Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Endpoint comparison for bone mineral density measurements in North Central Cancer Treatment Group cancer clinical trials N02C1 and N03CC (Alliance)

Bone mineral density (BMD) measurement can vary depending upon anatomical site, machine, and normative values used. This analysis compared different BMD endpoints in two clinical trials. Trial results differed across endpoints. Future clinical trials should consider inclusion of multiple endpoints in sensitivity analysis to ensure sound overall study conclusions.

INTRODUCTION

Methodological issues hamper efficacy assessment of osteoporosis prevention agents in cancer survivors. Osteoporosis diagnosis can vary depending upon which bone mineral density (BMD) anatomical site and machine is used and which set of normative values are applied. This analysis compared different endpoints for osteoporosis treatment efficacy assessment in two clinical studies.

METHODS

Data from North Central Cancer Treatment Group phase III clinical trials N02C1 and N03CC (Alliance) were employed involving 774 patients each comparing two treatments for osteoporosis prevention. Endpoints for three anatomical sites included raw BMD score (RawBMD); raw machine-based, sample-standardized, and reference population-standardized T scores (RawT, TSamp, TRef); and standard normal percentile corresponding to the reference population-standardized T score (TPerc). For each, treatment arm comparison was carried out using three statistical tests using change and percentage change from baseline (CB, %CB) at 1 year.

RESULTS

Baseline correlations among endpoints ranged from 0.79 to 1.00. RawBMD and TPerc produced more statistically significant results (14 and 19 each out of 36 tests) compared to RawT (11/36), TSamp (8/36), and TRef (7/36). Spine produced the most statistically significant results (26/60) relative to femoral neck (20/60) and total hip (13/60). Lastly, CB resulted in 44 statistically significant results out of 90 tests, whereas %CB resulted in only 15 significant results.

CONCLUSIONS

Treatment comparisons and interpretations were different across endpoints and anatomical sites. Transforming via sample statistics provided similar results as transforming via reference or machine-based norms. However, RawBMD and TPerc may be more sensitive to change as clinical trial endpoints.

Disease-free ovarian cancer patients report severe pain and fatigue over time: prospective quality of life assessment in a consecutive series

objective: Among ovarian cancer patients, cancer treatment is aggressive and yet survival is often so limited; hence, this study sought to measure quality of life with the ultimate goal of identifying ways of improving it over the duration of these patients' lives.

MATERIALS AND METHODS

The medical records of all ovarian cancer patients who received some/all of their initial chemotherapy at the Mayo Clinic in Rochester, Minnesota from late 2010 through 2012 were reviewed. Patient-reported quality of life was derived from the following ten-point linear analogue scale questions which had been administered to all patients: 1) How would you describe your degree of pain, on average? 2) How would you describe your level of fatigue, on average? 3) How would you describe your overall quality of life? Quality of life data were censored upon cancer recurrence.

RESULTS

Among 59 eligible patients, the median cumulative interval during which quality of life was serially assessed was 1.15 years (range: three months, 3.2 years). Area under the curve for pain, fatigue, and global quality of life showed no statistically significant differences between patients treated with dose-dense chemotherapy with carboplatin/paclitaxel (n = 10) versus three-week chemotherapy with carboplatin/paclitaxel (n = 36) versus other (n = 13). Although pain, fatigue, and global quality of life improved over time, 35 of 59 (59%) patients reported grade 4 or worse pain during follow up, and 47 of 59 (80%) reported grade 4 or worse fatigue (higher scores denote worse pain or fatigue). After completion of cancer treatment, 30 (51%) described grade 4 or worse pain or fatigue. The most common pain site was the abdomen/pelvis, followed by the back, followed by the hands, feet, fingers, and toes.

CONCLUSION

In ovarian cancer patients who remain cancer-free, severe pain and fatigue occur years after cancer treatment. Further research should focus on how best to address these symptoms.

Abstract P2-14-10: Self Reported Cognitive Function in Breast Cancer Survivors: A 12 Month Longitudinal Descriptive Study

Background: Changes in cognitive function are commonly reported in breast cancer (BC) survivors. Longitudinal studies have only recently been completed and are few. In particular, long term studies are lacking. The purpose of this abstract is to describe self-reported cognitive changes in women before the start, or after the first cycle of chemotherapy, through 12 months.

Methods: The data for this analysis were collected as part of a placebo-controlled randomized trial evaluating ginkgo biloba for the prevention of cognitive decline during adjuvant chemotherapy for BC. As there was no evidence that gingko biloba impacted cognitive function in any way, the sample was combined. Descriptive statistics were calculated to obtain the percent of women reporting worse perceived functioning or changes in their cognitive function at the start of chemotherapy, at the completion of treatment, and at 6, 12 and 24 months later (24 month data still being analyzed). 210 women, mostly white and mostly beginning anthracycline based chemotherapy, completed self report measures of cognition throughout the study. Women rated 10 areas of functioning by choosing a number from 1, signifying “functioning extremely less than normal”, to 7, signifying “extremely better than normal”. A score of 4 represented functioning perceived as “normal” for the respondent. Results: At baseline and after chemotherapy, the means for all 10 self reported cognitive items indicated “less than normal” functioning. Areas with the worst functioning included memory, ability to think clearly, staying focused, and planning ahead. At 6 and 12 months after chemotherapy, a percentage of participants reported worse functioning compared to baseline in every area. Changes in functioning are in the table below.

Table 1

At 12 months, the mean for only 4 items indicated these areas were at “normal” functioning. These were the ability to learn, solve problems, react quickly and balance a checkbook.

Discussion: For a subgroup of women, cognitive changes continue to worsen throughout 12 months and for many, perceived deficits remain.

Areas most negatively impacted relate to attention, memory and executive function. Future research should focus on identifying predictors of worse functioning and continued research is needed to elucidate targets for intervention research to prevent unwanted cognitive changes.

Joint NABTC + NCCTG prognostic factors analysis for high grade recurrent glioma

2075

Background: Multiple variables may impact endpoints used to assess therapeutic efficacy for patients with recurrent gliomas. To identify prognostic factors for each of 3 outcome variables, a master analysis file was constructed by pooling datasets summarizing key baseline factors and outcomes obtained in 15 North Central Cancer Treatment Group (NCCTG) trials (n=583, 1980–2004) and 12 North American Brain Tumor Consortium (NABTC) trials (n=596, 1998–2002). Methods: In addition to traditional variables (gender, age, performance score (PS), race, extent of primary resection, year of study entry, last known histology, time since initial diagnosis, baseline steroid use, prior chemotherapy (Y/N), prior nitrosoureas, baseline anticonvulsant use), we investigated prior t (TMZ), number of relapses, academic vs. community site and low grade at initial diagnosis. Outcome variables were: (1) overall survival (OS), (2) progression free survival (PFS) and (3) PFS6 = proportion of patients alive and progression-free 6 months after start of treatment. For all 3 endpoints, Classification and Regression Tree (CART) models and bootstrap samples were used to identify prognostic variables and to look for evidence of interactions among the independent variables affecting outcome. Results: For all outcomes the initial CART analysis selected last known grade (4 vs. 3) as the most important variable. Additional factors selected as predicting poor prognosis differed with grade and outcome measure and included prior TMZ, longer time since primary diagnosis, older age and poor PS. Community vs. academic was not a strong predictor in any of the models nor was low grade at initial diagnosis. Additional analyses are planned to better describe the impact of all the variables on outcome, including use of Cox models and logistic models considering all baseline variables with backwards selection. Conclusions: The results from analyses to date are consistent with current thinking that last known histology (grade) is an important factor. Time since initial diagnosis is likely a surrogate for number of relapses. More definitive conclusions await the completion of ongoing analyses.

No significant financial relationships to disclose.

The efficacy of lamotrigine in the management of chemotherapy-induced peripheral neuropathy: A phase III randomized, double blind, placebo-controlled NCCTG trial, N01C3

8530

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common dose limiting complication of chemotherapy. Lamotrigine (an anti-convulsant drug) appears to have some benefit when used to treat pain from neuropathy due to various etiologies. Based on these data, we conducted a phase III randomized placebo controlled study to determine the efficacy of lamotrigine in treating symptoms from CIPN. Methods: Patients with CIPN for 1 month or more were randomly assigned to lamotrigine (target dose 300 mg/day, increased by 50 mg/2 weeks) or placebo for 10 weeks. The co-primary endpoints were differences in average CIPN symptoms assessed by pro-rated area under the curve (AUC) of a numerical pain rating scale (NRS) and the Eastern Cooperative Oncology Group sensory neuropathy (ESN) scale. Accrual of 60 patients per group provided t-tests with 80% power to detect a difference of 0.57 standard deviation for each co-primary endpoint (moderate effect size) with a type I error of 0.025. Results: 131patients were enrolled, with complete data available for analysis in 93 (72%). Analyses were limited to this cohort but will be updated. Chemotherapy drugs considered to be causative of the CIPN were vinca alkaloids (30%), taxanes (25%), platinum-agents (7%), combinations (34%), and others (3%). Patients were equally matched with regards to baseline characteristics. Patients who enrolled had severe symptoms, with a baseline median ESN at enrollment of 3 (out of 3) in both groups. Toxicities were similar in both groups, however, more patients discontinued lamotrigine due to toxicities/refusals than those on placebo (32% vs 13% resp; p=0.04) and were therefore less likely to complete the 10 weeks therapy (60% vs. 78% resp, p=0.08). Average AUC of NRS score for patients on lamotrigine and placebo was 30.5 and 33.7 resp (p=0.48). The corresponding average AUC of the ESN scores were 12.4 and 14.5 (p=0.23). The proportions of patients with a 10 point (of 100) improvement in worst pain score (39% vs 36%) and a 1 point change in ESN (25% vs 27%) were similar between the lamotrigine and placebo arms, resp. Conclusions: These results suggest that lamotrigine is not effective for managing pain and symptoms due to CIPN.

No significant financial relationships to disclose.

Initially elevated osteoprotegerin serum levels may predict a perioperative myocardial lesion in patients undergoing coronary artery bypass grafting

OBJECTIVE

We investigated whether osteoprotegerin (OPG), an important regulator in the genesis of arteriosclerosis and bone formation, is able to identify patients at risk for perioperative myocardial infarction measured as cardiac troponin I (cTNI) and signs of myocardial ischemia in the electrocardiogram after coronary artery bypass grafting (CABG).

DESIGN

Observational study.

SETTING

Post-surgical intensive care unit of a tertiary care center.

PATIENTS

Ninety-seven patients undergoing elective CABG.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

OPG and cTNI were measured before and 24 hrs after CABG. Additionally, cTNI was measured after 12 hrs. Electrocardiography was done before and immediately after CABG. OPG before CABG (OPGpre) measurements correlated with cTNI measurements after 12 hrs (cTNI12) (r = 0.56; p < .0001) and with cTNI measurements after 24 hrs (cTNI24) (r = 0.77; p < .0001). OPGpre measurements correlated with electrocardiographic findings after surgery (r = 0.65; p < .0001). There was a positive correlation between OPGpre value and the number of bypasses (r = 0.95; p < .0001). A strong correlation was found between OPGpre and homocysteine (r = 0.96; p < .0001). The median OPG presurgical level for the four patients with cardiac complications was found to be notably elevated (28.1 [26.6/31.0] pmol/L) in comparison with that for patients without complications (10.2 [3.7/16.9] pmol/L).

CONCLUSIONS

OPG appears to be a useful marker for estimating risk for perioperative myocardial infarction in patients undergoing CABG, as demonstrated by signs of ischemia on electrocardiography.

Patients with reconstruction of craniofacial or intraoral defects: development of instruments to measure quality of life

Patients with reconstruction of craniofacial or intraoral defects experience a profound impact on their quality of life (QOL). This impact on QOL is influenced by the patients' medical conditions and the treatment interventions. Instruments to measure general QOL have been available for many years. A major criticism of QOL instruments is that too often the questions are not specific to the particular problems of a disease or condition. A search of the literature regarding QOL measurement for patients with maxillofacial implant-supported prostheses produced a short list of instruments, none of which were sufficiently developed or suited to the patients involved in reconstructive treatment. This study was designed to develop pretreatment and posttreatment questionnaires for measuring QOL for patients with reconstruction of a craniofacial defect and patients with reconstruction of loss of specific intraoral structures utilizing an implant-supported prosthesis (e.g., severe resorption of the maxilla or mandible or both). The goal was to develop brief, targeted instruments for this specific patient population. The produced instruments were sensitive and easy to administer and score, and no disruption of clinical care occurred with the administration of the questionnaires. The instruments were used with equal success both in face-to-face interviews and via mail.

A North Central Cancer Treatment Group phase II trial of topotecan in relapsed gliomas

Current systemic treatment options for patients with relapsed gliomas are limited. The topoisomerase I inhibitor topotecan has demonstrated broad antitumor activity in both preclinical studies as well as a number of phase I and II trials in humans. Studies in primates have shown good cerebrospinal fluid levels of topotecan following systemic administration. We therefore performed this phase II trial in patients who developed evidence of progressive glioma after definitive radiation therapy. Patients were treated with 1.5 mg/m2 intravenously daily for 5 consecutive days repeated every three weeks. For patients who had received prior nitrosourea-containing chemotherapy, the starting dose was 1.25 mg/m2. Thirty-three patients were entered on this study. All patients were eligible and evaluable for both response and toxicity. Seven patients experienced grade 4 leukopenia with 2 of these patients dying of infection-related complications. Six of these seven patients were not taking anticonvulsants during treatment. Nine patients developed grade 3-4 thrombocytopenia, seven of whom were not taking anticonvulsants. Nonhematologic side effects were infrequent and manageable. One patient experienced a partial response to this treatment for an overall response rate of 3% (95% binomial confidence interval 0.3%-20.4%). The median time to progression was 14.9 weeks and median survival 19.9 weeks. Topotecan at this dose and schedule showed no substantial activity in relapsed gliomas.

Efficacy of neuroradiological imaging, neurological examination, and symptom status in follow-up assessment of patients with high-grade gliomas

OBJECT

It is standard practice for the oncological follow-up of patients with brain tumors (especially in the setting of clinical trials) to include neurological examination and neuroradiological studies such as computerized tomography (CT) or magnetic resonance (MR) imaging in addition to evaluation of the patients' symptomatology and performance score. The validity of this practice and its impact on the welfare of patients with high-grade gliomas has not been adequately assessed. The purpose of this study is to provide such an assessment.

METHODS

The authors studied 231 similarly treated patients who were participating in three prospective North Central Cancer Treatment Group or Mayo Clinic trials who developed progressive disease during follow up. According to the protocol, the symptom status, performance score, results of neurological examination, and CT or MR status were recorded prospectively in each patient at each evaluation (every 6-8 weeks). At progression, 177 (77%) of 231 patients experienced worsening of their baseline symptoms or they developed new ones. In the remaining 54 asymptomatic patients (23%), neuroradiological imaging revealed the progression. Asymptomatic progression was more likely to be detected on MR imaging compared with CT studies (p < 0.01). In no asymptomatic patient was progression detected on neurological examination alone. The median survival time after tumor recurrence was 13.3 weeks in symptomatic patients compared with 41.7 weeks in the asymptomatic group (p < 0.0001). Asymptomatic patients were more aggressively treated, with surgery (p < 0.0001) and second-line chemotherapy (p < 0.0002). Multivariate analysis of survival time following first progression by using both classification and regression trees and Cox models showed that treatment at recurrence was the most important prognostic variable.

CONCLUSIONS

Symptoms are the most frequent indicators of progression in patients with high-grade gliomas (77%). All asymptomatic progressions were detected on neuroradiological studies; MR imaging was more likely than CT scanning to reveal asymptomatic recurrences. Survival after disease progression was significantly longer in asymptomatic patients and could be related both to treatment following progression and to other favorable prognostic factors such as performance score.

Physical, psychological and social well-being of women with breast cancer: the influence of disease phase

While research exists on the well-being of women during a specific phase of breast cancer, little research exists in which researchers utilized the same instruments to examine differences in women's well-being, based on the phase of their breast cancer. Using a trajectory framework, the purpose of this study is to examine the differences in the physical and social well-being of women during the following breast cancer states: newly diagnosed, adjuvant therapy, stable disease and recurrent disease. The convenience sample consisted of 35 women newly diagnosed with breast cancer, 52 women with breast cancer undergoing adjuvant therapy, 84 women whose breast cancer was considered stable and 64 women with recurrent breast cancer. Participants completed a packet of questionnaires which contained a demographic questionnaire, Short Form-36 (SF-36) Health Survey, a researcher designed (RD) questionnaire, Cancer Rehabilitation Evaluation System-Short Form (CARES-SF) and the Brief Symptom Inventory (BSI). Descriptive statistics, analysis of variance, and general linear F-tests were used to analyze the data. Differences were found across phases of disease on various subscales, including those representing perceived health states, overall impact, medical interactions, physical function, role function, fatigue, pain, social function and satisfaction with health. No significant differences were found between groups on the BSI subscales with the exception of somatization, global psychosocial measures, sexual and marital relation subscales. While individuals with recurrent disease often experienced more difficulties with their well-being than women in the other groups, women newly diagnosed and in the adjuvant group experienced more difficulties in select areas of well-being when compared with women in the stable group. Health care professionals need to recognize differences between groups to better meet the needs of patients with a breast cancer diagnosis.

A multidisciplinary healthcare delivery model for women with breast cancer: patient satisfaction and physical and psychosocial adjustment

PURPOSE/OBJECTIVES

To compare satisfaction with health and healthcare and physical and psychosocial adjustment of women who received their medical-oncology consultation in the hospital with that of women who received their consultation as part of a multidisciplinary outpatient clinic.

DESIGN

Descriptive, correlational.

SETTING

A large tertiary medical center in the Midwestern United States.

SAMPLE

55 of 66 women with newly diagnosed breast cancer who received their medical-oncology consult in the hospital and 66 of 102 women with newly diagnosed breast cancer who received their consult in the multidisciplinary outpatient clinic. Median participant age was 62 years in the hospital consultation group and 61 years in the outpatient group.

METHODS

Participants completed the Cancer Rehabilitation Evaluation System-Short Form and a researcher-designed satisfaction questionnaire.

MAIN RESEARCH VARIABLES

Satisfaction with care and physical and psychosocial adjustment.

FINDINGS

Women in the multidisciplinary outpatient clinic group reported significantly higher levels of physical function (p = 0.003) and satisfaction with their health (p < 0.01), physician (p < 0.001), and nursing care (p = 0.004) than women in the hospital group.

CONCLUSIONS

This study demonstrated the positive benefits of a multidisciplinary team approach in which a concerted effort is placed on providing information and psychosocial support in the outpatient clinic setting.

IMPLICATIONS FOR NURSING PRACTICE

These findings point to the benefits of establishing a multidisciplinary clinic in the outpatient setting.

Pilot evaluation of venlafaxine for the treatment of hot flashes in men undergoing androgen ablation therapy for prostate cancer

PURPOSE

Hot flashes may be a significant clinical problem in men undergoing androgen deprivation therapy with gonadotropin releasing hormone analogues, oral antiandrogens and/or surgical bilateral orchiectomy. Anecdotal information suggests that a low dose of the relatively new antidepressant venlafaxine may abrogate this clinical problem. We developed the current pilot trial to investigate further whether venlafaxine alleviates hot flashes in such men.

MATERIALS AND METHODS

The study included men in whom substantial hot flashes were associated with androgen deprivation therapy. Hot flash data were collected by daily diary questionnaires during a 1-week baseline period when no therapy was given for hot flashes, as well as for the next 4 weeks when study participants received 12.5 mg. venlafaxine orally twice daily. Questionnaires completed during the 4 weeks ofvenlafaxine therapy also documented data on potential drug toxicity.

RESULTS

Of the 16 evaluable patients who completed the study 10 (63%) had a greater than 50% decrease in hot flash score, as determined using the formula, frequency x severity, by week 4 of treatment versus the baseline week. Median weekly hot flash scores decreased 54% from baseline during week 4 of venlafaxine therapy. Average incidence of severe and very severe hot flashes was reduced from 2.3 daily at baseline to 0.6 daily at study end (p = 0.003). Therapy was generally well tolerated.

CONCLUSIONS

Venlafaxine hydrochloride appears to represent an efficacious new method for alleviating hot flashes in men undergoing androgen ablation therapy. Further evaluation of this compound for alleviating hot flashes is indicated.

Lack of effect of coumarin in women with lymphedema after treatment for breast cancer

BACKGROUND

Lymphedema of the arms can be a serious consequence of local and regional therapy in women with breast cancer. Coumarin has been reported to be effective for the treatment of women with lymphedema; we undertook a study in which we attempted to replicate those findings.

METHODS

We studied 140 women with chronic lymphedema of the ipsilateral arm after treatment for breast cancer. The women received 200 mg of oral coumarin or placebo twice daily for six months and then the other treatment for the following six months. The end points of the study consisted of the volume of the arm (calculated from measurements of hand and arm circumference) and the answers on a questionnaire completed by the patient about symptoms potentially related to lymphedema.

RESULTS

The volumes of the arms at 6 and 12 months, were virtually identical, regardless of whether coumarin or placebo was given first. After six months, the average volume of the affected arm increased by 21 ml during placebo treatment and 58 ml during coumarin treatment (P=0.80). In addition, answers to patient-completed questionnaires were similar in the two treatment groups. After six months only 15 percent of the women in the coumarin group and 10 percent of those in the placebo group reported that the study medication had helped a moderate or large amount (P=0.19). Coumarin was well tolerated, except that it resulted in serologic evidence of liver toxicity in 6 percent of the women.

CONCLUSIONS

Coumarin is not effective therapy for women who have lymphedema of the arm after treatment for breast cancer.

Quality of life and pain in patients with recurrent breast and gynecologic cancer

Pain is a central factor affecting quality of life for the cancer patient. This descriptive study was designed to explore the relationship between pain and several factors affecting quality of life. The factors explored included physical and social functioning, emotional health, and spiritual commitment in women with recurrent breast or gynecologic cancer. Pain frequency, amount, and interference with activities were found to correlate more strongly with objective measures of quality of life (i.e., physical and social functioning) than subjective measures (i.e., psychological or spiritual dimensions).

Prospective evaluation of vitamin E for hot flashes in breast cancer survivors

PURPOSE

Hot flashes represent a substantial clinical problem for some breast cancer survivors. Although estrogen or progesterone preparations can alleviate these symptoms in many patients, concern remains regarding the use of hormonal preparations in such women. Thus, there is a perceived need for nonhormonal treatments for hot flashes for breast cancer survivors. Based on anecdotal evidence that vitamin E was helpful, we designed a trial to investigate this matter.

METHODS

We developed and conducted a placebo-controlled, randomized, crossover trial where, after a 1 week baseline period, patients received 4 weeks of vitamin E 800 IU daily, then 4 weeks of an identical-appearing placebo, or vice versa. Diaries were used to measure potential toxicities and hot flashes during the baseline week and the two subsequent 4-week treatment periods.

RESULTS

The 120 patients evaluated for toxicity failed to show any. The 105 patients who finished the first treatment period showed a similar reduction in hot flash frequencies (25% v 22%; P = .90) for the two study arms. A crossover analysis, however, showed that vitamin E was associated with a minimal decrease in hot flashes (one less hot flash per day than was seen with a placebo) (P < or = .05). At the study end, patients did not prefer vitamin E over the placebo (32% v 29%, respectively).

CONCLUSION

Although this trial was able to show a statistically significant hot flash reduction with vitamin E compared to a placebo, the clinical magnitude of this reduction was marginal.

An evaluation of postoperative follow-up tests in colon cancer patients treated for cure

BACKGROUND

Currently patients with colon cancer who are potentially cured by surgery are followed periodically with physical examinations, blood tests and imaging studies to detect tumor recurrence early, on the presumption that intervention can effect outcome. There is little information to indicate whether frequent visits to the doctor's office or frequent testing improves survival or quality of life.

METHODS

Ninety-eight patients with resected stage B2, B3 or C (modified Astler-Coller) colon cancer who developed recurrent disease while enrolled in prospective adjuvant trials at Mayo Clinic sponsored by the North Central Cancer Treatment Group were studied to evaluate the utility of follow-up tests to detect the first recurrence of colon cancer and the outcome following various interventions for these recurrences. These patients had a history, physical examination, complete blood count, chemistry panel and chest x-ray approximately every 3-4 months in the 1st year and then every 6-12 months thereafter for a total of 5 years. Bowel evaluation was done at 6 months, 12 months and annually thereafter. In addition, a minority of patients had carcinoembryonic antigen (CEA) testing, and radioisotope liver scans at various intervals.

RESULTS

Symptoms signaled the diagnosis of recurrent disease in 55 patients, physical examination in 4 patients, and abnormalities in chest x-ray in 18 patients. An elevated CEA was the initial abnormal test in 5 patients, abnormal liver scans in 5 patients, elevated liver function tests in 6 patients and laparotomy for other reasons in 2 patients. Hemoglobin, barium enema, and fecal blood testing were useful in 1 patient each. Thirty-one percent of recurrences were diagnosed between scheduled visits. In our series, histories, physical examinations, and chest x-rays led to the detection of 79% of the recurrences while liver function tests, liver scans and CEAs led to the detection of 16% of recurrences. Sixteen patients underwent resection for cure for their first recurrence; the diagnosis of recurrence was signaled by symptoms in 6 patients, chest x-ray in 6 patients and abnormal liver function tests, CEA, hemoglobin, and laparotomy for colostomy closure in 1 patient each.

CONCLUSIONS

The majority of tumor recurrences were detected by symptoms, physical examinations and chest x-rays. Testing for asymptomatic tumor recurrences during the 1st follow-up year is likely to be much less fruitful for detecting resectable recurrences than testing patients in the 2nd through 4th follow-up years. Patients who had a disease recurrence in the 1st postoperative year were less likely to be candidates for curative intent surgery. Lower tumor grade at initial diagnosis correlated both with likelihood of undergoing secondary surgical resection and the chance of doing well following this. These data may be helpful for defining more appropriate follow-up test for detection of tumor recurrence in patients with resected colon cancer.

The psychological impact of modeling in a cancer survivors' fashion show

Our objective was to assess whether cancer survivors can serve as models to promote cancer prevention and screening without suffering psychological discomfort themselves. The disease coping literature suggests that if women knew more about what cancer treatment and life after surviving cancer were like, they would be more likely to accept cancer screening tests. Because cancer survivors are living examples showing that people can survive and thrive after cancer, survivors have the potential to promote cancer screening by teaching others in their community. However, if cancer survivors are to be asked to accept this task, it is essential to demonstrate that this activity does not cause psychological suffering for them. Cancer survivors were invited (n = 31) or volunteered (n = 22) to model in a cancer survivors' fashion show. All were asked to complete a brief biographical sketch before the event and a convenience subsample was interviewed by a trained ethnographer. A brief questionnaire was mailed to the models after the event. Individuals who did not return the mailed questionnaire were contacted by telephone. Forty-two of the models completed the mailed questionnaire and 10 were contacted by telephone. The models tended to report that the experience was very positive for themselves (mean = 9.0, standard deviation [SD] = 1.3 on a scale of 0 to 10 where 0 is extremely negative and 10 is extremely positive) and for their family and friends who attended the fashion show (mean = 9.1, SD = 1.3 on the same scale). Under the proper conditions, modeling survivorship to others can be a rewarding experience for cancer survivors. While the models are easy to recruit, it remains to be demonstrated that cancer survivors are effective lay advocates for cancer prevention and screening. Medical Subject Headings (MeSH): mammography, recruitment, cancer survivors, psychological effects.

Toxicity evaluation of difluoromethylornithine: doses for chemoprevention trials

This intergroup trial was developed to determine the toxicity of relatively low doses of difluoromethylornithine (DFMO) administered to humans for 1 year. The goal was to find an appropriate DFMO dose for use in human chemoprevention trials. Patients with resected superficial bladder cancers were studied. Following stratification, they were randomized to daily DFMO doses of 0.125, 0.25, 0.5, or 1.0 g/day for a planned period of 1 year. Patients were followed closely for evidence of drug toxicity. Seventy-six patients were evenly randomized (19 per group) to receive each dose of DFMO. Forty-nine patients received DFMO for more than 200 days while 35 received the drug for > or = 350 days. No substantial drug-related toxicity was observed at any dose. DFMO doses of > or = 1 g/day for periods up to 1 year appear to be without significant toxicity in most patients. This dose range may be appropriate for use in future human cancer chemoprevention trials.

Prospective evaluation of a chamomile mouthwash for prevention of 5-FU-induced oral mucositis

BACKGROUND

Stomatitis has been found to be a major dose-limiting toxicity from bolus 5-fluorouracil-based (5-FU) chemotherapy regimens, despite the use of oral cryotherapy. Pursuant to preliminary data which suggested that a chamomile mouthwash might ameliorate this toxicity, a prospective trial was developed to test chamomile in this situation.

METHODS

A Phase III, double-blind, placebo-controlled clinical trial was designed. Patients were entered into the study at the time of their first cycle of 5-FU-based chemotherapy. All patients received oral cryotherapy for 30 minutes with each dose of 5-FU. In addition, each patient was randomized to receive a chamomile or placebo mouthwash thrice daily for 14 days. Stomatitis scores were determined by health care providers and by patients themselves.

RESULTS

There were 164 evaluable and well-stratified patients equally randomized to both treatment groups. There was no suggestion of any stomatitis difference between patients randomized to either protocol arm. There was also no suggestion of toxicity. Subset analysis did reveal unsuspected differential effects between males and females that could not be explained by reasons other than chance.

CONCLUSION

The resultant data from this clinical trial did not support the prestudy hypothesis that chamomile could decrease 5-FU-induced stomatitis.

Utility of follow-up tests for detecting recurrent disease in patients with malignant melanomas

OBJECTIVE

To determine the effectiveness of follow-up tests for signaling recurrences in patients with intermediate- and high-risk malignant melanomas treated with curative intention.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

North Central Cancer Treatment Group.

PATIENTS

A total of 261 patients with resected local (> or = 1.69 mm) and regional nodal malignant melanomas who were enrolled in a single prospective adjuvant trial were studied. All patients were scheduled to be followed up monthly for 2 months, then every 2 months for the first year, every 4 months the second year, every 6 months the next 3 years, and annually thereafter, with each visit consisting of a history, physical examination, complete blood cell count, blood chemistry panel, and a chest x-ray.

RESULTS

Of the 145 evaluable patients who developed recurrent melanomas, 99 patients (68%) developed symptoms that signaled the diagnosis of recurrent disease. Physical examination of asymptomatic patients led to the diagnosis of recurrent disease in 37 patients (26%). The other nine patients (6%) with recurrent disease had abnormal chest x-rays. Laboratory results were never a sole indicator of recurrent disease.

CONCLUSION

The majority of recurrences following resection of primary melanomas are discovered by history and/or physical examination despite the frequent use of other follow-up tests. The present data indicate that routine blood analyses and chest x-rays have limited value in the postoperative follow-up of patients with resected intermediate- and high-risk melanomas.

Regular use of a verbal pain scale improves the understanding of oncology inpatient pain intensity

PURPOSE

This study was undertaken to determine if the daily use of a verbal pain scale could improve the correlation of pain perception between hospitalized oncology patients and their caregivers.

PATIENTS AND METHODS

Hospitalized oncology patients were asked to rate verbally their average pain over the past 24 hours on a scale ranging from 0 to 10. The patients' primary-care physicians and nurses were asked the same question on the same morning after they had evaluated their patients.

RESULTS

During a baseline study, only 64% of caregivers' pain scores were within two points of the respective patient's score. Caregivers tended to underestimate patients' pain scores. Caregivers were alerted to these poor results and then requested to ask each patient daily for the average pain score and record this score on the patient's medical record. Nonetheless, correlation between patients' and caregivers' pain scores remained poor (68% within two points of each other) during a second study. The major reason for the poor results appeared to be because caregivers did not routinely ask patients for pain scores. Subsequently, a renewed, more intensive educational effort was undertaken and a third study was conducted. During the third study, 85% of caregivers' and patients' pain scores were within two points of each other (P = .001 when compared with baseline).

CONCLUSION

The enforced use of a simple verbal pain assessment tool appears to improve caregiver's understanding of the pain status of hospitalized oncology patients.

Randomized trial of a chlorhexidine mouthwash for alleviation of radiation-induced mucositis

PURPOSE

To determine whether a chlorhexidine mouthwash could alleviate radiation-induced oral mucositis.

PATIENTS AND METHODS

Patients scheduled to receive radiation therapy to include greater than one third of the oral cavity mucosa were selected for study. Following stratification, they were randomized in a double-blind manner to receive a chlorhexidine mouthwash or a placebo mouthwash. Both groups were then similarly evaluated for mucositis and mouthwash toxicity.

RESULTS

Twenty-five patients were randomized to receive the chlorhexidine mouthwash, while 27 received the placebo mouthwash. Treatment arms were well balanced. There was a trend for more mucositis and there was substantially more toxicity (eg, mouthwash-induced discomfort, taste alteration, and teeth staining) on the chlorhexidine arm.

CONCLUSION

In contrast to the prestudy hypothesis that a chlorhexidine mouthwash might provide benefit for patients receiving radiation therapy to the oral mucosa, this study provides strong evidence suggesting that a chlorhexidine mouthwash is detrimental in this clinical situation.

Do American oncologists know how to use prognostic variables for patients with newly diagnosed primary breast cancer?

PURPOSE

This project was designed to investigate how American medical oncologists actually use prognostic information to treat primary breast cancer patients, and to study their difficulties in combining complex and sometimes contradictory information.

METHODS

A simple 2-page questionnaire was faxed in May and June 1993 to a sample of American medical oncologists who were members of the American Society of Clinical Oncology (ASCO).

RESULTS

When presented with simple case histories of patients with newly diagnosed invasive breast cancer and asked to assess prognosis on the basis of tumor size, number of involved axillary nodes, patient age, estrogen receptor level, and progesterone receptor level, there was a wide divergence of opinions about the probability of disease-free survival at 10 years (both for cases in which the patient received no adjuvant therapy and for those in which the patient did receive such therapy). The use of additional prognostic data (such as S-phase, tumor histologic and nuclear grading, and cathepsin D status) did not refine the estimates, but led to an equal or greater dispersion of estimates of prognosis.

CONCLUSION

There is a clear need for tools to help oncologists integrate prognostic information for primary breast cancer patients. Such tools might lead to greater accuracy and uniformity of prognostic estimates. Such tools might also help make clear what prognostic tests are worth using for routine clinical practice.

Circulating cellular immune response to oral immunization of humans with cholera toxin B-subunit

Peripheral blood mononuclear cells were taken from subjects before and after oral immunization with cholera toxin B-subunit. Cells obtained from naive volunteers before immunization did not proliferate in vitro to B-subunit. Oral immunization induced a proliferative response in all volunteers with a peak stimulation index of 20, and was detected up to 1 year later. The proliferative response kinetics suggest the appearance in the blood of primed T cells from the gut coinciding with the disappearance of primed plasmablasts from the circulation, supporting the concept of a common mucosal immune system in man for T and B cells.

Cloning, nucleotide sequence and heterologous expression of the protective outer-membrane protein P.68 pertactin from Bordetella bronchiseptica

The prn gene encoding the 68 kDa protective outer-membrane protein of Bordetella bronchiseptica (P.68 pertactin) was cloned, sequenced and expressed in Escherichia coli. The gene was isolated by DNA:DNA hybridization experiments using a radioactively-labelled fragment of the homologous prn gene from Bordetella parapertussis. DNA sequence analysis reveals that the gene is capable of encoding a protein with a molecular mass of 93996 Da (P.94); this precursor molecule is processed to form the P.68 antigen on the surface of B. bronchiseptica. Heterologous expression of the full-length gene encoding P.94 in Escherichia coli results in similar processing, with the P.68 antigen targeted to the bacterial outer membrane. Comparison of P.94 with the P.93 and P.95 precursors, encoding homologous proteins from Bordetella pertussis and B. parapertussis, shows a high degree (greater than 90%) of homology. The major differences between all three proteins occur in the number of repeats of the two families (Gly-Gly-Xaa-Xaa-Pro)n and (Pro-Gln-Pro)n of reiterated sequence motifs.

The early cellular and humoral immune response to primary and booster oral immunization with cholera toxin B subunit

The immune response to cholera toxin B subunit given orally was studied in 13 human volunteers. A serum IgG and IgA antitoxin response was observed, which was boosted by a second immunization. Using an immunospot assay, cells spontaneously secreting anti-toxin IgG and IgA, but not IgM appeared transiently in the blood after immunization. There were 105 IgG- and 87 IgA-secreting cells per 2 x 10(6) mononuclear cells 7 days after the first immunization, and 282 IgG- and 413 IgA-secreting cells 5 days after the second immunization. A polyclonal increase in total IgM-secreting cells was observed. Few anti-toxin-secreting cells were observed in the bone marrow at the peak of the circulating cell response, which could be accounted for by contamination of the sample with peripheral blood, suggesting that the bone marrow is not a significant site of anti-toxin-secreting cells after oral immunization.

Biologic and protective properties of the 69-kDa outer membrane protein of Bordetella pertussis: a novel formulation for an acellular pertussis vaccine

A combination of the 69-kDa outer membrane protein and filamentous hemagglutinin (FHA), both isolated from lymphocytosis promoting factor (LPF; pertussis toxin) minus mutants of Bordetella pertussis, is protective in the mouse intracerebral challenge potency (Kendrick) test. A combination of the same 69-kDa protein and LPF is approximately 15 times less effective. These data suggest that, surprisingly, the 69-kDa protein in tandem with FHA is the most relevant combination for mouse protection; consequently such a combination may be a more suitable acellular pertussis vaccine candidate than the LPF/FHA combinations, which have never been satisfactorily protective in the mouse test. Preparation of samples of the 69-kDa protein of acceptable protective quality remains difficult. Attempts were made to screen the most suitable batches of the preparations by exploiting some recently discovered properties of the 69-kDa protein: the characteristic chromatofocusing pattern of the protein, the affinity for lymphocytes, and the ability to bind to nicotinamide adenine dinucleotide. None of these tests was able to replace the mouse intracerebral challenge potency test for final quality assessment.

P.70 pertactin, an outer-membrane protein from Bordetella parapertussis: cloning, nucleotide sequence and surface expression in Escherichia coli

The gene prn encoding the outer-membrane protein P.70 (pertactin) from Bordetella parapertussis has been cloned in Escherichia coli and its DNA sequence determined. Analysis of the DNA sequence reveals that the gene has an open reading frame comprising 922 amino acids capable of encoding a protein with a molecular weight of 95,177 (P.95). In vivo processing of this precursor yields a protein with an estimated Mr of 70 kDa (P.70) which is located on the surface of B. parapertussis. Homology between the prn gene from B. parapertussis and that from Bordetella pertussis is 91.3%. The homology is 93% when the protein sequence of P.95 is aligned with that of P.93 from B. pertussis. The major differences between the P.70 pertactin from B. parapertussis and the P.69 pertactin from B. pertussis occur in the number of reiterated units within the repeat motifs found in both proteins; the sequence Gly-Gly-Xaa-Xaa-Pro is repeated four times in the P.70 pertactin, and five times in the P.69 pertactin, while the sequence Pro-Gln-Pro occurs nine times in P.70 pertactin and five times in P.69 pertactin. Cloning of the gene for P.95 in an E. coli expression vector results in the synthesis of a protein that mimics native gene expression in B. parapertussis, i.e. the P.95 protein is synthesized and subsequently processed to yield the P.70 form of the protein on the surface of the cell.

[Asymptomatic myocardial ischemia]

Silent (asymptomatic) myocardial ischemia (SMI) is defined as a transient alteration in myocardial perfusion in the absence of chest pain or the usual anginal equivalents. Patients may be classified as having one of the three types of SMI: type A--totally asymptomatic patients with no history of angina or myocardial infarction; type B--asymptomatic patients with previous myocardial infarction; type C--patients with angina and asymptomatic ischemic episodes. SMI has been found in 2.5% of all healthy males aged 40-59 and in 20% of all postinfarction patients. In type C-patients, 80% has been found to have asymptomatic ischemic episodes in addition to typical angina pectoris. The frequency of SMI may be up to three or four times that of anginal attacks. SMI patients have generally reduced sensitivity to pain an differences in severity an duration of ischemic episodes. Diagnosis is based on screening by means of exercise testing in patients working in specific professions (like pilots, busdrivers etc.), in postinfarction patients and in patients after unstable angina pectoris and after coronary bypass surgery or coronary angioplasty. Prognosis is the same as in asymptomatic ischemia. SMI is an indicator of instability in certain groups of patients (post infarction, after unstable angina pectoris). SMI persisting after medical therapy of unstable angina is associated with adverse short-term-prognosis, therefore coronary surgery or angioplasty is indicated.

Identification of a 68-kilodalton outer membrane protein as the major protective antigen of Bordetella bronchiseptica by using specific-pathogen-free piglets

Maternal antibody to an outer membrane 68-kilodalton (kDa) protein of Bordetella bronchiseptica was shown to be protective in experiments on specific-pathogen-free piglets. After challenge with B. bronchiseptica, 100% (n = 19) control piglets from nonimmunized sows developed pneumonia, coughing, and sneezing, and 74% of the animals developed severe atrophic rhinitis. In 12 piglets from a sow immunized with 68-kDa protein, pneumonia occurred only in 34% of offspring, coughing was reduced, the duration of coughing bouts was shortened, and severe atrophic rhinitis occurred in one animal only (8%). The difference in the occurrence of atrophic rhinitis and of pneumonia in immunized and nonimmunized offspring was statistically significant (P less than 0.05). Sera of protected piglets had high titers (enzyme-linked immunosorbent assay) of antibodies that showed a high specificity for the 68-kDa protein isolated from B. bronchiseptica, whereas their reactivity with an analogous 69-kDa protein isolated from Bordetella pertussis was low or absent. The 68-kDa protein of B. bronchiseptica appeared to be the major protective antigen in B. bronchiseptica infection; however, isolated protein alone did not induce such a solid protection, as observed in a previous study after the application of an effective whole cell vaccine.

Molecular cloning and characterization of protective outer membrane protein P.69 from Bordetella pertussis

Protein P.69 is localized on the outer membrane of Bordetella pertussis and is one of the virulence factors believed to contribute to the disease state of whooping cough. We demonstrate that protein synthesis of P.69 is under genetic control of the vir locus. Using oligonucleotide probes derived from the protein sequence of a cyanogen bromide fragment, we have cloned the gene for P.69 from B. pertussis CN2992. Analysis of the DNA sequence reveals a G + C-rich gene capable of encoding a protein of 910 amino acids with a Mr of 93,478, suggesting that P.69 is a processed form of a larger precursor. In common with some of the genes in the pertussis toxin operon, the sequence CCTGG was found 5' to the ATG initiation codon. At the 3' end, 29 bases after the TAA stop codon, the sequence GTTTTTCCT was found and may have some function in transcription termination. A full-length clone of the gene for P.69 carried by the cosmid pBPI69 was unable to direct the expression of P.69 protein in an Escherichia coli host. The generation of P.69-fusion products allowed the detection of P.69-specific protein products synthesized in E. coli.

Identification of a 69-kilodalton nonfimbrial protein as an agglutinogen of Bordetella pertussis

Cells of Bordetella pertussis BP353, a nonfimbriated Eldering serotype 1.3 strain, were used as an immunogen to produce three monoclonal antibodies, BPE3, BPD8, and BPE8, that agglutinated the immunizing cells, as well as certain other nonfimbriated and fimbriated serotype 3-containing B. pertussis strains. The antibodies did not agglutinate serotype 1 or nontypable B. pertussis cells. These monoclonal antibodies specifically detected a 69-kilodalton (kDa) band on Western blots (immunoblots) containing whole B. pertussis cell lysates of Eldering agglutinogen serotypes 1.3, 1.3.6, 1.2.3.4, and 1.2.3.4.6. This 69-kDa antigen was released from the bacteria by cell incubation for 60 min at 60 degrees C, and it was purified by affinity chromatography with a BPE3-agarose affinity matrix. Purified material was used to produce a polyclonal antiserum that agglutinated all nonfimbriated and fimbriated B. pertussis cells containing serotype 3 agglutinogen. Immunogold electron microscopy and indirect immunofluorescence studies demonstrated that it is an outer membrane constituent but nonfimbrial in appearance. BPE3 did not detect purified fimbriae on Western blots, and antibodies to these fimbriae did not bind to the 69-kDa component. Although B. bronchiseptica and B. parapertussis cells were not agglutinated by the monoclonal antibodies, antigenically similar proteins were detected in extracts of the bacteria. These results identify the 69-kDa protein as a nonfimbrial agglutinogen present on all virulent strains of B. pertussis. The monoclonal antibodies described here should be useful for further studies on the structure and function of this protein.

Correlation of fetal heart rate monitoring and acid-base status with periventricular/intraventricular hemorrhage in the low birthweight neonate

We investigated the correlation of fetal heart rate patterns and fetal acid-base findings with the occurrence of early periventricular/intraventricular hemorrhage and variants. Ninety-five consecutive singleton neonates with birthweights less than or equal to 2000 gm were investigated. One-third of them showed early periventricular/intraventricular hemorrhage or variants. Fetal heart rate scores and umbilical arterial/venous acid-base status showed no correlation with results of scanning. The implications of these findings are discussed.

Adenylate cyclase activity of a 68,000-molecular-weight protein isolated from the outer membrane of Bordetella bronchiseptica

A method was developed which is suitable for the isolation of substantial quantities of outer membrane proteins of Bordetella species in a water-soluble form. The extracted material may then be further fractionated in the absence of detergents by ion-exchange chromatography and preparative flat-bed isoelectrofocusing. These procedures facilitated the isolation of one of the proteins, of molecular weight 68,000, for which the antibody titer correlated with the degree of protection against nasal changes induced in specific-pathogen-free piglets by Bordetella bronchiseptica infection (P. Novotny, M. Kobisch, K. Cownley, A. P. Chubb, and J. A. Montaraz, Infect. Immun. 50:190-198). This protein, which banded between 7.0 and 7.6 pH in preparative isoelectrofocusing, may be further purified with a monoclonal immunosorbent. Immunopurified protein showed adenylate cyclase activity. The enzymatic activity was found to be unstable during processing; i.e., although the crude extract showed up to 150 nmol of cyclic AMP per mg/min, the immunopurified protein showed a maximum of only 200 nmol of cyclic AMP per mg/min. Two strains of B. bronchiseptica, isolated from herds of healthy pigs showing no signs of atrophic rhinitis, did not produce the 68,000-molecular-weight protein and were negative for adenylate cyclase. However, it is not known whether the 68,000-molecular-weight protein is a component of adenylate cyclase or whether it is an unrelated protein associated with this enzyme in some unknown way. Adenylate cyclase activity from culture supernatants of B. bronchiseptica, B. pertussis, and B. parapertussis can be absorbed equally to the same monoclonal immunosorbent.

Evaluation of Bordetella bronchiseptica vaccines in specific-pathogen-free piglets with bacterial cell surface antigens in enzyme-linked immunosorbent assay

The progenies of specific-pathogen-free sows which had been immunized with Bordetella bronchiseptica vaccines of various origin before parturition were challenged intranasally with B. bronchiseptica within 5 days of birth. Sera of piglets were taken weekly and investigated by enzyme-linked immunosorbent assay against a mixture of B. bronchiseptica cell surface antigens containing curled fibers and fimbriae, lipopolysaccharide, and a mixture of proteins mostly derived from the outer membrane. The serological response to this antigenic mixture was paradoxical; the highest titers were obtained with the least effective vaccines. Antibodies which did relate to protection were oriented against the outer-membrane-derived proteins, one of which, of 68,000 molecular weight, appeared to be particularly important for two reasons. First, its concentration within the antigenic mixture was dependent upon cultural conditions; of all the proteins present in virulent strains, it was the first to disappear upon modulation. Second, it was absent from a strain which was unable to induce atrophic rhinitis in specific-pathogen-free piglets. Although all vaccines tested had some beneficial effect on the various clinical manifestations of the disease, only two vaccines were effective (P less than 0.001) in the prevention of nasal pathological changes. These two vaccines also stimulated the highest titers against the 68,000-molecular-weight protein. A mouse protection test utilizing a lethal intraperitoneal challenge failed to monitor the efficacy of vaccines for protection against atrophic rhinitis.

CT of calcified bladder masses

Calcifications observed in bladder lesions are seen on plain films with an incidence of 0.5-7.0%. Four cases of calcification were noted on CT in 38 consecutive bladder scans (10.5%). Calcifications were noted both on the surface, and within the lesions. One of the cases with malakoplakia had calcification. This has not been reported to date. With CT, it is expected that calcification in bladder lesions will be found with increasing incidence, and should be looked for.

Identification of a 68-kilodalton protective protein antigen from Bordetella bronchiseptica

A 68-kilodalton (kd) outer membrane protein antigen of Bordetella bronchiseptica has been identified by using monoclonal antibodies that recognized two nonoverlapping determinants. Antibody BB05 also reacted with homologous proteins from Bordetella pertussis and Bordetella parapertussis but not with another 12 organisms from various bacterial genera. Passive injection of BB05 antibody protected mice from aerosol infection with B. bronchiseptica as shown by reduced mortality and reduced pathology of turbinate bones. The 68-kd B. bronchiseptica antigen was purified by BB05-based affinity chromatography and evaluated for its potency to immunize mice actively against either intraperitoneal or aerosol challenge with B. bronchiseptica. Immunization with the 68-kd antigen in incomplete Freund adjuvant significantly reduced the levels of mortality in intraperitoneally challenged mice. In the aerosol infection model, injection of the 68-kd antigen with complete or incomplete Freund adjuvant or saponin reduced the bacterial counts in the lungs of infected mice. These results suggest that the 68-kd protein may represent a potential "protective" antigen of B. bronchiseptica.

Modulation of Bordetella pertussis by nicotinic acid

Growth of Bordetella pertussis in a high concentration of nicotinic acid (NA) had a modulating effect on several properties and activities of the bacteria. Compared with normally grown cells, those grown in a high concentration of NA had reduced capacity for taking up both NA and nicotinamide (ND); they had reduced adenylate cyclase activity and showed loss of agglutinogen factors 2 and 3, but an increase in factor 1. By contrast, cells grown in a high concentration of ND showed only a slightly decreased capacity for uptake of ND and none of the other changes. Modulation of B. pertussis by NA varied with the strain and culture conditions and appeared to be distinct from the antigenic modulation induced by high Mg2+ in the culture medium. Evidence is presented for the association of a small proportion of the extracytoplasmic adenylate cyclase with the outer membrane of B. pertussis.