Chronic toxicity and liver histopathology of mosquito fish (Gambusia holbrooki) exposed to natural and modified nanoclays

Nanoclays are found in the air, water, and soil, and modified nanoclays are being developed and used in several consumer products. For example, modified nanoclays are used to remove pollutants from wastewater. Ironically, however, nanoclays are now considered emerging contaminants. Indeed, release of modified nanoclays in aquatic systems, even as remediating agents, could adversely affect associated wildlife. However, aquatic organisms have interacted with natural nanoclays for millennia, and it is unclear if modified nanoclays induce stronger effects than the nanoclays that occur naturally. The concentrations over which nanoclays occur and illicit negative effects are not well studied. This study investigated the dose response of a natural nanoclay (Na+montmorillonite) relative to two modified nanoclays (Cloisite®30B and Novaclay™) on survival, body condition, and liver pathomorphology of Gambusia holbrooki after 14 days of exposure. Although none of the nanoclays affected survival and body condition of G. holbrooki over 14 days, each nanoclay induced histopathological changes in liver tissues at very low concentrations (LOAEL: 0.01 mgL-1). The effects of nanoclays on hepatic cell circulatory (blood cell aggregation with increased number of Kupffer cells and hemosiderin deposits), regressive (hepatocyte vacuolization), and degenerative (cell death) changes of mosquito fish varied among nanoclay types. Novaclay™ at low concentrations caused circulatory changes on hepatic tissues of G. holbrooki, whereas both natural nanoclays and Cloisite®30B showed little effect on circulatory endpoints. In contrast, all of the nanoclays induced regressive and degenerative changes on liver tissues of mosquito fish across all concentrations tested. This study clearly reveals that natural and modified nanoclays have important health implications for fish and other aquatic organisms. Consequently, the widespread use of modified nanoclays in several applications and increased release of natural nanoclays through erosion or other processes needs to be evaluated in more detail especially in the context of their safety for aquatic systems.

Inhaled mRNA therapy for treatment of cystic fibrosis: Interim results of a randomized, double-blind, placebo-controlled phase 1/2 clinical study

BACKGROUND

MRT5005, a codon-optimized CFTR mRNA, delivered by aerosol in lipid nanoparticles, was designed as a genotype-agnostic treatment for CF lung disease.

METHODS

This was a randomized, double-blind, placebo-controlled Phase 1/2 study performed in the US. Adults with 2 severe class I and/or II CFTR mutations and baseline ppFEV1 values between 50 and 90% were randomized 3:1 (MRT5005: placebo). Six dose levels of MRT5005 (4, 8, 12, 16, 20, and 24 mg) or placebo (0.9% Sodium Chloride) were administered by nebulization. The single ascending dose cohort was treated over a range from 8 to 24 mg; the multiple ascending dose cohort received five weekly doses (range 8-20 mg); and the daily dosing cohort received five daily doses (4 mg).

RESULTS

A total of 42 subjects were assigned to MRT5005 [31] or placebo [11]. A total of 14 febrile reactions were observed in 10 MRT5005-treated participants, which were mild [3] or moderate [11] in severity; two subjects discontinued related to these events. Additionally, two MRT5005-treated patients experienced hypersensitivity reactions, which were managed conservatively. The most common treatment emergent adverse events were cough and headache. No consistent effects on FEV1 were noted.

CONCLUSIONS

MRT5005 was generally safe and well tolerated through 28 days of follow-up after the last dose, though febrile and hypersensitivity reactions were noted. The majority of these reactions resolved within 1-2 days with supportive care allowing continued treatment with MRT5005 and careful monitoring. In this small first-in-human study, FEV1 remained stable after treatment, but no beneficial effects on FEV1 were observed.

A77 THE ASSOCIATIONS OF OBJECTIVELY ASSESSED SEDENTARY TIME AND STEP COUNT ON ULCERATIVE COLITIS OUTCOMES

Background

Physical activity has been associated with positive health outcomes in those with Ulcerative Colitis (UC). The extent to which other more prominent behaviours occurring throughout the 24-hour day (i.e., sitting, standing, lying down, and stepping) are associated with UC outcomes is unknown.

Purpose

The purpose of this study was to explore whether objectively measured time spent sitting, lying down, standing, and stepping were associated with Total Mayo score (TMS), fecal calprotectin (FCP), and C-reactive protein (CRP) in patients with UC.

Method

Patients were recruited from the Foothills Medical Center in Calgary, Alberta and were given activPAL^TM accelerometers (PAL Technologies Limited, Glasgow, UK) to wear on their thigh for 7 days. Step count, sitting time, standing time, and time lying down (excluding sleep) were recorded for a minimum of 4 days, including at least one day on the weekend. TMS was used to determine disease activity and patients were categorized into normal/mild (TMS score <6) or moderate/severe (TMS score 6). FCP, a marker of gut inflammation, was measured using stool samples. Blood samples were collected to measure serum CRP, a marker of systemic inflammation. Univariate analysis of covariance (ANCOVA) was used to evaluate associations between the activPAL^TM daily activity variables, TMS, FCP (< or >250ug/g) and CRP (< or > 5 mg/L). Analyses were controlled for age, sex, body mass index (BMI), and antibiotic use.

Result(s)

Patients (N=29; 15 male, 14 female) were on average 38 years of age (SD=12.1). The average BMI was 26.2 kg/m² (SD=3.2). Based on TMS, 14 had moderate/severe disease activity and 16 had normal/mild disease activity. Average CRP was 2.16 mg/L (SD=2.49) while the mean FCP was 954.5 ug/g (SD=1427.7). Patients recorded an average of 8,137 steps (SD=3,051) per day. Average standing time was 240 minutes (SD=84) per day, sitting time was 503 minutes (SD=131) per day, and time spent lying down was 527 minutes (SD=111) per day. FCP was negatively associated with step count (D=-2,134 steps, 95% CI: -4,360 to 93, p=0.06). Patients with lower FCP values (<250mg/g) spent 60 fewer minutes sitting (p=.25), and 52 more minutes standing (p=.12) during the day compared to patients with higher FCP values (>250mg/g). Patients with normal/mild disease severity (TMS <6) spent 83 fewer minutes per day sitting compared to those with moderate/severe disease severity (TMS >6, p=.12). CRP was not associated with any behavioural outcomes.

Conclusion(s)

In our study, daily steps appeared to be most strongly associated with FCP. While not statistically significant, patients with lower FCP reported less sitting and more standing compared to those with higher FCP. Future studies with larger sample sizes should continue to explore these activity behaviours and their potential associations with UC disease outcomes.

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Alberta's Collaboration of Excellence for Nutrition in Digestive Diseases (ASCEND)

Disclosure of Interest

B. Chiew: None Declared, K. Lyden Consultant of: PAL Technologies, the company that manufactures the activPAL device., A. Schick: None Declared, C. Ohland: None Declared, K. McCoy: None Declared, S. Kaur: None Declared, M. Yousuf: None Declared, L. Taylor: None Declared, M. Raman Shareholder of: LyfeMD – Director, Shareholder, Grant / Research support from: Pfizer, Takeda, Speakers bureau of: Fresenius Kabi, Pfizer, Mckesson, Takeda, Lupin, J. Vallance Grant / Research support from: Canada Research Chairs Program

Lost time: COVID-19 indemnity claim reporting and results in the Wisconsin workers' compensation system from March 12 to December 31, 2020

BACKGROUND

The COVID-19 pandemic introduced a new compensable infectious disease to workplaces.

METHODS

This was a descriptive analysis of Wisconsin COVID workers' compensation (WC) claims between March 12 and December 31, 2020. The impact of the presumption law (March 12 to June 10, 2020) was also evaluated.

RESULTS

Less than 1% of working-age residents with COVID-19 filed a claim. COVID-19 WC claim rates (per 100,000 FTE) were notably low for frontline industry sectors such as Retail Trade (n = 115), Manufacturing (n = 88), and Wholesale Trade (n = 31). Healthcare workers (764 claims per 100,000 FTE) comprised 73.2% of COVID-19 claims. Most claims (52.8%) were denied and the proportion of denied claims increased significantly after the presumption period for both first responders and other occupations.

CONCLUSION

The presumption law made benefits accessible primarily to first responders. Further changes to WC systems are needed to offset the individual and collective costs of infectious diseases.

School District Prevention Policies and Risk of COVID-19 Among In-Person K-12 Educators, Wisconsin, 2021

Objectives. To assess the rate of COVID-19 among in-person K-12 educators and the rate's association with various COVID-19 prevention policies in school districts. Methods. We linked actively working, in-person K-12 educators in Wisconsin to COVID-19 cases with onset from September 2 to November 24, 2021. A mixed-effects Cox proportional hazards model, adjusted for pertinent person- and community-level confounders, compared the hazard rate of COVID-19 among educators working in districts with and without specific COVID-19 prevention policies. Results. In-person educators working in school districts that required masking for students and staff experienced 19% lower hazards of COVID-19 than did those in districts without any masking policy (hazard ratio = 0.81; 95% confidence interval = 0.72, 0.92). Reduced COVID-19 hazards were consistent and remained statistically significant when educators were stratified by elementary, middle, and high school environments. Conclusions. In Wisconsin's K-12 school districts, during the fall 2021 academic semester, a policy that required both students and staff to mask was associated with significantly reduced risk of COVID-19 among in-person educators across all grade levels. (Am J Public Health. 2022;112(12):1791-1799. https://doi.org/10.2105/AJPH.2022.307095).

Measuring Work-related Risk of Coronavirus Disease 2019 (COVID-19): Comparison of COVID-19 Incidence by Occupation and Industry-Wisconsin, September 2020 to May 2021

BACKGROUND

Work-related exposures play an important role in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, yet few studies have compared SARS-CoV-2 expsoure risk across occupations and industries.

METHODS

During September 2020 to May 2021, the Wisconsin Department of Health Services collected occupation and industry data as part of routine coronavirus disease 2019 (COVID-19) case investigations. Adults aged 18-64 years with confirmed or probable COVID-19 in Wisconsin were assigned standardized occupation and industry codes. Cumulative incidence rates were weighted for non-response and calculated using full-time equivalent (FTE) workforce denominators from the 2020 American Community Survey.

RESULTS

An estimated 11.6% of workers (347 013 of 2.98 million) in Wisconsin, ages 18-64 years, had COVID-19 from September 2020 to May 2021. The highest incidence by occupation (per 100 FTE) occurred among personal care and services workers (22.1), healthcare practitioners and support staff (20.7), and protective services workers (20.7). High-risk sub-groups included nursing assistants and personal care aides (28.8), childcare workers (25.8), food and beverage service workers (25.3), personal appearance workers (24.4), and law enforcement workers (24.1). By industry, incidence was highest in healthcare (18.6); the highest risk sub-sectors were nursing care facilities (30.5) and warehousing (28.5).

CONCLUSIONS

This analysis represents one of the most complete examinations to date of COVID-19 incidence by occupation and industry. Our approach demonstrates the value of standardized occupational data collection by public health and may be a model for improved occupational surveillance elsewhere. Workers at higher risk of SARS-CoV-2 exposure may benefit from targeted workplace COVID-19 vaccination and mitigation efforts.

Care navigation increases initiation of hepatitis C treatment following release from prison in a prospective randomised controlled trial: The C-LINK Study

Background

Prison-based hepatitis C treatment is safe and effective; however, many individuals are released untreated due to time or resource constraints. On community re-entry, individuals face a number of immediate competing priorities, and in this context, linkage to hepatitis C care is low. Interventions targeted at improving healthcare continuity after prison release have yielded positive outcomes for other health diagnoses; however, data regarding hepatitis C transitional care are limited.

Methods

We conducted a prospective randomized controlled trial comparing a hepatitis C care navigator intervention with standard of care for individuals released from prison with untreated hepatitis C infection. The primary outcome was prescription of hepatitis C direct-acting antivirals (DAA) within 6 months of release.

Results

Forty-six participants were randomized. The median age was 36 years and 59% were male. Ninety percent (n = 36 of 40) had injected drugs within 6 months before incarceration. Twenty-two were randomized to care navigation and 24 were randomized to standard of care. Individuals randomized to the intervention were more likely to commence hepatitis C DAAs within 6 months of release (73%, n = 16 of 22 vs 33% n = 8 of 24, P < .01), and the median time between re-entry and DAA prescription was significantly shorter (21 days [interquartile range {IQR}, 11–42] vs 82 days [IQR, 44–99], P = .049).

Conclusions

Care navigation increased hepatitis C treatment uptake among untreated individuals released from prison. Public policy should support similar models of care to promote treatment in this high-risk population. Such an approach will help achieve hepatitis C elimination as a public health threat.

Intersectionality in pandemic youth suicide attempt trends

INTRODUCTION

The COVID-19 pandemic has resulted in increased distress at a societal level, with youth and young people bearing a disproportionate burden. A series of recent Morbidity and Mortality Weekly Reports has highlighted emergency department (ED) visit rates for suicide attempts among youth ages 12-25 during the COVID-19 pandemic. This study expands those analyses by adding race and ethnicity to the examination of suspected suicide attempts among youth.

METHODS

This study uses National Syndromic Surveillance Program (NSSP) data for Wisconsin from hospitals that consistently reported ED visits between the study period of January 1, 2019 and September 30, 2021. Suspected suicide attempt visits were identified using the CDC-developed suicide attempt query.

RESULTS

During the study period, there were 8915 ED visits for suicide attempts by children and youth ages 12-25 in Wisconsin's NSSP system. We confirm gendered patterns of ED visit rates for suspected suicide attempts among youth that were first noted in studies using a non-representative national dataset. Large and significant 2019 vs. 2021 increases were noted for Black females ages 12-17 (79% increase) and White non-Hispanic females ages 12-17 (58%), but no significant change for Hispanic females ages 12-17. Black females ages 18-25 had high and relatively stable rates throughout this period.

A230 THE ROLE OF THE MICROBIOTA IN NOCICEPTOR DEVELOPMENT AND PAIN SENSITIVITY

Background

Pain is the most common cause of disability in IBD. What causes inter-individual variability in chronic pain after successful treatment of inflammation remains elusive. We have shown that activation of TRPV1+ colonic nociceptors is essential for the establishment of persistent pain in DSS colitis. Nociceptor development coincides with microbial colonization, while early life dysbiosis can lead to visceral hypersensitivity in adulthood. Whether the microbiota dictates nociceptor development and pain susceptibility remains unknown. Here we test the hypothesis that the microbiota programs nociceptor specification during early development, rendering them more susceptible to sensitization later in life. We have identified the aryl hydrocarbon receptor (AHR) that senses bacterial-derived metabolites as a candidate target that orchestrates transcriptional regulation in nociceptors.

Aims

We investigated the developmental regulation of nociceptors by the microbiome and how it influences pain sensitivity. We will determine the effects of AHR activation on nociceptor lineage and function as well as the long term impact of AHR signaling on pain sensitivity.

Methods

We have developed a germ-free (GF) TRPV1-GFP reporter mouse that was used to phenotype and visualise TRPV1+ nociceptors in the absence of a microbiota. We will isolate TRPV1+ neurons by FACS to identify genes that are under the control of the microbiota and to characterise the phosphoproteome of TRPV1+ nociceptors in GF conditions. Finally, we will investigate the role of AHR signaling in nociceptors both acutely and during development.

Results

We showed a reduction in thermal pain threshold and a reduction in capsaicin test responses in GF mice. The number and size of DRG neurons was unchanged in GF mice. Examination of molecular markers for peptidergic (CGRP) and non-peptidergic (IB4) neurons did not show a difference. Finally, there was no difference in the expression of TRPV1, suggesting post-translational modification of the channel. In cultured DRG neurons, we found a decrease in capsaicin induced action potentials and a decrease in the amplitude of the capsaicin response in GF mice. Using RNAscope, we showed that TRPV1+ neurons express AHR.

Conclusions

Our results highlight the importance of bacterial composition in regulating the development of nociceptors and pain sensitivity in adulthood. Furthermore, we are the first to demonstrate the expression of AHR in sensory neurons. These findings point to a role of the microbiota in programming nociceptors during development. My work will advance our understanding of the role of commensal bacteria in regulating pain and could lead to recommendations for the treatment of neonates in early life to reduce their risk of developing chronic pain later in life.

Funding Agencies

CAG, CIHR

A54 DIETARY COMPONENTS ARE ASSOCIATED WITH FECAL CALPROTECTIN IN ULCERATIVE COLITIS

Background

Ulcerative colitis (UC) is thought to arise from dysregulated immune responses due to intestinal dysbiosis and altered epithelial barrier function. Dietary components may affect the gut microbiome and contribute to either inflammation or its resolution. The relationship between diet and disease activity in UC warrants further investigation.

Aims

This prospective cohort study explored the relationship between dietary components, and markers of disease activity: fecal calprotectin (FCP) and partial Mayo score (PMS) in patients with UC.

Methods

40 participants were recruited from University of Calgary IBD clinics. Study staff obtained two 24-hour diet recalls using the validated automated self administered (ASA)-24 and captured PMS at baseline (T1) and follow-up at week 12 (T2). FCP samples were collected at T1 and T2. Diet variables included adjusted macro/micronutrients (n=44), food groups (n=36) and the validated Canadian healthy eating index-2009 (CHEI) where higher scores reflect healthier intake. CHEI captures intake of dark green and orange foods (DGO) and moderation scoring (MOD) of saturated fats (SF), sodium and added sugars. Higher CHEI scores result from increased intake of DGO and lower intake of SF, sodium and added sugars (higher MOD score). Associations with outcome variables were examined at T1 and T2 individually and across both timepoints (BT). Mixed effect logistic regression models identified relationships between dietary variables, FCP and PMS. Models were adjusted for age, sex, BMI, medications, probiotics, and for repeated measures in both timepoint analyses.

Results

A positive association was identified between FCP as a continuous variable and SF (T1:Coef=0.22, p_adj=0.02) and a negative association identified between FCP with citrus/melon/berries (BT:Coef=-1.01, p_adj =0.04), total sugars (BT:Coef=-0.06, p_adj=0.025) and HEI (BT:Coef=-0.13, p_adj =0.06 and T1 coef=-0.18, p_adj =7.0 e-5). FCP increased as SF (-0.30,p_adj=0.01), DGO (-0.60, p_adj=0.02), and MOD (-0.21, p_adj=0.02) scores decreased. The presence of inflammation (as a binary variable, FCP &gt;250) was negatively associated with higher fiber intake (BT: Odds Ratio (OR)= 0.016, CI(0.001,0.40) p_adj=0.08). For PMS as a continuous variable, HEI had a negative association with PMS (T2: -0.05, p_adj=0.06). With PMS as a discrete score (remission=PMS&lt;2) there was no significant association with any diet components.

Conclusions

This study suggests that a healthier diet, both in overall pattern and specific dietary components, was associated with lower FCP and PMS. Our findings related to SF, citrus/melons/berries, and DGO parallel the IOIBD dietary guidelines. Future research should explore through controlled intervention studies whether modifying dietary patterns and components independently reduces disease activity.

Funding Agencies

Crohn’s and Colitis Foundation

A36 THE ROLE OF MICROBIAL INDOLE METABOLITES IN CONTROLLING INFLAMMATORY RESPONSES AND HEALING IN RESPONSE TO DSS-INDUCED COLITIS

Background

Failure to resolve inflammation is often associate with the complications of Crohn’s Disease (CD). The pregnane X receptor (PXR), a xenobiotic receptor, is recognized for its role in suppressing inflammation and has recently been shown to influence fibrogenesis in the liver. In the intestine, PXR-signaling can be influenced by the microbial tryptophan metabolite indole-3- propionic acid (IPA), which can modulate intestinal inflammation, in turn influencing fibrogenesis, resolution and healing. This suggests that the gut microbiota could modulate mucosal homeostasis and resolution of inflammation via microbial metabolites

Aims

To understand and characterize the interplay between microbial complexity and the regulation of host inflammatory and healing responses, specifically focusing on the PXR and its microbial metabolite ligand IPA.

Methods

Intestinal inflammation was induced using DSS (1%, 1.5%, 2% and 3.5%) for 5 days followed by healing for 25 days in C57Bl/6 stably derived moderately diverse mouse microbiota 2 (sDMDMm2) colonized gnotobiotic and C57Bl/6 specific pathogen free (SPF) mice. Inflammation, architectural changes and fibrosis were assessed using Haemotoxylin and Eosin and Masson-Trichrome histological stains. Weight was recorded daily for the first 10 days and every other day after for 25 days, for a total of 30 days. Fecal lipocalin was quantified in samples collected throughout the study to assess inflammation. Innate immune cell influx was measured by flow cytometry, and the microbiota assessed via 16S rRNA sequencing.

Results

The gnotobiotic sDMDMm2 mice were exquisitely sensitive to DSS-induced colitis, exhibiting significantly increased mortality and morbidity at 2% and 3.5% w/v DSS compared to the SPF group. To elicit the same degree of disease to assess recovery, sDMDMm2 mice were exposed to 1.5% DSS and SPF mice to 3.5% DSS. Following 25 days recovery, sDMDMm2 colonized mice showed increased levels of fecal lipocalin 2, as compared to the SPF mice. DSS-treated sDMDMm2 mice supplemented with IPA during their recovery presented lower levels of fecal lipocalin, similar to colitic SPF mice. IPA supplemented sDMDMm2 mice also exhibited greater overall survival, with no significant differences in neutrophil count compared to mice given H20 during recovery.

Conclusions

A model system with a less complex microbiota (sDMDMm2) has a higher susceptibility to acute inflammation and a diminished capacity to resolve said inflammation. Addition of the microbial metabolite IPA normalized the recovery of the sDMDMm2 colonized mice, to a response indistinguishable from SPF mice, while also increasing survival. These data highlight the importance of microbial complexity in the regulation of intestinal mucosal homeostasis.

Funding Agencies

CAG, CCC, CIHR

A14 GUT-RESIDING BACTERIA CAN SHAPE HOST DRUG METABOLISM IN THE SMALL INTESTINE THROUGH AN INNATE LYMPHOID CELL-IL-22 DRIVEN AXIS

Background

The ability of the intestinal microbiota to influence drug metabolism has been recognized, however the mechanisms through which this occurs remain unexplored. Recent work in germ-free mice showed that conventionalization with specific pathogen free (SPF) microbiota influences the expression of cytochrome P450 (CYP) enzymes in the liver and small intestine (SI), two important sites of drug metabolism. Given that CYP enzymes, including CYP3A11 in mice, account for roughly 70% of total drug metabolism, we hypothesized that commensal gut bacteria can shape the CYP landscape to influence drug metabolism and therapeutic outcomes.

Aims

To investigate the role of specific gut-residing microbes in shaping the expression and activity of host drug metabolism enzymes.

Methods

Segmented filamentous bacteria (SFB)-free mice were obtained from Jackson Lab (Jax) and colonized with feces from SFB-mono-associated mice via oral gavage. 14 days later, expression of drug metabolism enzymes in the SI were probed using PCR arrays, and lamina propria cells isolated for flow cytometry. A monoclonal antibody for Thy1.2 was used to deplete innate lymphoid cells (ILCs) in RAG1-/- mice (lacking T- and B-cells). CYP3A11 activity was determined through the colorimetric breakdown of the CYP3A11-specific substrate 7-benzyloxyresorufin. SI organoids were generated from mice and humans, and treated with IL-22 to further assess the dynamics of CYP3A11/CYP3A4 expression and activity.

Results

Colonization of Jax mice with immunomodulatory SFB altered the expression of various CYP enzymes in the SI (but not liver), with Cyp3a11 being the most downregulated gene. Further analysis showed that SFB-induced IL-22 production by type 3 ILCs (ILC3) correlated with reduced SI Cyp3a11 expression. Additionally, SFB colonization had no effect on the expression of Cyp3a11 in the SI of mice in which ILCs were depleted. Both SFB colonization and administration of IL-23, to induce IL-22 from ILC3, increased the ability of the CYP3A11-metabolized drug glyburide to decrease blood glucose levels when given orally. In mouse SI enteroid cultures, IL-22 dose-dependently reduced the expression of Cyp3a11 and decreased the ability of enteroids to metabolize CYP3A11-specific substrates. Finally, IL-22 induced wide changes in the transcriptome of human SI enteroids, with substantial effects on a drug metabolism pathway centred around CYP3A.

Conclusions

Our data suggest that a gut-resident microbe (SFB) can influence the expression and activity of the drug metabolising enzyme CYP3A11 in the SI through an ILC3-IL-22 dependent mechanism. These findings provide an understanding of how the intestinal microbiota may modulate host drug metabolism to influence the efficacy and toxicity of various pharmaceutical compounds.

Funding Agencies

CAG, CIHRAbbvie, Lloyd Sutherland Investigatorship

A-81 MoCA Cutoffs for English/ Spanish Bilingual Veterans Assessed in English

Objective

The Montreal Cognitive Assessment (MoCA) is a well-known screener of global cognitive functioning. Multiple studies have determined optimal cutoff scores for detection of cognitive impairment in various clinical populations. This study aims to determine appropriate cutoff scores in a clinically mixed bilingual (English/Spanish) sample.

Methods

A sample of n = 57 self-identified bilingual veterans referred for neuropsychological evaluation at a VA hospital completed the MoCA as part of a full battery. All tests were administered in English. The majority were male (96.4%), Hispanic/Latinx, with 14.65 mean years of education. Only MoCA total score without adding one point for ≤12 years of education was included. Descriptive statistics were used for sample characterization. ROC curve analysis assessed diagnostic accuracy of the MoCA for classification of cognitive impairment (CI). The CI group (n = 40) included both major or mild neurocognitive disorder. The nonimpaired group (n = 17) included persons with no CI or psychiatric diagnosis.

Results

ROC curve analysis was significant (p < .001) with an AUC of .857 (95% confidence interval .746-.969). A cutoff score of ≤24 was yielded an optimal balance of sensitivity (.900) and specificity (.706). Follow-up independent samples t-test and ANOVA were conducted to examine differences between groups.

Conclusions

Among bilingual individuals, a cutoff of ≤24 on the MoCA maximized sensitivity and specificity of accurately identifying cases of cognitive impairment. Findings have implications for identifying patients requiring further neuropsychological assessment.

Urinary metabolomics reveals unique metabolic signatures in infants with cystic fibrosis

BACKGROUND

Biologic pathways and metabolic mechanisms underpinning early systemic disease in cystic fibrosis (CF) are poorly understood. The Baby Observational and Nutrition Study (BONUS) was a prospective multi-center study of infants with CF with a primary aim to examine the current state of nutrition in the first year of life. Its secondary aim was to prospectively explore concurrent nutritional, metabolic, respiratory, infectious, and inflammatory characteristics associated with early CF anthropometric measurements. We report here metabolomics differences within the urine of these infants as compared to infants without CF.

METHODS

Urine metabolomics was performed for 85 infants with predefined clinical phenotypes at approximately one year of age enrolled in BONUS via Ultrahigh Performance Liquid Chromatography-Tandem Mass Spectroscopy (UPLC-MS/MS). Samples were stratified by disease status (non-CF controls (n = 22); CF (n = 63, All-CF)) and CF clinical phenotype: respiratory hospitalization (CF Resp, n = 22), low length (CF LL, n = 23), and low weight (CF LW, n = 15).

RESULTS

Global urine metabolomics profiles in CF were heterogeneous, however there were distinct metabolic differences between the CF and non-CF groups. Top pathways altered in CF included tRNA charging and methionine degradation. ADCYAP1 and huntingtin were identified as predicted unique regulators of altered metabolic pathways in CF compared to non-CF. Infants with CF displayed alterations in metabolites associated with bile acid homeostasis, pentose sugars, and vitamins.

CONCLUSIONS

Predicted metabolic pathways and regulators were identified in CF infants compared to non-CF, but metabolic profiles were unable to discriminate between CF phenotypes. Targeted metabolomics provides an opportunity for further understanding of early CF disease.

TRIAL REGISTRATION

United States ClinicalTrials.Gov registry NCT01424696 (clinicaltrials.gov).

Human iPSC Glial Mouse Chimeras Reveal Glial Contributions to Schizophrenia

In this study, we investigated whether intrinsic glial dysfunction contributes to the pathogenesis of schizophrenia (SCZ). Our approach was to establish humanized glial chimeric mice using glial progenitor cells (GPCs) produced from induced pluripotent stem cells derived from patients with childhood-onset SCZ. After neonatal implantation into myelin-deficient shiverer mice, SCZ GPCs showed premature migration into the cortex, leading to reduced white matter expansion and hypomyelination relative to controls. The SCZ glial chimeras also showed delayed astrocytic differentiation and abnormal astrocytic morphologies. When established in myelin wild-type hosts, SCZ glial mice showed reduced prepulse inhibition and abnormal behavior, including excessive anxiety, antisocial traits, and disturbed sleep. RNA-seq of cultured SCZ human glial progenitor cells (hGPCs) revealed disrupted glial differentiation-associated and synaptic gene expression, indicating that glial pathology was cell autonomous. Our data therefore suggest a causal role for impaired glial maturation in the development of schizophrenia and provide a humanized model for its in vivo assessment.

Chimpanzee-origin adenovirus vectors as vaccine carriers

Vaccines based on replication-defective adenoviral vectors are being developed for infectious agents and tumor-associated antigens. Early work focused on vaccines derived from a common human serotype of adenovirus, that is, adenovirus of the serotype 5 (AdHu5). Neutralizing antibodies against AdHu5 virus, present in a large percentage of the human population, dampen the efficacy of vaccines based on this carrier. To circumvent this problem, we generated vectors derived from chimpanzee adenoviruses. Here we describe some basic parameters of vectors derived from chimpanzee adenoviruses C68 and C7, including growth characteristics, yields of infectious particles, effects of additional deletions in E3 and E4 and lengths of the inserted foreign sequence as they relate to the suitability for their eventual development as vaccine carriers for clinical use.

KRAS mutation analysis in patients (pts) with locally advanced pancreatic cancer (LAPC) treated with gefitinib and chemoradiation therapy (CT-RT) in a phase I trial

4106

Background: Correlative studies that incorporate biomarkers to rapidly analyze response to new agents are needed. Unique to pancreatic cancer is the high incidence of KRAS mutations (over 90%). This pilot study evaluated plasma KRAS mutations for disease monitoring in LAPC pts treated on a Phase I trial combining CT-RT with the EGFR inhibitor, gefitinib. Methods: DNA was extracted from plasma of 11 pts collected at 3 timepoints: pre-gefitinib, pre-CT-RT, and post-gefitinib+CT-RT. Matched tissue DNA was obtained from 4 pts with available paraffin blocks. KRAS codon 12 mutations were detected using a two-stage RFLP-PCR assay. Cell line controls: Calu-1 (mutant KRAS) and LNCaP (wild-type KRAS). Mutations were confirmed by direct DNA sequencing. Results were related to pt clinical data. Results: KRAS mutations were detected in the pre-gefitinib plasma of 5/11 pts, and in the matched tumor tissue of 3/4 pts. Of the 5 pts with plasma KRAS mutations, 2 pts with no detectable mutant KRAS in the plasma post-gefitinib+CT-RT had overall survival of 8 and 21 months, whereas 2 pts who retained mutant KRAS had overall survival of only 2 and 5 months, and one pt withdrew early. Of the 3 tumor tissues containing mutant KRAS, the mutations were also detectable in the matched plasma in 2 pts (67%). KRAS codon 12 mutations spectrum: 4 GGT→GAT, 2 GGT→GTT and 1 GGT→AGT. Conclusions: Plasma KRAS mutations are readily detectable in LAPC pts, and the clearance or persistence of plasma KRAS mutations after treatments reflected the clinical course in some cases. The use of plasma KRAS mutation as a marker of survival and response will be further assessed in a recently approved phase I trial using a proteasome inhibitor with chemoradiation at the University of Colorado.

No significant financial relationships to disclose.

Tolerability and compliance with risedronate in clinical practice

The purpose of this study was to determine compliance with dosing instructions, and the prevalence of possible adverse events, when risedronate is used in clinical practice. 219 patients were studied. We found that despite counseling one in four patients were non-compliant with dosing instructions. Those patients who did not stay upright after taking risedronate were more likely to have an adverse event and to discontinue the drug. Adverse events were experienced by 38% of patients, the commonest being gastrointestinal. Upper GI adverse events occurred in 21% of patients. A previous history of upper GI symptoms applied to 44% of patients and significantly more of them experienced upper GI adverse events than those with no history of GI problems. Forty two (19%) of patients taking risedronate stopped therapy due to adverse events, but only ten of these patients had contacted the Osteoporosis Unit about these symptoms. Approximately one third of the patients who experienced adverse events in this study had attempted a rechallenge with the drug. This was worthwhile, however, as in almost 50% of these patients their symptoms settled and they continued with therapy. This study has highlighted the importance of following up patients on long-term osteoporosis medication to ensure optimal compliance. The use of specialized osteoporosis nurses in clinics or primary care to follow up patients needs to be addressed.

How reliable is a radiological report in osteoporosis in diagnosing low bone density?

Patients are often referred to osteoporosis clinics with a radiological diagnosis of osteoporosis. Previous studies attempting to ascertain risk of osteoporosis from radiographs have been conflicting. The aim of our study was to determine how reliable spinal radiographs were at detecting low bone density compared with Dual Energy X ray Absorptiometry (DXA). We retrospectively measured the Bone Mineral Density (BMD) at the spine in 130 patients with a radiological diagnosis of osteopenia or osteoporosis in the absence of vertebral fractures. They were compared with a group of 119 age and sex matched patients with one or more low trauma vertebral fractures. There was a statistically significant difference in the mean BMD between these two groups. 12.7%, of the x-ray group with osteopenia reported, had a normal bone density, 49.2% had osteopenia (T-score -1 to -2.5) and 38.1% had osteoporosis (T-score <-2.5). Of those with a radiological report of osteoporosis, 12.8% had a normal bone density, 44.7% had osteopenia and 42.6% had osteoporosis. We conclude that a radiological report of low bone density is a strong predictor of osteopenia or osteoporosis by BMD measurement.

Early pulmonary infection, inflammation, and clinical outcomes in infants with cystic fibrosis

A thorough understanding of the early natural history of cystic fibrosis (CF) lung disease is critical for the development of effective interventions in the youngest patients. We assessed the evolution of pulmonary infection, inflammation, and clinical course among 40 infants over a 2-year period through annual bronchoalveolar lavage (BAL) for culture and measurements of pro- and anti-inflammatory cytokines, semiannual infant pulmonary function testing, and quarterly clinical evaluations. Both the prevalence of CF pathogens and their density in BAL fluid increased with age. Infants had neutrophilic lower airway inflammation and elevated IL-8 concentrations independent of whether CF pathogens were recovered. Total leukocyte and neutrophil densities and IL-8 concentrations increased with density of CF pathogens in BAL fluid, whether the isolated organism was P. aeruginosa or another pathogen. IL-10 concentrations were similar in CF subjects and non-CF historical controls. Infants generally had suboptimal growth (low weight and height percentiles) and obstructive lung disease (decreased expiratory flows and air trapping). Subjects from whom CF pathogens were isolated at > 10(5) cfu/mL had the worst air trapping and lowest Brasfield chest X-ray scores. Our findings provide a foundation for future studies of early intervention in CF lung disease, including antimicrobial and anti-inflammatory therapy.

IgA responses in the intestinal mucosa against pathogenic and non-pathogenic microorganisms

IgA is the most abundant immunoglobulin produced in mammals; most is secreted as a dimer across mucous membranes. This review discusses the different mechanisms of induction of IgA, and its role in protecting mucosal surfaces against pathogenic and non-pathogenic microorganisms.

Chronic aspiration without gastroesophageal reflux as a cause of chronic respiratory symptoms in neurologically normal infants

OBJECTIVE

To describe 13 neurologically normal infants with chronic respiratory symptoms who had swallowing dysfunction with silent chronic aspiration without gastroesophageal reflux (GER) as the cause of their respiratory symptoms.

BACKGROUND

Infants with neurologic disorders and infants with GER are known to have chronic respiratory symptoms. Isolated swallowing dysfunction and aspiration without GER in neurologically normal infants have not been widely reported.

DESIGN

Retrospective chart review.

SETTING

A tertiary pulmonary-care center at a children's hospital.

PATIENTS

One hundred twelve otherwise healthy infants referred for respiratory symptoms who underwent esophageal pH studies and videofluoroscopic swallow studies (VSSs).

METHODS

The records of infants referred between January 1997 and December 1999 to the Department of Pediatric Pulmonology who underwent 24-h esophageal pH monitoring and VSS as part of an evaluation for recurrent stridor and/or wheezing were reviewed. Significant GER was diagnosed if the percentage of time with esophageal pH < 4 was > 6%. Infants included in the study presented with recurrent respiratory symptoms, were born at term, were neurologically normal, had normal results of esophageal pH studies, but had abnormal results of VSSs (n = 13).

RESULTS

All 13 infants presented with a variety of recurrent respiratory symptoms including wheezing and intermittent stridor. Ten of 13 infants had spitting and/or choking episodes with feeding. The mean (+/- SD) age at the onset of symptoms was 2.0 +/- 1.6 months, and the mean age at VSS was 5.9 +/- 3.4 months. All 13 infants had normal results of 24-h esophageal pH studies but had abnormal results for VSSs. All infants had evidence of swallowing dysfunction and direct silent aspiration of liquids with thin consistency. Six infants also were aspirating liquids with thick and/or semi-thick consistencies. None of the infants had evidence of structural anomalies on esophagograms. Nine infants were treated with thickened food, and in four infants oral feedings were stopped. Three of these infants required nasojejunal feeding, and one infant required gastrostomy tube feeding. VSSs were repeated every 3 months. In all infants, swallowing dysfunction resolved within 3 to 9 months. All infants tolerated the resumption of oral feeding. Videofluoroscopic documentation of the resolution of aspiration was followed by the resolution of respiratory symptoms in all infants.

CONCLUSION

There is a subgroup of otherwise healthy infants, presenting with wheeze and/or stridor, who have isolated swallowing dysfunction and silent aspiration as the cause of their respiratory symptoms.

IgA production without mu or delta chain expression in developing B cells

Surface, membrane-bound, immunoglobulin M (IgM) or IgD expression early in B cell ontogeny is considered essential for the differentiation of antibody-producing cells in mammals; only in IgM+ B cells is the heavy chain locus rearranged to express antibodies of other classes. We show here that IgA is selectively expressed in muMT mice, which lack IgM or IgD expression and have a pro-B cell developmental block. muMT IgA binds proteins of commensal intestinal bacteria and is weakly induced by Salmonella infection, although not through conventional immunization. This muMT IgA pathway requires extrasplenic peripheral lymphoid tissues and may be an evolutionarily primitive system in which immature B cells switch to IgA production at peripheral sites.

Urinary leukotriene E(4) excretion during the first month of life and subsequent bronchopulmonary dysplasia in premature infants

BACKGROUND

Inflammation plays an important role in the pathogenesis of bronchopulmonary dysplasia (BPD), but the exact nature of this inflammatory process is incompletely understood. Older infants with established BPD have higher levels of urinary leukotriene E(4) (LTE(4)) compared to healthy infants of the same age. This suggests that cysteinyl leukotrienes may play a role in the abnormalities seen in BPD.

OBJECTIVES

To measure urinary LTE(4) levels during the first month of life in premature infants, and to determine whether there are significant differences in premature infants who develop BPD, as compared to those who do not develop BPD.

DESIGN

Prospective, blinded, controlled study.

SETTING

Neonatal ICUs of a tertiary-care university hospital.

METHODS

Thirty-seven premature infants (< 33 weeks of gestational age) were enrolled prospectively at birth. Urinary LTE(4) levels were measured blinded, using a standard radioimmunoassay technique at 2 days, 7 days, and 28 days of life. At 1 month of age, infants were classified as with or without BPD, based on need for supplemental oxygen, and characteristic chest radiographs. Clinical features and urinary LTE(4) were compared between the two groups.

RESULTS

Mean +/- SD gestational age was 29 +/- 2.6 weeks. None of the infants had a family history of asthma. Thirteen of 37 infants were classified as having BPD at 28 days after birth. Mean gestational age in infants who developed BPD was 27 +/- 2.4 weeks, compared to 30 +/- 2 weeks in infants who did not develop BPD (p < 0.05). In infants with BPD, mean urinary LTE(4) levels of urinary creatinine were 1,762 +/- 2,003 pg/mg, 1,236 +/- 992 pg/mg, and 5,541 +/- 5,146 pg/mg at days 2, 7, and 28, respectively, compared to 1,304 +/- 1,195 pg/mg, 1,158 +/- 1,133 pg/mg, and 2,800 +/- 2,080 pg/mg in infants without BPD. LTE(4) levels at 2 days, 7 days, and 28 days did not correlate with the subsequent development of BPD. LTE(4) levels at day 28 were significantly higher than LTE(4) levels at day 2 and day 7 in both groups, even after correcting for gestational age or birth weight (p < 0.05). There was significant inverse correlation between LTE(4) levels at day 2 with gestational age and birth weight (p < 0.05). All 13 infants with BPD received steroid pulses, compared to 3 of 26 infants without BPD. Gestational age and use of postnatal steroid pulses, diuretics, and theophylline (for apnea of prematurity) were significantly associated with each other and with the subsequent development of BPD.

CONCLUSION

Urinary LTE(4) levels measured on the second day of life in very-low-birth-weight infants inversely correlate with gestational age and birth weight. Urinary LTE(4) levels may reflect lung injury and/or inflammation in premature infants, not necessarily related to BPD as it is presently defined.

Rapid peptide turnover and inefficient presentation of exogenous antigen critically limit the activation of self-reactive CTL by dendritic cells

This study evaluated to what extent presentation of exogenously acquired self-Ags via MHC class I molecules on DC might contribute to the activation of self-reactive CTL and subsequent development of autoimmune disease. We show here by using the rat insulin promotor lymphocytic choriomeningitis virus glycoprotein model of autoimmune diabetes that the activation of self-reactive CTL by DC after uptake of exogenous Ag is very limited, first by the short half-life of MHC class I-associated peptides on DC in vitro and in vivo, and second by the rather inefficient MHC class I presentation of cell-associated self-Ags by DC. These two mechanisms are probably crucial in establishing high thresholds for the induction of self-reactive CTL that prevent autoimmune sequelae after release of sequestered and previously immunologically ignored tissue Ags.

Longitudinal assessment of Pseudomonas aeruginosa in young children with cystic fibrosis

Pseudomonas aeruginosa lung infection is an important cause of morbidity and mortality in cystic fibrosis (CF). Longitudinal assessment of the phenotypic changes in P. aeruginosa isolated from young children with CF is lacking. This study investigated genotypic and phenotypic changes in P. aeruginosa from oropharynx (OP) and bronchoalveolar lavage fluid (BALF) in a cohort of 40 CF patients during the first 3 years of life; antibody response was also examined. A high degree of genotypic variability was identified, and each patient had unique genotypes. Early isolates had a phenotype distinct from those of usual CF isolates: generally nonmucoid and antibiotic susceptible. Genotype and phenotype correlated between OP and BALF isolates. As determined by culture, 72.5% of patients demonstrated P. aeruginosa during their first 3 years. On the basis of combined culture and serologic results, 97.5% of patients had evidence of infection by age 3 years, which suggests that P. aeruginosa infection occurs early in CF and may be intermittent or undetectable by culture.

Compression of the trachea by the innominate artery in a 2-month-old child

SUMMARY. We utilized improved methods for assessing airway structure and function to define the clinical significance of the innominate artery syndrome. Both infant pulmonary function tests (IPFT) and noninvasive controlled ventilation computed tomography (CVCT) were used, along with traditional diagnostic techniques in a 2-month-old child with compression of the trachea by the innominate artery. These tests provided objective documentation of functional impairment before surgery and improvement postoperatively. These tests should aid in the understanding of this controversial syndrome and help to further define treatment options.

Adult-type pulmonary function tests in infants without respiratory disease

A new method that permits the measurement of adult-type maximal expiratory flow-volume curves and fractional lung volumes in sedated infants was recently described. The purpose of this study was to define the normal range for these new measures of pulmonary function in infants and young children. Measurements of forced expiratory flows and fractional lung volume were made on 35 occasions in 22 children (ages 3-120 weeks) without respiratory disease. Maximal expiratory flow-volume curves were measured by the raised lung volume, thoracoabdominal compression technique. Functional residual capacity (FRC) was measured plethysmographically. Measurements of total lung capacity (TLC), residual volume (RV), FRC, forced vital capacity (FVC), and forced expiratory flows at 25, 50, 75, 85, and between 25% and 75% of expired FVC (FEF(25), FEF(50), FEF(75), FEF(85), and FEF(25-75), respectively) all increased in relation to infant length (P<0.001). RV/TLC, FRC/TLC, and FEF(25-75)/FVC declined in relation to increasing length (P<0.001). The forced expiratory flow and fractional lung volume measurements using this method were similar to previously reported estimates using other methods. These estimates represent a reasonable reference standard for infants and young children with respiratory problems.

Role of eosinophils in the pathogenesis of Mycobacterium bovis BCG infection in gamma interferon receptor-deficient mice

A profound eosinophil infiltration of granulomas is observed in the lungs of Mycobacterium bovis bacillus Calmette Guérin-infected gamma interferon receptor-deficient mice. Blockade of eosinophil proliferation and recruitment into the lung by treatment with anti-interleukin-5 monoclonal antibody marginally reduced mycobacterial growth within the lung but did not affect dissemination of the infection to other tissues.

1,3-Diarylcycloalkanopyrazoles and diphenyl hydrazides as selective inhibitors of cyclooxygenase-2

Novel 1,3-diarylcycloalkanopyrazoles 1, and diphenyl hydrazides 2 were identified as selective inhibitors of cyclooxygenase-2. The 1,3-diaryl substitution pattern of the pyrazole ring in 1 differentiates these compounds from most of the known selective COX-2 inhibitors that contain two aryl rings at the adjacent positions on a heterocyclic or a phenyl ring. Similarly, the two phenyl rings in 2 are also separated by three atoms. SAR of both phenyl rings in 1 and 2, and the aliphatic ring in 1 will be discussed.

Diagnostic accuracy of oropharyngeal cultures in infants and young children with cystic fibrosis

The objective of this study was to assess the diagnostic accuracy of oropharyngeal (OP) cultures relative to simultaneous bronchoalveolar lavage (BAL) cultures in very young children with CF, and to examine the effects of bacterial density, age, and study cohort on diagnostic accuracy. Respiratory culture data were analyzed from three independent, prospective studies involving simultaneous collection of 286 OP and BAL cultures from 141 children with CF <5 years of age. For predicting any growth of Pseudomonas aeruginosa (Pa) from the lower airway in subjects </=18 months of age (mean age, 8 +/- 5 months), OP cultures had a sensitivity of 44% (95% CI 14%, 79%), specificity of 95% (90%, 99%), positive predictive value of 44% (14%, 79%), and negative predictive value of 95% (90%, 99%). Diagnostic accuracy was similar for Haemophilus influenzae (Hi). Specificity was significantly lower for Staphylococcus aureus (Sa). Sensitivity for all organisms improved if a positive lower airway culture was defined as >/=10(3) or >/=10(5) cfu/mL. Specificity for Pa declined significantly with increasing age. In children with CF <5 years of age, the specificity and negative predictive value of OP cultures for Pa are high, while the sensitivity and positive predictive value are poor. Thus, in this age range, a negative throat culture is helpful in "ruling out" lower airway infection with Pa. However, a positive culture does not reliably "rule in" the presence of Pa in the lower respiratory tract. These findings may have implications for study design and interpretation as well as clinical management of young children with CF.

CTLA-4 blockade enhances the immune response induced by mycobacterial infection but does not lead to increased protection

The murine immune response to a pulmonary mycobacterial infection is slow to develop, allowing bacterial numbers to increase in the lung for several weeks after infection. We sought to enhance the protective immune response induced during Mycobacterium bovis BCG infection by administering an antibody that blocks the interaction of CTLA-4 with its ligands, CD80 and CD86. We found that injection of anti-CTLA-4 monoclonal antibody (MAb) greatly enhanced and accelerated the immune response, as measured by increased cellularity of the draining mediastinal lymph nodes, and enhanced antigen-inducible proliferation and gamma interferon production by mediastinal lymphocytes in vitro. However, despite the apparently enhanced immune response in the mediastinal lymph node following treatment with anti-CTLA-4 MAb, there was no improvement in clearance of mycobacteria in the lungs, liver, or spleen. Examination of the primary site of infection, the lung, revealed that CTLA-4 blockade had no effect on the number or function of lymphocytes infiltrating the infected lung tissue. Taken together, these data suggest that in vivo CTLA-4 blockade enhances mycobacterial-infection-induced lymphocyte expansion and effector cell cytokine production in the draining lymph node but does not alter the number or function of lymphocytes at the primary site of infection and therefore does not lead to enhanced clearance of the infection.

Immunoregulatory networks in asthma

It is now well established that a subset of T-cell-derived cytokines (termed Th2 cytokines) programme the timing and characteristics of atopic airway disease including mast-cell sensitization, eosinophil and lymphocyte infiltration and recently mucus secretion. To date, attempts to devise ways to selectively limit the activities of Th2 cytokine-producing cells have been frustrated. However, the recent identification of the molecules which direct the activation and maturation of T cells has led to some successful attempts to block the activities of Th2 cells in models of atopic airway inflammation. Some of the agents with the most potential include antagonists of the T-cell costimulatory molecule CD28, local stimulators of the Thl subset of cytokines such as the BCG vaccine and potentially, antagonists of the eotaxin chemokine receptor and agonists of the T-cell costimulatory molecule CTLA-4. Not only do such agonists and antagonists represent potential new therapies, they could represent a rich hunting ground for those who aim to determine the ways in which atopic airway disease can be diagnosed and understood.