Patient characteristics and cancer prevalence in the Danish cancer patient pathway for patients with serious non-specific symptoms and signs of cancer-A nationwide, population-based cohort study.

BACKGROUND: A new cancer patient pathway for patients presenting with non-specific signs and symptoms (NSSC-CPP) was implemented nationally in Denmark in 2012. This study aims to describe, on a national level, the characteristics of patients referred to the Danish NSSC-CPP, and to estimate the prevalence and distribution of cancers and other diagnosis in this population. METHODS: A population-based cohort study using the Danish national registries, including all patients who completed a diagnostic course through the NSSC-CPP between 2012 and 2015. Cancer prevalence is presented as the percentage of included patients who were diagnosed with cancer after completing a NSSC-CPP diagnostic course. Associations between patient characteristics and cancer diagnosis were estimated in a multivariate logistic regression model. RESULTS: The mean age of the 23,934 patients included in the analysis was 64.6 years and 47% where male. In total, 11% of all patients received a cancer diagnosis after completing a diagnostic course in the NSSC-CPP; the most common types were breast cancer (18%) hematopoietic and lymphoid tissue cancer (15%), and malignant melanoma (12%). The most common non-cancer diagnosis was non-specific symptoms/observation (54%). Fifty-five patients were diagnosed with cancer within six months following a non-cancer diagnosis in the NSSC-CPP. CONCLUSIONS: The prevalence of cancer in the NSSC-CPP was 11%. The most common cancer diagnosis was breast cancer, hematopoietic and lymphoid cancer and malignant melanoma. A small proportion of patients receiving a non-cancer diagnosis in the NSSC-CPP were diagnosed with cancer in the six months following their NSSC-CPP course.

Health-related quality of life in patients with serious non-specific symptoms undergoing evaluation for possible cancer and their experience during the process: a mixed methods study.

PURPOSE: The purpose of this research was to measure changes in HRQoL during the diagnostic evaluation of patients presenting with non-specific symptoms possibly attributable to cancer, to describe their experiences of HRQoL and to merge these findings with intent to obtain a more comprehensive understanding of their HRQoL experience during this stressful life event. METHODS: A convergent mixed methods (MM) design was used and involved quantitative data about HRQoL measured by the EORTC-QLQ-C30 instrument and qualitative interview data about patients' HRQoL experiences. Participants completed the EORTC-QLQ-C30 questionnaire prior to and after evaluation. The baseline questionnaire informed the purposive sampling for the qualitative interview study, and open-end questions matched to the EORTC-QLQ-C30 constructs were used in the semi-structured interviews. RESULTS: A total of 838 patients were enrolled in the quantitative study; 680 (81 %) also completed follow-up. Twenty-one patients participated in interviews. The MM findings are the meta-inferences drawn by looking across the matched quantitative and qualitative findings: physical function, social function, role function, emotional function, cognitive function, social function, symptoms and quality of life. CONCLUSION: The survey results illustrate that HRQoL improved over time and the qualitative findings confirmed and further expanded the survey results. The MM analysis underlines that the HRQoL experience cannot be observed independently from context. Participants adapted to their situation over time, and this may change their perceptions of HRQoL. These findings can be used to enhance evidence-based care as clinicians need to be aware of how the context influences the HRQoL experience.

Efficacy of a minimal home-based psychoeducative intervention in patients with advanced COPD: A randomised controlled trial.

BACKGROUND: Anxiety is a common comorbidity in patients with advanced Chronic Obstructive Pulmonary Disease (COPD) with major impact on quality of life and associated with increased risk of death. The objective of this randomised controlled trial was to test the efficacy of a minimal home-based psychoeducative intervention versus usual care for reducing symptoms of anxiety in patients with advanced COPD. METHODS: The trial included 66 participants with advanced COPD and symptoms of anxiety. The primary outcome was anxiety assessed by the Hospital Anxiety and Depression scale (HADS) subscale for anxiety (HADS-A). The secondary outcome was mastery assessed by the Chronic Respiratory Questionnaire (CRQ) domain of mastery (CRQ-M). Assessments were performed at baseline and one and three months post-intervention. RESULTS: The intervention group had a lower post intervention HADS-A score on average, compared with the control group (p = 0.005), indicating a significant effect of the intervention. The average difference between the groups in HADS-A was 2.16 points (CI = [0.62; 3.71]) at one month and 2.32 points (CI = [0.74; 3.89]) at three months follow-up. The intervention group had a higher post intervention CRQ-M score on average compared with the control group (p = 0.016). The average differences between the groups were 0.58 points (CI = [0.09; 1.06]) after one month and 0.67 points (CI = [0.18; 1.17]) after three months. CONCLUSIONS: The psychoeducative intervention provided sustainable symptom relief and improved the patients' self-management abilities.

Mapping of a new immunodominant human linear B-cell epitope on the vpu protein of the human immunodeficiency virus type 1.

A random fragment expression library was used to identify and map a new human epitope on the vpu protein of the human immunodeficiency virus type 1 (HIV-1). The epitope was mapped to the central part of the protein within amino acids (aa) 37-50 comprising the sequence N-KIDRLIDRLI-ERAE-C. A alpha-galactosidase-vpu fusion protein representing aa 37-68 of vpu was used to screen 356 human serum samples from HIV-1-infected persons for antibodies to the novel epitope. A total of 125 (35.1%) of the samples reacted with this region of vpu. Antibodies against this region were significantly more prevalent among samples from individuals with CD4 cell counts < 400 cells/microliters than individuals with CD4 cell counts > or = 400 cells/microliters (37.6 vs. 17.6%; p < 0.0146, Fisher's exact test). Thus, the presence of antibodies against this epitope of vpu appears to be associated with a progressed state of disease.

Autologous antibody response against the principal neutralizing domain of human immunodeficiency virus type 1 isolated from infected humans.

High titers of neutralizing antibodies in human immunodeficiency virus type 1 (HIV-1) infection are directed primarily against the third hypervariable domain (V3) of the virion envelope glycoprotein gp120. This region has been designated the principal neutralizing domain of HIV-1. Because the frequency and significance of autologous V3 antibodies in natural infection are not fully clarified, we have cloned, sequenced, and expressed the V3 domain from virus of HIV-1-infected patients to test the autologous and heterologous V3 antibody response. The resulting recombinant Escherichia coli V3 fusion proteins reacted strongly with both autologous and heterologous patient antibodies in Western blots. Thirty-one different V3 fragments were cloned from 24 hemophiliac patients with different immunological and clinical statuses. Antibody reactivity against the autologous V3 fusion proteins was detected in all serum samples except one; moreover, all serum samples contained antibody reactivity against a vast majority of heterologous fusion proteins despite significant amino acid variability in V3. The results suggest that V3 antibodies are highly prevalent; further, we find no association between the stage of the HIV-1 infection and the presence of V3 antibodies.

Mapping of two new human B-cell epitopes on HIV-1 gp120.

OBJECTIVE: To map epitopes on gp120 defined by human antibodies and to examine the neutralizing activity of these antibodies. DESIGN AND METHODS: Serum from HIV-1-antibody-positive individuals was used to screen a random fragment expression library representing gp120 from the HIVIIIB clone BH10. The library was based on the pUEX1 expression vector. Serum was tested for in vitro neutralizing activity using H9 cells and the HIVIIIB isolate. RESULTS: Four different epitopes defined by human antibodies were mapped on gp120. Two of these have not previously been reported and are located within amino acids (aa) 90-100 in the C1 region and aa 355-365 in the semi-conserved region between V3 and V4. The other two are located within aa 140-145 and aa 286-309. These epitopes are situated in regions that have been shown to demarcate human epitopes. Three serum samples with neutralization titres > or = 1024 were identified. None of the purified antibody fractions defining the mapped epitopes on gp120 had any neutralizing capacity against HIVIIIB. CONCLUSIONS: This study is the first demonstration of the applicability of random fragment expression libraries for the direct screening of human serum in order to map epitopes on gp120. Two new epitopes and two previously identified epitopes were mapped in this way. However, none of the linear epitopes was defined by antibody fractions neutralizing HIVIIIB, and it was not possible to map epitopes defined by neutralizing antibodies in the serum samples capable of neutralizing HIVIIIB infection of H9 cells. Thus, it appears that the neutralizing activity of serum in this study was not due to anti-gp120 antibodies defining linear epitopes.

Mapping of linear B-cell epitopes on the major core protein p24 of human immunodeficiency virus type 1 (HIV-1).

Three murine monoclonal antibodies (MAbs) F5-2, F5-4, and F5-16 defining three different epitopes on the major core protein p24 of the human immunodeficiency virus type 1 (HIV-1) were epitope mapped using a random fragment expression library representing the p17- and p24-encoding part of the gag open reading frame. F5-2 defined an epitope within amino acids (aa) 14-23 at the N-terminus of p24, and F5-4 defined an epitope within aa 153-174 in the C-terminus of p24. F5-16 did not recognize any of the fusion proteins produced by the expression library indicating that this MAb defines a true conformational epitope on p24. Since the N-terminus of p24 has been reported to be immunosilent in humans, 356 HIV-1 antibody-positive serum samples were tested for reactivity against the region of p24 defined by F5-2. More than one third of the samples recognized this region indicating that it is immunoreactive and, further, the presence of antibodies against this region was associated with a reduced CD4 cell count.

HIV-2 infection in Denmark.

A collection of 3019 selected serum samples (ss), comprising 329 ss from intravenous drug abusers, 558 ss from homosexual men, 682 samples from persons attending a STD clinic, 100 ss from individuals of African origin, 300 ss from sexual contacts to Africans, 650 ss from Danish blood donors who resided in Africa greater than 2 years prior to donating the ss, and 400 ss with equivocal antibody reactions in an HIV-1 Western blot was tested for antibodies against HIV-2 by in-house HIV-2 ELISA and Western blot. Four ss were positive for antibodies against HIV-2. Three of the ss originated from West African men, the fourth belonged to the spouse of one of these men. Three of the samples presented with an uncharacteristic reaction in a HIV-1 Western blot. The study indicates that HIV-2 infection is not yet widespread in Denmark and that it remains closely related to West Africa.

PIP: Clinicians drew blood samples from 3019 people living in Denmark to determine whether HIV-2 had reached that country. The groups tested included drug users from Copenhagen, healthy HIV-1 positive and negative homosexual men from Copenhagen, patients at a clinic for sexually transmitted diseases (STDs), healthy Africans, Danes who had sexual intercourse with an African, Danish blood donors who went to Africa more than 2 years before they gave a blood sample, and people who had inconclusive HIV-1 Western Blot (WB) patterns. Laboratory personnel used an in-house HIV-1 ELISA and an in-house HIV-2 ELISA to test all samples and an in-house HIV-2 test. 4 (.13%) samples tested positive for HIV-2. 3 of the serum samples were from men from the Ivory Coast, Guinea Bissau and Senegal. The 4th sample belonged to the wife of one of these men. She was positive only for HIV-2 while the 3 men also tested positive for HIV-1. The serum of 2 of the 3 people who tested ELISA HIV-1 reactive had inconclusive HIV-1 WB patterns who tested ELISA HIV-1 reactive had inconclusive HIV-1 WB patterns which made the researchers suspect HIV-2 infection. The woman's serum reacted to the core and env proteins in both the HIV-1 Wb and HIV-2 WB, the HIV-1 ELISA was negative. RIPA and immunofluorescence tests confirmed HIV-2 infection. Her case demonstrates the need to do both HIV-1 and HIV-2 ELISA tests. None of the 650 blood donors who had been in Africa within the last 10 years tested positive for HIV-2. These findings indicated that HIV-2 was not prevalent in Denmark and was limited to West Africa. Health workers whose patients have ties with West Africa and have an inconclusive HIV-1 WB pattern should request testing for HIV-2. The researchers suggested that serological surveillance for HIV-2 should be done at regular intervals.

Neutralizing antibodies against two HIV-1 strains in consecutively collected serum samples: cross neutralization and association to HIV-1 related disease.

97 sera collected during a 10-year period from 10 HIV-1 infected individuals were tested for neutralizing capacity against a virus isolate FICPH-22 obtained from a Danish AIDS patient, and the laboratory strain HTLV-IIIB. Three patterns of serum neutralizing activity were demonstrated: (a) patients developing high neutralizing activity against both HIV strains; (b) patients developing high neutralizing activity against the Danish virus isolate; and (c) patients developing only low titers of neutralizing antibodies (NA) against both HIV strains. The HTLV-IIIB strain was less sensitive to serum neutralization than the FICPH-22 isolate and the appearance of NA against HTLV-IIIB was typically lacking several years behind that against FICPH-22 indicating a broadening of the NA response over time. No difference in clinical outcome was observed comparing patients reaching high titers of NA and patients with low titers. Development of AIDS among patients reaching high titers of NA was preceded by a decline in NA titers, indicating an association of high titers of NA with the healthy carrier state and of declining or low titers of NA with disease progression. The majority of the neutralizing activity was mediated by IgG, but some neutralizing activity was demonstrated in the IgG depleted serum, indicating the presence of additional neutralizing substances in serum.

Competition ELISA using a human monoclonal antibody for detection of antibodies against human immunodeficiency virus type 1.

A novel competition ELISA for detection of antibodies against HIV-1 was developed. The assay is based on competition at the single epitope level and utilises a human monoclonal antibody and an E. coli-produced fragment of the transmembrane glycoprotein gp41. The sensitivity of the assay was 100% in tests on 247 serum samples obtained from 219 individuals previously shown to be HIV-1 antibody positive by both conventional indirect ELISA and the immunoblotting test. The patients represented various clinical and immunological stages of HIV-1 infection. Likewise, the specificity of the assay was 100% in tests on 105 serum samples from normal individuals previously tested negative by indirect ELISA. Further, among 105 serum samples selected due to consistent false positive reactions in the indirect ELISA only 2 samples (1.9%) demonstrated false positive reactions in the competition ELISA, i.e. 98.1% specificity. Finally, only 2 of 57 (3.5%) serum samples from HIV-2 infected individuals showed positive reactions in the assay, while 54 (94.7%) had absorbance values similar to the negative controls. These results demonstrate that human monoclonal antibodies may form the basis for highly sensitive and specific assays for detection of antibodies to HIV-1.

Analysis of a highly immunodominant epitope in the human immunodeficiency virus type 1 transmembrane glycoprotein, gp41, defined by a human monoclonal antibody.

A human monoclonal antibody, 41-7 [immunoglobulin G1(kappa)], directed against the transmembrane glycoprotein gp41 of the human immunodeficiency virus type 1 (HIV-1) has been produced by direct fusion of lymph node cells from an HIV-1-infected individual with a human B-lymphoblastoid cell line. The minimal essential epitope for 41-7 was mapped to a conserved seven-amino acid sequence, N-CSGKLIC-C, located within the N-terminal part of gp41. Antibodies blocking the binding of 41-7 could be detected in the serum of all HIV-1-infected individuals tested, irrespective of the stage of the infection. The epitope is located externally to the plasma membrane, and it is accessible to antibody in the native conformation of the glycoprotein. Despite this, no neutralizing activity of 41-7 could be demonstrated in vitro. These data indicate, directly and indirectly, that this immunodominant epitope on gp41, although exposed on the viral surface, elicits antibodies lacking antiviral activity and, hence, should be avoided in future vaccine candidates.

T-cell subset alterations and lymphocyte responsiveness to mitogens and antigen during severe primary infection with HIV: a case series of seven consecutive HIV seroconverters.

Seven consecutive patients who presented with a severe acute mononucleosis-like illness associated with HIV seroconversion were evaluated by T-cell subset enumerations and measurements of lymphocyte transformation responses to mitogens and antigen during both their primary illness and a 1-year follow-up period. We observed a characteristic pattern of response to primary HIV infection; initial lymphopenia was followed by CD8 lymphocytosis and inversion of the CD4:CD8 ratio. During follow-up, the CD8 count gradually returned to normal, whereas the CD4:CD8 ratio remained inverted because of a relatively low number of CD4 lymphocytes. Primary infection was followed by prolonged and severe cellular hyporesponsiveness to both mitogens and antigen. At the last follow-up, responses to pokeweed mitogen were still severely impaired, with a median 19% (range 7-50%) of that observed in healthy controls. We conclude that severe primary HIV infection may be followed by sustained lymphocyte hyporesponsiveness, a sustained low percentage of CD4 lymphocytes and sustained inversion of the CD4:CD8 ratio.

Markers of human immunodeficiency virus infection in high-risk individuals seronegative by first generation enzyme-linked immunosorbent assay.

A total of 228 stored serum samples from 140 high risk individuals was examined for serological markers of human immunodeficiency virus (HIV) infection by second generation enzyme-linked immunosorbent assay, immunoblot, and HIV antigen assay. All the samples were negative in first generation enzyme-linked immunoassay (ELISA). Seventy-four of the serum samples had been obtained from 40 sexual partners of HIV antibody positive individuals. Two of the samples were reactive for p24 in immunoblot, but no other markers of HIV infection were found. From 80 sexually active male homosexuals, 117 serum samples were obtained. They were all negative by the tests employed. Further, 37 serum samples from 20 seroconverters were studied. Four patients had antigenaemia 6-12 months before seroconversion was detected by first generation ELISA. Our data do not support the notion that serological signs of HIV infection are common in high risk individuals seronegative by first generation ELISA. However, HIV infection do occur in subjects negative by first generation ELISA, which emphasises the need for more sensitive screening assays and/or the use of antigen detection as part of screening in high risk individuals. The advent of second generation ELISAs has not in a substantial way reduced this demand.

Clinical course of primary HIV infection: consequences for subsequent course of infection.

OBJECTIVE: To investigate the impact of the clinical course of the primary HIV infection on the subsequent course of the infection. DESIGN: Prospective documenting of seroconversion, follow up at six month intervals, and analysis of disease progression by life tables. PATIENTS: 86 Men in whom seroconversion occurred within 12 months. PRIMARY OUTCOME MEASURE: Progression of HIV infection, defined as CD4 lymphocyte count less than 0.5 X 10(9)/l, recurrence of HIV antigenaemia, or progression to Centers for Disease Control group IV. MAIN RESULTS: Median follow up was 670 (range 45-1506) days. An acute illness like glandular fever occurred in 46 (53%) subjects. Three year progression rates to Centers for Disease Control group IV was 78% at three years for those who had longlasting illnesses (duration greater than or equal to 14 days) during seroconversion as compared with 10% for those who were free of symptoms or had mild illness. All six patients who developed AIDS had had longlasting primary illnesses. Three year progression rates to a CD4 lymphocyte count less than 0.5 X 10(9)/l and to recurrence of HIV antigenaemia were significantly higher for those who had longlasting primary illnesses than those who had no symptoms or mild illness (75% v 42% and 55% v 14%, respectively). CONCLUSION: The course of primary infection may determine the subsequent course of the infection.

Antibodies against the major core protein p24 of human immunodeficiency virus: relation to immunological, clinical and prognostic findings.

In 79 homosexual men positive for antibody to human immunodeficiency virus (HIV), the titer and avidity of p24 antibody was determined by an indirect ELISA and the serum tested for the presence of HIV antigen. Results were examined for a possible correlation with clinical, immunological and prognostic findings. High titers and low avidity of p24 antibodies correlated significantly with a normal pokeweed mitogen response, early lymph node changes, and an asymptomatic and stable clinical condition. In HIV antigen negative patients, low titers and high avidity of p24 antibodies correlated significantly with a progressive clinical condition. The finding of primarily high avidity antibodies against p24 antigen in patients with more advanced immunodeficiency indicates that a decline of p24 antibodies during the clinical course of HIV infection may not be explained exclusively by an increased production of viral proteins.

Investigation of immunosuppressive properties of inactivated human immunodeficiency virus and possible neutralization of this effect by some patient sera.

Retroviral infections are accompanied by immunosuppression in a variety of species. For feline leukemia virus, the immunosuppression has been ascribed to the transmembrane envelope protein, p15E, which suppresses the proliferative responses of cat, mouse, and human lymphocytes. A similar suppressive effect has been shown for a lysate of human immunodeficiency virus (HIV), strain HTLV-IIIB. Here we determined that detergent-disrupted HTLV-IIIB lystate exerted a strong suppressive effect on PHA-stimulated lymphocytes. Preparations of whole virions, a lysate of a local HIV isolate grown on MP-6 cells, and a commercially obtained UV and psoralene-inactivated lysate were examined and demonstrated to have a similar suppressive effect. The HIV lysate was not directly cytotoxic to lymphocytes and did not contain tumor necrosis factor or lymphotoxin. The HIV lysate specifically suppressed the proliferation of a range of hemopoietic cell lines from man and mouse including three EBV transformed CD4- and IL-2 receptor-negative B-cell lines. The lysate also suppressed the formation of human bone marrow colonies, whereas the lysate had only a slight or no effect on fibroblasts. The suppression of lymphocyte proliferation was not abrogated by addition of IL-2 or IL-1 and the HIV lysate inhibited the expression of IL-2 receptors on suboptimal PHA-stimulated mononuclear cells. The suppressive factor(s) has not been characterized in molecular terms, but suppressive activity was recovered in fractions with a molecular weight of about 67,000 and in both the glycoprotein fraction and in the glycoprotein-depleted fraction of the HIV lysate. Sera from one-third of a small series (N = 13) of individuals with antibodies to HIV seem to be able to neutralize the suppressive properties of HIV lysate in cultures.