Cas9-induced single cut enables highly efficient and template-free repair of a muscular dystrophy causing founder mutation

With thousands of patients worldwide, CAPN3 c.550delA is the most frequent mutation causing severe, progressive, and untreatable limb girdle muscular dystrophy. We aimed to genetically correct this founder mutation in primary human muscle stem cells. We designed editing strategies providing CRISPR-Cas9 as plasmid and mRNA first in patient-derived induced pluripotent stem cells and applied this strategy then in primary human muscle stem cells from patients. Mutation-specific targeting yielded highly efficient and precise correction of CAPN3 c.550delA to wild type for both cell types. Most likely a single cut generated by SpCas9 resulted in a 5' staggered overhang of one base pair, which triggered an overhang-dependent base replication of an A:T at the mutation site. This recovered the open reading frame and the CAPN3 DNA sequence was repaired template-free to wild type, which led to CAPN3 mRNA and protein expression. Off-target analysis using amplicon sequencing of 43 in silico predicted sites demonstrates the safety of this approach. Our study extends previous usage of single cut DNA modification since our gene product has been repaired into the wild-type CAPN3 sequence with the perspective of a real cure.

LMNA Co-Regulated Gene Expression as a Suitable Readout after Precise Gene Correction

LMNA-related muscular dystrophy is an autosomal-dominant progressive disorder caused by mutations in LMNA. LMNA missense mutations are becoming correctable with CRISPR/Cas9-derived tools. Evaluating the functional recovery of LMNA after gene editing bears challenges as there is no reported direct loss of function of lamin A/C proteins in patient-derived cells. The proteins encoded by LMNA are lamins A/C, important ubiquitous nuclear envelope proteins but absent in pluripotent stem cells. We induced lamin A/C expression in induced pluripotent stem cells (iPSCs) of two patients with LMNA-related muscular dystrophy, NM_170707.4 (LMNA): c.1366A > G, p.(Asn456Asp) and c.1494G > T, p.(Trp498Cys), using a short three-day, serum-induced differentiation protocol and analyzed expression profiles of co-regulated genes, examples being COL1A2 and S100A6. We then performed precise gene editing of LMNA c.1366A > G using the near-PAMless (PAM: protospacer-adjacent motif) cytosine base editor. We show that the mutation can be repaired to 100% efficiency in individual iPSC clones. The fast differentiation protocol provided a functional readout and demonstrated increased lamin A/C expression as well as normalized expression of co-regulated genes. Collectively, our findings demonstrate the power of CRISPR/Cas9-mediated gene correction and effective outcome measures in a disease with, so far, little perspective on therapies.

mRNA-mediated delivery of gene editing tools to human primary muscle stem cells

Muscular dystrophies are approximately 50 devastating, untreatable monogenic diseases leading to progressive muscle degeneration and atrophy. Gene correction of transplantable cells using CRISPR/Cas9-based tools is a realistic scenario for autologous cell replacement therapies to restore organ function in many genetic disorders. However, muscle stem cells have so far lagged behind due to the absence of methods to isolate and propagate them and their susceptibility to extensive ex vivo manipulations. Here, we show that mRNA-based delivery of SpCas9 and an adenine base editor results in up to >90% efficient genome editing in human muscle stem cells from many donors regardless of age and gender and without any enrichment step. Using NCAM1 as an endogenous reporter locus expressed by all muscle stem cells and whose knockout does not affect cell fitness, we show that cells edited with mRNA fully retain their myogenic marker signature, proliferation capacity, and functional attributes. Moreover, mRNA-based delivery of a base editor led to the highly efficient repair of a muscular dystrophy-causing SGCA mutation in a single selection-free step. In summary, our work establishes mRNA-mediated delivery of CRISPR/Cas9-based tools as a promising and universal approach for taking gene edited muscle stem cells into clinical application to treat muscle disease.

Generation of hiPSC-Derived Skeletal Muscle Cells: Exploiting the Potential of Skeletal Muscle-Derived hiPSCs

Cell therapies for muscle wasting disorders are on the verge of becoming a realistic clinical perspective. Muscle precursor cells derived from human induced pluripotent stem cells (hiPSCs) represent the key to unrestricted cell numbers indispensable for the treatment of generalized muscle wasting such as cachexia or intensive care unit (ICU)-acquired weakness. We asked how the cell of origin influences efficacy and molecular properties of hiPSC-derived muscle progenitor cells. We generated hiPSCs from primary muscle stem cells and from peripheral blood mononuclear cells (PBMCs) of the same donors (n = 4) and compared their molecular profiles, myogenic differentiation potential, and ability to generate new muscle fibers in vivo. We show that reprogramming into hiPSCs from primary muscle stem cells was faster and 35 times more efficient than from blood cells. Global transcriptome comparison revealed significant differences, but differentiation into induced myogenic cells using a directed transgene-free approach could be achieved with muscle- and PBMC-derived hiPSCs, and both cell types generated new muscle fibers in vivo. Differences in myogenic differentiation efficiency were identified with hiPSCs generated from individual donors. The generation of muscle-stem-cell-derived hiPSCs is a fast and economic method to obtain unrestricted cell numbers for cell-based therapies in muscle wasting disorders, and in this aspect are superior to blood-derived hiPSCs.

Base editing repairs an SGCA mutation in human primary muscle stem cells

Skeletal muscle can regenerate from muscle stem cells and their myogenic precursor cell progeny, myoblasts. However, precise gene editing in human muscle stem cells for autologous cell replacement therapies of untreatable genetic muscle diseases has not yet been reported. Loss-of-function mutations in SGCA, encoding α-sarcoglycan, cause limb-girdle muscular dystrophy 2D/R3, an early-onset, severe, and rapidly progressive form of muscular dystrophy affecting both male and female patients. Patients suffer from muscle degeneration and atrophy affecting the limbs, respiratory muscles, and heart. We isolated human muscle stem cells from 2 donors, with the common SGCA c.157G>A mutation affecting the last coding nucleotide of exon 2. We found that c.157G>A is an exonic splicing mutation that induces skipping of 2 coregulated exons. Using adenine base editing, we corrected the mutation in the cells from both donors with > 90% efficiency, thereby rescuing the splicing defect and α-sarcoglycan expression. Base-edited patient cells regenerated muscle and contributed to the Pax7⁺ satellite cell compartment in vivo in mouse xenografts. Here, we provide the first evidence to our knowledge that autologous gene–repaired human muscle stem cells can be harnessed for cell replacement therapies of muscular dystrophies.

Generation of three age and gender matched pairs of human induced pluripotent stem cells derived from myoblasts (MDCi011-A, MDCi012-A, MDCi013-A) and from peripheral blood mononuclear cells (MDCi011-B, MDCi012-B, MDCi013-B) from the same donor

We describe the generation and characterization of three pairs of human induced pluripotent stem cell (hiPSC) lines reprogrammed from myoblasts and from peripheral blood mononuclear cells (PBMCs) of the same donor. All donors were free of neuromuscular disorders, female and between 47 and 50 years of age. For reprogramming we used Sendai-virus delivery of the four Yamanaka factors. The pluripotent identity of the hiPSC lines was confirmed by the expression of pluripotency markers and their capacity to differentiate into all three germ layers. These hiPSCs constitute a tool to study tissue of origin specific differences in the identity of hiPSCs.

Generation of two human induced pluripotent stem cell lines derived from myoblasts (MDCi014-A) and from peripheral blood mononuclear cells (MDCi014-B) from the same donor

We describe the generation and characterization of two human induced pluripotent stem cell (hiPSCs) lines reprogrammed from myoblasts and from peripheral blood mononuclear cells (PBMCs) from the same donor. The donor was free of neuromuscular disorders, male and 18 years of age. For reprogramming we used Sendai-virus delivery of the four Yamanaka factors. The pluripotent identity of the hiPSC lines was confirmed by the expression of pluripotency markers and their capacity to differentiate into all three germ layers. These hiPSCs constitute a tool to study tissue of origin specific differences in the identity of hiPSCs.

Human muscle-derived CLEC14A-positive cells regenerate muscle independent of PAX7

Skeletal muscle stem cells, called satellite cells and defined by the transcription factor PAX7, are responsible for postnatal muscle growth, homeostasis and regeneration. Attempts to utilize the regenerative potential of muscle stem cells for therapeutic purposes so far failed. We previously established the existence of human PAX7-positive cell colonies with high regenerative potential. We now identified PAX7-negative human muscle-derived cell colonies also positive for the myogenic markers desmin and MYF5. These include cells from a patient with a homozygous PAX7 c.86-1G > A mutation (PAX7null). Single cell and bulk transcriptome analysis show high intra- and inter-donor heterogeneity and reveal the endothelial cell marker CLEC14A to be highly expressed in PAX7null cells. All PAX7-negative cell populations, including PAX7null, form myofibers after transplantation into mice, and regenerate muscle after reinjury. Transplanted PAX7neg cells repopulate the satellite cell niche where they re-express PAX7, or, strikingly, CLEC14A. In conclusion, transplanted human cells do not depend on PAX7 for muscle regeneration.

Skeletal muscle stem cells express the transcription factor Pax7. Here, the authors isolate, from human muscle, cells that are positive for the endothelial marker CLEC14A and show that despite not expressing pax7, these cells regenerate muscle and contribute to the muscle stem cell niche when transplanted into mice.

The impact of neurally adjusted ventilatory assist mode on respiratory severity score and energy expenditure in infants: a randomized crossover trial

OBJECTIVE

Examine respiratory severity scores (RSS) (mean airway pressure × fraction of inspired oxygen) and resting energy expenditure (REE) on neurally adjusted ventilatory assist (NAVA) compared with synchronized intermittent mandatory ventilation with pressure controlled and supported breath (SIMV (PC)PS).

STUDY DESIGN

A randomized, crossover trial in a level IV neonatal intensive care unit. Twenty-four patients were ventilated with NAVA or SIMV (PC) PS for 12 h and then crossed over to the alternative mode for 12 h. The primary outcome (RSS) and additional secondary respiratory outcomes were analyzed.

RESULTS

RSS and measured REE were not different between modes. On NAVA, peak inspiratory pressures were lower (17.8 vs 19.9 cmH₂O (P<0.05)) without higher oxygen requirements. Respiratory rates were higher on NAVA (52 vs 39 (P<0.05)), estimated work of breathing (WOB) (0.01 vs 0.04 J l^-1 (P<0.05)) was improved.

CONCLUSION

NAVA mode can be safe without increase in RSS or REE. Although respiratory rates were higher, this was offset by lower peak inspiratory pressures and WOB during NAVA.

Localized irradiation of mouse legs using an image-guided robotic linear accelerator

BACKGROUND

To investigate the potential of human satellite cells in muscle regeneration small animal models are useful to evaluate muscle regeneration. To suppress the inherent regeneration ability of the tibialis muscle of mice before transplantation of human muscle fibers, a localized irradiation of the mouse leg should be conducted. We analyzed the feasibility of an image-guided robotic irradiation procedure, a routine treatment method in radiation oncology, for the focal irradiation of mouse legs.

METHODS

After conducting a planning computed tomography (CT) scan of one mouse in its customized mold a three-dimensional dose plan was calculated using a dedicated planning workstation. 18 Gy have been applied to the right anterior tibial muscle of 4 healthy and 12 mice with immune defect in general anesthesia using an image-guided robotic linear accelerator (LINAC). The mice were fixed in a customized acrylic mold with attached fiducial markers for image guided tracking.

RESULTS

All 16 mice could be irradiated as prevised without signs of acute radiation toxicity or anesthesiological side effects. The animals survived until scarification after 8, 21 and 49 days as planned. The procedure was straight forward and the irradiation process took 5 minutes to apply the dose of 18 Gy.

CONCLUSIONS

Localized irradiation of mice legs using a robotic LINAC could be conducted as planned. It is a feasible procedure without recognizable side effects. Image guidance offers precise dose delivery and preserves adjacent body parts and tissues.

Full-length Dysferlin Transfer by the Hyperactive Sleeping Beauty Transposase Restores Dysferlin-deficient Muscle

Dysferlin-deficient muscular dystrophy is a progressive disease characterized by muscle weakness and wasting for which there is no treatment. It is caused by mutations in DYSF, a large, multiexonic gene that forms a coding sequence of 6.2 kb. Sleeping Beauty (SB) transposon is a nonviral gene transfer vector, already used in clinical trials. The hyperactive SB system consists of a transposon DNA sequence and a transposase protein, SB100X, that can integrate DNA over 10 kb into the target genome. We constructed an SB transposon-based vector to deliver full-length human DYSF cDNA into dysferlin-deficient H2K A/J myoblasts. We demonstrate proper dysferlin expression as well as highly efficient engraftment (>1,100 donor-derived fibers) of the engineered myoblasts in the skeletal muscle of dysferlin- and immunodeficient B6.Cg-Dysf(prmd) Prkdc(scid)/J (Scid/BLA/J) mice. Nonviral gene delivery of full-length human dysferlin into muscle cells, along with a successful and efficient transplantation into skeletal muscle are important advances towards successful gene therapy of dysferlin-deficient muscular dystrophy.

Human satellite cells have regenerative capacity and are genetically manipulable

Muscle satellite cells promote regeneration and could potentially improve gene delivery for treating muscular dystrophies. Human satellite cells are scarce; therefore, clinical investigation has been limited. We obtained muscle fiber fragments from skeletal muscle biopsy specimens from adult donors aged 20 to 80 years. Fiber fragments were manually dissected, cultured, and evaluated for expression of myogenesis regulator PAX7. PAX7+ satellite cells were activated and proliferated efficiently in culture. Independent of donor age, as few as 2 to 4 PAX7+ satellite cells gave rise to several thousand myoblasts. Transplantation of human muscle fiber fragments into irradiated muscle of immunodeficient mice resulted in robust engraftment, muscle regeneration, and proper homing of human PAX7+ satellite cells to the stem cell niche. Further, we determined that subjecting the human muscle fiber fragments to hypothermic treatment successfully enriches the cultures for PAX7+ cells and improves the efficacy of the transplantation and muscle regeneration. Finally, we successfully altered gene expression in cultured human PAX7+ satellite cells with Sleeping Beauty transposon-mediated nonviral gene transfer, highlighting the potential of this system for use in gene therapy. Together, these results demonstrate the ability to culture and manipulate a rare population of human tissue-specific stem cells and suggest that these PAX7+ satellite cells have potential to restore gene function in muscular dystrophies.

Luteinizing hormone pulse frequency is increased by arginine infusion in prepubertal sheep

Puberty in sheep is initiated by a complex neuroendocrine interplay which cascades into an increased LH pulsatility at this time. Blood-borne amino acids have been proposed as metabolic signals for the stimulation of GnRH/LH secretion, a mandatory requirement for pubertal onset. In previous experiments we have demonstrated that a 1 h infusion of L-arginine (ARG) was capable of stimulating the LH secretion in prepubertal ewes. The aim of the present study was to further examine the effect of an intravenous infusion of ARG on LH secretion. Prepubertal ewes were infused for 6 h with 15 (Group ARG15, n = 5) or 30 g (Group ARG30, n = 5) of L-ARG dissolved in 500 mL saline (pH 7.4), while saline was administered as control (Group S, n = 5). Since ARG is metabolized to ornithine (ORN), equimolar doses of L-ORN were additionally tested (Group ORN12 and ORN24, n = 5, respectively). Blood samples were obtained at 15 minute intervals during and after experimental infusions to characterize the LH pulsatile secretion. The resulting hormone data arrays were searched for significant fluctuations by the PULSAR program. The LH pulse frequency was found to be higher in groups of ARG treated than in saline or ORN infused sheep during the 6-h infusion period: 5.6 +/- 1.0 (ARG15) vs. 5.0 +/- 0.5 (ARG30) vs. 2.0 +/- 0.9 (S, p < 0.01) vs. 3.4 +/- 0.9 (ORN12) vs. 3.4 +/- 0.9 pulses/6 h (ORN24, p < 0.05). The total number of pulses was higher in ARG infused lambs than in saline or ORN infused animals: 11.2 +/- 1.2 (ARG15) vs. 10 +/- 1.1 (ARG30) vs. 13.8 +/- 1.4 (S) vs. 5.8 +/- 1.7 (ORN12) vs. 5.8 +/- 2.0 pulses/12h (ORN24), respectively. The LH mean secretion was comparable during both 6-h periods in all groups. Results of our experiments demonstrate increased LH pulse frequencies during ARG infusions, suggesting an action of ARG to stimulate hypothalamic GnRH release. Thus, ARG may be a critical determinant for enhanced LH pulsatility as a prerequirement for the onset of puberty in the sheep.

Acute renal failure associated with bilateral enlargement of the kidneys: a rare manifestation of acute lymphoblastic leukemia (ALL)

We report a 6-year-old patient who presented with acute renal failure resolving after vigorous intravenous hydration. Renal biopsy was taken because of unexplained enlargement of both kidneys. Histological workup showed infiltration by lymphoblasts while blood counts showed a normal differential. Subsequent bone marrow aspiration revealed 34% lymphoblasts of T-lineage origin, leading to the diagnosis of T-ALL. This case underlines that malignant hematologic infiltration should be considered in patients presenting with unexplained renal failure and enlarged kidneys.

[Cervical cancer prevention: an update]

It has been seen an increase of the cervical cancer and of intraepithelial cancer in the last years. The most important risk factors for cervical cancer are sexual conduct, early of sexual relationships, number of partners, cigarettes, oral anticonceptive, pregnancy, immunosuppression, sexually transmitted illness. And an important role of the Human Papilloma Virus. The HPV has been classified in 3 groups; low risk, the most frequents are 11 and 6, middle risk, tipe 31, 33 and 35, and high risk, 16 and 18, that have frequent association with cervical cancer and with high grade intraepithelial lesions. The cervicovaginal citology is still the most accurate diagnosis method to detect SIL or CIN and invasive cancer in early stages, it is discussed the periodicity and group of women to whom the method must point. There are different options depending if it is a SIL of low or high grade or and cancer. With the possibility of doing follow up or treatment, such as. LLETZ, Laser, Criotraphy, cone and interferon for the preneoplastic lesions. The achievement of a vaccine for HPV could have a significant impact on these pathology.

Nontuberculous mycobacteria in patients with cystic fibrosis

The prevalence and clinical implications of colonization with nontuberculous mycobacteria were prospectively studied in 37 patients who had cystic fibrosis. Sputum samples were cultured on Coletsos and Löwenstein-Jensen selective media after decontamination with sodium hydroxide and oxalic acid. Oxalic acid-decontaminated fractions were also cultured in selective liquid medium. Nontuberculous mycobacteria were isolated from 6 patients (16.1%). Mycobacterium chelonae and Mycobacterium avium-intracellulare complex were the most common species. Three patients with positive results of culture had at least 1 positive result by acid-fast smear. Oxalic acid decontamination and culture in liquid medium had the lowest contamination rate (6.7%). Colonization with nontuberculous mycobacteria was associated with humoral response to mycobacteria (immunoglobulin G titers against antigen A60) in patients with samples that tested positive by acid-fast smear. An improvement in pulmonary function was observed in 2 patients after they received a course of antimycobacterial therapy. Screening for nontuberculous mycobacteria in patients with cystic fibrosis will contribute to understanding the relevance of these pathogens with regard to deterioration of pulmonary function in patients with cystic fibrosis.

Persistence and variability of Stenotrophomonas maltophilia in cystic fibrosis patients, Madrid, 1991-1998

During 1991 to 1998 at least one Stenotrophomonas maltophilia pulmonary infection was observed in 25 (24%) of 104 cystic fibrosis patients at the same unit of our hospital in Spain. Ribotyping and pulse-field gel electrophoresis (PFGE) characterization of 76 S. maltophilia isolates from these patients indicated an overall clonal incidence of 47.1%, reflecting new strains in 44% of patients with repeated positive cultures for S. maltophilia. Six patients with repeated episodes were persistently colonized (> or = 6 months) with the same strain. S. maltophilia bacterial counts were higher (geometric mean, 2.9 x 10(8) cfu/mL) in patients with repeated episodes than in those with a single episode (8.4 x 10(4) cfu/mL, p < 0.01). Single episodes of S. maltophilia occurred in patients < 10 years of age (43% [6/14]), whereas chronic colonization occurred more frequently in older patients (> 16 years of age).

A beta-turn rich oats peptide as an antigen in an ELISA method for the screening of coeliac disease in a paediatric population

BACKGROUND

ELISA methods for the measurement of IgA antigliadin antibodies (AGA), both home-made and commercial systems, routinely employ wheat gliadin fractions as coating antigens. We investigate the sensitivity and specificity for CD diagnosis of a new ELISA method using a highly immunoreactive beta-turn rich gamma3-avenin peptide as an alternative coating antigen.

METHODS

The assay was standardized with antihuman IgA peroxidase-conjugated as the second antibody. Alternatively, an ELISA based on the use of protein A-peroxidase was assayed to measure both IgG plus IgA antibodies. Sixty-three sera from healthy controls were analyzed to establish the system's cut-off point. Sera from 103 coeliac and from 65 noncoeliac children were tested; for diagnosis purposes, a small intestinal biopsy had been performed in all of them.

RESULTS

For the IgA class antibodies assay a high sensitivity and specificity of 90.3% and 98.5%, respectively, was obtained, comparable to those achieved for IgA antiendomysium antibodies (EmA) with the same sera.

CONCLUSIONS

In view of the high sensitivity and specificity obtained together with water solubility of the peptide and easiness for large-scale reproducible synthesis, the new AGA IgA avenin peptide ELISA represents a significant improvement in CD diagnosis in comparison with conventional established AGA IgA ELISA using crude gliadins as coating antigens.

Suspected sexual abuse: an unusual presentation form of congenital myotonic dystrophy

In children, anal abnormalities due to various causes may be confused with sexual abuse. We present the case of a child in whom the suspicion of abuse due to anal dilatation led to the previously unknown diagnosis of myotonic dystrophy. Myopathic involvement of the perianal musculature is a known feature of congenital myotonic dystrophy that usually appears in late childhood or adolescence.

CONCLUSION

We stress the importance of considering an underlying myopathic condition in the differential diagnosis of anal laxity. Further studies, such as anal ultrasonography, may help when the diagnosis of abuse is not clear.

Intraepithelial lymphocytes and coeliac disease: permanent changes in CD3-/CD7+ and T cell receptor gammadelta subsets studied by flow cytometry

Permanent changes in intestinal intraepithelial lymphocytes have been observed in coeliac patients. The aim of this investigation was to study small intestinal intraepithelial lymphocytes by using flow cytometry and to evaluate its diagnostic value in coeliac disease. Three-colour flow cytometry analyses were performed on isolated epithelial cells of 117 intestinal biopsies obtained from 113 children (54 coeliac disease, 4 other enteropathies, 18 Helicobacter pylori associated gastritis and 37 normal controls). A multiple logistic regression model was developed to select the best intraepithelial lymphocytes subset predictor of coeliac disease. Coeliac patients had significant higher levels of T cell receptor gammadelta intraepithelial lymphocytes than control patients (p < 0.01), H. pylori patients (p < 0.01) and other enteropathies (p < 0.05). The density of CD3-/CD7+ intraepithelial lymphocytes, a intraepithelial lymphocyte subset poorly characterized by immunohistochemical methods, was significantly lower in coeliac patients than in the control group (p < 0.01). H. pylori group (p < 0.01) and other enteropathies (p < 0.01). Both changes remained altered independent of the coeliac patient's diet. The data were used on a logistic regression analysis in order to calculate sensitivity [94.4%; 95% confidence interval (CI) 83.7-98.6%], specificity (94.9%; 95% CI 84.9-98.7%) and likelihood ratio for a positive test 18.5 (95% CI 6.1-55.8) in the diagnosis of coeliac disease.

CONCLUSION

Changes in T cell receptor gammadelta and CD3-/CD7+ intraepithelial lymphocytes subsets are permanently observed in paediatric coeliac disease. Their assessment, by three-colour flow cytometry on routine diagnostic biopsies, permits a better characterization of coeliac enteropathy and represents a valuable procedure to identify coeliac patients with different clinical presentations.

Anal endosonography in children with chronic constipation

BACKGROUND

Hypertrophy of the internal anal sphincter may be apparent in some children, but its significance has not yet been determined.

OBJECTIVE

To assess anal endosonographic findings in children with chronic constipation. Materials and methods. We performed anal endosonography in 46 children with chronic constipation and compared the results with values considered normal.

RESULTS

We did not find a significant relationship between age and thickness of the internal or external anal sphincters. The clinical response to medical management did not differ between patients with or without sphincter hypertrophy.

CONCLUSIONS

Although we did not find a significant correlation between sphincter hypertrophy and constipation or age, further studies may clarify its place amongst other techniques which are used in the investigation of anorectal pathology.

Beta structure motif recognition by anti-gliadin antibodies in coeliac disease

A 20-amino acid synthetic peptide from the N-terminal region of gamma3 avenin yields a surprisingly strong reactivity with anti-gliadin antibodies (AGA) of coeliac sera, comparable to that of a gliadin extract. In contrast, a low reactivity is observed with five similar peptides derived from alpha-gliadin, gamma70 and omega1 secalins. Circular dichroism studies of these peptides show that the avenin peptide displays the highest beta-turn content (30%), while other peptides yield much lower values. In agreement with circular dichroism data, nuclear magnetic resonance data point to the presence of a beta-turn in the avenin peptide DPSEQ segment, a sequence with a high statistical beta-turn preference. A strong linear dependence between AGA reactivity and beta-turn content was observed for these peptides, indicating for the first time a role of beta-turn motifs in anti-gliadin antibodies recognition in coeliac disease. This suggests that circulating AGA in coeliac patients comprise not only linear but also conformational antibodies against beta-turn motifs. Polyclonal antibodies raised against the avenin peptide containing beta-turn motifs react by immunoblotting with all gliadin, hordein and secalin proteins, which are rich in beta-turn conformations, despite that their primary structures are unrelated to that of the peptide.

Use of interferon-alpha in laryngeal papillomatosis: eight years of the Cuban national programme

Laryngeal papillomatosis is one of the first diseases where interferon (IFN) was found to be effective. In 1983, a programme for the treatment of all such cases started in Cuba. Up to December 1991, 125 patients (92 children, 33 adults) have been treated: 102 with leucocyte IFN-alpha, 12 with recombinant IFN-alpha-2b, and 11 have received both preparations. Case management consisted of surgical removal of the lesions followed by an IFN schedule starting with 10(5) IU/kg of weight in children or 6 x 10(6) IU in adults, i.m. daily. The dose was progressively reduced, as long as no relapses occurred. At the end of the one-year schedule the doses were reduced to 5 x 10(4) IU/kg in children or 3 x 10(6) IU in adults, weekly. If there was a relapse, it was removed surgically and the patient returned to a higher dose level. Most cases (89; 71 per cent) have not relapsed after the treatment; 60 of them have been followed for more than three years. In those with relapses, the frequency of recurrence decreased in all but four patients. The treatment seemed to be more effective if initiated less than three months after the disease onset. The tracheostomy could be removed in five out of seven patients who needed it before the IFN treatment and was necessary in only three new cases during IFN treatment. In two of these, decannulation was possible later on. In a total of 14 patients relapses persisted after several cycles of IFN treatment. They were considered resistant to such treatment. No severe side effects were reported. The most frequent ones were fever, drowsiness, increased bronchial secretion, chills and headache. The establishment of this programme has maintained the disease under control in Cuba.

Long-term persistence of ciprofloxacin-resistant Haemophilus influenzae in patients with cystic fibrosis

Ciprofloxacin has been a major advance in the treatment of chronic respiratory infections. Three patients with cystic fibrosis and colonized by 5 nontypeable Haemophilus influenzae strains exhibiting low- (MIC, 2 microg/mL) and high-level ciprofloxacin resistance (MICs, 16-32 microg/mL) are described. The patients had received several courses of ciprofloxacin. These MICs represent a decrease in ciprofloxacin susceptibility of 200-3200 times. Molecular epidemiologic methods demonstrated that 2 patients were chronically colonized by their own ciprofloxacin-resistant strains for > or = 15-17 months. Three strains showed simultaneous resistance to ampicillin and chloramphenicol by enzyme inactivation, and 2 had ampicillin resistance without beta-lactamase activity. These data suggest that the emergence and long-term persistence of ciprofloxacin-resistant H. influenzae in patients with cystic fibrosis can be a consequence of antibiotic treatment.

Carbapenem resistance in Pseudomonas aeruginosa from cystic fibrosis patients

The evolution of imipenem resistance was evaluated in Pseudomonas aeruginosa sequentially isolated from 42 patients with cystic fibrosis. Susceptibility was determined using a commercial microdilution system and imipenem resistance was confirmed by the agar dilution technique. Resistance to imipenem increased during the years from 1988 to 1992. A total of 12 patients (28.5%) carried resistant strains (11.6% of the total P. aeruginosa isolates) but only two of them were treated with the carbapenem. The other patient under imipenem treatment did not harbour resistant isolates. Sixty-four per cent of the imipenem resistant isolates were also meropenem resistant and showed low susceptibility to the other beta-lactams and tobramycin and amikacin. Twenty-one strains were selected for biochemical study. Imipenem susceptible strains showed normal OprD in two strains and diminished OprD in two more. Five strains with MIC of imipenem of 4-8 mg/L lacked OprD while another two had a band with decreased density. All strains with MIC higher than 8 completely lacked this band in western-blot analysis. Imipenem MICs of 0.5-2 mg/L only slightly increased to 1-4 mg/L when a pattern of beta-lactamase derepression was observed. While those with imipenem MICs between 8-16 mg/L increased the imipenem MIC to 16-64 mg/L in the population with a beta-lactamase derepression phenotype.

[Microbiological parameters of clinical interest in pulmonary infection in cystic fibrosis]

BACKGROUND

A 5-year study in patients with cystic fibrosis was carried out in order to gain a better understanding of the microbiological factors influencing clinical status and evolution.

METHODS

Fifty-two patients were evaluated (mean age 16.6 years, range 0-36) during a 5 years-period (July 1988- July 1992). The clinical score of Shwachman and pulmonary function were evaluated at the beginning and at the end of the study period. Quantitative bacterial cultures were performed every 3 weeks recording the different colonical morphotypes of Pseudomonas aeruginosa.

RESULTS

Beside the expected results regarding the prevalence of P. aeruginosa (80.7%) and Staphylococcus aureus (65.5%), a low rate of chronic infection with Burkholderia cepacia (1.9%) and high with S. maltophilia (9.6%) was found and it is worth noting the presence of Salmonella spp. in 3 patients. Microbial colonization followed the classical age-related sequence with 53.8% of patients older than 10 colonized with mucoid strains of P. aeruginosa. Colonization with mucoid Pseudomonas, increase in sputum bacterial counts and high diversity in colonizing morphotypes were parameters related with reduced clinical scores.

CONCLUSIONS

The sequential study of the bacterial colonization in cystic fibrosis is important to follow the prognosis and evolution of the disease, and therefore, to choose the most effective therapy.

Horizontal transmission of hepatitis C virus in households of infected children

Anti-hepatitis C antibodies were measured in 80 household contacts of 27 children infected with hepatitis C virus. Antibodies were demonstrated in only one brother of an infected patient. The results suggest that intrafamilial transmission from infected children may occur, but at a low rate.

Intestinal permeability to 51Cr-EDTA and orocecal transit time in cystic fibrosis

Intestinal permeability was investigated in 16 children with cystic fibrosis and 14 age-matched controls, making use of 51Cr-EDTA as probe molecule. Orocecal transit time was also evaluated using the lactulose/hydrogen breath test. There was an increase in permeability to 51Cr-EDTA in patients with cystic fibrosis (mean 13.62%) compared with the control group (mean 1.08%). The orocecal transit time was prolonged in patients with cystic fibrosis compared with controls. Mean fasting breath hydrogen concentration was significantly greater in cystic fibrosis patients (13 ppm) compared with control patients (3 ppm). There was no correlation between the percentage of 51Cr-EDTA excreted and the orocecal transit time in either control or cystic fibrosis patients.