Characterization of patients with adrenal insufficiency and frequent adrenal crises.

OBJECTIVE: This study aimed to characterize the clinical and biochemical features of patients with primary (PAI) and secondary (SAI) adrenal insufficiency who developed adrenal crises (ACs) and estimate the incidence of ACs in these patients. DESIGN: Retrospective case-control analysis of the European Adrenal Insufficiency Registry (EU-AIR; NCT01661387). METHODS: Two thousand six hundred and ninety-four patients with AI (1054 PAI; 1640 SAI) enrolled in EU-AIR. Patients who developed ≥ 1 AC were matchd 1:3 with patients without ACs for age, sex and AI type. Data were collected at baseline and follow-up (mean ± s.d.: PAI 3.2 ± 1.7 years; SAI 2.9 ± 1.7 years). RESULTS: One hundred and forty-eight out of 2694 patients (5.5%; n = 84 PAI; n = 64 SAI) had an AC during the study: 6.53 (PAI) and 3.17 (SAI) ACs/100 patient-years. Of patients who experienced an AC, 16% (PAI) and 9.4% (SAI) experienced ≥ 1 AC/year. The incidence of adverse events, infectious intercurrent illnesses and infectious serious adverse events were higher in patients with ACs than without ACs. No differences were observed in BMI, HbA1c, blood pressure and frequencies of diabetes mellitus or hypertension between subgroups (PAI and SAI, with and without ACs). At baseline, PAI patients with AC had higher serum potassium (4.3 ± 0.5 vs 4.2 ± 0.4 mmol/L; P = 0.03) and lower sodium (138.5 ± 3.4 vs 139.7 ± 2.9 mmol/L; P = 0.004) than patients without AC. At last observation, SAI patients with AC had higher hydrocortisone doses than patients without AC (11.9 ± 5.1 vs 10.1 ± 2.9 mg/m2; P < 0.001). CONCLUSIONS: These results demonstrate that concomitant diseases and cardiovascular risk factors do not feature in the risk profile of AC; however, patients with AC had a higher incidence of infectious events.

Glucocorticoid management of adrenal insufficiency in the United Kingdom: assessment using real-world data.

Background and objectives Glucocorticoids are used to manage adrenal insufficiency (AI). We describe treatments used in the United Kingdom and real-world clinical outcomes for each treatment. Methods We used 2010-2016 primary care data from The Health Improvement Network (THIN). Descriptive analyses were conducted, and differences in variables between patients prescribed immediate-release hydrocortisone (IR HC), prednisolone or modified-release hydrocortisone (MR HC) were assessed using Fisher's exact test. Results Overall, 2648 patients were included: 1912 on IR HC (72%), 691 on prednisolone (26%) and 45 (2%) on MR HC. A total of 1174 (44.3%) had primary and 1150 (43.4%) had secondary AI. Patients on prednisolone were older (P < 0.001) and had a greater history of smoking (292/691, P < 0.001) and CVD (275/691, P < 0.001). Patients on MR HC had more PCOS (3/45, P = 0.001) and diabetes (27/45, P = 0.004). The number of GP visits/patient/year was 6.50 in IR HC, 9.54 in prednisolone and 9.11 in MR HC cohorts. The mean number of A&E visits and inpatient and outpatient hospital admissions ranged from 0.42 to 0.93 visits/patient/year. The mean number of adrenal crises/patient/year was between 0.02 and 0.03 for all cohorts. Conclusion IR HC is most commonly used for the management of AI in the United Kingdom, followed by prednisolone. Few patients receive MR HC. The prednisolone and MR HC cohorts displayed a greater prevalence of vascular risk factors compared with IR HC. The occurrence of AC and primary and secondary resource use were similar between treatment cohorts, and they indicate significant resource utilisation. Improved treatment and management of patients with AI is needed.

Facilitated subcutaneous immunoglobulin administration (fSCIg): a new treatment option for patients with secondary immune deficiencies.

The number of patients with secondary immune deficiencies (SID) is on the rise, mostly since the arrival on the market of novel targeted therapies that have increased the survival rates of patients with hematological malignancies. The recent changes in the SID landscape have brought with them new and diverse medical needs that treatments for SID management should strive to meet. In this special report, we study the opportunities provided by facilitated subcutaneous immunoglobulin administration (fSCIg) to treat patients for whom the conventional routes (intravenous and subcutaneous) are sub-optimal. Experts in the treatment of SID describe real-life cases from their daily practice, in which fSCIg has led to reducing the burden of treatment and increasing the treatment satisfaction.

Epidemiology and distribution of tick-borne encephalitis.

Tick-borne encephalitis (TBE) is the main tick-borne virus infection in Eurasia. It is prevalent across the entire continent from Japan to France and occurs in endemic foci. Expansion of prevalence in areas including northern Russia, Sweden, and Finland has been observed in recent years. Ticks are the most important vectors and may transmit the TBE virus to animals and humans. TBE can also be transmitted to humans in milk containing the virus. TBE has been implicated as a travel-acquired illness and there are isolated reports of its occurrence in countries outside the known areas of prevalence. Therefore, TBE should be included in the differential diagnosis for all central nervous system diseases inside or outside endemic areas.

Prevention of tick-borne encephalitis by FSME-IMMUN vaccines: review of a clinical development programme.

The need for highly effective tick-borne encephalitis (TBE) vaccines has increased globally due to a variety of factors including climate, social, economic and demographic changes, which are thought to have promoted the expansion of the endemic region of TBE viruses. The first TBE vaccine, FSME-IMMUN Inject, was introduced in the 1970s and has been continually improved since then to enhance both its safety and immunogenicity. The current formulation was established in 2001 and is marketed as FSME-IMMUN. This review summarizes findings of the clinical development programme since 2001 regarding determination of the optimal dose, conventional and rapid vaccination schedules, vaccination in adults, the elderly and special patient populations, safety, immunogenicity, and immunopersistence in adults and children, comparison of FSME-IMMUN with another commercially available TBE vaccine as well as post-marketing vaccination outcome. This successful research programme demonstrated the strong immunogenicity and continued safety of the FSME-IMMUN vaccine, which is further confirmed by the performance reported under field conditions.

The influence of carrier protein on the immunogenicity of simultaneously administered conjugate vaccines in infants.

Continuing additions of new vaccines to routine infant vaccination schedules have prompted concerns about potential interactions between vaccine components reducing desired protective effects. One hypothesis is that increasing loads of carrier protein may interfere with immune responses to polysaccharide components of co-administered glycoconjugate vaccines. Based upon a critical appraisal of existing evidence, however, neither carrier protein type nor dose adequately explains observed interference. Moreover, in five clinical trials, enhancement of anti-polyribosylribitol phosphate Haemophilus influenzae type b antibody has been demonstrated after co-administration of monovalent meningococcal C conjugate vaccine with tetanus toxoid carrier. Empirical observations do not fit well with carrier-induced epitope suppression as an underlying mechanism of interference. Thus, co-administration of conjugate vaccines can have positive as well as negative effects, and predictors of vaccine interactions are still lacking.

Long-term thermal stability of group C meningococcal polysaccharide-tetanus toxoid conjugate vaccine.

The stability of vaccines during storage and handling is a prerequisite for optimal potency at the time of immunization. Meningococcal group C conjugate vaccines have been successfully incorporated in mass immunization programs, however, thus far no long-term real-time stability studies of these vaccines have been reported. Stability of de-O-acetylated group C meningococcal polysaccharide coupled to tetanus toxoid (GCMP-TT) was evaluated in real time on the basis of immunogenicity and physiochemical properties. The vaccine is formulated as a 0.5 mL suspension containing 10 mug GCMP conjugated to 10-20 mug of TT adsorbed on 0.5 mg aluminum in saline. The single dose syringes were stored under refrigeration (5 +/- 3 degrees C) and at room temperature (25 +/- 2 degrees C) for up to 42 months and at elevated temperature (40 +/- 2 degrees C) for up to 6 months. At both refrigerated and room temperatures, no time-dependent change in animal potency was detectable through 42 months. After the nine months maximum recommended storage period at room temperature, 96% of the baseline serum bactericidal antibody (SBA) titer was maintained. Time-dependent decreases in SBA level and anti-GCMP-TT IgG level were observed at 40 +/- 2 degrees C. No changes in GCMP-TT adsorption and pH occurred in all the studies. Loss of integrity increased over six months at 40 +/- 2 degrees C (p = 0.004). Free sugar content did not change over 36 months under refrigeration. GCMP-TT retained immunogenicity and physicochemical properties under refrigeration and at room temperature (25 +/- 2 degrees C) for up to 42 months.

Group C meningococcal polysaccharide-tetanus toxoid conjugate vaccine: a meta-analysis of immunogenicity, safety and posology.

A conjugate vaccine comprised of de-O-acetylated group C meningococcal polysaccharide coupled to tetanus toxoid (GCMP-TT) has been licensed in 32 countries and incorporated in a comprehensive UK vaccination program. Extensive evidence, forming the subject of this meta-analysis, has rapidly accumulated on the immunogenicity, safety and posology of GCMP-TT as well as its epidemiological impact. GCMP-TT has been shown effective after a single dose in individuals >12 months of age, and initial posology specified three doses in infants. However, based on a recent clinical trial, posology was reduced to two doses in infants. Pooled protection rate, defined as proportion of subjects with serum bactericidal antibody (SBA) levels > or = 1:8, was 99.4% (CI, 98.2-99.9%) in seven clinical trials covering all age groups. Robust responses to GCMP-TT have been demonstrated with respect to SBA, IgG levels and antibody avidity. In post-marketing pharmacosurveillance encompassing >12 x 10(6) GCMP-TT doses distributed worldwide, the vaccine has been well tolerated with an incidence rate of 0.01% for all the most commonly encountered types of adverse events. After a catch-up UK vaccination campaign where 5-8 year old children were primarily given GCMP-TT, a 93% decline in meningococcal disease incidence was observed. In view of its immunogenicity, safety and potential suitability for use among infants in reduced dose schedules, GCMP-TT appears to mark a major advance over predecessor polysaccharide vaccines for the prevention of meningococcal C disease.

Interaction of the EWS NH2 terminus with BARD1 links the Ewing's sarcoma gene to a common tumor suppressor pathway.

In 85% of Ewing family tumors, the NH2 terminus of EWS is fused to the DNA-binding domain of FLI1, an ets transcription factor. The resulting chimeric protein is a strong transcriptional activator with transforming activity. We report that EWS and EWS-FLI1 interact via their common NH2 terminus with the COOH terminus of BARD1, a putative tumor suppressor, in vitro and in vivo. Because BARD1 associates via its NH2-terminal RING domain with the breast cancer susceptibility gene BRCA1 that provides a platform for interactions with proteins involved in DNA repair and checkpoint control, our results provide a link between the Ewing's sarcoma gene product and the genome surveillance complex.