When sequential use of mepolizumab and dupilumab in a severe atopic eosinophilic asthmatic questions the role of eosinophils in mediating the clinical expression of the disease: a case report

BACKGROUND

The advent of biologics has resulted in major progress in the treatment of severe T2 high asthmatics. There are currently several classes of biologics approved for severe asthma including anti-immunoglobulin E, anti-interleukin-5/interleukin 5R, anti-interleukin 4/interleukin 13R, and anti-thymic stromal lymphopoietin.

CASE PRESENTATIONS

Here we report the case of a 55-year-old Caucasian man with severe eosinophilic atopic asthma, who sequentially benefited from a treatment with mepolizumab, an anti-interleukin-5 monoclonal antibody, followed by treatment with dupilumab, an anti-interleukin-4/interleukin-13R antibody, the switch being justified by a flare-up of dermatitis while on mepolizumab. Overall, the patient has been followed for 72 months, including 42 months on mepolizumab and 30 months on dupilumab. Close monitoring of exacerbations, asthma control, lung function, asthma quality of life, and biomarkers shows that both biologics reduced asthma exacerbation and provided an improvement in asthma control and quality of life, with the patient achieving remission after 30 months on dupilumab. However, the effects of the two biologics on the biomarkers were very different, with mepolizumab controlling eosinophilic inflammation and dupilumab reducing serum immunoglobulin E and fractional exhaled nitric oxide levels.

CONCLUSION

The originality of this case resides in the description of clinical status and biomarker evolution after a sequential use of mepolizumab and dupilumab in a severe atopic eosinophilic asthmatic. It shows that mepolizumab reduces exacerbation and improves asthma control by curbing eosinophilic inflammation whereas dupilumab provides asthma remission without controlling airway eosinophilic inflammation.

P–576 Preimplantation genetic testing for consanguineous couple carrying an identical reciprocal translocation: clinical, ethical considerations and quandaries

Study question

Which ethical and clinical aspects should be considered for preimplantation genetic testing PGT-SR strategy management for a consanguineous couple carrying the same reciprocal translocation?

Summary answer

PGT-SR management required specific probe designs to distinguish chromosomal patterns of balanced embryos, leading to complex transfer choices that required an adapted genetic counseling.

What is known already

Reciprocal translocation is a classic case in PGT-SR management, since all balanced embryos are transferable without distinguish between normal and balanced embryos. In accordance with the several recommendations, professionals calculated the reproductive risk related to the abnormalities and established an appropriate genetic counseling. However, an extreme case, such as the same reciprocal translocation carried by both members of a couple complicates PGT-SR management at all levels. Mainly, the genetics counseling around balanced embryo transfers. To date, only one study has reported a similar case, however, genetic counseling and the choice of embryos to be transferred have been poorly documented

Study design, size, duration

This study reports an extremely rare case of a couple (26-year-old woman and 29-year-old man) who was referred to our PGT center of the Montpellier University Hospital after 4 spontaneous miscarriages. The couple, first degree cousins in whom both partners are carrying the same reciprocal translocation 46,XX/XY,t(3;18) t(q26.1;q12.1). The patients were informed of the investigations and gave their consent before participation in the study.

Participants/materials, setting, methods

Peripheral blood of each member was investigated by FISH to caracterize chromosomal breakpoints. Secondly, a theoretical estimation of different segregation products to find a normal or balanced embryos were performed considering the extreme complexity of the case. Finally, an adapted PGT-SR probe strategy was conceived and proposed to a couple. Choices of balanced embryos to transfer were detailed to ensure that the patient is aware of risks and potential benefits.

Main results and the role of chance

In this particular case where both members of the couple are carrying the same reciprocal translocation, the chance of finding a normal or balanced embryo was further lowered 2% (4/196). It is estimated that the couple would produce 1 normal embryo and 15 balanced embryos. Diagnostic was possible on 16 biopsied embryos on day 3. Probe signal interpretations revealed four balanced embryos. Two embryos were proposed for a transferred on day 4. These balanced embryos had a different probe patterns, the first balanced embryo was normal and the second balanced embryo resulting from an adjacent–1 segregation mode presented an uniparental disomy (UPD).

Limitations, reasons for caution

ESHRE recommendations were established for common chromosomal rearrangements. In specific cases, limitations are strongly related to the complexity of the human genome. In this study, the choice of the embryos to be transferred depended entirely to our knowledge of phenotypic consequences of a homozygous gene alterations involved in chromosomal breakpoints.

Wider implications of the findings: Professionals were confronted with requests to transfer balanced embryos with a partial/complete UPD or a balanced double translocation homozygote to improve the transfer rate from 3/196 of balanced combinations to 16/196. Dilemma between risks and benefits were considered for counseling to ensure an informed decision-making by patients.

Trial registration number

NA

Time intervals between semen production, initiation of analysis, and IUI significantly influence clinical pregnancies and live births

PURPOSE

Does IDEF mapping help monitor the technical process of IUI and explore the potential improvements which might contribute to increased pregnancy and live birth rates?

METHOD

Retrospective analysis of 1729 homologous IUI cycles of couples attending a fertility clinic in a university hospital setting. Standardized conventional semen parameters were analyzed and the semen samples prepared via discontinuous density gradient centrifugation.

RESULTS

There was no significant association between sperm concentration, motility and morphology (analysis phase), and pregnancy outcome. Only female and male ages were significantly associated with the pregnancy outcome. There was a significant difference in the odds on clinical pregnancies and live births when analysis was ≤ 21 min initiated, and < 107 min between sample production and IUI, adjusted for male and female age.

CONCLUSIONS

Adjusting for the couple's age, we could show that time intervals between semen production and analysis and IUI when kept low significantly influenced clinical pregnancies and live births.

A New Pneumatic Pump for Extracorporeal Circulation: TPP (True Pulsatile Pump). Experimental and First Clinical Results

A pulsatile, membrane type pump, TPP, was developed for use in routine cardiac surgery. The artificial ventricle consists of a polycarbonate housing with an inlet and outlet polyurethane tricuspid valve. The membrane is actuated hydraulically. For pre-clinical studies, we designed a study in sheep. After a pump run of 6 hours the animals were allowed to recover and sacrificed after 72 hours. All clinical parameters returned to normal values (p>0.05 vs. control values). During pump run we found elevated free plasma hemoglobine. However, these values returned to normal until the end of the observation period. Thereafter, the device was used in ten routine cardiac surgery procedures. All patients survived the procedure and were discharged from hospital. The postoperative course of lab parameters (kidney, liver and blood count) was no different to routine cardiac surgical procedures. This pulsatile pump system can thus be safely employed in cardiac surgery.

Recoil polarization and beam-recoil double polarization measurement of eta electroproduction on the proton in the region of the S11(1535) resonance

The beam-recoil double polarization P(x')(h) and P(z')(h) and the recoil polarization P(y') were measured for the first time for the p(e,e'p)eta reaction at a four-momentum transfer of Q(2) = 0.1 GeV(2)/c(2) and a center of mass production angle of theta = 120 degrees at the Mainz Microtron MAMI-C. With a center of mass energy range of 1500 MeV<W<1550 MeV the region of the S11(1535) and D13(1520) resonance was covered. The results are discussed in the framework of a phenomenological isobar model (Eta-MAID). While P(x')(h) and P(z')(h) are in good agreement with the model, P(y') shows a significant deviation, consistent with existing photoproduction data on the polarized-target asymmetry.

PaCO(2)/ETCO(2) gradient: early indicator of thrombolysis efficacy in a massive pulmonary embolism

End tidal CO(2) measurement may be helpful in detecting the efficacy of thrombolysis after a massive pulmonary embolism. We report the case of a 76-year-old man with a massive pulmonary embolism, who required early intubation and mechanical ventilation. Thrombolysis with rtpA (total dosage: 60 mg) was initiated. During this procedure, clinical data, arterial blood gases and end-tidal CO(2) with a capnograph were recorded. Before thrombolysis the P(a-ET)CO(2) gradient was raised to 25 mmHg. During thrombolysis, the clinical data improved and the P(a-ET) gradient fell to 14 mmHg. We postulate that the P(a-ET)CO(2) gradient seems to be a reasonable indicator of efficacy of thrombolysis in this setting. However, the gradient did not return to normal values (4-5 mmHg). The possible reasons for this may be that during mechanical ventilation there was a large ventilation-perfusion ratio and the cardiac output may have still reduced. With these limitations, we conclude that the P(a-ET)CO(2) gradient should be evaluated as an indicator of pulmonary reperfusion in massive pulmonary embolism.

Home care business opportunities in Europe

The demand for home care services will continue to grow exponentially around the world. This demand is being driven by demographics, technology, and personal choice. Providers of home care have a great deal to teach and learn from each other. The opportunities for collaboration and joint ventures are great now and will continue to increase with the passing of time. This article has been extracted from a 1996 panel discussion at the International Home Care Forum held in Nashville, Tennessee.

A new pneumatic pump for extracorporeal circulation: TPP (true pulsatile pump). Experimental and first clinical results

A pulsatile, membrane type pump, TPP, was developed for use in routine cardiac surgery. The artificial ventricle consists of a polycarbonate housing with an inlet and outlet polyurethane tricuspid valve. The membrane is actuated hydraulically. For pre-clinical studies, we designed a study in sheep. After a pump run of 6 hours the animals were allowed to recover and sacrificed after 72 hours. All clinical parameters returned to normal values (p > 0.05 vs. control values). During pump run we found elevated free plasma hemoglobine. However, these values returned to normal until the end of the observation period. Thereafter, the device was used in ten routine cardiac surgery procedures. All patients survived the procedure and were discharged from hospital. The postoperative course of lab parameters (kidney, liver and blood count) was no different to routine cardiac surgical procedures. This pulsatile pump system can thus be safely employed in cardiac surgery.

Kaposi's sarcoma during immunosuppressive therapy for atopic dermatitis

We describe an HIV-negative homosexual man who developed Kaposi's sarcoma (KS). He had CD4 lymphocytopenia during azathioprine and topical corticosteroid therapy for atopic dermatitits (AD). KS was observed after only 2 months of immunosuppressive therapy. No regression was observed despite discontinuation of immunosuppressive therapy and normalization of the CD4+ cell count. This patient appears to be the first case of KS associated with AD. Moreover, as our patient had been sexually inactive for 15 years, this case raises the questions about the latency and about the sexual transmission of a novel herpes-like virus (KHSHV) recently detected in all forms of KS.

Assessment of a method of isolation, purification, and cultivation of rat liver sinusoidal endothelial cells

BACKGROUND

This paper describes a simple, low cost, and rapid method for the isolation, purification, and cultivation of rat liver sinusoidal endothelial cells (LEC). With regard to the purity, morphology, and responsiveness of the LEC, a detailed electron microscopy study was performed. In addition, we developed a method of automatic detection and analysis of the endothelial fenestrations using digitized scanning electron microscope images, allowing us to collect large sets of data.

EXPERIMENTAL DESIGN

LEC were isolated by collagenase perfusion of the liver, isopycnic sedimentation in a two-step Percoll gradient, and selective adherence. The purification and cultivation of LEC was evaluated by light and electron microscopy. The addition of ethanol to LEC cultures showed responsiveness of LEC.

RESULTS

Purity and viability of LEC after selective adherence was 73.7 +/- 5.8% and > or = 95%, respectively. LEC purity was further enhanced during adherence and spreading on collagen (type I, III). After 8 hours of culture, LEC monolayers were contaminated with less than 5% of other cells. After treatment with ethanol for 90 minutes, the diameters of LEC fenestrae increased approximately 10%.

CONCLUSIONS

LEC isolated by this method provide a vital and responsive cell population enabling the study of structure and function of these cells in vitro. This method, in combination with a computer-assisted, on-line image analysis allows the acquisition of large numbers of measurements on these cells with high accuracy and with a minimum of bias.

[An unusual cause of chronic diarrhea: lymphocytic colitis]

We report a case of lymphocytic colitis in a 74-year-old woman presenting with watery diarrhea since 1 year and in whom previous extensive investigations were normal. The diagnosis could be made on the basis of typical pathological pattern in colonic biopsies. The outcome was favourable with salazopyrine therapy. The clinical, histological and pathophysiological aspects of lymphocytic colitis are discussed.

Is there potential for granulocyte or granulocyte-macrophage colony stimulating factors in radiotherapy?

The purpose of this communication was to explore which situations in radiotherapy might benefit from concomitant administration of haematopoietic growth factors (HGF). Only large-field radiotherapy is likely to induce bone marrow depression, such as irradiation of Hodgkin's disease. Therefore, we studied 122 patients irradiated for Hodgkin's disease, looking at peripheral blood cell count before, during and after the treatment. One hundred and four treatments were preceded by chemotherapy (MOPP and/or ABVD) and the radiation dose was between 36 and 44 Gy in 2 Gy per fraction sessions. Severe leucopenia (grade III WHO) was very uncommon and justified treatment interruption only twice. In both cases, it was paired with thrombocytopenia. No infection developed. It is concluded that when radiotherapy is used alone, prophylactic use of HGFs does not seem justified. This, of course, does not apply to radiochemotherapy combinations, although thorough investigations in this field are still awaited.

The ovarian hyperstimulation syndrome in in-vitro fertilization: a Belgian multicentric study. II. Multiple discriminant analysis for risk prediction

The considerable overlap of distributions of values for different parameters between control and ovarian hyperstimulation syndrome (OHSS) populations makes any single variable inefficient for risk prediction. Combinations of variables were studied in a discriminant function in order to increase predictivity and decrease the false negative rate. Such analyses were performed on two groups of in-vitro fertilization (IVF) patients: all OHSS cases (n = 128) (group A) and only severe OHSS cases (n = 92) (group B). Progressive introduction and automated stepwise selection of variables were applied to both groups. The best prediction (78.5%) was obtained in group A under post-oocyte retrieval conditions using log oestradiol, slope of log oestradiol increment, human menopausal gonadotrophin (HMG) dosage, number of oocytes retrieved and ratio of luteinizing hormone/follicle stimulating hormone (LH/FSH), in the formula. The corresponding false negative rate was 18.1%. However, effective prevention of OHSS implies the ability to withhold human chorionic gonadotrophin injection. Therefore a formula for pre-oocyte retrieval conditions was established yielding a prediction rate of 76.1% with a false negative rate of 18.1%. To be validated, such formulae have to be applied to another population of IVF cases used as a 'testing-set'.

Prolactin-independent induction of alpha-lactalbumin gene expression in mammary gland explants from pregnant Balb/c mice

A four-fold increment of alpha-lactalbumin mRNA was induced in mammary gland explants from mid-pregnant Balb/c mice cultured for 24h in media containing insulin, cortisol and T3, and this response was enhanced by 40% with the addition of prolactin. In contrast, elevated beta-casein gene expression was evident only in explants cultured in media with insulin, cortisol, T3 and prolactin. These results suggest that the induction of the alpha-lactalbumin gene was prolactin-independent and did not result from retention of endogenous prolactin, or its effects, by the mammary explants.

Management and outcome of 21 triplet and quadruplet pregnancies

The course of gestation and the outcome of fifteen triplet and six quadruplet pregnancies are reviewed. Twenty pregnancies followed induction of ovulation and only one was spontaneous. Bed rest, the use of beta-mimetics and betamethasone, and prolonged hospitalisation were part of the management. Elective cervical suture was not used. The most frequent antenatal complications were preterm labor, preterm rupture of membranes and pregnancy-induced hypertension. The median gestational age was 33.5 weeks in the triplets and 32 weeks in the quadruplets. The overall perinatal and neonatal mortality was 4.9%. The neonatal complications resulted from prematurity and sepsis.

The influence of renal function on lactate and glucose metabolism

The relationship of lactate metabolism to renal function was studied in the isolated perfused rat kidney. A new radioisotopic method has been developed that enables the simultaneous measurement of lactate production and consumption in the presence of physiological concentrations of both lactate and glucose. In kidneys from fed rats, when glucose was absent, lactate production was only 12 mumol/h per g dry wt, and in kidneys from starved rats there was no lactate production, indicating that neither the phosphoenolpyruvate/pyruvate substrate cycle nor other analogous cycles for the recycling of lactate carbon are operating in the intact kidney cortex. Lactate production from glucose occurred at a high rate, at the same time as lactate consumption, demonstrating that lactate recycling between renal cortex and medulla can occur in the intact kidney. Lactate production from glucose correlated with glomerular filtration rate (P less than 0.001), urine flow rate (P less than 0.01) and sodium reabsorption (P less than 0.05). There was significant basal lactate production at zero glomerular filtration rate. Lactate consumption was not correlated with any renal function. When Na+ reabsorption was inhibited with the diuretic frusemide, or when filtration was entirely prevented (the 'non'-filtering kidney'), lactate production was decreased by 39% and 50% respectively. Basal lactate production determined in this way was the same as that calculated above by linear regression. Prevention of filtration, but not the addition of frusemide, significantly inhibited lactate consumption. It is concluded that glycolysis is required for medullary Na+ transport, and that some different transport function(s) require lactate oxidation.

The metabolic fate of lactate in renal cortical tubules

1. Isolated kidney cortex tubules prepared from fed rats and incubated with near-physiological concentrations of [(14)C]lactate decrease the specific radioactivity of the added lactate. This effect may be attributable to at least two mechanisms; formation of lactate from endogenous precursors, or entry of unlabelled carbon into the lactate pool as a result of substrate cycling, via phosphoenolpyruvate, pyruvate and oxaloacetate, together with equilibration of the oxaloacetate pool with malate and fumarate. Such substrate cycling could occur within a single cell, or between two populations of different cells, one glycolytic and the other gluconeogenic. These possibilities have been investigated by using metabolic inhibitors or alternative metabolic substrates. 2. Tubules from fed rats produced a fall in specific radioactivity of 14.4% when incubated for 40min with 2mm-lactate alone. A mathematical treatment of this result is presented, which allows the rate of fall in specific radioactivity to be expressed as the addition of unlabelled lactate to the pool. This corresponds to a rate of formation of unlabelled lactate of 121+/-22mumol/h per g dry wt., a rate close to that of gluconeogenesis. In tubules from fasting rats, there was no reduction of the specific radioactivity of lactate, indicating that fasting for 24h suppresses production of unlabelled-lactate carbon. 3. Addition of 2mm-fumarate resulted in a significantly greater decrease in the specific radioactivity of lactate, but aspartate (2mm), malate (2mm) and glucose (5mm) were without effect. Total inhibition of gluconeogenesis with 3-mercaptopicolinate did not prevent the fall in specific radioactivity of lactate observed in tubules from fed-rat kidney, thereby excluding significant activity of the substrate cycle pyruvate-->oxaloacetate-->phosphoenolpyruvate-->pyruvate. 4. The capacity of pyruvate kinase under the test conditions in tubules prepared from kidneys of fed or starved rats was at least ten times higher than the observed rate of production of lactate, so that failure to observe recycling of lactate in starved-rat tubules indicates suppression of pyruvate kinase activity. 5. The endogenous glycogen and glucose content of isolated renal cortex tubules is too low to account for the dilution of label of lactate. Endogenous concentrations of glycerol and amino acids were also very low. As for glycogen, the possibility that very rapid turnover of these metabolites, in fed rats but not in starved rats, may account for formation of unlabelled lactate cannot be excluded. 6. It is concluded that substrate cycling via phosphoenolpyruvate does not occur to any significant extent in either fed or starved-rat kidney. In fed rats recycling of lactate carbon does occur and the rate of this reaction is similar to the rate of gluconeogenesis at physiological concentrations of lactate. The present results favour participation of oxaloacetate decarboxylase rather than ;malic' enzyme in this cycle.