A retrospective 'real-world' cohort study of azole therapeutic drug monitoring and evolution of antifungal resistance in cystic fibrosis

BACKGROUND

Individuals with cystic fibrosis (CF) have an increased susceptibility to fungal infection/allergy, with triazoles often used as first-line therapy. Therapeutic drug monitoring (TDM) is essential due to significant pharmacokinetic variability and the recent emergence of triazole resistance worldwide.

OBJECTIVES

In this retrospective study we analysed the 'real-world' TDM of azole therapy in a large CF cohort, risk factors for subtherapeutic dosing, and the emergence of azole resistance.

METHODS

All adults with CF on azole therapy in a large single UK centre were included. Clinical demographics, TDM and microbiology were analysed over a 2 year study period (2015-17) with multivariate logistic regression used to identify risk factors for subtherapeutic dosing.

RESULTS

91 adults were treated with azole medication during the study period. A high prevalence of chronic subtherapeutic azole dosing was seen with voriconazole (60.8%) and itraconazole capsule (59.6%) use, representing significant risk factors for subtherapeutic levels. Rapid emergence of azole resistance was additionally seen over the follow-up period with a 21.4% probability of CF patients developing a resistant fungal isolate after 2 years. No significant relationship was found however between subtherapeutic azole dosing and azole resistance emergence.

CONCLUSIONS

Our study demonstrates a high prevalence of subtherapeutic azole levels in CF adults with increased risk using itraconazole capsules and voriconazole therapy. We show rapid emergence of azole resistance highlighting the need for effective antifungal stewardship. Further large longitudinal studies are needed to understand the effects of antifungal resistance on outcome in CF and the implications of subtherapeutic dosing on resistance evolution.

Multi-element survey of wild edible fungi and blackberries in the UK

A survey of 12 metals including lead (Pb), copper (Cu), cadmium (Cd), mercury (Hg), arsenic (As) and platinum (Pt) was carried out using ICP-MS in 34 samples of wild fungi and 48 samples of wild blackberries collected from sites across the UK. On a fresh weight basis (mg/kg) levels of Pb were in the range 0.003-5.990, Cu 0.596-34.800, Cd<0.001-19.6, Hg<0.001-4.150, As 0.001-0.972 and Pt (microg/kg) 0.006-0.200, with higher concentrations found in fungi than in blackberries. The results of the survey showed that the concentrations of the metals were consistent with previous studies, where available. Concentrations in wild fungi of Pt, tin (Sn), and titanium (Ti) were significantly higher at urban sites than at rural sites. Urban blackberries had significantly higher levels of Pb, Ti, and Cd than rural ones, but lower levels of manganese (Mn). Pb, Ti and Sn concentrations were significantly higher in blackberries sampled near main roads rather than in rural areas.

Structure of a slow processing precursor penicillin acylase from Escherichia coli reveals the linker peptide blocking the active-site cleft

Penicillin G acylase is a periplasmic protein, cytoplasmically expressed as a precursor polypeptide comprising a signal sequence, the A and B chains of the mature enzyme (209 and 557 residues respectively) joined by a spacer peptide of 54 amino acid residues. The wild-type AB heterodimer is produced by proteolytic removal of this spacer in the periplasm. The first step in processing is believed to be autocatalytic hydrolysis of the peptide bond between the C-terminal residue of the spacer and the active-site serine residue at the N terminus of the B chain. We have determined the crystal structure of a slowly processing precursor mutant (Thr263Gly) of penicillin G acylase from Escherichia coli, which reveals that the spacer peptide blocks the entrance to the active-site cleft consistent with an autocatalytic mechanism of maturation. In this mutant precursor there is, however, an unexpected cleavage at a site four residues from the active-site serine residue. Analyses of the stereochemistry of the 260-261 bond seen to be cleaved in this precursor structure and of the 263-264 peptide bond have suggested factors that may govern the autocatalytic mechanism.

Revealing the existence of child abuse in the context of marital breakdown and custody and access disputes

OBJECTIVE

Child abuse in the context of legal and de facto marital breakdown has received little attention internationally. Many believe it does not exist in this context and regard it as just a "gambit in the divorce wars." Recently, however, family courts in a number of countries have become concerned over the management of child abuse allegations in custody and access cases, known more commonly now as residence and contact cases. This article presents a unique research study, which investigated how the Family Court of Australia dealt with such cases. The study, covering all forms of child abuse, sought to discover who were the families bringing these problems to family courts, what precisely the abuse was and how the courts dealt with it.

METHOD

The study reviewed court records of some 200 families where child abuse allegations had been made in custody and access disputes in jurisdictions in two states, observed court proceedings and interviewed court and related services' staff.

RESULTS

The findings showed that these cases had become a core component of the court's workload without any public or professional awareness of this change, that the abuse was real, that it was severe and serious, and that the courts and child protection services did not provide appropriate services to the families.

CONCLUSION

A new specialized intervention system was developed based on the research and it is now being trialed and evaluated. The new intervention system contains features derived from the research findings that may be suitable internationally for implementation.

Crystallization of a precursor penicillin acylase from Escherichia coli

The crystallization of a mutant precursor penicillin acylase [penicillin amidohydrolase (amidase) E.C. 3.5.1.11] from Escherichia coli W (ATCC 11105) using the hanging-drop method is reported. The crystals are in space group P1 with unit-cell parameters a = 51.04, b = 63.58, c = 71.17 A, alpha = 103.0, beta = 110.6, gamma = 105.3 degrees, with one molecule in the asymmetric unit, and diffract to 1. 8 A using synchrotron radiation.

Structure of d(TGCGCA)2 and a comparison to other DNA hexamers

The X-ray crystal structure of d(TGCGCA)2 has been determined at 120 K to a resolution of 1.3 A. Hexamer duplexes, in the Z-DNA conformation, pack in an arrangement similar to the 'pure spermine form' [Egli et al. (1991). Biochemistry, 30, 11388-11402] but with significantly different cell dimensions. The phosphate backbone exists in two equally populated discrete conformations at one nucleotide step, around phosphate 11. The structure contains two ordered cobalt hexammine molecules which have roles in stabilization of both the Z-DNA conformation of the duplex and in crystal packing. A comparison of d(TGCGCA)2 with other Z-DNA hexamer structures available in the Nucleic Acid Database illustrates the elusive nature of crystal packing. A review of the interactions with the metal cations Na+, Mg2+ and Co3+ reveals a relatively small proportion of phosphate binding and that close contacts between metal ions are common. A prediction of the water structure is compared with the observed pattern in the reported structure.

Serial cranial and spinal cord magnetic resonance imaging in multiple sclerosis

Twenty-nine mildly disabled patients with multiple sclerosis underwent serial clinical and magnetic resonance imaging (MRI) evaluations (pre- and postgadolinium cranial and spinal cord MRI) on at least 3 occasions at 13-week intervals and during periods of suspected relapse. Using clinical judgment of the presence of recent active disease as the gold standard, combined MRI studies confirmed the clinical impression of active disease in 93% of follow-up visits (sensitivity) and the absence of active MS in 63% of follow-up visits (specificity). None of the cranial and spinal MRI-detected abnormalities disappeared. Gadolinium administration particularly increased the yield of spinal MRI. Cranial MRI alone detected 80% of the MRI-active visits. Clinical and MRI concordance was significantly better for the presence of recent disease activity than for the anatomical localization of the presumed site of activity. MRI evidence of apparent ongoing disease activity was seen more frequently in patients believed to have active multiple sclerosis in the preceding year (13 of 21) than in patients who had been in clinical remission for at least the 2 preceding years (2 of 8). Although clinical evidence of new disease activity was much less common in patients with active, chronic-progressive disease (1 of 8) than in patients with active, relapsing disease (9 of 13), the proportion of patients with either infrequent relapses, frequent relapses, or slow chronic-progressive disease in the preceding year in whom MRI activity developed and the pattern of this new MRI activity was similar between these types of active patients.(ABSTRACT TRUNCATED AT 250 WORDS)

A two-dimensional intervention plan to reduce risk factors for ischaemic heart disease

Although most cardiologists and public health officials are convinced of the great value of reducing risk factors for cardiovascular diseases, efforts to reduce these factors have seldom reached effectively beyond those persons in direct touch with physicians. This paper describes nine channels which health officials can utilise to inform, motivate, and change health behaviours in the general public. The channels are: individuals, family and friends, health professionals and institutions, schools and teachers, business and labour, mass media, local organizations, community leaders, regional and national government. Using all these channels in an integrated programme to reduce multiple risk factors in the community results in a two-dimensional intervention plan in which the various components reinforce one another. Specific programmatic suggestions are made for each of the following cardiovascular risk factors: cigarette smoking, high blood pressure, lack of exercise, high serum cholesterol, and stress.

Autoradiographic visualization of kappa opioid receptors with labelled dynorphins in guinea pig brain

The distribution of kappa opioid receptors in guinea pig brain was measured by in vitro receptor autoradiography using [3H]dynorphin A1-9, [3H]dynorphin A1-8 and [3H]bremazocine as ligands. The sites labelled by the two dynorphins had identical, heterogeneous distributions in brain sections. High levels of kappa receptors were seen in striatum, claustrum, nucleus accumbens and laminae V and VI of the cerebral cortex. The substantia nigra and superior colliculus also had high dynorphin binding levels. The [3H]dynorphin autoradiographs were closely similar to those obtained using [3H]bremazocine in the presence of mu and delta receptor displacers. It is concluded that tritiated dynorphin A fragments can be used for autoradiographic studies of kappa opioid receptors in brain.

Desipramine binding: relationship to central and sympathetic noradrenergic activity

We examined the effects of treatments affecting norepinephrine release on the number of norepinephrine reuptake recognition sites as reflected by desipramine binding. To do this, we used manipulations having similar presynaptic but contrasting postsynaptic effects. Presynaptic inhibition by 6-hydroxydopamine lesion or by clonidine, and postsynaptic receptor stimulation by isoproterenol, reduced desipramine binding. Presynaptic stimulation by d-amphetamine and postsynaptic receptor blockade by prazosin increased desipramine binding. Similar effects and binding properties were seen in cerebral cortex, heart, and soleus muscle. After unilateral noradrenergic lesions, reduction in desipramine binding correlated with reduction in norepinephrine uptake. These results show that norepinephrine reuptake appears to be regulated by transmitter release regardless of effects on postsynaptic transmission, and that this regulation is analogous in the central and sympathetic nervous systems.

Thrombin inhibition by malignant and normal cells: a cell-bound antithrombin effect

Analysis of fresh surgical specimens of normal tissue and tumor tissue show a cellular antithrombin activity to be present in certain organs. In normal tissues it was noted chiefly in normal colon, testes, breast, and uterus. In malignant tissues it was prominent in adenocarcinomas of the colon, breast, and lung. No epidermoid tumors showed evidence of thrombin binding. The thrombin- binding activity required the presence of intact cells and was distinct from the soluble antithrombins normally present in plasma and serum. There is growing evidence to suggest an interrelationship between clotting and the growth and dissemination of cancer. The implications of cellular antithrombins are reviewed in this context.

Coagulant Effects of Normal and Malignant Tissue

A prospective study has been conducted on the procoagulant activity of tumor tissues and normal tissues removed during the course of surgery and therapeutic procedures. The presence of potent tissue thromboplastic action was demonstrated in cells removed from certain types of normal and malignant tissue. A less potent incomplete thromboplastin can be isolated from certain tumor tissues. The bulk of the activity is present in the cellular fraction although partial recovery can be achieved from the supernate after freezing and thawing. Assays for prothrombin, thrombin, fibrinogen and coagulant inhibitors revealed no activity by the standard assays which were employed.