Protocol for the unclassified primary antibody deficiency (unPAD) study:Characterization and classification of patients using the ESID online registry

BACKGROUND: Primary antibody deficiencies (PADs) without an identified monogenetic origin form the largest and most heterogeneous group of primary immunodeficiencies. These patients often remain undiagnosed for years and many present to medical attention in adulthood after several infections risking structural complications. Not much is known about their treatment, comorbidities, or prognosis, nor whether the various immunological forms (decreased total IgG, IgG subclass(es), IgM, IgA, specific antibody responses, alone or in combination(s)) should be considered as separate, clearly definable subgroups. The unclassified primary antibody deficiency (unPAD) study aims to describe in detail all PAD patients without an identified specific monogenetic defect regarding their demographical, clinical, and immunological characteristics at presentation and during follow-up. In constructing these patterns, the unPAD study aims to reduce the number of missed and unidentified PAD patients in the future. In addition, this study will focus on subclassifying unPAD to support the identification of patients at higher risk for infection or immune dysregulation related complications, enabling the development of personalized follow-up and treatment plans. METHODS AND ANALYSIS: We present a protocol for a multicenter observational cohort study using the ESID online Registry. Patients of all ages who have given informed consent for participation in the ESID online Registry and fulfill the ESID Clinical Working Definitions for ‘unclassified antibody deficiency’, ‘deficiency of specific IgG’, ‘IgA with IgG subclass deficiency’, ‘isolated IgG subclass deficiency’, ‘selective IgM deficiency’, ‘selective IgA deficiency’ or ‘common variable immunodeficiency’ will be included. For all patients, basic characteristics can be registered at first registration and yearly thereafter in level 1 forms. Detailed characteristics of the patients can be registered in level 2 forms. Consecutive follow-up forms can be added indefinitely. To ensure the quality of the collected data, all data will be fully monitored before they are exported from the ESID online Registry for analysis. Outcomes will be the clinical and immunological characteristics of unPAD at presentation and during follow-up. Subgroup analyses will be made based on demographical, clinical and immunological characteristics

Design of the FemCure study: prospective multicentre study on the transmission of genital and extra-genital Chlamydia trachomatis infections in women receiving routine care

BACKGROUND: In women, anorectal infections with Chlamydia trachomatis (CT) are about as common as genital CT, yet the anorectal site remains largely untested in routine care. Anorectal CT frequently co-occurs with genital CT and may thus often be treated co-incidentally. Nevertheless, post-treatment detection of CT at both anatomic sites has been demonstrated. It is unknown whether anorectal CT may play a role in post-treatment transmission. This study, called FemCure, in women who receive routine treatment (either azithromycin or doxycycline) aims to understand the post-treatment transmission of anorectal CT infections, i.e., from their male sexual partner(s) and from and to the genital region of the same woman. The secondary objective is to evaluate other reasons for CT detection by nucleic acid amplification techniques (NAAT) such as treatment failure, in order to inform guidelines to optimize CT control. METHODS: A multicentre prospective cohort study (FemCure) is set up in which genital and/or anorectal CT positive women (n = 400) will be recruited at three large Dutch STI clinics located in South Limburg, Amsterdam and Rotterdam. The women self-collect anorectal and vaginal swabs before treatment, and at the end of weeks 1, 2, 4, 6, 8, 10, and 12. Samples are tested for presence of CT-DNA (by NAAT), load (by quantitative polymerase chain reaction -PCR), viability (by culture and viability PCR) and CT type (by multilocus sequence typing). Sexual exposure is assessed by online self-administered questionnaires and by testing samples for Y chromosomal DNA. Using logistic regression models, the impact of two key factors (i.e., sexual exposure and alternate anatomic site of infection) on detection of anorectal and genital CT will be assessed. DISCUSSION: The FemCure study will provide insight in the role of anorectal chlamydia infection in maintaining the CT burden in the context of treatment, and it will provide practical recommendations to reduce avoidable transmission. Implications will improve care strategies that take account of anorectal CT. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02694497

The effect of mirabegron on energy expenditure and brown adipose tissue in healthy lean South Asian and Europid men

Aim: To compare the effects of cold exposure and the β3-adrenergic receptor agonist mirabegron on plasma lipids, energy expenditure and brown adipose tissue (BAT) activity in South Asians versus Europids. Materials and Methods: Ten lean Dutch South Asian (aged 18-30 years; body mass index [BMI] 18-25 kg/m2 ) and 10 age- and BMI-matched Europid men participated in a randomized, double-blinded, cross-over study consisting of three interventions: short-term (~ 2 hours) cold exposure, mirabegron (200 mg one dose p.o.) and placebo. Before and after each intervention, we performed lipidomic analysis in serum, assessed resting energy expenditure (REE) and skin temperature, and measured BAT fat fraction by magnetic resonance imaging. Results: In both ethnicities, cold exposure increased the levels of several serum lipid species, whereas mirabegron only increased free fatty acids. Cold exposure increased lipid oxidation in both ethnicities, while mirabegron increased lipid oxidation in Europids only. Cold exposure and mirabegron enhanced supraclavicular skin temperature in both ethnicities. Cold exposure decreased BAT fat fraction in both ethnicities. After the combination of data from both ethnicities, mirabegron decreased BAT fat fraction compared with placebo. Conclusions: In South Asians and Europids, cold exposure and mirabegron induced beneficial metabolic effects. When combining both ethnicities, cold exposure and mirabegron increased REE and lipid oxidation, coinciding with a higher supraclavicular skin temperature and lower BAT fat fraction.Diabetes Research Foundation Fellowship 2015.81.1808Netherlands CardioVascular Research Initiative: 'the Dutch Heart Foundation, Dutch Federation of University Medical Centers, the Netherlands Organisation for Health Research and Development and the Royal Netherlands Academy of Sciences' CVON2014-02 ENERGISE CVON2017-20 GENIUS-IIEuropean Union (EU) 602485European Research Council (NOMA-MRI) PCNR is an Established Investigator of the Netherlands Heart Foundation 2009T03

Modélisation du poly-époxy DGEBA-EDA et de sa réactivité vis-à-vis du cuivre : approche expérimentale et numérique

Grâce à la métallisation de leur surface, des pièces en polymères peuvent substituer certains composants métalliques dans les industries de l'aérospatiale et du transport. Les polymères ont des masses volumiques plus faibles que les métaux et une réactivité chimique limitée, ce qui en fait des candidats idéaux pour les applications spatiales. En combinant techniques expérimentales et simulations numériques, nous avons étudié les mécanismes fondamentaux de la métallisation de surface d'un polymère poly-époxy (DGEBA / EDA). L'objectif de notre étude était de développer un modèle non empirique prenant en compte les mécanismes régissant la nucléation et la croissance des films minces métalliques. Notre groupe a une longue expérience des dépôts chimiques en phase vapeur, CVD. Mais cette technique n'a pas été choisie pour la métallisation de nos surfaces de polymères car les températures requises dans le réacteur étaient trop élevées. Comme alternative, nous avons effectué une évaporation sous ultravide de Cu à température ambiante, conduisant à une diffusion des atomes en phase gazeuse sans énergie cinétique. Les processus d'adsorption et de diffusion sont donc plus proches des conditions thermodynamiques associées aux calculs. Un protocole expérimental a été mis en place afin de créer une surface polymère chimiquement homogène présentant une faible rugosité. Le polymère obtenu a été caractérisé (i) par spectroscopie infrarouge à transformée de Fourier, pour déterminer le taux de polymérisation (supérieur à 90%), (ii) par calorimétrie différentielle à balayage pour obtenir la température de transition vitreuse (Tg) ( 118,1 °C), (iii) par microscopie à force atomique (AFM) pour estimer la rugosité de la surface (Ra ˜ 1 nm), et (iv) par spectroscopie de photoélectrons X (XPS) pour caractériser les liaisons chimiques de surface. La surface de polymère a ensuite été métallisée. Grâce à des analyses AFM, l'épaisseur du film mince a été estimée à 6 nm. Nous avons ensuite utilisé l'XPS pour caractériser les liaisons interfaciales Cu / Poly-époxy. Nous avons déduit de l'interprétation des spectres XPS que le Cu est adsorbé préférentiellement sur un atome d'oxygène spécifique du polymère. Pour identifier clairement ces sites d'adsorption de Cu, nous avons ensuite simulé les spectres XPS du polymère non revêtu, par des calculs quantiques, en utilisant un modèle moléculaire (dimère : 1 molécule de DGEBA liée à 1 molécule d'EDA). Les méthodes Hartree-Fock (HF) et de la théorie de la fonctionnelle de la densité (DFT) nous ont permis de simuler des spectres XPS pour la surface nue, en prenant en compte les effets d'état final et initial. Grâce à ces résultats, nous avons pu décomposer le spectre expérimental en 8 contributions, ce qui conduit à des résultats beaucoup plus précis que les résultats habituels obtenus par l'utilisation exclusive des expériences et de la littérature. Nous avons ensuite effectué des simulations de dynamique moléculaire classique (MD) pour passer d'un modèle moléculaire (dimère) à un modèle de polymère amorphe. Nous avons utilisé le champ de force Amber généralisé (GAFF) et nous avons développé un code de réticulation des molécules de monomères. Le système initial était un mélange stœchiométrique de molécules DGEBA et EDA qui a été équilibré à 700K. Lorsque l'équilibre a été atteint, certaines propriétés structurales (par exemple, la distribution des liaisons) ont été extraites des simulations NPT. À partir de ce mélange liquide de monomères, notre code de réticulation a identifié et relié les atomes réactifs (à une distance interatomique prédéfinie < 3 Å). Après chaque étape de polymérisation, le système a été rééquilibré à 700K (simulations NPT). Après plusieurs cycles de réticulation/simulation de dynamique moléculaire, nous avons pu atteindre un taux de polymérisation de 93% et la fonction de distribution radiale (RDF), la masse volumique (1.115 à 300K) et la température de transition vitreuse Tg (115,5 °C) ont été calculées. La Tg est en accord avec la valeur expérimentale de 118,1 °C, validant notre approche numérique pour développer un modèle pour les polymères poly-époxy.Metallization of polymer surfaces can lead to the substitution of metallic components. Polymers have lower densities and limited chemical reactivity, making them ideal candidates for the space applications. Through experiments and calculations, we studied the fundamental mechanisms of surface metallization of a poly-epoxy polymer (DGEBA/EDA). The objective of our study was to develop a non-empirical model that could take into account the mechanisms governing the nucleation and growth of thin metal films. Our group has a long experience in chemical vapor deposition, CVD, and metallization of polymer composites. But we did not applied CVD at first because of the high temperatures required in the reactor. We alternatively used ultrahigh vacuum evaporation of Cu at ambient temperature. Therefore, we make sure that atoms diffuse in the gas phase without kinetic energy. Adsorption and diffusion processes are thus closer to thermodynamic conditions that prevails in calculations. An experimental protocol was refined in order to create a chemically homogeneous polymer surface with a low roughness (Ra<1nm). The bulk and the surface of the pristine polymer were characterized (i) by Fourier Transform Infrared Spectroscopy, to determine the polymerization rate (above 90%), (ii) by differential scanning calorimetry in order to obtain the glass transition temperature (Tg) (118.1 °C), (iii) by atomic force microscopy (AFM) to calculate surface roughness (Ra ˜ 1 nm), and (iv) by X-ray photoelectron spectroscopy (XPS) to characterize surface chemical bonding. The surface was then metallized. Through AFM, the thickness of the thin film was estimated at 6 nm. We then used XPS to characterize the Cu/Poly-epoxy interfacial bonding. We deduced that Cu adsorbed preferentially on a specific oxygen atom of the polymer. To clearly identify this Cu adsorption site, we further simulated the XPS spectra of our clean or metallized polymer by quantum calculations, using a dimer model (1 molecule of DGEBA connected to 1 molecule of EDA). In the Hartree-Fock (HF) and Density Functional Theory (DFT) framework, we first simulated the XPS spectra for the pristine surface taking into account initial and final state effects. Thanks to these results, we were able to analyze the experimental spectrum with 8 contributions, leading to much more accurate results than the usual results obtained by the exclusive use of experiments and literature. We then performed classical Molecular Dynamics (MD) simulations to move from a dimer model to an amorphous polymer model. We used the general Amber force field (GAFF) and we developed a code to mimic the reticulation of monomers molecules. We started from a stoichiometric mixture of DGEBA and EDA molecules. When equilibration was reached, structural properties at 700K (e.g. distribution of bonds) were extracted from the results of the NPT simulations. From this melt of monomers, the homemade reticulation code identified and connected reactive atoms (at a pre-defined inter-atomic distance < 3Å). After each step of polymerization, the system was equilibrated at 700K (NPT simulations). After multiple reticulation/MD cycles we could achieve a polymerization rate of 93% and the Radial Distribution Function (RDF), the density and the glass transition temperature Tg were calculated. The value of the computed density was 1.115 at 300K and the calculated Tg (115.5 °C) was in good agreement with the experimental Tg of 118.1 °C, validating our numerical approach to develop a model for poly-epoxies

Design of the FemCure study: Prospective multicentre study on the transmission of genital and extra-genital Chlamydia trachomatis infections in women receiving routine care

Background: In women, anorectal infections with Chlamydia trachomatis (CT) are about as common as genital CT, yet the anorectal site remains largely untested in routine care. Anorectal CT frequently co-occurs with genital CT and may thus often be treated co-incidentally. Nevertheless, post-treatment detection of CT at both anatomic sites has been demonstrated. It is unknown whether anorectal CT may play a role in post-treatment transmission. This study, called FemCure, in women who receive routine treatment (either azithromycin or doxycycline) aims to understand the post-treatment transmission of anorectal CT infections, i.e., from their male sexual partner(s) and from and to the genital region of the same woman. The secondary objective is to evaluate other reasons for CT detection by nucleic acid amplification techniques (NAAT) such as treatment failure, in order to inform guidelines to optimize CT control. Methods: A multicentre prospective cohort study (FemCure) is set up in which genital and/or anorectal CT positive women (n=400) will be recruited at three large Dutch STI clinics located in South Limburg, Amsterdam and Rotterdam. The women self-collect anorectal and vaginal swabs before treatment, and at the end of weeks 1, 2, 4, 6, 8, 10, and 12. Samples are tested for presence of CT-DNA (by NAAT), load (by quantitative polymerase chain reaction -PCR), viability (by culture and viability PCR) and CT type (by multilocus sequence typing). Sexual exposure is assessed by online self-administered questionnaires and by testing samples for Y chromosomal DNA. Using logistic regression models, the impact of two key factors (i.e., sexual exposure and alternate anatomic site of infection) on detection of anorectal and genital CT will be assessed. Discussion: The FemCure study will provide insight in the role of anorectal chlamydia infection in maintaining the CT burden in the context of treatment, and it will provide practical recommendations to reduce avoidable transmission. Implications will improve care strategies that take account of anorectal CT

Prioritization of genes driving congenital phenotypes of patients with de novo genomic structural variants

Background:Genomic structural variants (SVs) can affect many genes and regulatory elements. Therefore, the molecular mechanisms driving the phenotypes of patients carrying de novo SVs are frequently unknown. Methods:We applied a combination of systematic experimental and bioinformatic methods to improve the molecular diagnosis of 39 patients with multiple congenital abnormalities and/or intellectual disability harboring apparent de novo SVs, most with an inconclusive diagnosis after regular genetic testing. Results: In 7 of these cases (18%), whole-genome sequencing analysis revealed disease-relevant complexities of the SVs missed in routine microarray-based analyses. We developed a computational tool to predict the effects on genes directly affected by SVs and on genes indirectly affected likely due to the changes in chromatin organization and impact on regulatory mechanisms. By combining these functional predictions with extensive phenotype information, candidate driver genes were identified in 16/39 (41%) patients. In 8 cases, evidence was found for the involvement of multiple candidate drivers contributing to different parts of the phenotypes. Subsequently, we applied this computational method to two cohorts containing a total of 379 patients with previously detected and classified de novo SVs and identified candidate driver genes in 189 cases (50%), including 40 cases whose SVs were previously not classified as pathogenic. Pathogenic position effects were predicted in 28% of all studied cases with balanced SVs and in 11% of the cases with copy number variants. Conclusions:These results demonstrate an integrated computational and experimental approach to predict driver genes based on analyses of WGS data with phenotype association and chromatin organization datasets. These analyses nominate new pathogenic loci and have strong potential to improve the molecular diagnosis of patients with de novo SVs

Protocol for the unclassified primary antibody deficiency (unPAD) study: Characterization and classification of patients using the ESID online registry

Background: Primary antibody deficiencies (PADs) without an identified monogenetic origin form the largest and most heterogeneous group of primary immunodeficiencies. These patients often remain undiagnosed for years and many present to medical attention in adulthood after several infections risking structural complications. Not much is known about their treatment, comorbidities, or prognosis, nor whether the various immunological forms (decreased total IgG, IgG subclass(es), IgM, IgA, specific antibody responses, alone or in combination(s)) should be considered as separate, clearly definable subgroups. The unclassified primary antibody deficiency (unPAD) study aims to describe in detail all PAD patients without an identified specific monogenetic defect regarding their demographical, clinical, and immunological characteristics at presentation and during follow-up. In constructing these patterns, the unPAD study aims to reduce the number of missed and unidentified PAD patients in the future. In addition, this study will focus on subclassifying unPAD to support the identification of patients at higher risk for infection or immune dysregulation related complications, enabling the development of personalized follow-up and treatment plans. Methods and analysis: We present a protocol for a multicenter observational cohort study using the ESID online Registry. Patients of all ages who have given informed consent for participation in the ESID online Registry and fulfill the ESID Clinical Working Definitions for ‘unclassified antibody deficiency’, ‘deficiency of specific IgG’, ‘IgA with IgG subclass deficiency’, ‘isolated IgG subclass deficiency’, ‘selective IgM deficiency’, ‘selective IgA deficiency’ or ‘common variable immunodeficiency’ will be included. For all patients, basic characteristics can be registered at first registration and yearly thereafter in level 1 forms. Detailed characteristics of the patients can be registered in level 2 forms. Consecutive follow-up forms can be added indefinitely. To ensure the quality of the collected data, all data will be fully monitored before they are exported from the ESID online Registry for analysis. Outcomes will be the clinical and immunological characteristics of unPAD at presentation and during follow-up. Subgroup analyses will be made based on demographical, clinical and immunological characteristics

Enhancing the contribution of research to health care policy-making: a case study of the Dutch Health Care Performance Report

OBJECTIVES: The Dutch Health Care Performance Report, issued by the National Institute of Public Health and the Environment, aims to monitor health care performance in The Netherlands. Both the National Institute and the Ministry of Health wish to increase the contribution of the Report to health care policy-making. Our aim was to identify ways to achieve that. METHOD: We used contribution mapping as a theoretical framework that recognizes alignment of research as crucial to managing contributions to policy-making. To investigate which areas need alignment efforts by researchers and/or policy-makers, we interviewed National Institute researchers and policy-makers from the Ministry of Health and assessed the process for developing the 2010 Report. RESULTS: We identified six areas where alignment is specifically relevant for enhancing the contributions of future versions of the Dutch Health Care Performance Report: well-balanced information for different ministerial directorates; backstage work; double role actors; reports of other knowledge institutes; data collection/generation and presentation forms. CONCLUSION: The contribution of health care performance reporting to policy-making is complex and requires continuous alignment efforts between researchers and policy-makers. These efforts should form an inseparable part of health care performance reporting and although this demands considerable resources, it is worth considering since it may pay back in better contributions to policy-making

The clinical relevance of IgM and IgA anti‐pneumococcal polysaccharide ELISA assays in patients with suspected antibody deficiency

Unlike immunoglobulin (Ig)G pneumococcal polysaccharide (PnPS)‐antibodies, PnPS IgA and IgM‐antibodies are not routinely determined for the assessment of immunocompetence. It is not yet known whether an isolated inability to mount a normal IgM or IgA‐PnPS response should be considered a relevant primary antibody deficiency (PAD). We studied the clinical relevance of anti‐PnPS IgM and IgA‐assays in patients with suspected primary immunodeficiency in a large teaching hospital in ’s‐Hertogenbosch, the Netherlands. Serotype‐specific‐PnPS IgG assays were performed; subsequently, 23‐valent‐PnPS IgG assays (anti‐PnPS IgG assays), and later anti‐PnPS IgA and IgM assays, were performed in archived material (240 patients; 304 samples). Eleven of 65 pre‐ and six of 10 post‐immunization samples from good responders to PnPS serotype‐specific IgG testing had decreased anti‐PnPS IgA and/or IgM titres. Of these, three pre‐ and no post‐immunization samples were from patients previously classified as ‘no PAD’. Determination of anti‐PnPS IgA and IgM in addition to anti‐PnPS IgG did not reduce the need for serotype‐specific PnPS IgG testing to assess immunocompetence [receiver operating characteristic (ROC) analysis of post‐immunization samples: anti‐PnPS IgA + IgG area under the curve (AUC) = 0.80, 95% confidence interval (CI) = 0.63–0.97; anti‐PnPS IgM + IgG AUC 0.80, 95% CI = 0.62–0.98; anti‐PnPS IgA + IgG + IgM AUC = 0.71, 95% CI = 0.51–0.91; anti‐PnPS IgG AUC = 0.93, 95% CI = 0.85–1.00]. Our data show that patients classified as having an intact antibody response based on measurement of serotype‐specific PnPS IgG can still display impaired anti‐PnPS IgM and IgA responses, and that the additional measurement of anti‐PnPS IgA and IgM could not reduce the need for serotype‐specific IgG testing. Future studies are needed to investigate the clinical relevance of potential ‘specific IgA or IgM antibody deficiency’ in patients with recurrent airway infections in whom no PAD could be diagnosed according to the current definitions