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King C, Ridge K, Smyth J, Flinn AM, Leahy TR, Conlon N. Experience of pediatric to adult transition in immunology services: patient experience questionnaire and micro-costing analysis. Front Immunol 2024; 15:1270451. [PMID: 38510252 PMCID: PMC10952820 DOI: 10.3389/fimmu.2024.1270451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
The effective transition from pediatric to adult care for individuals with chronic medical conditions should address the medical, psychosocial and educational needs of the cohort. The views and experiences of service users and their families are an integral component of service development. This study sought to evaluate the current provision of transition services from pediatric immunology services to adult immunology services for patients with a diagnosis of an inborn error of immunity at St. James's Hospital, Dublin. We gathered patient perspectives on the experience of the transition process using a structured survey. In addition, we adopted a micro-costing technique to estimate the cost of implementing the current standard of care for these patients. Results of a micro-costing analysis suggest that the most significant component of cost in assessing these patients is on laboratory investigation, an area where there is likely significant duplication between pediatric and adult care. Perspectives from patients suggested that the transition period went well for the majority of the cohort and that they felt ready to move to adult services, but the transition was not without complications in areas such as self-advocacy and medication management. The transition process may benefit from enhanced communication and collaboration between pediatric and adult services.
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Affiliation(s)
- Catherine King
- Diagnostic and Clinical Immunology, St. James’s Hospital, Dublin, Ireland
| | - Katie Ridge
- Diagnostic and Clinical Immunology, St. James’s Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - James Smyth
- Finance Department, St. James’s Hospital, Dublin, Ireland
| | - Aisling M. Flinn
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- Department of Pediatric Immunology, Children’s Health Ireland at Crumlin, Dublin, Ireland
| | - Timothy Ronan Leahy
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- Department of Pediatric Immunology, Children’s Health Ireland at Crumlin, Dublin, Ireland
| | - Niall Conlon
- Diagnostic and Clinical Immunology, St. James’s Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
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2
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Bojanic I, Worel N, Pacini CP, Stary G, Piekarska A, Flinn AM, Schell KJ, Gennery AR, Knobler R, Lacerda JF, Greinix HT, Pulanic D, Crossland RE. Extracorporeal photopheresis as an immunomodulatory treatment modality for chronic GvHD and the importance of emerging biomarkers. Front Immunol 2023; 14:1086006. [PMID: 36875063 PMCID: PMC9981637 DOI: 10.3389/fimmu.2023.1086006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/01/2023] [Indexed: 02/19/2023] Open
Abstract
Haematopoietic stem cell transplantation (HSCT) is the treatment of choice for malignant haematological diseases. Despite continuous improvements in pre- and post-transplantation procedures, the applicability of allo-HSCT is limited by life-threatening complications such as graft-versus-host disease (GvHD), engraftment failure, and opportunistic infections. Extracorporeal photopheresis (ECP) is used to treat steroid resistant GvHD with significant success. However, the molecular mechanisms driving its immunomodulatory action, whilst preserving immune function, require further understanding. As ECP is safe to administer with few significant adverse effects, it has the potential for earlier use in the post-HSCT treatment of GvHD. Thus, further understanding the immunomodulatory mechanisms of ECP action may justify more timely use in clinical practice, as well as identify biomarkers for using ECP as first line or pre-emptive GvHD therapy. This review aims to discuss technical aspects and response to ECP, review ECP as an immunomodulatory treatment modality for chronic GvHD including the effect on regulatory T cells and circulating vs. tissue-resident immune cells and consider the importance of emerging biomarkers for ECP response.
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Affiliation(s)
- Ines Bojanic
- Department of Transfusion Medicine and Transplantation Biology, University Hospital Center Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Nina Worel
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
| | - Carolina P Pacini
- Hematology and Transplantation Immunology, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Georg Stary
- Department of Dermatology, Medical University of Vienna, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria
| | - Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Aisling M Flinn
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kimberly J Schell
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.,Paediatric Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | - Robert Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - João F Lacerda
- Hematology and Transplantation Immunology, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | | | - Drazen Pulanic
- School of Medicine, University of Zagreb, Zagreb, Croatia.,Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Rachel E Crossland
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
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3
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Flinn AM, Gennery AR. Recent advances in graft-versus-host disease. Fac Rev 2023; 12:4. [PMID: 36923700 PMCID: PMC10009889 DOI: 10.12703/r/12-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Acute and chronic graft-versus-host disease (GVHD) continue to present a significant challenge to physicians, accounting for considerable haematopoietic stem cell transplant (HSCT)-related morbidity and mortality, particularly those patients with steroid-refractory disease. In this review, we discuss recent advances in understanding the underlying pathophysiology, prevention and management of acute and chronic GVHD. Barriers to progress include the difficulty in obtaining high-quality evidence with sufficient patient numbers to identify optimal preventative and treatment strategies, with the heterogeneity of multiple patient, donor, graft and transplant-related factors, in addition to limited availability of human tissue to study the underlying pathophysiology, particularly in steroid-refractory disease. Continued collaborative efforts to improve our understanding of the pathophysiology involved, particularly in steroid-refractory disease, identification of biomarkers to permit risk stratification, and further well-designed randomised clinical trials are essential to help physicians determine optimal GVHD preventative and treatment strategies for each individual patient.
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Affiliation(s)
- Aisling M Flinn
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
- Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
- Great North Children’s Hospital, Newcastle upon Tyne, UK
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4
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Abstract
Primary Immune Regulatory Disorders (PIRD) describe a group of conditions characterized by loss of normal inflammatory control and immune tolerance mechanisms, with autoimmunity as a predominant clinical feature. PIRD can arise due to defects in the number or function of regulatory T-lymphocytes, defects in the immune mechanisms required to ‘turn off’ inflammation such as in perforin-dependent cytotoxicity or alterations in cytokine signalling pathways. Diagnosis of PIRD is a significant challenge to physicians due to their rarity, complexity, and diversity in clinical manifestations. Many of these individual conditions lack a genotype–phenotype correlation and display incomplete penetrance. However, establishing a diagnosis is integral in optimizing patient management, including the use of individualized treatment approaches. Increasing awareness among physicians is necessary as patients are likely to present to different subspecialties. Due to the rarity of these conditions, worldwide collaboration and data-sharing is essential to improve our knowledge of the clinical spectrum and disease course in PIRD, and to optimize therapeutic strategies including identification of which patients can benefit from hematopoietic stem cell transplant.
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Affiliation(s)
- Aisling M Flinn
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew R Gennery
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
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5
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Flinn AM, Macheka S, Slatter M, Ewins A, Gibson B, Lawson S, Tailby A, Lucchini G, New H, James B, Alfred A, Scarisbrick J, Gennery AR. A survey of extracorporeal photopheresis treatment in pediatric patients in the United Kingdom. eJHaem 2020; 1:293-296. [PMID: 35847736 PMCID: PMC9175897 DOI: 10.1002/jha2.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 11/11/2022]
Abstract
Extracorporeal photopheresis (ECP) is a second‐line therapy in acute and chronic GVHD and solid organ transplant rejection. We report ECP use in 98 pediatric patients in seven UK centers from 2010 to 2017, the majority treated for aGVHD (73.5%). ECP was safe and well tolerated including in low body weight patients. Most patients were on multiple immunosuppressive therapies prior to ECP; 45.9% were able to reduce or stop immunosuppression with treatment. Complete or partial response was reported in almost 60%. This study supports the need to include ECP treatment data to national transplant databases to provide accurate information regarding service provision, patient outcomes, and safety.
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Affiliation(s)
- Aisling M. Flinn
- Department of Paediatric Immunology and Haematopoietic Stem Cell TransplantationGreat North Children's Hospital Newcastle upon Tyne UK
| | - Sheba Macheka
- Department of Paediatric Immunology and Haematopoietic Stem Cell TransplantationGreat North Children's Hospital Newcastle upon Tyne UK
| | - Mary Slatter
- Department of Paediatric Immunology and Haematopoietic Stem Cell TransplantationGreat North Children's Hospital Newcastle upon Tyne UK
| | - Anna‐Maria Ewins
- Haematology/Oncology DepartmentThe Royal Hospital for Children Glasgow UK
| | - Brenda Gibson
- Haematology/Oncology DepartmentThe Royal Hospital for Children Glasgow UK
| | - Sarah Lawson
- Department of HaematologyBirmingham Children's Hospital Birmingham UK
| | - Anna Tailby
- Department of HaematologyBirmingham Children's Hospital Birmingham UK
| | | | - Helen New
- NHS Blood and TransplantLondon Imperial College London UK
| | - Beki James
- Regional Centre for Paediatric HaematologyLeeds Children's Hospital Leeds UK
| | - Arun Alfred
- Department of PhotopheresisRotherham Foundation Trust Rotherham UK
| | - Julia Scarisbrick
- Department of DermatologyUniversity Hospital Birmingham Birmingham UK
| | - Andrew R Gennery
- Department of Paediatric Immunology and Haematopoietic Stem Cell TransplantationGreat North Children's Hospital Newcastle upon Tyne UK
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6
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Deya-Martinez A, Flinn AM, Gennery AR. Neonatal thymectomy in children-accelerating the immunologic clock? J Allergy Clin Immunol 2020; 146:236-243. [PMID: 32169378 DOI: 10.1016/j.jaci.2020.02.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/25/2020] [Accepted: 02/26/2020] [Indexed: 12/29/2022]
Abstract
The thymus is critical for central tolerance and diverse T-lymphocyte repertoire development, to provide lifelong defense against pathogens while maintaining self-tolerance. Peak thymic output occurs in utero, during infancy, and in early childhood, diminishing throughout life. Infants with congenital heart disease requiring sternotomy often undergo thymectomy to clear the surgical field. The long-term effects of early thymectomy are just being appreciated. Many patients remain asymptomatic despite immunologic findings mirroring those of immunosenescence. Few develop increased infection or lymphoreticular malignancy risk. When considering the effects of infant thymectomy, patients with partial DiGeorge syndrome or hypomorphic recombination-activating gene (RAG) mutations may be instructive. These patients are lymphocytopenic, with increased early-onset infection and autoimmunity risk that is not seen in most patients who underwent thymectomy during infancy. The thymic structure of patients with partial DiGeorge syndrome or hypomorphic RAG is abnormal, with disrupted architecture inclining to perturbation of central tolerance. Similar findings may be seen in patients with myasthenia gravis, although disrupted peripheral tolerance may play a greater role in autoimmunity development. In conclusion, thymectomy during infancy may increase future risk of infection or autoimmunity, with premature immunosenescence mediated through disruption of central and peripheral tolerance mechanisms initiated by early cessation or diminution of thymic output. Ideally, some thymic tissue should be preserved at the time of surgery.
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Affiliation(s)
- Angela Deya-Martinez
- Functional Unit of Clinical Immunology and Primary Immunodeficiencies, Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, University of Barcelona, Pediatric Research Institute Sant Joan de Déu, Barcelona, Spain
| | - Aisling M Flinn
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Paediatric Immunology and Haematopoietic Stem Cell Transplantation, Great North Childrens' Hospital, Newcastle upon Tyne, United Kingdom; Primary Immunodeficiency Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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7
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Abstract
Adenosine deaminase (ADA) deficiency leads to an accumulation of toxic purine degradation by-products, most potently affecting lymphocytes, leading to adenosine deaminase-deficient severe combined immunodeficiency. Whilst most notable affects are on lymphocytes, other manifestations include skeletal abnormalities, neurodevelopmental affects and pulmonary manifestations associated with pulmonary-alveolar proteinosis. Affected patients present in early infancy, usually with persistent infection, or with pulmonary insufficiency. Three treatment options are currently available. Initial treatment with enzyme replacement therapy may alleviate acute symptoms and enable partial immunological reconstitution, but treatment is life-long, immune reconstitution is incomplete, and the reconstituted immune system may nullify the effects of the enzyme replacement. Hematopoietic stem cell transplant has long been established as the treatment of choice, particularly where a matched sibling or well matched unrelated donor is available. More recently, the use of gene addition techniques to correct the genetic defect in autologous haematopoietic stem cells treatment has demonstrated immunological and clinical efficacy. This article reviews the biology, clinical presentation, diagnosis and treatment of ADA-deficiency.
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Affiliation(s)
- Aisling M Flinn
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Great North Children's Hospital, Clinical Resource Building, Floor 4, Block 2, Queen Victoria Road, NE1 4LP, Newcastle upon Tyne, UK
| | - Andrew R Gennery
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK. .,Great North Children's Hospital, Clinical Resource Building, Floor 4, Block 2, Queen Victoria Road, NE1 4LP, Newcastle upon Tyne, UK.
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8
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Flinn AM, Gavin PJ, McMahon CJ, Oslizok P, Butler KM. Kawasaki Disease - A Review of Treatment and Outcomes in an Irish Paediatric Cohort 2010-14. Ir Med J 2018; 111:691. [PMID: 29952440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Diagnosis of Kawasaki Disease (KD) can be challenging due to lack of a diagnostic test, and some children present with 'incomplete' KD when not all diagnostic criteria are met. Treatment with intravenous immunoglobulin (IVIG) and aspirin reduces the risk of coronary artery complications. There is sub-group of patients who are resistant to IVIG/aspirin therapy and are at increased risk of complications. Recent evidence suggests that additional treatment of this high-risk group with corticosteroids is beneficial in reducing this risk. We examine the treatment and coronary artery outcomes, by retrospective review of medical records, of a cohort of 32 paediatric patients with KD admitted to a single Irish tertiary centre from January 2010-December 2014. Twenty-eight percent of patients (9/32) had an incomplete diagnosis of KD; these patients received IVIG later compared to those with a complete KD diagnosis. 15/32 (47%) had abnormal echocardiogram findings in the acute phase, 8/32 (25%) had echocardiogram abnormalities at 6-week follow-up, and 4/32 (12.5%) had persisting abnormalities. This study highlights the potential for adverse outcome in KD, the difficulty in diagnosis in 'incomplete' cases, and the need to identify children at higher risk for adverse outcome where adjunctive therapies would be most beneficial.
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Affiliation(s)
- A M Flinn
- Our Lady's Children's Hospital, Dublin, Ireland
| | - P J Gavin
- Our Lady's Children's Hospital, Dublin, Ireland
| | - C J McMahon
- Health Intelligence Unit, Health and Wellbeing Directorate, HSE, Dublin 8
- University College Dublin, Ireland
| | - P Oslizok
- Our Lady's Children's Hospital, Dublin, Ireland
| | - K M Butler
- Health Intelligence Unit, Health and Wellbeing Directorate, HSE, Dublin 8
- University College Dublin, Ireland
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9
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Flinn AM, Roberts CF, Slatter MA, Skinner R, Robson H, Lawrence J, Guest J, Gennery AR. Thymopoiesis following HSCT; a retrospective review comparing interventions for aGVHD in a pediatric cohort. Clin Immunol 2018; 193:33-37. [PMID: 29395846 DOI: 10.1016/j.clim.2018.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 12/18/2017] [Accepted: 01/17/2018] [Indexed: 01/31/2023]
Abstract
Acute graft-versus-host disease (aGVHD) complicates allogeneic hematopoietic stem cell transplantation (HSCT), and is treated with topical and/or systemic corticosteroids. Systemic corticosteroids and aGVHD damage thymic tissue. We compared thymopoietic effect of topical steroid therapy, corticosteroids and extracorporeal photopheresis (ECP) in 102 pediatric allogeneic HSCT patients. We categorized patients into 4 groups: - no aGVHD, aGVHD treated with topical or systemic steroid, or ECP. Naïve CD4+CD45RA+CD27+ T-lymphocyte values at 3, 6, 9, 12months post-HSCT were recorded: for ECP patients, values were recorded at 3, 6, 9, 12months during ECP. Differences were compared using the Kruskal-Wallis test. 41 patients had no aGVHD, 23 had aGVHD treated topically or systemically (25), 13 received ECP. Rate of thymopoiesis was significantly different between all groups at all time-points post-transplant (p=0.002, p<0.001, p<0.001, p=0.001 respectively). Even mild aGVHD impairs thymopoiesis. Worst recovery was in ECP patients. Earlier institution of ECP may speed thymic recovery.
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Affiliation(s)
- A M Flinn
- Institute of Cellular Medicine, Newcastle University, United Kingdom.
| | - C F Roberts
- Institute of Cellular Medicine, Newcastle University, United Kingdom
| | - M A Slatter
- Institute of Cellular Medicine, Newcastle University, United Kingdom; Great North Childrens' Hospital, Newcastle-upon-Tyne, United Kingdom
| | - R Skinner
- Great North Childrens' Hospital, Newcastle-upon-Tyne, United Kingdom
| | - H Robson
- Great North Childrens' Hospital, Newcastle-upon-Tyne, United Kingdom
| | - J Lawrence
- Great North Childrens' Hospital, Newcastle-upon-Tyne, United Kingdom
| | - J Guest
- Great North Childrens' Hospital, Newcastle-upon-Tyne, United Kingdom
| | - A R Gennery
- Institute of Cellular Medicine, Newcastle University, United Kingdom; Great North Childrens' Hospital, Newcastle-upon-Tyne, United Kingdom
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10
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Flinn AM, Gennery AR. Treatment of Pediatric Acute Graft-versus-Host Disease-Lessons from Primary Immunodeficiency? Front Immunol 2017; 8:328. [PMID: 28377772 PMCID: PMC5359217 DOI: 10.3389/fimmu.2017.00328] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/07/2017] [Indexed: 11/13/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplant (HSCT) is used to treat increasing numbers of malignant and non-malignant disorders. Despite significant advances in improved human leukocyte antigens-typing techniques, less toxic conditioning regimens and better supportive care, resulting in improved clinical outcomes, acute graft-versus-host disease (aGvHD) continues to be a major obstacle and, although it principally involves the skin, gastrointestinal tract, and liver, the thymus is also a primary target. An important aim following HSCT is to achieve complete and durable immunoreconstitution with a diverse T-cell receptor (TCR) repertoire to recognize a broad range of pathogens providing adequate long-term adaptive T-lymphocyte immunity, essential to reduce the risk of infection, disease relapse, and secondary malignancies. Reconstitution of adaptive T-lymphocyte immunity is a lengthy and complex process which requires a functioning and structurally intact thymus responsible for the production of new naïve T-lymphocytes with a broad TCR repertoire. Damage to the thymic microenvironment, secondary to aGvHD and the effect of corticosteroid treatment, disturbs normal signaling required for thymocyte development, resulting in impaired T-lymphopoiesis and reduced thymic export. Primary immunodeficiencies, in which failure of central or peripheral tolerance is a major feature, because of intrinsic defects in hematopoietic stem cells leading to abnormal T-lymphocyte development, or defects in thymic stroma, can give insights into critical processes important for recovery from aGvHD. Extracorporeal photopheresis is a potential alternative therapy for aGvHD, which acts in an immunomodulatory fashion, through the generation of regulatory T-lymphocytes (Tregs), alteration of cytokine patterns and modulation of dendritic cells. Promoting normal central and peripheral immune tolerance, with selective downregulation of immune stimulation, could reduce aGvHD, and enable a reduction in other immunosuppression, facilitating thymic recovery, restoration of normal T-lymphocyte ontogeny, and complete immunoreconstitution with improved clinical outcome as the ability to fight infections improves and risk of secondary malignancy or relapse diminishes.
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Affiliation(s)
- Aisling M Flinn
- Medical School, Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
| | - Andrew R Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University , Newcastle upon Tyne , UK
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11
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Abstract
Acute graft-versus-host disease (aGvHD) continues to be a major obstacle to allogeneic haematopoietic stem cell transplantation. Thymic damage secondary to aGvHD along with corticosteroids and other non-selective T lymphocyte-suppressive agents used in the treatment of aGvHD concurrently impair thymopoiesis and negatively impact on immunoreconstitution of the adaptive immune compartment and ultimately adversely affect clinical outcome. Extracorporeal photopheresis (ECP) is an alternative therapeutic strategy that appears to act in an immunomodulatory fashion, potentially involving regulatory T lymphocytes and dendritic cells. By promoting immune tolerance and simultaneously avoiding systemic immunosuppression, ECP could reduce aGvHD and enable a reduction in other immunosuppression, allowing thymic recovery, restoration of normal T lymphopoiesis, and complete immunoreconstitution with improved clinical outcome. Although the safety and efficacy of ECP has been demonstrated, further randomised controlled studies are needed as well as elucidation of the underlying mechanisms responsible and the effect of ECP on thymic recovery.
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Affiliation(s)
- Aisling M Flinn
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew R Gennery
- Primary Immunodeficiency Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; Paediatric Haematopoietic Stem Cell Unit, Great North Children's Hospital, Newcastle upon Tyne, UK
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12
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Flinn AM, Travers CP, Laffan EE, O'Donnell CPF. Estimating the endotracheal tube insertion depth in newborns using weight or gestation: a randomised trial. Neonatology 2015; 107:167-72. [PMID: 25592171 DOI: 10.1159/000369375] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/28/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND When intubating newborns, clinicians aim to place the tip of the endotracheal tube (ETT) in the mid-trachea. Clinicians usually estimate the ETT insertion depth based on weight. ETT tips are often incorrectly positioned in newborns. Estimating the insertion depth based on gestation may be more accurate. OBJECTIVE To determine whether estimating the ETT insertion depth using gestation, compared to weight, results in more correctly placed ETTs. METHODS Newborn infants without congenital anomalies who were intubated orally were randomised to having their ETT insertion depth estimated using weight [insertion depth (cm) = weight (kg) + 6] or gestation [value determined from a table]. The primary outcome was correct ETT position, defined as an ETT tip between the upper border of the first thoracic vertebra (T1) and the lower border of the second thoracic vertebra (T2) on a chest X-ray. The primary outcome was determined by one paediatric radiologist who was masked to group assignment. RESULTS Ninety infants were enrolled and the groups were well matched. The proportion of correctly placed ETTs was not significantly different between the groups [weight, 25/49 (51%), vs. gestation, 16/41 (39%), p = 0.293]. We found no significant differences in the secondary outcomes measured. CONCLUSION Estimating the ETT insertion depth in newborns using gestation compared to weight did not result in more correctly placed ETTs.
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13
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Abstract
Identifications of ubiquinone isoprenologues are presented for isolates identified with six species of Taphrina and for isolates of the two species of Symbiotaphrina. All had Q-10 as the major ubiquinone system. The inclusion of T. populina and S. buchneri, the respective type species, establishes this as the value for these genera. Both species of Symbiotaphrina were urease positive even though, according to the literature, they are unable to utilize urea as a sole nitrogen source. The urease results for the Taphrina isolates were mixed.
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Affiliation(s)
- R T Moore
- Department of Biological & Biomedical Sciences, University of Ulster, Coleraine, Northern Ireland
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14
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Flinn AM, Atkins CA, Pate JS. Significance of photosynthetic and respiratory exchanges in the carbon economy of the developing pea fruit. Plant Physiol 1977; 60:412-8. [PMID: 16660104 PMCID: PMC542627 DOI: 10.1104/pp.60.3.412] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The nutritional economy of the developing fruit of Pisum sativum L. (cv. Greenfeast) was studied in terms of intake of translocate, incorporation of C and N into dry matter, transpiration, and CO(2) exchanges of the fruit with its external and internal atmospheres. The environmental conditions were 12-hr days (22 C, 850 mueinsteins m(-2) sec(-1) at fruit level); 12-hr nights of 15 C.Between 6 and 30 days after anthesis, pod photosynthesis resulted in small gains of CO(2) from the external atmosphere, and assimilated most of the CO(2) respired by the fruit during the day. From then until maturity (40 days) the fruit lost CO(2) during the day. Night losses of CO(2) increased with fruit age.The gas cavity of the fruit contained 0.15 to 1.5% (v/v) CO(2). Lower levels were maintained in the day than at night. CO(2) levels were influenced by fruit age, radiant flux, and temperature. Labeled CO(2) injected into the gas cavity was fixed by the pod but not by seeds in the light, and by neither pod nor seeds in darkness. Dark-to-light or light-to-dark transfer of a fruit promoted rapid changes in CO(2) and O(2) levels of the gas space, consistent with a shift in the assimilation-respiration balance of the pod.The fruit transpired 27.6 cm(3) H(2)O per gram dry matter accumulated. Daytime ventilation was greatest 12 to 15 days after anthesis and declined as pod photosynthesis became increasingly involved in the retrieval of CO(2) respired by pod and seeds. Most, 69% by weight, of the translocate from the parent plant was converted to dry matter of seeds; nearly half, 45%, to useful seed reserves (sugar plus starch-protein-oil, 45:20:1). Illumination resulted in a fruit requiring 16% less translocate than if laying down an equal amount of dry matter in darkness.
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Affiliation(s)
- A M Flinn
- Department of Botany, University of Western Australia, Nedlands, Western Australia 6009
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Smith DL, Flinn AM. Histology and histochemistry of the cotyledons of pisum arvense L. during germination. Planta 1967; 74:72-85. [PMID: 24549873 DOI: 10.1007/bf00385172] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/1966] [Indexed: 06/03/2023]
Abstract
The mature cotyledon of Pisum arvense L. comprises several distinct tissue regions; these are the epidermis, hypodermis, storage parenchyma and procambium. The storage parenchyma includes two zones: an outer abaxial zone and an inner adaxial zone. The cells of both zones contain abundant starch grains and protein bodies. Scattered through the storage tissue but increasing in frequency towards the periphery are certain cells which differ to a slight extent from the majority of the parenchyma cells. They have a more opaque, granular cytoplasm and a higher level of cytoplasmic RNA. the cotyledon has a complex, reticulate vascular system. Differentiation of the conducting elements from the procambium appears to begin about 12 hours and to be completed 48 hours after the commencement of imbibition. Differentiation of phloem preceeds that of xylem. The relationship between the timing of vascular differentiation and various physiological events in the cotyledon is discussed.Mobilization of the reserves in the storage parenchyma is initiated at the periphery of the cotyledon and proceeds inwards. There appears to be a correlation between the breakdown of the reserves and changes in DNA and RNA content of the cells.
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Affiliation(s)
- D L Smith
- Botany Department, Queen's University, Belfast, Northern Ireland
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Flinn AM, Smith DL. The localization of enzymes in the cotyledons of Pisum arvense L. during germination. Planta 1967; 75:10-22. [PMID: 24550010 DOI: 10.1007/bf00380834] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/1966] [Indexed: 06/03/2023]
Abstract
Enzyme activity is not uniformly distributed through the cotyledon of Pisum arvense. Initially the peripheral region, certain scattered cells of the storage tissue and the procambium show a high level of activity of succinic dehydrogenase, cytochrome oxidase, acid phosphatase and esterase. Activity of acid phosphatase declines sharply after the first day of germination; activity of the other enzymes declines after about three days. In the storage tissue, where activity is lower initially, it declines after about five days and is correlated with the disappearance of the reserves. The pattern of alkaline phosphatase activity is similar except that activity is lower in the procambium but increases in the sieve-elements during differentiation of the phloem. 5-nucleotidase and glucose-6-phosphatase activity is low throughout the cotyledon but it also increases to a significant level in the sieve-elements. Activity of starch synthesizing enzymes is high in the parenchymatous bundle sheath, where they may be involved in the pathway from lipids to soluble carbohydrates.
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Affiliation(s)
- A M Flinn
- Botany Department, Queen's University, Belfast, Northern Ireland
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