Long-term safety and efficacy of lentiviral hematopoietic stem/progenitor cell gene therapy for Wiskott-Aldrich syndrome.

Patients with Wiskott-Aldrich syndrome (WAS) lacking a human leukocyte antigen-matched donor may benefit from gene therapy through the provision of gene-corrected, autologous hematopoietic stem/progenitor cells. Here, we present comprehensive, long-term follow-up results (median follow-up, 7.6 years) (phase I/II trial no. NCT02333760 ) for eight patients with WAS having undergone phase I/II lentiviral vector-based gene therapy trials (nos. NCT01347346 and NCT01347242 ), with a focus on thrombocytopenia and autoimmunity. Primary outcomes of the long-term study were to establish clinical and biological safety, efficacy and tolerability by evaluating the incidence and type of serious adverse events and clinical status and biological parameters including lentiviral genomic integration sites in different cell subpopulations from 3 years to 15 years after gene therapy. Secondary outcomes included monitoring the need for additional treatment and T cell repertoire diversity. An interim analysis shows that the study meets the primary outcome criteria tested given that the gene-corrected cells engrafted stably, and no serious treatment-associated adverse events occurred. Overall, severe infections and eczema resolved. Autoimmune disorders and bleeding episodes were significantly less frequent, despite only partial correction of the platelet compartment. The results suggest that lentiviral gene therapy provides sustained clinical benefits for patients with WAS.

Agglutination by anti-capsular polysaccharide antibody is associated with protection against experimental human pneumococcal carriage.

The ability of pneumococcal conjugate vaccine (PCV) to decrease transmission by blocking the acquisition of colonization has been attributed to herd immunity. We describe the role of mucosal immunoglobulin G (IgG) to capsular polysaccharide (CPS) in mediating protection from carriage, translating our findings from a murine model to humans. We used a flow cytometric assay to quantify antibody-mediated agglutination demonstrating that hyperimmune sera generated against an unencapsulated mutant was poorly agglutinating. Passive immunization with this antiserum was ineffective to block acquisition of colonization compared to agglutinating antisera raised against the encapsulated parent strain. In the human challenge model, samples were collected from PCV and control-vaccinated adults. In PCV-vaccinated subjects, IgG levels to CPS were increased in serum and nasal wash (NW). IgG to the inoculated strain CPS dropped in NW samples after inoculation suggesting its sequestration by colonizing pneumococci. In post-vaccination NW samples pneumococci were heavily agglutinated compared with pre-vaccination samples in subjects protected against carriage. Our results indicate that pneumococcal agglutination mediated by CPS-specific antibodies is a key mechanism of protection against acquisition of carriage. Capsule may be the only vaccine target that can elicit strong agglutinating antibody responses, leading to protection against carriage acquisition and generation of herd immunity.

Antibody blocks acquisition of bacterial colonization through agglutination.

Invasive infection often begins with asymptomatic colonization of mucosal surfaces. A murine model of bacterial colonization with Streptococcus pneumoniae was used to study the mechanism for mucosal protection by immunoglobulin. In previously colonized immune mice, bacteria were rapidly sequestered within large aggregates in the nasal lumen. To further examine the role of bacterial agglutination in protection by specific antibodies, mice were passively immunized with immunoglobulin G (IgG) purified from antipneumococcal sera or pneumococcal type-specific monoclonal human IgA (hIgA1 or hIgA2). Systemically delivered IgG accessed the mucosal surface and blocked acquisition of colonization and transmission between littermates. Optimal protection by IgG was independent of Fc fragment and complement and, therefore, did not involve an opsonophagocytic mechanism. Enzymatic digestion or reduction of IgG before administration showed that protection required divalent binding that maintained its agglutinating effect. Divalent hIgA1 is cleaved by the pneumococcal member of a family of bacterial proteases that generate monovalent Fabα fragments. Thus, passive immunization with hIgA1 blocked colonization by an IgA1-protease-deficient mutant (agglutinated) but not the protease-producing wild-type parent (not agglutinated), whereas protease-resistant hIgA2 agglutinated and blocked colonization by both. Our findings highlight the importance of agglutinating antibodies in mucosal defense and reveal how successful pathogens evade this effect.

Moderate alcohol consumption contributes to women's well-being through the menopausal transition.

OBJECTIVES: To examine the association of alcohol consumption with well-being in mid-aged Australian women, taking into account other lifestyle factors. METHODS: A prospective, observational study was carried out among 438 urban Australian women aged 45-55 years at baseline. They were assessed annually for 8 years using a questionnaire on health and lifestyle, including self-ratings of well-being and daily 'hassles'. Statistical analyses were performed using cluster and repeated measures analyses. RESULTS: About 80% of the women had consumed alcohol in the week preceding the interview. Alcohol intake was weakly associated with well-being overall (p = 0.094). Women who consumed alcohol at moderate levels had higher well-being scores than non-drinkers or heavy drinkers, however, provided they were also non-smokers and exercised weekly or more (p for interaction = 0.023) (21% of all study participants). Everyday symptoms and stresses had a negative impact on well-being (all p values < 0.001). CONCLUSIONS: Among women undergoing menopausal transition, well-being is positively associated with moderate alcohol consumption along with other lifestyle factors in a synergistic fashion, rather than any individual factor having a dominant or an independent effect.

Just scratching the surface: varied coagulation effects of polymer containers on TEG variables.

BACKGROUND AND OBJECTIVE: Different types of polymer surfaces affect the activation of platelets and coagulation pathway containers depending on their surface qualities. Importantly, this could produce variability of coagulation results obtained with thrombelastographical analysis. We assessed the effects of blood storage on thrombelastograph, TEG, variables using polypropylene and polycarbonate containers. METHODS: An in vitro experiment was performed, with eight volunteers in each limb. Fresh whole blood was stored in polypropylene or polycarbonate tubes prior to TEGanalysis, to assess the role of these plastics in the TEG results obtained. RESULTS: The polycarbonate tubes displayed slower onset of coagulation and greater variability of data for all four basic TEG variables (r-time, k-time, alpha-angle and maximum amplitude, P < 0.05). Polycarbonate results fell outside manufacturer reference ranges. CONCLUSIONS: It is likely that this is due to the altered surface properties and charge effects of the containers affecting proteins and platelets differently. Caution should be used in choosing which containers are used for storage of fresh blood prior to coagulation assessment, as variable results will follow where different types of plastic containers are employed.

Plasma volume changes associated with two hydroxyethyl starch colloids following acute hypovolaemia in volunteers.

This randomised double blind prospective study compared the effective intravascular volume expansion and maintenance, with two types of starches following induced haemorrhagic hypovolaemia. Twenty healthy male volunteers aged between 18 and 65 year were bled 10% of their total blood volume in fully monitored conditions and under the supervision of a trained specialist doctor and research nurse. The lost blood volume was replaced using one of the starch solutions. Effective intravascular volume expansion was monitored hourly using the (51)Cr radio-labelled red blood cell dilution technique, we compared the effects of two hydroxyethyl starch colloid preparations, one a high molecular weight and the other a low molecular weight preparation, on the plasma volume changes over time. The large molecular weight starch (Hextend) provided a less well-sustained volume expansion effect than the smaller one (Voluven)

The effects of a one unit blood donation on auto-haemodilution and coagulation.

The effect of haemodilution on coagulation has been extensively investigated. We investigated auto-haemodilution following a 10% blood loss (480 ml) and its effect on coagulation. Ten healthy, unstarved volunteers were enrolled. One unit of blood was taken from each volunteer. Concurrently blood was taken from the opposite arm prior to and immediately after the blood donation, and at 1, 2, 4 and 6 hours. It was tested for thrombelastography, haematocrit and endorphins. There was a significant decrease in r-time from the control sample to the sample taken immediately post blood donation. This value returned to baseline at 1 hour post donation and did not change again. There were no other significant changes in thromboelastographic parameters. Fractional plasma noradrenaline changes were significantly raised at 1 hour post donation (P = 0.048), returning to baseline by 2 hours post donation. The haematocrit showed a rapid (approximately 4%) fall during donation followed by a slow, but progressive decrease over six hours, falling by a mean of 8.3% from pre-donation values. A state of relative hypercoagulability is found immediately after a rapid 10% loss in circulating blood volume. This may be related to the rapid immediate haemodilution. It is unlikely that the sympathetic response to blood loss plays a role. However, after the initial drop, slow restoration of circulating blood volume by autodilution takes six to eight hours, and is not associated with enhanced coagulation. Of interest is that a 10% blood loss in a healthy person does not require volume replacement.

Citrated blood does not reliably reflect fresh whole blood coagulability in trials of in vitro hemodilution.

IMPLICATIONS: Citration and storage of whole blood markedly alter the Thrombelastograph effects of hemodilution on coagulation. The results of hemodilution studies in which citrated blood has been used to study coagulation may not be reliable.

Coagulation effects of in vitro serial haemodilution with a balanced electrolyte hetastarch solution compared with a saline-based hetastarch solution and lactated Ringer's solution.

The hydroxyethyl starches are a group of compounds that has been associated with impairment of coagulation when large volumes are administered. The thrombelastograph is commonly used to assess point-of-care whole blood coagulation. Little is known about the dose-response relationships of haemodilution, and it is reasonable to assume that a linear association exists. This may not be the case with altered electrolyte compositions of the fluids used for haemodilution. We have therefore conducted an in vitro study of haemodilution of human whole blood using lactated Ringer's solution and two high molecular weight hetastarches, one in a balanced salt solution, the other in a 0.9% saline solution. The thrombelastograph, commonly used for the assessment of the coagulation effects of synthetic colloids, was used as the coagulation assessment device. Serial haemodilution with hetastarch in a balanced salt solution demonstrated a biphasic response (of r-times and k-times, as well as alpha angles), with haemodilution in the 20-40% range causing enhanced coagulation, and higher degrees of dilution causing a decrease in overall coagulation performance. A similar picture was observed with lactated Ringer's solution, but only significantly so in alpha angles. Hetastarch in saline did not display this initial increased coagulability at mild to moderate dilutions. This biphasic response of lactated Ringer's solution and hetastarch in a balanced salt solution reflects the complex interaction of fluids and the coagulation system, and that these effects cannot be attributed to simple haemodilution. On the other hand, there was a linear decrease in maximum amplitude with haemodilution. Maximum amplitude was particularly affected by both starches, which is an expected finding in view of the known interaction between the hydroxyethyl starches and von Willebrand's factor.

Interactional skills of students from traditional and non-traditional medical schools before and after alcohol education.

OBJECTIVE: To compare alcohol-related intervention and general interactional skills performance of medical students from a traditional (Sydney) and a non-traditional (Newcastle) medical school, before and after participation in an alcohol education programme about brief intervention. DESIGN: In two controlled trials, students received either a didactic alcohol education programme or didactic input plus skills-based training. Prior to and after training, all students completed videotaped interviews with simulated patients. SETTING: The Faculties of Medicine at the University of Newcastle and the University of Sydney, Australia. SUBJECTS: Fifth-year medical students (n=154). RESULTS: Both alcohol-related intervention and general interactional skills scores of the Newcastle students were significantly higher than those of the Sydney students at pre-test but not after training. Although alcohol-related interactional skills scores improved after training at both universities, they did not reach a satisfactory level. The educational approach used had no effect on post-test scores at either university. CONCLUSIONS: Significant baseline differences in interactional skills scores favouring non-traditional over traditional students were no longer evident after both groups had been involved in an alcohol education programme. Further research is required to develop more effective alcohol intervention training methods.

Teaching medical students alcohol intervention skills: results of a controlled trial.

OBJECTIVE: To assess the relative effectiveness of videotape feedback and lecture methods for teaching alcohol brief intervention skills. DESIGN: In a controlled trial, two student blocks received a manual, lecture and demonstration about the principles and practice of brief alcohol intervention. In addition, experimental students made a 20-min videotape and participated in a 1.5-h small group feedback session. Prior to and after training, all students completed questionnaires and videotaped interviews with simulated patients. SETTING: Faculty of Medicine and Health Sciences of the University of Newcastle, Australia. SUBJECTS: Final-year medical students. RESULTS: Levels of alcohol-related knowledge, attitudes and interactional skills as well as general interactional skills were significantly improved after teaching. Alcohol-related interactional skills that were unsatisfactory at pretest reached satisfactory standards at post-test. An intergroup comparison of the improvement between pre- and post-teaching scores indicated that there was no significant difference in the effectiveness of the two methods. CONCLUSIONS: Training can improve medical student performance in alcohol intervention. Further research is required to examine the relative effectiveness of different teaching methods.

Harm reduction: roads less travelled to the holy grail.

In recent years, a number of countries have embraced harm reduction as their principal philosophical stance and policy platform on alcohol and other drug-related problems. Harm reduction, while argued by some as not being a new concept, has dramatically changed the overall orientation of many health and human service approaches. We argue that as a result many important considerations have been overlooked. This paper explores the merits of harm reduction and examines the limitations and potential pitfalls that may exist in its application in the real world. For instance, where do we position non-drug-use? Such questions are raised in light of the impression perpetuated by some leading practitioners in this field that harm reduction is a global panacea for alcohol and drug problems. Without exploring all possible paths, progress toward our holy grail of minimising the harms and maximising the potential benefits of drug use will be hampered. An integrated model is discussed, which we believe provides an opportunity for wider acceptance and ownership by alcohol and drug stakeholders, politicians and the community.

Have efforts to improve medical students' drug and alcohol knowledge, skills and attitudes worked?

A series of surveys were undertaken at one Australian medical school to examine alcohol and drug-related knowledge, skills and attitudes before and after the introduction of the National Campaign Against Drug Abuse and also before and after major alcohol and drug medical education initiatives. The surveys were conducted with 5th year medical students at the University of Sydney in 1986, 1990 and 1993 (total n = 379). Response rates of approximately 70% were achieved in each of the survey years. The three cohorts of students were similar demographically with the exception that significantly more males in 1990 and 1993 reported that English was not their first language. Very low prevalence levels for smoking were reported. By 1993, only 3% of 5th year medical students reported that they smoked. There was a significant decrease in the frequency of drinking occasions for males and females between 1986 and 1990. There was also a four-fold increase in both male and female abstainers. There was no significant difference in the amount of alcohol consumed on any drinking occasion, although there was a trend in that direction. There was a significant increase in alcohol and drug-related knowledge in the 1990 and 1993 groups, compared to the 1986 group. Skill levels were not found to change significantly across the three year groups. Students' ability to recognize NHMRC hazardous consumption levels increased substantially between 1986 and 1990. Only 4% of 1986 students considered <30 of alcohol a day to be hazardous for females compared to 47% in 1990. For men, only 8% of students considered 31-60 hazardous drinking in 1986 compared to 55% in 1990 and 61% in 1993. More recently trained students tended to express slightly more tolerant and accepting views about patients with alcohol and benzodiazepine dependence and had greater confidence in success of interventions. The present studies indicate important progress and achievements have been made. The paper discusses the further work needed to ensure that newly graduating medical practitioners are adequately equipped to deal effectively with alcohol and drug-related problems.

A controlled trial of educational strategies to teach medical students brief intervention skills for alcohol problems.

OBJECTIVES: Comparatively little is known about the most effective educational strategies to train medical students to successfully intervene in their patients' alcohol problems. The relative effectiveness of two educational programs to teach medical students brief intervention skills for managing alcohol problems was examined. METHODS: Teaching took place over 3 hr and was either the traditional didactic teaching program on the principles and practice of brief and early intervention or an interactive program involving a shortened lecture, clinical practice, and small group feedback on clinical performance. Students were assessed on a 10-min videotaped encounter with a simulated patient before and after teaching according to how they addressed alcohol-related issues and on their general interactional skills. RESULTS: Performance on alcohol-related issues and interactional skills were significantly improved after teaching, although still poor in terms of clinical performance. A between-groups comparison on pre/ postteaching difference scores indicated interactive training was no more effective than traditional didactic lectures in developing the knowledge and skills needed for a brief alcohol intervention. CONCLUSION: The need for more detailed teaching sessions on sensitive areas such as alcohol use in indicated.

Training experiences immediately after medical school.

Trainees in all teaching hospitals in New South Wales were surveyed using a self-completion, postal questionnaire to assess perceptions of the quality and extent of training received for interactional and technical skills. The response rate was 67.1%. Mean age was 25.4 years and 38.8% were female. Overall, training was found to be generally poor in terms of time and educational strategies used. Interactional skills were found to receive lower levels of training than technical skills both prior to and during the intern year with significantly fewer (P < 0.000) educational strategies reported for training received in interactional skills than for technical skills. Trainees' perceptions of the adequacy of training was significantly more negative for interactional than technical skills (P < 0.001). Assessment of competence was also significantly lower for interactional than technical skills (P < 0.001). On average, fewer than one in three trainees considered themselves to be competent in interactional skills compared to two-thirds who reported themselves as competent for technical skills. The findings of this study highlight the need for improved efforts with regard to both the quality and quantity of training provided during the intern year. Considerable scope exists for improved educational experiences for both interactional and technical skill areas, but particularly for interactional skills. Overall, greater use of a range of basic educational strategies such as the provision of 'observation' and 'critical feedback' is indicated. Efforts also need to be directed toward the training of clinical educators to optimize the potential of the preregistration period.

The shifting sands of alcohol prevention: rethinking population control approaches.

This paper identifies seven major conceptual and perceptual shifts which have occurred in the alcohol field in recent years and which influence approaches to the prevention of alcohol-related problems. The paper highlights the shift away from measures of mean consumption, as the principal indicator of use and problems, towards an incorporation of temporal patterns of use. No longer is the traditional parameter of mean per capita consumption seen to be the predominant measure by which alcohol and its associated problems are assessed. Also examined are the relative merits of prevention strategies that include the whole population and those aimed at people at high risk. The key shifts identified are: 1. acceptance that there is no single distribution theory that adequately accounts for alcohol consumption; 2. alcohol may represent an exception to the population health models based on mean distributions (for example, as found in the relationship between salt and hypertension); 3. there is no prevention paradox if episodes of intoxication are examined instead of mean consumption levels; 4. population control measures to reduce overall alcohol consumption may deprive some people of the protective cardiovascular effects of moderate alcohol consumption; 5. it is more useful to focus on at-risk drinking than attempt to locate groups of at-risk drinkers; 6. alcohol-consumption guidelines are meaningful only when defined on the basis of daily consumption, and then with further caveats; and 7. harm minimisation offers a constructive conceptual vehicle by which to shift the focus from consumption to consequences of use.