Immunoglobulin free light chains in severe asthma patient: Could they be a new biomarker?

BACKGROUND: Increasing evidence is available about the presence of increased serum concentration of immunoglobulin (Ig) free light chains (FLCs) in both atopic and non-atopic inflammatory diseases, including severe asthma, providing a possible new biomarker of disease. METHODS: We analyzed clinical and laboratory data, including FLCs, obtained from a cohort of 79 asthmatic subjects, clinically classified into different GINA steps. A control group of 40 age-matched healthy donors (HD) was considered. Particularly, HD have been selected according to the absence of monoclonal components (in order to exclude paraproteinemias), were tested for total IgE (that were in the normal ranges) and were negative for aeroallergens specific IgE. Moreover, no abnormality of common inflammatory markers (i.e., erythrocyte sedimentation rate and C-reactive protein) was detectable. RESULTS: FLC-k levels were significantly increased in the asthmatic population, compared to the control group. Despite the absence of statistically significant differences in FLC-λ levels, the FLC-k/FLC-λ ratio displayed remarkable differences between the two groups. A positive correlation between FLC-κ and FLC-λ levels was found. FLC- λ level displayed a significant negative correlation with the FEV1 value. Moreover, the FLC-κ /FLC- λ ratio was negatively correlated with the SNOT-22 score and a positive correlation was observed between FLCs and Staphylococcus Aureus IgE enterotoxins sensitization. CONCLUSIONS: Our findings confirmed the role of FLCs in asthma as a potential biomarker in an inflammatory disease characterized by different endotypes and phenotypes. In particular, FLC-κ and FLC-k/FLC-λ ratio could be a qualitative indicator for asthma, while FLC-λ levels could be a quantitative indicator for clinical severity parameters.

Performance of helmet CPAP using different configurations: Turbine-driven ventilators vs Venturi devices.

BACKGROUND: Traditionally, Venturi-based flow generators have been preferred over mechanical ventilators to provide continuous positive airway pressure (CPAP) through the helmet (h-CPAP). Recently, modern turbine-driven ventilators (TDVs) showed to be safe and effective in delivering h-CPAP. We aimed to compare the pressure stability during h-CPAP delivered by Venturi devices and TDVs and assess the impact of High Efficiency Particulate Air (HEPA) filters on their performance. METHODS: We performed a bench study using an artificial lung simulator set in a restrictive respiratory condition, simulating two different levels of patient effort (high and low) with and without the interposition of the HEPA filter. We calculated the average of minimal (Pmin), maximal (Pmax) and mean (Pmean) airway pressure and the time product measured on the airway pressure curve (PTPinsp). We defined the pressure swing (Pswing) as Pmax - Pmin and pressure drop (Pdrop) as End Expiratory Pressure - Pmin. RESULTS: Pswing across CPAP levels varied widely among all the tested devices. During "low effort", no difference in Pswing and Pdrop was found between Venturi devices and TDVs; during high effort, Pswing (p<0.001) and Pdrop (p<0.001) were significantly higher in TDVs compared to Venturi devices, but the PTPinsp was lower (1.50 SD 0.54 vs 1.67 SD 0.55, p<0.001). HEPA filter addition almost doubled Pswing and PTPinsp (p<0.001) but left unaltered the differences among Venturi and TDVs systems in favor of the latter (p<0.001). CONCLUSIONS: TDVs performed better than Venturi systems in delivering a stable positive pressure level during h-CPAP in a bench setting.

Vitamin D and disease severity in bronchiectasis.

BACKGROUND: Bronchiectasis is a complex respiratory disease characterised by permanent dilatation of bronchi. Vitamin D plays a role in infective disease by modulating the inflammation. Patients affected by bronchiectasis are frequently Vitamin D deficient and it correlates with lung function decline. We want to understand if there is a correlation between Vitamin D and clinical and radiological severity of bronchiectasis. METHODS: We included 57 patients (17 males/40 female with mean age 60 ±â€¯12 years) between October 2017 and March 2018. We excluded patients with cystic fibrosis, traction bronchiectasis and reporting Vitamin D supplementation. Bronchiectasis severity index (BSI) and Bhalla score were calculated, blood inflammatory markers and Vit. D were measured and lung function tests were performed. RESULTS: Vitamin D is deficient in 64% of patients, sufficient in 36% and normal in 7%. Mean BSI is 7.5 ±â€¯5 and mean Bhalla score is 16 ±â€¯4. Vitamin D levels correlate with Bhalla score (R2 = 0.68, p < 0.001) and BSI (R2 = 0.58, p < 0.0001). The correlation appears to be stronger than other markers of inflammation such as ESR and CRP [R2 = 0.33, p = 0.001 and R2 = 0.39, p = 0.001 respectively]. CONCLUSIONS: We consider Vitamin D as a good predictor of clinical and radiological severity of bronchiectasis.

Higher serum levels of periostin and the risk of exacerbations in moderate asthmatics.

BACKGROUND: In asthma, exacerbations and poor disease control are linked to airway allergic inflammation. Serum periostin has been proposed as a systemic biomarker of eosinophilic inflammation. This pilot study aims at evaluating whether in patients with moderate asthma, higher baseline levels of serum periostin are associated with a greater risk of exacerbation. METHODS: Fifteen outpatients with moderate allergic asthma were recruited. Serum concentrations of periostin were assessed (ELISA) at baseline, and the frequency of asthma exacerbations was recorded during a one-year follow-up. RESULTS: Patients (M/F: 10/5, mean age of 47.6 ± 11.0 years) had mean ACQ score of 5.5 ± 4.2 and FEV1%pred of 81.9 ± 21.7 %. Baseline serum levels of periostin did not correlate with lung function parameters, nor with the ACQ score (p ≥0.05 for all analyses). Five subjects (33 % of the study group) reported one or more exacerbations during the following year. Baseline serum levels of periostin were significantly higher in subjects who experienced one or more exacerbations during the one year period of follow-up, compared with subjects with no exacerbations: median serum periostin level was 4047 ng/ml (range: 2231 to 4889 ng/ml) and 222 ng/ml (range 28.2 to 1631 ng/ml) respectively; p = 0.001. CONCLUSION: The findings of the present pilot study could form the basis for the design of larger studies aiming at developing strategies to identify asthmatic patients at risk for exacerbations.

Survey of non-invasive ventilation practices: a snapshot of Italian practice.

BACKGROUND: In Italy, NIV began to be employed in the late 1980s. Because it was adopted earlier than in Italy than in other countries, the pattern and rate of utilization of NIV may be different. We aim to determine factors that may influence Italian physicians' preferences towards NIV use, with a particular emphasis on the primary specialty of these physicians and the type of hospital in which they work. METHODS: We re-examined the data from our European survey conducted in 2008 and focused our analysis on the Italian subsets of respondents to explore factors that influence physicians' perceptions of their NIV practices in four scenarios: acute hypercapnic respiratory failure (AHRF), cardiogenic pulmonary edema (CPE), de novo respiratory failure, and weaning/post-extubation failure (W/PE). RESULTS: On average, NIV was equally applied in university and community hospitals (P>0.05) and its utilization rate was higher for pulmonologists (62% reported >20% of patients treated with NIV a year) vs. intensivists (17%) and others (21%) (P<0.05). A greater use of NIV was related to a smaller number of unit beds in de novo respiratory failure (56% vs. 40%) and a larger amount of unit beds in AHRF (16% vs. 7%) (P<0.05). Dedicated NIV platforms and ICU ventilators with NIV modules were the preferred machines in AHRF (P<0.05), while a greater utilization of ICU ventilators with NIV modules was observed in de novo respiratory failure. In all the scenarios, a facial mask was predominantly used (P<0.05), with the helmet rated as the second preferred choice in CPE. CONCLUSION: Overall, Italian physicians perceived that NIV represents an essential tool when dealing with acute episodes of respiratory failure, irrespective of the type of hospital in which they worked.

A European survey of noninvasive ventilation practices.

Although noninvasive ventilation (NIV) is becoming very popular, little is known about its pattern of clinical and technical utilisation in different environments. We conducted a web-based survey in Europe to identify the perceived pattern of NIV utilisation and the reason for choosing a specific ventilator and interface type in four common clinical scenarios: acute hypercapnic respiratory failure (AHRF), cardiogenic pulmonary oedema (CPE), de novo hypoxic respiratory failure and weaning/post-extubation failure (W/PE). A response was obtained from 272 (51.3%) out of 530 selected European physicians involved in NIV practice. The NIV utilisation rate was higher for pulmonologists than intensivists/anesthesiologists (p<0.05). The most common indication for all the physicians was AHRF (48%). Physicians were more likely to use NIV dedicated ventilator in AHRF and CPE and an intensive care unit (ICU) ventilator with NIV module in de novo hypoxic respiratory failure and W/PE, mainly because of the possibility of using the double circuit and inspiratory oxygen fraction control. Overall, the oro-nasal mask was the most frequently used interface, irrespective of clinical scenarios. The use of NIV in Europe is generally relatively high, especially among pulmonologists and in AHRF. Dedicated NIV ventilators and ICU ventilators with NIV modules are preferably in AHRF and in de novo hypoxic respiratory failure, respectively, together with oro-nasal masks.

Optimization of epitope processing enhances immunogenicity of multiepitope DNA vaccines.

Experimental DNA vaccines comprised of multiple minimal cytotoxic T lymphocytes (CTL) epitopes can effectively induce broad CTL responses; however, such constructs frequently exhibit significant variation in epitope immunogenicity. Antigenicity assays utilizing human cells transfected with one such multiepitope construct revealed that the epitopes with poor immunogenicity were inefficiently processed in transfected cells. Compilation of a database of 94 epitope/flanking region combinations, for which immunogenicity was measured experimentally, revealed that the type of residue immediately following the carboxyl-terminus of the epitope exerted a prominent effect on immunogenicity. Experiments utilizing a variety of HBV-specific vaccine constructs demonstrated epitope immunogenicity could be modulated by the insertion of a single amino acid and the effect on immunogenicity could be ascribed to modulation of processing efficiency. These findings demonstrate that multiepitope DNA vaccines can be engineered to enhance CTL immunogenicity by increasing processing efficiency.

Immunization with the HBV core 18-27 epitope elicits CTL responses in humans expressing different HLA-A2 supertype molecules.

The human leukocyte antigen (HLA)-A2 restricted HBV core 18-27 epitope is immunodominant in the context of HLA-A2.1 and subdominant in the context of the other HLA-A2 supertype molecules, as defined by frequency of recognition by memory cytotoxic T lymphocyte (CTL) responses from acute hepatitis B virus (HBV) patients, and on the basis of its binding affinity to purified HLA molecules in vitro. Herein, we show that immunization with a lipopeptide containing HBV core 18-27 epitope induces CTL responses in patients expressing different HLA-A2 supertype molecules, with indistinguishable frequency and magnitude. No difference in responses was noted between patients expressing either one or two different HLA-A2 supertype molecules. Thus, complexes of HBV core 18-27 bound to different HLA-A2 supertype alleles do not appear to act as altered peptide ligands, and do not cross antagonize CTL responses. These results substantiate the immunological relevance of the HLA supertypes concept, and illustrate its potential usefulness for the development of vaccines.

Utilization of MHC class I transgenic mice for development of minigene DNA vaccines encoding multiple HLA-restricted CTL epitopes.

We engineered a multiepitope DNA minigene encoding nine dominant HLA-A2.1- and A11-restricted epitopes from the polymerase, envelope, and core proteins of hepatitis B virus and HIV, together with the PADRE (pan-DR epitope) universal Th cell epitope and an endoplasmic reticulum-translocating signal sequence. Immunization of HLA transgenic mice with this construct resulted in: 1) simultaneous CTL induction against all nine CTL epitopes despite their varying MHC binding affinities; 2) CTL responses that were equivalent in magnitude to those induced against a lipopeptide known be immunogenic in humans; 3) induction of memory CTLs up to 4 mo after a single DNA injection; 4) higher epitope-specific CTL responses than immunization with DNA encoding whole protein; and 5) a correlation between the immunogenicity of DNA-encoded epitopes in vivo and the in vitro responses of specific CTL lines against minigene DNA-transfected target cells. Examination of potential variables in minigene construct design revealed that removal of the PADRE Th cell epitope or the signal sequence, and changing the position of selected epitopes, affected the magnitude and frequency of CTL responses. Our results demonstrate the simultaneous induction of broad CTL responses in vivo against multiple dominant HLA-restricted epitopes using a minigene DNA vaccine and underline the utility of HLA transgenic mice in development and optimization of vaccine constructs for human use.

Altered helper T lymphocyte function associated with chronic hepatitis B virus infection and its role in response to therapeutic vaccination in humans.

Theradigm-hepatitis B virus (HBV) is an experimental lipopeptide vaccine designed to stimulate induction of HBV-specific CTL responses in HLA-A2 individuals. Previous studies had demonstrated high immunogenicity in healthy volunteers, but comparatively weak CTL responses in chronically infected HBV patients. Herein, we examined helper T lymphocyte (HTL) responses in chronically infected patients. Despite normal proliferation and IL-2 secretion, IL-12 and IFN-gamma secretion in vitro in response to the vaccine was reduced compared with healthy volunteers. A similar pattern of cytokine secretion was observed following mitogen stimulation, suggesting a general altered balance of Th1/Th2 responses. Further analysis indicated that HTL recall responses to whole tetanus toxoid protein were reduced in chronically infected subjects, and reduced responsiveness correlated with the outcome of Theradigm-HBV immunization. Finally, experiments in HBV transgenic mice indicated that the nonnatural Pan DR HTL epitope, PADRE, is capable of inducing high levels of IFN-gamma secretion and that its inclusion in a lipopeptide incorporating an immunodominant Ld-restricted CTL epitope resulted in breaking tolerance at the CTL level. Overall, our results demonstrate an alteration in the quality of HTL responses induced in chronically infected HBV patients and suggest that use of a potent HTL epitope may be important to overcome CTL tolerance against specific HBV Ags.

The hepatitis B virus-specific CTL responses induced in humans by lipopeptide vaccination are comparable to those elicited by acute viral infection.

We have previously described the development of a lipopeptide-based vaccine, Theradigm-HBV, capable of inducing CTL responses in humans. This vaccine incorporates the HLA-A2.1-restricted CTL epitope hepatitis B core Ag 18-27, linked to the universal helper T lymphocyte (HTL) epitope tetanus toxoid (TT) 830-843. Herein, we report the results of a phase I trial designed to examine the effects of Theradigm-HBV dose and regimen on the magnitude and duration of the memory CTL response. A total of four injections of up to 5 mg/dose were found to be a safe and effective means of generating substantial memory CTL responses. Precursor frequency analysis demonstrated CTL responses of similar magnitude to those previously observed in patients who successfully cleared hepatitis B virus infection and to influenza-specific memory CTL responses induced by natural exposure to influenza virus. Theradigm-HBV induced CTL responses that persisted for more than 9 months after the last injection. HTL responses were associated with significant CTL responses, and sustained HTL activity was necessary for development of persistent memory CTL activity. These results represent the first demonstration of the importance of HTL activity for development of long-lived memory CTL responses in humans. In conclusion, our results show that lipopeptides safely induce specific CTL activity in humans of such magnitude and persistence as to be of potential therapeutic significance.

Identification of A2-restricted hepatitis C virus-specific cytotoxic T lymphocyte epitopes from conserved regions of the viral genome.

We have focused on conserved regions of the hepatitis C Virus (HCV) genome to identify viral peptides that contain HLA class I binding motifs and bind with high affinity to the corresponding purified HLA molecules. Accordingly, we have identified 31 candidate epitopes in the HCV that have the potential to be recognized by either HLA-A1, A2.1-, A3, A11- or A24-restricted cytotoxic T lymphocytes (CTL). Twelve conserved peptides that bind HLA-A2.1 with high or intermediate affinity were tested for immunogenicity in vitro in human primary CTL cultures and in vivo by direct immunization of HLA-A2.1/Kb transgenic mice. Six HLA-A2.1-restricted CTL epitopes were immunogenic in both systems. At least three of these peptide epitopes were endogenously processed and presented for CTL recognition. Overall, these data illustrate the value of this approach for the development of virus-specific, peptide-based vaccines.

In vitro induction of primary, antigen-specific CTL from human peripheral blood mononuclear cells stimulated with synthetic peptides.

A protocol for in vitro induction of primary, antigen-specific CTL from human peripheral blood mononuclear cells (PBMCs) was developed. Antigen presenting cells (APCs) consisted of Staphylococcus aureus Cowan-I (SAC-I) activated PBMCs treated with a citrate-phosphate buffer at pH 3 to release endogenous peptides bound to surface MHC. This treatment resulted in transient expression of empty class I molecules which could be subsequently stabilized with peptide and beta 2-microglobulin (beta 2m). SAC-I activated PBMCs from HLA-A2.1 normal donors loaded with HBV core 18-27 peptide following acid treatment were used to stimulate PBMCs depleted of CD4+ T cells, in the presence of recombinant interleukin-7 (rIL-7). After 12 days, cells were restimulated with autologous, peptide-pulsed, adherent cells and tested for CTL activity 7 days later. In 23 independent experiments from 13 different HLA-A2.1 donors, this protocol resulted in induction of primary CTL more than 90% of the time. As indicated by both the frequency and magnitude of the response against peptide-sensitized target cells, SAC-I activated PBMCs treated with acid were the most efficient stimulator APC. Thirteen per cent of the cultures generated were capable of lysing target cells transfected with the HBV core antigen and, in general, these CTL cultures exhibited high avidity for the HBV core peptide. This protocol is generally applicable to different antigens and class I alleles, and thus, may be utilized to screen large numbers of peptides to identify human CTL epitopes.

Induction of anti-tumor cytotoxic T lymphocytes in normal humans using primary cultures and synthetic peptide epitopes.

Cytotoxic T lymphocytes (CTLs) recognize peptide antigens associated with cell surface major histocompatibility complex (MHC) molecules. The identification of tumor cell-derived peptides capable of eliciting anti-tumor CTL responses would enable the design of antigen-specific immunotherapies. Our strategy to identify such potentially therapeutic peptides relies on selecting high-affinity MHC binders from known tumor-associated antigens. These peptides are subsequently tested for their ability to induce CTLs capable of killing tumor cells. With this strategy, we have identified a nine-residue epitope, derived from the product of the tumor-associated gene MAGE-3, which has the capacity to induce in vitro CTLs that kill melanoma and other tumor cell lines. These results show the primary in vitro induction of tumor-specific human CTLs and illustrate the feasibility of ex vivo antigen-specific approaches to the immunological therapy of cancer.

Fine restriction analysis and inhibition of antigen recognition in HLA-DQ-restricted T cells by major histocompatibility complex blockers and T cell receptor antagonists.

The role of polymorphic residues of the beta chain of human histocompatibility leukocyte antigen-DQw5/w6 in antigen presentation to a hepatitis B surface antigen-specific T cell clone was studied. The results obtained demonstrate that the residue situated at position 57 of the beta chain (a valine) is critical for presentation of antigen by antigen-presenting cells to the DQ-restricted T cell clone. Experiments were also done to study the feasibility of peptide blocking of antigen recognition by DQ-restricted T cells. The results indicate that peptides known to associate with DQ molecules are capable of blocking the presentation of antigen to the DQ-restricted T cell clone, presumably by competing with antigen for binding to major histocompatibility complex (MHC) molecules. Moreover, truncations of the stimulatory antigenic peptide resulted in the production of T cell receptor antagonists, which inhibited the response of the T cells to antigen at 10-100-fold lower concentrations than conventional MHC blockers. The role of DQ-restricted T cell responses and peptide blocking approaches in autoimmunity are discussed.

Identification of developmental disabilities and health problems among individuals under child protective services.

Although a relation between child abuse and developmental disabilities has been established, information about the health and developmental status of children referred to child protective services is not adequately obtained. Case records of 150 children identified to child protective services were reviewed in order to determine the availability of health and developmental information. A screening protocol was developed for the purpose of reviewing case records that has potential for use by child protective services workers.

Improper office disposal of needles and other sharps: an occupational hazard outside of health care institutions.

An employee of a private disposal company suffered a finger needlestick injury while collecting waste at curbside from a building containing medical offices. Subsequent inspection of the contents of the garbage bags revealed the presence of used syringes and unsheathed needles. The Ministry of the Environment has developed a regulation and guidelines for the handling and disposal of biomedical waste including needles and other sharps. These specify that approved carriers and receivers are required for disposal; properly decontaminated waste is considered non-hazardous solid waste and can go to landfills. However, responsibility for curbside pickup of waste lies with municipalities; some municipalities have enacted by-laws which prohibit collection of this waste at the curbside. This incident illustrates that improper disposal of biomedical waste (including that from private practitioners' offices) may occur despite efforts to control its handling, and that needlestick injuries can occur outside of health care facilities among personnel who are not health care workers. Efforts are needed to increase the level of awareness among health professionals regarding their responsibility to ensure proper biomedical waste disposal from private offices. In addition, efforts should be made to bridge the gap between all levels of government regarding the disposal of biomedical waste.