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Tishad A, Vadakal S, Talati J, Louis M, Jacob R. Comprehensive Care for Adults with Down Syndrome in Primary Care Settings. South Med J 2024; 117:296-301. [PMID: 38830582 DOI: 10.14423/smj.0000000000001693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
This review article aims to bridge the knowledge gap in providing comprehensive care to adults with Down syndrome (DS) in primary care settings. Despite the increasing prevalence of adults with DS, there is a significant lack of familiarity and comprehensive guidelines for their health care among primary care physicians. This often results in subpar health promotion, preventive screenings, and individualized care. This article attempts to provide guidance for healthcare providers on previsit preparation, clinic visit characteristics, testing and screening considerations, and decision making/guardianship for adults with DS. By emphasizing a patient-centered approach, this review aims to enhance the quality of care, reduce associated morbidity and mortality, and ultimately improve the health outcomes of adults with DS.
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Affiliation(s)
| | | | - Jay Talati
- From the University of Florida, Jacksonville
| | - Mariam Louis
- University of Florida College of Medicine - Jacksonville, Jacksonville
| | - Rafik Jacob
- Division of General Internal Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville
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2
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Ramba M, Bogunovic D. The immune system in Down Syndrome: Autoimmunity and severe infections. Immunol Rev 2024; 322:300-310. [PMID: 38050836 PMCID: PMC10950520 DOI: 10.1111/imr.13296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 12/07/2023]
Abstract
Over 200,000 individuals in the United States alone live with Down Syndrome (DS), the most common genetic disorder associated with intellectual disability. DS has a constellation of features across the body, including dysregulation of the immune system. Individuals with DS have both a higher frequency of autoimmunity and more severe infections than the general population, highlighting the importance of understanding the immune system in this population. Individuals with DS present with dysregulation of both the innate and adaptive immune systems. Elevated cytokine levels, increased type I and type II IFN signaling, a shift toward memory phenotypes in T cells, and a decrease in the size of the B-cell compartment are observed in individuals with DS, which contribute to both autoinflammation and severe infections. Herein, we discuss the current knowledge of the immune system in individuals with Down Syndrome as well as ideas of necessary further investigations to decipher the mechanisms by which trisomy 21 leads to immune dysregulation, with the ultimate goal of identifying clinical targets to improve treatment.
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Affiliation(s)
- Meredith Ramba
- Center for Inborn Errors of Immunity, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai New York, NY, USA
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai New York, NY, USA
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dusan Bogunovic
- Center for Inborn Errors of Immunity, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai New York, NY, USA
- Precision Immunology Institute, Icahn School of Medicine at Mount Sinai New York, NY, USA
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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3
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Sánchez Moreno B, Adán-Lirola L, Rubio-Serrano J, Real de Asúa D. Causes of mortality among adults with Down syndrome before and after the COVID-19 pandemic in Spain. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2024; 68:128-139. [PMID: 37779228 DOI: 10.1111/jir.13096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The life expectancy of people with Down syndrome (DS) is limited by Alzheimer's disease (AD)-related deaths, mainly due to respiratory infections. The emergence of the COVID-19 pandemic could have changed known, past trends in mortality in this population. We analysed the differences in causes of mortality between individuals with DS deceased before and after the onset of the pandemic. METHOD This is a cross-sectional study of adults with DS recruited at a tertiary, university outpatient clinic in Madrid, Spain. Demographic and clinical data were retrospectively collected from their medical records, including information on their deaths, if any. RESULTS Five hundred seventy-two adults were included in the study, and 67 (11.7%) died. The main cause of death was respiratory infections, which occurred in 36 participants [9 (45.0%) before, and 27 (58.7%) after the appearance of COVID-19]. No significant differences were found in the determinants of pre-pandemic and post-pandemic death after adjusting for age and AD, except for an association between the use of psychotropic medication and death in the post-pandemic period (odds ratio: 2.24; 95% confidence interval: 1.04-4.82). Vaccination against COVID-19 showed a marked protective effect against mortality (odds ratio: 0.0002; 95% confidence interval: 6.7e10-6 to 0.004). CONCLUSIONS The appearance of COVID-19 has not impacted the overall trend of increase in mean age of death of adults with DS in our milieu, probably thanks to the very important protective effect of vaccination, which supports prioritising people with DS in future immunisation campaigns. The association between psychotropic medication use and mortality requires further exploration.
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Affiliation(s)
- Beatriz Sánchez Moreno
- Department of Internal Medicine, Adult Down Syndrome Unit, Hospital Universitario de La Princesa, Madrid, Spain
- Fundación de Investigación Biomédica del Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Laura Adán-Lirola
- Department of Internal Medicine, Adult Down Syndrome Unit, Hospital Universitario de La Princesa, Madrid, Spain
- Fundación de Investigación Biomédica del Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Javier Rubio-Serrano
- Department of Internal Medicine, Adult Down Syndrome Unit, Hospital Universitario de La Princesa, Madrid, Spain
- Fundación de Investigación Biomédica del Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Diego Real de Asúa
- Department of Internal Medicine, Adult Down Syndrome Unit, Hospital Universitario de La Princesa, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
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Perrotta F, Piscopiello D, Rizzo D, Iosa G, Garzya G, Calò P, Gemma D. Cytomegalovirus Pneumonia in a Patient with Down Syndrome. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:242. [PMID: 38399530 PMCID: PMC10890385 DOI: 10.3390/medicina60020242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/16/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024]
Abstract
Down syndrome (DS) is a chromosomal disorder due to the presence of an additional chromosome 21 that causes intellectual deficit and physical anomalies and predisposes patients to develop infections throughout their lives. Pneumonias are more serious in patients with DS, requiring hospitalization, and they represent an important cause of mortality in this population. Cytomegalovirus (CMV) causes widespread and serious infections in immunocompromised individuals, affecting the respiratory tract and, when causing interstitial pneumonia, associated with a high mortality rate. However, CMV-induced pneumonia is not reported in DS patients. The prevalence and severity of CMV respiratory infections in subjects with DS is unknown. This case describes a 50-year-old female patient with DS who developed extensive bilateral pneumonia with severe respiratory failure which required hospitalization in intensive care, intubation, and mechanical ventilation after approximately 10 days of empiric antibiotic and anitimycotic therapy for fever, cough, and dyspnea. The patient was diagnosed with CMV pneumonia and recovered after treatment with ganciclovir. To the best of our knowledge, this is the first reported case of CMV pneumonia in a patient with DS. This case aims to highlight that CMV pneumonia in individuals with DS can be a life-threatening condition. It also clarifies the importance of early diagnosis of infections from opportunistic pathogens such as CMV to ensure timely and efficient treatment.
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Affiliation(s)
- Francesco Perrotta
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera Cardinale Panico, 73039 Tricase, Italy; (D.P.); (D.R.); (G.I.); (G.G.); (P.C.); (D.G.)
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Familiar-Macedo D, Dias HG, Carvalho FR, Pauvolid-Corrêa A, da Silveira MN, de Oliveira MC, Gonçalves RDCF, Vianna RADO, Cardoso CAA, Boy da Silva RT, Baumblatt AP, de-Oliveira-Pinto LM. Serological investigation of vaccine-induced antibodies for measles, rubella, and yellow fever viruses in children vertically exposed to Zika virus or with down syndrome. Front Pediatr 2023; 11:1250059. [PMID: 38155740 PMCID: PMC10753015 DOI: 10.3389/fped.2023.1250059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 11/28/2023] [Indexed: 12/30/2023] Open
Abstract
Background Vaccination schedules, as well as their effectiveness and contraindications, need to be evaluated regularly, especially in specific situations. Congenital Zika Syndrome (CZS) is a severe condition that results in extensive functional and neurological impairment of fetuses and newborns due to Zika virus tropism for fetal neural progenitor cells. Down Syndrome (DS) is the leading genetic cause of intellectual disability. The immune impairment in DS has already been described, but little is known about the immune response of CZS children. Thus, CZS and DS are specific conditions that can be considered for a reassessment of the available immunizations. Here, we carried out serological analyses of attenuated vaccines-induced antibodies for measles, rubella, and yellow fever viruses in children aged 2-7, grouped into asymptomatic controls, DS children, and CZS children. Methods Plasma samples were taken, and vaccination records were compiled during clinical follow-up. Enzymatic immunoassays for quantifying anti-measles and anti-rubella IgG were performed to assess the response to the Measles, Mumps, and Rubella (MMR) vaccine. Plaque Reduction Neutralization Test (PRNT) was performed to investigate neutralizing antibodies in response to the Brazilian vaccine strain of yellow fever (YF-17DD). Results We highlight similar levels of anti-measles IgG and neutralizing antibodies for YF-17DD among CZS, DS, and asymptomatic children, although low positivity of measles data was seen in the three groups. In DS children, the 2-4-year-old group had an increased level of anti-measles IgG compared to the older group of children aged five to seven years. Lower anti-rubella IgG levels were observed in CZS and DS children compared to asymptomatic children. For anti-rubella IgG, the good performance of vaccination in asymptomatic children is due to younger ones rather than older ones. Conclusions There were no reports of adverse events after the use of the MMR and YF-17DD indicating that CZS and DS could continue to receive these vaccines, but our data draws attention to the necessity of monitoring the vaccination response in CZS and DS children over time and the possible need to adhere to national measles vaccination campaigns. Scientific research needs to continue to help develop appropriate CZS and DS health guidelines.
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Affiliation(s)
- Débora Familiar-Macedo
- Laboratório das Interações Vírus-Hospedeiros (LIVH), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (IOC/Fiocruz), Rio de Janeiro, Brazil
| | - Helver Gonçalves Dias
- Laboratório das Interações Vírus-Hospedeiros (LIVH), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (IOC/Fiocruz), Rio de Janeiro, Brazil
| | - Fabiana Rabe Carvalho
- Laboratório Multiusuário de Apoio à Pesquisa em Nefrologia e Ciências Médicas (LAMAP), Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
| | - Alex Pauvolid-Corrêa
- Laboratório de Virologia Veterinária de Viçosa (LAVEV), Departamento de Veterinária, Universidade Federal de Viçosa (UFV), Viçosa, Brazil
| | - Mayara Neto da Silveira
- Ambulatório Multidisciplinar de Síndrome de Down (AMBDOWN), Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana Cavalcante de Oliveira
- Laboratório das Interações Vírus-Hospedeiros (LIVH), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (IOC/Fiocruz), Rio de Janeiro, Brazil
| | | | | | - Claudete Aparecida Araujo Cardoso
- Laboratório Multiusuário de Apoio à Pesquisa em Nefrologia e Ciências Médicas (LAMAP), Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
- Departamento Materno Infantil, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Brazil
| | - Raquel Tavares Boy da Silva
- Ambulatório Multidisciplinar de Síndrome de Down (AMBDOWN), Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Anna Paula Baumblatt
- Ambulatório Multidisciplinar de Síndrome de Down (AMBDOWN), Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luzia Maria de-Oliveira-Pinto
- Laboratório das Interações Vírus-Hospedeiros (LIVH), Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (IOC/Fiocruz), Rio de Janeiro, Brazil
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Santoro SL, Baloh CH, Hart SJ, Horick N, Kishnani PS, Krell K, Oreskovic NM, Shaffer M, Talib N, Torres A, Spiridigliozzi GA, Skotko BG. Pneumonia vaccine response in individuals with Down syndrome at three specialty clinics. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2023; 193:e32070. [PMID: 37864360 DOI: 10.1002/ajmg.c.32070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/22/2023] [Accepted: 10/06/2023] [Indexed: 10/22/2023]
Abstract
Individuals with Down syndrome (DS) have been particularly impacted by respiratory conditions, such as pneumonia. However, the description of co-occurring recurrent infections, the response to pneumococcal immunization, and the association of these was previously unknown. We screened individuals with DS using an 11-item screener and prospectively collected pneumococcal titers and laboratory results. We found that the screener did not successfully predict which individuals with DS who would have inadequate pneumococcal titers. Thirty four of the 55 individuals with DS (62%) had abnormal pneumococcal titers demonstrating an inadequate response to routine immunization. In the absence of a valid screener, clinicians should consider screening all individuals with DS through the use of pneumococcal titers to 23 serotypes to assess vaccine response.
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Affiliation(s)
- Stephanie L Santoro
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Carolyn H Baloh
- Department of Medicine, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah J Hart
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Nora Horick
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Priya S Kishnani
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Kavita Krell
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nicolas M Oreskovic
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Mikayla Shaffer
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nasreen Talib
- Children's Mercy Hospital, Overland Park, Kansas, USA
| | - Amy Torres
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gail A Spiridigliozzi
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke Medical Center, Durham, North Carolina, USA
| | - Brian G Skotko
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Grace SL, Mortimer GL, Kozhakhmetova A, Leveret J, Newton R, Reimand K, Shield JPH, Uibo R, Williams AJK, Gillespie KM. Increased levels of anti-BSA antibodies in children with Down syndrome. Front Endocrinol (Lausanne) 2023; 14:1056925. [PMID: 36817608 PMCID: PMC9935828 DOI: 10.3389/fendo.2023.1056925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/10/2023] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Autoimmune diabetes occurs more often in the first 2 years of life in children with Down syndrome (DS) compared with the general population. We previously observed increased frequencies of islet autoantibodies, including insulin autoantibodies (IAA), in children with DS. Assays for IAA using 125I-labelled insulin require competition to overcome cross reactivity with antibodies to the cow's milk protein, bovine serum albumin (BSA). 125I-IAA assay results suggested that levels of antibodies to BSA may also be increased in children with DS. The aim of this study therefore was to determine whether the levels of anti-BSA antibodies differed in children with DS compared with controls. METHODS Samples were available from two populations with DS: one from the UK, (UK DS cohort n=106, 58 male, median age 12.5 years) and one from Estonia (Estonian DS cohort: n=121, 65 male, median age 9.75 years). A UK control population was provided by sex and age-matched healthy siblings of probands participating in the Bart's Oxford (BOX) family study of type 1 diabetes. A competitive-displacement radiobinding assay (RBA) and a Dissociation Enhanced Lanthanide Fluoroimmunoassay (DELFIA) were developed to measure and confirm anti-BSA antibody levels. HLA class II genotype was analysed by PCR using sequence specific primers (PCR-SSP). RESULTS Overall, levels of anti-BSA antibodies were increased in those with DS compared with controls (p<0.0001) but this was not HLA associated. CONCLUSION Increased levels of anti-BSA antibodies may reflect a defect in immune maturation or increased gut permeability in children with DS, increasing their risk of developing autoimmunity.
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Affiliation(s)
- Sian L. Grace
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | | | - Jamie Leveret
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Richard Newton
- Department of Neurology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Koit Reimand
- Department of Immunology, Institute of Bio- and Translational Medicine, University of Tartu, Tartu, Estonia
| | - Julian P. H. Shield
- National Institute for Health and Care Research (NIHR) Bristol Biomedical Research Centre, Nutrition Theme, University of Bristol, Bristol, United Kingdom
| | - Raivo Uibo
- Department of Immunology, Institute of Bio- and Translational Medicine, University of Tartu, Tartu, Estonia
| | | | - Kathleen M. Gillespie
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
- *Correspondence: Kathleen M. Gillespie,
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Esparcia-Pinedo L, Yarci-Carrión A, Mateo-Jiménez G, Ropero N, Gómez-Cabañas L, Lancho-Sánchez Á, Almendro-Vázquez P, Martín-Gayo E, Paz-Artal E, Sanchez-Madrid F, Moldenhauer F, Gutiérrez-Cobos A, Real de Asúa D, Alfranca A. Development of an Effective Immune Response in Adults With Down Syndrome After Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Vaccination. Clin Infect Dis 2022; 76:e155-e162. [PMID: 35869848 PMCID: PMC9384526 DOI: 10.1093/cid/ciac590] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/10/2022] [Accepted: 07/14/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Immune dysregulation in individuals with Down syndrome (DS) leads to an increased risk for hospitalization and death due to coronavirus disease 2019 (COVID-19) and may impair the generation of protective immunity after vaccine administration. METHODS The cellular and humoral responses of 55 individuals with DS who received a complete SARS-CoV-2 vaccination regime at 1 to 3 (visit [V 1]) and 6 (V2) months were characterized. RESULTS SARS-CoV-2-reactive CD4+ and CD8+ T lymphocytes with a predominant Th1 phenotype were observed at V1 and increased at V2. Likewise, an increase in SARS-CoV-2-specific circulating Tfh (cTfh) cells and CD8+ CXCR5+ PD-1hi lymphocytes was already observed at V1 after vaccine administration. Specific immunoglobulin G (IgG) antibodies against SARS-CoV-2 S protein were detected in 96% and 98% of subjects at V1 and V2, respectively, although IgG titers decreased significantly between both time points. CONCLUSIONS Our findings show that DS individuals develop an effective immune response to usual regimes of SARS-CoV-2 vaccination.
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Affiliation(s)
| | | | - Gloria Mateo-Jiménez
- Fundación de Investigación Biomédica del Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Noelia Ropero
- Immunology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Laura Gómez-Cabañas
- Biobanco, Fundación de Investigación del Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | - Ángel Lancho-Sánchez
- Biobanco, Fundación de Investigación del Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | | | - Enrique Martín-Gayo
- Immunology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain,Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Estela Paz-Artal
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Francisco Sanchez-Madrid
- Immunology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain,Department of Medicine, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Fernando Moldenhauer
- Internal Medicine Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Madrid, Spain
| | | | | | - Arantzazu Alfranca
- Correspondence: A. Alfranca, Immunology Department, Hospital Universitario de La Princesa, Dieo de León 62, 28006 Madrid, Spain ()
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9
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Atkinson TP. Defective immune response to SARS-CoV-2 immunization in Down syndrome correlates with increased susceptibility to severe illness with infection. J Infect Dis 2022; 226:755-756. [PMID: 35749348 PMCID: PMC9450085 DOI: 10.1093/infdis/jiac237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- T Prescott Atkinson
- Professor and Director Division of Pediatric Allergy & Immunology University of Alabama at Birmingham
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11
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Illouz T, Biragyn A, Iulita MF, Flores-Aguilar L, Dierssen M, De Toma I, Antonarakis SE, Yu E, Herault Y, Potier MC, Botté A, Roper R, Sredni B, London J, Mobley W, Strydom A, Okun E. Immune Dysregulation and the Increased Risk of Complications and Mortality Following Respiratory Tract Infections in Adults With Down Syndrome. Front Immunol 2021; 12:621440. [PMID: 34248930 PMCID: PMC8267813 DOI: 10.3389/fimmu.2021.621440] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 06/02/2021] [Indexed: 12/12/2022] Open
Abstract
The risk of severe outcomes following respiratory tract infections is significantly increased in individuals over 60 years, especially in those with chronic medical conditions, i.e., hypertension, diabetes, cardiovascular disease, dementia, chronic respiratory disease, and cancer. Down Syndrome (DS), the most prevalent intellectual disability, is caused by trisomy-21 in ~1:750 live births worldwide. Over the past few decades, a substantial body of evidence has accumulated, pointing at the occurrence of alterations, impairments, and subsequently dysfunction of the various components of the immune system in individuals with DS. This associates with increased vulnerability to respiratory tract infections in this population, such as the influenza virus, respiratory syncytial virus, SARS-CoV-2 (COVID-19), and bacterial pneumonias. To emphasize this link, here we comprehensively review the immunobiology of DS and its contribution to higher susceptibility to severe illness and mortality from respiratory tract infections.
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Affiliation(s)
- Tomer Illouz
- The Leslie and Susan Gonda Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat Gan, Israel
- The Paul Feder Laboratory on Alzheimer’s Disease Research, Bar-Ilan University, Ramat Gan, Israel
| | - Arya Biragyn
- Laboratory of Molecular Biology and Immunology, National Institute on Aging, National Institute of Health, Baltimore, MD, United States
| | - Maria Florencia Iulita
- Sant Pau Memory Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Biomedical Research Institute Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- Center of Biomedical Investigation Network for Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Lisi Flores-Aguilar
- Department of Anatomy and Cell Biology, McGill University, Montreal, QC, Canada
| | - Mara Dierssen
- Center for Genomic Regulation, The Barcelona Institute for Science and Technology, Barcelona, Spain
- University Pompeu Fabra, Barcelona, Spain
- Biomedical Research Networking Center for Rare Diseases (CIBERER), Barcelona, Spain
| | - Ilario De Toma
- Center for Genomic Regulation, The Barcelona Institute for Science and Technology, Barcelona, Spain
- University Pompeu Fabra, Barcelona, Spain
- Biomedical Research Networking Center for Rare Diseases (CIBERER), Barcelona, Spain
| | - Stylianos E. Antonarakis
- Department of Genetic Medicine and Development, University of Geneva, Geneva, Switzerland
- Medigenome, Swiss Institute of Genomic Medicine, Geneva, Switzerland
- iGE3 Institute of Genetics and Genomics of Geneva, Geneva, Switzerland
| | - Eugene Yu
- The Children’s Guild Foundation Down Syndrome Research Program, Genetics and Genomics Program and Department of Cancer Genetics and Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States
- Genetics, Genomics and Bioinformatics Program, State University of New York at Buffalo, Buffalo, NY, United States
| | - Yann Herault
- Université de Strasbourg, CNRS, INSERM, Institut de Génétique Biologie Moléculaire et Cellulaire, IGBMC - UMR 7104 - Inserm U1258, Illkirch, France
| | - Marie-Claude Potier
- Paris Brain Institute (ICM), CNRS UMR7225, INSERM U1127, Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Alexandra Botté
- Paris Brain Institute (ICM), CNRS UMR7225, INSERM U1127, Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Randall Roper
- Department of Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States
| | - Benjamin Sredni
- The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
| | | | - William Mobley
- Department of Neurosciences, University of California, San Diego, San Diego, CA, United States
| | - Andre Strydom
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry Psychology and Neuroscience, King’s College London, London, United Kingdom
- South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Eitan Okun
- The Leslie and Susan Gonda Multidisciplinary Brain Research Center, Bar-Ilan University, Ramat Gan, Israel
- The Paul Feder Laboratory on Alzheimer’s Disease Research, Bar-Ilan University, Ramat Gan, Israel
- The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
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12
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Tyler CV, Wells MD. A Community-Health System Intervention to Improve the Primary Healthcare of Adults With Down Syndrome Through Electronic Consultations. INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2021; 59:256-264. [PMID: 34030182 DOI: 10.1352/1934-9556-59.3.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/29/2020] [Indexed: 06/12/2023]
Abstract
Health systems often fail to tap the expertise of the developmental disabilities community support and service system. In this 9-month pilot health system-level quality improvement project, a multi-disciplinary team of physician, pharmacist, and disabilities advocate reviewed electronic records of patients with Down syndrome in advance of pre-scheduled appointments with their primary care physician (PCP) and generated 100 electronic consultations. Post-consultation chart review documented meaningful uptake of clinical recommendations, including screening for thyroid disease, celiac disease, and heart disease, pneumococcal vaccination, and screening physical examination for myelopathy. In addition to clinical recommendations regarding screening, diagnosis, and treatment, each consultation provided an average of eight tailored suggestions for potential community-based resources related to mental and behavioral health, recreation, socialization, and other relevant services and supports. "Push" multi-disciplinary electronic consultations in advance of primary care appointments enriched with input from disabilities community experts have the potential to improve the quality of health care provided to persons with developmental disabilities.
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Affiliation(s)
- Carl V Tyler
- Carl V. Tyler and Michael D. Wells, Cleveland Clinic
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13
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Jensen KM, Campagna EJ, Juarez-Colunga E, Prochazka AV, Runyan DK. Low Rates of Preventive Healthcare Service Utilization Among Adolescents and Adults With Down Syndrome. Am J Prev Med 2021; 60:1-12. [PMID: 33191063 PMCID: PMC7750281 DOI: 10.1016/j.amepre.2020.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/10/2020] [Accepted: 06/15/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION People with Down syndrome have health risks that require specific lifelong preventive health care. With increasing life expectancy, people with Down syndrome also face health conditions typical of their unaffected peers and thus need coordinated health care. The purpose of this study is to describe rates of age/sex- and Down syndrome-specific preventive healthcare activities among adolescents and adults with Down syndrome. METHODS Using Medicaid claims (2006-2010) in California, Colorado, Michigan, and Pennsylvania, the cohort was defined as people with Down syndrome aged ≥12 years seen by primary care providers and enrolled in Medicaid for ≥45 of 60 months without dual Medicare enrollment (n=3,501). Age focus-consistent primary care providers were defined as having a focus concordant with a patient's age: 12-17 years, child or mixed-focus; ≥26 years, adult or mixed-focus; 18-25 years, any focus. Differences in healthcare activities were evaluated using Pearson's chi-square, Fisher's exact, and Kruskal-Wallis tests. Analyses were performed in 2015-2017. RESULTS Of the cohort, 79% had an age focus-consistent primary care provider. However, 40% of adults aged ≥26 years received care from a child-focused primary care provider. Only 43% with an age focus-consistent provider had ≥1 well examination (age focus-inconsistent primary care provider: 35%, p<0.001). Most preventive activities had poor rates (<50%) regardless of age focus consistency between provider and patient age or whether they were age/sex- or Down syndrome-specific (well examinations; vaccinations; sleep apnea; hearing; and breast, cervical, and colon cancer screenings). Lipids, vision, and thyroid screenings reached moderate levels (50% to <80%). CONCLUSIONS Rates of age/sex- and Down syndrome-specific preventive recommendations were low among adolescents and adults with Down syndrome, regardless of the age focus consistency of their primary care provider. This represents a significant opportunity to improve primary care in this vulnerable population.
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Affiliation(s)
- Kristin M Jensen
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado.
| | - Elizabeth J Campagna
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth Juarez-Colunga
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado; University of Colorado School of Public Health, Aurora, Colorado
| | - Allan V Prochazka
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Desmond K Runyan
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado; Kempe Center for the Prevention of Child Abuse and Maltreatment, University of Colorado School of Medicine, Aurora, Colorado
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14
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Down syndrome, accelerated aging and immunosenescence. Semin Immunopathol 2020; 42:635-645. [PMID: 32705346 PMCID: PMC7666319 DOI: 10.1007/s00281-020-00804-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/29/2020] [Indexed: 12/11/2022]
Abstract
Down syndrome is the most common chromosomal disorder, associated with moderate to severe intellectual disability. While life expectancy of Down syndrome population has greatly increased over the last decades, mortality rates are still high and subjects are facing prematurely a phenomenon of atypical and accelerated aging. The presence of an immune impairment in Down syndrome subjects is suggested for a long time by the existence of an increased incidence of infections, the incomplete efficacy of vaccinations, and a high prevalence of autoimmunity. Immunologic abnormalities have been described since many years in this population, both from a numerical and a functional points of view, and these abnormalities can mirror the ones observed during normal aging. In this review, we summarize our knowledge on immunologic disturbances commonly observed in subjects with Down syndrome, and in innate and adaptive immunity, as well as regarding chronic inflammation. We then discuss the role of accelerated aging in these observed abnormalities and finally review the potential age-associated molecular and cellular mechanisms involved.
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15
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A Prevalent CXCR3 + Phenotype of Circulating Follicular Helper T Cells Indicates Humoral Dysregulation in Children with Down Syndrome. J Clin Immunol 2020; 40:447-455. [PMID: 31993866 DOI: 10.1007/s10875-020-00755-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/20/2020] [Indexed: 12/14/2022]
Abstract
Patients with Down syndrome (DS) are characterized by increased susceptibility to autoimmunity and respiratory tract infections that are suggestive of humoral immunity impairment. Here, we sought to determine the follicular helper (Tfh) and follicular regulatory (Tfr) T cell profile in the blood of children with DS. Blood was collected from 24 children with DS, nine of which had autoimmune diseases. Children with DS showed skewed Tfh differentiation towards the CXCR3+ phenotype: Tfh1 and Tfh1/17 subsets were increased, while Tfh2 and Tfh17 subsets were reduced. While no differences in the percentage of Tfr cells were seen, the ratio of Tfh1 and CXCR3+PD-1+ subsets to Tfr cells was significantly increased in the affected children. The excessive polarization towards a CXCR3+ phenotype in children with DS suggests that re-calibration of Tfh subset skewing could potentially offer new therapeutic opportunities for these patients.
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16
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Huggard D, Doherty DG, Molloy EJ. Immune Dysregulation in Children With Down Syndrome. Front Pediatr 2020; 8:73. [PMID: 32175298 PMCID: PMC7056667 DOI: 10.3389/fped.2020.00073] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022] Open
Abstract
Down syndrome (DS) is the most common genetic syndrome associated with immune defects. The extent of immune dysregulation in DS is substantial, spanning the innate and adaptive systems and including anomalies in: T and B cells, monocytes, neutrophil chemotaxis, circulating cytokines, and suboptimal antibody responses which all contribute to an increased risk of infections, poorer clinical outcomes and chronic inflammation in this vulnerable cohort. Other aspects of innate immunity may also be abnormal and contribute to the increased morbidity and warrant further interrogation such as: gamma delta T cell function, the inflammasome, Toll-like receptors and their pathways. Pharmacotherapies such as pavilizumab, pneumococcal and influenza immunizations, as well as potential immunoprophylactic agents such as pidotimod, azithromycin and Broncho-Vaxom may help alleviate the infectious consequences. Children with DS need to be managed with a heightened sense of awareness and urgency in the setting of sepsis and signs of chronic inflammation need regular screening and appropriate follow up.
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Affiliation(s)
- Dean Huggard
- Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland.,Trinity Translational Medicine Institute (TTMI), Trinity College Dublin, Dublin, Ireland.,Paediatrics, Children's Hospital Ireland at Crumlin and Tallaght, Dublin, Ireland.,National Children's Research Centre Dublin, Dublin, Ireland
| | - Derek G Doherty
- Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland.,Trinity Translational Medicine Institute (TTMI), Trinity College Dublin, Dublin, Ireland
| | - Eleanor J Molloy
- Paediatrics, Trinity College, The University of Dublin, Dublin, Ireland.,Trinity Translational Medicine Institute (TTMI), Trinity College Dublin, Dublin, Ireland.,Paediatrics, Children's Hospital Ireland at Crumlin and Tallaght, Dublin, Ireland.,National Children's Research Centre Dublin, Dublin, Ireland.,Coombe Women and Infants University Hospital, Dublin, Ireland
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17
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Trisomy 21 dysregulates T cell lineages toward an autoimmunity-prone state associated with interferon hyperactivity. Proc Natl Acad Sci U S A 2019; 116:24231-24241. [PMID: 31699819 PMCID: PMC6883781 DOI: 10.1073/pnas.1908129116] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Triplication of human chromosome 21, or trisomy 21 (T21), causes the condition known as Down syndrome (DS). People with DS show a markedly different disease spectrum relative to typical people, being highly predisposed to conditions such as Alzheimer’s disease, while being protected from other conditions, such as most solid malignancies. Interestingly, people with DS are affected by high rates of autoimmune disorders, whereby the immune system mistakenly attacks healthy tissues. This manuscript reports an exhaustive characterization of the T cells of people with DS, demonstrating many alterations in this key immune cell type that could explain their high risk of autoimmunity. These results reveal opportunities for therapeutic intervention to modulate T cell function and improve health outcomes in DS. Trisomy 21 (T21) causes Down syndrome (DS), a condition characterized by high prevalence of autoimmune disorders. However, the molecular and cellular mechanisms driving this phenotype remain unclear. Building upon our previous finding that T cells from people with DS show increased expression of interferon (IFN)-stimulated genes, we have completed a comprehensive characterization of the peripheral T cell compartment in adults with DS with and without autoimmune conditions. CD8+ T cells from adults with DS are depleted of naïve subsets and enriched for differentiated subsets, express higher levels of markers of activation and senescence (e.g., IFN-γ, Granzyme B, PD-1, KLRG1), and overproduce cytokines tied to autoimmunity (e.g., TNF-α). Conventional CD4+ T cells display increased differentiation, polarization toward the Th1 and Th1/17 states, and overproduction of the autoimmunity-related cytokines IL-17A and IL-22. Plasma cytokine analysis confirms elevation of multiple autoimmunity-related cytokines (e.g., TNF-α, IL17A–D, IL-22) in people with DS, independent of diagnosis of autoimmunity. Although Tregs are more abundant in DS, functional assays show that CD8+ and CD4+ effector T cells with T21 are resistant to Treg-mediated suppression, regardless of Treg karyotype. Transcriptome analysis of white blood cells and T cells reveals strong signatures of T cell differentiation and activation that correlate positively with IFN hyperactivity. Finally, mass cytometry analysis of 8 IFN-inducible phosphoepitopes demonstrates that T cell subsets with T21 show elevated levels of basal IFN signaling and hypersensitivity to IFN-α stimulation. Therefore, these results point to T cell dysregulation associated with IFN hyperactivity as a contributor to autoimmunity in DS.
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18
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Abstract
During the past decades, life expectancy of subjects with Down syndrome (DS) has greatly improved, but age-specific mortality rates are still important and DS subjects are characterized by an acceleration of the ageing process, which affects particularly the immune and central nervous systems. In this chapter, we will first review the characteristics of the ageing phenomenon in brain and in immune system in DS and we will then discuss the biological hallmarks of ageing in this specific population. Finally, we will also consider in detail the knowledge on epigenetics in DS, particularly DNA methylation.
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19
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Huggard D, Molloy EJ. Question 1: Do children with Down syndrome benefit from extra vaccinations? Arch Dis Child 2018; 103:1085-1087. [PMID: 30120141 DOI: 10.1136/archdischild-2018-315541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Dean Huggard
- Discipline of Paediatrics, University of Dublin, Trinity College, Dublin, Ireland
| | - Eleanor J Molloy
- Discipline of Paediatrics, University of Dublin, Trinity College, Dublin, Ireland.,Paediatrics, Tallaght Hospital, Dublin, Ireland.,Neonatology, Our Lady's Children's Hospital, Dublin, Ireland.,Neonatology, Coombe Women's and Infants University Hospital, Dublin, Ireland
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20
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Underlying factors of recurrent infections in patients with down syndrome. North Clin Istanb 2018; 5:163-168. [PMID: 30374487 PMCID: PMC6191560 DOI: 10.14744/nci.2017.69379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 07/30/2017] [Indexed: 11/20/2022] Open
Abstract
Down syndrome is the most common chromosomal aberration. Patientswith Down syndrome suffer more infections than those without the disease. Underlying immunological disorders are consideredto be the reason for the increasing frequency of infections in patients with Down syndrome. In addition, some anatomical abnormalities in the respiratory tractaccompanying Down syndrome can disturb the innate immunity and contribute to the increase in infection rate. Respiratory tract infections are one of the most common causes of mortality in patients with Down syndrome. Awareness of the underlying reason for frequent respiratory tract infections should result in a decrease in mortality among these patients and contribute to an improvementin their quality of life.
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21
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Brockmeyer DL, Sivakumar W, Mazur MD, Sayama CM, Goldstein HE, Lew SM, Hankinson TC, Anderson RCE, Jea A, Aldana PR, Proctor M, Hedequist D, Riva-Cambrin JK. Identifying Factors Predictive of Atlantoaxial Fusion Failure in Pediatric Patients: Lessons Learned From a Retrospective Pediatric Craniocervical Society Study. Spine (Phila Pa 1976) 2018; 43:754-760. [PMID: 29189644 DOI: 10.1097/brs.0000000000002495] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Multicenter retrospective cohort study with multivariate analysis. OBJECTIVE To determine factors predictive of posterior atlantoaxial fusion failure in pediatric patients. SUMMARY OF BACKGROUND DATA Fusion rates for pediatric posterior atlantoaxial arthrodesis have been reported to be high in single-center studies; however, factors predictive of surgical non-union have not been identified by a multicenter study. METHODS Clinical and surgical details for all patients who underwent posterior atlantoaxial fusion at seven pediatric spine centers from 1995 to 2014 were retrospectively recorded. The primary outcome was surgical failure, defined as either instrumentation failure or fusion failure seen on either plain x-ray or computed tomography scan. Multiple logistic regression analysis was undertaken to identify clinical and technical factors predictive of surgical failure. RESULTS One hundred thirty-one patients met the inclusion criteria and were included in the analysis. Successful fusion was seen in 117 (89%) of the patients. Of the 14 (11%) patients with failed fusion, the cause was instrumentation failure in 3 patients (2%) and graft failure in 11 (8%). Multivariate analysis identified Down syndrome as the single factor predictive of fusion failure (odds ratio 14.6, 95% confidence interval [3.7-64.0]). CONCLUSION This retrospective analysis of a multicenter cohort demonstrates that although posterior pediatric atlantoaxial fusion success rates are generally high, Down syndrome is a risk factor that significantly predicts the possibility of surgical failure. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT
| | - Walavan Sivakumar
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT
| | - Marcus D Mazur
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT
| | - Christina M Sayama
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR.,Neuro-Spine Program, Division of Pediatric Neurosurgery, Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Hannah E Goldstein
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY
| | - Sean M Lew
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, CO
| | - Richard C E Anderson
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY
| | - Andrew Jea
- Goodman Campbell Brain and Spine, Indianapolis, IN.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Philipp R Aldana
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Florida, Jacksonville, FL
| | - Mark Proctor
- Department of Pediatric Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Daniel Hedequist
- Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jay K Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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22
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Chan M, Park JJ, Shi T, Martinón-Torres F, Bont L, Nair H. The burden of respiratory syncytial virus (RSV) associated acute lower respiratory infections in children with Down syndrome: A systematic review and meta-analysis. J Glob Health 2018; 7:020413. [PMID: 29302319 PMCID: PMC5735780 DOI: 10.7189/jogh.07.020413] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Acute lower respiratory tract infections (ALRIs) caused by respiratory syncytial virus (RSV) are a leading cause of hospitalization in infants. Numerous risk factors have been identified in the aetiology of severe RSV–associated ALRI necessitating hospitalisation, including prematurity and congenital heart disease. Down syndrome (DS), a common genetic disorder associated with congenital and dysmorphic features, has recently been identified as an independent risk factor for RSV–associated ALRI requiring hospitalisation; however, the disease burden of RSV–associated ALRI in this population has not yet been established. Similarly, the impact of DS as an independent risk factor has not yet been quantified. We aimed therefore to estimate the incidence of admissions in children with DS, and by comparing this with unaffected children, to quantify the risk of DS independent of other risk factors. Methods A systematic review of the existing literature published between 1995 and March 1, 2017 was performed to quantify the incidence of hospitalisation due to RSV–associated ALRI in children with DS. Meta–analyses were performed on extracted data using STATA statistical software, and hospitalisation rates for children with and without DS under the age of 2 were calculated. Findings 5 articles were ultimately deemed eligible for analyses. Analyses were limited to children under the age of 2 years. We calculated the hospitalisation rate for children with DS in this age group to be 117.6 per 1000 child–years (95% CI 67.4–205.2), vs a rate of 15.2 per 1000 child–years (95% CI 8.3–27.6) in unaffected children. This indicates DS contributes to a 6.8 (95% CI 5.5–8.4) fold increase in the relative risk of hospitalisation for RSV–associated ALRI. Interpretation Though limited by a small number of articles, this review found sufficient evidence to conclude DS was a significant independent risk factor for the development of severe RSV–associated ALRI requiring hospitalisation. Further studies are needed to define the impact of DS in conjunction with other comorbidities on the risk of severe RSV infection. Determining benefits of immunoprophylaxis or future vaccines against RSV in this at–risk population is warranted.
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Affiliation(s)
- Markus Chan
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, UK.,Joint first authroship
| | - John J Park
- Harvard TH Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.,Joint first authroship
| | - Ting Shi
- Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, the Netherlands
| | - Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Louis Bont
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, Netherlands
| | - Harish Nair
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, UK
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23
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Schoch J, Rohrer TR, Kaestner M, Abdul-Khaliq H, Gortner L, Sester U, Sester M, Schmidt T. Quantitative, Phenotypical, and Functional Characterization of Cellular Immunity in Children and Adolescents With Down Syndrome. J Infect Dis 2017; 215:1619-1628. [PMID: 28379413 DOI: 10.1093/infdis/jix168] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/29/2017] [Indexed: 01/08/2023] Open
Abstract
Background Infections and autoimmune disorders are more frequent in Down syndrome, suggesting abnormality of adaptive immunity. Although the role of B cells and antibodies is well characterized, knowledge regarding T cells is limited. Methods Lymphocyte subpopulations of 40 children and adolescents with Down syndrome and 51 controls were quantified, and phenotype and functionality of antigen-specific effector T cells were analyzed with flow cytometry after polyclonal and pathogen-specific stimulation (with varicella-zoster virus [VZV] and cytomegalovirus [CMV]). Results were correlated with immunoglobulin (Ig) G responses. Results Apart from general alterations in the percentage of lymphocytes, regulatory T cells, and T-helper 1 and 17 cells, all major T-cell subpopulations showed higher expression of the inhibitory receptor PD-1. Polyclonally stimulated effector CD4+ T-cell frequencies were significantly higher in subjects with Down syndrome, whereas their inhibitory receptor expression (programmed cell death 1 [PD-1] and cytotoxic T-lymphocyte antigen 4 [CTLA-4]) was similar to that of controls and cytokine expression profiles were only marginally altered. Pathogen-specific immunity showed age-appropriate levels of endemic infection, with correlation of CMV-specific cellular and humoral immunity in all subjects. Among VZV IgG-positive individuals, a higher percentage of VZV-specific T-cell-positive subjects was seen in those with Down syndrome. Conclusions Despite alterations in lymphocyte subpopulations, individuals with Down syndrome can mount effector T-cell responses with similar phenotype and functionality as controls but may require higher effector T-cell frequencies to ensure pathogen control.
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Affiliation(s)
| | | | | | | | - Ludwig Gortner
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria
| | - Urban Sester
- Internal Medicine IV, Saarland University, Homburg, Germany; and
| | | | - Tina Schmidt
- Departments of Transplant and Infection Immunology
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24
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Valentini D, Marcellini V, Bianchi S, Villani A, Facchini M, Donatelli I, Castrucci MR, Marasco E, Farroni C, Carsetti R. Generation of switched memory B cells in response to vaccination in Down syndrome children and their siblings. Vaccine 2015; 33:6689-96. [PMID: 26518399 DOI: 10.1016/j.vaccine.2015.10.083] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/05/2015] [Accepted: 10/17/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Immunodeficiency is an integral aspect of Down syndrome, as demonstrated by the increased susceptibility to infection of affected. Mortality is still higher than in general population, with respiratory infections among the major causes of death. As more people with Down syndrome are living today than ever before, it is indispensable to develop strategies to prevent and cure the associated disorders. Vaccination is the most successful instrument of preventive medicine. Special seasonal influenza and pneumococcal vaccination strategies have been designed for individuals with risk conditions of all ages. Down syndrome individuals are not included in the high-risk categories. METHODS We enrolled in our study 15 children with Down syndrome and their siblings, vaccinated for the first time with seasonal influenza vaccine and receiving a booster dose of a glyco-conjugated pneumococcal vaccine. We compared the immunological features and response to vaccination measuring serum antibody titers and frequency of specific memory B cells. RESULTS We confirm that a severe reduction of switched memory B cells is always associated to Down syndrome. After primary vaccination Down syndrome children generate significantly less specific switched memory B cells than their siblings. The response to a booster dose of vaccine is instead comparable in both groups. The production of specific antibodies was equally effective in Down syndrome and controls both after primary and secondary immunization. CONCLUSIONS Down syndrome individuals should be considered a high risk group, because of their increased susceptibility to infection and reduced number of switched memory B cells. Tailored vaccination protocols are needed in order to reduce their burden of infections throughout life.
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Affiliation(s)
- Diletta Valentini
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Marcellini
- Immunology Unit, Immunology and Pharmacotherapy Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Bianchi
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Marzia Facchini
- Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Isabella Donatelli
- Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Maria Rita Castrucci
- Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Emiliano Marasco
- Immunology Unit, Immunology and Pharmacotherapy Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Farroni
- Immunology Unit, Immunology and Pharmacotherapy Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rita Carsetti
- Immunology Unit, Immunology and Pharmacotherapy Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Diagnostic Immunology Unit, Department of Oncohematology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
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25
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Stagliano DR, Nylund CM, Eide MB, Eberly MD. Children with Down syndrome are high-risk for severe respiratory syncytial virus disease. J Pediatr 2015; 166:703-9.e2. [PMID: 25596098 DOI: 10.1016/j.jpeds.2014.11.058] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 11/10/2014] [Accepted: 11/25/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess Down syndrome as an independent risk factor for respiratory syncytial virus (RSV) hospitalization in children younger than 3 years of age and to evaluate illness severity. STUDY DESIGN A retrospective cohort study of children enrolled in the military health system database was conducted. The effect of Down syndrome on RSV hospitalization was assessed by Cox proportional hazards model, while we controlled for risk factors. Disease severity was assessed by length of hospital stay, need for respiratory support, and age at hospitalization. RESULTS The study included 633 200 children and 3 209 378 person-years. Children with Down syndrome had a hospitalization rate of 9.6% vs 2.8% in children without Down syndrome. Down syndrome had a greater adjusted hazard ratio (HR) for RSV hospitalization than most risk factors, 3.46 (95% CI 2.75-4.37). A sensitivity analysis demonstrated HR 3.21 (95% CI 2.51-4.10) for patients with Down syndrome ages 0-23 months and HR 5.07 (95% CI 2.21-11.59) ages 24-36 months. The median (IQR) length of stay of children with and without Down syndrome was 4 days (2-7) and 2 days (1-4) (P < .001). Patients with Down syndrome had a greater risk of requiring respiratory support (relative risk 5.5; 95% CI, 2.5-12.3). The median (IQR) ages at admission for children with and without Down syndrome were 9.8 months (5.5-17.7) and 3.5 months (1.7-8.7) (P < .001). CONCLUSIONS Down syndrome is independently associated with an increased risk for RSV hospitalization. Children with Down syndrome are older at time of RSV hospitalization and have more severe RSV illness than children without Down syndrome. This increased risk for hospitalization continues beyond 24 months.
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Affiliation(s)
- David R Stagliano
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD; Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Cade M Nylund
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Matilda B Eide
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Matthew D Eberly
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
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Carsetti R, Valentini D, Marcellini V, Scarsella M, Marasco E, Giustini F, Bartuli A, Villani A, Ugazio AG. Reduced numbers of switched memory B cells with high terminal differentiation potential in Down syndrome. Eur J Immunol 2014; 45:903-14. [PMID: 25472482 PMCID: PMC4674966 DOI: 10.1002/eji.201445049] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/07/2014] [Accepted: 11/28/2014] [Indexed: 01/21/2023]
Abstract
Children with Down syndrome (DS) have increased susceptibility to infections and a high frequency of leukemia and autoimmune disorders, suggesting that immunodeficiency and immune dysfunction are integral parts of the syndrome. A reduction in B-cell numbers has been reported, associated with moderate immunodeficiency and normal immunoglobulin levels. Here, we compared B-cell populations of 19 children with DS with those in healthy age-matched controls. We found that all steps of peripheral B-cell development are altered in DS, with a more severe defect during the later stages of B-cell development. Transitional and mature-naïve B-cell numbers are reduced by 50% whereas switched memory B cells represent 10–15% of the numbers in age-matched controls. Serum IgM levels were slightly reduced, but all other immunoglobulin isotypes were in the normal range. The frequency of switched memory B cells specific for vaccine antigens was significantly lower in affected children than in their equivalently vaccinated siblings. In vitro switched memory B cells of patients with DS have an increased ability to differentiate into antibody-forming cells in response to TLR9 signals. Tailored vaccination schedules increasing the number of switched memory B cells may improve protection and reduce the risk of death from infection in DS.
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Affiliation(s)
- Rita Carsetti
- Immunology Unit, Immunology and Pharmacotherapy Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy; Diagnostic Immunology Unit, Department of Laboratories, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Defective B-cell memory in patients with Down syndrome. J Allergy Clin Immunol 2014; 134:1346-1353.e9. [DOI: 10.1016/j.jaci.2014.07.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 06/22/2014] [Accepted: 07/10/2014] [Indexed: 01/01/2023]
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Nisihara R, De Bem RS, Negreiros PHR, Utiyama SRR, Oliveira NP, Amarante H. Low hepatitis B vaccine response in children with Down syndrome from Brazil. Child Care Health Dev 2014; 40:607-9. [PMID: 23952481 DOI: 10.1111/cch.12099] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND It has been reported that vaccination against hepatitis B is less effective among people with Down syndrome than in the general population. We aimed to evaluate the rate of seroconversion to hepatitis B vaccine in children with Down syndrome from Brazil. METHODS A total of 120 people with Down syndrome were included. All of them received the vaccine at intervals of 0, 30 and 180 days and serum samples were tested for the presence of antibodies to the hepatitis B surface antigen (anti-HBs) 30 days after the last dose. RESULTS In the studied group, 58.3% (70/120) were male and 41.7% (50/120) female, with the median age of 5 years (range 2-15 years). Fifty-eight of 120 (48.3%) developed anti-HBs after vaccination. No association was found between gender and/or age and vaccine response. CONCLUSIONS The low rate of seroconversion in response to hepatitis B vaccine suggests that all patients with Down syndrome immunized against hepatitis B should be followed and monitored by clinicians.
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Affiliation(s)
- R Nisihara
- Department of Medicine, University Positivo, Curitiba, Paraná, Brazil; Laboratory of Immunopathology, Clinical Hospital, Federal University of Paraná Curitiba, Curitiba, Paraná, Brazil
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Increased production of interleukin-10 in children with Down syndrome upon ex vivo stimulation with Streptococcus pneumoniae. Pediatr Res 2014; 75:109-13. [PMID: 24126819 DOI: 10.1038/pr.2013.173] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 05/30/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Children with Down syndrome (DS) have an increased susceptibility to infections, due to altered humoral and/or cellular immunity. The aim of the study was to determine the cytokine production in whole blood of children with DS upon stimulation with heat-killed Streptococcus pneumoniae and lipopolysaccharide (LPS), in comparison with their healthy siblings. METHODS Whole blood of 61 children with DS and 57 of their healthy siblings was stimulated with 200 ng/ml LPS and 4 × 10(7) colony-forming units/ml S. pneumoniae during 6, 24, and 48 h. Concentrations of pro- and anti-inflammatory cytokines, tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, IL-12p70, and IL-10 were determined at all time points. RESULTS Children with DS show an increased IL-10 production upon stimulation with S. pneumoniae compared to their healthy siblings. At most time points, no significant differences were seen in cytokine production upon stimulation with LPS. CONCLUSION Children with DS may be prone to a severe course of pneumococcal pneumonia, because of an increased anti-inflammatory response.
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Affiliation(s)
- Kelsey C Bertrand
- 1University of Queensland School of Medicine, Brisbane, Queensland, Australia
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Verma IC, Lall M, Dua Puri R. Down syndrome in India--diagnosis, screening, and prenatal diagnosis. Clin Lab Med 2013; 32:231-48. [PMID: 22727002 DOI: 10.1016/j.cll.2012.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Down syndrome (DS) is the most common genetic cause of mental retardation. Clinical manifestations are variable, and children have psychomotor impairment, multiple malformations, and medical conditions. Confirmation of the diagnosis is by karyotype analysis. The cytogenetic abnormality can be classified into pure trisomy 21, translocation, or mosaicism. Risk of recurrence depends on the primary cytogenetic abnormality in the proband. Prenatal screening is by biochemical and ultrasound markers in the first and second trimester. Definitive prenatal diagnosis is by analysis of fetal chromosomes in fetal chorionic villi, amniocytes, or cord blood. A noninvasive test for trisomy 21 in maternal blood has been developed by massively parallel shotgun sequencing. Therapeutic studies in Ts65Dn mice suggest an exciting prospect of improvement of learning ability and memory deficits.
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Affiliation(s)
- Ishwar C Verma
- Center of Medical Genetics, Sir Ganga Ram Hospital, Rajender Nagar, New Delhi, India.
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Kusters MAA, Verstegen RHJ, de Vries E. Down syndrome: is it really characterized by precocious immunosenescence? Aging Dis 2011; 2:538-545. [PMID: 22396900 PMCID: PMC3295065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 08/12/2011] [Accepted: 08/15/2011] [Indexed: 05/31/2023] Open
Abstract
The immune system declines with aging, leading to an increased susceptibility to infections and higher incidence and progression of autoimmune phenomena and neoplasia. Down syndrome prematurely shows clinical manifestations that are normally seen with aging. This review provides a concise overview of abnormalities in the adaptive immune system of Down syndrome in comparison to normal and precocious (Progeria syndromes) aging. Clinical signs and immunological changes are reviewed. We challenge the hypothesis that the immunological abnormalities in Down syndrome should be interpreted as precocious immunosenescence.
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Affiliation(s)
- Maaike AA. Kusters
- Department of Pediatrics, Jeroen Bosch Hospital,’s-Hertogenbosch, the Netherlands
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Ruud HJ. Verstegen
- Department of Pediatrics, Jeroen Bosch Hospital,’s-Hertogenbosch, the Netherlands
- Department of Pediatrics, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Esther de Vries
- Department of Pediatrics, Jeroen Bosch Hospital,’s-Hertogenbosch, the Netherlands
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