Efficacy and safety of nivolumab for patients with pre-treated type B3 thymoma and thymic carcinoma: results from the EORTC-ETOP NIVOTHYM phase II trial

BACKGROUND

Thymic malignancies are rare intrathoracic tumors, which may be aggressive and difficult to treat. They represent a therapeutic challenge in the advanced/metastatic setting, with limited treatment options after the failure of first-line platinum-based chemotherapy. They are frequently associated with autoimmune disorders that also impact oncological management.

MATERIALS AND METHODS

NIVOTHYM is an international, multicenter, phase II, two-cohort, single-arm trial evaluating the activity and safety of nivolumab [240 mg intravenously (i.v.) q2 weeks] alone or with ipilimumab (1 mg /kg i.v. q6 weeks) in patients with advanced/relapsed type B3 thymoma or thymic carcinoma, after exposure to platinum-based chemotherapy. The primary endpoint is progression-free survival rate at 6 months (PFSR-6) based on RECIST 1.1 as per independent radiological review.

RESULTS

From April 2018 to February 2020, 55 patients were enrolled in 15 centers from 5 countries. Ten patients (18%) had type B3 thymoma and 43 (78%) had thymic carcinoma. The majority were male (64%), and the median age was 58 years. Among the 49 eligible patients who started treatment, PFSR-6 by central review was 35% [95% confidence interval (CI) 22% to 50%]. The overall response rate and disease control rate were 12% (95% CI 5% to 25%) and 63% (95% CI 48% to 77%), respectively. Using the Kaplan-Meier method, median progression-free survival and overall survival by local assessment were 6.0 (95% CI 3.1-10.4) months and 21.3 (95% CI 11.6-not estimable) months, respectively. In the safety population of 54 patients, adverse events (AEs) of grade 1/2 were observed in 22 (41%) patients and grade 3/4 in 31 (57%) patients. Treatment-related AEs of grade 4 included one case of neutropenia, one case of immune-mediated transaminitis, and two cases of myocarditis.

CONCLUSIONS

Nivolumab monotherapy demonstrated an acceptable safety profile and objective activity, although it has been insufficient to meet its primary objective. The second cohort of NIVOTHYM is currently ongoing to assess the combination of nivolumab plus ipilimumab.

Primary immune thrombocytopenia in adults: Belgian recommendations for diagnosis and treatment anno 2021 made by the Belgian Hematology Society

The Belgian Hematology Society (BHS) updated the 2013 guidelines for diagnosis and treatment of primary immune thrombocytopenia (ITP) [1]. As knowledge about ITP pathophysiology is increasing, the mode of action of old therapies is better understood and novel drugs are introduced to target more specific pathways.Corticosteroids with or without intravenous immunoglobulins (IgIV) remain the first-line treatment. According to the updated international guidelines a short course of corticosteroids rather than a prolonged treatment has to be recommended. The same guidelines stress that consequent therapies as thrombopoietic agents (TPO-RAs) and rituximab should be available independent of duration of ITP.Although the majority of recommendations is based on very low-quality evidence, it is strongly advised to individualize the ITP management taking patient values. and preferences in account. The main treatment goal in all ITP patients must be to maintain a safe platelet count to prevent or stop bleeding with a minimum of toxicity and not to normalize the platelet count.

Updated results from the phase 3 HELIOS study of ibrutinib, bendamustine, and rituximab in relapsed chronic lymphocytic leukemia/small lymphocytic lymphoma

We report follow-up results from the randomized, placebo-controlled, phase 3 HELIOS trial of ibrutinib+bendamustine and rituximab (BR) for previously treated chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) without deletion 17p. Overall, 578 patients were randomized 1:1 to either ibrutinib (420 mg daily) or placebo, in combination with 6 cycles of BR, followed by ibrutinib or placebo alone. Median follow-up was 34.8 months (range: 0.1-45.8). Investigator-assessed median progression-free survival (PFS) was not reached for ibrutinib+BR, versus 14.3 months for placebo+BR (hazard ratio [HR] [95% CI], 0.206 [0.159-0.265]; P < 0.0001); 36-month PFS rates were 68.0% versus 13.9%, respectively. The results are consistent with the primary analysis findings (HR = 0.203, as assessed by independent review committee, with 17-month median follow-up). Median overall survival was not reached in either arm; HR (95% CI) for ibrutinib+BR versus placebo: 0.652 (0.454-0.935; P = 0.019). Minimal residual disease (MRD)-negative response rates were 26.3% for ibrutinib+BR and 6.2% for placebo+BR (P < 0.0001). Incidence of treatment-emergent adverse events (including grades 3-4) were generally consistent with the initial HELIOS report. These long-term data support improved survival outcomes and deepening responses with ibrutinib+BR compared with BR in relapsed CLL/SLL.

Recruiting general practitioners for palliative care research in primary care: real-life barriers explained

Background

The implementation of early palliative care within a primary care setting is a recent academic topic. Recruiting General Practitioners (GPs) to participate in a palliative care study can be challenging. The pro-Spinoza project implemented a Care Pathway for Primary Palliative Care in 5 areas in Belgium. During this project, the feasibility of the recruitment of GPs and palliative care patients was evaluated.

Methods

The recruitment process was recorded in detail via an electronic logbook combining quantitative and qualitative data. Quantitative recordings included the contact types and the number of contacts with eligible GPs and were analysed descriptively. Qualitative recordings included field notes with feedback from the GPs and other stakeholders and were thematically analysed starting from the Grol and Wensing framework for professional behaviour change.

Results

Of 4065 eligible GPs working in 5 areas under research, 787 GPs (19%) were contacted individually, 398 GPs (9,8%) were contacted face-to-face and most of these 398 GPs showed high interest in the topic. 112 GPs (2,8%) signed the collaboration agreement, but finally only 65 GPs (1,6%) delivered at least a completed baseline-questionnaire. Despite the initial interest in participating, the unpredictable and busy daily workloads of the GPs, as well as inexperience with research protocols, impeded the ability of the GPs to fully engage in the study. This resulted in the high dropout rate. Participating GPs reported that they had underestimated the effort required to effectively participate in the project.

Conclusions

Recruitment of GPs to palliative care research is challenging. Primary care is a vital service to engage in palliative care research however the practical limitations reduce the ability of the service to effectively engage in the research. More research is needed to determine how GPs might be better supported in research.

Trial registration

ClinicalTrials.gov, NCT02266069, Registered 16th October 2014, retrospectively registered.

An international study to revise the EORTC questionnaire for assessing quality of life in lung cancer patients

BACKGROUND

The European Organization for Research and Treatment of Cancer (EORTC) QLQ-LC13 was the first module to be used in conjunction with the core questionnaire, the QLQ-C30. Since the publication of the LC13 in 1994, major advances have occurred in the treatment of lung cancer. Given this, an update of the EORTC QLQ-LC13 was undertaken.

METHODS

The study followed phases I to III of the EORTC Module Development Guidelines. Phase I generated relevant quality-of-life issues using a mix of sources including the involvement of 108 lung cancer patients. Phase II transformed issues into questionnaire items. In an international multicenter study (phase III), patients completed both the EORTC QLQ-C30 and the 48-item provisional lung cancer module generated in phases I and II. Patients rated each of the items regarding relevance, comprehensibility, and acceptance. Patient ratings were assessed against a set of prespecified statistical criteria. Descriptive statistics and basic psychometric analyses were carried out.

RESULTS

The phase III study enrolled 200 patients with histologically confirmed lung cancer from 12 centers in nine countries (Cyprus, Germany, Italy, Israel, Spain, Norway, Poland, Taiwan, and the UK). Mean age was 64 years (39 - 91), 59% of the patients were male, 82% had non-small-cell lung cancer, and 56% were treated with palliative intent. Twenty-nine of the 48 questions met the criteria for inclusion.

CONCLUSIONS

The resulting module with 29 questions, thus currently named EORTC QLQ-LC29, retained 12 of the 13 original items, supplemented with 17 items that primarily assess treatment side-effects of traditional and newer therapies.

Water Vapour Transfer Properties of Spunbonded Plastic Films

The water vapour permeances of two types of spunbonded plastic roofunderlay films are measured using different methods. Experiments with isother mal permeance cup procedures are discussed. Because of the high permeance of the tested films, the analysis of these measurements is not as simple as described in most standards. To obtain reliable results of the cup tests, the influence of the water vapour diffusion resistance of the air films is separately investigated. A non-isothermal per meance test was developed to measure the effect of surface condensation on the va pour permeance of the films. The paper describes the apparatus and discusses the re liability of the method. The properties measured by the non-isothermal test method are compared to those obtained with the isothermal method.

Interstitial Condensation Due to Air Leakage: A Sensitivity Analysis

This paper presents an approach to evaluate the sensitivity of a roof design to condensation problems, given the uncertainty to achieve continuity of airtightness in practice. The approach consists of a repeated number of simulations with a 2D heat, air and vapour transfer model to predict the variation in roof moisture performance due to various discontinuities in roof geometry. The set of discontinuities is calibrated by comparing measuring data of roof airtightness to simulation results. On the basis of the methodology, the paper explores the effectiveness of different measures to reduce the sensitivity of cavity insulated roofs to condensation problems. The results show that even when a roof design complies with condensation control standards, a lightweight system remains sensitive to condensation problems as a result of air leakage through the discontinuities, joints and perforations, common to most existing construction methods. The sensitivity of a roof to interstitial condensation due to air leakage essentially depends on the heat and vapour transfer properties and design of the layers outside of the thermal insulation (roofing and underlay)

ICRP Publication 126: Radiological Protection against Radon Exposure

In this report, the Commission provides updated guidance on radiological protection against radon exposure. The report has been developed considering the latest ICRP recommendations for the system of radiological protection, all available scientific knowledge about the risks of radon, and the experience gained by many organisations and countries in the control of radon exposure. The report describes the characteristics of radon exposure, covering sources and transfer mechanisms, the health risks associated with radon, and the challenges of managing radon exposure. The Commission recommends an integrated approach for controlling radon exposure, relying as far as possible on the management of buildings or locations in which radon exposure occurs, whatever the use of the building. This approach is based on the optimisation principle, and is graded reflecting the responsibilities of key stakeholders, notably in workplaces, and the intent of the national authorities to control radon exposure. The report also provides recommendations on managing radon exposure when workers’ exposures are considered as occupational, and the appropriate requirements of the Commission should be applied.

Routine implementation of EGFR mutation testing in clinical practice in Flanders: 'HERMES' project

Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) is the recommended first-line treatment in metastatic EGFR-mutation-positive non-small cell lung cancer (NSCLC) patients. Such a personalized treatment requires fast EGFR mutation testing. This study was performed to determine the turn around time (TAT) for EGFR mutation testing on tumour samples of NSCLC in the clinical care in the region of Antwerp (Belgium). The secondary aim was to determine the frequency of EGFR mutations in this Flemish population. Tumour tissue was prospectively obtained from lung cancer patients in participating hospitals and sent from the local pathology laboratory (lab) to two central laboratories (labs) where EGFR-mutation analysis was performed. Results were returned from the central labs to the clinicians and the local pathology lab. TAT was defined as the interval between the request from the oncologist and the result obtained by the oncologist. One hundred and seven specimens were analysed. The clinician got the result from the local lab in a median time of 10 days (3-37 days) and from the central lab in 9 days (3-29 days). We detected seven mutations (7%) in this study population, all occurring in tumours with an adenocarcinoma histology, four (57%) in men and five (71%) in (ex-)smokers. There were six exon 19 deletions and one L858R mutation. It is possible to implement EGFR-mutation testing with timely reporting of the EGFR-mutation status. EGFR-mutation occurs in 7% of Flemish patients with NSCLC. Patients with advanced non-squamous NSCLC should be tested for EGFR mutation regardless of their gender and smoking history.

Treatment with lenalidomide (Revlimid®), cyclophosphamide (Endoxan®) and prednisone (REP) in relapsed/refractory multiple myeloma patients: results of a single centre retrospective study

Lenalidomide (Revlimid®) combined with intermittent dexamethasone (the RD regimen) is one of the current standards for treatment of patients with relapsed/refractory multiple myeloma (MM). However, since the disease in the majority of patients will become resistant to RD, or treatment with RD needs to be discontinued due to side effects, we evaluated the combination lenalidomide, low-dose oral cyclophosphamide, with prednisone (REP) in patients with relapsed/refractory MM previously exposed to RD. For this purpose, we performed a single centre retrospective study of the efficacy of REP in 19 patients with relapsed/refractory MM. Overall response rate (partial response or better) with REP was 68% compared with 83% with RD, but with a shorter time to response with the triplet REP. Time to progression after REP was 6 months. Overall the REP regimen was better tolerated compared to RD. We conclude that the REP regimen is an effective treatment regimen for patients with relapsed/refractory MM with good tolerance, warranting further exploration in prospective randomized trials.

Customizing systemic therapy in patients with advanced non-small cell lung cancer

Lung cancer is the leading cause of cancer deaths worldwide. Standard chemotherapy has been shown to improve quality of life and has a modest influence on overall survival. This modest improvement in survival is partly due to the choice of chemotherapy regimens that have been based on prognostic factors such as age, performance status and comorbidities of the patient. This underlines the importance of developing a more personalized therapy for patients with non-small cell lung cancer. Such an approach may reduce the variation in how individual patients respond to medications by tailoring therapies to their genetic profile. In this review we focus on several aspects of customized therapy, looking not only at patient characteristics but also to tumor histology and specific tumor biomarkers.

Flexoelectric rotation of polarization in ferroelectric thin films

Strain engineering enables modification of the properties of thin films using the stress from the substrates on which they are grown. Strain may be relaxed, however, and this can also modify the properties thanks to the coupling between strain gradient and polarization known as flexoelectricity. Here we have studied the strain distribution inside epitaxial films of the archetypal ferroelectric PbTiO(3), where the mismatch with the substrate is relaxed through the formation of domains (twins). Synchrotron X-ray diffraction and high-resolution scanning transmission electron microscopy reveal an intricate strain distribution, with gradients in both the vertical and, unexpectedly, the horizontal direction. These gradients generate a horizontal flexoelectricity that forces the spontaneous polarization to rotate away from the normal. Polar rotations are a characteristic of compositionally engineered morphotropic phase boundary ferroelectrics with high piezoelectricity; flexoelectricity provides an alternative route for generating such rotations in standard ferroelectrics using purely physical means.

ICRP Publication 111 - Application of the Commission's recommendations to the protection of people living in long-term contaminated areas after a nuclear accident or a radiation emergency

In this report, the Commission provides guidance for the protection of people living in long-term contaminated areas resulting from either a nuclear accident or a radiation emergency. The report considers the effects of such events on the affected population. This includes the pathways of human exposure, the types of exposed populations, and the characteristics of exposures. Although the focus is on radiation protection considerations, the report also recognises the complexity of post-accident situations, which cannot be managed without addressing all the affected domains of daily life, i.e. environmental, health, economic, social, psychological, cultural, ethical, political, etc. The report explains how the 2007 Recommendations apply to this type of existing exposure situation, including consideration of the justification and optimisation of protection strategies, and the introduction and application of a reference level to drive the optimisation process. The report also considers practical aspects of the implementation of protection strategies, both by authorities and the affected population. It emphasises the effectiveness of directly involving the affected population and local professionals in the management of the situation, and the responsibility of authorities at both national and local levels to create the conditions and provide the means favouring the involvement and empowerment of the population. The role of radiation monitoring, health surveillance, and the management of contaminated foodstuffs and other commodities is described in this perspective. The Annex summarises past experience of longterm contaminated areas resulting from radiation emergencies and nuclear accidents, including radiological criteria followed in carrying out remediation measures.

Psychopathology among preterm infants using the Diagnostic Classification Zero to Three

AIM

To compare the prevalence of psychopathology in infants born preterm with matched full-term infants at the corrected age of 1 year.

METHODS

Between June 2003 and April 2005, a case-control longitudinal cohort study was conducted at the neonatal unit of the University Hospital of Antwerp, Belgium. We prospectively enrolled 123 live-born infants between 25 and 35 weeks of gestation and/or infants with a birth-weight of <1500 g. Thirty full-term infants were recruited among day care centres in the region. Diagnoses were based on the Diagnostic Classification Zero to Three (DC: 0-3), using the MacArthur Communicative Developmental Inventory Dutch version, Infant-Toddler Sensory Profile, Bayley Scales of Infant Development II, Parent Infant Relationship Global Assessment Scale and Functional Emotional Assessment Scale.

RESULTS

At the (corrected) age of 12 months, 89 infants were eligible for follow-up and complete data were available for 69 (77%) infants. Fifty-four percentage of the preterm infants fulfilled one or more DC 0-3 diagnoses. Premature infants had significantly more diagnoses than full-term infants on axis I, axis III and axis V of the DC: 0-3.

CONCLUSION

In this study, the prevalence of psychopathology was significantly higher among preterm infants in comparison with full-term infants. This study did not confirm previous findings of higher rates of relationship disorders among preterm infants.

The value of endoscopic ultrasound after bronchoscopy to diagnose thoracic sarcoidosis

A clinicoradiological presentation of thoracic sarcoidosis requires histopathology in order to establish the diagnosis. Flexible bronchoscopy has a reasonable diagnostic yield and is the procedure of first choice for diagnosis. Endoscopic ultrasound (endoscopic ultrasound-guided fine needle aspiration/endobronchial ultrasound-guided transbronchial needle aspiration) can help in the diagnosis of sarcoidosis. An implementation strategy of endoscopic ultrasound for the diagnosis of sarcoidosis following negative flexible bronchoscopy results was examined prospectively in 15 clinics. A total of 137 patients (92 males; median age 43 yrs) were included, and sarcoidosis was found in 115 (84%). Alternative diagnoses were tuberculosis, lymphangitis carcinomatosa, pneumoconiosis and alveolitis. All patients were sent for flexible bronchoscopy, which was performed in 121 (88%), resulting in a definite diagnosis in 57 (42%). A total of 80 patients were sent for endoscopic ultrasound, which could be performed in 72 (90%), yielding a definite diagnosis in 47 (59%). Endoscopic ultrasound following negative flexible bronchoscopy avoided a surgical procedure in 47 out of 80 patients. The sensitivity of flexible bronchoscopy for sarcoidosis was 45% (95% confidence interval 35-54%), but 62% (50-72%) if biopsy specimens were taken. The sensitivity of endoscopic ultrasound following negative flexible bronchoscopy results was 71% (58-82%). With this strategy, 97 out of 115 (84% (76-90%)) of proven sarcoidosis was diagnosed using endoscopy. This large prospective implementation study (trial number NCT00888212; ClinicalTrials.gov) shows that endoscopic ultrasound is valuable for diagnosing sarcoidosis after negative flexible bronchoscopy results.

Rituximab in auto-immune haemolytic anaemia and immune thrombocytopenic purpura: a Belgian retrospective multicentric study

OBJECTIVES

For better characterizing the effect of anti-CD20 therapy, we analysed the use of rituximab in Belgian patients experiencing auto-immune haemolytic anaemia (AIHA) and immune thrombocytopenic purpura (ITP).

DESIGN

We performed a retrospective multicentric analysis of patients with AIHA and ITP treated with rituximab in Belgium.

SETTING

Haematological departments were invited to fill in a questionnaire about patient and disease characteristics.

SUBJECTS

All patients with AIHA and ITP, both primary and secondary to other diseases, who received one or more courses of rituximab during their disease course were included. Sixty-eight courses of rituximab in 53 patients with AIHA and 43 courses in 40 patients with ITP were analyzed.

INTERVENTION

Response rates, duration of response and factors predictive for response were assessed.

RESULTS

All patients were given rituximab after failing at least one previous line of treatment, including splenectomy in 19% and 72.5% of AIHA-patients and ITP-patients respectively. Overall response rates were 79.2% in AIHA and 70% in ITP, with a median follow-up since first rituximab administration of 15 months (range 0.5-62) in AIHA and 11 months (range 0-74) in ITP. Progression free survival at 1 and 2 years were 72% and 56% in AIHA and 70% and 44% in ITP. In this retrospective analysis we were not able to identify pretreatment characteristics predictive for response to rituximab. Nine patients with AIHA and three patients with ITP were given one or more additional courses of rituximab. Most of these patients, who had responded to a previous course, experienced a new response comparable to the previous one, both in terms of quality and of duration of response. Finally, the outcome of patients who failed to respond to rituximab therapy was poor both in terms of response to subsequent therapy and in terms of survival.

CONCLUSIONS

This study confirms that rituximab induces responses in a majority of previously treated patients with AIHA and ITP. Response duration generally exceeds 1 year. Retreatment with rituximab in responding patients is most often successful. The outcome of patients who fail on rituximab is poor. We were not able to identify pretreatment patient characteristics predicting for response.

Psychopathology among children and adolescents in child welfare: a comparison across different types of placement in Flanders, Belgium

BACKGROUND

Children and adolescents in child welfare are characterised by a high rate of psychopathology. However, prevalence estimates vary greatly, and comparisons between studies are limited owing to different target populations, measurement tools and how results are presented. In addition, little is known about the situation of children under child welfare care still living with their parents.

METHODS

The Achenbach System of Empirically Based Assessment and the Strengths and Difficulties Questionnaire used to measure psychopathology, were administered to parent, agency carer and adolescent (if older than 11). Data of 292 children aged 3-17 years (mean age, 12.13 years) with at least one respondent of four types of placement, namely foster care, residential care, day care and home-based care, were included (response rate, 78%). Socioeconomic characteristics and psychopathology were examined across these four types of placement.

RESULTS

Overall, the proportion of children scoring within the clinical range according to at least one informant was 56% according to the Strengths and Difficulties Questionnaire and 54% according to the Achenbach System of Empirically Based Assessment. Rates were highest among children living at home and significantly lower among children in out-of-home placement, even after correcting for age, income and duration of the ongoing placement. Adolescents scored themselves lower on psychopathology in comparison with their parents and the agency carer.

CONCLUSIONS

The prevalence of psychopathology in this child welfare population was very high; however, the findings were consistent with results obtained in previous studies. The prevalence estimates differed depending on the type of placement: the highest rates were found among children in home-based care, and children in foster care suffered less psychopathology. The findings stress the vulnerable mental status of children in child welfare and the need for additional support for child welfare professionals and children, as well as their parents, especially for those living with their parents.

Polar domains in lead titanate films under tensile strain

Thin films of PbTiO3, a classical ferroelectric, have been grown under tensile strain on single-crystal substrates of DyScO3. The films, of only 5 nm thickness, grow fully coherent with the substrate, as evidenced by synchrotron x-ray diffraction. A mapping of the reciprocal space reveals intensity modulations (satellites) due to regularly spaced polar domains in which the polarization appears rotated away from the substrate normal, characterizing a low-symmetry phase not observed in the bulk material. This could have important practical implications since these phases are known to be responsible for ultrahigh piezoelectric responses in complex systems.

Modulation of the Ca2 permeable cation channel TRPV4 by cytochrome P450 epoxygenases in vascular endothelium

TRPV4 is a broadly expressed Ca2+-permeable cation channel in the vanilloid subfamily of transient receptor potential channels. TRPV4 gates in response to a large variety of stimuli, including cell swelling, warm temperatures, the synthetic phorbol ester 4alpha-phorbol 12,13-didecanoate (4alpha-PDD), and the endogenous lipid arachidonic acid (AA). Activation by cell swelling and AA requires cytochrome P450 (CYP) epoxygenase activity to convert AA to epoxyeicosatrienoic acids (EETs) such as 5,6-EET, 8,9-EET, which both act as direct TRPV4 agonists. To evaluate the role of TRPV4 and its modulation by the CYP pathway in vascular endothelial cells, we performed Ca2+ imaging and patch-clamp measurements on mouse aortic endothelial cells (MAECs) isolated from wild-type and TRPV4(-/-) mice. All TRPV4-activating stimuli induced robust Ca2+ responses in wild-type MAECs but not in MAECs isolated from TRPV4(-/-) mice. Upregulation of CYP2C expression by preincubation with nifedipine enhanced the responses to AA and cell swelling in wild-type MAECs, whereas responses to other stimuli remained unaffected. Conversely, inhibition of CYP2C9 activity with sulfaphenazole abolished the responses to AA and hypotonic solution (HTS). Moreover, suppression of EET hydrolysis using 1-adamantyl-3-cyclo-hexylurea or indomethacin, inhibitors of soluble epoxide hydrolases (sEHs), and cyclooxygenases, respectively, enhanced the TRPV4-dependent responses to AA, HTS, and EETs but not those to 4alpha-PDD or heat. Together, our data establish that CYP-derived EETs modulate the activity of TRPV4 channels in endothelial cells and shows the unraveling of novel modulatory pathways via CYP2C modulation and sEH inhibition.

Regulatory aspects of radiation protection

The paper introduces the projects launched by the European Community to foster prospects in dosimetry, radiation protection and best use of equipment in the medical field. These projects are put in perspective with the European legal framework for radiation protection, in particular, the Basic Safety Standards Directive, the Medical Exposures Directive and the Directive on High-Activity Sealed Sources. A summary is given of the overall mission statements of the commission services in the field of radiation protection, including the field of research, and how they relate to other actions in the overall health policy of the EU. In conclusion, a number of priority areas for future work in the medical field are highlighted.

Results of the European Commission Marina II study: part II--effects of discharges of naturally occurring radioactive material

Enhanced levels of naturally occurring radioactive materials (NORM) are produced through various industrial operations and may lead to discharges to the marine environment. A recent study, called MARINA II, carried out for the European Commission considered discharges of radionuclides from the NORM industries to north European marine waters and their consequences. There are two main sources that were considered in the study. The use of phosphogypsum during the production of phosphoric acid by the fertiliser industry and the pumping of oil and gas from the continental shelf in the North Sea which produces large quantities of water contaminated with enhanced levels of naturally occurring radionuclides. Discharges of alpha emitting radionuclides from these two industries have contributed significantly to the total input of alpha emitters to north European waters over the period 1981-2000 (data were not available prior to 1981). Discharges due to the use of phosphogypsum have declined since the early 1990s and are now very low. Discharges from the oil and gas industries stabilised in the second half of the 1990s and are now the major contributor to alpha discharges to the region. As most European countries do not report discharges of radioactivity with the water produced during extraction, there is considerable uncertainty in the discharges used in the study. The impact of the discharges has been estimated both in terms of the effect on non-human biota and the radiological impact for people. In the 1980s the radiation dose rates to marine biota in the region around a phosphate plant on the north-west coast of England were as high due to the discharges from the phosphate plant as those near to the Sellafield reprocessing plant due to its discharges. In recent years the additional dose to marine biota in this region due to the past NORM discharges is of the same order of magnitude as the natural background. The collective dose rate was estimated to determine the radiological impact on people. The peak collective dose rate from the NORM industries occurred in 1984 and was just over 600 manSv y(-1). The collective dose rate fell with time as discharges from the phosphate industry reduced and was estimated as under 200 manSv y(-1) in 2000.

Results of the European Commission MARINA II study: part I--general information and effects of discharges by the nuclear industry

From the collated data relevant to discharges by the nuclear industry, it results that the input of beta activity (excluding Chernobyl fallout and tritium) into the OSPAR region decreased by a factor of 4 from 1986 to 1991, reaching by this date the same level as in the early 1950s. Over the same period the discharges of the alpha activity into the OSPAR region also decreased by a factor 3, the same trend has been seen also for tritium. Since 1986 the effective dose to members of the critical group in the vicinity of Sellafield and Cap de La Hague was consistently below the ICRP and EU limit of 1 mSv per year to members of the general public. The overall radiological impact from nuclear industry on the population of the European Union from the OSPAR area has decreased from 280 manSv y(-1) in 1978 to 14 manSv y(-1) in 2000.

Cell swelling, heat, and chemical agonists use distinct pathways for the activation of the cation channel TRPV4

TRPV4 is a Ca(2+)- and Mg(2+)-permeable cation channel within the vanilloid receptor subgroup of the transient receptor potential (TRP) family, and it has been implicated in Ca(2+)-dependent signal transduction in several tissues, including brain and vascular endothelium. TRPV4-activating stimuli include osmotic cell swelling, heat, phorbol ester compounds, and 5',6'-epoxyeicosatrienoic acid, a cytochrome p450 epoxygenase metabolite of arachidonic acid (AA). It is presently unknown how these distinct activators converge on opening of the channel. Here, we demonstrate that blockers of phospholipase A(2) (PLA(2)) and cytochrome p450 epoxygenase inhibit activation of TRPV4 by osmotic cell swelling but not by heat and 4alpha-phorbol 12,13-didecanoate. Mutating a tyrosine residue (Tyr-555) in the N-terminal part of the third transmembrane domain to an alanine strongly impairs activation of TRPV4 by 4alpha-phorbol 12,13-didecanoate and heat but has no effect on activation by cell swelling or AA. We conclude that TRPV4-activating stimuli promote channel opening by means of distinct pathways. Cell swelling activates TRPV4 by means of the PLA(2)-dependent formation of AA, and its subsequent metabolization to 5',6'-epoxyeicosatrienoic acid by means of a cytochrome p450 epoxygenase-dependent pathway. Phorbol esters and heat operate by means of a distinct, PLA(2)- and cytochrome p450 epoxygenase-independent pathway, which critically depends on an aromatic residue at the N terminus of the third transmembrane domain.

Molecular cytogenetic analysis of 10;11 rearrangements in acute myeloid leukemia

MLLT10 (previously called AF10) is a moderately common MLL fusion partner predominantly occurring in acute monoblastic leukemia (AML-M5). 10;11 rearrangements require at least three breaks in order to generate an in-frame MLL-MLLT10 fusion as a result of the opposite orientations of both genes on the respective chromosome arms. In this study, we describe a detailed molecular cytogenetic analysis of MLL-MLLT10 positive 10;11 rearrangements in two patients. We observed an as yet unreported chromosomal mechanism with at least four breakpoints, leading to MLL-MLLT10 gene fusion in a 24-year-old male. An inversion of 11q13-q23 with a breakpoint in the MLL gene was followed by an additional break 3' of MLL prior to insertion of the 11q segment into MLLT10. In a second patient, a 37-year-old male with AML-M5b, molecular cytogenetic analysis of an apparent 10;11 reciprocal translocation showed an intrachromosomal inversion of 3'MLLT10followed by a reciprocal translocation between 10p12 and 11q23. Review of the literature showed that all cases were the result of an inversion of either 10p or 11q followed by translocation 10p;11q or insertion of the inverted segment into MLLT10 or MLL.

Aspartate residues of the Glu-Glu-Asp-Asp (EEDD) pore locus control selectivity and permeation of the T-type Ca(2+) channel alpha(1G)

The structural determinant of the permeation and selectivity properties of high voltage-activated (HVA) Ca(2+) channels is a locus formed by four glutamate residues (EEEE), one in each P-region of the domains I-IV of the alpha(1) subunit. We tested whether the divergent aspartate residues of the EEDD locus of low voltage-activated (LVA or T-type) Ca(2+) channels account for the distinctive permeation and selectivity features of these channels. Using the whole-cell patch-clamp technique in the HEK293 expression system, we studied the properties of the alpha(1G) T-type, the alpha(1C) L-type Ca(2+) channel subunits, and alpha(1G) pore mutants, containing aspartate-to-glutamate conversions in domain III, domain IV, or both. Three characteristic features of HVA Ca(2+) channel permeation, i.e. (a) Ba(2+) over Ca(2+) permeability, (b) Ca(2+)/Ba(2+) anomalous mole fraction effect (AMFE), and (c) high Cd(2+) sensitivity, were conferred on the domain III mutant (EEED) of alpha(1G). In contrast, the relative Ca(2+)/Ba(2+) permeability and the lack of AMFE of the alpha(1G) wild type channel were retained in the domain IV mutant (EEDE). The double mutant (EEEE) displayed AMFE and a Cd(2+) sensitivity similar to that of alpha(1C), but currents were larger in Ca(2+)- than in Ba(2+)-containing solutions. The mutation in domain III, but not that in domain IV, consistently displayed outward fluxes of monovalent cations. H(+) blocked Ca(2+) currents in all mutants more efficiently than in alpha(1G). In addition, activation curves of all mutants were displaced to more positive voltages and had a larger slope factor than in alpha(1G) wild type. We conclude that the aspartate residues of the EEDD locus of the alpha(1G) Ca(2+) channel subunit not only control its permeation properties, but also affect its activation curve. The mutation of both divergent aspartates only partially confers HVA channel permeation properties to the alpha(1G) Ca(2+) channel subunit.

Molecular cytogenetic and clinical findings in ETV6/ABL1-positive leukemia

Rearrangements of 12p, resulting from deletions or translocations, are common findings in hematologic malignancies. In many cases, these rearrangements target the ETV6 gene (previously called TEL) located at 12p13. Various partner genes have been implicated in the formation of fusion genes with ETV6. These include PDGFRB, JAK2, NTRK3, ABL2, and ABL1, each of which encodes for proteins with tyrosine kinase activity. To date, ETV6/ABL1 transcripts have been detected in only four patients with a leukemic disorder. Here, we describe one adult with chronic myeloid leukemia and a child with T-cell acute lymphocytic leukemia with ETV6/ABL1. Molecular cytogenetic analysis confirmed that formation of an ETV6/ABL1 fusion in these patients required at least three chromosomal breaks and showed that each of these translocations is the result of a complex chromosomal rearrangement. Molecular analysis showed the presence of two fusion transcripts in both patients as the result of alternative splicing, questioning the suggested role of these transcripts in the lineage specificity. Clinical findings of these patients were compared to those of previously reported cases, and the possible clinical and biological similarities between ETV6/ABL1 and other fusion genes leading to increased tyrosine kinase activity are discussed.

Pyoderma gangrenosum as an early revelator of acute leukemia

Bullous pyoderma gangrenosum is an atypical, more superficial variety of the classical pyoderma and is often associated with myeloproliferative disorders. We present the case of a patient who presented initially with subcutaneous nodules and who developed bullous lesions afterwards. Histological evaluation showed the presence of neutrophilic infiltrates in both lesions. A few months after the diagnosis of bullous pyoderma gangrenosum, an underlying leukemia was revealed. Our case illustrates the importance of regular blood and bone marrow examinations in patients with atypical bullous pyoderma gangrenosum, resulting in a rapid diagnosis of the underlying disease.

Repetitive analyses of P-glycoprotein in chronic myeloid leukaemia

P-glycoprotein, a pump located in the plasma cell membrane, extrudes several clinically important drugs from the cell, and hence causes multidrug resistance. Reversing clinical drug resistance is possible by using agents that inhibit the activity of P-glycoprotein. We describe the results of sequential flow cytometric determinations of P-glycoprotein expression and activity in two patients suffering from acute lymphoblastic transformation of chronic myeloid leukaemia. Neither P-glycoprotein expression, nor its activity could be detected in the initial sample of the first patient. In the second patient, no P-glycoprotein expression was found at diagnosis. However, after chemotherapy containing P-glycoprotein substrates, a significant expression was found in both patients and the functional flow cytometric test was positive. In order to achieve an accurate selection of patients that might benefit from the clinical use of P-gp inhibitors, repeated analyses are indicated in each patient suffering from acute leukaemia, during the course of the illness.

Ferritin-associated iron induces neutrophil dysfunction in hemosiderosis

Neutrophils (PMNs) from patients with secondary iron overload have an increased iron and ferritin content as well as a phagocytosis defect. Several serum components might be incriminated in the cellular iron accumulation. We therefore compared the effects on the PMN phagocytosis of total serum as well as the ferritin and transferrin fractions of serum derived from patients with thalassemia major and healthy control subjects. An incubation system of PMNs was developed. PMN phagocytosis was measured before and after incubation. Total serum from patients with thalassemia induced a defect that was prevented by co-incubation with deferoxamine (DFO). Gel-filtration chromatography was performed to separate the serum fraction containing transferrin and albumin from that containing ferritin. The transferrin-albumin fraction had no effect on PMN phagocytosis. On the contrary, the ferritin fraction of normal serum was deleterious to PMN phagocytosis, and the same fraction from thalassemic serum decreased PMN phagocytosis even more. Co-incubation with DFO or catalase improved this defect. Moreover, a cellular increase in the L-type subunit of ferritin was observed after the incubation of PMNs with the ferritin-containing fraction from thalassemic serum. In conclusion, serum from patients with thalassemia is toxic to PMNs, and this toxicity is due to ferritin-associated iron.

Erythromelalgia: a clue to the diagnosis of polycythemia vera

We report the case of a 74-year-old woman with recurrent episodes of symmetrical congestion and erythema in the distal lower legs causing a burning distress. Laboratory and clinical investigations revealed an underlying myeloproliferative disorder. The cutaneous symptoms were atypical of erythromelalgia. Salicylates and treatment of the underlying polycythemia were able to eliminate the skin lesions but not entirely suppress the subjective discomfort.