Presumptive Evidence Research Articles

The Potential of Molecular Genetic Analysis for Diagnostic and Prognostic Decision Making in Clonal Cytopenia of Undetermined Significance (CCUS) and MDS - a Study on 576 Patients

Background: Several specific therapies for MDS are now available. Molecular genetics plays a key role, as some therapies target distinct mutations and others are particularly effective for molecularly defined subgroups (e.g. SF3B1). In parallel, broad mutation studies suggest a continuous progression from clonal cytopenia of undetermined significance (CCUS) to MDS. Since panel sequencing is available for routine laboratory workflows, we evaluated its potential for diagnosis of CCUS and extended the question to possible (future) therapeutic decisions. Aim: (1) Identify the frequency of clonality (mutations) in a real life MDS vs. cytopenia cohort; (2) subdivide CCUS with a low and high risk of developing MDS; (3) identify the subset of patients qualifying for personalized treatments Patients and Methods: We performed morphology and cytogenetic analysis according to current WHO gold standard algorithms in 576 patients (F:221, M:355; median age: 72 [17-94]) with cytopenia and clinical conditions requiring bone marrow biopsy to exclude or diagnose MDS. Individuals with other possible explanations (e.g. lymphoma, PNH) had been excluded upfront by combining morphology and flow cytometry. DNA was isolated from bone marrow; sequencing was performed on NovaSeq after NextFlex library preparation (Illumina, ILMN, San Diego, CA) and hybrid capture of a 41 gene panel (IDT Inc. Coralville, IA). Data was analyzed with Pisces and Pindel (for FLT3-ITD) (BaseSpace, ILMN) using a minimum sensitivity of 3%. Genetic variants were classified by combining databases and in silico predictions. Results: We found 499 mutations in 181/213 (85%) patients with diagnosis of MDS, and 259 mutations in 132/363 (36%) other cytopenic patients (p <0.01). Cases with mutations are by definition CCUS and without mutation ICUS (idiopathic cytopenia of undetermined significance). CCUS and MDS patients were significantly older than ICUS (CCUS: 74, MDS: 75 vs. ICUS: 66 years, p <0.02, each). MDS patients had significantly more mutations per case than CCUS (average: 2.8 vs. 2.0, p<0.01). By contrast, the typical aging pattern (DNMT3A, TET2 and ASXL1 mutations [DTA] with VAF <10%) as the only molecular genetic aberration was significantly more frequent in CCUS than in MDS with mutations: 25% vs. 4% (33/132 vs. 7/181; p<0.01). The International Working Group for the Prognosis of MDS - IWG-PM - (Malcovati, et al. Blood 2020) suggested SF3B1 mutations to define the first subgroup of patients by molecular genetics. Using their criteria, 12% of our MDS (26/213) patients fall into this novel category of SF3B1-mutated MDS. Due to the high risk of developing MDS, the IWG-PM suggests to use the mutation as presumptive evidence of MDS even without definitive morphological features. In our CCUS cohort the same genetic SF3B1 constellation was significantly less frequent, however 5% of individuals (7/132, p=0.03) qualified for MDS diagnoses by molecular genetics. In addition, CCUS patients show other MDS typical mutations: e.g. 4% (5/132) had RUNX1 mutations and 30% (39/132) had splicing factor mutations other than SF3B1. Malcovati et. al. (Blood 2017) defined a "highly specific pattern" of mutations for patients with a 20% risk of developing a myeloid malignancy per year. This pattern was frequent in MDS (71%, 151/213), but was detected in 55% of CCUS (72/132), which corresponds to 20% of cytopenia patients without a definitive MDS diagnosis (72/363). Next, we subdivided the cohorts according to their potential treatment options (Figure 1). (A) SF3B1 mutations would suggest use of Luspatercept. (B) According to Bejar et al. (ASH 2015), 95/213 (45%) of our MDS and 37/132 (28%) of our CCUS have a high-risk genetic profile. Individuals with high-risk mutations could be considered for alloSCT depending on progression of disease or clinical settings. (C) A potential for targeted therapies (mutations in CSNK1A1, FLT3 [ITD, TKD], IDH1, IDH2, KRAS, NRAS) was found in 6% (12/213) of the remaining MDS and 3% (4/132) of the CCUS cohort. Conclusions: We suggest that molecular genetic markers should be recognized as presumptive evidence of MDS and allow the diagnoses to be based on three cornerstones: morphology, cytogenetics and molecular genetics. In two thirds of MDS and one third of CCUS patients mutations can be identified that allow personalized treatment based on respective molecular genetics even independent of other currently used diagnostic labels. Disclosures No relevant conflicts of interest to declare.

The Absurd Injunction to Not Belong and the Bidūn in Kuwait

In a tweet posted on 29 March 2018, a bidūn activist—who was later jailed from July 2019 to January 2020 for peacefully protesting against the inhumane conditions under which the bidūn are living—shared a video. The brief video zooms in closely on an ID card, recognizable as one of those issued to the bidūn, or long-term residents of Kuwait who are in contention with the state regarding their legal status. More precisely, the mobile phone camera focuses on the back of the ID card, on one line with a special mention added by the Central System (al-jihāz al-markazī), the administration in charge of bidūn affairs. Other magnetic strip cards hide the personal data written above and below it. A male voice can be heard saying that he will read this additional remark, but before even doing so he bursts into laughter. The faceless voice goes on to read out the label in an unrestrained laugh: “ladayh qarīb … ladayh qarīna … dālla ʿalā al-jinsiyya al-ʿIrāqiyya” (he has a relative … who has presumptive evidence … suggesting an Iraqi nationality). The video shakes as the result of a contagious laugh that grows in intensity. In the Kuwaiti dialect, the voice continues commenting: “Uqsim bil-Allāh, gaʿadt sāʿa ufakkir shinū maʿanāt hal-ḥatchī” (I swear by God, it took me an hour to figure out the meaning of this nonsense), before reading the sentence again, stopping and guffawing, and asking if he should “repeat it a third time,” expressing amazement at its absurdity. The tweet, addressed to the head of the Central System (mentioned in the hashtag #faḍīḥat Sāliḥ al-Faḍāla, or #scandal Salih al-Fadala), reads: In lam tastaḥī fa-'ktub mā shaʾt (Don't bother, write what you want).

Clinical Relevance of Clonal Hematopoiesis in the Oldest-Old Population

Background: Clonal hematopoiesis of indeterminate potential (CHIP) is associated with increased risk of cancers and inflammation-related diseases. The phenomenon becomes very common in oldest-old individuals, in whom the implications of CHIP are not well defined. Here we investigate the relationships between CHIP and associated pathologies in people aged >80 years. Methods: We performed a mutational screening in 1794 oldest-old individuals enrolled in two population-based studies (“Health_&_Anemia” and “Monzino_80+”). Findings: Clonal mutations were observed in one third of oldest-old individuals and were associated with reduced survival and increased risk of cancers. Mutations in JAK2 and splicing genes (SF3B1, SRSF2, U2AF1, ZRSR2), multiple mutations (DNMT3A, TET2, ASXL1) combined with additional genetic lesions) and variant allele frequency ≥0.14 had positive predictive value for myeloid neoplasms. Combining mutation profiles with abnormalities in red blood cell indices improved the ability of myeloid neoplasm prediction. On this basis, we defined a predictive model that identifies 3 risk groups with different probabilities of developing myeloid neoplasms. Mutations in DNMT3A, TET2, ASXL1 or JAK2 (most occurring as single lesion) were associated with coronary heart disease and rheumatoid arthritis. Cytopenia (most including anemia) was a common finding in oldest-old population (>20%), the underlying cause remaining unexplained in 30% of cases. Among individuals with unexplained cytopenia, the presence of highly-specific mutation patterns was associated with a myeloid neoplasms-like phenotype and a probability of survival comparable to that of myeloid neoplasms. Accordingly, 7.5% of oldest-old subjects with cytopenia had presumptive evidence of myeloid neoplasm. Interpretation: Specific mutational patterns define different risk of developing cancers vs. inflammatory-associated diseases in oldest-old population. In individuals with unexplained cytopenia, mutational status may identify those subjects with presumptive evidence of myeloid neoplasms. Trial Registration: (ClinicalTrials.gov number:NCT03907553) Funding: Supported by European Union; Cariplo Foundation, Italy; Italian Association for Cancer Research; Italian Ministry of Health and Research. Declaration of Interests: The Authors declare no competing interests. Ethics Approval Statement: Study procedures were in accordance with the Declaration of Helsinki. Ethics Committees of Humanitas Research Hospital and Mario Negri Pharmacological Institute, Milan Italy approved the study. Written informed consent was obtained prior to blood sampling.

Regulation of NF-κB, FHC and SOD2 in response to oxidative stress in the freeze tolerant wood frog, Rana sylvatica

The wood frog, Rana sylvatica, is the primary model animal used for studying vertebrate freeze tolerance. Freeze tolerance adaptations by wood frogs are mediated by a set of well-tuned regulatory controls at the molecular level, starting from cell signal transduction and gene expression events that are ultimately reflected in protective responses by multiple cell systems. Previous studies provided excellent presumptive evidence for the involvement of the NF-κB transcription factor in freeze tolerance. The present study of the NF-κB pathway focussed on freezing time points, 4 h frozen and 24 h frozen for liver and skeletal muscle in wood frog. The total protein levels of the major NF-κB subunits p50 and p65, its inhibitor, p-IκB, and downstream targets, ferritin heavy chain (FHC) and manganese superoxide dismutase (MnSOD) were quantified using western blots. Results showed a significant increase in the levels of NF-κB subunits and its downstream targets during freezing. Nuclear distributions of NF-κB subunits and transcript levels of FHC were analysed to delve deeper into the pathway. Results obtained from nuclear distribution analysis were consistent with the total protein levels showing increased levels of p50 and p65 during 24 h freezing conditions compared to controls but no change in phospho-p65 levels. Further, FHC transcript levels increased in 24 h frozen liver but did not change in frozen muscles. These findings suggest the activation of NF-κB antioxidant defenses in wood frogs during freezing in potential anticipation of high oxidative stress during reperfusion during thawing.

Role of Glutathione in Chalcone Derivative Induced Apoptosis of Brugia malayi and its Possible Therapeutic Implication.

Oxidative stress is an essential component of innate response against microbes. The oxidative impact has a very subtle connection with apoptosis. Our previous work indicated presumptive evidence of apoptosis by the chalcone derivatives against the human lymphatic filarial parasite. Evidence suggests the involvement of glutathione-S-transferase (GST) in the mechanism of action of chalcone drugs. In the present study, we explored the implications of redox status in apoptosis of the parasite by this drug. Treatment with the representative drug, 4t, significantly decreased GSH level and increased GST activity in the Brugia malayi microfilariae (Mf) in comparison to Mf without 4t treatment. Drug-induced loss of motility of the parasites was reversed by the treatment with GSH (41%) and NAC (19%). A significant fall in rGST activity was observed due to drug addition, which could be reversed by the addition of GSH co-substrate, but not with the re-addition of rGST, indicating a vital role of GSH. In silico study demonstrated a favorable drug-GST enzyme interaction. Oxidative stress was reflected by increased protein carbonylation and intracellular reactive oxygen species level, in the drug-treated parasite. Mitochondrial oxygen consumption was reduced by the drug, which was reversed on the addition of GSH. Mitochondrial dysfunction was confirmed by MTT and cytochrome c assay. Apoptosis was confirmed by the inhibition in PARP activity. We conclude that the depletion of GSH by chalcone with concomitant mitochondrial dysfunction revealed a novel rationale of apoptosis in the parasite. Such a mechanism might have wide therapeutic implications.

Isolation and Cultivation of a New Isolate of BTV-25 and Presumptive Evidence for a Potential Persistent Infection in Healthy Goats.

Recently, several so-called “atypical” Bluetongue virus (BTV) serotypes were discovered, including BTV-25 (Toggenburg virus), in Switzerland. Most “atypical” BTV were identified in small ruminants without clinical signs. In 2018, two goats from a holding in Germany tested positive for BTV-25 genome by RT-qPCR prior to export. After experimental inoculation of the two goats with the BTV-25 positive field blood samples for generation of reference materials, viremia could be observed in one animal. For the first time, the BTV-25-related virus was isolated in cell culture from EDTA-blood and the full genome of isolate “BTV-25-GER2018” could be generated. BTV-25-GER2018 was only incompletely neutralized by ELISA-positive sera. We could monitor the BTV-25 occurrence in the respective affected goat flock of approximately 120 goats over several years. EDTA blood samples were screened with RT-qPCR using a newly developed BTV-25 specific assay. For serological surveillance, serum samples were screened using a commercial cELISA. BTV-25-GER2018 was detected over 4.5 years in the goat flock with intermittent PCR-positivity in some animals, and with or without concomitantly detected antibodies since 2015. We could demonstrate the viral persistence of BTV-25-GER2018 in goats for up to 4.5 years, and the first BTV-25 isolate is now available for further characterization.

Immunization programs for hospital healthcare workers in Northern-Italy, can we do more?

Abstract Background Coverage for vaccine-preventable diseases (VPDs) among healthcare workers (HCWs) in Italy remains low, and WHO strongly recommends to tailor immunization programs to tackle hesitancy. Aim of the study was to investigate HCW-specific immunization programs within Friuli Venezia Giulia (FVG) Region in order to plan new common strategies. Methods In December 2019 we collected information about FVG hospitals and HCWs immunization programs conducted within each of them, including: number of HCWs employed, monitored VPDs, immunization assumption, vaccination strategies and refusers management. Results We obtained data from 7/7 hospitals, for a total of 12,557 employed HCWs (average 1,794; range 467-3,922); 2 hospitals are academic centers, while 2 are research institutions. All hospitals have immunization programs for measles, mumps, rubella; the majority for hepatitis B (6/7); 5 for diphtheria, tetanus, pertussis, chicken pox. Presumptive evidence of immunity is established when written vaccination documentation is available or in presence of laboratory evidence. HCWs immunization programs are responsibility of the occupational doctor in most hospitals (6/7). Vaccination promotion strategies include: mail or email personal invitation, training courses, video and notice display on hospital website, reminders. Most hospitals set up a dedicated vaccination service located in a hospital common area (4) or outside the hospital (2); one hospital also offered ward on-site vaccination. For airborne or droplets transmission diseases, refusers are asked to wear a mask during shift in 2 hospitals. Conclusions HCWs immunization programs in FVG Region are heterogeneous, and their specific effectiveness has to be studied yet. This study represents the first step in the process of FVG hospitals engagement in sharing effective actions in order to plan a new regional strategy for HWCs immunization. Key messages The investigation of effective strategies conducted in different FVG hospitals is essential for their scaling-up evaluation. A common regional plan for healthcare workers immunization is needed to tackle hesitancy and reduce infectious risk within hospitals.

Post-mortem surveillance of bovine tuberculosis in Ireland: herd-level variation in the probability of herds disclosed with lesions at routine slaughter to have skin test reactors at follow-up test.

Post-mortem surveillance in Ireland discloses skin-test negative cattle with presumptive evidence of infection of Mycobacterium bovis (lesions at routine slaughter (LRS)), the causative agent of bovine tuberculosis (bTB). Laboratory confirmation of lesions has impacts on trade restrictions for herds, therefore if laboratory capacity was diminished, how herds are treated would require an informed risk policy. Here we report the proportion of herds with subsequent evidence of within-herd transmission, based on skin-test results. We assess how herd-size, herd-type, and bTB-history affect the probability of additional reactors at follow-up test using univariable and multivariable random-effects models. The study represents a rapid response to developing an evidential base for policy demands during an extraordinary event, the COVID-19 epidemic in Ireland. A dataset from 2005 to 2019 of breakdowns were collated. Overall, 20,116 breakdowns were initiated by LRS cases. During the index tests of these breakdowns, 3931 revealed ≥1 skin-test reactor animals (19.54%; ≥1 standard reactors: 3827; 19.02%). Increasing herd-size was associated with reactor disclosure on follow-up. For small herds (<33 animals), 11.74% of follow-up tests disclosed ≥1 reactor; 24.63% of follow-up tests from very large herds (>137) disclosed ≥1 reactors. Beef (13.87%) and “other” (13%) herd production types had lower proportion of index tests with reactors in comparison with dairy (28.27%) or suckler (20.48%) herds. Historic breakdown size during the previous 3-years was associated reactor disclosure risk on follow-up. Our results are useful for rapid tailored policy development aimed at identifying higher risk herds.Electronic supplementary materialThe online version of this article (10.1007/s11259-020-09777-w) contains supplementary material, which is available to authorized users.

The Effects of Ḥanafī and Ẓāhirī Methodists’ Opinions About the Indication of General Utterances in Qur’ān and the Subject of Their Specification by al-Khabar al-Wāhid on Islamic Law Regulations

Âmm lafızların kullanımda fertlerinin hepsine delâletinin kat‘îliği ve zannîliği hususu usûlcüler arasında tartışmalıdır. Hanefî usûlcüler âmm lafzın tüm fertlerine delâletini kat‘î olarak görür ve başlangıçta kat‘î bir delille tahsîs edilmedikçe zannî bir delille tahsîse uğratılamayacağı görüşünü savunurlar. Zâhirî usûlcüler de hanefîler gibi âmm lafzın fertlerinin tamamına delâletinin kat‘î olduğunu ve tahsîsinin yine kendi derecesindeki başka bir delille olabileceğini savunurlar. İki grup arasındaki temel fark haber-i vâhidin sübût itibarıyla zannî bir delil mi yoksa kat‘î bir delil mi olduğu meselesinde odaklanır. Hanefîlere göre haber-i vâhid zannî bir delildir ve Kur’an’daki âmm lafızlar başlangıç itibarıyla başka kat‘î bir delille tahsîs edilmezse haber-i vâhidle tahsîs edilemez. Zâhirîlere göre ise haber-i vâhid kat‘î bir delil olup Kur’an’daki âmm lafızları tahsîs edebilir. Bu çalışmada iki mezhebin usûlcülerinin Kur’an’daki âmm lafızların delâleti ve haber-i vâhidle tahsîsine ilişkin görüşlerinin mukayesesi yapılıp daha sonra aradaki ihtilafın fıkhî düzenlemelere etkisi incelenmektedir. Buna göre çalışmada namazda Fatiha suresini okumanın hükmü, hısımlık oluşturan süt emme sayısı, bâin talâkla boşanan kadınların hakları ve ölüm cezasının Harem bölgesinde infazı meseleleri üzerinden iki mezhebin yaklaşımları mukayese edilmektedir.Özet: Bu çalışmanın amacı Amr Osman tarafından 2010 yılında tamamlanan The History and Doctrine of the Ẓāhirī Madhhab isimli doktora tezindeki bir iddianın hatalı olduğunu ortaya koymaya çalışmaktır. Amr Osman, çalışmasında özetle klasik sınıflandırmada mezheplerin ehl-i hadis ve ehl-i re’ye mensubiyetinin yanlış konumlandırıldığını iddia eder. Ona göre Zâhirî mezhebi bilinenin aksine ehl-i hadis içerisinden çıkan mezheplere değil Hanefî mezhebine daha yakındır. Bu çalışmada onun iddiasını desteklemek üzere dayandığı argümanlardan bir tanesi ele alınarak iddiasının isabetsiz olduğu ispatlanmaya çalışılmaktadır. Osman, Hanefî ve Zâhirî mezheplerinin âmm lafızların; kullanımda, tüm fertlerine şamil olması ve yine kapsamındaki tüm fertlerine delâletinin kesinliği yönündeki ortak görüşlerini esas alarak zâhirîlerin hanefîlere daha yakın olduklarını iddia eder. Bu aşamada her iki mezhebin görüşü ortak olsa da hanefîler sübûtunu zannî kabul ettikleri haber-i vâhidlerle Kur’an’ın umûmî ifadelerinin tahsîs edilebileceği görüşünü reddederler. Hâlbuki zâhirîlere göre haber-i vâhidlerin sübûtu tıpkı mütevâtir haberler gibi kesindir, dolayısıyla kendi kuvvetindeki Kur’an’ın umûmî ifadelerini tahsîs edebilir. Mezhepler arasındaki söz konusu ihtilaf birçok fıkhî düzenlemeye yansımıştır. İhtilaflardan bazıları şunlardır:1. Hanefîler, “Artık, Kur’an’dan kolayınıza geleni okuyun” âyetinin umûmuyla amel ederek namazda Kur’an’ın herhangi bir ya da birkaç âyeti okunarak kıraat rüknünün ifa edilebileceğini belirtirler. Buna mukabil zâhirîler ilgili umûmî emri “Ümmü’l-Kur’ân’ı [Fatiha] okumayanın namazı yoktur.” haberine dayanarak tahsîs etmişler ve namazda Fatiha suresini okumanın farz olduğunu belirtmişlerdir.2. Hanefîler, “Size şunlarla evlenmek haram kılındı: … sizi emziren sütanneleriniz, süt kız kardeşleriniz…” âyetinde sütanne ve süt kız kardeş ifadeleri umûmî olarak geçtiği için bir çocuğun bir sefer emmesiyle bile süt hısımlığının oluşacağını belirtirler. Onlar âyeti tahsîse götüren süt hısımlığının ancak üç ya da beş sefer emmekle oluşacağını bildiren haber-i vâhidlerle amel etmezler. Hâlbuki zahirîlerden Dâvûd ez-Zâhirî, âyeti çocuk üç defa emmedikçe süt hısımlığının oluşmayacağını bildiren haberle, İbn Hazm ise beş defa emmekle akrabalığın oluşacağını bildiren Salim hadisiyle tahsîs etmişlerdir.3. Hanefîlere göre “Onları (boşadığınız kadınları) gücünüz nispetinde, oturduğunuz yerin bir bölümünde oturtun.” âyetinin umûmuna göre boşanan kadın için, ister bâin ister ric‘î talâkla boşansın boşayan kocası tarafından sağlanmak üzere iddet süresi içerisinde nafaka ve süknâ hakkı vardır. Onlar âyetin umûmunu tahsîs eden Fatıma binti Kays haberiyle amel etmemişlerdir. Zâhirîler ise âyeti bâin talâkla boşanan kadına Hz. Peygamber’in nafaka ve süknâ hakkı vermediğine dair haberle tahsîs ederek söz konusu hakkı sadece hamile kadınlar ve ric‘î talâkla boşanan kadınlar için tanımışlardır.4. Hanefîlere göre ölüm cezası gerektirecek bir suç işleyip Harem bölgesine sığınan suçluya “Oraya kim girerse, güven içinde olur.” âyetinin umûmî ifadesine göre Harem’deyken ceza infaz edilemez. Zâhirîlerden Dâvûd ez-Zâhirî ise Hz. Peygamber’in Mekke’nin fethi gününde İbn Hattal’a Harem’de cezanın infaz edilmesini onayladığına dair haberle âyeti tahsîs etmiş Harem’de de olsa ölüm cezalarının suçlu nerede yakalanırsa orada infaz edilebileceğini ifade etmiştir. İbn Hazm, bu meselenin hükmüyle ilgili hanefîlerle aynı görüşe sahiptir. Fakat onun görüşünün gerekçesi İbn Hattal’la ilgili haberin o güne mahsus bir olay olmasından kaynaklanmaktadır. Görüldüğü üzere hanefîlerle zâhirîler âmm lafızların tüm fertlerine delâletinin kesin olduğu hususunda aynı görüşü paylaşsalar da Kur’an’ın âmm lafızlarının haber-i vâhidlerle tahsîsi hususunda ihtilaf etmişler sonuçta da iki mezhep arasında bu ihtilaftan kaynaklanan birçok farklı fıkhî düzenleme sadır olmuştur. Son tahlilde Amr Osman’ın iddiası kanaatimizce ihtiyatla karşılanmalıdır.

Qualitative Variation among Commercial Immunoassays for Detection of Measles-Specific IgG.

Measurement of measles virus-specific IgG is used to assess presumptive evidence of immunity among immunocompetent individuals with uncertain immune or vaccination status. False-negative test results may lead to unnecessary quarantine and exclusion from activities such as employment, education, and travel or result in unnecessary revaccination. In contrast, false-positive results may fail to identify susceptible individuals and promote spread of disease by those who are exposed and unprotected. To better understand the performance characteristics of tests to detect measles IgG, we compared five widely used, commercially available measles IgG test platforms using a set of 223 well-characterized serum samples. Measles virus neutralizing antibodies were also measured by in vitro plaque reduction neutralization, the gold standard method, and compared to IgG test results. Discrepant results were observed for samples in the low-positive ranges of the most sensitive tests, but there was good agreement across platforms for IgG-negative sera and for samples with intermediate to high levels of IgG. False-negative test results occurred in approximately 11% of sera, which had low levels of neutralizing antibody.

Measles Immunity among New Health Personnel at a Faculty of Medicine in Khon Kaen Province, Thailand, 2019

Measles continues to be an important global health problem despite the implementation of vaccination. Health personnel, a high-risk group, are considered to have immunity to measles. We aimed to investigate the measles immunity status among health personnel during pre-placement at the Faculty of Medicine, Khon Kaen University, northeastern Thailand. The sample included health personnel who were examined in the pre-placement program from October 2018 to September 2019. Data collected included sex, age, department, job characteristic (direct or indirect contact with patients), position, measles immunity status, based on serology tests, history of previous infection, and history of immunization. A total of 652 health personnel were included, of which 53.8% tested positive to measles IgG class antibodies, indicating prior exposure to the virus. Among them, the percentage testing positive to measles immunity was 59.5%. Two-thirds of personnel who could not recall their infection or vaccination history had a positive measles immunity status. A consensus for the definition of acceptable presumptive evidence of measles immunity in Thailand according to context must be stipulated, leading to improved management of measles immunization.

Population-based screen-detected type 2 diabetes mellitus is associated with less need for insulin therapy after 10 years

IntroductionWith increased duration of type 2 diabetes, most people have a growing need of glucose-lowering medication and eventually might require insulin. Presumptive evidence is reported that early detection (eg, by...

Complex multi-system illnesses occurring within a family: Presumptive evidence for an infectious disease process

Society is witnessing an increasing incidence of illnesses with neuropsychiatric manifestations. Prominent examples include autism and learning disorders in children, depression and chronic fatigue syndrome in adults and neurodegenerative diseases in the elderly. Although clinically diverse, all of these illnesses could be contributed to by infectious agents. If so, one might expect to trace the occurrence and progression of various brain damaging illnesses among various family members. An example of this occurring in three generations of a family was unsuccessfully submitted for publication in another journal 2015; in part because of its Public Health implications. It is submitted to this journal because of definitive evidence for the transmission to humans of infectious cellular sequences incorporated into monkey-derived stealth adapted viruses.

Immunity to rubella: an Italian retrospective cohort study

BackgroundInternational guidelines recommend that healthcare workers (HCWs) have presumptive evidence of immunity to rubella and that susceptible HCWs and doubt cases receive two doses of the MMR vaccine. However, a small percentage of the fully immunized will remain unprotected against wild viruses. Moreover, protective levels of antibodies induced by the vaccine have been shown to decline over time, but a formal recommendation regarding the testing of immunized HCWs for the persistence of IgG against rubella is lacking.MethodsThe aim of this study was to evaluate the long-term immunogenicity conferred by rubella vaccination and the effectiveness of a strategy for the management of immunized individuals in whom IgG against rubella could not be demonstrated (non-responders). The study enrolled students and medical residents who attended the Hygiene Department of Bari Policlinico University Hospital for biological risk assessment (April 2014 to June 2018).ResultsTwo thousand students and residents with documented immunization (≥2 doses of rubella or MMR vaccine) were tested. In 181 (9%), IgG against rubella was not detectable. The seronegative rate was higher among participants vaccinated at age < 2 years (89.6%) and lower among those immunized at age ≥ 2 years (93.6%; p < 0.0001). The administration of a single MMR booster dose resulted in a seroconversion rate of 98% in the seronegative group. The seroconversion rate after a second booster dose was 100%. No serious adverse events in the re-immunized were recorded.ConclusionsAn important proportion of individuals immunized for rubella or MMR do not have a protective titer for the disease(s). Our management strategy (booster followed by re-test and, for those who are still negative, a second booster and re-test) is consistent with the goal of achieving immunological memory.

Tolerogenic dendritic cell-based treatment for multiple sclerosis (MS): a harmonised study protocol for two phase I clinical trials comparing intradermal and intranodal cell administration

IntroductionBased on the advances in the treatment of multiple sclerosis (MS), currently available disease-modifying treatments (DMT) have positively influenced the disease course of MS. However, the efficacy of DMT is...

Frequency of Acquired Genetic Mutations and Their Prognostic Impact on Patients with Incidental Finding of Isolated 20q- in Bone Marrow without Morphologic Evidence of a Myeloid Neoplasm

IntroductionMyelodysplastic syndromes (MDS) are heterogeneous myeloid disorders characterized by dysplasia in one or more hematopoietic cell lines, peripheral cytopenia(s), and distinct cytogenetic abnormalities. The presence of certain cytogenetic abnormalities [e.g. 7/del(7q), -5/del(5q), 13/del(13q), i(17p)], in the setting of unexplained persistent cytopenia, has been considered presumptive evidence of MDS, despite definitive morphologic features of MDS. Conversely, chromosomal abnormalities such as isolated 20q- are not considered definitive evidence for MDS, in the absence of dysplasia. Based on our previous findings, patients with isolated 20q- without morphologic features of a myeloid neoplasm have varied clinical outcomes (Jawad MD et al. Am J Hematol.2016). In this study, we investigate the frequency of recurrent somatic gene mutations in these patients, and their relationship to progression to a myeloid neoplasm.MethodsWe retrospectively reviewed the bone marrow pathology reports of patients evaluated at our institution from 01/2005 to 09/2015 who had isolated 20q- in at least 2 of 20 metaphases. Patients with isolated 20q- and without myeloid neoplasms were included in the study, along with medical record review. A 35-gene next generation sequencing (NGS) panel (OncoHeme) targeting myeloid neoplasms was performed on available archived bone marrow aspirate pellets. Statistical analyses were performed using JMP Pro software version 13. Parametric (t-test) or nonparametric tests such as the Fisher-exact test, chi-square test, or Wilcoxon rank-sum test, were utilized as appropriate for test variables. Statistical significance was based on a 2-sided significance level of .05. Kaplan-Meier analysis was used for analyzing time to progression to myeloid neoplasms and progression-free survival (i.e. time to progression to myeloid neoplasms or death from any cause).ResultsFifty-six (42 males, 14 females) patients with isolated 20q- were identified. The average percentage of 20q- was 38.5 % (±29.3). The median age was 68 years (range: 44-90) and the median hemoglobin (Hb), absolute neutrophil count (ANC) and platelet count (Plt) were 11.7 g/dL (range: 8.3-15.1), 2.7 x 10(9)/L (range: 0.6-9.4) and 138 x 10(9)/L (range: 16-392), respectively. The indications for bone marrow biopsies ranged from cytopenia (21), multiple myeloma (20), non-Hodgkin lymphoma (10), amyloidosis (2), CLL (2) and transplant donor evaluation (1). Twenty-three patients harbored pathogenic mutations (15 had one mutation, 1 had two mutations and 7 had three mutations). The identified pathogenic mutations included ASXL1 (8), TET2 (8), SRSF2(3),PHF6 (2), SF3B1 (2), CBL (2), U2AF1 (2), IDH1 (1), IDH2 (1), BCOR (1), JAK2 (1), PTPN11(1), TP53 (1) and RUNX1 (1). Nine patients (16.1%) progressed to myeloid neoplasms (5 MDS, 2 acute myeloid leukemia, 2 chronic myeloid neoplasm-not otherwise specified) at a median follow-up of 36.7 months (range: 1.9-57.4). Of these 9 patients, 5 had one mutation (BCOR, TET2, DNM3TA, CBL, IDH2), 1 had two mutations (SF3B1/CBL) and 3 had three mutations (ASXL1/IDH1/SRSF2,DNM3TA/PTPN11/TET2, PHF6/TET2/TET2). In contrast, only 29.8% of non-progressed cases showed at least 1 mutation. Kaplan-Meier analysis demonstrated the presence of genetic mutations in patients with isolated 20q- carried significantly higher chance of progression to myeloid neoplasms (p<.05, Figure 1A and 1B). However, the number of genetic mutations was not predictive of progression in our relatively small study cohort (p=.66). There was no significant difference between those who did and did not progress with respect to age, gender, Hb, ANC, Plt, 20q- or mutational allele burden.ConclusionsMost of the patients with isolated 20q- and without morphologic features of a myeloid neoplasm did not harbor myeloid neoplasm associated gene mutations and further did not develop a myeloid neoplasm during the course of our study. Among patients with pathogenic mutations, nearly one-third showed progression to a myeloid neoplasm. Of the clinical and laboratory variables, the presence of genetic mutation is a significant risk factor for progression to a myeloid neoplasm. This study revealed the underlying molecular heterogeneity of isolated 20q- in the absence of morphologic features of a myeloid neoplasm, and underscored the prognostication value of genetic mutation analysis in these cases. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Ex Post Facto Considerations in Transfer Pricing of Hard-to-Value Intangibles: Practical and Methodical Issues with the HTVI Approach

The OECD Transfer Pricing Guidelines released in July 2017 contain updates from the BEPS Final Reports on Actions 8-10 (Aligning Transfer Pricing Outcomes with Value Creation) following the work by the OECD to align domestic rules affecting cross-border activities, strengthen international tax standards and improve transparency. The new additions to the Guidelines include a definition of hard-to-value intangibles, as well as a discussion on asymmetric access to information for taxpayers and tax administrations in valuations of such intangibles, among other things. It is concluded in the Guidelines that, due to this asymmetry, ex post facto results should provide presumptive evidence for tax administrations of the reliability of ex ante projections made by the taxpayer at the time of a transaction, referred to as the HTVI approach. Although argued by the OECD to be consistent with the arm’s length principle, the approach raises a number of questions related to its compatibility with the existing transfer pricing regime developed by the OECD, as well as its application in general. This article explores the purpose of the HTVI approach, evaluates the guidance so far released on the topic and identifies potential issues that may arise from its usage.

Mumps Outbreaks at Four Universities - Indiana, 2016.

From February to April 2016, the Indiana State Department of Health (ISDH) confirmed mumps outbreaks at four universities (three public and one private). All universities were located within 65 miles of Indianapolis; however, epidemiologic links among outbreaks were limited. ISDH and local health departments investigated the outbreaks and initiated control measures at all universities. A protocol describing recommended testing for mumps, testing priorities during the outbreak, and a preauthorization process for submitting specimens to the ISDH Laboratory (ISDHL) was developed and disseminated to providers and public health partners (1). Outbreaks at each university were declared over after two incubation periods* elapsed without identified cases; the last outbreak ended September 10, 2016. Among the 281 confirmed and probable cases identified, 216 (76.9%) persons had documentation of presumptive evidence of immunity† (2). At some universities, documentation of receipt of 2 doses of measles, mumps, rubella vaccine (MMR), which is a criterion for evidence of immunity, was not available and required substantial personnel time to verify. Implementation of policies for excluding susceptible persons from classes and other group settings was also difficult. The laboratory testing protocol increased the percentage of specimens testing positive and improved case detection. Outbreak-specific laboratory testing guidance on specimen collection for mumps confirmation and standardized vaccination documentation in highly vaccinated settings could aid outbreak management. Evaluation of exclusion policies might also be necessary. In 2018, the Advisory Committee on Immunization Practices (ACIP) published a recommendation that persons previously vaccinated with 2 doses of MMR who are determined by public health authorities to be part of a group at increased risk for infection during a mumps outbreak receive a third dose of MMR (3).

How I investigate Clonal cytogenetic abnormalities of undetermined significance.

Myelodysplastic syndromes are a group of hematopoietic stem cell diseases characterized by cytopenia(s), morphological dysplasia, and clonal hematopoiesis. In some patients, the cause of cytopenia(s) is uncertain, even after thorough clinical and laboratory evaluation. Evidence of clonal hematopoiesis has been used to support a diagnosis of myelodysplastic syndrome in this setting. In patients with cytopenia(s), the presence of clonal cytogenetic abnormalities, except for +8, del(20q) and -Y, can serve as presumptive evidence of myelodysplastic syndrome. Recent advances in next-generation sequencing have detected myeloid neoplasm-related mutations in patients who do not meet the diagnostic criteria for myelodysplastic syndrome. Various terms have been adopted to describe these cases, including clonal hematopoiesis of indeterminate potential (CHIP) and clonal cytopenia of undetermined significance (CCUS). Similarly, studies have shown that certain chromosomal abnormalities, including ones commonly detected in myelodysplastic syndrome, may not be associated necessarily with an underlying myelodysplastic syndrome. These clonal cytogenetic abnormalities of undetermined significance (CCAUS) are similar to CHIP and CCUS. Here, we review the features of CCAUS, distinguishing CCAUS from clonal cytogenetic abnormalities associated with myelodysplastic syndrome, and the potential impact of CCAUS on patient management.

The Amoralist and the Anaesthetic

AbstractThis article puts pressure on moral motivational internalism and rejects normative motivational internalism by arguing that we should be aesthetic motivational externalists. Parallels between aesthetic and moral normativity give us new reason to doubt moral internalism. I address possible disanalogies, arguing that either they fail, or they succeed, but aren't strong enough to underwrite a motivational difference between the domains. Furthermore, aesthetic externalism entails normative externalism, providing further presumptive evidence against moral internalism. I also make the case that, regardless of these particular conclusions, examining different normative domains alongside each other is a fruitful way to move debates forward.