Deborah Nyirenda, Kate Gooding, Wezzie Lora, Moses Kumwenda, Meredith McMorrow, Dean Everett, Nicola Desmond

by Deborah Nyirenda, Kate Gooding, Wezzie Lora, Moses Kumwenda, Meredith McMorrow, Dean Everett, Nicola Desmond Background Community engagement on research design is widely highlighted as an important approach for ethical research. This article reports the experience of consulting with communities on the logo used for an influenza study in Malawi. The logo was designed for use on badges worn by study researchers, participant information sheets and other project documents, and could affect perceptions of the study and consequent engagement in the research. Methods Four focus group discussions were conducted with populations targeted by the influenza study: pregnant women, people with HIV, mothers and community members. The focus groups incorporated a participatory matrix exercise focusing on key themes emerging from the discussions such as: attractiveness, comprehension, acceptability and suggestions for improvement. Findings from the focus groups were analyzed according to these key themes. Results The consultation highlighted important benefits of discussion with communities on research design, including providing new perspectives and helping to avoid harm. For example, people living with HIV felt that one of the possible logos could increase stigma within communities. The experience also indicated potential challenges of consultation. In particular, there were contrasting perspectives among the groups, such that the consultation did not provide a clear answer about which logo should be selected. Conclusions Our experience adds to current evidence on community engagement by reporting on an area where there is less discussion of community consultation for design of a study logo. The consultation exercise reaffirmed the value of community engagement, but also the difficulty of relying on a brief consultation for decision-making in research design. Further ethical guidance is required on how to negotiate contradictory views during consultations.

Tetsuo Koshizuka, Kuniaki Toriyabe, Yuko Sato, Kazufumi Ikuta, Tomoaki Ikeda, Tatsuo Suzutani

Iacopo Franconi, Olga Theou, Lindsay Wallace, Andrea Malagoli, Cristina Mussini, Kenneth Rockwood, Giovanni Guaraldi

by Iacopo Franconi, Olga Theou, Lindsay Wallace, Andrea Malagoli, Cristina Mussini, Kenneth Rockwood, Giovanni Guaraldi Background Standard care for HIV clinical practice has started focusing on age-related problems, but despite this recent change physicians involved in HIV care do not often screen HIV patients for frailty. Our aim was to construct three indexes from an HIV clinical database (i.e. Frailty Index, (FI), HIV Index, (HIVI), and Protective Index (PI)) and to assess levels of frailty, HIV severity and demographic and protective lifestyle factors among HIV patients. Methods and findings We included data from 1612 patients who attended an Italian HIV clinic between September 2016 and December2017 (mean±SD age: 53.1±8 years, 73.9% men).We used 92 routine variables collected by physicians and other health care professionals to construct three indexes: a 72-item FI (biometric, psychiatric, blood test, daily life activities, geriatric syndromes and nutrition data), a 10-item HIVI (immunological, viral and therapeutics) and a 10-item PI (income, education, social engagement, and lifestyle habits data)(the lower the FI and HIVI scores, and the higher the PI scores, the lower the risk for participants).The FI, HIVI and PI scores were 0.19±0.08, 0.48±0.17 and 0.62±0.13, respectively. Men had higher FI (0.19±0.08 vs 0.18±0.08; p = 0.010) and lower HIVI (0.47±0.18 vs 0.50±0.15; p = 0.038) scores than women. FI and HIVI scores both increased 1.9% per year of age (p < 0.001), whereas the PI decreased 0.2% per year (p…

Kapetshi J, Fausther-Bovendo H, Corbett C, et al.

AbstractDetection of chains of transmission is critical to interrupt Ebola virus (EBOV) outbreaks. For >25 years, quantitative reverse transcription polymerase chain reaction performed on biological fluids has been the reference standard for EBOV detection and identification. In the current study, we investigated the use of environmental sampling to detect EBOV shed from probable case patients buried without the collection of bodily fluids. During the 2012 Bundibugyo virus (BDBV) outbreak in the Democratic Republic of the Congo, environmental samples were screened for BDBV RNA by means of real-time polymerase chain reaction. Low levels of BDBV genomic RNA were detected in a hospital and in a house. Detection of BDBV RNA in the house led to the identification of the last chain of transmission still active, which resulted in the safe burial of the person with the last laboratory-confirmed case of this outbreak. Overall, environmental sampling can fill specific gaps to help confirm EBOV positivity and therefore be of value in outbreak management.

Low, L. M., Ssemaganda, A., Liu, X. Q., Ho, M.-F., Ozberk, V., Fink, J., Sundac, L., Alcorn, K., Morrison, A., OCallaghan, K., Gerrard, J., Stanisic, D. I., Good, M. F.

Naturally acquired immunity to malaria is robust and protective against all strains of the same species of Plasmodium. This develops as a result of repeated natural infection, taking several years to develop. Evidence suggests that apoptosis of immune lymphocytes due to uncontrolled parasite growth contributes to the slow acquisition of immunity. To hasten and augment the development of natural immunity, we studied controlled infection immunization (CII) using low dose exposure to different parasite species (P. chabaudi, P. yoelii or P. falciparum) in two rodent systems (BALB/c and C57BL/6) and in human volunteers, with drug therapy commencing at the time of initiation of infection. CIIs with infected erythrocytes and in conjunction with doxycycline or azithromycin, which are ‘delayed death’ drugs targeting the parasite’s apicoplast, allow extended exposure to parasites at low levels. In turn, this induces strong protection in all immunized mice against homologous challenge. We show that P. chabaudi/P. yoelii infection initiated at the commencement of doxycycline therapy leads to cellular or antibody-mediated protective immune responses in mice, with a broad Th1 cytokine response providing the best correlate of protection against homologous and heterologous species of Plasmodium. P. falciparum CII with doxycycline was additionally tested in a pilot clinical study (n=4) and was found to be well tolerated and immunogenic, with immunological studies primarily detecting increased cellular-associated immune responses. Furthermore, we report that a single dose of the longer-acting drug, azithromycin, given to mice (n=5) as a single subcutaneous treatment at the initiation of infection controlled P. yoelii infection and protected all mice against subsequent challenge.

Qianqian Fan, Wai-kit Ming, Wai-ying Yip, Joyce H.S. You

Hong Kong is a high-income city of China with intermediate tuberculosis (TB) burden and 1% of TB cases were multidrug-resistant tuberculosis (MDR-TB). We aimed to examine the potential cost-effectiveness of adding bedaquiline or delamanid to background regimen (BR) for treatment of MDR-TB in Hong Kong.

Kazumi Yamasaki, Junko Tanaka, Akemi Kurisu, Tomoyuki Akita, Masayuki Ohisa, Kazuaki Sakamune, Ko Ko, Aya Sugiyama, Takahiro Yasaka, Satoshi Shirahama

K. T. Bruner et al.

Seydlova, G., Sokol, A., Liskova, P., Konopasek, I., Fiser, R.

Daptomycin is a calcium-dependent lipodepsipeptide antibiotic clinically used to treat serious infections caused by Gram-positive pathogens. Its precise mode of action is somewhat controversial; the biggest issue is daptomycin pore formation, which we directly investigated here. We first performed a screening experiment using propidium iodide (PI) entry to Bacillus subtilis cells and chose the optimum and therapeutically relevant conditions (10 µg/mL daptomycin and 1.25 mM CaCl2) for the subsequent analyses. Using conductance measurements on planar lipid bilayers, we show that daptomycin forms non-uniform oligomeric pores with conductance ranging from 120 pS up to 14 nS. The smallest conductance unit is probably a dimer, however tetramers and pentamers occur in the membrane most frequently. Moreover, daptomycin pore-forming activity is exponentially dependent on the applied membrane voltage. We further analyzed the membrane permeabilizing activity in B. subtilis cells using fluorescence methods (PI, DiSC3(5)). Daptomycin most rapidly permeabilizes cells with high initial membrane potential and dissipates it within a few minutes. Low initial membrane potential hinders daptomycin pore formation.

Manyando Simbotwe, Daisuke Fujikura, Miyuki Ohnuma, Ryosuke Omori, Yoshikazu Furuta, Geoffrey Munkombwe Muuka, Bernard Mudenda Hang’ombe, Hideaki Higashi

by Manyando Simbotwe, Daisuke Fujikura, Miyuki Ohnuma, Ryosuke Omori, Yoshikazu Furuta, Geoffrey Munkombwe Muuka, Bernard Mudenda Hang’ombe, Hideaki Higashi In Zambia, anthrax outbreaks among cattle are reported on nearly an annual basis. Presently, there is a lack of serological assays and information to develop an anthrax management and control strategy. In this study, an indirect enzyme-linked immunosorbent assay (ELISA) based on recombinant protective antigen domain 1 (rPA-D1) of Bacillus anthracis was developed and used to detect anti-PA antibodies in cattle in Zambia. An antigen coating of 10 ng/well and a serum dilution of 1:100 were determined to be the optimal rPA-D1 ELISA titration conditions. The intra- and inter-assay % coefficients of variation were less than 10% and 15%, respectively. The rPA-D1 ELISA could detect seroconversion in the cattle 1 month after anthrax vaccination. In a cross-sectional study conducted in the Western Province, Zambia, 187 serum samples from 8 herds of cattle were screened for anti-PA antibodies using the rPA-D1 ELISA. The seropositive rate of the serum samples was 8%, and the mean anti-PA antibody was 0.358 ELISA units. Additionally, we screened 131 cattle serum samples from Lusaka, which is a nonendemic area, and found no significant association between the antibody levels and sampling area (endemic versus nonendemic area). Conversely, significant differences were observed between the anti-PA antibody levels and herds, anti-PA antibody levels and vaccination status and anti-PA antibody levels and vaccination timing. Collectively, these findings suggest that the rPA-D1 ELISA is a useful tool for the detection of anti-PA antibodies in cattle in Zambia. The low proportion of seropositive sera indicates that there is inadequate cattle vaccination in the Western Province and, in addition to other epidemiological factors, this may precipitate the anthrax outbreak recurrence.

Tanimoto, Y., Tamai, S., Matsuzaki, T., Takeuchi, N., Noju, T., Yanagida, S., Kage-Nakadai, E., Yamaguchi, Y., Kodama, T., Nakamura, S., Motooka, D., Iida, T., Nishikawa, Y.

Diarrheagenicity of diffusely adherent Escherichia coli (DAEC) remains controversial. Previously, we found that motile DAEC strains isolated from diarrheal patients induced high levels of interleukin 8 (IL-8) secretion via Toll-like receptor 5 (TLR5). However, DAEC strains from healthy carriers hardly induced IL-8 secretion, irrespective of their possessing flagella. In this study, we demonstrated that SK1144, a DAEC strain from a healthy carrier, suppressed IL-8 and IL-6 secretion from human epithelial cell lines. Suppression of IL-8 in human embryonic kidney (HEK293) cells that were transformed to express TLR5 was observed not only upon inflammatory stimulation by flagellin but also in response to tumor necrosis factor-alpha (TNF-α) and phorbol myristate acetate (PMA), despite the fact that the TNF-α- and PMA-induced inflammatory pathways reportedly are not TLR5-mediated. SK1144 neither decreased IL-8 transcript accumulation nor increased intracellular retention of IL-8. No suppression was observed when the bacteria were cultured in Transwell cups above the epithelial cells; however, a non-adherent bacterial mutant (lacking the afimbrial adhesin gene) still inhibited IL-8 secretion. Direct contact between the bacteria and epithelial cells was necessary, but diffuse adhesion was dispensable for the inhibitory effects. Infection in the presence of chloramphenicol did not suppress cytokine release by the epithelial cells, suggesting that suppression depended on effectors synthesized de novo. Inflammatory suppression was attenuated with infection by a bacterial mutant deleted for hcp (encoding a component of a type-VI secretion system). In conclusion, DAEC strains from healthy carriers impede epithelial cell cytokine secretion, possibly by interfering with translation via the type-VI secretion system.

Jason Rho

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 8, Page 1055-1063, October 15, 2018.

Kieran Palmer

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 8, Page 1102-1103, October 15, 2018.

Abstract Background Ongoing epidemiological transitions across Africa are particularly evident in fast-growing towns, such as Ifakara in the Kilombero valley, south-eastern Tanzania. This town and its environs (population ~ 70,000) historically experienced moderate to high malaria transmission, mediated mostly by Anopheles gambiae and Anopheles funestus. In early 2000s, malaria transmission [Plasmodium falciparum entomological inoculation rate (PfEIR)] was estimated at ~ 30 infectious bites/person/year (ib/p/yr). This study assessed the PfEIR after 15 years, during which there had been rapid urbanization and expanded use of insecticide-treated nets (ITNs). Methods Randomly-selected 110 households were sampled across Ifakara town and four adjacent wards. Mosquitoes were trapped nightly or monthly (June.2015–May.2016) using CDC-light-traps indoors, Suna® traps outdoors and human landing catches (HLC) indoors and outdoors. All Anopheles mosquitoes were morphologically identified and analysed by ELISA for Plasmodium circumsporozoite proteins. Mosquito blood meals were identified using ELISA, and sub-samples of An. gambiae and An. funestus examined by PCR to distinguish morphologically-similar siblings. Insecticide resistance was assessed using WHO-susceptibility assays, and some Anopheles were dissected to examine ovariole tracheoles for parity. Results After 3572 trap-nights, one Plasmodium-infected Anopheles was found (an An. funestus caught outdoors in Katindiuka-ward by HLC), resulting in overall PfEIR of 0.102 ib/p/yr. Nearly 80% of malaria vectors were from Katindiuka and Mlabani wards. Anopheles gambiae densities were higher outdoors (64%) than indoors (36%), but no such difference was observed for An. funestus. All An. funestus and 75% of An. gambiae dissected were parous. Anopheles gambiae complex consisted entirely of Anopheles arabiensis, while An. funestus included 84.2% An. funestus s.s., 4.5% Anopheles rivulorum, 1.4% Anopheles leesoni and 9.9% with unamplified-DNA. Anopheles gambiae were susceptible to bendiocarb and malathion, but resistant to pyrethroids, DDT and pirimiphos-methyl. Most houses had brick walls and/or iron roofs (> 90%), and 52% had screened windows. Conclusion Malaria transmission in Ifakara has decreased by > 99% since early-2000s, reaching levels nearly undetectable with current entomological methods. These declines are likely associated with ITNs use, urbanization and improved housing. Remaining risk is now mostly in peri-urban wards, but concerted efforts could further decrease local transmission. Parasitological surveys are required to assess actual prevalence, incidence and importation rates.

Abstract Background Long-lasting insecticide-treated nets and indoor residual spraying protect against indoor-biting and indoor-resting mosquitoes but are largely ineffective for early-biting and outdoor-biting malaria vectors. Complementary tools are, therefore, needed to accelerate control efforts. This paper describes simple hessian ribbons treated with spatial repellents and wrapped around eaves of houses to prevent outdoor-biting and indoor-biting mosquitoes over long periods of time. Methods The eave ribbons are 15 cm-wide triple-layered hessian fabrics, in lengths starting 1 m. They can be fitted onto houses using nails, adhesives or Velcro, without completely closing eave-spaces. In 75 experimental nights, untreated ribbons and ribbons treated with 0.02%, 0.2%, 1.5% or 5% transfluthrin emulsion (spatial repellent) were evaluated against blank controls using two experimental huts inside a 202 m2 semi-field chamber where 500 laboratory-reared Anopheles arabiensis were released nightly. Two volunteers sat outdoors (one/hut) and collected mosquitoes attempting to bite them from 6 p.m. to 10 p.m. (outdoor-biting), then went indoors and slept under bed nets, beside which CDC-light traps collected mosquitoes from 10 p.m. to 6.30 a.m. (indoor-biting). To assess survival, 200 caged mosquitoes were suspended near the huts nightly and monitored for 24 h thereafter. Additionally, field tests were done in experimental huts in a rural Tanzanian village to evaluate treated ribbons (1.5% transfluthrin). Here, indoor-biting was assessed using window traps and Prokopack® aspirators, and outdoor-biting assessed using volunteer-occupied double-net traps. Results Indoor-biting and outdoor-biting decreased > 99% in huts fitted with eave ribbons having ≥ 0.2% transfluthrin. Even 0.02% transfluthrin-treated ribbons provided 79% protection indoors and 60% outdoors. Untreated ribbons however reduced indoor-biting by only 27% and increased outdoor-biting by 18%, though these were non-significant (P > 0.05). Of all caged mosquitoes exposed near treated huts, 99.5% died within 24 h. In field tests, the ribbons provided 96% protection indoors and 84% outdoors against An. arabiensis, plus 42% protection indoors and 40% outdoors against Anopheles funestus. Current prototypes cost ~ 7USD/hut, are made of widely-available hessian and require no specialized expertise. Conclusion Transfluthrin-treated eave ribbons significantly prevented outdoor-biting and indoor-biting malaria vectors and could potentially complement current tools. The technique is simple, low-cost, highly-scalable and easy-to-use; making it suitable even for poorly-constructed houses and low-income groups.

Thierry Troosters

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 8, Page 1021-1032, October 15, 2018.

Neodo, A., Schulz, J. D., Huwyler, J., Keiser, J.

Soil-transmitted helminth (STH) infections still remain a major health problem in poor rural settings. The lack of efficacious drugs against all STH species raises the interest in drug combinations. Drug-drug interactions are, however, of major concern so that careful in vitro and in vivo characterization is needed. The combination of tribendimidine with either ivermectin or oxantel pamoate targets a broad range of STH and thus, represents a promising treatment alternative. Drug-drug interactions, however, have not yet been investigated. Therefore, the effect of combinations of ivermectin, oxantel pamoate and tribendimidine’s active metabolite deacylated amidantel (dADT) on the CYP450 metabolism was evaluated followed by a pharmacokinetic analysis of tribendimidine and ivermectin alone and in combination in healthy rats. Oxantel pamoate is only poorly absorbed and was therefore excluded from pharmacokinetic analysis. No evident effect was observed for tribendimidine-oxantel pamoate at CYP450 metabolism level, whereas a combination of tribendimidine and ivermectin led to a moderately increased CYP2D6 inhibition as compared to ivermectin or tribendimidine alone. Co-administration of tribendimidine with ivermectin altered neither the Tmax nor elimination half-lives of dADT, adADT and ivermectin. While the AUCs and Cmax of dADT, adADT and ivermectin are reduced by co-administration, the change is insufficient to declare that a DDI has been detected. Further studies are necessary to understand the observed interaction of tribendimidine and ivermectin, which is not related to P450 metabolism, and its significance for the situation in human.

Abstract Background Artemisinin-based combination therapy (ACT) is the first-line anti-malarial treatment of uncomplicated malaria in most malaria endemic countries, including Tanzania. Unfortunately, there have been reports of artemisinin resistance and ACT failure from South East Asia highlighting the need to monitor therapeutic efficacy of ACT in these countries as recommended by World Health Organization. Methods Open-label single arm studies in mainland Tanzania were conducted in nine sentinel sites in 2011, 2012 and 2015 to assess the efficacy and safety of artemether/lumefantrine (AL) and artesunate/amodiaquine (ASAQ) using 28 days follow-up and dihydroartemisinin/piperaquine (DHAPQ) using 42 days follow-up. Mutations in the propeller domain of the Plasmodium falciparum kelch 13 (k13) gene and amplification of the P. falciparum plasmepsin 2 (pm2) gene, associated with artemisinin and piperaquine (PQ) resistance, were also investigated. Results Of the 428 patients enrolled, 328 patients provided study endpoint. For AL, the PCR corrected per-protocol analysis showed adequate clinical and parasitological response (ACPR) of 90.3% (n = 28; 95% CI 74.2–98.0) in Kyela 2012, 95.7% (n = 22; 95% CI 78.1–99.0) in Chamwino, 100% in Muheza (n = 29; 95% CI 88.1–100), 100% in Nagaga (n = 39; 95% CI 91.0–100) and Kyela 2015 (n = 60; 95% CI 94.0–100). For ASAQ, PCR corrected ACPR of 98% (n = 49; 95% CI 89.4–99.9) and 100% (n = 25; 95% CI 86.3–100) were observed in 2011 in Ujiji and Kibaha, respectively. For DHAPQ, the ACPR was 100% (n = 71; 95% CI 94.9–100). Of the 235 samples with genetic interpretable results, only 7 (3%) had non-synonymous k13 mutations. None of these are candidate or validated markers of artemisinin resistance and all patients carrying these alleles cleared the parasites on day 3. Of the DHAPQ group, 10% (3/29) of the samples with interpretable results had pm2 multiple copies and none of them was associated with treatment failure. Conclusion All the tested ACT in mainland Tanzania were highly efficacious and none of validated k13 mutants associated with artemisinin resistance was observed. However, three isolates with multiple copy numbers of pm2 gene associated with PQ resistance among the limited samples tested successfully calls for further investigation. Trial registration Number ACTRN12615000159550. Registered 18th February 2015, https://www.anzctr.org.au/trial/MyTrial.aspx…

Glampedakis, E., Coste, A. T., Aruanno, M., Bachmann, D., Delarze, E., Erard, V., Lamoth, F.

Invasive fungal infections due to Aspergillus calidoustus with decreased azole susceptibility are emerging in the setting of azole prophylaxis and are associated with poor outcomes. We assessed the in vitro activity of antifungal drugs used alone or in combinations against A. calidoustus and found a synergistic effect between voriconazole and terbinafine at concentrations within the therapeutic range. An invertebrate Galleria mellonella model of A. calidoustus infection tended to support the potential benefit of this combination.

Neha Rastogi, Surbhi Khurana, Balaji Veeraraghavan, Francis Yesurajan Inbanathan, Suresh Kumar Rajamani Sekar, Deepak Gupta, Keshav Goel, Ashish Bindra, Navdeep Sokhal, Ashutosh Panda, Rajesh Malhotra, Purva Mathur

This study describes a detailed epidemiological and molecular characterization of an outbreak of Burkholderia cepacia at a neuro-trauma intensive care unit of a level-1 trauma centre. It emphasizes stringent infection control interventions taken to successfully curb this outbreak.

Abstract Background Possible cardiotoxicity of sofosbuvir in humans has not been demonstrated yet. Also, since HCV can exert deleterious effects on hearth function, it is of interest to know whether HCV eradication provides any benefits using global longitudinal strain (GLS), a measure of left ventricular function more reliable than ejection fraction (EF). Methods Patients eligible for treatment with the combination therapy for HCV were invited to perform a transthoracic cardiac ultrasound at four different time points: before starting treatment, after one month, at the end of treatment and, after six month. Left ventricular function was measured with both EF and GLS. Results From March 2015 to December 2016, 82 patients were enrolled. Fifty-six percent patients were males. Mean age was 66.12 (SD: 9.25) years. About 20% patients did not present any cardiovascular risk factors or comorbidities. A worsening trend of GLS was observed. Variations were not found to be statistically significant when EF was studied along the follow-up. However, when GLS was studied, its variations were found to be statistically significant indicating a worsening effect, albeit with different trends in patients who underwent treatment for three months compared to six months. Worsening of GLS was found to be statistically significant even after adjusting for body mass index and liver fibrosis, independently from treatment duration. Conclusions Our results showed unexpected worsening of left ventricular function when measured through GLS after HCV treatment response induced by DAAs including sofosbuvir. Although this result is not proven to be clinically significant, the safety profile of sofosbuvir-based regimens needs to be studied further.

Danielle M. Yugo, Caitlin M. Cossaboom, C. Lynn Heffron, Yao‐Wei Huang, Scott P. Kenney, Amelia R. Woolums, David J. Hurley, Tanja Opriessnig, Linlin Li, Eric Delwart, Isis Kanevsky, Xiang‐Jin Meng

Abstract Genotypes 3 and 4 hepatitis E virus (HEV) strains within the species Orthohepevirus A in the family Hepeviridae are zoonotic. Recently, a genotype 4 HEV was reportedly detected in fecal samples of cows; although, independent confirmation is lacking. In this study, we first tested serum samples from 983 cows in different regions in the United States for the presence of IgG anti‐HEV and found that 20.4% of cows were seropositive. The highest seroprevalence rate (68.4%) was from a herd in Georgia. In an attempt to genetically identify HEV from cattle, a prospective study was conducted in a known seropositive dairy herd by monitoring 10 newborn calves from birth to 6 months of age for evidence of HEV infection. At least three of the 10 calves seroconverted to IgG anti‐HEV, and importantly, the antibodies present neutralized genotype 3 human HEV, thus indicating the specificity of IgG anti‐HEV in cattle. However, our extensive attempts using broad‐spectrum RT‐PCR assays and MiSeq deep‐sequencing technology to identify HEV‐related sequences in cattle failed. The results suggest the existence of an agent antigenically‐related to HEV in cattle; although, contrary to published reports, we showed that the IgG recognizing HEV in cattle was not caused by HEV infection. This article is protected by copyright. All rights reserved.

Rochwerg, Bram; Alhazzani, Waleed; Sevransky, Jonathan E.

No abstract available…

Abstract Background This study aimed to identify factors at individual and community level influencing insecticide-treated net (ITN) usage among groups of women of childbearing age (WOCBA) in Malawi. Methods Factors influencing ITN usage in Malawi were assessed through interviews with 16,130 WOCBA (15–49 years) across 850 communities who participated in the 2015–2016 Malawi Demographic Health Survey. Multilevel logistic regression analysis was used. Results ITN use was similar between pregnant women and non-pregnant women with children under 5 years (45.9% and 46.9%, respectively), but slightly lower among non-pregnant women without children under 5 years (39.1%). Both individual and community characteristics were associated with ITN use among WOCBA and varied significantly across subgroups. Specifically, non-pregnant women with children under 5 years living in communities where women had high autonomy in health care decisions had an 18% greater odds of using an ITN compared with those from communities where women had low health care autonomy (adjusted odds ratio [aOR] = 1.18; 95% confidence interval [CI] 1.00–1.38). Distance to health care facility influenced ITN usage among pregnant women; those who did not regard distance as a problem had a 44% greater odds of using an ITN than those for whom distance was seen as a problem (aOR = 1.44; 95% CI 1.09–1.89). Number of household members, region, urbanization, and community ITN coverage influenced ITN usage across all WOCBA groups. Conclusion The findings confirmed the importance of assessing various factors affecting ITN usage among groups of WOCBA. Both individual- and community-level factors should be considered when designing and implementing ITN programmes in Malawi.

Eyasu Ejeta, Getenet Beyene, Getu Balay, Zegeye Bonsa, Gemeda Abebe

by Eyasu Ejeta, Getenet Beyene, Getu Balay, Zegeye Bonsa, Gemeda Abebe Background Tuberculosis (TB) is a leading cause of public health challenges among immigrant refugees and their surrounding communities in developing countries. Evaluating the treatment outcome of TB patients is one of the key indicators to understand the performance of TB control program. Hence, this study aims to assess profile, treatment outcome and factors associated with unsuccessful outcome of TB patients treated under the TB control program among refugees and their surrounding communities (SCs) in Gambella Regional State, Ethiopia. Methodology Retrospective study was conducted in the health facilities of refugee and their SCs in Gambella Regional State from March 1 to May 30, 2017. Demographic and related data of all TB patients registered in TB Control Program between September, 2008 and October, 2017 in health facilities of refugee and the SCs was extracted using data extraction format. Eight years trend of TB, treatment outcome and factors associated with unsuccessful outcome among refugees and the SCs were computed using SPSS version 20.0 software. Result A total of 886 refugees and 3284 SCs TB patients, registered for anti TB treatment in the last eight years, were evaluated in the study. The trend of all forms of TB is progressively increasing among refugees contrary to the SCs in the course of the study period (X2 trend = 207.7; p

Abstract Background Using bacteria to express and deliver anti-parasite molecules in mosquitoes is among the list of genetic tools to control malaria. The introduction and spread of transgenic bacteria through wild adult mosquitoes is one of the major challenges of this strategy. In prospect of future field experiments, an open field study with blank (without bacteria) attractive sugar bait (ASB) was performed under the assumption that transgenic bacteria would be spread to all sugar fed mosquitoes. Methods Two types of ASB stations were developed, one with clay pots (CP) placed at mosquito resting sites and one with window entry traps (WET) placed inside inhabited houses. The ASB consisted in either glucose, honey or fruit cocktail solutions. In addition, mark-release-recapture (MRR) experiment of mosquitoes after feeding them with glucose was also conducted to check the proportion of the mosquito population that can be reached by the two ASB stations as well as its suitability to complement the ASB stations for disseminating bacteria. Results Overall, 88% of the mosquitoes were collected in the WET_ASB. The CP_ASB stations were much less attractive with the highest average of 82 ± 11 mosquitoes/day in the CP near the wood piles. The proportions of sugar fed mosquitoes upon ASB were low in both type of ASB stations, ~ 2% and ~ 14% in WET and CP, respectively. Honey solution was the most attractive solution compared to the glucose and the fruit cocktail solutions. The recapture rate in the MRR experiment was low: ~ 4.1% over 7 days. Conclusion The WET_ASB looks promising to disseminate transgenic bacteria to endophilic West Africa Anopheles mosquito. However, this feeding station may not be fully effective and could be combined with the CP_ASB to also target outdoor resting mosquitoes. Overall, efforts are needed to improve the mosquito-feeding rates upon ASB.

Abstract Background While the distribution of mosquito bed nets is a widely adopted approach for malaria prevention, studies exploring how the usage of a net may be influenced by its source and other factors remain sparse. Methods A standardized questionnaire and home-visit observations were used to collect data from 9 villages in Budondo sub-county, Uganda in 2016. Household- and individual-level data were collected, such as bed net ownership (at least one net versus none), acquirement source (free versus purchased), demographics, as well as knowledge of malaria and preventative measures. Net-level data, including alternative uses, and bed net quantity and integrity, were also collected. Mixed effects logistic regression models were performed to identify the key determinants of bed net use. Results Overall, the proportion of households with at least one bed net was 40%, while bed net availability was only reported among 27% of all household members. Awareness of the benefits of bed net use was statistically significantly associated with ownership of at least one net (OR = 1.72, 95% CI 1.11–2.68, p = 0.02). Among those who own net(s), the odds of a bed net being correctly used (i.e., to sleep under) after adjusting for potential confounders were significantly lower for nets that were obtained free compared to nets that were purchased by the owners themselves (OR = 0.33, 95% CI 0.21–0.51, p 

Peter Lindholm

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 8, Page 1088-1089, October 15, 2018.

Dupnik, K. M., Reust, M. J., Vick, K. M., Yao, B., Miyaye, D., Lyimo, E., Mukerebe, C., Mngara, J., Kalluvya, S. E., de Dood, C. J., Corstjens, P. L. A. M., van Dam, G. J., Zhang, T., Xiang, J., Lee, M. H., Downs, J. A.

Schistosome worms infect over 200 million people worldwide. They live in the host’s bloodstream and alter host immunity. Epidemiological data suggest that males and females have different responses to schistosome infection, but the effect of sex on systemic response is undetermined. Our objective was to characterize differences in peripheral blood transcriptional profiles in people with or without active S. haematobium infection, and to determine whether this signature differs between males and females.Messenger RNA was isolated using poly(A) selection and sequenced on an Illumina Hi-Seq4000 platform. Transcripts were aligned to the human hg19 reference genome and counted with the HTSeq package. Genes were compared for differential expression using DESeq2. Ingenuity Pathway Analysis was used to identify gene networks altered in the presence of S. haematobium.We enrolled 33 participants from villages in rural Tanzania where S. haematobium is endemic. After correction for multiple comparisons, we observed 383 differentially-expressed genes between those with and without S. haematobium infection when sex was included as a covariate. Heat-mapping of the genes with greater than 1.5-fold differences in gene expression revealed clustering by S. haematobium infection status. Top networks included development, cell death and survival, cell signaling, and immunologic disease pathways.We observed a distinct whole blood transcriptional profile, as well as differences in men and women, with S. haematobium infection. Additional studies are needed to determine the clinical effects of these divergent responses. Attention to sex-based differences should be included in studies of human schistosome infection.

Abstract Background Human norovirus is the leading cause of viral gastroenteritis globally, and the GII.4 has been the most predominant genotype for decades. This genotype has numerous variants that have caused repeated epidemics worldwide. However, the molecular evolutionary signatures among the GII.4 variants have not been elucidated throughout the viral genome. Method A metagenomic, next-generation sequencing method, based on Illumina RNA-Seq, was applied to determine norovirus sequences from clinical samples. Results Herein, the obtained deep-sequencing data was employed to analyze full-genomic sequences from GII.4 variants prevailing in Canada from 2012 to 2016. Phylogenetic analysis demonstrated that the majority of these sequences belong to New Orleans 2009 and Sydney 2012 strains, and a recombinant sequence was also identified. Genome-wide similarity analyses implied that while the capsid gene is highly diverse among the isolates, the viral protease and polymerase genes remain relatively conserved. Numerous amino acid substitutions were observed at each putative antigenic epitope of the VP1 protein, whereas few amino acid changes were identified in the polymerase protein. Co-infection with other enteric RNA viruses was investigated and the astrovirus genome was identified in one of the samples. Conclusions Overall this study demonstrated the application of whole genome sequencing as an important tool in molecular characterization of noroviruses.

Sakamoto, N., Akeda, Y., Sugawara, Y., Takeuchi, D., Motooka, D., Yamamoto, N., Laolerd, W., Santanirand, P., Hamada, S.

We report here the K. pneumoniae strains carrying chromosomal blaNDM-1 in Thailand. The genomes of these two isolates include a 160-kbp insertion containing blaNDM-1, which is almost identical to that in the IncHI1B-like plasmid. Further analysis indicated that IS5-mediated intermolecular transposition and Tn3-transposase-mediated homologous recombination resulted in the integration of blaNDM-1 into the chromosome from an IncHI1B-like plasmid. The spread of this type of carbapenem-resistant Enterobacteriaceae may threaten public health and warrants further monitoring.

Yang, J., Pemberton, A., Morrison, W. I., Connelley, T.

There is established evidence that cytotoxic CD8+ T cells are important mediators of immunity against the bovine intracellular protozoan parasite T. parva. However, the mechanism by which the specific CD8+ T cells kill parasitized cells is not understood. Although the predominant pathway used by human and murine CD8+ T cells to kill pathogen-infected cells is granule exocytosis, involving release of perforin and granzyme B, there is to date a lack of published information on the biological activities of bovine granzyme B. The present study set out to define the functional activities of bovine granzyme B and determine its role in mediating killing of T. parva-parasitized cells. DNA constructs encoding functional and non-functional forms of bovine granzyme B were produced and the proteins expressed in Cos-7 cells were used to establish an enzymatic assay to detect and quantify expression of functional granzyme B protein. Using this assay, the levels of killing of different T. parva-specific CD8+ T cell clones were found to be significantly correlated with levels of granzyme B protein, but not mRNA transcript, expression. Experiments using inhibitors specific for perforin and granzyme B confirmed that CD8+ T cell killing of parasitized cells is dependent on granule exocytosis and specifically granzyme B. Further studies showed that granzyme B-mediated death of parasitized cells is independent of caspases and that granzyme B activates the pro-apoptotic molecule Bid.

Toliver-Kinsky, T., Cui, W., Törö, G., Lee, S.-J., Shatalin, K., Nudler, E., Szabo, C.

The biological mediator hydrogen sulfide (H2S) is produced by bacteria and has been shown to be cytoprotective against oxidative stress and to increase the sensitivity of various bacteria to a range of antibiotic drugs. Here we evaluated whether bacterial H2S provides resistance against the immune response, using two bacterial species that are common sources of nosocomial infections, Escherichia coli and Staphylococcus aureus. Elevations in H2S increased the resistance of both species to immune-mediated killing. Clearance of infections with wild type and genetically H2S-deficient E. coli and S. aureus was compared in vitro and in mouse models of abdominal sepsis and burn wound infection. Also, inhibitors of H2S-producing enzymes were used to assess bacterial killing by leukocytes. We found that inhibition of bacterial H2S production can increase susceptibility of both bacterial species to rapid killing by immune cells and can improve bacterial clearance after severe burn, an injury that increases susceptibility to opportunistic infections. These findings support the role of H2S as a bacterial defense mechanism against the host response and implicate bacterial H2S inhibition as a potential therapeutic intervention in the prevention or treatment of infections.

Michelson Y, Lustig Y, Avivi S, et al.

AbstractBackgroundZika virus has created global alarm as it has been associated with catastrophic fetal abnormalities, including microcephaly, spontaneous abortion, and intrauterine growth restriction. Current serological assays that detect antiviral antibodies suffer from low sensitivity and high cross-reactivity among different flaviviruses.MethodsHere, utilizing a novel Magnetic Modulation Biosensing (MMB) system and the Zika non-structural 1 (NS1) protein, we show highly sensitive and specific Zika serological assays. We blindly tested 60 reverse transcription-PCR Zika-positive samples and healthy patients’ serum samples, as well as 44 serum samples from ELISA West Nile- and dengue-positive patients. The Zika-positive samples were collected from Israeli travelers returning from Zika endemic areas.ResultsThe MMB Zika assays have 88–97% sensitivity, much higher than the current state-of-the-art Euroimmun ELISA assays (38–74%). Additionally, the specificity is 100%, and the cross reactivity with West Nile and dengue viruses is minimal (0–4%). Furthermore, the MMB assays detected Zika IgM antibodies as early as 5 days and as late as 180 days post symptoms onset, significantly extending the number of days that the antibodies are detectable.ConclusionsThe sensitivity, specificity, and simplicity of the MMB assays may significantly improve Zika diagnosis and provide accurate results for public health agencies.

Tugume L, Rhein J, Hullsiek K, et al.

AbstractBackgroundCryptococcal meningitis can occur in persons with less apparent immunosuppression. We evaluated clinical characteristics and outcomes of persons with HIV-related Cryptococcus presenting with higher CD4 counts.MethodsWe enrolled 736 participants from two prospective cohorts in Uganda and South Africa from November 2010 to May 2017. We compared participants with CD4 =100 cells/mcL. Participants with CD4 >=100 cells/mcL presented more often with altered mental status (52% vs 39%; P=.03) despite a 10-fold lower initial median CSF fungal burden of 7,850 (IQR 860–65,500) vs 79,000 (IQR 7,400–380,000) CFU/mL; P=100 cells/mcL had higher median CSF levels of interferon-gamma,interleukin (IL)-6, IL-8, and IL-13; and lower monocyte chemokine, CCL2 (P=100 cells/mcL presented more frequently with altered mental status despite having 10-fold lower fungal burden and with greater Th2 (IL-13) immune response. Higher CD4 count was protective despite an increased propensity for immune-mediated damage, consistent with damage-response framework.

Yu J, Peterson D, Baran A, et al.

AbstractWe compared nasal and blood samples for evaluation of the host transcriptomic response in children with acute respiratory syncytial virus (RSV) infection, symptomatic non-RSV respiratory virus infections, asymptomatic rhinovirus infection, and virus-negative asymptomatic controls. Despite lower quality of nasal RNA, the number of genes detected by microarray in each sample type was equivalent. Nasal gene expression signal derived mainly from epithelial cells but also included a variable leukocyte contribution. The number of genes with increased expression in virus-infected children was comparable in nasal and blood samples, while nasal samples also had decreased expression of many genes associated with ciliary function and assembly. Using nested leave-one-pair-out cross-validation and supervised principal components analysis, we defined small sets of genes whose expression patterns accurately classified subjects. Gene classification scores were validated using an external data set. Our results support the use of nasal samples to augment pathogen-based tests to diagnose viral respiratory infection.

Lee N, Winer R, Cherne S, et al.

AbstractBackgroundHigh-risk human papillomavirus (HrHPV) causes cervical cancer. In the U.S., approximately 40% of women aged 14-59 years from all racial and ethnic groups are infected with HPV, and prevalence typically declines with age. However, American Indian women are insufficiently sampled to permit a population-specific estimate of HrHPV prevalence. MethodsVaginal swabs were self-collected by 698 AI women aged 21-65 years from a tribal community in the Great Plains. We estimated the population prevalence of HrHPV and identified predominant genotypes.ResultsThe combined prevalence of HrHPV genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68 was 34.8%. HPV-51 (7.6%), HPV-58 (5.3%), HPV-52 (4.3%), HPV-18 (4.3%), and HPV-16 (3.9%) were most prevalent. HrHPV prevalence declined with age, from 42.2% in women aged 21-24 years to 27.9% in women aged 50-65 years. ConclusionHPV-51 was the single most prevalent oncogenic genotype. The combined prevalence of HrHPV among AI women in our sample was high, particularly among women aged 50-65 years, for whom HrHPV prevalence was approximately triple that of other races. Cervical cancer screening efforts should be increased particularly among women from the community aged 30 years and older.

Gabriela P. Martino, Cristian E. Perez, Christian Magni, Víctor S. Blancato

by Gabriela P. Martino, Cristian E. Perez, Christian Magni, Víctor S. Blancato Citrate is an ubiquitous compound in nature. However, citrate fermentation is present only in a few pathogenic or nonpathogenic microorganisms. The citrate fermentation pathway includes a citrate transporter, a citrate lyase complex, an oxaloacetate decarboxylase and a regulatory system. Enterococcus faecalis is commonly present in the gastro-intestinal microbiota of warm-blooded animals and insect guts. These bacteria can also cause infection and disease in immunocompromised individuals. In the present study, we performed whole genome analysis in Enterococcus strains finding that the complete citrate pathway is present in all of the E. faecalis strains isolated from such diverse habitats as animals, hospitals, water, milk, plants, insects, cheese, etc. These results indicate the importance of this metabolic preservation for persistence and growth of E. faecalis in different niches. We also analyzed the role of citrate metabolism in the E. faecalis pathogenicity. We found that an E. faecalis citrate fermentation-deficient strain was less pathogenic for Galleria mellonella larvae than the wild type. Furthermore, strains with deletions in the oxaloacetate decarboxylase subunits or in the α-acetolactate synthase resulted also less virulent than the wild type strain. We also observed that citrate promoters are induced in blood, urine and also in the hemolymph of G. mellonella. In addition, we showed that citrate fermentation allows E. faecalis to grow better in blood, urine and G. mellonella. The results presented here clearly indicate that citrate fermentation plays an important role in E. faecalis opportunistic pathogenic behavior.

Caitlin N. Dodd, Maria de Ridder, Wan-Ting Huang, Daniel Weibel, Maria Giner-Soriano, Silvia Perez-Vilar, Javier Diez-Domingo, Lawrence W. Svenson, Salahddin M. Mahmud, Bruce Carleton, Monika Naus, Jeffrey C. Kwong, Brian J. Murray, Lisen Arnheim-Dahlstrom, Lars Pedersen, Rosa Morros, Francisco Javier Puertas, Steven Black, Miriam Sturkenboom

by Caitlin N. Dodd, Maria de Ridder, Wan-Ting Huang, Daniel Weibel, Maria Giner-Soriano, Silvia Perez-Vilar, Javier Diez-Domingo, Lawrence W. Svenson, Salahddin M. Mahmud, Bruce Carleton, Monika Naus, Jeffrey C. Kwong, Brian J. Murray, Lisen Arnheim-Dahlstrom, Lars Pedersen, Rosa Morros, Francisco Javier Puertas, Steven Black, Miriam Sturkenboom Background & objectives Vaccine safety signals require investigation, which may be done rapidly at the population level using ecological studies, before embarking on hypothesis-testing studies. Incidence rates were used to assess a signal of narcolepsy following AS03-adjuvanted monovalent pandemic H1N1 (pH1N1) influenza vaccination among children and adolescents in Sweden and Finland in 2010. We explored the utility of ecological data to assess incidence of narcolepsy following exposure to pandemic H1N1 virus or vaccination in 10 sites that used different vaccines, adjuvants, and had varying vaccine coverage. Methods We calculated incidence rates of diagnosed narcolepsy for periods defined by influenza virus circulation and vaccination campaign dates, and used Poisson regression to estimate incidence rate ratios (IRRs) comparing the periods during which wild-type virus circulated and after the start of vaccination campaigns vs. the period prior to pH1N1 virus circulation. We used electronic health care data from Sweden, Denmark, the United Kingdom, Canada (3 provinces), Taiwan, Netherlands, and Spain (2 regions) from 2003 to 2013. We investigated interactions between age group and adjuvant in European sites and conducted a simulation study to investigate how vaccine coverage, age, and the interval from onset to diagnosis may impact the ability to detect safety signals. Results Incidence rates of narcolepsy varied by age, continent, and period. Only in Taiwan and Sweden were significant time-period-by-age-group interactions observed. Associations were found for children in Taiwan (following pH1N1 virus circulation) and Sweden (following vaccination). Simulations showed that the individual-level relative risk of narcolepsy was underestimated using ecological methods comparing post- vs. pre-vaccination periods; this effect was attenuated with higher vaccine coverage and a shorter interval from disease onset to diagnosis. Conclusions Ecological methods can be useful for vaccine safety assessment but the results are influenced by diagnostic delay and vaccine coverage. Because ecological methods assess risk at the population level, these methods should be treated as signal-generating methods and drawing conclusions regarding individual-level risk should be avoided.

Micheva-Viteva, S. N., Ross, B. N., Gao, J., Adikari, S., Zhang, P., Mourant, J. R., Wu, T. H., Werner, J. H., Torres, A. G., Hong-Geller, E.

Bacterial persistence, known as non-inherited antibacterial resistance, is a contributing factor to the establishment of long-lasting chronic bacterial infections. In this study, we examined the ability of nicotinamide (NA) to potentiate different classes of antibiotics against Burkholderia thailandensis persister cells. Here we demonstrate that addition of NA in in vitro models of B. thailandensis infection resulted in a significant depletion of the persister population in response to various classes of antibiotics. We applied microfluidic bioreactors with a continuous media flow to study the effect of supplementation with a NA gradient on the recovery of B. thailandensis persister populations. A co-culture of human neutrophils pre-activated with 50 µM NA and B. thailandensis resulted in the most efficient reduction in the persister population. Applying single cell RNA FISH analysis and quantitative PCR, we found that NA inhibited gene expression of the stringent response regulator relA, implicated in the regulation of the persister metabolic state. We also demonstrate that a therapeutic dose of NA (250mg/kg), previously applied as immunoprophylaxis against antibiotic-resistant bacterial species, produced adverse effects in an in vivo murine infection model of the highly pathogenic Burkholderia pseudomallei, indicating that therapeutic dose and metabolite effects have to be carefully evaluated and tailored for every case of potential clinical application.

Denis E. O’Donnell

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 8, Page 977-978, October 15, 2018.

Kedir N. Turi

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 8, Page 1064-1073, October 15, 2018.

Jian Wang, Wei Cheng, Shaoji Zhang, Yousheng Li, Jieshou Li

Abstract Objectives Intestinal tuberculosis (ITB) remains prevalent and a big health hazard in China. The aim of this study was to retrospectively analyze its clinico‐pathological features. Methods Retrospective study of 85 consecutive ITB patients in two tertiary hospitals in East China. Relevant clinical, laboratory examination, radiological, endoscopic and histopathological features of ITB were recorded. Results The mean age was 37.3±16.0 years; 56 patients (65.9%) were male. 67.1% had ITB secondary to pulmonary tuberculosis. The overall median length of hospital stay was 28 days and was significantly longer in patients with intestinal complications (p = 0.003) and malnutrition (p = 0.042). Abdominal pain (88.2%) and weight loss (75.3%) were the commonest symptoms. The positive rate of the PPD test was 88.2%; of the T‐spot, 85.7%. Histopathology revealed caseating granuloma in 70.6% and caseating necrosis in 24.7% of patients. The most commonly affected sites were the ileocecal valve (56, 65.9%), terminal ileum (40, 47.1%) and cecum (33, 38.8%). Only 17 (20%) patients were initially diagnosed as ITB, the other 68 patients were misdiagnosed. 6 patients with cecum tuberculosis were misdiagnosed as appendicitis, 4 of whom had improper surgical procedures followed by postoperative intestinal fistulas; 2 died due to MODS. Conclusions Diagnosis of ITB is often misdirected and delayed, which may lead to inappropriate treatment and high mortality. High diagnostic suspicion is necessary for patients with unexplained abdominal complaints. Diagnosis is not easy but could benefit from taking into consideration coexisting pulmonary tuberculosis, T‐spot, CT imaging, colonoscopy, pathological features, acid‐fast bacilli, and response to anti‐tuberculosis therapy (ATT). This article is protected by copyright. All rights reserved.

Abstract Background Cryptococcal meningitis remains the leading cause of adult meningitis in Sub-Saharan Africa. Immune Reconstitution Inflammatory Syndrome (IRIS) following anti-retroviral therapy (ART) initiation is an important complication. Here we report the first documented case of a IRIS reaction presenting as an ischemic stroke. Case presentation A 38 year old newly diagnosed HIV-infected, ART naive Malawian male presented to a tertiary referral hospital in Blantyre, Malawi with a 2 week history of headache. A diagnosis of cryptococcal meningitis was made and the patient was started on 1200 mg fluconazole once daily and flucytosine 25 mg/kg four times daily as part of the Advancing Cryptococcal Treatment for Africa (ACTA) clinical trial. There was an initial clinical and microbiological response to anti-fungal treatment and anti-retroviral therapy was started at week 4. The patient re-presented 16 days later with recurrence of headache, fever, and a sudden onset of left sided weakness in the context of rapid immune reconstitution; peripheral CD4 count had increased from a baseline of 29 cells/μl to 198 cells/μl. Recurrence of cryptococcal meningitis was excluded through CSF examination and fungal culture. Magnetic Resonance Imaging (MRI) of the brain demonstrated multi-focal DWI (diffusion weighted imaging) positive lesions consistent with an ischemic stroke. Given the temporal relationship to ART initiation, these MRI findings in the context of sterile CSF with raised CSF protein and a rapid immune reconstitution, following an earlier favorable response to treatment is most consistent with a paradoxical Immune Reconstitution Inflammatory Syndrome. Conclusions Stroke is an increasing cause of morbidity and mortality amongst HIV infected persons. Ischemic stroke is a recognized complication of cryptococcal meningitis in the acute phase and is thought to be mediated by an infectious vasculitis. This is the first time an ischemic stroke has been described as part of a paradoxical IRIS reaction. This report adds to the spectrum of clinical IRIS presentations recognized and highlights to clinicians the potential complications encountered at ART initiation in severely immunocompromised patients.

de Vries, Vera A.; Müller, Marcella C. A.; Arbous, M. Sesmu; Biemond, Bart J.; Blijlevens, Nicole M. A.; Kusadasi, Nuray; Span, Lambert R. F.; Vlaar, Alexander P. J.; van Westerloo, David J.; Kluin-Nelemans, Hanneke C.; van den Bergh, Walter M.; on behalf of the HEMA-ICU Study Group

Objectives: Historically, patients with a hematologic malignancy have one of the highest mortality rates among cancer patients admitted to the ICU. Therefore, physicians are often reluctant to admit these patients to the ICU. The aim of our study was to examine the survival of patients who have a hematologic malignancy and multiple organ failure admitted to the ICU. Design: This retrospective cohort study, part of the HEMA-ICU study group, was designed to study the survival of patients with a hematologic malignancy and organ failure after admission to the ICU. Patients were followed for at least 1 year. Setting: Five university hospitals in the Netherlands. Patients: One-thousand ninety-seven patients with a hematologic malignancy who were admitted at the ICU. Interventions: None. Measurements and Main Results: Primary outcome was 1-year survival. Organ failure was categorized as acute kidney injury, respiratory failure, hepatic failure, and hemodynamic failure; multiple organ failure was defined as failure of two or more organs. The World Health Organization performance score measured 3 months after discharge from the ICU was used as a measure of functional outcome. The 1-year survival rate among these patients was 38%. Multiple organ failure was inversely associated with long-term survival, and an absence of respiratory failure was the strongest predictor of 1-year survival. The survival rate among patients with 2, 3, and 4 failing organs was 27%, 22%, and 8%, respectively. Among all surviving patients for which World Health Organization scores were available, 39% had a World Health Organization performance score of 0–1 3 months after ICU discharge. Functional outcome was not associated with the number of failing organs. Conclusions: Our results suggest that multiple organ failure should not be used as a criterion for excluding a patient with a hematologic malignancy from admission to the ICU. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. All participating investigators are listed in Appendix 1. The authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: v.a.de.vries@umcg.nl Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

James C. Ross

American Journal of Respiratory and Critical Care Medicine, Volume 198, Issue 8, Page 1033-1042, October 15, 2018.

Luna-Tapia, A., Butts, A., Palmer, G. E.

Increased expression of drug efflux pumps and changes in the target enzyme, Erg11p, are known to contribute to azole resistance in Candida albicans, one of the most prevalent fungal pathogens. Mutations that inactivate ERG3, which encodes sterol 5,6-desaturase also confer in vitro azole resistance. However, it is unclear if loss of Erg3p activity is sufficient to confer resistance within the mammalian host, and relatively few erg3 deficient mutants have been reported among azole-resistant clinical isolates. ‘Trailing growth’ (residual growth in the presence of the azoles) is a phenotype observed with many C. albicans isolates, and in its extreme form can be mistaken for resistance. The purpose of this study was to determine if growth of Erg3p-deficient C. albicans mutants in the presence of the azoles possesses the characteristics of azole resistance, or of an exaggerated form of trailing growth. Our results demonstrate that similar to trailing isolates, the capacity of an erg3/ mutant to endure the consequences of azole exposure is at least partly dependent upon both temperature and pH. This contrasts with true azole resistance that results from enhanced drug efflux and/or changes in the target enzyme. The erg3/ mutant and trailing isolates also appear to sustain significant membrane damage upon azole treatment, further distinguishing them from resistant isolates. However, the erg3/ mutant’s insensitivity to the azoles is unaffected by the calcineurin inhibitor cyclosporin A, distinguishing it from trailing isolates. In conclusion, the erg3 mutant phenotype is qualitatively and quantitatively distinct from both azole resistance and trailing growth.

Guo, F.-S., Day, B. M., Chen, Y.-C., Tong, M.-L., Mansikkamäki, A., Layfield, R. A.

Single-molecule magnets (SMMs) containing only one metal center may represent the lower size limit for molecule-based magnetic information storage materials. Their current drawback is that all SMMs require liquid-helium cooling to show magnetic memory effects. We now report a chemical strategy to access the dysprosium metallocene cation [(CpiPr5)Dy(Cp*)]+ (CpiPr5 = penta-iso-propylcyclopentadienyl, Cp* = pentamethylcyclopentadienyl), which displays magnetic hysteresis above liquid-nitrogen temperatures. An effective energy barrier to reversal of the magnetization of Ueff = 1,541 cm–1 is also measured. The magnetic blocking temperature of TB = 80 K for this cation overcomes an essential barrier towards the development of nanomagnet devices that function at practical temperatures.

Ming-Chia Lee, Chen-Yuan Chiang, Chih-Hsin Lee, Cheng-Maw Ho, Chia-Hao Chang, Jann-Yuan Wang, Shih-Ming Chen

by Ming-Chia Lee, Chen-Yuan Chiang, Chih-Hsin Lee, Cheng-Maw Ho, Chia-Hao Chang, Jann-Yuan Wang, Shih-Ming Chen Human studies on the use of metformin as host-directed therapy (HDT) for tuberculosis (TB) are rare. We performed a nationwide cohort study to evaluate the effect of metformin on mitigating the risk of active TB among patients with diabetes mellitus (DM). Among newly diagnosed DM patients identified in the Taiwan National Health Insurance Research Database, metformin users, defined on the basis of >90 cumulative defined daily doses within 1 year, and propensity-score-matched metformin nonusers were selected. The primary outcome was incident TB, identified using diagnostic criteria validated by real patient data at a medical center. Independent predictors were investigated using Cox regression analysis. Similar analysis was performed in a subpopulation without a history of hypertensive nephropathy and renal replacement therapy. A total of 88,866 metformin users and 88,866 propensity-score-matched nonusers were selected. Validation results showed that the TB diagnostic criteria had a sensitivity of 99.13% and specificity of 99.90%. During follow-up, 707 metformin users and 807 nonusers developed active TB. Metformin use was independently associated with a lower risk of incident TB (hazard ratio [HR]: 0.84 [0.74–0.96]). TB risk was lower in high-dose metformin users than in low-dose users (HR: 0.83 [0.72–0.97]). The effect of metformin remained when analysis was restricted in the subpopulation without renal function impairment. Newly diagnosed diabetic patients without contraindication should receive metformin as an anti-diabetic medication, with potential additional benefit against TB.

Espinel-Ingroff, A., Turnidge, J., Alastruey-Izquierdo, A., Botterel, F., Canton, E., Castro, C., Chen, Y.-C., Chen, Y., Chryssanthou, E., Dannaoui, E., Garcia-Effron, G., Gonzalez, G. M., Govender, N. P., Guinea, J., Kidd, S., Lackner, M., Lass-Flörl, C., Linares-Sicilia, M. J., Lopez-Soria, L., Magobo, R., Pelaez, T., Quindos, G., Rodriguez-Iglesia, M. A., Ruiz, M. A., Sanchez-Reus, F., Sanguinetti, M., Shields, R., Szweda, P., Tortorano, A., Wengenack, N. L., Bramati, S., Cavanna, C., DeLuca, C.,

Although the Sensitrite Yeast-One (SYO) and Etest methods are widely utilized, interpretive criteria are not available for triazole susceptibility testing of Candida or Aspergillus species. We collected fluconazole, itraconazole, posaconazole and voriconazole SYO and Etest MICs from 39 laboratories representing all continents for (method-agent-dependent): 11,171 Candida albicans, 215 C. dubliniensis, 4,418 C. glabrata species complex (SC), 157 C. (Meyerozyma) guilliermondii, 676 C. krusei (Pichia kudriavzevii), 298 C. (Clavispora) lusitaniae, 911 and 3,691 C. parapsilosis sensu stricto (SS) and C. parapsilosis SC, respectively, 36 C. metapsilosis, 110 C. orthopsilosis, 1,854 C. tropicalis, 244 Saccharomyces cerevisiae, 1,409 Aspergillus fumigatus, 389 A. flavus, 130 A. nidulans, 233 A. niger, and 302 A. terreus complexes. SYO/Etest MICs for 282 confirmed non-WT isolates were included: ERG11 (C. albicans), ERG11 and MRR1 (C. parapsilosis), cyp51A (A. fumigatus), and CDR2, CDR1 overexpression (C. albicans and C. glabrata, respectively). Interlaboratory modal agreement was superior by SYO for yeast spp., and by the Etest for Aspergillus spp. Distributions fulfilling CLSI criteria for ECV definition were pooled and we proposed SYO ECVs for S. cerevisiae, 9 yeast and 3 Aspergillus species, and Etest ECVs for 5 yeast and 4 Aspergillus species. The posaconazole SYO ECV of 0.06 µg/ml for C. albicans and the Etest itraconazole ECV of 2 µg/ml for A. fumigatus were the best predictors of non-WT isolates. These findings support the need for method-dependent ECVs, as overall, the SYO appears to perform better for susceptibility testing of yeast spp. and the Etest for Aspergillus spp. Further evaluations should be conducted with more Candida mutants.