Adverse impact of a high CD4/CD8 ratio in the allograft may be overcome by methotrexate- but not mycophenolate- or posttransplant cyclophosphamide-based graft versus host disease prophylaxis

INTRODUCTION

A high CD4/CD8 T cell ratio in hematopoietic stem cell transplant (HSCT) allografts was observed to predict graft-versus-host disease (GVHD) and non-relapse mortality (NRM) but has not been comparatively examined in settings of various GVHD-prophylaxis regimens.

METHODS

This retrospective monocentric study included all consecutive HSCT performed with peripheral blood stem cells (PBSC) between January 2000 and June 2021. The impact of the graft CD4/CD8 ratio was analyzed in three cohorts with different GVHD-prophylaxis platforms.

RESULTS

In the cyclosporine/mycophenolate-mofetil (CSA/MMF) cohort (n = 294, HLA-matched HSCT), a high (> 75^th percentile) CD4/CD8 ratio was associated with increased overall mortality (HR 1.56; P=0.01), increased NRM (HR 1.85; P=0.01) and GVHD-associated mortality (HR 2.13; P=0.005). In the post-transplant cyclophosphamide (PTCy)/tacrolimus/MMF cohort (n = 113, haploidentical-related or mismatched-unrelated HSCT), a high CD4/CD8 ratio was associated with increased overall mortality (HR 2.07; P=0.04) and aGVHD3-4 (HR 2.24; P=0.02). By contrast, in the CSA/methotrexate (CSA/MTX) cohort (n = 185, HLA-matched HSCT) the CD4/CD8 ratio had no significant impact on any of the investigated endpoints.

CONCLUSION

A high CD4/CD8 ratio in the allograft has an adverse impact on GVHD and survival in CSA/MMF- and PTCy-based HSCT, while MTX-based prophylaxis may largely alleviate this important risk factor.

Pre-activated antiviral innate immunity in the upper airways controls early SARS-CoV-2 infection in children

Children have reduced severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates and a substantially lower risk for developing severe coronavirus disease 2019 compared with adults. However, the molecular mechanisms underlying protection in younger age groups remain unknown. Here we characterize the single-cell transcriptional landscape in the upper airways of SARS-CoV-2-negative (n = 18) and age-matched SARS-CoV-2-positive (n = 24) children and corresponding samples from adults (n = 44), covering an age range of 4 weeks to 77 years. Children displayed higher basal expression of relevant pattern recognition receptors such as MDA5 (IFIH1) and RIG-I (DDX58) in upper airway epithelial cells, macrophages and dendritic cells, resulting in stronger innate antiviral responses upon SARS-CoV-2 infection than in adults. We further detected distinct immune cell subpopulations including KLRC1 (NKG2A)+ cytotoxic T cells and a CD8+ T cell population with a memory phenotype occurring predominantly in children. Our study provides evidence that the airway immune cells of children are primed for virus sensing, resulting in a stronger early innate antiviral response to SARS-CoV-2 infection than in adults.

Comparison of SARS-CoV-2 Antibody Response 4 Weeks After Homologous vs Heterologous Third Vaccine Dose in Kidney Transplant Recipients: A Randomized Clinical Trial

IMPORTANCE

Fewer than 50% of kidney transplant recipients (KTRs) develop antibodies against the SARS-CoV-2 spike protein after 2 doses of an mRNA vaccine. Preliminary data suggest that a heterologous vaccination, combining mRNA and viral vector vaccines, may increase immunogenicity.

OBJECTIVE

To assess the effectiveness of a third dose of an mRNA vs a vector vaccine in KTRs who did not have antibodies against the SARS-CoV-2 spike protein after 2 doses of an mRNA vaccine.

DESIGN, SETTING, AND PARTICIPANTS

This was a single center, single-blinded, 1:1 randomized clinical trial of a third dose of vaccine against SARS-CoV-2, conducted from June 15 to August 16, 2021, in 201 KTRs who had not developed SARS-CoV-2 spike protein antibodies after 2 doses of an mRNA vaccine. Data analyses were performed from August 17 to August 31, 2021.

INTERVENTIONS

mRNA (BNT162b2 or mRNA-1273) or vector (Ad26COVS1) as a third dose of a SARS-CoV-2 vaccine.

MAIN OUTCOMES AND MEASURES

The primary study end point was seroconversion after 4 weeks (29-42 days) following the third vaccine dose. Secondary end points included neutralizing antibodies and T-cell response assessed by interferon-γ release assays (IGRA). In addition, the association of patient characteristics and vaccine response was assessed using logistic regression, and the reactogenicity of the vaccines was compared.

RESULTS

Among the study population of 197 kidney transplant recipients (mean [SD] age, 61.2 [12.4] years; 82 [42%] women), 39% developed SARS-CoV-2 antibodies after the third vaccine. There was no statistically significant difference between groups, with an antibody response rate of 35% and 42% for the mRNA and vector vaccines, respectively. Only 22% of seroconverted patients had neutralizing antibodies. Similarly, T-cell response assessed by IGRA was low with only 17 patients showing a positive response after the third vaccination. Receiving nontriple immunosuppression (odds ratio [OR], 3.59; 95% CI, 1.33-10.75), longer time after kidney transplant (OR, 1.44; 95% CI, 1.15-1.83, per doubling of years), and torque teno virus plasma levels (OR, 0.92; 95% CI, 0.88-0.96, per doubling of levels) were associated with vaccine response. The third dose of an mRNA vaccine was associated with a higher frequency of local pain at the injection site compared with the vector vaccine, while systemic symptoms were comparable between groups.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that 39% of KTRs without an immune response against SARS-CoV-2 after 2 doses of an mRNA vaccine developed antibodies against the SARS-CoV-2 spike protein 4 weeks after a third dose of an mRNA or a vector vaccine. The heterologous vaccination strategy with a vector-based vaccine was well tolerated and safe but not significantly better than the homologous mRNA-based strategy.

TRIAL REGISTRATION

EudraCT Identifier: 2021-002927-39.

Low SARS-CoV-2 seroprevalence in the Austrian capital after an early governmental lockdown

We analyzed SARS-CoV-2 seroprevalence in a large, well-described representative Viennese cohort after an early governmental lockdown with respect to the occurrence of symptoms and household transmission. Participants of the LEAD Study, a population-based cohort study from Vienna, Austria, were invited along with their household members (April 20th to May20th 2020). Sera were analyzed using anti-SARS-CoV-2 immunoassay including a neutralization test as a confirmatory assay. A total of 12,419 individuals participated (5984 LEAD participants; 6435 household members), 163 (1.31%; 59 LEAD cohort members) of whom were SARS-CoV-2 antibody positive. The estimated number of COVID-19 cases projected from our findings by age and sex for Vienna was 21,504 (1.13%). Cumulative number of positively tested cases in Vienna until May 20th 2020 was 3020, hence 7.1 times (95% confidence interval 5.5-9.1) lower than projected. Relative risk (RR) of seropositivity by age was highest for children aged 6-9 years [RR compared to age group 20-49: 1.21 (CI 0.37-4.01)], lowest for ≥ 65 years [RR 0.47 (CI 0.21-1.03)]. Half of the positive individuals developed no or mild symptoms. In a multivariate analysis, taste and smell disturbances were most strongly related to SARS-CoV-2 positivity. Infection probability within households with one confirmed SARS-CoV-2-specific antibody-positive person was 31%. Although seroprevalence was very low (1.13%) for a central European capital city, due to an early governmental lockdown, SARS-CoV-2 infections were more prevalent than officially reported polymerase chain reaction-positive cases. Of note, seroprevalence was highest in young children. Half of SARS-CoV-2 antibody-positive subjects had no or only mild symptoms. Taste and smell disturbances were most prominent, possibly guiding clinicians in diagnosing SARS-CoV-2 infection.

Defying the Rally During COVID-19 Pandemic: A Regression Discontinuity Approach

OBJECTIVE

Do people set aside their partisan differences and rally around elected officials during a pandemic? President Trump's delegation of responsibility to the states during the COVID-19 pandemic placed governors on the frontlines of the battle; some have shined and garnered positive national attention, others have wilted under the pressure of the national spotlight.

METHODS

We use regression discontinuity design and exploit a discontinuity in the state's political events to assess the support of a governor's response to the pandemic.

RESULTS

Using survey data from Florida's registered voters, we find that Governor DeSantis's approval dropped by 7 percentage points following his "Safer at Home" order press conference on April 1.

CONCLUSION

Our results suggest that under certain circumstances partisanship can blunt a "rally around the flag" effect. This finding provides context to understanding when and under which circumstances elected officials can expect increases (or decreases) in public support.

A Case Report of Multiple Myeloma Associated With Myeloperoxidase and Proteinase-3 Antibodies Posing a Diagnostic Dilemma

Multiple myeloma (MM) is a clonal proliferation of antibody-producing plasma cells that can precipitate renal injury through multiple mechanisms. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is an inflammatory condition that can result in renal failure through mononuclear cell infiltration and consequent destruction of glomeruli. Several case reports have identified clinical situations where differentiating these entities has been challenging. Renal biopsy is an invaluable tool in differentiating between MM and AAV when clinical uncertainty exists. We report the case of an 85-year-old man who presented with a rapid decline in renal function and serologies positive for both MM and AAV. Renal biopsy findings confirmed the diagnosis of myeloma kidney and excluded vasculitis. This case highlights an unusual clinical scenario in which both proteinase-3 (PR-3) and myeloperoxidase (MPO) antibodies are positive. While these antibodies are both individually associated with ANCA vasculitis, they are seldom simultaneously positive. Our case would suggest that positive PR-3 and MPO antibodies should raise concern for an alternative diagnosis. Indeed, ANCA, PR-3, and MPO antibodies can all be positive in patients with monoclonal gammopathy in the absence of vasculitis. Our case underscores the value of renal biopsy in the setting of MM.

101 Dothideomycetes genomes: A test case for predicting lifestyles and emergence of pathogens

Dothideomycetes is the largest class of kingdom Fungi and comprises an incredible diversity of lifestyles, many of which have evolved multiple times. Plant pathogens represent a major ecological niche of the class Dothideomycetes and they are known to infect most major food crops and feedstocks for biomass and biofuel production. Studying the ecology and evolution of Dothideomycetes has significant implications for our fundamental understanding of fungal evolution, their adaptation to stress and host specificity, and practical implications with regard to the effects of climate change and on the food, feed, and livestock elements of the agro-economy. In this study, we present the first large-scale, whole-genome comparison of 101 Dothideomycetes introducing 55 newly sequenced species. The availability of whole-genome data produced a high-confidence phylogeny leading to reclassification of 25 organisms, provided a clearer picture of the relationships among the various families, and indicated that pathogenicity evolved multiple times within this class. We also identified gene family expansions and contractions across the Dothideomycetes phylogeny linked to ecological niches providing insights into genome evolution and adaptation across this group. Using machine-learning methods we classified fungi into lifestyle classes with >95 % accuracy and identified a small number of gene families that positively correlated with these distinctions. This can become a valuable tool for genome-based prediction of species lifestyle, especially for rarely seen and poorly studied species.

Fast Electron and Slow Hole Relaxation in InP-Based Colloidal Quantum Dots

Colloidal InP-based quantum dots are a promising material for light-emitting applications as an environment friendly alternative to their Cd-containing counterparts. Especially for their use in optoelectronic devices, it is essential to understand how charge carriers relax to the emitting state after injection with excess energy and if all of them arrive at this desired state. Herein, we report time-resolved differential transmission measurements on colloidal InP/ZnS and InP/ZnSe core/shell quantum dots. By optically exciting and probing individual transitions, we are able to distinguish between electron and hole relaxation. This, in turn, allows us to determine how the initial excess energy of the charge carriers affects the relaxation processes. According to the electronic level scheme, one expects a strong phonon bottleneck for electrons, whereas holes should relax easier as their energy levels are more closely spaced. On the contrary, we find that electrons relax faster than holes. The fast electron relaxation occurs via an efficient Auger-like electron-hole scattering mechanism. On the other hand, a small wave function overlap between core and shell states slows the hole relaxation. Additionally, holes can be trapped at the core/shell interface, leading to either slow detrapping or nonradiative recombination. Overall, these results demonstrate that it is crucial to construct devices enabling the injection of charge carriers energetically close to their emitting states in order to maximize the radiative efficiency of the system.

Telemedically augmented palliative care : Empowerment for patients with advanced cancer and their family caregivers

BACKGROUND

Studies have shown that initiating early palliative care of patients with end-stage cancer can improve their quality of life and decrease symptoms of depression. The challenge is to find an effective way to care for these patients while minimizing the burden on healthcare resources. Telemedicine can play a vital role in solving this problem.

METHODS

A user-friendly telemedical device enabling patients encountering medical problems to send a direct request to a palliative care team was developed. A controlled feasibility study was conducted by assigning 15 patients with advanced cancer and their family caregivers to receive either standard palliative care or telemedically augmented palliative care. Th quality of life (QoL) was assessed using standardized validated questionnaires as well as frequency and duration of hospital admissions and user satisfaction. The primary goal of this study was to increase the QoL of patients and their family caregivers. The secondary goal of this study was to decrease the frequency and duration of hospital admissions.

RESULTS

This study showed a good feasibility despite the low overall willingness to participate in a relatively "technical" trial. The hospital anxiety and depression scale (HADS) was significantly lower in the intervention group, suggesting an improved quality of life. Although a decrease in the number of hospital admissions could not be shown, the user satisfaction was very good.

CONCLUSION

Telemedicine could be a useful tool to enhance the general well-being of palliative oncology patients. Now that the feasibility of this approach has been confirmed, larger studies are needed to verify its positive impact on the QoL.

The value of manure - Manure as co-product in life cycle assessment

Livestock production is important for food security, nutrition, and landscape maintenance, but it is associated with several environmental impacts. To assess the risk and benefits arising from livestock production, transparent and robust indicators are required, such as those offered by life cycle assessment. A central question in such approaches is how environmental burden is allocated to livestock products and to manure that is re-used for agricultural production. To incentivize sustainable use of manure, it should be considered as a co-product as long as it is not disposed of, or wasted, or applied in excess of crop nutrient needs, in which case it should be treated as a waste. This paper proposes a theoretical approach to define nutrient requirements based on nutrient response curves to economic and physical optima and a pragmatic approach based on crop nutrient yield adjusted for nutrient losses to atmosphere and water. Allocation of environmental burden to manure and other livestock products is then based on the nutrient value from manure for crop production using the price of fertilizer nutrients. We illustrate and discuss the proposed method with two case studies.

Firearm Violence and Effects on Concealed Gun Carrying: Large Debate and Small Effects

Research has yet to identify a predictive relationship between crime and the issuance of aggregated concealed gun permits. The present study examines if a macro-level relationship exists between both concealed carry firearm applications and permits and violent crime committed with a firearm. Florida county-level data for concealed carry applications and violent crime are combined with police employment, socioeconomic, political, and firearm subculture variables across two temporal periods using both county and year fixed effects models. Unstandardized negative binomial regressions are employed with multiple alternative model specifications and diagnostic tests. Findings indicate a positive association between crime, especially those committed with a firearm, and concealed carry applications and permits. The effect size of firearm violent crime on concealed carry applications and permits is minimal. There is a demonstrable link between firearm violence and concealed carry applications and permits issued, net all covariates. Findings should be tempered by the minimal effect sizes.

ANCA-Associated Vasculitis Co-Occurrence With Systemic Sclerosis: A Case Report of a Rare Diagnostic Dilemma

Systemic sclerosis (SSc) is a rare autoimmune disorder that is typically divided into limited cutaneous systemic sclerosis and diffuse cutaneous systemic sclerosis. Scleroderma renal crisis (SRC) is a severe complication of SSc and typically presents with new-onset hypertension and a reduction in renal functioning. In patients presenting with typical features of SRC, treatment with an angiotensin-converting enzyme inhibitor along with dialysis as needed is typically initiated empirically. Renal biopsy is not recommended in patients with SSc presenting with typical features of SRC. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare co-occurrence with SSc, in around 2.5% to 9% of patients. AAV is an inflammatory condition that can result in renal failure due to mononuclear cell infiltration and destruction of blood vessels. Treatment of AAV is drastically different from SRC and typically consists of immunosuppressants and dialysis if needed. SRC and AAV can only reliably be distinguished by renal biopsy. We present a rare case of a 70-year-old female with limited cutaneous systemic sclerosis who presented to the emergency department with new-onset renal failure. Her serology was found to be positive for antinuclear antibodies and myeloperoxidase antibodies, resulting in a renal biopsy, which revealed an acute necrotizing vasculitis consistent with AAV. We suggest consideration of a renal biopsy in patients with SSc who present with new-onset renal failure, especially with nonresponse to SRC treatment or positive serology.

Behandlung der oberflächlichen Thrombophlebitis

Die oberflächliche Thrombophlebitis ist eine häufige Erkrankung, von der Frauen aufgrund ihrer Risikofaktoren stärker betroffen sind als Männer. Diagnostisch sollte eine eventuell gleichzeitig vorkommende tiefe Venenthrombose mit bildgebenden Verfahren abgegrenzt werden. In der Therapie sind Heparin bzw. niedermolekulare Heparine indiziert, wenn tiefe Venenthrombosen vorliegen bzw. ein Risiko hierfür besteht. Im akuten Stadium können nichtsteroidale Antiphlogistika oral genommen werden, um Schmerz und Entzündung zu lindern. Liegt gleichzeitig eine chronisch venöse Insuffizienz vor, unterstützen so genannte Ödemprotektiva (z.B. Rosskastaniensamenextrakt und flavonoidhaltige Präparate) die Behandlung.

Bei entzündlichen Veränderungen relativ kurzer oberflächlicher Venenabschnitte ohne Beteiligung des tiefen Venensystems ist die Beschränkung auf lokale Behandlungsmaßnahmen möglich. Neben der Kompressionstherapie sind mehrmalige tägliche Anwendungen heparin- und heparinoidhaltiger Salben bzw. Gele üblich.

Bewährt hat sich insbesondere die Anwendung von topischen Präparaten, die Mukopolysaccharidpolyschwefelsäureester (MPS) enthalten.

Die Problematik, die Wirksamkeit topischer Präparate bei der Behandlung der oberflächlichen Thrombophlebitis unter den gegenwärtig strengen Kautelen unserer Aufsichtsbehörde nachzuweisen und neue Produkte zu entwickeln, wird diskutiert.

Hypertrophic osteoarthropathy in a young adult male from Berber, Sudan (2nd-3rd century CE)

Hypertrophic osteoarthropathy (HOA) is a pathological condition characterised by extensive periosteal new bone formation (NBF) on the diaphyses of the long bones, metacarpal and metatarsal bones. In modern clinical contexts, the secondary form of the disease is common and most often occurs secondary to intra-thoracic cancer and other forms of chronic pulmonary disease. Paleopathological evidence for HOA on the other hand has only occasionally been reported. Here we report a young adult male from the Meriotic cemetery at Berber in Sudan (2nd-3rd century CE) displaying widespread NBF on the diaphyses of the upper and lower limb bones, metacarpal and metatarsal bones, as well as the pelvis and scapulae. While several pathological conditions have to be considered as differential diagnostic options for NBF in the post-cranial skeleton, HOA is the most likely diagnosis, based on the distribution of the changes observed in this individual, as well as their macroscopic and radiographic characteristics. A chronic pulmonary condition as indicated by NBF on the visceral side of the ribs may represent the underlying cause for the HOA. This individual represents the first paleopathological case of HOA reported from an archaeological site in Africa.

High-dose chemotherapy with autologous haematopoietic stem cell support for relapsed or refractory primary CNS lymphoma: a prospective multicentre trial by the German Cooperative PCNSL study group

To investigate safety and efficacy of high-dose chemotherapy followed by autologous stem cell transplantation (HCT-ASCT) in relapsed/refractory (r/r) primary central nervous system lymphoma (PCNSL), we conducted a single-arm multicentre study for immunocompetent patients (<66 years) with PCNSL failing high-dose methotrexate)-based chemotherapy. Induction consisted of two courses of rituximab (375 mg/m²), high-dose cytarabine (2 × 3 g/m²) and thiotepa (40 mg/m²) with collection of stem cells in between. Conditioning for HCT-ASCT consisted of rituximab 375 mg/m², carmustine 400 mg/m² and thiotepa (4 × 5 mg/kg). Patients commenced HCT-ASCT irrespective of response after induction. Patients not achieving complete remission (CR) after HCT-ASCT received whole-brain radiotherapy. Primary end point was CR after HCT-ASCT. We enrolled 39 patients; median age and Karnofsky performance score are 57 years and 90%, respectively. About 28 patients had relapsed and 8 refractory disease. About 22 patients responded to induction and 32 patients commenced HCT-ASCT. About 22 patients (56.4%) achieved CR after HCT-ASCT. Respective 2-year progression-free survival (PFS) and overall survival (OS) rates were 46.0% (median PFS 12.4 months) and 56.4%; median OS not reached. We recorded four treatment-related deaths. Thiotepa-based HCT-ASCT is an effective treatment option in eligible patients with r/r PCNSL. Comparative studies are needed to further scrutinise the role of HCT-ASCT in the salvage setting.

Oesophageal lichen planus: the efficacy of topical steroid-based therapies

BACKGROUND

Oesophageal lichen planus is an idiopathic inflammatory disorder characterized by significant oesophageal stricturing. Oesophageal lichen planus is a rare, difficult to diagnose, and likely an under recognized disease. As a result, there is no standardized approach to therapy and treatment strategies vary.

AIM

To examine the utility of topical steroid therapy (fluticasone or budesonide) in the management of oesophageal lichen planus.

METHODS

A retrospective chart review was conducted of patients diagnosed with oesophageal lichen planus who underwent baseline and follow up endoscopy pre and post topical steroid therapy between 1995 and 2016 at Mayo Clinic, Rochester MN. Average time between upper GI endoscopy was 3.2 months (0.7-11.7). Swallowed steroid preparations included fluticasone 880 μg twice daily or budesonide 3 mg twice daily. Patients were reviewed for symptomatic response to therapy using the Dakkak-Bennett dysphagia score (0-4, no dysphagia to total aphagia). Pre- and post-endoscopic findings were assessed. Additional baseline demographic, endoscopic, and histologic data were also obtained.

RESULTS

We identified 40 patients who met the inclusion criteria. A significant reduction in median dysphagia score from 1 (0-4) to 0 (0-3) after steroid therapy (P < 0.001) was noted. 62% of patients reported resolution of their dysphagia after receiving topical corticosteroids. 72.5% had an endoscopic response to steroid therapy.

CONCLUSION

Topical swallowed budesonide or fluticasone appear to effective treatment for oesophageal lichen planus.

fMRI Study of Sentence Generation by Early Bilinguals Differing in Proficiency Level

The aim of this study was to identify the functional anatomy of the cerebral speech regions involved in speaking in native and foreign language in the same subject using functional magnetic resonance imaging.

Experimental design consisted of two activation runs. Each of them included two kinds of tasks arranged in series of five blocks lasting for 30s. In the experimental condition of the first run subjects were required to speak in their native language and in the second run the task was to speak in the foreign language. In both runs, baseline condition was the same and subjects were supposed to lie silently inside the bore. We observed the influence of proficiency on brain activation. In subjects with equal proficiency in the first and the second language, differences were not observed. In the subjects with unequal proficiency in the first and the second language we observed two main effects.

First was difference in the strength and extension of activation, the second effect was activation of new regions for the second language, in which proficiency was lower.

Gonococcal infections in Austria: a long-term observation of prevalence and resistance profiles from 1999 to 2014

BACKGROUND AND OBJECTIVES

The increase in minimum inhibitory concentrations (MICs) of cephalosporins for Neisseria gonorrhoeae has given rise to concerns regarding potentially untreatable gonococcal infections. The goal was to ascertain the prevalence of gonorrhea in a Viennese patient group and determine resistance patterns. Another objective was to evaluate resistance profiles and MIC values of gonococcal isolates in an Austria-wide surveillance project.

PATIENTS AND METHODS

From 1999 to 2014, 350,000 individuals were tested for gonococci at the Viennese Outpatient Clinic. In addition, from 2010 to 2014, the MICs of recommended antibiotics was determined in 3,584 gonococcal isolates, initially by agar dilution and breakpoint determination, and, from 2012 onwards, by Etest®.

RESULTS

During the observation period, the prevalence of gonorrhea increased eightfold, with a significantly greater number of quinolone, penicillin, and tetracycline- resistant strains. In gonococcal strains isolated from across Austria, there was an increase in cefixime and ceftriaxone MICs toward breakpoints. Twenty-one isolates showed cefixime resistance, and while there was an increase in azithromycin resistance from 0.9 % (2013) to 3.2 % (2014), no resistance to ceftriaxone was observed.

CONCLUSION

Currently, there is no imminent risk of untreatable gonorrhea in Austria. However, continuing the use of gonococcal cultures as a diagnostic tool for establishing resistance profiles is essential in order to monitor trends in the development of Neisseria (N.) gonorrhoeae resistance.

A Prospective Study of Mobile Phones for Dermatology in a Clinical Setting

We evaluated the accuracy of diagnoses made from pictures taken with the built-in cameras of mobile phones in a ‘real-life’ clinical setting. A total of 263 patients took part, who photographed their own lesions where possible, and provided clinical information via a questionnaire. After the teledermatology procedure, each patient was examined face-to-face and a gold standard diagnosis was made. The telemedicine data and pictures were diagnosed by 15 dermatologists. The 299 cases contained 1–22 clinical images each (median 3). Nine dermatologists finished all the cases and the remaining six completed some of them, thus providing 2893 decisions. Overall, 61% of all cases were rated as possible to diagnose and of those, 80% were correct in comparison with the face-to-face diagnosis. Image quality was evaluated and the median was 5 on a 10-point scale. There was a significant correlation between the correct diagnosis and the quality of the photographs taken ( P & 0.001). In nearly two-thirds of all cases, a teledermatology diagnosis was possible; however, there was insufficient information to make a telemedicine diagnosis in about one-third of the cases. If applied carefully, mobile phones could be a powerful tool for people to optimize their health care status.

Environmental impact of using specialty feed ingredients in swine and poultry production: A life cycle assessment

Livestock production has a variety of environmental impacts such as greenhouse gas emissions, water pollution, acidification, and primary energy consumption. The demand for livestock products is expected to grow substantially, creating even more environmental pressure. The use of specialty feed ingredients (SFI) such as supplemented AA and phytase can reduce nutrient input into the system without compromising productivity and consequently can reduce emissions. The global change impact of using SFI in pig and broiler production systems in Europe and North and South America was studied. A life cycle assessment according to international standards (ISO 14040/44) analyzed contributions from producing SFI and animals to global change. Three different alternatives were analyzed. In addition, partial sensitivity analysis was conducted using 5 scenarios for each region for both production systems. Specialty feed ingredient supplementation in pig and broiler diets reduced greenhouse gas emissions (cradle to farm gate) by 56% and 54% in Europe, 17% and 15% in North America, and 33% and 19% in South America, respectively, compared to an unsupplemented diet. A total of 136 Mt CO equivalent (CO eq) was saved in 2012, rising to 146 Mt CO eq in 2050 on the basis of United Nations population projections. Considerable benefits of supplementation with SFI were apparent in European and South American diets when direct land use change was considered because of the reduced demand for soybean meal. The eutrophication potential of unsupplemented diets was reduced by up to 35% in pig and 49% in broiler production systems compared to supplemented alternatives. The acidification potential of supplemented strategies was reduced by up to 30% in pig and 79% in broiler production systems. The primary energy demand was similar in all alternatives, and this could be an area where the SFI industry can improve. Overall, SFI supplementation substantially reduced the global warming, eutrophication, and acidification potentials in all regions studied.

Towards quantification of the crucial impact of auger recombination for the efficiency droop in (AlInGa)N quantum well structures

Recent experimental investigations on the reduction of internal quantum efficiency with increasing current density in (AlInGa)N quantum well structures show that Auger recombination is a significant contributor to the so-called "droop" phenomenon. Using photoluminescence (PL) test structures, we find Auger processes are responsible for at least 15 % of the measured efficiency droop. Furthermore, we confirm that electron-electron-hole (nnp) is stronger than electron-hole-hole (npp) Auger recombination in standard LEDs. The ratio of respective Auger coefficients is determined to be in the range 1 < Cnnp/Cnpp ≤ 12. This asymmetry is shown to limit the detection efficiency of Auger processes in our PL-based approach.

Pharmacological insight into the anti-inflammatory activity of sesquiterpene lactones from Neurolaena lobata (L.) R.Br. ex Cass

PURPOSE

Neurolaena lobata is a Caribbean medicinal plant used for the treatment of several conditions including inflammation. Recent data regarding potent anti-inflammatory activity of the plant and isolated sesquiterpene lactones raised our interest in further pharmacological studies. The present work aimed at providing a mechanistic insight into the anti-inflammatory activity of N. lobata and eight isolated sesquiterpene lactones, as well as a structure-activity relationship and in vivo anti-inflammatory data.

METHODS

The effect of the extract and its compounds on the generation of pro-inflammatory proteins was assessed in vitro in endothelial and monocytic cells by enzyme-linked immunosorbent assay. Their potential to modulate the expression of inflammatory genes was further studied at the mRNA level. In vivo anti-inflammatory activity of the chemically characterized extract was evaluated using carrageenan-induced paw edema model in rats.

RESULTS

The compounds and extract inhibited LPS- and TNF-α-induced upregulation of the pro-inflammatory molecules E-selectin and interleukin-8 in HUVECtert and THP-1 cells. LPS-induced elevation of mRNA encoding for E-selectin and interleukin-8 was also suppressed. Furthermore, the extract inhibited the development of acute inflammation in rats.

CONCLUSIONS

Sesquiterpene lactones from N. lobata interfered with the induction of inflammatory cell adhesion molecules and chemokines in cells stimulated with bacterial products and cytokines. Structure-activity analysis revealed the importance of the double bond at C-4-C-5 and C-2-C-3 and the acetyl group at C-9 for the anti-inflammatory activity. The effect was confirmed in vivo, which raises further interest in the therapeutic potential of the compounds for the treatment of inflammatory diseases.

Role of Growth arrest-specific gene 6-Mer axis in multiple myeloma

Multiple myeloma is a mostly incurable malignancy characterized by the expansion of a malignant plasma cell (PC) clone in the human bone marrow (BM). Myeloma cells closely interact with the BM stroma, which secretes soluble factors that foster myeloma progression and therapy resistance. Growth arrest-specific gene 6 (Gas6) is produced by BM-derived stroma cells and can promote malignancy. However, the role of Gas6 and its receptors Axl, Tyro3 and Mer (TAM receptors) in myeloma is unknown. We therefore investigated their expression in myeloma cell lines and in the BM of myeloma patients and healthy donors. Gas6 showed increased expression in sorted BMPCs of myeloma patients compared with healthy controls. The fraction of Mer(+) BMPCs was increased in myeloma patients in comparison with healthy controls whereas Axl and Tyro3 were not expressed by BMPCs in the majority of patients. Downregulation of Gas6 and Mer inhibited the proliferation of different myeloma cell lines, whereas knocking down Axl or Tyro3 had no effect. Inhibition of the Gas6 receptor Mer or therapeutic targeting of Gas6 by warfarin reduced myeloma burden and improved survival in a systemic model of myeloma. Thus, the Gas6-Mer axis represents a novel candidate for therapeutic intervention in this incurable malignancy.

Resilience in patients and spouses faced with malignant melanoma. A qualitative longitudinal study

Life-threatening diseases like malignant tumours are associated with considerable existential distress. Little is known about the factors that promote resilience within these individuals. This longitudinal qualitative partner study aimed to analyse resilience as per Antonovsky's sense of coherence. Eight patients with malignant melanoma and their partners were interviewed. They were asked about their coping strategies, attitudes towards the meaning of life and their cancer, and comprehension of what is happening to them. The questions were asked shortly after their diagnosis was made and 6 months later. All interviews were audio-taped and later transcribed and analysed according to the method of qualitative content analysis described by P. Mayring. At baseline, the majority of statements made (261; patients = 141/spouses = 120) related to coping/manageability of disease, with only 26 statements (patients = 15/spouses = 11) related to meaning and 127 (patients = 64/spouses = 63) to comprehension. There were no significant differences between the responses of patients and their partners and no significant changes in the number of statements during the 6-month interview. The most significant theme that emerged was manageability of disease, with distraction the most commonly utilised coping skill. The comprehension and meaning themes were far less prevalent. Hence, support should focus on disease and situational manageability.

[Effect of the liquid milk nutritional supplement with enhanced content of whey protein on the nutritional status of the elderly]

AIM

The aim of this study was to evaluate the effect of long-term administration of liquid nutritional supplement with increased amounts of whey protein and reduced amounts of lactose, produced in accordance with a new recipe "Nutrisen" on the elderly living in institutionalized care.

METHODS

The study was carried out from May to July, 2013, on 47 retirement home residents, living in Prague, all of which were 65 years or older. Supplemented group (n = 23) consumed (200 ml) milk drinks with three different flavours on a daily basis for eight weeks. The reference group was on a normal diet. There was no significant difference in baseline characteristics between participants in both groups. Anthropometric and biochemical indicators of nutritional status and tolerance of the nutritional supplement during long-term use were evaluated.

RESULTS

Both compliance (daily intake program) and tolerance of the nutritionally defined supplement were very good. For the supplemented group, there was an average weight increased of 700 grams after the 8 week nutritional supplement test period. Average levels of albumin and prealbumin increased significantly (from the beginning to the end of the program), 35.5 ± 4.52 g/l vs 36.19 ± 4.1 g/l and 0.160 ± 0.05 vs 0.174 ± 0.04 g/l (p < 0.05), vitamin D levels increased from 31.2 ± 16.4 nmol/l to 36.8 ± 17.7 nmol/l (p < 0.001) and HDL-cholesterol levels increased from 1.29 ± 0.33 mmol/l to 1.35 ± 0.35 mmol/l (p < 0.001).

CONCLUSION

The specific nutritionally defined milk drink (Nutrisen), used in this study, was well tolerated by the elderly study participants, over the eight-week clinical study. We observed a positive effect on the participants weight, serum albumin, prealbumin, vitamin D and HDL-cholesterol.

An Arden-Syntax-based clinical decision support framework for medical guidelines--Lyme borreliosis as an example

Medicine is evolving at a very fast pace. The overwhelming quantity of new data compels the practician to be consistently informed about the most recent scientific advances. While medical guidelines have proven to be an acceptable tool for bringing new medical knowledge into clinical practice and also support medical personnel, reading them may be rather time-consuming. Clinical decision support systems have been developed to simplify this process. However, the implementation or adaptation of such systems for individual guidelines involves substantial effort. This paper introduces a clinical decision support platform that uses Arden Syntax to implement medical guidelines using client-server architecture. It provides a means of implementing different guidelines without the need for adapting the system's source code. To implement a prototype, three Lyme borreliosis guidelines were aggregated and a knowledge base created. The prototype employs transfer objects to represent any text-based medical guideline. As part of the implementation, we show how Fuzzy Arden Syntax can improve the overall usability of a clinical decision support system.

Utility of sepsis biomarkers and the infection probability score to discriminate sepsis and systemic inflammatory response syndrome in standard care patients

Physicians are regularly faced with severely ill patients at risk of developing infections. In literature, standard care wards are often neglected, although their patients frequently suffer from a systemic inflammatory response syndrome (SIRS) of unknown origin. Fast identification of patients with infections is vital, as they immediately require appropriate therapy. Further, tools with a high negative predictive value (NPV) to exclude infection or bacteremia are important to increase the cost effectiveness of microbiological examinations and to avoid inappropriate antibiotic treatment. In this prospective cohort study, 2,384 patients with suspected infections were screened for suffering from two or more SIRS criteria on standard care wards. The infection probability score (IPS) and sepsis biomarkers with discriminatory power were assessed regarding their capacity to identify infection or bacteremia. In this cohort finally consisting of 298 SIRS-patients, the infection prevalence was 72%. Bacteremia was found in 25% of cases. For the prediction of infection, the IPS yielded 0.51 ROC-AUC (30.1% sensitivity, 64.6% specificity). Among sepsis biomarkers, lipopolysaccharide binding protein (LBP) was the best parameter with 0.63 ROC-AUC (57.5% sensitivity, 67.1% specificity). For the prediction of bacteremia, the IPS performed slightly better with a ROC-AUC of 0.58 (21.3% sensitivity, 65% specificity). Procalcitonin was the best discriminator with 0.78 ROC-AUC, 86.3% sensitivity, 59.6% specificity and 92.9% NPV. Furthermore, bilirubin and LBP (ROC-AUC: 0.65, 0.62) might also be considered as useful parameters. In summary, the IPS and widely used infection parameters, including CRP or WBC, yielded a poor diagnostic performance for the detection of infection or bacteremia. Additional sepsis biomarkers do not aid in discriminating inflammation from infection. For the prediction of bacteremia procalcitonin, and bilirubin were the most promising parameters, which might be used as a rule for when to take blood cultures or using nucleic acid amplification tests for microbiological diagnostics.

Alternaria redefined

Alternaria is a ubiquitous fungal genus that includes saprobic, endophytic and pathogenic species associated with a wide variety of substrates. In recent years, DNA-based studies revealed multiple non-monophyletic genera within the Alternaria complex, and Alternaria species clades that do not always correlate to species-groups based on morphological characteristics. The Alternaria complex currently comprises nine genera and eight Alternaria sections. The aim of this study was to delineate phylogenetic lineages within Alternaria and allied genera based on nucleotide sequence data of parts of the 18S nrDNA, 28S nrDNA, ITS, GAPDH, RPB2 and TEF1-alpha gene regions. Our data reveal a Pleospora/Stemphylium clade sister to Embellisia annulata, and a well-supported Alternaria clade. The Alternaria clade contains 24 internal clades and six monotypic lineages, the assemblage of which we recognise as Alternaria. This puts the genera Allewia, Brachycladium, Chalastospora, Chmelia, Crivellia, Embellisia, Lewia, Nimbya, Sinomyces, Teretispora, Ulocladium, Undifilum and Ybotromyces in synonymy with Alternaria. In this study, we treat the 24 internal clades in the Alternaria complex as sections, which is a continuation of a recent proposal for the taxonomic treatment of lineages in Alternaria. Embellisia annulata is synonymised with Dendryphiella salina, and together with Dendryphiella arenariae, are placed in the new genus Paradendryphiella. The sexual genera Clathrospora and Comoclathris, which were previously associated with Alternaria, cluster within the Pleosporaceae, outside Alternaria s. str., whereas Alternariaster, a genus formerly seen as part of Alternaria, clusters within the Leptosphaeriaceae. Paradendryphiella is newly described, the generic circumscription of Alternaria is emended, and 32 new combinations and 10 new names are proposed. A further 10 names are resurrected, while descriptions are provided for 16 new Alternaria sections.

Three-dimensional multiphoton/optical coherence tomography for diagnostic applications in dermatology

A preliminary clinical trial using state-of-the-art multiphoton tomography (MPT) and optical coherence tomography (OCT) for three-dimensional (3D) multimodal in vivo imaging of normal skin, nevi, scars and pathologic skin lesions has been conducted. MPT enabled visualization of sub-cellular details with axial and transverse resolutions of <2 μm and <0.5 μm, respectively, from a volume of 0.35 × 0.35 × 0.2 mm(3) at a frame rate of 0.14 Hz (512 × 512 pixels). State-of-the-art OCT, operating at a center wavelength of 1300 nm, was capable of acquiring 3D images depicting the layered architecture of skin with axial and transverse resolutions ~8 μm and ~20 μm, respectively, from a volume of 7 × 3.5 × 1.5 mm(3) at a frame rate of 46 Hz (1024 × 1024 pixels). This study demonstrates the clinical diagnostic potential of MPT/OCT for pre-screening relatively large areas of skin using 3D OCT to identify suspicious regions at microscopic level and subsequently using high resolution MPT to obtain zoomed in, sub-cellular level information of the respective regions.

Electrophysiological correlates of attentional processes in patients with liver cirrhosis without minimal or clinically-overt hepatic encephalopathy

Liver cirrhosis is often accompanied by a spectrum of cognitive deficits, labelled hepatic encephalopathy (HE). The precise specification of cognitive impairment associated with HE has not been yet elucidated. The aim of this study was an attempt to examine cortical function in cirrhotic patients using EEG event-related potentials during a demanding task involving selective attention. We compared group of 30 patients with liver cirrhosis without minimal or overt HE with education-, age- and sex-matched 29 non-cirrhotic controls. Both groups performed an attentional blink (AB) task, which requires detecting and identifying two target characters in a longer series of rapidly and sequentially presented characters. EEG signals from 32 electrodes were measured and then analyzed in the paradigm of event-related potentials (ERP). Though the groups did not differ in the detection rate of the target stimuli, ERP waveforms revealed two group differences of component amplitudes. The first difference was related to the waveform amplitude within the 200-400 ms after first target in the right frontal region (frontocentral N2 component). Moreover, in patient group this amplitude positively correlated with the blood plasma level of alkaline phosphatase and gamma-glutamyl transpeptidase. The second amplitude difference was observed in the midline parieto-occipital regions within the 400-600 ms after the first target (P3b component). The AB task and ERP analysis allowed to find differences in cortical functioning in cirrhotic patients even without overt cognitive deficits. Our finding demonstrates that liver dysfunction can influence cortical processing associated with detecting and categorizing stimulus change.

Cognitive evoked response potentials in patients with liver cirrhosis without diagnosis of minimal or overt hepatic encephalopathy. A pilot study

Liver cirrhosis is often accompanied by cognitive deficits called minimal hepatic encephalopathy (MHE) when it is observed to a moderate extent. In the present study, brain activity and cognitive functioning were examined in patients with liver cirrhosis without MHE or overt clinical hepatic encephalopathy. A battery of neuropsychological tests and event related potentials (ERPs) were used. Moreover, an additional n-back task was administered with two difficulty levels (1- and 2-back). This task was designed to engage cognitive processes of storage and manipulation of information in working memory. The participants have to decide whether the letter shown was the same as a target (congruence condition). No significant differences were found in the performance of either the neuropsychological tests or the n-back task. However, the expected effects of decreased performance as well as a decrease in P3 amplitude with difficulty level were identified. The interaction of group x congruence condition was also observed in the P2 component time window. These results may indicate group differences manifesting in early stages of information processing in working memory. It confirms that the patients whose neuropsychological performance is within the normal range can still reveal subtle changes in CNS functioning visible in ERP research. The study confirms the usability of the ERP method in diagnosis of neurocognitive functions in patients with liver cirrhosis, which seems to be more sensitive than neuropsychological tests.

Site-dependent actinic skin damage as risk factor for melanoma in a central European population

Sun exposure is causal for melanoma but is subject to bias of recall so that it is difficult to dissect the role of particular patterns of sun exposure. In this hospital-based case-control study (n = 1991), we aimed to analyze pigmentation traits and signs of actinic damage at different anatomic locations as markers of melanoma risk in central European patients. Although all signs of actinic damage (freckling, wrinkling and solar lentigos) were significantly associated with melanoma risk in multivariate logistic regression models adjusting for age and sex, the strongest associations were observed for the dorsal parts of the body: adjusted odds ratios [OR] were 4.22 for wrinkling on the neck, 3.43 for solar lentigos and 3.37 for freckling on the back (all P < 0.001), respectively. These associations were independent of age, sex and pigmentation traits. Our results indicate that signs of actinic damage are predictors of melanoma risk, particularly on the back.

Differential expression of the demosponge (Suberites domuncula) carotenoid oxygenases in response to light: protection mechanism against the self-produced toxic protein (Suberitine)

The demosponge Suberites domuncula has been described to contain high levels of a proteinaceous toxin, Suberitine, that displays haemolytic activityIn the present study this 7-8 kDa polypeptide has been isolated and was shown to exhibit also cytotoxic effects on cells of the same species. Addition of retinal, a recently identified metabolite of β-carotene that is abundantly present in S. domuncula was found to reduce both the haemolytic and the cell toxic activity of Suberitine at a molar ratio of 1:1. Spectroscopic analyses revealed that the interaction between β-carotene and Suberitine can be ascribed to a reversible energy transfer reaction. The enzyme that synthesises retinal in the sponge system is the β,β-carotene-15,15'-dioxygenase [carotene dioxygenase]. In order to clarify if this enzyme is the only β-carotene-metabolizing enzyme a further oxygenase had been identified and cloned, the (related) carotenoid oxygenase. In contrast to the dioxygenase, the carotenoid oxygenase could not degrade β-carotene or lycopene in Escherichia coli strains that produced these two carotenoids; therefore it had been termed related-carotenoid oxygenase. Exposure of primmorphs to light of different wavelengths from the visible spectrum resulted after 3 days in a strong upregulation of the dioxygenase in those 3D-cell aggregates that had been incubated with β-carotene. The strongest effect is seen with blue light at a maximum around 490 nm. It is concluded that the toxin Suberitine is non-covalently modified by retinal, the cleavage product from β-carotene via the enzyme carotene dioxygenase, a light inducible oxygenase. Hence, this study highlights that in S. domuncula the bioactive metabolite, retinal, has the property to detoxify its homologous toxin.

Differences in examination characteristics of pigmented skin lesions: results of an eye tracking study

OBJECTIVE

To use computer-based eye tracking technology to record and evaluate examination characteristics of the diagnosis of pigmented skin lesions.

METHODOLOGY

16 study participants with varying levels of diagnostic expertise (little, intermediate, superior) were recorded while diagnosing a series of 28 digital images of pigmented skin lesions, obtained by non-invasive digital dermatoscopy, on a computer screen. Eye tracking hardware recorded the gaze track and fixations of the physicians while they examined the lesion images. Analysis of variance was used to test for differences in examination characteristics between physicians grouped according to expertise.

RESULTS

There were no significant differences between physicians with little and intermediate levels of expertise in terms of average time until diagnosis (6.61 vs. 6.19s), gaze track length (6.65 vs. 6.15 kilopixels), number of fixations (23.1 vs. 19.1), and time in fixations (4.91 vs. 4.17s). The experts were significantly different with 3.17s time until diagnosis, 4.53 kilopixels gaze track length, 9.9 fixations, and 1.74s in fixations, respectively. Differentiation between benign and malignant lesions had no effect on examination measurements.

CONCLUSION

The results show that experience level has a significant impact on the way in which lesion images are examined. This finding can be used to construct decision support systems that employ important diagnostic features identified by experts, and to optimize teaching for less experienced physicians.