Future Directions in the Diagnosis and Treatment of APDS and IEI: a Survey of German IEI Centers

IntroductionThe diagnosis and treatment of inborn errors of immunity (IEI) is a major challenge as the individual conditions are rare and often characterized by a variety of symptoms, which are often non disease-specific. Ideally, patients are treated in dedicated centers by physicians who specialize in the management of primary immune disorders. In this study, we used the example of Activated PI3Kδ syndrome (APDS), a rare IEI with an estimated prevalence of 1:1,000,000. We conducted surveys by questionnaire and interviewed physicians at different IEI centers in Germany.MethodsWe queried structural aspects of IEI care in Germany, diagnostic procedures in IEI care (including molecular diagnostics), distribution of APDS patients, APDS symptoms and severity, treatment algorithms in APDS, the role of stem cell transplantation and targeted therapies in IEI with focus on APDS. We were especially interested in how genetic diagnostics may influence treatment decisions, e.g. with regard to targeted therapies.Results/discussionMost centers care for both pediatric and adult patients. A total of 28 APDS patients are currently being treated at the centers we surveyed. Patient journeys vary considerably, as does severity of disease. Genetic diagnosis continues to gain importance - whole genome sequencing is likely to become routine in IEI in the next few years. According to the experts interviewed, stem cell transplantation and - with new molecules being approved - targeted therapies, will gain in importance for the treatment of APDS and IEI in general

Association of CLEC16A with human common variable immunodeficiency disorder and role in murine B cells

Common variable immunodeficiency disorder (CVID) is the most common symptomatic primary immunodeficiency in adults, characterized by B-cell abnormalities and inadequate antibody response. CVID patients have considerable autoimmune comorbidity and we therefore hypothesized that genetic susceptibility to CVID may overlap with autoimmune disorders. Here, in the largest genetic study performed in CVID to date, we compare 778 CVID cases with 10, 999 controls across 123, 127 single-nucleotide polymorphisms (SNPs) on the Immunochip. We identify the first non-HLA genome-wide significant risk locus at CLEC16A (rs17806056, P = 2.0 x 10(-9)) and confirm the previously reported human leukocyte antigen (HLA) associations on chromosome 6p21 (rs1049225, P = 4.8 x 10(-16)). Clec16a knockdown (KD) mice showed reduced number of B cells and elevated IgM levels compared with controls, suggesting that CLEC16A may be involved in immune regulatory pathways of relevance to CVID. In conclusion, the CLEC16A associations in CVID represent the first robust evidence of non-HLA associations in this immunodeficiency condition

Disease Evolution and Response to Rapamycin in Activated Phosphoinositide 3-Kinase δ Syndrome: The European Society for Immunodeficiencies-Activated Phosphoinositide 3-Kinase δ Syndrome Registry

Activated phosphoinositide 3-kinase (PI3K) δ Syndrome (APDS), caused by autosomal dominant mutations in PIK3CD (APDS1) or PIK3R1 (APDS2), is a heterogeneous primary immunodeficiency. While initial cohort-descriptions summarized the spectrum of clinical and immunological manifestations, questions about long-term disease evolution and response to therapy remain. The prospective European Society for Immunodeficiencies (ESID)-APDS registry aims to characterize the disease course, identify outcome predictors, and evaluate treatment responses. So far, 77 patients have been recruited (51 APDS1, 26 APDS2). Analysis of disease evolution in the first 68 patients pinpoints the early occurrence of recurrent respiratory infections followed by chronic lymphoproliferation, gastrointestinal manifestations, and cytopenias. Although most manifestations occur by age 15, adult-onset and asymptomatic courses were documented. Bronchiectasis was observed in 24/40 APDS1 patients who received a CT-scan compared with 4/15 APDS2 patients. By age 20, half of the patients had received at least one immunosuppressant, but 2–3 lines of immunosuppressive therapy were not unusual before age 10. Response to rapamycin was rated by physician visual analog scale as good in 10, moderate in 9, and poor in 7. Lymphoproliferation showed the best response (8 complete, 11 partial, 6 no remission), while bowel inflammation (3 complete, 3 partial, 9 no remission) and cytopenia (3 complete, 2 partial, 9 no remission) responded less well. Hence, non-lymphoproliferative manifestations should be a key target for novel therapies. This report from the ESID-APDS registry provides comprehensive baseline documentation for a growing cohort that will be followed prospectively to establish prognostic factors and identify patients for treatment studies

Higher COVID-19 pneumonia risk associated with anti-IFN-α than with anti-IFN-ω auto-Abs in children

We found that 19 (10.4%) of 183 unvaccinated children hospitalized for COVID-19 pneumonia had autoantibodies (auto-Abs) neutralizing type I IFNs (IFN-alpha 2 in 10 patients: IFN-alpha 2 only in three, IFN-alpha 2 plus IFN-omega in five, and IFN-alpha 2, IFN-omega plus IFN-beta in two; IFN-omega only in nine patients). Seven children (3.8%) had Abs neutralizing at least 10 ng/ml of one IFN, whereas the other 12 (6.6%) had Abs neutralizing only 100 pg/ml. The auto-Abs neutralized both unglycosylated and glycosylated IFNs. We also detected auto-Abs neutralizing 100 pg/ml IFN-alpha 2 in 4 of 2,267 uninfected children (0.2%) and auto-Abs neutralizing IFN-omega in 45 children (2%). The odds ratios (ORs) for life-threatening COVID-19 pneumonia were, therefore, higher for auto-Abs neutralizing IFN-alpha 2 only (OR [95% CI] = 67.6 [5.7-9,196.6]) than for auto-Abs neutralizing IFN-. only (OR [95% CI] = 2.6 [1.2-5.3]). ORs were also higher for auto-Abs neutralizing high concentrations (OR [95% CI] = 12.9 [4.6-35.9]) than for those neutralizing low concentrations (OR [95% CI] = 5.5 [3.1-9.6]) of IFN-omega and/or IFN-alpha 2

Autoantibodies against type I IFNs in patients with critical influenza pneumonia

In an international cohort of 279 patients with hypoxemic influenza pneumonia, we identified 13 patients (4.6%) with autoantibodies neutralizing IFN-alpha and/or -omega, which were previously reported to underlie 15% cases of life-threatening COVID-19 pneumonia and one third of severe adverse reactions to live-attenuated yellow fever vaccine. Autoantibodies neutralizing type I interferons (IFNs) can underlie critical COVID-19 pneumonia and yellow fever vaccine disease. We report here on 13 patients harboring autoantibodies neutralizing IFN-alpha 2 alone (five patients) or with IFN-omega (eight patients) from a cohort of 279 patients (4.7%) aged 6-73 yr with critical influenza pneumonia. Nine and four patients had antibodies neutralizing high and low concentrations, respectively, of IFN-alpha 2, and six and two patients had antibodies neutralizing high and low concentrations, respectively, of IFN-omega. The patients' autoantibodies increased influenza A virus replication in both A549 cells and reconstituted human airway epithelia. The prevalence of these antibodies was significantly higher than that in the general population for patients 70 yr of age (3.1 vs. 4.4%, P = 0.68). The risk of critical influenza was highest in patients with antibodies neutralizing high concentrations of both IFN-alpha 2 and IFN-omega (OR = 11.7, P = 1.3 x 10(-5)), especially those <70 yr old (OR = 139.9, P = 3.1 x 10(-10)). We also identified 10 patients in additional influenza patient cohorts. Autoantibodies neutralizing type I IFNs account for similar to 5% of cases of life-threatening influenza pneumonia in patients <70 yr old

Vaccine breakthrough hypoxemic COVID-19 pneumonia in patients with auto-Abs neutralizing type I IFNs

Life-threatening `breakthrough' cases of critical COVID-19 are attributed to poor or waning antibody response to the SARS- CoV-2 vaccine in individuals already at risk. Pre-existing autoantibodies (auto-Abs) neutralizing type I IFNs underlie at least 15% of critical COVID-19 pneumonia cases in unvaccinated individuals; however, their contribution to hypoxemic breakthrough cases in vaccinated people remains unknown. Here, we studied a cohort of 48 individuals ( age 20-86 years) who received 2 doses of an mRNA vaccine and developed a breakthrough infection with hypoxemic COVID-19 pneumonia 2 weeks to 4 months later. Antibody levels to the vaccine, neutralization of the virus, and auto- Abs to type I IFNs were measured in the plasma. Forty-two individuals had no known deficiency of B cell immunity and a normal antibody response to the vaccine. Among them, ten (24%) had auto-Abs neutralizing type I IFNs (aged 43-86 years). Eight of these ten patients had auto-Abs neutralizing both IFN-a2 and IFN-., while two neutralized IFN-omega only. No patient neutralized IFN-ss. Seven neutralized 10 ng/mL of type I IFNs, and three 100 pg/mL only. Seven patients neutralized SARS-CoV-2 D614G and the Delta variant (B.1.617.2) efficiently, while one patient neutralized Delta slightly less efficiently. Two of the three patients neutralizing only 100 pg/mL of type I IFNs neutralized both D61G and Delta less efficiently. Despite two mRNA vaccine inoculations and the presence of circulating antibodies capable of neutralizing SARS-CoV-2, auto-Abs neutralizing type I IFNs may underlie a significant proportion of hypoxemic COVID-19 pneumonia cases, highlighting the importance of this particularly vulnerable population

Circularity of the Everyday: A Pattern Language for the Transition towards a Circular Food System of the Everyday Life in Schalkwijk

The current linear food system in the Netherlands has a negative impact on the environment, requiring almost ten times the biocapacity the country has to offer. The food sector plays a big role in generating this inequality - this overconsumption, and of the entire food supply chain up to a third of food waste is generated by the consumer. The linear food system contributes to environmental problems such as loss of biodiversity and wasting of food. Negative effects – such as rising vulnerability to extreme weather conditions, low urban quality, decreasing biodversity, and higher obesity rates - can be seen in the urban built environment, especially in Dutch post-war neighbourhoods like Schalkwijk, Haarlem. Changing peoples’ behaviour in their day-to-day life can be a starting point for establishing loops for food, water, and energy resources.This project highlights a significant knowledge gap in the effective integration of circular principles into the built environment at the neighbourhood scale and underlines the importance of social and environmental integration in research. Previous research has identified significant vulnerability to climate risks and inadequate availability of nutritious, locally grown food, resulting in high levels of obesity and vulnerability to climate extremes in the selected post-war neighbourhood. In addition, the opportunity to separate organic waste from general waste is not fully realised, resulting in the loss of recyclable organic matter, which would have a great potential for energy transformation and introducing local agriculture. However, this waste separation needs to start in our daily lives. In contrast, food production takes place in isolation from our daily lives.This raises the question: How can the transformation of Dutch post war neighbourhoods facilitate actions of our daily life towards a circular foodscape?The main objective of this research project is to create a pattern language as a co-design method for the transition to a circular built environment in Dutch post-war neighbourhoods. The creation of circular networks, such as mobility, sewage, heating infrastructure, and social networks that are interconnected, are very much needed to support the transition to a holistic circular system for everyday life in the respective neighbourhoods.The project will use a design approach, conduct qualitative and quantitative research, and confirm the results with workshops and design development - in particular creating a pattern language. A systemic design approach will form the basis of this research and design process, as it embraces urban metabolism, co-creation and respects the diverse and complex nature of the project. The use of a pattern language as a research and design tool allows for the exchange of research and design through a co-creation approach and possible spatial implementations of a circular neighbourhood with circular actions in the everyday life of the inhabitants of Schalkwijk.The primary outcome of this project is the design of a co-creation process, using the developed pattern language to show possible outcomes of a circular built environment. This includes bringing food production closer to our everyday lives and integrating circular systems within the local community. Urban planners have a facilitating role in presenting options for a circular future, starting processes that support the information and interest exchange of stakeholders, and providing participatory methods for shaping spatial circular strategies in post-war neighbourhoods.The research highlights how outcomes can vary based on perspectives, interests, and needs during the co-creation process. While the study concentrates on the food system, it also recognises wider aspects of circularity within the built environment, such as water and energy supply. The unpredictable human element in the co-creation process affects workshop dynamics and results.In short, this project aligns with the continual changes in sustainable development, participation, and circularity. It presents the pattern language as a useful tool for stakeholders working on circularity transitions, offering new opportunities for collaboration and resource efficiency at the neighbourhood scale. The findings contribute to filling existing research gaps by proposing a way to a sustainable, participatory, and circular urban development in Dutch post-war neighbourhoods.Architecture, Urbanism and Building Sciences | Urbanis

Rapid Flow Cytometry-Based Test for the Diagnosis of Lipopolysaccharide Responsive Beige-Like Anchor (LRBA) Deficiency

The diagnosis of lipopolysaccharide-responsive beige-like-anchor-protein (LRBA) deficiency currently relies on gene sequencing approaches that do not support a timely diagnosis and clinical management. We developed a rapid and sensitive test for clinical implementation based on the detection of LRBA protein by flow cytometry in peripheral blood cells after stimulation. LRBA protein was assessed in a prospective cohort of 54 healthy donors and 57 patients suspected of LRBA deficiency. Receiver operating characteristics analysis suggested an LRBA:MFI ratio cutoff point of 2.6 to identify LRBA-deficient patients by FACS with 94% sensitivity and 80% specificity and to discriminate them from patients with a similar clinical picture but other disease-causing mutations. This easy flow cytometry-based assay allows a fast screening of patients with suspicion of LRBA deficiency reducing therefore the number of patients requiring LRBA sequencing and accelerating the treatment implementation. Detection of biallelic mutations in LRBA is however required for a definitive diagnosis

Syn-energy: An interconnected, renewable and fair energy system in South Holland, by 2050

Our society is dealing with multiple wicked problems: the Climate Crisis, poverty, inequality and our need for a sustainable and healthy environment to live in. The Climate Crisis increases the urge to reduce the dependency on fossil fuels and requires a structural transformation to our management and distribution of space, economy and community. More than 8% of the Dutch population faces energy poverty, and this percentage will increase with the rising energy prices and unstructured national framework. The Province of South Holland, in the Netherlands, is a region thriving from an economy based not only in the biggest port in Europe, the Port of Rotterdam, but also thriving design, technologies and innovations in the cultural centres of cities like Delft, Leiden, Rotterdam and The Hague. This region has a great potential to strategically change the energy generation towards alternative, renewable sources, as well as the energy consumption of the region to tackle social inequalities such as energy poverty. This report will elaborate on the question of how a just energy transition towards 100% renewable energy of the Province of South Holland can be created through synergising and adjusting the spatial distribution. Through research by design, approached by students of the department of urbanism of ‘Bouwkunde’ at the TU Delft, the scope and application of regional planning for energy development will be illustrated to facilitate an adaptive, inclusive and collaborative energy transition in the Province of South Holland.A systemic change is needed, which will create the opportunity for the Port of Rotterdam to evolve from the current petrolscape to a renewable energyscape and to become a leading role model in the energy transition towards regional renewable energy generation and distribution, and a global hydrogen hub. A fair system without energy poverty, accessible, affordable and efficient energy and mobility, a repurposed energyspace for diverse renewable energy systems and a recycling system, and a local energy production will enable a just transition towards a fossil fuel free future for the Province of South Holland.AR2U086 R&D Studio – Spatial Strategies for the Global MetropolisArchitecture, Urbanism and Building Science

Rapid Flow Cytometry-Based Test for the Diagnosis of Lipopolysaccharide Responsive Beige-Like Anchor (LRBA) Deficiency

The diagnosis of lipopolysaccharide-responsive beige-like-anchor-protein (LRBA) deficiency currently relies on gene sequencing approaches that do not support a timely diagnosis and clinical management. We developed a rapid and sensitive test for clinical implementation based on the detection of LRBA protein by flow cytometry in peripheral blood cells after stimulation. LRBA protein was assessed in a prospective cohort of 54 healthy donors and 57 patients suspected of LRBA deficiency. Receiver operating characteristics analysis suggested an LRBA:MFI ratio cutoff point of 2.6 to identify LRBA-deficient patients by FACS with 94% sensitivity and 80% specificity and to discriminate them from patients with a similar clinical picture but other disease-causing mutations. This easy flow cytometry-based assay allows a fast screening of patients with suspicion of LRBA deficiency reducing therefore the number of patients requiring LRBA sequencing and accelerating the treatment implementation. Detection of biallelic mutations in LRBA is however required for a definitive diagnosis