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Microabstract Immunoparesis is associated with poor survival in myeloma (MM). We demonstrate that the etiological cytogenetic abnormality influences the degree and clinical impact of immunoparesis in newly diagnosed patients in a large clinical trial. As the depth of IgM immunoparesis impacts survival for hyperdiploid patients, this may be used to further risk-stratify this cytogenetic subgroup of patients for future clinical decisions. Introduction/Background Immunoparesis, or low polyclonal immunoglobulin levels, is commonly seen in multiple myeloma (MM) and is associated with poor clinical outcomes. MM can be divided into subgroups with distinct biology and outcomes based on etiological cytogenetic abnormalities. These include hyperdiploidy and translocations of t(11;14), t(4;14), t(14;16), and t(14;20), with the latter three associated with high-risk disease. We hypothesized that the different etiological cytogenetic abnormalities drive bone marrow microenvironmental changes, resulting in different degrees of immunoparesis and subgroup-dependent effects on clinical outcomes. Materials and Methods We performed a retrospective review of 985 newly diagnosed patients enrolled in the Myeloma IX and XI trials. Immunoglobulin levels, survival outcomes, and infection rates were evaluated for each cytogenetic subgroup. Results A significant proportion of patients with high-risk t(4;14), t(14;16), or t(14;20) had suppressed polyclonal immunoglobulins compared to standard-risk patients with hyperdiploidy or t(11;14). The clinical impact of immunoparesis depended on the cytogenetic subgroup, with the degree of IgM suppression effecting progression-free and overall survival only in the hyperdiploid subgroup. There was no significant difference in infection rates amongst the etiological subgroups. Conclusions These findings demonstrate that the etiological cytogenetic subgroup influences the degree and clinical impact of immunoparesis. This suggests that the underlying cytogenetic abnormality affects remodeling of the bone marrow plasma cell niche, resulting in suppressed normal plasma cell function and low immunoglobulin levels.

Monoclonal gammopathy of renal significance (MGRS) is a new concept with evolving evidence for treatment. MGRS in the transplant kidney is a rare cause of renal transplant dysfunction that can lead to graft loss. Most cases of post-transplant MGRS are due to recurrent disease. Clone-specific chemotherapy is required to target the underlying clone, and this may improve graft survival; however, this can be challenging, as most patients are elderly with age-related comorbidities and may have complications associated with increasing immunosuppression. Here, we report 3 cases of renal allograft MGRS, and each case highlights different challenges in the diagnosis and management of this condition.

Background: The threshold of protection for anti-SARS-CoV-2 spike glycoprotein antibodies and their longevity are not known. Interpretation of serological results in with respect to international reference material can inform this essential question. Methods: 1,507 West Midlands dental care professionals were recruited into this study in June 2020. Baseline seroprevalence of antibodies directed against the SARS-CoV-2 spike glycoprotein was determined and the cohort was followed longitudinally for 6 months until January/February 2021 through the second wave of the COVID-19 pandemic in the United Kingdom, and commencement of vaccination. Findings: Baseline seroprevalence was 16.3% in this cohort, compared to estimates in the general population of between 6-7%. Seropositivity was retained in over 70% of participants at 3 and 6-month follow up and conferred a 74% reduced risk of infection. During follow-up, no PCR-proven infections occurred in individuals with a baseline anti-SARS-CoV-2 IgG level greater than 3.69 IU/ml with respect to the World Health Organization international standard 20-136. Post-vaccination, antibody responses were more rapid and of higher magnitude in individuals with who were seropositive at baseline. Interpretation: Natural infection leads to a serological response that remains detectable in over 70% of individuals 6 months after initial sampling and 9 months from the peak of the first wave of the pandemic. This response is associated with protection from future infection. Even if serological responses wane, a single dose of the Pfizer-BioNTech vaccine is associated with an antibody response indicative of immunological memory. Funding: The Association of Clinical Biochemistry and Laboratory Medicine and The Institute for Global Innovation (IGI) of the University of Birmingham. Conflict of Interest: MTD reports personal fees from Abingdon Health, outside the submitted work. AMC isan employee of the Binding Site Group. All other authors declare no competing interests. Ethical Approval: The study was approved by the London - Camden and Kings Cross Research EthicsCommittee (reference 20/HRA/1817). All participants provided written informed consent prior to enrolment in the study.

Background Minimal residual disease (MRD) status after autologous stem cell transplant (ASCT) predicts progression-free and overall survival outcomes in patients with multiple myeloma. The prognostic impact of MRD when assessed at serial time points in the context of maintenance therapy and the interaction between MRD and molecular risk are less well defined. Methods In the phase III Myeloma XI trial eligible patients were randomly assigned to lenalidomide maintenance or no maintenance at 3 months following ASCT. MRD status was assessed by flow cytometry prior to maintenance randomization (ASCT+3) and 6 months after maintenance randomization (ASCT+9). The relationship between MRD status and progression-free survival (PFS) and overall survival (OS) was examined. PFS is landmarked as the time from the date of ASCT+3/ASCT+9 to the date of progression or death from any cause. OS is landmarked as the time from the date of ASCT+3/ASCT+9 to the date of death from any cause. Participants who had not met the endpoint were censored at the date last known to have not met the endpoint. Adverse molecular risk abnormalities were defined as gain(1q), del(17p), t(4;14), t(14;16) or t(14;20). Results At ASCT+3, of 750 patients with informative samples, 475 (63.3%) were MRD negative and 275 (36.6%) were MRD positive. MRD negative status at ASCT+3 was associated with a 57% reduction in PFS events (HR=0.43, 95% CI 0.34-0.55; P Conclusions In patients with multiple myeloma, MRD status at both ASCT+3 and ASCT+9 is a powerful predictor of PFS and OS. At both time points, regardless of MRD status, lenalidomide maintenance was associated with improved PFS and OS, whilst high-risk molecular features were associated with adverse outcomes.

Background Patients with myeloma often face significant diagnostic delay, with over a quarter of patients in the UK diagnosed following emergency presentation (EP) [1]. Compared with other presentation routes, patients presenting as an emergency have more advanced disease, increased complications and poorer prognosis. Methods An economic model was developed using a decision-tree framework and a lifetime time horizon to estimate costs related to presentation routes (EP, general practitioner [GP] suspected cancer referral with a maximum two-week wait [TWW], GP urgent, GP routine and consultant-to-consultant, categorised by Howell et al [2017] [1]) for patients diagnosed with myeloma in the UK. Following diagnosis, patients received one of three first-line management options (observation, active treatment with anti-myeloma drugs, or end-of-life [EOL] care). Those receiving observation were assumed to have a diagnosis of smouldering myeloma but could progress to active myeloma and receive active treatment. Inputs were derived from UK health technology assessments, targeted literature reviews, or based on authors’ clinical experience where data were unavailable. Active treatment (drug acquisition, administration, adverse event and monitoring for several treatment lines), complication and EOL care costs were included. The model took a UK National Health Service and personal social service perspective. Results The average, undiscounted, per patient cost of treating myeloma (across all routes) was estimated at £168,000. The average per patient cost associated with EP (£174,987) was higher than for other routes (£151,370–£170,371). Complication and EOL care costs were higher for EP (£56,091) than other routes (£36,987–£49,844). Active treatment at diagnosis comprised 94% of total treatment costs for EP, versus 64–78% for other routes. For EP, 5% of total treatment costs were attributed to patients who received initial observation, but progressed to active disease and received treatment, whilst for other routes this ranged from 20–35%. In the absence of data, active treatment was modelled identically for patients receiving active treatment at diagnosis or after initial observation, thus total treatment costs were similar across routes. Should initial observation impact subsequent active treatment (e.g. duration of treatment-free intervals), total treatment costs may differ between EP and other routes. Conclusions An economic benefit may be associated with earlier diagnosis, gained via reduced complication and EOL care costs, with a difference of £19,104 per patient observed between EP and the GP routine route. The impact of initial observation on subsequent active treatment remains a key data gap. Acknowledgements This research was conducted free-of-charge on a pro bono basis by Costello Medical.

Background Outcome for patients with ultra high-risk (UHiR) newly diagnosed multiple myeloma (NDMM) or plasma cell leukemia (PCL) continues to be adverse, and UHiR patients are underrepresented in clinical trials. Recently, deepened responses have been reported for anti-CD38 monoclonal antibody combination therapy in NDMM. We report here protocol defined endpoints for the risk-stratified OPTIMUM/MUKnine (NCT03188172) trial for UHiR NDMM and PCL. Patients received daratumumab, cyclophosphamide, bortezomib, lenalidomide, dexamethasone (Dara-CVRd) induction and bortezomib-augmented HDMEL and ASCT. Early endpoints response and MRD from induction to day 100 post ASCT are reported. Methods Between Sep 2017 and Jul 2019, 472 patients with suspected NDMM from 39 UK hospitals were centrally molecularly screened. Of these, 107 patients were identified as having UHiR NDMM by trial genetic (≥2 high-risk lesions (double-hit): t(4;14), t(14;16), t(14;20), gain(1q), del(1p), del(17p)) or gene expression SKY92 (SkylineDx) profiling, or with PCL (circulating plasmablasts >20%) and enrolled in OPTIMUM. Induction consisted of 6 cycles of Dara-CVRd, HDMEL and ASCT augmented with bortezomib, followed by Dara-VR(d) consolidation for 18 cycles and Dara-R maintenance. Primary trial endpoints are minimal residual disease (MRD) status post ASCT and progression-free survival. Secondary endpoints include response, safety and quality of life. Results Median follow-up for the 107 patients in the safety population was 22.2 months (95% CI: 20.6 – 23.9). At baseline, 27% of patients were ISS stage I, 40% stage II and 32% stage 3 with 1.0% missing data and patient median age was 60 (range 35 to 78) years. 53% of patient tumors carried double-hit genetics and 77% a SKY92 high-risk signature. Two patients died early during induction due to myeloma-related infection. Bone marrow aspirates suitable for MRD assessment by flow (10-5 sensitivity) were available for 81% of patients at end of induction and 78% at D100 post ASCT. Responses in the ITT population at end of induction were 94% ORR with 22% CR, 58% VGPR, 15% PR, 1% PD, 5% timepoint not reached (TNR; withdrew, became ineligible or died) and at D100 post ASCT 83% ORR with 47% CR, 32% VGPR, 5% PR, 7% PD, 10% TNR. For PCL patients, response post ASCT was lower with 22% CR, 22% VGPR, 22% PR and 22% PD, 11% TNR. MRD status was 41% MRD-neg, 40% MRD-pos and 19% not evaluable post induction and 64% MRD-neg, 14% MRD-pos and 22% not evaluable at D100 post ASCT. Most frequent induction grade 3/4 AEs were neutropenia (21%), thrombocytopenia (12%) and infection (12%). Conclusions We report here high response and MRD-negativity rates with Dara-CVRd quintuplet induction and augmented ASCT in difficult-to-treat UHiR NDMM and PCL patients, with good tolerability and all-oral/subcutaneous deliverability. However, some early progressors highlight the ongoing need for innovation in UHiR MM and PCL.

Background: Inflammation is increasingly understood as playing an important role in type 2 diabetes mellitus (T2D) development. A critical mechanism of the inflammatory cascade in developing T2D is nuclear factor-kappa B (NF-kB) activation. As immunoglobulin free light chains (FLC) could be a biomarker of activation of NF-kB, we measured FLC in patients with T2D. Methods: The age range of the 77 patients with T2D and the 75 healthy control participants were 45 to 87 years (median 60) and 25 to 72 years (median 51), respectively.Serum FLC kappa and lambda were assayed by a competitive-inhibition multiplex Luminex assay. Findings: The concentration of circulating FLC kappa and the kappa/lambda ratio was lower, while in contrast, FLC lambda was higher, in patients with T2D than in healthy volunteers (p

Background: Myeloma causes profound immunodeficiency and recurrent, serious infections. There are approximately 5,500 new UK cases of myeloma per annum; a quarter will have a serious infection within 3 months of diagnosis. Newly diagnosed patients may benefit from antibiotic prophylaxis to prevent infection and early death but this may be associated with healthcare-associated infections (HCAI). Methods: The TEAMM trial was a multicentre randomised, double-blind, placebo-controlled trial in newly-diagnosed myeloma patients randomised to receive Levofloxacin or placebo for 12 weeks at the start of anti-myeloma treatment. Follow-up was 4-weekly to 16 weeks and again at 1 year. The primary outcome was time to first febrile episode or death in the first 12 weeks from start of trial treatment. Secondary outcomes included number of infections, deaths, healthcare-associated organism carriage and invasive infections, and overall survival (OS). Findings: 977 patients were randomised (489 levofloxacin, 488 placebo). Primary events (febrile episodes, deaths, febrile episodes with death) in levofloxacin versus placebo arms were 19% vs 27% (87, 4, 4 vs 112, 15, 7), respectively; HR=0.66 (95% CI 0.51-0.86) p=0.002. There was no difference for new acquisitions of clostridium difficile, Methicillin-resistant Staphylococcus aureus and Extended Spectrum Beta Lactamase-positive (ESBL) Gram-negative coliforms when assessed up to 16 weeks. There was an OS benefit at 12 weeks (p=0.008) but not at one year (p=0.94). Interpretation: The addition of prophylactic levofloxacin to active myeloma treatment during the first 12 weeks of therapy significantly reduced febrile episodes and deaths without increasing healthcare associated infections or carriage. Trial Registration Number: ISRCTN number: ISRCTN51731976 and EudraCT number: 2011-000366-35. Funding Statement: Funded by NIHR Health Technology Assessment Programme. 08/116/69. Declaration of Interests: None. Ethics Approval Statement: Approved by the UK Coventry & Warwickshire Multi-Research Ethics Committee on 29th July 2011. All patients provided written informed consent.

The Myeloma X trial previously reported improved durability of response (time to disease progression) in patients with relapsed multiple myeloma with salvage autologous stem-cell transplantation (ASCT) compared with oral cyclophosphamide in patients with multiple myeloma relapsing after a first ASCT. We report the final overall survival results of the trial.BSBMT/UKMF Myeloma X was a multicentre, randomised, open-label, phase 3 trial done at 51 centres in the UK. Eligible patients with multiple myeloma relapsing after a previous ASCT were re-induced with intravenous bortezomib (1·3 mg/m(2) on days 1, 4, 8, 11), intravenous doxorubicin (9 mg/m(2) per day on days 1-4), and oral dexamethasone (40 mg/day on days 1-4, 8-11, and 15-18 during cycle 1 and days 1-4 during cycles 2-4), with supportive care as per local institutional protocols before randomisation in a 1:1 ratio to either high-dose melphalan (200 mg/m(2)) and salvage ASCT or weekly oral cyclophosphamide (400 mg/m(2) per week for 12 weeks). Randomisation was by permuted blocks stratified by length of first remission and response to re-induction treatment. The primary endpoint was time to disease progression; the study was also powered to detect a difference in the secondary endpoint, overall survival. Further secondary endpoints were the proportion of patients achieving an objective response, progression-free survival, overall survival, toxic effects and safety, pain, and quality of life. Prespecified exploratory endpoints included time to second objective disease progression (PFS2). Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747877, and the European Clinical Trials Database, number 2006-005890-24, and is now in long-term follow-up.Between April 16, 2008, and Nov 19, 2012, 297 patients were registered into the study and 174 were randomly assigned to receive either high-dose melphalan and salvage ASCT (n=89) or oral weekly cyclophosphamide (n=85). 173 (58%) of 297 patients relapsed after more than 24 months from first ASCT. 75 (43%) of 174 randomised patients had died at follow-up: salvage ASCT (n=31 [35%]) versus oral weekly cyclophosphamide (n=44 [52%]). Updated time to disease progression shows continued advantage in the salvage ASCT group compared with the weekly cyclophosphamide group (19 months [95% CI 16-26] vs 11 months [9-12]; hazard ratio [HR] 0·45 [95% CI 0·31-0·64] log-rank p0·0001). Median overall survival was superior in the salvage ASCT group compared with weekly cyclophosphamide group (67 months [95% CI 55-not estimable] vs 52 months [42-60]; log-rank p=0·022; HR 0·56 [0·35-0·90], p=0·0169). Time to second objective disease progression was superior in the salvage ASCT group compared with the weekly cyclophosphamide group (67 months [52-not estimable] vs 35 months [31-43]; HR 0·37 [0·24-0·57], log-rank p0·0001). During extended follow-up, no further treatment-related or treatment-unrelated adverse events were reported. 15 second primary malignancies were reported in 12 patients (salvage ASCT [n=7] vs oral weekly cyclophosphamide [n=5]). The cumulative incidence of second primary malignancies at 60 months after trial entry was 5·2% (2·1-8·2).Salvage ASCT increases overall survival during consolidation of re-induction treatment in patients with multiple myeloma at first relapse after a first ASCT. The delay of salvage ASCT to third-line treatment or later might not confer the same degree of advantage as seen with salvage ASCT at first relapse.Cancer Research UK, Janssen-Cilag, and Chugai Pharma UK.

Background Polyclonal FLCs can be used as a biomarker of inflammation and immune activation in a range of diseases. This study evaluated the performance of new FLC ELISAs (Seralite FLC ELISA) for the quantitation of polyclonal κ and λ FLC, including comparisons to existing assays. Methods Technical performance was assessed for the ELISA and reference ranges were generated using healthy donor serum (N = 91). Patients with a range of conditions associated with polyclonal FLC dysregulation (N = 164) were measured across platforms. Results The ELISAs generated references ranges of: 8.72–23.0 mg/L κ FLC, and 8.52–25.24 mg/L for λ FLC. ELISAs demonstrated linearity across the calibration range and intra-assay (≤ 8.7%) and inter-assay (≤ 12.3%) imprecision was low. The limit of detection was 0.63 mg/L for κ and 0.57 mg/L for λ FLC. Minimal cross-reactivity was observed for interference agents, alternate FLC and whole immunoglobulin (median change ≤3.6 mg/L). Assays showed good batch-to-batch consistency. For patient samples, methods generated different κ and λ FLC concentrations and differences were seen between methods for the number of patients classified as below, with and above references ranges for κ and λ FLC. There was no significant difference in the FLC sum between the different techniques. Conclusions The ELISAs displayed good analytical and technical performance. The quantification of individual κ and λ FLC appears inherently different between platforms. These differences are attenuated if using the FLC sum, which was similar between methods and provided agreement in relation to patients having normal or elevated FLCs.

Psychological stress induces a beta-adrenergic dependent mobilization of CD8 + T lymphocytes (CTL) into the peripheral blood. Here we identified infection with Cytomegalovirus (CMV) as a major determinant of this mobilization, and characterized the cellular and transcriptional alterations that underlie enhanced responsivity. During acute stress (TSST), CMV-positive individuals (N = 35) demonstrated a 3-fold greater CTL mobilization compared to CMV-negative individuals (N = 48). Enhanced CTL mobilization was entirely confined to cells with an effector-memory phenotype (EMRA), which become markedly enriched in CMV-infected individuals. A beta-adrenergic receptor (beta-AR) dependent mechanism was confirmed by studies showing that stress-induced EMRA mobilization; (1) correlated with catecholamine release; (2) was completely abrogated by the beta-AR antagonist propranolol, and; (3) was reproduced by infusion of the beta-AR agonist isoproterenol. Micro-array analyses demonstrated selective 8-fold up-regulation of the beta2-AR gene (ADRB2) in EMRA as well as CMV-specific CTL. Longitudinal analyses confirmed that CMV-infection de novo induced rapid and lasting ADRB2 up-regulation in CTL, in conjunction with a Th1 T-bet/EOMES transcriptional profile. Subsequent studies in vitro replicated that functional beta2-AR expression increased with progressive CTL differentiation assessed as T-bet/Th1 expression. The present study identified a novel mechanism through which host–microbe interactions can regulate immune system responses to stress: CMV-infection induced T-bet differentiation accompanied by beta2-AR upregulation, which hereby enriched the CTL compartment with EMRA cells exhibiting an increased adrenergic sensitivity and enhanced mobilization during stress.

The ability to interpret someone’s mental state such as their emotions and intentions (denoted Theory of Mind, ToM), is key to human social interaction. This ability is impaired in several psychopathologies including major depression, and inflammation has been proposed as a candidate mechanism of such impairments. Experimental studies using LPS injection support a role of inflammation, but LPS-induced symptoms of sickness could themselves cause the observed reductions in ToM behaviors. Here we experimentally replicated these effects using a manipulation that minimized these potentially confounding side-effects. Forty healthy male participants (mean age = 25, SD= 5) completed the Reading the Mind in the Eyes Test (a measure of ToM) in this double-blind placebo-controlled within-subjects crossover triaI. Inflammation was induced using Salmonella Typhi vaccination (0.025 mg; Typhim Vi, Sanofi Pasteur) and saline-injection was used as a control. IL-6 was used as a marker of inflammation. Vaccination increased IL-6 levels (+419%, p .001), without inducing fever or sickness symptoms (e.g., nausea), or mood changes (all p > .10). The results showed that typhoid vaccination significantly reduced ToM performance compared to placebo (M = 71%, SD = 13%’ placebo M = 65%, SD = 13%; p .05). The present findings provide further support for the idea that emotion recognition is impaired during immune activation. Inflammation may in part drive social-cognitive deficits in pathologies that exhibit enhanced inflammation, such as major depression.

Introduction: Mental stress is considered to be a trigger for acute myocardial infarction (MI), with inflammation thought to provide a mechanism. Inflammation is reciprocally linked to oxidative stress, which h as also been implicated in MI. The purpose of this study was to assess the effects of experimentally-induced inflammation on the oxidative stress response to mental stress in healthy participants. Methods: Healthy males undertook one of two inflammatory stimuli: typhoid vaccination (Vaccination paradigm, N= 17) or eccentric exercise (Eccentric exercise paradigm, N= 17). All participants completed a mental arithmetic stress task twice (within-subject design): 6. h after the inflammatory stimulus, and during a control non-inflammation condition. Blood samples were taken before, immediately and 30. min after the stress task. Plasma was assessed for interleukin-6 (IL-6), protein carbonyls (PC), lipid hydroperoxides (LOOH), total antioxidant capacity (TAC) and nitric oxide metabolites (NOx). Results: Vaccination paradigm: IL-6, PC and NOx were significantly higher in the vaccination condition, relative to the control condition (p < .05). PC, TAC, LOOH and NOx were unchanged in response to mental stress in both the vaccination and control conditions. Eccentric Exercise paradigm: IL-6 and TAC were significantly higher in the eccentric exercise condition (p < .05), relative to the control condition. PC, TAC and NOx were unchanged in response to mental stress in both the eccentric exercise and control conditions. Conclusions: Two different inflammatory paradigms were successful in increasing selective plasma markers of inflammation and oxidative stress prior to a mental stress task. However, experimentally induced transient inflammation had no impact on mental stress-induced changes in plasma LOOH, PC, TAC or NOx in young healthy participants.

Summary Background Relapsed multiple myeloma has no standard treatment, and the role of autologous stem-cell transplantation (ASCT) has not been fully defined. We aimed to compare high-dose melphalan plus salvage ASCT with cyclophosphamide in patients with relapsed multiple myeloma who had previously undergone ASCT. Methods This multicentre, randomised, open-label, phase 3 study recruited patients aged at least 18 years with multiple myeloma who needed treatment for first progressive or relapsed disease at least 18 months after a previous ASCT from 51 centres across the UK. Before randomisation, eligible patients received bortezomib, doxorubicin, and dexamethasone (PAD) induction therapy and then underwent peripheral blood stem-cell mobilisation and harvesting if applicable. Eligible patients (with adequate stem-cell harvest) were randomly assigned (1:1), using an automated telephone randomisation line, to either high-dose melphalan 200 mg/m 2 plus salvage ASCT or oral cyclophosphamide (400mg/m 2 per week for 12 weeks). Randomisation was stratified by length of first remission or plateau and response to PAD re-induction therapy. The primary endpoint was time to disease progression, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747877, and EudraCT, number 2006-005890-24. Findings Between April 16, 2008, and Nov 19, 2012, 297 patients were registered, of whom 293 received PAD re-induction therapy. Between Aug 26, 2008, and Nov 16, 2012, 174 patients with sufficient PBSCs were randomised to salvage ASCT (n=89) or cyclophosphamide (n=85). After a median follow-up of 31 months (IQR 19–42), median time to progression was significantly longer in the salvage ASCT than in the cyclophosphamide group (19 months [95% CI 16–25] vs 11 months [9–12]; hazard ratio 0·36 [95% CI 0·25–0·53]; p 10% of patients) grade 3–4 adverse events with PAD induction, salvage ASCT, and cyclophosphamide were: neutropenia (125 [43%] of 293 patients after PAD, and 63 [76%] of 83 patients in the salvage ASCT group vs 11 [13%] of 84 patients in the cyclophosphamide group), thrombocytopenia (150 [51%] after PAD, and 60 [72%] vs four [5%], respectively), and peripheral neuropathy (35 [12%] after PAD, and none vs none, respectively). Interpretation This study provides evidence for the improved efficacy of high-dose melphalan plus salvage ASCT when compared with cyclophosphamide in patients with relapsed multiple myeloma eligible for intensive therapy, which might help to guide clinical decisions regarding the management of such patients. Funding Cancer Research UK.

There is an established link between social isolation and poor health outcomes, although the exact mechanisms explaining this association remain unclear. Lonely individuals show an enhanced inflammatory response to acute stress, and in the present study we investigated if loneliness also predicts inflammatory responses to a standardized immune challenge (typhoid vaccination). Using a within-subjects crossover design (double-blind, placebo-controlled), 40 healthy male participants (mean age = 25, SD = 5) received a Salmonella Typhi vaccination (0.025 mg; Typhim Vi, Sanofi Pasteur, UK) or Placebo (saline) on two separate occasions, at least 1 week apart. Loneliness was assessed using the UCLA-R loneliness scale. As expected, vaccination increased IL-6 levels (vaccination + 419%; placebo −10%; p .001). This response was not accompanied by fever, sickness symptoms (e.g., nausea), or mood changes (all p > .10). Regression analyses showed that those scoring higher on loneliness showed a stronger IL-6 response (beta = 0.416, p .05; using placebo as a reference). This association withstood adjustment for a range of potentially confounding variables, including health behaviors (e.g., exercise, alcohol) and depressive symptoms. Enhanced inflammatory reactivity in more lonely individuals may form a pathway linking perceived social isolation to poorer health outcomes.

Fatigue and dysphoria are highly prevalent in patients with chronic medical diseases, characterized by impairments in motivated behavior. Inflammation has been proposed as a biological mechanism, but supporting evidence has mostly been accrued through animal studies and correlational human data, while experimental human studies have remained sparse. Hence, the current study tested the effects of induced inflammation on motivated and goal-directed behavior in humans. This double-blinded placebo-controlled within-subjects study (N = 40 healthy males, mean age = 25 SD = 5) used salmonella typhoid vaccination (0.025 mg; Typhim Vi, Sanofi Pasteur) to induce acute inflammation; saline was used as placebo-control. Participants completed a reward-learning task that assessed distinguishable aspects of motivational learning. These are contingency learning, i.e., association of Abstract symbols with monetary rewards/punishments; maintenance of reward-based responses, and goal-directed adaptation to an unannounced change in reward-contingencies. Vaccination increased IL-6 levels (vaccination + 419%; placebo −10%; p .001), confirming presence of inflammation. While in both vaccine and placebo conditions participants reached the same optimum performance level, vaccinated participants required more trials to reach this optimal level, indicating slower reward-based learning. Moreover, in the inflammation condition participants were less able to maintain optimal performance over successive trials and showed less goal-directed behavior, p’s .05. The current results provide the first human evidence that inflammation impaired motivated learning, specifically reducing stability and maintenance of motivated behaviors, and goal-directed behavior.

Acute exercise at the time of vaccination can enhance subsequent immune responses. However, the potential benefit of this effect will be its efficacy in boosting poor responses, and thus protection in at-risk populations. The current study tested the effect of exercise on the response to either a full- or half-dose Pneumococcal (Pn) vaccination to elicit stronger and weaker responses. Subjects were 133 young healthy adults, randomised to one of four groups: exercise or control task, receiving a full- or half-dose Pn vaccination. Prior to vaccination, exercise groups completed a 15 min arm and shoulder exercise task, control groups rested quietly. Antibody levels to 11 Pn strains were evaluated at baseline and 1-month. Across all participants, exercise groups showed significantly greater increase in antibody levels than control groups. When doses were compared, it emerged that those who exercised had significantly larger responses than those who rested in the half-dose group, but in the full-dose groups responses were similar. This data indicates the effectiveness of exercise as a vaccine adjuvant, particularly in weaker responses. Thus, given the potential public health benefits of no-cost behavioural intervention to enhance response to vaccination, testing in at-risk populations should be pursued.

High intensity acute exercise at the time of vaccination has been shown to enhance the subsequent antibody response. This study examines whether an acute moderate intensity aerobic intervention prior to vaccination can enhance antibody response to pneumonia and half dose influenza vaccination. Sixty young (age (SD) = 22.0 (6.1) years) and 60 older (age (SD) = 57.5 (6.5) years) adults attended the laboratory on two separate occasions. At the first session, baseline antibody titres were determined, before participants completed either a brisk walk around campus at >55% of their age-predicted heart rate maximum, or a resting control condition, for 45 min. After the intervention, all participants received a full-dose pneumococcal vaccination and a half-dose influenza vaccination. Four weeks later, participants returned for a follow up blood sample. Multivariate ANOVA revealed an increase in total antibody titres against the influenza vaccine (F(12, 106) = 25.76, p < .001, η2 = .75) and both the IgM (F(12, 106) = 17.10, p < .001, η2 = .66) and IgG (F(12, 106) = 25.76, p < .001, η2 = .75) antibody titres against the pneumococcal vaccine. However, there were no significant Time × Group interactions (p’s all >.15), indicating that a 45 min brisk walk prior to vaccination did not affect antibody response to either the influenza or pneumonia vaccine. The results suggest that higher intensity exercise is necessary to augment antibody response to vaccination.

Objectives In some trials, particularly in oncology, patients whose disease progresses under the comparator treatment are crossed over into the experimental arm. This unplanned crossover can introduce bias in analyses because patients who crossover likely have a different prognosis than those who do not cross over; for instance, sicker patients not responding to standard therapy or those expected to benefit the most may be selectively chosen to receive the experimental treatment. Standard statistical methods cannot adequately correct for this bias. We describe an approach designed to minimize the impact of crossover, and illustrate this by using data from two randomized trials in multiple myeloma (MM). Methods The MM-009/010 trials compared lenalidomide and high-dose dexamethasone (Len+Dex) with dexamethasone alone (Dex). Nearly half (47%) of the patients randomized to Dex crossed over to Len with or without Dex (Len+/-Dex) at disease progression or study unblinding. Data from these trials was used to predict survival in an economic model evaluating the cost-effectiveness of lenalidomide. To adjust for crossover, the prediction equations were calibrated to match survival with Dex or Dex-equivalent therapies in trials conducted by the Medical Research Council (MRC) in the United Kingdom. To adjust for differences between the MM and MRC trial populations, a prediction equation was developed from the MRC data and used to predict survival by setting predictors to mean values for patients in the MM-009/010 trials. The expected survival with Dex without crossover was then predicted from the calibrated MM-009/010 equation (i.e., adjusted to match survival predicted from the MRC equation). Results The adjusted median overall survival predicted by the MRC equation was 19.5 months (95%CI, 16.6–22.9) for patients with one prior therapy, and 11.6 months (95% CI, 9.5–14.2) for patients with >1 prior therapy. These estimates are considerably shorter than was observed in the clinical trials: 33.6 months (27.1-NE) and 27.3 months (95% CI, 23.3–33.3) as of December 2005. Conclusion The calibration method described here is simple to implement, provided that suitable data are available; it can be implemented with other types of endpoints in any therapeutic area.

Summary Background Bisphosphonates reduce the risk of skeletal events in patients with malignant bone disease, and zoledronic acid has shown potential anticancer effects in preclinical and clinical studies. We aimed to establish whether bisphosphonates can affect clinical outcomes in patients with multiple myeloma. Methods Patients of age 18 years or older with newly diagnosed multiple myeloma were enrolled from 120 centres in the UK. Computer-generated randomisation sequence was used to allocate patients equally, via an automated telephone service, to receive 4 mg zoledronic acid as an infusion every 3–4 weeks or 1600 mg oral clodronic acid daily. Patients also received intensive or non-intensive induction chemotherapy. No investigators, staff, or patients were masked to treatment allocation, and bisphosphonate and maintenance therapy continued at least until disease progression. The primary endpoints were overall survival, progression-free survival, and overall response rate. We assessed between-group differences with Cox proportional hazards models for progression-free survival and overall survival, and with logistic regression models for overall response rate. Analysis was by intention to treat. This trial is registered, number ISRCTN68454111. Findings 1970 patients were enrolled between May, 2003, and November, 2007, of whom 1960 were eligible for intention-to-treat analysis: 981 in the zoledronic acid group (555 on intensive chemotherapy, 426 on non-intensive chemotherapy); and 979 on clodronic acid (556 on intensive chemotherapy, 423 on non-intensive chemotherapy). The treatment cutoff was Oct 5, 2009, with patients receiving bisphosphonates for a median of 350 days (IQR 137–632) before disease progression, with a median of 3·7 years' follow-up (IQR 2·9–4·7). Zoledronic acid reduced mortality by 16% (95% CI 4–26) versus clodronic acid (hazard ratio [HR] 0·84, 95% CI 0·74–0·96; p=0·0118), and extended median overall survival by 5·5 months (50·0 months, IQR 21·0 to not reached vs 44·5 months, IQR 16·5 to not reached; p=0·04). Zoledronic acid also significantly improved progression-free survival by 12% (95% CI 2–20) versus clodronic acid (HR 0·88, 95% CI 0·80–0·98; p=0·0179), and increased median progression-free survival by 2·0 months (19·5 months, IQR 9·0–38·0 vs 17·5 months, IQR 8·5–34·0; p=0·07). Rates of complete, very good partial, or partial response did not differ significantly between the zoledronic acid and clodronic acid groups for patients receiving intensive induction chemotherapy (432 patients [78%] vs 422 [76%]; p=0·43) or non-intensive induction chemotherapy (215 [50%] vs 195 [46%]; p=0·18). Both bisphosphonates were generally well tolerated, with similar occurrence of acute renal failure and treatment-emergent serious adverse events, but zoledronic acid was associated with higher rates of confirmed osteonecrosis of the jaw (35 [4%]) than was clodronic acid (3 [ Interpretation Consistent with the potential anticancer activity of zoledronic acid, overall survival improved independently of prevention of skeletal-related events, showing that zoledronic acid has treatment benefits beyond bone health. These findings support immediate treatment with zoledronic acid in patients with newly diagnosed multiple myeloma, not only for prevention of skeletal-related events, but also for potential antimyeloma benefits. Funding Medical Research Council (London, UK), with unrestricted educational grants from Novartis, Schering Health Care, Chugai, Pharmion, Celgene, and Ortho Biotech.

B-cell lines of diverse neoplastic origin express the serotonin transporter (SERT/SLC6A4) and growth arrest in response to SERT-ligands, including the antidepressants chlomipramine and fluoxetine. Here we detail SLC6A4 transcript (Q-PCR) and protein (FACS) expression in primary cells from patients with: chronic lymphocytic leukaemia; mantle cell lymphoma; follicular lymphoma; Burkitt's lymphoma; and diffuse large B-cell lymphoma. The ability of the SERT-binding antidepressants to impact the growth of these cells when sustained on CD154-transfected fibroblasts was also determined. The results reveal a broad spectrum of primary B-cell malignancies expressing SLC6A4 with a proportion additionally displaying growth arrest on SERT-ligand exposure.

An acute bout of exercise prior to vaccination can improve the antibody and cell-mediated responses to influenza vaccination. The mechanisms underpinning this adjuvant effect remain unclear, and further investigation to determine the optimal exercise protocol is warranted. The aim of the current study was to determine whether exercise augmented the immune response to vaccination, and whether the timing of exercise relative to vaccination affected the efficacy of the intervention. One hundred and fifty-six (76 men) healthy participants were randomly assigned to a control group or one of three intervention groups who exercised immediately, 6h or 48 h prior to administration of a standard trivalent influenza vaccine. The exercise groups performed 50 repetitions of the eccentric portion of both the bicep curl and lateral raise movements at an intensity eliciting 85% of each participant's pre-determined concentric one repetition maxima. Antigen-specific serum antibody titres were measured at baseline and 28 days post-vaccination as indicators of the humoral response. All three viral strains elicited strong antibody responses; however, eccentric exercise did not further augment any antibody responses compared to the control group. Cell-mediated immunity at 28 days post-vaccination was determined by measuring the IFN-gamma response to in vitro stimulation of the blood with whole vaccine. There were no differences in cell-mediated immunity among the groups. Although these null findings were unexpected, they are consistent with previous research showing that exercise-induced immunoenhancement was only observed when the control group had relatively poor responses. In conclusion, it is likely that the robust immune responses to the vaccine observed in this study may have limited any further immune enhancement by exercise.

Objective: To examine the relationship between cardiovascular activity in response to acute psychological stress and the antibody response to vaccination. Methods: Fifty-seven healthy participants were vaccinated with the trivalent influenza vaccine and meningococcal A+C polysaccharides. Antibody levels were measured at baseline and 5-weeks post-vaccination. Cardiovascular activity was measured at rest, during and following a mental arithmetic stress task in 54 participants. Results: Participants demonstrating a four-fold increase in antibody titre to the A/Panama and B/Shangdong influenza strains and to meningococcal A showed greater blood pressure reactions toward the end of the acute stress task. In addition, there was some evidence of delayed diastolic blood pressure recovery in those who were responders to A/Panama and B/Shangdong influenza strains. Conclusion: The present results suggest that heightened cardiovascular reactivity to stress and delayed recovery may not necessarily be detrimental to all aspects of health, and may be associated with an enhanced immune response to antigen challenge.

peer-reviewed In older populations, caregiving for a spouse with dementia has been associated with a poor antibody response to vaccination. The present study examined whether younger caregivers, specifically the parents of children with developmental disabilities, would also show a diminished antibody response to vaccination. At baseline assessment, 30 parents of children with developmental disabilities and 29 parents of typically developing children completed standard measures of depression, perceived stress, social support, caregiver burden, and child problem behaviours. They also provided a blood sample and were then vaccinated with a pneumococcal polysaccharide vaccine. Further blood samples were taken at 1- and 6-month follow-ups. Caregivers mounted a poorer antibody response to vaccination than control parents at both follow-ups. This effect withstood adjustment for a number of possible confounders and appeared to be, at least in part, mediated by child problem behaviours. The negative impact of caregiving on antibody response to vaccination is not restricted to older spousal caregivers, but is also evident in younger parents caring for children with developmental disabilities. The behavioural characteristics of the care recipients may be a key consideration in whether or not immunity is compromised in this context. ACCEPTED peer-reviewed

peer-reviewed The present study examined the association between psychological stress, social support and antibody response to both thymus-dependent and thymus-independent vaccinations. Stressful life events in the previous year and customary social support were measured by standard questionnaires at baseline in 75 (41 females) healthy students. Antibody status was assessed at baseline, 4 and 18 weeks following vaccination with formaldehyde inactivated hepatitis A virus and pneumococcal polysaccharides, which induce thymus-dependent and -independent antibody responses respectively. Controlling for baseline antibody status, life event stress was negatively associated with antibody response to the hepatitis A vaccine at the 18-week follow-up; participants reporting a greater number of stressful life events had a poorer antibody response. There was no relationship between psychological stress and antibody response to pneumococcal vaccination. Social support was not associated with the antibody response to hepatitis A vaccination. However, there was a significant association between support and the antibody response to the thymus-independent pneumococcal vaccine at 4-week followup; participants with larger social networks mounted a better response. These relationships could not be accounted for by age and sex, or by variations in health behaviours. Psychosocial factors would appear to influence the response to both thymusdependent and thymus-independent vaccines, but not in the same manner.

The immune response to vaccination in animals can be enhanced by exposure to acute stress at the time of vaccination. The efficacy of this adjuvant strategy for vaccination in humans requires investigation. The current study employed a randomised controlled trial design to examine the effects of eccentric exercise prior to influenza vaccination on the antibody and cell-mediated responses. Sixty young healthy adults (29 men, 31 women) performed eccentric contractions of the deltoid and biceps brachii muscles of the non-dominant arm (exercise group) or rested quietly (control group), and were vaccinated 6h later in the non-dominant arm. Change in arm circumference and pain were measured to assess the physiological response to exercise. Antibody titres were measured pre-vaccination and at 6- and 20-week follow-ups. Interferon-gamma in response to in vitro stimulation by the whole vaccine, an index of the cell-mediated response, was measured 8 weeks post-vaccination. Interferon-gamma responses were enhanced by exercise in men, whereas antibody titres were enhanced by eccentric exercise in women but not in men. Men showed greater increase in arm circumference after eccentric exercise than women but there was no difference in reported pain. The interferon-gamma response was positively associated with the percentage increase in arm circumference among the exercise group. Eccentric exercise exerted differential effects on the response to vaccination in men and women, with enhancement of the antibody response in women, but enhancement of the cell-mediated response in men. Eccentric exercise of the muscle at the site of vaccine administration should be explored further as a possible behavioural adjuvant to vaccination.

This study determined whether stressful life events and social support were related to antibody status following both thymus-dependent and thymus-independent vaccinations. Life events in the previous year and customary social support were measured in 57 healthy students at baseline. Antibody status was also assessed at baseline and at five weeks and five months following vaccination with the trivalent influenza vaccine and the meningococcal A+C polysaccharide vaccine. Taking into account baseline antibody titre, high life events scores prior to vaccination were associated with lower responses to the B/Shangdong influenza strain at both five weeks and five months and meningococcal C at five weeks. Life events scores were not associated with response to the other two influenza viral strains nor response to meningococcal A. Those with high social support scores had stronger 5-week and 5-month antibody responses to the A/Panama influenza strain, but not to any of the other strains. These associations could not be accounted for by demographic or health behaviour factors, and also emerged from analyses comparing those who exhibited a four-fold increase in antibody titre from baseline with those who did not. Life events and social support were related to antibody status following influenza vaccination in distinctive ways that may be partly determined by vaccine novelty and prior naturalistic exposure. Life events also predicted poor antibody response to meningococcal C polysaccharide vaccination after previous meningococcal C conjugate vaccination. Neither psychosocial factor was associated with response to primary meningococcal A polysaccharide vaccination.

Objective Chronic stress has been associated with impaired response to influenza vaccination in the elderly. This study investigated whether mild, intermittent stress experienced by young, healthy adults has a similar effect. Methods Antibody and psychological status were determined prevaccination and 5 weeks and 5 months later; a fourfold increase in antibody to at least one viral strain was considered protective. Results At 5 months, unprotected participants reported significantly more life events and tended to report more perceived stress than those who were protected. Conclusion Psychological stress is detrimental to long-term maintenance of antibody levels following vaccination in young, healthy adults.

The purpose of this review is to determine the effects of psychosocial stress on antibody response to vaccination in humans, consider possible mechanisms, and identify agenda for future research. Studies of the association between stress and vaccination response in humans were reviewed. There is evidence of a negative association between stress and antibody response to vaccination, which is most apparent with thymus-dependent vaccines and when measured at extended times after vaccination. Preliminary findings implicate the hypothalamic-pituitary-adrenal axis and sympathetic nervous system as potential mechanisms, although a role for unhealthy behaviours cannot be discounted at this stage. Results to date are sufficiently indicative to direct future research to untangling their theoretical ramifications, as well as realising their clinical implications.

Measurement of urine free light chains (flc) is important for assessing monoclonal plasma cell diseases. However, since the kidneys metabolize large amounts of flc, urine concentrations may not accurately reflect plasma cell synthesis. From a theoretical viewpoint, serum measurements would be preferable, just as blood glucose measurements are preferable to urine measurements for managing patients with diabetes mellitus. Unfortunately, the development of satisfactory serum flc immunoassays has been hampered by the lack of specific, high-affinity antisera. Recent publications indicate that this situation has now changed. Serum flc have been quantified using routine clinical laboratory instruments and have produced useful diagnostic results in several diseases. Thus, 100% of patients with light-chain multiple myeloma, 75% of patients with nonsecretory myeloma and more than 95% of patients with primary amyloidosis could be diagnosed using serum flc assays. This improvement in disease detection rates and the potential for superior disease monitoring may obviate the need for urine flc tests in most patients with monoclonal plasma cell diseases.

Although previous evidence suggests that mucosal immunity may be influenced by mental stress, the importance of the duration of stress exposure on secretory immunoglobulin A (sIgA) has yet to be fully elucidated. Salivary sIgA and cardiovascular activity were measured at rest, following 14 and 28 min of mental arithmetic, and after recovery in 24 men and women on two sessions 2-4 days apart. Mental arithmetic was, on both sessions and after both the early and late phases of the task, associated with increases in sIgA concentration and sIgA secretion rate compared to rest and recovery. Task levels of sIgA concentration and sIgA secretion rate showed moderate to high intra- and inter-session test-retest reliability, while test-retest reliability was lower for change scores. Blood pressure and pulse rate were also elevated by the mental stress task, although correlational analyses revealed that stress-induced changes in sIgA were not related to cardiovascular reactions.

This study aims to guide the integration of serum free light chain (sFLC) tests into clinical practice, including a new rapid test (Seralite®). Blood and urine analysis from 5573 newly diagnosed myeloma patients identified 576 light chain only (LCO) and 60 non-secretory (NS) cases. Serum was tested by Freelite® and Seralite® at diagnosis, maximum response and relapse. 20% of LCO patients had urine FLC levels below that recommended for measuring response but >97% of these had adequate sFLC levels (oligosecretory). The recommended Freelite® sFLC ≥100 mg/l for measuring response was confirmed and the equivalent Seralite® FLC difference (dFLC) >20 mg/l identified. By both methods, ≥38% of NS patients had measurable disease (oligosecretory). Higher sFLC levels were observed on Freelite® at all time points. However, good clinical concordance was observed at diagnosis and in response to therapy. Achieving at least a very good partial response according to either sFLC method was associated with better patient survival. Relapse was identified using a Freelite® sFLC increase >200 mg/l and found 100% concordance with a corresponding Seralite® dFLC increase >30 mg/l. Both Freelite® and Seralite® sensitively diagnose and monitor LCO/oligosecretory myeloma. Rapid testing by Seralite® could fast-track FLC screening and monitoring. Response by sFLC assessment was prognostic for survival and demonstrates the clinical value of routine sFLC testing.

1alpha,25-Dihydroxyvitamin D(3) (D(3)) provokes growth arrest and monocytic differentiation in myeloid cells. Although it is usually assumed that the cellular events leading to growth arrest start within one cell cycle of D(3) addition, there is also evidence that D(3) provokes the expression of proliferation-related genes and accelerates cell division. Herein we clarify the relationship between proliferation and maturation in differentiating HL60 cells. Cells were cultured singly, D(3) was added at various stages of the cell cycle, the progeny were counted, and the proportions of mature monocytes were determined. Initially, the D(3)-treated cells proliferated at an accelerated rate, and they matured only later. If cells encountered D(3) early in G1 they divided two to four times before maturing, and if they encountered D(3) later in the cell cycle they underwent an extra division. Indomethacin slows HL60 cell multiplication by prolonging G1, and when these slower-growing cells were exposed to D(3), they matured after the usual period but underwent one division less than indomethacin-free cells. Contrary to common assumptions, we conclude that promyeloid cells do not initiate growth arrest or monocytic maturation immediately after exposure to D(3). Instead, an encounter with D(3) early in G1 sets in train a complex differentiation program. This consists of 2-3 days of rapid proliferation-probably employing cell cycles with a shortened G1 phase-that is followed by growth arrest and maturation. As a result, a single D(3)-treated promyeloid cell gives rise to 10 or more mature monocytes. These observations not only explain why "differentiating" cells express proliferation-related characteristics soon after D(3) addition, but they also show that the process of D(3)-induced monocytic differentiation is much more complex than has previously been realized.

Induction of growth arrest and monocyte differentiation of HL-60 leukemia cells by 1alpha,25 dihydroxyvitamin D3 (1alpha,25(OH)2D3) is well established. By contrast, we have observed, that 1alpha,25(OH)2D3 and its metabolites play separate roles in clonal expansion and survival of differentiating HL-60 cells. Cells that had differentiated by 48 h (CD14 positive) grew slower than control cells, whereas CD14 negative cells were growing faster at this time point. Inhibiting 1alpha,25(OH)2D3 or 1alpha,25(OH)2-20-epi-D3 metabolism, by the 25(OH)D3-24-hydroxylase inhibitor ketoconazole, abolished hyperproliferation of CD14 negative cells. Instead, both the onset of differentiation and subsequent apoptosis were enhanced. These events were associated with immediate up-regulation of the cyclin-dependent kinase inhibitor p21(waf1) and a lack of sustained expression, respectively. Stimulation and inhibition of growth by vitamin D3-related compounds was observed to be concentration and metabolite specific. Low amounts of 1alpha,25(OH)2-20-epi-D3 and 1alpha,24,25(OH)3-20-epi-D3 stimulated HL-60 cell growth. At higher concentrations, 1alpha,25(OH)2-20-epi-D3 was a more potent inducer than 1alpha,24,25(OH)3-20-epi-D3 of HL-60 differentiation; 1alpha,25(OH)2-20-epi-24-oxo-D3 was exclusively pro-differentiative at all concentrations. 1alpha,25(OH)2-20-epi-D3 and 1alpha,24,25(OH)3-20-epi-D3 stimulated proliferation of KG-1a leukemia cells, but neither of these compounds nor 1alpha,25(OH)3-20-epi-24-oxo-D3 exerted pro-differentiative effects on these cells. These findings shed new light on the pro- and anti-proliferative effects of 1alpha,25(OH)2D3 and lead to the postulate that metabolism of 1alpha,25(OH)2D3 and its 20-epi analog regulates different subsets of genes so as to co-ordinate population expansion and the differentiation process. Furthermore, 1alpha,25(OH)2D3 metabolism and/or sensitivity to the effects of metabolites may be altered in transformed cells to derive a clonal advantage.

The effect of leflunomide (Lef) donor pretreatment (DPT) on rat cardiac allograft survival was investigated. In untreated Lewis recipients of untreated DA hearts, median graft survival was 5 days. DPT (Lef 5 or 10 mg/kg per day for 30 days) reduced median grafts survival to 4.0 and 4.5 days, respectively. In immunosuppressed (Lef 5 mg/kg for 10 or 30 days) Lewis recipients of untreated DA hearts, median graft survival was 21 and 33 days, respectively. DPT with Lef 5 mg/kg per day for 5 days or 30 days reduced median graft survival to 12 and 23.5 days, respectively (p < 0.05). DPT with Lef resulted in earlier graft rejection but the histological appearance at the time of rejection was the same as in untreated controls. DPT with lef resulted in a 40% reduction in MHC class II-psotive cells in the heart. Histological examination of rejecting hearts showed no obvious difference in the nature of the rejection process between DPT and untreated control hearts. The paradox between class II reduction but earlier rejection indicates that DPT is exerting a deleterious effect through some unrecognized property of the graft.

Exercise-induced leukocyte mobilisation is well defined, but few studies have examined their precursors – haematopoietic stem cells (HSCs). Seventeen males (33 ± 13 years, BMI 24 ± 3 kg·m2 and VO2max 60 ± 5 ml·kg·min) ran for 60 min at 80% VO2max. Blood was collected at rest, during the final minute of exercise, then 15, 60 and 120 min later. HSC populations were identified using flow cytometry: HSCs (CD34+CD45dim); Common Lymphoid Progenitor cells (CLP, CD34+CD45dimCD38-CD7+); Common Myeloid Progenitor cells (CMP, CD34+CD45dimCD38+CD123+CD45RA-); Megakaryocyte/Erythroid Progenitor cells (MEP, CD34+CD45dimCD38+CD123-CD45RA-); and Granulocyte/Macrophage Progenitor cells (GMP, CD34+CD45dimCD38+CD123+CD45RA+). HSCs increased by 100% during exercise, returning to baseline within 15 min, and fell 10% below baseline 60–120 min post-exercise (p η 2 = 0.44). CLP, CMP and GMPs were un-changed during or following exercise, but CMPs and GMPs fell 30–40% below baseline 1–2 h later (p’s η 2 = 0.37). HSC mobilisation was higher (+80%) in younger men (n = 10, 23 ± 3 years) compared to older men (n = 7, 48 ± 5 years; interaction p η 2 = 0.15). Controlling statistically for absolute heart rate during exercise attenuated the age-effect (p > 0.05; η 2 = 0.14), suggesting the smaller HSC mobilisation in older men was partly due to lower cardiac output and concomitant haemodynamic/shear forces. Exercise-induced HSC mobilisation could increase apheresis yields for transplant, but compared to younger donors, the elderly may require a more prolonged stimulus.