Professionally led support groups for people living with advanced or metastatic cancer: a systematic scoping review of effectiveness and factors critical to implementation success within real-world healthcare and community settings

PURPOSE

To examine the effectiveness of professionally led support groups for people with advanced or metastatic cancer, and identify factors critical to implementation success within real-world settings.

METHODS

Databases (MEDLINE; PsychINFO; CINAHL) and grey literature were searched for empirical publications and evaluations. Articles were screened for eligibility and data systematically extracted, charted and summarised using a modified scoping review methodology. Implementation factors were mapped using Proctor's implementation framework and the Consolidated Framework for Implementation Research 2.0.

RESULTS

A total of 1691 publications were identified; 19 were eligible for inclusion (8 randomised controlled trials, 7 qualitative studies, 2 cohort studies, 2 mixed methods studies). Most (n=18) studies focused on tumour-specific support groups. Evidence supported professionally led support groups in reducing mood disturbances (n=5), distress (i.e. traumatic stress, depression) (n=4) and pain (n=2). Other benefits included social connectedness (n=6), addressing existential distress (n=5), information and knowledge (n=6), empowerment and sense of control (n=2), relationships with families (n=2) and communication with health professionals (n=2). Thirteen studies identified factors predicting successful adoption, implementation or sustainment, including acceptability (n=12; 63%), feasibility (n=6; 32%) and appropriateness (n=1; 5%). Key determinants of successful implementation included group leaders' skills/experience, mode of operation, travelling distance, group composition and membership and resourcing.

CONCLUSIONS

Professionally led tumour-specific support groups demonstrate effectiveness in reducing mood disturbances, distress and pain among patients. Successful implementation hinges on factors such as leadership expertise, operational methods and resource allocation.

IMPLICATIONS FOR CANCER SURVIVORS

Professionally led support groups may fill an important gap in supportive care for people with advanced or metastatic cancer.

AB0044 REDUCED PERIPHERAL BLOOD MYELOID CELLS IN PATIENTS WITH VEXAS SYNDROME

Background

Systemic inflammatory or dysimmune diseases (SIDDs) are encountered in up to a quarter of patients with myelodysplastic syndromes (MDS). Recently identified VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, associated with somatic mutations in UBA1, encompasses a range of severe inflammatory conditions along with hematologic abnormalities, including myelodysplasia. Only limited data are available on the pathophysiology of MDS-associated SIDDs, and especially about the role of different myeloid cell subsets.

Objectives

The aim of this study was to describe the phenotype of myeloid immune cells (dendritic cells and monocytes) in MDS patients with associated SIDDs, and to compare their distribution with MDS patients without SIDDs and controls.

Methods

Phenotype analysis by flow cytometry from PBMCs of 14 MDS patients with SIDDs, 23 MDS patients without SIDDs and 7 controls without MDS and SIDDs. Eight of the 14 MDS/SIDDs patients (57%) had a somatic UBA1 mutation.

Results

In this study analyzing peripheral blood myeloid immune cells in MDS patients with and without SIDDs, we observed a quantitative reduction of different DC and monocyte subsets in MDS/SIDDs patients, especially in patients with active SIDDs and above all in patients with newly described VEXAS syndrome.

Conclusion

Further functional studies are warranted to better understand the mechanisms and the consequences of the phenotypic modulations of immune myeloid cells in the pathophysiology of MDS-associated SIDDs, especially in VEXAS syndrome.

Disclosure of Interests

None declared

Further characterization of clinical and laboratory features occurring in VEXAS syndrome in a large-scale analysis of multicenter case-series of 116 French patients

BACKGROUND

A new autoinflammatory syndrome related to somatic mutations of UBA1 was recently described and called VEXAS syndrome.

OBJECTIVE

To describe clinical characteristics, laboratory findings and outcomes of VEXAS syndrome.

DESIGN

Case-series.

SETTING

Patients referred to a French multicenter registry between November 2020 and May 2021.

PATIENTS

116 patients with VEXAS syndrome.

MEASUREMENTS

Frequency and median of parameters and vital status, from diagnosis to the end of the follow-up.

RESULTS

Main clinical features were skin lesions (83.5%), non-infectious fever (63.6%), weight loss (62%), lung involvement (49.6%), ocular symptoms (38.8%), relapsing chondritis (36.4%), venous thrombosis (34.7%), lymph nodes (33.9%), and arthralgia (27.3%). Hematological disease was present in 58 cases (50%), considered as myelodysplastic syndrome (MDS, n= 58) and monoclonal gammapathy of unknown significance (n=12).UBA1 mutations included p.M41T (44.8%), p.M41V (30.2%), p.M41L (18.1%), and splice mutations (6.9%). After a median follow-up of 3.0 years, 18 patients died (15.5%), from infectious origin (n=9) and MDS progression (n=3). Unsupervised analysis identified 3 clusters: cluster 1 (47%) with mild-to-moderate disease; cluster 2 (16%) with underlying MDS and higher mortality rates; cluster 3 (37%) with constitutional manifestations, higher C-reactive protein levels and less frequent chondritis. Five-year probability of survival was 84.2% in cluster 1, 50.5 % in cluster 2, and 89.6% in cluster 3. UBA1 p.Met41Leu mutation was associated with a better prognosis.

CONCLUSION

VEXAS syndrome displays a large spectrum of organ manifestations and shows different clinical and prognostic profiles. It also raises a potential impact of the identified UBA1 mutation.

AB0161 CLONAL HEMATOPOIESIS IS INCREASED AND NOT RELATED TO AGING IN SYSTEMIC SCLEROSIS

Background:

Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis, microangiopathy and immune dysfunctions including dysregulation of proinflammatory cytokines. Clonal hematopoiesis of indeterminate potential (CHIP) is defined by the acquisition of somatic mutations in hematopoietic stem cells leading to detectable clones in the blood. Recent data have shown a higher risk of cardiovascular disease in patients with CHIP resulting from increased production of proinflammatory cytokines and accelerated atherosclerosis. Eventual links between CHIP and autoimmune diseases are undetermined.

Objectives:

The aim of our study was to evaluate the prevalence of CHIP in SSc patients and its association with clinical phenotype.

Methods:

Forty-one genes frequently mutated in myeloid malignancies were sequenced in peripheral blood mononuclear cells from 90 SSc patients and from 44 healthy donors.

Results:

A total of 15 somatic variants was detected in 13/90 SSc patients (14%) and 4 somatic variants in 4/44 (9%) HD (p=0.58). The prevalence of CHIP was significantly higher in younger SSc patients than in HD: 25% (6/24) vs 4% (1/26) (p=0.045) under 50 years and 17% (7/42) vs 3% (1/38) (p=0.065) under 60 years. The prevalence of CHIP in patients over 70 years was similar in SSc patients and healthy donors

For SSc patients the most common mutations occurred inDNMT3A(7 variants). Other variants involvedATM,SF3B1, SETBP1, TET2,TP53,NF1orCBL. The distribution of gene mutations was overall comparable in SSc patients and in previously described CHIP series (3)

In most SSc patients, we identified a single CHIP mutation. Several mutations were detected in two SSc patients:SETBP1andNF1in one and,TET2andATMin the other Clonal mutations included missense (n=10), nonsense (n=3), frameshift (n=1) and a single splice site mutation. In all HD we detected a single CHIP mutation which occurred inDNMT3A, TP53 and CSF3R

Variant allele frequencies (VAF) of CHIP mutations ranged from 2 to 18.6% and did not differ between genes (DNMT3Aor others). Mean age was the same in patients withDNMT3Amutations or with other mutations. However, C>T transversions, that have been associated with ageing were more frequent inDNMT3Avariants than in other genes, suggesting distinct mechanisms for mutation acquisition or clonal selection No major differences in clinical and laboratory data were observed between SSc patients with or without CHIP. SSc subtypes, disease duration, different organ involvements and the prevalence of ischemic events were not associated with the presence of CHIP, except less frequent pyrosis in patients with CHIP than those without. SSc patients with CHIP had significantly more anti-RNA polymerase III antibodies than those without CHIP (p=0.045) At the time of analysis, 45 SSc patients had received a treatment for SSc which consisted in low-dose steroids, hydroxychloroquine, mycophenolate mofetil, cyclophosphamide or methotrexate. SSc patients with CHIP were significantly more exposed to cyclophosphamide (3/13 vs. 3/77) (p=0.04) (5, 6.5 and 11 gram respectively between 5 years to 8 years before the NGS sequencing analysis), but among these cyclophosphamide-exposed SSc the age was over 65 in 2/3 of them. When considering all immunosuppressive drugs (cyclophosphamide, methotrexate and mycophenolate mofetil) SSc patients with CHIP were not more exposed than those without CHIP (p=0.75) No patient developed any hematologic malignancy and no cytopenia during the median follow-up of 13 months (0-24 months). One SSc patients with CHIP developed a small lung cancer few months after NGS testing.

Conclusion:

Whether CHIP increases the risk to develop SSc or is a consequence of a SSc-derived modified bone marrow micro-environment remains to be explored.

Acknowledgments:

na

Disclosure of Interests:

None declared

A Longitudinal Study of the Factor VII Rise during Pregnancy

A longitudinal study of 21 pregnant women has been undertaken using a variety of factor VII assays, including factor VIIa, to investigate the increase of factor VIIc. All assays demonstrated significant rises (p <0.001), most marked for factor VIIa (82%) and factor VIIc rabbit (81%). Smaller rises were seen for factor VIIc bovine (50%) and VII antigen (40%). Three indirect measures of activity state, factor VIIc rabbit:antigen, bovine:antigen and bovine:rabbit, provided conflicting data. Factor VIIa:antigen showed a significant increase of 36% (p <0.001). Within individual pregnancies the change in factor VIIc rabbit and antigen correlated with maternal weight gain (p <0.05). Two activity state measures, bovine:rabbit and bovine:antigen, showed negative correlation with birthweight. The increases in both zymogen and in activity state appear to contribute to the factor VIIc rise. The extent of this rise appears to be influenced by maternal weight gain. Increased factor VII activation is associated with reduced foetal growth.

Clinical and economic impact of various strategies for varicella immunity screening and vaccination of health care personnel

BACKGROUND

Exposure to patients with varicella or herpes zoster causes considerable disruption to a health care facility's operations and has a significant health and economic impact. However, practices related to screening for immunity and immunization of health care personnel (HCP) for varicella vary widely.

METHODS

A decision tree model was built to evaluate the cost-effectiveness of 8 different strategies of screening and vaccinating HCP for varicella. The outcomes are presented as probability of acquiring varicella, economic impact of varicella per employee per year, and cost to prevent additional cases of varicella. Monte Carlo simulations and 1-way sensitivity analyses were performed to address the uncertainties inherent to the model. Alternative epidemiologic and technologic scenarios were also analyzed.

RESULTS

Performing a clinical screening followed by serologic testing of HCP with negative history diminished the cost impact of varicella by >99% compared with not having a program. Vaccinating HCP with negative screen cost approximately $50,000 per case of varicella prevented at the current level of U.S. population immunity, but was projected to be cost-saving at 92% or lower immunity prevalence. Improving vaccine acceptance rates and using highly sensitive assays also optimize cost-effectiveness.

CONCLUSION

Strategies relying on screening and vaccinating HCP for varicella on employment were shown to be cost-effective for health care facilities and are consistent with current national guidelines for varicella prevention.

Proximal row carpectomy: Is early postoperative mobilisation the right rehabilitation protocol?

PURPOSE OF THE STUDY

To determine the feasibility and interest of an early rehabilitation protocol with no initial immobilisation after proximal row carpectomy.

MATERIAL AND METHODS

Thirteen patients were included in this retrospective study. Range of motion (ROM) and wrist strength (grip strength and grasp strength) were evaluated 3 and 6 weeks after surgery on the both wrists (operated and non-operated). Postoperatively, patients had no immobilisation of the wrist, and began a rehabilitation program immediately after surgery in the department of Physical Therapy and Rehabilitation under multidisciplinary team supervision. The same surgical technique was used for all patients by the same surgeon.

RESULTS

Six weeks after PRC, there was a 25-51% deficit in passive ROM and 54-64% deficit in active ROM compared to the corresponding non-operated wrist. Six weeks after PRC, mean overall grip strength was nearly 55% and Jamar dynamometer grip strength was 51% of the contralateral side.

DISCUSSION

This study shows that immediate immobilisation following PRC is unnecessary, and that early rehabilitation is of the essence. Early rehabilitation could reduce the delay necessary to recover range of motion and strength, and probably the time to return to work.

LEVEL OF EVIDENCE

Level 4, prospective cohort study.

Neutron activation analysis for the demonstration of amphibolite rock-weathering activity of a yeast

Neutron activation analysis was employed in a survey of weathering abilities of rock surface microorganisms. A yeast isolated from an amphibolite of a megalithic grave was found actively to concentrate, in media and in or on cells, iron and other elements when grown in the presence of ground rock. This was demonstrated by comparing a spectrum of neutron-activated amphibolite powder (particle size, 50 to 100 mum) with the spectra of neutron-activated, lyophilized yeast cells which had grown with or without amphibolite powder added to different media. The most active yeast (IFAM 1171) did not only solubilize Fe from the rock powder, but significant amounts of Co, Eu, Yb, Ca, Ba, Sc, Lu, Cr, Th, and U were also mobilized. The latter two elements occurred as natural radioactive isotopes in this amphibolite. When the yeast cells were grown with neutron-activated amphibolite, the cells contained the same elements. Furthermore, the growth medium contained Fe, Co, and Eu which had been solubilized from the amphibolite. This indicates the presence, in this yeast strain, of active rockweathering abilities as well as of uptake mechanisms for solubilized rock components.

Isolation and properties of ferromanganese-depositing budding bacteria from baltic sea ferromanganese concretions

Hyphal budding bacteria were observed by electron microscopy in thin sections of surface material from Baltic Sea ferromanganese concretions. Similar bacteria were also observed in and isolated from enrichment cultures prepared from the same concretion material. Three morphologically similar strains of Mn-Fe-depositing budding bacteria were isolated from the enrichment cultures. Strain B-4 possessed extracellular anionic polymers that accumulated Mn oxides. Mn deposition by B-4 was inhibited by elevated concentrations of Mn, 0.05% glutaraldehyde, 0.1 mM HgCl(2), and heating at 93 degrees C for 15 min, suggesting the participation of an enzyme protein in the Mn-depositing activity.

Diversity and structure of hyphomicrobium populations in a sewage treatment plant and its adjacent receiving lake

Budding methylotrophic bacteria resembling Hyphomicrobium spp. were counted for 12 months in a German sewage treatment plant by most-probable-number (MPN) methods. Influent samples contained up to 2 x 10(sup4) cells ml(sup-1), activated sludge consistently contained 1 x 10(sup5) to 5 x 10(sup5) cells ml(sup-1), and the effluent contained 1 x 10(sup3) to 4 x 10(sup3) cells ml(sup-1). The receiving lake had only 2 to 12 cells ml(sup-1). Six morphological groups with different growth requirements could be observed among 1,199 pure cultures that had been isolated from MPN dilutions. With dot blot DNA hybridizations, 671 isolates were assigned to 30 hybridization groups (HGs) and 84 could not be classified. Only HG 22 hybridized with a known species, Hyphomicrobium facilis IFAM B-522. Fourteen HGs (HGs 8 to 20 and HG 22) were specific for the lake; most others occurred only in the treatment plant. HGs 1, 3, and 26 were found in the activated sludge tank throughout the year, and HGs 27 and 28 were found for most of the year. In summary, it was demonstrated that bacteria with nearly identical and specific morphologies and nutritional types showed a high level of genetic diversity, although they were isolated under the same conditions and from the same treatment plant or its receiving lake. A directional exchange of these genetically different populations was possible but less significant, as was shown by the establishment of distinct populations in specific stations.

Interaction of integrin receptors with extracellular matrix is involved in trophoblast giant cell migration in bovine placentomes

Integrins are heterodimeric glycoproteins involved in cell-cell and cell-extracellular matrix adhesion and signal transduction. We evaluated the distribution and the putative role of integrin receptors and extracellular matrix (ECM) proteins during trophoblast giant cell (TGC) migration and fusion with uterine epithelial cells in the cow. Placentomes from 24 cows, covering day 80 to day 270 of gestation, were used for indirect immunohistochemistry against integrin subunits alpha(1), alpha(2), alpha(3), alpha(4), alpha(5), alpha(6), alpha(v), beta(1), beta(3), beta(4)and ECM proteins collagen type I and IV, fibronectin, laminin. The basement membranes of fetal and maternal epithelia and endothelia were immunoreactive for laminin, fibronectin and collagen IV. Collagens I and IV were found in maternal stroma, while fibronectin was present in fetal and maternal stroma. The integrin subunits alpha(2), alpha(6)and beta(1)were observed in basal aspects of fetal and maternal epithelial and endothelial cells. Additionally, the alpha(6)and beta(1)integrin subunits were colocalized with laminin on TGC. The integrin alpha(2)subunit was also found on TGC, but localized with a strong gradient to the basal side. Cells of the maternal connective tissue, including endothelium, expressed alpha(1), alpha(2), alpha(3), alpha(5), alpha(6), alpha(v), beta(3)and beta(4). The expression of alpha(2), alpha(5), alpha(v), beta(3)and beta(4) occurred mainly in the septal tips. Cells of the fetal mesenchyme were positive for integrin subunits alpha(1), alpha(2), alpha(3), alpha(4), alpha(5), alpha(6), and beta(1). Our results indicate that alpha(2)beta(1)collagen and alpha(6)beta(1)laminin receptors anchor epi- and endothelial cells to basement membranes. We suggest that TGC migrate along a matrix of laminin and maintain cell-cell contact with mononuclear trophoblast cells via alpha(2)beta(1)heterodimers. Integrins in maternal stroma and fetal mesenchyme may be involved in the regulation of proliferation and differentiation of maternal septa and fetal villi.

Characterization of 15 selected coccal bacteria isolated from Antarctic rock and soil samples from the McMurdo-Dry Valleys (South-Victoria Land)

Approximately 1500 cultures of microorganisms were isolated from rocks and soils of the Ross Desert (McMurdo-Dry Valleys). From these, 15 coccoid strains were chosen for more detailed investigation. They were characterized by morphological, physiological and chemotaxonomical properties. All isolates were Gram-positive, catalase-positive and nonmotile. Six strains showed red pigmentation and could be identified as members of the genera Micrococcus (M. roseus, M. agilis) or Deinococcus. In spite of their coccoid morphology, the remaining nine strains had to be associated with coryneform bacteria (Arthrobacter, Brevibacterium), because of their cell wall composition and G+C ratios. Most of the strains were psychrotrophic, but one strain was even obligately psychrophilic, with a temperature maximum below 20 degrees C. Red cocci had in vitro pH optima above 9.0 although they generally originated from acid samples. Most isolates showed a preference for sugar alcohols and organic acids, compounds which are commonly known to be released by lichens, molds and algae, the other components of the cryptoendolithic ecosystem. These properties indicate that our strains are autochthonous members of the natural Antarctic microbial population.

Transfusion transmissible virus TTV and its putative role in the etiology of liver disease

TTV, the transfusion transmissible hepatitis virus infects mainly patients at risk for parenteral exposure and hence, prone to develop chronic liver disease, as well as healthy populations worldwide. Most TTV infections appear to occur parenterally, with viremia detected frequently in blood donors and blood products. The substantial proportion of asymptomatic individuals never exposed to blood-borne agents, and its high prevalence among healthy subjects implicates the fecal-oral route as another potential for transmission. According to the TTV DNA levels detected in liver tissue, it apparently replicates in hepatocytes, and TTV DNA is present in sera of patients with posttransfusion hepatitis of unknown etiology closely correlated with ALT levels. However, TTV initiating the development of chronic liver disease or causing posttransfusion hepatitis could not be confirmed, as most patients positive for TTV DNA remain asymptomatic and those progressing towards chronic liver disease are invariably coinfected with either the hepatitis B or C virus. Also, TTV coinfection does not aggravate the symptoms associated with hepatitis B or C. Similarly, it does not cause posthepatitis aplastic anemia, and high-risk patients can immunologically clear the viral DNA. In conclusion, being widely distributed and apparently nonpathogenic, TTV might represent an opportunistic but innocent virus reminiscent of hepatitis G virus, with a negligible role in the etiology of chronic liver disease.

Core promoter and precore mutants of hepatitis B virus: prevalence and clinical relevance in chronic hepatitis patients

The present study was conducted to determine prevalence and exact type, as well as nucleotide position of the precore/core mutations of hepatitis B virus found in Thai patients diagnosed with chronic hepatitis and/or cirrhosis in relation to the clinical parameters established with the respective patients. To that end, 24 HBeAg-positive and 56 HBeAg-negative individuals were selected at random from a cohort of altogether 256 chronic liver disease patients. DNA was extracted from their blood sera, amplified by polymerase chain reaction using semi-nested primers and subjected to direct sequencing. Clinically, the HBeAg-positive chronic hepatitis patients displayed significantly higher transaminase levels than those negative for HBeAg. Our results showed 2 of the 7 (28.6%) PCR-positive HBeAg-positive sera displaying double mutations in the core promoter region at position 1762/64. The nucleotide sequences obtained from the 24 PCR-positive HBeAg-negative sera revealed 18 (75%) mutations in the core promoter region (1762/64), and/or 7 (29.2%) mutations at position 1753, and/or 6 (25%) mutations of the start codon (1814), and/or 8 of (33.3%) nucleotide 1896 turning codon 28 into a stop codon and one sample (4.2%) displaying a deletion between nucleotides 1758-1772. It is suggested that the mutations observed have an impact on the DNA secondary structure in such a way that successful transcription of the HBeAg gene is rendered impossible. To what extent this mutation influences the severity of chronic liver disease remains to be elucidated.

Increasing susceptibility to HAV among members of the young generation in Thailand

The prevalence of antibodies to hepatitis A virus was studied in 961 children and adolescents, randomly selected from five different provinces in Thailand (Chonburi, Lopburi, Udonthani, Nakhon Si Thammarat and Lopburi). The highest prevalence was found in Nakhon Si Thammarat, with 32.1 percent of those aged 10-14 years and 57.1 percent of those aged 15-18 years showing evidence of protective immunity. However, this high rate could be explained by an outbreak of hepatitis A in 1992. In the remaining four provinces, the pattern was typically age-related in that all individuals showed between zero and 13 percent antibody prevalence until reaching the 15-to-18-year age group where it increased to between 5.6 and 22.7 percent. The overall sero-prevalence among all age groups was 7.9 percent. Thus, the majority of the younger generation is susceptible to hepatitis A virus infection thereby enhancing the impact, should an outbreak occur. Preventive measures that might be taken are education aimed at better hygiene and sanitation, as well as vaccination of susceptible individuals within high-risk populations.

Clinical associations and prognostic significance of serum anti-p53 antibodies in Thai patients with hepatocellular carcinoma

Mutations of the p53 gene have been reported to be of prognostic significance in hepatocellular carcinoma (HCC). However, the clinical associations and prognostic value of anti-p53 antibodies, known to be products of the host immune response to these mutations, have been controversial. Serum anti-p53 antibodies were measured in 121 Thai patients diagnosed with HCC using a specific enzyme-linked immunosorbent assay (ELISA) kit. The clinical/pathological characteristics of the patients were compared with respect to the presence of serum anti-p53 antibodies. Cox regression analysis was performed to assess factor interaction and association with survival. Anti-p53 antibodies were detected in 13.2% (16 of 121) of our patients. There were no differences between groups with regard to age, sex, viral markers (HBsAg or anti-HCV), severity of liver disease and tumor advancement. The median survival rates for patients positive and negative for anti-p53 antibodies were 4.0 and 3.0 months, respectively (p = 0.443, by log-rank test). Multivariate analysis demonstrated that an advanced Okuda stage, lack of therapy and presence of portal vein thrombosis were independent factors related to the prognosis of the patients. Nonetheless, the presence of anti-p53 antibodies did not constitute a predictive variable associated with a poorer prognosis. Serum assay of anti-p53 antibodies, although rapid and easily performed, may not be suitable as an alternative to molecular detection of mutations in assessing tumor advancement and prognosis of patients with HCC.

Impact of hepatitis B immunisation as part of the EPI

Since 1992, hepatitis B vaccine has been an integrated part of Thailand's expanded programme on immunisation (EPI). Based on the data from five representative provinces, we have evaluated its impact on the countrywide prevalence of HBV infection and carrier rate. The population studied comprised 400-488 healthy and immuno-competent, subjects per area. The subjects' ages ranged from 6 months to 18 years. We examined their sera for viral hepatitis markers using commercially available test kits and established the coverage rate of hepatitis B vaccination after its inclusion into the EPI to be 71.2-94.3%. The number of individuals undergoing the complete course of vaccinations had increased four-fold. Consequently, only 0.7% of the children born after the implementation of this the novel EPI strategy were HBV carriers.

Parvovirus B19 antibodies in immunocompromized children in Thailand

Parvovirus B19, a non-enveloped single stranded DNA virus is distributed worldwide. Sero-prevalence in adult populations amounts to approximately 50%. Clinical manifestations vary depending on the Immune status of the infected individuals and may include mild childhood Infection as well as hydrops fetalis due to intrauterine infection. To determine the prevalence of this infection among the immunocompromized individuals in Thailand, we determined, by indirect ELISA, levels of IgM and IgG antibodies to the parvovirus B19 in 106 immunocompromized children. These included 49 children who were on chemotherapy for treatment of malignancies, 18 who were receiving immunosuppressive drugs after organ transplantations, 14 who were under a regimen of corticosteroids and 25 who were positive for antibodies to HIV. The average prevalence of IgG antibodies in 106 children was 16.0%; the prevalence of antibodies was 33.3% in post-transplanted group, 16% in children positive for HIV, 12.2% in the group receiving chemotherapy for malignancies and 7.6% in the group treated with corticosteroids. All children were negative for IgM antibodies to parvovirus B19.

Persistence of antibodies to the surface antigen of the hepatitis B virus (anti-HBs) in children subjected to the Expanded Programme on Immunization (EPI), including hepatitis-B vaccine, in Thailand

Will hepatitis-B vaccine administered at birth, and at 2 and 6 months of age, as an integral part of Thailand's Expanded Programme on Immunization, provide long-term protection? In an attempt to answer this question, residents of five provinces (representing five distinct geographical areas of Thailand) who were aged 1-10 years and had received this course of vaccination were enrolled on a serological study. Each was tested, with ELISA, for the surface antigen of hepatitis B (HBsAg) and for antibodies against this antigen (anti-HBs) or against the core antigen (anti-HBc). Over all age-groups, the prevalences of HBsAg, anti-HBs and anti-HBc were 0.67%, 71.4% and 5.5%, respectively. Although the prevalence of anti-HBs decreased with age, it remained at 56%-65% among those aged 6-10 years. Between 2% and 17% of the subjects aged 1-9 years had high titres of anti-HBs. Based on these results, an additional booster, still a controversial issue, does not appear to be required in order to prevent infection with hepatitis B virus and thus permit the eventual eradication of chronic carriage and its fatal sequelae in Thailand.

Prevalence of antibodies to parvovirus B 19 in Thailand

Infection with human parvovirus B 19, a single-stranded non-enveloped DNA virus of worldwide distribution, is rather common and displays a broad spectrum of clinical manifestations of varying severity, depending on the patient's immune response. As the target of infection are the erythroid precursor cells, patients can experience an aplastic crisis. Usually, at least in immunocompetent individuals, viremia ceases with the appearance of virus-specific antibodies in the patient's serum whereupon the patients retain lifelong immunity to reinfection. Since data as to the prevalence of this agent has not been established for Thailand, the purpose of the present study was to investigate its frequency among 3 distinct groups, comprising 30 healthy children. 64 children with acute unrelated illness, and 35 voluntary blood donors, respectively, by means of enzyme linked immunosorbent assay. Our results have shown that, as reported for other countries, anti-parvovirus IgG increases in an age-dependent manner and is established at an overall prevalence of 20.16%, inviting the conclusion that the local population is infected by this agent as frequently as those of other countries in the Far East. Further studies need to be undertaken in order to elucidate its prevalence among members of high-risk groups.

New LL-diaminopimelic acid-containing actinomycetes from hypersaline, heliothermal and meromictic Antarctic Ekho Lake: Nocardioides aquaticus sp. nov. and Friedmanniella [correction of Friedmannielly] lacustris sp. nov

Two Gram-positive, non-motile and aerobic bacteria were isolated from a water sample of the hypersaline Ekho Lake, Antarctica. The cocci or short rods grew well on oligotrophic PYGV agar of pH 7.5 and at 26 degrees C. Strains EL-17KT and EL-17AT both required thiamine and biotin, strain EL-17AT also required nicotinic acid. Carbon sources utilized by both strains were acetate, pyruvate, alpha-D-glucose, glutamate and (weakly) citrate, but succinate, malate or butyrate were utilized only by EL-17KT. Gelatin, starch and DNA were hydrolyzed, NH, was formed from peptone, and nitrate was reduced aerobically by both strains. The isolates had the same temperature tolerance for growth in the range tested (below 3 to above 33.5 degrees C) and pH range (<5.5 to >9.5) and were sensitive to chloramphenicol and penicillin G. Their cell walls contained LL-diaminopimelic acid and had a single glycine residue as interpeptide bridge. Strain EL-17AT contained glycine at position 1 of the peptide subunit (peptidoglycan type A 3gamma'). Isolates EL-17KT and EL-17AT differed in their maximum NaCl tolerance, which was 15% or 6-8%, respectively. The major fatty acid of EL-17KT was C18:1 and that of EL-17AT was ai-C15:0. The major respiratory quinones of EL-17KT and EL-17AT were MK-8(H4) and MK-9(H4), respectively. The former isolate had 69 mol% G+C, the latter had 73 mol% G+C. Comparative 16S rRNA gene sequencing revealed phylogenetic relationships of isolate EL-17KT with the genus Nocardioides, with N. pyridinolyticus and N. plantarum as the closest relatives. Phenotypic and genotypic characteristics support the description of a new species, Nocardioides aquaticus sp. nov., with EL-17KT as the type strain (= DSM 11439T). Isolate EL-17AT is related to the genus Friedmanniella, with E antarctica and E spumicola as the closest relatives. The differentiating characteristics support the description of a new species, Friedmanniella lacustris sp. nov., with EL-17AT as the type strain (= DSM 11465T).

Differentiation of newly described antarctic bacterial isolates related to Roseobacter species based on 16S-23S rDNA internal transcribed spacer sequences

The 16S-23S rDNA internal transcribed spacer (ITS) of Roseobacter denitrificans, Roseobacter litoralis, Ruegeria algicola and strains of the recently described species Antarctobacter heliothermus and Roseovarius tolerans were analysed in order to examine DNA sequence variations and to draw conclusions about inter- and intraspecific relationships. A. heliothermus included four strains with an ITS fragment length of 1092 bp. Roseovarius tolerans was described on the basis of eight strains. Five of these harboured two ITS fragments of different lengths (959 and about 1100 bp), while the others had one fragment of either 1083 bp (two strains) or 1165 bp (one strain). ITS lengths of the related species Roseobacter denitrificans, Roseobacter litoralis and Ruegeria algicola were found to be 980, 984 and 1158 bp, respectively. Phylogenetic analyses of the DNA sequences allowed species affiliation of strains with sequence length differences of > 200 bp and recognition of relationships based on a well-supported ITS tree. The strains of A. heliothermus and Roseovarius tolerans each formed a monophyletic branch and they were separated from each other by Ruegeria algicola. This species was now clearly separated from Roseobacter denitrificans and Roseobacter litoralis, which corresponded to the new genus affiliation of Ruegeria algicola. These data were additionally supported by analyses of the structure, relative position and order of genes for tRNA(Ile) and tRNA(Ala) found within the ITS of each strain. Comparative DNA sequence analyses of ITS and 16S rDNA revealed limitations, on species and strain levels, with respect to the phylogenetic resolution of the 16S rDNA due to the limited number of informative (variable) sites, while ITS sequence analyses provided more variable and sufficiently conserved positions to discriminate between strains and to reconstruct their taxonomic relationships.

Modestobacter multiseptatus gen. nov., sp. nov., a budding actinomycete from soils of the Asgard Range (Transantarctic Mountains)

Oligotrophic PYGV medium, inoculated with soils from Linnaeus Terrace (1600 m, Antarctica), yielded four aerobic actinomycetes with short rods, multiple and irregular septa and often motile buds. Cells were 1.0-2.8 x 1.0-3.0 microm and colonies were beige to pink. The isolates were nearly identical in physiological and biochemical tests. Three strains grew from 0 degrees C to 25-28 degrees C, but one was psychrophilic with a maximum growth temperature of 20 degrees C. Carbon sources utilized were D-glucose, D-galactose, lactose, sucrose or mannitol; malate, succinate, fumarate, pyruvate or glutarate were decarboxylated aerobically. Peptone and yeast extract were the preferred nitrogen sources. Nitrate was reduced aerobically or anaerobically. Cell walls contained meso-diaminopimelic acid, glutamate, alanine, glycine, galactose, glucose and ribose. Major fatty acids of strains AA-802, -824, -825 and -826T were n18:1, i16:0 and ai17:0. Major respiratory quinones were MK-9(H4) and MK-8(H4). Polar lipids were diphosphatidylglycerol, phosphatidylethanolamine and phosphatidylinositol. Phosphatidylglycerol was found in most strains. The DNA G+C contents were 68-70 mol%. In 16S rDNA analyses, similarity values obtained for 500 nucleotides from the 5' terminus were > 99.5%. Almost complete sequences from AA-826T and -825 were 99.9% similar. Strain AA-826T belonged to a novel cluster of desert soil and rock isolates within the Geodermatophilaceae and was equidistantly related to members of Geodermatophilus and to a Blastococcus lineage. The four isolates represent a new genus, Modestobacter gen. nov., with Modestobacter multiseptatus sp. nov. as the type species. The type strain, Modestobacter multiseptatus AA-826T, was deposited in the DSMZ as DSM 44406T.

Full scale co-digestion of organic waste

Operational results of a co-digestion facility were assessed over a period of 18 months. The organic fraction of municipal solid waste (OFMSW) contains a considerable amount of contaminants and grit (up to 6% w/w). A BTA-Pulper efficiently treated the different waste streams and converted a high amount of volatile solids (VS) into the digester feedstock. The seasonal fluctuations of the waste composition significantly influenced the biogas production. The impact of this seasonally variant degradability of VS had to be considered by evaluating the operation results. The waste streams investigated did not show any negative impact on digester performance. The hydraulic retention time (HRT) in the digester considerably affected the VS-reduction. Despite a considerable decrease of VS-degradation a reduction of HRT from 14 to 8 days slightly improves the gas production rate (GPR). An activated sludge system efficiently reduced the pollution of the effluent. The nutrient content of the anaerobic compost was favourable and the content of pollutants was low. The facility produced surplus electrical power up to 290 MJ/t. An overall energy balance shows that the facility substitutes primary energy.

Staleya guttiformis gen. nov., sp. nov. and Sulfitobacter brevis sp. nov., alpha-3-Proteobacteria from hypersaline, heliothermal and meromictic antarctic Ekho Lake

Two Gram-negative, aerobic, pointed and budding bacteria were isolated from various depths of hypersaline, heliothermal and meromictic Ekho Lake (Vestfold Hills, East Antarctica). 16S rRNA gene sequence comparisons show the isolates to be phylogenetically close to the genera Sulfitobacter and Roseobacter. Cells can be motile and contain storage granules. Sulfite addition does not stimulate growth. Isolate EL-38T can produce bacteriochlorophyll a and has a weak requirement for sodium ions; polar lipids include phosphatidylglycerol, phosphatidylcholine, phosphatidylethanolamine and an unidentified amino lipid, but not diphosphatidylgycerol. The dominant fatty acid is 18:1omega7c; other characteristic fatty acids are 3-OH 10:0, 3-OH 14:1, 16:0, 18:0, 18:2 and 19:1. The DNA base composition is 55.0-56.3 mol% G+C. Isolate EL-162T has an absolute requirement for sodium ions. Diphosphatidylglycerol, phosphatidylglycerol, phosphatidylcholine, phosphatidylethanolamine and an unidentified amino lipid are present in the polar lipids. Dominant fatty acids of this isolate are 18:1omega7c and 18:1omega9c as well as 18:2 which is present as two isomers. Other characteristic fatty acids are 3-OH 10:0, 3-OH 14:1, 16:0 and 18:0. The G+C content is 57.9-58.1 mol%. Morphological, physiological and genotypic differences from related, thus far known genera support the description of Staleya guttiformis gen. nov. and sp. nov. with EL-38T (= DSM 11458T) as the type strain and of Sulfitobacter brevis sp. nov. with the type strain EL-162T (= DSM 11443T).

Prevalence of core promotor and precore mutants of hepatitis B virus in thailand by RFLP and sequencing

Hepatitis B virus has been known to frequently undergo mutations of its genome at various sites, mostly due to it employing a reverse transcriptase devoid of proofreading capacity in the course of its replication. The purpose of the present study has been to screen 257 HBsAg-positive chronic liver disease patients, more specifically 78 cases chosen at random out of those negative for HBeAg and 33 of the HBeAg-positive cases serving as controls for three discreet point mutations in the precore/core region of hepatitis B virus. To that end, HBV DNA extracted from sera was amplified by polymerase chain reaction (PCR) using semi-nested primers and subsequently subjected to restriction fragment length polymorphism (RFLP) analysis, 36 HBeAg-negative versus 30 HBeAg-positive sera, respectively, as well as to direct sequencing in some samples randomly selected to corroborate the RFLP results. Our results showed double mutations at positions 1762 and 1764 of the core promoter in between 25/36 (69.4%) and 19/25 (76%) of the sera tested, a missense mutation of the start codon in between 8/36 (22.2%), and 5/25 (20%) and a mutation turning codon 1896 into a stop codon in between 9/36 (25%) and 6/25 (24%) determined by RFLP and sequencing, respectively. These data indicate the double mutation at positions 1762 and 1764 to be the most prevalent among HBeAg-negative chronic hepatitis patients in Thailand whereas, in contrast to reports from other Asian countries, the mutation at nucleotide 1896 occurred in a mere 25%, while on the other hand the mutation abolishing the start of protein synthesis was observed to occur at a higher frequency than determined in several other geographical areas.

Cytomegalovirus infection in immunocompromised children in Thailand

Cytomegalovirus (CMV) constitutes the most widespread cause of congenital and perinatal viral infections on a global scale, exceeding a 90%-prevalence among blood donors in Thailand. The present study was aimed at determining the prevalence of CMV in the sera of 113 immunocompromised children by means of serology, as well as polymerase chain reaction using nested primers. Our results showed anti-CMV IgG, i.e. latent infection, prevalent in an age-dependent manner irrespective of the disorder underlying the children's immunocompromised condition, whereas anti-CMV IgM was equally prevalent throughout all age groups and disease patterns and, therefore, unreliable as a marker. Detection of serum CMV DNA by PCR represented the most exact diagnostic parameter by far, indicating active infection long before clinical symptoms may appear. In conclusion, based on the high prevalence of latent CMV infection among the general population in Thailand, we recommend especially the sera of immunocompromised patients be examined for the presence of viral DNA by means of PCR in order to provide clinical guidelines for their proper management.

Coinfections with hepatitis g and/or c virus in hepatitis B-related chronic liver disease

Concurrent infections with HGV and/or HCV (HGV/HCV) were investigated in 196 patients with HBV-related chronic liver disease (115 chronic hepatitis, 31 liver cirrhosis, 50 hepatocellular carcinoma), and in 100 HBsAg carriers. Coinfections were detected in 18 (9.2%) patients with HGV (10) or HCV (5) or both agents (3), but in none of the HBsAg carriers. Patients with coinfection were more frequently exposed to blood transfusions (55.6% vs 5.6%) and also were more commonly anti-HBe positive. Serum levels of HBV-DNA were lower in patients with HCV coinfection than in those coinfected with HGV. Interferon was administered to 39 patients with chronic active hepatitis including 7 patients with HGV/HCV coinfection. Sustained clearance of HBV-DNA was observed in 10 (25.6%) patients who were solely infected with HBV. These patients were significantly younger and had much lower histological scores than non-responders. Patients with HCV coinfection had significantly higher pre-treatment histological scores than those without HCV. After interferon treatment, a significant reduction in histological scores was observed in all patients except those coinfected with HGV/HCV. None of the 7 patients with coinfection had sustained clearance of HBV-DNA or HCV-RNA, and only one had cleared HGV-RNA. These results suggest that parenteral exposure is a risk factor for HGV/HCV coinfection in chronic HBV infection. HGV infection shows no significant impact on chronic HBV infection. HCV coinfection appears to inhibit HBV replication, but causes more severe chronic hepatitis and increases resistance to interferon therapy.

The predominant genotypes of hepatitis B virus in Thailand

In Thailand, chronic liver disease (CLD) as a consequence of infection with hepatitis B virus (HBV) constitutes a public-health burden. Control and treatment are complicated by the virus exhibiting an unusually high mutation rate, with some genotypes apparently causing more severe disease than others. Restriction-fragment-length-polymorphism (RFLP) analysis of the pre-S region of the viral genome, amplified by PCR, was used to determine which genotypes were most prevalent among Thai patients chronically infected with the virus. The patients were chronic HBV carriers (40) or cases of chronic hepatitis (34), cirrhosis (14) or hepatocellular carcinoma (30). As indicated by the results of earlier studies on CLD patients in South-east Asia, genotype C (68.6%) was clearly predominant. RFLP patterns permitted the C1 (12.7%), C7 (45.7%), C8 (10.2%) and B1 (29.7%) subtypes to be identified. Two samples that could not be typed by RFLP were analysed by direct sequencing, categorized as type C, and tentatively designated as subtype C9. As comparison of the present data with those previously obtained by direct sequencing of PCR products indicates that RFLP analysis is as specific and reliable as sequencing and less expensive and time-consuming, RFLP analysis may be particularly useful for epidemiological studies.

Acute, hepatitis-A super-infection in HBV carriers, or chronic liver disease related to HBV or HCV

The impact of acute super-infection with hepatitis A virus (HAV) was determined in 20 asymptomatic carriers of the surface antigen (HBsAg) of hepatitis B virus (HBV), eight patients with HBV-related chronic liver disease (CLD), and four patients with CLD related to hepatitis C virus (HCV). For comparison, 100 patients with isolated HAV infection were also studied. The HBsAg carriers and patients with CLD related to HBV or HCV were significantly older than the patients with isolated HAV infection, with mean (S.D.) ages of 43.9 (14.1), 46.4 (16.0), 52.5 (8.6) and 28.4 (10.7) years, respectively (P < or = 0.02). There were no significant between-group differences in the baseline serum concentrations of alanine aminotransferase. All the patients with isolated HAV infection fully recovered. Fulminant or submassive hepatitis occurred in 11 (55%) of the HBsAg carriers and four (33%) of the 12 patients with CLD related to either HBV or HCV. Nine of the 15 patients with severe hepatitis died and the mortality rate among the HBsAg carriers was not significantly different from that among the CLD patients (25% v. 33%; P = 0.15). These fatal cases were all aged > 50 years and were significantly older [59.0 (2.1) years] than the six severe cases who recovered [43.2 (10.7) years] as well as the remaining 17 uncomplicated cases with CLD or HBsAg [40.3 (13.0) years] (P < or = 0.001). The results indicate that acute HAV is rarely fatal in young adults but may be severe and potentially fatal in patients with underlying chronic HBV or HCV infection, especially among the elderly. Vaccination against HAV should be considered for the patients at high risk who are negative for anti-HAV.

Hepatitis viruses and chronic liver disease

We have investigated several groups of Thai patients diagnosed with chronic liver disease including chronic hepatitis, cirrhosis and hepatocellular carcinoma, as well as cholangiocarcinoma, for the prevalence of infection with either one of the hepatitis viruses B, C, G and the novel hepatitis virus TT (TTV). The 168 patients tested comprised 120 men and 48 women with their median age ranging from 42.3 to 62.3 years. Screening for antibodies to HBV and HCV was performed by a commercially available serological test kit, for the presence of HBV and TTV DNA by PCR, and of HCV and HGV RNA by RT-PCR, respectively. There was a clear two-fold higher prevalence of HBV (49%) over HCV (27%) infection and a four-fold higher frequency compared to HGV (13%) and TTV (11%) infection, respectively, in those individuals with chronic hepatitis, cirrhosis, and hepatocellular carcinoma, whereas all but one patient with cholangiocarcinoma the etiology of which has been ascribed to parasitic infestation, were free of all viral markers. In Thailand chronic HBV, and to a lesser extent, chronic HCV infection represent the two most common causes of hepatitis potentially proceeding to chronic liver disease, whereas the clinical significance pertinent to HGV and TTV remains to be elucidated.

TT virus infection in intravenous drug users

Our group has investigated 201 intravenous drug users for the presence of TTV DNA by means of polymerase chain reaction (PCR). The majority of the individuals tested were male, their age ranging from 16 to 63 years, and the duration of intravenous drug use from one to 40 years. TTV DNA was present in 62 of the 201 IVDUs (30.8%) with its prevalence on the ascent between the age groups below 20 and those between 21 and 30 years, as well as between the groups below 60 and between 60 to 120 months' duration of drug intake, respectively. When tested again after 9 months, nine IVDU (23.7%) were found TTV negative by PCR hinting at potential immunological clearance. Our control group comprised 200 healthy blood donors, 7% of whom were found to harbor TTV DNA in an age-dependent fashion, as observed with the IVDU. From the liver function tests performed we could not detect any statistically significant difference regarding ALT elevation observed in TTV-positive compared with TTV-negative individuals. To date, TTV does not appear to cause any serious liver disease in the majority of cases examined.

Clearance of hepatitis TT virus infection among thalassemia children and IVDU

The novel transfusion transmissible hepatitis virus TTV first isolated by a group from Japan has predominantly been detected in members of groups at high risk for contracting blood borne viruses. Aside from elevated liver enzymes, the symptoms associated with its infection have been reported to range from asymptomatic to hepatic failure. The purpose of the present study was to determine if and to what extent the host's immune response is capable of clearing TTV infection. Hence, we extracted DNA from sera obtained from altogether 201 intravenous drug users (IVDU) and 80 thalassemia children--both groups at high risk of parenteral exposure--and performed PCR using semi-nested primers. Those positive for TTV DNA were once again subjected to PCR after approximately one year in order to determine how many still harbored the virus. Our results showed TTV DNA to be absent in merely 20.6% of the formerly positive IVDU, whereas it was still present in all the thalassemia children who could be tested for the second time. Based on the small sample size and the high-risk environment, these results ought to be interpreted with caution and definitely merit further investigation.