Suggested role for neutrophil extracellular trap formation in Ewing sarcoma immune microenvironment

Ewing sarcoma (EWS) is a highly aggressive cancer with a survival rate of 70%-80% for patients with localized disease and under 30% for those with metastatic disease. Tumor-infiltrating neutrophils (TIN) can generate extracellular net-like DNA structures known as neutrophil extracellular traps (NETs). However, little is known about the presence and prognostic significance of tumor-infiltrating NETs in EWS. Herein, we investigated 46 patients diagnosed with EWS and treated in the Tel Aviv Medical Center between 2010 and 2021. TINs and NETs were identified in diagnostic biopsies of EWS by immunofluorescence. In addition, NETs were investigated in neutrophils isolated from peripheral blood samples of EWS patients at diagnosis and following neoadjuvant chemotherapy. The relationships between the presence of TINs and NETs, pathological and clinical features, and outcomes were analyzed. Our results demonstrate that TIN and NETs at diagnosis were higher in EWS patients with metastatic disease compared with those with local disease. High NET formation at diagnosis predicted poor response to neoadjuvant chemotherapy, relapse, and death from disease (p < 0.05). NET formation in peripheral blood samples at diagnosis was significantly elevated among patients with EWS compared with pediatric controls and decreased significantly following neoadjuvant chemotherapy. In conclusion, NET formation seems to have a role in the EWS immune microenvironment. Their presence can refine risk stratification, predict chemotherapy resistance and survival, and serve as a therapeutic target in patients with EWS.

Neutrophils extracellular traps formation may serve as a biomarker for disease activity in oligoarticular juvenile idiopathic arthritis: a pilot study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children, causing significant morbidity. Despite the dramatic improvement in treatment, many patients do not achieve complete remission, and biomarkers for subclinical disease, flares, and response to treatment are lacking. Neutrophils and neutrophil extracellular traps (NETs) play key roles in the pathogenesis of autoimmune and inflammatory conditions. In this study, we characterized neutrophil enzyme activity and NETs formation in oligoarticular and polyarticular JIA and explored their association with disease activity.

METHODS

Neutrophils from 6 healthy controls and 7 patients with oligoarticular and polyarticular JIA were freshly isolated at time of diagnosis and after glucocorticoid intra-articular injection. Enzymatic activity of neutrophil granular enzymes was monitored by colorimetry and PMA-activated NETs formation was assessed using fluorescent microscopy.

RESULTS

In this pilot and feasibility study, we revealed that NETs were significantly increased in oligoarticular JIA patients at time of diagnosis compared to healthy controls. Anti-inflammatory treatment using intra-articular steroid injection normalized NETs formation in these patients. Correlation between NETs formation and clinical Juvenile Activity Disease Activity Score-10 (cJADAS-10) was linear and significant (P = 0.007) in oligo but not in poly JIA patients.

CONCLUSIONS

This is the first study exploring the link of NETs formation with oligo and poly JIA activity. We demonstrated a statistically significant linear correlation between cJADAS-10 and NETs formation in oligo but not in poly JIA patients. Hence, we suggest that NETs may reflect clinical disease activity in JIA, and may serve as a putative biomarker. Further work is needed to validate these initial results and determine the dynamics of NETs formation in JIA.

Propranolol reduces IFN-γ driven PD-L1 immunosuppression and improves anti-tumour immunity in ovarian cancer

The immune system plays an important role in controlling epithelial ovarian cancer (EOC). EOC is considered to be a "cold tumour," a tumour that has not triggered a strong response by the immune system. However, tumour infiltrating lymphocytes (TILs) and the expression of programmed cell death ligand (PD-L1) are used as prognostic indicators in EOC. Immunotherapy such as PD-(L)1 inhibitors have shown limited benefit in EOC. Since the immune system is affected by behavioural stress and the beta-adrenergic signalling pathway, this study aimed to explore the impact of propranolol (PRO), a beta-blocker, on anti-tumour immunity in both in vitro and in vivo EOC models. Noradrenaline (NA), an adrenergic agonist, did not directly regulate PD-L1 expression but PD-L1 was significantly upregulated by IFN-γ in EOC cell lines. IFN-γ also increased PD-L1 on extracellular vesicles (EVs) released by ID8 cells. PRO significantly decreased IFN-γ levels in primary immune cells activated ex vivo and showed increased viability of the CD8⁺ cell population in an EV-immune cell co-incubation. In addition, PRO reverted PD-L1 upregulation and significantly decreased IL-10 levels in an immune-cancer cell co-culture. Chronic behavioural stress increased metastasis in mice while PRO monotherapy and the combo of PRO and PD-(L)1 inhibitor significantly decreased stress-induced metastasis. The combined therapy also reduced tumour weight compared to the cancer control group and induced anti-tumour T-cell responses with significant CD8 expression in tumour tissues. In conclusion, PRO showed a modulation of the cancer immune response by decreasing IFN-γ production and, in turn, IFN-γ-mediated PD-L1 overexpression. The combined therapy of PRO and PD-(L)1 inhibitor decreased metastasis and improved anti-tumour immunity offering a promising new therapy.

Selinexor, a selective inhibitor of nuclear export, inhibits human neutrophil extracellular trap formation in vitro

Neutrophils are central players in the innate immune system. To protect against invading pathogens, neutrophils can externalize chromatin to create neutrophil extracellular traps (NETs). While NETs are critical to host defense, they also have deleterious effects, and dysregulation of NETs formation has been implicated in autoimmune diseases, atherosclerosis and thrombotic conditions, cancer progression and dissemination, and acute respiratory distress syndrome. Here, we report that selinexor, a first-in-class selective inhibitor of nuclear export approved for the treatment of multiple myeloma and diffuse large B-cell lymphoma, markedly suppressed the release of NETs in vitro. Furthermore, we demonstrate a significant inhibitory effect of selinexor on NETs formation, but not on oxidative burst or enzymatic activities central to NETs release such as neutrophil elastase, myeloperoxidase or peptidyl arginine deiminase type IV. The inhibitory effect of selinexor was demonstrated in neutrophils activated by a variety of NETs-inducers, including PMA, TGF-β, TNF-α and IL-8. Maximal inhibition of NETs formation was observed using TGF-β, for which selinexor inhibited NETs release by 61.6%. These findings pave the way to the potential use of selinexor in an effort to reduce disease burden by inhibition of NETs.

Determination of reference intervals for neutrophil granular enzymes is affected by cell isolation techniques

OBJECTIVES

Neutrophils and their granular enzymes such as neutrophil elastase (NE) and myeloperoxidase (MPO) play important roles in inflammatory diseases, and might be utilized as biomarkers for disease severity and progression. The aim of this study was to determine reference intervals for NE and MPO activity in healthy volunteers comparing two methods of neutrophil isolation.

METHODS

Neutrophils were isolated using ficoll density gradient centrifugation or immunomagnetic negative selection in two separate volunteers' cohorts. Subsequently, cells were lysed and incubated with chromogens for NE and MPO activity measurements, then measured with a microplate reader at 415 or 450 nm respectively.

RESULTS

The enzymatic activity of NE and MPO depended on the neutrophil isolation technique. Both enzymatic activities were significantly higher (P < 0.001) after isolating neutrophils with ficoll density gradient centrifugation than using the immunomagnetic negative selection.

CONCLUSIONS

We demonstrated that neutrophil isolation is an important factor that influences the outcome of enzymatic activity measurements. Techniques based on immunomagnetic negative selection are favorable, specifically for investigations related to NE and MPO activity. When using NE and MPO activity measurements in clinical practice, care must be taken to interpret the data depending on the applied cell isolation technique.

Health services gaps experienced by non-standard workers in Ontario, Canada: Policy implications

Background

While the Canadian universal health system provides access to basic services, key health benefits are employer dependent. Given that non-standard workers (NSWs) only rarely have access to such benefits they have increased vulnerability to the many insecurities derived from their precarious employment, as clearly seen during the pandemic. The growing problem of non-standard work and workers’ heightened risk for health status deterioration, followed by a possible accentuation of health inequities, is a population health concern. This study summarizes several health services gaps experienced by NSWs and discusses policy implications and possible solutions.

Methods

From January to July 2021, we conducted semi-structured interviews with a purposive sample of 40 NSWs in Ontario, Canada, part of a larger mixed-methods six-country study, including three European countries. The target population consisted of workers aged 25 to 55 who, at the time of the survey, were in non-standard employment or lost their job due to the COVID-19 pandemic.

Results

Our findings highlight complex physical and mental health problems and an overall high burden of disease facing NSWs during the pandemic as linked to a combination of constant stress and worry arising from their employment insecurity, the limited and inconsistent income available to cover their basic needs, and the inadequate and unsafe working conditions they are afraid to challenge. Despite their increased health needs, given that specialized health services are not available to them for free they face financial barriers in accessing much needed health services that could help improve their health status and as a result, delay seeking care or avoid it altogether.

Conclusions

Sustainable multi sectorial policy solutions are needed including the adoption of relevant labour market legislation and increases in social and health expenditures along with re-adjustments in the ways in which health services are delivered.

Key messages

• During the pandemic non-standard workers in Ontario, Canada experienced complex health problems and, despite increased health needs, encountered barriers in accessing specialized health services.

• The growing problem of non-standard work and workers’ heightened risk for health status deterioration, followed by a possible accentuation of health inequities, is a population health concern.

Hustle: Experiences of making work ‘work’ for non-standard and precariously employed workers in NYC

Background

Precarious and non-standard employment (NSE) has negative implications for workers’ health. As part of a six-country comparative mixed methods case study, this research explores US-based workers’ experiences in NSE and its influences on their health and well-being in a context of weak labor regulations and social welfare programs.

Methods

To understand US policy context, we analyzed country-level labor regulatory and social protection frameworks using 2019 Organization for Economic Cooperation and Development data. To understand workers’ experiences, we conducted in-depth interviews with NSE workers in various occupations in New York City (N = 40) between January and May 2021. We recruited and screened eligibility via Facebook advertisements and an online questionnaire, respectively. We used deductive and inductive thematic analysis for interview data.

Results

With heavy reliance on market competition in the US, minimal state regulation and flexible labor markets create less secure employment along with limited government-funded social supports. Workers’ experiences center on the Hustle, i.e., figuring out how to make NSE work for them and their families. They lack healthcare coverage and have low expectations of other supportive employment and social protections (e.g., paid leave). While NSE payoffs (e.g., perceived flexibility) were common for most, almost all experience NSE tradeoffs (e.g., job insecurity and instability) that create stress and overwork, negatively implicating overall health and well-being. These impacts differ by access to resources associated with social location (e.g., immigration status). COVID-19 exacerbated these experiences.

Discussion

Low expectations of supportive policies of US workers in NSE are linked to the individualized hustle, as they attempt to counter NSE tradeoffs often relying on family to fill those gaps. Over-reliance on privatization for social supports such as healthcare coverage can be detrimental to workers’ health.

Key messages

Labor and social protection gaps impacting health of non-standard workers: An international study

Background

Labor regulations and social protection structures are intended to protect workers, but the needs of those in precarious and non-standard employment (NSE) are often missed, which may negatively impact health and well-being. The aim of this research is to document how workers in NSE in six countries - Belgium, Canada, Chile, Spain, Sweden, and the US - with varying policy contexts experience aspects of employment that are linked to health.

Methods

We employed a mixed methods approach for this study. To understand policy contexts, we analyzed country-level labor regulatory and social protection frameworks using 2019 Organization for Economic Cooperation and Development data. To understand the experiences of workers in NSE, we conducted 250 in-depth interviews with workers at different levels of employment precariousness between January and June 2021.

Results

Overall, European countries have the most social expenditures and North American countries have the weakest labor market regulations. In all these varying contexts, workers in NSE reported multiple unmet needs, e.g., inadequate paid sick and parental leave and unemployment compensation. These unmet needs occur due to various barriers, including poor enforcement, legal loopholes, or required minimum employment time. Workers’ living accommodations are also affected, as home financing or rental contracts are dependent on permanent employment. In response, they tended to rely disproportionately on individual or family resources for financial and social support rather than on government or employer resources.

Conclusions

Findings suggested that diverse labor regulatory and welfare regime contexts are unsupportive of workers in NSE due to multiple gaps in policies essential to public health. The shifting of responsibility for key employment and social supports to individuals and their families is likely to increase health inequities for workers in NSE.

Key messages

• Our study documents multiple policy gaps affecting key employment-related social determinants of health among workers in NSE.

• This occurred across diverse labor and social structure contexts in six countries.

The various insecurities experienced among non-standard workers across different policy-contexts

Background

Over the last decades, the prevalence of non-standard employment (NSE) has increased in many countries, with negative implications for worker health and well-being. Research at the micro level, mostly quantitative, has linked NSE with poor health through insecurity. Macro-level studies investigating whether political economic factors buffer the harms of NSE have generated mixed results. This study describes how various types of insecurity are experienced by workers in NSE, in general and during COVID-19, and how this influences their health and well-being, in six countries with different welfare states: Belgium, Canada, Chile, Spain, Sweden and the United States.

Methods

In-depth interviews with 250 workers in NSE were analysed using a multiple-case study approach and using the welfare state typology as a macro-level framework.

Results

Despite differences in welfare states, workers in all six countries experienced multiple forms of insecurity as well as relational tension with employers or clients, with clear negative effects on their well-being, in ways that were shaped by broader social inequalities (e.g., related to gender, age, and access to family support). Simultaneously, differences in welfare states were reflected in the level of workers’ exclusion from social protections, the temporality of difficulties they faced in planning their lives (e.g., threats to daily survival or to longer-term life planning), and their ability to derive control from NSE despite the insecurity it created. Workers in less generous welfare states experienced heightened insecurity and greater stress from the COVID-19, but the severity of the health and economic crisis was felt by workers in all study countries.

Conclusions

This study sheds light on the ways that welfare regimes can support - or fail to support - workers in NSE, and suggests the need in all six countries for stronger state responses to NSE, a pressing social determinant of health.

Key messages

Safety of Inulin and Sinistrin: Combining Several Sources for Pharmacovigilance Purposes

Introduction: Inulin and its analog sinistrin are fructose polymers used in the food and pharmaceutical industries. In 2018, The French National Agency for the Safety of Medicines and Health Products (ANSM) decided to withdraw products containing sinistrin and inulin due to several reports of serious hypersensitivity reactions, including a fatal outcome.

Objective: To assess the safety of inulin and sinistrin use in France.

Methods: We searched multiple sources to identify adverse reactions (ARs) to inulin or sinistrin: first, classical pharmacovigilance databases including the French Pharmacovigilance (FPVD) and the WHO Database (VigiBase); second, data from a clinical trial, MultiGFR; third, data regarding current use in an hospital. All potential ARs to inulin or sinistrin were analyzed with a focus on hypersensitivity reactions and relationships to batches of sinistrin.

Results: From 1991 to 2018, 134 ARs to inulin or sinistrin were registered in the FPVD or VigiBase. Sixty-three cases (47%) were classified as serious, and 129 cases (96%) were hypersensitivity reactions. We found an association between a batch of sinistrin and the occurrence of hypersensitivity reactions. During the MultiGFR clinical trial, 7 patients (7/163 participants) had an Adverse reaction; of these, 4 were hypersensitivity reactions including one case of grade 4 anaphylactic shock. In the hospital, no ARs were observed. In the literature, ARs to inulin and sinistrin are very rarely reported and mostly benign.

Conclusion: Most ARs to inulin and sinistrin are hypersensitivity reactions that appear to be associated with sinistrin batches.

Comment on: "A novel approach to peatlands as archives of total cumulative spatial pollution loads from atmospheric deposition of airborne elements complementary to EMEP data: Priority pollutants (Pb, Cd, Hg)" by Ewa Miszczak, Sebastian Stefaniak, Adam Michczyński, Eiliv Steinnes and Irena Twardowska

A recent paper by Miszczak et al. (2020) examines metal contamination of mires in Poland and Norway. The authors conclude that lead (Pb) records in ombrotrophic peatlands cannot be used to reconstruct the chronological history of anthropogenic activities due to post-depositional mobility of the metal. We contest this general conclusion which stands in contrast with a significant body of literature demonstrating that Pb is largely immobile in the vast majority of ombrotrophic peatlands. Our aim is to reaffirm the crucial contribution that peat records have made to our knowledge of atmospheric Pb contamination. In addition, we reiterate the necessity of following established protocols to produce reliable records of anthropogenic Pb contamination in environmental archives.

[Cesarean sections in the Centre-Val de Loire region: Practices and indications-the Robson Classification]

BACKGROUND

To study the cesarean section (c-section) practices in the French Centre-Val de Loire region: incidence of planned c-section and rate variations between maternities, incidence of potentially avoidable cesarean sections.

METHODS

The data were extracted from the 2016 regional birth register, which permitted classification of each planned c-section according to the pre-existing risk of c-section (high or low) as defined by the Robson classification. To enhance the data, especially the indications for c-section, which are not included in the register, a survey was conducted from September 2016 to February 2017 in all of the 20 maternities in the region.

RESULTS

In 2016, nearly 26,000 women gave birth in the CVL region, of whom 19.2% by c-section (7.0% planned c-sections). The planned c-section rate was higher for breech presentation and scarred uterus, and decreased according to level of the maternity (I 41% - II 35% - III 32%). Concerning the c-section indications, 1,979 c-sections were studied during the period (18.6% of births), including 762 planned c-sections (7.1% of births). Among them, 246 (32%) were potentially avoidable, mainly isolated indications of scarred uterus with only one previous c-section or breech presentation, and 17 due to unfavorable radiologic pelvimetry in nulliparous women.

CONCLUSION

Specific actions were identified: targeted use of radiologic pelvimetry, targeted c-section on scarred uterus with only one previous cesarean section or breech presentation, as recommended by the national guidelines. The Robson classification should be widely used to evaluate and enhance practices, in particularly through painstakingly interpreted inter-maternity comparisons.

92 Relocation in Care Homes (RICH) Study: The Experience of Different Stakeholders

Introduction

In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes.

Methods

In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes.

Results

Seven themes were identified and organised under three stages: pre-move (communication and involvement; preparation for the move; and attitudes towards the move), day-of-the-move (organisation of the move), and post-move (environmental change and impact; staff organisation and management; and settling in). Family and staff members reported that the pre-move information provided was inconsistent and staff did not feel involved in the planning and design process. Pre-move visits and staff and family support were beneficial for residents’ preparation for the move. All participants expressed sadness about the closure, and reported apprehension about moving. The moving day felt disorganised and stressful to staff who had to spread between the two homes. Post-move, the new care home was perceived by many participants as a ‘hotel’ rather than a home. Its larger size and confusing layout impacted negatively on residents and staff. New staff and changes in management structure were perceived by the different stakeholders to cause increased staff workload. Residents adjusted variably to the new home, with family support and staff continuity of care proving to be facilitators.

Conclusions

Despite extensive planning, relocation and adjustment was challenging. Recommendations for future relocations include: increasing involvement of staff in the planning and design of the home; ensuring consistent communication and organising staff rotas to maintain continuity of care.

Colorectal cancer (CRC) monitoring by 6-monthly 18FDG-PET/CT: an open-label multicentre randomised trial

Background

[¹⁸F]2-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (¹⁸FDG-PET/CT) has high sensitivity for detecting recurrences of colorectal cancer (CRC). Our objective was to determine whether adding routine 6-monthly ¹⁸FDG-PET/CT to our usual monitoring strategy improved patient outcomes and to assess the effect on costs.

Patients and methods

In this open-label multicentre trial, patients in remission of CRC (stage II perforated, stage III, or stage IV) after curative surgery were randomly assigned (1 : 1) to usual monitoring alone (3-monthly physical and tumour marker assays, 6-monthly liver ultrasound and chest radiograph, and 6-monthly whole-body computed tomography) or with 6-monthly ¹⁸FDG-PET/CT, for 3 years. A multidisciplinary committee reviewed each patient’s data every 3 months and classified the recurrence status as yes/no/doubtful. Recurrences were treated with curative surgery alone if feasible and with chemotherapy otherwise. The primary end point was treatment failure defined as unresectable recurrence or death. Relative risks were estimated, and survival was analysed using the Kaplan–Meier method, log-rank test, and Cox models. Direct costs were compared.

Results

Of the 239 enrolled patients, 120 were in the intervention arm and 119 in the control arm. The failure rate was 29.2% (31 unresectable recurrences and 4 deaths) in the intervention group and 23.7% (27 unresectable recurrences and 1 death) in the control group (relative risk = 1.23; 95% confidence interval, 0.80–1.88; P = 0.34). The multivariate analysis also showed no significant difference (hazards ratio, 1.33; 95% confidence interval, 0.8–2.19; P = 0.27). Median time to diagnosis of unresectable recurrence (months) was significantly shorter in the intervention group [7 (3–20) versus 14.3 (7.3–27), P = 0.016]. Mean cost/patient was higher in the intervention group (18 192 ± 27 679 € versus 11 131 ± 13  €, P < 0.033).

Conclusion

¹⁸FDG-PET/CT, when added every 6 months, increased costs without decreasing treatment failure rates in patients in remission of CRC. The control group had very close follow-up, and any additional improvement (if present) would be small and hard to detect.

ClinicalTrials.gov identifier

NCT00624260

Indications and practices of Cesarean Sections in a French region – The Robson classification

Background

Cesarian-section (CS) deliveries, although sometimes vital, are associated with increasing immediate- and long-term maternal and/or neonatal risks. The objective was to describe the indications of scheduled CS, measure the potentially avoidable CS and study the rate variations between maternities in one French region, Centre Val-de-Loire (CVL).

Methods

A cross-sectional study was conducted from September 2016 to February 2017. Information about all CS performed in the maternities of the region was collected: medical history, indication, schedule. Data collection was completed with the 2016 regional birth data repository (25,864 deliveries, including 19.2% of CS, among which 7.0% were scheduled). CS were classified according to the pre-existing risk high or low of CS as defined by the Robson classification.

Results

During the study period, 1,979 CS (18.6% of deliveries) were performed, of which 762 were scheduled (7.1% of deliveries). The main indications for planning a CS were: scarred uterus (60%, of which 56% with only one previous CS) or breech presentation (25%), considered at high risk of CS according to the Robson classification. For these two contexts, the regional birth repository showed decreasing scheduled CS rates from high to low level of maternities’ expertise. Remarkly, 22 nulliparous women with a single cephalic pregnancy in spontaneous labor before term (Robson’s low risk of CS) had a CS performed for unfavorable pelvimetry (0.2% of deliveries).

Conclusions

This study allowed identifying specific potential interventions: targeted CS on scarred uterus with only one previous CS or breech presentation, as recommended by national guidelines, and targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices through cautious maternity comparisons to improve quality of care.

Key messages

Although potentially avoidable c-sections are rare, interventions were identified: targeted CS on uterus with one previous CS or breech presentation, targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices, in order to improve healthcare quality.

Neutrophil Elastase Activity as a Surrogate Marker for Neutrophil Extracellular Trap Formation following Hematopoietic Stem Cell Transplantation

Impaired neutrophil extracellular trap (NET) formation compromises the host defense after engraftment following hematopoietic stem cell transplantation (HSCT) despite adequate neutrophil counts. The aims of the present study were to determine reference ranges for the activity of key enzymes of NET formation-neutrophil elastase (NE) and myeloperoxidase (MPO)-in a healthy population and to unravel the recovery dynamics of NET formation over time following HSCT, along with NE and MPO enzymatic activities. Reference ranges of NE and MPO activity were derived from 50 healthy volunteers. During 2017 to 2018, 11 consecutive pediatric patients undergoing allogeneic or autologous HSCT were recruited at a single referral center for pediatric hemato-oncology. Patients were followed for up to 1 year following engraftment. The mean reference value was 7.5 ± .4 mU for NE activity and 2.17 ± .4 U for MPO activity in the healthy population, and enzymatic activity of MPO was significantly higher in males. At 3 weeks following neutrophil engraftment, all study participants demonstrated extremely low enzymatic NE activity, whereas MPO activity was above the lower normal reference range at all time points. Reduced NE activity corresponded to the inability to form NETs. Neutrophil function improved over time, but partial impairment persisted for 7 months following transplantation. The ability of neutrophils to form NETs was significantly impaired for 3 weeks after engraftment in the setting of HSCT, exposing patients to bacterial infections. NE activity might serve as a surrogate marker for the capacity of neutrophils to form NETs.

[Functional diagnostics in pneumology]

Alongside imaging techniques, pulmonary function testing helps in the diagnosis of underlying disorders such as asthma and chronic obstructive pulmonary disease (COPD) or fibrosing lung disease. However, disease severity grading is also important, as well as disease follow-up under therapy. The value of spirometry as a first-line diagnostic test, whole-body plethysmography in advanced diagnostics, the measurement of transfer factor, as well as blood gas analysis are outlined. The importance of spiroergometry, echocardiography, and right-heart catheterization, particularly in the functional assessment of pulmonary vascular disorders, is described. Tests in respiratory sleep medicine, such as polysomnography, as well as tests for diagnosing chronic respiratory failure, are part of the respiratory physician's diagnostic armamentarium.

A randomized controlled trial protocol assessing the effectiveness, safety and cost-effectiveness of methotrexate vs. ciclosporin in the treatment of severe atopic eczema in children: the TREatment of severe Atopic eczema Trial (TREAT)

BACKGROUND

Oral systemic immunomodulatory medication is regularly used off-licence in children with severe atopic eczema. However, there is no firm evidence regarding the effectiveness, safety, cost-effectiveness and impact on quality of life from an adequately powered randomized controlled trial (RCT) using systemic medication in children.

OBJECTIVES

To assess whether there is a difference in the speed of onset, effectiveness, side-effect profile and reduction in flares post-treatment between ciclosporin (CyA) and methotrexate (MTX), and also the cost-effectiveness of the drugs. Treatment impact on quality of life will also be examined in addition to whether FLG genotype influences treatment response. In addition, the trial studies the immune-metabolic effects of CyA and MTX.

METHODS

Multicentre, parallel group, assessor-blind, pragmatic RCT of 36 weeks' duration with a 24-week follow-up period. In total, 102 children aged 2-16 years with moderate-to-severe atopic eczema, unresponsive to topical treatment will be randomized (1 : 1) to receive MTX (0·4 mg kg^-1 per week) or CyA (4 mg kg^-1 per day).

RESULTS

The trial has two primary outcomes: change from baseline to 12 weeks in Objective Severity Scoring of Atopic Dermatitis (o-SCORAD) and time to first significant flare following treatment cessation.

CONCLUSIONS

This trial addresses important therapeutic questions, highlighted in systematic reviews and treatment guidelines for atopic eczema. The trial design is pragmatic to reflect current clinical practice.

Expression of a recombinant, 4'-Phosphopantetheinylated, active M. tuberculosis fatty acid synthase I in E. coli

Background

Fatty acid synthase 1 (FAS I) from Mycobacterium tuberculosis (Mtb) is an essential protein and a promising drug target. FAS I is a multi-functional, multi-domain protein that is organized as a large (1.9 MDa) homohexameric complex. Acyl intermediates produced during fatty acid elongation are attached covalently to an acyl carrier protein (ACP) domain. This domain is activated by the transfer of a 4'-Phosphopantetheine (4'-PP, also termed P-pant) group from CoA to ACP catalyzed by a 4'-PP transferase, termed acyl carrier protein synthase (AcpS).

Methods

In order to obtain an activated FAS I in E. coli, we transformed E. coli with tagged Mtb fas1 and acpS genes encoded by a separate plasmid. We induced the expression of Mtb FAS I following induction of AcpS expression. FAS I was purified by Strep-Tactin affinity chromatography.

Results

Activation of Mtb FAS I was confirmed by the identification of a bound P-pant group on serine at position 1808 by mass spectrometry. The purified FAS I displayed biochemical activity shown by spectrophotometric analysis of NADPH oxidation and by CoA production, using the Ellman reaction. The purified Mtb FAS I forms a hexameric complex shown by negative staining and cryo-EM.

Conclusion

Purified hexameric and active Mtb FAS I is required for binding and drug inhibition studies and for structure-function analysis of this enzyme. This relatively simple and short procedure for Mtb FAS I production should facilitate studies of this enzyme.

Key features of bone and joint infections following the implementation of reference centers in France

OBJECTIVES

French reference centers for bone and joint infections (BJI) were implemented from 2009 onwards to improve the management of complex BJIs. This study compared BJI burden before and after the implementation of these reference centers.

PATIENTS AND METHODS

BJI hospital stays were selected from the 2008 and 2013 national hospital discharge database using a validated algorithm, adding the new complex BJI code created in 2011. Epidemiology and economic burden were assessed.

RESULTS

BJI prevalence increased in 2013 (70 vs. 54/100,000 in 2008). Characteristics of BJI remained similar between 2008 and 2013: septic arthritis (50%), increasing prevalence with age and sex, case fatality 5%, mean length of stay 17.5 days, rehospitalization 20%. However, device-associated BJIs increased (34 vs. 26%) as well as costs (€421 million vs. €259 in 2008). Similar device-associated BJI characteristics between 2008 and 2013 were: septic arthritis (70%), case fatality (3%), but with more hospitalizations in reference centers (34 vs. 30%) and a higher cost per stay. Among the 7% of coded complex BJIs, the mean length of stay was 22.2 days and mean cost was €11,960.

CONCLUSIONS

BJI prevalence highly increased in France. Complex BJI prevalence assessment is complicated by the absence of clinical consensus and probable undercoding. A validation of clinical case definition of complex BJI is required.

CheY acetylation is required for ordinary adaptation time in Escherichia coli chemotaxis

Recent studies demonstrated the dependence of speed adaptation in Escherichia coli on acetylation of the chemotaxis signaling molecule CheY. Here, we examined whether CheY acetylation is involved in chemotactic adaptation. A mutant lacking the acetylating enzyme acetyl-CoA synthetase (Acs) requires more time to adapt to attractant stimulation, and vice versa to repellent stimulation. This effect is avoided by conditions that favor production of acetyl-CoA, thus enabling Acs-independent CheY autoacetylation, or reversed by expressing Acs from a plasmid. These findings suggest that CheY should be acetylated for ordinary adaptation time, and that the function of this acetylation in adaptation is to enable the motor to shift its rotation to clockwise. We further identify the enzyme phosphotransacetylase as a third deacetylase of CheY in E. coli.

Estimated or Measured GFR in Living Kidney Donors Work-up?

The value of estimated glomerular filtration rate (eGFR) in living kidney donors screening is unclear. A recently published web-based application derived from large cohorts, but not living donors, calculates the probability of a measured GFR (mGFR) lower than a determined threshold. Our objectives were to validate the clinical utility of this tool in a cohort of living donors and to test two other strategies based on chronic kidney disease epidemiology collaboration (CKD-EPI) and on MDRD-eGFR. GFR was measured using ⁵¹ Cr- ethylene-diamine tetraacetic acid urinary clearance in 311 potential living kidney donors (178 women, mean age 50 ± 11.6 years). The web-based tool was used to predict those with mGFR < 80 mL/min/1.73 m² . Inputs to the application were sex, age, ethnicity, and plasma creatinine. In our cohort, a web-based probability of mGFR <90 mL/min/1.73 m² higher than 2% had 100% sensitivity for detection of actual mGFR <80 mL/min/1.73 m² . The positive predictive value was 0.19. A CKD-EPI-eGFR threshold of 104 mL/min/1.73 m² and an MDRD-eGFR threshold of 100 mL/min/1.73 m² had 100% sensitivity to detect donors with actual mGFR <80 mL/min/1.73 m² . We obtained similar results in an external cohort of 354 living donors. We confirm the usefulness of the web-based application to identify potential donors who should benefit from GFR measurement.