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BACKGROUND Specific allergy sensitization pattern, using "component-resolved diagnosis" (CRD), is a central component of allergy and asthma in childhood. Besides this, allergic asthma has been characterized by a Th2-shifted endotype with elevation of classical Th2 cytokines. Recently, other endotypes with distinct mechanisms focusing on cytokine regulation evolved, yet those pathways are still not well understood. OBJECTIVE (a) To define reproducible immunological endotypes using cytokine expression in an asthma cohort and (b) to characterize their sensitization profile and clinical phenotype. METHODS Supernatants from PBMCs of 234 children (median age 10 years) of an asthma cohort were analysed for cytokine expressions. The children were split into a training (n = 49) and validation (n = 185) group. The training group was used to identify immunological endotypes by clustering cytokine expressions, which were then assessed regarding clinical characteristics and specific IgE of recombinant allergen components. Next, our findings were validated in the validation group. RESULTS We identified novel endotypes based on primarily unstimulated cytokine expression. One endotype showed an IFN-γ/Interleukin (IL)-17/IL-5 predominance, a different sensitization pattern (high in birch/apple; p

Asthma is the most common chronic disease in children. Underlying immunologic mechanisms-in particular of different phenotypes-are still just partly understood. The objective of the study was the identification of distinct cellular pathways in allergic asthmatics (AA) and nonallergic asthmatics (NA) vs healthy controls (HC).Peripheral blood mononuclear cells (PBMCs) of steroid-naïve children (n(AA/NA/HC) = 35/13/34)) from the CLARA study (n = 275) were stimulated (anti-CD3/CD28, LpA) or kept unstimulated. Gene expression was investigated by transcriptomics and quantitative RT-PCR. Differentially regulated pathways between phenotypes were assessed after adjustment for sex and age (KEGG pathways). Networks based on correlations of gene expression were built using force-directed graph drawing.Allergic asthmatics vs NA and asthmatics overall vs HC showed significantly different expression of CaCa

Background: Allergic and non-allergic childhood asthma has been characterized by distinct immune mechanisms. While interferon regulating factor 1 (IRF-1) polymorphisms (SNPs) influence atopy risk, the effect of SNPs on asthma phenotype-specific immune mechanisms is unclear. We assessed whether IRF-1 SNPs modify distinct immune-regulatory pathways in allergic and non-allergic childhood asthma (AA/NA). Methods: In the CLARA study, asthma was characterized by doctor's diagnosis and AA vs NA by positive or negative specific IgE. Children were genotyped for four tagging SNPs within IRF-1 (n = 172). mRNA expression was measured with qRT-PCR. Gene expression was analyzed depending on genetic variants within IRF-1 and phenotype including haplotype estimation and an allelic risk score. Results: Carrying the risk alleles of IRF-1 in rs10035166, rs2706384, or rs2070721 was associated with increased risk for AA. Carrying the non-risk allele in rs17622656 was associated with lower risk for AA but not NA. In AA carrying the risk alleles, an increased pro-inflammatory expression of ICAM3, IRF-8, XBP-1, IFN-., RGS13, RORC, and TSC2 was observed. NOD2 expression was decreased in AA with risk alleles in rs2706384 and rs10035166 and with risk haplotype. Further, AA with risk haplotype showed increased IL-13 secretion. NA with risk allele in rs2070721 compared to non-risk allele in rs17622656 showed significantly upregulated calcium, innate, mTOR, neutrophil, and inflammatory-associated genes. Conclusion: IRF-1 polymorphisms influence the risk for childhood allergic asthma being associated with increased pro-inflammatory gene regulation. Thus, it is critical to implement IRF-1 genetics in immune assessment for childhood asthma phenotypes.

BACKGROUND Asthma is the most common chronic disease in children. Underlying immunological mechanisms - in particular of different phenotypes - are still just partly understood. The objective of the study is the identification of distinct cellular pathways in allergic asthmatics (AA) and non-allergic asthmatics (NA) vs healthy controls (HC). METHODS Peripheral blood mononuclear cells (PBMCs) of steroid-naive children (n(AA/NA/HC) = 35/13/34)) from the CLARA study (n=275) were stimulated (anti-CD3/CD28, LpA) or kept unstimulated. Gene-expression was investigated by transcriptomics and quantitative RT-PCR. Differentially regulated pathways between phenotypes were assessed after adjustment for sex and age (KEGG-pathways). Networks based on correlations of gene expression were built using force-directed graph drawing. RESULTS AA vs NA and asthmatics overall vs HC showed significantly different expression of Ca2+ - and innate immunity-associated pathways. PCR-analysis confirmed significantly increased Ca2+ -associated gene-regulation (ORMDL3 and ATP2A3) in asthmatics vs HC, most prominent in AA. Innate immunity receptors (LY75, TLR7), relevant for virus infection, were also upregulated in AA and NA compared to HC. AA and NA could be differentiated by increased ATP2A3 and FPR2 in AA, decreased CLEC4E in AA and increased IFIH1 expression in NA following anti-CD3/28-stimulation vs unstimulated (fold change). CONCLUSIONS Ca2+ -regulation and innate immunity response pattern to viruses were activated in PBMCs of asthmatics. Asthma phenotypes were differentially characterized by distinct regulation of ATP2A3 and expression of innate immune receptors (FPR2, CLEC4E, IFIH1). These genes may present promising targets for future in depth investigation with the long-term goal of more phenotype-specific therapeutic interventions in asthmatics. This article is protected by copyright. All rights reserved.

Individual tree mortality prediction is a key component of single tree-based stand simulators. However, accurate modeling of long-term research plot data is hampered by rare events, variable lengths of observation, and multiple sources of heterogeneity. This study makes use of a result from medicine that demonstrates the equivalence of logistic and Cox proportional hazards regression for modeling survival data in the case of large sample sizes, rare events, and variable interval periods of observation. Pooled logistic regression models are used to model tree mortality across multiple observation periods with random effects to account for heterogeneity due to plots and calendar year. The models are applied to data from 21,051 observation periods (each approximately 5 years) from 9,292 beech trees in a Bavarian long-term forest research plot network. Among the observation periods studied, 604 (2.9%) resulted in a mortality. Indices measuring competition from light, trees of the same species, conifer trees, and shading are significantly associated with mortality, whereas other variables, including dbh, fail to add additional predictive value. Analytic equations for predicting mortality in new trees are provided and yield an area underneath the receiver operating characteristic curve of 91.5%.

OBJECTIVES: To assess the applicability of the Prostate Cancer Prevention Trial High Grade (Gleason grade ≥ 7) Risk Calculator (PCPTHG) in ten international cohorts, representing a range of populations. METHODS: A total of 25,512 biopsies from 10 cohorts (6 European, 1 UK and 3 US) were included; 4 implemented 6-core biopsies, and the remaining had 10 or higher schemes; 8 were screening cohorts, and 2 were clinical. PCPTHG risks were calculated using prostate-specific antigen, digital rectal examination, age, African origin and history of prior biopsy and evaluated in terms of calibration plots, areas underneath the receiver operating characteristic curve (AUC) and net benefit curves. RESULTS: The median AUC of the PCPTHG for high-grade disease detection in the 10- and higher-core cohorts was 73.5% (range, 63.9-76.7%) compared with a median of 78.1% (range, 72.0-87.6%) among the four 6-core cohorts. Only the 10-core Cleveland Clinic cohort showed clear evidence of under-prediction by the PCPTHG, and this was restricted to risk ranges less than 15%. The PCPTHG demonstrated higher clinical net benefit in higher-core compared with 6-core biopsy cohorts, and among the former, there were no notable differences observed between clinical and screening cohorts, nor between European and US cohorts. CONCLUSIONS: The PCPTHG requires minimal patient information and can be applied across a range of populations. PCPTHG risk thresholds ranging from 5 to 20%, depending on patient risk averseness, are recommended for clinical prostate biopsy decision-making.

The Prostate Cancer Prevention Trial (PCPT) was a 7-year double-blind randomized trial of the chemopreventive effects of finasteride (5 mg/day) on prostate cancer; 18,882 men aged 55 years or older with a prostate-specific antigen (PSA) level of 3.0 ng/mL or lower, a normal digital rectal examination (DRE), and no previous diagnosis of prostate cancer were randomized.1 A unique feature of the trial was that in addition to the recommendation for prostate biopsy based on a PSA >4.0 ng/mL or an abnormal DRE, all cancer-free participants were recommended to undergo an end-of-study biopsy after 7 years of participation. Initial analyses revealed higher than anticipated prostate cancer and high-grade cancer (Gleason grade ≥7) rates than previously anticipated and no lower PSA cutoff below which prostate cancer could not be detected.2 Because end-of-study biopsies were performed regardless of PSA and DRE, the PCPT allowed comprehensive risk assessment of multiple factors affecting biopsy results, making it the biopsy cohort most immune to ascertainment bias. We found the statistically significant predictors of prostate cancer to include PSA, DRE, first-degree family history, and history of a previous negative biopsy (the latter reducing risk) and for high-grade cancer, the same risk factors minus family history but including age and African American race.3 In a subsequent assessment of men in the finasteride group, similar effects were observed, resulting in the online posting of risk calculators for prostate cancer and high-grade disease for men older than 55 years with no previous diagnosis of prostate cancer, including men receiving finasteride.4 More recently, recognizing that the study protocol of a 6-core biopsy might under-sample the prostate compared with the more common current practice of 10-12 cores and the growing evidence that prostate volume might affect cancer detection, we undertook an analysis of the effect of the number of biopsy cores, prostate volume, and the American Urological Association symptom score (AUASS – a validated measure of outlet symptoms related to benign prostatic hyperplasia [BPH]) on prostate cancer detection in the placebo arm of the PCPT.5 We found that increasing the number of biopsy cores significantly improved detection of prostate cancer and high-grade cancer at biopsy; similarly, measurement of prostate volume significantly enhanced risk assessment. AUASS was not independently associated with detection after adjustment for prostate volume, but was independently predictive if volume was not included. Commonly used to treat patients with BPH, the 5 alpha-reductase inhibitor finasteride reduces prostate volume and approximately halves PSA. In previous studies, we found that despite a significant reduction in risk of prostate cancer with finasteride, the performance of prostate biopsy is significantly improved in men receiving this medication, presumably because of the reduction in prostate volume.6 Given this effect and our previous finding of the need for an increased number of biopsy cores to maintain high sensitivity for detection of high-grade prostate cancer, we herein describe our assessment of this phenomenon in men receiving finasteride.

OBJECTIVES: To evaluate the discrimination, calibration, and net benefit performance of the Prostate Cancer Prevention Trial Risk Calculator (PCPTRC) across five European randomized study of screening for prostate cancer (ERSPC), 1 United Kingdom, 1 Austrian, and 3 US biopsy cohorts. METHODS: PCPTRC risks were calculated for 25,733 biopsies using prostate-specific antigen (PSA), digital rectal examination, family history, history of prior biopsy, and imputation for missing covariates. Predictions were evaluated using the areas underneath the receiver operating characteristic curves (AUC), discrimination slopes, chi-square tests of goodness of fit, and net benefit decision curves. RESULTS: AUCs of the PCPTRC ranged from a low of 56% in the ERSPC Goeteborg Rounds 2-6 cohort to a high of 72% in the ERSPC Goeteborg Round 1 cohort and were statistically significantly higher than that of PSA in 6 out of the 10 cohorts. The PCPTRC was well calibrated in the SABOR, Tyrol, and Durham cohorts. There was limited to no net benefit to using the PCPTRC for biopsy referral compared to biopsying all or no men in all five ERSPC cohorts and benefit within a limited range of risk thresholds in all other cohorts. CONCLUSIONS: External validation of the PCPTRC across ten cohorts revealed varying degree of success highly dependent on the cohort, most likely due to different criteria for and work-up before biopsy. Future validation studies of new calculators for prostate cancer should acknowledge the potential impact of the specific cohort studied when reporting successful versus failed validation.

The DiGeorge syndrome is a congenital disorder that affects the heart, parathyroid glands, and thymus. In complete DiGeorge syndrome, patients have severely reduced T-cell function.We treated five infants (age, one to four months) with complete DiGeorge syndrome by transplantation of cultured postnatal thymus tissue. Follow-up evaluations included immune phenotyping and proliferative studies of peripheral-blood mononuclear cells plus biopsy of the thymus allograft. Thymic production of new T cells was assessed in peripheral blood by tests for T-cell-receptor recombination excision circles, which are formed from excised DNA during the rearrangement of T-cell-receptor genes.After the transplantation of thymus tissue, T-cell proliferative responses to mitogens developed in four of the five patients. Two of the patients survived with restoration of immune function; three patients died from infection or abnormalities unrelated to transplantation. Biopsies of grafted thymus in the surviving patients showed normal morphologic features and active T-cell production. In three patients, donor T cells could be detected about four weeks after transplantation, although there was no evidence of graft-versus-host disease on biopsy or at autopsy. In one patient, the T-cell development within the graft was demonstrated to accompany the appearance of recently developed T cells in the periphery and coincided with the onset of normal T-cell function. In one patient, there was evidence of thymus function and CD45RA+CD62L+ T cells more than five years after transplantation.In some infants with profound immunodeficiency and complete DiGeorge syndrome, the transplantation of thymus tissue can restore normal immune function. Early thymus transplantation - before the development of infectious complications - may promote successful immune reconstitution.

Complete DiGeorge syndrome is characterized by the clinical triad of cardiac malformation, hypocalcemia, and T cell immunodeficiency due to congenital athymia. We describe an infant with complete DiGeorge syndrome who at presentation had no circulating T cells detectable by flow cytometry. The patient spontaneously developed circulating T cells but these cells did not proliferate in response to mitogens. The T cell receptor Vbeta repertoire was severely restricted. All T cells were host, not maternal, as assessed by fluorescent in situ hybridization evaluation of 22q11 hemizygosity. At autopsy, this patient had no grossly detectable thymus tissue and no microscopic evidence for thymopoiesis. These findings suggest that appearance of T cells in infants with complete DiGeorge syndrome may represent oligoclonal expansions of a small number of T cells that may have matured extrathymically and which do not respond in vitro to mitogen stimulation.

Gastrointestinal and respiratory symptoms and failure to thrive not associated with infections or medications were noted in patients with severe combined immunodeficiency.The aim of our study was to determine the frequency of gastroesophageal reflux in patients with severe combined immunodeficiency.We studied the case histories of 73 pediatric patients who had been treated at Duke University Medical Center for severe combined immunodeficiency between 1982 and 1995. Charts were reviewed for documentation of gastroesophageal reflux on the basis of clinical course and results of barium swallow, esophageal pH probe monitoring, or endoscopy. To compare the incidence of gastroesophageal reflux in patients with severe combined immunodeficiency to known high-risk populations, we additionally tabulated the underlying diagnoses in an age-matched group of patients who underwent Nissen fundoplication from 1990 to 1995.We found clinically significant gastroesophageal reflux in 15 of the 73 patients (20.5%), much higher than has been reported in the normal population (0.1% to 0.3%, p0.001). Of patients treated between 1990 and the present, 10 of 36 (27.7%) had significant gastroesophageal reflux compared with five of 37 patients (13.5%) in the previous years. Thus with greater recognition and improved methods for diagnosis, the observed incidence of gastroesophageal reflux has increased greatly. The clinical presentations were not different from those of patients with other well-documented underlying diagnoses. Seven of the 15 patients (46.6%) did not respond to medical treatment with antacids, H2-blockers, and prokinetic agents and underwent surgical treatment. Indications for surgery included persistent esophagitis, vomiting, pneumonia, and growth failure.The reason for the high incidence of gastroesophageal reflux in patients with severe T-cell disorders remains unclear. Considering the frequency of this association, early recognition and treatment is important to enable adequate nutrition and prevent damage to the esophagus and lungs.

We assessed the independent predictive value of prostate volume, number of biopsy cores and AUASS (American Urological Association symptom score) compared to risk factors included in the PCPTRC (Prostate Cancer Prevention Trial risk calculator for prostate cancer) and PCPTHG (Prostate Cancer Prevention Trial risk calculator for high grade cancer [Gleason grade 7 or greater]).Of 5,519 PCPT (Prostate Cancer Prevention Trial) participants used to construct the PCPTRC 4,958 with AUASS and prostate specific antigen 10 ng/ml or less were included on logistic regression analysis. Risk algorithms were evaluated in 571 EDRN (Early Detection Research Network) participants using the ROC AUC.A total of 1,094 participants (22.1%) had prostate cancer, of whom 232 (21.2%) had high grade disease. For prostate cancer prediction higher prostate specific antigen, abnormal digital rectal examination, family history of prostate cancer and number of cores were associated with increased risk, while volume was associated with decreased risk. Excluding prostate volume and number of cores, a history of negative biopsy and increased AUASS were also associated with lower risk. For high grade cancer higher prostate specific antigen, abnormal digital rectal examination, black race and number of cores were associated with increased risk and volume, while AUASS was associated with decreased risk. The AUC of the PCPTRC adjusted for volume and number of cores was 72.7% (using EDRN data), 68.2% when adjusted for AUASS alone and 67.6% PCPTRC. For high grade disease the AUCs were 74.8%, 74.0% and 73.5% (PCPTHG), respectively.Adjusted PCPT risk calculators for volume, number of cores and AUASS improve cancer detection.

The purpose of this study was to determine whether thymic transplantation in addition to highly active antiretroviral therapy (HAART) will restore T cell function in HIV infection. Eight treatment-naive HIV-infected patients with CD4+ T cell counts of 200-500/mm3 were randomized into thymic transplantation and control arms. All patients received HAART (zidovudine, lamivudine, and ritonavir) for 6 weeks prior to transplantation. Thymic transplantation was done without immunosuppression, using postnatal HLA-unmatched cultured allogeneic thymus tissue. Patients were immunized every 6 months with the neoantigen keyhole limpet hemocyanin (KLH) and the recall antigen tetanus toxoid (TT). T cell phenotype and function and T cell receptor rearrangement excision circles (TRECs) were assessed. Thymic allografts were biopsied at 2 months. Six HIV-infected patients completed the study. Four patients received cultured allogeneic postnatal thymic grafts, two others were controls. CD4+ T cell counts increased and T cell-proliferative responses to Candida antigen and TT normalized in all patients. Proliferative responses to KLH developed in three of four transplant recipients and one of two controls. Patients responding to KLH after secondary immunization had greater TREC increases compared with the patients who did not respond. All thymic allografts were rejected within 2 months. In summary, four of six patients developed T cell-proliferative responses to the neoantigen KLH over the first 2 years of HAART. The transplanted thymus tissue, however, was rejected. There was no clear difference in restoration of T cell function in the transplant recipients compared with the controls. Increases in TRECs after initiation of HAART may correlate with improved immune function.

A 2-month-old infant presented to our emergency department with fever, altered consciousness, and focal seizures of acute onset. He had vesicular skin lesions over the right preauricular region. CT brain showed a large hypodense lesion involving the left temporo-parietal region, left basal ganglia and left thalamus. MRI brain revealed bilateral multifocal corticomedullary lesions suggestive of encephalitis. CSF-PCR was positive for herpes simplex virus (HSV) type I. He was treated with standard dose intravenous acyclovir for 15 days along with a trial of pulse methylprednisolone, but was readmitted within a week with features of an early relapse. The infant survived but developed significant neurological sequelae. Although treatment of HSV is available, the neurological outcome is guarded even with adequate antiviral therapy. Adjunct corticosteroid therapy did not appear to attenuate the neurological sequelae.

Objectives This report investigated whether annual changes in body mass index (BMI) are associated with the opposite changes in prostate-specific antigen (PSA). Previous studies have confirmed lower PSA levels among men with higher BMI. Methods Normal linear mixed models were used to characterize annual PSA, BMI and the ratio of PSA to BMI profiles for 2641 men undergoing prostate cancer screening for up to 8 years as part of a San Antonio screening study. Results Among the 1898 participants (71.9%) who never received a prostate biopsy during the study and the 585 participants (22.1%) who had one or more biopsies, all negative for prostate cancer, BMI was higher for Hispanics than other racial groups, lower for older men at study entry, and increased every year during the study; and PSA and PSA/BMI ratios were higher for older men at study entry and increased each year on study (all P values