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Introduction In primary ciliary dyskinesia (PCD) impaired mucociliary clearance leads to recurrent airway infections and progressive lung destruction, and concern over chronic airway infection and patient-to-patient transmission is considerable. So far, there has been no defined consensus on how to control infection across centres caring for patients with PCD. Within the BEAT-PCD network, COST Action and ERS CRC together with the ERN-Lung PCD core a first initiative has now been taken towards creating such a consensus statement. Methods A multidisciplinary international PCD expert panel was set up to create a consensus statement for infection prevention and control (IP&C) for PCD, covering diagnostic microbiology, infection prevention for specific pathogens considered indicated for treatment and segregation aspects. Using a modified Delphi process, consensus to a statement demanded at least 80% agreement within the PCD expert panel group. Patient organisation representatives were involved throughout the process. Results We present a consensus statement on 20 IP&C statements for PCD including suggested actions for microbiological identification, indications for treatment of Pseudomonas aeruginosa, Burkholderia cepacia and nontuberculous mycobacteria and suggested segregation aspects aimed to minimise patient-to-patient transmission of infections whether in-hospital, in PCD clinics or wards, or out of hospital at meetings between people with PCD. The statement also includes segregation aspects adapted to the current coronavirus disease 2019 (COVID-19) pandemic. Conclusion The first ever international consensus statement on IP&C intended specifically for PCD is presented and is targeted at clinicians managing paediatric and adult patients with PCD, microbiologists, patient organisations and not least the patients and their families., For the first time ever, an international consensus statement for infection prevention and control in PCD is presented. A total of 20 statements were developed in a collaboration of BEAT-PCD, COST Action, ERS CRC and ERN-LUNG PCD Core Network. https://bit.ly/3yuahKt

BackgroundPrimary ciliary dyskinesia (PCD) is a heterogeneous inherited disorder caused by mutations in approximately 50 cilia-related genes. PCD genotype–phenotype relationships have mostly arisen from small case series because existing statistical approaches to investigating relationships have been unsuitable for rare diseases.MethodsWe applied a topological data analysis (TDA) approach to investigate genotype–phenotype relationships in PCD. Data from separate training and validation cohorts included 396 genetically defined individuals carrying pathogenic variants in PCD genes. To develop the TDA models, 12 clinical and diagnostic variables were included. TDA-driven hypotheses were subsequently tested using traditional statistics.ResultsDisease severity at diagnosis, measured by forced expiratory volume in 1 s (FEV1) z-score, was significantly worse in individuals with CCDC39 mutations (compared to other gene mutations) and better in those with DNAH11 mutations; the latter also reported less neonatal respiratory distress. Patients without neonatal respiratory distress had better preserved FEV1 at diagnosis. Individuals with DNAH5 mutations were phenotypically diverse. Cilia ultrastructure and beat pattern defects correlated closely to specific causative gene groups, confirming these tests can be used to support a genetic diagnosis.ConclusionsThis large scale, multi-national study presents PCD as a syndrome with overlapping symptoms and variations in phenotype according to genotype. TDA modelling confirmed genotype–phenotype relationships reported by smaller studies (e.g. FEV1 worse with CCDC39 mutation) and identified new relationships, including FEV1 preservation with DNAH11 mutations and diversity of severity with DNAH5 mutations.

Background It is estimated that 1–13% of cases of bronchiectasis in adults globally are attributable to primary ciliary dyskinesia (PCD) but many adult patients with bronchiectasis have not been investigated for PCD. PCD is a disorder caused by mutations in genes required for motile cilium structure or function, resulting in impaired mucociliary clearance. Symptoms appear in infancy but diagnosis is often late or missed, often due to the lack of a “gold standard” diagnostic tool and non-specific symptoms. Mutations in > 50 genes account for around 70% of cases, with additional genes, and non-coding, synonymous, missense changes or structural variants (SVs) in known genes presumed to account for the missing heritability. Methods UK patients with no identified genetic confirmation for the cause of their PCD or bronchiectasis were eligible for whole genome sequencing (WGS) in the Genomics England Ltd 100,000 Genomes Project. 21 PCD probands and 52 non-cystic fibrosis (CF) bronchiectasis probands were recruited in Wessex Genome Medicine Centre (GMC). We carried out analysis of single nucleotide variants (SNVs) and SVs in all families recruited in Wessex GMC. Results 16/21 probands in the PCD cohort received confirmed (n = 9), probable (n = 4) or possible (n = 3) diagnosis from WGS, although 13/16 of these could have been picked up by current standard of care gene panel testing. In the other cases, SVs were identified which were missed by panel testing. We identified variants in novel PCD candidate genes (IFT140 and PLK4) in 2 probands in the PCD cohort. 3/52 probands in the non-CF bronchiectasis cohort received a confirmed (n = 2) or possible (n = 1) diagnosis of PCD. We identified variants in novel PCD candidate genes (CFAP53 and CEP164) in 2 further probands in the non-CF bronchiectasis cohort. Conclusions Genetic testing is an important component of diagnosing PCD, especially in cases of atypical disease history. WGS is effective in cases where prior gene panel testing has found no variants or only heterozygous variants. In these cases it may detect SVs and is a powerful tool for novel gene discovery.

Primary ciliary dyskinesia is an incurable, rare, inherited, chronic condition. Treatment includes regular clearing of airway mucus, aggressive treatment of infections and management of hearing loss. Caregiver burden has not been explored, hence we interviewed 18 English speaking mothers and 6 English speaking fathers of children under 6 years who were diagnosed with PCD around the world. The parents described how the child’s diagnosis, treatment regimen, and health status impacted their life. They discussed the impact of the COVID-19 pandemic and they talked about the different ways they cope with challenges that arise. The need for integrated social care is discussed.

Air&ndash, liquid interface (ALI) culture of nasal epithelial cells is a valuable tool in the diagnosis and research of primary ciliary dyskinesia (PCD). Ex vivo samples often display secondary dyskinesia from cell damage during sampling, infection or inflammation confounding PCD diagnostic results. ALI culture enables regeneration of healthy cilia facilitating differentiation of primary from secondary ciliary dyskinesia. We describe a revised ALI culture method adopted from April 2018 across three collaborating PCD diagnostic sites, including current University Hospital Southampton COVID-19 risk mitigation measures, and present results. Two hundred and forty nasal epithelial cell samples were seeded for ALI culture and 199 (82.9%) were ciliated. Fifty-four of 83 (63.9%) ex vivo samples which were originally equivocal or insufficient provided diagnostic information following in vitro culture. Surplus basal epithelial cells from 181 nasal brushing samples were frozen in liquid nitrogen, 39 samples were ALI-cultured after cryostorage and all ciliated. The ciliary beat patterns of ex vivo samples (by high-speed video microscopy) were recapitulated, scanning electron microscopy demonstrated excellent ciliation, and cilia could be immuno-fluorescently labelled (anti-alpha-tubulin and anti-RSPH4a) in representative cases that were ALI-cultured after cryostorage. In summary, our ALI culture protocol provides high ciliation rates across three centres, minimising patient recall for repeat brushing biopsies and improving diagnostic certainty. Cryostorage of surplus diagnostic samples was successful, facilitating PCD research.

Background: nNO, alongside clinical history, is established in PCD screening. We describe our experience measuring nNO across the age range comparing methods, analysers, PCD diagnostic status & outliers. Methods: 856 patients (0.4-82.8yrs) referred to Southampton had nNO measured. Technically acceptable measurements were obtained using chemiluminescent analysers Niox Flex (2006-14)/ Ecomedics CLD88sp (2014-20) or electrochemical analysers Niox Mino (2013-17)/ Niox Vero (2017-2020). Cut-off 77nL/min was used for all measurements although this is defined only for velum closure, chemiluminescent measurements. Diagnostic status followed ERS Diagnostic Guideline (2016). Results: 9/113 (8%) positive patients had normal nNO. 17% of patients who were diagnosed ‘PCD unlikely’ had nNO We obtained reproducible measurements in 110 children CLD88sp & Vero provided acceptable velum closure measurements but were more difficult for patients to achieve on Vero. Pursed lip TB was acceptable using both instruments allowing for measurement in younger children. Nasal TB can be measured using CLD88sp. Conclusions: nNO is a good screening tool for PCD but should not be used diagnostically alone. nNO can be measured across age range on CLD88 & Vero with age appropriate method. nNO Historical data review against current standards may highlight missed cases.

ObjectiveIn England, the National Health Service commissioned a National Management Service for children with primary ciliary dyskinesia (PCD). The aims of this study were to describe the health of children seen in this Service and compare lung function to children with cystic fibrosis (CF).DesignMulti-centre service evaluation of the English National Management PCD Service.SettingFour nationally commissioned PCD centres in England.Patients333 children with PCD reviewed in the Service in 2015; lung function data were also compared with 2970 children with CF.ResultsMedian age at diagnosis for PCD was 2.6 years, significantly lower in children with situs inversus (1.0 vs 6.0 years, p1) was 76.8% in PCD (n=240) and 85.0% in CF, and FEV1 was lower in children with PCD up to the age of 15 years. Approximately half of children had some hearing impairment, with 26% requiring hearing aids. Children with a lower body mass index (BMI) had lower FEV1 (pHaemophilus influenzae.ConclusionsWe provide evidence that children with PCD in England have worse lung function than those with CF. Nutritional status should be considered in PCD management, as those with a lower BMI have significantly lower FEV1. Hearing impairment is common but seems to improve with age. Well-designed and powered randomised controlled trials on management of PCD are needed to inform best clinical practice.

Primary ciliary dyskinesia (PCD) is an autosomal recessive condition characterized by dysmotile cilia. Typically associated with defects in the cilia structure, it results in impaired mucociliary clearance of pathogens from the lungs and sinuses. Consequently, patients suffer from recurrent sinopulmonary and middle ear infections. We report on the management of a 5-year-old boy who presented with increased work of breathing, fever and crepitations, with an existing diagnosis of PCD with situs inversus totalis. Chest X-ray imaging revealed right lower lobe collapse. He was managed with intensive physiotherapy, nebulized mucolytic agents and antibiotics. However, due to a poor response, he underwent flexible bronchoscopy, which allowed removal of a mucus plug and subsequent re-expansion of his collapsed lobe. Although there is limited evidence for the management of PCD, here we discuss the accepted strategies for its management, based on expert opinion and guidelines for other suppurative lung diseases.

We welcome the correspondence from Lavie and Amirav (1), highlighting the difficulties diagnosing primary ciliary dyskinesia (PCD) and the role of high-speed video analysis (HSVA). As members of the European Respiratory Society (ERS) PCD Diagnostic Task Force (2) and/or large PCD Centres, we agree that HSVA has an important role that is not recognized by the American Thoracic Society (ATS) PCD Diagnostic Guideline (3). This risks a large proportion of false-negative “missed” diagnoses and a sizable number of false-positive cases; we make additional important observations.

Primary ciliary dyskinesia (PCD) is a rare heterogeneous disorder, usually inherited as an autosomal recessive condition but X-linked inheritance is also described. Abnormal ciliary function in childhood leads to neonatal respiratory distress in term infants, persistent wet cough, bronchiectasis, chronic rhinosinusitis, and hearing impairment; approximately 50% of patients have situs inversus. There is a paucity of evidence for treating PCD, hence consensus guidelines are predominantly influenced by knowledge from cystic fibrosis (CF). Extrapolation of evidence from other diseases is inappropriate since differences in pathophysiology, morbidity and prognosis risk treatment failure and lack of adherence. Areas covered: Review authors searched PubMed and Cochrane databases for publications relating to management of children with PCD. Because of the paucity of data, we emphasise the need for well-designed clinical trials with PCD patients rather than reliance on evidence from other diseases. Expert commentary: The evidence for treatment of PCD is poor, and management is often extrapolated from studies of patients with CF or chronic rhinosinusitis. However, much work is underway to improve the situation and international consortia and networks are conducting well-designed projects to inform the management of children with PCD.

Background: To review children and their family’s experiences of PCD care provided by the 4 specialist teams commissioned to deliver PCD care in England, and establish if the current service meets their needs. Methods: Satisfaction surveys were developed: one for teenagers (12–18yrs), another for parents/carers. These were available in electronic (online) and paper form. Teenagers/families were approached at clinic, by telephone and via email and the survey was also publicised through the UK PCD Family Support Group. Responses were collected between March and October 2018. Results: 407 patients (176 teenagers) from 324 families were under the care of this Service at the time of the surveys. Of these 324 families, 93 parents/carers and 38 teenagers participated. In general, those who responded felt access to the specialist PCD team met their ideals however 51% would like access to a psychologist with only 22% having been offered a review by one and 20% would like input from a social worker. Attitudes towards research were positive, with 87% agreeing it was important to have access to participate in research studies. Of note, 40% of parents/carers reported having problems accessing antibiotics in the community. Encouragingly, 93% of parents/carers and 94% of teenagers believed the specialist PCD service had improved their care. Conclusions: >93% of parents/carers and teenagers felt that the specialist PCD service had improved their PCD care and the current service for the most part met their ideals. Access to psychology and social work services and difficulties obtaining antibiotics in the community were highlighted as issues to be addressed.

Introduction: Primary ciliary dyskinesia (PCD) is a rare condition where impaired mucociliary clearance leads to recurrent sinopulmonary infection & bronchiectasis. A National Children9s PCD management service was commissioned in England in 2012 across 4 Centres. The aim of this study was to describe the characteristics of all children in England within this new service. Methods: Detailed diagnostic, phenotypic & management data were collected at annual review assessments for all children seen in 2014. Results: 334 children underwent annual review. Median age at review was 9.8yrs. Median age at diagnosis was 2.6yrs, however was significantly lower in patients with dextrocardia (1.0yr vs 6.2yrs, p Conclusion We provide evidence that, far from being a mild respiratory condition, children with PCD have worse lung function than those with CF. This highlights the need for intensive management of PCD by a multi-professional specialist team.

Primary ciliary dyskinesia (PCD) generally causes symptoms from the first weeks of life, but diagnosis is usually delayed for years or can be missed altogether. Referral for diagnostic testing is often late because key symptoms, such as wet cough, chronic rhinitis and recurrent upper and lower respiratory tract infection, are non-specific. An international survey of patients reported that 37% had >40 visits to medical professionals due to PCD-related symptoms before being referred for diagnostic testing [1]. Approximately 50% of children with PCD have situs inversus, a rare condition in the general population, and it is therefore not surprising that these patients are investigated earlier. A European survey found that age of diagnosis was at 3.5 years in those with situs inversus and 5.8 years in children with normal situs [2]. Assuming a prevalence of 1 in 10 000 [3], we expect ∼1180 diagnosed children in England (childhood population ∼11.8 million); however, there are currently only ∼340 children in the National Paediatric PCD Service. This highlights a huge proportion of undiagnosed patients even in a country with a national PCD service [4]. This is in stark contrast to cystic fibrosis (CF) where neonatal screening programmes ensure that diagnosis occurs in early infancy in many countries, with positive impact on clinical outcome [5]. Young children with PCD have similarly impaired forced expiratory volume in 1 s to children with CF [6], and require multidisciplinary treatment. Early diagnosis facilitates a management plan, including regular airway clearance physiotherapy, surveillance for airway pathogens with treatment of respiratory exacerbations, genetic counselling for families, audiology monitoring and management of conductive hearing loss [7, 8]. We expect that early diagnosis would delay respiratory decline and ensure specialist treatment of ear, hearing and nasal issues, thereby optimising health, psychological, social and educational outcomes. There is no single gold standard test for PCD diagnosis. Presently, the diagnosis is made in patients with a compatible medical history following a demanding combination of tests including nasal nitric oxide (nNO), high-speed video microscopy, transmission electron microscopy, genetics, and culture of respiratory epithelial cells [7, 9–12]. These tests are costly and need experienced staff using sophisticated equipment, hence testing is restricted to reference centres which may be geographically distant from the patient. Identifying the correct patients for testing is therefore important and screening tools are needed. Although individual symptoms are non-specific, the pattern of symptoms is often characteristic. A typical history might include neonatal respiratory distress in an infant with no risk factors, a daily wet cough starting in early infancy, recurrent chest infections, persistent rhinitis and serous otitis media. Screening tools (e.g. PICADAR) to identify patients based on their clinical history are helpful but require a history that might not yet have evolved in young infants [13, 14].

Primary ciliary dyskinesia (PCD) is a rare, heterogeneous genetic disorder where impaired mucociliary clearance is caused by dysfunctional motile cilia leading to bronchiectasis. There is limited evidence characterising the nutritional status of children with PCD, although lower body mass index (BMI) z-score has been associated with worse lung function (FEVAll children (n = 43) with PCD, aged16 years, from a single tertiary centre were prospectively enrolled. Information on clinical phenotype and nutritional status including bioelectrical impedance spectroscopy (BIS) phase-angle was collected.There was a weak positive association between height-for-age z-score (HAZ) and FEVWe have characterised the nutritional phenotype of a cohort of children with PCD. Monitoring vitamin D levels is important in PCD patients. There is a weak association between lung function and nutritional status, and measures of BIS phase-angle. The use of BIS phase-angle may allow for early identification of at risk children and may therefore be of benefit for nutritional assessments in the clinical setting. These findings will help inform a future nutritional intervention strategy in children with PCD.

Primary ciliary dyskinesia (PCD) is a rare heterogenous condition that causes progressive suppurative lung disease, chronic rhinosinusitis, chronic otitis media, infertility and abnormal situs. ‘Better Experimental Approaches to Treat Primary Ciliary Dyskinesia’ (BEAT-PCD) is a network of scientists and clinicians coordinating research from basic science through to clinical care with the intention of developing treatments and diagnostics that lead to improved long-term outcomes for patients. BEAT-PCD activities are supported by EU funded COST Action (BM1407). The second BEAT-PCD conference, and third PCD training school were held jointly in April 2017 in Valencia, Spain. Presentations and workshops focussed on advancing the knowledge and skills relating to PCD in: basic science, epidemiology, diagnostic testing, clinical management and clinical trials. The multidisciplinary conference provided an interactive platform for exchanging ideas through a program of lectures, poster presentations, breakout sessions and workshops. Three working groups met to plan consensus statements. Progress with BEAT-PCD projects was shared and new collaborations were fostered. In this report, we summarize the meeting, highlighting developments made during the meeting. Electronic supplementary material The online version of this article (10.1186/s12919-018-0098-9) contains supplementary material, which is available to authorized users.

RationalePrimary ciliary dyskinesia is a genetically heterogeneous inherited condition characterised by progressive lung disease arising from abnormal cilia function. Approximately half of patients have situs inversus. The estimated prevalence of primary ciliary dyskinesia in the UK South Asian population is 1:2265. Early, accurate diagnosis is key to implementing appropriate management but clinical diagnostic tests can be equivocal.ObjectivesTo determine the importance of genetic screening for primary ciliary dyskinesia in a UK South Asian population with a typical clinical phenotype, where standard testing is inconclusive.MethodsNext-generation sequencing was used to screen 86 South Asian patients who had a clinical history consistent with primary ciliary dyskinesia. The effect of a CCDC103 p.His154Pro missense variant compared with other dynein arm-associated gene mutations on diagnostic/phenotypic variability was tested. CCDC103 p.His154Pro variant pathogenicity was assessed by oligomerisation assay.ResultsSixteen of 86 (19%) patients carried a homozygous CCDC103 p.His154Pro mutation which was found to disrupt protein oligomerisation. Variable diagnostic test results were obtained including normal nasal nitric oxide levels, normal ciliary beat pattern and frequency and a spectrum of partial and normal dynein arm retention. Fifteen (94%) patients or their sibling(s) had situs inversus suggesting CCDC103 p.His154Pro patients without situs inversus are missed.ConclusionsThe CCDC103 p.His154Pro mutation is more prevalent than previously thought in the South Asian community and causes primary ciliary dyskinesia that can be difficult to diagnose using pathology-based clinical tests. Genetic testing is critical when there is a strong clinical phenotype with inconclusive standard diagnostic tests.

Background Airway NO synthase (NOS) isoenzymes are responsible for rapid and localised nitric oxide (NO) production and are expressed in airway epithelium. We sought to determine the localisation of neuronal NOS (nNOS) in airway epithelium due to the paucity of evidence. Methods and results Sections of healthy human bronchial tissue in glycol methacrylate resin and human nasal polyps in paraffin wax were immunohistochemically labelled and reproducibly demonstrated nNOS immunoreactivity, particularly at the proximal portion of cilia; this immunoreactivity was blocked by a specific nNOS peptide fragment. Healthy human epithelial cells differentiated at an air–liquid interface (ALI) confirmed the presence of all three NOS isoenzymes by immunofluorescence labelling. Only nNOS immunoreactivity was specific to the ciliary axonemeand co-localised with the cilia marker β-tubulin in the proximal part of the ciliary axoneme. Conclusions We report a novel localisation of nNOS at the proximal portion of cilia in airway epithelium and conclude that its independent and local regulation of NO levels is crucial for normal cilia function.

Background: PCD is an inherited heterogenous disorder of impaired mucociliary clearance. Early colonisation of the lower airways with non-typeable Haemophilus influenzae (NTHi) is common. Chronic inflammation and recurrent infections inevitably lead to irreversible bronchiectasis. It is unknown whether epithelial dysfunction contributes to morbidity. We compared the host responses of healthy and PCD respiratory epithelium to NTHi biofilm using proteomic approaches. Method: Nasal epithelial cells were cultured from 5 PCD subjects with DNAH11 mutations and 3 healthy volunteers. Differentiated ciliated cells were co-cultured with a clinical isolate of NTHi for 72 hours in order to colonise the epithelium with biofilm. Following Label-free LC/MS proteomic analyses, proteins were analysed using the Gene Ontology (GO) PANTHER analysis tool. Results: Differences in protein expression between PCD and healthy epithelial cells included upregulation of the following pathways in PCD: “sodium ion export from cell” (adjusted p=0.045) and “cell-cell adhesion” (adj p=0.001). Downregulated PCD pathways were “positive regulation of substrate adhesion-dependent cell spreading” (adj p=0.020) and “cytoskeletal organisation” (adj p Conclusions: We found epithelial dysfunction in PCD in the form of aberrant responses to colonising NTHi. Our data provide potential mechanistic insights into this dysfunction.

Background: Primary ciliary dyskinesia (PCD) is a rare genetic disease that impedes ciliary function, leading to recurrent upper and lower airway infections. The Southampton PCD Diagnostic Centre has been commissioned by NHS England since 2006. We aimed to describe the characteristics of patients diagnosed at the centre. Methods: We conducted a cross-sectional study using data from local PCD registry, electronic health records and medical notes for all patients diagnosed with PCD in Southampton from 2006 to 2016. Results: Of 1,720 referrals, we diagnosed 142 patients with PCD (8%). Diagnosis was always based on at least one diagnostic test. The number of tests has increased in the last 5 years particularly in genotyping (65% vs 56% before 2011). Nasal nitric oxide was measured in 82% of patients over 5 years of age. Overall, 84% had high-speed video analysis, of which 70% showed predominantly static cilia, with the remainder exhibiting a variety of beat patterns; 131 patients had transmission electron microscopy, which showed ‘hallmark’ defects in 70% of cases; and 59% were genotyped. Median age at initial assessment was 10 years, younger for the 43% with situs abnormalities (7 vs 12 years, p=0.062). 11% had congenital heart disease, considerably higher than previously reported (3-6%). 72% reported neonatal respiratory symptoms, of which 58% needed respiratory support. Mean FEV1% was low in both children and adults (79% vs 71% respectively, p=0.26) at the time of diagnosis. Conclusion: We found a high prevalence of congenital heart disease and neonatal respiratory symptoms. Lung function was impaired in both children and adults. These findings highlight the need for early care for PCD in specialised centres.

Primary ciliary dyskinesia (PCD) is a genetically heterogeneous condition characterised by progressive lung disease arising from abnormal motile ciliary function. Approximately half of patients have situs inversus. The estimated prevalence of PCD in the UK South Asian population is 1:2,265. Early, accurate diagnosis is key to implementing appropriate management but clinical diagnostic tests can be equivocal. The aim of this study was to determine the importance of genetic screening for primary ciliary dyskinesia in a UK South Asian population with a typical clinical phenotype, where standard testing is inconclusive. Next-generation sequencing was used to screen 86 South Asian patients who had a clinical history consistent with PCD. The effect of a CCDC103 c.461A>C p.His154Pro missense variant on phenotypic variability was tested and variant pathogenicity was assessed by oligomerisation assay. Sixteen of 86(19%) patients carried a homozygous CCDC103 p.His154Pro mutation which was found to disrupt protein oligomerisation. Variable diagnostic test results were obtained including normal nasal nitric oxide levels (7/15 patients tested), normal ciliary beat pattern or frequency (9/16 cases) and a spectrum of partial and normal dynein arm retention (9/16 cases). Fifteen (94%) patients or their sibling (s) had situs inversus suggesting in CCDC103 p.His154Pro patients without situs inversus the diagnosis is missed. In conclusion, the CCDC103 p.His154Pro mutation is more prevalent than previously thought in the South Asian community and causes PCD that can be difficult to diagnose using pathology-based clinical tests. Genetic testing is critical when there is a strong clinical phenotype with inconclusive or normal diagnostic tests

International audience; The diagnosis of primary ciliary dyskinesia is often confirmed with standard, albeit complex and expensive, tests. In many cases, however, the diagnosis remains difficult despite the array of sophisticated diagnostic tests. There is no “gold standard” reference test. Hence, a Task Force supported by the European Respiratory Society has developed this guideline to provide evidence-based recommendations on diagnostic testing, especially in light of new developments in such tests, and the need for robust diagnoses of patients who might enter randomised controlled trials of treatments. The guideline is based on pre-defined questions relevant for clinical care, a systematic review of the literature, and assessment of the evidence using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. It focuses on clinical presentation, nasal nitric oxide, analysis of ciliary beat frequency and pattern by high-speed video-microscopy analysis, transmission electron microscopy, genotyping and immunofluorescence. It then used a modified Delphi survey to develop an algorithm for the use of diagnostic tests to definitively confirm and exclude the diagnosis of primary ciliary dyskinesia; and to provide advice when the diagnosis was not conclusive. Finally, this guideline proposes a set of quality criteria for future research on the validity of diagnostic methods for primary ciliary dyskinesia.

Nasal nitric oxide (nNO) concentrations are low in patients with primary ciliary dyskinesia (PCD) providing a noninvasive screening test.We conducted a systematic review of the literature to examine the utility of nNO in screening for PCD, in particular 1) different respiratory manoeuvres during sampling (velum closure, tidal breathing, etc.), 2) accuracy in screening young/uncooperative children, 3) stationary versus portable analysers, and 4) nNO in “atypical” PCD.96 papers were assessed according to modified PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria and 22 were included in this review.Meta-analysis of 11 studies comparing nNO during a velum closure breath hold gave a mean±sd nNO of 19.4±18.6 nL·min-1 in PCD (n = 478) and 265.0±118.9 nL·min-1 in healthy controls (n = 338). Weighted mean difference for PCD versus healthy controls was 231.1 nL·min-1 (95% CI 193.3–268.9; n = 338) and 114.1 nL·min-1 (95% CI 101.5–126.8; n = 415) for PCD versus cystic fibrosis. Five studies of nNO measurement during tidal breathing demonstrated that this is an acceptable manoeuvre in young children where velum closure is not possible, but the discriminatory value was reduced. Four small studies of portable NO analysers suggest these are reliable tools for screening for PCD. However, nNO must be interpreted alongside clinical suspicion. Future studies should focus on standardising sampling techniques and reporting.

Primary ciliary dyskinesia (PCD) is an autosomal recessive disease associated with bronchiectasis, chronic rhinosinusitis, infertility and situs inversus. Estimates of prevalence vary widely, but is probably between 1:10,000- 1:40,000 in most populations. A number of observational studies indicate that access to services to diagnose and manage patients with PCD vary both between and within countries. Diagnosis is often delayed and frequently missed completely. The prognosis of patients with PCD is variable, but evidence suggests that it is improved by early diagnosis and specialist care. This article briefly reviews the literature concerning PCD and the evidence that specialist care will improve healthcare outcomes. The article specifically refers to a new national service in the UK.

Primary ciliary dyskinesia (PCD) is a heterogeneous autosomal recessive condition affecting around 1:15,000. In people with PCD, microscopic motile cilia do not move normally resulting in impaired clearance of mucus and debris leading to repeated sinopulmonary infection. If diagnosis is delayed, permanent bronchiectasis and deterioration of lung function occurs. Other complications associated with PCD include congenital heart disease, hearing impairment and infertility. A small number of longitudinal studies suggest that lung function deteriorates before diagnosis of PCD but may stabilise following diagnosis with subsequent specialist management. Early diagnosis is therefore essential, but for a number of reasons referral for diagnostic testing is often delayed until older childhood or even adulthood. Functional diagnostic tests for PCD are expensive, time consuming and require specialist equipment and scientists. In the last few years, there have been considerable developments to identify genes associated with PCD, currently enabling 65% of patients to be identified by bi-allelic mutations. The rapid identification of new genes continues. This review will consider the evidence that early diagnosis of PCD is beneficial. It will review the recent advances in identification of PCD-associated genes and will discuss the role of genetic testing in PCD. It will then consider whether screening for PCD antenatally or in the new born is likely to become a feasible and acceptable for this rare disease.

BACKGROUND: We report on a follow-up clinical and serological investigation of 274 children who received seasonal influenza vaccine (trivalent inactivated vaccine [TIV]) 1 year after receipt of either AS03(B)-adjuvanted subunit or whole virus monovalent A(H1N1)pdm09 vaccine and describe the antibody responses to the H3N2 A/Perth/16/2009 and B/Brisbane/60/2008 components of TIV. METHODS: Vaccine responses were analyzed using hemagglutination inhibition (HAI) assays. In children aged 3 years, responses to the H3 and B components of TIV were similar between vaccine groups. Sera taken before and after the pandemic vaccine were also analyzed by HAI using A/Perth/16/2009 virus. This analysis showed that 11.1% of children receiving the AS03(B)-adjuvanted vaccine but only 1.4% in the nonadjuvanted group had a 4-fold rise to A/Perth/16/2009. CONCLUSION: AS03B-adjuvanted A(H1N1)pdm09 influenza vaccine generates a cross-reactive antibody response to H3N2 in children and enhances responses to heterologous subtypes in children aged

Background Allergic rhinitis (AR) is a significant issue in children. Treatment options include allergen avoidance, pharmacotherapy and immunotherapy. The use of nasal saline douching (NSD) in children has recently gained acceptability. However, there is limited data regarding the acceptability and tolerability of NSD in children with AR. Methods A search was conducted using Medline and Embase databases from January 1946 until June 2015 on the use of NSD in children aged 4–12 years with AR. All publications identified that assessed the beneficial effects, acceptability and tolerability were included. Results 40 studies were analyzed. Data varied considerably in terms of saline solutions used, modality of application, participant numbers, study design, follow up and outcomes. Factors that appear to influence the acceptability and tolerability of NSD include parental and health professionals' preconceptions, and characteristics of the solution. Conclusions Nasal saline douching appears to be effective, being accepted and tolerated in the majority of children (78–100%). NSD has a significant positive impact on the quality of life in children with allergic rhinitis. When used as an adjunctive treatment having mainly a cleansing property, NSD potentiates the effects and may reduce the dose required of AR medications. Among the principal factors that influence the acceptability and tolerability of NSD are the child's age, delivery system and method, and tonicity. Nasal saline douching provides an accessible, low cost, low morbidity, easy to use treatment in children with allergic rhinitis.

Introduction: Cystic fibrosis (CF) and primary ciliary dyskinesia (PCD) both cause recurrent pulmonary infections resulting in bronchiectasis. CF is considered the more severe condition. Nutritional status is fundamental to outcome in CF but there is little evidence about its importance in PCD. Aim: To compare BMI and lung function of pancreatic sufficient (PS) and insufficient (PI) CF children to those with PCD. Methods: Cross sectional data (2015) from 204 CF (189 PI, 15 PS) and 46 PCD children, obtained at annual review at our Paediatric Respiratory Centre were compared. Results: Age, sex and mean BMI centile were comparable across the three groups. Mean age (SD) at diagnosis was significantly older in the PCD compared to the PI-CF cohort (4.8yrs (4.6) vs 0.6yrs (1.3) P 1 % did not vary significantly with BMI centile in PS-CF, a lower BMI centile was associated with a lower FEV 1 % in both PI-CF and PCD cohorts, even when adjusted by age. FEV 1 declined similarly in the PS-CF and PCD groups with increasing age although the rate of decline was greater in the PI-CF cohort. Of note, the mean (SD) FEV 1 % was significantly lower in the PCD cohort than both PI-CF and PS-CF children (73.8% (19.4), 84.9% (21.2), 96.1% (15.9) P Conclusion: Similar to PI-CF, a lower BMI centile was associated with a lower FEV 1 % in our PCD cohort. Whilst a greater decline in FEV 1 % with increasing age was observed in the PI-CF patients, the mean FEV 1 % in the PCD patients was significantly lower and they were significantly older at diagnosis. Optimising nutritional status and earlier diagnosis might be of importance in improving lung function amongst PCD patients.

Diagnosis of primary ciliary dyskinesia (PCD) lacks a “gold standard” test and is therefore based on combinations of tests including nasal nitric oxide (nNO), high-speed video microscopy analysis (HSVMA), genotyping and transmission electron microscopy (TEM). There are few published data on the accuracy of this approach. Using prospectively collected data from 654 consecutive patients referred for PCD diagnostics we calculated sensitivity and specificity for individual and combination testing strategies. Not all patients underwent all tests. HSVMA had excellent sensitivity and specificity (100% and 93%, respectively). TEM was 100% specific, but 21% of PCD patients had normal ultrastructure. nNO (30 nL·min−1 cut-off) had good sensitivity and specificity (91% and 96%, respectively). Simultaneous testing using HSVMA and TEM was 100% sensitive and 92% specific. In conclusion, combination testing was found to be a highly accurate approach for diagnosing PCD. HSVMA alone has excellent accuracy, but requires significant expertise, and repeated sampling or cell culture is often needed. TEM alone is specific but misses 21% of cases. nNO (≤30 nL·min−1) contributes well to the diagnostic process. In isolation nNO screening at this cut-off would miss ∼10% of cases, but in combination with HSVMA could reduce unnecessary further testing. Standardisation of testing between centres is a future priority., Combination testing in PCD diagnosis remains the most accurate approach, but standardisation is needed http://ow.ly/TLEDu

Symptoms of primary ciliary dyskinesia (PCD) are nonspecific and guidance on whom to refer for testing is limited. Diagnostic tests for PCD are highly specialised, requiring expensive equipment and experienced PCD scientists. This study aims to develop a practical clinical diagnostic tool to identify patients requiring testing. Patients consecutively referred for testing were studied. Information readily obtained from patient history was correlated with diagnostic outcome. Using logistic regression, the predictive performance of the best model was tested by receiver operating characteristic curve analyses. The model was simplified into a practical tool (PICADAR) and externally validated in a second diagnostic centre. Of 641 referrals with a definitive diagnostic outcome, 75 (12%) were positive. PICADAR applies to patients with persistent wet cough and has seven predictive parameters: full-term gestation, neonatal chest symptoms, neonatal intensive care admittance, chronic rhinitis, ear symptoms, situs inversus and congenital cardiac defect. Sensitivity and specificity of the tool were 0.90 and 0.75 for a cut-off score of 5 points. Area under the curve for the internally and externally validated tool was 0.91 and 0.87, respectively. PICADAR represents a simple diagnostic clinical prediction rule with good accuracy and validity, ready for testing in respiratory centres referring to PCD centres., PICADAR is a simple diagnostic prediction tool for PCD with good accuracy and validity that is now ready for testing http://ow.ly/X6y9s

Two doses of AS03B-adjuvanted pandemic influenza vaccine may be sufficient to maintain seroprotection across 2 influenza seasons. Administration of trivalent influenza vaccine to children who previously received 2 doses of pandemic influenza vaccine is safe and is immunogenic for the H1N1 strain., Background. We investigated antibody persistence in children 1 year after 2 doses of either an AS03B-adjuvanted split-virion or nonadjuvanted whole-virion monovalent pandemic influenza vaccine and assessed the immunogenicity and reactogenicity of a subsequent dose of trivalent influenza vaccine (TIV). Methods. Children previously immunized at age 6 months to 12 years in the original study were invited to participate. After a blood sample was obtained to assess persistence of antibody against swine influenza A/H1N1(2009) pandemic influenza, children received 1 dose of 2010/2011 TIV, reactogenicity data were collected for 7 days, and another blood sample was obtained 21 days after vaccination. Results. Of 323 children recruited, 302 received TIV. Antibody persistence (defined as microneutralization [MN] titer ≥1:40) 1 year after initial vaccination was significantly higher in the AS03B-adjuvanted compared with the whole-virion vaccine group, 100% (95% confidence interval [CI], 94.1%–100%) vs 32.4% (95% CI, 21.5%–44.8%) in children immunized

Chronic Obstructive Pulmonary Disease (COPD) has a high mortality. Many indices have been developed to classify disease severity including the 2007 and 2011 GOLD classification and BODE index. However, no study has compared the prediction of mortality by those indices. This is an observational study of 96 patients with COPD and followed prospectively for a median of 60 months. We performed at baseline pulmonary function tests, 6-minute walking test, dyspnea scale mMRC, anthropometric and questionnaire measures of exacerbations. BODE index and GOLD 2007 and GOLD 2011 classification was calculated. The capacity of all indices to predict mortality was compared using Cox proportional hazard analysis and Kaplan Meier survival cruves. A total of 55 men and 41 women were studied, of whom 50% died during a follow-up time mean of 69 +/- 37 months. The mean FEV1 was 27% +/- 5%. Statistically significant associations were observed between mortality and BODE index (p = 0.024) and male sex (p = 0.021). Cox regression analysisshowed that the only statistically significant association was with BODE (p=0,037; IC: 95% 1,024-2,17). The Kaplan-Meier curves for BODE, 2007 GOLD and GOLD ABCD were calculated and are The BODE index predicts all cause mortality better than the old GOLD classification based on FEV1 and the new ABCD grading . We also observed that patients classified as GOLD B has higher mortality than those classified as GOLD C.

Background: Nasal nitric oxide (nNO) is usually low in primary ciliary dyskinesia (PCD) and measurement is part of a complex diagnostic work-up. Previous research has failed to define the accuracy of nNO testing in differing patient populations. Aims: Use accuracy data of nNO testing in patients referred to a UK national diagnostic service to calculate the predictive value of nNO testing in children with persistent wet cough (estimated 5% PCD prevalence) and in the general population (1:10,000 prevalence). Methods: From June 2006 to January 2014, 282 consecutive referrals (aged 6-79 years) had nNO measured by breath hold technique on the chemiluminescent NIOX Flex analyser. PCD was diagnosed by high resolution video microscopy and quantitative electron microscopy. Sensitivity and specificity was calculated and used to derive positive and negative predictive values (PPV & NPV) for each population. Results: 31 patients were PCD positive. Using a published cut-off of 77 nl/min (256 parts per billion on NIOX Flex), sensitivity was 93.6% (95% CI 78.5-99.0) and specificity 84.1% (95% CI 78.9-88.4). PPV was 42% (30.2-54.5%) and NPV 99.1% (96.6-99.9%) for referrals (prevalence of PCD 11%). PPV was 23.6% for persistent wet cough and Conclusion: PPV is poor and diminishes rapidly with lower PCD prevalence therefore screening should be targeted at those with high clinical suspicion of PCD. Whilst NPV is excellent, it must be interpreted alongside clinical history given published cases of PCD with normal nNO. These findings highlight the importance of using clinical features to select those who undergo nNO testing.

Robust diagnosis of primary ciliary dyskinesia (PCD) is important if patients are to receive appropriate specialist management before irreversible deterioration of lung function occurs. Early diagnosis also enables patients and their families to receive appropriate genetic counseling, disease-specific management of ear and rhino-sinus disease, and screening for PCD-associated problems (e.g., cardiac problems) (1, 2). The association of extremely low levels of nasal nitric oxide (nNO) in PCD has been recognized for over 15 years, and measurement of nNO is increasingly used as a screening test for PCD in Europe (1). The manuscript by Leigh and coworkers in this edition of AnnalsATS (3) provides an important advance in the use of nNO for clinical and research purposes. Their data confirm that nNO is a reliable investigation for PCD in the North American population and setting, including identification of “atypical” patients with PCD who might otherwise be missed due to normal ciliary ultrastructure. The authors provide evidence that a standardized protocol using different NO analyzers can be used to reliably differentiate patients with PCD from patients without PCD and from healthy children, in geographically dispersed centers. They have additionally developed cutoff values using data from their large study population, which can now be validated in other populations. There is no “gold standard” diagnostic test to identify all PCD phenotypes, and diagnostic workup requires access to a number of specialist investigations. Previously, ciliary ultrastructure analyzed by electron microscopy (EM) was considered diagnostic, but there is an increasing literature on normal ciliary ultrastructure, at EM resolution, in PCD. This indicates that PCD will be missed in centers where diagnosis depends solely on EM (2, 4). It is also recognized that certain EM defects previously considered diagnostic might on occasion represent secondary changes that resolve on repeat testing (4, 5). In Europe, assessment of ciliary beat frequency (CBF) and pattern (CBP) by high-resolution, high-speed video microscopy (HSVm) is recommended as a functional test for PCD (1, 6). If HSVm analysis is abnormal, re-differentiation of basal epithelial cells at an air–liquid interface (ALI) in cell culture enables reassessment of ciliary function and ultrastructure to differentiate primary from secondary dyskinesia (1). Alternatively, immunoflorescent (IF) staining of ciliary proteins can support diagnosis of PCD (7). EM, HSVm, ALI-culture, and IF all require a high degree of expertise in addition to expensive equipment and infrastructure. These techniques are therefore restricted to a few highly specialized centers, limiting easy access to diagnostic testing (8). Diagnosis supported by bi-allelic mutations in genes known to be associated with PCD is promising; currently genotyping detects only 50–65% of patients (2), but as new genes are rapidly identified this will become increasingly sensitive. The evidence provided by Leigh and coleagues (3) is therefore to be welcomed by clinicians, researchers, and in particular families who are unable to travel to a highly specialized center. It is to be hoped that the U.S. Food and Drug Administration and other regulatory authorities will approve nNO analyzers for clinical use given the evidence that nNO is a reliable screening test for PCD and that valid measurements can be taken at sites geographically distant from a diagnostic center using standardized protocols. Leigh and coworkers report a cutoff value for nNO of 77 nL/min providing sensitivity of 0.98 and specificity greater than 0.999. This cutoff value was validated across six other sites, identifying 70 of the 71 (98.6%) participants with confirmed PCD. A previous study used a cutoff for nNO of 105 parts per billion and reported a specificity of 88%, a sensitivity of 100%, and a positive predictive value of 89% for correctly diagnosing PCD (9). While there are now substantial data to demonstrate that nNO measurement is helpful in guiding the diagnostic pathway, we need to recognize limitations of this measurement. Standardized methods (10) to measure nNO are not appropriate for younger children, precisely the age group that need targeting for diagnostic measurement. Tidal measurements allow levels to be measured in young infants, although there is limited experience in this younger age group (1, 11, 12). Patients with other with upper and lower airway diseases have been reported to have reduced nNO levels, although usually not as low as in PCD; such diseases include cystic fibrosis, nasal polyps and chronic sinusitis. A few groups have recently reported normal levels of nasal NO in a minority of patients with PCD (1, 11, 13). These studies highlight that patients with a history strongly suggestive of PCD should not be excluded from further diagnostic evaluation on the basis of nNO, and also that, while providing an excellent screening test, nNO is not diagnostic and low levels should trigger referral to a highly specialized diagnostic center. A priority for researchers is to understand the cause of the extraordinarily low nNO observed in PCD (14). From a clinical perspective, the next hurdle to overcome is the lack of regulatory approvals of nNO analyzers for PCD diagnosis, as well as the cost and therefore availability of devices. Until recently, the only commercially available analyzers for measuring nNO were nonportable desktop analyzers, which are extremely expensive. More reasonably priced portable machines (15) are now available, although they are not yet fully validated nor approved for clinical use. Manufacturers should be encouraged to develop, validate, and seek approvals for user-friendly, reasonably priced nNO analyzers. This will lead to a step change in the diagnosis of PCD by reliably identifying patients for referral to specialist diagnostic centers.

Before routine infant pneumococcal immunisation and improved access to neuroimaging, around 25% of children with pneumococcal meningitis (PM) suffered ischaemic stroke (IS).1 ,2 In a population-based retrospective audit (UHS ZAUD2053), we investigated the postimmunisation prevalence of stroke/cerebrovascular disease (CVD), and compared features of children with and without IS/CVD. We included all cases of PM in children 5 white cells in the CSF and/or signs of meningism and/or focal neurology and/or meningeal enhancement on CT with contrast. Stroke and/or CVD were identified on CT …

Objective: To determine the quality of life in individuals with corrected tetralogy of Fallot. Methods and subjects: Questionnaires concerning quality of life were sent to all 87 surviving patients aged between 16 and 40 years who had undergone intracardiac repair of tetralogy of Fallot and follow-up in the Wessex Cardiothoracic Unit, and to 87 age and sex matched controls, with medically treated haemodynamically insignificant ventricular septal defects. Results: The only significant difference found between the cases and controls was in requirements for schooling, where those with tetralogy of Fallot were more likely to require additional educational help at school (p = 0.044). For all other aspects of quality of life examined by the questionnaire, including social and genetic history, exercise ability, and health related quality of life, no significant differences were found. Different operative techniques, such as transjunctional patching, right ventriculotomy, and previous palliative shunting, did not affect the quality of life of our population with Tetralogy of Fallot, on average twenty years after their surgery, although the range of operative techniques was limited. Neither age at surgery, nor time since surgery, was correlated with measurements of quality of life. Conclusions: Those who have undergone surgical correction of tetralogy of Fallot have a normal quality of life, with few differences compared to controls.

1article. The study was approved by the Southampton and South West Hampshire Research Ethics Committee (06/Q1702/109). Airway epithelium from patients with PCD and control patients without PCD was obtained by nasal brushing and was cultured at the air-liquid interface until differentiated and ciliated. We quantifi ed the presence of NO using a total NO detection assay (Enzo Life Sciences, Inc) within phosphate-buffered saline washes applied to the apical surface of air-liquid interface cultures. NO levels were measured before and after epithelial cells were apically cocultured for 72 h with NTHi at a multiplicity of infection of 100 to evaluate biofi lm infection. Cell viability was demonstrated by daily stable transepithelial electrical resistance (PCD and non-PCD) and ciliary beat frequency measurements (control subjects without PCD). We also measured levels following an 18-h incubation with a cocktail of proinflammatory cytokines (10 ng/mL each of IL-1 b /interferon- g /tumor necrosis factor- a ) applied basolaterally to the cells (n 5 14 for each experiment). Our baseline data were consistent with that of Smith et al, 1

Background Nasal nitric oxide (nNO) levels are very low in primary ciliary dyskinesia (PCD) and it is used as a screening test. Methods We assessed the reliability and usability of a hand-held analyser in comparison to a stationary nitric oxide (NO) analyser in 50 participants (15 healthy, 13 PCD, 22 other respiratory diseases; age 6–79 years). Nasal NO was measured using a stationary NO analyser during a breath-holding maneuver, and using a hand-held analyser during tidal breathing, sampling at 2 ml/sec or 5 ml/sec. The three methods were compared for their specificity and sensitivity as a screen for PCD, their success rate in different age groups, within subject repeatability and acceptability. Correlation between methods was assessed. Results Valid nNO measurements were obtained in 94% of participants using the stationary analyser, 96% using the hand-held analyser at 5 ml/sec and 76% at 2 ml/sec. The hand-held device at 5 ml/sec had excellent sensitivity and specificity as a screening test for PCD during tidal breathing (cut-off of 30 nL/min,100% sensitivity, >95% specificity). The cut-off using the stationary analyser during breath-hold was 38 nL/min (100% sensitivity, 95% specificity). The stationary and hand-held analyser (5 ml/sec) showed reasonable within-subject repeatability(% coefficient of variation = 15). Conclusion The hand-held NO analyser provides a promising screening tool for PCD.

Nitric oxide is continually synthesized in the respiratory epithelium and is upregulated in response to infection or inflammation. Primary ciliary dyskinesia is characterized by recurrent sinopulmonary infections due to impaired mucociliary clearance. Despite chronic infections, nasal nitric oxide in such patients is markedly reduced and is used as a screening test for this condition. These low levels were first described over 15 years ago but the underlying mechanisms have yet to be fully elucidated. We review epithelial nitric oxide synthesis, release and measurement in the upper airways with particular reference to primary ciliary dyskinesia. The key hypotheses that have been proposed to explain the low levels in this condition are explored and the potential benefits of augmenting airway nitric oxide levels are considered. Further work in these patients clarifying both whether the respiratory epithelium is able to biosynthesise normal levels of nitric oxide and the role played by abnormalities in the anatomy of the paranasal sinuses is essential. While nitric oxide augmentation is unlikely to be beneficial in common primary ciliary dyskinesia phenotypes, it has potential in the treatment of secondary dyskinesias and may also improve treatment of bacterial infections, particularly where biofilms are implicated.

Introduction: Pandemic influenza A H1N1 infections occurred worldwide from 2009. Children were particularly vulnerable. Novel vaccines were used during the pandemic. Objective: To assess the persistence of antibody to H1N1 influenza 1 year after children aged 6 months to 12 years had been immunised with two doses of either a non-adjuvanted whole-virion H1N1 influenza vaccine or an AS03 B-adjuvanted split-virion H1N1 influenza vaccine; and also to assess the immunogenicity and reactogenicity in this population of a single dose of 2010-11 trivalent seasonal influenza vaccine. Design: Multicentre, open-label, follow-on from randomised, head-to-head trial. Setting: Five UK sites (Southampton, Oxford, Bristol, London and Exeter). Participants: Children who completed last year's head-to-head randomised study were invited to participate. Children who had subsequently received a further dose of H1N1 vaccine, or who had already received a dose of 2010-11 trivalent seasonal influenza vaccine, were excluded. Interventions: In the previous study, children were randomised (in a 1: 1 ratio) to receive two doses, 21 days apart, of either a non-adjuvanted whole-virion H1N1 influenza vaccine or an AS03 B-adjuvanted split-virion H1N1 influenza vaccine. In this follow-on study, a blood sample was taken to assess the persistence of antibody 1 year later, followed by administration of one 0.5 ml-dose of trivalent seasonal influenza vaccine. A second blood sample was taken 3 weeks later. Main outcome measures: Comparison between vaccines of the percentage of participants with a microneutralisation (MN) titre ≥ 1: 40 and a haemagglutination titre ≥ 1: 32, 1 year after vaccination. Immunogenicity of the trivalent seasonal influenza vaccine was assessed 3 weeks after vaccination by both the MN and the haemagglutination inhibition (HI) titres. Reactogenicity data were recorded for 7 days after vaccination. Results: A total of 323 children were enrolled and 318 were included in the analysis of the persistence of antibody. One year after receipt of whole-virion vaccine, the MN titre was ≥ 1: 40 in 32.4% of those vaccinated when < 3 years old and in 65.9% of those vaccinated when ≥ 3 years old; the HI titre was ≥ 1: 32 in 63.2% and 79.1% of children in the respective age groups. One year after receipt of the adjuvanted vaccine, the MN titre was ≥ 1: 40 in 100% of those vaccinated when < 3 years old and in 96.9% of those vaccinated when ≥ 3 years old; the HI titre was ≥ 1: 32 in 98.4% and 96.9% of children in the respective age groups. Three hundred and two children were given trivalent seasonal influenza vaccination. Three weeks later, sera were obtained from 282 children; 100% had an MN titre ≥ 1: 40 and HI titre ≥ 1: 32. Trivalent seasonal influenza vaccine was well tolerated, although in children < 5 years old, fever ≥ 38 °C was reported in 13.6% of those who had previously received whole-virion vaccine, and in 18.3% of those who had received adjuvanted vaccine. Conclusions: Nearly all children who received two doses of AS03 B-adjuvanted split-virion pandemic H1N1 influenza vaccine had titres of antibody deemed protective (HI titre ≥ 1: 32, MN titre ≥ 1: 40) 1 year later. Children who received two doses of whole-virion vaccine had lower titres, although many were above the putative protective thresholds. One year after either pandemic vaccine, the 2010-11 trivalent seasonal influenza vaccine produced a marked serological response to the H1N1 component of the vaccine and was well tolerated. We propose to investigate whether or not previous receipt of monovalent influenza vaccines affected serological response to the H3N2 and B components of the 2010-11 seasonal influenza vaccine, using stored sera. Trial registration: ClinicalTrials.gov NCT01239537. Funding: The National Institute for Health Research Health Technology Assessment programme. © Queen's Printer and Controller of HMSO 2011.

Primary ciliary dyskinesia (PCD) is an autosomal recessive disease with an incidence estimated between 1:2,000 and 1:40,000. Ciliated epithelia line the airways, nasal and sinus cavities, Eustachian tube and fallopian tubes. Congenital abnormalities of ciliary structure and function impair mucociliary clearance. As a consequence, patients present with chronic sinopulmonary infections, recurrent glue ear and female subfertility. Similarities in the ultrastructure of respiratory cilia, nodal cilia and sperm result in patients with PCD also presenting with male infertility, abnormalities of left-right asymmetry (most commonly situs inversus totalis) and congenital heart disease. Early diagnosis is essential to ensure specialist management of the respiratory and otological complications of PCD. Diagnostic tests focus on analysis of ciliary function and electron microscopy structure. Analysis is technically difficult and labour intensive. It requires expertise for interpretation, restricting diagnosis to specialist centres. Management is currently based on the consensus of experts, and there is a pressing need for randomised clinical trials to inform treatment.

In 2009, 943 children aged 6 months to 10 years were randomised to receive two doses of an oil-in water AS03B-adjuvanted split virion or a non-adjuvanted whole virion H1N1 (2009) vaccine. The large numbers allowed investigation of possible predictors of immune response and reactogenicity. We used regression analysis to examine the effect of variables including past receipt of seasonal vaccine, antipyretics post-vaccination, interval between doses and pre-existing antibodies to H1N1 (2009) on immunogenicity. We also examined the relationship between immunogenicity and reactogenicity and whether prior infection or underlying conditions affected reactogenicity. For both vaccines, haemagglutination-inhibition titres were 60% higher in children with fever ≥38. °C after vaccination and 29% lower in those previously given seasonal vaccine. Early use of antipyretics did not affect immunogenicity. Post-vaccination titres were higher with longer intervals between doses and in those with evidence of prior infection, but reactogenicity in the latter was unaffected. In the adjuvanted vaccine group, reactions were more common in children with atopy. Both vaccines were safe and immunogenic in those with prior infection. Reduction in the interval between doses for earlier protection would be at the cost of reduced immunogenicity. The effect of seasonal vaccine on immunogenicity merits further investigation. © 2011 Elsevier Ltd.

The first cases of pandemic influenza A (H1N1) 2009 infection were seen in Mexico in March 2009. Since then, it is thought to have been responsible for at least 18,337 deaths globally. Owing to the young age of fatalities, there have been an estimated 2 million years of life lost, which is comparable to the previous pandemics of 1957 and 1968. In this article, we consider the available data on a monovalent inactivated split-virion AS03-adjuvanted pandemic influenza A (H1N1) vaccine, Pandemrix™ (GlaxoSmithKline, Rixensart, Belgium). At present, Pandemrix appears to be highly immunogenic in all age groups, including children and infants under 3 years of age, with an acceptable safety profile in the context of an influenza pandemic. However, owing to the novel adjuvant, further studies on the safety, immunogenicity and vaccine effectiveness of Pandemrix together with robust post-marketing surveillance are required.

Background: Children are a priority for vaccination in an influenza pandemic, but safety and immunogenicity data for new-generation adjuvanted and whole-virion vaccines are limited. Objectives: Immunogenicity •How does the percentage of children aged 6 months to 12 years of age with a fourfold rise in microneutralisation titres between the prevaccination sample and the sample taken 3 weeks after completion of a two-dose course of the non-adjuvanted, whole-virion vaccine and the AS03B-adjuvanted split-virion vaccine compare? •How does the percentage of children aged 6 months to 12 years of age with haemagglutination inhibition titres of ? 1 : 32 3 weeks after completion of a two-dose course of the non-adjuvanted, whole-virion vaccine and the AS03B-adjuvanted split-virion vaccine compare? •How does the percentage of children aged 6 months to 12 years of age with a fourfold rise in haemagglutination inhibition titres between the prevaccination sample and the sample taken 3 weeks after completion of a two-dose course of the non-adjuvanted, whole-virion vaccine and the AS03B-adjuvanted split-virion vaccine compare? •What is the geometric mean fold rise in haemagglutination inhibition titres from baseline to 3 weeks after two doses of the non-adjuvanted, whole-virion vaccine and the AS03B-adjuvanted split-virion vaccine? •What is the geometric mean haemagglutination inhibition titre 3 weeks after two doses of the non-adjuvanted, whole-virion vaccine and the AS03B-adjuvanted split-virion vaccine? Reactogenicity •How does the percentage of children aged 6 months to 12 years of age experiencing fever and local reactions within the 7 days following each dose of the non-adjuvanted, whole-virion and the AS03B-adjuvanted split-virion vaccines compare? •What percentage of children aged 6 months to 12 years of age experience non-febrile systemic reactions within the 7 days following each dose of the non-adjuvanted, whole-virion and the AS03B-adjuvanted split-virion vaccine? Methods: The safety, reactogenicity and immunogenicity of a tocopherol/oil-in-water emulsion-adjuvanted (AS03B) egg culture-derived split-virion H1N1 vaccine and a non-adjuvanted cell culture-derived whole-virion vaccine, given as a two-dose schedule, 21 days apart, were compared in a randomised, open-label trial of children aged 6 months to 12 years of age. Local reactions and systemic symptoms were collected for 1 week post immunisation, and serum was collected at baseline and after the second dose. Results: Among 937 children receiving vaccine, per-protocol seroconversion rates were higher after the AS03B-adjuvanted vaccine than after the whole-virion vaccine (98.2% vs 80.1% in children 38.0°C in those under 5 years of age (8.9% vs 22.4%). Conclusion: In this first direct comparison of an AS03B-adjuvanted split-virion vaccine versus whole-virion non-adjuvanted H1N1 vaccine, the adjuvanted vaccine – while reactogenic – was more immunogenic, especially in younger children, indicating the potential for improved immunogenicity of influenza vaccines in this age group.

OBJECTIVES: To compare the safety, reactogenicity, and immunogenicity of an adjuvanted split virion H1N1 vaccine and a non-adjuvanted whole virion vaccine used in the pandemic immunisation programme in the United Kingdom. DESIGN: Open label, randomised, parallel group, phase II study. SETTING: Five UK centres (Oxford, Southampton, Bristol, Exeter, and London). PARTICIPANTS: Children aged 6 months to less than 13 years for whom a parent or guardian had provided written informed consent and who were able to comply with study procedures were eligible. Those with laboratory confirmed pandemic H1N1 influenza or clinically diagnosed disease meriting antiviral treatment, allergy to egg or any other vaccine components, or coagulation defects, or who were severely immunocompromised or had recently received blood products were excluded. Children were grouped by age: 6 months-or=1:40 from before vaccination to three weeks after the second dose). RESULTS: Seroconversion rates were higher after the adjuvanted split virion vaccine than after the whole virion vaccine, most notably in the youngest children (163 of 166 participants with paired serum samples (98.2%, 95% confidence interval 94.8% to 99.6%) v 157 of 196 (80.1%, 73.8% to 85.5%), Por=38 masculineC in those aged under 5 (24 (8.9%, 5.8% to 12.9%) v 57 (22.4%, 17.5% to 28.1%), P

Summary Background Patients with primary ciliary dyskinesia (PCD) have abnormal ciliary function and low nitric oxide levels. Nitric oxide (NO) biosynthesis is dependent on nitric oxide synthases (NOS). Cilia line the bronchial but not the alveolar epithelium. It has been hypothesised that NOS function relies on normal ciliary function and that in PCD bronchial but not alveolar NO might therefore be reduced. The aim of this study was to assess bronchial and alveolar NO levels primarily comparing healthy children to PCD and secondarily to cystic fibrosis (CF) and asthmatic children. Methods Multiple flow-rate fractional exhaled and nasal NO measurements were performed using a NIOX ® Flex NO analyser (Aerocrine, Sweden) in children with PCD ( n = 14), asthma ( n = 18), CF ( n = 12) and healthy controls ( n = 18). Alveolar and bronchial NO levels were derived using a model of pulmonary NO exchange-dynamics. Results Both the bronchial and alveolar NO were significantly lower in PCD than healthy controls (mean (SD) 264 (209) picolitres/second (pl/s) vs. 720 (514) pl/s, p = 0.024 and 1.7 (0.8) parts per billion (ppb) vs. 3.5 (1.3) ppb, p = 0.001 respectively.) In asthmatics bronchial NO was found to be significantly higher than in healthy controls and in children with CF alveolar NO was significantly lower (2100 (1935) pl/s, p = 0.045 and 2.5 (1.2) ppb, p = 0.034 respectively.) Conclusion Our findings do not support the hypothesis that NOS and ciliary function are coupled instead suggesting a more generalised mechanism for the low levels of NO seen in PCD. Our findings in CF and asthma corroborate evidence that these are diseases of the lung peripheries and bronchi respectively.