Rationale: Asbestos is posited to cause otherwise 'idiopathic' pulmonary fibrosis (IPF); establishing this has important diagnostic and therapeutic implications. Objectives: To determine the association between occupational asbestos exposure and IPF; to investigate interaction with MUC5B rs35705950 genotype. Methods: Multi-centre, incident case-control study. Cases (n=494) were men diagnosed with IPF at 21 United Kingdom hospitals. Controls (n=466) were age-matched men who attended a hospital clinic in the same period. Asbestos exposure was measured using a validated job exposure matrix and a source-receptor model. The primary outcome was the association between asbestos exposure and IPF, estimated using logistic regression adjusted for age, smoking and centre. Interaction with MUC5B rs3570950 was investigated using a genetic dominant model. Measurements and Main Results: 327 (66%) cases and 293 (63%) controls ever had a high or medium asbestos exposure risk job; 8% of both cases and controls, had cumulative exposure estimates [≥] 25 fibre/ml.years. Occupational asbestos exposure was not associated with IPF, adjusted OR 1.1(95%CI 0.8-1.4; p=0.6) and there was no gene-environment interaction (p=0.2). Ever smoking was associated with IPF, OR 1.4 (95%CI 1-1.9; p=0.04). When stratifying for genotype there was significant interaction between smoking and work in an exposed job (p<0.01) for carriers of the minor allele of MUC5B rs3570950. Conclusions: Occupational asbestos exposure alone, or through interaction with MUC5B rs35705950 genotype, was not associated with IPF. However, exposure to asbestos and smoking interact to increase IPF risk in carriers of the minor allele of MUC5B rs3570950. Clinical trial registered with www.clinicaltrials.gov (NCT03211507).

Exploiting the immune status of the tumour microenvironment (TME) is increasingly being adopted for many cancer types. Investigation into immune phenotype composition of the TME is at present lacking for malignant pleural mesothelioma (MPM) but critically important in light of the cancer’s overall poor prognosis and lack of targeted therapy as clinical standard of care. In this study, CD8+ve tumour infiltrating lymphocyte (TIL) level has been used as a starting point to compare differences in mutational patterns, histology and survival in MPM. Bulk RNA sequencing of tumour tissue from 35 MPM patients (in-house cohort) was performed. Sequencing read alignment and gene count estimation were performed using STAR (v.2.5.2b). To increase the sample size, raw data from Bueno et al. (n=211 subjects) was accessed and gene count estimations performed. In addition, the TCGA-MESO cohort (n=86 subjects) count data was included from the GDC (Genomic Data Commons) website. All count data were normalized cohort-wise using the ‘voom’ method implemented in limma package. Deconvolution of constituent immune phenotypes in the TME from the bulk RNA-sequencing data was performed by applying CIBERSORT (v.1.04) on normalized count data sets. For assessing the genetic context of observed immune phenotypes, somatic mutations were profiled using targeted sequencing of a custom gene panel for the in-house cohort. For the Bueno et al. and the TCGA-MESO cohorts, somatic mutations were either available from an overlap of whole-exome sequencing (WES) and targeted gene panel, or from WES only. A total of 27 samples (3 of 35 (8.6%), 21 of 211 (9.9%) and 3 of 86 (3.5%) from the in-house, Bueno et al. and TCGA-MESO cohorts respectively) were identified with immune phenotype enriched for CD8+ve TIL. Histological subtype distribution in the CD8+ve enriched samples was seen to be almost equivalently split between Epithelioid and Biphasic subtypes (51.85% and 48.15% respectively). Interestingly, BAP1 mutation was found to be present in only 7.7% of the samples. Considering in addition the genes NF2, SETD2, SETD6, SETDB1, TP53 and LATS1/2, mutations were only found to be present in 57.7% of the samples in total. As such >40% of samples with CD8+ve TIL do not have any mutations detected in known hotspot genes for MPM. Histological subtype is not significantly different between these ‘wild-type’ and hotspot gene(s) mutated samples. Median survival for the groups was found to be 1.85 and 0.73 years respectively. In the present study, approximately 3-10% of MPM samples were found to have enrichment for CD8+ve TIL. Nonetheless on closer examination of the genetic context, mutation patterns emerge that warrant further investigation. For samples that have TP53 (n=3) mutation or mutations in multiple hotspot genes (BAP1, NF2, SETD2, LATS2; n=1), survival understandably is lowest (0.27 years average). This raises a number of further questions including what sustains a tumour despite high CD8+ve TIL population? And more importantly with lack of tumour mutational burden what other TME signals draw effector immune cells? Further investigations, by comparing additional immune markers with copy number changes that might be present in hotspot genes, are therefore required.

Malignant pleural mesothelioma (MPM) is an aggressive tumour with dismal prognosis and overall survival. To expand our understanding of molecular background of MPM and to identify novel targetable aberrations we report an integrated genomic analysis of 121 tumour samples. Fresh-frozen tumour samples (obtained from Mesobank UK,the BLF funded Mick Knighton Mesothelioma Tissue Bank, Respiratory BRU Biobank Diagnostic Archive, Royal Brompton Hospital and an Imperial College London prospective study) were analysed by whole exome sequencing (WES, n=50), SNP genotyping (n=118) and targeted capture sequencing (n=119) for 57 genes. Sequencing libraries were prepared using Target Enrichment Systems for the Illumina Multiplexed Sequencing platform. Somatic mutations were called using VarScan after recalibration of alignments by Genome Analysis Toolkit (GATK). SNP genotyping was performed with the Human Infinium Omni-Express-Exome v1.3/1.4 Bead Chips arrays. Segmentation and copy number calling was performed using a combination of Allelic specific copy number analysis of tumour (ASCAT), DNACopy and GISTIC softwares. Analysis of WES paired samples revealed a median of 31 non-synonymous somatic mutations per tumour, lower than melanoma (315 somatic mutations) or lung cancer (187.5 for squamous and 158 for adenocarcinoma), two types of tumours linked to known carcinogen exposure. Investigation of copy number showed significant frequent deletion (q-value>0.05) of 9p21 locus where CDKN2A, MTAP and IFN type I genes are located. Deletion of CDKN2A was seen in 71/121 patients with homozygous deletion in 58/71 patients. Homozygous co-deletion of CDKN2A and IFN type I was seen in 38/58 patients, homozygous codeletion with MTAP in 49/58 patients while 37 patients showed all three as homozygous co-deleted. Patients with CDKN2A and IFN type I deletions had worse overall survival compared with the CDKN2A wild type and patients CDKN2A only deleted patients (median 8.3 months vs 13.1 months, p-value=0.016). Deletion of 3p21.1 locus and mutations in BAP1 were detected in 54.5% of the patients, making BAP1 the second most commonly altered gene. RB1 (13q14.2) was commonly altered mainly by deletion in 25.6% of the patients. NF2 and TP53 were affected by mutations in 19.8% and 7.4% of the patients, repectively. Patients with mutations in TP53 had worse overall survival compared with TP53 wild type patients (p-value=0.0005). Co-deletion of CDKN2A, MTAP and IFN type I genes could have therapeutic implications for the patients. Deletion of IFN type I may have direct implications for patient responses to immunotherapy. In the contex of multiple vulnerabilities, the presence of both CDKN2A and RB1 loss might define an important group of patients susceptible to CDK4/6i targeted therapies.

BACKGROUND:Recent studies have suggested that the birth order effect in allergy may be established during the prenatal period and that the protective effect may originate in the mother. HLA class II disparity between mother and foetus has been associated with significantly increased Th1 production. In this study, we investigated whether production of HLA antibodies 4 years after pregnancy with index child is associated with allergic outcomes in offspring at 8 years.METHODS:Anti-HLA class I and II antibodies were measured in maternal serum (n = 284) and levels correlated to numbers of pregnancies and birth order, and allergic outcomes in offspring at 8 years of age.RESULTS:Maternal anti-HLA class I and II antibodies were significantly higher when birth order, and the number of pregnancies were larger. Anti-HLA class II, but not class I antibodies were associated with significantly less atopy and seasonal rhinitis in the offspring at age 8 years. Mothers with nonatopic (but not atopic) offspring had a significant increase in anti-HLA class I and II antibodies with birth order.CONCLUSION:This study suggests that the 'birth order' effect in children may be due to parity-related changes in the maternal immune response to foetal antigens. We have observed for the first time an association between maternal anti-HLA class II antibodies and protection from allergy in the offspring. Further work is required to determine immunologically how HLA disparity between mother and father can protect against allergy.

BACKGROUND:Sensitization to rats and mice can develop in laboratory animal workers exposed to only one species. Reasons for this dual sensitization are unclear but may reflect a genetic predisposition to developing allergy (atopy) or alternatively cross-reactivity between rat and mouse urinary allergens. We examined cross-reactivity between rat and mouse urine and the effect atopy has on dual sensitization in laboratory animal workers.METHODS:In a cross-sectional study the frequency of sensitization to rat and/or mouse was analysed in 498 employees exposed to both rat and mouse at work and 220 to rat only. RAST inhibitions, western blots and blot inhibitions were carried out on a subset of five individuals to assess cross-reactivity.RESULTS:Fourteen per cent of workers were sensitized to rats and 9% to mouse. Over half (62%) of rat sensitized individuals were also mouse sensitized and the majority (91%) of mouse sensitized individuals were also rat sensitized. IgE cross-reactivity was demonstrated between rat and mouse urine using RAST inhibitions. Rates of atopy did not differ between rat only sensitized individuals compared with those sensitized to both species. Sensitization to cats and rabbits was more common amongst those with dual sensitization.CONCLUSIONS:Dual sensitization to rat and mouse reflects IgE cross-reactivity rather than atopy. Individuals with dual sensitization are more likely to be sensitized to other animal allergens. These findings will have implications for individuals working with only one rodent species who develop sensitization and symptoms to be aware of the potential for allergy to other species.

Rationale Laboratory animal workers who are sensitized to rats are highly likely also to be sensitized to mice. In a recent study of 100 individuals with specific IgE to rat urine, 62% were also IgE positive to mouse urine. Conversely 95% of mouse-sensitized individuals were also rat sensitized. Rat and mouse urinary proteins both belong to the lipocalin group of proteins and share 66% sequence homology. It is likely that rat and mouse urinary allergens share common B cell epitopes. We have therefore investigated the degree of cross reactivity between rat and mouse urinary allergens. Methods Six individuals with a RAST binding to rat and mouse of greater than 10% were selected for RAST inhibition experiments. Individual sera were incubated overnight with 1mg, 0.1mg, 0.01mg or 0.001mg rat and mouse urine. RAST to rat and mouse urinary protein were carried out the following day using the inhibited sera. Results All individuals exhibited very different inhibition profiles, irrespective of their specific IgE levels to rat and mouse urinary allergens. In general rat urine inhibited the binding of IgE to mouse urine (55-95% inhibition) more strongly than mouse urine was capable of inhibiting specific IgE to rat urine (30–80% inhibition). There was almost complete inhibition with homologous urinary protein. Conclusions These finding confirm immunologically that rat and mouse urinary allergens have common and some unique B cell epitopes which result in varying inhibitions profiles.

Rationale Laboratory animal allergy is a common occupational health problem in occupationally exposed individuals. Exposure is a well-defined risk factor for sensitization and asthma to rats. However the incidence of sensitization is often reduced in the highest exposed categories. One explanation is the phenomenon of high dose tolerance. It has been shown that exposure to cat allergen induces an IgG and IgG4 antibody response, without sensitization or risk of asthma. This has been explained as a modified Th2 response. We have investigated the relationship between IgE, IgG and IgG 4 and exposure to rats. Methods A cross sectional study was carried out on individuals exposed to laboratory animals at six pharmaceutical sites across the UK. Specific IgE was measured using RAST. Specific IgG and IgG4 antibodies to rat urinary allergen were measured in 689 and 401 exposed individuals respectively using ELISA. Results Using two different measures of exposure to rats, the prevalence of sensitization increased with increasing exposure intensity. However in the highest exposure category, the prevalence of sensitization decreased. Conversely levels of IgG and IgG4 increased in parallel with increasing exposure to rats. In support of high IgG 4 :IgE ratio in non sensitized individuals at highest exposure, we also observed higher IgG 4 :IgE ratios in asymptomatics compared with those with symptoms. Conclusions High exposure to rats was associated with an increased production of specific IgG and IgG4 with a decreased production of IgE. The development of IgG 4 may protect against symptoms.

We report two cases of occupational asthma caused by sensitisation to powdered fungicides fluazinam and chlorothalonil, from the same fungicide formulation plant. Both developed work related lower respiratory symptoms after a latent interval of asymptomatic exposure. The diagnosis in each case was confirmed with a serial peak flow record in the workplace followed by specific inhalation tests. These fungicides are known to cause dermatitis; this report indicates that these compounds can induce specific immunological reactions in the airways as well as skin.

Background Family size and high birth order were related to the prevalence of hayfever and positive skin prick test. However, this association may be explained by maternal atopy. We examined the relationship between maternal atopy and the number of offspring in three European cohorts of pregnant women.Methods The mothers and their children (n = 1487) were recruited for the Asthma Multi-centre Infants Cohort Study (AMICS). The three concurrent cohorts (Ashford, Kent (UK); Menorca island (Spain) and Barcelona city (Spain) followed the same research protocol. Maternal and paternal atopy was identified by skin prick tests at different times at the three centres.Results Maternal atopy was inversely related to the number of offspring, an association which occurred in each of the three cohorts and remained when atopy was defined separately for individual allergens (a positive response to testing with either Der p 1 or grass pollen) and which was not confounded by maternal age, smoking nor social class (the adjusted odds ratios were 0.71, 0.79 and 0.26 for increasing number of offspring, P = 0.002). Neither maternal asthma (P = 0.43) nor paternal atopy (P = 0.58) were associated with the number of offspring. Maternal atopy was not related to reproductive outcomes.Conclusions The association between maternal atopy and parity challenges the role of family size on child atopy, which should be studied in other populations.

The development of allergic asthma is thought to involve environmental and inherited genetic components and has pathophysiological features reflecting in part the activity of T cell cytokines. Interleukin-13, a product primarily of activated lymphocytes, is considered to be a critical effector molecule in allergic airway response and has been found to be overexpressed in the airways of patients with asthma. The IL-13 gene is located on chromosome 5q31, one of the major loci to be linked to asthma susceptibility, and amongst a cluster of genes which dominate the immunopathology of allergic disease. Recently, an IL-13 promoter polymorphism was found to be associated with allergic asthma. In the present study we report the identification of four novel biallelic polymorphisms in the IL-13 gene, two intronic and two exonic, one of which results in a basic to hydrophilic amino acid change. We characterised the frequencies of these four biallelic polymorphisms and the frequencies of the haplotypes, resulting from the combination of these four biallelic polymorphisms, in a population of 196 UK Caucasoid healthy individuals.

Professor Seaton criticises the approach adopted by the Industrial Injuries Advisory Council (IIAC) in its most recent report on chronic obstructive pulmonary disease (COPD) in coal miners.1 Among other things he is concerned that its recommendation, now accepted by the Government, that benefit should be awarded where miners with COPD have worked underground for 20 years or longer, even if there is no evidence of pneumoconiosis on a chest radiograph, will lead to increased payments “to compensate smokers”, and that it will remove an incentive to the coal industry to control dust exposures. He also expresses concern that pressure will now be brought on the IIAC to reduce the qualifying period of employment to less than 20 years. As chairmen of the Council and its Research Working Group, we wish to respond. The remit of the IIAC is to advise the Secretary of State for Social Security on matters relating to the operation of the industrial injuries scheme, and on the occupational diseases that can be prescribed for the purposes of social security compensation. While the prevention of occupational illness is a concern for all who work in this field, it is not the prime responsibility of the Council. It would be wrong in principle for the IIAC to withhold a recommendation for justifiable compensation because it might compromise efforts towards disease prevention. However, in practice we do not think that …

To determine the prevalence of work related symptoms among radiographers compared with a control group of physiotherapists.A postal questionnaire was used to collect information from radiographers and physiotherapists who registered in the United Kingdom during 1985-9.Satisfactory questionnaires were returned by 2354 (65%) of the radiographers and 3048 (69%) of the physiotherapists. There was a clear excess of work related symptoms among the radiographers. In particular, they were more likely to complain of symptoms that were worse at work, mouth soreness, sore, itchy, or runny eyes, persistent blocked nose, persistent itchy nose or sneezing, sore throat, headache, and of lower respiratory tract symptoms, which were also worse on workdays. These symptoms were associated particularly with the use of automatic processing machines. 235 radiographers gave a history of wheeze or chest tightness that had been worse at work or on days when at work.Work related symptoms suggesting irritation of the eyes and upper airways were more common in radiographers than controls, and may be related to exposure to x ray film processing chemicals. Men and women who reported work related wheeze or chest tightness will be followed up in more detail to assess the prevalence of occupational asthma in the cohort.

Neonatal encephalopathy is an important clinical problem * In this study the incidence of moderate or severe encephalopathy was found to be 3-75 per 1000 live term births, with a case fatality of almost 8% * Intrapartum hypoxia, determined with tradi- tional criteria, was not the cause of neonatal encephalopathy in most cases * Signs of intrapartum fetal distress may be the first signs of pre-existing neurological abnor- mality, and events occurring in the antepartum period are an important cause of neurological abnormality in newborn infants * These results have implications for obste- tricians, paediatricians, and legal practitioners insult that lead to neonatal encephalopathy we therefore need (a) more specific markers of intrapartum insult than those currently used, (b) better antepartum and preconceptional history to reduce the problem of non-random missing data and unknown exposures, (c) a reliable assessment of the state of the fetus and its reserve towards the end of the antepartum period before starting labour, and (d) larger population based studies that may be analysed with methodologies such as path analysis3' so that hypotheses based on complex causal chains can be investigated.We thank staff in the study hospitals and all metropolitan and regional paediatricians for their cooperation.In particular we thank

This study was designed to test the hypothesis that the risk of lung cancer from asbestos exposure is confined to persons with radiographic evidence of pulmonary fibrosis. Occupational and smoking histories were obtained from 271 patients with a confirmed diagnosis of primary lung cancer and 678 referents (279 with other respiratory disease and 399 with cardiac disease). Histories were reviewed blind to assess the timing, duration, and probability of exposure to asbestos. To allow for a lag between asbestos exposure and the development of lung cancer, subjects were classified by the time they had spent in an occupation entailing definite or probable exposure more than 15 years before diagnosis. The presence and extent of fibrosis was assessed blindly from chest radiographs by three readers and scored for small opacities with the ILO 1989 International Classification of Radiographs of the Pneumoconioses. 93 (34.3%) cases had worked in an occupation with definite or probable asbestos exposure compared with 176 (25. 8%) referents (crude odds ratio for lung cancer 1.49, 95% CI 1.09-2.04). After adjustment for age, sex, smoking history, and area of referral, the odds ratio (95% CI) was 2.03 (1.00-4.13) in the subgroup of 211 with a median ILO score for small parenchymal opacities of 1/0 or more, and 1.56 (1.02-2.39) in the 738 with a score of 0/1 or less (ie, those without radiological evidence of pulmonary fibrosis). These results suggest that asbestos is associated with lung cancer even in the absence of radiologically apparent pulmonary fibrosis.