The increasing threat to European forests from the invasive foliar pine pathogen, Lecanosticta acicola

European forests are threatened by increasing numbers of invasive pests and pathogens. Over the past century, Lecanosticta acicola, a foliar pathogen predominantly of Pinus spp., has expanded its range globally, and is increasing in impact. Lecanosticta acicola causes brown spot needle blight, resulting in premature defoliation, reduced growth, and mortality in some hosts. Originating from southern regions of North American, it devastated forests in the USA's southern states in the early twentieth century, and in 1942 was discovered in Spain. Derived from Euphresco project 'Brownspotrisk,' this study aimed to establish the current distribution of Lecanosticta species, and assess the risks of L. acicola to European forests. Pathogen reports from the literature, and new/ unpublished survey data were combined into an open-access geo-database (http://www.portalofforestpathology.com), and used to visualise the pathogen's range, infer its climatic tolerance, and update its host range. Lecanosticta species have now been recorded in 44 countries, mostly in the northern hemisphere. The type species, L. acicola, has increased its range in recent years, and is present in 24 out of the 26 European countries where data were available. Other species of Lecanosticta are largely restricted to Mexico and Central America, and recently Colombia. The geo-database records demonstrate that L. acicola tolerates a wide range of climates across the northern hemisphere, and indicate its potential to colonise Pinus spp. forests across large swathes of the Europe. Preliminary analyses suggest L. acicola could affect 62% of global Pinus species area by the end of this century, under climate change predictions. Although its host range appears slightly narrower than the similar Dothistroma species, Lecanosticta species were recorded on 70 host taxa, mostly Pinus spp., but including, Cedrus and Picea spp. Twenty-three, including species of critical ecological, environmental and economic significance in Europe, are highly susceptible to L. acicola, suffering heavy defoliation and sometimes mortality. Variation in apparent susceptibility between reports could reflect variation between regions in the hosts' genetic make-up, but could also reflect the significant variation in L. acicola populations and lineages found across Europe. This study served to highlight significant gaps in our understanding of the pathogen's behaviour. Lecanosticta acicola has recently been downgraded from an A1 quarantine pest to a regulated non quarantine pathogen, and is now widely distributed across Europe. With a need to consider disease management, this study also explored global BSNB strategies, and used Case Studies to summarise the tactics employed to date in Europe.

Plain language summaries of publications of company-sponsored medical research: what key questions do we need to address?

OBJECTIVES

We aimed to gather multi-stakeholder insights on key issues relating to plain language summaries (PLS) of company-sponsored medical research to inform future industry recognized guidelines.

METHODS

We identified diverse stakeholders based on expertise, familiarity with PLS, and geographical location. A Working Group (n = 11) with extensive expertise in PLS developed an initial list of 14 questions relating to PLS, which were shared with stakeholders. We used a modified Delphi approach to prioritize the 10 key questions that were then used to structure stakeholder discussions to collect evidence on the key challenges and opportunities to inform best practice for PLS.

RESULTS

Overall, 29 stakeholders took part in the study, representing different professional sectors and geographies. There was strong alignment among stakeholders on the priority questions for PLS, with high response rates for both surveys (69% and 90%). Moderated online sessions were attended by 27/29 stakeholders and opportunities to improve PLS uptake were highlighted: developing industry-wide PLS guidelines would help define and maintain quality, including having a clear directive for when publications should have a PLS; further advocacy is needed by target audiences to ensure PLS become an established part of company-sponsored research publications; a searchable repository could facilitate discoverability and broad dissemination of PLS to multiple target audiences.

CONCLUSIONS

Key issues identified by stakeholders provide broad insights into the real and perceived barriers relating to PLS uptake. Each emerging theme presents a possible action that could accelerate PLS uptake and facilitate sharing of new medical research with lay audiences.

Optimizing Readability and Format of Plain Language Summaries for Medical Research Articles: Cross-sectional Survey Study

Background

Plain language summaries (PLSs) are intended to provide readers with a clear, nontechnical, and easily understandable overview of medical and scientific literature; however, audience preferences for specific PLS formats have yet to be fully explored.

Objective

This study aims to evaluate the preferred readability level and format for PLSs of medical research articles of different disease states via a web-based survey of audiences of different age groups.

Methods

Articles describing phase III clinical trials published in top-level, peer-reviewed journals between May 2016 and May 2018 were identified for 3 chronic disease states representing a range of adult patient age groups: (1) psoriasis, a skin disease representative of younger patients; (2) multiple sclerosis (MS), a neurological disease representative of middle-aged patients; and (3) rheumatoid arthritis (RA), a painful joint disease representative of older patients. Four PLSs were developed for each research article, of which 3 were text-only summaries (written with high, medium, and low complexity) and 1 was an infographic. To evaluate each of the 4 PLS formats, a 20-question open survey (specific to one of the 3 diseases) was sent to a representative sample selected via UK-based patient association websites, Twitter, and Facebook patient groups. A weighted-average calculation was applied to respondents’ ranked preferences for each PLS format.

Results

For all 3 articles, the weighted-average preference scores showed that infographic (psoriasis 2.91, MS 2.71, and RA 2.78) and medium-complexity text-based PLS (reading age 14-17 years, US Grade 9-11; psoriasis 2.90; MS 2.47; RA 2.77) were the two most preferred PLS formats.

Conclusions

Audience preferences should be accounted for when preparing PLSs to accompany peer-reviewed original research articles. Oversimplified text can be viewed negatively, and graphical summaries or medium-complexity text-based summaries appear to be the most popular.

Plain Language Summary

Patients and caregivers should have the chance to read about medical research in a format they can understand. However, we do not know much about the formats that people with different illnesses or ages prefer. Researchers wanted to find out more about this. They selected 3 medical articles about illnesses that affect different age groups: psoriasis (younger patients), multiple sclerosis (middle-aged patients), and rheumatoid arthritis (older patients). They created 4 summaries of each article. One was a graphical summary, and the other 3 were words-only summaries of high, medium, and low complexity. Then, the researchers posted surveys on UK patient group websites and Facebook patient groups to ask people what they thought of the summaries. The surveys were taken by 167 people. These people were patients with psoriasis, multiple sclerosis, or rheumatoid arthritis, or their caregivers. Most were women, and about half had a university degree. For each illness, most people preferred the graphical summary. Among the word-only summaries, most people preferred the medium-complexity wording written for a reading age of 14 to 17 years. People felt that the graphical and medium-complexity summaries were clear and concise, while the others used jargon or were too simple. Authors of medical articles should remember these results when writing summaries for patients. More research is needed about the preferences of other people, such as those with other illnesses. (See Multimedia Appendix 1 for the graphical summary of the plain language summary.)

Tin titanate-the hunt for a new ferroelectric perovskite

We review all the published literature and show that there is no experimental evidence for homogeneous tin titanate SnTiO₃ in bulk or thin-film form. Instead a combination of unrelated artefacts are easily misinterpreted. The x-ray Bragg data are contaminated by double scattering from the Si substrate, giving a strong line at the 2θ angle exactly where perovskite SnTiO₃ should appear. The strong dielectric divergence near 560 K is irreversible and arises from oxygen site detrapping, accompanied by Warburg/Randles interfacial anomalies. The small (4 µC cm^-2) apparent ferroelectric hysteresis remains in samples shown to be pure (Sn,Ti)O₂ rutile/cassiterite, in which ferroelectricity is forbidden. Only very recent work reveals real bulk SnTiO₃, but it possesses an ilmenite-like structure with an elaborate array of stacking faults, not suitable for ferroelectric devices. Unpublished TEM data reveal an inhomogeneous SnO layered structured thin films, related to shell-core structures. The harsh conclusion is that there is a combination of unrelated artefacts masquerading as ferroelectricity in powders and ALD films; and only a trace of a second phase in PLD film data suggests any perovskite content at all. The fact that x-ray, dielectric, and hysteresis data all lead to the wrong conclusion is instructive and reminds us of earlier work on copper calcium titanate (a well-known boundary-layer capacitor).

Artificial Intelligence and Machine Learning Algorithms For Informing the Diagnostic Process of Mild Cognitive Impairment and Dementia

Objective

Differentiating between a clinical diagnosis of Mild Cognitive Impairment (MCI) and dementia is difficult due to expansive data needs in concert with ambiguity of clinical criteria. Novel artificial intelligence (AI) and machine learning algorithms provide potential avenues for efficiently analyzing data sets and informing clinical judgment in distinguishing MCI from dementia. To date no formal meta-analysis of extant studies has been conducted to compare the efficacy of such procedures. A meta-analysis was conducted to synthesize the sensitivity and specificity of AI and machine learning programs in distinguishing between MCI and dementia as compared to traditional diagnostic protocols.

Data Selection

A search of studies using EBSCOhost databases using the keywords: “artificial intelligence,” “machine learning,” “MCI,” and “dementia” retrieved a total of 127 studies. Excluded were 106 studies due to non-reporting of sensitivity and specificity data. In total, 21 studies were included in the present meta-analysis.

Data Synthesis

Sensitivity and specificity data as well as the number of true-false categorizations were extracted and analyzed using OpenMeta[Analyst]. A bivariate correlation produced a summary point with sensitivity of 82% and specificity of 82%. A follow-up Rutter-Gatsonis multivariate correlation HSROC curve was created to correct for significant correlations (47%), and produced an adjusted mean specificity of 79% and sensitivity of 83%.

Conclusions

Results suggest AI and machine-learning algorithms are effective in distinguishing MCI from dementia. AI procedures have potential in aiding clinical judgment given a larger body of empirical research.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Promoting and achieving excellence in the delivery of Integrated Allergy Care: the European Academy of Allergy & Clinical Immunology competencies for allied health professionals working in allergy

The multi-disciplinary team approach is an effective model for patient care. Allied health professionals (AHPs) are an important part of such teams, bringing specific knowledge and skills related to the target patient population. The AHPs most often involved in allergy care are nurses and dietitians. Nurses are often involved in the care of patients with all types of allergy and also with asthma, whilst allergy-specialist dietitians provide vital nutritional and dietary support for the diagnosis and management of food allergy. There are many other AHPs who have a role to play in allergy care, including physiotherapists, psychologists, pharmacists and speech therapists, and their involvement is likely to develop as allergy care becomes more rooted in the community. With the development of multi-professional teams comes the requirement for disease-specific knowledge and skill sets, with all allergy team members required to have baseline knowledge and competency of the condition being managed. Whilst some competencies for AHPs practising in other disease states have been published, none are available for allergic disease against which AHPs can be benchmarked. The European Academy of Allergy & Clinical Immunology (EAACI) recognised this need, and supported the establishment of a Task Force to develop allergy-focussed competencies for AHPs. The varied skills, expertise and professional background of the Task Force members enabled the creation of a set of allergy competencies relevant to all AHPs working in allergy. It is recognised that the training and allergy expertise of AHPs, and their role within the allergy setting, will vary considerably depending on the country. However, it is important for patient care, that all AHP involved in allergy services have access to training, of a sufficiently high enough level to be aspirational and enable the continued growth and development of a wide range of allergy services, given the increasing need. The EAACI competencies will provide an important benchmark for allergy knowledge and skills against which education and training can be designed and health care professionals can subsequently be measured. However, more importantly, the EAACI AHP allergy competencies will enable the development and reach of specialist allergy services, with allergy-specialist AHPs undertaking key roles, especially in the community care setting.

Low-energy spin dynamics of orthoferrites AFeO3 (A = Y, La, Bi)

YFeO₃ and LaFeO₃ are members of the rare-earth orthoferrites family with Pbnm space group. Using inelastic neutron scattering, the low-energy spin excitations have been measured around the magnetic Brillouin zone center. Splitting of magnon branches and finite magnon gaps (∼2 meV) are observed for both compounds, where the Dzyaloshinsky-Moriya interactions account for most of this gap with some additional contribution from single-ion anisotropy. We also make comparisons with multiferroic BiFeO₃ (R3c space group), in which similar behavior was observed. By taking into account all relevant local Dzyaloshinsky-Moriya interactions, our analysis allows for the precise determination of all experimentally observed parameters in the spin-Hamiltonian. We find that different properties of the Pbnm and R3c space group lead to the stabilization of a spin cycloid structure in the latter case but not in the former, which explains the difference in the levels of complexity of magnon band structures for the respective compounds.

The deep pectoral muscle flap in the cat: its vascular supply and potential use

The vascular anatomy of the deep pectoral muscle in the cat was defined by contrast radiography of twelve deep pectoral muscles from six feline cadavers. The deep pectoral, muscle in the cat was found to have a type V vascular pattern with a dominant pedicle based on the lateral thoracic artery, with a contribution from the external thoracic artery, and secondary segmental pedicles arising from the internal thoracic artery, with numerous anastomoses between these two vascular fields. Following division of the sternal origin and elevation of the muscle flap, perfusion of the entire muscle from the dominant pedicle was identified. Transposition of the muscle flap within a wide arc of rotation was possible to include the chest wall, sternum, axilla and medial forelimb. This study demonstrates the potential suitability of the deep pectoral muscle flap for use in reconstructive surgery.

The feline deep pectoral muscle has a type V vascular pattern, with a dominant pedicle based on the lateral thoracic artery, with a contribution from the external thoracic artery, and secondary segmental pedicles arising from the internal thoracic artery A clinically useful flap, supplied by the dominant pedicle, may be developed by incising the sternal origin of the muscle.

Rapid Mobilization Reveals a Highly Engraftable Hematopoietic Stem Cell

Hematopoietic stem cell transplantation is a potential curative therapy for malignant and nonmalignant diseases. Improving the efficiency of stem cell collection and the quality of the cells acquired can broaden the donor pool and improve patient outcomes. We developed a rapid stem cell mobilization regimen utilizing a unique CXCR2 agonist, GROβ, and the CXCR4 antagonist AMD3100. A single injection of both agents resulted in stem cell mobilization peaking within 15 min that was equivalent in magnitude to a standard multi-day regimen of granulocyte colony-stimulating factor (G-CSF). Mechanistic studies determined that rapid mobilization results from synergistic signaling on neutrophils, resulting in enhanced MMP-9 release, and unexpectedly revealed genetic polymorphisms in MMP-9 that alter activity. This mobilization regimen results in preferential trafficking of stem cells that demonstrate a higher engraftment efficiency than those mobilized by G-CSF. Our studies suggest a potential new strategy for the rapid collection of an improved hematopoietic graft.

A Microbiologic Study of Enteral Feeding Hang Time in a Burn Hospital: Can Feeding Costs be Reduced Without Compromising Patient Safety?

BACKGROUND

Procedural changes for hospitalized patients must always balance safety with fiscal constraints. Microbiologic contamination of enteral feeding solutions has been previously associated with nosocomial infections. Formula manipulation and hang time contribute to microbial load, and there is considerable variation in hang time recommendations in the medical literature. With cost containment in mind, the purpose of this performance improvement study was to determine if an increase in hang time of a modular tube feeding product would increase microbial load or affect the nosocomial infection rate in pediatric burn patients.

METHODS

This biphasic trial initially evaluated the microbial load of the feeding after delivery of two 4-hour aliquots into a container using the same delivery set (total hang time of 8 hours; number of tests = 20). Second, once this feeding procedure was deemed microbiologically safe, tube feedings were administered to patients, and both microbial load and nosocomial infection rate were monitored for 1 year.

RESULTS

Contamination levels at the end of the 8-hour period using the same feeding set with 2 consecutive 4-hour feeding aliquots (number of tests = 38) were lower than standard recommendations. The hospital's nosocomial infection rate was not altered by this procedural change, and feeding-set expenses were reduced.

CONCLUSIONS

The hang time of our enteral feeding administration set can be increased safely from 4 hours to 8 hours, with the tube feeding preparation added as two 4-hour aliquots without a significant change in microbial load or nosocomial infection rate, thus promoting simultaneous fiscal responsibility and patient safety.

Standing on the Shoulders of Stem Cell Gene Therapists: History, Hyperbole, and Hope for the Future

A new type of medicine approved in Europe at the end of May represents the culmination of the successful convergence of two fields of science: stem cell transplantation and gene therapy. Strimvelis, a patient-specific gene-modified stem cell medicine for ADA-SCID (adenosine deaminase deficiency leading to severe combined immunodeficiency; a fatal immunometabolic disorder similar to the bubble-boy disease), was developed by scientists at the San Raffaele Telethon Institute for Gene Therapy (TIGET) in Milan, Italy, which then later partnered with GlaxoSmithKline (GSK, Brentford, UK). The journey took more than 25 years of dedicated work by many groups and involved a pivotal trial with 12 children and their brave families. I was fortunate to be involved on the GSK side of the TIGET alliance from 2010 to 2015, building on my previous experiences with gene-modified stem cells during a postdoctoral fellowship in the mid-1990s and at Chiron, which had acquired Viagene, an early gene therapy biotech firm. I thought it was timely to pick out a couple of observations from the development of Strimvelis, to see how these might apply to the future of stem cell gene therapy and perhaps act like shoulders for the related chimeric antigen receptor T-cell (CAR-T) and gene-editing technologies to stand on.

Curcurbita pepo subspecies delineates striped cucumber beetle (Acalymma vittatum) preference

The striped cucumber beetle (Acalymma vittatum (F.)) is a destructive pest of cucurbit crops, and management could be improved by host plant resistance, especially in organic farming systems. However, despite the variation in striped cucumber beetle preference observed within the economically important species, Cucurbita pepo L., plant breeders and entomologists lacked a simple framework to classify and exploit these differences. This study used recent phylogenetic evidence and bioassays to organize striped cucumber beetle preference within C. pepo. Our results indicate preference contrasts between the two agriculturally relevant subspecies: C. pepo subsp. texana and C. pepo subsp. pepo. Plants of C. pepo subsp. pepo were more strongly preferred than C. pepo subsp. texana plants. This structure of beetle preference in C. pepo will allow plant breeders and entomologists to better focus research efforts on host plant non-preference to control striped cucumber beetles.

The phototoxicity of vemurafenib: An investigation of clinical monochromator phototesting and in vitro phototoxicity testing

BACKGROUND

Vemurafenib is a targeted therapy approved for the treatment of patients with metastatic melanoma harbouring the BRAF V600E mutation. Photosensitivity has been reported in over 50% of patients and has been demonstrated to involve at least the broadband UVA spectrum in most patients. Erythrocyte protoporphyrin levels have also been reported as elevated in some patients.

OBJECTIVES

We report the results of monochromator phototesting in one patient recorded before and while taking vemurafenib. Analysis of porphyrin levels was also conducted.

RESULTS

After one month of vemurafenib therapy the patient demonstrated markedly increased light sensitivity in the UVA spectrum between 335 ± 27 nm, 365 ± 27 nm and 400 ± 27 nm. However responses in the UVB (305 ± 5 nm) and blue light (430 ± 27 nm) regions were normal. There was no abnormal immediate erythemal response. Pre-vemurafenib baseline phototesting was normal, as was repeat testing two months later when the patient was taking high doses of systemic steroid. No abnormal porphyrins were detected and the antinuclear antibody test was normal. In parallel studies, HaCaT keratinocytes incubated with vemurafenib were killed by UVA but not by visible (blue) light and did not show evidence of detectable intracellular porphyrin in the presence of the drug.

CONCLUSION

These data confirm vemurafenib induced UVA photosensitivity with a probable phototoxic mechanism not mediated via enhanced porphyrin.

Inhibition of human mitochondrial peptide deformylase causes apoptosis in c-myc-overexpressing hematopoietic cancers

Inhibition of human mitochondrial peptide deformylase (HsPDF) depolarizes the mitochondrial membrane, reduces mitochondrial protein translation and causes apoptosis in Burkitt's lymphoma. We showed that HsPDF mRNA and protein levels were overexpressed in cancer cells and primary acute myeloid leukemia samples. Myc regulates mitochondria and metabolism; we also demonstrated c-myc regulated the expression of HsPDF, likely indirectly. Inhibition of HsPDF by actinonin blocked mitochondrial protein translation and caused apoptotic death of myc-positive Burkitt's lymphoma, but not myc-negative B cells. Inhibition of mitochondrial translation by chloramphenicol or tetracycline, structurally different inhibitors of the mitochondrial ribosome, which is upstream of deformylase activity, followed by treatment with actinonin, resulted in reversal of the biochemical events and abrogation of the apoptosis induced by actinonin. This reversal was specific to inhibitors of HsPDF. Inhibition of HsPDF resulted in a mitochondrial unfolded protein response (increased transcription factors CHOP and CEB/P and the mitochondrial protease Lon), which may be a mechanism mediating cell death. Therefore, HsPDF may be a therapeutic target for these hematopoietic cancers, acting via a new mechanism.

Lentiviral hematopoietic stem cell gene therapy in patients with Wiskott-Aldrich syndrome

Wiskott-Aldrich syndrome (WAS) is an inherited immunodeficiency caused by mutations in the gene encoding WASP, a protein regulating the cytoskeleton. Hematopoietic stem/progenitor cell (HSPC) transplants can be curative, but, when matched donors are unavailable, infusion of autologous HSPCs modified ex vivo by gene therapy is an alternative approach. We used a lentiviral vector encoding functional WASP to genetically correct HSPCs from three WAS patients and reinfused the cells after a reduced-intensity conditioning regimen. All three patients showed stable engraftment of WASP-expressing cells and improvements in platelet counts, immune functions, and clinical scores. Vector integration analyses revealed highly polyclonal and multilineage haematopoiesis resulting from the gene-corrected HSPCs. Lentiviral gene therapy did not induce selection of integrations near oncogenes, and no aberrant clonal expansion was observed after 20 to 32 months. Although extended clinical observation is required to establish long-term safety, lentiviral gene therapy represents a promising treatment for WAS.

Lentiviral hematopoietic stem cell gene therapy benefits metachromatic leukodystrophy

Metachromatic leukodystrophy (MLD) is an inherited lysosomal storage disease caused by arylsulfatase A (ARSA) deficiency. Patients with MLD exhibit progressive motor and cognitive impairment and die within a few years of symptom onset. We used a lentiviral vector to transfer a functional ARSA gene into hematopoietic stem cells (HSCs) from three presymptomatic patients who showed genetic, biochemical, and neurophysiological evidence of late infantile MLD. After reinfusion of the gene-corrected HSCs, the patients showed extensive and stable ARSA gene replacement, which led to high enzyme expression throughout hematopoietic lineages and in cerebrospinal fluid. Analyses of vector integrations revealed no evidence of aberrant clonal behavior. The disease did not manifest or progress in the three patients 7 to 21 months beyond the predicted age of symptom onset. These findings indicate that extensive genetic engineering of human hematopoiesis can be achieved with lentiviral vectors and that this approach may offer therapeutic benefit for MLD patients.

The use of adrenaline autoinjectors by children and teenagers

BACKGROUND

Although adrenaline is recommended as first line treatment for anaphylaxis, it is often not utilized. There has been a debate about when adrenaline autoinjectors should be prescribed and how many should be dispensed.

OBJECTIVES

To see how many adrenaline autoinjectors were used during anaphylactic reactions and to determine why they were not used in situations where they were clinically indicated.

METHODS

Patients were recruited prospectively at 14 paediatric allergy clinics throughout UK. Participants completed a questionnaire covering demographic data, atopic status and details of allergic reactions in the previous year and reasons for using more than one device.

RESULTS

A total of 969 patients were recruited of whom 466 (48.1%, 95% CI: 37.9-58.2) had had at least one reaction in the previous year; 245 (25.3%, 95% CI: 16.2-34.4) of these reactions were anaphylaxis. An adrenaline autoinjector was used by 41 (16.7%, 95% CI: 11.7-21.3) participants experiencing anaphylaxis. Thirteen participants received more than one dose of adrenaline, for nine of these a health professional gave at least one. The commonest reasons for using more than one were severe breathing difficulties (40%), lack of improvement with first dose (20%) and miss-firing (13.3%). The commonest reasons for not using adrenaline in anaphylaxis were 'thought adrenaline unnecessary' (54.4%) and 'unsure adrenaline necessary' (19.1%). Many with wheeze did not use their autoinjector.

CONCLUSIONS AND CLINICAL RELEVANCE

Adrenaline is used by only a minority of patients experiencing anaphylaxis in the community. Thirteen of the 41 patients with anaphylaxis who used their autoinjector needed another dose of adrenaline. Further research is needed to consider how to best encourage the usage of adrenaline when clinically indicated in anaphylaxis.

A national audit of pollen immunotherapy for children in the United Kingdom: patient selection and programme safety

BACKGROUND

Specific immunotherapy (SIT) is an effective treatment for grass and/or tree pollen-induced severe allergic rhinoconjunctivitis. However, there are limited detailed data on the use of immunotherapy in children in the United Kingdom.

OBJECTIVES

We audited NHS paediatric practice against current national guidelines to evaluate patient selection, SIT modalities and adverse events (AEs).

METHODS

Paediatricians offering pollen SIT were identified through the British Society of Allergy and Clinical Immunology Paediatric Allergy Group (BSACI-PAG) and the database of SIT providers compiled for the Royal College of Physicians and Royal College of Pathologists 2010 joint working group. Standardized proformas were returned by 12 of 20 centres (60%), including 12 of 14 centres offering subcutaneous immunotherapy (SCIT) (85%).

RESULTS

Three hundred and twenty-three children, with mean age 11 years at initiation (69% boys), had undergone 528 SIT cycles (SCIT 31%) over 10 years. Fifty-five percent of all patients had asthma. Among SCIT programmes 24.5% patients had perennial (± seasonal) asthma; 75.6% of asthmatics undertaking SCIT had treatments at BTS/SIGN step 2 or above. AEs occurred frequently (50.4% of all SIT cycles) but were mild. In sublingual immunotherapy (SLIT) treatment, local intraoral immediate reactions were most common (44.9% SLIT cycles), as compared with delayed reactions around the injection site in SCIT (28.3% SCIT cycles). An asthma diagnosis had no impact on the number of cycles with AEs, or the severity reported. Few cycles (2.9%) were discontinued as a result of AE(s).

CONCLUSIONS AND CLINICAL RELEVANCE

Pollen SIT is available across England, though small numbers of children are being treated. Current national guidelines to exclude asthmatic children in SIT programmes are not being adhered to by most specialist paediatric allergy centres. SCIT and SLIT has been well tolerated. Review of patient selection criteria is needed and may allow greater use of this therapeutic option in appropriate clinical settings.