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Microorganisms play crucial roles in water recycling, pollution removal and resource recovery in the wastewater industry. The structure of these microbial communities is increasingly understood based on 16S rRNA amplicon sequencing data. However, such data cannot be linked to functional potential in the absence of high-quality metagenome-assembled genomes (MAGs) for nearly all species. Here, we use long-read and short-read sequencing to recover 1083 high-quality MAGs, including 57 closed circular genomes, from 23 Danish full-scale wastewater treatment plants. The MAGs account for ~30% of the community based on relative abundance, and meet the stringent MIMAG high-quality draft requirements including full-length rRNA genes. We use the information provided by these MAGs in combination with >13 years of 16S rRNA amplicon sequencing data, as well as Raman microspectroscopy and fluorescence in situ hybridisation, to uncover abundant undescribed lineages belonging to important functional groups., Microbes play key roles in wastewater treatment. Here, Singleton et al. use long-read and short-read sequencing to recover 1083 high-quality metagenome-assembled genomes from 23 wastewater treatment plants, and combine this information with amplicon data, Raman microspectroscopy and FISH to reveal functionally important lineages.

New lineages of SARS-CoV-2 are of potential concern due to higher transmissibility, risk of severe outcomes, and/or escape from neutralizing antibodies. Lineage B.1.1.7 (the Alpha variant) became dominant in early 2021, but the association between transmissibility and risk factors, such as age of primary case and viral load remains poorly understood. Here, we used comprehensive administrative data from Denmark, comprising the full population (January 11 to February 7, 2021), to estimate household transmissibility. This study included 5,241 households with primary cases; 808 were infected with lineage B.1.1.7 and 4,433 with other lineages. Here, we report an attack rate of 38% in households with a primary case infected with B.1.1.7 and 27% in households with other lineages. Primary cases infected with B.1.1.7 had an increased transmissibility of 1.5–1.7 times that of primary cases infected with other lineages. The increased transmissibility of B.1.1.7 was multiplicative across age and viral load., Establishing the relative transmissibility of emerging variants of SARS-CoV-2 is key for pandemic management. Here, the authors use full-population administrative data from Denmark linked to PCR test results and estimate that the Alpha variant was ~60% higher than other strains circulating in early 2021.

Settleability of particles in activated sludge systems can be impaired by an overgrowth of filamentous bacteria, a problem known as bulking. These filaments are often members of the phylum Chloroflexi, sometimes reaching abundances in excess of 30% of the biovolume. The uncultured Chloroflexi phylotype, Candidatus Amarolinea, has been observed in high abundances in Danish full-scale activated sludge systems by 16S rRNA gene amplicon surveys, where it has been associated with bulking. In this study, fluorescence in situ hybridization was applied to confirm their high abundance, filamentous morphology, and contribution to the interfloc bridging that characterizes filamentous bulking. Furthermore, genome-centric metagenomics using both Illumina and Oxford Nanopore sequencing was used to obtain a near complete population genome (5.7 Mbp) of the Ca. Amarolinea phylotype, which belongs to the proposed novel family Amarolineaceae within the order Caldilineales of Chloroflexi. Annotation of the genome indicated that the phylotype is capable of aerobic respiration, fermentation, and dissimilatory nitrate reduction to ammonia. The genome sequence also gives a better insight into the phylogenetic and evolutionary relationships of the organism. The name Candidatus Amarolinea aalborgensis is proposed for the species.

Anaerobic digestion (AD) is a key technology at many wastewater treatment plants (WWTPs) for converting primary and surplus activated sludge to methane-rich biogas. However, the limited number of surveys and the lack of comprehensive datasets have hindered a deeper understanding of the characteristics and associations between key variables and the microbial community composition. Here, we present a six-year survey of 46 anaerobic digesters, located at 22 WWTPs in Denmark, which is the first and largest known study of the microbial ecology of AD at WWTPs at a regional scale. For three types of AD (mesophilic, mesophilic with thermal hydrolysis pretreatment, and thermophilic), we present the typical value range of 12 key parameters including operational variables and performance parameters. High-resolution bacterial and archaeal community analyses were carried out at species level using amplicon sequencing of >1,000 samples and the new ecosystem-specific MiDAS 3 reference database. We detected 42 phyla, 1,600 genera, and 3,584 species in the bacterial community, where 70% of the genera and 93% of the species represented environmental taxa that were only classified based on MiDAS 3 de novo placeholder taxonomy. More than 40% of the bacterial species were found not to grow in the mesophilic and thermophilic digesters and were only present due to immigration with the feed sludge. Ammonium concentration was the main driver shaping the bacterial community while temperature and pH were main drivers for the archaea in the three types of ADs. Sub-setting for the growing microbes improved significantly the correlation analyses and revealed the main drivers for the presence of specific species. Within mesophilic digesters, feed sludge composition and other key parameters (organic loading rate, biogas yield, and ammonium concentration) correlated with specific growing species. This survey provides a comprehensive insight into community structure at species level, providing a foundation for future studies of the ecological significance/characteristics and function of the many novel or poorly described taxa.

Anaerobic digestion (AD) is a key technology at many wastewater treatment plants (WWTPs) for converting surplus activated sludge to methane-rich biogas. However, the limited number of surveys and the lack of comprehensive data sets have hindered a deeper understanding of the characteristics and associations between key variables and the microbiome composition. Here, we present a six-year survey of 46 anaerobic digesters, located at 22 WWTPs in Denmark, which is the largest known study of the microbial ecology of AD at WWTPs at a regional scale. For three types of AD (mesophilic, mesophilic with thermal hydrolysis pretreatment, and thermophilic), we present the typical value range of 12 key parameters including operational variables and performance parameters. The bacterial and archaeal microbiomes were analyzed at species-level resolution using amplicon sequencing in >1,000 samples and the new ecosystem-specific MiDAS 3 reference database. We detected 42 phyla, 1,600 genera and 3,584 species in the bacterial microbiome, where 70% of the genera and 93% of the species represented uncultivated taxa that were only classified based on MiDAS 3 denovo placeholder taxonomy. More than 40% of the 100 most abundant bacterial species did not grow in the digesters and were only present due to immigration with the feed sludge. Temperature, ammonium concentration, and pH were the main drivers shaping the microbiome clusters of the three types of ADs for both bacteria and for archaea. Within mesophilic digesters, feed sludge composition and other key parameters (organic loading rate, biogas yield, and ammonium concentration) correlated with the growing bacterial microbiome. Furthermore, correlation analysis revealed the main drivers for specific species among growing bacteria and archaea, and revealed the potential ecological function of many novel taxa. Our study highlights the influence of immigration on bacterial AD microbiome. Subsetting the growing microbes improves the understanding of the diversity and main drivers of microbiome assembly, and elucidates functionality of specific species-level microorganisms. This six-year survey provides a comprehensive insight into microbiome structure at species level, engineering and ecological performance, and a foundation for future studies of the ecological significance/characteristics and function of the novel taxa.

Microorganisms are critical to water recycling, pollution removal and resource recovery processes in the wastewater industry. While the structure of this complex community is increasingly understood based on 16S rRNA gene studies, this structure cannot currently be linked to functional potential due to the absence of high-quality metagenome-assembled genomes (MAGs) with full-length rRNA genes for nearly all species. Here, we sequence 23 Danish full-scale wastewater treatment plant metagenomes, producing >1 Tbp of long-read and >0.9 Tbp of short-read data. We recovered 1083 high-quality MAGs, including 57 closed circular genomes. The MAGs accounted for ~30% of the community, and meet the stringent MIMAG high-quality draft requirements including full-length rRNA genes. We show how novel high-quality MAGs in combination with >13 years of amplicon data, Raman microspectroscopy and fluorescence in situ hybridisation can be used to uncover abundant undescribed lineages belonging to important functional groups.

Improvements to wastewater resource recovery and treatment efficiency are essential for fulfilling the UN sustainable development goals for both sustainable cities (goal 11) and responsible production and consumption (goal 12). Microbes are central to the processes underpinning wastewater treatment, however knowledge of this complex community is limited to isolates, marker genes or incomplete genomes. To improve our capacity to characterise this community at the genome level, we conducted large-scale long-read sequencing of 23 Danish full-scale wastewater treatment plant (WWTP) metagenomes using the Nanopore PromethION platform, producing >1 Tbp (or 17 TB raw) of long-read data. These data enabled the recovery of 987 metagenome-assembled genomes (MAGs), including 36 circular genomes, after short-read data polishing (>0.9 Tbp Illumina). The recovered MAGs met stringent high-quality draft requirements of >90% completeness

Wastewater treatment traditionally relies on the separation of the sludge and water phase before leading the effluent water into the environment. The so-called settleability of the sludge depends on the microbial community, which forms granules of varying sizes. Filamentous bacteria can impair settleability, which is known as bulking. Bacteria belonging to the phylum Chloroflexi are filamentous and often associated with bulking and foaming in activated sludge. An amplicon survey of 24 Danish wastewater treatment plants found several OTUs associated with uncultured members of a novel class in high relative abundance in several plants, suggesting a likely role in bulking problems. As this genus was only known by its 16S rRNA gene, this could not be confirmed. In this study, a genome representing the C10_SB1A phylotype was assembled from a full-scale activated sludge metagenome and the bacterium visualized using fluorescent in situ hybridization.Three samples, in which the target Chloroflexi was in different relative abundances, were paired-end sequenced on an Illumina MiSeq. The bin of interest was extracted using differential coverage and paired-end information. The genome was reassembled and scaffolded with Nanopore reads, producing the first complete genome in the novel class. A fluorescent in situ hybridization probe, designed to target the phylotype on a genus-level, confirmed the validity of our findings.The assembly of this genome will help shed light on the ecology of an uncultured Chloroflexi species, which eventually can lead to a better understanding of bulking in activated sludge.

Poster presented by Patrick Skov Schacksen at the DCB13 conference in Vejle 2018.

Background Wastewater treatment plants depend heavily on microbial communities to clean sewage water, which has to pass strict nutrient requirements before the effluent goes into waterways. The biological processes are generally stable. However, problems do occur occasionally, can arise quickly and lead to process breakdown, leading to increased operational costs and potential environmental hazards[1,2]. With current methods, it is often impossible to predict a system crash before it is too late. Monitoring the microbial community for critical changes is tedious, as the process from sample to results generally take several days and requires expert knowledge as well as expensive lab facilities. A faster workflow is therefore necessary to ensure a more efficient wastewater management in the future.Experimental design Protocols were developed with focus on portability, ease-of-use and equipment cost. DNA extraction was performed with a mobile bead beater with a 3D-printed adapter, a table centrifuge and beads for solid phase reversible immobilization (SRPI beads). Full-length 16S rRNA amplicon libraries were produced using a miniPCR™ (Amplyus, USA) and the SQK-RAB201 kit from Oxford Nanopore (Oxford Nanopore Technologies, UK). The amplicon libraries were sequenced on a MinION (Oxford Nanopore Technologies, UK) and data for the first 10 minutes of sequencing was base-called on a local laptop, mapped to the MiDAS database using minimap2 and analysed in the R environment using the R package ampvis2[3].Results and Discussion The developed workflow enabled us to go on-site a wastewater treatment plant and perform the workflow from sampling to a resulting community composition profile in 6 hours. This rapid workflow could currently provide actionable information to plant operators in time to mitigate a process breakdown, and based on ongoing developments it is our belief that plant operators will soon be able to monitor and report the microbial status as a routine measurement alongside simple process characteristics such as pH and temperature. With further improvements the workflow will be simple enough for on-site lab technicians, without experience in molecular biology, to perform the complete workflow per routine.

Denne rapport beskriver driftsdata for de renseanlæg, som har været tilmeldt den mikrobiologiske database for danske rådnetanke i 2011-2016.Den store mængde driftsdata indhentet i 2016 er gennemgået, sammenlignet anlæggene imellem, og sammenholdt med normværdier fra litteraturen for at vurdere driften.Undersøgelsen har vist, at de fleste rådnetanke drives inden for de anbefalede værdier, men at der kan være stor forskel i gasproduktion både anlæggene imellem og i samme rådnetank over tid. Der er især fundet en sammenhæng til den organiske belastning, hvor gasproduktionen er omvendt korreleret med belastningen. Det anbefales derfor at holde godt styr på belastningen, hvilket kræver jævnlige analyser af samtlige fødestrømme ind i rådnetankene.Flere anlæg har ikke mulighed for at monitere gasproduktionen, hvilket gør optimering af effekten svær. Det anbefales at alle rådnetanke udstyres med online sensorer til måling af gas flow, da der kan være mange penge at tjene på optimering af gasproduktionen.Ved analyser af kortkædede fedtsyrer udført i 2016 er det fundet, at der ofte sker store overestimeringer ved brug af Hach LCK365 kittet, som er almindeligt anvendt til bestemmelse af VFA koncentrationer. De målte koncentrationer kan i nogle tilfælde bruges som indikation på skift i den reelle koncentration. Enkelte renseanlæg er begyndt at bruge titrering i stedet, hvilket umiddelbart ikke kan anbefales da denne metode ligeledes overestimerer VFA-koncentrationen i rådnetankene. Fokus bør lægges på at bruge sammenlignelige metoder på alle renseanlæg, hvilket i nogle tilfælde kan indebære koncentrationsbestemmelse af VFA på et akkrediteret laboratorium.Det er blevet observeret, at der ofte er store daglige variationer i de analyserede parametre i rådnetankene, hvilket gør det svært at identificere korrelationer mellem mikrobiologi og driftsdata. Kun få korrelationer er fundet. For at finde flere korrelationer er der behov for en højere tidsopløselighed af mikrobiologiske prøver fra rådnetanke med gode driftsdata.

Wastewater treatment plants depend heavily on microbial communities to clean sewage water, which has to pass strict nutrient requirements before the effluent goes into waterways. The biological processes are generally stable. However, problems do occur occasionally, can arise quickly and lead to process breakdown. To mitigate this, operators have to act fast to control problematic microbes. With current methods, it is often impossible to predict a system crash before it is too late. Monitoring the microbial community for critical changes is tedious, as the process from sample to results take several days and requires expert knowledge as well as expensive lab facilities. In this project, we developed rapid protocols to make a profile of all bacteria and detect problematic microorganisms, such as pathogens or process critical bacteria from wastewater treatment plants, onsite in a matter of hours. This will provide actionable information to plant operators in time to mitigate a process breakdown. The key to this is the development of simple, cheap and easy to use protocols that will ultimately allow plant operators to monitor and report the microbial status as a routine measurement alongside simple process characteristics such as pH and temperature.

Background. Anaerobic digestion (AD) is a key technology for a sustainable future and is employed worldwide to produce biogas and degrade organic wastes. The strong emphasis on circular economy at Danish wastewater treatment plants (WWTPs) has had the consequence that many plants utilise AD to treat primary and secondary sludge. Although AD has been extensively studied in lab- and pilot-scale, studies describing full-scale operation of AD at WWTPs are few. An improved understanding of how full-scale ADs are operated and how they perform is important for future optimisation of design and operation. Research question. The main objective was to learn how the Danish ADs treating wastewater sludge are operated, and investigate whether correlations between performance and microbiology could be identified.Methods. We conducted a six-year survey of operational data from 46 ADs at 22 Danish WWTPs. Data included feeding sludge flows, gas yield, and operational parameters such as volatile fatty acids, alkalinity and ammonium. The microbial communities (archaea and bacteria) were analysed using 16S rRNA gene amplicon sequencing of all 400+ samples.Main results. Unexpected difficulties arose when comparing the different plants since the chemical parameters analysed, analytical methods and sensors used, and possibilities for accessing data, varied a lot. The survey proved that there is need for standardisation of chemical analyses and equipment. Data suggested that, in most cases, thermal hydrolysis pre-treatment and thermophilic operating conditions were more efficient than mesophilic single-phase digesters. The lack of standardisation between WWTPs made identification of correlations between performance and microbiology difficult. The bacterial community was more diverse in mesophilic digesters and methanogenesis occurred predominantly through the acetoclastic pathway, while the hydrogenotrophic pathway was prevalent in thermophilic.Take-home messages. Further research is needed to optimise methane yield and sludge degradation, which are essential parameters for achieving a good circular economy at Danish WWTPs.Acknowledgements. The Danish wastewater treatment plants are acknowledged for their support with funding, samples and data and the Villum foundation for funding.References.1. Kirkegaard, R.H., S.J. McIlroy, J.M. Kristensen, M. Nierychlo, S.M. Karst, M.S. Dueholm, M. Albertsen and P.H. Nielsen (2016): Identifying the abundant and active microorganisms common to full-scale anaerobic digesters. bioRxiv.doi.org/10.1101/104620. 2. McIlroy, S.J., R.H. Kirkegaard, B. McIlroy, M. Nierychlo, J.M. Kristensen, S.M. Karst, M. Albertsen and P.H. Nielsen (2017): MiDAS 2.0: An ecosystem-specific taxonomy and online database for the organisms of wastewater treatment systems expanded for anaerobic digester groups. Database (in press).

Anaerobic digestion (AD) is a key technology for a sustainable future and is employed worldwide as a means to produce biogas and degrade various organic wastes. The strong emphasis on circular economy at the Danish wastewater plants (WWTP) has therefore had the consequence that many plants also include AD to treat primary and secondary sludge. Although AD has been extensively studied in lab- and pilot-scale, studies describing full-scale operation of AD at WWTPs are few. An improved understanding of how full-scale ADs are operated and how they perform is important for future optimisation of design and operation. In this study, we conducted a six-year survey of operational data from 46 anaerobic digesters located at 22 Danish WWTPs. These data included feeding sludge flows, gas yield, and some operating parameters such as volatile fatty acids, alkalinity and ammonium. Also the microbial communities (archaea and bacteria) were analysed using 16S rRNA gene amplicon sequencing of all 400+ samples. The main objective was to learn how the Danish anaerobic digesters treating wastewater sludge are operated, and investigate whether it was possible to identify correlations between performance and microbiology. Large differences in the general operation and performance of the ADs were recorded. However, it was unexpectedly difficult to compare the different plants since the type of chemical parameters analysed, type of analytical methods and sensors, and possibilities for accessing data, varied a lot. The survey proved that there is need for better standardisation of some chemical analyses and some equipment. The data suggested that, in most cases, thermal hydrolysis pre-treatment and thermophilic operating conditions were more efficient than mesophilic single-phase digesters, although exceptions were found. The difficulties in comparing the operation and performance of the plants made it difficult to identify correlations between performance and microbiology. However, the microbial community analysis indicated that methanogenesis occurred predominantly through the acetoclastic pathway in mesophilic digesters while the hydrogenotrophic pathway was prevalent in thermophilic. Mesophilic digesters were found to have a more diverse bacterial community than thermophilic digesters. Further research is needed to optimise methane yield and sludge degradation, which are essential parameters for achieving a good circular economy at Danish WWTPs.

Introduction: Today, a number of therapeutic options are available as the patient with myeloma relapses from initial treatment with high-dose melphalan and autologous stem cell transplantation (ASCT). For patients who experience a durable response to primary ASCT, retreatment with high-dose melphalan is recommended by many current guidelines. Yet, toxicity is an important aspect in the choice of relapse treatment, and a second ASCT in this setting could be associated with enhanced toxicity. As the goal for the treatment for relapsed myeloma should be disease control while maintaining quality of life, lower doses of melphalan might be preferable. Methods and Objectives: In this retrospective study, we account for the outcome of 66 patients with myeloma in first systemic relapse after ASCT, who were treated with intermediate-dose melphalan, 100 mg/m2, and stem cell support (MEL 100). The aim was to evaluate this treatment in relation to prior response duration after initial ASCT and with respect to response rate, toxicity and survival. Results: The overall response rate was 62%. There was limited, mostly haematological, toxicity, and no treatment–related mortality was observed. The median progression-free survival (PFS) was 8.5 months, and the median overall survival was 24 months. Patients with time to progression of 34 months or more (n = 17; ≥75th percentile) after initial ASCT had a median PFS of 12.5 months after MEL 100. Conclusion: For patients with a long-lasting response after ASCT, MEL 100 could be a therapeutic option with low toxicity and with efficacy comparable to newer immunomodulatory drugs.

From October 1983 until December 1988, 50 patients with asymptomatic multiple myeloma stage I were included in a prospective randomized multi-centre study comparing melphalan-prednisone (MP) therapy started at the time of diagnosis with deferred therapy where MP was started at the time of disease progression. Twenty-five patients were randomized to each group. The median time from diagnosis to start of therapy in the group with deferred therapy was 12 months. The reasons for starting therapy were increasing M-protein in 8 cases, symptomatic bone disease in 9 and anaemia in 5. In 2 cases, disease progression was complicated by vertebral fractures necessitating radiotherapy. Two patients in the group in which MP was started at the time of diagnosis developed acute leukaemia. No differences in response rate, response duration or survival were observed between the treatment groups. We conclude that in asymptomatic myeloma deferral of chemotherapy is feasible in well-informed and well-controlled patients but conveys no advantage in survival. In clinical practice the benefits of treatment deferral are to some extent outweighed by disease progression before start of treatment.

This study describes the occurrence of renal failure among 1353 newly diagnosed cases of multiple myeloma. Renal function was evaluated by serum creatinine concentration in 1353 cases, 31% of whom had renal failure at the time of diagnosis. In 1206 cases an estimation of creatinine clearance was made. When renal failure was defined by using creatinine clearance estimation, 49% had renal failure at the time of diagnosis. Renal failure was present in 24% of patients with an M component of IgG-, 31% of IgA- and 100% of IgD-type. 52% of patients with light chain disease had renal failure. The frequency of renal failure was similar in lambda- and kappa-light chain disease. Patients with a high excretion of Bence Jones protein in the urine (> 10 g/24 h) had renal failure significantly more often than patients with lower excretion. Renal failure was related to advanced disease; 41% of patients with stage III (Durie-Salmon) disease had renal failure. Renal failure was found in 45% of patients with hypercalcaemia. When estimated creatinine clearance was used as a predictor of renal function, the same trends were found as mentioned above. In addition, the proportion of patients with renal failure was found to increase with advancing age.

Bone disease is an important feature of multiple myeloma, and hypercalcaemia is a frequent complication of this disease. We examined the association between serum calcium and quality of life (QOL) scores of 686 multiple myeloma patients at the time of diagnosis. Data from two Nordic studies using the EORTC QLQ-C30 questionnaire were analysed by means of linear regression analysis and a curve fitting program. Serum calcium was independently related to appetite loss, nausea/vomiting and physical functioning (P < 0.001) and to cognitive functioning (P = 0.001), i.e. scores reflecting symptoms that are well known in non-malignant hypercalcaemia. In addition, we found a highly significant independent relationship between serum calcium and the scores for fatigue and pain (P < 0.001). Serum calcium appeared to be as strong a predictor for fatigue as the concentration of haemoglobin. A cubic model (y = a + bx3) fitted the data slightly better than the simple linear model (y = a + bx) and suggested worsening QOL scores at levels of serum calcium above 2.5-3.0 mmol/L. Hypercalcaemia in patients with multiple myeloma seems to be associated with the same symptoms as in non-malignant hypercalcaemia. In addition, an increased level of serum calcium may aggravate the pain and fatigue caused by the skeletal disease itself.

Increased fuel prices and public awareness of environment impacts from shipping have attracted large efforts in maritime sector to increase its energy efficiency as a factor of competitiveness. Weather routing has become a recognized measure, which can partly help to achieve the targets as well as enhancing safety. A routing system requires a reliable optimization algorithm to consider a ship’s operational costs, expected time of arrival, and cargo safety etc. simultaneously. Hence, the service provided by a weather routing system is highly dependent on a properly selected optimization algorithm and associated input parameters. In this paper the concept of weather routing is broken down into many elements for further analysis. Focus is given to algorithms, constraints and weather forecasts used in the optimized routing plan. Two different aspects of state-of-the-art have been considered. The first is a study of software already in use and the second is a study of methods investigated in the research community. Furthermore, this paper also provides examples of development trends, for example the fatigue based routing, and the risk based routing, as well as its integration with onboard monitoring systems for more reliable weather and ship specific response information.

Earlier studies showing a negative impact of anaemia on quality of life (QOL) lack adequate adjustment for confounding factors such as disease stage and tumour response. We examined the impact of haemoglobin concentration on QOL scores of 745 multiple myeloma patients followed from diagnosis, adjusting for objective disease parameters. Data from two Nordic studies with the EORTC QLQ-C30 questionnaire were analysed using linear regression analysis. Haemoglobin was independently related only to fatigue at baseline (P = 0.001) and at 12 months (P = 0.010). In multivariate analysis, extent of skeletal disease was at least as strong a predictor for fatigue at diagnosis as haemoglobin and was also related to other important QOL scores such as physical functioning, role functioning, global QOL and pain (P < 0.001). At 12 months' follow-up, response to therapy was related to physical functioning (P < 0.001) and pain (P = 0.001). In conclusion, haemoglobin and extent of skeletal disease were both predictors for fatigue in patients with newly diagnosed multiple myeloma, but extent of skeletal disease was also associated with other important QOL scores. During follow-up, response to therapy emerged as an important predictor variable. When examining the effect of haemoglobin on QOL, it is essential to adjust for disease parameters and response to therapy in order not to overestimate the impact of haemoglobin on QOL. Our findings imply that uncontrolled studies on the effect of erythropoietin (EPO) in cancer patients may be making exaggerated claims for the effect of EPO on QOL.

Sixty-five patients who were primary or secondary refractory to melphalan/prednisone or other type of chemotherapy, or relapsed within 6 months after high dose chemotherapy with stem cell support, were given thalidomide at a dose of 200 mg/d escalating to 800 mg. The patients were followed for a median of 2 years and 22 weeks. Response was evaluated according to M-protein reduction combined with improvement of haemoglobin (Hb) concentration, renal function and pain. Altogether, 14% of patients had a minor response, 14% partial response and 6% complete response. Median survival was 12 months and 29% were alive at last contact. Decline of M protein started early and a minimum 25% reduction of M protein was detected in 14 of 20 responders (70%) after 3 weeks, and in 20 of 22 responders (91%) after 5 weeks of treatment. Reduction of M protein continued for 3 months and further decline was observed in only four patients. The Hb concentration showed a different time course, with a significant increase after 3 months and further increases continued for up to 12 months. Blood concentration levels of thalidomide from 40 patients were used to evaluate the pharmacokinetics of the drug. Rate of absorption, rate of elimination, volume of distribution, clearance and elimination half-life were calculated to be 0.200/h, 0.140/h, 0.886 l/kg, 0.126 l/h/kg and 4.98 h respectively. We found no relationship between thalidomide concentration and effect after 12 weeks.

We have published previously a prototype of a decision model for anaemic patients with myelodysplastic syndromes (MDS), in which transfusion need and serum erythropoietin (S-Epo) were used to define three groups with different probabilities of erythroid response to treatment with granulocyte colony-stimulating factor (G-CSF) + Epo. S-Epo 500 U/l and >/= 2 units/month for a poor response, whereas the presence of only one negative prognostic marker predicted an intermediate response. A total of 53 patients from a prospective study were included in our evaluation sample. Patients with good or intermediate probability of response were treated with G-CSF + Epo. The overall response rate was 42% with 28.3% achieving a complete and 13.2% a partial response to treatment. The response rates were 61% and 14% in the good and intermediate predictive groups respectively. The model retained a significant predictive value in the evaluation sample (P < 0.001). Median duration of response was 23 months. Scores for global health and quality of life (QOL) were significantly lower in MDS patients than in a reference population, and fatigue and dyspnoea was significantly more prominent. Global QOL improved in patients responding to treatment (P = 0.01). The validated decision model defined a subgroup of patients with a response rate of 61% (95% confidence interval 48-74%) to treatment with G-CSF + Epo. The majority of these patients have shown complete and durable responses.

An outbreak of Legionnaires' disease (LD) occurred in August 2004 in Sweden in the town of Lidkoping, by Lake Vanern. Two genotypes of Legionella pneumophila serogroup (sg) 1 were found by culture in patient samples, and one belonging to subgroup Benidorm (genotype A) and the other to subgroup Bellingham (genotype B). The indirect immunofluorescent antibody technique (IFAT) is still a standard method for antibody assay in patients with legionellosis, allowing for the screening of antibodies against several species and subtypes of Legionella. A serological study was therefore undertaken to assess the impact of the legionella outbreak on all pneumonia cases that occurred in the town. Patient samples were also tested for antibodies against other atypical pneumonia agents, i.e. Mycoplasma pneumoniae and Chlamydophila pneumoniae. Local experience in the laboratory using more than one subgroup of antigen had been shown earlier to increase sensitivity. Optimal sensitivity of immunofluorescent antibody tests in serological diagnosis of L. pneumphila sg 1 infections requires the use of an antigen subgroup that is in agreement with the antigenic setup of the epidemic strain.

We evaluated the costs and the cost utility of high-dose melphalan and autologous stem cell support followed by interferon maintenance relative to conventional treatment with melphalan and prednisone, in patients less than 60 yr of age with multiple myeloma. From March 1994 to July 1997, 274 patients with newly diagnosed, symptomatic multiple myeloma were enrolled in a prospective, non-randomized, population-based, multicenter study to evaluate the treatment with high-dose melphalan and autologous blood stem cell support. Health-related quality-of-life was measured prior to treatment and during follow-up, using the EORTC QLQ-C30 questionnaire. Resource consumption was also recorded prospectively. The intensive treatment yielded a significant increase in median survival time from 44 to 62 months compared to conventionally treated patients. The corresponding gain in quality-adjusted life years (QALY) was found to be 1.2. Cost per QALY gained by the treatment with high-dose melphalan and autologous blood stem cell support was estimated at NOK 249,000 (USD 27,000).

In a population-based study, the Nordic Myeloma Study Group found a survival advantage for high-dose melphalan with autologous blood stem-cell support compared to conventional chemotherapy in myeloma patients under 60 yr of age (risk ratio: 1.62; confidence interval [CI] 1.22-2.15; p = 0.001). A study of health-related quality of life (HRQoL) was integrated in the trial, using the EORTC QLQ-C30 questionnaire. Of the 274 patients receiving intensive therapy 221 (81%) were compared to 113 (94%) of 120 patients receiving conventional melphalan-prednisone treatment. Prior to treatment, there were no statistically significant differences in any HRQoL score between the two groups. One month after the start of induction chemotherapy, the patients on intensive treatment had more sleep disturbance than the control patients. At 6 mo, corresponding to a mean of 52 d after high-dose melphalan, the patients on intensive treatment had moderately lower scores for global QoL and role and social functioning and there was also a significantly higher score for appetite loss. At 12 and 24 mo, the HRQoL was similar to that of the control patients. At 36 mo, there was a trend toward less fatigue, pain, nausea, and appetite loss in the intensive-treatment group. Thus, the 18 mo of prolonged survival seem to be associated with a good health-related quality of life. Despite the moderate HRQoL reduction associated with the early intensive chemotherapy phase, this treatment modality must be regarded as an important step forward in the care of multiple myeloma.

The purpose of the present study was to analyse the importance and prognostic value of renal failure in multiple myeloma patients. The frequency and reversibility of renal failure in 775 multiple myeloma patients diagnosed between 1984-86 and 1990-92 in the Nordic countries were studied. Renal failure, defined as plasma creatinine > 130 micromol/l, was observed in 29% of the cases at the time of diagnosis. During the first year after diagnosis 58% achieved normalisation of p-creatinine, and this was achieved mainly during the first 3 months. Reversibility of renal failure was more frequently observed in patients with moderate renal failure, hypercalcaemia and low Bence-Jones protein excretion. In a multivariate analysis renal failure, high age, stage III disease and hypercalcaemia were independent prognostic factors for survival. Patients who needed dialysis had a poor prognosis, with a median survival of 3.5 months. A 12-months landmark analysis showed that reversibility of renal failure was a more important prognostic factor than response to chemotherapy. It is concluded that renal failure in multiple myeloma is reversible in about half the cases, and reversibility of renal failure improves long-term survival.