Inhibition of IL-25/IL-17RA improves immune-related adverse events of checkpoint inhibitors and reveals antitumor activity

BACKGROUND

Immune checkpoint inhibitors (ICIs) have improved outcomes and extended patient survival in several tumor types. However, ICIs often induce immune-related adverse events (irAEs) that warrant therapy cessation, thereby limiting the overall effectiveness of this class of therapeutic agents. Currently, available therapies used to treat irAEs might also blunt the antitumor activity of the ICI themselves. Therefore, there is an urgent need to identify treatments that have the potential to be administered alongside ICI to optimize their use.

METHODS

Using a translationally relevant murine model of anti-PD-1 and anti-CTLA-4 antibodies-induced irAEs, we compared the safety and efficacy of prednisolone, anti-IL-6, anti-TNFɑ, anti-IL-25 (IL-17E), and anti-IL-17RA (the receptor for IL-25) administration to prevent irAEs and to reduce tumor size.

RESULTS

While all interventions were adequate to inhibit the onset of irAEs pneumonitis and hepatitis, treatment with anti-IL-25 or anti-IL-17RA antibodies also exerted additional antitumor activity. Mechanistically, IL-25/IL-17RA blockade reduced the number of organ-infiltrating lymphocytes.

CONCLUSION

These findings suggest that IL-25/IL-17RA may serve as an additional target when treating ICI-responsive tumors, allowing for better tumor control while suppressing immune-related toxicities.

SLAMF6 compartmentalization enhances T cell functions

Signaling lymphocyte activation molecule family member 6 (SLAMF6) is a T cell co-receptor. Previously, we showed that SLAMF6 clustering was required for T cell activation. To better understand the relationship between SLAMF6 location and function and to evaluate the role of SLAMF6 as a therapeutic target, we investigated how its compartmentalization on the cell surface affects T cell functions. We used biochemical and co-culture assays to show that T cell activity is enhanced when SLAMF6 colocalizes with the CD3 complex. Mechanistically, co-immunoprecipitation analysis revealed the SLAMF6-interacting proteins to be those essential for signaling downstream of T cell receptor, suggesting the two receptors share downstream signaling pathways. Bispecific anti-CD3/SLAMF6 antibodies, designed to promote SLAMF6 clustering with CD3, enhanced T cell activation. Meanwhile, anti-CD45/SLAMF6 antibodies inhibited SLAMF6 clustering with T cell receptor, likely because of the steric hindrance, but nevertheless enhanced T cell activation. We conclude that SLAMF6 bispecific antibodies have a role in modulating T cell responses, and future work will evaluate the therapeutic potential in tumor models.

Single-cell RNA sequencing reveals distinct T cell populations in immune-related adverse events of checkpoint inhibitors

PD-1 is an inhibitory receptor in T cells, and antibodies that block its interaction with ligands augment anti-tumor immune responses. The clinical potential of these agents is limited by the fact that half of all patients develop immune-related adverse events (irAEs). To generate insights into the cellular changes that occur during anti-PD-1 treatment, we performed single-cell RNA sequencing of circulating T cells collected from patients with cancer. Using the K-nearest-neighbor-based network graph-drawing layout, we show the involvement of distinctive genes and subpopulations of T cells. We identify that at baseline, patients with arthritis have fewer CD8 TCM cells, patients with pneumonitis have more CD4 TH2 cells, and patients with thyroiditis have more CD4 TH17 cells when compared with patients who do not develop irAEs. These data support the hypothesis that different populations of T cells are associated with different irAEs and that characterization of these cells' pre-treatment has the potential to serve as a toxicity-specific predictive biomarker.

Neutralization of the adaptor protein PAG by monoclonal antibody limits murine tumor growth

The transmembrane adaptor phosphoprotein associated with glycosphingolipid-enriched microdomains 1 (PAG) is phosphorylated in T cells downstream of PD-1 signaling and contributes to the resulting functional inhibition of multiple cellular processes. Furthermore, PAG expression is negatively correlated with survival in multiple human tumors and is a driver of murine tumor growth and immune evasion. Here we develop an antibody that targets the extracellular domain of human PAG, with cross-reactivity to murine PAG. We demonstrate that this antibody binds to extracellular PAG on intact cells and affects T cell activation. Finally, we show that administration of anti-PAG monoclonal antibody in combination with anti-PD-1 antibody to mice bearing MC38 tumors limited tumor growth and enhanced T cell infiltration to tumors.

807 The Association between Blood Transfusion and Outcome in Hip Fracture Patients

Aim

Hip Fractures are endemic in older adults across Europe, with potential increases in incidence expected as the population ages. Management of blood loss and anaemia is a mainstay of care for these patients, but there is still significant debate regarding balance between benefit and risk of liberal versus restrictive transfusion policies. Understanding the association between providing blood products and adverse healthcare outcomes in hip fracture patients is a key component in the transfusion decision-making process.

Method

This retrospective cohort study uses national audit data from the Scottish Hip Fracture Audit (SHFA) and the Scottish National Blood Transfusion Service (SNBTS) to examine the association between blood transfusion and important hip fracture process of care measures and healthcare outcomes.

Results

A total of 28 461 patient records were included for assessment across 19 acute hospitals. Blood transfusion during admission was associated with a small but statistically significant decrease in survival at both 30 and 60 days. Those receiving blood transfusion during admission were less likely to be mobilised by the end of the 1st post-operative day, less likely to have a length of stay below the average and had far lower probability of discharge.

Conclusion

This study found that blood transfusion is associated with poor healthcare outcomes following hip fracture, even when adjusted for potential confounding factors. This likely reflects the potential harm of perioperative anaemia rather than any direct impact from transfusion. Further work to reduce perioperative blood loss is therefore key to improving important hip fracture outcomes.

Immunohistochemistry of Immune Cells and Cells Bound to in vivo Administered Antibodies in Liver, Lung, Pancreas, and Colon of B6/lpr Mice

Employing a novel mouse model of immune related adverse events (irAEs) induced by combination of anti-PD1 and anti-CTLA-4 antibodies, we visualized immune infiltration into the liver, lung, pancreas, and colon. Here, we describe the avidin-biotin conjugate (ABC) method used to stain T cells (CD4 and CD8), B cells (CD19), macrophages (F4/80), and cells bound by the in vivo administered rat anti-mouse antibodies for chromogenic immunohistochemistry (IHC). Using a biotinylated goat anti-rat antibody, we detected the localization of cells bound to the in vivo antibodies for PD-1 and CTLA-4. IHC has advantages over other techniques, namely antibody availability, resistance to photobleaching, and greater sensitivity. Additionally, detection and localization of in vivo antibodies can be used in mice models to infer their therapeutic efficacy, stability, and function. Graphical abstract.

Baseline peripheral T-cell composition in relation to radiographic phenotypes of immune-related pneumonitis

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Background: Pneumonitis is one of the most morbid complications from immune checkpoint inhibitor (ICI) treatment, but pathogenic mechanisms are unclear and no biomarkers permit pre-treatment risk assessment. We sought to characterize peripheral T cell subsets of pneumonitis patients on the single cell level. Methods: Blood was collected before and during ICI treatment in 24 patients. Cells were processed for single cell RNA sequencing (scRNAseq) employing CITEseq methodology using multiplexed cell surface markers labelled with a cocktail of oligonucleotide-tagged Total-Seq anti-human antibodies against CD4, CD8, CD45RA and CD27 followed by Chromium 10X sequencing. Principal Component Analysis was performed with iCellR, K-nearest-neighbor-based Network graph drawing Layout, and PhenoGraph clustering to assign cell types. CT scans were performed per standard of care and were reviewed by an experienced thoracic radiologist. Results: Seven of 24 patients developed pneumonitis; 9 did not experience an immune-related adverse event, and the remainder experienced arthritis (4), thyroiditis (3), or neurotoxicity (1). Pneumonitis patients had expanded proportions of TH2 TCF7+ T cells at baseline as compared to the other patients. Radiographically, two patients’ pneumonitis manifested as Chronic Hypersensitivity Pneumonitis (CHP), and four had Organized Pneumonia (OP). At baseline, CHP patients had significantly lower levels of CD8+ TCM cells (CXCR3+), double-positive T cells, gamma-delta T cells, and higher levels of naïve-like CD4+ TN TCF7+LEF1+ and CD4+ TH1/2 CXCR3+GATA3+ cells compared to OP. Gene expression levels also distinguished between these radiographic phenotypes. Conclusions: The peripheral T cell composition of patients who developed pneumonitis was distinct from those who did not in our cohort and unique by radiographic manifestation, suggesting potential pathogenic mechanisms and a prelude to circulating predictive markers of ICI toxicity.

PD-1-stimulated T cell subsets are transcriptionally and functionally distinct

Despite the obvious inhibitory outcome of PD-1 signaling, an additional series of functions are activated. We have observed that T cells stimulated through the T cell receptor (TCR) and PD-1 primarily do not proliferate; however, there is a population of cells that proliferates more than through TCR stimulation alone. In this study, we performed flow cytometry and RNA sequencing on individual populations of T cells and discovered that unlike naive T cells, which were inhibited following PD-1 ligation, T cells that proliferated more following PD-1 ligation were associated with effector and central memory phenotypes. We showed that these populations had different gene expression profiles following PD-1 ligation with PD-L1 compared to PD-L2. The presence of transcriptionally and functionally distinct T cell populations responsive to PD-1 ligation provides new insights into the biology of PD-1 and suggest the use of T cell subset-specific approaches to improve the clinical outcome of PD-1 blockade.

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Most of the genes induced or regulated by PD-1 are T cell subsets specific

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PD-1 ligation with PD-L1 or PD-L2 results in diverged transcriptomic signatures

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PD-1-induced STAT1 upregulation correlates with responses to checkpoint blockade

SHP2 Targets ITK Downstream of PD-1 to Inhibit T Cell Function

PD-1 is a critical therapeutic target in cancer immunotherapy and antibodies blocking PD-1 are approved for multiple types of malignancies. The phosphatase SHP2 is the main effector mediating PD-1 downstream signaling and accordingly attempts have been made to target this enzyme as an alternative approach to treat immunogenic tumors. Unfortunately, small molecule inhibitors of SHP2 do not work as expected, suggesting that the role of SHP2 in T cells is more complex than initially hypothesized. To better understand the perplexing role of SHP2 in T cells, we performed interactome mapping of SAP, an adapter protein that is associated with SHP2 downstream signaling. Using genetic and pharmacological approaches, we discovered that SHP2 dephosphorylates ITK specifically downstream of PD-1 and that this event was associated with PD-1 inhibitory cellular functions. This study suggests that ITK is a unique target in this pathway, and since ITK is a SHP2-dependent specific mediator of PD-1 signaling, the combination of ITK inhibitors with PD-1 blockade may improve upon PD-1 monotherapy in the treatment of cancer.

Transmembrane adaptor protein PAG is a mediator of PD-1 inhibitory signaling in human T cells

The inhibitory receptor PD-1 is expressed on T cells to inhibit select functions when ligated. The complete signaling mechanism downstream of PD-1 has yet to be uncovered. Here, we discovered phosphoprotein associated with glycosphingolipid-enriched microdomains 1 (PAG) is phosphorylated following PD-1 ligation and associate this with inhibitory T cell function. Clinical cohort analysis correlates low PAG expression with increased survival from numerous tumor types. PAG knockdown in T cells prevents PD-1-mediated inhibition of cytokine secretion, cell adhesion, CD69 expression, and ERK204/187 phosphorylation, and enhances phosphorylation of SRC527 following PD-1 ligation. PAG overexpression rescues these effects. In vivo, PAG contributes greatly to the growth of two murine tumors, MC38 and B16, and limits T cell presence within the tumor. Moreover, PAG deletion sensitizes tumors to PD-1 blockade. Here PAG is established as a critical mediator of PD-1 signaling and as a potential target to enhance T cell activation in tumors.

Data on the identification of VRK2 as a mediator of PD-1 function

Therapeutic programmed cell death protein 1 (PD-1) blockade enhances T cell mediated anti-tumor immunity, but many patients do not respond, and a significant proportion develops inflammatory toxicities. To develop better therapeutics and to understand the signaling pathways downstream of PD-1 we performed phosphoproteomic interrogation of PD-1 to identify key mediators of PD-1 signaling. Hereby, supporting data of the research article "VRK2 inhibition synergizes with PD-1 blockade to improve T cell responses" are presented. In the primary publication, we proposed that VRK2 is a unique therapeutic target and that combination of VRK2 inhibitors with PD-1 blockade may improve cancer immunotherapy. Here, we provide data on the effect of other kinases on PD-1 signaling utilizing shRNA knockdown of the different kinases in Jurkat T cells. In addition, we used VRK2 inhibition by a pharmacologic approach in the MC38 tumor mouse model, to show the combined outcome of anti PD-1 treatment with VRK2 inhibition. These data provide additional targets downstream PD-1 and point toward methods of testing the effect of the inhibition of these targets on tumor progression in vivo.

VRK2 inhibition synergizes with PD-1 blockade to improve T cell responses

Therapeutic programmed cell death protein 1 (PD-1) blockade enhances T cell mediated anti-tumor immunity but many patients do not respond and a significant proportion develops inflammatory toxicities. To develop better therapeutics and to understand the signaling pathways downstream of PD-1 we performed phosphoproteomic analysis of PD-1 and identified vaccinia related kinase 2 (VRK2) as a key mediator of PD-1 signaling. Using genetic and pharmacological approaches, we discovered that VRK2 is required for PD-1-induced phosphorylation of the protein p21 activated kinase 2 (PAK2), and for the inhibition of IL-2, IL-8, and IFN-γ secretion. Moving into in vivo syngeneic tumor models, pharmacologic inhibition of VRK2 in combination with PD-1 blockade enhanced tumor clearance through T cell activation. This study suggests that VRK2 is a unique therapeutic target and that combination of VRK2 inhibitors with PD-1 blockade may improve cancer immunotherapy.

A novel mouse model for checkpoint inhibitor-induced adverse events

Immune checkpoint inhibitors have demonstrated significant efficacy in the treatment of a variety of cancers, however their therapeutic potential is limited by abstruse immune related adverse events. Currently, no robust animal model exists of checkpoint inhibitor-induced adverse events. Establishing such a model will improve our mechanistic understanding of this process, which in turn will inform design of improved therapies. We developed a mouse model to determine inflammatory toxicities in response to dual checkpoint blockade in the presence of syngeneic tumors. Mice from susceptible genetic backgrounds received intraperitoneal injections of anti-mouse PD-1 and CTLA-4 antibodies. The mice were monitored for weight loss and histologic evidence of inflammation. Blood was collected for basic metabolic panels and titers of anti-nuclear antibodies. In parallel, mice were also treated with prednisolone, which is commonly used to treat immune related adverse events among cancer patients. Among all the genetic backgrounds, B6/lpr mice treated with anti-CTLA-4 and anti-PD-1 antibodies developed more substantial hepatitis, pancreatitis, colitis, and pneumonitis characterized by organ infiltration of immune cells. Mice that developed tissue infiltration demonstrated high serum levels of glucose and high titers of anti-nuclear antibodies. Finally, while administration of prednisolone prevented the development of the inflammatory adverse events, it also abrogated the protective anti-tumor effect of the checkout inhibitors. Genetic background and treatment modalities jointly modified the inflammatory adverse events in tumor bearing mice, suggesting a complex mechanism for checkpoint inhibitor-related inflammation. Future studies will assess additional genetic susceptibility factors and will examine possible contributions from the administration of other anti-inflammatory drugs.

Acute fibrinous pleuropneumonia and septicaemia caused by Bibersteinia trehalosi in neonatal calves in New Zealand

Case history: In July and August 2019, 15/40, ≤48-hour-old calves became acutely ill. The calves were all born on-farm, transferred to pens soon after birth, and fed with "gold" colostrum. The hygiene, biosecurity and ventilation in the pens were poor. Of the 15 calves, 11 died or were euthanised and four calves, ≤48-hour-old, that became acutely ill later in the outbreak were treated with cefquinome, a fourth-generation cephalosporin, and recovered. Clinical findings: The affected calves presented with acute recumbency, lethargy, tachypnoea, tachycardia, increased lung sounds, inability to stand or feed, and dehydration without pyrexia. Pathological findings: Gross findings in a calf that died naturally included fibrinous pleuropneumonia, marked oedematous expansion of the interlobular septa, especially in the ventral lung lobes, fibrinous polyserositis and fibrinous polyarthritis. A second calf that was euthanised had strikingly similar lung lesions. Histologically, the pulmonary interlobular septa of both calves were prominently expanded by oedema, dilated lymphatics and the infiltration of numerous neutrophils and macrophages interspersed with small Gram-negative rod bacteria. Likewise, the visceral pleura showed fibrinopurulent inflammation with numerous small Gram-negative rods. Microbiological findings: Microbial culture and matrix-assisted laser desorption ionisation time-of-flight (MALDI-TOF) mass spectrometry identified Bibersteinia trehalosi in the lung, stifle joint and peritoneal cavity of the first calf and lung of the second. Diagnosis: B. trehalosi acute fibrinous pleuropneumonia and septicaemia. Clinical relevance: This is the first report of the clinical findings and histological lesions of B. trehalosi pleuropneumonia and septicaemia in calves in New Zealand. The pathogen is isolated with increasing frequency from cases of bovine respiratory disease in dairy cows, feedlot cattle and calves in the United Kingdom and North America. The importance of microbial culture in cases such as this with unusual lung lesions in calves <48 hours of age, cannot be over emphasised. Cefquinome was administered to all remaining heifer calves and four calves that became ill later in the outbreak recovered after cefquinome treatment.

PLCε1 suppresses tumor growth by regulating murine T cell mobilization

Phospholipase C epsilon 1 (PLCε1) is a unique member of the phospholipase family, in that it also functions as a guanine nucleotide exchange factor (GEF) for the small GTPase Rap1. It is this function as a Rap1 GEF that gives PLCε1 an essential role in chemokine-mediated T cell adhesion. We have utilized a syngeneic tumor model, MC38 cells in C57BL/6 mice, and observed that tumors grow larger and more quickly in the absence of PLCε1. Single-cell analysis revealed an increased CD4⁺ /CD8⁺ ratio in the spleens, lymph nodes and tumors of PLCε1 knock-out tumor-bearing mice. T cells isolated from PLCε1 knock-out mice were less activated by multiple phenotypical parameters than those from wild-type mice. We additionally noted a decrease in expression of the chemokine receptors C-X-C chemokine receptor type 4 (CXCR4) and C-C motif chemokine receptor 4 (CCR4) on CD4⁺ T cells from the spleens, lymph nodes and tumors of PLCε1 knock-out mice compared to wild-type mice, and diminished migration of PLCε1-depleted CD3⁺ T cells towards stromal cell-derived factor (SDF)-1α. Based on these results, we conclude that PLCε1 is a potential regulator of tumor-infiltrating lymphocytes, functioning, at least in part, at the level of T cell trafficking and recruitment.

SLAMF6 clustering is required to augment T cell activation

The signaling lymphocytic activation molecule (SLAM) family is comprised of nine distinct receptors that are expressed exclusively on hematopoietic cells. Most of these transmembrane receptors are homotypic by nature and downstream signaling occurs when cells that express the same SLAM receptor interact. Previous studies have determined that anti-SLAMF6 antibodies can have a therapeutic effect in autoimmunity and cancer. However, little is known about the role of SLAMF6 in the adaptive immune responses and in order to utilize SLAMF6 interventional approaches, a better understanding of the biology of this receptor in T cell is warranted. Accordingly, the objective of our study was to investigate both functionally and structurally the role of SLAMF6 in T cell receptor (TCR) mediated responses. Biochemical and genetic experiments revealed that SLAMF6 was required for productive TCR downstream signaling. Interestingly, SLAMF6 ectodomain was required for its function, but not for its recruitment to the immunological synapse. Flow-cytometry analysis demonstrated that tyrosine 308 of the tail of SLAMF6 was crucial for its ability to enhance T cell function. Imaging studies revealed that SLAMF6 clustering, specifically with the TCR, resulted in dramatic increase in downstream signaling. Mechanistically, we showed that SLAMF6 enhanced T cell function by increasing T cell adhesiveness through activation of the small GTPase Rap1. Taken together SLAMF6 is an important regulator of T cell activation where both its ectodomain and its endodomain contribute differentially to T cell functions. Additional studies are underway to better evaluate the role of anti-SLAMF6 approaches in specific human diseases.

EF Hand Domain Family Member D2 Is Required for T Cell Cytotoxicity

Programmed cell death 1 (PD-1) is a major coinhibitory receptor and a member of the immunological synapse (IS). To uncover proteins that regulate PD-1 recruitment to the IS, we searched for cytoskeleton-related proteins that also interact with PD-1 using affinity purification mass spectrometry. Among these proteins, EF hand domain family member D2 (EFHD2), a calcium binding adaptor protein, was functionally and mechanistically analyzed for its contribution to PD-1 signaling. EFHD2 was required for PD-1 to inhibit cytokine secretion, proliferation, and adhesion of human T cells. Interestingly, EFHD2 was also required for human T cell-mediated cytotoxicity and for mounting an antitumor immune response in a syngeneic murine tumor model. Mechanistically, EFHD2 contributed to IS stability, lytic vesicles trafficking, and granzyme B secretion. Altogether, EFHD2 is an important regulator of T cell cytotoxicity and further studies should evaluate its role in T cell-mediated inflammation.

Application of risk management techniques for the remediation of an old mining site in Greece

This article summarizes the project and risk management of a remediation/reclamation project in Lavrion, Greece. In Thoricos the disposal of mining and metallurgical wastes in the past resulted in the contamination with heavy metals and acid mine drainage. The objective of this reclamation project was to transform this coastal zone from a contaminated site to an area suitable for recreation purposes. A separate risk assessment study was performed to provide the basis of determining the relevant environmental contamination and to rate the alternative remedial schemes involved. The study used both existing data available from comprehensive studies, as well as newly collected field data. For considering environmental risk, the isolation and minimization of risk option was selected, and a reclamation scheme, based on environmental criteria, was applied which was comprised of in situ neutralization, stabilization and cover of the potentially acid generating wastes and contaminated soils with a low permeability geochemical barrier. Additional measures were specifically applied in the areas where highly sulphidic wastes existed constituting active acid generation sources, which included the encapsulation of wastes in HDPE liners installed on clay layers.

Oral graft vs. host disease in children--treatment with topical tacrolimus ointment

Oral chronic graft vs. host disease (GVHD) frequently presents in patients with sclerotic features of skin GVHD and is often associated with considerable limitations of oral food intake and decreased quality of life. Systemic tacrolimus is efficacious for prophylaxis and treatment of acute and chronic GVHD and topical tacrolimus has shown activity in chronic GVHD skin lesions. We therefore initiated a pilot study to investigate the safety and efficacy of topical tacrolimus ointment in children with oral GVHD. Six patients suffering from oral GVHD (five chronic and one acute) were included in the study. Tacrolimus ointment 0.1% was applied twice daily using sterile gauze. The only side-effects observed were a slight burning discomfort after the first application in one patient and after food intake in another patient. Tacrolimus was absorbed systemically in four of six patients. Of six patients, we observed a complete response in two, a very good partial response (VGPR) in two, and a PR in two patients, respectively. We conclude that topical application of tacrolimus ointment holds promise as a safe and efficacious treatment for oral GVHD in children. The Food and Drug Administration has recently issued a health advisory about a potential cancer risk associated with topical tacrolimus treatment of the skin; therefore, its benefits should be weighed against its potential risks and diligent long-term follow-up should be carried out especially in children.

Feasibility of brief tobacco cessation advice for tuberculosis patients: a study from Sudan

SETTING

Twenty-four health care centres in Sudan.

OBJECTIVE

To examine the feasibility of introducing a tobacco cessation intervention into tuberculosis (TB) treatment programmes.

DESIGN

A feasibility study of a tobacco cessation intervention for new cases of pulmonary tuberculosis (PTB) in men compared survey centres (controls) and tobacco cessation intervention centres. Feasibility was evaluated by examining 1) acceptance by health staff and 2) the impact of additional tasks on TB treatment outcomes. A secondary assessment looked at rate of stopping tobacco use among those enrolled in the intervention condition.

RESULTS

Staff members did not differ in personal use of tobacco, in enforcing rules banning the use of tobacco at health centres or in rates of recruitment into the study. A total of 513 patients (44% of those eligible) were enrolled. Differences in TB treatment success were found between patients who were enrolled and those who were not: respectively 83% and 59% were cured or completed treatment. Of identified tobacco users undergoing the cessation intervention, 66% reported abstinence at the end of their TB treatment.

CONCLUSION

Although differences existed between patients enrolled or not enrolled, the intervention was demonstrated to be feasible to implement and effective for those enrolled within routine TB services.

HLA antigens in Greek children with allergic bronchial asthma

The aim of our study was to investigate the genetic linkage between mite allergic bronchial asthma and HLA class I and II antigens and haplotypes. Sixty Greek children with allergic bronchial asthma due to mite sensitivity (Dermatophagoides pteronyssinus and Dermatophagoides farinae) and their family members were typed for HLA class I and II antigens (total 263 subjects). One hundred and twenty-five healthy, unrelated Greek children without medical history of atopy were also typed as control group. Major histocompatibility complex class I and II gene analysis revealed that only HLA-DRB1*04 and HLA-DQA1*0301 alleles are possibly important factors in the development of atopic asthma in Greek children with sensitivity to mites. No significant differences among the HLA-DRB1*04 subtypes have been established. Transmission disequilibrium test revealed that no specific HLA-A, -B, -DRB1, -DQA1 and -DQB1 alleles were transmitted preferentially to the affected children. HLA-DQB1*0301-4 alleles were associated with high levels of total serum immunoglobulin E in affected children. The study of the HLA haplotypes failed to demonstrate any significant association between any extended or natural selection haplotype and mite allergic bronchial asthma in Greek children.

Attachment disorganization and dissociative symptoms in clinically treated adolescents

OBJECTIVE

To examine the association of unresolved and unclassifiable attachment with dissociative symptomatology in a sample of 133 adolescents in psychiatric treatment.

METHOD

The study compared 69 adolescents who were unresolved and unclassifiable with 64 adolescents who were not unresolved and unclassifiable. Attachment organization was assessed using the Adult Attachment Interview (AAI). Dissociative symptomatology was assessed using a scale derived from the Youth Self Report (YSR) behaviour checklist.

RESULTS

A continuing unresolved and unclassifiable response to attachment-related trauma was correlated with dissociative symptomatology for both male and female adolescents.

CONCLUSIONS

Cognitive disorganization may be an important variable mediating between the effects of earlier traumatic caregiving experiences and later dissociative symptoms.

HLA class II DNA-RFLP typing in 102 individuals from Northern Greece

The serological identification of HLA class II alleles is often doubtful. Since accurate HLA typing is essential for the matching of donor-recipient pairs in allogeneic transplantation, an effort was made to establish DNA restriction fragment length polymorphism (RFLP) typing and to assess the correlation between the serological and RFLP techniques in the population of Northern Greece. One hundred and two healthy individuals (204 HLA-DR alleles) from Northern Greece were HLA-DR, DQ typed with both the microcytotoxicity and the Taq I RFLP method, using three exon-specific probes. DNA-RFLP typing revealed (1) concordant results with serology in 69.9% (142/204) of the alleles and (2) at least one HLA-DR allele discrepant to serology in 30.4% (62/204) of the alleles. Incorrect serological DR types (weak reactions or inability to distinguish between two alleles with a common epitope) were identified in 54 alleles (26.5%), while 3.9% (8/204) of serological "blank" alleles turned out to be definable alleles by RFPL. Of the individuals tested, 10.8% (11/102) were DR-homozygous by RFLP. This comparison of results obtained by serology and RFLP demonstrated the necessity of the clinical application of DNA typing, especially for organ transplantation where accurate HLA typing has an important influence on graft survival.

Selection of the most compatible graft recipient by computer program, used in regional tissue typing laboratory of Hellas (R.T.T.L.)

The purpose of this study was to present the new computer program that we developed in the regional tissue typing laboratory (R.T.T.L.) and use for the selection of the most suitable recipient for cadaveric allografts in a more efficient way. This new program was written and compiled in TURBO PASCAL 6.0, sorts all possible recipients to the HLA type of a donor, checks for the existence of splits and utilises them, and when requested, gives out results to more specific inquiries, i.e. all compatible recipients from 2DR2B2A to 1DR0B0A matching. It can also forecast success percentages according to different factors, i.e. combination of donor's and recipient's ages, HLA matching etc. The material used for this study were the patients who are registered in the formal cadaveric transplantation list of R.T.T.L. We have used this program since 2 January 1992 together with the old one. Since then we found that the new program is faster in sorting all the possible recipients of cadaveric renal allografts according to the criteria already mentioned. The total selection time, with all the criteria activated, averages a few seconds, whereas with the old program it took approximately 2 min just for the sorting of HLA matching, without any other criteria activated. In the printout of the final result of each inquiry are all the possible recipients in the sorted order together with relevant data (telephone number, address etc.). As a result, the laboratory personnel has been free from the tedious task of this sorting which was initially done by hand and the possibility of error has been eliminated. The program was developed exclusively by doctors and all the updates needed are done by the users. More important, however, is the fact that in many cases the time of cold ischaemia was reduced by more than 30 min with all the obvious advantages for the longevity of the graft's life.

Can HLA typing predict the outcome of grass pollen immunotherapy?

OBJECTIVE

The aim of this study was to investigate the relationship between HLA molecules and the positive or negative response of atopic patients to specific immunotherapy (SIT).

METHODS

We studied 42 atopic multisensitive patients undergoing grass pollen immunotherapy, 42 parents of patients (30 mothers and 12 fathers) and 173 control individuals. HLA class I and class II antigens were typed by a microlymphocytotoxicity test. The typing of DRB1* alleles for atopic patients and their parents was based on the reverse hybridization principle, while for the control group, DNA-RFLP and PCR-SSP methods were used.

RESULTS

The frequency of B14 and DRB1*1101-4 antigens/alleles, as well as the A2B5DR11 haplotype, showed a statistically significant difference in those patients who responded to immunotherapy. On the other hand, HLA-A28, B8 and DRB1*0301 antigens/alleles, as well as the frequency of the A1B8 and A1B8DR3 haplotypes, were found to be significantly higher in patients who responded poorly to SIT.

DISCUSSION

Our findings support the hypothesis that treatment responsiveness may show an association to HLA molecules, which could thus play a role in the immunological selection and monitoring of atopic patient candidacy for SIT.

The Adolescent Unresolved Attachment Questionnaire: the assessment of perceptions of parental abdication of caregiving behavior

This article reports on the Adolescent Unresolved Attachment Questionnaire (AUAQ), a brief questionnaire that assesses the caregiving experiences of unresolved adolescents (as recipients of caregiving). The AUAQ was developed and validated in a large normative sample (n = 691) and a sample of 133 adolescents in psychiatric treatment. It is a self-report questionnaire consisting of 3 scales with Likert-type responses ranging from strongly disagree to strongly agree. The Aloneness/Failed Protection Scale assesses the adolescent's perception of the care provided by the attachment figure. The Fear Scale taps the fear generated by the adolescent's appraisal of failed attachment figure care. The Anger/Dysregulation Scale assesses negative affective responses to the perceived lack of care from the attachment figure. All scales demonstrated satisfactory internal reliability and agreement between scores for adolescents (n = 91) from the normative sample who completed the AUAQ twice. Adolescents in the clinical sample also completed the Adult Attachment Interview (AAI; C. George, N. Kaplan, & M. Main, 1984/1985/1996); the AUAQ demonstrated high convergent validity with the AAI.

Confirmation of paternal disomy in a twin molar pregnancy. A case report

BACKGROUND

Paternal dispermy can be the pathogenesis of complete molar pregnancy.

CASE

A 23-year-old, white woman, gravida 4, para 1, was pregnant with a twin gestation by ovulation induction with metrodin. Ultrasound evaluation confirmed an intrauterine pregnancy in conjunction with what appeared to be a hydatidiform mole. The karyotype in the molar pregnancy, obtained from chorionic villus sampling, showed a pair of paternally derived inverted chromosomes 9, confirming the diagnosis of a complete mole. Uncontrollable hemorrhage with a rapid rise in the beta-human chorionic gonadotropin titer necessitated evacuation of the uterus. The patient was followed with beta-human chorionic gonadotropin titers for a year, with no evidence of recurrence.

CONCLUSION

This case illustrates paternal disomy in a complete molar pregnancy documented by a paternal chromosome 9 inversion.

Nationwide collaborative study of HLA class II associations with distinct types of juvenile chronic arthritis (JCA) in Greece

The aim of this study was to investigate the association of different groups and subgroups of juvenile chronic arthritis (JCA) with HLA class II (DR, DP, DQ) alleles and/or haplotypes. Groups and subgroups were mainly distinguished on the basis of the type of onset, the course and complications of the disease, and some predefined disease markers according to the criteria proposed by the ILAR Standing Committee (Chile, 1994). On the basis of these criteria the following five JCA groups and their subgroups were included in the study: (1) define systemic onset (n = 25) and systemic progressing to persistent arthritis (n = 14); (2) JCA of oligoarthritis onset (O-JCA, n = 124) and of oligoarthritis onset and course (n = 98), O-JCA of early (< 6 years) or late (> 6 years) onset (EOO-JCA n = 71 and LOO-JCA n = 44), O-JCA with ANA positive (n = 69) or negative (n = 55) and O-JCA progressing to extended arthritis (n = 22); (3) JCA of polyarthritis onset (P-JCA) with rheumatic factor (RF) negative (n = 29), and P-JCA RF negative with antinuclear antibodies (ANA) positive (n = 13) or negative (n = 16); (4) JCA complicated with chronic anterior uveitis (CAU, n = 32); (5) juvenile psoriatic arthritis (n = 20). To assess the HLA allele frequencies in the above 223 Greek children with JCA, these frequencies were compared to those of 98 age-matched and 250 adult controls. The main findings were the following. A common HLA-DRB1* allele was not involved in the JCA groups and subgroups studied; on the other hand, the DQA1*0501 allele was found to be associated with different JCA groups/subgroups (O-JCA, P-JCA RF-negative ANA-positive, JCA with CAU), probably suggesting a closer relationship of this locus with the immunogenetic background of JCA. The DPB1*0201 allele was associated with the development of either EOO-JCA or CAU. Susceptibility to CAU was stronger when the DPB1*0201 was combined with the presence of DRB1*13. Another allele, DQB1*0301, was also associated with O-JCA and CAU. Finally, no specific HLA class II allele was found to be related to the presence of ANA or psoriatic lesions or to the severity of the arthritis. Our findings suggest that the wide clinical and laboratory spectrum of JCA is associated with an immunogenetic background that is linked with HLA alleles of more than one locus. Some of them, such as the DPB1*0201 allele, confer susceptibility to certain clinical onsets and courses or complications of the disease. The rapidly advancing techniques of typing of DNA profiles may lead to more definite conclusions.

Doppler echocardiography as a predictor of pregnancy outcome in the presence of aortic stenosis: A case report

Aortic stenosis in pregnancy can be a life-threatening condition, but fortunately it is rare. In the modern era, careful obstetric and cardiologic monitoring, particularly through echocardiography, have improved fetal and maternal outcomes. However, a test that could predict outcome has not been available for patients with aortic stenosis who seek prepregnancy counseling. We report a case in which exercise Doppler echocardiography was used to predict cardiac function and maximal gradients in a woman with a bicuspid aortic valve who wished to become pregnant.

Left ventricular diastolic function in normal human pregnancy

BACKGROUND

Little information is available about changes in left ventricular diastolic function during pregnancy. We used mitral inflow and pulmonary venous flow profiles to evaluate left ventricular diastolic function in 37 healthy pregnant women 26 to 41 years old (mean, 32 years).

METHODS AND RESULTS

Echocardiographic studies were performed at the end of each trimester. Eight subjects (control group) underwent similar testing 1 to 3.5 months (mean, 1.7 months) postpartum. During pregnancy, the cardiac output increased significantly as a result of an increased heart rate and, to a lesser degree, stroke volume. Significantly decreased systemic vascular resistance and increased left ventricular mass were also noted. Peak mitral flow velocity in early diastole (E) increased 13. 3% during the first trimester and remained at the high end of normal throughout pregnancy. Peak A-wave velocity (A) increased maximally in the third trimester. Compared with control subjects, first-trimester subjects had a significantly increased E/A ratio. The ratio subsequently decreased, reflecting the augmented A-wave velocity. Pulmonary venous peak systolic forward flow velocity increased, peaking in the second trimester (nonsignificant), but returned to baseline levels postpartum. The pulmonary venous diastolic time-velocity integral decreased significantly from the first to the third trimester. Peak pulmonary venous reverse flow velocity at atrial contraction increased significantly, without being markedly changed in duration.

CONCLUSIONS

Pregnancy, a chronic, natural volume-overload state, has important effects on hemodynamic and echocardiographic variables. Based on pulmonary venous flow and left ventricular inflow velocities, our results provide a standard reference concerning diastolic filling dynamics by trimester.

Frequency of HLA antigens in Graves' hyperthyroidism and mitral valve prolapse

BACKGROUND AND AIMS OF THE STUDY

An association between Graves' hyperthyroidism (G) and mitral valve prolapse (MVP) has been reported, but possible genetic linkage between the two disorders has not.

METHODS

One hundred and five patients (pts) with G were studied after therapy, in a euthyroid state. MVP (auscultatory plus echocardiographic findings) was present in 33 pts (31%). Frequency of human lymphocyte antigens (HLA) in pts with G and in pts with G plus MVP was compared to 170 normal subjects (NL). There was no difference in HLA-A antigens among the three groups.

RESULTS

The frequency of HLA B-15 was greater in pts with G plus MVP (18.9%) compared to NL (3%) and to G without MVP (4.2), p < 0.01. The frequency of HLA-B39 was greater in G without MVP (13.8%) compared to NL (4.1%), p < 0.01. The HLA DRB1*1601-2 was more frequent in G with (30.3%) or without (29.2%) MVP compared to NL (13.5%), p < 0.01. The frequency of HLA DRB1*1401-10 and DQA1*0104 were greater in NL (16.5%) compared to G with (3.0%) or without (4.2%) MVP, p < 0.01.

CONCLUSIONS

The data confirmed previous observations that the frequency of MVP is high in pts with G. Further, the data indicated a possible genetic linkage between the two abnormalities.