Experiences of a communication-skills course for care partners of people living with dementia, empowered conversations: A qualitative framework analysis

OBJECTIVES

Our aims were to examine whether an experiential course for care partners of people living with dementia, Empowered Conversations (EC), was acceptable to participants and to explore participants' perceptions of the impact of the course upon their communicative interactions. EC is based on an integrative model derived from psychological and linguistic theory and empirical evidence. EC is based on mentalisation theory, perceptual control theory and linguistic theory (The Communicative Impact Model).

METHODS

Qualitative data were collected via 28 semistructured interviews. Framework analysis was used to analyse data.

RESULTS

Three superordinate themes, 'improved communication', 'improved well-being' and 'support through others' were identified. Twenty-seven out of the 28 participants described feeling that they were able to better connect with the person living with dementia that they were supporting through attending EC.

CONCLUSIONS

The findings indicated that EC was acceptable and beneficial to care partners. Care partners developed a range of strategies and understandings that enabled them to communicate better with the person they were supporting, enhanced well-being and relationships, as well as developing social networks. This is the first qualitative study to examine a psychosocial intervention for care partners of people living with dementia using a non-CBT framework and indicates that perceived control could influence how care partners respond to stress and difficulties.

A flexible proton beam imaging energy spectrometer (PROBIES) for high repetition rate or single-shot high energy density (HED) experiments (invited)

The PROBIES diagnostic is a new, highly flexible, imaging and energy spectrometer designed for laser-accelerated protons. The diagnostic can detect low-mode spatial variations in the proton beam profile while resolving multiple energies on a single detector or more. When a radiochromic film stack is employed for "single-shot mode," the energy resolution of the stack can be greatly increased while reducing the need for large numbers of films; for example, a recently deployed version allowed for 180 unique energy measurements spanning ∼3 to 75 MeV with <0.4 MeV resolution using just 20 films vs 180 for a comparable traditional film and filter stack. When utilized with a scintillator, the diagnostic can be run in high-rep-rate (>Hz rate) mode to recover nine proton energy bins. We also demonstrate a deep learning-based method to analyze data from synthetic PROBIES images with greater than 95% accuracy on sub-millisecond timescales and retrained with experimental data to analyze real-world images on sub-millisecond time-scales with comparable accuracy.

Safety, immunological effects and clinical response in a phase I trial of umbilical cord mesenchymal stromal cells in patients with treatment refractory SLE

BACKGROUND

Reports of clinical improvement following mesenchymal stromal cell (MSC) infusions in refractory lupus patients at a single centre in China led us to perform an explorative phase I trial of umbilical cord derived MSCs in patients refractory to 6 months of immunosuppressive therapy.

METHODS

Six women with a SLEDAI >6, having failed standard of care therapy, received one intravenous infusion of 1×10⁶ MSCs/kg of body weight. They maintained their current immunosuppressives, but their physician was allowed to adjust corticosteroids initially for symptom management. The clinical endpoint was an SRI of 4 with no new British Isles Lupus Activity Guide (BILAG) As and no increase in Physician Global Assessment score of >0.3 with tapering of prednisone to 10 mg or less by 20 weeks.

RESULTS

Of six patients, five (83.3%; 95% CI 35.9% to 99.6%) achieved the clinical endpoint of an SRI of 4. Adverse events were minimal. Mechanistic studies revealed significant reductions in CD27IgD double negative B cells, switched memory B cells and activated naïve B cells, with increased transitional B cells in the five patients who met the endpoint. There was a trend towards decreased autoantibody levels in specific patients. Two patients had increases in their Helios+Treg cells, but no other significant T cell changes were noted. GARP-TGFβ complexes were significantly increased following the MSC infusions. The B cell changes and the GARP-TGFβ increases significantly correlated with changes in SLEDAI scores.

CONCLUSION

This phase 1 trial suggests that umbilical cord (UC) MSC infusions are very safe and may have efficacy in lupus. The B cell and GARP-TGFβ changes provide novel insight into mechanisms by which MSCs may impact disease.

TRIAL REGISTRATION NUMBER

NCT03171194.

"It's just so important that people's voices are heard": The dementia associate panel

Including the views and experiences of people living with dementia in research and wider decision making is vital. The impact for the subjective wellbeing of its members of an approach known as The Dementia Associate Panel (DAP) is explored. The panel, based on a social citizenship model, aimed to provide a platform to work with and hear the voices of people living with dementia in a region of England. A mixed method approach using semi-structured interviews, self-report questionnaires, and focus groups was adopted. There were 16 participants; six people living with dementia and ten care partners. Participant motivations to join the panel were based on a desire for individuals' voices and experiences to be heard. Following participation in the panel, participants reported experiencing belonging and purpose. Collective and personal contributions to the development of local health and care policies, education provision, research studies, and to raising general public awareness about dementia was beneficial to reported participant wellbeing. The DAP model has the potential to be developed and adapted when working with people living with dementia in different settings; at national or regional levels across the globe.

9 BRAF mutations are associated with T-helper cell infiltration and polarization in melanoma

Background

BRAF mutations are highly prevalent in patients with melanoma (50–65%), and mark tumors which are responsive to combination immune checkpoint inhibition (ICI) with nivolumab (αPD-1) and ipilimumab (αCTLA-4). Interestingly, this combination does not improve outcomes over nivolumab alone for patients with BRAF wild-type melanoma.1 We propose that BRAF mutations shape the immunological response to ICI through tumor derived cytokines and chemokines. While BRAF mutations can influence cytokine production and myeloid cell infiltration, the influence of BRAF mutations on tumor infiltrating CD4+ T-helper cells is underexplored in all tumor types. However, one study described a unique association between BRAF mutant melanoma and signatures of Th17 biology using transcriptomic analysis.2 We hypothesize that BRAF mutations create a unique cytokine and chemokine milieu which support the infiltration and polarization of Th17 cells.

Methods

To address this hypothesis we employed the congenic BRAF wild-type murine melanoma lines B16F10 and YUMM4.1, and the BRAF mutant line YUMM1.7. These cell lines were implanted subcutaneously into female C57BL/6 mice. Blood cytokines, splenocytes and tumor infiltrating lymphocytes were analyzed at 1 week and 3 weeks post tumor implantation to simulate both early stage and late-stage tumors respectively. Flow cytometry was used to define T-helper cell and myeloid cell phenotypes. In vitro analysis of chemokines and cytokines produced by each cell line were conducted via array and confirmed by ELISA.

Results

Th1 and Th17 cells preferentially infiltrated early stage (1 week) BRAF wild-type and mutant tumors respectively while the CD4+ compartment of all tumors was dominated by an overwhelming Treg presence. The CD4+ compartment of endpoint (3 week) B16F10 tumors were almost entirely dominated by Tregs, while YUMM1.7 tumors were infiltrated by a diverse array of T-helper cells. In parallel with these results, we found YUMM1.7 tumors contained more dendritic cells and F4/80hiMHC-II+ macrophages as a percentage of the CD45+ infiltrate. Unique chemokine profiles were associated with each cell line, highlighted by relatively high expression of CXCL10 by BRAF wild-type lines and CXCL12 by both YUMM4.1 and YUMM1.7 cell lines.

Conclusions

This work indicates the mutational landscape of melanoma can dynamically impact CD4+ T cell responses to melanoma. This ongoing work is directly translatable and will aid the development of novel cellular therapies tailored to specific immunological phenotypes of patients. Further, this work may help explain disparities in the response to ICI observed between patient populations with defining mutational signatures.

Acknowledgements

We would like to acknowledge Emory University, The Winship Shared Resource, and the Pediatrics/Winship Flow Cytometry Core

References

Ma VT, Daignault-Newton S, Waninger JJ, Journey S, Chopra Z, Tezel A, Redman BG, Fecher LA, Green MD, Alva AS, Lao CD. The impact of BRAF mutation status on clinical outcomes with anti-PD-1 monotherapy versus combination ipilimumab/nivolumab in treatment-naïve advanced stage melanoma. Pigment Cell Melanoma Res. 2021 May;34(3):629–640.

Tomei S, Bedognetti D, De Giorgi V, Sommariva M, Civini S, Reinboth J, Al Hashmi M, Ascierto ML, Liu Q, Ayotte BD, Worschech A, Uccellini L, Ascierto PA, Stroncek D, Palmieri G, Chouchane L, Wang E, Marincola FM. The immune-related role of BRAF in melanoma. . 2015Mol OncolJan;9(1):93–104.

Ethics Approval

All animal studies were conducted under the approval of the Emory Institutional Animal Care and Use Committee and ethical guidelines established by this committee were strictly adhered to.

223 Potent inhibition of PI3Kδ promotes enhanced T cell stemness and mitochondrial fitness

Background

Durable responses have been observed with adoptive T cell therapy (ACT) in chemotherapy and immunotherapy refractory patients. However, current T cell products do not always lead to therapeutic responses. Therapy failure has been attributed to terminally-differentiated T cell profiles, diminished host engraftment and poor mitochondrial metabolism. T cell activation and a switch towards glycolysis is regulated by signals downstream of the PI3K signaling pathway. We hypothesized that by inhibiting the T cell specific PI3Kδ subunit, that we would prevent overt T cell differentiation, enhance mitochondrial metabolism and improve anti-tumor immunity of adoptively transferred T cells.

Methods

To test this, we primed melanoma-specific CD8+ pmel-1 T cells in the presence of increasing concentrations of CAL-101, a PI3Kδ specific inhibitor, and infused them into B16F10 tumor-bearing mice, following non-myeloablative total body irradiation. In vitro we tested how PI3Kδ inhibition altered T cell stemness features by flow cytometry and RNA sequencing. Further, we tested the ability of PI3Kδ inhibited T cells to survive against antigen rechallenge, and assessed how mitochondrial phenotypes changed using dyes indicating mass, membrane potential and reactive oxygen species. Moreover, we tested how real time mitochondrial respiration was changed with PI3Kδ inhibition via seahorse.

Results

Potent inhibition of PI3Kδ in vitro enhanced tumor immunity and survival in a dose dependent manner. High doses of CAL-101 enriched T cells with phenotypic and transcriptional signatures of stemness. We found that CAL-101 decreased glucose uptake and increased mitochondrial mass and membrane potential while reducing mitochondrial reactive oxygen species. Potent inhibition of PI3Kδ enhanced mitochondrial respiration, however gene expression of fatty acid oxidation was not enriched, suggesting an alternative pathway involved in the enhanced spare respiratory capacity of CAL-101 treated T cells.

Conclusions

These findings indicate that blocking PI3Kδ is sufficient to mediate lasting tumor immunity of adoptively transferred T cells by preserving stemness features and improving mitochondrial fitness. Our data suggest that addition of CAL-101 to ACT expansion protocols could greatly improve responses to solid tumors by rewiring T cell stemness and promoting mitochondrial fitness.

Acknowledgements

We would like to thank all the researchers and clinicians leading the way in translating immunological principles into effective therapies, as well as the patients whose support is integral for the furthering of medicine.

Ethics Approval

All animal procedures performed at the Medical University of South Carolina or Emory University were approved by each university’s Institutional Animal Care & Use Committee, protocol number 0488 or 201900225, respectively

904 Repurposing CD26 (DPP4) inhibitors to enhance immunotherapy response in pancreatic ductal adenocarcinoma

Background

Pancreatic ductal adenocarcinoma (PDAC) is refractory to immunotherapy due in part to cellular cross-talk with cancer associated fibroblasts (CAFs). These interactions shape the microenvironment in a manner that is profoundly immunosuppressive. Our group is identifying novel targets in the PDAC stroma that can be manipulated to enhance immunotherapy efficacy. We hypothesize dysregulation of the serine protease, CD26/DPP4 in PDAC contributes to the limited efficacy of immunotherapy. Further, we posit targeting CD26 enzymatic activity using inhibitors that are FDA-approved for adult patients with Type 2 Diabetes Mellitus can enhance the efficacy of immunotherapy in PDAC.

Methods

Primary CAFs isolated from patient PDAC resection specimens under an IRB-approved protocol, were subject to NanoString analysis.1 CD26 protein expression was measured in primary and immortalized CAFs and PDAC cells by immunoblot, flow cytometry and immunofluorescence, while ELISA detected soluble CD26. For in vivo efficacy, luciferase-expressing KPC-tumor cells were implanted orthotopically in the pancreas of immune-competent C57BL/6 mice. Bioluminescence imaging (BLI) confirmed established tumors and mice were randomized to sitagliptin (75 mg/kg in drinking water, CD26/DPP4 inhibitor), anti-PD-L1 Ab (200 ug 2x/week), or both combined for 3 weeks. Controls received vehicle or isotype control Ab. BLI utilized to track tumor progression and tissues harvested for analysis at study endpoint (day 18 of treatment).

Results

NanoString analysis identified CD26/DPP4 as significantly upregulated in RNA transcripts from primary CAFs vs. fibroblasts from normal pancreas (figure 1). We confirmed abundant CD26 expression on patient-derived CAFs and immortalized CAF cell lines, however, lower CD26 expression was observed on human PDAC cell lines (HPAC, PANC-1) by immunoblot, flow cytometry and immunofluorescence (figure 5).

Abstract 904 Figure 1

(A) Schema for analysis of transcript from n=10 primary CAFs (PSC) from PDAC patients vs. normal human pancreatic fibroblasts (HPPFC) via NanoString nCounter PanCancer Immune Profiling Panel. (B) Heat map of gene expression with upregulate DPP4 or CD26 transcript detected. Adapted from Mace et al., 2016.

Abstract 904 Figure 2

Validation of CD26 protein expression in human PDAC-derived CAF and PDAC cell lines by immunoblot analysis

Abstract 904 Figure 3

Analysis of surface human CD26 expression in PBMCs, PDAC-derived CAFs (h-iPSC-PDAC-1), and PDAC cells (PANC-1) by flow cytometry. Histograms representing human surface CD26 expression

Abstract 904 Figure 4

Immunofluorescence analysis of CD26/DPP4 cellular localization in a human PDAC-derived CAF cell line

Abstract 904 Figure 5

Combined Sitagliptin and PD-L1 blockade in a murine orthotopic model of PDAC. Fold change in tumor volume, determined by BLI, comparing baseline (Day 0 of treatment) to Day 18 of treatment. Each bar represents fold change in BLI determined tumor volume for each animal

Conclusions

Our results are the first to describe CD26 expression on PDAC-derived CAFs and indicate that sitagliptin augments anti-tumor activity of anti-PD-L1 in PDAC tumor-bearing mice. Our ongoing work will provide insight into specific immune cell populations responsible for efficacy of immunotherapy in murine models of PDAC, and the role of CD26 in various cellular compartments within the PDAC microenvironment.

References

Mace TA, Shakya R, Pitarresi JR, Swanson B, McQuinn CW, Loftus S, Nordquist E, Cruz-Monserrate Z, Yu L, Young G, Zhong X, Zimmers TA, Ostrowski MC, Ludwig T, Bloomston M, Bekaii-Saab T, Lesinski GB. IL-6 and PD-L1 antibody blockade combination therapy reduces tumour progression in murine models of pancreatic cancer. Gut 2018;67(2):320–32.

708 Novel ways to exploit IL-21 to augment adoptive T cell transfer therapy against tumors

Background

IL-21 enhances the anti-tumor capacity of adoptively transferred CD8+ T cells, while IL-2 and IL-15 impair T cell immunity by driving their expansion to a more differentiated status. Yet, these cytokines can act on many different immune cells. Given the potency of IL-21, we tested if this cytokine directly augments T cells or rather if it enhances other immune cells in the culture that indirectly improves T cell therapy.

Methods

To test this question, splenocytes from pmel-1 transgenic mice were used, as all CD8+ T cells express a transgenic TCR specific for tumor-antigen gp10025–33 overexpressed on melanoma. We then peptide activated naïve CD8+ T cells enriched or not from the spleen of pmel-1 mice and expanded them in the presence of IL-21 or IL-2 (10 ng/mL) for four days. Expanded pmel-1 from these various cultures were then restimulated with irradiated splenocytes pulsed with gp10025–33 and grown an additional seven days with IL-2 (10 ng/mL), irrespective of their initial cytokine condition. The in vitro memory phenotype, exhaustion profile, and cytokine secretion of these cultures were then assayed. Furthermore, mice bearing B16KVP melanoma tumors were infused with pmel-1 T cells expanded via these various approaches and compared for their relative capacity to engraft, persist, and regress tumor in vivo.

Results

Interestingly, we discovered that IL-21-treated T cells generated from bulk splenocytes are phenotypically and functionally distinct from IL-21-treated isolated T cells. Upon restimulation, IL-21-treated T cells from bulk splenocytes exhibited an exhausted phenotype that was like anergic IL-2-treated T cells. Moreover, few cells expressed CD62L but expressed heightened markers of suppression, including TIM3, PD-1, and EOMES. Moreover, they produced more effector molecules, including granzyme B and IFN-gamma. In vivo IL-21-treated T cells expanded from bulk splenocytes engrafted and persisted poorly, in turn mediating suboptimal regression of melanoma. Conversely, IL-21 dramatically bolstered the engraftment and antitumor activity of T cells only if they were first isolated from the spleen prior to their expansion and infusion into the animal.

Conclusions

Collectively, our data shows that IL-21 may improve ACT therapy best when used directly on antitumor CD8+ T cells. Further studies will illuminate the mechanism behind this striking difference and determine whether other cell subsets reactive to IL-21 cause T cell dysfunction and/or reduced bioavailability. These findings are important for defining the best culture conditions in which to use IL-21 for ACT.

Acknowledgements

We would like to acknowledge Emory University, The Winship Cancer Institute, and the Pediatrics/Winship Flow Cytometry Core.

Ethics Approval

All animal procedures were approved by the Institutional Animal Care and Use Committee of Emory University, protocol number 201900225.

196 TLR9-activated B cells directly license adoptively transferred CD8+ T cells with potent tumor immunity

Background

The use of immunotherapies such as immune checkpoint blockade or adoptive cell therapy has substantially improved outcomes for many patients with advanced malignancies. However, a majority of these patients still do not respond or relapse. Thus, extensive efforts are being made to improve these therapies. We and others have demonstrated that adoptive cell therapy can be improved by the co-administration of TLR agonists intratumorally. TLR agonists have also been administered to patients alongside a number of other immunotherapies, but often induce toxic side effects that may be exacerbated by cell therapy. We hypothesized that TLR agonists could alternatively be used in ex vivo cell culture to propagate a more potent cell therapy product.

Methods

To address our question, we used a transgenic mouse model of tumor-infiltrating lymphocyte (TIL) therapy, pmel-1, in which CD8+ T cells express a TCR specific for a melanoma/melanocyte antigen. We activated CD8+ pmel-1 T cells with APCs and the Toll-like receptor 9 agonist, CpG. Cell therapy efficacy was determined against mice bearing established B16F10 melanoma. Mechanisms underlying TLR-improved T cell products were determined using ex vivo cell depletion strategies and blocking antibodies.

Results

CpG-expanded pmel-1 T cell products were much more effective against B16F10 melanoma in vivo than traditionally expanded T cells; they conferred more durable antitumor responses and improved survival of mice. CD8+ T cells generated in the presence of CpG also had heightened engraftment and persistence in the mice. We found that CpG did not act directly on T cells in culture, but on B cells, as depletion of B cells alone (not DCs, macrophages, NK cells, or CD4 cells) ablated the effects of CpG. B cells in CpG-treated cultures expressed a unique cytokine profile and upregulated several costimulatory markers on their cell surface, so we next questioned whether CpG improved the B cell/T cell axis via a direct or indirect (soluble) factor. Together, cell supernatant transfer experiments and costimulatory blockade experiments revealed that the direct interaction between B and T cells was required for the CpG-mediated improvement of the T cell product.

Conclusions

Our findings reveal a novel role for B cells in the generation of potent CD8+ T cell therapies against an aggressive solid tumor. These findings highlight a unique way B cells can become powerful APCs for generating effective antitumor CD8+ T cells and can be directly translated to improve cell therapy products for patients with advanced malignancies.

Ethics Approval

All animal procedures performed at the Medical University of South Carolina or Emory University were approved by each university’s Institutional Animal Care & Use Committee, protocol number 0488 or 201900225, respectively.

1173 Airway and Breathing Problems in Pierre Robin Sequence: A Systematic Review Protocol

Aim

The primary aim is to systematically review the specific airway and/or breathing problems which have been reported in Pierre Robin Sequence (PRS). Secondary aims are to understand the prevalence and severity of these airway and breathing problems, and options for screening, assessment, and monitoring.

Method

A search strategy will be designed to search the following databases: MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials(CENTRAL) including a grey literature search, to identify publications on airway and/or breathing problems in Pierre Robin Sequence patients. Airway or breathing problems to be included are defined upper airway conditions (e.g., sleep apnoea) or clinically or objectively defined airway/breathing problems (e.g., increased respiratory rate, polysomnography). Screening will exclude non-English articles, abstracts, letters, editorials, expert opinions and breathing problems not anatomically related to craniofacial underdevelopment.

Results

This systematic review has been successfully registered on the PROSPERO International Prospective Register of Systematic Reviews (CRD42020210572)

Conclusions

PRS is a rare craniofacial condition which presents at birth, consisting of micrognathia, glossoptosis and airway problems, and is usually, but not always, associated with a cleft palate. There is no consensus on the type of airway problems that affect patients with PRS. The findings of this systematic review will help to develop a consensus on the airway and breathing problems in PRS and options for assessment and monitoring of the airway and breathing problem. This data may also contribute to development of a standardized guideline for management of airway and breathing problems in PRS.

A qualitative evaluation of the impact of a Good Life Club on people living with dementia and care partners

BACKGROUND

Research suggests there is a lack of post-diagnostic support to enable people living with dementia to fulfil social and active lives throughout their dementia journey. Gardening has been found to have many benefits for people living with dementia. Although such research is important, most research frames people with dementia as passive recipients of stimulation. Research into the impact of a community-based gardening group, where people living with dementia are active in the development of an outdoor space, is underdeveloped. Knowledge about the impact of participating in such groups is also sparse. The Good Life Club (GLC) was co-developed and evaluated to respond to these gaps.

OBJECTIVES

The primary aim of this article is to present the findings regarding the impact of attending the GLC on the self-reported well-being for people living with dementia and care partners.

METHODS

Qualitative data were collected via 22 semi-structured interviews. Fourteen interviews were conducted before the GLC and eight after the GLC. Thematic analysis was used to analyse data. Dementia Care Mapping data were collected to supplement the interview data.

FINDINGS

Four key themes were identified. The first was that participants considered having active participation in social life to be a key aspect of living a good life. The second was that the way that the GLC was set up and delivered gave the participants ownership of the GLC and within this they felt able to contribute. The third was the importance of social connectedness and peer support to the well-being of both people living with dementia and care partners. Fourth, positive mood and well-being was directly experienced through gardening.

CONCLUSIONS

The combination of long-term investment of time and energy to the GLC, ongoing friendships and in-session autonomy act as key ingredients in creating a group that is relaxed, full of humour and highly valued.

119 IL-6 is critical for memory responses elicited by Th17 cells to tumors

Background

Translation of novel T cell therapies is limited by cost and time-consuming protocols involving long-term T cell expansion. We found that shortening ex vivo expansion of either TCR-specific murine Th17 cells or human CAR Th17 cells licenses the cell product to eradicate large tumors in low doses and generate long-lived memory against tumor.1 Therapeutic Th17 cells induce the systemic release of IL-6, IL-17, GM-CSF, and MCP-1 among other cytokines in tumor-bearing hosts, reminiscent of clinical cytokine release syndrome. As the toxicity of cytokine release is managed in patients through IL-6 blockade, we addressed the impact of IL-6 on efficacy and durability of Th17 cell therapy. We hypothesized that IL-6, induced by Th17 cells, was fueling the durable memory properties of this cell product.

Methods

Th17 cells were expanded ex vivo using the TRP-1 transgenic mouse model in which CD4+ T cells express a TCR that recognizes tyrosinase-related protein 1 on melanoma. Naïve CD4+ T cells were polarized to the Th17 phenotype and infused into mice with B16F10 melanoma after a nonmyeloablative total body irradiation (5 Gy) preparative regimen.

Results

IL-6 blockade, targeting either IL-6R or neutralization of the cytokine, did not significantly impact the primary immune response of adoptively transferred Th17 cells against tumor. However, administering IL-6 blockade acutely after Th17 transfer resulted in a higher incidence of tumor relapse upon secondary tumor challenge, thereby compromising long-lived antitumor immunity.1 Mounting a secondary response to tumor was dependent on CD4+ T cells, but not CD8+ T cells, persisting in the host. Mechanistically, IL-6 blockade reduced pSTAT3 and Bcl2 in transferred T cells but did not greatly impact the concentration of other systemic cytokines. As a small fraction of Tregs remain in the Th17 cell product ex vivo, we examined the engraftment of those Tregs after transfer. IL-6 was critical to suppress engraftment of FoxP3+ donor T cells from the CD4+ T cell product. Thus, IL-6 promoted robust tumor infiltration by donor effector over regulatory cells for early Th17 cells relative to cell products expanded longer durations ex vivo.1

Conclusions

Overall, short-term expanded Th17 cells uniquely induced IL-6 unlike Th17 cells expanded longer ex vivo. IL-6 promoted Th17 survival, reduced engraftment of tumor-specific Tregs, and was critical to durable memory. This work may suggest that the universal strategy to inhibit IL-6 during cytokine release syndrome may come at the expense of long-term efficacy for specific cell therapy approaches.

Reference

Knochelmann HM, Dwyer CJ, Smith AS, Bowers JS, Wyatt MM, Nelson MH, Rangel Rivera GO, Horton JD, Krieg C, Armeson K, Lesinski GB, Rubinstein MP, Li Z, Paulos CM. IL-6 fuels durable memory for Th17 cell-mediated responses to tumors. Cancer Res. 2020. Epub ahead of print. PMID: 32561531.

Inhibition of PI3Kδ improves tumor specific T cell immunity and metabolic fitness

Durable responses have been observed with adoptive T cell therapy (ACT) in some patients. However, current protocols used to expand T cells often exhibit suboptimal tumor control. Failure in these therapies has been attributed to premature differentiation and impaired metabolism of the infused T cells. Previous work done in our lab showed that reduced PI3Kδ signaling improved ACT. Because PI3Kγ and PI3Kδ have critical regulatory roles in T cell differentiation and function, we tested whether inhibiting PI3Kγ could recapitulate or synergize PI3Kδ blockade. To test this, we primed melanoma specific CD8+ pmel-1 T cells in the presence of PI3Kγ (IPI-459), PI3Kδ (CAL101 or TGR-1202) or PI3Kγ/δ (IPI-145) inhibitors and infused them into B16F10 tumor bearing mice. Sole inhibition of PI3Kδ or PI3Kγ in vitro promoted greater tumor immunity and survival compared to dual inhibition. To understand how PI3Kδ or PI3Kγ blockade improved T cell therapy, we assessed their phenotype. CAL101 treatment produced more CD62Lhi CD44lo T cells compared to IPI-459, while TGR-1202 enriched mostly CD62LhiCD44hi T cells. Because decreased T cell differentiation is associated with mitochondrial metabolism, we focused on CAL101 treated T cells to study their metabolism. We found that CAL101 decreased glucose uptake and increased mitochondrial respiration in vitro, indicating augmented mitochondrial function. These findings indicate that blocking PI3Kδ is sufficient to mediate lasting tumor immunity of adoptively transferred T cells by preventing premature differentiation and improving mitochondrial fitness. Our data suggest that addition of CAL101 to ACT expansion protocols could greatly improve T cell therapies for solid tumors.

IL-6 fuels durable memory for Th17 cell-mediated responses to tumors

Accessibility of T cell transfer therapies is hindered by cost and time required for product development. We found that shortening ex vivo expansion of Th17 cells licenses a proinflammatory cell product which induces cytokine storm with high levels of systemic IL-6 in tumor-bearing hosts. Unique from other helper subsets, briefly expanded Th17 cells eradicate large tumors in low doses and generate long-lived memory against tumor rechallenge, suggesting a benefit to the inflammatory state. As the toxicity of cytokine release is managed in patients through IL-6 blockade, we addressed the physiologic impact of IL-6 on efficacy and durability of Th17 cell therapy in this immunocompetent model. We hypothesized that peak IL-6 induced by Th17 cells was critical to their durable memory properties. To address this, we used the TRP-1 transgenic mouse model where CD4+ T cells express a TCR that recognizes TRP-1 of B16F10 melanoma. Acute IL-6 blockade post Th17 transfer did not impact the primary antitumor response, yet abrogated long-term responses by promoting tumor relapse upon secondary challenge. Mechanistically, IL-6 blockade reduced pSTAT3 and Bcl2 in transferred T cells and promoted a greater frequency of FoxP3+ Treg cells in the peripheral blood and tumor-draining lymph nodes. Finally, serum IL-6 was inversely correlated with engraftment of tumor-specific Tregs from the transferred product. Overall, short-term expanded Th17 cells uniquely induce IL-6, which promotes Th17 survival, suppresses engraftment of tumor-specific Tregs, and is critical to durable memory. This work may suggest that the universal strategy to inhibit IL-6 during cytokine release syndrome may come at the expense of long-term efficacy for cell therapy.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

The Potential of Painting: Unlocking Disenfranchised Grief for People Living With Dementia

As part of the Creative Well program at a local health board, one of the authors qualitatively investigated how painting can access a means of communication for people living with dementia. In a workshop setting within a gallery environment, participants living with dementia were facilitated on a one-to-one basis the opportunity to paint alongside the researcher. During the workshops, a number of experiences were articulated. These included experiences of illness, crisis, and loss. They were captured through observations, interviews, visual art, and video to contribute to new understandings and models of engagement through art for people living with dementia and their carers. Focusing on theory and practice in arts-based research and the social sciences, this article investigates the potential of painting to unlock experiences such as disenfranchised grief for people living with dementia. The conclusions of this article do not measure how and if participants felt disenfranchised grief but rather provide an alternative to augment the body of knowledge surrounding how people living with dementia can communicate feelings of disenfranchised grief through painting.

Position of the greater trochanter and functional femoral antetorsion: Which factors matter in the management of femoral antetorsion disorders?

Aims

The primary aim of this study was to define and quantify three new measurements to indicate the position of the greater trochanter. Secondary aims were to define 'functional antetorsion' as it relates to abductor function in populations both with and without torsional abnormality.

Patients and Methods

Three new measurements, functional antetorsion, posterior tilt, and posterior translation of the greater trochanter, were assessed from 61 CT scans of cadaveric femurs, and their reliability determined. These measurements and their relationships were also evaluated in three groups of patients: a control group (n = 22), a 'high-antetorsion' group (n = 22) and a 'low-antetorsion' group (n = 10).

Results

In the cadaver group, the mean anatomical antetorsion was 14.7° (sd 8.5; 0 to 36.5) and the functional antetorsion 21.5° (sd 8.1; 3.6 to 44.3): the posterior tilt was 73.3° (sd 10.8; 46.9 to 88.7) and the posterior translation 0.59 (sd 0.2; 0.2 to 0.9). These measurements had excellent intra and interobserver agreement with a range from 0.93 to 0.99. When the anatomical antetorsion decreased, the greater trochanter was more tilted and translated posteriorly in relation to the axis of the femoral neck, and the difference between functional and anatomical antetorsion increased. The results the three patient groups were similar to those of the cadaver group.

Conclusion

The position of the greater trochanter and functional antetorsion varied with anatomical antetorsion. In the surgical management of femoral retrotorsion, subtrochanteric osteotomy can result in an excessively posterior position of the greater trochanter and an increase in functional antetorsion. Cite this article: Bone Joint J 2018;100-B:712-19.

Analysis of intensive care admissions among paediatric obstructive sleep apnoea referrals

Introduction The aim of this study was to identify the proportion of children referred to a paediatric tertiary referral centre who required admission to the paediatric intensive care unit (PICU) following surgery for obstructive sleep apnoea (OSA) and to establish risk factors for these admissions. Methods Retrospective review of case notes and the operative database was performed for all children undergoing adenotonsillectomy for sleep disordered breathing and OSA symptoms in Great Ormond Street Hospital over a 10-year period. Results Overall, 1,328 children underwent adenotonsillectomy for sleep disordered breathing and OSA. The mean age was 3.1 years (standard deviation [SD]: 1.7 years). A total of 37 (2.8%) were admitted to the PICU postoperatively (mean length of PICU stay: 1.2 days, standard deviation [SD]: 0.6 days) and 282 (21.2%) required nasopharyngeal airway (nasal prong) insertion intraoperatively. The mean length of stay on the ward following surgery was 1.4 days (SD: 0.8 days). Patients with severe OSA (apnoea-hypopnoea index [AHI] >10) and ASA (American Society of Anesthesiologists) grade ≥3 were more likely to require postoperative PICU admission (22/37 vs 381/1,291 [p<0.001] and 29/37 vs 660/1,291 [p=0.001] respectively). Severe OSA was also more common in children who required nasal prong insertion intraoperatively (186/282 vs 217/1,046, p<0.001). Conclusions Very few children referred to a paediatric tertiary referral centre actually require PICU admission following surgery. This may be in part due to the use of a nasopharyngeal airway in patients where postoperative obstruction is anticipated. In children with severe OSA (AHI >10) and an ASA grade of ≥3, nasopharyngeal airway insertion and potential admission to the PICU should be considered.

Late Sterile Abscess Formation in Carotid Endarterectomy Following Use of BioGlue: A Word of Caution

Introduction

BioGlue (CryoLife Inc., Kennesaw, GA) is a commonly used surgical adhesive, designed to achieve haemostasis following large vessel cardiovascular operations.

Report

An 88-year-old female presents with an enlarging right sided neck mass 9 months after carotid endarterectomy with bovine pericardial patch repair which utilised BioGlue seal the patch suture line.

Conclusion

BioGlue should be used properly and with caution. In cases of late wound complication following BioGlue use, simple drainage, debridement, and removal of BioGlue remnants may be a satisfactory approach.

Nasal dermoids in children: a proposal for a new classification based on 103 cases at Great Ormond Street Hospital

OBJECTIVES

Nasal dermoids are rare developmental anomalies seen in children. This study reports the largest case series of 103 patients seen in a quaternary specialist unit over a 10-year period. We report the surgical and radiological findings and propose a new classification system, which clearly describes the extent of the lesions, thus allowing better surgical planning.

METHODS

A retrospective review of case notes was conducted. Data collection included demographics, initial presentation, site of lesion, pre-operative CT and MRI imaging, surgical procedure, intraoperative findings (including depth of lesion), complications and recurrence. Surgical findings were correlated with radiological findings.

RESULTS

A total of 103 patients were included in the study. The mean age at presentation was 29 months. 89% of children presented with a naso-glabellar or columellar lesion and 11% had a medial canthal lesion. All the patients underwent preoperative imaging and were treated with surgical excision. 58 children had superficial lesions, 45 had subcutaneous tracts extending to varying depths. Of these, 38 had intraosseous extension into the frontonasal bones, eight extended intracranially but remained extradural and two had intradural extension. There was good correlation between radiological and surgical findings. The superficial lesions were locally excised. The lesions with intraosseous tracts were removed via open rhinoplasty and the frontonasal bones drilled for access. Intracranial extension was approached either via a bicoronal flap and frontal craniotomy or the less invasive anterior small window craniotomy.

CONCLUSIONS

This report describes the largest published cases series of nasal dermoids. The cases demonstrate the presenting features and the variable extent of the lesions. The new proposed classification; superficial, intraosseous, intracranial extradural and intracranial intradural, allows precise surgical planning. In the presence of intracranial extension, the low morbidity technique of using a brow incision and small window anterior craniotomy avoids the more invasive and commonly used bicoronal flap and frontal craniotomy.

Multi-faceted case management: reducing compensation costs of musculoskeletal work injuries in Australia

OBJECTIVES

This study aimed to determine whether a multi-faceted model of management of work related musculoskeletal disorders reduced compensation claim costs and days of compensation for injured workers.

METHODS

An intervention including early reporting, employee centred case management and removal of barriers to return to work was instituted in 16 selected companies with a combined remuneration over $337 million. Outcomes were evaluated by an administrative dataset from the Victorian WorkCover Authority database. A 'quasi experimental' pre-post design was employed with 492 matched companies without the intervention used as a control group and an average of 21 months of post-intervention follow-up. Primary outcomes were average number of days of compensation and average cost of claims. Secondary outcomes were total medical costs and weekly benefits paid.

RESULTS

Information on 3,312 claims was analysed. In companies where the intervention was introduced the average cost of claims was reduced from $6,019 to $3,913 (estimated difference $2,329, 95 % CI $1,318-$3,340) and the number of days of compensation decreased from 33.5 to 14.1 (HR 0.77, 95 % CI 0.67-0.88). Medical costs and weekly benefits costs were also lower after the intervention (p < 0.05). Reduction in claims costs were noted across industry types, injury location and most employer sizes.

CONCLUSIONS

The model of claims management investigated was effective in reducing the number of days of compensation, total claim costs, total medical costs and the amount paid in weekly benefits. Further research should investigate whether the intervention improves non-financial outcomes in the return to work process.

A robust MRI-compatible system to facilitate highly accurate stereotactic administration of therapeutic agents to targets within the brain of a large animal model

Achieving accurate intracranial electrode or catheter placement is critical in clinical practice in order to maximise the efficacy of deep brain stimulation and drug delivery respectively as well as to minimise side-effects. We have developed a highly accurate and robust method for MRI-guided, stereotactic delivery of catheters and electrodes to deep target structures in the brain of pigs. This study outlines the development of this equipment and animal model. Specifically this system enables reliable head immobilisation, acquisition of high-resolution MR images, precise co-registration of MRI and stereotactic spaces and overall rigidity to facilitate accurate burr hole-generation and catheter implantation.

To demonstrate the utility of this system, in this study a total of twelve catheters were implanted into the putamen of six Large White Landrace pigs. All implants were accurately placed into the putamen. Target accuracy had a mean Euclidean distance of 0.623 mm (standard deviation of 0.33 mm). This method has allowed us to accurately insert fine cannulae, suitable for the administration of therapeutic agents by convection-enhanced delivery (CED), into the brain of pigs. This study provides summary evidence of a robust system for catheter implantation into the brain of a large animal model. We are currently using this stereotactic system, implantation procedure and animal model to develop catheter-based drug delivery systems that will be translated into human clinical trials, as well as to model the distribution of therapeutic agents administered by CED over large volumes of brain.

Sm-p80-based DNA vaccine formulation induces potent protective immunity against Schistosoma mansoni

No effective vaccine exists for the human parasitic disease, schistosomiasis. We have targeted a functionally important antigen, Sm-p80 as a vaccine candidate because of its consistent immunogenicity, protective potential and important role in the immune evasion process. In this study we report that a Sm-p80-based DNA vaccine formulation confers 59% reduction in worm burden in mice. Animals immunized with Sm-p80-pcDNA3 exhibited a decrease in egg production by 84%. Sm-p80 DNA elicited strong immune responses that include IgG2A and IgG2B antibody isotypes in vaccinated animals. Splenocytes proliferated in response to Sm-p80 produced appreciably more Th1 response enhancing cytokines (IL-2, IFN-gamma) than Th2 response enhancing cytokines (IL-4, IL-10). These data reinforce the potential of Sm-p80 as an excellent vaccine candidate for schistosomiasis.

Growth and nutritional status in residential center versus home-living children and adolescents with quadriplegic cerebral palsy

OBJECTIVE

To describe growth and nutrition in nonambulatory youth (<19 years of age) with cerebral palsy (CP) living in residential centers compared with similar youth living at home.

STUDY DESIGN

A multicenter, cross-sectional, single observational assessment of 75 subjects living in a residential care facility compared with 205 subjects living at home. Primary outcome measures included anthropometric measures of height, weight, triceps, and subscapular skinfolds, and mid-upper-arm muscle area. Z scores were calculated from reference values for healthy children. Age, use of a feeding tube, and Gross Motor Functional Classification System (GMFCS) level were included as important confounders.

RESULTS

Use of a feeding tube was associated with higher skinfold Z scores, and a significantly higher percentage of the residential subjects had a feeding tube. Height, weight, and arm-muscle area Z scores all diverged (negatively) from reference values with age, and the residential subjects were on average older than the home-living subjects. After controlling for age, GMFCS level and use of a feeding tube, residential living was associated with significantly greater weight, height, skinfold thicknesses, and mid-arm muscle area Z scores.

CONCLUSION

Poor growth and nutrition in children with CP is a prevalent, important, and complex problem. Although factors intrinsic to the condition of CP likely play a significant role, it is also clear that environmental factors, including the living situation of the child, can have an impact.

Are initial demyelinating event recovery and time to second event under differential control?

BACKGROUND

Relapsing-remitting multiple sclerosis (RRMS) begins with an initial demyelinating event (IDE) that can be monosymptomatic, polysymptomatic, or polyregional. Failure to recover from the IDE is a known predictor of later development of disability. Factors that predict IDE recovery (outside optic neuritis) and time to second event are relatively unknown. The authors speculate that IDE recovery and time to second event are under separate biologic or genetic control, and as such, their clinical predictors are different.

METHODS

Data on all UCSF MS clinic patients are entered prospectively into an ACCESS database. The authors identified all patients seen at the UCSF clinic within 1 year of their IDE. Expanded Disability Status Scale scores, functional system scores, and visual acuity were used to define IDE severity and recovery.

RESULTS

The cohort included 186 patients (127 women, 59 men) with an average onset age of 34 +/- 10 years with 150 whites (non-Hispanic), 15 African Americans, 11 Hispanics, eight Asians, and two unknown/unreported. Worse onset severity predicted worse IDE recovery (23.1% of the patients with severe onset vs 32.9% with moderate severity vs 56.4% with mild onset recovered completely, p < 0.001). Polyregional onset predicted poor recovery compared to monoregional onset (46.2% vs 14.4%, p < 0.001). Nonwhite patients were 2.48 times more likely than whites to experience a second episode within 1 year from onset (95% CI: 1.45 to 4.23, p < 0.001). Similarly, age younger than 30 years predicted higher risk of a second exacerbation (hazard ratio 1.92, 95% CI: 1.17 to 3.15, p = 0.010).

CONCLUSION

Initial demyelinating event recovery and time to second event may have distinct predictors. These findings suggest that recovery and time to second event might be under separate biologic control.

Comparison of treatment planning dose calculations with measurements and Monte Carlo calculations in a RANDO phantom

Solid tumours are often treated with external beams of photons generated by Bremsstrahlung radiation. These beams are shaped and filtered to optimise the dose to specific regions defined by the treatment plans, which may involve irradiations from multiple angles. It is important that doses to healthy tissue do not exceed tolerance doses and that the dose to the tumour is maximised. To accomplish these objectives, commercially available 3-D treatment planning software is used to calculate doses to healthy tissue and to the tumour. It is generally believed that these commercial software packages calculate doses through the patient to within a few per cent. In order to examine this claim, dose calculations obtained from ADAC software for external beam treatment to the pelvic region of a RANDO phantom are compared with 37 thermoluminescence dosemeters placed into several slices of a RANDO phantom. The phantom was irradiated to obtain a prescription dose of 180 cGy at the tumour location. Data from homogeneous regions agree within several per cent with results obtained from ADAC software, whereas this comparison is less favourable in regions of heterogeneity. Results from Monte Carlo calculations in a homogeneous phantom are comparable to results from ADAC treatment planning software.

2001 Volvo Award Winner in Clinical Studies: Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice

STUDY DESIGN

Quasi-experimental, nonrandomized, nonequivalent, parallel group-controlled study involving before and after telephone surveys of the general population and postal surveys of general practitioners was conducted, with an adjacent state used as a control group.

OBJECTIVES

To evaluate the effectiveness of a population-based intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and workers' compensation-related costs.

SUMMARY OF BACKGROUND DATA

A multimedia campaign begun during 1997 in Victoria, Australia, positively advised patients with back pain to stay active and exercise, not to rest for prolonged periods, and to remain at work.

METHODS

The campaign's impact on population beliefs about back pain and fear-avoidance beliefs was measured in telephone surveys, and the effect of the campaign on the potential management of low back pain by general practitioners was assessed by eliciting their likely approach to two hypothetical scenarios in mailed surveys. Demographically identical population groups in Victoria and the control state, New South Wales, were surveyed at three times: before, during, and after intervention in Victoria.

RESULTS

The studies were completed by 4730 individuals in the general population and 2556 general practitioners. There were large statistically significant improvements in back pain beliefs over time in Victoria (mean scores on the Back Beliefs Questionnaire, 26.5, 28.4, and 29.7), but not in New South Wales (26.3, 26.2, and 26.3, respectively). Among those who reported back pain during the previous year, fear-avoidance beliefs about physical activity improved significantly in Victoria (mean scores on the Fear-Avoidance Beliefs Questionnaire for physical activity, 14, 12.5, and 11.6), but not in New South Wales (13.3, 13.6, and 12.7, respectively). General practitioners in Victoria reported significant improvements over time in beliefs about back pain management, as compared with their interstate colleagues. There were statistically significant interactions between state and time for 7 of 10 responses on management of acute low back pain, and for 6 of 10 responses on management of subacute low back pain.

CONCLUSION

A population-based strategy of providing positive messages about back pain improves the beliefs of the general population and general practitioners about back pain and appears to influence medical management.

Population based intervention to change back pain beliefs and disability: three part evaluation

OBJECTIVE

To evaluate the effectiveness of a population based, state-wide public health intervention designed to alter beliefs about back pain, influence medical management, and reduce disability and costs of compensation.

DESIGN

Quasi-experimental, non-randomised, non-equivalent, before and after telephone surveys of the general population and postal surveys of general practitioners with an adjacent state as control group and descriptive analysis of claims database.

SETTING

Two states in Australia.

PARTICIPANTS

4730 members of general population before and two and two and a half years after campaign started, in a ratio of 2:1:1; 2556 general practitioners before and two years after campaign onset.

MAIN OUTCOME MEASURES

Back beliefs questionnaire, knowledge and attitude statements about back pain, incidence of workers' financial compensation claims for back problems, rate of days compensated, and medical payments for claims related to back pain and other claims.

RESULTS

In the intervention state beliefs about back pain became more positive between successive surveys (mean improvement in questionnaire score 1.9 (95% confidence interval 1.3 to 2.5), P<0.001 and 3.2 (2.6 to 3.9), P<0.001, between baseline and the second and third survey, respectively). Beliefs about back pain also improved among doctors. There was a clear decline in number of claims for back pain, rates of days compensated, and medical payments for claims for back pain over the duration of the campaign.

CONCLUSIONS

A population based strategy of provision of positive messages about back pain improves population and general practitioner beliefs about back pain and seems to influence medical management and reduce disability and workers' compensation costs related to back pain.

Two sox9 genes on duplicated zebrafish chromosomes: expression of similar transcription activators in distinct sites

Sox9 is a transcription factor required for cartilage formation and testis determination in mammals. We have cloned from zebrafish two sox9 genes, termed sox9a and sox9b. Gene phylogenies showed that both genes are orthologous to tetrapod SOX9 genes. Genetic mapping showed that these two loci reside on chromosome segments that were apparently duplicated in a large-scale genomic duplication event in ray fin fish phylogeny. Both Sox9a and Sox9b proteins bind to the HMG consensus DNA sequences in vitro. We tested different domains for transactivation potential and identified a potential activation domain located in the middle of both Sox9a and Sox9b. During embryogenesis, sox9a and sox9b expression patterns are distinct but overlap in some regions of the brain, head skeleton, and fins. Expression of sox9a/b correlates well with that of col2a1 in chondrogenic elements. In the adults, sox9a is expressed in many tissues including brain, muscle, fin, and testis, whereas sox9b expression is restricted to previtellogenic oocytes of the ovary. This expression pattern predicts that sox9a and sox9b may have unique functions in some specific tissues during development. The role of gene duplication for the evolution of developmental gene function is discussed.

Functional laryngeal dyskinesia: an important cause of stridor

Functional laryngeal dyskinesia is a disorder that presents with stridor. Failure to recognize its features can result in inappropriate investigation and treatment for a condition that has a psychogenic origin. The key feature in diagnosis is paradoxical vocal fold adduction on inspiration, as seen on fibre-optic nasendoscopy. This phenomenon together with the associated stridor may disappear after distraction techniques or when the patient is asleep. We present five such cases which presented to hospitals in south west London over a 12 month period.

Six cases of fibromatosis of the head and neck in children

Six cases of aggressive fibromatosis occurring in the head and neck in children are described. Fibromatosis is a rare, benign but locally infiltrative condition. Primary excision is not always possible in the head and neck areas. It is not always appropriate to treat children using the same modalities as adults due to associated growth problems. The case histories illustrate the management difficulties that can be encountered when treating the paediatric population.

Dercum's disease (adiposis dolorosa)

Dercum's disease (adiposis dolorosa) is a rare condition characterized by progressively painful fatty deposits, usually, in menopausal women with obesity, asthenia and mental phenomena. We report a case of a 48-year-old woman with recurrent neck swelling and pain in the neck and parotid region, and a review of management of this uncommon problem.

Laryngeal paraganglioma in a five-year-old child--the youngest case ever recorded

A paraganglioma is a neuroendocrine neoplasm that originates from the paraganglion cells of the parasympathetic system. The average age of presentation is in the fifth decade. We report a case of laryngeal paraganglioma in a five-year-old child, the youngest case ever recorded. The features of paraganglioma which differentiate it from other tumours are also discussed.