Nick A Francis, Rebecca Cannings-John, Cherry-Ann Waldron, Emma Thomas-Jones, Tom Winfield, Victoria Shepherd, Debbie Harris, Kerenza Hood, Deborah Fitzsimmons, Amanda Roberts, Colin Powell, Micaela Gal, Christopher C Butler

Otitis media with effusion in children with documented hearing loss and attributable symptoms for at least 3 months has a high rate of spontaneous resolution. A short course of oral prednisolone is not an effective treatment for most children aged 2–8 years with persistent otitis media with effusion, but is well tolerated. One in 14 children might achieve improved hearing but not quality of life. Discussions about watchful waiting and other interventions will be supported by this evidence.

Wilbur H Chen, Kathleen M Neuzil, C Rebecca Boyce, Marcela F Pasetti, Mardi K Reymann, Lionel Martellet, Nancy Hosken, F Marc LaForce, Rajeev M Dhere, Sambhaji S Pisal, Amol Chaudhari, Prasad S Kulkarni, Ray Borrow, Helen Findlow, Valerie Brown, Megan L McDonough, Len Dally, Mark R Alderson

The adjuvanted and non-adjuvanted NmCV-5 vaccines were well tolerated and did not produce concerning adverse effects and resulted in immune responses that are predicted to confer protection against all five targeted serogroups of invasive meningococcal disease. Further clinical testing of NmCV-5 is ongoing, and additional clinical trials are necessary to confirm the safety and immunogenicity of NmCV-5 in target populations.

Karina-Doris Vihta, Nicole Stoesser, Martin J Llewelyn, T Phuong Quan, Tim Davies, Nicola J Fawcett, Laura Dunn, Katie Jeffery, Chris C Butler, Gail Hayward, Monique Andersson, Marcus Morgan, Sarah Oakley, Amy Mason, Susan Hopkins, David H Wyllie, Derrick W Crook, Mark H Wilcox, Alan P Johnson, Tim E A Peto, A Sarah Walker

Increases in E coli bloodstream infections in Oxfordshire are primarily community associated, with substantial co-amoxiclav resistance; nevertheless, we found little or no change in mortality. Focusing interventions on primary care facilities, particularly those with high co-amoxiclav use, could be effective in reducing the incidence of co-amoxiclav-resistant E coli bloodstream infections, in this region and more generally.

Michelangelo La Placa, Marco Adriano Chessa

A 41-year-old woman presented to our clinic because of the sudden appearance of erosions on and swelling of her lips. On clinical examination, diffuse erythema of the labial mucosae with small vesicles and crusted erosions on both the superior and inferior vermillion borders were noted (figure). Further inspection of her mouth showed erythema and erosions on the inner cheek and mild focal desquamated gingivitis. The patient was otherwise healthy, with good oral hygiene. No other lesions were seen on the rest of her body.

The Lancet

Following an incident in Bangladesh on July 29, in which two students were hit by a speeding bus and killed, protests were launched in Dhaka against the current state of road safety in the country. The spontaneous direct action involved high-school and college-age students standing in the roads of Dhaka, directing traffic and policing behaviour.

The Lancet

Zika virus infection during pregnancy can cause infants to be born with microcephaly and other congenital abnormalities, with further possible adverse developmental outcomes later in life. Last week, the US Centers for Disease Control and Prevention published the first and largest study to assess health and development problems in children aged 1 year or older in Puerto Rico and other US territories who were born to mothers with laboratory-confirmed or possible Zika infection during pregnancy and had received some follow-up care.

Marco De Ambrogi

Sometimes people who make a difference in an outbreak response are not those who are officially in charge or appear regularly in the headlines. Such is the case of Oliver Johnson and Sinead Walsh, who found themselves in Sierra Leone in 2014, just when the Ebola virus disease outbreak started. Oliver and Sinead—because after reading the book, you will want to call them by their first names and have them as friends—discuss their experience of two complementary fronts of the response to the outbreak in their book Getting to zero: a doctor and a diplomat on the Ebola frontline.

Richard Barnett

Thanks to my insightful and industrious academic colleagues, the challenge of writing this column usually lies in trying to do justice to a heap of monographs and articles in a few hundred words. Compared with cholera, cancer, or hysteria, though, cerebral palsy has provoked little historical scholarship—a curious omission at a time when the recovery of lost voices and experiences lies at the heart of historiographical practice. Even after a century and more of research and debate, in the words of the neurologists Anamarija Kavčič and David B VoduÅ�ek, “it is still easier to explain what cerebral palsy is not”.

Sharmila Devi

At a time of competing priorities, Iraq provides a striking example of how humanitarian aid must continue its support to the country after fighting has subsided. Sharmila Devi reports.

Becky McCall

An expert consensus statement draws attention to the thousands of HIV-related prosecutions and convictions worldwide. Becky McCall reports.

Yu, C., Gan, H., Serra-Cardona, A., Zhang, L., Gan, S., Sharma, S., Johansson, E., Chabes, A., Xu, R.-M., Zhang, Z.

How parental histone (H3-H4)2 tetramers, the primary carriers of epigenetic modifications, are transferred onto leading and lagging strands of DNA replication forks for epigenetic inheritance remains elusive. Here we show that parental (H3-H4)2 tetramers are assembled into nucleosomes onto both leading and lagging strands, with a slight preference for lagging strands. The lagging strand preference increases markedly in cells lacking Dpb3 and Dpb4, two subunits of the leading strand DNA polymerase, Pol , due to the impairment of parental (H3-H4)2 transfer to leading strands. Dpb3-Dpb4 binds H3-H4 in vitro and participates in the inheritance of heterochromatin. These results indicate that different proteins facilitate the transfer of parental (H3-H4)2 onto leading vs lagging strands, and that Dbp3-Dpb4 plays a significant role in this poorly understood process.

Jinglan Jin MD, PhD , Hongqin Xu PhD , Ruihong Wu MM , Junqi Niu MD PhD , Shibo Li MD PhD

Abstract Purpose We aimed to study the aberrant DNA methylation profile associated with hepatitis B virus (HBV) infection and to identify key genes and pathways associated with the HBV infection stage. Methods A total of 54 antiviral treatment‐naive HBV‐infected patients and 6 healthy controls were included. Genome‐wide methylated DNA immunoprecipitation analysis was performed, as previously described, after which the chip data were preprocessed. Subsequently, Cytoscape software was used for the construction of a protein–protein interaction network, and Database for Annotation, Visualization, and Integrated Discovery software was used to conduct functional enrichment analysis. Results A total of 711,794 CpGs were obtained after data quality control, among which 152,780, 113,814, 90,747, and 175,868 CpGs showed differential methylation in acute hepatitis B (AHB) vs. Control, Total‐C vs. Control, CH1 vs. CA1, and AHB vs. Total‐C, respectively. Furthermore, RIPK3, PRDM10, JUN, and SNAI1 were at the center of the four associated networks, respectively. Differential methylated genes differentially methylated in these four comparisons were significantly enriched with olfactory transduction; positive regulation of transport; negative regulation of protein amino acid phosphorylation (e.g., JUN), phosphorylation, phosphorus metabolic process, and phosphate metabolic process; and programmed cell death, respectively. Conclusion RIPK3, PRDM10, JUN, and SNAI1 as well as olfactory transduction, positive regulation of transport, negative regulation of phosphorylation, and programmed cell death are important for the transformation associated with HBV infection stage. Moreover, JUN may be involved in HBV infection, mainly via the negative regulation of amino acid phosphorylation. This article is protected by copyright. All rights reserved.

Ankcorn M, Moreira F, Ijaz S, et al.

AbstractBackgroundPersistent hepatitis E virus (HEV) infection is described in a number of immunosuppressive conditions. We aimed to determine the risk of persistent HEV infection in patients with primary or secondary antibody deficiency.MethodsTwo hundred and forty five antibody deficient patients on regular immunoglobulin replacement were tested for HEV RNA and anti-HEV IgG. Immunoglobulin products and plasma from nine antibody-deficient patients pre- and post-IVIG, five recently treated patients with persistent HEV infection and five healthy patients recovered from acute HEV infection were analysed for anti-HEV IgG and for antibody reacting with HEV antigen (HEV-Ag).ResultsNo antibody deficient patient had detectable plasma HEV RNA. Anti-HEV IgG was detected in 38.8% of patients. All ten immunoglobulin products tested contained anti-HEV capable of neutralising HEV-Ag. Plasma samples following IVIG infusion demonstrated higher anti-HEV IgG and neutralising activity compared with pre-IVIG samples. Neutralising activity was similar to healthy patients with recent acute HEV infection.ConclusionThe risk of persistent HEV infection in patients with antibody deficiency appears extremely low. This may be due to passive seroprotection afforded by the ubiquitous presence of anti-HEV in immunoglobulin replacement products.

José Moreira, Ariane Paixão, Juliana Oliveira, Waldir Jaló, Ofélio Manuel, Rafaela Rodrigues, Alexandra Oliveira, Leonardo Tinoco, João Lima, Beatriz Grinsztejn, Valdiléa G. Veloso, André M. Japiassú, Cristiane C. Lamas

To compare the discriminatory capacity of the quick Sequential Organ Failure Assessment (qSOFA) versus the Systemic Inflammatory Response Syndrome (SIRS) score for predicting 30-day mortality and intensive care unit (ICU) admission in patients with suspicion of infection at an HIV reference center.

Elaine M. Richards

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 422-423, August 15, 2018.

Nenortas, N. P., Cinelli, M. A., Morrell, A. E., Cushman, M., Shapiro, T. A.

African sleeping sickness is responsible for thousands of deaths annually and new therapeutics are needed. This study evaluated aromathecins, experimental inhibitors of mammalian topoisomerase IB, against Trypanosoma brucei African trypanosomes. The compounds had selectively toxic antiparasitic potency, had in situ poisoning activity against the phylogenetically unique topoisomerase in these parasites, and a representative compound intercalated into DNA with micromolar affinity. DNA intercalation and topoisomerase poisoning may contribute to the antitrypanosomal activity of aromathecins.

Dou Qu, Xiaoni Zhong, Guiyuan Xiao, Jianghong Dai, Hao Liang, Ailong Huang

Malcolm S. Duthie, Aurore Lison, Orin Courtenay

Visceral leishmaniasis (VL) is a life-threatening outcome of Leishmania infantum or Leishmania donovani infection. Dogs are the primary domestic reservoir of L. infantum parasites, and ownership of infected dogs increases the risk of human VL. Controlling infection within dog populations is regarded as critical to VL management in endemic countries, both preventing progression of canine disease and limiting parasite transmission to humans and dogs. Here we discuss various strategies that are used to diagnose canine visceral leishmaniasis (CVL) and the possibilities of adapting these for use within population screening and control programs.

Abstract Background Much of the extensive research regarding transmission of malaria is underpinned by mathematical modelling. Compartmental models, which focus on interactions and transitions between population strata, have been a mainstay of such modelling for more than a century. However, modellers are increasingly adopting agent-based approaches, which model hosts, vectors and/or their interactions on an individual level. One reason for the increasing popularity of such models is their potential to provide enhanced realism by allowing system-level behaviours to emerge as a consequence of accumulated individual-level interactions, as occurs in real populations. Methods A systematic review of 90 articles published between 1998 and May 2018 was performed, characterizing agent-based models (ABMs) relevant to malaria transmission. The review provides an overview of approaches used to date, determines the advantages of these approaches, and proposes ideas for progressing the field. Results The rationale for ABM use over other modelling approaches centres around three points: the need to accurately represent increased stochasticity in low-transmission settings; the benefits of high-resolution spatial simulations; and heterogeneities in drug and vaccine efficacies due to individual patient characteristics. The success of these approaches provides avenues for further exploration of agent-based techniques for modelling malaria transmission. Potential extensions include varying elimination strategies across spatial landscapes, extending the size of spatial models, incorporating human movement dynamics, and developing increasingly comprehensive parameter estimation and optimization techniques. Conclusion Collectively, the literature covers an extensive array of topics, including the full spectrum of transmission and intervention regimes. Bringing these elements together under a common framework may enhance knowledge of, and guide policies towards, malaria elimination. However, because of the diversity of available models, endorsing a standardized approach to ABM implementation may not be possible. Instead it is recommended that model frameworks be contextually appropriate and sufficiently described. One key recommendation is to develop enhanced parameter estimation and optimization techniques. Extensions of current techniques will provide the robust results required to enhance current elimination efforts.

Sravanthi Nandavaram

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 521-523, August 15, 2018.

Jiao Zhang

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 509-520, August 15, 2018.

Malancha Karmakar

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 541-544, August 15, 2018.

Arendrup, M. C., Chowdhary, A., Astvad, K. M. T., Jorgensen, K. M.

APX001A is the active moiety of the first-in-class drug candidate APX001. So far, most susceptibility testing studies have examined ≤30 isolates/species, and only one with the EUCAST method. We investigated the in vitro activity of APX001A and five comparators against 540 candidaemia and 122 C. auris isolates.Isolates (17 Candida and 3 yeast species) were identified using CHROMagar, MALDI-TOF and when needed ITS-sequencing. EUCAST E.Def 7.3.1 susceptibility testing included APX001A, amphotericin B, anidulafungin, micafungin, fluconazole, and voriconazole. Wild-type upper limits (WT-UL) were established following the EUCAST-principles for Epidemiological cut off value setting for APX001A allowing classification as WT or non-WT.APX001A MIC50 values (mg/L) were: C. albicans, C. dubliniensis and C. tropicalis 0.004-0.008, C. parapsilosis and C. auris 0.016, C. glabrata 0.06 and C. krusei >0.5. APX001A MICs varied against the rare species from C. pelliculosa ≤0.0005 to C. norvegensis >0.5. APX001A was equally or more in vitro active than the comparators against all species except C. krusei and C. norvegensis. Four isolates were APX001A non-WT, all of which were fluconazole resistant. A correlation was observed between APX001A and fluconazole MICs across all species except C. guilliermondii and C. auris, and when comparing high and low fluconazole MIC isolates of C. albicans, C. dubliniensis, C. glabrata, C. tropicalis and C. auris.APX001A showed promising in vitro activity against most Candida and other yeast species including C. auris when compared to five comparators. WT-ULs were suggested for the common species and a new and un-explained correlation to fluconazole susceptibility was observed.

Tim Lahm

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page e15-e43, August 15, 2018.

Lourdes González-Valero, José María Montiel-Company, Carlos Bellot-Arcís, Teresa Almerich-Torres, José Enrique Iranzo-Cortés, José Manuel Almerich-Silla

by Lourdes González-Valero, José María Montiel-Company, Carlos Bellot-Arcís, Teresa Almerich-Torres, José Enrique Iranzo-Cortés, José Manuel Almerich-Silla To examine the available evidence on the association between exposure to tobacco use in the womb and in infancy and the presence of caries in primary and permanent dentition in children and adolescents. A systematic review was conducted through searches in 4 data bases (Pubmed, Scopus, Embase and Web of Science), complemented by hand-searching. Of the 559 articles identified, 400 were duplicates. Finally, 28 articles were included in the qualitative review and 21 in the meta-analysis. Their quality was assessed using the Newcastle-Ottawa scale. The quality was medium in 44% of the articles included and high in 56%. The overall meta-analysis gave a significant odds ratio (OR = 1.53, 95% confidence interval 1.39–1.68, Z test p-value = 0.000) and high heterogeneity (Q = 200.3, p = 0.000; I2 = 86.52%). Separate meta-analyses were also performed for three subgroups: exposure in the womb (prenatal) and caries in primary dentition, which resulted in a significant OR = 1.46 with a 95% CI of 1.41–1.52 (Z test p = 0.000), without heterogeneity (Q = 0.91, p = 0.824; I2 = 0%); exposure in infancy (postnatal) and caries in primary dentition, with OR = 1.72 (95% CI 1.45–2.05) and high heterogeneity (Q = 76.59, p = 0.00; I2 = 83.01%); and postnatal exposure and caries in permanent dentition, with OR = 1.30 (95% CI 1.25–1.34) and no heterogeneity (Q = 4.48, p = 0.880; I2 = 0%). In children and adolescents, a significant though moderate association was found between passive tobacco exposure and caries.

Manyoo A. Agarwal

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 534-537, August 15, 2018.

Matthew S. Perzanowski

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 532-534, August 15, 2018.

Abstract Background Bacterial meningitis is a life-threatening infection that remains a public health concern. Bacterial meningitis is commonly caused by the following species: Neisseria meningitidis, Streptococcus pneumoniae, Listeria monocytogenes, Haemophilus influenzae and Escherichia coli. Here, we describe BMScan (Bacterial Meningitis Scan), a whole-genome analysis tool for the species identification of bacterial meningitis-causing and closely-related pathogens, an essential step for case management and disease surveillance. BMScan relies on a reference collection that contains genomes for 17 focal species to scan against to identify a given species. We established this reference collection by supplementing publically available genomes from RefSeq with genomes from the isolate collections of the Centers for Disease Control Bacterial Meningitis Laboratory and the Minnesota Department of Health Public Health Laboratory, and then filtered them down to a representative set of genomes which capture the diversity for each species. Using this reference collection, we evaluated two genomic comparison algorithms, Mash and Average Nucleotide Identity, for their ability to accurately and rapidly identify our focal species. Results We found that the results of Mash were strongly correlated with the results of ANI for species identification, while providing a significant reduction in run-time. This drastic difference in run-time enabled the rapid scanning of large reference genome collections, which, when combined with species-specific threshold values, facilitated the development of BMScan. Using a validation set of 15,503 genomes of our species of interest, BMScan accurately identified 99.97% of the species within 16 min 47 s. Conclusions Identification of the bacterial meningitis pathogenic species is a critical step for case confirmation and further strain characterization. BMScan employs species-specific thresholds for previously-validated, genome-wide similarity statistics compiled from a curated reference genome collection to rapidly and accurately identify the species of uncharacterized bacterial meningitis pathogens and closely related pathogens. BMScan will facilitate the transition in public health laboratories from traditional phenotypic detection methods to whole genome sequencing based methods for species identification.

Abstract Background Tuberculosis, bacterial community-acquired pneumonia (CAP), and Pneumocystis jirovecii pneumonia (PJP) are the three commonest causes of hospitalisation in HIV-infected adults. Prompt diagnosis and treatment initiation are important to reduce morbidity and mortality, but are hampered by limited diagnostic resources in resource poor settings. C-reactive protein (CRP) and procalcitonin have shown diagnostic utility for respiratory tract infections, however few studies have focussed on their ability to distinguish between tuberculosis, CAP, and PJP in HIV-infected inpatients. Methods We evaluated the diagnostic accuracy of CRP and procalcitonin, compared with composite reference standards, to discriminate between the three target infections in adult HIV-infected inpatients in two district level hospitals in Cape Town, South Africa. Participants were admitted with current cough and danger signs in accordance with the WHO algorithm for tuberculosis in seriously ill HIV-infected patients. Study clinicians were blinded to CRP and procalcitonin results. Results Two hundred forty-eight participants met study case definitions: 133 with tuberculosis, 61 with CAP, 16 with PJP, and 38 with mixed infection. In the 210 particpants with single infections the differences in median CRP and procalcitonin concentrations between the three infections were statistically significant, but distributions overlapped considerably. CRP and procalcitonin concentrations were highest in the CAP group and lowest in the PJP group. CRP and procalcitonin cut-offs with sensitivities of ≥90% were found for all three target infection pairs, but corresponding specificities were low. Highest receiver operating characteristic areas under the curve for CRP and procalcitonin were for PJP versus tuberculosis and PJP versus CAP (0.68 and 0.71, and 0.74 and 0.69 respectively). Conclusions CRP and procalcitonin showed limited value in discriminating between the three target infections due to widely overlapping distributions, but diagnostic accuracy was higher for discriminating PJP from CAP or tuberculosis. Our findings show limitations for CRP and procalcitonin, particularly for discriminiation of tuberculosis form CAP, however they may have greater diagnostic utility as part of a panel of biomarkers or in clinical prediction rules.

Felix Ratjen

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 526-528, August 15, 2018.

Abstract Background Influenza causes an estimated 3000 to 50,000 deaths per year in the United States of America (US). Timely and representative data can help local, state, and national public health officials monitor and respond to outbreaks of seasonal influenza. Data from cloud-based electronic health records (EHR) and crowd-sourced influenza surveillance systems have the potential to provide complementary, near real-time estimates of influenza activity. The objectives of this paper are to compare two novel influenza-tracking systems with three traditional healthcare-based influenza surveillance systems at four spatial resolutions: national, regional, state, and city, and to determine the minimum number of participants in these systems required to produce influenza activity estimates that resemble the historical trends recorded by traditional surveillance systems. Methods We compared influenza activity estimates from five influenza surveillance systems: 1) patient visits for influenza-like illness (ILI) from the US Outpatient ILI Surveillance Network (ILINet), 2) virologic data from World Health Organization (WHO) Collaborating and National Respiratory and Enteric Virus Surveillance System (NREVSS) Laboratories, 3) Emergency Department (ED) syndromic surveillance from Boston, Massachusetts, 4) patient visits for ILI from EHR, and 5) reports of ILI from the crowd-sourced system, Flu Near You (FNY), by calculating correlations between these systems across four influenza seasons, 2012–16, at four different spatial resolutions in the US. For the crowd-sourced system, we also used a bootstrapping statistical approach to estimate the minimum number of reports necessary to produce a meaningful signal at a given spatial resolution. Results In general, as the spatial resolution increased, correlation values between all influenza surveillance systems decreased. Influenza-like Illness rates in geographic areas with more than 250 crowd-sourced participants or with more than 20,000 visit counts for EHR tracked government-lead estimates of influenza activity. Conclusions With a sufficient number of reports, data from novel influenza surveillance systems can complement traditional healthcare-based systems at multiple spatial resolutions.

Susan L. Norris, Veronica Ivey Sawin, Mauricio Ferri, Laura Reques Sastre, Teegwendé V. Porgo

by Susan L. Norris, Veronica Ivey Sawin, Mauricio Ferri, Laura Reques Sastre, Teegwendé V. Porgo…

HirokiMiura MD , YoshikiKawamura MD, PhD , FumihikoHattori MD, PhD , KeiKozawa MD , MasaruIhira PhD , TamaeOhye PhD , HirokiKurahashi MD, PhD , TetsushiYoshikawa MD, PhD

Sebastian-Perez, V., Hendrickx, S., Munday, J. C., Kalejaiye, T., Martinez, A., Campillo, N. E., de Koning, H., Caljon, G., Maes, L., Gil, C.

The available treatments for leishmaniasis are less than optimal due to inadequate efficacy, toxic side-effects and the emergence of resistant strains, clearly endorsing the urgent need for discovery and development of novel drug candidates. Ideally, these should act via an alternative mechanism-of-action to avoid cross-resistance with the current drugs. As cyclic nucleotide specific phosphodiesterases (PDEs) of L. major have been postulated as putative drug targets, a series of potential inhibitors of Leishmania PDEs was explored. Several displayed potent and selective in vitro activity against L. infantum intracellular amastigotes. One imidazole derivative, compound 35, was shown to reduce the parasite loads in vivo and dose-dependently increase the cellular cAMP level at just 2x and 5x the IC50, indicating a correlation between antileishmanial activity and increased cellular cAMP. Docking studies and molecular dynamics simulations pointed to imidazole 35 exerting its activity through PDE inhibition. This study establishes for the first time that inhibition of cAMP PDEs can potentially be exploited for new antileishmanial chemotherapy.

Paul A. Reyfman

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 440-446, August 15, 2018.

Itzchak Levy, Shiraz Geffen − Halevi, Israel Nissan, Natan Keller, Shlomo Pilo, Anat Wieder − Finesod, Vlady Litchevski, David Shasha, Eynat Kedem, Galia Rahav

Abstract Background During the fifth wave of human H7N9 infections, a novel highly pathogenic (HP) H7N9 variant emerged with an insertion of multiple basic amino acids in the HA cleavage site. Moreover, a neuraminidase inhibitor (NAI) resistance (R292K in NA) mutation was found in H7N9 isolates from humans, poultry and the environment. In this study, we set out to develop and validate a multiplex quantitative reverse transcript polymerase chain reaction (qRT-PCR) to simultaneously detect the presence of H7N9 and further identify the HP and NAI-resistance mutations. Methods A quadruple qRT-PCR to simultaneously detect the presence of H7N9 and further identify the HP and NAI-resistance mutations was designed based on the analyses of the HA and NA genes of H7N9. This assay was further tested for specificity and sensitivity, and validated using clinical samples. Results The assay was highly specific and able to detect low pathogenic (LP)- or HP-H7N9 with/without the NAI-resistance mutation. The detection limit of the assay was determined to be 50 genome-equivalent copies and 2.8 × 10− 3 50% tissue culture infectious doses (TCID50) of live H7N9 per reaction. Clinical validation was confirmed by commercial kits and Sanger sequencing with ten clinical samples. Conclusions We developed and validated a rapid, single-reaction, one-step, quadruple real-time qRT-PCR to simultaneously detect the presence of H7N9 and further identify the HP- and NAI-resistance strains with excellent performance in specificity and sensitivity. This assay could be used to monitor the evolution of H7N9 viruses in the laboratory, field and the clinic for early-warning and the prevention of H7N9 infections.

Basil J. Petrof

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 416-418, August 15, 2018.

Jeremy Herrera

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 4, Page 486-496, August 15, 2018.

Chuanhui Xu, Junxiong Pang, Jung Pu Hsu, Yee Sin Leo, David Chien Boon Lye

by Chuanhui Xu, Junxiong Pang, Jung Pu Hsu, Yee Sin Leo, David Chien Boon Lye Dengue is endemic in Singapore but not China. We compared clinical features and disease severity of dengue between local and migrant Chinese, most of whom were construction workers, in Singapore. A retrospective study with all hospitalized dengue patients from 2005 to 2008 were performed, including 2609 local and 1195 migrant Chinese. Compared with local Chinese, migrant Chinese were younger. There were more males, but fewer had comorbidities. Migrant Chinese had more headache, eye pain, nausea and myalgia. They had significantly lower median leukocyte count, ALT and AST, and higher platelet count nadir. Among warning signs, migrant Chinese had significantly less persistent vomiting, clinical fluid accumulation, hepatomegaly, hematocrit rise with rapid platelet drop, and more mucosal bleeding. Adjusted for age, gender and comorbidities, migrant Chinese were significantly at higher risk of dengue hemorrhagic fever (DHF) (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.03–1.41) and dengue shock syndrome (aOR: 1.49, 95% CI: 1.06–2.10), and had longer hospitalization (β coefficient value: 0.27, 95%CI: 0.09–0.44, p = 0.003). There was 1 death among migrant Chinese and 2 deaths among local Chinese. We documented differences in clinical and laboratory features, and dengue severity between local and migrant Chinese in Singapore. Migrant Chinese may need more medical attention given higher risk of DHF.

Nanny N.M. Soetedjo , Susan M. McAllister , Cesar Ugarte‐Gil , Adela G. Firanescu , Katharina Ronacher , Bachti Alisjahbana , Anca L. Costache , Carlos Zubiate , Stephanus T. Malherbe , Raspati C. Koesoemadinata , Yoko V. Laurence , Fiona Pearson , Sarah Kerry‐Barnard , Rovina Ruslami , David A.J. Moore , Mihai Ioana , Leanie Kleynhans , Hikmat Pernama , Philip C. Hill , Maria Mota , Gerhard Walzl , Hazel M. Dockrell , Julia A. Critchley , Reinout van Crevel ,

Abstract Objective To describe the characteristics and management of Diabetes mellitus (DM) patients from low‐ and middle‐income countries (LMIC). Methods We systematically characterized consecutive DM patients attending public health services in urban settings in Indonesia, Peru, Romania and South Africa, collecting data on DM treatment history, complications, drug treatment, obesity, HbA1c, and cardiovascular risk profile; and assessing treatment gaps against relevant national guidelines. Results Patients (median 59 years, 62.9% female) mostly had type 2 diabetes (96%), half for >5 years (48.6%). Obesity (45.5%) and central obesity (females 84.8%; males 62.7%) were common. The median HbA1c was 8.7% (72 mmol/mol), ranging from 7.7% (61 mmol/mol; Peru) to 10.4% (90 mmol/mol; South Africa). Antidiabetes treatment included metformin (62.6%), insulin (37.8%), and other oral glucose‐lowering drugs (34.8%). Disease complications included eyesight problems (50.4%), EGFR…

Alexander, M. K., Miu, A., Oh, A., Reichelt, M., Ho, H., Chalouni, C., Labadie, S., Wang, L., Liang, J., Nickerson, N. N., Hu, H., Yu, L., Du, M., Yan, D., Park, S., Kim, J., Xu, M., Sellers, B. D., Purkey, H. E., Skelton, N., Koehler, M. F. T., Payandeh, J., Verma, V., Xu, Y., Koth, C. M., Nishiyama, M.

There is a critical need for new antibacterial strategies to counter the growing problem of antibiotic resistance. In Gram-negative bacteria, the outer membrane (OM) provides a protective barrier against antibiotics and other environmental insults. The outer leaflet of the outer membrane is primarily composed of lipopolysaccharide (LPS). Outer membrane biogenesis presents many potentially compelling drug targets, as this pathway is absent in higher eukaryotes. Most proteins involved in LPS biosynthesis and transport are essential; however, few compounds have been identified that inhibit these proteins. The inner membrane ABC transporter MsbA carries out the first essential step in the trafficking of LPS to the outer membrane. We conducted a biochemical screen for inhibitors of MsbA, and identified a series of quinoline compounds that kill E. coli through inhibition of its ATPase and transport activity, with no loss of activity against clinical multidrug resistant strains. Identification of these selective inhibitors indicates that MsbA is a viable target for new antibiotics, and the compounds we identified serve as useful tools to further probe the LPS transport pathway in Gram-negative bacteria.

Abstract Background Vivax malaria is a leading public health concern worldwide. Due to the high prevalence of Duffy-negative blood group population, Plasmodium vivax in Africa historically is less attributable and remains a neglected disease. The interaction between Duffy binding protein and its cognate receptor, Duffy antigen receptor for chemokine plays a key role in the invasion of red blood cells and serves as a novel vaccine candidate against P. vivax. However, the polymorphic nature of P. vivax Duffy binding protein (DBP), particularly N-terminal cysteine-rich region (PvDBPII), represents a major obstacle for the successful design of a DBP-based vaccine to enable global protection. In this study, the level of pvdbpII sequence variations, Duffy blood group genotypes, number of haplotypes circulating, and the natural selection at pvdbpII in Sudan isolates were analysed and the implication in terms of DBP-based vaccine design was discussed. Methods Forty-two P. vivax-infected blood samples were collected from patients from different areas of Sudan during 2014–2016. For Duffy blood group genotyping, the fragment that indicates GATA-1 transcription factor binding site of the FY gene (− 33T > C) was amplified by PCR and sequenced by direct sequencing. The region II flanking pvdbpII was PCR amplified and sequenced by direct sequencing. The genetic diversity and natural selection of pvdbpII were done using DnaSP ver 5.0 and MEGA ver 5.0 programs. Based on predominant, non-synonymous, single nucleotide polymorphisms (SNPs), prevalence of Sudanese haplotypes was assessed in global isolates. Results Twenty SNPs (14 non-synonymous and 6 synonymous) were identified in pvdbpII among the 42 Sudan P. vivax isolates. Sequence analysis revealed that 11 different PvDBP haplotypes exist in Sudan P. vivax isolates and the region has evolved under positive selection. Among the identified PvDBP haplotypes five PvDBP haplotypes were shared among Duffy-negative as well as Duffy-positive individuals. The high selective pressure was mainly found on the known B cell epitopes (H3) of pvdbpII. Comparison of Sudanese haplotypes, based on 10 predominant non-synonymous SNPs with 10 malaria-endemic countries, demonstrated that Sudanese haplotypes were prevalent in most endemic countries. Conclusion This is the first pvdbp genetic diversity study from an African country. Sudanese isolates display high haplotype diversity and the gene is under selective pressure. Haplotype analysis indicated that Sudanese haplotypes are a representative sample of the global population. However, studies with a large number of samples are needed. These findings would be valuable for the development of PvDBP-based malaria vaccine.

Karvellas, Constantine J.; Garcia-Lopez, Elisabet; Fernandez, Javier; Saliba, Faouzi; Sy, Eric; Jalan, Rajiv; Pavesi, Marco; Gustot, Thierry; Ronco, Juan J.; Arroyo, Vicente; for the Chronic Liver Failure Consortium and European Foundation for the Study of Chronic Liver Failure

Objectives: To evaluate the Chronic Liver Failure-Consortium Acute on Chronic Liver Failure score in acute on chronic liver failure patients admitted to ICUs from different global regions and compare discrimination ability with previously published scores. Design: Retrospective pooled analysis. Setting: Academic ICUs in Canada (Edmonton, Vancouver) and Europe (Paris, Barcelona, Chronic liver failure/Acute-on-Chronic Liver Failure in Cirrhosis [CANONIC] study). Patients: Sample of analysis of 867 cirrhotic patients with acute on chronic liver failure admitted to ICU. Cumulative incidence functions of death were estimated by acute on chronic liver failure grade at admission and at day 3. Survival discrimination abilities of Chronic Liver Failure-Consortium Acute on Chronic Liver Failure, Model for End-Stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, and Child-Turcotte-Pugh scores were compared. Interventions: ICU admission for organ support. Measurements and Main Results: At admission 169 subjects (19%) had acute on chronic liver failure 1, 302 (35%) acute on chronic liver failure 2, and 396 (46%) had acute on chronic liver failure 3 with 90-mortality rates of 33%, 40%, and 74%, respectively (p < 0.001). At admission, Chronic Liver Failure-Consortium Acute on Chronic Liver Failure demonstrated superior discrimination at 90 days compared with Acute Physiology and Chronic Health Evaluation II (n = 532; concordance index 0.67 vs 0.62; p = 0.0027) and Child-Turcotte-Pugh (n = 666; 0.68 vs 0.64; p = 0.0035), but not Model for End-Stage Liver Disease (n = 845; 0.68 vs 0.67; p = 0.3). A Chronic Liver Failure-Consortium Acute on Chronic Liver Failure score greater than 70 at admission or on day 3 was associated with 90-day mortality rates of approximately 90%. Ninety-day mortality in grade 3 acute on chronic liver failure patients at admission who demonstrated improvement by day 3 was 40% (vs 79% in patients who did not). Conclusions: The Chronic Liver Failure-Consortium Acute on Chronic Liver Failure demonstrated better discrimination at day 28 and day 90 compared with Acute Physiology and Chronic Health Evaluation II and Child-Turcotte-Pugh. Patients who demonstrated clinical improvement post-ICU admission (e.g., acute on chronic liver failure 3 to 1 or 2) at day 3 had better outcomes than those who did not. In high-risk ICU patients (Chronic Liver Failure-Consortium Acute on Chronic Liver Failure > 70), decisions regarding transition to palliation should be explored between patient families and the ICU providers after a short trial of therapy. This article followed the Strengthening the Reporting of Observational Studies in Epidemiology guideline (Supplementary File 9, Supplemental Digital Content 9, http://links.lww.com/CCM/D901). This work was performed at the University of Alberta, European Foundation for the Study of Chronic Liver Failure, Barcelona Clinic, University of British Columbia and Hospital Paul-Brousse (Paris, France). Dr. Karvellas conceived the idea for the study, performed data analysis, and drafted the article. Ms. Garcia-Lopez performed statistical analyses and significantly revised final article. Drs. Fernandez, Saliba, Sy, Jalan, Pavesi, Gustot, Ronco provided data and significantly revised final article. Dr. Arroyo assisted with study design and analysis and significantly revised final article. All authors approve the final manuscript. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Supported, in part, by the European Association for the Study of Liver Chronic Liver Failure Consortium has an unrestricted grant from Grifols. Dr. Karvellas disclosed that the European Association for the Study of Liver Chronic Liver Failure Consortium has an unrestricted grant from Grifols (however, he is not part of this consortium). Ms. Garcia-Lopez disclosed work for hire. Dr. Fernandez received funding from Grifols SA. Dr. Jalan’s institution received funding from Yaqrit Limited (he founded this company to develop three interventions that were developed in his laboratory and University, and he has collaborative grants), Ocera Therapeutics (a drug he invented for the treatment of hepatic encephalopathy is licensed by his university to this company), Sequana Medical (chief investigator on a study funded by this company), and Takeda (research collaboration). The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Constantine J. Karvellas, MD, FRCPC, Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1–40 Zeidler Ledcor Building, Edmonton, AB T6G-2X8, Canada. E-mail: dean.karvellas@ualberta.ca Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Peter Ssebutinde, Imelda T. Kyamwanga, Eleanor Turyakira, Stephen Asiimwe, Francis Bajunirwe

by Peter Ssebutinde, Imelda T. Kyamwanga, Eleanor Turyakira, Stephen Asiimwe, Francis Bajunirwe Background The prevalence of HIV infection among older persons is increasing yet older age at initiation of antiretroviral therapy (ART) may be associated with poorer treatment outcomes including mortality. However, majority of these studies have been done in the western world and there is limited data in resource limited settings. Our study used routinely collected health facility data to assess trends in age at initiation of ART, the effect of age at ART initiation on mortality and immunological response at a large urban hospital in south western Uganda. Methods We conducted a retrospective records review of patients attending the HIV clinic at Mbarara Regional Referral Hospital in western Uganda. We retrieved records for 8,533 patients who started ART between January 2006 and December 2012. Their data had been collected and stored as part of the larger International Epidemiological Database for the Evaluation of AIDS (IeDEA). Age was stratified into three categories namely; 18–34 (young adults), 35–49 (mid-age) and 50 years or older (older adults). Survival analysis procedures with Kaplan-Meier’s plots were used to calculate the survival probability with mortality as the endpoint and Poisson regression analysis used to determine the adjusted relative risks (RR) of mortality. Results The proportion of young adults and patients at WHO stage I initiating ART increased steadily over the 7-year period. Older age at ART initiation (> = 50 years) was associated with a higher risk of mortality with adjusted relative risk (RR) at 1.63, (95% CI 1.26–2.11) compared to younger age. Male gender, WHO stages III and IV, lower CD4 count and lower body mass index were also all independently and significantly associated with higher risk for mortality. Older adults also had a poorer immunological response RR = 1.79 (95% CI 0.89–3.58) but was not statistically significant. Conclusions Following ART initiation, older adults compared to the young, have a higher risk of mortality. This age group should be targeted first for ‘screen and treat’ approach. Optimization of ART treatment regimens for this age group is also required to reduce mortality and improve immunological response.

David Elias Kayabu, James Samwel Ngocho, Blandina Theophil Mmbaga

by David Elias Kayabu, James Samwel Ngocho, Blandina Theophil Mmbaga Background Linkage to care and treatment is an important part of efforts to accelerate HIV prevention, treatment, care, and support. It offers an opportunity for PLHIV to receive information and services in a timely manner. Clients who present late for HIV care and treatment may miss out on timely initiation of prophylaxis and ART, which may accelerate disease progression and lead to an increased rate of HIV transmission within the community. The objective of this study was to determine the factors influencing effective linkages of newly diagnosed PLHIV from the point of testing to entry in care and treatment centres (CTCs) in Tanga Region, Tanzania. Methods This cross-sectional study examined five clinics with a high volume of clients in each of the three districts in Tanga Region. All adults ages 18 years and above at the time of CTC enrolment, between 2010 and 2014, were eligible to participate in the study.The study engaged both secondary and primary data. To complement the secondary data, mixed methods were applied in primary data collection. Using a structured questionnaire, interviews with the sampled CTC clients while focus group discussions with healthcare providers and in-depth interviews with CTC clients.The qualitative data were analysed using a thematic analysis framework. The outcome of interest was whether a client enrolled in a CTC within three months of his or her first positive HIV test. A logistic regression model was used to determine factors associated with effective linkage of newly diagnosed HIV clients to CTC. Results A total of 16,041 adults from the three study districts were enrolled at a CTC from 2010 to 2014. A total of 1,096 clients from the sampled CTCs were recruited into the study for interview. The characteristics of these clients were representative of the larger group (16,041). The majority (72.4%) were female. More than half (52.1%) were married, and almost a quarter (21.2%) were single. The majority (59.6%) of participants completed primary education and almost half (45.1%) were subsistence farmers. The median CD4 count at enrolment was 218 (87–397) cells/mL with more than half (56.3%) having CD4 counts of less than 350 cells per millilitre (mL). Nearly all (91%) of the clients presented at a CTC within three months of receiving a positive HIV test. In a multivariate analysis, factors that remained significantly associated with early entry in CTC were level of education, CD4 count, and point of diagnosis. Participants’ responses were consistent with many of the factors explained by participants to be barriers to effective linkages and referrals repeated in the FGDs and IDIs across the study sites. For instance, FGD respondent expressed that clients were worried about stigma from their relatives, which creates a delay in seeking treatment. Conclusion Although the rate of early entry in care and treatment services is high, surprisingly was a marked increase in those who waited more than three months to seek treatment. To meet the target, issues such as disclosure and stigma need to be addressed.

Yasu, T., Konuma, T., Oiwa-Monna, M., Kato, S., Tanoue, S., Isobe, M., Mizusawa, M., Kuroda, S., Takahashi, S., Tojo, A.

Liposomal amphotericin B (L-AMB) is widely used for empirical or preemptive therapy and treatment of invasive fungal infection after cord blood transplantation (CBT). We retrospectively examined the efficacy and safety of low-dose L-AMB in 48 adult patients of CBT from between 2006 and 2017 in our institute. Among the entire cohort, 42 (88%) patients received L-AMB as an empirical or preemptive therapy. The median daily dose of L-AMB and the median cumulative dose of L-AMB were 1.20 mg/kg/day (range, 0.62–2.60 mg/kg/day) and 30.6 mg/kg (range, 0.7–241.5 mg/kg), respectively. The median duration of L-AMB administration was 21.5 days (range, 1–313 days). Documented breakthrough fungal infection occurred in 1 patient during L-AMB treatment, and 43 (90%) patients survived for at least 7 days after the end of L-AMB treatment. Grade 3 or higher hypokalemia and hepatotoxicity were frequently observed during L-AMB treatment. However, no patients developed an increase in serum creatinine of grade 3 or higher. In the univariate analysis using a logistic regression model, a duration of L-AMB treatment of more than 21 days and a cumulative dose of L-AMB more than 30 mg/kg were significantly associated with nephrotoxicity and grade 3 hypokalemia. These data suggest that low-dose L-AMB may be safe and effective in adult patients undergoing CBT.

P. P. Kohler et al.

Manuja, A., Kumar, B., Kumar, R., Chopra, M., Dilbaghi, N., Kumar, S., Yadav, S. C.

Quinapyramine sulfate (QS) produces trypanocidal effect against the parasite Trypanosoma evansi, but often poorly tolerated and causes serious local reactions in animals. The encapsulation of QS in chitosan/mannitol to provide the sustained release would improve both the therapeutic effect of QS and the quality of life of animals treated with this formulation. QS was encapsulated into nanoformulation prepared from chitosan, tripolyphosphate and mannitol nanomatrix (ChQS-NPs). ChQS-NPs were well-ordered in shape with nanoparticle size as determined by transmission electron microscopy and atomic force microscopy. Our research revealed a dose-dependent biosafety and DNA damage in mammalian cells treated with ChQS-NPs. ChQS-NPs were absolutely risk-free at effective as well as many times higher doses against T. evansi. ChQS-NPs were effective in rabbits as they killed the parasites, relieving the animals from the clinical symptoms of the disease. The extent of this protection was similar to that observed with the conventional drug at higher dosages (5 mg QS/Kg Bwt). ChQS-NPs are safe, non toxic and effective as compared to QS and offer a promising alternative to drug-delivery against trypanosomosis in animal models. ChQS-NPs may be useful for the treatment of trypanosomosis due to reduced dosages and frequency of administration.

Abstract Background Measles is a highly infectious and serious respiratory viral disease which caused by a virus. It is a significant cause of illness and death worldwide. This data analysis was conducted to describe the trend and determine the reporting rate of measles cases in Addis Ababa to make recommendation for the government of the city to strengthening measles control interventions. Methods We obtained and extracted ten years (2005–2014) Addis Ababa city’s measles surveillance data from national database. We carried out retrospective descriptive data analysis by time, place and person variables. We calculated cumulative and specific reporting rates by dividing measles cases (lab confirmed, epidemiologically linked and compatible cases) to respective population and multiplying by 100,000. We divided average of ten years measles cases to midyear population and multiplied by 100,000 to calculate annualized reporting rate. We analyzed non-measles febrile rash rate by dividing laboratory negative cases to total population and multiplying by 100,000. Results A total of 4203 suspected measles cases were identified. Among them 1154 (27.5%) were laboratory confirmed, 512 (12.2%) were clinically compatible, 52 (1.2%) were epidemiologically linked cases and the rest 2485 (59.1%) were IgM negative for measles which makes total measles cases 1718 (40.9%). Median age was 5 years with 2–18 years interquartile-range. The annualized measles reporting rate was 5.9, which was 40.2 among > 1 year, 11.5 among 1–4 years, 6.0 among 5–14 years, 4.1 among 15–44 years and 0.01 among ≥ 45 years per 100,000 population. Among the total measles cases; 380 (22%) were received at least one dose of measles containing vaccine (MCV) while 415 (24%) cases were not vaccinated and the vaccination status of 923 (54%) cases were not known. Conclusion Our analysis revealed that the reporting rate was higher among young children than older age group. Among all the patients 22% were received at least one dose of measles vaccine whereas 13% were not vaccinated against measles antigen. Routine immunization should be strengthened to reach all children through well monitored vaccine cold chain management.