Cryptococcus neoformans, a global threat to human health

BACKGROUND

Emerging fungal pathogens pose important threats to global public health. The World Health Organization has responded to the rising threat of traditionally neglected fungal infections by developing a Fungal Priority Pathogens List (FPPL). Taking the highest-ranked fungal pathogen in the FPPL, Cryptococcus neoformans, as a paradigm, we review progress made over the past two decades on its global burden, its clinical manifestation and management of cryptococcal infection, and its antifungal resistance. The purpose of this review is to drive research efforts to improve future diagnoses, therapies, and interventions associated with fungal infections.

METHODS

We first reviewed trends in the global burden of HIV-associated cryptococcal infection, mainly based on a series of systematic studies. We next conducted scoping reviews in accordance with the guidelines described in the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews using PubMed and ScienceDirect with the keyword Cryptococcus neoformans to identify case reports of cryptococcal infections published since 2000. We then reviewed recent updates on the diagnosis and antifungal treatment of cryptococcal infections. Finally, we summarized knowledge regarding the resistance and tolerance of C. neoformans to approved antifungal drugs.

RESULTS

There has been a general reduction in the estimated global burden of HIV-associated cryptococcal meningitis since 2009, probably due to improvements in highly active antiretroviral therapies. However, cryptococcal meningitis still accounts for 19% of AIDS-related deaths annually. The incidences of CM in Europe and North America and the Latin America region have increased by approximately two-fold since 2009, while other regions showed either reduced or stable numbers of cases. Unfortunately, diagnostic and treatment options for cryptococcal infections are limited, and emerging antifungal resistance exacerbates the public health burden.

CONCLUSION

The rising threat of C. neoformans is compounded by accumulating evidence for its ability to infect immunocompetent individuals and the emergence of antifungal-resistant variants. Emphasis should be placed on further understanding the mechanisms of pathogenicity and of antifungal resistance and tolerance. The development of novel management strategies through the identification of new drug targets and the discovery and optimization of new and existing diagnostics and therapeutics are key to reducing the health burden.

The Relationship between Psychological Distress and Physical Frailty in Japanese Community-Dwelling Older Adults: A Cross-Sectional Study

BACKGROUND

Older adults' mental health and physical frailty have been a frequent research focus, but few studies have investigated the relationship between them.

OBJECTIVES

To investigate the association between mental health and physical frailty in community-dwelling older Japanese people.

DESIGN

Cross-sectional study from the Itoshima Frail Study.

SETTING

Itoshima City, Fukuoka, Japan.

PARTICIPANTS

A total of 919 community-dwelling older individuals aged 65-75 years.

MEASUREMENTS

Physical frailty was measured based on five criteria proposed by the Fried scale, and the subjects were classified into three groups: robust, pre-frailty, and frailty. Psychological distress was used to assess the subjects' mental health, with the Kessler 6-Item Psychological Distress Scale (K6) score; the subjects were divided into three groups based on their K6 score: 0-1, 2-4, and ≥5. Psychological distress was defined by K6 score ≥5. Ordinal logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CIs) between the psychological distress and physical frailty status.

RESULTS

Psychological distress was identified in 190 subjects (20.7%). Forty-six subjects (5.0%) presented with physical frailty, and 24 subjects (2.6%) had both psychological distress and physical frailty. With the increase in the K6 score, more subjects had pre-frailty and physical frailty (p<0.001). Significant positive associations were observed between psychological distress and the risks of pre-frailty (OR 2.94, 95%CI: 1.95-4.43) and frailty (OR 10.71, 95%CI: 4.68-24.51), even in a multivariable-adjusted analysis. In a subgroup analysis of components of frailty, one-point increment in K6 score was associated with higher odds of shrinking and fatigue.

CONCLUSION

A severe psychological distress was associated with increased risks of physical frailty and the frailty sub-items of shrinking and fatigue in community-dwelling older Japanese adults.

[The influence of various myelosuppression degrees during neoadjuvant chemotherapy on the curative effect and prognosis of triple-negative breast cancer]

Objective: To investigate the effect of the degrees of myelosuppression on the curative effect and prognosis of triple-negative breast cancer with neoadjuvant chemotherapy. Methods: The clinical, pathological and follow-up data of 206 patients with triple negative breast cancer who received neoadjuvant chemotherapy with docetaxel combined with epirubicin combined with cyclophosphamide regimen in the Department of Breast Surgery in the Third Affiliated Hospital of Zhengzhou University from January 2013 to December 2018 were collected retrospectively. All were female, aged 28-71 (47.8±10.7) years. According to the WHO classification standard of acute and subacute toxicity of anticancer drugs, the patients were divided into 98 cases in the mild group (0-Ⅱ degree) and 108 cases in the severe group (Ⅲ-Ⅳ degree) according to the degree of bone marrow suppression after chemotherapy. The baseline clinicopathological features, pathological complete remission rate (PCR) and objective remission rate (ORR) of the two groups were compared. The survival curve was drawn by Kaplan Meier method, and the differences of disease-free survival (DFS), local recurrence free survival (LRFS), distant metastasis free survival (DMFS) and overall survival (OS) between the two groups were analyzed by log rank test. Cox regression risk model was used to analyze the related factors affecting the survival of the patients. Results: There were no significant differences in baseline clinicopathological characteristics of patients between the two groups, such as age, physical status score, menopausal status, body mass index, histological grade, clinical T stage, clinical N stage and Ki-67 index (all P>0.05). The severe group had higher PCR, longer median DFS and median DMFS than the mild group [50.9%(55/108) vs 36.7%(36/98); not reached vs 72 months; not reached vs 84 months] (all P<0.05). There was no significant difference in ORR, LRFS and OS between the two groups [89.8%(97/108) vs 81.6%(80/98); both not reached; both not reached] (all P>0.05). The degree of bone marrow suppression after neoadjuvant chemotherapy was an influential factor of DFS in TNBC patients (P=0.025). Compared with mild myelosuppression group, severe myelosuppression group had better disease-free survival prognosis (HR=0.571, 95%CI: 0.349-0.934). Conclusion: The prognosis of grade Ⅲ/Ⅳ myelosuppression is better than grade 0/Ⅰ/Ⅱ myelosuppression in patients with triple-negative breast cancer during neoadjuvant chemotherapy with TEC regimen, which is helpful for judging efficacy.

Equations of motion for weakly compressible point vortices

Equations of motion for compressible point vortices in the plane are obtained in the limit of small Mach number, M, using a Rayleigh-Jansen expansion and the method of Matched Asymptotic Expansions. The solution in the region between vortices is matched to solutions around each vortex core. The motion of the vortices is modified over long time scales [Formula: see text] and [Formula: see text]. Examples are given for co-rotating and co-propagating vortex pairs. The former show a correction to the rotation rate and, in general, to the centre and radius of rotation, while the latter recover the known result that the steady propagation velocity is unchanged. For unsteady configurations, the vortex solution matches to a far field in which acoustic waves are radiated. This article is part of the theme issue 'Mathematical problems in physical fluid dynamics (part 2)'.

Safety, pharmacokinetics, and efficacy of BPI-15086 in patients with EGFR T790M-mutated advanced non-small-cell lung cancer: results from a phase I, single-arm, multicenter study

Background

Epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) resistance frequently occurs in patients with non-small-cell lung cancer (NSCLC). EGFR Thr790Met mutation (T790M+) is seen in ∼50% of patients. We assessed the safety, tolerability, and pharmacokinetics (PK) of BPI-15086, a novel, ATP-competitive, irreversible, third-generation, mutation-selective EGFR-TKI in patients with EGFR T790M-mutated NSCLC.

Patients and methods

This two-center, phase I, dose-escalation study included patients who were 18-65 years old, with an Eastern Cooperative Oncology Group performance status of 0-2, with histologically or cytologically confirmed locally advanced or metastatic T790M+ NSCLC who were not surgical or radiotherapy candidates, and had imaging-identified disease progression after prior EGFR-TKIs. This dose-escalation study enrolled patients using a 3 + 3 study design. Patients received 25, 50, 100, 200, and 300 mg/day orally in 21-day cycles. The primary endpoints were safety, tolerability, and PK. Secondary endpoints were objective response rate (ORR) and disease control rate (DCR). The dose-expansion study was not conducted.

Results

We enrolled 17 patients from 29 December 2016 to 16 May 2018, in the safety and full analysis sets. All patients completed a single dosing trial, and no adverse events (AEs) causing drug discontinuation were seen. Grade 1-2 nausea, hypoalbuminemia, and decreased appetite were the most common treatment-related AEs. Grade 3 hyperglycemia was seen in one patient dosed at 300 mg/day. The ORR and DCR were 17.7% [95% confidence interval (CI) 3.8% to 43.4%] and 47.1% (95% CI 23.0% to 72.2%), respectively.

Conclusion

BPI-15086 is a safe and tolerable third-generation EGFR-TKI with a rationale for further clinical studies.

•

BPI-15086 is safe and has partial effectiveness in patients with advanced T790M+ NSCLC after previous EGFR-TKI therapy.

•

A different safety profile for BPI-15086 compared with other third-generation EGFR-TKIs.

•

The modest efficacy in this study is still deemed important and should be added to the literature of third-generation TKIs.

Routine HIV testing in acute care hospitals: Changing practice to curb a local HIV epidemic in Vancouver, BC

Early treatment of HIV infection increases life expectancy and reduces infectivity; however, delayed HIV diagnosis remains common. Implementation and sustainability of hospital-based routine HIV testing in Vancouver, British Columbia, was evaluated to address a local HIV epidemic by facilitating earlier diagnosis and treatment. Public health issued a recommendation in 2011 to offer HIV testing to all patients presenting to three Vancouver hospitals as part of routine care, including all patients admitted to medical/surgical units with expansion to emergency departments (ED). We evaluated acceptability, feasibility, and effectiveness from 2011 to 2014 and continued monitoring through 2016 for sustainability. Between October 2011-December 2016, 114,803 HIV tests were administered at the three hospitals; an 11-fold increase following implementation of routine testing. The rate of testing was sustained and remained high through 2018. Of those tested, 151 patients were diagnosed with HIV for a testing yield of 0.13%. Review of 12,996 charts demonstrated 4935/5876 (96·9%) of admitted patients agreed to have an HIV test when offered. People diagnosed in hospital were significantly more likely to be diagnosed with acute stage (aOR 1·96, 95% CI 1·19, 3·23) infection, particularly those diagnosed in the ED. This study provides practice-based evidence of the feasibility, acceptability, and effectiveness of implementing a recommendation for routine HIV testing among inpatient and emergency department admissions, as well as the ability to normalize and sustain this change. Routine hospital-based HIV testing can increase diagnoses of acute HIV infection and facilitate earlier initiation of antiretroviral treatment.

Testicular tissue cryopreservation: 8 years of experience from a coordinated network of academic centers

STUDY QUESTION

Is it feasible to disseminate testicular tissue cryopreservation with a standardized protocol through a coordinated network of centers and provide centralized processing/freezing for centers that do not have those capabilities?

SUMMARY ANSWER

Centralized processing and freezing of testicular tissue from multiple sites is feasible and accelerates recruitment, providing the statistical power to make inferences that may inform fertility preservation practice.

WHAT IS KNOWN ALREADY

Several centers in the USA and abroad are preserving testicular biopsies for patients who cannot preserve sperm in anticipation that cell- or tissue-based therapies can be used in the future to generate sperm and offspring.

STUDY DESIGN, SIZE, DURATION

Testicular tissue samples from 189 patients were cryopreserved between January 2011 and November 2018. Medical diagnosis, previous chemotherapy exposure, tissue weight, and presence of germ cells were recorded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Human testicular tissue samples were obtained from patients undergoing treatments likely to cause infertility. Twenty five percent of the patient's tissue was donated to research and 75% was stored for patient's future use. The tissue was weighed, and research tissue was fixed for histological analysis with Periodic acid-Schiff hematoxylin staining and/or immunofluorescence staining for DEAD-box helicase 4, and/or undifferentiated embryonic cell transcription factor 1.

MAIN RESULTS AND THE ROLE OF CHANCE

The average age of fertility preservation patients was 7.9 (SD = 5) years and ranged from 5 months to 34 years. The average amount of tissue collected was 411.3 (SD = 837.3) mg and ranged from 14.4 mg-6880.2 mg. Malignancies (n = 118) were the most common indication for testicular tissue freezing, followed by blood disorders (n = 45) and other conditions (n = 26). Thirty nine percent (n = 74) of patients had initiated their chemotherapy prior to undergoing testicular biopsy. Of the 189 patients recruited to date, 137 have been analyzed for the presence of germ cells and germ cells were confirmed in 132.

LIMITATIONS, REASONS FOR CAUTION

This is a descriptive study of testicular tissues obtained from patients who were at risk of infertility. The function of spermatogonia in those biopsies could not be tested by transplantation due limited sample size.

WIDER IMPLICATIONS OF THE FINDINGS

Patients and/or guardians are willing to pursue an experimental fertility preservation procedure when no alternatives are available. Our coordinated network of centers found that many patients request fertility preservation after initiating gonadotoxic therapies. This study demonstrates that undifferentiated stem and progenitor spermatogonia may be recovered from the testicular tissues of patients who are in the early stages of their treatment and have not yet received an ablative dose of therapy. The function of those spermatogonia was not tested.

STUDY FUNDING/COMPETING INTEREST(S)

Support for the research was from the Eunice Kennedy Shriver National Institute for Child Health and Human Development grants HD061289 and HD092084, the Scaife Foundation, the Richard King Mellon Foundation, the Departments of Ob/Gyn & Reproductive Sciences and Urology of the University of Pittsburgh Medical Center, United States-Israel Binational Science Foundation (BSF), and the Kahn Foundation. The authors declare that they do not have competing financial interests.

Curcumin restores innate immune Alzheimer's disease risk gene expression to ameliorate Alzheimer pathogenesis

Alzheimer's disease (AD) genetics implies a causal role for innate immune genes, TREM2 and CD33, products that oppose each other in the downstream Syk tyrosine kinase pathway, activating microglial phagocytosis of amyloid (Aβ). We report effects of low (Curc-lo) and high (Curc-hi) doses of curcumin on neuroinflammation in APPsw transgenic mice. Results showed that Curc-lo decreased CD33 and increased TREM2 expression (predicted to decrease AD risk) and also increased TyroBP, which controls a neuroinflammatory gene network implicated in AD as well as phagocytosis markers CD68 and Arg1. Curc-lo coordinately restored tightly correlated relationships between these genes' expression levels, and decreased expression of genes characteristic of toxic pro-inflammatory M1 microglia (CD11b, iNOS, COX-2, IL1β). In contrast, very high dose curcumin did not show these effects, failed to clear amyloid plaques, and dysregulated gene expression relationships. Curc-lo stimulated microglial migration to and phagocytosis of amyloid plaques both in vivo and in ex vivo assays of sections of human AD brain and of mouse brain. Curcumin also reduced levels of miR-155, a micro-RNA reported to drive a neurodegenerative microglial phenotype. In conditions without amyloid (human microglial cells in vitro, aged wild-type mice), Curc-lo similarly decreased CD33 and increased TREM2. Like curcumin, anti-Aβ antibody (also reported to engage the Syk pathway, increase CD68, and decrease amyloid burden in human and mouse brain) increased TREM2 in APPsw mice and decreased amyloid in human AD sections ex vivo. We conclude that curcumin is an immunomodulatory treatment capable of emulating anti-Aβ vaccine in stimulating phagocytic clearance of amyloid by reducing CD33 and increasing TREM2 and TyroBP, while restoring neuroinflammatory networks implicated in neurodegenerative diseases.

M30/M65 ratio predicts the outcome of paclitaxel chemotherapy for NSCLC

PURPOSE

Paclitaxel is an effective treatment for some of the non-small-cell lung cancer (NSCLC) patients. However, prediction of the outcome of paclitaxel treatment at the early stage of the chemotherapy is difficult. M30 and M65 are circulating fragments of cytokeratin 18 released during apoptosis or necrosis, respectively, and have been used as markers to evaluate chemotherapy in some cancers. Here, we aimed to examine M30 and M65 values for predicting the therapeutic outcome of paclitaxel treatment of NSCLC.

METHODS

The serum levels of M30 and M65 before and after paclitaxel treatment in advance-stage NSCLC patients were analyzed, and compared to those in healthy controls. The importance of the M30 and M65 levels to the outcome of chemotherapy was analyzed.

RESULT

We found that the serum M30 and M65 levels were higher in patients with NSCLC (n = 44) than in control healthy subjects (n = 56) (p < 0.001). Two days after paclitaxel treatment, the serum levels of both M30 and M65 significantly increased in NSCLC patients (p < 0.001). Neither marker alone significantly correlated with overall patient survival, but the ratio of M30 vs M65 appeared to be an important prognostic factor for the overall survival of the patients (p < 0.01).

CONCLUSION

Our results suggest that the serum M30/M65 ratio may be a prognostic factor for the outcome of paclitaxel treatment in NSCLC.

The impact of ionizing radiation on placental trophoblasts

INTRODUCTION

Exposure to low-dose radiation is widespread and attributable to natural sources. However, occupational, medical, accidental, and terrorist-related exposures remain a significant threat. Information on radiation injury to the feto-placental unit is scant and largely observational. We hypothesized that radiation causes trophoblast injury, and alters the expression of injury-related transcripts in vitro or in vivo, thus affecting fetal growth.

METHODS

Primary human trophoblasts (PHTs), BeWo or NCCIT cells were irradiated in vitro, and cell number and viability were determined. Pregnant C57Bl/6HNsd mice were externally irradiated on E13.5, and placentas examined on E17.5. RNA expression was analyzed using microarrays and RT-qPCR. The experiments were repeated in the presence of the gramicidin S (GS)-derived nitroxide JP4-039, used to mitigate radiation-induced cell injury.

RESULTS

We found that survival of in vitro-irradiated PHT cell was better than that of irradiated BeWo trophoblast cell line or the radiosensitive NCCIT mixed germ cell tumor line. Radiation altered the expression of several trophoblast genes, with a most dramatic effect on CDKN1A (p21, CIP1). Mice exposed to radiation at E13.5 exhibited a 25% reduction in mean weight by E17.5, and a 9% reduction in placental weight, which was associated with relatively small changes in placental gene expression. JP4-039 had a minimal effect on feto-placental growth or on gene expression in irradiated PHT cells or mouse placenta.

DISCUSSION AND CONCLUSION

While radiation affects placental trophoblasts, the established placenta is fairly resistant to radiation, and changes in this tissue may not fully account for fetal growth restriction induced by ionizing radiation.