Immuno-oncology-the new paradigm of lung cancer treatment.

Systemic therapy is an essential part of treatment for all patients with small-cell lung cancer (sclc) and for most patients with non-small-cell lung cancer (nsclc). Standards of care have evolved dramatically since 2009, especially in the setting of incurable or advanced nsclc. Part of that evolution has been the incorporation of immuno-oncology drugs, especially immune checkpoint inhibitors (icis) into multiple therapeutic scenarios. In the present review, we discuss the role of the immune system in lung cancer and the previous failures of immunotherapy for patients with lung cancer. We then provide an overview of the existing evidence for the use of icis in patients with advanced nsclc that is either treatment-naïve or pretreated, for consolidative treatment after chemoradiotherapy in stage iii nsclc, and for palliative therapy in patients with sclc. Finally, we discuss duration of treatment, special populations, and the future of immuno-oncology for patients with lung cancer. Overall, we provide an evidence-based snapshot of immuno-oncology agents in the treatment of lung cancer up to early 2019.

Descriptive analysis of dosing and outcomes for patients with ibrutinib-treated relapsed or refractory chronic lymphocytic leukemia in a Canadian centre.

Background: Ibrutinib is an approved treatment for relapsed or refractory chronic lymphocytic leukemia (cll) and small lymphocytic lymphoma (sll). The effect of ibrutinib dose reduction compared with discontinuation in a population-based setting is unclear. Methods: To examine the patterns of ibrutinib use in a Canadian population-based setting, we analyzed a retrospective cohort of patients with relapsed or refractory cll or sll treated with ibrutinib. Results: The 64 patients diagnosed with cll or sll had a median age of 76.5 years. Most had unmutated ighv (immunoglobulin variable heavy chain). A hematologic response occurred in 39 patients regardless of the ibrutinib dose. The most common toxicities were infection, bruising or bleeding, and musculoskeletal problems, with a median time to first toxicity of 14 days. More than half the cohort experienced a dose reduction, with musculoskeletal problems, cytopenias, and infection being the leading causes; surgery was the most frequent indication for holding treatment. Only 26 of the 64 patients (40.6%) stayed on the recommended maximal dose of ibrutinib. No differences in reported toxicities or hematologic response rates were evident between the patients receiving maximal and submaximal therapy. At the end of the study period, 53 patients from the initial cohort remained on ibrutinib. Conclusions: More than half the study patients received ibrutinib therapy at a submaximal dose without evidence of increased frequency of toxicities or disease progression. The rate of ibrutinib discontinuation was lower in our cohort than has been reported in other settings. Submaximal ibrutinib dosing will have to be further systematically evaluated.

Ergot alkaloid transport across ruminant gastric tissues.

Ergot alkaloids cause fescue toxicosis when livestock graze endophyte-infected tall fescue. It is generally accepted that ergovaline is the toxic component of endophyte-infected tall fescue, but there is no direct evidence to support this hypothesis. The objective of this study was to examine relative and potential transport of ergoline and ergopeptine alkaloids across isolated gastric tissues in vitro. Sheep ruminal and omasal tissues were surgically removed and placed in parabiotic chambers. Equimolar concentrations of lysergic acid, lysergol, ergonovine, ergotamine, and ergocryptine were added to a Kreb's Ringer phosphate (KRP) solution on the mucosal side of the tissue. Tissue was incubated in near-physiological conditions for 240 min. Samples were taken from KRP on the serosal side of the chambers at times 0, 30, 60, 120, 180, and 240 min and analyzed for ergot alkaloids by competitive ELISA. The serosal KRP remaining after incubation was freeze-dried and the alkaloid species quantified by HPLC. The area of ruminal and omasal tissues was measured and the potential transportable alkaloids calculated by multiplying the moles of transported alkaloids per square centimeter of each tissue type by the surface area of the tissue. Studies were conducted to compare alkaloid transport in reticular, ruminal, and omasal tissues and to determine whether transport was active or passive. Ruminal tissue had greater ergot alkaloid transport potential than omasal tissue (85 vs 60 mmol) because of a larger surface area. The ruminal posterior dorsal sac had the greatest potential for alkaloid transport, but the other ruminal tissues were not different from one another. Alkaloid transport was less among reticular tissues than among ruminal tissues. Transport of alkaloids seemed to be an active process. The alkaloids with greatest transport potential were lysergic acid and lysergol. Ergopeptine alkaloids tended to pass across omasal tissues in greater quantities than across ruminal tissues, but their transport was minimal compared to lysergic acid and lysergol.

Anti-inflammatory effects of ergotamine in steers.

The objective of this experiment was to investigate whether the ergot alkaloid, ergotamine (ET), an alkaloid used to model fescue toxicosis in cattle, modifies the response of cattle to endotoxin (LPS) challenge. Steers (n = 16) were divided into the following treatment groups: control (C), ergotamine (ET), endotoxin (LPS), and ET + LPS. ET and ET + LPS groups received a single bolus intravenous injection of ET (40 microg. kg. body wt(-1)), whereas C and LPS steers received a single bolus injection of sterile vehicle. Thirty minutes after ET/vehicle administration, a single bolus intravenous injection of LPS (0.2 microg. kg. body wt(-1)) was given. Blood was collected at various time points for 48 hr post. Endotoxin increased rectal temperature (RT) and the circulating levels of tumor necrosis factor-alpha (TNF-alpha), cortisol, haptoglobin (Hp), thromboxane B(2) (TXB(2)). The circulating Hp, TNF-alpha, and TXB(2) increases were blunted by pretreatment with ET compared with ET + LPS. Ergotamine by itself increased circulating cortisol and RT, whereas it decreased serum prolactin (PRL). Therefore, whereas administration of LPS at 0.2 microg/kg to steers resulted in an expected response, the combination of ET + LPS attenuated major effects of LPS alone. Thus, acute administration of ET appeared to be anti-inflammatory as it decreased the inflammatory response to LPS, an effect likely driven at least in part by the ET-caused cortisol increase.

Urinary alkaloid excretion as a diagnostic tool for fescue toxicosis in cattle.

Fescue toxicosis research studies have often included serum prolactin as a physiologic index of the disorder. Serum prolactin has not been used as a clinical measure of fescue toxicosis because of variation associated with sex and physiologic condition of the animal and climatic and seasonal factors. The primary excretory route of the alkaloids responsible for this toxicosis is the urine. Three pasture experiments were conducted to examine serum prolactin and urinary ergot alkaloid variability among steers continuously grazing endophyte-infected (E+) or endophyte-free (E-) tall fescue and among steers that were switched from one pasture form to the other. A fourth grazing experiment was used to examine how to best to manage the steers prior to sampling for urinary ergot alkaloid excretion. Coefficients of variability for urinary alkaloid excretion were consistently lower (46-65%) than serum prolactin (64-142%). Urinary alkaloid excretion patterns changed within 12 hours following switching steers from E+ to E- pasture or vice versa, but serum prolactin was recalcitrant to change. Because it is less variable and more dynamic than serum prolactin, urinary alkaloid excretion can be used for health assessment of steers grazing E+ and E- pastures. Regression analysis established a quadratic relationship between alkaloid excretion and average daily weight gain, with a regression coefficient of 0.86. Urinary alkaloid analysis was useful in determining whether cattle were consuming toxic tall fescue.

Children's needs in shelters: mother's perceptions.

The needs of children who witness violence directed at their mothers have only recently gained attention. While shelter services to address children's responses are increasingly evident, there is still much we do not understand about their plight, particularly from the perspective of their mothers. This study used focus-group methodology to identify mothers' perceptions of their children's needs while they were in shelters. Five focus group sessions were held with 27 mothers who had experienced violence in their homes and had used shelter services within the previous two-year period. Data were analyzed to identify six dominant categories of need and 12 supporting thematic categories. The dominant categories included: the counselling needs of the children; day-to-day living needs, such as maintaining family integrity and normality; recreational needs; the needs of children with respect to parenting; and finally, aspects of shelter support for mothers, and the impact of the shelter environment on children. The implications of the findings for program development are discussed.

Vaccination against ergot alkaloids and the effect of endophyte-infected fescue seed-based diets on rabbits.

Three sequential experiments were conducted with rabbits to 1) determine the effect of endophyte-infected (E+) tall fescue seed on rabbit performance and examine the effect of anti-ergot alkaloid immunization on rabbit performance and protectiveness against fescue toxicosis, 2) compare immunogens designed to elicit systemic anti-ergot alkaloid antibodies, and 3) select a superior adjuvant. In Exp. 1, rabbits (n = 6/treatment) fed E+ fescue seed diets (20%, 340 ppb total ergot alkaloids) had reduced (P < .05) intake and weight gain compared with endophyte-free (E-) controls, whereas apparent diet digestibility was not different between E+ and E-. Rabbits immunized against ergot alkaloids (E+ vac) with lysergol conjugated to human serum albumin (Ly-HSA) had greater (P < .05) intake than E+ rabbits during the wk 1 of a 3-wk dietary challenge. In Exp. 2, rabbits (n = 4/treatment) were immunized with Ly-HSA, with H100-B (ergot alkaloid hapten, H100-different protein carrier, B conjugate), or combinations of both with alum as adjuvant. Greatest (P < .001) anti-ergot alkaloid antibody (Ab) titer developed in the group immunized with H100-B. In Exp. 3, rabbits (n = 4/treatment) were immunized with the immunogen H100-B in conjunction with six adjuvants. Freund's incomplete adjuvant (FIA) in combination with DEAE-dextran and FIA alone gave highest anti-ergot titers. In summary, rabbit weight gain and intake were reduced by feeding E+ fescue seed diets, immunization against ergot alkaloids provided temporary improvement in intake, and H100-B conjugate with FIA or FIA + DEAE-dextran as adjuvants elicited a superior anti-ergot immune response. We believe that rabbits may serve as a model animal for fescue toxicosis research.

Urinary and biliary excretion of ergot alkaloids from steers that grazed endophyte-infected tall fescue.

Ergot alkaloids cause fescue toxicosis when livestock graze endophyte-infected (E+) tall fescue. Little is known about the bioavailability of the ergot alkaloid classes (lysergic acid, lysergic acid amides, or ergopeptine alkaloids) in livestock, and this hampers development of pharmacological strategies to ameliorate the toxicosis. One method used to determine bioavailability of ergot alkaloids is to examine urinary and biliary excretion patterns. Thus, our objectives were to compare ergot alkaloid excretion via urinary or biliary systems and to determine the rate of appearance or clearance of these alkaloids in cattle that were grazing E+ or endophyte-free (E-) tall fescue. In autumn 1996, bile and urine samples were collected from eight steers (203 kg), each grazing E+ and E- tall fescue, and total alkaloid excretion was quantified using competitive ELISA. Approximately 96% of the ergot alkaloids were excreted in urine. The same steers were used to examine the rate of appearance in, or clearance from, urine when switched from E+ to E-, or from E- to E+, pastures in comparison with steers that were continuously grazing E+ or E- tall fescue at 0, 2, 5, and 7 d. Steers were returned to their original pastures after 7 d, and urine was collected at 2, 5, and 7 d. Urinary alkaloid concentrations in steers switched from E- to E+ pastures were similar (P = .55) to those in steers that continuously grazed E+ tall fescue after 2 d. Steers switched from E+ to E- pastures had urinary alkaloid concentrations similar (P = .91) to those in steers that continuously grazed E- pastures after 2 d. In 1997, two trials were conducted in which steers (191 kg) were switched or remained on E+ or E- pastures, and urine was collected at 0, 12, 24, 48, and 96 h to estimate rate of alkaloid appearance or clearance. Steers switched from E- to E+ 1) had about 33% as much urinary alkaloids as steers grazing E+ pasture after 12 h, 2) were not different after 24 h (P = .76), 3) had twice those of the E+ steers at 48 h (P < .05), and 4) were not different after 96 h. Steers switched from E+ to E- tall fescue had approximately 33% less (P < .05) urinary alkaloids than those grazing E+ at 12 h, 67% less (P < .05) at 24 and 48 h, and were not different (P = .86) from steers continuously grazing E- pastures after 96 h. Urinary alkaloid excretion patterns were similar to ergot alkaloid solubility patterns from in vitro digestion of E+ tall fescue. We suggest that alkaloids, liberated from the forage by ruminal microorganisms, were rapidly absorbed as lysergic acid amides and biotransformed ergopeptine alkaloids.

Low-intensity, range-of-motion exercise: invaluable nursing care for elderly patients.

This study looked at the effect of a single session of mild exercise in a group of cognitively unimpaired institutionalized elderly patients, aged 70+, on tests of cognitive performance. Results indicate that mild exercise, such as range-of-motion, does improve the ability to recall and that the effect lasts for at least half an hour. Mild exercise programmes appear to be a practical, low-cost nursing intervention that can enhance memory and independence. Programmes that are designed to meet individual needs and that are incorporated into daily routine and activities without imposing extra effort or inconvenience are more appealing to elderly patients. Exercise can be easily learned and implemented by nurses, personal care attendants or nurse aides. This is an extremely important consideration in a health care system that demands low-cost quality care.

Antibody binding of circulating ergot alkaloids in cattle grazing tall fescue.

Direct evidence linking alkaloids found in endophyte-infected tall fescue forage with the livestock disorder known as fescue toxicosis is lacking. Physiologic effects of fescue toxicosis include reduced serum prolactin concentration in cattle. A monoclonal antibody specific to the lysergic moiety of ergot alkaloids was developed in mice after creating an immunogen by linking lysergol to human serum albumin. The antibody was specific to the lysergic moiety and, therefore, it cross-reacted with ergot alkaloids, lysergic acid, and lysergol. The antibody did not cross-react with alkaloid derivatives that had bromated or hydrogenated lysergic ring moieties. Fescue toxicosis conditions were elicited in yearling Angus steers by permitting them to graze endophyte-infected tall fescue containing > 650 micrograms/kg of ergovaline for 60 days. Passive immunization of steers by infusion of the monoclonal antibody increased serum prolactin concentration by 7 ng/ml, beginning immediately after infusion. Control steers did not respond to treatment with bovine serum albumin. Active immunization of yearling Angus heifers with immunogens containing lysergol or ergonovine linked to human serum albumin resulted in an antibody response.

Going through the motions.

The benefits of exercise to a person's health and self-esteem are well recognized. Yet, for the institutionalized elderly person, exercise can be a rarity. Unfortunately, too many gerontological nurses struggle to enhance their patients' quality of life and to reduce the risk of physical and mental deterioration while ignoring this basis nursing measure. Range-of-motion (ROM) exercise is one simple activity that can have unqualified results. It can strengthen an elderly person's quality of life by increasing self-control, self-functioning, independence and, thus, self-esteem.

Delayed hypersensitivity testing as a clinical measure of cell-mediated immunity in the cat.

The purposes of this study were to examine the cell-mediated immune response of the normal cat to the modified live feline viral rhinitis, calicivirus, and parvovirus (FVRCP) vaccine (Felocell CVR, Norden, Lincoln, NE), and to evaluate the intradermal skin test as a clinical measure of the immune response of cats. Vaccine and diluent were injected intradermally on the dorsal pinna of 34 normal adult cats. Skin thickness measurements, lymphocyte counts, and Concanavalin A mitogenesis indices were evaluated in 18 of these cats. Skin biopsies were obtained in 16 cats. In normal cats, the FVRCP vaccine induced a delayed hypersensitivity response characterized by a mononuclear infiltrate most pronounced at 72 h. Five cats with either feline leukemia (FeLV) or feline immunodeficiency virus (FIV) were tested and had a significantly reduced response to the skin test. The skin test provides a clinically useful method of evaluating immune function in cats and may be useful in development of a prognostic index.

Acute exercise facilitates semantically cued memory in nursing home residents.

OBJECTIVE: To study the acute effects of non-strenuous physical exercise on memory retrieval and visuo-motor performance in old-old nursing home residents. DESIGN: A randomized control trial. SETTING: A nursing home. PARTICIPANTS: Ambulatory volunteers from the nursing home, with all 20 shown to be normal on mental status. Three were male and 17 female, with a means of 84.5 years for age and 9.3 years for education. They were divided at random into an exercise and a control group. INTERVENTION: A single 15-minute standardized bout of non-strenuous exercise administered independently to each participant in the exercise group. Control group participants watched a video of similar exercises for 15 minutes. MEASUREMENTS: Two measures requiring the retrieval of category instances with semantic or initial consonant cues. Retrieval time was 60 seconds for each of four categories per measure. Visuo-motor performance was measured by Symbol Digit coding. Testing sessions were held before exercise, immediately post-exercise and 30 minutes post-exercise. RESULTS: The group-by-time interaction was significant only for semantically cued memory (P < 0.01), with higher retrieval at post-testing only in the exercised group. The higher retrieval was mainly attributable to more new items retrieved by the exercise group at the immediate post-test (P < 0.05). CONCLUSIONS: This study provides preliminary support for the hypothesis that non-strenuous physical exercise has positive acute effects on meaningfully cued memory.

A qualitative assay for beta cell antibodies. Preliminary results in dogs with diabetes mellitus.

Purified beta cells from a radiation-induced transplantable rat insulinoma were used to detect beta cell antibodies in serum from untreated diabetic dogs. Serum from dogs in which anti-beta cell antibodies were induced by injecting a purified beta cell suspension subcutaneously was used as positive control. Following incubation with test sera, fluorescein-labeled anti-dog immunoglobulins were used to visualize binding between the beta cells and dog gamma globulins. Nine of the 23 diabetic dogs showed a strongly positive reaction which was characterized by a ring fluorescence, three showed a weak reaction and 11 were negative, i.e. they showed diffuse fluorescence. In contrast, 14 of the 15 healthy dogs showed diffuse fluorescence and one dog showed a weakly positive reaction. Thyroid, liver and kidney cells did not elicit ring fluorescence. Although females (spayed and intact) represented the majority of the diabetic dogs, there was no correlation between sex and the occurrence of antibodies in the diabetic dogs. There was also no correlation to the age of the dogs. In conclusion, we have developed a specific test for anti-beta cell antibodies. The test is reproducible and economical to perform on a large number of samples.

Mitogen and antigen-specific induction of lymphoblast transformation in cats with subclinical toxoplasmosis.

Lymphoblast transformation in whole blood was assessed by 3H-thymidine incorporation after stimulation by concanavalin A and Toxoplasma gondii secretory and intracellular antigens in samples from cats with experimentally induced toxoplasmosis. Toxoplasma gondii-specific immunoglobulin M, immunoglobulin G, and circulating antigens were also measured throughout the study period. Lymphocytes from all cats were responsive to concanavalin A pre- and post-inoculation with T. gondii. Suppression of mitogen-stimulated lymphoblast transformation during the course of infection was not observed. Both the secretory and intracellular antigens stimulated lymphoblast transformation in many cats from Week 2 to Week 52 post-inoculation. Lymphoblast transformation was stimulated more frequently by intracellular antigens (66.25%) than by secretory antigens (48.75%). Lymphoblast transformation was not induced by T. gondii antigens in any cat prior to appearance of T. gondii-specific antibodies in serum or during the oocyst shedding period. Cats with persistent antigenemia had the most consistent lymphoblast transformation results induced by T. gondii-specific antigens.

An immunofluorescence test to determine the occurrence of type II collagen in muscle biopsies from cattle with rectovaginal constriction.

Type II collagen occurs in the muscles of rectovaginal constriction (RVC) affected and carrier cattle but not in normal cattle. Muscle biopsies from known RVC affected and carrier cattle and normal cattle were examined for the presence of Type II collagen using affinity purified goat anti-collagen II serum in a fluorescent antibody test. Type II collagen was consistently found in RVC affected animals (22 of 23 samples score positive). Rectovaginal constriction carrier animals had variable staining for the Type II collagen (25 of 47 samples scored positive). Some positive staining was also observed in the control animals (8 of 34 samples scored positive). Because of the variable occurrence of Type II collagen, the value of fluorescent antibody staining to identify RVC carrier animals is uncertain.

Unexpected pattern of antibody response of hens following infectious bursal disease virus vaccine.

The antibody titers to infectious bursal disease virus (IBDV) of a group of hens were determined every 2 weeks during the laying period using a kinetic-based enzyme-linked immunosorbent assay (ELISA). When the titers of the flock were regressed against time, the flock titer decayed with statistically significant linearity. However, when the antibody titers of individual hens were measured, their titers regressed on time in a significant quartic curvilinear fashion. Since these hens were not reimmunized, this suggests that a anamnestic response was stimulated from an unknown external source.

Prevalence of Toxoplasma gondii infection in cats in Georgia using enzyme-linked immunosorbent assays for IgM, IgG, and antigens.

Serologic prevalence of Toxoplasma gondii infection was determined using enzyme-linked immunosorbent assays detecting immunoglobulin M (IgM), immunoglobulin G (IgG), and circulating T. gondii antigens (Ag) in 81 healthy cats and 107 cats with clinical signs referable to toxoplasmosis. A higher prevalence of infection was detected using the three assays together in healthy cats, clinically ill cats, and combined healthy and clinically ill cats than when IgG class antibody detection alone was used. IgM titers greater than or equal to 1:256 and IgG titers greater than or equal to 1:512 were present more frequently in cats with clinical signs of disease. Prevalence of present or prior infection as defined by these three assays combined increased with advancing age in both groups of cats.

Diagnosis of recent Toxoplasma gondii infection in cats by use of an enzyme-linked immunosorbent assay for immunoglobulin M.

Subclinical Toxoplasma gondii infection was induced in young and adult cats by oral administration of tissue cysts. An antibody-capture ELISA to detect anti-Toxoplasma IgM-class antibodies in the serum of cats was developed. The serologic response to experimental infection was followed in the 2 groups of cats by use of anti-Toxoplasma IgM and IgG detection. This study shows that anti-Toxoplasma IgM-class antibody titers develop early in the course of experimental infection in cats and that the combination of IgM- and IgG-class antibody titer measurement can aid in the detection of recent subclinical toxoplasmosis.