Chronic urticaria in the real‐life clinical practice setting in the UK: results from the non‐interventional multicentre AWARE study

Abstract Background Chronic urticaria (CU) is a skin condition characterised by repeated occurrence of itchy wheals and/or angioedema for >6 weeks. Aim To provide data demonstrating the real‐life burden of CU in the UK. Methods This UK subset of the worldwide, prospective, non‐interventional AWARE study included patients aged 18–75 years diagnosed with H1‐antihistamine (H1‐AH)‐refractory chronic spontaneous urticaria (CSU) for >2 months. Baseline characteristics, disease activity, treatments, comorbidities and healthcare resource use were documented. Quality of life, work productivity and activity impairment were assessed. Results Baseline analysis included 252 UK patients. Mean age and body mass index were 45.0 years and 29.0 kg/m2, respectively. Most patients were female (77.8%) and had moderate/severe disease activity (mean Urticaria Activity Score over 7 days, 18.4) and a ‘spontaneous’ component to their CU (73.4% CSU; 24.6% CSU and chronic inducible urticaria). Common comorbidities included depression/anxiety (24.6%), asthma (23.8%) and allergic rhinitis (12.7%). A previous treatment was recorded for 57.9% of patients. Mean Dermatology Life Quality Index score was 9.5 and patients reported impairments in work productivity and activity. Healthcare resource use was high. Severity of CSU was associated with gender, obesity, anxiety and diagnosis. Only 28.5% of patients completed all nine study visits, limiting analysis of long‐term treatment patterns and disease impact. Conclusions Adult H1‐AH‐refractory CU patients in the UK reported high rates of healthcare resource use and impairment in quality of life, work productivity and activity at baseline. The differing structures of UK healthcare may explain the high study discontinuation rates versus other countries

CD4(+)CD25(+)FOXP3(+) Regulatory T Cells Suppress Anti-Tumor Immune Responses in Patients with Colorectal Cancer

BACKGROUND: A wealth of evidence obtained using mouse models indicates that CD4(+)CD25(+)FOXP3(+) regulatory T cells (Treg) maintain peripheral tolerance to self-antigens and also inhibit anti-tumor immune responses. To date there is limited information about CD4(+) T cell responses in patients with colorectal cancer (CRC). We set out to measure T cell responses to a tumor-associated antigen and examine whether Treg impinge on those anti-tumor immune responses in CRC patients. METHODOLOGY AND PRINCIPAL FINDINGS: Treg were identified and characterized as CD4(+)CD25(+)FOXP3(+) using flow cytometry. An increased frequency of Treg was demonstrated in both peripheral blood and mesenteric lymph nodes of patients with colorectal cancer (CRC) compared with either healthy controls or patients with inflammatory bowel disease (IBD). Depletion of Treg from peripheral blood mononuclear cells (PBMC) of CRC patients unmasked CD4(+) T cell responses, as observed by IFNγ release, to the tumor associated antigen 5T4, whereas no effect was observed in a healthy age-matched control group. CONCLUSIONS/SIGNIFICANCE: Collectively, these data demonstrate that Treg capable of inhibiting tumor associated antigen-specific immune responses are enriched in patients with CRC. These results support a rationale for manipulating Treg to enhance cancer immunotherapy

Loss of function NFKB1 variants are the most common monogenic cause of CVID in Europeans.

BACKGROUND: The genetic etiology of primary immunodeficiency disease (PID) carries prognostic information. OBJECTIVE: We conducted a whole-genome sequencing study assessing a large proportion of the NIHR-BioResource - Rare Disease cohort. METHODS: In the predominantly European study population of principally sporadic unrelated PID cases (n=846), a novel Bayesian method identified NFKB1 as one most strongly associated with PID, and the association was explained by 16 novel heterozygous truncating, missense and gene deletion variants. This accounted for 4% of common variable immunodeficiency (CVID) cases (n=390) in the cohort. Amino-acid substitutions predicted to be pathogenic were assessed by analysis of structural protein data. Immunophenotyping, immunoblotting and ex vivo stimulation of lymphocytes determined the functional effects of these variants. Detailed clinical and pedigree information was collected for genotype-phenotype co-segregation analyses. RESULTS: Both sporadic and familial cases demonstrated evidence of the non-infective complications of CVID, including massive lymphadenopathy (24%), unexplained splenomegaly (48%) and autoimmune disease (48%), features prior studies correlate with worse clinical prognosis. Although partial penetrance of clinical symptoms was noted in certain pedigrees, all carriers have a deficiency in B lymphocyte differentiation. Detailed assessment of B lymphocyte numbers, phenotype and function identifies the presence of a raised CD21lowB cell population: combined with identification of the disease-causing variant, this distinguishes between healthy individuals, asymptomatic carriers and clinically affected cases. CONCLUSION: We show that heterozygous loss-of-function variants in NFKB1 are the most common known monogenic cause of CVID that results in a temporally progressive defect in the formation of immunoglobulin-producing B cells.This study was supported by The National Institute for Health Research England (grant number RG65966), and by the Center of Immunodeficiencies Amsterdam (CIDA). JET is supported by an MRC Clinician Scientist Fellowship (MR/L006197/1). AJT is supported by both the Wellcome Trust (104807/Z/14/Z) and by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. EO receives personal fees from CSL Behring and MSD

On Orthogonal Special Class of Caterpillars Squares

Orthogonal Double Cover (ODC) is a set G of 2n subgraphs of a complete bipartite graph Kn,n of a graph G such that each edge in graph Kn,n appears once in both subgraphs of set G , and all subgraphs are isomorphic to graph G. we aim to construct two graph squares by a new engineering method that uses two induced starter functions to find the ODC of Kn,n. we also compose ODC from small to obtain a larger ODC. Starting from ODC F of Kq,q by qK2 we replace each point with n new points and each edge with the ODC of Kn,n to obtain the ODC of Kqn,qn by Some disjoint caterpillar unions, where q,n ∈ Z+

Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed?

In 1993, the British Thoracic Society (BTS) issued guidelines for the management of spontaneous pneumothorax. The aim of this study was to determine the level of adherence to and awareness of these guidelines at a London teaching hospital. A retrospective case note audit of 59 episodes of acute spontaneous pneumothorax was performed. In patients undergoing intervention, the initial procedure was simple aspiration in 32 (73%) and chest tube insertion in 12 (27%) cases, contrasting with the BTS recommendation that aspiration should be attempted first in all such patients. Simple aspiration was successful on 34% of occasions. Successful aspiration was associated with a significantly shorter hospital stay (median 3, range 1–11 days) than either failed aspiration (7, 3–66 days; p=0.003) or chest tube insertion without aspiration (9, 3–16 days; p=0.005). Other areas where practice differed from the BTS guidelines were clamping of chest tubes and use of a pursestring suture for wound closure. A follow up questionnaire survey suggested a lack of familiarity with the guidelines. These findings indicate that current management of spontaneous pneumothorax deviates from the BTS guidelines in a number of potentially important respects. Attention should be directed to improving awareness of and access to clinical guidelines

Multiple Ets factors and interferon regulatory factor-4 modulate CD68 expression in a cell type-specific manner.

CD68 is a transmembrane glycoprotein expressed in all cells of the mononuclear phagocyte lineage including monocytes and tissue resident macrophages. Deletion analysis of the 5'-flanking sequences of the gene demonstrated that the proximal -150-bp sequence of the CD68 promoter exhibits high level promoter activity in macrophages. Mutations that abolish Ets factor binding at positions -106 and -89 reduce promoter activity in macrophages to 12 and 30%, respectively. Band shift experiments show that PU.1 associates with the -89 site whereas, Elf-1 preferentially binds the -106 Ets binding site and enhances CD68 activity in vitro. Furthermore, chromatin immunoprecipitation experiments confirm that Elf-1 and PU.1 associate with the CD68 proximal promoter in vivo in THP-1 cells. PU.1 does not bind to the CD68 promoter alone but instead forms heterocomplexes with members of the interferon regulatory factor family (IRF) including IRF-4 and IRF-8. IRF-4 and IRF-8 typically mediate transcriptional activation when associated with PU.1 on composite elements. However, our data show that PU.1/IRF-4 and IRF-8 heterocomplexes down-regulate CD68 promoter activity in macrophages and repression is dependent on the integrity of both the IRF and PU.1 half-sites of this composite element. Chromatin immunoprecipitation data reveal that neither IRF-4 nor IRF-8 associate with the CD68 proximal promoter in macrophages in vivo but IRF-4 is associated with the promoter in B lymphocytes. We propose that expression of CD68 in myeloid cells requires the Ets transcription factors Elf-1 and PU.1 and CD68 expression is down-regulated in lymphoid cells by combinatorial interactions between PU.1 and IRF-4

Evaluation of a novel automated allergy microarray platform compared with three other allergy test methods

Microarray platforms, enabling simultaneous measurement of many allergens with a small serum sample, are potentially powerful tools in allergy diagnostics. We report here the first study comparing a fully automated microarray system, the Microtest allergy system, with a manual microarray platform, Immuno‐Solid phase Allergen Chip (ISAC), and two well‐established singleplex allergy tests, skin prick test (SPT) and ImmunoCAP, all tested on the same patients. One hundred and three adult allergic patients attending the allergy clinic were included into the study. All patients were tested with four allergy test methods (SPT, ImmunoCAP, Microtest and ISAC 112) and a total of 3485 pairwise test results were analysed and compared. The four methods showed comparable results with a positive/negative agreement of 81–88% for any pair of test methods compared, which is in line with data in the literature. The most prevalent allergens (cat, dog, mite, timothy, birch and peanut) and their individual allergen components revealed an agreement between methods with correlation coefficients between 0·73 and 0·95. All four methods revealed deviating individual patient results for a minority of patients. These results indicate that microarray platforms are efficient and useful tools to characterize the specific immunoglobulin (Ig)E profile of allergic patients using a small volume of serum sample. The results produced by the Microtest system were in agreement with diagnostic tests in current use. Further data collection and evaluation are needed for other populations, geographical regions and allergens