Phosphodiesterase-5 (PDE-5) Inhibitors as Therapy for Cerebrovascular Dysfunction in Chronic Traumatic Brain Injury

Multiple phase III randomized controlled trials (RCTs) for pharmacologic interventions in traumatic brain injury (TBI) have failed despite promising results in experimental models. The heterogeneity of TBI, in terms of pathomechanisms and impacted brain structures, likely contributes to these failures. Biomarkers have been recommended to identify patients with relevant pathology (predictive biomarkers) and confirm target engagement and monitor therapy response (pharmacodynamic biomarkers). Our group focuses on traumatic cerebrovascular injury as an understudied endophenotype of TBI and is validating a predictive and pharmacodynamic imaging biomarker (cerebrovascular reactivity; CVR) in moderate-severe TBI. We aim to extend these studies to milder forms of TBI to determine the optimal dose of sildenafil for maximal improvement in CVR. We will conduct a phase II dose-finding study involving 160 chronic TBI patients (mostly mild) using three doses of sildenafil, a phosphodiesterase-5 (PDE-5) inhibitor. The study measures baseline CVR and evaluates the effect of escalating sildenafil doses on CVR improvement. A 4-week trial of thrice daily sildenafil will assess safety, tolerability, and clinical efficacy. This dual-site 4-year study, funded by the Department of Defense and registered in ClinicalTrials.gov (NCT05782244), plans to launch in June 2023. Biomarker-informed RCTs are essential for developing effective TBI interventions, relying on an understanding of underlying pathomechanisms. Traumatic microvascular injury (TMVI) is an attractive mechanism which can be targeted by vaso-active drugs such as PDE-5 inhibitors. CVR is a potential predictive and pharmacodynamic biomarker for targeted interventions aimed at TMVI. (Trial registration: NCT05782244, ClinicalTrials.gov ).

Targeted dietary interventions to reduce pain in persistent post-traumatic headache among service members: Protocol for a randomized, controlled parallel-group trial

INTRODUCTION

Post-traumatic headache (PTH) is common after traumatic brain injury (TBI), especially among active-duty service members (SMs), affecting up to 35% of patients with chronic TBI. Persistent PTH is disabling and frequently unresponsive to treatment and is often migrainous. Here, we describe a trial assessing whether dietary modifications to increase n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and reduce n-6 linoleic acid (LA), will alter nociceptive lipid mediators and result in clinical improvements in persistent PTH.

METHODS

This prospective, randomized, controlled trial tests the efficacy, safety, and biochemical effects of targeted, controlled alterations in dietary n-3 and n-6 fatty acids in 122 adult SMs and military healthcare beneficiaries with diagnosed TBI associated with actively managed persistent frequent (>8 /month) PTH with migraine. Following a 4-week baseline, participants are randomized to one of two equally intensive dietary regimens for 12 additional weeks: 1) increased n-3 EPA + DHA with low n-6 LA (H3L6); 2) usual US dietary content of n-3 and n-6 fatty acids (Control). During the intervention, participants receive diet arm-specific study oils and foods sufficient for 75% of caloric needs and comprehensive dietary counseling. Participants complete daily headache diaries throughout the intervention. Clinical outcomes, including the Headache Impact Test (HIT-6), headache hours per day, circulating blood fatty acid levels, and bioactive metabolites, are measured pre-randomization and at 6 and 12 weeks. Planned primary analyses include pre-post comparisons of treatment groups on clinical measures using ANCOVA and mixed-effects models. Similar approaches to explore biochemical and exploratory clinical outcomes are planned.

CLINICALTRIALS

gov registration: NCT03272399.

High-volume culture and quantitative real-time PCR for the detection of Aspergillus in sputum

OBJECTIVES

Sputum culture is an insensitive method for the diagnosis of pulmonary aspergillosis. Growth of the organism allows identification of the causative species and susceptibility testing, both of which can inform treatment choices. The current practice is to culture an aliquot of diluted sputum. We assessed the value of culturing large volumes of unprocessed sputum, a method that we have termed high-volume culture (HVC).

METHODS

Specimens were processed by conventional culture (using an aliquot of homogenized, diluted sputum on Sabouraud agar at 37°C and 45°C for up to 5 days) and HVC (using undiluted sputum on Sabouraud agar at 30°C for up to 14 days). A separate specimen was tested by quantitative real-time PCR. Antifungal susceptibility testing was performed by the EUCAST standard.

RESULTS

We obtained sputum specimens from 229 individuals with the following conditions: chronic pulmonary aspergillosis (66.8%, 153/229), allergic bronchopulmonary aspergillosis (25.3%, 58/229) and Aspergillus bronchitis (7.9%, 18/229). Individuals with invasive pulmonary aspergillosis were not included. The positivity rate of conventional culture was 15.7% (36/229, 95% CI 11.6%-21.0%) and that of HVC was 54.2% (124/229, 95% CI 47.7%-60.5%) (p < 0.001). The higher positivity rate of HVC was demonstrated regardless of administration of antifungal treatment. Quantitive real-time PCR had an overall positivity rate of 49.2% (65/132, 95% CI 40.9%-57.7%), comparable to that of HVC.

CONCLUSION

Detection of Aspergillus spp. in sputum is greatly enhanced by HVC. HVC allows for detection of azole-resistant isolates that would have been missed by conventional culture. This method can be performed in any microbiology laboratory without the need for additional equipment.

Impact of a diagnostics-driven antifungal stewardship programme in a UK tertiary referral teaching hospital

Objectives

A concise invasive candidosis guideline (based on the ESCMID candidaemia guideline) utilizing an informative biomarker [serum β-1-3-d-glucan (BDG)] was developed in 2013 by an antifungal stewardship (AFS) team and implemented with the help of an AFS champion in 2014. The main aims of the AFS programme were to reduce inappropriate use of antifungals and improve patient outcomes. The aim of this project was to evaluate the compliance of the ICU teams with the invasive candidosis guideline and the impact of the AFS programme on mortality and antifungal consumption on the ICUs (total of 71 beds).

Methods

All patients who were prescribed micafungin for suspected or proven invasive candidosis during 4 month audit periods in 2014 and 2016 were included. Prescriptions and patient records were reviewed against the guideline. Antifungal consumption and mortality data were analysed.

Results

The number of patients treated for invasive candidosis decreased from 39 in 2014 to 29 in 2016. This was mainly due to the reduction in patients initiated on antifungal therapy inappropriately: 18 in 2014 and 2 in 2016. Antifungal therapy was stopped following negative biomarker results in 12 patients in 2014 and 10 patients in 2016. Crude mortality due to proven or probable invasive candidosis decreased to 19% from 45% over the period 2003-07. Antifungal consumption reduced by 49% from 2014 to 2016.

Conclusions

The AFS programme was successful in reducing the number of inappropriate initiations of antifungals by 90%. Concurrently, mortality due to invasive candidosis was reduced by 58%. BDG testing can guide safe cessation of antifungals in ICU patients at risk of invasive candidosis.

Prospective multicenter international surveillance of azole resistance in Aspergillus fumigatus

To investigate azole resistance in clinical Aspergillus isolates, we conducted prospective multicenter international surveillance. A total of 3,788 Aspergillus isolates were screened in 22 centers from 19 countries. Azole-resistant A. fumigatus was more frequently found (3.2% prevalence) than previously acknowledged, causing resistant invasive and noninvasive aspergillosis and severely compromising clinical use of azoles.

Performance of two Aspergillus IgG EIA assays compared with the precipitin test in chronic and allergic aspergillosis

Detection of Aspergillus IgG antibodies is important in the diagnosis of chronic pulmonary aspergillosis and allergic bronchopulmonary aspergillosis. Immunoprecipitation techniques to detect these antibodies appear to lack sensitivity and accurate quantitation compared with enzyme immunoassays (EIA). This study assessed the performance of two commercial EIAs compared with counterimmunoelectrophoresis (CIE). This was a prospective cohort study of 175 adult patients with chronic or allergic pulmonary aspergillosis. Aspergillus IgG antibodies were detected using CIE, Phadia ImmunoCap Aspergillus IgG and Bio-Rad Platelia Aspergillus IgG. Inter-assay reproducibility was determined for each method and 25 patients had two serum samples analysed within a 6-month interval. When compared with CIE, both ImmunoCap and Platelia Aspergillus IgG had good sensitivity (97 and 93%, respectively) for detection of Aspergillus IgG antibodies. The level of agreement between the two EIAs for positive results was good, but the concentration of antibodies was not correlated between the tests or with CIE titre. ImmunoCap IgG inter-assay coefficient of variation was 5%, whereas Platelia IgG was 33%. Median ImmunoCap IgG values for CPA and allergic aspergillosis were 95 and 32 mg/L, respectively, whereas Platelia IgG values were >80 and 6 AU/mL. The direction of CIE titre change over 6 months was mirrored by ImmunoCap IgG levels in 92% of patients, and by Platelia IgG in 72% of patients. Both ImmunoCap and Platelia Aspergillus IgG EIAs are sensitive measures of Aspergillus IgG antibodies compared with CIE. However, ImmunoCap appears to have better reproducibility and may be more suitable for monitoring patient disease.

Mannose-binding lectin genotype and serum levels in patients with chronic and allergic pulmonary aspergillosis

Several studies suggest mannose-binding lectin (MBL) deficiency is associated with various manifestations of aspergillosis. MBL serum levels and function are genetically determined, but levels rise during inflammation. We address the relative frequency of deficient genotypes, the relationship between serum level and genotype and both age and disease manifestations in patients with chronic pulmonary (CPA) and allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS). DNA was extracted from blood samples, and MBL2 genotyping was performed using the INNO-LiPA MBL2 kit. Serum MBL concentrations were determined using ELISA. One hundred and eight patients were evaluated, 70 (65%) with CPA, 38 (35%) with allergic disease (ABPA, SAFS or undefined) and 13 (12%) had both CPA and ABPA. The mean MBL serum level was 1849 μg L(-1) and did not differ between groups. Forty subjects (37%) had exon 1 genotypes producing nonfunctional MBL (A/B, A/C, A/D and O/O), a frequency not different from published normal controls. A/A subjects with CPA had higher levels (2981 μg L(-1)) compared with allergic A/A subjects (2202 μg L(-1)) (pc0.012). No single haplotype, genotype or allele was significantly related to any aspergillosis phenotype. Worse breathlessness was associated with higher MBL levels among A/A subjects (P = 0.009) and conversely nonfunctional genotypes. Mean MBL values were higher in those with an Medical Research Council (MRC) breathlessness score of 5 compared with those with and MRC score of 1 (P = 0.023). A/A allergic subjects (n = 27) in this study were ≈ 11 years younger than allergic A/O subjects (n = 11, P = 0.02). Subjects with worse respiratory status or more severe CPA had higher MBL serum levels (P = 0.023; P = 0.034). Bronchiectasis was not associated with MBL levels in CPA or allergic aspergillosis. MBL genotype and serum level modulate progression of aspergillosis.

Electrolytic dissolution of iron meteorites

When iron meteorites are dissolved anodically in neutral solution, nonmetallic inclusions are not attached and collect at the bottom of the anode compartment. When the meteorites contain both kamacite and taenite, the kamacite dissolves preferentially, revealing a three-dimensional Widmanstätten pattern.

High incidence of antifungal drug resistance in Candida tropicalis

Drug resistance among yeasts is an increasing problem. Isolates of Candida krusei and Candida glabrata are recognized as having reduced susceptibility to fluconazole and resistance to this drug has also arisen in Candida albicans isolated from AIDS patients on long term azole therapy. Candida tropicalis (CT) is being increasingly isolated from human disease and is associated with invasive infection, however, data regarding this organism's drug susceptibility is limited. We report our findings on 60 isolates of CT isolated from patients with serious infection in the North West of England. Over 60% of isolates were from adult Intensive Care Unit (ICU) patients, and almost half were from the respiratory tract. Susceptibility to fluconazole, flucytosine, itraconazole and ketoconazole were tested by standardised methods - 48% of the isolates were resistant to fluconazole (MIC > 12.5 mg/l), and 10% had intermediate susceptibility (MIC 6.25-12.5 mg/l). For flucytosine 17% of isolates were resistant (MIC > 8 mg/l) and 22% had intermediate susceptibility (MIC 2-8 mg/l). Three isolates were resistant to both drugs. For itraconazole 17% of isolates were resistant (MIC > 1 mg/l), and 12% showed intermediate susceptibility (MIC 0.5-1 mg/l). Resistance to ketoconazole was seen in 33% of isolates (MIC > 1 mg/l) and 10% showed intermediate susceptibility (MIC 0.5-1 mg/l). Differences in the degree of cross resistance between the azole drugs was observed. Candida tropicalis should be added to the list of yeasts in which drug resistance is commonly found. Given the high invasiveness of Candida tropicalis, its affinity for patients on ICU and the high incidence of drug resistance in this species, identification and susceptibility tests should be performed on all yeast isolates from patients on ICU.

Establishing an appropriate mode of comparison for measuring the performance of marbling score output from video image analysis beef carcass grading systems

A beef carcass instrument grading system that improves accuracy and consistency of marbling score (MS) evaluation would have the potential to advance value-based marketing efforts and reduce disparity in quality grading among USDA graders, shifts, and plants. The objectives of this study were to use output data from the Video Image Analysis-Computer Vision System (VIA-CVS, Research Management Systems Inc., Fort Collins, CO) to develop an appropriate method by which performance of video image analysis MS output could be evaluated for accuracy, precision, and repeatability for purposes of seeking official USDA approval for using an instrument in commerce to augment assessment of quality grade, and to use the developed standards to gain approval for VIA-CVS to assist USDA personnel in assigning official beef carcass MS. An initial MS output algorithm was developed (phase I) for the VIA-CVS before 2 separate preliminary instrument evaluation trials (phases II and III) were conducted. During phases II and III, a 3-member panel of USDA expert graders independently assigned MS to 1,068 and 1,242 stationary carcasses, respectively. Mean expert MS was calculated for each carcass. Additionally, a separate 3-member USDA expert panel developed a consensus MS for each carcass in phase III. In phase II, VIA-CVS stationary triple-placement and triple-trigger instrument repeatability values (n = 262 and 260, respectively), measured as the percentage of total variance explained by carcasses, were 99.9 and 99.8%, respectively. In phases II and III, 95% of carcasses were assigned expert MS for which differences between individual expert MS, and for which the consensus MS in phase III only, was < or = 96 MS units. Two differing approaches to simple regression analysis, as well as a separate method-comparability analysis that accommodates error in both dependent and independent variables, were used to assess accuracy and precision of instrument MS predictions vs. mean expert MS. Method-comparability analysis was more appropriate in assessing the bias and precision of instrument MS predictions. Ether-extractable fat percentages (n = 257; phase II) differed among MS (P < 0.05) but were not suitable to predict or validate assigned MS. The performance and reproducibility of expert MS assignment in future evaluations was considered, and an official USDA performance standard was established, to which an instrument must conform to be approved for official on-line MS assessment. The VIA-CVS subsequently was approved to assign MS to carcasses on-line after completion of a 2006 USDA instrument approval trial conducted according to methods developed during completion of this study.

Decreased C-reactive protein levels in Alzheimer disease

C-reactive protein (CRP) is an acute-phase reactant that has been found to be associated with Alzheimer disease (AD) in histopathological and longitudinal studies; however, little data exist regarding serum CRP levels in patients with established AD. The current study evaluated CRP levels in 192 patients diagnosed with probable AD (mean age = 75.8 +/- 8.2 years; 50% female) as compared to 174 nondemented controls (mean age = 70.6 +/- 8.2 years; 63% female). Mean CRP levels were found to be significantly decreased in AD (2.9 microg/mL) versus controls (4.9 microg/mL; P = .003). In adjusted models, elevated CRP significantly predicted poorer (elevated) Clinical Dementia Rating Scale sum of boxes (CDR SB) scores in patients with AD. In controls, CRP was negatively associated with Mini-Mental State Examination (MMSE) scores and positively associated with CDR SB scores. These findings, together with previously published results, are consistent with the hypothesis that midlife elevations in CRP are associated with increased risk of AD development though elevated CRP levels are not useful for prediction in the immediate prodrome years before AD becomes clinically manifest. However, for a subgroup of patients with AD, elevated CRP continues to predict increased dementia severity suggestive of a possible proinflammatory endophenotype in AD.

Physiologic and functional outcome correlates of brain tissue hypoxia in traumatic brain injury

OBJECTIVE

Assess the prevalence of brain tissue hypoxia in patients with severe traumatic brain injuries (TBI), and to characterize the relationship between brain tissue hypoxia and functional outcome.

DESIGN

Retrospective review of severe TBI patients.

SETTING

Intensive care unit of a level I trauma center.

PATIENTS

Twenty-seven patients with severe TBI requiring intracranial pressure (ICP) monitoring. Median age was 22 yrs, and a majority (63%) had traumatic subarachnoid hemorrhage.

INTERVENTIONS

Hourly assessments of ICP, brain tissue oxygen, mean arterial pressure, fraction of inspired oxygen (FiO2), partial pressure of arterial carbon dioxide (PaCO2), and hemoglobin concentration (hemoglobin) were recorded. Outcome was assessed 6-9 months postinjury.

MEASUREMENTS AND MAIN RESULTS

Mean (SD) ICP and BTpO2 were 13.7 (6.6) cm H2O and 30.8 (13.6) mm Hg. A total of 13.5% (379) of the BTpO2 values recorded were < 20 mm Hg, only 86 of which were associated with ICP > or = 20 cm H2O. This prevalence was comparable with episodes of ICP elevations above 20 cm H2O (14.1%, 397). Hypoxic episodes were more common when cerebral perfusion pressure was below 60 mm Hg (relative risk = 3.0, p < 0.0001). We did not find an association in hypoxic risk and hemoglobin in the range of 7-12 g/dL or PaCO2 in the range of 25-40 mm Hg. Subjects with hourly episodes (epochs) of hypoxia > 20% of the time had poorer scores on outcome measures compared with those with fewer hypoxic epochs.

CONCLUSIONS

Hypoxic episodes are common after severe TBI, and most are independent of ICP elevations. Most episodes of hypoxia occur while cerebral perfusion pressure and mean arterial pressure are within the accepted target range. There is no clear association between PaCO2 and hemoglobin with BTpO2. The young age and high prevalence of traumatic subarachnoid hemorrhage in this cohort may limit its generalizability. Increased frequency of hypoxic episodes is associated with poor functional outcome.

Flucytosine therapeutic monitoring: 15 years experience from the UK

BACKGROUND

There is uniform consensus that flucytosine blood concentrations should be measured to avoid toxicity and ensure adequate efficacy.

OBJECTIVES AND METHODS

The purpose of this study was to evaluate all flucytosine levels performed in a regional centre in the UK from October 1991 to May 2006. Concentrations were measured by bioassay.

RESULTS

We reviewed 1071 flucytosine levels in 233 patients, including 33 neonates. Overall, only 20.5% of levels were in the expected therapeutic range. Low levels were observed in 40.5%, of which 5.1% were undetectable levels (<12.5 mg/L). High levels occurred in 38.9%, of which 9.9% were considered potentially toxic (>100 mg/L). High flucytosine levels occurred more frequently amongst neonates, which could be related to an immature renal system resulting in drug accumulation.

CONCLUSIONS

Our findings reveal that the vast majority of patients were out of range for flucytosine levels. These data emphasize the importance of monitoring flucytosine levels.

Comparison of two fluorescent whiteners, Calcofluor and Blankophor, for the detection of fungal elements in clinical specimens in the diagnostic laboratory

Fluorescent whiteners, such as Blankophor and Calcofluor white, bind to chitin and cellulose, and fluoresce when exposed to UV light. Detection of fungal elements from skin and nail samples was faster and more accurate using Blankophor compared with potassium hydroxide preparations and Calcofluor (sensitivity and specificity 100% and 86% vs. 83-90% and 84-88%, or 80% and 84%, respectively). Visibility was improved, and the procedures were simple, inexpensive and rapid, all of which are important considerations in a busy diagnostic laboratory.

Fungal contamination of bedding

BACKGROUND

It is currently believed that most fungal exposure occurs external to the home.

AIMS

To enumerate the fungal flora of used synthetic and feather pillows and the dust vacuumed from them, in the UK.

METHODS

10 pillows aged between 1.5 and >20 years in regular use were collected and quantitatively cultured for fungi. Swatches were taken from nine sections of the pillow and dust was also collected by vacuum from five pillows. Pillow vacuuming was carried out prior to pillow culture. All were cultured at room temperature, 30 and 37 degrees C for 7 days in broth before plating, and a subset were also cultured for 24 h in broth and then plated. Fungi were identified by standard morphological methods.

RESULTS

The commonest three species isolated were Aspergillus fumigatus (n = 10), Aureobasidium pullulans (n = 6) and Rhodotorula mucilaginosa (n = 6). Another 47 species were isolated from pillows and vacuum dust. The number of species isolated per pillow varied from 4 to 16, with a higher number from synthetic pillows. Compared with the nonallergenic A. pullulans, more A. fumigatus was found in synthetic than feather pillows.

CONCLUSIONS

We have examined pillows for fungal contamination, and show that the typical used pillow contains a substantial load of many species of fungi, particularly A. fumigatus. Given the time spent sleeping, and the proximity of the pillow to the airway, synthetic and feather pillows could be the primary source of fungi and fungal products. This has important implications for patients with respiratory disease, and especially asthma and sinusitis.

Enhancement of cellular and humoral immunity following embryonic exposure to melatonin in turkeys (Meleagris gallopavo)

Two experiments were performed to determine the effect of in ovo melatonin supplementation on the ontogeny of immunity in the Large White turkey poult. Different levels of melatonin were injected into the air cell of the egg 4 days prior to hatch. In Experiment 1, turkey embryos received 3 ml of solution containing 200, 100, 50, 25, 10, or 1 microg/ml of melatonin. The hatchability at each dose was determined and compared to vehicle-injected controls. In Experiment 2, only poults from melatonin treatments in Experiment 1 that resulted in normal hatchability (10 and 1 microg/ml) were used. Lymphoproliferative responses to phytohemagglutinin (PHA-P) and primary antibody responses to Chukar red blood cells (CRBC) were determine at five time intervals: 0, 1, 7, 14, and 21 days post-hatch. At each of these times, including 28 days post-hatch, treatment effects on body weights were determined. At 28 days post-hatch, bursal, thymic, and splenic weights were obtained. In ovo melatonin administration significantly accelerated (P0.05) the development of cell-mediated (PHA-P) and humoral (CRBC) immune responses, and these responses were significantly elevated above vehicle-injected controls through 21 days post-hatch. No effect was observed on bursal, thymic, splenic or body weights. These data suggest that embryonic exposure to melatonin enhances post-hatch immune development and responsiveness.

Correlation of statin-increased platelet APP ratios and reduced blood lipids in AD patients

Platelets, like neurons, contain 120- to 130- and 110-kd amyloid precursor proteins (APPs). Their ratio is reduced in AD, further reductions correlating with reduced Mini-Mental Status Examination scores [r(11) = 0.69, p < 0.05]. As statins alter APP processing, platelet APPs were analyzed in patients with AD given anticholesterol drugs for 6 weeks. APP ratios increased [t(37) = -3.888, p = 0.0004], proportionally with reduced cholesterol [r(36) = -0.45, p = 0.005]. Longer trials may reveal slowed cognitive loss, validating this index.

Multicenter evaluation of the reproducibility of the proposed antifungal susceptibility testing method for fermentative yeasts of the Antifungal Susceptibility Testing Subcommittee of the European Committee on Antimicrobial Susceptibility Testing (AFST-EUCAST)

OBJECTIVE

To evaluate the intra- and inter-laboratory reproducibility of a new standard for susceptibility testing of fermentative yeasts. This standard is based on the M27-A procedure of the National Committee for Clinical Laboratory Standards (NCCLS), but incorporates several modifications, including spectrophotometric growth-dependent endpoint reading.

METHODS

Nine laboratories participated in the study. Common material lots were used to test six Candida species (one each of C. albicans, C. tropicalis, C. parapsilosis, C. glabrata, C. krusei, and C. lusitaniae), and two quality control strains (C. krusei ATCC6258 and C. parapsilosis ATCC22019). Triplicate testing on three separate days was performed in microtiter format with RPMI-2% glucose, pH 7.0. Flucytosine, fluconazole and itraconazole were tested. In total, 3888 MIC values were included in the analyses. Reproducibility was calculated by means of agreement (percentage of MICs within one two-fold dilution of the mode) and intraclass correlation coefficient (ICC, maximum value of 1).

RESULTS

The average intra-laboratory agreements were 99% and 96% after 24 h and 48 h of incubation, respectively, with ICCs of 0.98 and 0.97 (P < 0.05). Two strains exhibiting a trailing effect showed intra-laboratory agreement of 92% and ICCs of < 0.91 at 48 h. The inter-laboratory agreement was 94% and 88% after 24 h and 48 h, respectively, with ICCs of 0.93 and 0.91 (P < 0.05). Lower values of agreement and ICCs were obtained for strains exhibiting trailing after 48 h of incubation. Itraconazole yielded the lowest values of reproducibility.

CONCLUSION

The new procedure of EUCAST for antifungal susceptibility testing is a reproducible method within and between laboratories and offers several advantages over the NCCLS approved method.

Melatonin enhances cellular and humoral immune responses in the Japanese quail (Coturnix coturnix japonica) via an opiatergic mechanism

It is known that melatonin has important immunomodulatory properties in the Japanese quail. However, the mechanism of melatonin action on the immune system is not clearly understood in avian species. In mammals, the immunostimulatory properties of melatonin are mediated by the release of opioid peptides from activated T-lymphocytes. The present study was performed to determine if these same melatonin-induced opioids (MIO) are involved with the immunoenhancing effects of melatonin in quail. Three treatment groups were given melatonin (50 microg/ml) in the drinking water ad libitum along with naltrexone, a known opioid receptor-blocking agent. Melatonin was administered throughout the 3 week study and each bird received a daily intramuscular injection of naltrexone at a dose of 0.1, 1.0, or 10.0 mg/kg. In addition, three control groups were established that received only melatonin, naltrexone, or diluent. Evaluation of the cellular and humoral immune responses was initiated after 2 weeks of treatments. A cutaneous basophil hypersensitivity reaction to phytohemagglutinin (PHA-P) was measured to evaluate the cellular immune response. To evaluate the humoral immune response, primary antibody titers were determined 7 days post-intravenous injection with a Chukar red blood cell (CRBC) suspension. Both the cellular and humoral immune responses were significantly increased by 22 and 34%, respectively, upon melatonin exposure as compared to quail receiving diluent only. Concomitant administration of naltrexone and melatonin significantly reduced the immunoenhancing effect of melatonin across all naltrexone doses. We conclude that melatonin enhances a cellular and humoral immune response in Japanese quail via an opiatergic mechanism.

Immune function in turkey breeder hens during the short day prelighting period and renewal of photosensitivity for egg production

Photorefractoriness (PR) in the turkey breeder hen is characterized by a lack of responsiveness to photoperiods that previously induced or maintained egg production. The consequence of PR is spontaneous regression of ovarian function and cessation of lay. Photosensitivity (PS) may be regained by giving at least 8 wk of short photoperiod (8L:16D) (light restriction). Following the transition from PR to PS, the birds may be photostimulated with long photoperiods, which allows for the recrudescence of ovarian function and normal egg production. Although the return of reproductive viability is the parameter for determining the successful recycle of ovarian function, there are no known reports of the physiological costs of this transition on immune function in the turkey breeder hen. We conducted an experiment to determine the immune responsiveness at various stages of recycle in the turkey breeder hen. Fifty photorefractory birds were selected and distributed equally among five treatment groups (time points). All birds were given an 8-wk period of light restriction (8L:16D) followed by a 12-wk period of photostimulation (16L:8D). The cellular (cutaneous basophil hypersensitivity CBH) and humoral (antibody titer) immune responses were determined in each treatment group (sequential time points): prelight restriction, 2-wk light restriction, 7-wk light restriction, 2-wk photostimulation, and 12-wk photostimulation. After 2-wk light restriction, there was a reduction in the cellular (64.1%) and humoral (59.5%) immune responses from that of the PR hens at the start. After 7-wk light restriction, the humoral responses increased (33.5%) as compared to the 2-wk light restriction time point Upon photostimulation, both the cellular (23.3%) and humoral (52.4%) immune responses were reduced at 2 wk of photostimulation as compared to the prior 7-wk light restriction time point. Finally, there was a rise in cellular (45.7%) and humoral (72.3%) immune responses after 12 wk of photostimulation as compared to the prior 2-wk photostimulation time point. We concluded that recycling of PR turkey hens was associated with altered cellular and humoral immune responses characterized by initial decline then recovery in both the light restriction and the postphotostimulation periods.

Effect of melatonin supplementation on the ontogeny of immunity in the Large White turkey poult

An experiment was performed to determine the effect of melatonin supplementation on the ontogeny of immunity in the Large White turkey poult. Melatonin (50 microg/mL) or diluent only (control) was administered via the drinking water from hatch to 28 d of age. The cutaneous basophil hypersensitivity (CBH) reaction to phytohemagglutinin (PHA-P) and primary antibody responses to Chukar red blood cells (CRBC) were determined at five intervals; 0, 1, 7, 14, and 21 d posthatch. At each of these times, including 28 d posthatch, 10 poults were killed and lymphoid organ and body weights were determined. Melatonin administration accelerated (P < or = 0.05) the development of cell-mediated (PHA-P-induced CBH reaction) and humoral (CRBC-induced antibody titer) immune responses, and these responses were elevated above controls through 21 d posthatch. The bursal weight, but not thymus or spleen, was elevated in melatonin treated poults as compared to controls. Body weights were increased in melatonin treated poults as compared to controls. These data suggest that posthatch melatonin supplementation is beneficial to neonatal immune parameters and growth responses of Large White turkey poults.

Melatonin can produce immunoenhancement in Japanese quail (Coturnix coturnix japonica) without prior immunosuppression

In recent years, it has been determined that melatonin has important immunostimulatory properties in mammalian and avian species. Typically, this immunoenhancement has only been examined in immunosuppressed animals. The effect of melatonin on normal (unsuppressed) immune systems is yet to be evaluated in avian species. An experiment was performed to determine if transient and/or continuous melatonin treatments could enhance immune functions in Japanese quail without prior immunosuppression. All quail were kept on a short photoperiod (8:16LD) throughout the study. In this experiment, 50.0 microg/ml melatonin was provided ad libitum to adult Japanese quail in the drinking water either continuously or for 3h per day. Control birds received diluent continuously throughout the experiment. Both the cellular and humoral immune responses were determined immediately after 3 weeks treatment. A cutaneous basophil hypersensitivity reaction to phytohemagglutinin (PHA-P) was measured to evaluate the cellular immune response. To evaluate the humoral immune response, primary antibody titers were calculated 7 days post-intravenous injection with a Chukar red blood cell (CRBC) suspension. The cellular and humoral immune responses were significantly elevated in the transient (3h) and continuous (24h) melatonin treatment groups as compared to the control group (0 h). As compared to the control group, the cellular immune response was increased 25% and 38% for the 3 and 24h melatonin treatments, respectively. The humoral immune response was increased 26% and 32% for the 3 and 24h melatonin treatments, respectively. Furthermore, continuous (24h) melatonin availability significantly increased the cellular, but not humoral immune responses as compared to the transient (3h) group, given melatonin for 3h prior to the scotophase (13:00-16:00 h). From these data, it was clear that transient and continuous administration of melatonin increased the cellular and humoral immune responses of Japanese quail without prior immunosuppression. These data suggest that the immunoenhancing effect of melatonin is not limited to reconstitution of weakened immune systems, but can be observed in normal, immunologically unsuppressed birds.

In vitro interaction of terbinafine with itraconazole, fluconazole, amphotericin B and 5-flucytosine against Aspergillus spp

We investigated the in vitro interaction of terbinafine with itraconazole, fluconazole, amphotericin B and 5-flucytosine, against Aspergillus spp. We tested three isolates of Aspergillus fumigatus (one resistant to itraconazole), and two each of Aspergillus flavus, Aspergillus niger and Aspergillus terreus. We employed a broth microdilution-based method derived from an in vivo validated method capable of detecting itraconazole resistance in A. fumigatus. We studied the effect on the MICs by calculation of the fractional inhibitory concentration (FIC) and fractional fungicidal concentration (FFC) (99.99% kill). Itraconazole and terbinafine were synergic or additive in all strains (FIC = 0.15-1.0). Fluconazole and terbinafine were synergic with A. fumigatus, A. terreus and A. flavus (FIC = 0.3-0.5) and indifferent with A. niger (FIC = 2) isolates. Amphotericin B and terbinafine were mostly indifferent or antagonistic (FIC = 1.0-4.02). Flucytosine and terbinafine were usually indifferent or antagonistic (FIC = 0.63-8.5). FFCs were generally in accord with FICs. The use of terbinafine in combination therapy for Aspergillus infections with azoles seems promising, whereas terbinafine and amphotericin B or flucytosine in combination were less effective.

Pineal melatonin secretion, but not ocular melatonin secretion, is sufficient to maintain normal immune responses in Japanese quail (Coturnix coturnix japonica)

Reports that plasma melatonin is an important immune regulator in avian species have been rather sparse and contradictory. Also, the primary source of immune-modulating melatonin has yet to be determined in birds. In Japanese quail (Coturnix coturnix japonica), the pineal gland and eyes contribute roughly two thirds and one third of the melatonin found in the blood, respectively. Two experiments were conducted to evaluate melatonin as an immune modulator in Japanese quail and to determine the primary source of immune-modulating melatonin in this species. Experiment 1 was designed to evaluate the involvement of the pineal gland and the eyes in immunocompetence. Each of three groups of quail was assigned a surgical treatment and the cellular and humoral immune responses were determined 8 weeks following surgery. The surgical treatments were pinealectomy (Px), sham pinealectomy (SH-Px), and ocular enucleation (eye removal (Ex)). Experiment 2 utilized exogenous melatonin as a replacement to reconstitute immune responses in surgically immunocompromised birds. In this experiment, 50.0 microg/ml of melatonin, or diluent only, was provided to Px and SH-Px birds in the drinking water ad libitum. The cellular and humoral immune responses were determined after 8 weeks of melatonin treatment. In both experiments, a cutaneous basophil hypersensitivity reaction to phytohemagglutinin was measured to evaluate the cellular immune response. To evaluate the humoral immune response, primary antibody titers were determined 7 days postintravenous injection with a Chukar red blood cell suspension. Flow cytometric analysis of peripheral blood lymphocytes was performed to determine the relative percentage of CD4(+) and CD8(+) T- and B-lymphocytes in all treatments of Experiment 2. In Experiment 1, both the SH-Px and Ex surgical treatments produced similar cellular and humoral immune responses, and these responses were significantly greater than those in Px-treated birds. Pinealectomy significantly reduced the cellular and humoral immune responses from SH-Px by 25.8% and 41.3%, respectively. In Experiment 2, Px again resulted in depressed cellular and humoral immune responses. In addition, Px significantly reduced CD8(+) T-lymphocyte numbers compared to SH-Px, while B-lymphocytes remained unchanged. Melatonin administration to Px birds increased the cellular (32.9%) and humoral (30.6%) immune responses to the level of control (SH-Px) birds, although this reconstitution was not due to increased CD8(+) T- or B-lymphocytes. From these data, it was clear that removal of the pineal gland, but not the eyes, reduced cellular and humoral immune responses, which were reconstituted to normal levels by exogenous melatonin. These data suggest that immunodepression is only observed in birds with two thirds of the plasma melatonin removed by pinealectomy. Removal of one third of the plasma melatonin (by ocular enucleation) is not sufficient to reduce cellular and humoral responses in the Japanese quail.

Antifungal susceptibility testing of fluconazole by flow cytometry correlates with clinical outcome

Susceptibility testing of fungi by flow cytometry (also called fluorescence-activated cell sorting [FACS]) using vital staining with FUN-1 showed a good correlation with the standard M27-A procedure for assessing MICs. In this study we determined MICs for blood culture isolates from patients with candidemia by NCCLS M27-A and FACS methods and correlated the clinical outcome of these patients with in vitro antifungal resistance test results. A total of 24 patients with candidemia for whom one or more blood cultures were positive for a Candida sp. were included. Susceptibility testing was performed by NCCLS M27-A and FACS methods. The correlation of MICs (NCCLS M27-A and FACS) and clinical outcome was calculated. In 83% of the cases, the MICs of fluconazole determined by FACS were within 1 dilution of the MICs determined by the NCCLS M27-A method. For proposed susceptibility breakpoints, there was 100% agreement between the M27-A and FACS methods. In the FACS assay, a fluconazole MIC of <1 microg/ml was associated with cure (P < 0.001) whereas an MIC of > or =1 microg/ml was associated with death (P < 0.001). The M27-A-derived fluconazole MICs did not correlate with outcome (P = 1 and P = 0.133).

In vitro activities of terbinafine against Aspergillus species in comparison with those of itraconazole and amphotericin B

Compared with the in vitro activities of itraconazole (geometric mean MIC [GM], 0.56 microg/ml) and amphotericin B (GM, 0.66 microg/ml), the in vitro activity of terbinafine was inferior against Aspergillus fumigatus (GM, 19.03 microg/ml) (P < 0.05) and superior against A. flavus (GM, 0.10 microg/ml), A. terreus (GM, 0.16 microg/ml), and A. niger (GM, 0.19 microg/ml). Clinical correlation is required, as trailing endpoints are problematic.

Susceptibility testing of Aspergillus flavus: inoculum dependence with itraconazole and lack of correlation between susceptibility to amphotericin B in vitro and outcome in vivo

We have attempted to validate in Aspergillus flavus the main in vitro methodologies that have been used to detect resistance in Aspergillus fumigatus. We developed a murine model with two A. flavus isolates, one that was apparently resistant in vitro to amphotericin B (AFL5) and another that was resistant to itraconazole (AFL8). No correlation was found for amphotericin B in AFL5, since the in vivo response was compatible with a susceptible isolate. Modification of the in vitro susceptibility test methodology for amphotericin B was unsuccessful. Although AFL8 was apparently resistant to itraconazole in vitro, it was found to be susceptible in vivo. Additional in vitro work has detected weaknesses in the in vitro susceptibility methodology validated for A. fumigatus when applied to A. flavus. The principal problems are that changes in the inoculum have a large effect on the MICs of itraconazole for some A. flavus strains and that a trailing end point and spore sediment often appear when an inoculum with a higher colony count is used. We propose a modified method using a final inoculum of 2.5 x 10(4) CFU per ml of RPMI 1640 medium with 2% glucose buffered to pH 7.0 in a microtiter format, incubated for 48 h with no growth end point. Validation of this methodology requires one or more itraconazole-resistant A. flavus isolates, which have yet to be identified.

Chronic hyperlactatemia in HIV-infected patients taking antiretroviral therapy

OBJECTIVE

To determine the prevalence, course and risk factors for hyperlactatemia in HIV-infected patients.

DESIGN

A prospective, longitudinal study of venous lactate concentrations over an 18-month period in 349 participants of the Western Australian HIV Cohort Study.

RESULTS

In 516 patient-years of observation, two patients experienced severe fulminant lactic acidosis (lactate > 5 mmol/l) and hepatic steatosis attributable to nucleoside analogue reverse transcriptase inhibitors (NRTI). A further five patients with lesser elevations of lactate (2.8-4.1 mmol/l) but with symptoms of nausea or abdominal discomfort and evidence of hepatic steatosis had NRTI therapy revised, with relief of symptoms and a fall in lactate levels. Most remaining patients on highly active antiretroviral therapy (HAART) had mild, chronic, asymptomatic hyperlactatemia, with mean lactate level between 1.5 mmol/l and 3.5 mmol/l most commonly. Longitudinal data was analysed in a non-linear mixed effects growth model which indicated that average lactate levels rose after the start of HAART but tended to stabilise at low-grade elevation, with an average 0.23 mmol/l greater long term level in stavudine users compared with zidovudine users (p < 0.01). A multiple linear regression model showed that the association between stavudine and higher lactate level was not confounded by longer duration of total NRTI exposure. Risk of hyperlactatemia was not significantly associated with use of other NRTIs, protease inhibitors, non-nucleoside analogue reverse transcriptase inhibitors or multiple immunological and virological factors in multivariate analyses.

CONCLUSIONS

Chronic, compensated, asymptomatic hyperlactatemia is common in patients taking HAART. Decompensated, life-threatening lactic acidosis/hepatic steatosis is rare. Treatment with stavudine appears to be the predominant risk factor for development of chronic hyperlactatemia.

In vitro activity of a new echinocandin, LY303366, and comparison with fluconazole, flucytosine and amphotericin B against Candida species

OBJECTIVE

To investigate the in vitro activity of LY303366 (LY) against Candida isolates comprising nine different species and comparison with fluconazole (FLU), flucytosine (5FC) and amphotericin B (AMB).

METHODS

The method used was a microtitre modification of the NCCLS M27-A accepted standard using either RPMI-1640 with 2% glucose (5FC and FLU) or antibiotic medium 3 with 2% glucose (LY and AMB). The minimum inhibitory concentration (MIC) was the lowest drug concentration that reduced growth by 80% compared with the drug-free control. Minimum fungicidal concentrations (MFCs; 99% kill) were also determined for all isolates for LY and AMB.

RESULTS

Overall, 58 of 105 (55.2%) isolates were resistant to FLU (MIC < or = 16 mg/L). There was no relationship between FLU and LY MICs for C. albicans or non-albicans species. For all isolates, geometric mean (GM) MIC values and ranges (in mg/L) were: LY 0.011 and < or = 0.001-16, FLU 8.72 and < or = 0.125- > 128, 5FC 0.393 and < or = 0.03- > 32, AMB 0.046 and 0.008-0.125. Differences in susceptibility to LY were seen: C. parapsilosis (n = 12, GM 0.4 and range 0.125-16) and C. guilliermondii (n = 8, GM 0.46 and range 0.25-1) were both found to be significantly less susceptible to LY than all other species (P < or = 0.05). For all isolates, geometric mean MFC values and ranges (in mg/L) were: LY 0.032 and 0.002-16, AMB 0.143 and 0.03-2. The MFC value was the same as or only one drug dilution higher than the MIC value for 69.5% and 48.6% of isolates tested for LY and AMB, respectively. Tolerance was described in 13.3% and 5.7% of isolates for LY and AMB, respectively. A reproducibility study performed on 20% of the isolates showed that 90.5%, 100%, 95.2% and 100% of isolates retested were the same or within one well of the original MIC value for LY, FLU, 5FC and AMB, respectively.

CONCLUSIONS

LY303366 shows promising antifungal activity in vitro and warrants further in vivo investigation.

In vivo activity of amphotericin B lipid complex in immunocompromised mice against fluconazole-resistant or fluconazole-susceptible Candida tropicalis

We compared four doses of amphotericin B lipid complex (ABLC) with three doses of fluconazole in temporarily neutropenic mice in a murine model of disseminated candidiasis due to four different isolates of Candida tropicalis. The mice were infected with a 90% lethal dose of four strains of C. tropicalis for which the fluconazole MICs ranged from 1 to >125 mg/liter 3 days after receiving 200 mg of cyclophosphamide/kg of body weight. Treatment was started 18 h after infection and lasted for 7 days. ABLC (1, 2, 5, and 10 mg/kg) was administered once a day intravenously, fluconazole was administered by oral gavage once daily (25 and 50 mg/kg/day) or twice daily (125 mg/kg). MICs determined in five different ways with 24- and 48-h endpoints were also compared. The overall survival rates were controls, 14%; fluconazole, 64%; and ABLC, 82%. Treatment with ABLC at 2 to 10 mg/kg increased survival compared to controls (P = <0.0001) and was also superior to fluconazole at 25 and 50 mg/kg (P = 0.006). In the fluconazole-resistant C. tropicalis model (MIC, 128 microg/ml), ABLC at 2 to 10 mg/kg was superior to fluconazole at 250 mg/kg and ABLC at 10 mg/kg was superior to all fluconazole doses (P = <0.05). Fluconazole at 250 mg/kg daily was superior to both 25 and 50 mg/kg at reducing mortality with most isolates. ABLC was superior to fluconazole (P = <0.01), and fluconazole at 250 mg/kg was superior to fluconazole at both 25 and 50 mg/kg (P = 0.02) in all models at reducing C. tropicalis counts in the kidneys. Neither drug consistently sterilized the brain or kidneys. A 48-h endpoint reading with the NCCLS susceptibility testing microtiter variation overestimates resistance to fluconazole. ABLC is an effective treatment for fluconazole-resistant C. tropicalis at all doses tested.

Contribution of nucleoside analogue reverse transcriptase inhibitors to subcutaneous fat wasting in patients with HIV infection

BACKGROUND

Progressive subcutaneous fat wasting, fat accumulation, dyslipidaemia and insulin resistance in HIV-infected patients on antiretroviral therapy has been attributed to the long-term toxicity of HIV protease inhibitors (PI). More recently, fat wasting has been observed in patients who have never taken a PI, implicating an independent effect of nucleoside analogue reverse transcriptase inhibitor (NRTI) therapy.

OBJECTIVES

To determine the relative contribution of NRTI and PI, as well as any other factors, to fat wasting in HIV-infected patients.

DESIGN

Longitudinal cohort study involving 277 participants of the Western Australian HIV Cohort Study.

METHODS

The time to onset of clinically apparent fat wasting in patients receiving different antiretroviral regimens was compared using standardized clinical criteria. Regional fat measured by dual energy X-ray absorptiometry (DEXA) in 161 patients was also compared. The average rate of percentage fat reduction was estimated in 70 patients who had consecutive DEXA scans at approximately 6-monthly intervals. Multiple confounding factors were considered in the analyses.

RESULTS

Progressive subcutaneous fat wasting, indistinguishable from that described in PI-treated patients, does occur in PI-naive, NRTI-treated patients. In patients taking triple combination antiretroviral therapy, age (relative risk = 1.052 per year; P < 0.0001), white race (relative risk = 3.9; P = 0.023), longer duration of dual NRTI therapy prior to addition of PI (relative risk = 1.021 per month; P = 0.0046) and increased cumulative time on stavudine-containing regimens compared with time on zidovudine-containing regimens (relative risk = 1.085 per month; P < 0.0001) are associated with increased risk of fat wasting. Stavudine increases the risk of fat wasting by 265% per year compared with zidovudine. However PI therapy is associated with faster progression to clinically apparent wasting compared with dual NRTI therapy without PI. The results of DEXA scanning supports these clinical data and suggest a non-linear decline in fat over time.

CONCLUSIONS

NRTIs do have an independent contribution to fat wasting, but PI are the predominant influence and may act synergistically with NRTIs. NRTIs appear to predispose individuals to slowly progressive fat loss, which is markedly accelerated when a PI and NRTIs are combined. Of the NRTIs, stavudine leads to an earlier onset of clinically apparent fat wasting compared with zidovudine. Fat wasting associated with NRTI use may be a manifestation of mitochondrial toxicity, which may be exacerbated by PI use.

Effects of lighting conditions and melatonin supplementation on the cellular and humoral immune responses in Japanese quail Coturnix coturnix japonica

Two experiments were conducted to determine the effects of lighting conditions and melatonin supplementation on the cellular and humoral immune responses in Japanese quail. The first experiment was designed to evaluate differing light regimes as immune modulators in both adult and juvenile quail. The cellular and humoral immune responses were determined for three lighting conditions; short days (8:16LD), long days (16:8LD), and constant light (LL). In the second experiment, melatonin was administered in varying doses to adult quail placed in LL. The doses used in this experiment were 0.0, 0.5, 5.0, and 50.0 microg/ml melatonin given in the drinking water for 16 h per day for 2 weeks. The cellular and humoral immune responses were evaluated after 1 week of melatonin treatment. In both experiments, a cutaneous basophil hypersensitivity reaction to phytohemagglutinin (PHA-P) was measured to evaluate the cellular immune response. To evaluate the humoral immune response, primary antibody titers were calculated 7 days postintravenous injection with a Chukar red blood cell suspension. In the adult birds of experiment 1, both the 8:16LD and 16:8LD treatments produced similar cellular and humoral immune responses but these responses were significantly greater than those observed in LL. The juvenile birds held under 8:16LD also had significantly greater cellular and humoral immune responses as compared to juvenile birds held in LL. In experiment 2, there was a clear melatonin dose response on immune function in LL. The humoral immune response increased to a peak at the 5.0 microg/ml dose while the cellular immune response increased across all dose levels. From the present study it was clear that quail placed in daily light-dark cycles (LD), possessing a diurnal rhythm of melatonin, had significantly elevated immune responses as compared to those birds in LL. Furthermore, melatonin supplemented to birds exposed to LL was immuno-enhancing. This suggests that melatonin may be a mediator of the differences seen between LD and LL lighting conditions and may have important immune modulating properties.

Integration of repellents, attractants, and insecticides in a "push-pull" strategy for managing German cockroach (Dictyoptera: Blattellidae) populations

"Push-pull" is a behavior manipulation strategy in which behavior-modifying stimuli are integrated with a pest control agent. We evaluated the efficacy of an insecticide bait in combination with attractants ("pull"), repellents ("push"), or both ("push-pull") using a hydramethylnon-based bait, feces-contaminated surfaces as an attractant, and methyl neodecanamide-treated surfaces to repel cockroaches. Both adult males and first-instar German cockroaches, Blattella germanica (L.), chose shelters nearest the attractant-treated surfaces and farthest from the repellent-treated surfaces. Food consumption was highest from food nearest the preferred shelters, and mortality was highest when the insecticide bait was near the preferred shelter. These patterns were more apparent in first instars than in adults. Our results from large arena studies in the laboratory show that the push-pull strategy can be used to displace pests from resources or commodities that are to be protected, and simultaneously lure the pest to an attractant source coupled with a pest control agent. Concentrating cockroaches into a limited area should facilitate the precision-targeting of the pest population and promises to reduce insecticide use.

In vitro activity of the new triazole BMS-207147 against Aspergillus species in comparison with itraconazole and amphotericin B

The in vitro activity of BMS-207147 against 80 clinical isolates of Aspergillus was compared with that of itraconazole and amphotericin B, using a validated microtiter method. Geometric mean MICs (in microg/ml) were as follows: 1.71 for BMS-207147, 0.67 for itraconazole, and 0.63 for amphotericin B. The range of concentrations of each drug was 0.125 to >16 microg/ml. Aspergillus fumigatus was significantly more susceptible to BMS-207147 (P < 0. 05) than A. terreus and A. flavus. No BMS-207147-resistant A. fumigatus isolates were identified, though eight itraconazole-resistant (MIC, >8 microg/ml) isolates were. BMS-207147 is active against Aspergillus spp. at slightly high concentrations compared with itraconazole and amphotericin B.

Lack of correlation of in vitro amphotericin B susceptibility testing with outcome in a murine model of Aspergillus infection

Amphotericin B has been the standard therapy for invasive aspergillosis since its introduction in 1957. It is only moderately effective. Many susceptibility tests have been used but little variation has been noted between strains. We have studied three strains of Aspergillus fumigatusand one of Aspergillus terreusin a neutropenic mouse model of invasive aspergillosis and attempted to correlate the variable efficacy in vivowith MICs generated by over 30 different susceptibility test formats. One strain of A. fumigatus(AF65) and the strain of A. terreus(AT49) were 'resistant' and the remaining two strains of A. fumigatus(AF210 and AF294) were 'susceptible' in vivo. Only AT49 had elevated MICs of amphotericin (MIC 2 mg/L) by 41 of 54 in vitrotesting systems. With each test format, including Etest, there was no distinction between MICs obtained for AF65, AF210 and AF294 (MICs 0.125-64 mg/L depending on the test). Thus despite extensive efforts we have been unable to correlate susceptible test results with in vivooutcome in A. fumigatusbut we have with A. terreus, with some test formats. This suggests that, at present, amphotericin B susceptibility testing of A. fumigatus is of limited clinical value and further work needs to be done to find testing systems that can identify the 'resistance' documented in vivo.

Zinc-dependent structural stability of human Sonic hedgehog

The role of the zinc site in the N-terminal fragment of human Sonic hedgehog (ShhN) was explored by comparing the biophysical and functional properties of wild-type ShhN with those of mutants in which the zinc-coordinating residues H140, D147, and H182, or E176 which interacts with the metal ion via a bridging water molecule, were mutated to alanine. The wild-type and E176A mutant proteins retained 1 mol of zinc/mol of protein after extensive dialysis, whereas the H140A and D147A mutants retained only 0.03 and 0.05 mol of zinc/mol of protein, respectively. Assay of the wild-type and mutant proteins in two activity assays indicated that the wild-type and E176A mutant proteins had similar activity, whereas the H140A and D147A mutants were significantly less active. These assays also indicated that the H140A and D147A mutants were susceptible to proteolysis. CD, fluorescence, and (1)H NMR spectra of the H140A, D147A, and E176A mutants measured at 20 or 25 degrees C were very similar to those observed for wild-type ShhN. However, CD measurements at 37 degrees C showed evidence of some structural differences in the H140A and D147A mutants. Guanidine hydrochloride (GuHCl) denaturation studies revealed that the loss of zinc from the H140A and D147A mutants destabilized the folded proteins by approximately 3.5 kcal/mol, comparable to the effect of removing zinc from wild-type ShhN by treatment with EDTA. Thermal melting curves of wild-type ShhN gave a single unfolding transition with a midpoint T(m) of approximately 59 degrees C, whereas both the H140A and D147A mutants displayed two distinct transitions with T(m) values of 37-38 and 52-54 degrees C, similar to that observed for EDTA-treated wild-type ShhN. Addition of zinc to the H140A and D147A mutants resulted in a partial restoration of stability against thermal and GuHCl denaturation. The ability of these mutants to bind zinc was confirmed using a fluorescence-based binding assay that indicated that they bound zinc with K(d) values of approximately 1.6 and approximately 15 nM, respectively, as compared to a value of </=100 pM for wild-type ShhN. The properties of the E176A mutant were indistinguishable from those of wild-type ShhN in all biophysical and functional assays, indicating that this residue does not contribute significantly to stabilization of the zinc-binding site and that ShhN does not require hydrolase activity for in vitro biological function.

Periodontal attachment loss in HIV-infected patients is associated with the major histocompatibility complex 8.1 haplotype (HLA-A1,B8,DR3)

Periodontal attachment loss is mediated by overproduction of tumour necrosis factor (TNF) and interleukin (IL)-1, and appears to have a genetic component. The 8.1 major histocompatibility complex (MHC) ancestral haplotype (HLA-A1,B8,TNFA-308(2),DR3) is associated with elevated TNF production and predisposes carriers to several autoimmune/immunopathological disorders, including rapid progression of HIV disease, but not early onset periodontal disease in healthy individuals. Rather a high proportion of subjects with severe periodontal disease carry allele 2 at IL-1A-889 and IL-1B+3953. We predicted that genetic associations may be different or clearer in HIV patients, as they often show elevated production of TNF and IL-1 and periodontal attachment loss. Hence periodontal parameters and IL-1 polymorphisms were assessed in HIV-positive subjects expressing HLA-B8 with or without other markers of the 8.1 haplotype. Of 16 HLA-B8 subjects, 13 demonstrated elevated probing pocket depth and clinical attachment loss. The difference was statistically significant and did not correlate with smoking, age, CD4 T-cell counts, HIV viral load or levels of dental plaque. As TNFA-308 (allele 2) was present in four non-B8 subjects who had minimal attachment loss, it may not mediate the effect of the 8.1 haplotype. Moreover, polymorphisms at IL-1A-889 and IL-1B+3953 did not significantly affect periodontal parameters. Thus a central MHC gene characteristic of the 8.1 haplotype was the clearest determinant of periodontal attachment loss in HIV-infected individuals.

Activity of pradimicin BMS-181184 against Aspergillus spp

The pradimicins are a new class of antifungal agents with activity against the majority of human fungal pathogens. In this study, the in vitro activity of pradimicin BMS-181184 was investigated against a range of the most common species of Aspergillus. The results were compared with itraconazole and amphotericin B. BMS-181184 was found to be active against most Aspergillus spp., but at higher concentrations than itraconazole and amphotericin B.

Playing for time: adolescent perspectives of lung transplantation for cystic fibrosis

A single-case study approach was used to provide an in-depth examination of the special events surrounding the decision of a 21-year-old adolescent to undergo lung transplantation for end-stage cystic fibrosis. The central theme "playing for time" characterized the interplay between the disease progression and adolescent development as illustrated by 3 subthemes: (a) a strange balance; (b) playing chicken; and (c) being listed. The adolescent's developmental needs provided the context for the struggle with the competing demands of physiologic and psychologic readiness for the transplant, quality-of-life issues, and a renewed hope for the future. Developmental needs were more important to the adolescent than the opportunity for increased length of survival provided by lung transplantation. Advanced practice nurses are in an excellent position to provide continuity of care for chronic illness management over time and across settings.

Comparison of in vitro activity of liposomal nystatin against Aspergillus species with those of nystatin, amphotericin B (AB) deoxycholate, AB colloidal dispersion, liposomal AB, AB lipid complex, and itraconazole

We compared the in vitro activity of liposomal nystatin (Nyotran) with those of other antifungal agents against 60 Aspergillus isolates. Twelve isolates were itraconazole resistant. For all isolates, geometric mean (GM) MICs (micrograms per milliliter) were 2.30 for liposomal nystatin, 0.58 for itraconazole, 0.86 for amphotericin B (AB) deoxycholate, 9.51 for nystatin, 2.07 for liposomal AB, 2.57 for AB lipid complex, and 0.86 for AB colloidal dispersion. Aspergillus terreus (GM, 8.72 micrograms/ml; range, 8 to 16 micrograms/ml) was significantly less susceptible to all of the polyene drugs than all other species (P = 0.0001).

In vitro activity of the echinocandin antifungal agent LY303,366 in comparison with itraconazole and amphotericin B against Aspergillus spp

LY303,366 (LY) is a novel derivative of the echinocandin class of antifungal agents. The in vitro activities of LY, itraconazole (ITZ), and amphotericin B (AMB) were assessed against 60 Aspergillus isolates, including 35 isolates of A. fumigatus, eight isolates of A. terreus, eight isolates of A. flavus, eight isolates of A. niger and one isolate of A. nidulans. Four A. fumigatus isolates were resistant to ITZ. Susceptibility testing for all drugs was performed with a broth microdilution procedure. LY was tested in two media: antibiotic medium 3 (AM3) and Casitone with 2% glucose (CAS) with an inoculum of 2 x 10(3) spores/ml. ITZ and AMB were tested in RPMI 1640 with 2% glucose with an inoculum of 1 x 10(6) spores/ml. All tests were incubated at 37 degrees C for 48 h. A novel end point was used to determine a minimal effective concentration (MEC) for LY, i. e., almost complete inhibition of growth save a few tiny spherical colonies attached to the microplate. MICs were measured for ITZ and AMB with a no-growth end point. Ranges and geometric mean (GM) MECs were from 0.0018 to >0.5 and 0.0039 mg/liter and from 0.0018 to >0.5 and 0.008 mg/liter for LY in AM3 and LY in CAS, respectively. Differences between species were apparent, with A. flavus being significantly less susceptible to LY than any other species tested with both media (P </= 0.05). Ranges and GM MICs were from 0.125 to >16 and 0.7 mg/liter for ITZ and from 0.25 to 16 and 1.78 mg/liter for AMB. Minimal fungicidal concentrations (MFCs) were also determined for all drugs. GM MFCs were 0.018, 0.09, 19.76, and 12.64 mg/liter for LY in AM3, LY in CAS, ITZ, and AMB, respectively. LY in AM3 and LY in CAS were fungicidal for 86.7 and 68% of isolates, respectively (98% killing). In comparison, ITZ and AMB were fungicidal for 35 and 70% of isolates, respectively (99.99% killing). A reproducibility study was performed on 20% of the isolates. For 12 isolates retested, the MEC or MIC was the same or was within 1 dilution of the original value for 11, 11, 10, and 9 isolates for LY in AM3, LY in CAS, ITZ, and AMB, respectively. In conclusion, LY seems to be a promising antifungal agent with excellent in vitro activity against Aspergillus spp.

In-vitro activity of voriconazole against Aspergillus spp. and comparison with itraconazole and amphotericin B

The in-vitro activity of the triazole antifungal agent voriconazole was compared with itraconazole and amphotericin B against 60 aspergillus isolates. Susceptibility tests were performed using two methods: a macrodilution and a microdulution method. For macrodilution methodology, geometric mean (GM) MIC values and ranges were 0.4 and 0.125-4 mg/L for voriconazole, 0.24 and 0.06-->16 mg/L for itraconazole, and 1.04 and 0.5-4 mg/L for amphotericin B. For the microdilution method, GM MICs and ranges were 0.66 and 0.125-2 mg/L for voriconazole, 0.27 and 0.06-->16 mg/L for itraconazole, and 1.62 and 0.25-32 mg/L for amphotericin B. In conclusion, voriconazole is active against Aspergillus spp. in vitro, and at similar concentrations to itraconazole.

Activity of SCH 56592 compared with those of fluconazole and itraconazole against Candida spp

The in vitro activity of Schering 56592, a new azole drug, was compared with those of fluconazole and itraconazole against 103 isolates of Candida comprising 10 different species. Schering 56592 was more active than itraconazole and fluconazole, and it was active against many fluconazole-resistant isolates.

Speaker normalization in the perception of Mandarin Chinese tones

This study investigated speaker normalization in perception of Mandarin tone 2 (midrising) and tone 3 (low-falling-rising) by examining listeners' use of F0 range as a cue to speaker identity. Two speakers were selected such that tone 2 of the low-pitched speaker and tone 3 of the high-pitched speaker occurred at equivalent F0 heights. Production and perception experiments determined that turning point (or inflection point of the tone), and delta F0 (the difference in FO between onset and turning point) distinguished the two tones. Three tone continua varying in either turning point, delta FO, or both acoustic dimensions, were then appended to a natural precursor phrase from each of the two speakers. Results showed identification shifts such that identical stimuli were identified as low tones for the high precursor condition, but as high tones for the low precursor condition. Stimuli varying in turning point showed no significant shift, suggesting that listeners normalize only when the precursor varies in the same dimension as the stimuli. The magnitude of the shift was greater for stimuli varying only in delta FO, as compared to stimuli varying in both turning point and delta FO, indicating that normalization effects are reduced for stimuli more closely matching natural speech.