Inhibition of VEGF binding to neuropilin-2 enhances chemosensitivity and inhibits metastasis in triple-negative breast cancer

Although blocking the binding of vascular endothelial growth factor (VEGF) to neuropilin-2 (NRP2) on tumor cells is a potential strategy to treat aggressive carcinomas, a lack of effective reagents that can be used clinically has hampered this potential therapy. Here, we describe the generation of a fully humanized, high-affinity monoclonal antibody (aNRP2-10) that specifically inhibits the binding of VEGF to NRP2, conferring antitumor activity without causing toxicity. Using triple-negative breast cancer as a model, we demonstrated that aNRP2-10 could be used to isolate cancer stem cells (CSCs) from heterogeneous tumor populations and inhibit CSC function and epithelial-to-mesenchymal transition. aNRP2-10 sensitized cell lines, organoids, and xenografts to chemotherapy and inhibited metastasis by promoting the differentiation of CSCs to a state that is more responsive to chemotherapy and less prone to metastasis. These data provide justification for the initiation of clinical trials designed to improve the response of patients with aggressive tumors to chemotherapy using this monoclonal antibody.

Efzofitimod: a novel anti-inflammatory agent for sarcoidosis

Efzofitimod is a first-in-class biologic based on a naturally occurring splice variant of histidyl-tRNA synthetase (HARS) that downregulates immune responses via selective modulation of neuropilin-2 (NRP2). Preclinical data found high expression of NRP2 in sarcoidosis granulomas. Treatment with efzofitimod reduced the granulomatous inflammation induced by P. acnes in an animal model of sarcoidosis. A dose escalating trial of efzofitimod in sarcoidosis with chronic symptomatic pulmonary disease found that treatment with efzofitimod was associated with improved quality of life with a trend towards reduced glucocorticoid use and stable to improved pulmonary function. These studies have led to a large Phase 3 trial of efzofitimod in symptomatic pulmonary sarcoidosis.

Inflammatory Non-CpG Antisense Oligonucleotides Are Signaling Through TLR9 in Human Burkitt Lymphoma B Bjab Cells

Nucleic acid-based phosphorothioate containing antisense oligonucleotides (PS-ASOs) have the potential to activate cellular innate immune responses, and the level of activation can vary quite dramatically with sequence. Minimizing the degree of proinflammatory effect is one of the main selection criteria for compounds intended to move into clinical trials. While a recently developed human peripheral blood mononuclear cell (hPBMC)-based assay showed excellent ability to detect innate immune active PS-ASOs, which can then be discarded from the developmental process, this assay is highly resource intensive and easily affected by subject variability. This compelled us to develop a more convenient high-throughput assay. In this study, we describe a new in vitro assay, utilizing a cultured human Bjab cell line, which was developed and validated to identify PS-ASOs that may cause innate immune activation. The assay was calibrated to replicate results from the hPBMC assay. The Bjab assay was designed to be high throughput and more convenient by using RT-qPCR readout of mRNA of the chemokine Ccl22. The Bjab assay was also shown to be highly reproducible and to provide a large dynamic range in determining the immune potential of PS-ASOs through comparison to known benchmark PS-ASO controls that were previously shown to be safe or inflammatory in clinical trials. In addition, we demonstrate that Bjab cells can be used to provide mechanistic information on PS-ASO TLR9-dependent innate immune activation.

Early-Stage Identification and Avoidance of Antisense Oligonucleotides Causing Species-Specific Inflammatory Responses in Human Volunteer Peripheral Blood Mononuclear Cells

A human peripheral blood mononuclear cell (PBMC)-based assay was developed to identify antisense oligonucleotide (ASO) with the potential to activate a cellular innate immune response outside of an acceptable level. The development of this assay was initiated when ISIS 353512 targeting the messenger ribonucleic acid for human C-reactive protein (CRP) was tested in a phase I clinical trial, in which healthy human volunteers unexpectedly experienced increases in interleukin-6 (IL-6) and CRP. This level of immune stimulation was not anticipated following rodent and nonhuman primate safety studies in which no evidence of exaggerated proinflammatory effects were observed. The IL-6 increase induced by ISIS 353512 was caused by activation of B cells. The IL-6 induction was inhibited by chloroquine pretreatment of PBMCs and the nature of ASOs suggested that the response is mediated by a Toll-like receptor (TLR), in all likelihood TLR9. While assessing the inter PBMC donor variability, two classes of human PBMC responders to ISIS 353512 were identified (discriminator and nondiscriminators). The discriminator donor PBMCs were shown to produce low level of IL-6 after 24 h in culture, in the absence of ASO treatment. The PBMC assay using discriminator donors was shown to be reproducible, allowing to assess reliably the immune potential of ASOs by comparison to known benchmark ASO controls that were previously shown to be either safe or inflammatory in clinical trials. Clinical Trial registration numbers: NCT00048321 NCT00330330 NCT00519727.

P-020 Influence of vanadium and lead in seminal fluid on assisted reproductive techniques

Study question

In recent decades there has been an increase in environmental contaminants than can affect assisted reproduction techniques. We analyze the influence of vanadium (V) and lead (Pb) on these results.

Summary answer

Higher seminal fluid V levels affect fertilization rate (FR). Higher Pb and V levels decrease embryo cleavage rate (CR).

What is known already

Some animal studies have shown that V produces toxicity in the male reproductive system through oxidative stress, and this leads to decreases sperm count and motility, as well increased concentration of abnormal sperm.

Pb is one of the main pollutants and, it accumulates in the male reproductive organs, deteriorates the quality of semen, increases the frequency of spontaneous abortion and male infertility. And it has also been seen that it inhibits sperm functions in vitro, although its mechanism of action is still unknown.

Study design, size, duration

A prospective study was conducted in 102 males, with a mean age of 38.0 ± 5.7, attended successively for initial evaluation, in the Human Reproduction Unit of the Hospital Universitario de Canarias, between february and april 2018, who underwent a semen analysis and metal detection and, subsequently, an IVF/ICSI treatment during years 2019 and 2020 (n = 92). The relationship between the presence of metals and the results of ART has been established.

Participants/materials, setting, methods

We included two groups based on semen parameters: 41 patients with pathological spermiograms (40.2%), while the remaining 61 (59.8%) had a normal semen analysis and constituted the control group.The study of seminal parameters was performed according to the WHO guidelines. The metals analysis was carried out in the Toxicology Area of the Universidad de La Laguna, using the digestion for microwave method. Metal measurement was performed using inductively coupled plasma optical emission spectrometry (ICP-OES).

Main results and the role of chance

In our study we have observed 79.4% of patients have V in semen. Significant differences have been found in the concentration of V in semen (t100=1.988, p = 0.05), is higher in patients who drink alcohol (0.51± 0.40 mg/Kg) than in abstinent patients (0.35± 0.30 mg/Kg).

The group with FR above 75% presented lower V values compared to those with rates below 75% (p = 0.039). Within this last group, 33.3% present V values higher than 0.7 mg / kg compared to 15.8% who present it in the group with FR greater than 75% (OR = 2.67 CI95% 1.01, 7.52; p = 0.048).

A statistical relationship was found between CR and Pb and V. Those who did not reach 100% CR presented higher Pb values (p = 0.052). Of them, 63.6% presented Pb compared to 38.5% in the group reaching 100% division. This same relationship was observed for V, with higher values in the group that did not reach 100% (p = 0.032), and V being present in 90.9% of the samples compared to 79.5% in the group reaching 100%.

Limitations, reasons for caution

The limitation of this study was the volume of semen that could be obtained for the metal detection, only 0.5 ml. This was because the semen sample was used at the same time to make a diagnosis of infertility though a spermiogram

Wider implications of the findings

The determination of metals in semen opens a new field in the study of infertility, and many cases of unknown infertility could due to metal presence or absence in seminal fluid, with the option of performing several treatments to correct these possible anomalies.

Trial registration number

not applicable

699 ATYR2810 an anti-NRP2 monoclonal antibody targets tumor-associated macrophages

Background

Neuropilin-2 (NRP2) is a single transmembrane pleiotropic receptor that utilizes co-receptors for signal transduction and is known to impact tumor progression and metastasis.1 Deletion of NRP2 in murine tumor-associated macrophages (TAMs) downregulated several immunosuppressive and tumor-promoting genes and upregulated immune-stimulatory genes in the myeloid compartment.2 However, little is known about the role of NRP2 in human TAMs. We previously reported significant expression of NRP2 on TAMs derived from triple negative breast cancer (TNBC),3 and demonstrated the ability of ATYR2810, a monoclonal anti-NRP2 antibody, to regulate epithelial-mesenchymal transition (EMT) genes, such as the transcription factor ZEB1, and to enhance chemotherapeutic efficacy for aggressive breast cancer.4 Knowing TAMs play an important role in EMT transition and therapy resistance of cancer, and also rely on ZEB1 for their cancer promoting roles such as immune regulation,5 we sought to investigate the effects of ATYR2810 on TAMs.

Methods

MDA-MB-231 TAMs were generated from monocytes in the presence or absence of ATYR2810. TAM phenotypes, gene expression and ability to secrete cytokines were assessed by flow cytometry, qRT-PCR and MSD respectively. TAM suppressive-ness was measured in co-culture experiments. T cell proliferation and activation markers were monitored by flow cytometry and cytokine production by MSD.

Results

NRP2 is highly expressed on TAMs, which suppress T cell proliferation, activation and cytokine release. When differentiated in the presence of ATYR2810, a significant decrease in their suppressive capabilities against T cells was observed. Briefly, T cells were more proliferative, active and altered cytokine production when co-cultured with TAMs exposed to ATYR2810 compared to TAMs differentiated in its absence. Interestingly, we observed a significant decrease in ZEB1 gene and protein expression in ATYR2810 treated TAMs compared to non-treated TAMs. ATYR2810 also decreased the suppressive ability of TAMs when present in co-culture experiments.

Conclusions

We show here for the first time that ATYR2810, known to bind NRP2 tumor cells, can also bind and exert effects on human TAMs. Given the intricate relationship between TAMs and tumors, we believe that this novel finding provides additional insight into the mechanism of action of ATYR2810 as a potential immune regulator. We show for the first time that NRP2 has the ability to regulate ZEB1 expression in TAMs; reducing their suppressive nature, pointing to a novel role of NRP2 in TAMs. These findings indicate ATYR2810s potential to be an effective anti-cancer agent through regulation of ZEB1 in both TAMs and tumors.

References

Caunt M, Mak J, Liang W-C, Stawicki S, Pan Q, Tong RK, Kowalski J, Ho C, Reslan HB, Ross J, Berry L, Kasman I, Zlot C, Cheng Z, Le Couter J, Filvaroff EH, Plowman G, Peale F, French D, Carano R, Koch AW, Wu Y, Watts RJ, Tessier-Lavigne M, Bagri A. Blocking Neuropilin-2 function inhibits tumor cell metastasis. 2008;13(4):331–342. https://doi.org/10.1016/j.ccr.2008.01.029.

Roy S, Bag AK, Dutta S, Polavaram NS, Islam R, Schellenburg S, Banwait J, Guda C, Ran S, Hollingsworth MA, Singh RK, Talmage JE, Muders MH, Batra SK, Datta K. Macrophage-derived neuropilin-2 exhibits novel tumor-promoting functions. Cancer Res 2018;78(19):5600–5617. doi: 10.1158/0008–5472.CAN-18-0562.

Tyler S, Ferrer M, Polizzi C, Da Silva R, Eide L, Walwick K, Seikkula M, Burkart C, Paz S, Nangle L. Neuropilin-2 is expressed on immune cells present in the tumor microenvironment, and may contribute to the suppression of immune regulation leading to progression and metastasis of cancer. Keystone Symposia: Tumor Metabolism and the Microenvironment. 2021. https://www.atyrpharma.com/wp-content/uploads/2021/01/Jan-2021-Keystone-Poster_ST_FINAL.pdf.

Xu Z, Burkart C, Goel HL, Rahman J, Polizzi C, Seikkula M, Burman L, Mercurio AM, Nangle LA. A domain-specific antibody to NRP2 down-regulated epithelial-mesenchymanl transition genes and enhanced efficacy of stnadar-of-care therapeutics for aggressive breast cancer. American Society for Cancer Research, 2021. https://www.atyrpharma.com/wp-content/uploads/2021/04/2021Mar_AACR-poster_ZX_Final_v2.pdf.

Cortés M, Sanchez-Moral L, de Barrios O, Fernández-Aceñero MJ, Martínez-Campanario MC, Esteve-Codina A, Darling DS, Gyórffy B, Lawrence T, Dean, DC, Postigo A. Tumor-associated macrophages (TAMs) depend on ZEB1 for their cancer-promoting roles. EMBO 2017;36(22):3336–3355. doi: 10.15252/embj.201797345. Epub 2017 Oct 16.

Cost-effectiveness of the CNIC-polypill strategy for the secondary prevention of CV disease in male and female patients with established coronary heart disease based on improved risk factor control

Background

The burden of CV disease is a health and economic challenge to societies that is expected to grow in future years due to an increased prevalence in CV risk factors. Adequate management and appropriate therapy positively modify risk factors and, consequently, improve outcomes and cost-effectiveness of care. The CNIC-polypill has demonstrated in real-life, clinical effectiveness studies, its superiority over monocomponents in improving the lipidic parameters and in reduction of blood pressure in secondary CV prevention patients.

Purpose

To assess the cost-effectiveness of the CNIC-polypill (acetylsalicylic acid 100mg, atorvastatin 20/40mg, ramipril 2.5/5/10mg) compared to usual care with individual monocomponents for the secondary prevention of CV events in patients with a history of coronary heart disease (CHD) based on control of CV risk factors.

Methods

A Markov cost-effectiveness model (1-year cycles; 4 health states: stable disease, subsequent CHD, subsequent stroke, death; payer perspective; direct medical costs; lifetime horizon; 4% discount rate) based on changes in TC (10,1% reduction), HDL-c (7.4% increment) and SBP (2.6% reduction) obtained from the NEPTUNO* – a real-life, clinical effectiveness study conducted in Spain – was set for Portugal (base case). The probability of transition between health states was based on the SMART risk equation (S0, t=10= 0.8107). Cost-effectiveness was calculated for a hypothetical population (n=1,000) that replicated the characteristics of the population in the proACS registry, comprised of Portuguese patients with previous CHD. Systematic reviews identified epidemiological, costs, utility and mortality data. Outcomes were costs (€, 2020), life years (LY) and quality adjusted LY (QALY) gained.

Results

In patients with a history of CHD, the incremental cost of the CNIC-polypill strategy reaches €365,527, while preventing 35 recurrent CHD events and 17 subsequent strokes. In women and men with previous CHD, the incremental cost reaches €392,529 and €354,444 respectively while preventing recurrent 47 and 30 CHD events and 19 and 16 subsequent strokes respectively. The ICER is €5,130/LY gained for the overall population, €5,768/LY gained for women and €4,884/LY gained for men. The ICUR is €5,332/QALY gained in total, €5,817/QALY gained for women and €5,137/QALY gained for men. Assuming a willingness-to-pay (WTP) threshold of €30,000/QALY gained, there is 76.1% chances in total, 75.8% in women and 76.9% in men for the CNIC-polypill to be cost-effective and 27.8% chances overall, 27.7% in women and 25.5% in men of it being cost saving compared to usual care.

Conclusion

The CNIC-polypill seems to be a cost-effective strategy in men and women compared to usual care with monocomponents for the secondary prevention of CV disease based on improved control of risk factors. A larger reduction in the number of recurrent events is seen in women compared to men at a slightly higher cost.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Ferrer International S.A. Base case resultsProbabilistic sensitivity analysis

P–059 Association between seminal levels of Fe and semen quality

Study question

The detection of metals in semen offers a new field in the study of male infertility.

Summary answer

Normozoospermia is associated with higher amounts of Fe. In males with pathological spermiogram, the percentage of men with Fe in semen was lower than expected.

What is known already

Increased levels of Fe in human semen appear to have a significant correlation with male fertility, suggesting that Fe in human seminal plasma has an important factor in male reproductive function. Fe acts as an antioxidant being a co-factor of catalasa, which protects sperm. On the other hand, elevated Fe levels are associated with sperm damage and continues to increase the lipid peroxidation that will affect the plasma membrane and the sperm motility. Most authors associate Fe with sperm motility and higher estimated fertility potential, based on standard semen parameters in fertile men, which are associated with lower levels of Fe.

Study design, size, duration

A prospective study was carried out in 102 men in a Reproduction unit in Tenerife, from February to April 2018 as a part on an epidemiologic study of environmental contaminants and male reproduction. The participant were categorized into two groups, according to the results of semen analysis following the World Health Organization guidelines: the pathological and the normal semen group that constituted the control group. The metal was determined in semen samples.

Participants/materials, setting, methods

Semen quality and levels of Fe were measured in seminal plasma on a total of 102 men attended successively, for the initial infertility evaluation, The collected samples were used for both semen analysis following the World Health Organization (WHO) guidelines and metal detection and carried out using a Makler® counting chamber (Irvine Scientific, CA) and for metals, were determined by ICP-OES (Inductively Coupled Plasma-Optical Emission Spectrometry) in semen samples.

Main results and the role of chance

The percentage of males with the presence of Fe was 97.1% and the average level were 0.6283 mg/Kg. When analyzing the relationship between the spermiogram parameters with the levels of Fe in the semen, significant differences were found. All men with a normal sperm analysis presented Fe in semen, but among men diagnosed with altered spermiogram, the percentage of men with Fe in semen (92.7%) was lower than expected (97%) (χ2 128 1 =4.59; p = 0.032). As for the concentration of Fe in spermiogram in the first quartile (25% lower), measuring 0.33 mg/Kg, more pathological samples were found than expected (X2 133 2 =6.921; p = 0.031) having a higher probability of being more pathological (52% vs 31.4%). On the other hand, men with pathological sperm concentration, have higher levels of Fe, in the fourth quartile (0.61 mg/kg), with more frequency than expected (90.6% vs 97%) (χ2 136 1 =6.48; p = 0.011). The association between BMI and the presence of Fe was statistically significant. In obese males (BMI ≥30.0 kg/m2), the percentage of men with Fe in semen (80%) was lower than expected (97%) (χ2 42 2 =11.302; p = 0.001).

Limitations, reasons for caution

The limitation of this study was the volume of semen that could be obtained for metal detection, only 0.8 mL. because the collected samples were used for both semen analysis and metal detection.

Wider implications of the findings: The determination of metals in semen opens a new field in the study of male infertility and many cases of unknown infertility could be due to metal presence or absence in semen, with the option of performing treatments.

Trial registration number

Not applicable

Cost-effectiveness of a cardiovascular polypill strategy (aspirin, atorvastatin, ramipril) for the secondary prevention of cardiovascular disease based on real life improvement in risk factor control

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Ferrer Internacional

Background

The cardiovascular (CV) polypill has consistently demonstrated cost-effectives in decreasing the risk of CV disease in patients in secondary prevention. Previous pharmacoeconomic studies addressed improvements in adherence as a driver of health gains. This economic assessment focuses on the implications of improved control of risk factors with the polypill as observed in clinical practice.

Purpose

To assess the cost-effectiveness of a fixed-dose combination polypill (ASA 100mg, atorvastatin 20/40mg, ramipril 2.5/5/10mg) strategy for the secondary prevention of CV and cerebrovascular events in adults with a history of coronary heart disease (CHD) or stroke compared to usual care with monocomponents.

Methods

A Markov cost-effectiveness model (1-year cycles; 4 health states: stable disease, subsequent CHD, subsequent stroke, death; payer perspective; direct medical costs; lifetime horizon; 4% discount rate) based on changes in CV risk factors (total cholesterol, 18.3% reduction; high density lipoprotein cholesterol, 2.1% increment; systolic blood pressure, 11.46% reduction) obtained from a real-life effectiveness study was set for Portugal. The probability of transition between health states was based on the SMART risk equation. Cost-effectiveness was calculated for two cohorts (n = 1,000) of secondary prevention patients with previous CHD or stroke. Systematic reviews, Portuguese registries, mortality tables and official reports were searched to identify effectiveness, epidemiological, costs and utility data. Outcomes were costs (€, 2020) per life year (LY) and Quality Adjusted LY (QALY) gained. One-way (OWA) and probabilistic (PSA) sensitivity analyses tested consistency. Assumptions were validated by experts.

Results

In the CHD cohort, the incremental cost-effectiveness ratio for the polypill strategy (ICER) is 2,402 €/LY and the incremental cost-utility ratio (ICUR) is 2,328 €/QALY. Incremental cost reaches 278,927 € (polypill, 13,198,506 €; monocomponents: 12,919,579 €) with less subsequent CV events (552.31 vs 641.88) and CV deaths (102.4 vs 118.68). Assuming a willingness-to-pay (WTP) threshold of 30.000 €/QALY gained, the PSA shows a 81.4% probability for the polypill to be cost-effective and 39.1% chances to be costs saving compared to usual care. In the stroke cohort, the ICER is 386 €/LY and the ICUR is 553 €/QALY. Incremental costs are 34,178 € (polypill, 10,138,807 €; monocomponents: 10,104,629 €) with less subsequent CV events (481.99 vs 564.50) and CV deaths (101.00 vs. 117.23) with the polypill. There is a 75.9% probability for the polypill to be cost-effective and 49.5% chances to be costs saving.

Conclusion

The CV polypill is a cost-effective secondary prevention strategy compared to usual care with monocomponents. Its ICER is well below acceptable thresholds in both CV and cerebrovascular disease patients. It reduces the number of recurrent events at a moderately higher cost compared to monocomponents.

How consistent are cost-effectiveness estimates of a cardiovascular polypill strategy for the secondary prevention of cardiovascular disease across different cardiovascular risk equations?

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Ferre Internacional

Background

Risk equations (RE) are crucial to individualise estimates and properly adjust preventive treatments in patients with previous cardiovascular (CV) disease. RE are also routinely incorporated into health economic assessments but it is unknown if the cost-effectiveness results vary according to the RE applied.

Purpose

To determine the cost-effectiveness of a CV polypill (ASA 100mg, atorvastatin 20/40mg and ramipril 2.5/5/10mg) strategy compared to usual practice of combining monocomponents in the prevention of recurrent events in patients with previous coronary heart disease (CHD) or stroke applying two different CV RE: SMART and FRAMINGHAM, respectively.

Methods

A Markov cost-effectiveness model (1-year cycles; 4 health states: stable disease, subsequent CHD, subsequent stroke; death; payer perspective; direct medical costs; lifetime horizon; 4% discount rate) was developed for Portugal. Transition probability between health states was based on the SMART RE and an adaptation for secondary CV prevention of the FRAMINGHAM RE, respectively. Cost-effectiveness was calculated for a mixed cohort of secondary prevention patients (weighed post-CHD: 57.9%; post-stroke: 42.1%). Systematic literature reviews, Portuguese registries, mortality tables and official reports ware used to identify effectiveness, epidemiological, costs and utility data. Outcomes were costs (€, 2020) per life year (LY) and Quality Adjusted Life Year (QALY) gained. One-way (OWA) and probabilistic (PSA) sensitivity analyses tested the consistency of results. Assumptions were validated by experts.

Results

Applying the SMART RE, the incremental cost-effectiveness ratio (ICER) is 1,555€/LY gained and the incremental cost-utility ratio (ICUR) is 1,785€/QALY gained for the polypill strategy. The incremental costs of adopting the polypill strategy are 171,378€. Recurrent CV events (550.68 vs 642.13) and CV deaths (106.05 vs 122.81) are also less frequent with the polypill strategy compared with monocomponents. Assuming a willingness-to-pay (WTP) threshold of 30.000 €/QALY gained, there is a 77.80% probability for the polypill strategy to be cost-effective and 43.00% chances to be costs saving when used in a mixed cardiovascular and cerebrovascular disease population. Applying the FRAMINGHAM RE, the ICER is 998€/LY gained and the ICUR is 1,242€/QALY. The incremental costs amount 175,122€. Recurrent CV events (452.66 vs 563.48) and CV deaths (104.77 vs 127.32) are less frequent with the polypill strategy. The PSA shows a 99.5% probability for the polypill strategy to be cost-effective and 46.8% chances to be costs saving.

Conclusion

Both risk equations result in comparable results on the cost-effectiveness of interventions for the secondary prevention of CV disease. The polypill strategy remains cost-effective compared to the common practice of using individual monocomponents concomitantly, reducing recurrent CV events at a moderately higher cost.

Impacts of climate change on Public Health of the Mediterranean population

The Mediterranean Basin is undergoing a warming trend with longer and warmer summers, an increase in the frequency and the severity of heat waves, changes in precipitation patterns and a reduction in rainfall amounts. This populated region is characterized by significant gaps in the socio-economic levels, parallel with population growth and migration, increased water demand and forest fires risk. Consequently, the vulnerability of the Mediterranean population to human health risks as result of climate change increases significantly.

Climatic changes impact the health of the Mediterranean population directly through extreme heat, drought or storms, or indirectly by changes in water availability, food provision and quality, air pollution and other stressors. The main health effects are related to extreme weather events, changes in the distribution of climate-sensitive diseases and changes in environmental and social conditions. The poorer countries, particularly in North Africa and the Levant, are at highest risk. Climate change affects the vulnerable sectors of the region, including an increasingly older population, with a larger percentage of those with chronic diseases, as well as poor people, which are therefore more susceptible to the effects of extreme temperatures. For those populations, a better surveillance and control systems are especially needed parallel with adaptation planning that become ever more imperative. In order to achieve these goals, it is essential to define indicators of vulnerability and exposure based on health impact assessment, as well as indicators that will promote adaptation planning and resilience for health risk management. In view of the climatic projections and the vulnerability of Mediterranean countries, such indicators will contribute to correct preparedness at the regional and national levels.

Developing urban resilience in Haifa: preparedness to climate change in health and welfare agencies

Background

Extreme climate events (wildfires, floods, heatwaves, cold spells) are becoming more frequent in the Mediterranean, but adaptation levels in the health and welfare sectors remain low. The city of Haifa in northern Israel is prone to both war and extreme climate events. Focusing on Haifa, we aim to 1) examine local officials' risk perceptions of different extreme events, 2) compare preparedness to war vs. climate events, and 3) conduct a spatial analysis of climate and health vulnerabilities.

Methods

Mixed-Methods: a qualitative component including 30 in-depth interviews with local government health and welfare officials, and a qualitative component that includes mapping vulnerability indicators such as socio-economic status, recipients of welfare allowances, and temperature, focusing on urban heat islands.

Results

The city of Haifa developed a comprehensive resilience policy for war and wildfire. However, there is no awareness or preparedness for other climate events that have not yet been experienced. Similarly, hospitals are prepared for emergencies, but not for extreme climate events. There are no national budget or guidelines for climate adaptation at the city level or in hospitals. Correspondingly, risk perceptions of climate change among health and welfare officials remain low. At the city level, social and climatic vulnerabilities are correlated, so that downtown neighborhoods are characterized by poorer socio-economic, health and welfare conditions, and higher summer temperatures.

Conclusions

Haifa has good preparedness for events that had been experienced in the past. While emergency preparedness provides a good infrastructure for climate change preparedness, awareness and adaptation to the unique aspects of climate change preparations are needed, including reference to related spatial dimensions. Identifying the gaps between preparedness to various emergency events, can contribute to better climate change preparedness at the local level.

Key messages

In the city of Haifa, emergency preparedness exists but is not extended to extreme climate events, and awareness to health risks of climate change remains low in the health and welfare agencies. Learning from emergency preparedness to wars, wildfires and earthquakes may contribute to enhancing preparedness to extreme climate events at the local level.

A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare

BACKGROUND

Determining the mental capacity of psychiatric patients for making healthcare related decisions is crucial in clinical practice. This meta-review of review articles comprehensively examines the current evidence on the capacity of patients with a mental illness to make medical care decisions.

METHODS

Systematic review of review articles following PRISMA recommendations. PubMed, Scopus, CINAHL and PsycInfo were electronically searched up to 31 January 2020. Free text searches and medical subject headings were combined to identify literature reviews and meta-analyses published in English, and summarising studies on the capacity of patients with serious mental illnesses to make healthcare and treatment related decisions, conducted in any clinical setting and with a quantitative synthesis of results. Publications were selected as per inclusion and exclusion criteria. The AMSTAR II tool was used to assess the quality of reviews.

RESULTS

Eleven publications were reviewed. Variability on methods across studies makes it difficult to precisely estimate the prevalence of decision-making capacity in patients with mental disorders. Nonetheless, up to three-quarters of psychiatric patients, including individuals with serious illnesses such as schizophrenia or bipolar disorder may have capacity to make medical decisions in the context of their illness. Most evidence comes from studies conducted in the hospital setting; much less information exists on the healthcare decision making capacity of mental disorder patients while in the community. Stable psychiatric and non-psychiatric patients may have a similar capacity to make healthcare related decisions. Patients with a mental illness have capacity to judge risk-reward situations and to adequately decide about the important treatment outcomes. Different symptoms may impair different domains of the decisional capacity of psychotic patients. Decisional capacity impairments in psychotic patients are temporal, identifiable, and responsive to interventions directed towards simplifying information, encouraging training and shared decision making. The publications complied satisfactorily with the AMSTAR II critical domains.

CONCLUSIONS

Whilst impairments in decision-making capacity may exist, most patients with a severe mental disorder, such as schizophrenia or bipolar disorder are able to make rational decisions about their healthcare. Best practice strategies should incorporate interventions to help mentally ill patients grow into the voluntary and safe use of medications.

Underlying Immune Disorder May Predispose Some Transthyretin Amyloidosis Subjects to Inotersen-Mediated Thrombocytopenia

Inotersen, a 2'-O-methoxyethyl (2'-MOE) phosphorothioate antisense oligonucleotide, reduced disease progression and improved quality of life in patients with hereditary transthyretin amyloidosis with polyneuropathy (hATTR-PN) in the NEURO-TTR and NEURO-TTR open-label extension (OLE) trials. However, 300 mg/week inotersen treatment was associated with platelet count reductions in several patients. Mean platelet counts in patients in the NEURO-TTR-inotersen group remained ≥140 × 10⁹/L in 50% and ≥100 × 10⁹/L in 80% of the subjects. However, grade 4 thrombocytopenia (<25 × 10⁹/L) occurred in three subjects in NEURO-TTR trial, and one of these suffered a fatal intracranial hemorrhage. The two others were treated successfully with corticosteroids and discontinuation of inotersen. Investigations in a subset of subjects in NEURO-TTR (n = 17 placebo; n = 31 inotersen) and OLE (n = 33) trials ruled out direct myelotoxicity, consumptive coagulopathy, and heparin-induced thrombocytopenia. Antiplatelet immunoglobulin G (IgG) antibodies were detected at baseline in 5 of 31 (16%) inotersen-treated subjects in NEURO-TTR, 4 of whom eventually developed grade 1 or 2 thrombocytopenia while on the drug. In addition, 24 subjects in the same group developed treatment-emergent antiplatelet IgG antibodies, of which 2 developed grade 2, and 3 developed grade 4 thrombocytopenia. Antiplatelet IgG antibodies in two of the three grade 4 thrombocytopenia subjects targeted GPIIb/IIIa. Plasma cytokines previously implicated in immune dysregulation, such as interleukin (IL)-23 and a proliferation-inducing ligand (APRIL) were often above the normal range at baseline. Collectively, these findings suggest an underlying immunologic dysregulation predisposing some individuals to immune-mediated thrombocytopenia during inotersen treatment.

Placental levels of metals and associated factors in urban and sub-urban areas of Seville (Spain)

Environmental exposure to metals among women, revealed their adverse effects on pregnancy. The fetus is exposed to these toxic elements only via the placenta which are able to accumulate there or cross it, compromising the protective functions of this organ. Numerous studies have shown associations between the prenatal exposition to some metals and an impact on cognitive, motor and intellectual development of the child. Sixty two placental samples were taken at delivery to determine the mineral content (Al, B, Ba, Ca, Cd, Cr, Cu, Fe, K, Li, Mg, Mn, Mo, Na, Ni, Pb, Sr, V, Zn) by ICP-OES. Among these metals, essential ones (B, Ca, Cu, Fe, Mg, Mn, Mo, Na, Zn) can have health beneficial effects at low levels however, in high concentration are potentially toxic. On the other hand, elements such as Al, Cd, Pb, are classified as toxic metals, no matter what its concentration is. The aim of this study is to find the potential relationships between these metals levels, newborn's parameters, pregnancy details and the epidemiologic information obtained using a questionnaire data from the participant pregnant women from Seville (Spain). The main maternal determinant of detectable placenta Cd levels was smoking during pregnancy. Other maternal factors that may affect placenta metal levels were gestational age (Al, B, Ba, and Pb) or dietary supplement (Fe). It has to be stressed that our results have to be interpreted with caution, because of the small study group and the low exposure levels, along with the lack of information on potential sources of exposure to these metals. The use of placenta samples obtained at delivery can be considered strength of this study since the concentration of some metals in placenta can indicate the extent of maternal exposure during gestation.

Metal Concentrations in Wild-Harvested Phaeophyta Seaweed from the Atlantic Ocean (Canary Islands, Spain)

Seaweeds are being consumed more often worldwide and are a source of essential minerals, fiber, vitamins, amino acids, and various bioactive compounds that have many beneficial effects on human health. However, marine pollution and the high capacity of seaweed to absorb metals may mean this food can also be dangerous to human health. The concentrations of some trace elements (B, Ba, Fe, Ni, Li, and V) and toxic metals (Al, Cd, and Pb) were determined in various species of wild seaweeds in the Phaeophyta group of brown algae from the Atlantic Ocean. Inductively coupled plasma atomic emission spectrometry revealed high concentrations of Al (256 mg/kg dry weight), Pb (3.92 mg/kg dry weight), and Cd (0.20 mg/kg dry weight) in Padina pavonica. Pb contributed the most to the tolerable daily intake (TDI) of toxic metals in these samples; 57.2 and 45.3% of the TDI for Pb was found in 5 g of dehydrated P. pavonica and Halopteris scoparia, respectively. This percent contribution is half of the recommended TDI for this metal, which is 34.24 μg/day; therefore, high consumption of these species is discouraged. The maximum TDIs established by various institutions for the other metals were not exceeded from the daily consumption of 5 g of the other dehydrated seaweeds evaluated in this study.

Metal Concentrations in Samples of Frozen Cephalopods (Cuttlefish, Octopus, Squid, and Shortfin Squid): An Evaluation of Dietary Intake

Cephalopods are an important source of nutrients and some of the most widely consumed marine foods. However, because of contamination of the oceans and the bioaccumulative nature of toxic metals, these foods may pose a health risk. For this reason, the concentrations of some trace elements (chromium [Cr], lithium, strontium [Sr], copper [Cu], and nickel) and toxic metals (aluminum [Al], cadmium, and lead) were determined in 65 frozen samples of cuttlefish, octopus, common squid, and shortfin squid by inductively coupled plasma optical emission spectrometry to evaluate dietary intake and toxic risk. Sr was the major trace element (3.03 mg/kg) in cuttlefish; however, Cu (1.57 mg/kg) was found in the highest concentration in common squid. Among the toxic metals, Al had the highest concentration (3.09 mg/kg) in common squid. Al can pose an important health risk to individuals with kidney problems and to children because these groups are most vulnerable to the toxic effects. Significant differences among the four cephalopod types were found in the concentrations of most of the metals examined. Taking into account the average consumption of cephalopods, the contribution of toxic metals does not pose a risk to the health of adults.

The Distinct and Cooperative Roles of Toll-Like Receptor 9 and Receptor for Advanced Glycation End Products in Modulating In Vivo Inflammatory Responses to Select CpG and Non-CpG Oligonucleotides

Antisense oligonucleotides (ASOs) are widely accepted therapeutic agents that suppress RNA transcription. While the majority of ASOs are well tolerated in vivo, few sequences trigger inflammatory responses in absence of conventional CpG motifs. In this study, we identified non-CpG oligodeoxy-nucleotide (ODN) capable of triggering an inflammatory response resulting in B cell and macrophage activation in a MyD88- and TLR9-dependent manner. In addition, we found the receptor for advance glycation end product (RAGE) receptor to be involved in the initiation of inflammatory response to suboptimal concentrations of both CpG- and non-CpG-containing ODNs. In contrast, dosing RAGE KO mice with high doses of CpG or non-CpG ODNs lead to a stronger inflammatory response than observed in wild-type mice. Together, our data provide a previously uncharacterized in vivo mechanism contingent on ODN-administered dose, where TLR9 governs the primary response and RAGE plays a distinct and cooperative function in providing a pivotal role in balancing the immune response.

Relapse rates in chronic hepatitis B naïve patients after discontinuation of antiviral therapy with entecavir

Registration studies show entecavir (ETV) to be effective and safe in NUC-naïve patients with chronic hepatitis B, but relapse rates after treatment discontinuation have not been well established. Relapse rates and predictors of relapse were evaluated in naïve HBeAg-positive and HBeAg-negative patients treated with ETV. Treatment duration was defined according to international guidelines. Virological relapse was defined as reappearance in serum of hepatitis B virus (HBV) DNA to >2000 IU/mL after discontinuation of treatment. A hundred and sixty-nine consecutive patients were treated for a median 181 weeks. 61% were HBeAg positive, 23% had cirrhosis, and mean HBV DNA level was 6.88 ± 1.74 log10 IU/mL. Ninety-two per cent became HBV DNA negative; 71% of HBeAg+ve patients became HBeAg negative and 68% anti-HBe positive; 14% became HBsAg negative and 13% anti-HBs positive. At the end of the study, 36 patients discontinued treatment: one due to breakthrough associated with resistant variants and 35 (20%) due to sustained virological response; 33 of these patients developed HBeAg seroconversion and 18 HBsAg seroconversion. Median off-treatment time was 69 weeks. Nine patients (26%), all HBeAg positive at baseline, developed virological relapse after a median 48 weeks off-treatment, 3 of them showed HBeAg reversion and 4 lost anti-HBe. No patient with HBsAg seroconversion relapsed. HBeAg clearance after week 48 of treatment was associated with an increase risk of relapse. After ETV discontinuation, HBsAg seroconversion was maintained in 100% of the patients, HBeAg seroconversion maintained in 90%, and virological relapse rate was 24%.

Systems analysis of a RIG-I agonist inducing broad spectrum inhibition of virus infectivity

The RIG-I like receptor pathway is stimulated during RNA virus infection by interaction between cytosolic RIG-I and viral RNA structures that contain short hairpin dsRNA and 5′ triphosphate (5′ppp) terminal structure. In the present study, an RNA agonist of RIG-I was synthesized in vitro and shown to stimulate RIG-I-dependent antiviral responses at concentrations in the picomolar range. In human lung epithelial A549 cells, 5′pppRNA specifically stimulated multiple parameters of the innate antiviral response, including IRF3, IRF7 and STAT1 activation, and induction of inflammatory and interferon stimulated genes - hallmarks of a fully functional antiviral response. Evaluation of the magnitude and duration of gene expression by transcriptional profiling identified a robust, sustained and diversified antiviral and inflammatory response characterized by enhanced pathogen recognition and interferon (IFN) signaling. Bioinformatics analysis further identified a transcriptional signature uniquely induced by 5′pppRNA, and not by IFNα-2b, that included a constellation of IRF7 and NF-kB target genes capable of mobilizing multiple arms of the innate and adaptive immune response. Treatment of primary PBMCs or lung epithelial A549 cells with 5′pppRNA provided significant protection against a spectrum of RNA and DNA viruses. In C57Bl/6 mice, intravenous administration of 5′pppRNA protected animals from a lethal challenge with H1N1 Influenza, reduced virus titers in mouse lungs and protected animals from virus-induced pneumonia. Strikingly, the RIG-I-specific transcriptional response afforded partial protection from influenza challenge, even in the absence of type I interferon signaling. This systems approach provides transcriptional, biochemical, and in vivo analysis of the antiviral efficacy of 5′pppRNA and highlights the therapeutic potential associated with the use of RIG-I agonists as broad spectrum antiviral agents.

Development of safe and effective drugs that inhibit virus replication remains a challenge. Activation of natural host defense using interferon (IFN) therapy has proven an effective treatment of certain viral infections. As a distinct variation on this concept, we analyzed the capacity of small RNA molecules that mimic viral components to trigger the host antiviral response and to inhibit the replication of several pathogenic human viruses. Using gene expression profiling, we identified robust antiviral and inflammatory gene signatures after treatment with a 5′-triphosphate containing RNA (5′pppRNA), including an integrated set of genes that is not regulated by IFN treatment. Delivery of 5′pppRNA into lung epithelial cells in vitro stimulated a strong antiviral immune response that inhibited the multiplication of several viruses. In a murine model of influenza infection, inoculation of the agonist protected animals from a lethal challenge of H1N1 influenza and inhibited virus replication in mouse lungs during the first 24–48 h after infection. This report highlights the therapeutic potential of naturally derived RIG-I agonists as potent stimulators of the innate antiviral response, with the capacity to block the replication of diverse human pathogenic viruses.

Linear ubiquitination of NEMO negatively regulates the interferon antiviral response through disruption of the MAVS-TRAF3 complex

The RIG-I/Mda5 sensors recognize viral intracellular RNA and trigger host antiviral responses. RIG-I signals through the adaptor protein MAVS, which engages various TRAF family members and results in type I interferon (IFNs) and proinflammatory cytokine production via activation of IRFs and NF-κB, respectively. Both the IRF and NF-κB pathways also require the adaptor protein NEMO. We determined that the RIG-I pathway is differentially regulated by the linear ubiquitin assembly complex (LUBAC), which consists of the E3 ligases HOIL-1L, HOIP, and the accessory protein SHARPIN. LUBAC downregulated virus-mediated IFN induction by targeting NEMO for linear ubiquitination. Linear ubiquitinated NEMO associated with TRAF3 and disrupted the MAVS-TRAF3 complex, which inhibited IFN activation while stimulating NF-κB-dependent signaling. In SHARPIN-deficient MEFs, vesicular stomatitis virus replication was decreased due to increased IFN production. Linear ubiquitination thus switches NEMO from a positive to a negative regulator of RIG-I signaling, resulting in an attenuated IFN response.

Competitividad de los haras de Sangre Pura de carrera en función de los factores clave de éxito

La industria hípica en general y la de Sangre Pura de Carrera (SPC) en particular, es un sector preponderante en la economía agraria argentina. Un grupo reducido de empresas se alternan permanentemente entre los diez primeros lugares del Stud Book de SPC, condición que permite establecer que las mismas poseen factores claves de éxito (FCE), tanto por su gestión empresarial como productiva. Este trabajo, mediante la realización de una encuesta a 20 empresas de SPC pertenecientes al Stud Book, intenta determinar la presencia de FCE. Se estudiaron 52 variables reunidas en siete áreas temáticas de FCE (ubicación geográfica, infraestructura, modelo productivo, recursos tecnológicos, equipamiento aplicado a la producción y programa sanitario). Se detectaron tres grupos productivos claramente regionalizados y un grupo disperso de empresas, asimismo se detectó heterogeneidad con respecto a los éxitos comerciales y deportivos además de diferentes niveles de adopción de innovaciones productivas. El agrupamiento ubicado en el norte de la Provincia de Buenos Aires (Argentina), podría ser considerado como equivalente a un distrito industrial, por la coexistencia de cooperación-competencia. En esta zona se concentra la mayoría de las empresas exitosas. El presente trabajo pretende ser un aporte de nuevos conocimientos relativos al sector hípico del SPC argentino.

Effectiveness of entecavir in chronic hepatitis B NUC-naive patients in routine clinical practice

INTRODUCTION

Registration studies showed entecavir (ETV) to be effective and safe in NUC-naïve patients with chronic hepatitis B virus (HBV), but its effectiveness in routine clinical practice is unknown.

MATERIALS AND METHODS

Sixty-nine HBeAg positive and negative NUC naïve chronic HBV patients were treated with ETV for 110 weeks. 63% were HBeAg positive, 16% were cirrhotics, mean HBV-DNA was 7.09 log IU/ml and mean ALT was 157 IU/ml.

RESULTS

Sixty-one (88%) patients achieved undetectable DNA, with 46%, 77% and 100% virological response rates at week 24, 48 and 96 of treatment, respectively. Thirty-seven (84%) patients in the HBeAg-positive population achieved undetectable DNA, with 67% and 100% virological response rates at week 48 and 96 of treatment, respectively. Twenty-four (96%) patients in the HBeAg-negative population achieved undetectable DNA, with 91% and 100% virological response rates at week 48 and 96 of treatment, respectively. Twenty-three (53%) patients cleared HBeAg and 19 (44%) patients seroconverted to antiHBe positive status; seven (10%) patients cleared hepatitis B surface antigen and five (7%) patients developed antiHBs. At the end of the study, 10 patients successfully stopped therapy: nine HBeAg positive (four developed antiHBs positive) and one HBeAg negative. None of the patients had primary non-response. ETV resistance was not tested. None of the patients developed hepatocellular carcinoma, underwent liver transplantation or died because of liver-related events. No serious adverse events were reported.

CONCLUSION

The ETV monotherapy showed high virological response rates, a favourable safety profile for NUC-naive HBeAg-positive and negative patients treated in routine clinical practice.

Willingness to pay and conjoint analysis to determine women's preferences for ovarian stimulating hormones in the treatment of infertility in Spain

BACKGROUND

Despite many advances in assisted reproductive techniques (ART), little is known about preferences for technological developments of women undergoing fertility treatments. The aims of this study were to investigate the preferences of infertile women undergoing ART for controlled ovarian stimulation (COS) treatments; to determine the utility values ascribed to different attributes of COS treatments; and to estimate women's willingness to pay (WTP) for COS.

METHODS

A representative sample of ambulatory patients ready to receive, or receiving, COS therapies for infertility were recruited from seven specialized private centres in six autonomous communities in Spain. Descriptive, inferential and conjoint analyses (CA) were used to elicit preferences and WTP. Attributes and levels of COS treatments were identified by literature review and two focus groups with experts and patients. WTP valuations were derived by a combination of double-bounded (closed-ended) and open questions and contingent ranking methods.

RESULTS

In total, 160 patients [mean (standard deviation; SD) age: 35.8 (4.2) years] were interviewed. Over half of the participants (55.0%) had a high level of education (university degree), most (78.8%) were married and half (50.0%) had an estimated net income of >€1502 per month and had paid a mean (SD) €1194.17 (€778.29) for their most recent hormonal treatment. The most frequent causes of infertility were related to sperm abnormalities (50.3%). In 30.6% of cases, there were two causes of infertility. The maximum WTP for COS treatment was €800 (median) per cycle; 35.5% were willing to pay an additional €101-€300 for a 1-2% effectiveness gain in the treatment. Utility values (CA) showed that effectiveness was the most valued attribute (39.82), followed by costs (18.74), safety (17.75) and information sharing with physicians (14.93).

CONCLUSIONS

WTP for COS therapies exceeds current cost. Additional WTP exists for 1-2% effectiveness improvement. Effectiveness and costs were the most important determinants of preferences, followed by safety and information sharing with physicians.

Hepatitis B virus in Buenos Aires, Argentina: genotypes, virological characteristics and clinical outcomes

Hepatitis B virus (HBV) is classified into eight major genotypes, A-H, which are geographically distributed worldwide. The aim of this work was to describe the clinical characteristics associated with the HBV genotypes circulating in Buenos Aires city. The study included 139 patients infected with HBV, whose clinical courses were classified as acute symptomatic self-limiting hepatitis, inactive carrier state and chronic active hepatitis (HBV e-antigen (HBeAg)-positive and HBeAg-negative). The HBV genotypes were determined in 128 patients by PCR-restriction fragment length polymorphism and phylogenetic analysis. Biochemical, virological, clinical and histological features were analysed. A differential distribution of genotypes between acute symptomatic and chronic infections was found. Among the acute cases, genotype F was predominant (65.2%, 30/46) and genotype D was rare (4.3%, 2/46), whereas among the chronic infections, a homogeneous distribution of genotypes A (26.8%, 22/82), D (31.7%, 26/82) and F (36.6%, 30/82), with an unusual presence of genotypes B (1.2%, 1/82) and C (3.7%, 3/82), was observed. Regarding the liver histology of chronically infected patients, genotype F tended to display higher histological activity indexes. Mutations related to HBV surface antigen immunoreactivity, antiviral resistance and HBeAg-negative status were studied. This work constitutes, to our knowledge, the first description of the clinical characteristics related to HBV genotypes in Argentina, where the distribution of genotypes in patients with acute infection has not been reported previously. Finally, it was established that genotype F is the prevalent genotype among the acute symptomatic infections in Buenos Aires city, and that it shows a tendency to cause an adverse disease outcome among the chronic cases.

[Tuberculous peritonitis in HIV-infected patients]

In order to describe the clinical and laboratory findings of Mycobacterium tuberculosis peritonitis M. tuberculosis in HIV+ patients, we conducted a retrospective analysis of the medical records of HIV+ patients with isolation of M. tuberculosis from ascitic fluid (AF), assisted at Hospital Muñiz, Buenos Aires, Argentina (1996-2005).

RESULTS

21 patients were included. Median age: 33, male sex: 52%; peripheral blood CD4-T lymphocyte count (median): 85/mm3; prior history of tuberculosis: 40%; cirrhosis: 65%; enolism: 45%; HCV coinfection: 85%. The most frequent symptoms were abdominal distension (71%), fever (62%) and abdominal pain (19%). The chemical characteristics of the AF were (median): leukocyte count: 751/mm3 (mononuclear predominance: 79%), protein: 3.1 g/dl, LDH: 351 IU/l. AF samples positive for acid fast bacilli at direct microscopic examination: 14%. Infection with multidrug resistant M. tuberculosis (TB-MR): 20%. M. tuberculosis was isolated from other clinical samples in 79%. Fifteen patients received treatment for tuberculosis; in 30% of cases, it was not appropriate due to the susceptibility of the isolated strain. Overall mortality was 66.4%.

CONCLUSION

high mortality was observed, which may be attributable to the high frequency of TB-MR, the level of immunosuppression and the prevalence of cirrhosis secondary to enolism and/or HCV coinfection.

Polo-like kinase 1 (PLK1) regulates interferon (IFN) induction by MAVS

The mitochondria-bound adapter MAVS participates in IFN induction by recruitment of downstream partners such as members of the TRAF family, leading to activation of NF-kappaB, and the IRF3 pathways. A yeast two-hybrid search for MAVS-interacting proteins yielded the Polo-box domain (PBD) of the mitotic Polo-like kinase PLK1. We showed that PBD associates with two different domains of MAVS in both dependent and independent phosphorylation events. The phosphodependent association requires the phosphopeptide binding ability of PBD. It takes place downstream of the proline-rich domain of MAVS, within an STP motif, characteristic of the binding of PLK1 to its targets, where the central Thr234 residue is phosphorylated. Its phosphoindependent association takes place at the C terminus of MAVS. PLK1 strongly inhibits the ability of MAVS to activate the IRF3 and NF-kappaB pathways and to induce IFN. Reciprocally, depletion of PLK1 can increase IFN induction in response to RIG-I/SeV or RIG-I/poly(I)-poly(C) treatments. This inhibition is dependent on the phosphoindependent association of PBD at the C terminus of MAVS where it disrupts the association of MAVS with its downstream partner TRAF3. IFN induction was strongly inhibited in cells arrested in G2/M by nocodazole, which provokes increased expression of endogenous PLK1. Interestingly, depletion of PLK1 from these nocodazole-treated cells could restore, at least partially, IFN induction. Altogether, these data demonstrate a new function for PLK1 as a regulator of IFN induction and provide the basis for the development of inhibitors preventing the PLK1/MAVS association to sustain innate immunity.

Climate change and the emergence of Vibrio vulnificus disease in Israel

In 1996, a major unexplained outbreak of systemic Vibrio vulnificus infection erupted among Israeli fish market workers. The origins of this emergent infectious disease have not been fully understood. A possible link between climate change and disease emergence is being investigated. Meteorological service data from 1981, the earliest detection and reporting of V. vulnificus for the time in Israel, to 1998 for two stations located within the main inland fish farm industry were analyzed. The 1996-1998 summers were identified as the hottest ever recorded in Israel in the previous 40 years. Time series of monthly minimum, maximum, and mean temperatures showed significant increase in the summer temperatures along the 18 years. The highest minimum temperature value was recorded in summer 1996. Lag correlation analysis revealed significant correlations between temperature values and hospital admission dates. The eruption appeared 25-30 days after the extreme heat conditions in summer 1996, at a lag of 3 weeks in summer 1997 while the results for 1998 were at a lag of less than a week. Higher significant results were detected for the daily minimum temperatures in summer 1996 compatible with the disease eruption. These findings suggest that high water temperature might have impacted the ecology of our study area and caused the emergence of the disease, as an effect of global climate change.

Manipulation of the nuclear factor-kappaB pathway and the innate immune response by viruses

Viral and microbial constituents contain specific motifs or pathogen-associated molecular patterns (PAMPs) that are recognized by cell surface- and endosome-associated Toll-like receptors (TLRs). In addition, intracellular viral double-stranded RNA is detected by two recently characterized DExD/H box RNA helicases, RIG-I and Mda-5. Both TLR-dependent and -independent pathways engage the IkappaB kinase (IKK) complex and related kinases TBK-1 and IKKvarepsilon. Activation of the nuclear factor kappaB (NF-kappaB) and interferon regulatory factor (IRF) transcription factor pathways are essential immediate early steps of immune activation; as a result, both pathways represent prime candidates for viral interference. Many viruses have developed strategies to manipulate NF-kappaB signaling through the use of multifunctional viral proteins that target the host innate immune response pathways. This review discusses three rapidly evolving areas of research on viral pathogenesis: the recognition and signaling in response to virus infection through TLR-dependent and -independent mechanisms, the involvement of NF-kappaB in the host innate immune response and the multitude of strategies used by different viruses to short circuit the NF-kappaB pathway.