DLCO Biologic Quality-Control Findings From a Multi-Center Global Study.

BACKGROUND: The 2017 American Thoracic Society/European Respiratory Society (ATS/ERS) diffusing capacity of the lung for carbon monoxide (DLCO) standards specify a control rule for assessing biologic quality control (BioQC) but have limited guidance on how to establish expected values for control rule variables. This study aimed to determine expected values for DLCO BioQC using coefficient of variation (CV) and compare that the mean ± 2 SD control rule yields the same precision as mean ± 12% of the mean. METHODS: DLCO BioQC data were collected from a multi-center inhaled medication study. This descriptive study spanned 42 months ending in 2018. The annual DLCO CV was based upon 10 DLCO values separated by at least 5 d. The root mean square CV (RMSCV) was computed for each year and Friedman test evaluated within subject annual CV changes. Ninetieth percentile values were computed for annual control rule limits/mean DLCO. RESULTS: Of 217 BioQCs, the study's first year had 168 subjects with fewer in subsequent years. Annual CV values from RMSCV were 5.3, 4.5, and 4.6% in years 1, 2, and 3, respectively. No change was seen in the CV for those subjects with data for all 3 years, n = 24, P = .07. The 90th percentile of measurements 2 SD/mean DLCO were 15, 12.4, and 11% in years 1, 2, and 3, respectively. CONCLUSIONS: A DLCO BioQC CV ≤ 6% is achievable across multiple sites, technologists, and brands of equipment. This CV value assures that measurements for control rule variables emerge from an expected range. A control rule of mean ± 2 SD appeared to yield similar results as the mean ± 12% of the mean rule reported in the 2017 ATS/ERS DLCO standards.

Variations in FVC and FEV1 Biologic Quality Control Measures in a Global Multi-Center Clinical Trial.

BACKGROUND: Although quality control standards are recommended to ensure accurate test results, the coefficient of variation for the FVC and FEV1 biologic quality control (BioQC) is not specified. The primary aim of this study was to evaluate variations in spirometry BioQCs in a large and diverse cohort of individuals to determine an acceptable standard for the coefficient of variation. METHODS: The FVC and FEV1 biologic control data were secondary analyses from an inhaled medication trial that was conducted over 3 y ending in 2018 that included 114 laboratories. Results were sent to a central repository for expert review. The FVC and FEV1 coefficients of variation were based upon a minimum of 10 spirometry values annually separated by at least 5 d. A second method of computing the coefficient of variation used 10 values within 28 d. Descriptive statistics were computed. Wilcoxon signed-rank tests were conducted to compare whether the median coefficient of variation values between the 2 methods differed, tested at α = 0.05 using SPSS. RESULTS: Of 249 biologic control participants, 170 met the first year's inclusion criteria. The coefficient of variation for the 5-d separated method was < 5% for 94.1% of FVC and 93.5% of FEV1 values in the first year. By year 3, 90% of FVC and FEV1 coefficient of variation values were < 4%. The medians for the 5-d separated and the 28-d measure showed no difference for either FVC coefficient of variation or FEV1 coefficient of variation, Z = -1.764, P = .78, and Z = -0.980, P = .33, respectively. CONCLUSIONS: Interlab biologic control variation values of < 4% for FVC and FEV1 are achievable; however, individual labs should strive to attain lower values. Acceptable coefficients of variation can be achieved within 28 d.

Demodex and rosacea revisited.

Demodex mites are part of the vast microbiome living on and within human skin. The interaction of the various microorganisms with the skin plays a key role in the maintenance of homeostasis. The precise role and function of Demodex mites within normal and diseased human skin remains elusive. The emergence of ivermectin as a key therapy for rosacea has refocused interest in the role of Demodex mites in the pathogenesis of this skin disease and the ability of Demodex to modulate the host immune system.

Abacavir-reactive memory T cells are present in drug naïve individuals.

BACKGROUND: Fifty-five percent of individuals with HLA-B*57:01 exposed to the antiretroviral drug abacavir develop a hypersensitivity reaction (HSR) that has been attributed to naïve T-cell responses to neo-antigen generated by the drug. Immunologically confirmed abacavir HSR can manifest clinically in less than 48 hours following first exposure suggesting that, at least in some cases, abacavir HSR is due to re-stimulation of a pre-existing memory T-cell population rather than priming of a high frequency naïve T-cell population. METHODS: To determine whether a pre-existing abacavir reactive memory T-cell population contributes to early abacavir HSR symptoms, we studied the abacavir specific naïve or memory T-cell response using HLA-B*57:01 positive HSR patients or healthy controls using ELISpot assay, intra-cellular cytokine staining and tetramer labelling. RESULTS: Abacavir reactive CD8+ T-cell responses were detected in vitro in one hundred percent of abacavir unexposed HLA-B*57:01 positive healthy donors. Abacavir-specific CD8+ T cells from such donors can be expanded from sorted memory, and sorted naïve, CD8+ T cells without need for autologous CD4+ T cells. CONCLUSIONS: We propose that these pre-existing abacavir-reactive memory CD8+ T-cell responses must have been primed by earlier exposure to another foreign antigen and that these T cells cross-react with an abacavir-HLA-B*57:01-endogenous peptide ligand complex, in keeping with the model of heterologous immunity proposed in transplant rejection.

The role of interleukin-17 in immune-mediated inflammatory myopathies and possible therapeutic implications.

The idiopathic inflammatory myopathies are a heterogeneous group of autoimmune muscle disorders with distinct clinical and pathological features and underlying immunopathogenic mechanisms. Traditionally, CD4(+) Th1 cells or CD8(+) cytotoxic effector T cells and type I/II interferons have been primarily implicated in the pathogenesis of the inflammatory myopathies. The presence of IL-17A producing cells in the inflamed muscle tissue of myositis patients and the results of in vitro studies suggest that IL-17A and the Th17 pathway may also have a key role in these diseases. The contribution of IL-17A to other chronic inflammatory and autoimmune diseases has been well established and clinical trials of IL-17A inhibitors are now at an advanced stage. However the precise role of IL-17A in the various forms of myositis and the potential for therapeutic targeting is currently unknown and warrants further investigation.

Antiviral drug allergy.

Antiviral drugs used to treat HIV and hepatitis C are common causes of delayed drug hypersensitivities for which many of the more severe reactions have been recently shown to be immunogenetically mediated such as abacavir hypersensitivity where HLA-B(∗)57:01 is now used routinely as a screening test to exclude patients carrying this allele from abacavir prescription. Most antiviral drug allergies consist of mild to moderate delayed rash without other serious features (eg, fever, mucosal involvement, blistering rash, organ impairment. In these cases treatment can be continued with careful observation and symptomatic management and the discontinuation rate is low.

IL-17A expression is localised to both mononuclear and polymorphonuclear synovial cell infiltrates.

INTRODUCTION: This study examines the expression of IL-17A-secreting cells within the inflamed synovium and the relationship to in vivo joint hypoxia measurements. METHODS: IL-17A expression was quantified in synovial tissue (ST), serum and synovial fluid (SF) by immunohistochemistry and MSD-plex assays. IL-6 SF and serum levels were measured by MSD-plex assays. Dual immunofluorescence for IL-17A was quantified in ST CD15+ cells (neutrophils), Tryptase+ (mast cells) and CD4+ (T cells). Synovial tissue oxygen (tpO(2)) levels were measured under direct visualisation at arthroscopy. Synovial infiltration was assessed using immunohistochemistry for cell specific markers. Peripheral blood mononuclear and polymorphonuclear cells were isolated and exposed to normoxic or 3% hypoxic conditions. IL-17A and IL-6 were quantified as above in culture supernatants. RESULTS: IL-17A expression was localised to mononuclear and polymorphonuclear (PMN) cells in inflamed ST. Dual immunoflourescent staining co-localised IL-17A expression with CD15+ neutrophils Tryptase+ mast cells and CD4+T cells. % IL-17A positivity was highest on CD15+ neutrophils, followed by mast cells and then CD4+T-cells. The number of IL-17A-secreting PMN cells significantly correlated with sublining CD68 expression (r = 0.618, p<0.01). IL-17A SF levels correlated with IL-6 SF levels (r = 0.675, p<0.01). Patients categorized according to tp0(2)< or >20 mmHg, showed those with low tp0(2)<20 mmHg had significantly higher IL-17A+ mononuclear cells with no difference observed for PMNs. Exposure of mononuclear and polymorphonuclear cells to 3% hypoxia, significantly induced IL-6 in mononuclear cells, but had no effect on IL-17A expression in mononuclear and polymorphonuclear cells. CONCLUSION: This study demonstrates IL-17A expression is localised to several immune cell subtypes within the inflamed synovial tissue, further supporting the concept that IL-17A is a key mediator in inflammatory arthritis. The association of hypoxia with Il-17A expression appears to be indirect, probably through hypoxia-induced pro-inflammatory pathways and leukocyte influx within the joint microenvironment.

Interleukin-17A induction of angiogenesis, cell migration, and cytoskeletal rearrangement.

OBJECTIVE: To examine the ability of interleukin-17A (IL-17A) to stimulate angiogenesis, cell migration, and cytoskeletal rearrangement. METHODS: The effect of IL-17A on microvascular tube formation and extracellular matrix invasion by human dermal endothelial cells (HDECs) was assessed using Matrigel matrix and Transwell Matrigel invasion chambers. IL-17A-induced growth-related oncogene α (GROα) and monocyte chemotactic protein 1 (MCP-1) production in rheumatoid arthritis synovial fibroblasts (RASFs) and HDECs was measured by enzyme-linked immunosorbent assay. IL-17A-induced migration was assessed using peripheral blood mononuclear cell (PBMC) migration assays and wound-repair scratch assays, with or without anti-GROα and anti-MCP-1 antibodies. Binding of ß1 integrin receptors was assessed using integrin binding assays. Cytoskeletal assembly/disassembly in RASFs and HDECs were assessed by immunofluorescence staining for F-actin. IL-17A-induced cell migration and cytoskeletal disassembly were assessed in the presence of a Rac1 inhibitor (NSC23766). Rac1 activation following IL-17 stimulation in the presence or absence of anti-GROα, anti-MCP-1, or IgG control was assessed by Rac GTPase pull-down assays and Western blotting. RESULTS: IL-17A significantly up-regulated angiogenesis and endothelial cell invasion. It significantly induced GROα and MCP-1 expression in RASFs. Migration of PBMCs, RASFs, and HDECs was induced by IL-17A; these effects were blocked by anti-GROα or anti-MCP-1 antibodies. IL-17A significantly up-regulated ß1 integrin receptor binding and induced cytoskeletal disassembly in RASFs and HDECs. Rac1 activation was directly induced by IL-17A. IL-17A-induced wound repair and actin rearrangement were inhibited by a pharmacologic inhibitor of Rac1 (NSC23766). Anti-GROα or anti-MCP-1 antibodies had no effect on IL-17A-induced Rac1 activation. CONCLUSION: IL-17A induces angiogenesis, cell migration, and cell invasion, all of which are key processes in the pathogenesis of rheumatoid arthritis and ones that are mediated in part through chemokine- and cytoskeleton-dependent pathways.

Human rheumatoid arthritis tissue production of IL-17A drives matrix and cartilage degradation: synergy with tumour necrosis factor-alpha, Oncostatin M and response to biologic therapies.

INTRODUCTION: The aim of this study was to examine IL-17A in patients, following anti-TNF-alpha therapy and the effect of IL-17A on matrix turnover and cartilage degradation. METHODS: IL-17A expression was examined by ELISA and immunohistology in the rheumatoid arthritis (RA) joints. RA whole synovial tissue explant (RA ST), primary synovial fibroblasts (RASFC), human cartilage and chondrocyte cultures were stimulated with IL-17A +/- TNF-alpha and Oncostatin M (OSM). Matrix metalloproteinase (MMP) and tissue inhibitor (TIMP-1) were assessed by ELISA and zymography. Cartilage proteoglycan release was assessed histologically by Safranin-O staining. Clinical parameters, IL-17A, MMP/TIMP were assessed in patients pre/post biologic therapy. RESULTS: IL-17A levels were higher in RA vs osteoarthritis (OA)/normal joints (P < 0.05). IL-17A up-regulated MMP-1, -2, -9, and -13 in RA ST, RASFC, cartilage and chondrocyte cultures (P < 0.05). In combination with TNF-alpha and OSM, IL-17A shifted the MMP:TIMP-1 ratio in favor of matrix degradation (all P < 0.05). Cartilage proteoglycan depletion in response to IL-17A was mild; however, in combination with TNF-alpha or OSM showed almost complete proteoglycan depletion. Serum IL-17A was detected in 28% of patients commencing biologic therapy. IL-17A negative patients demonstrated reductions post therapy in serum MMP1/TIMP4, MMP3/TIMP1 and MMP3/TIMP4 ratios and an increase in CS846 (all P < 0.05). No significant changes were observed in IL-17A positive patients. CONCLUSIONS: IL-17A is produced locally in the inflamed RA joint. IL-17A promotes matrix turnover and cartilage destruction, especially in the presence of other cytokines, mimicking the joint environment. IL-17A levels are modulated in vivo, following anti-TNF therapy, and may reflect changes in matrix turnover.

IRAK-2 participates in multiple toll-like receptor signaling pathways to NFkappaB via activation of TRAF6 ubiquitination.

Toll-like receptor (TLR) signaling is known to involve interleukin-1 receptor-associated kinases (IRAKs), however the particular role of IRAK-2 has remained unclear. Further, although IRAK-1 was originally thought to be central for the TLR-NFkappaB signaling axis, recent data have shown that it is dispensable for NFkappaB activation for some TLRs and demonstrated an alternative role for it in interferon regulatory factor activation. Here we show that IRAK-2 is critical for the TLR-mediated NFkappaB activation pathway. The poxviral TLR antagonist A52 inhibited NFkappaB activation by TLR2, -3, -4, -5, -7, and -9 ligands, via its interaction with IRAK-2, while not affecting interferon regulatory factor activation. Knockdown of IRAK-2 expression by small interfering RNA suppressed TLR3, TLR4, and TLR8 signaling to NFkappaB in human cell lines, and importantly, TLR4-mediated chemokine production in primary human cells. IRAK-2 usage by different TLRs was distinct, because it acted downstream of the TLR adaptors MyD88 and Mal but upstream of TRIF. Expression of IRAK-2, but not IRAK-1, led to TRAF6 ubiquitination, an event critical for NFkappaB activation. Further, IRAK-2 loss-of-function mutants, which could not activate NFkappaB, were incapable of promoting TRAF6 ubiquitination. Thus we propose that IRAK-2 plays a more central role than IRAK-1 in TLR signaling to NFkappaB.