CD1d-unrestricted NKT cells are endowed with a hybrid function far superior than that of iNKT cells

Invariant natural killer T (iNKT) cells to date represent the best example of cells known to have a hybrid function, representing both innate and adaptive immunity. Shared phenotypic similarities with NK cells together with a rapid response to a cytokine stimulus and a productive TCR engagement are the features that underline the hybrid nature of iNKT cells. Using these criteria, we provide molecular and functional evidence demonstrating that CD1d-independent (CD1d^ind) NKT cells, a population of CD1d-unrestricted NKT cells, are endowed with a hybrid function far superior to that of iNKT cells: (i) an extensive shared program with NK cells, (ii) a closer Euclidian distance with NK cells, and (iii) the ability to respond to innate stimuli (Poly:IC) with cytotoxic potential in the same manner as NK cells identify a hybrid feature in CD1d^indNKT cells that truly fulfills the dual function of an NK and a T cell. Our finding that CD1d^indNKT cells are programmed to act like NK cells in response to innate signals while being capable of adaptive responses is unprecedented, and thus might reemphasize CD1d-unrestricted NKT cells as a subset of lymphocytes that could affect biological processes of antimicrobial and tumor immunity in a unique way.Natural killer T (NKT) cells are increasingly regarded as cells endowed with a hybrid function between an NK cell and a T cell (1, 2). The current classification of NKT cells places them into three categories: type I, type II, and NKT-like cells (1). Type I comprises invariant NKT (iNKT) cells that recognize the glycolipid α-galactosylceramide (α-GalCer) loaded into the MHC class I molecule, CD1d, and contain an invariant TCR repertoire of Vα14-Jα18 (3–5). Type II NKT cells are also CD1d dependent but do not respond to α-GalCer in the same way as iNKT cells do (6, 7). NKT-like cells encompass all other NKT cells and are CD1d independent (CD1d^ind) (8); they are by far the most heterogeneous and the least characterized.Recent studies have increasingly shown a shared expression of NK cell-related receptors on other effector cells. CD8⁺ T cells are known to up-regulate NK markers, such as NK1.1, and can even respond quickly like NK cells (9). Other work has described NKT cells that express NKp46 (10), a marker selectively associated with conventional NK cells and NK22 cells in the gut (11). Moreover, γδ T cells have been shown to express NK markers and display an innate-like response (12). Collectively, these reports converge to raise the following key questions. What qualifies as an NKT cell? Do the cells need to express only NK1.1 and CD3 to be eligible for NKT nomenclature? With the continuous development of both NK and T-cell fields, the simplistic definition that NKT cells are subsets of T cells that express the NK1.1 marker is becoming increasingly misleading and even inaccurate. For instance, NK1.1 complex is expressed in the BALB/c strain but there are allelic divergences with the polymorphism leading to the PK136 antibody not reacting to the BALB/c NK.1.1 (NKrp1) complex (13). This definition is also limited in the C57BL/6 strain because of the discovery of NK1.1⁻CD1d⁺ NKT cells (14). Although phenotypic similarities can be misleading, the criteria that best describes an NKT cell is the ability to perform with a hybrid function between an NK cell and a T cell (2).Nonetheless, the concept of hybrid function is also an elusive notion allowing for a gradient of functions. A number of works refer to an NKT hybrid function as the ability of a T cell with phenotypic similarities to NK cells to perform with innate-like response. The best example of cells endowed with a hybrid NKT cell function are thought to be iNKT cells (2). In this study, we provide molecular and functional evidence demonstrating that CD1d^indNKT cells—a population of MHC-unrestricted T cells—are endowed with a hybrid function that associates them to the NK cell lineage in a manner far superior to the known link between NK and iNKT cells. An extensive shared program with NK cells, a similarity in the gene expression profile with NK cells, and their ability to respond (like NK cells) not only to cytokine signals (IL-12 plus IL-18) but also to innate stimuli [in vivo treatment with Poly:IC (Fisher)] with massive production of key effector players of the cytotoxic pathway collectively identify a hybrid feature in CD1d^indNKT cells that uniquely fulfills the function of an NK cell and a T cell.     

Development of multi-criteria decision analysis (MCDA) framework for off-patent pharmaceuticals – an application on improving tender decision making in Indonesia

Background

Off-patent pharmaceuticals (OPPs) hold vital importance in meeting public health objectives, especially in developing countries where resources are limited. OPPs are comprised of off-patent originals, branded generics and unbranded generics; nonetheless, these products are not identical and often there are differences in their equivalence, manufacturing quality standards and reliability of supply. This necessitates reconsideration of the lowest price policy objective in pharmaceutical decision making. The aim of this study was to develop a Multi-Criteria Decision Analysis (MCDA) framework through a pilot workshop to inform the national procurement of OPPs in Indonesia.

Methods

An initial list of potentially relevant criteria was identified based on previous work and a literature review. In a 2-day pilot policy workshop, twenty local experts representing different stakeholder groups and decision-making bodies selected the final criteria, approved the scoring function for each criterion, and assigned weights to each criterion.

Results

An MCDA framework was proposed for OPP drug decision making in developing countries, which included price and 8 non-price criteria. Based on the pilot policy workshop 6?+?1 criteria were considered relevant for Indonesia: pharmaceutical price (40% weight), manufacturing quality (18.8%), equivalence with the reference product (12.2%), product stability and drug formulation (12.2%), reliability of drug supply (8.4%), real world clinical or economic outcomes, such as adherence or non-drug costs (4.2%) and pharmacovigilance (3.6%).

Conclusions

According to the pilot policy workshop, other criteria apart from price need to be strengthened in the tendering process. The introduction of additional criteria for OPP procurement in an MCDA framework creates incentives for manufacturers to invest into improved manufacturing standards, equivalence proof, product quality, reliability of supply or even additional real-world data collection, which ultimately may result in more health gain for the society.

     

Haploidentical transplantation in high-risk pediatric leukemia: A retrospective comparative analysis on behalf of the Spanish working Group for bone marrow transplantation in children (GETMON) and the Spanish Grupo for hematopoietic transplantation (GETH)

A total of 192 pediatric patients, median age 8.6 years, with high-risk hematological malignancies, underwent haploidentical stem cell transplantation (haplo-HSCT) using post-transplantation cyclophosphamide (PT-Cy), or ex vivo T cell-depleted (TCD) graft platforms, from January 1999 to December 2016 in 10 centers in Spain. Some 41 patients received an unmanipulated graft followed by PT-Cy for graft-vs-host disease (GvHD) prophylaxis. A total of 151 patients were transplanted with CD3-depleted peripheral blood stem cells (PBSCs) by either CD34⁺ selection, CD3⁺CD19⁺ depletion, TCRαβ⁺CD19⁺ depletion or CD45RA⁺ depletion, added to CD34⁺ selection for GvHD prophylaxis. The PBSCs were the only source in patients following ex vivo TCD haplo-HSCT; bone marrow was the source in 9 of 41 patients following PT-CY haplo-HSCT. Engraftment was achieved in 91.3% of cases. A donor younger than 30 years, and the development of chronic GvHD were positive factors influencing survival, whereas positive minimal residual disease (MRD) before transplant and lymphoid disease were negative factors. The probability of relapse increased with lymphoid malignancies, a donor killer-cell immunoglobulin-like receptor (KIR) haplotype A and positive MRD pretransplant. No difference was found in overall survival, disease-free survival or relapse incidence between the two platforms. Relapse is still of concern in both platforms, and it should be the focus of future efforts. In conclusion, both platforms for haplo-HSCT were effective and could be utilized depending on the comfort level of the center.     

High dose daily interferon-alpha induction and secondary adjunction of ribavirin in treatment-naive patients with chronic hepatitis C. A multicentric, randomised, controlled trial

OBJECTIVES: To evaluate in naive patients with chronic hepatitis C 1- the efficacy and safety of one month interferon alpha (IFN-alpha) induction regimen; 2- the potential virological benefit of a secondary adjunction of ribavirin among HCV RNA negative patients after 20 weeks of IFN therapy, with or without an initial 4-week IFN induction. MATERIAL AND METHODS: 151 naive HCV-RNA positive patients presenting with biopsy- proven chronic hepatitis C and elevated ALT were randomised in a 2: 1 ratio in two arms: IFN-alpha 3 MU thrice a week (tiw) for 24 weeks (non-induced patients); IFN-alpha 6 MU daily for two weeks, then 3 MU daily for two weeks then 3 MU tiw for 20 weeks (induced patients). At week 24, HCV-RNA negative patients were randomised to receive in addition or not ribavirin 1-1.2 g daily for 24 additional weeks. Induction efficacy was assessed on the early viral response (EVR) defined as undetectable HCV RNA at week 4 then week 20. Ribavirin efficacy was assessed on the proportion of maintained complete response until the end of follow-up, 24 weeks after discontinuation of treatment. Data were analysed on an intent-to-treat basis. RESULTS: Efficacy of IFN-alpha induction: 104 patients were randomised to the non-induction group, 47 to the induction group. Gender, age, genotype distribution and HCV viral load at baseline did not differ significantly between the two groups. There was one treatment discontinuation because of adverse events in induced patients versus four in non-induced patients (P > 0.05). The 4 week EVR was significantly greater in induced patients in patients with HCV genotype 1, 4 or 5 (47% vs 12%, P=0.0002) only. There was no impact of induction in patients with HCV genotype 2 or 3. Efficacy of ribavirin: at week 24, 28 and 26 HCV-RNA negative patients were randomised to addition of ribavirin or not, respectively. Patients randomised to secondary additive ribavirin were more often HCV-RNA negative at the end of follow-up than patients treated with IFN-alpha alone: 18/28 (64%) vs 10/26 (39%); P=0.06. Among patients randomised to bitherapy, the relapse rate was significantly lower in patients with genotype 2 or 3 (0/12 vs 6/13, P=0.01) and not in those with genotype 1, 4 or 5 (5/11 vs 3/6, P=0.99). CONCLUSION: A 4 week IFN-alpha induction significantly increases the EVR rate in patients with HCV genotype 1, 4 or 5. Late secondary adjunction of ribavirin to IFN-alpha for 6 months in HCV-RNA negative patients after 6 months of IFN-alpha significantly decreases the relapse rate in patients with HCV genotype 2 or 3, but not in patients with genotypes 1, 4 or 5.     

Primary amenorrhea secondary to imperforate hymen

Hymen imperforation is uncommon. Symptoms include primary amenorrhea, cyclical lower abdominal pain, and rarely a pelvic mass syndrome. Delayed discovery may lead to endometriosis and infertility. Pelvic ultrasound and nuclear magnetic resonance detect associated genito‐urinary malformations. Hymenectomy is the standard surgical treatment.     

Calcium needs in hemodialyzed-parathyroidectomized patients

Parathyroidectomy changes the homeostasis of calcium balance in patients under dialysis for kidney failure. The aim of this work is to value calcium needs in 20 hemodialysed patients who underwent parathyroidectomy, in the department of nephrology of UHC Ibn Rochd of Casablanca from January 1994 to June 1999. These patients, 12 women (60%) and 8 men (40%), aged between 14 and 70 years (mean=46.10+/-13.62 years). Hungry bone syndrome was noted in 8 patients and postoperative hypocalcemia in 15 (75%). Mean minimal serum calcium was 196+/-0.21 mmol/l, with clinical signs in 6 patients. Mean calcium supplement the first postoperative week was 18.1+/-0,54 g/day in the 8 patients with hungry bone syndrome and 14.28+/-0,86 g/day in the 12 remaining patients. Between 6 and 18 months postoperatively, required calcium supplementation was 4.5 to 12 g/day in patients with hungry bone syndrome compared with 3 to 6g/day at the remaining patients. Mean serum calcium remained stable between 2.16 mmol/l to the 3(rd) month and 2.48 mmol/l to the 36(th) month. Postoperative hypocalcemia remains a major concern after parathyroidectomy requiring massive substitution with calcium and active vitamin D metabolite under close supervision to spare these patients from hypercalcemia resulting from parathyroid dysfunction.     

Hemodialysis-related pruritus. A study of 134 Moroccans

The prevalence of pruritus varies from 60% to 90% in patients receiving hemodialysis. The aim to this study was to evaluate the frequency of pruritus and its characteristics among moroccan patients receiving hemodialysis. Pruritus related to primary skin disease or other identified cause than chronic renal failure was excluded. Biological parameters were compared between patients with pruritus and those without. Pruritus occurred in 74.4% of hemodialysis patients and concerned 66 men and 68 women, mean age 44.8 + 14 years. Duration of hemodialysis varied between 5 months to 10 years. Main characteristics of pruritus were a general pattern in 70%, moderate intensity in 50%, appearance after dialysis in 81.2% and severe psychologic repercussion in 20.8%. Antihistamines first-line treatment was rarely effective. UVB radiation used in 7 cases leaded to a marked improvement. This study underlined the high frequency of pruritus in moroccan patients with chronic renal failure on maintenance hemodialysis. Hemodialysis can initiate this symptom as well as improve it. Biological parameters were not different between patients with or without pruritus. It also pointed out on therapeutic challenges. However, UVB radiation seems to be an effective therapy in intractable itching as well as increased frequency of weekly courses of hemodialysis. Long term skin hydratation should be also highly recommended.     

Chronic diazepam administration differentially affects melatonin synthesis in rat pineal and Harderian glands

RATIONALE: Pineal and Harderian gland melatonin production as well as plasma melatonin levels were investigated in male Wistar rats (12 weeks old) after administration of diazepam, a benzodiazepine widely used as anxiolytic. OBJECTIVE: The present study investigates the effects of a chronic administration of diazepam on pineal and Harderian gland melatonin contents. METHODS: Diazepam was administered subcutaneously, for 21 days, at a dosage of 3 mg/kg body weight per day, 1 h before the onset of darkness. RESULTS: Diazepam clearly affected pineal melatonin biosynthesis and plasma melatonin levels. Diazepam reduced the pineal melatonin content (by a factor of 2) and the activity of N-acetyltransferase (NAT) (by a factor of 3.5), as well as plasma melatonin levels (by a factor of 1.5), but had no effects on pineal hydroxyindole-O-methyltransferase activity. By contrast to the pineal gland, diazepam failed to affect the Harderian gland melatonin content. CONCLUSIONS: Our results suggest that the inhibition of melatonin production induced by diazepam in vivo may be due to a direct action of this benzodiazepine on the pineal gland, through its action on NAT, the key enzyme of melatonin synthesis, and that the control of melatonin production in the Harderian glands may be different from that observed in the pineal gland.