Immuno-oncological effects of standard anticancer agents and commonly used concomitant drugs: an in vitro assessment

BACKGROUND

It has become evident in the field of oncology that the outcome of medical treatment is influenced by the combined effect exerted on both cancer- and immune cells. Therefore, we evaluated potential immunological effects of 46 standard anticancer agents and 22 commonly administered concomitant non-cancer drugs.

METHODS

We utilized a miniaturized in vitro model system comprised of fluorescently labeled human colon and lung cancer cell lines grown as monocultures and co-cultured with activated peripheral blood mononuclear cells (PBMCs). The Bliss Independence Model was then applied to detect antagonism and synergy between the drugs and activated immune cells.

RESULTS

Among the standard anticancer agents, tyrosine kinase inhibitors (TKIs) stood out as the top inducers of both antagonism and synergy. Ruxolitinib and dasatinib emerged as the most notably antagonistic substances, exhibiting the lowest Bliss scores, whereas sorafenib was shown to synergize with activated PBMCs. Most concomitant drugs did not induce neither antagonism nor synergy. However, the statins mevastatin and simvastatin were uniquely shown to synergize with activated PBMC at all tested drug concentrations in the colon cancer model.

CONCLUSION

We utilized a miniaturized tumor-immune model to enable time and cost-effective evaluation of a broad panel of drugs in an immuno-oncology setting in vitro. Using this approach, immunomodulatory effects exerted by TKIs and statins were identified.

Validation of the Swedish Quality Register for Ear Surgery - SwedEar

BACKGROUND

The Swedish Quality Register for Ear Surgery (SwedEar) is a national register monitoring surgical procedures and outcomes of ear surgery to facilitate quality improvement. The value of the register is dependent on the quality of its data. SwedEar has never been validated regarding data quality or missing entries. Therefor, the purpose of this study was to assess coverage, completeness and response rate in the register and validate the physicians' reported data accuracy.

METHODS

In this validation study, the completeness, response rate and missing registrations were analysed. Data in SwedEar were compared with the yearly collected statistics of otosurgical procedures in The Swedish Otosurgical Society and the comparison of rates between groups was calculated with Fisher's exact test. Validation of registered data accuracy was performed on every 20th registered case during a five-year period. Data were reabstracted from medical records and compared with the original registration. Interrater agreement, reliability measures, Cohen's kappa, Gwet's AC1 and positive predictive value were calculated.

RESULTS

SwedEar has a coverage of 100%. The completeness of registered cases was 84% and the response rate was 74%. The validation of data accuracy assessed 13 530 variables, including audiograms. Less than 3% of incorrect or missing variables were identified. For most of the pre- and postoperative variables the Kappa and Gwet´s AC1 results show an almost perfect agreement (> 0.80). For audiogram data the ICC shows an excellent reliability (> 0.9) for all but one value.

CONCLUSION

This validation shows that SwedEar has excellent coverage, high completeness, and that the data in the register have almost perfect reliability. The data are suitable for both clinical and research purposes. Further efforts to improve completeness are warranted.

Increased levels of plasma cytokines and correlations to organ failure and 30-day mortality in critically ill Covid-19 patients

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Fifteen cytokines were increased at ICU admission in Covid-19 patients.

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A relatively moderate increase in cytokine concentrations was observed.

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IL-1ra, IL-6 and IP-10 correlated with respiratory failure and acute kidney injury.

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IL-8 may be a future biomarker due to its correlation with 30-day mortality.

Background

The infection caused by SARS CoV-2 has been postulated to induce a cytokine storm syndrome that results in organ failure and even death in a considerable number of patients. However, the inflammatory response in Corona virus disease-19 (Covid-19) and its potential to cause collateral organ damage has not been fully elucidated to date. This study aims to characterize the acute cytokine response in a cohort of critically ill Covid-19 patients.

Method

24 adults with PCR-confirmed Covid-19 were included at time of admission to intensive care a median of eleven days after initial symptoms. Eleven adult patients admitted for elective abdominal surgery with preoperative plasma samples served as controls. All patients were included after informed consent was obtained. 27 cytokines were quantified in plasma. The expression of inflammatory mediators was then related to routine inflammatory markers, SAPS3, SOFA score, organ failure and 30-day mortality.

Results

A general increase in cytokine expression was observed in all Covid-19 patients. A strong correlation between respiratory failure and IL-1ra, IL-4, IL-6, IL-8 and IP-10 expression was observed. Acute kidney injury development correlated well with increased levels of IL-1ra, IL-6, IL-8, IL-17a, IP-10 and MCP-1. Generally, the cohort demonstrated weaker correlations between cytokine expression and 30-day mortality out of which IL-8 showed the strongest signal in terms of mortality.

Conclusion

The present study found that respiratory failure, acute kidney injury and 30-day mortality in critically ill Covid-19 patients are associated with moderate increases of a broad range of inflammatory mediators at time of admission.

Mebendazole is unique among tubulin-active drugs in activating the MEK-ERK pathway

We recently showed that the anti-helminthic compound mebendazole (MBZ) has immunomodulating activity in monocyte/macrophage models and induces ERK signalling. In the present study we investigated whether MBZ induced ERK activation is shared by other tubulin binding agents (TBAs) and if it is observable also in other human cell types. Curated gene signatures for a panel of TBAs in the LINCS Connectivity Map (CMap) database showed a unique strong negative correlation of MBZ with MEK/ERK inhibitors indicating ERK activation also in non-haematological cell lines. L1000 gene expression signatures for MBZ treated THP-1 monocytes also connected negatively to MEK inhibitors. MEK/ERK phosphoprotein activity testing of a number of TBAs showed that only MBZ increased the activity in both THP-1 monocytes and PMA differentiated macrophages. Distal effects on ERK phosphorylation of the substrate P90RSK and release of IL1B followed the same pattern. The effect of MBZ on MEK/ERK phosphorylation was inhibited by RAF/MEK/ERK inhibitors in THP-1 models, CD3/IL2 stimulated PBMCs and a MAPK reporter HEK-293 cell line. MBZ was also shown to increase ERK activity in CD4+ T-cells from lupus patients with known defective ERK signalling. Given these mechanistic features MBZ is suggested suitable for treatment of diseases characterized by defective ERK signalling, notably difficult to treat autoimmune diseases.

Cardiovascular and cancer mortality in relation to dietary polychlorinated biphenyls and marine polyunsaturated fatty acids: a nutritional-toxicological aspect of fish consumption

BACKGROUND

Co-exposure to environmental contaminants present in fish could mitigate the beneficial effects of fish consumption and possibly explain the lack of association observed for mortality in some geographical regions.

OBJECTIVE

To assess the independent associations of dietary exposure to polychlorinated biphenyls (PCBs) and long-chain omega-3 fish fatty acids intake with cardiovascular and cancer mortality.

METHODS

We used the prospective population-based Swedish Mammography Cohort and the Cohort of Swedish Men comprising 32 952 women and 36 545 men, free from cancer, cardiovascular disease and diabetes at baseline in 1998. Validated estimates of dietary PCBs and long-chain omega-3 fish fatty acids [i.e. eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] intake were obtained via a food frequency questionnaire at baseline. Information on death was ascertained through register linkage.

RESULTS

During a mean follow-up of 15.5 years, we ascertained 16 776 deaths. We observed for cardiovascular mortality, comparing extreme quintiles in multivariable models mutually adjusted for PCBs and EPA-DHA, dose-dependent associations for dietary PCB exposure, hazard ratio (HR) 1.31 (CI 95%: 1.08 to 1.57; P-trend 0.005) and for dietary EPA-DHA intake, HR 0.79 (CI 95%: 0.66 to 0.95; P-trend 0.041). For cancer mortality, no clear associations were discerned.

CONCLUSION

The beneficial effect of fish consumption on the cardiovascular system seems compromised by co-exposure to PCBs - one likely explanation for the inconsistent associations observed between fish consumption and mortality.

Mebendazole-induced M1 polarisation of THP-1 macrophages may involve DYRK1B inhibition

OBJECTIVE

We recently showed that the anti-helminthic compound mebendazole (MBZ) has immunomodulating activity by inducing a M2 to M1 phenotype switch in monocyte/macrophage models. In the present study we investigated the potential role of protein kinases in mediating this effect.

RESULTS

MBZ potently binds and inhibits Dual specificity tyrosine-phosphorylation-regulated kinase 1B (DYRK1B) with a Kd and an IC50 of 7 and 360 nM, respectively. The specific DYRK1B inhibitor AZ191 did not mimic the cytokine release profile of MBZ in untreated THP-1 monocytes. However, in THP-1 cells differentiated into macrophages, AZ191 strongly induced a pro-inflammatory cytokine release pattern similar to MBZ and LPS/IFNγ. Furthermore, like MBZ, AZ191 increased the expression of the M1 marker CD80 and decreased the M2 marker CD163 in THP-1 macrophages. In this model, AZ191 also increased phospho-ERK activity although to a lesser extent compared to MBZ. Taken together, the results demonstrate that DYRK1B inhibition could, at least partly, recapitulate immune responses induced by MBZ. Hence, DYRK1B inhibition induced by MBZ may be part of the mechanism of action to switch M2 to M1 macrophages.

Mebendazole stimulates CD14+ myeloid cells to enhance T-cell activation and tumour cell killing

Mebendazole (MBZ) was recently shown to induce a tumor suppressive M1 phenotype in THP-1 monocytes and macrophages. In the present study the immune effects of MBZ was further investigated using human peripheral blood mononuclear cells (PBMCs) co-cultured with tumour cells. The Biomap platform was used to screen for biomarkers induced from MBZ exposed co-cultures of T-cell receptor activated PBMCs, HT29 colon cancer cells and either human fibroblasts or human umbilical vein endothelial cells (HUVEC) cells. In these co-culture systems MBZ at 0.3-10 μM induced significant increases in TNFα and IFNγ indicating immune stimulation. PBMC cultures alone were subsequently tested for activation status and only in PBMCs activated by CD3/IL2 stimulation and MBZ, at a clinically achievable concentration, was able to increase PBMC clustering and release of pro-inflammatory IFNγ, TNFα, IL6 and IL1β cytokines. Moreover, when PBMC cultures were functionally tested for immune cell killing of lung cancer A549NucLightRed cells, MBZ significantly increased tumour cell apoptosis and reduced the number of surviving tumour cells. This effect was dependent on the presence of CD14 monocytes/macrophages in the co-culture. In summary, MBZ potentiated the immune stimulatory and anticancer effects of anti-CD3/IL2 activated PBMCs which could be relevant to explain the anticancer activity of MBZ observed in the clinic.

The anticancer effect of mebendazole may be due to M1 monocyte/macrophage activation via ERK1/2 and TLR8-dependent inflammasome activation

Mebendazole (MBZ), a drug commonly used for helminitic infections, has recently gained substantial attention as a repositioning candidate for cancer treatment. However, the mechanism of action behind its anticancer activity remains unclear. To address this problem, we took advantage of the curated MBZ-induced gene expression signatures in the LINCS Connectivity Map (CMap) database. The analysis revealed strong negative correlation with MEK/ERK1/2 inhibitors. Moreover, several of the most upregulated genes in response to MBZ exposure were related to monocyte/macrophage activation. The MBZ-induced gene expression signature in the promyeloblastic HL-60 cell line was strongly enriched in genes involved in monocyte/macrophage pro-inflammatory (M1) activation. This was subsequently validated using MBZ-treated THP-1 monocytoid cells that demonstrated gene expression, surface markers and cytokine release characteristic of the M1 phenotype. At high concentrations MBZ substantially induced the release of IL-1β and this was further potentiated by lipopolysaccharide (LPS). At low MBZ concentrations, cotreatment with LPS was required for MBZ-stimulated IL-1β secretion to occur. Furthermore, we show that the activation of protein kinase C, ERK1/2 and NF-kappaB were required for MBZ-induced IL-1β release. MBZ-induced IL-1β release was found to be dependent on NLRP3 inflammasome activation and to involve TLR8 stimulation. Finally, MBZ induced tumor-suppressive effects in a coculture model with differentiated THP-1 macrophages and HT29 colon cancer cells. In summary, we report that MBZ induced a pro-inflammatory (M1) phenotype of monocytoid cells, which may, at least partly, explain MBZ's anticancer activity observed in animal tumor models and in the clinic.

Myringoplasty Outcomes From the Swedish National Quality Registry

OBJECTIVES/HYPOTHESIS

Data from patients registered for myringoplasty during 2002 to 2012 in the Swedish National Quality Registry for Myringoplasty.

STUDY DESIGN

Both conventional myringoplasty and fat-graft techniques were used aimed at healing the tympanic membrane in noninfected ears.

METHODS

Analysis was performed on data in a national database collected from 32 ear, nose, and throat clinics. Surgical procedures and outcomes, and patient satisfaction from a questionnaire were studied.

RESULTS

The database was comprised of 3,775 surgical procedures, with follow-up available for analysis. One-third were children under the age of 15 years. The most common indication for surgery was infection prophylaxis. The overall healing rate of the tympanic membrane after surgery was 88.5%, with a high mean patient satisfaction. Complications registered were postoperative infection, tinnitus, or taste disturbance that occurred in 5.8% of patients.

CONCLUSIONS

Swedish results for a large number of patients who completed myringoplasty are presented. The success rate in this study is comparable to other studies, and good patient-reported outcome measures of myringoplasty are presented. Databases for surgical procedures and clinical audits are systematic processes for continuous learning in healthcare. This study shows that clinical databases can be utilized to analyze national results of surgical procedures.

LEVEL OF EVIDENCE

2b Laryngoscope, 127:2389-2395, 2017.

Assessment of mRNA Levels for Matrix Molecules and TGF-β1 in Rabbit Flexor and Peroneus Tendons Reveals Regional Differences in Steady-State Expression

This study analysed the differences on a molecular level between two segments of the deep flexor tendon, and compared the intrasynovial flexor tendon with the tendon sheath and the extrasynovial peroneus tendon in a rabbit model. The TRIspin method of RNA extraction was combined with the reverse transcription polymerase chain reaction to assess mRNA levels in the tissue segments. Significant differences were detected for all genes studied. mRNA levels for aggrecan, biglycan and collagen III were significantly higher in the fibrocartilaginous proximal segment of the flexor tendon. Collagen I was higher in the flexor tendon than the sheath and the peroneus tendon, and TGF-β1 was significantly lower in the peroneus tendon. This study demonstrates differences at the mRNA level between different segments of tendon, indicating that the tendon tissue may be adapted to its environment.

Abstract 2415: GBM exhibits phenotypic microheterogeneity and harbors pre-existing multi- resistant clones with a mesenchymal transition signature

Glioblastoma multiforme (GBM) remains in the group of incurable malignancies, with a median survival of 15 months. Intratumoral heterogeneity is a key factor driving relapse by providing the basis for escape of therapy-resistant cells. While the heterogeneous genomic and transcriptomic landscape of cancers is currently thoroughly characterized, phenotypic heterogeneity within tumors is less well understood. The overall goal in this study was to identify pre-existing treatment resistant clones with disease relapse potential and biomarkers linked to resistance vs sensitivity. To enable functional studies of isolated tumor clones we adopted an in vitro subcloning strategy. An adherent glioma neural stem cell culturing protocol was used to enrich for cells with stem-like properties and to permit efficient phenotypic screening.

We established six libraries of clonal cell cultures from fresh GBM surgical specimens, corresponding to five different patient tumors. In all 708 clonal cultures were expanded. These were considered representatives of the self-renewing compartment within the tumor cell population. We found a remarkable variation in drug and radiation response within the clone libraries. A striking observation was that clones resistant to one drug, also tended to be resistant to most of the drugs we used, regardless of the drug's mechanism of action. This indicates that resistance in large parts is mediated by a general mechanism.

Most clones carried genetic aberrations that were unique or found only in a few clones but it was primarily the transcriptome data that demonstrated a clear link to the phenotypic data.

A continuous gradient between multi-resistance and sensitivity was found to be connected to a gradual transition between a mesenchymal (MES), in resistant clones, and a more proneural (PN) and proliferative character in sensitive clones. The continuous distributions and lack of discrete groups in clonal response phenotypes and in linked signatures points to a general cell-state related resistance mechanism.

We also found that resistant clones had a lower methylation level in promoters of known master regulators of MES subtype associated genes. This indicates that the phenotypic heterogeneity is driven by fluctuations in the epigenetic status.

Taken together, our findings imply that intratumoral heterogeneity in GBM includes general clonal resistance mechanisms among glioma- initiating cells driven by epigenetic mechanisms. This evokes hope that new therapeutic approaches involving epigenetic reprogramming can be applied to sensitize cells toward conventional treatment.

Citation Format: Anna Segerman, Maria Niklasson, Caroline Haglund, Tobias Bergstrom, Malin Jarvius, Yuan Xie, Demet Caglayan Simov, Annika Hermansson, Marianne Kastemar, Zeinab Naimaie-Ali, Malin Berglund, Ann Westermark, Magnus Sundstrom, Goran Hesselager, Lene Uhrbom, Mats Gustafsson, Rolf Larsson, Marten Fryknas, Bo Segerman, Bengt Westermark. GBM exhibits phenotypic microheterogeneity and harbors pre-existing multi- resistant clones with a mesenchymal transition signature. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2415.

A pilot study on the feasibility of European harmonized human biomonitoring: Strategies towards a common approach, challenges and opportunities

In 2004 the European Commission and Member States initiated activities towards a harmonized approach for Human Biomonitoring surveys throughout Europe. The main objective was to sustain environmental health policy by building a coherent and sustainable framework and by increasing the comparability of data across countries. A pilot study to test common guidelines for setting up surveys was considered a key step in this process. Through a bottom-up approach that included all stakeholders, a joint study protocol was elaborated. From September 2011 till February 2012, 17 European countries collected data from 1844 mother-child pairs in the frame of DEMOnstration of a study to COordinate and Perform Human Biomonitoring on a European Scale (DEMOCOPHES).(1) Mercury in hair and urinary cadmium and cotinine were selected as biomarkers of exposure covered by sufficient analytical experience. Phthalate metabolites and Bisphenol A in urine were added to take into account increasing public and political awareness for emerging types of contaminants and to test less advanced markers/markers covered by less analytical experience. Extensive efforts towards chemo-analytical comparability were included. The pilot study showed that common approaches can be found in a context of considerable differences with respect to experience and expertize, socio-cultural background, economic situation and national priorities. It also evidenced that comparable Human Biomonitoring results can be obtained in such context. A European network was built, exchanging information, expertize and experiences, and providing training on all aspects of a survey. A key challenge was finding the right balance between a rigid structure allowing maximal comparability and a flexible approach increasing feasibility and capacity building. Next steps in European harmonization in Human Biomonitoring surveys include the establishment of a joint process for prioritization of substances to cover and biomarkers to develop, linking biomonitoring surveys with health examination surveys and with research, and coping with the diverse implementations of EU regulations and international guidelines with respect to ethics and privacy.

Interpreting biomarker data from the COPHES/DEMOCOPHES twin projects: Using external exposure data to understand biomarker differences among countries

In 2011 and 2012, the COPHES/DEMOCOPHES twin projects performed the first ever harmonized human biomonitoring survey in 17 European countries. In more than 1800 mother-child pairs, individual lifestyle data were collected and cadmium, cotinine and certain phthalate metabolites were measured in urine. Total mercury was determined in hair samples. While the main goal of the COPHES/DEMOCOPHES twin projects was to develop and test harmonized protocols and procedures, the goal of the current paper is to investigate whether the observed differences in biomarker values among the countries implementing DEMOCOPHES can be interpreted using information from external databases on environmental quality and lifestyle. In general, 13 countries having implemented DEMOCOPHES provided high-quality data from external sources that were relevant for interpretation purposes. However, some data were not available for reporting or were not in line with predefined specifications. Therefore, only part of the external information could be included in the statistical analyses. Nonetheless, there was a highly significant correlation between national levels of fish consumption and mercury in hair, the strength of antismoking legislation was significantly related to urinary cotinine levels, and we were able to show indications that also urinary cadmium levels were associated with environmental quality and food quality. These results again show the potential of biomonitoring data to provide added value for (the evaluation of) evidence-informed policy making.

Gender differences in cadmium and cotinine levels in prepubertal children

Susceptibility to environmental stressors has been described for fetal and early childhood development. However, the possible susceptibility of the prepubertal period, characterized by the orchestration of the organism towards sexual maturation and adulthood has been poorly investigated and exposure data are scarce. In the current study levels of cadmium (Cd), cotinine and creatinine in urine were analyzed in a subsample 216 children from 12 European countries within the DEMOCOPHES project. The children were divided into six age-sex groups: boys (6-8 years, 9-10 years and 11 years old), and girls (6-7 years, 8-9 years, 10-11 years). The number of subjects per group was between 23 and 53. The cut off values were set at 0.1 µg/L for Cd, and 0.8 µg/L for cotinine defined according to the highest limit of quantification. The levels of Cd and cotinine were adjusted for creatinine level. In the total subsample group, the median level of Cd was 0.180 µg/L (range 0.10-0.69 µg/L), and for cotinine the median wet weight value was 1.50 µg/L (range 0.80-39.91 µg/L). There was no significant difference in creatinine and cotinine levels between genders and age groups. There was a significant correlation between levels of cadmium and creatinine in all children of both genders. This shows that even at such low levels the possible effect of cadmium on kidney function was present and measurable. An increase in Cd levels was evident with age. Cadmium levels were significantly different between 6-7 year old girls, 11 year old boys and 10-11 year old girls. As there was a balanced distribution in the number of subjects from countries included in the study, bias due to data clustering was not probable. The impact of low Cd levels on kidney function and gender differences in Cd levels needs further investigation.

Dietary exposure to polychlorinated biphenyls is associated with increased risk of stroke in women

OBJECTIVE

The potentially beneficial effects of fish consumption on stroke may be modified by major food contaminants in fish. Polychlorinated biphenyls (PCBs) in particular are proposed to play a role in the aetiology of stroke. The aim of this study was to assess the association between dietary PCB exposure and stroke risk with the intake of long-chain omega-3 fish fatty acids and fish consumption.

DESIGN

The prospective population-based Swedish Mammography Cohort was examined. It was comprised of 34,591 women free of cardiovascular diseases and cancer at baseline in 1997 and followed up for 12 years. Validated estimates of dietary PCB exposure were obtained via a food frequency questionnaire at baseline. Incident cases of stroke were ascertained through register linkage.

RESULTS

During 12 years of follow-up (397,309 person-years), there were 2015 incident cases of total stroke (1532 ischaemic strokes, 216 intracerebral haemorrhages, 94 subarachnoid haemorrhages and 173 unspecified strokes). Multivariable-adjusted relative risks (RR), controlled for known stroke risk factors and fish consumption, were 1.67 [95% confidence interval (CI), 1.29-2.17] for total stroke, 1.61 (95% CI, 1.19-2.17) for ischaemic stroke and 2.80 (95% CI, 1.42-5.55) for haemorrhagic stroke for women in the highest quartile of dietary PCB exposure (median 288 ng day(-1) ) compared with women in the lowest quartile (median 101 ng day(-1) ).

CONCLUSION

Dietary exposure to PCBs was associated with an increased stroke risk in women, especially haemorrhagic stroke. The results provide important information regarding the risk-benefit analysis of fish consumption, particularly for cerebrovascular disease prevention.

U-2932: two clones in one cell line, a tool for the study of clonal evolution

Genetic heterogeneity is common in tumors, explicable by the development of subclones with distinct genetic and epigenetic alterations. We describe an in vitro model for cancer heterogeneity, comprising the diffuse large B-cell lymphoma cell line U-2932 which expresses two sets of cell surface markers representing twin populations flow-sorted by CD20 vs CD38 expression. U-2932 populations were traced to subclones of the original tumor with clone-specific immunoglobulin IgVH4-39 hypermutation patterns. BCL6 was overexpressed in one subpopulation (R1), MYC in the other (R2), both clones overexpressed BCL2. According to the combined results of immunoglobulin hypermutation and cytogenetic analysis, R1 and R2 derive from a mother clone with genomic BCL2 amplification, which acquired secondary rearrangements leading to the overexpression of BCL6 (R1) or MYC (R2). Some 200 genes were differentially expressed in R1/R2 microarrays including transcriptional targets of the aberrantly expressed oncogenes. Other genes were regulated by epigenetic means as shown by DNA methylation analysis. Ectopic expression of BCL6 in R2 variously modulated new candidate target genes, confirming dual silencing and activating functions. In summary, stable retention of genetically distinct subclones in U-2932 models tumor heterogeneity in vitro permitting functional analysis of oncogenes against a syngenic background.

Imported laryngeal and cutaneous diphtheria in tourists returning from western Africa to Sweden, March 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

Towards understanding and managing the learning process in mail sorting

OBJECTIVE

This paper was based on case study research at the Swedish Mail Service Division and it addresses learning time to sort mail at new districts and means to support the learning process on an individual as well as organizational level.

PARTICIPANTS

The study population consisted of 46 postmen and one team leader in the Swedish Mail Service Division.

METHODS

Data were collected through measurements of time for mail sorting, interviews and a focus group.

RESULTS

The study showed that learning to sort mail was a much more complex process and took more time than expected by management. Means to support the learning process included clarification of the relationship between sorting and the topology of the district, a good work environment, increased support from colleagues and management, and a thorough introduction for new postmen.

CONCLUSIONS

The identified means to support the learning process require an integration of human, technological and organizational aspects. The study further showed that increased operations flexibility cannot be reinforced without a systems perspective and thorough knowledge about real work activities and that ergonomists can aid businesses to acquire this knowledge.

Associations between polysubstance use and psychiatric problems in a criminal justice population in Sweden

BACKGROUND

Polysubstance use is common in substance users, and may complicate their clinical course. This study, in a criminal justice setting in Sweden, examines the association between the number of concurrently used substance types and psychiatric symptoms during 30 days before incarceration, while controlling for background variables such as family history (drug and alcohol problems, psychiatric problems, criminality), demographic data and history of emotional, physical or sexual abuse.

METHODS

The data material comprised 5659 criminal justice clients reporting a substance use problem, examined with the Addiction Severity Index. Variables were compared in a multinomial regression analysis, comparing clients reporting one (n=1877), two (n=1408), three (n=956), four (n=443) and five or more (n=167) substance types.

RESULTS

The 30-day prevalence of most psychiatric symptoms included in the study (depression, anxiety, cognitive problems, hallucinations, difficulty controlling violent behaviour, suicidal ideation, suicide attempts) was higher in individuals with a higher number of concurrent substance types used. In multinomial regression analysis, while controlling for background variables, these associations remained for concurrent suicidal ideation, cognitive problems, hallucinations and violent behaviour, with the latter two being associated with the higher numbers of substance types. Binge alcohol drinking, tranquilizers, opioids and the number of substance types reported were associated with several of the psychiatric symptoms.

CONCLUSIONS

In the present criminal justice setting in Sweden, the use of multiple substance types and concurrent psychiatric symptoms appear to be associated, and a sub-group reporting particularly high numbers of concurrent substance types are particularly likely to report potentially severe psychiatric problems.

Assessment of early-life lead exposure in rural Bangladesh

Lead is a well-known neurotoxic metal and one of the most toxic chemicals in a child's environment. The aim of this study was to assess early-life lead exposure in a pristine rural area of Bangladesh. The exposure was expected to be very low because of the absence of vehicle traffic and polluting industries. Lead was measured in erythrocytes, urine, and breast milk of 500 randomly selected pregnant women, participating in a randomized food and micronutrient supplementation trial in Matlab (MINIMat). Lead was also measured in urine of their children at 1.5 and 5 years of age, and in rice, well water, cooking pots, and materials used for walls and roof. All measurements were performed using ICPMS. We found that the women had relatively high median erythrocyte lead levels, which increased considerably from early pregnancy to late lactation (81-136microg/kg), probably due to release from bone. Urinary lead concentrations were unchanged during pregnancy (median approximately 3.5microg/L) and non-linearly associated with maternal blood lead levels. Children, at 1.5 and 5 years of age, had a median urinary lead concentration of 4microg/L, i.e., similar to that in their mothers. Rice, the staple food in Matlab, collected from 63 homes of the study sample, contained 1-89microg/kg (median 13microg/kg) dry weight and seems to be an important source of lead exposure. Other sources of exposure may be cooking pots and metal sheet roof material, which were found to release up to 380 and 4200microg/L, respectively, into acidic solutions. Based on breast milk lead concentrations (median 1.3microg/L) a median daily intake of 1.2microg was estimated for 3 months old infants. However, alternatives to breast-feeding are likely to contain more lead, especially rice-based formula. To conclude, lead exposure in women and their children in a remote unpolluted area was found to be surprisingly high, which may be due to their living conditions.

Prediction of irinotecan and 5-fluorouracil toxicity and response in patients with advanced colorectal cancer

Irinotecan and 5-fluorouracil (5-FU) are used to treat metastatic colorectal cancer. Irinotecan's active metabolite is inactivated by UDP-glucuronosyltransferase 1A1 (UGT1A1), which is deficient in Gilbert's syndrome. Irinotecan and metabolites are transported by P-glycoprotein, encoded by ABCB1. 5-FU targets folate metabolism through inhibition of thymidylate synthase (TYMS). Methylenetetrahydrofolate reductase (MTHFR) generates active folate necessary for haematopoiesis. We retrospectively genotyped 140 Swedish and Norwegian irinotecan and 5-FU-treated colorectal cancer patients from the Nordic VI clinical trial for selected variants of UGT1A1, ABCB1, TYMS and MTHFR. We found an increased risk of clinically relevant early toxicity in patients carrying the ABCB1 3435 T/T genotype, Odds ratio (OR)=3.79 (95% confidence interval (CI)=1.09–13.2), and in patients carrying the UGT1A1^*28/^*28 genotype, OR=4.43 (95% CI=1.30–15.2). Patients with UGT1A1^*28/^*28 had an especially high risk of neutropenia, OR=6.87 (95% CI=1.70–27.7). Patients who had reacted with toxicity during the first two cycles were in total treated with fewer cycles (P<0.001), and less often responded to treatment (P<0.001). Genetic variation in ABCB1 was associated with both early toxicity and lower response to treatment. Carriers of the ABCB1 1236T-2677T-3435T haplotype responded to treatment less frequently (43 vs 67%, P=0.027), and survived shorter time, OR=1.56 (95% CI=1.01–2.45).

Factors Associated with the History of Attempted Suicide

Background: The present study examines a population of criminal justice clients for suspected substance-related problems. Aims: It aims to identify variables associated with a history of suicide attempt (SA). Method: 6,836 clients were interviewed with the Addiction Severity Index (ASI). Attempters were compared to nonattempters regarding substance use, medical/psychiatric status, family history, and social relationships in a stepwise forward logistic regression. Results: Attempters (21%) were more likely to report binge drinking, intake of illicit drugs, injection of drugs, physical and mental illness, problematic family history, and history of being abused. After logistic regression, SA was independently associated with older age, female gender, binge drinking, delirium tremens, injection, overdose, medical problems, psychiatric symptoms, family history of alcohol or psychiatric problems, and sexual, physical, and emotional abuse. The psychiatric and family/social domains (including being abused) most strongly separated attempters from nonattempters. Conclusions: Family background factors, psychiatric symptoms, severity of substance use, and sexual, physical, and emotional abuse appear to be factors associated with SA among criminal justice clients.

Characteristics of primary amphetamine users in Sweden: a criminal justice population examined with the Addiction Severity Index

BACKGROUND/AIMS

Characteristics of primary amphetamine, heroin and cocaine users were compared in a criminal justice population.

METHODS

7,085 clients with suspected or reported substance use were studied using the Addiction Severity Index. Variables separating amphetamine, heroin and cocaine users were analyzed in stepwise logistic regression.

RESULTS

There were considerably more primary amphetamine users (n = 1,396) than heroin (n = 392) and cocaine (n = 119) users. Amphetamine users were older, a more rural population, and less likely to be non-Nordic immigrants. Compared with heroin, amphetamine use was associated with older age, Nordic origin, nonurban residence, memory/concentration problems, parental alcohol problems, and less history of other opioid use, overdose and detoxification. Compared with cocaine, amphetamine use was associated with older age, Nordic origin, nonurban residence, injecting, tobacco and institution treatment. Overlap of drug use between groups was relatively uncommon.

CONCLUSION

This pattern of amphetamine use, common among Swedish criminals, has relatively distinct boundaries from heroin and cocaine use, commonly involves injecting, and differs from other countries. Psychiatric problems and alcohol heredity were common, and evidence-based treatment for amphetamine users is needed. The connection between amphetamine use and criminal behavior is insufficiently understood and should be further addressed.

The inflammatory response and hyaluronan synthases in the rabbit flexor tendon and tendon sheath following injury

Using a rabbit model of flexor tendon injury, mRNA levels for a subset of relevant molecules involved in inflammatory and fibrotic processes were assessed by reverse transcriptase-polymerase chain reaction 3, 6, 12 and 24 days after injury. Increased levels of COX-2, IL-1beta, MMP-13 and TIMP-1 mRNA were detected in both tendon and tendon sheath following injury, with each molecule exhibiting tissue and time-dependent changes. MMP-13 and TIMP-1 mRNA levels were markedly upregulated in both tissues, whereas COX-2 and IL-1beta predominantly increased in tendon. Both hyaluronan synthase (HAS) 2 and 3 exhibited increases in mRNA levels in tendon tissue after injury, HAS 2 being more pronounced. These findings support the concept that healing in the flexor tendon and the sheath involve different molecular events and that each tissue may require unique modifications if healing is to be enhanced and adhesions reduced.

Buprenorphine misuse among heroin and amphetamine users in Malmo, Sweden: purpose of misuse and route of administration

Buprenorphine misuse by injecting drug users was assessed in a survey of 350 needle exchangers, either amphetamine (57%) or heroin users (42%). 89% of heroin users and 24% of amphetamine users reported using buprenorphine at some time during the previous year. Most users reported illicit acquisition. Among illicit users, 87% of heroin users reported intake for withdrawal treatment or self-detoxification, and 11% for euphoria. Euphoria seeking was more common among amphetamine users (62%, p < 0.001). Intravenous misuse was reported by 43% of illicit users, and snorting by 29%. Sole sublingual intake was more common among heroin users than among amphetamine users (46 vs. 20%, p < 0.05), and less common among patients reporting euphoria seeking (20 vs. 46%, p < 0.05).

Labeling the human skeleton with 41Ca to assess changes in bone calcium metabolism

Bone research is limited by the methods available for detecting changes in bone metabolism. While dual X-ray absorptiometry is rather insensitive, biochemical markers are subject to significant intra-individual variation. In the study presented here, we evaluated the isotopic labeling of bone using 41Ca, a long-lived radiotracer, as an alternative approach. After successful labeling of the skeleton, changes in the systematics of urinary 41Ca excretion are expected to directly reflect changes in bone Ca metabolism. A minute amount of 41Ca (100 nCi) was administered orally to 22 postmenopausal women. Kinetics of tracer excretion were assessed by monitoring changes in urinary 41Ca/40Ca isotope ratios up to 700 days post-dosing using accelerator mass spectrometry and resonance ionization mass spectrometry. Isotopic labeling of the skeleton was evaluated by two different approaches: (i) urinary 41Ca data were fitted to an established function consisting of an exponential term and a power law term for each individual; (ii) 41Ca data were analyzed by population pharmacokinetic (NONMEM) analysis to identify a compartmental model that describes urinary 41Ca tracer kinetics. A linear three-compartment model with a central compartment and two sequential peripheral compartments was found to best fit the 41Ca data. Fits based on the use of the combined exponential/power law function describing urinary tracer excretion showed substantially higher deviations between predicted and measured values than fits based on the compartmental modeling approach. By establishing the urinary 41Ca excretion pattern using data points up to day 500 and extrapolating these curves up to day 700, it was found that the calculated 41Ca/40Ca isotope ratios in urine were significantly lower than the observed 41Ca/40Ca isotope ratios for both techniques. Compartmental analysis can overcome this limitation. By identifying relative changes in transfer rates between compartments in response to an intervention, inaccuracies in the underlying model cancel out. Changes in tracer distribution between compartments were modeled based on identified kinetic parameters. While changes in bone formation and resorption can, in principle, be assessed by monitoring urinary 41Ca excretion over the first few weeks post-dosing, assessment of an intervention effect is more reliable approximately 150 days post-dosing when excreted tracer originates mainly from bone.

AN INTERVENTION PROGRAM FOR UNIVERSITY STUDENTS WHO HAVE PARENTS WITH ALCOHOL PROBLEMS: A RANDOMIZED CONTROLLED TRIAL

AIM

To study the effects of alcohol and coping intervention among University students who have parents with alcohol problems.

METHODS

A total of 82 university students (56 women and 22 men, average age 25) with at least one parent with alcohol problems were included. The students were randomly assigned to one of three programs: (i) alcohol intervention program, (ii) coping intervention program, and (iii) combination program. All programs were manual based and individually implemented during two 2-h sessions, 4 weeks apart. This assessment contained both a face-to-face interview and six self-completion questionnaires; AUDIT, SIP, EBAC, coping with parents' abuse questionnaire, SCL-90 and ISSI. Follow-up interviews were conducted after 1 year.

RESULTS

All participants finished the baseline assessment, accepted and completed the intervention, while 95% of the students completed the 12-month follow-up assessment. The two groups that received alcohol intervention improved their drinking pattern significantly more than the group that did not receive alcohol intervention [change of standardized scores -0.27 (CI -0.53 to -0.03)]. The groups receiving coping intervention did not differ from the group not receiving coping intervention concerning their ability to cope with their parents' alcohol problems. Nor did they differ regarding changes in their own mental health or in their social interaction capacity.

CONCLUSION

The intervention improved drinking patterns in adult children of alcoholics.

Serum interleukin-1 receptor antagonist is an early indicator of colitis onset in Gαi2-deficient mice

AIM: To study the serum concentration of IL-1β, IL-1 receptor antagonist (IL-1Ra) and IL-18 in Gαi2-deficient mice at the age of 6 (healthy), 12 (pre-colitic) and 24 wk (colitic) and in healthy control mice.

METHODS: At the time of killing, serum samples were collected and IL-1β, IL-1Ra and IL-18 levels were measured using enzyme-linked immunosorbent assays.

RESULTS: Serum concentration of IL-1Ra was significantly increased in pre-colitic (median: 524 ng/L; P = 0.02) and colitic (450 ng/L; P  = 0.01), but not in healthy (196 ng/L) Gαi2-deficient mice as compared with controls (217 ng/L). Serum concentrations of IL-1β did not differ between Gαi2-deficient mice and their controls, irrespective of age, IL-18 was significantly increased in colitic, but not in pre-colitic mice compared with controls (510 ng/L vs 190 ng/L; P  = 0.05).

CONCLUSION: The increased serum concentrations of IL-18 and IL-1Ra in established diseases are suggested as markers of ongoing colitis. Interestingly, the significantly increased serum concentration of IL-1Ra in pre-colitic mice is found to be an early marker of disease progression.

Exposure to methylmercury in non-fish-eating people in Sweden

The extensive use of fish meal as a source of protein for poultry and swine may lead to additional exposure to methylmercury (MeHg). We determined the concentration of MeHg and inorganic mercury (I-Hg) in blood and total mercury (T-Hg) in hair in 27 persons (9 men and 18 women, 20-58 years of age) who stated that they had consumed no fish for a period of 2 years or more. The participants answered a food frequency questionnaire and reported their number of dental amalgam fillings. The MeHg concentrations in blood (median, 0.10 microg/L; range, 0.0-1.0 microg/L) were very low and did not constitute a concern for health effects. We also analyzed selenium (Se) in serum. The median concentration was 76 microg/L (range, 53-103 microg/L), which is in agreement with previous studies of the Swedish general population, indicating that the Se status of non-fish-eating individuals is not substantially lower than that of people who include fish in their diet. We found a significant association (P=0.002) between the number of dental amalgam fillings and the I-Hg concentration in blood (median, 0.09 microg/L; range, 0.03-0.57 microg/L). The T-Hg in hair (median, 0.06 mg/kg; range, 0.04-0.32 mg/kg) was significantly associated (R2=0.89; P<0.001) with the MeHg in blood, but not with the I-Hg in blood. Therefore, the T-Hg in hair seems to reflect MeHg exposure and not I-Hg exposure even in persons with no intake of fish.

A 6-month controlled naltrexone study: combined effect with cognitive behavioral therapy in outpatient treatment of alcohol dependence

BACKGROUND

In several studies, patients with alcohol dependence treated with the opioid antagonist naltrexone have shown fewer relapses to heavy drinking than those receiving placebo. An interaction between the naltrexone effect and the type of psychological therapy has been observed.

METHODS

A 6-month, double-blind, placebo-controlled, parallel-group study was performed at 10 different investigation sites. After a placebo run-in period of 1 week, 118 patients were randomized into 4 treatment groups-50 mg of naltrexone daily or placebo in combination with either cognitive behavioral therapy (CBT) or supportive therapy. The CBT was performed over nine sessions according to the manual of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). The supportive therapy was defined as "the treatment as usual." Alcohol consumption, craving, carbohydrate-deficient transferrin, medication compliance by tablet count, and adverse clinical events were assessed at all visits. Other liver enzymes and psychiatric symptoms were also determined.

RESULTS

Ninety-one (77%) patients completed the study, and 92 (78%) were 80% compliant with the medication regimen. A lower percentage of heavy-drinking days was shown in the naltrexone group (p = 0.045) compared with the placebo group, as was a lower craving score (p = 0.029). These results are supported by the lower levels of liver enzyme activities (p < 0.010 for aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyltransferase), but not by the carbohydrate-deficient transferrin levels, in the naltrexone group. The mean time period before the first day of heavy drinking was longer for the group treated with CBT (p = 0.010), especially in combination with naltrexone (p = 0.007). Naltrexone was well tolerated, and no patients discontinued the study due to side effects.

CONCLUSIONS

This study supports the effect of naltrexone in outpatient treatment of alcohol dependence and suggests that a beneficial interaction effect with CBT can be expected.

Methyl mercury and inorganic mercury in Swedish pregnant women and in cord blood: influence of fish consumption

We studied exposure to methyl mercury (MeHg) in Swedish pregnant women (total mercury [T-Hg] in hair) and their fetuses (MeHg in cord blood) in relation to fish intake. The women were recruited at antenatal care clinics in late pregnancy to participate in an exposure study of environmental pollutants. Fish consumption was evaluated using food frequency questionnaires including detailed questions on fish consumption. In addition, we determined inorganic mercury (I-Hg) and selenium (Se) in cord blood. On average, the women consumed fish (all types) 6.7 times/month (range 0-25 times/month) during the year they became pregnant. They reported less consumption of freshwater fish--species that might contain high concentrations of MeHg--during than before pregnancy. T-Hg in maternal hair (median 0.35 mg/kg; range 0.07-1.5 mg/kg) was significantly associated (R2 = 0.53; p < 0.001) with MeHg in cord blood (median 1.3 microg/L; range 0.10-5.7 microg/L). Both hair T-Hg and cord blood MeHg increased with increasing consumption of seafood (r = 0.41; p < 0.001 and r = 0.46; p < 0.001, respectively). Segmental hair analysis revealed that T-Hg closer to the scalp was lower and more closely correlated with MeHg in cord blood than T-Hg levels in segments corresponding to earlier in pregnancy. We found a weak association between Se (median 86 microg/L; range 43-233 microg/L) and MeHg in cord blood (r = 0.26; p = 0.003), but no association with fish consumption. I-Hg in cord blood (median 0.15 microg/L; range 0.03-0.53 microg/L) increased significantly with increasing number of maternal dental amalgam fillings.

Metals and women's health

There is a lack of information concerning whether environmental-related health effects are more or less prevalent or manifested differently in women compared to men. Previously, most research in the area of toxicology and environmental and occupational health involved male subjects. The present work aims at reviewing exposure and health effects of cadmium, nickel, lead, mercury, and arsenic manifested differently in women than in men. The gender difference in exposure to nickel results in a much higher prevalence of nickel allergy and hand eczema in women than in men. The internal cadmium dose is generally higher in women than in men, due to a higher gastro-intestinal absorption at low iron stores. This was probably one major reason why Itai-itai disease was mainly a woman's disease. Yet, data are sparse regarding the risk for women relative to men to develop cadmium-induced kidney damage in populations exposed to low levels of cadmium. Lead is accumulated mainly in bone and increased endogenous lead exposure has been demonstrated in women during periods of increased bone turnover, e.g., menopause. Both lead and mercury exposure in pregnant women has to be kept low in order to prevent neurodevelopment effects in the developing fetus and child. Limited data indicate that women are more affected than men following exposure to methylmercury at adult age, while males seem to be more sensitive to exposure during early development. Regarding arsenic, some data indicate gender differences in the biotransformation by methylation, possibly also in susceptibility to certain arsenic-related cancers. Obviously, gender-related differences in exposure and health effects caused by metals are highly neglected research areas, which need considerable focus in the future.