Exact confidence limits for prevalence of a disease with an imperfect diagnostic test.

Estimation of prevalence of disease, including construction of confidence intervals, is essential in surveys for screening as well as in monitoring disease status. In most analyses of survey data it is implicitly assumed that the diagnostic test has a sensitivity and specificity of 100%. However, this assumption is invalid in most cases. Furthermore, asymptotic methods using the normal distribution as an approximation of the true sampling distribution may not preserve the desired nominal confidence level. Here we proposed exact two-sided confidence intervals for the prevalence of disease, taking into account sensitivity and specificity of the diagnostic test. We illustrated the advantage of the methods with results of an extensive simulation study and real-life examples.

Periparturient insulin secretion and whole-body insulin responsiveness in dairy cows showing various forms of ketone pattern with or without puerperal metritis.

To study the effect of time and different forms of hyperketonemia, with or without puerperal metritis, on insulin and glucose responses, 31 Holstein cows were subjected to glucose (GTT) and insulin tolerance tests (ITT) between 18 and 22 d before, and on days 7 and 60-70 after calving. Plasma concentrations of beta-hydroxybutyrate (BHB), nonesterified fatty acids, glucose, insulin, insulin-like growth factor I and leptin were measured from 18 d before until 70 d after calving. The revised quick insulin sensitivity index (RQUICKI) was calculated at each time point. First postpartum (PP) ovulation was monitored by milk progesterone. Based on BHB patterns and clinical findings, animals were classified as 1) Normoketonemic (NK, n=9); 2) Transiently hyperketonemic (tHK, n=7); 3) Continuously HK (cHK, n=7); and 4) Continuously HK, with signs of puerperal metritis (cHK+PM, n=6). Insulin area under the curve (AUC) and insulin response to glucose were significantly lower in the early PP period than in late-pregnancy (P<0.001), and on day 7 after calving in cHK and cHK+PM groups compared to NK and tHK groups (P<0.001). On day 7, insulin stimulated a decrease in plasma glucose in cHK, cHK+PMthan NK, and tHK groups. Normoketonemic cows (group 1) ovulated earlier than all other groups (P=0.002). There was no correlation between GTT and ITT variables and the RQUICKI. Time had a significant effect on RQUICKI. Long-term hyperketonemia, especially combined with puerperal metritis, interacts with secretion of insulin and whole-body IR, and results in a significant delay in PP ovarian activity in dairy cows.

Efficacy of a live bovine herpesvirus type 1 marker vaccine under field conditions in three countries.

The performance of a live marker vaccine for bovine herpesvirus type 1 (bhv-1) was studied in the field in three European Union countries with different farming conditions. The progress in the eradication of the virus was followed in a large herd in Germany and one in Italy, and a major serological survey involving 147 farms was conducted in Hungary. Commercial batches of the same vaccine were used in all three studies. The herds were vaccinated according to agreed protocols and the animals' bhv-1 antibody status was determined at local institutes by using commercial glycoprotein B (gB)- and glycoprotein E (gE)-elisas. In all three studies, the seroprevalence of bhv-1 gE decreased progressively. Given the starting conditions and the long duration of the studies, reactivation events and virus circulation would have been more likely to have occurred if the herds had not been vaccinated.

Bacterial complications of postpartum uterine involution in cattle.

The bacterial contamination of the postpartum uterus is a frequent finding which by itself does not disturb the anatomical and histological restoration of tubular genital tract. The improper balance between uterine infection and the intrauterine antimicrobial self-defence mechanisms, however, often results in complications, such as puerperal metritis, clinical endometritis, pyometra and subclinical endometritis. After reviewing the bacteriology of uterine involution, and the predisposing factors for its bacterial complications, this paper defines the different clinical forms, and summarizes their pathology, furthermore, the recent progress in diagnostic considerations and principles of current treatments for these diseases of bovine genitals.

Equid herpesvirus (EHV-1) live vaccine strain C147: efficacy against respiratory diseases following EHV types 1 and 4 challenges.

The temperature sensitive and host range mutant clone 147 of equine herpesvirus 1 (EHV-1) was assessed for its ability to protect conventional, susceptible adult horses against respiratory infection by EHV-1 and equine herpesvirus 4 (EHV-4). Intranasal (IN) vaccination with 5.2 log(10) TCID(50) did not cause adverse clinical reactions although a limited virus shedding and viraemia (leukocytes) was observed in 11 of 15 and 10 of 15 vaccinated horses respectively. All 15 vaccinated horses showed a significant seroresponse to both EHV-1 and EHV-4 for virus neutralising (VN) antibody. None of 14 control horses shed virus or became viraemic or seroconverted prior to challenge. EHV-1 challenge (dose 6.0 log(10)) 6 weeks after vaccination resulted in pyrexia in all eight control horses while eight vaccinated horses remained unaffected. Six control horses developed nasal discharge, five of which were mucopurulent nasal discharge (mean duration 3.2 days) which also occurred in four vaccinated horses for 1 day. All eight control horses shed challenge EHV-1 at a significantly higher level (group mean titre 2.6+/-0.4 log(10) TCID(50) per sample) and for much longer (mean duration 4.8+/-1.5 days) than that (group mean titre 1.4+/-0.8 log(10) TCID(50) per sample and mean duration 1.5+/-0.5 days) in six vaccinated horses. Furthermore, all eight control horses became viraemic (mean duration 2.9 days) but viraemia did not occur in eight vaccinated horses. Following EHV-1 challenge, all eight control horses showed a significant VN antibody rise to both EHV-1 and EHV-4 but this occurred in only one vaccinated horse and to EHV-4 only. In EHV-4 challenge (dose of 4.2 log(10) TCID(50)) of a separate pair of seven vaccinated and six control horses, 6 weeks after EHV-1 vaccination resulted in pyrexia (mean duration 2.3 days) and nasal discharge (mean duration 1.8 days) in three and five control horses respectively but the only reaction observed in the vaccinated group was nasal discharge for 1 day in one animal. All six control animals shed virus (mean titre 2.5+/-0.6 log(10) TCID(50) per sample and mean duration 2+/-0.6 days) compared to one vaccinated animal. Although EHV-4 viraemia is rare, 3 of 6 control horses became viraemic after EHV-4 challenge but this was not observed in vaccinated horses. After EHV-4 challenge 3 and 5 of 6 control horses seroconverted for VN antibody to EHV-1 and EHV-4 respectively; a non-responsive control horse had high level of pre-existing VN antibody to EHV-4. However, only 1 of 7 vaccinated horses showed a significant antibody rise and only to EHV-4.

Immunoglobulin repertoire of B lymphocytes infiltrating breast medullary carcinoma.

Tumor specific peptides recognized by T lymphocytes infiltrating solid tumors, as well as the corresponding T cell receptor (TcR) repertoire usage, have been extensively investigated. By contrast, tumor infiltrating B cells and their immunoglobulin (Ig) repertoire have been studied only in a limited number of tumors. The objective of the present study was to determine, whether DNA sequence analysis of the expressed immunoglobulin variable regions of B cells that infiltrate breast cancer, could be used to reveal a potential specific tumor binding capacity of the antibodies. To answer this question, about 200 expressed Ig heavy (VH) and light chain variable gene (VL) regions were cloned, sequenced and comparatively analysed from a typical medullary beast carcinoma (MBC), where the massive B and plasma cell infiltration correlates with favourable prognosis despite of its high grade. The tumor infiltrating B cell Ig heavy and light chain sequences could be classified into clusters, families and subgroups, based on the identity level to germline, showing a pattern of oligoclonality. Some overrepresented clusters could be determined. In the course of a detailed analysis and search in Blastn database, a number of VH and VL sequences showed more than 99% homology to DNA sequences of Ig VH region, with proved tumor antigen binding capacity. Our data suggest, that potential tumor binder Ig VH and VL sequences might be selected using a detailed immunoglobulin variable region analysis. This new approach might have a benefit for further antibody engineering, as difficulties in search for tumor binders by phage library selection might be reduced and the time for selection shortened.

Acute myeloid leukaemia of donor cell origin developing 5 years after allogeneic bone marrow transplantation for chronic myeloid leukaemia.

We report the case of a male patient with Ph-positive CML who developed AML 5 years after allogeneic BMT. Clinically, the AML seemed to develop on the basis of a myelodysplasia. The myeloid origin of blasts has been proven by immunophenotyping. The variable number of tandem repeats (VNTRs) and short tandem repeat (STR) showed donor-type haemopoiesis. The interphase FISH showed the XX genotype directly in the morphologically identifiable blasts and in the CD34-positive sorted bone marrow cells. This proved the new leukaemia to be of donor origin. The necessity of using multiple techniques and the advantage of combined immunophenotyping and FISH methods in this case is emphasized.

Autologous hematopoietic stem cell transplantation in chronic myeloid leukemia with different clinical stages.

Seven patients with Philadelphia (Ph) chromosome-positive chronic myeloid leukemia (CML) were treated with an ICE-based regimen plus G-CSF with the aim of mobilizing and collecting Ph-negative peripheral stem cells in the setting of an autologous transplant program. Five patients had CML in the first chronic phase and 2 in the accelerated phase. All patients had been previously treated with interferon-alpha. Median value and ranges for harvested mononuclear cells, CD34+ cells and CFU-GM, respectively: 5.65 x 10(8)/kg (2.61-11.38); 1.48 x 10(6)/kg (0.216-3.5), and 3.43 x 10(4)/kg (0.243-11.6). FISH was the only useful method for detection of minimal residual disease on apheresis product showing <5% t(9;22) positive cells in 2 cases and <10% positive cells in 4 other cases. Four of seven autologous grafts have been transplanted to date. Busulfan conditioning was used in 1 case and TBI/Cy conditioning in 3 other cases. All patients are alive and well following transplantation and are on interferon-alpha therapy.

[Role of molecular genetic investigations in the diagnosis of acute leukemias and in the detection of minimal residual disease]. / Molekuláris genetikai vizsgálatok szerepe az akut leukaemiák diagnosztikájában és a maradék leukaemia kimutatásában.

Chimera gene products, the molecular hallmark of acute leukemias were detected and quantified for diagnostic purposes and for follow up of therapy and characterization of minimal residual disease. In acute lymphoid leukemia mainly the bcr-abl, and in acute myeloid leukemias, depending on the morphological classification, the aml-eto, bcr-abl, pml-rara, plzf-rara, and cbfb-myh chimeras were investigated. The determinations were based on reverse transcriptase-polymerase chain reaction. The results were used in diagnosis of 315 new leukemic patients, and in follow up of 70 ones. In the present paper the usefulness of the applied methods is illustrated by presentation of data of 38 (27, acute myeloid leukemias and 11 acute lymphoid ones) patients out of the 139 treated in the National Institute during the last years.

Remarkably reduced transplant-related complications by dibromomannitol non-myeloablative conditioning before allogeneic bone marrow transplantation in chronic myeloid leukemia.

A non-myeloablative conditioning protocol containing dibromomannitol (DBM/cytosine arabinoside/cyclophosphamide) has been applied to 36 chronic myeloid leukemia (CML) patients followed by bone marrow transplantation (BMT) from sibling donors. Risk factors include: accelerated phase (10 patients), older age (17 patients over >40 years) and long interval between diagnosis and BMT (27 months on average). Severe mucositis did not occur. Venoocclusive liver disease was absent. Infectious complications were rare. Although grade II-IV acute graft-versus-host disease (GVHD) was present in 9 (25%) cases, there were only 2 serious (III-IV) ones. Chronic GVHD occurred in 25 (69%) cases, preceded by acute GVHD in 9 of the 25 affected patients. Early hematological relapse, 7-29 weeks after BMT, developed in 6 patients (17.6%). No relapse was noted in the completely chimeric patients, however molecular genetic residual disease was observed in 6 patients, in most of them after transient short-term mixed chimeric state. Overall actual survival rate is 83.3% for the 36 cases, and leukemia-free survival is 72.2% for the 34 engrafted patients.

[Autologous hematopoietic stem cell transplantation in chronic myeloid leukaemia with different clinical stages] / Autológ hemopoetikus ôssejt-transzplantáció eredményei chronicus myeloid leukaemiában.

For most chronic myeloid leukaemia patients the option of a potentially curative allogeneic stem cell transplantation is not available because of age or lack of donor. Alternative therapy with interferon-alpha appears to prolong survival but is probably not curative. The aim of the study is to analyse the clinical results of the first Hungarian autologous transplantations in CML. METHODS: Seven patients were treated with ICE-based regimen plus G-CSF with the aim of mobilising and collecting Ph-negative peripheral stem cells in the setting of autologous transplant program. Five patients had CML in first chronic phase and two in accelerated phase. All patients have been previously treated with interferon-alpha. RESULTS: Median value and ranges for harvested mononuclear cells, CD34(+) cells and CFU-GM were: 5.65x10(8)/kg (2.61-11.38), 1.48x10(6)/kg (0.216-3.5) and 3.43x10(4)/kg (0.243-11.6), respectively. Four out of seven autologous grafts have been transplanted. Busulfan conditioning was used in one case and TBI/Cy conditioning in three patients. All patients are alive and well post-transplant being on interferon-alpha therapy. CONCLUSIONS: Based on the clinical advantages of autologous transplantation including long-term chronic phase, achievement of second chronic phase and improved response to interferon-alpha therapy, the procedure can offer an alternative treatment in CML in lack of HLA-identical donor.

[Clinical and immunopathological significance of chimerism in bone marrow and organ transplantations] / A kimerizmus immunpatológiai és klinikai jelentosége csontvelô-transzplantációban és szervátültetésekben.

Chimerism is an exceptional immunogenetic state, characterized by the survival and collaboration of cell populations originated from two different individuals. The prerequisites to induce chimerism are immunosuppression, myeloablation or severe immunodeficiency of the recipients on one side and donor originated immuno-hematopoietic cells in the graft on the other. Special immunogenetic conditions to establish chimerism are combined with bone marrow transplantation, transfusion and various kinds of solid organ grafting. There are various methods to detect the type of chimera state depending on the immunogenetic differences between the donor and recipient. The chimera state seems to be one of the leading factors to influence the course of the post-transplant period, the frequency and severity of graft-versus-host disease (GVHD), and the rate of relapse. However, the most important contribution of the chimeric state is the development of graft versus leukemia (GVL) effect. A new conditioning protocol (DBM/Ara-C/Cy) for allogeneic BMT in CML patients and its consequence on chimera state and GVL effect is demonstrated.

Detection of a b3a3 type chimera in chronic myeloid leukemia by double hybridisation of RT-PCR products.

The standard RT-PCR method performed on RNA of a chronic myeloid leukemia patient resulted in a product of unusual size. Hybridisation to a probe containing the a2 sequences yielded a very faint band. Rehybridisation of the same blot to b3 sequences has given a firm signal. Based on the size of the product and on results of hybridisation tests, a translocation, resulting in a b3a3 juxtaposition, was supposed. The direct sequencing of the RT-PCR product has proven this hypothesis. We concluded, that double hybridisation of RT-PCR products of standard methods is a useful tool in detection of rare bcr-abl chimeras.

[Immunophenotyping in acute leukemia: detection of minimal residual disease]. / Immunfenotípus vizsgálata akut leukaemiákban: a minimális reziduális betegség kimutatási lehetósége.

Immunophenotyping improves both accuracy and reproducibility of the acute leukaemia classification and is considered particularly useful for identifying poorly differentiated subtypes of acute myeloid leukaemia and lineage association of acute lymphoid leukaemia. Immunological studies of leukaemic blasts has become critical also identifying biphenotypic leukaemias and acute myeloid leukaemia expressing lymphoid associated markers. At present, while the prognostic value of individual antigen expressions is still controversial, the immunologic detection of minimal residual disease seems to be important in monitoring the acute leukaemia patients in remission. In the present study immunophenotyping of bone marrow samples of 42 patients with acute myeloid leukaemia and 13 patients with acute lymphoid leukaemia was analysed. Patients were assessed both before and after treatment by immunophenotyping, cytogenetics and polymerase chain reaction amplification. The immunophenotyping have allowed more sensitive definition of acute leukaemia relapse, but molecular genetic methods are recommended for detection of elimination of residual disease.

[Detection of minimal residual diseases in B-cell tumors using PCR specific for the immunoglobulin heavy chain gene]. / A minimális reziduális betegség kimutatása B-sejtes tumorok esetében az immunglobulin nehézlánc génre specifikus polimeráz láncreakció segítségével.

In B-cell non-Hodgkin's lymphomas (NHL), clonal rearrangement of the immunoglobulin heavy chain (IgH) gene provides a useful marker for the detection of minimal residual disease (MRD) after treatment. To explore clinical usefulness of polymerase chain reaction (PCR) analysis of clonal IgH gene rearrangement in the detection of MRD a follow up study of 10 patients with B-cell NHL have been performed. At the time of diagnosis, tumor DNAs were PCR-amplified using sense primer specific for the heavy chain variable region (VH) and antisense primer specific for the heavy chain joining region (JH) of the IgH gene. The clonal rearrangement of IgH gene detected by PCR was used as clonal marker to determine MRD after treatment. In three cases, where clinical remission was not achieved, clonal IgH gene rearrangement was detected after the treatment. In seven cases, clinical remission was achieved after induction therapy but the PCR analysis revealed clonal IgH gene rearrangement in three of the cases. In all of the three cases, where MRD was detected by PCR, clinical relapse developed after 7-28 months of the therapy. In all cases that have relapsed, the IgH gene rearrangement was identical at the time of initial diagnosis and at the relapse. This study demonstrates that PCR analysis of clonal IgH gene rearrangement is a useful method to monitor and detect MRD before clinical relapse.

Immunological importance of chimerism in transplantation: new conditioning protocol in BMT and the development of chimeric state.

Chimerism is an exceptional immunogenetic state, characterized by the survival and collaboration of cell populations originated from two different individuals. The prerequisits to induce chimerism are immuno-suppression, myeloablation, or severe immunodeficiency of the recipients on the one side and donor originated immuno-hematopoietic cells in the graft on the other. The pathologic or special immunogenetic conditions to establish chimerism are combined with bone marrow transplantation, transfusion, and various kinds of solid organ grafting. Different types of chimerism are known including complete, mixed and mosaic, or split chimerism. There are various methods used to detect the type of chimera state, depending on the immunogenetic differences between the donor and recipient. The induction of complete or mixed chimerism is first determinated by the effect of myeloablative therapy. The chimera state seems to be one of the leading factors to influence the course of the post-transplant period, the frequency and severity of GVHD, and the rate of relapse. However, the most important contribution of the chimeric state is in development of graft versus leukemia effect. A new conditioning protocol (DBM/Ara-C/Cy) for allogeneic BMT in CML patients and its consequence on chimera state and GVL effect is demonstrated.

Differential gene expression pattern between normal human trophoblast and choriocarcinoma cell lines: downregulation of heat shock protein-27 in choriocarcinoma in vitro and in vivo.

OBJECTIVE: Our purpose was to identify potential differences in gene expression between normal trophoblast and choriocarcinoma cells. METHODS: The Atlas human cDNA expression array hybridization technique was used to study the gene expression pattern in normal trophoblast and choriocarcinoma cell lines. Furthermore, to confirm heat shock protein-27 (Hsp-27) expression data, reverse transcriptase-PCR (RT-PCR), Western blot, and immunohistochemical analyses were used in vitro with cell lines and in vivo with paraffin sections. RESULTS: The expression of nine genes was strongly different comparing a normal trophoblast cell line with choriocarcinoma cells on the Atlas membranes. Compared to normal trophoblast cells, six genes were upregulated and three were downregulated in choriocarcinoma cells. Furthermore, the downregulation of Hsp-27 in choriocarcinoma cells was confirmed both in vitro with cell lines and in vivo with paraffin sections using RT-PCR, Western blot, and immunohistochemical techniques. CONCLUSION: cDNA expression array is a useful technique for identifying differentially expressed gene patterns in normal trophoblast and choriocarcinoma cells. The strong expression of Hsp-27 in placental villous trophoblast cells may play a role in trophoblast differentiation. The downregulation of Hsp-27 in choriocarcinoma may contribute to the extreme sensitivity of trophoblastic tumors to chemotherapy.

Immunoglobulin variable regions usage by B-lymphocytes infiltrating a human breast medullary carcinoma.

Breast medullary carcinoma are heavily infiltrated by B-lymphocytes and associated with a good prognosis despite their high histological grade. We investigated the Ig repertoire of B-lymphocytes infiltrating one such tumour. A single cell suspension was obtained from a tumor specimen by enzymatic digestion. VH, Vkappa, and Vlambda regions were amplified by RT-PCR using mixtures of primers optimized to maximize the diversity of the PCR products. They were then cloned and sequenced. Analysis of 9 VH, 5 Vkappa, and 10 Vlambda sequences using the Kabat database indicated that several VH and VL region subgroups (I, II and III) are expressed by B-lymphocytes infiltrating this tumor. The analysis of CDR3 regions also showed a variability, although some VH and VL clones exhibited identical or nearly identical sequences. Thus, the B-cell infiltration observed in this breast medullary carcinoma does not reflect a monoclonal proliferation and represents an oligoclonal or a polyclonal B-cell proliferation.