Incidence and outcome of acquired demyelinating syndromes in Dutch children: update of a nationwide and prospective study

Introduction: Acquired demyelinating syndromes (ADS) are immune-mediated demyelinating disorders of the central nervous system in children. A nationwide, multicentre and prospective cohort study was initiated in the Netherlands in 2006, with a reported ADS incidence of 0.66/100,000 per year and MS incidence of 0.15/100,000 per year in the period between 2007 and 2010. In this study, we provide an update on the incidence and the long-term follow-up of ADS in the Netherlands. Methods: Children < 18 years with a first attack of demyelination were included consecutively from January 2006 to December 2016. Diagnoses were based on the International Paediatric MS study group consensus criteria. Outcome data were collected by neurological and neuropsychological assessments, and telephone call assessments. Results: Between 2011 and 2016, 55/165 of the ADS patients were diagnosed with MS (33%). This resulted in an increased ADS and MS incidence of 0.80/100,000 per year and 0.26/100,000 per year, respectively. Since 2006 a total of 243 ADS patients have been included. During follow-up (median 55 months, IQR 28–84), 137 patients were diagnosed with monophasic disease (56%), 89 with MS (37%) and 17 with multiphasic disease other than MS (7%). At least one form of residual deficit including cognitive impairment was observed in 69% of all ADS patients, even in monophasic ADS. An Expanded Disability Status Scale score of ≥ 5.5 was reached in 3/89 MS patients (3%). Conclusion: The reported incidence of ADS in Dutch children has increased since 2010. Residual deficits are common in this group, even in monophasic patients. Therefore, long-term follow-up in ADS patients is warranted

Autoantibodies against type I IFNs in patients with life-threatening COVID-19

Interindividual clinical variability in the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is vast. We report that at least 101 of 987 patients with life-threatening coronavirus disease 2019 (COVID-19) pneumonia had neutralizing immunoglobulin G (IgG) autoantibodies (auto-Abs) against interferon-w (IFN-w) (13 patients), against the 13 types of IFN-a (36), or against both (52) at the onset of critical disease; a few also had auto-Abs against the other three type I IFNs. The auto-Abs neutralize the ability of the corresponding type I IFNs to block SARS-CoV-2 infection in vitro. These auto-Abs were not found in 663 individuals with asymptomatic or mild SARS-CoV-2 infection and were present in only 4 of 1227 healthy individuals. Patients with auto-Abs were aged 25 to 87 years and 95 of the 101 were men. A B cell autoimmune phenocopy of inborn errors of type I IFN immunity accounts for life-threatening COVID-19 pneumonia in at least 2.6% of women and 12.5% of men

Has the Rate of CD4 Cell Count Decline before Initiation of Antiretroviral Therapy Changed over the Course of the Dutch HIV Epidemic among MSM?

Introduction:Studies suggest that the HIV-1 epidemic in the Netherlands may have become more virulent, leading to faster disease progression if untreated. Analysis of CD4 cell count decline before antiretroviral therapy (ART) initiation, a surrogate marker for disease progression, may be hampered by informative censoring as ART initiation is more likely with a steeper CD4 cell count decline.Methods:Development of CD4 cell count from 9 to 48 months after seroconversion was analyzed using a mixed-effects model and 2 models that jointly modeled CD4 cell counts and time to censoring event (start ART

Non-AIDS defining cancers in the D:A:D Study-time trends and predictors of survival : a cohort study

BACKGROUND:Non-AIDS defining cancers (NADC) are an important cause of morbidity and mortality in HIV-positive individuals. Using data from a large international cohort of HIV-positive individuals, we described the incidence of NADC from 2004-2010, and described subsequent mortality and predictors of these.METHODS:Individuals were followed from 1st January 2004/enrolment in study, until the earliest of a new NADC, 1st February 2010, death or six months after the patient's last visit. Incidence rates were estimated for each year of follow-up, overall and stratified by gender, age and mode of HIV acquisition. Cumulative risk of mortality following NADC diagnosis was summarised using Kaplan-Meier methods, with follow-up for these analyses from the date of NADC diagnosis until the patient's death, 1st February 2010 or 6 months after the patient's last visit. Factors associated with mortality following NADC diagnosis were identified using multivariable Cox proportional hazards regression.RESULTS:Over 176,775 person-years (PY), 880 (2.1%) patients developed a new NADC (incidence: 4.98/1000PY [95% confidence interval 4.65, 5.31]). Over a third of these patients (327, 37.2%) had died by 1st February 2010. Time trends for lung cancer, anal cancer and Hodgkin's lymphoma were broadly consistent. Kaplan-Meier cumulative mortality estimates at 1, 3 and 5 years after NADC diagnosis were 28.2% [95% CI 25.1-31.2], 42.0% [38.2-45.8] and 47.3% [42.4-52.2], respectively. Significant predictors of poorer survival after diagnosis of NADC were lung cancer (compared to other cancer types), male gender, non-white ethnicity, and smoking status. Later year of diagnosis and higher CD4 count at NADC diagnosis were associated with improved survival. The incidence of NADC remained stable over the period 2004-2010 in this large observational cohort.CONCLUSIONS:The prognosis after diagnosis of NADC, in particular lung cancer and disseminated cancer, is poor but has improved somewhat over time. Modifiable risk factors, such as smoking and low CD4 counts, were associated with mortality following a diagnosis of NADC

Rhinovirus infection induces procoagulant changes in parallel with eosinophilic airway inflammation

Background: Asthma exacerbations are frequently triggered by rhinovirus infections. Asthma itself is associated with activated coagulation and increased risk of venous thromboembolism1 and also respiratory viruses may activate hemostasis. Vice versa, a prothrombotic state in the lung can also induce or aggravate pulmonary inflammation. Aim: To determine whether rhinovirus infection and asthmatic airway inflammation act on the local and systemic hemostatic balance in patients in vivo. Methods: In a two-groups parallel study design 28 volunteers (14 patients with mild asthma (seven females, 19-26 years) and 14 healthy controls (13 females, 19-31 years)) were experimentalliy infected with low-dose rhinovirus serotype 16 (RV16). Patients with mild asthma were stable after discontinuation of their asthma medication 2 weeks prior to RV16 inoculation. Venous plasma and bronchoalveolar lavage fluid (BAL fluid) were obtained 1 day before and 6 days after rhinovirus challange to evaluate several key markers of coagulation activation in plasma and BAL fluid, as well as the coagulant features of microparticles in BAL fluid. Thrombin-antithrombin complexes (TATc), von Willebrand factor (vWF), Plasmin-antiplasmin complexes (PAP), Plasminogen activator inhibitor type-1 (PAI-1), and eosinophil cationic protein (ECP) in plasma and BAL fluid were measured by immunoassay. Endogenous thrombin potential (ETP) was analysed using the Calibrated Automated Thrombogram® and tissue factor bearing microparticles, measured by fibrin generation test (FGT). Eosinophils were counted on cytospin preparations. Comparisons and correlations were performed by non-parametric testing. Results: In plasma, RV16 challange resulted in increased PAI-1 levels in patients with asthma after viral infection (26.5 ng/mL in patients with astma vs. 10.0 ng/mL in healthy controls, P = 0.01) and decreased PAP levels (318 vs. 534 ng/mL resp., P = 0.04). Changes in PAI-1 levels were significantly elevated in asthma than in control subjects (3.0 vs. -3.5 ng/L respectively, P = 0.024), while changes in TATc, D-dimer, vWF and ETP did not differ between both groups. In BAL fluid, the FGT shortened after viral infection in asthma (t = -1 day: 689s vs. t = 6 days: 516 s; P = 0.011), but not in healthy controls (t = -1 day: 695s vs. t = 6 days: 672 s; P = 0.79). The changes in TATc and PAP did not differ between both groups and vWF, D-dimer and PAI-1 were below the detection limit. Both FGT and TATc in BAL fluid correlated (Spearman) with eosinophil counts and ECP (r = -0.583 and -0.682 resp. for FGT and r = 0.535 and 0.619 resp. for TATc, all P <0.01) Conclusion: Experimental rhinovirus infection induces procoagulant changes in patients with asthma systemically through PAI-1 and in the airways by TF-bearing microparticles. This did not lead to changes in global assays of hemostasis, probably due to the relatively mild infection in patients with mild to intermittent asthma. In the airways, microparticle-associated procoagulant changes are associated with eosinophilic inflammation, suggesting that virus infection and eosinophilic inflammation both act on the hemostatic (dis)balance during asthma exacerbations

Immediate versus postponed intervention for infected necrotizing pancreatitis

BACKGROUND Infected necrotizing pancreatitis is a potentially lethal disease that is treated with the use of a step-up approach, with catheter drainage often delayed until the infected necrosis is encapsulated. Whether outcomes could be improved by earlier catheter drainage is unknown. METHODS We conducted a multicenter, randomized superiority trial involving patients with infected necrotizing pancreatitis, in which we compared immediate drainage within 24 hours after randomization once infected necrosis was diagnosed with drainage that was postponed until the stage of walled-off necrosis was reached. The primary end point was the score on the Comprehensive Complication Index, which incorporates all complications over the course of 6 months of follow-up. RESULTS A total of 104 patients were randomly assigned to immediate drainage (55 patients) or postponed drainage (49 patients). The mean score on the Comprehensive Complication Index (scores range from 0 to 100, with higher scores indicating more severe complications) was 57 in the immediate-drainage group and 58 in the postponed-drainage group (mean difference, −1; 95% confidence interval [CI], −12 to 10; P=0.90). Mortality was 13% in the immediate-drainage group and 10% in the postponed-drainage group (relative risk, 1.25; 95% CI, 0.42 to 3.68). The mean number of interventions (catheter drainage and necrosectomy) was 4.4 in the immediate-drainage group and 2.6 in the postponed-drainage group (mean difference, 1.8; 95% CI, 0.6 to 3.0). In the postponed-drainage group, 19 patients (39%) were treated conservatively with antibiotics and did not require drainage; 17 of these patients survived. The incidence of adverse events was similar in the two groups. CONCLUSIONS This trial did not show the superiority of immediate drainage over postponed drainage with regard to complications in patients with infected necrotizing pancreatitis. Patients randomly assigned to the postponed-drainage strategy received fewer invasive interventions