Heterogeneity of sensitization profiles and clinical phenotypes among patients with seasonal allergic rhinitis in Southern European countries-The @IT.2020 multicenter study

BACKGROUND

Pollen allergy poses a significant health and economic burden in Europe. Disease patterns are relatively homogeneous within Central and Northern European countries. However, no study broadly assessed the features of seasonal allergic rhinitis (SAR) across different Southern European countries with a standardized approach.

OBJECTIVE

To describe sensitization profiles and clinical phenotypes of pollen allergic patients in nine Southern European cities with a uniform methodological approach.

METHODS

Within the @IT.2020 multicenter observational study, pediatric and adult patients suffering from SAR were recruited in nine urban study centers located in seven countries. Clinical questionnaires, skin prick tests (SPT) and specific IgE (sIgE) tests with a customized multiplex assay (Euroimmun Labordiagnostika, Lübeck, Germany) were performed.

RESULTS

Three hundred forty-eight children (mean age 13.1 years, SD: 2.4 years) and 467 adults (mean age 35.7 years SD: 10.0 years) with a predominantly moderate to severe, persistent phenotype of SAR were recruited. Grass pollen major allergenic molecules (Phl p 1 and/or Phl p 5) ranged among the top three sensitizers in all study centers. Sensitization profiles were very heterogeneous, considering that patients in Rome were highly poly-sensitized (sIgE to 3.8 major allergenic molecules per patient), while mono-sensitization was prominent and heterogeneous in other cities, such as Marseille (sIgE to Cup a 1: n = 55/80, 68.8%) and Messina (sIgE to Par j 2: n = 47/82, 57.3%). Co-sensitization to perennial allergens, as well as allergic comorbidities also broadly varied between study centers.

CONCLUSIONS

In Southern European countries, pollen allergy is heterogeneous in terms of sensitization profiles and clinical manifestations. Despite the complexity, a unique molecular, multiplex, and customized in-vitro IgE test detected relevant sensitization in all study centers. Nevertheless, this geographical diversity in pollen allergic patients imposes localized clinical guidelines and study protocols for clinical trials of SAR in this climatically complex region.

Deep Dive Into Gaps and Barriers to Implementation of Antimicrobial Stewardship Programs in Hospitals in Latin America

BACKGROUND

Antimicrobial resistance has worsened in Latin America. There is an urgent need to understand the development of antimicrobial stewardship programs (ASPs) and the barriers to implementing effective ASPs in light of limited national action plans or policies to promote ASPs in the region.

METHODS

We performed a descriptive mixed-methods study of ASPs in 5 Latin American countries in March-July 2022. An electronic questionnaire with an associated scoring system (hospital ASP self-assessment) was used, and ASP development was classified based on the scores (inadequate, 0-25; basic, 26-50; intermediate, 51-75; or advanced, 76-100). Interviews among healthcare workers (HCWs) involved in antimicrobial stewardship (AS) inquired about behavioral and organizational factors that influence AS activities. Interview data were coded into themes. Results from the ASP self-assessment and interviews were integrated to create an explanatory framework.

RESULTS

Twenty hospitals completed the self-assessment, and 46 AS stakeholders from these hospitals were interviewed. ASP development was inadequate/basic in 35% of hospitals, intermediate in 50%, and advanced in 15%. For-profit hospitals had higher scores than not-for-profit hospitals. Interview data validated the self-assessment findings and provided further insight into ASP implementation challenges, which included limited formal hospital leadership support, inadequate staffing and tools to perform AS work more efficiently, limited awareness of AS principles by HCWs, and limited training opportunities.

CONCLUSIONS

We identified several barriers to ASP development in Latin America, suggesting the need to create accurate business cases for ASPs to obtain the necessary funding for their effective implementation and sustainability.

Primary Pancreatic Mature T-Cell Lymphoma as a Cause of Obstructive Jaundice: A Case Report and Review of the Literature

Primary pancreatic lymphoma (PPL) is an extremely rare type of non-Hodgkin's lymphoma (NHL). It accounts for 0.1% of all lymphomas and less than 1% of pancreatic tumors. Within this subtype, T-cell lymphomas only account for up to 6.7% of pancreatic lymphomas. In this study, we present the case of a 78-year-old Hispanic man who presented with obstructive jaundice associated with a mass within the head of the pancreas; pathologic analysis of the tumor revealed a mature T-cell lymphoma, not otherwise specified (NOS).

Primary bedaquiline resistance in Karakalpakstan, Uzbekistan

BACKGROUND: Bedaquiline (BDQ) is widely used in the treatment of rifampicin-resistant TB (RR-TB). However, resistance to BDQ is now emerging. There are no standardised regimens for BDQ-resistant TB. This study aims to share experience in managing primary BDQ-resistant TB.METHODS: We performed a retrospective study of patients treated for RR-TB in Karakalpakstan, Uzbekistan, from January 2017 to March 2022. We identified patients with resistance to BDQ with no history of BDQ exposure. We describe baseline characteristics, treatment and follow-up of these patients.RESULTS: Twelve of the 1,930 patients (0.6%) had baseline samples resistant to BDQ with no history of BDQ exposure, 75% (9/12) of whom had been previously treated for TB. Ten (83.3%) were resistant to fluoroquinolones; respectively 66% and 50% had culture conversion by Month 3 and Month 6. The interim treatment outcomes were as follows: unfavourable treatment outcomes (3/12, 25%), favourable outcomes (2/12, 17%); the remaining seven (58%) were continuing treatment.CONCLUSIONS: A large proportion of the cases had previously been treated for TB and had TB resistant to quinolone. Both patients who had not experienced culture conversion by Month 3 had an unfavourable treatment outcome. Therefore, we recommend monthly monitoring of culture status for patients on treatment regimens for BDQ resistance.

A phase Ib trial of mivavotinib (TAK-659), a dual SYK/FLT3 inhibitor, in patients with relapsed/refractory acute myeloid leukemia

Mivavotinib (TAK-659) is an investigational type 1 tyrosine kinase inhibitor with dual activity against spleen tyrosine kinase (SYK) and FMS-like tyrosine kinase 3 (FLT3). We conducted a phase Ib study to investigate the safety, tolerability, and efficacy of mivavotinib in patients with refractory and/or relapsed (R/R) acute myeloid leukemia (AML). Both daily (QD) and twice daily (BID) dosing regimens were evaluated. A total of 43 patients were enrolled, and there were 5 complete responses (4 with incomplete count recovery). In the QD dosing regimen, the maximum tolerated dose (MTD) was not reached up to 160 mg QD per protocol; 140 mg QD was identified as the recommended phase II dose. In the BID dosing regimen, the MTD was 60 mg BID. Thirty patients (70%) experienced a bleeding event on study; the majority were grades 1 or 2, were resolved without mivavotinib modification, and were not considered related to study treatment. Eleven patients (26%) experienced grade ≥3 bleeding events, which were observed most frequently with the 80 mg BID dose. We conducted platelet aggregation studies to investigate the potential role of mivavotinib-mediated SYK inhibition on platelet function. The bleeding events observed may have been the result of several confounding factors, including AML disease status, associated thrombocytopenia, and high doses of mivavotinib. Overall, these findings indicate that the activity of mivavotinib in R/R AML is modest. Furthermore, any future clinical investigation of this agent should be undertaken with caution, particularly in thrombocytopenic patients, due to the potential bleeding risk of SYK inhibition. ClinicalTrials.gov: NCT02323113.

Social and Structural Influences on Multiracial Identification and Health: a Public Health Mandate to Precisely Measure, Theorize, and Better Understand Multiracial Populations

There is a growing group of adolescents and young adults in the USA who identify as multiracial. However, very little research, especially health research, focuses on understanding multiracial identification and health and behavioral outcomes for multiracial populations in comparison to their single-race counterparts. Understanding the intersectional influences on this identification process is critical to updating the literature on racial and ethnic identity and health with more accurate identifications and categories. It is especially critical that there is an explicit focus on understanding the impact of structural racism and discrimination when studying the process of racial identification and the impact on health. This review takes an interdisciplinary approach relying on a review of multiple research literatures: the historical literature on race, racism and categorization, psychological and adolescent medicine literatures on adolescent development, the sociological literature on racial and ethnic identification, and the limited public health research beginning to disentangle multiracial health outcomes. An empirically testable conceptual framework is offered to frame the organization of this review-demonstrating the multiple spheres of influence on racial and ethnic identification and the implication for health outcomes.

RNA-guided DNA base damage repair via DNA polymerase-mediated nick translation

DNA repair is mediated by DNA synthesis guided by a DNA template. Recent studies have shown that DNA repair can also be accomplished by RNA-guided DNA synthesis. However, it remains unknown how RNA can guide DNA synthesis to repair DNA damage. In this study, we revealed the molecular mechanisms underlying RNA-guided DNA synthesis and base damage repair mediated by human repair DNA polymerases. We showed that pol β, pol κ, and pol ι predominantly synthesized one nucleotide, and pol η, pol ν, and pol θ synthesized multi-nucleotides during RNA-guided DNA base damage repair. The steady-state kinetics showed that pol η exhibited more efficient RNA-guided DNA synthesis than pol β. Using molecular dynamics simulation, we further revealed dynamic conformational changes of pol β and pol η and their structural basis to accommodate the RNA template and misoriented triphosphates of an incoming nucleotide. We demonstrated that RNA-guided base damage repair could be accomplished by the RNA-guided DNA strand-displacement synthesis and nick translation leading to nick ligation in a double-strand DNA region. Our study revealed a novel RNA-guided base damage repair pathway during transcription and DNA replication.

AB1585-PARE DO PATIENT AND PHYSICIAN ASSESSMENTS OF A HEALTH CARE VISIT MATCH FOR HISPANIC/LATINX PATIENTS WITH RHEUMATOID ARTHRITIS IN THE UNITED STATES AND PUERTO RICO?

Background

Nonlinear associations in rheumatoid arthritis (RA) prevalence and sociodemographic indices suggest social determinants of health affect RA.1 RA screening tools have lower sensitivity and specificity for Hispanic/Latinx individuals compared with white individuals (77% vs 85% sensitivity and 45% vs 87% specificity).2 Hispanic/Latinx people also present to physicians later and with more severe RA.3 There is little research in this population to explain these differences or how they can be addressed. Because it is known the Hispanic/Latinx population has lower English-language proficiency, we hypothesized this is in part because of the lack of validated Spanish-language educational materials and research tools for RA.

Objectives

To validate a Spanish-language patient-provider questionnaire (PPQ) for Hispanic/Latinx patients with RA that had previously been validated as concordant for primary care visits in Sweden.4

To understand if rheumatologist and patient assessments for Hispanic/Latinx people with RA are concordant when using a Spanish-language digital PPQ.

To determine if a Spanish-language rheumatologist-completed PPQ could be a proxy for patient impressions in a prospective clinical study.

Methods

A Spanish-language PPQ for RA was created by translating 9 of 13 questions previously validated in the Swedish study,4 and adding a question about treating to target specific to RA. The survey was made available on tablet devices in 4 rheumatology clinics in the U.S. and Puerto Rico. Clinic staff obtained patient consent and gathered demographic information to generate a unique confidential identifier code for each visit, which was inputted into surveys on tablet devices. After the visit ended the patient and rheumatologist were each given the PPQ coded for that visit to complete independently of one another. The PPQs were submitted electronically to a secure database in which the visit code was the only identifier recorded.

Results

Across 114 clinical visits, 96.75% of possible answers were recorded and were almost invariably positive with scores of 5 (strongly agree; 88%), 4 (agree; 12%), or 3 (neither agree nor disagree; 0.09%). Physicians responded with 4 (agree) more often than patients (18% vs 6% of responses). Responses from both patient and physician were available for (96.64%) of answered questions. Within these paired answers, 80.67% were concordant (same answer from both patient and physician). Physicians answered 4 when patients answered 5 in 76.5% of discordant responses (different ratings from patient and physician). Most physician ratings of 4 came from 1 of the 4 physicians involved and only 12.5% of patients were responsible for 75% of the patient responses of 4.

Conclusion

Hispanic/Latinx patients with RA and their rheumatologist rated their communication, goal setting, and relationships extremely positively, making it difficult to evaluate true concordance and not possible to use rheumatologist-completed PPQs as proxy for patient assessments. Notably, ratings were substantially different from what is typically seen on Likert scales, which normally skew positively but with a normal distribution. This finding may reflect social determinants of health or cultural differences such as a social-desirability bias toward positive statements about physician-patient interactions. Heterogeneity within the participants is also a plausible explanation, considering that a distinct subset of respondents account for almost all responses below the 5 rating. Further research is needed to identify best practices for measuring treatment to target and patient-rheumatologist interactions in the Hispanic/Latinx population with RA.

References

[1]Safiri S, et al. Ann Rheum Dis. 2019;78(11):1463-71. doi:10.1136/annrheumdis-2019-215920

[2]Potter J, et al. J Rheumatol. 2008;35(8):1545-9. PMID: 18597406

[3]Riad M, et al. J Clin Rheumatol. 2019. doi:10.1097/RHU.0000000000001085

[4]Ahlén GC, et al. Fam Pract. 2007;24(5):498503. doi.org/10.1093/fampra/cmm043

Acknowledgements

We wish to acknowledge the important contributions of our HOPE CAPE RA participants, including the patients and providers and Anne Sydor, PhD for her invaluable advice and help throughout the project.

This project was funded by the Bristol Myers Squibb Foundation.

Disclosure of Interests

Daniel Hernandez Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Julio Bravo Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Juan Jose Maya Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Oscar Soto-Raíces Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Angel Tapia Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, Guillermo Valenzuela Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation, W. Benjamin Nowell Grant/research support from: This research was supported by the Bristol Myers Squibb Foundation, Shilpa Venkatachalam Grant/research support from: This project is supported by the Bristol Myers Squibb Foundation

Major Allergen Content In Allergen Immunotherapy Products: The Limited Value of Numbers

The prevalence of allergic disorders drastically increased over the last 50 years that today they can be considered epidemic. At present, allergen-specific immunotherapy (AIT) is the only therapy targeting the underlying cause of allergic disorders, and its superior evidence is based on accumulated data from clinical trials and observational studies demonstrating efficacy and safety. However, several aspects remain unsolved, such as harmonization and standardization of manufacturing and quantification procedures across manufacturers, homogeneous reporting of strength, and also the establishment of international reference standards for many allergens. This article discusses the issues related to the measurement of major allergen content in AIT extracts, raising the question of whether comparison of products by different manufacturers are appropriate as basis to choose among the different AIT products. Allergen standardization in immunotherapy products is critical to ensure quality and thereby safety and efficacy. However, lack of harmonization in manufacturing process, allergen quantification (methodologies and references), national regulatory differences, clinical practice, and labeling shows that the comparison of AIT products solely based on major allergen amounts is not rationale and, in fact, impossible. Moreover, further inherent characteristics of products and their clinical use such as their state of extract modification, addition of adjuvant or adjuvant-system, route of administration (sublingual/subcutaneous) and cumulative dose as per posology (including the volume per administration) need to be taken into account, when rating the information given for a specific product. Finally, only convincing clinical data can serve as the product-specific evaluation, or the basis for cross-product comparability, for individual products.

Bisphenol A Exposure Induces Sensory Processing Deficits in Larval Zebrafish during Neurodevelopment

Because of their ex utero development, relatively simple nervous system, translucency, and availability of tools to investigate neural function, larval zebrafish are an exceptional model for understanding neurodevelopmental disorders and the consequences of environmental toxins. Furthermore, early in development, zebrafish larvae easily absorb chemicals from water, a significant advantage over methods required to expose developing organisms to chemical agents in utero Bisphenol A (BPA) and BPA analogs are ubiquitous environmental toxins with known molecular consequences. All humans have measurable quantities of BPA in their bodies. Most concerning, the level of BPA exposure is correlated with neurodevelopmental difficulties in people. Given the importance of understanding the health-related effects of this common toxin, we have exploited the experimental advantages of the larval zebrafish model system to investigate the behavioral and anatomic effects of BPA exposure. We discovered that BPA exposure early in development leads to deficits in the processing of sensory information, as indicated by BPA's effects on prepulse inhibition (PPI) and short-term habituation (STH) of the C-start reflex. We observed no changes in locomotion, thigmotaxis, and repetitive behaviors (circling). Despite changes in sensory processing, we detected no regional or whole-brain volume changes. Our results show that early BPA exposure can induce sensory processing deficits, as revealed by alterations in simple behaviors that are mediated by a well-defined neural circuit.

Incorporation of 5',8-cyclo-2'deoxyadenosines by DNA repair polymerases via base excision repair

5',8-cyclo-2-deoxy nucleosides (cdPus) are the smallest tandem purine lesions including 5',8-cyclo-2'-deoxyadenosine (cdA) and 5',8-cyclo-2'-deoxyguanosine (cdG). They can inhibit DNA and RNA polymerases causing mutations, DNA strand breaks, and termination of DNA replication and gene transcription. cdPus can be removed by nucleotide excision repair with low efficiency allowing them to accumulate in the genome. Recent studies suggest that cdPus can be induced in damaged nucleotide pools and incorporated into the genome by DNA polymerases. However, it remains unknown if and how DNA polymerases can incorporate cdPus. In this study, we examined the incorporation of cdAs by human DNA repair polymerases, DNA polymerases β (pol β), and pol η during base excision repair. We then determined the efficiency of cdA incorporation by the polymerases using steady-state kinetics. We found that pol β and pol η incorporated cdAs opposite dT and dC with low efficiency, and incorporated cdAs were readily extended and ligated into duplex DNA. Using molecular docking analysis, we found that the 5',8-covalent bond in cdA disrupted its hydrogen bonding with a template base suggesting that the phosphodiester bond between the 3'-terminus nucleotide and the α-phosphate of cdATP were generated in the absence of hydrogen bonding. The enzyme kinetics analysis further suggests that pol β and pol η increased their substrate binding to facilitate the enzyme catalysis for cdA incorporation. Our study reveals unique mechanisms underlying the accumulation of cdPu lesions in the genome resulting from nucleotide incorporation by repair DNA polymerases.

Echocardiographic markers of mortality at 60 days in patients with COVID-19 in the intensive care unit

Introduction

Coronavirus disease (COVID)-19 predominantly produces its effects through lung damage, but an important component of multi-organ dysfunction is cardiac involvement. We have few reports that inform about the behavior of echocardiographic images of patients with the most severe forms of the disease.

Purpose

The present work aims to identify prognostic markers for 60-day mortality in patients hospitalized in intensive care based on echocardiographic findings.

Methodology

A single-center retrospective cohort was conducted. Hospitalized patients were included in one of the nine intensive care units for COVID-19 confirmed by RT-PCR from May to October 2020. Patients with previous conditions that determined a limitation of the therapeutic effort, those who died before 24 hours and pregnant women were excluded. Portable echocardiograms were performed by two expert cardiologists following the recommendations for isolation and personal protection. The time to death was evaluated as outcome. A Cox proportional hazards model was constructed, HR and 95% confidence intervals with their p values. The study was approved by the institutional ethics committee.

Results

Of 326 patients included, 153 patients had an echocardiogram. The mean age was 60.7 years, 47 (30.7%) were female and 67 (44.7%) had positive troponin. 91 patients (59.5%) not survive, the mean long of stay was 8.4 (SD: 4.2) days. 111 (72.5%) had shock, 128 (83.7%) severe ARDS (PaO2 / FiO2 <100 mmHg), 142 (92.8%) required invasive ventilatory support, and 86 (56.2%) acute kidney injury. 27 (17.6%) patients had acute pulmonary embolism, 16 (10.4%) acute myocardial infarction and 9 (5.9%) myocarditis. The mean right ventricular ejection fraction was 37%, TAPSE was decreased in 16 cases (10.4%). 41 cases (26.8%) had right diastolic dysfunction. 34/48 (71%) cases had pulmonary hypertension. The average LVEF was 59.3% and 74 (48.4%) had some left ventricular diastolic dysfunction. 12 (7.8%) had left ventricular segmental wall motion abnormality and 16 (10.4%) had pericardial effusion. Univariate analysis identified TAPSE, PSAP, acute cor pulmonale and right ventricular dilatation as variables related to the outcome of mortality. The multivariate Cox model (Table 2) documented that acute cor pulmonale with a HR of 12.8 (95% CI 3.51 - 46.63, p<0.001) and right ventricular dilation with a HR of 4, 87 (95% CI 1.36–17.46, P 0.016) were associated with mortality.

Conclusions

In patients hospitalized in the intensive care unit for COVID-19, acute cor pulmonale and right ventricular dilatation behaved as independent predictors of in-hospital death.

Funding Acknowledgement

Type of funding sources: None. Table 1. Baselines characteristicsTable 2. Multivariate analisys

High sensitivity troponin as a 60-day mortality marker in patients with COVID-19 in intensive care at a Latin American hospital

Introduction

Coronavirus disease (COVID) - 19 presents with periodic outbreaks with a large number of critical cases that overwhelm the health system. One of the objectives of screening and management is to have markers that can efficiently stratify the individual risk of experiencing adverse results. High-sensitivity troponin has been proposed as one of the possible prognostic markers.

Purpose

To evaluate the prevalence of troponin elevation and its performance for predicting 60-days mortality in patients in ICU due to COVID - 19 in a Latin American population.

Methodology

A single-center retrospective cohort study was carried out in which patients in ICU for COVID-19 confirmed by RT-PC between May and December 2020 were included. Patients with previous conditions that determined a limitation of therapeutic effort and pregnant women were excluded. The outcome was 60-days mortality. Kaplan Meier survival curves were constructed, a ROC curve was generated for the prediction of death according to troponin levels by calculating the area under the curve. Finally, a Cox proportional hazards model was generated.

Results

296 patients were included, 110 (37.2%) female, the mean age was 60 (SD 14) years and the duration of symptoms before admission to the ICU was 8.4 (SD 4.2) days. 81.4% of the patients had at least one comorbidity, 117 (39.5%) had hypertension, 65 (21.9%) had diabetes, and 63 (21.3%) had chronic lung disease. Mortality occurred in 151 cases (51%), 225 (76%) presented shock, 242 (81.8%) severe ARDS (PaO2 / FiO2 <100 mmHg), 232 (78.4%) required invasive ventilatory support, and 153 (5.7%) developed acute kidney injury. The APACHE II average was 13.1 and SOFA 4.8. Troponin was positive in 118 (39.9%) patients, 29.6% of the survivors and 49.7% in non survivors. The AUC was 0.65 (95% CI 0.59–0.71) for predicting mortality (Figure 1). The Kaplan Meier curves are shown in Figure 2 with a p less than 0.001 by achieving the test. In the bivariate analysis, troponin obtained a HR of 1.94 and p<0.001, but in the multivariate model it was 1.39 (95% CI of 0.21–1.56) and p of 0.12.

Conclusions

High sensitivity troponin was found to be elevated in patients hospitalized for COVID-19 in the intensive care unit who died, with regular discrimination (AUC: 0.65), even though the univariate analysis by the Cox and Kaplan Meier methods showed association with 60-days mortality, this was not maintained in the multivariate model.

Funding Acknowledgement

Type of funding sources: None. Figure 1. ROC curveFigure 2. Kaplan Meier survival curves

Correction to: Large‑scale pathway specific polygenic risk and transcriptomic community network analysis identifies novel functional pathways in Parkinson disease

A correction to this paper has been published: https://doi.org/10.1007/s00401-021-02309-z

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

BACKGROUND

Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents.

METHODS

Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre.

RESULTS

3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004).

CONCLUSIONS

The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

A novel combination regimen of BET and FLT3 inhibition for FLT3-ITD acute myeloid leukemia

Acute myeloid leukemia (AML) patients with FLT3-ITD mutations have a high risk of relapse and death. FLT3 tyrosine kinase inhibitors improve overall survival, but their efficacy is limited and most patients who relapse will ultimately die of the disease. Even with potent FLT3 inhibition, the disease persists within the bone marrow (BM) microenvironment, mainly due to BM stroma activating parallel signaling pathways that maintain pro-survival factors. BET inhibitors suppress pro-survival factors such as MYC and BCL2, but these drugs thus far have shown only limited single-agent clinical potential. We demonstrate here, using pre-clinical and clinical correlative studies, that the novel 4-azaindole derivative, PLX51107, has BET-inhibitory activity in vitro and in vivo. The combination of BET and FLT3 inhibition induces a synergistic anti-leukemic effect in a murine xenograft model of FLT3- ITD AML, and against primary FLT3-ITD AML cells co-cultured with BM stroma. Using suppression of MYC as a surrogate for BET inhibition, we demonstrate BET inhibition in human patients. The short plasma half-life of PLX51107 results in intermittent target inhibition to promote tolerability while overcoming the protective effect of the microenvironment. Mechanistically, the synergistic cytotoxicity is associated with suppression of key survival genes such as MYC. These data provide the scientific rationale for a clinical trial of a BET plus FLT3 inhibitor for the treatment of relapsed/refractory FLT3-ITD AML. A clinical trial of PLX51107 as monotherapy in patients with different malignancies is underway and will be reported separately.

Midostaurin after allogeneic stem cell transplant in patients with FLT3-internal tandem duplication-positive acute myeloid leukemia

We evaluated standard-of-care (SOC) treatment with or without midostaurin to prevent relapse following allogeneic hematopoietic stem cell transplant (alloHSCT) in patients with acute myeloid leukemia (AML) harboring internal tandem duplication (ITD) in FLT3. Adults (aged 18–70 years) who received alloHSCT in first complete remission, had achieved hematologic recovery, and were transfusion independent were randomized to receive SOC with or without midostaurin (50 mg twice daily) continuously in twelve 4-week cycles. The primary endpoint was relapse-free survival (RFS) 18 months post-alloHSCT. Sixty patients were randomized (30/arm); 30 completed all 12 cycles (midostaurin + SOC, n = 16; SOC, n = 14). The estimated 18-month RFS (95% CI) was 89% (69–96%) in the midostaurin arm and 76% (54–88%) in the SOC arm (hazard ratio, 0.46 [95% CI, 0.12–1.86]; P = 0.27); estimated relapse rates were 11% and 24%, respectively. Inhibition of FLT3 phosphorylation to <70% of baseline (achieved by 50% of midostaurin-treated patients) was associated with improved RFS. The most common serious adverse events were diarrhea, nausea, and vomiting. Rates of graft-vs-host disease were similar between both arms (midostaurin + SOC, 70%; SOC, 73%). The addition of midostaurin maintenance therapy following alloHSCT may provide clinical benefit in some patients with FLT3-ITD AML. (ClinicalTrials.gov identifier: NCT01883362).

Urinary tract infections in hospitalized patients

INTRODUCTION

Urinary Tract Infections (UTI) are an important cause of morbidity in the community, constituting one of the main reasons for hospitalization, and the fourth cause of healthcare-associated infection. The objectives of this study were to determine the frequency of community-acquired UTI (CA-UTI) with need of hospitalization and healthcare-associated UTI (HA-UTI), their risk factors, etiologic agents and their antimicrobial susceptibility spectrum.

METHODS

A prospective and analytic study was conducted, in which all admissions regarding CA-UTI with need of hospitalization and HA-UTI were evaluated during the period between 2016 and 2017 in two university hospitals.

RESULTS

A total of 279 episodes of UTI in hospitalized patients were identified and, among those, 178 episodes corresponded to CA-UTI and 101 to HA-UTI. On average, patients were 60 years old in both groups. HA-UTI were more frequently associated with kidney transplant, recurrent UTI and chronic kidney disease compared with CA-UTI. The instrumentation of urinary tract within the previous month was more frequent in HA-UTI (75.2% vs 32.6%, p<0.001). Escherichia coli was the most frequent isolated microorganism (62.9% in CA-UTI and 56.4% in HA-UTI), followed by Klebsiella pneumoniae and Pseudomonas aeruginosa. A total of 101 multidrug resistant microorganisms were isolated, of which 53.5% were CA-UTI, and were associated with male patients, use of antimicrobials within the previous three months, chronic kidney disease and recurrent UTI.

CONCLUSION

It is of great importance for the institutions to identify the local antimicrobial susceptibility spectrum of UTI in order to stablish adequate empiric treatments.

A Phase 1 Study of IRX195183, a RARα-Selective CYP26 Resistant Retinoid, in Patients With Relapsed or Refractory AML

Subsets of non-acute promyelocytic leukemia (APL) acute myelogenous leukemia (AML) exhibit aberrant retinoid signaling and demonstrate sensitivity to retinoids in vitro. We present the results of a phase 1 dose-escalation study that evaluated the safety, pharmacodynamics, and efficacy of IRX195183, a novel retinoic acid receptor α agonist, in patients with relapsed or refractory myelodysplastic syndrome (MDS) or AML. In this single center, single arm study, eleven patients with relapsed or refractory MDS/AML were enrolled and treated. Oral IRX195183 was administered at two dose levels: 50 mg daily or 75 mg daily for a total of two 28-day cycles. Patients with stable disease or better were allowed to continue on the drug for four additional 28-day cycles. Common adverse events included hypertriglyceridemia, fatigue, dyspnea, and edema. Three patients at the first dose level developed asymptomatic Grade 3 hypertriglyceridemia. The maximally tolerated dose was not reached. Four of the eleven patients had (36%) stable disease or better. One had a morphological complete remission with incomplete hematologic recovery while on the study drug. Two patients had evidence of in vivo leukemic blast maturation, as reflected by increased CD38 expression. In a pharmacodynamics study, plasma samples from four patients treated at the lowest dose level demonstrated the capacity to differentiate leukemic cells from the NB4 cell line in vitro. These results suggest that IRX195183 is safe, achieves biologically meaningful plasma concentrations and may be efficacious in a subset of patients with MDS/AML. Clinical Trial Registration: clinicaltrials.gov, identifier NCT02749708.

Large-scale pathway specific polygenic risk and transcriptomic community network analysis identifies novel functional pathways in Parkinson disease

Polygenic inheritance plays a central role in Parkinson disease (PD). A priority in elucidating PD etiology lies in defining the biological basis of genetic risk. Unraveling how risk leads to disruption will yield disease-modifying therapeutic targets that may be effective. Here, we utilized a high-throughput and hypothesis-free approach to determine biological processes underlying PD using the largest currently available cohorts of genetic and gene expression data from International Parkinson's Disease Genetics Consortium (IPDGC) and the Accelerating Medicines Partnership-Parkinson's disease initiative (AMP-PD), among other sources. We applied large-scale gene-set specific polygenic risk score (PRS) analyses to assess the role of common variation on PD risk focusing on publicly annotated gene sets representative of curated pathways. We nominated specific molecular sub-processes underlying protein misfolding and aggregation, post-translational protein modification, immune response, membrane and intracellular trafficking, lipid and vitamin metabolism, synaptic transmission, endosomal-lysosomal dysfunction, chromatin remodeling and apoptosis mediated by caspases among the main contributors to PD etiology. We assessed the impact of rare variation on PD risk in an independent cohort of whole-genome sequencing data and found evidence for a burden of rare damaging alleles in a range of processes, including neuronal transmission-related pathways and immune response. We explored enrichment linked to expression cell specificity patterns using single-cell gene expression data and demonstrated a significant risk pattern for dopaminergic neurons, serotonergic neurons, hypothalamic GABAergic neurons, and neural progenitors. Subsequently, we created a novel way of building de novo pathways by constructing a network expression community map using transcriptomic data derived from the blood of PD patients, which revealed functional enrichment in inflammatory signaling pathways, cell death machinery related processes, and dysregulation of mitochondrial homeostasis. Our analyses highlight several specific promising pathways and genes for functional prioritization and provide a cellular context in which such work should be done.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Mechanical thrombectomy with a novel stent retriever with multifunctional zones: Initial clinical experience with the NeVa™ thrombectomy device

BACKGROUND AND PURPOSE

The NeVa™ (Vesalio, Nashville, Tennessee) thrombectomy device is a CE-approved novel hybrid-cell stent retriever with offset enlarged openings coupled with functional zones and a closed distal end. The device was designed to incorporate and trap resistant emboli. The purpose was to determine the safety and efficacy of the NeVa™ stent.

METHODS

Prospective data was collected on the first thirty consecutive patients treated at four stroke centers with NeVa™ as first line treatment between December 2017 and May 2018. Clinical outcome measures included re-perfusion scores after each pass, complications (per-procedural complications, device related adverse events, all intracerebral hemorrhage (ICH) and symptomatic ICH (sICH) on follow up imaging), 24 hour NIHSS, mRS at discharge and 90 days. Baseline data as well as treatment parameters were documented.

RESULTS

Mean presenting NIHSS was 16. Sites of primary occlusion were 10 ICA, 16 M1-MCA, 3 M2-MCA and one basilar. There were five tandem occlusions. Reperfusion outcomes after each NeVa pass; TICI ≥ 2b after first pass 63%, after 1 or 2 passes 83%, after 1 to 3 passes 90%. TICI 2c-3 after first pass 47%, after 1-2 passes 57%, after 1-3 passes 60%. TICI ≥ 2b after final pass 93%; TICI 2c-3, 63%. There were no device related serious averse events and no sICH. Clot material was partially or completely incorporated into the device after 70% passes. The mean 24 hour NIHSS was 7 and the 90 day mRS was 0-2 in 53%.

CONCLUSIONS

The NeVa™ device demonstrated a high rate of first pass complete reperfusion effect, a good safety profile and favorable 90 day clinical outcomes in this initial clinical experience.

Regulation of drug metabolizing enzymes in the leukaemic bone marrow microenvironment

The bone marrow (BM) microenvironment contributes to drug resistance in acute myeloid leukaemia (AML) and multiple myeloma (MM). We have shown that the critical drug metabolizing enzymes cytochrome P450 (CYP) 3A4 and cytidine deaminase (CDA) are highly expressed by BM stroma, and play an important role in this resistance to chemotherapy. However, what factors influence the chemoprotective capacity of the BM microenvironment, specifically related to CYP3A4 and CDA expression, are unknown. In this study, we found that the presence of AML cells decreases BM stromal expression of CYP3A4 and CDA, and this effect appears to be at least partially the result of cytokines secreted by AML cells. We also observed that stromal CYP3A4 expression is up‐regulated by drugs commonly used in AML induction therapy, cytarabine, etoposide and daunorubicin, resulting in cross‐resistance. Cytarabine also up‐regulated CDA expression. The up‐regulation of CYP3A4 associated with disease control was reversed by clarithromycin, a potent inhibitor of CYP3A4. Our data suggest that minimal residual disease states are characterized by high levels of stromal drug metabolizing enzymes and thus, strong microenvironment‐mediated drug resistance. These results further suggest a potential role for clinically targeting drug metabolizing enzymes in the microenvironment.

SEIS: Insight's Seismic Experiment for Internal Structure of Mars

By the end of 2018, 42 years after the landing of the two Viking seismometers on Mars, InSight will deploy onto Mars' surface the SEIS (Seismic Experiment for Internal Structure) instrument; a six-axes seismometer equipped with both a long-period three-axes Very Broad Band (VBB) instrument and a three-axes short-period (SP) instrument. These six sensors will cover a broad range of the seismic bandwidth, from 0.01 Hz to 50 Hz, with possible extension to longer periods. Data will be transmitted in the form of three continuous VBB components at 2 sample per second (sps), an estimation of the short period energy content from the SP at 1 sps and a continuous compound VBB/SP vertical axis at 10 sps. The continuous streams will be augmented by requested event data with sample rates from 20 to 100 sps. SEIS will improve upon the existing resolution of Viking's Mars seismic monitoring by a factor of ∼ 2500 at 1 Hz and ∼ 200 000 at 0.1 Hz. An additional major improvement is that, contrary to Viking, the seismometers will be deployed via a robotic arm directly onto Mars' surface and will be protected against temperature and wind by highly efficient thermal and wind shielding. Based on existing knowledge of Mars, it is reasonable to infer a moment magnitude detection threshold of M w ∼ 3 at 40 ∘ epicentral distance and a potential to detect several tens of quakes and about five impacts per year. In this paper, we first describe the science goals of the experiment and the rationale used to define its requirements. We then provide a detailed description of the hardware, from the sensors to the deployment system and associated performance, including transfer functions of the seismic sensors and temperature sensors. We conclude by describing the experiment ground segment, including data processing services, outreach and education networks and provide a description of the format to be used for future data distribution.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s11214-018-0574-6) contains supplementary material, which is available to authorized users.

Whole-exome sequencing of the BDR cohort: evidence to support the role of the PILRA gene in Alzheimer's disease

AIM

Late-onset Alzheimer's disease (LOAD) accounts for 95% of all Alzheimer's cases and is genetically complex in nature. Overlapping clinical and neuropathological features between AD, FTD and Parkinson's disease highlight the potential role of genetic pleiotropy across diseases. Recent genome-wide association studies (GWASs) have uncovered 20 new loci for AD risk; however, these exhibit small effect sizes. Using NGS, here we perform association analyses using exome-wide and candidate-gene-driven approaches.

METHODS

Whole-exome sequencing was performed on 132 AD cases and 53 control samples. Exome-wide single-variant association and gene burden tests were performed for 76 640 nonsingleton variants. Samples were also screened for known causative mutations in familial genes in AD and other dementias. Single-variant association and burden analysis was also carried out on variants in known AD and other neurological dementia genes.

RESULTS

Tentative single-variant and burden associations were seen in several genes with kinase and protease activity. Exome-wide burden analysis also revealed significant burden of variants in PILRA (P = 3.4 × 10^-5 ), which has previously been linked to AD via GWAS, hit ZCWPW1. Screening for causative mutations in familial AD and other dementia genes revealed no pathogenic variants. Variants identified in ABCA7, SLC24A4, CD33 and LRRK2 were nominally associated with disease (P < 0.05) but did not withstand correction for multiple testing. APOE (P = 0.02) and CLU (P = 0.04) variants showed significant burden on AD.

CONCLUSIONS

In addition, polygenic risk scores (PRS) were able to distinguish between cases and controls with 83.8% accuracy using 3268 variants, sex, age at death and APOE ε4 and ε2 status as predictors.

Cabozantinib is well tolerated in acute myeloid leukemia and effectively inhibits the resistance-conferring FLT3/tyrosine kinase domain/F691 mutation

BACKGROUND

Cabozantinib, a tyrosine kinase inhibitor of FMS-like tyrosine kinase 3 (FLT3), MET, AXL, vascular endothelial growth factor receptor, and KIT, is approved for use in multiple malignancies. We assessed the safety and tolerability of cabozantinib in AML, given up-regulation of multiple relevant pathways.

METHODS

Adults were eligible if they were 18 years old or older with relapsed/refractory AML or if they were 70 years old or older with newly diagnosed AML but were ineligible for conventional therapy. Cabozantinib was administered in 28-day cycles, and dose escalation occurred via cohorts. A pharmacodynamic evaluation of serial plasma samples via a plasma inhibitory assay (PIA) was used to assess FLT3-inhibitory activity in FLT3-mutant cell lines.

RESULTS

Among 18 patients enrolled, 5 were found to harbor FLT3/ITD mutations. Sixteen patients (89%) had relapsed/refractory AML, and most were treated with 2 or more lines of prior treatment. No dose-limiting toxicities (DLTs) were detected at the first dose level (40 mg daily), but 2 patients experienced DLTs at the next level (60 mg daily). The remaining patients were then dosed at 40 mg daily, the maximum tolerated dose (MTD). Additional grade 2 or higher toxicities, possibly/probably related to cabozantinib, included fatigue, nausea, transaminitis, and electrolyte imbalance. No patients had a marrow response according to formal criteria, but 4 had peripheral blast reductions; 2 of these 4 patients transiently cleared circulating blasts. One patient experienced a reduction in marrow blasts, and 1 had stable disease. The FLT3-inhibitory activity of plasma samples, as assessed with the PIA, revealed potent and sustained inhibition in FLT3/ITD and, notably, F691 tyrosine kinase domain (TKD)-mutant cells.

CONCLUSIONS

Cabozantinib is well tolerated in AML patients at an MTD of 40 mg daily and is a potent inhibitor of FLT3/ITD- and F691 TKD-altered tyrosine kinases. Cancer 2018;124:306-14. © 2017 American Cancer Society.

Genetics of Hereditary Ataxia in Scottish Terriers

BACKGROUND

Scottish Terriers have a high incidence of juvenile onset hereditary ataxia primarily affecting the Purkinje neuron of the cerebellar cortex and causing slowly progressive cerebellar dysfunction.

OBJECTIVE

To identify chromosomal regions associated with hereditary ataxia in Scottish Terriers.

ANIMALS

One hundred and fifty-three Scottish Terriers were recruited through the Scottish Terrier Club of America.

MATERIALS AND METHODS

Prospective study. Dogs were classified as affected if they had slowly progressive cerebellar signs. When possible, magnetic resonance imaging and histopathological evaluation of the brain were completed as diagnostic aids. To identify genomic regions connected with the disease, genome-wide mapping was performed using both linkage- and association-based approaches. Pedigree evaluation and homozygosity mapping were also performed to examine mode of inheritance and to investigate the region of interest, respectively.

RESULTS

Linkage and genome-wide association studies in a cohort of Scottish Terriers both identified a region on CFA X strongly associated with the disease trait. Homozygosity mapping revealed a 4 Mb region of interest. Pedigree evaluation failed to identify the possible mode of inheritance due to the lack of complete litter information.

CONCLUSION AND CLINICAL IMPORTANCE

This finding suggests that further genetic investigation of the potential region of interest on CFA X should be considered in order to identify the causal mutation as well as develop a genetic test to eliminate the disease from this breed.

Neurocognitive profile of patients with early stages of HIV infection

HIV-associated neurocognitive disorders (HAND) may include neurological disorders of various severities such as AIDS dementia complex (ADC) also known as HIV dementia and HIV-associated dementia (HAD), HIV encephalopathy, and Mild Neurocognitive Disorder (MND). As it seems HIV-associated neurocognitive disorders are associated with a metabolic encephalopathy induced by HIV infection and fueled by immune activation of macrophages and microglia. Despite of a group, evidences have described presence of cognitive alterations in HIV patients at different stages of HIV infection so far; little is known about the neurocognitive state of patients at very early stages of HIV infection. Here, we explored the neurocognitive profile of a group of cases of HIV patients at very early stages of HIV infection. We have analyzed of three groups of subjects, thus, we have studied a group of patients with early HIV infection, a healthy control group and a group of patients with mild cognitive impairment due to neurodegenerative causes. Our results suggested that cognitive processes are sensitive to very early neuropathological changes in HIV infection. Noteworthy, our results also showed that neurocognitive profile of HIV patients differs from those cognitive alterations in patients with mild cognitive disorders associated to primary neurodegeneration. Together, our results point out that HIV infection generates neural changes even at early stages of infection. Furthermore, our results highlight the importance of a deep neurocognitive exploration at very early stages of HIV infection as this approach allow improve the accompaniment, clinical attachment and interventions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Chronic airway inflammation provides a unique environment for B cell activation and antibody production

BACKGROUND

B cells play many roles in health and disease. However, little is known about the mechanisms that drive B cell responses in the airways, especially in humans. Chronic rhinosinusitis (CRS) is an inflammatory disease of the upper airways that affects 10% of Europeans and Americans. A subset of CRS patients develop nasal polyps (NPs), which are characterized by type 2 inflammation, eosinophils and group 2 innate lymphoid cells (ILC2s). We have reported that NP contain elevated levels of B cells and antibodies, making NP an ideal system for studying B cells in the airways.

OBJECTIVE

We sought to determine the mechanisms that drive B cell activation and antibody production during chronic airway inflammation.

METHODS

We analysed B cells from NP or tonsil, or after ILC2 coculture, by flow cytometry. Antibody production from tissue was measured using Luminex assays and the frequency of antibody-secreting cells by ELISpot. Formation of B cell clusters was assessed using immunohistochemistry. Expression of genes associated with B cell activation and class switch recombination was measured by qRT-PCR.

RESULTS

NP contained significantly elevated frequencies of plasmablasts, especially those that expressed the extrafollicular marker Epstein-Barr virus-induced protein 2 (EBI2), but significantly fewer germinal centre (GC) B cells compared with tonsil. Antibody production and the frequency of antibody-secreting cells were significantly elevated in NP, and there was evidence for local class switch recombination in NP. Finally, ILC2s directly induced EBI2 expression on B cells in vitro.

CONCLUSIONS AND CLINICAL RELEVANCE

Our data suggest there is a unique B cell activation environment within NP that is distinct from classic GC-mediated mechanisms. We show for the first time that ILC2s directly induce EBI2 expression on B cells, indicating that ILC2s may play an important role in B cell responses. B cell-targeted therapies may provide new treatment options for CRSwNP.

Asociación de los alelos del gen BoLA-DRB3 con la infección natural de Babesia spp en el ganado criollo Hartón del Valle

En 191 individuos de la raza bovina criolla Hartón del Valle, se evaluó la infección por los protozoarios Babesia bovis y Babesia bigemina mediante PCR convencional, los polimorfismos del gen BoLA-DRB3,2* mediante PCR-SBT y la asociación entre ambos (Odds Ratio, OR). Los alelos fueron categorizados según su asociación en resistentes (R), susceptibles (S) o neutrales (N) a la infección y los individuos genotipados según la clasificación de sus alelos como: N/N, N/R, N/S, R/R, R/S y S/S. Ningún animal fue positivo a la infección por B. bovis y por tanto no se realizaron estimaciones de asociación. La infección con B. bigemina fue del 13,1%. Se encontraron 36 alelos BoLA-DRB3,2, los más frecuentes fueron el *1101 (0,196), *20012 (0,097), *2006 (0,053) y *2703 (0,053). Se encontró una asociación positiva (p