient receiving insulin should do so with a pen, just as it is incorrect to recommend multiple injections for all type I diabetics. Whether such a therapeutic strategy is indicated should be established for each patient individually. In addition, the fashion for pens should not distract us from all the other problems associated with inadequate diabetic control, such as foot care and systematic blood pressure measurements.

Symptomatology of late-life minor depression among primary care patients

Patients of four general internists and four family physicians were interviewed by two psychiatrists to identify those suffering from depressive disorders. Nineteen elderly (60 years of age and older) patients and 22 younger (between 18 and 59 years of age) patients met Research Diagnostic Criteria (RDC) for minor depressive disorder, and 73 elderly and 79 younger patients had no psychiatric disorder. In general, the elderly depressed medical outpatients and the younger depressed medical outpatients had similar symptomatology, as did the elderly and nonelderly medical outpatients without psychiatric disorders.

[Mushroom ileus without previous intestinal obstruction]

A case is described of obstruction of the small bowel after consumption of 500 g edible mushrooms (Cantharellus cibarius). No fibrous bands or adhesions were found on laparotomy. When preparing the meal the mushrooms were not cut up, nor were they properly chewed due to the patient's defective dental prosthesis. 11 days after the meal the patient passed largely intact mushrooms. In retrospect the impacted mushrooms could be assumed on X-ray after barium meal. Since even without intra-abdominal adhesions impacted mushrooms can cause mechanical obstruction, it is recommended that mushrooms be cut up, chewed well and consumed only in moderate portions even when large quantities are available.