Monocyte Function in Parkinson's Disease and the Impact of Autologous Serum on Phagocytosis.

Background: Increasing evidence implicates involvement of the innate immune system in the initiation and progression of Parkinson's disease (PD). Monocytes and monocyte-derived cells perform a number of functions, such as phagocytosis, chemotaxis, and cytokine secretion, which may be particularly relevant to PD pathology. The behavior of these cells in early-moderate disease, in conditions more similar to the in-vivo environment has not been fully evaluated. Research Question: Does monocyte function, including phagocytosis, chemotaxis and cytokine secretion, differ in early-moderate PD compared to age and gender-matched controls? Methods: Participants included PD patients (n = 41) with early-moderate stage disease (Hoehn and Yahr ≤2) and age and gender matched controls (n = 41). Peripheral blood mononuclear cells (PBMCs) were isolated from whole blood and monocytes were further separated using CD14 magnetic beads. Functional assays, including bead phagocytosis (in standard medium and autologous serum), Boyden chamber trans-well chemotaxis, and cytokine secretion on lipopolysaccharide stimulation were performed. Monocyte surface markers relating to chemotaxis were measured using immunohistochemistry and flow cytometry. Between-group analysis was performed using paired t-tests. Results: An autologous serum environment significantly increased bead phagocytosis compared to standard medium as expected, in both patients and controls. When in autologous serum, PD monocytes demonstrated enhanced phagocytosis compared to control monocytes (p = 0.029). The level of serum-based phagocytosis was influenced by complement inactivation and the origin of the serum. There were no significant differences between PD and controls in terms of standard medium based monocyte migration or cytokine secretion in this cohort. Conclusions: Autologous serum has a significant influence on monocyte phagocytosis and reveals increased phagocytic capacity in early-moderate PD compared to controls. These conditions may better reflect the function of monocytes in-vivo in PD patients than standard medium based phagocytosis assays. Further studies will be required to replicate these results in larger cohorts, including earlier and later stages of disease, and to understand which serum factors are responsible for this observation and the potential mechanistic relevance to PD pathogenesis.Funding for this work was provided by Addenbrooke’s Charitable Trust, the Rosetrees Trust and the NIHR Cambridge Biomedical Research Centre. RSW was supported by a Fellowship from Addenbrooke’s Charitable Trust. DKV is supported by a Junior Research Fellowship from Homerton College, Cambridge. KMS is supported by a Fellowship from the Wellcome Trust. CHWG is supported by a Clinician Scientist Fellowship from the Medical Research Council. RAB is an NIHR Senior Investigator and is supported by the Wellcome Trust-MRC Cambridge Stem Cell Institute

The hidden burden of adult allergic rhinitis : UK healthcare resource utilisation survey

Funding Funding for this survey was provided by Meda Pharma.Peer reviewedPublisher PD

Expert Panel Review of alternative biological matrices for use as an evidential sample for drug driving

Review to recommend an alternative biological matrix that could be used as evidence for the new drug driving offence.Executive Summary 1 METHODOLOGY AND ANALYTICAL TECHNIQUES AVAILABLE FOR THE DETECTION OF DRUGS INCLUDED IN THE DRUG-DRIVING LEGISLATION It is standard practice in Forensic Science for the methodology employed for the screening test to be qualitatively different from the confirmation test. In the UK drug-driving context, a Point of Contact Test (POCT) for an oral fluid (OF) screening device is used as the initial test and whole blood for the confirmatory (evidential) test. The confirmatory test is carried out in the laboratory using liquid or gas chromatography and mass spectrometry (LC or GC-MS). It is a requirement of law that confirmatory (evidential) tests are undertaken. 1.1 SCREENING TESTS Immunoassays are the basis for initial screening tests (POCT) undertaken at the roadside or in the police station. Such testing offers advantages in simplicity and ease of performance but this may be offset by potential problems concerning the lack of a positive control. Those interpreting the test result to reach a conclusion with serious consequences such as driving under the influence of drugs need to be sure of the validity of the findings. Drug testing at the roadside can therefore only be carried out with equipment that has been type-approved by the Secretary of State after testing by the Home Office’s Centre for Applied Science and Technology (CAST). Although roadside screening to detect psychoactive drug use is carried out using an OF immunoassay, developments such as the portable Surface-Enhanced Raman Spectroscope (SERS) analyser may offer an alternative technique, particularly if a handheld version comes to market. In terms of roadside testing the Panel recommends that the Home Office could expand the list of type-approved screening tests to include, in addition to THC and cocaine (which also provides a route to the cocaine metabolite benzoylecgonine (BZE)), the amphetamine-type drugs (methamphetamine and MDMA) and ketamine to reflect the growing use of these compounds in driving populations. 1.2 CONFIRMATORY TESTS More sophisticated equipment is needed for the confirmatory test than the screening test. Sample preparation (the extraction of the drug from the biological matrix) is required in order to quantify the presence of a specific drug. The direct injection of neat biological sample into chromatographic systems is an emerging development and significantly speeds up the analytical process. The confirmatory test can only take place in an accredited Forensic Service Provider (FSP) laboratory. The Panel confirmed that the substances included in section 5A of the drug-driving legislation can be easily quantified in whole blood or OF in the laboratory using GC or LC-MS. 1.2.1 Relationship between whole blood, Oral Fluid (OF), urinary, and hair drug concentrations It is widely accepted that blood and, to a lesser degree, OF are likely to give the most accurate measurement of drugs currently active in the body. Urine provides a somewhat longer detection period (drug use over the last 2-3 days), but with less quantitative accuracy. Hair provides a substantially longer detection window but does not usually used to indicate recent drug use in relation to a road traffic incident. The Panel acknowledged that OF collected at the roadside for confirmatory purposes would be particularly advantageous in terms of reducing the time lag between the driving incident and evidential testing for illicit drugs such as THC, cocaine and heroin that are known to decline rapidly in blood after use. 1.2.2 The maturity of confirmatory analysis in blood and OF To date, OF tests have not been fully validated as an alternative tool to whole blood for ‘per se’ evidential testing but, has more potential when a Lowest-Limit-of-Quantification (LLOQ) approach is utilised. The scientific evidence suggests that commercial OF immunoassay POCT devices are not suitable for evidential testing (although some devices allow for the collection of OF for separate evidential testing at the laboratory). The Panel recognised maturity in the chromatographic methodology available for the analysis of drugs included in the section 5A offence and this was at the level of sophistication that enabled the measurement of low concentrations of drugs in various matrices including whole blood and OF. The Panel recommends that the validity of the evidential drug-test requires that the level of confidence in the analytical methodology be known. Uncertainty data following chromatographic analysis of different drugs in whole blood (summarised in Table 1), can be found in the literature and are presented in the full report. The Panel noted that for whole blood an analytical uncertainty based on 3 standard deviations (k = 3) was preferred by the Home Office and should be achievable for chromatographic assays (confirmatory tests) of the drugs included in the Section 5A offence as follows: Table 1 Uncertainty data following chromatographic analysis of different drugs in whole blood summarised from the scientific literature (section 2.7 full report) Drug % Uncertainty Drug % Uncertainty THC 16 – 30.0 Amphetamine 34 Cocaine 21 - 29.5 Morphine 33 – 45 BZE 17 - 30.5 Methadone 27-33 LSD 30 Diazepam 7-12 MDMA 24 Lorazepam <33 Methamphetamine <30 Oxazepam <30 6-MAM 42 Temazepam <30 Ketamine 35 Clonazepam <34 Flunitrazepam <36 2 IDENTIFICATION OF ALTERNATIVE BIOLOGICAL MATRICES FOR EVIDENTIAL TESTING OF DRIVERS APPREHENDED FOR DRUG DRIVING 2.1 BLOOD Whole blood is currently the matrix used for evidential testing in those suspected of committing a drug-driving offence in Great Britain. This is based on the sound principle that drug concentrations in blood provide an accurate picture of the amount of drug(s) present in the body at the time of sampling and presents the strongest scientific evidence in relation to impaired driving performance. It remains the gold standard in this regard. However, the Panel acknowledged that care needs to be taken when collecting blood to ensure that sample integrity is assured; appropriate use of a preservative and an anticoagulant is mandated. Standardisation of the sampling kit and blood collection tubes for evidential tests are warranted with attention given to temperature and light during storage, transportation, and the timeliness of sample collection in relation to the driving incident. The Panel recommends that where whole blood is used for evidential tests there should be a specification (minimum standard) for the sample collection kit and the blood collection tube that includes details of the amount of preservative and anticoagulant required. The Panel also recommends moving towards the use of a vacutainer blood sampling device for safer sampling and in keeping with current practice within the NHS. 2.2 URINE Urine reflects drug use over the previous few days or longer and in this sense is not helpful in the drug-driving context since a relationship between observed impairment or time when drug consumption last occurred cannot be determined. Despite the advantage of having a matrix that requires little laboratory preparation and that can be collected in large volumes, urinalysis presents difficulties as a confirmatory test for drug driving purposes when efforts are made to correlate drug concentration directly with impairment. Urine drug test results provide information regarding the manner in which a drug is eliminated from the body rather than an indication of drug activity in the body. Excretion patterns of drugs vary within and between individuals such that the setting of cut-off values with this in mind would be very difficult. Although the relationship between blood concentrations and urine concentrations have been researched over many years, the general consensus is that urine cannot be used to determine current pharmacological drug activity in the body. The other major limitation with urine testing is with regard to the inconvenience of urine sample collection and the potential lack of integrity. Unless voidance of urine is observed, the authenticity of the sample may be called into question since urine can easily be contaminated. The possibility of false negative results following adulteration of urine with chemicals or by dilution is well described. Special facilities must be provided to be able to observe the sample collection to avoid adulteration, which may be time consuming and impractical. Urine is only suitable for the confirmation that drug use has taken place at some point in the past. However, when a zero tolerance approach is used and a laboratory LLOQ analysis is employed as the cut-off, then urinalysis can be used to support an impairment test result, as is the case for section 4 legislation. 2.3 ORAL FLUID (OF) There are several potential advantages with OF not least that it is readily accessible, and requires no medical personnel for sampling. OF collected at the roadside for confirmatory purposes would remove the need for specialist personnel to attend the police station to carry out sampling and therefore reduce the delay between the driving incident and sample collection so that drug concentrations reflective of those at the time of the driving incident were more likely. A threshold-based approach where the intention is to detect the presence of a psychoactive substance using OF and relate it to a time when the driver had been apprehended deemed impaired and to be a high road safety risk would be problematic. For confirmatory testing purposes using a per se (threshold) approach, the usefulness of OF as a possible matrix would be dependent on consistent oral fluid-whole blood (OF: B) ratios. For OF concentrations to predict whole blood concentrations accurately, the OF: B ratio would need to be independent of drug concentration and consistent within and between individuals. However due to large individual variations, ratios have been difficult to agree and cannot be easily determined for most psychoactive drugs, although some correlation has been described. OF: blood ratios have been shown to vary from drug to drug, from person to person, and even intra-individually making efforts to relate OF drug concentration at an equivalent blood drug concentration very challenging. The Panel agreed that blood concentrations could not be correlated with those in OF so that the ‘risk threshold’ limits set in the Section 5A legislation for medicinal controlled drugs (UK Government, 2014) could not be translated into OF cut-offs. The Panel concluded that the wide range of the ratios recorded does not allow reliable estimation of blood drug concentrations from OF concentrations. OF could conceivably be utilised for evidential testing where a LLOQ approach was employed and in this regard OF testing would be much better suited to illicit substances than to medicinal controlled drugs. For evidential testing using OF, the Panel recommended the OF cut-off limits published in the ‘Guide to Type-Approval Procedures for Preliminary Drug Testing Devices Used for Transport Law Enforcement in Great Britain’ in 2012, could be used with illicit drugs (Table 2). These were based on the approach taken for whole blood, i.e. the lowest limit of quantification (LLOQ) that most laboratories would be able to detect, yet above the concentrations commonly associated with passive (accidental) exposure. Table 2 Lowest Limit of Quantification (Cut-offs) for illicit drugs detected (µg/L) in OF (above concentrations commonly associated with passive exposure). Drug Group Drug to be detected LLOQ Cut-off (µg/L) Cannabinoids Delta-9-THC 10 Cocaine Cocaine Benzoylecgonine 30 30 (as composite) Amphetamines Methamphetamine MDMA 25 25 Opiates (heroin) 6-MAM 10 Hallucinogens LSD Ketamine 1 20 This matrix has been successfully used for preliminary drug testing (screening) where immediate results are required and, to this end, a number of jurisdictions around the world have adopted OF as a roadside screening tool for the detection of illicit drugs and psychoactive medicines in those suspected of drug-driving offences. However, the scientific evidence suggests that commercial OF immunoassay POCT devices are not suitable for evidential testing (indeed they were not designed with this in mind). This should not defer efforts to explore this matrix using other methodology. Although many OF immunoassay POCT drug screening devices involve the collection of a small volume of OF, some have a facility to send part of the sample to the laboratory for evidential tests. Evidential tests using the OF Cozart® Rapiscan has been successfully used in the State of Victoria, Australia for the detection of illicit substances (MDMA, THC and methamphetamine) in apprehended drug drivers. There would be practical limitations to overcome in order to use POCT OF devices for evidential testing. Should such an approach be envisaged and given the variability in performance of the commercial OF POCT devices on the market, the Panel recommend that sensitivity, specificity and accuracy criteria should be specified for OF POCT device(s). Criteria used for evidential tests has been set at ≥95 % (accuracy), ≥90 % sensitivity and ≥90 % specificity in the State of Victoria, Australia. Minimum standards were also established by the European Integrated Project DRUID (Driving under the Influence of Drugs, Alcohol and Medicines) and was set at 80% for each parameter; the Dräger DrugTest (DDT) 5000® type-approved by the Home Office fulfilled the DRUID criteria for all drug classes included in the section 5A offence. Evidential testing to quantify up to 17 compounds would likely require significantly more OF than currently used in the POCT roadside screening test: estimates by FSPs suggest 2 4 mL OF would be required. The collection of OF would therefore need to involve an OF collection device. There are important differences between OF commercial collection devices currently on the market. Buffer solutions are varied and differing volumes of OF/buffer solutions are collected which require ‘correction’ before reporting quantitative results. If OF is to be collected using a commercial device for evidential purposes, then the Panel recommend that recovery of the analytes of interest and the overall reliability of the device would need to be specified for use at the roadside or in the police station. The collection of the OF needs to be used in conjunction with collection volume imprecision data (i.e. whether the OF collected was above, below or had achieved the minimum volume required), and uncertainty of measurement to provide the OF drug concentration in neat fluid to satisfy the criminal justice system. The specification (minimum standard) for the sample collection kit and the OF collection tube should include details of the amount of preservative, stabiliser and buffer required. Whilst full type-approval is unlikely to be necessary the equipment would need to be independently assessed so that it meets the above standards. This might be part of the FSP accreditation process (See Section 4 on page 11). Based on what is known, the Panel recommends that OF samples should be refrigerated (3 – 5 °C) as quickly as possible after collection and transported to the laboratory at a controlled temperature to avoid bacterial contamination and degradation of drugs. It is also recommended that OF samples should be stored in glass tubes, away from fluorescent light and direct sunlight. OF samples should be frozen (ideally at -20 oC), if not available for immediate analysis. OF as a possible matrix for confirmatory testing may have other limitations. Potential confounders include the effects of pH variation on the appearance of drugs in OF, the potential for buccal cavity contamination and dry mouth syndrome (hyposalivation). To conclude, there is a stronger argument for the use of OF as an evidential matrix when using laboratory based cut-offs (LLOQ) such as those suggested by the DRUID studies, as the concentration above which an offence would occur. This approach would be in line with a zero tolerance approach, rather than a road safety risk based approach. With regards to the drug cut-off levels in the section 5A regulations, OF limits could not be identified for the medicinal drugs where a risk-based approach underpins the cut-off concentrations in whole blood. 2.4 SWEAT The use of a sweat POCT screening device has been employed in Europe to test those apprehended at the roadside and thought to be under the influence of illicit drugs. This approach uses immunoassay devices also employed for OF collection. However, sweat testing per se has yet to be shown to be applicable for confirmatory drug-driving tests. Consideration would need to be given to the issue of external contamination and how this can be negated as part of the sample collection procedure. 2.5 HAIR It takes about 7 days for a drug to be incorporated into a hair follicle making any attempt to correlate hair drug concentration with driving behaviour extremely difficult. This factor and the inconvenience of sample collection and the requirement for enough hair sample to be collected to test for all 17 compounds in the schedule 5A legislation impact on the usefulness of hair as an evidential test matrix. However, hair testing has been used in many European countries to confirm abstinence from illicit drugs in persons whose driving licences have been suspended for drug-driving offences. The Panel recommends that hair testing is an appropriate matrix to use as an adjunct to medical assessment for re-licensing since hair testing provides a much longer window of detection than either blood, urine or OF and would enable the determination of a history of past exposures to illicit or medicinal controlled substances. 2.6 DRIED BLOOD SPOTS (DBS) AND SMALL LIQUID SAMPLES As yet the procedures and technology for either dried blood spot (DBS) sampling or small liquid samples has not progressed far enough to be used as an evidential test in an environment such as a police station or at the roadside. However, the development of commercial devices may be suitable in the future for use by law enforcement officers in those suspected of drug-driving offences. 2.7 LATENT FINGERPRINTS The analysis of drugs in latent fingerprints is an exciting new development that shows promise in a number of arenas that require flexible drug screening services. The Panel noted that quantitative analysis of drugs of interest is not currently well developed and therefore could not recommend the use of latent fingerprints as an alternative to blood for evidential testing. Consideration will need to be given to the issue of external contamination and how this can be negated as part of the sample collection procedure. 2.8 EXHALED BREATH CONDENSATE (EBC) Exhaled breath condensate (EBC) is a further innovation with regard to drug testing matrices and is based on the premise that therapeutic and illicit drugs are present as non-volatile components in human breath. In Sweden the EBC (SensAbues®) has been used as a screening tool to test those apprehended on suspicion of a drug driving offence but as yet this matrix cannot be collected in a manner that would make it suitable for evidential testing in the British criminal justice system. 3 INTERNATIONAL APPROACHES TO SETTING CONCENTRATION THRESHOLDS FOR DRUG DRIVING A brief review of international practice in terms of drug-driving has shown that countries take different approaches to roadside drug testing both from a legislative and an analytical point of view. The number of drugs targeted differs according to national prevalence, although OF is commonplace as a screening tool. The LLOQ and/or a zero tolerance (LOD) limit seems to be the consensus for illegal drugs, in some cases with the additional requirement of evidence of impairment. A more pragmatic approach is taken with medicinal controlled drugs. It is becoming increasingly well known that drivers who misuse psychoactive substances may take more than one psychoactive substance together at one time before driving. In many instances this includes the use of alcohol as highlighted in the Technical report ‘Driving under the influence of drugs’. The Panel recommends that some discussion is needed with regard to the approach taken when more than one substance is detected in the evidential sample and particularly, whether consideration should be given to substances with a known impairing effect that are present below the level currently set in legislation but may in combination with other psychoactive substances be a risk to driver safety. In some countries a limit has been set for a drug class (e.g., the amphetamines), such that an offence occurs if any combination of the different drugs within the class, when summed, exceed the cut-off. There is also growing awareness that drugs with similar pharmacological mechanisms of action to those included in the section 5A legislation, but which are not controlled other than through the provisions of the Psychoactive Substances Act 2016, pose similar impairing effects on driving performance. In addition, new evidence is emerging for some drugs controlled under the Misuse of Drugs Act (1971) and these have been included in drug driving legislation elsewhere. Gamma-hydroxybutyrate (GHB) with sedative and anaesthetic effects is a good example. The Panel recommends that the Department for Transport keeps a watchful brief on developments in other drug-driving communities as well as the scientific literature in order to make informed decisions about the addition of further drugs to the section 5A drug-driving legislation. 4 THE CAPABILITY OF UK FORENSIC LABORATORIES TO U

A Systematic Review and Meta-Analysis of Alpha Synuclein Auto-Antibodies in Parkinson's Disease

Immune dysfunction has been associated with Parkinson's disease (PD) and its progression. Antibodies play an important role in both innate and adaptive responses, acting as powerful effector molecules that can propagate inflammation by activating innate immune cells. Alpha synuclein binding antibodies have been described in PD patients with conflicting associations. In this article, we consider the potential mechanistic basis of alpha synuclein auto-antibody development and function in PD. We present a systematic review and meta-analysis of antibody studies in PD cohorts showing that there is weak evidence for an increase in alpha synuclein auto-antibodies in PD patients particularly in early disease. The confidence with which this conclusion can be drawn is limited by the heterogeneity of the clinical cohorts used, inclusion of unmatched controls, inadequate power and assay related variability. We have therefore made some recommendations for the design of future studies

B cell receptor repertoire kinetics after SARS-CoV-2 infection and vaccination

B cells are important in immunity to both severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and vaccination, but B cell receptor (BCR) repertoire development in these contexts has not been compared. We analyze serial samples from 171 SARS-CoV-2-infected individuals and 63 vaccine recipients and find the global BCR repertoire differs between them. Following infection, immunoglobulin (Ig)G1/3 and IgA1 BCRs increase, somatic hypermutation (SHM) decreases, and, in severe disease, IgM and IgA clones are expanded. In contrast, after vaccination, the proportion of IgD/M BCRs increase, SHM is unchanged, and expansion of IgG clones is prominent. VH1-24, which targets the N-terminal domain (NTD) and contributes to neutralization, is expanded post infection except in the most severe disease. Infection generates a broad distribution of SARS-CoV-2-specific clones predicted to target the spike protein, while a more focused response after vaccination mainly targets the spike's receptor-binding domain. Thus, the nature of SARS-CoV-2 exposure differentially affects BCR repertoire development, potentially informing vaccine strategies

Peripheral innate immune and bacterial signals relate to clinical heterogeneity in Parkinson's disease.

The innate immune system is implicated in Parkinson's disease (PD), but peripheral in-vivo clinical evidence of the components and driving mechanisms involved and their relationship with clinical heterogeneity and progression to dementia remain poorly explored. We examined changes in peripheral innate immune-related markers in PD cases (n = 41) stratified according to risk of developing early dementia. 'Higher Risk'(HR) (n = 23) and 'Lower Risk' (LR) (n = 18) groups were defined according to neuropsychological predictors and MAPT H1/H2 genotype, and compared to age, gender and genotype-matched controls. Monocyte subsets and expression of key surface markers were measured using flow cytometry. Serum markers including alpha-synuclein, inflammasome-related caspase-1 and bacterial translocation-related endotoxin were measured using quantitative immuno-based assays. Specific markers were further investigated using monocyte assays and validated in plasma samples from a larger incident PD cohort (n = 95). We found that classical monocyte frequency was elevated in PD cases compared to controls, driven predominantly by the HR group, in whom Toll-Like Receptor (TLR)4+ monocytes and monocyte Triggering Receptor Expressed on Myeloid cells-2 (TREM2) expression were also increased. Monocyte Human Leukocyte Antigen (HLA)-DR expression correlated with clinical variables, with lower levels associated with worse cognitive/motor performance. Notably, monocyte changes were accompanied by elevated serum bacterial endotoxin, again predominantly in the HR group. Serum alpha-synuclein and inflammasome-related caspase-1 were decreased in PD cases compared to controls regardless of group, with decreased monocyte alpha-synuclein secretion in HR cases. Further, alpha-synuclein and caspase-1 correlated positively in serum and monocyte lysates, and in plasma from the larger cohort, though no associations were seen with baseline or 36-month longitudinal clinical data. Principal Components Analysis of all monocyte and significant serum markers indicated 3 major components. Component 1 (alpha-synuclein, caspase-1, TLR2+ monocytes) differentiated PD cases and controls in both groups, while Component 2 (endotoxin, monocyte TREM2, alpha-synuclein) did so predominantly in the HR group. Component 3 (classical monocytes, alpha-synuclein) also differentiated cases and controls overall in both groups. These findings demonstrate that systemic innate immune changes are present in PD and are greatest in those at higher risk of rapid progression to dementia. Markers associated with PD per-se (alpha-synuclein, caspase-1), differ from those related to cognitive progression and clinical heterogeneity (endotoxin, TREM2, TLR4, classical monocytes, HLA-DR), with mechanistic and therapeutic implications. Alpha-synuclein and caspase-1 are associated, suggesting inflammasome involvement common to all PD, while bacterial translocation associated changes may contribute towards progression to Parkinson's dementia. Additionally, HLA-DR-associated variations in antigen presentation/clearance may modulate existing clinical disease

Impact of Excess Auditor Remuneration on the Cost of Equity Capital around the World

This study examines the relation between excess auditor remuneration and the implied required rate of return (IRR hereafter) on equity capital in global markets. We conjecture that when auditor remuneration is excessively large, investors may perceive the auditor to be economically bonded to the client, leading to a lack of independence. This perceived lack of independence increases the information risk associated with the credibility of financial statements, thereby increasing IRR. Consistent with this notion, we find that IRR is increasing in excess auditor remuneration, but only in countries with stronger investor protection. Finding evidence of a relation only in stronger investor protection countries is consistent with the more prominent role of audited financial statements for investors' decisions in these countries. In settings in which investors are less likely to rely on audited financial statements and instead rely on alternative sources of information (i.e., in countries with weaker investor protection), the impact of client-auditor bonding should have less of an effect on investors' decisions.Yeshttps://us.sagepub.com/en-us/nam/manuscript-submission-guideline

A pilot study evaluating GSK1070806 inhibition of interleukin-18 in renal transplant delayed graft function.

INTRODUCTION: Delayed graft function (DGF) following renal transplantation is a manifestation of acute kidney injury (AKI) leading to poor long-term outcome. Current treatments have limited effectiveness in preventing DGF. Interleukin-18 (IL18), a biomarker of AKI, induces interferon-γ expression and immune activation. GSK1070806, an anti-IL18 monoclonal antibody, neutralizes activated (mature) IL18 released from damaged cells following inflammasome activation. This phase IIa, single-arm trial assessed the effect of a single dose of GSK1070806 on DGF occurrence post donation after circulatory death (DCD) kidney transplantation. METHODS: The 3 mg/kg intravenous dose was selected based on prior studies and physiologically based pharmacokinetic (PBPK) modeling, indicating the high likelihood of a rapid and high level of IL18 target engagement when administered prior to kidney allograft reperfusion. Utilization of a Bayesian sequential design with a background standard-of-care DGF rate of 50% based on literature, and confirmed via extensive registry data analyses, enabled a statistical efficacy assessment with a minimal sample size. The primary endpoint was DGF frequency, defined as dialysis requirement ≤7 days post transplantation (except for hyperkalemia). Secondary endpoints included safety, pharmacokinetics and pharmacodynamic biomarkers. RESULTS: GSK1070806 administration was associated with IL18-GSK1070806 complex detection and increased total serum IL18 levels due to IL18 half-life prolongation induced by GSK1070806 binding. Interferon-γ-induced chemokine levels declined or remained unchanged in most patients. Although the study was concluded prior to the Bayesian-defined stopping point, 4/7 enrolled patients (57%) had DGF, exceeding the 50% standard-of-care rate, and an additional two patients, although not reaching the protocol-defined DGF definition, demonstrated poor graft function. Six of seven patients experienced serious adverse events (SAEs), including two treatment-related SAEs. CONCLUSION: Overall, using a Bayesian design and extensive PBPK dose modeling with only a small sample size, it was deemed unlikely that GSK1070806 would be efficacious in preventing DGF in the enrolled DCD transplant population. TRIAL REGISTRATION: NCT02723786

The impact of hypoxia on B cells in COVID-19

Background: Prominent early features of COVID-19 include severe, often clinically silent, hypoxia and a pronounced reduction in B cells, the latter important in defence against SARS-CoV-2. This presentation resembles the phenotype of mice with VHL-deficient B cells, in which Hypoxia-Inducible Factors are constitutively active, suggesting hypoxia might drive B cell abnormalities in COVID-19. Methods: Detailed B cell phenotyping was undertaken by flow-cytometry on longitudinal samples from patients with COVID-19 across a range of severities (NIHR Cambridge BioResource). The impact of hypoxia on the transcriptome was assessed by single-cell and whole blood RNA sequencing analysis. The direct effect of hypoxia on B cells was determined through immunisation studies in genetically modified and hypoxia-exposed mice. Findings: We demonstrate the breadth of early and persistent defects in B cell subsets in moderate/severe COVID-19, including reduced marginal zone-like, memory and transitional B cells, changes also observed in B cell VHL-deficient mice. These findings were associated with hypoxia-related transcriptional changes in COVID-19 patient B cells, and similar B cell abnormalities were seen in mice kept in hypoxic conditions. Interpretation: Hypoxia may contribute to the pronounced and persistent B cell pathology observed in acute COVID-19 pneumonia. Assessment of the impact of early oxygen therapy on these immune defects should be considered, as their correction could contribute to improved outcomes. Funding: Evelyn Trust, Addenbrooke's Charitable Trust, UKRI/NIHR, Wellcome Trus

Emerging Infectious Disease leads to Rapid Population Decline of Common British Birds

Emerging infectious diseases are increasingly cited as threats to wildlife, livestock and humans alike. They can threaten geographically isolated or critically endangered wildlife populations; however, relatively few studies have clearly demonstrated the extent to which emerging diseases can impact populations of common wildlife species. Here, we report the impact of an emerging protozoal disease on British populations of greenfinch Carduelis chloris and chaffinch Fringilla coelebs, two of the most common birds in Britain. Morphological and molecular analyses showed this to be due to Trichomonas gallinae. Trichomonosis emerged as a novel fatal disease of finches in Britain in 2005 and rapidly became epidemic within greenfinch, and to a lesser extent chaffinch, populations in 2006. By 2007, breeding populations of greenfinches and chaffinches in the geographic region of highest disease incidence had decreased by 35% and 21% respectively, representing mortality in excess of half a million birds. In contrast, declines were less pronounced or absent in these species in regions where the disease was found in intermediate or low incidence. Also, populations of dunnock Prunella modularis, which similarly feeds in gardens, but in which T. gallinae was rarely recorded, did not decline. This is the first trichomonosis epidemic reported in the scientific literature to negatively impact populations of free-ranging non-columbiform species, and such levels of mortality and decline due to an emerging infectious disease are unprecedented in British wild bird populations. This disease emergence event demonstrates the potential for a protozoan parasite to jump avian host taxonomic groups with dramatic effect over a short time period