Foreign Medical Teams in support of the Ebola outbreak: a UK military model of pre-deployment training and assurance

We discuss the training methodology developed and utilised to prepare UK military medical teams to establish an Ebola Treatment Centre in Sierra Leone. We highlight the process of identifying and mitigating nosocomial risk in the Pre-Deployment Training process, encompassing the challenges of developing, training and assuring a capability at pace, which deployed to deliver high quality clinical care to patients with Ebola Virus Disease.

Infective endocarditis in the military patient

Infective endocarditis (IE) is a potentially fatal cardiac infection associated with an inhospital mortality rate of up to 22%. Fifty per cent of IE cases develop in patients with no known history of valve disease. It is therefore important to remain vigilant to the possibility of the diagnosis in patients with a febrile illness and unknown source. From a military perspective, our patients are unique due to the breadth of pathogens they are exposed to, and blood-culture-negative IE is a risk. In particular, there should be awareness of Coxiella burnetii as a possible causative pathogen. In this review we incorporate the latest consensus from systematic reviews and publications identified by a literature search through Medline. We describe the diagnosis and management of IE with particular reference to the military population.

People with diagnosed HIV infection not attending for specialist clinical care: UK national review

Background

Regular clinical care is important for the well-being of people with HIV. We sought to  audit and describe the characteristics of adults with diagnosed HIV infection not reported to be attending for clinical care in the UK.

Methods

Public Health England (PHE) provided clinics with lists of patients diagnosed or seen for specialist HIV care in 2010 but not linked to a clinic report or known to have died in 2011. Clinics reviewed case-notes of these individuals and completed questionnaires. A nested case–control analysis was conducted to compare those who had remained in the UK in 2011 while not attending care with individuals who received specialist HIV care in both 2010 and 2011.

Results

Among 74,418 adults living with diagnosed HIV infection in the UK in 2010, 3510 (4.7 %) were not reported as seen for clinical care or died in 2011. Case note reviews and outcomes were available for 2255 (64 %) of these: 456 (20.2 %) remained in the UK and did not attend care; 590 (26.2 %) left UK; 508 (22.6 %) received care in the UK: 73 (3.2 %) died and 628 (27.8 %) had no documented outcome. Individuals remaining in the UK and not attending care were more likely to be treatment naïve than those in care, but duration since HIV diagnosis was not significant. HIV/AIDS related hospitalisations were observed among non-attenders.

Conclusion

Retention in UK specialist HIV care is excellent. Our audit indicates that the ‘true’ loss to follow up rate in 2011 was <2.5 % with no evidence of health tourism. Novel interventions to ensure high levels of clinic engagement should be explored to minimise disease progression among non-attenders.

Fungal Planet description sheets: 154-213

Novel species of microfungi described in the present study include the following from South Africa: Camarosporium aloes, Phaeococcomyces aloes and Phoma aloes from Aloe, C. psoraleae, Diaporthe psoraleae and D. psoraleae-pinnatae from Psoralea, Colletotrichum euphorbiae from Euphorbia, Coniothyrium prosopidis and Peyronellaea prosopidis from Prosopis, Diaporthe cassines from Cassine, D. diospyricola from Diospyros, Diaporthe maytenicola from Maytenus, Harknessia proteae from Protea, Neofusicoccum ursorum and N. cryptoaustrale from Eucalyptus, Ochrocladosporium adansoniae from Adansonia, Pilidium pseudoconcavum from Greyia radlkoferi, Stagonospora pseudopaludosa from Phragmites and Toxicocladosporium ficiniae from Ficinia. Several species were also described from Thailand, namely: Chaetopsina pini and C. pinicola from Pinus spp., Myrmecridium thailandicum from reed litter, Passalora pseudotithoniae from Tithonia, Pallidocercospora ventilago from Ventilago, Pyricularia bothriochloae from Bothriochloa and Sphaerulina rhododendricola from Rhododendron. Novelties from Spain include Cladophialophora multiseptata, Knufia tsunedae and Pleuroascus rectipilus from soil and Cyphellophora catalaunica from river sediments. Species from the USA include Bipolaris drechsleri from Microstegium, Calonectria blephiliae from Blephilia, Kellermania macrospora (epitype) and K. pseudoyuccigena from Yucca. Three new species are described from Mexico, namely Neophaeosphaeria agaves and K. agaves from Agave and Phytophthora ipomoeae from Ipomoea. Other African species include Calonectria mossambicensis from Eucalyptus (Mozambique), Harzia cameroonensis from an unknown creeper (Cameroon), Mastigosporella anisophylleae from Anisophyllea (Zambia) and Teratosphaeria terminaliae from Terminalia (Zimbabwe). Species from Europe include Auxarthron longisporum from forest soil (Portugal), Discosia pseudoartocreas from Tilia (Austria), Paraconiothyrium polonense and P. lycopodinum from Lycopodium (Poland) and Stachybotrys oleronensis from Iris (France). Two species of Chrysosporium are described from Antarctica, namely C. magnasporum and C. oceanitesii. Finally, Licea xanthospora is described from Australia, Hypochnicium huinayensis from Chile and Custingophora blanchettei from Uruguay. Novel genera of Ascomycetes include Neomycosphaerella from Pseudopentameris macrantha (South Africa), and Paramycosphaerella from Brachystegia sp. (Zimbabwe). Novel hyphomycete genera include Pseudocatenomycopsis from Rothmannia (Zambia), Neopseudocercospora from Terminalia (Zambia) and Neodeightoniella from Phragmites (South Africa), while Dimorphiopsis from Brachystegia (Zambia) represents a novel coelomycetous genus. Furthermore, Alanphillipsia is introduced as a new genus in the Botryosphaeriaceae with four species, A. aloes, A. aloeigena and A. aloetica from Aloe spp. and A. euphorbiae from Euphorbia sp. (South Africa). A new combination is also proposed for Brachysporium torulosum (Deightoniella black tip of banana) as Corynespora torulosa. Morphological and culture characteristics along with ITS DNA barcodes are provided for all taxa.

Sexual health and HIV in the Army

Sexual acquisition of infections has always been an important part of military history and although disease patterns have changed over time, the problem has not gone away. This article will look at how to recognise infection, the general principles of management, where to access guidance and how to get specialised help within the complexities of the military environment.

Parasitic castration of plants by fungi

If the production of genetically variable offspring is a mechanism of host defense against parasites, then parasites capable of suppressing sexual reproduction in hosts may gain a selective advantage over parasites that do not do so. Recent work has shown that a range of systemic fungi infecting plants sterilize their hosts, effectively preventing coevolutionary responses by host populations to avoid infection, while stimulating clonal spread of the infected plant. Indeed, parasitic castration of plants may represent a widespread fungal adaptation.

Microbial communities and interactions in the lone star tick, Amblyomma americanum

To quantify microbial composition and interactions, we identified prokaryotic communities in the lone star tick (Amblyomma americanum) based on 16S rRNA gene sequences and direct probing. The lone star tick is the vector of emerging diseases and host to additional symbionts of unknown activity, and is representative of other blood-sucking arthropods. We evaluated the potential for vertical (transovarial) transmission by molecular analysis of microbial symbionts from egg and larval clutches. Direct probing of adults (N = 8 populations from the southeastern and midwestern USA, 900 ticks total) revealed three vertically transmitted symbionts: a Coxiella symbiont occurred at 100% frequency, Rickettsia species occurred in 45-61% of all ticks in every population and an Arsenophonus symbiont occurred in 0-90% of ticks per population. Arsenophonus and Rickettsia exhibited significant heterogeneity in frequency among populations. The human pathogens Ehrlichia chafeensis and Borrelia lonestari were rare in most populations. Additional microbes were detected sporadically. Most ticks (78%) were co-infected by two or three microbes but statistical analysis indicated no significant deviation from random co-occurrence. Our findings indicate that microbial communities within lone star ticks are diverse, and suggest that direct probing for a wider range of prokaryotes and application of quantitative polymerase chain reaction (PCR) may provide further insights into microbial interactions within disease vectors. Our results also emphasize the close phylogenetic relationship between tick symbionts and human pathogens, and consistent differences in their prevalence.

Trade-off between virulence and vertical transmission and the maintenance of a virulent plant pathogen

The continuum hypothesis predicts that parasites should evolve reduced virulence if they have higher opportunity for vertical transmission. However, when there is a trade-off between virulence and vertical transmission, selection may favor horizontal transmission and higher virulence. Atkinsonella hypoxylon is a fungal pathogen that reduces Danthonia fitness by 50% or more when it completely castrates hosts' chasmogamous inflorescences, despite the high opportunity for vertical transmission through cleistogamous seeds. Sporadically, infected hosts with partially castrated inflorescences (which have higher fecundity than completely castrated hosts) are observed in natural populations. Why are partially castrated plants rare if selection favors reduced virulence? We investigated whether there was genetic diversity for virulence among A. hypoxylon genotypes and the relationship between virulence and vertical transmission. We found that the fungal genotype significantly affects the occurrence of partial castration in Danthonia compressa. The proportion of seedlings that were vertically infected by their maternal plant was lower for partially castrated than for completely castrated plants. Our results demonstrate a trade-off between virulence and vertical transmission, explaining the maintenance of more virulent, completely castrating fungal genotypes in natural populations, and suggest that vertical transmission in plants is more complex than what is considered in current models.

Informed patient choice: patient-centered valuing of surgical risks and benefits

The risks and benefits of any health care intervention are valued differently by stakeholders. One of the ethical imperatives of patient-centered care is the balanced, evidence-based presentation of risks and benefits by providers to patients. Using the example of musculoskeletal surgery with devices, we advocate the use of shared decision-making tools and processes known to improve knowledge, adjust unrealistic expectations, and elicit values about benefits desired and the degree of acceptable risks for individual patients. We describe feasibility and efficacy within our organization and address ways to foster the further adoption of this approach.

Evidence for the involvement of the NADPH oxidase enzyme complex in the optimal accumulation of Platelet-activating factor in the human cell line PLB-985

Platelet-activating factor (PAF) is an early product of the inflammatory environment, influencing development and resolution of inflammation. Its production is greater in neutrophils and macrophages, which predominantly synthesize 1-alkyl sn-2 acetyl glycerophosphocholine (GPC) than in nongranulocytes (B cells and endothelial cells), which lack a respiratory burst and synthesize 1-acyl sn-2 acetyl GPC as their major PAF species. This study investigated whether the respiratory burst was responsible for the quantitative and qualitative differences in sn-2 acetyl GPC species generation by neutrophils and macrophages versus those cells lacking the NADPH oxidase complex. The myeloid cell line PLB-985 (capable of differentiation into neutrophils) was used to test this hypothesis, since these cells had previously been generated with a non-functional respiratory burst (X-CGD PLB-985). Differentiated PLB-985 cells underwent a large respiratory burst in response to PMA (phorbol ester), and smaller respiratory bursts in response to A23187 (calcium ionophore), and the bacterial polypeptide fMLP (receptor mediated activation). Concurrently, treated cells were assessed for production of 1-hexadecyl and 1-palmitoyl sn-2 acetyl GPC species by gas chromatography/mass spectrometry. Neither cell type generated these lipid species in response to PMA, but both cell types generated equal levels of sn-2 acetyl GPC in response to A23187, with five times more 1-hexadecyl than 1-palmitoyl species. Upon fMLP activation, X-CGD PLB-985 cells produced significantly less 1-hexadecyl and 1-palmitoyl sn-2 acetyl GPC in comparison to the wild-type PLB-985 cells. These findings suggest phagocytic oxidant production by NADPH oxidase is not essential for sn-2 acetyl GPC generation, but appears important for optimal production of PAF in response to some stimuli.

Soil pathogens and spatial patterns of seedling mortality in a temperate tree

The Janzen-Connell hypothesis proposes that host-specific, distance- and/or density-dependent predators and herbivores maintain high tree diversity in tropical forests. Negative feedback between plant and soil communities could be a more effective mechanism promoting species coexistence because soil pathogens can increase rapidly in the presence of their host, causing conditions unfavourable for local conspecific recruitment. Here we show that a soil pathogen leads to patterns of seedling mortality in a temperate tree (Prunus serotina) as predicted by the Janzen-Connell hypothesis. In the field, the mean distance to parent of seedling cohorts shifted away from maternal trees over a period of 3 years. Seedlings were grown in soil collected 0-5 m or 25-30 m from Prunus trees. Sterilization of soil collected beneath trees improved seedling survival relative to unsterilized soil, whereas sterilization of distant soil did not affect survival. Pythium spp., isolated from roots of dying seedlings and used to inoculate healthy seedlings, decreased survival by 65% relative to controls. Our results provide the most complete evidence that native pathogens influence tree distributions, as predicted by the Janzen-Connell hypothesis, and suggest that similar ecological mechanisms operate in tropical and temperate forests.

Fungal endophyte symbiosis and plant diversity in successional fields

Increasing evidence suggests that microbial interactions are important determinants of plant biodiversity. The hypothesis that fungal endophyte symbiosis reduces diversity in successional fields was tested by manipulating infection of tall fescue, the most abundant perennial grass in the eastern United States. Over a 4-year period, species richness declined and tall fescue dominance increased in infected plots relative to uninfected plots without differences in total productivity. A host-specific endophyte, with negligible biomass, altered plant community structure in this long-term field experiment and may be reducing plant diversity throughout its expanding range.

The Red Queen Hypothesis and plant/pathogen interactions

The Red Queen Hypothesis (RQH) explains how pathogens may maintain sexual reproduction in hosts. It assumes that parasites become specialized on common host genotypes, reducing their fitness. Such frequency-dependent selection favors sexual reproduction in host populations. Necessary conditions are that resistance and virulence are genotype specific so that host genotype frequencies respond to changes in pathogen genotype frequencies, and vice versa. Empirical evidence on the genetic basis of disease, variation in resistance and virulence, and patterns of infection in sexual and asexual plants support certain features of the hypothesis. However, gene-for-gene interactions are generally not consistent with the RQH because they do not result in cycling of gene frequencies, unlike a matching allele mechanism. A conclusion of whether the RQH can explain the maintenance of sexual reproduction cannot be reached at present. Nevertheless, the RQH theory has shed light on many aspects of plant/pathogen interactions important for reducing pathogen damage in agricultural systems.

Suppressive effects of a novel antioxidant compound on human T cell functions in vitro

The use of antioxidant compounds with differing modes of action has clearly demonstrated involvement of oxidative processes in the activation of T lymphocytes. In this paper, we show that a novel antioxidant (lazaroid U75412E, a free radical scavenger) suppressed mitogen-induced T cell proliferation in vitro. Similar results were obtained with diphenylene iodonium (DPI), a known inhibitor of NADPH oxidase. The lazaroid was further shown to inhibit IL 2 production but to be less potent in suppressing IL 2 receptor expression. Thus, scavenger-type antioxidants act on T cells primarily by blocking a signal necessary for the induction of IL 2 synthesis such as the activation of NF kappa B. Furthermore, the potent inhibition of lymphocyte responses caused by the specific enzyme inhibitor DPI provides direct proof of the source of the oxidants involved in these processes.

Alkaloids ofStipa robusta (sleepygrass) infected with anAcremonium endophyte

Stipa robusta (= Stipa vaseyi) is a perennial grass found in certain areas of the southwestern United States. It is commonly known as sleepygrass, as horses that ingest this grass may become profoundly somnolent or stuporous for periods of time lasting up to several days. In an attempt to determine the active principle(s), fractionation of a methanolic extract of sleepygrass infected with an Acremonium endophyte has yielded lysergic acid amide (20 micrograms/g dry wt), isolysergic amide (8), 8-hydroxylsergic acid amide (0.3), ergonovine (7), chanoclavine-I (15), and N-formylloline (18). Related alkaloids have been found in many endophyte-infected grasses. The dominant alkaloid constituent in sleepygrass, lysergic acid amide, has not previously been identified in a grass in such high concentration. Lysergic acid amide is likely to be the basis for the extreme sedative effects on animals, given past pharmacological work on the compound from the ergot fungus Claviceps paspali.

The protein kinase C inhibitor, K252a, inhibits superoxide production in human neutrophils activated by both PIP2-dependent and -independent mechanisms

We report that the putative protein kinase C inhibitor, K252a, at concentrations of 0.2 and 1 microM, inhibited the respiratory burst induced by fluoride and formyl-methionyl-leucyl-phenyl-alanine respectively, both in human neutrophils primed with a subthreshold dose of phorbol myristate acetate and in non-primed neutrophils. In addition, K252a effectively inhibited ConA-zymosan-mediated superoxide generation in Ca2(+)-depleted neutrophils, with virtually maximal inhibition seen at 1 microM. These results suggest that protein kinase C is involved in the putative phosphatidylinositol bisphosphate-independent signal transduction mechanism of the respiratory burst as well as the pathway dependent on phosphatidylinositol bisphosphate hydrolysis.

Angiotensin II causes formation of platelet activating factor in cultured rat mesangial cells

Angiotensin II may contribute to the progression of renal glomerular diseases. Beneficial effects of converting enzyme inhibition in models of renal disease are, however, not always explicable by hemodynamic consequences of angiotensin II inhibition. Angiotensin increases intracellular calcium in glomerular mesangial cells and activates phospholipase A2, factors required for the formation of the lipid mediator of inflammation platelet activating factor (PAF). We therefore examined whether angiotensin II could stimulate PAF production in cultured rat mesangial cells. During a 15-minute incubation angiotensin II caused formation of PAF in a dose-dependent manner with a threshold around 10(-9) M. In four experiments PAF formation in response to angiotensin II (10(-8) M) occurred within 5 minutes and was 29 +/- 8 pmol PAF/mg protein. The amount of PAF detected then declined to 9 +/- 2 and 13 +/- 3 pmol after 15 and 30 minutes of incubation with angiotensin II. More than 90% of the PAF remained cell-associated. The PAF formation was confirmed by negative ion chemical ionization mode of mass spectrometry. A single species of PAF was detected and identified as hexadecyl PAF. We speculate that part of the detrimental effects of angiotensin II in progressive renal disease may relate to PAF formation. The PAF generated may in turn influence glomerular function, platelets, and eicosanoid synthesis, all factors implicated in renal disease. Furthermore, we speculate that angiotensin II-induced PAF formation may contribute to microvasculature pathology in general.

Evidence for immunoglobulin Fc receptor-mediated prostaglandin2 and platelet-activating factor formation by cultured rat mesangial cells

The possibility of Fc-dependent uptake of IgG immune complexes was examined in subcultured rat mesangial cells free of monocytes. 195Au-labeled colloidal gold particles were coated either with BSA only or with BSA followed by rabbit anti-BSA-IgG or the F(ab')2 fragment of the IgG. Mesangial cells preferentially took up 195Au particles covered with BSA-anti-BSA-IgG over those covered with BSA or the F(ab')2 fragment. This uptake was a time-dependent and saturable process inhibitable by sodium azide or cytochalasin B. Using phase-contrast microscopy in the light reflectance mode, it was established that essentially all mesangial cells took up IgG-coated gold particles. By electron microscopy the process was shown to consist of vesicular uptake with delivery to endosomes. Mesangial binding-uptake of the IgG-covered particles was associated with stimulation of PGE2 synthesis and production of platelet-activating factor, a lipid mediator of inflammation. To characterize the potential Fc receptor for IgG we used the rosetting technique with sheep red blood cells coated with IgG subclass-specific mouse monoclonal antibodies. 50% of mesangial cells exhibited rosetting with red cells coated with mouse IgG2a, whereas negligible rosetting was observed with IgG2b or IgG1. Competition experiments confirmed the specificity of IgG2a binding. We conclude that cultured rat mesangial cells exhibit specific receptors for IgG and that occupancy of Fc receptors results in endocytosis and is associated with generation of PGE2 and platelet-activating factor. These observations may be of significance for immune-mediated glomerular diseases.

The measurement of small-scale environmental heterogeneity using clonal transplants of Anthoxanthum odoratum and Danthonia spicata

To assess the scale of micro-environmental heterogeneity perceived by two co-occurring grass species, Anthoxanthum odoratum and Danthonia spicata, cloned tillers of each species were planted into the natural habitat at a range of spacings (from 2 cm to more than 2 m apart) and measured for survival and fecundity over three years. A. odoratum responded to heterogeneity at a scale of 4-8 cm and at a scale of 2-8 m but not to intermediate scales. D. spicata did not respond significantly to heterogeneity. However one genotype infected with the systemic fungus Atkinsonella hypoxylon showed a large response to heterogeneity at both small and large spatial scales. The results showed that the scale and level of environmental heterogeneity as measured by its fitness impact depends on the species and genotype involved. The results indicate that small scale environmental heterogeneity could play a role in the maintenance of sexual reproduction in A. odoratum.

Organic acids in ethylene glycol intoxication

Ethylene glycol intoxication produces a severe metabolic acidosis with an increased anion gap. We examined three patients with this intoxication to identify the organic acids that cause acidemia in humans and to determine how effectively these acids can be removed during dialysis. All patients had markedly elevated glycolic acid levels of more than 7 meq/L and two patients had lactic acidosis, with lactic acid levels of greater than 5.0 meq/L. Hemodialysis clearance of glycolic acid was 105 mL/min, and 159 meq was removed in 3 hours. After hemodialysis using a bicarbonate dialysate, the mean anion gap decreased from 34 to 23 meq/L; the mean serum bicarbonate concentration increased from 5.5 to 20 meq/L. Therefore, glycolic and lactic acids are important in the acidosis caused by ethylene glycol intoxication in humans. Hemodialysis treatment with a bicarbonate dialysate is an efficient method for removing glycolic acid and resolving acidemia.

THE EFFECT OF THE FUNGUS ATKINSONELLA HYPOXYLON (CLAVICIPITACEAE)ON THE REPRODUCTIVE SYSTEM AND DEMOGRAPHY OF THE GRASS DANTHONIA SPICATA

The Balansiae (Clavicipitaceae, Ascomycetes) consists of five genera of fungi that parasitize grasses, sedges and rushes. Most or all species produce alkaloids that are toxic to mammalian and insect herbivores. Previous reports suggest that infected grasses are more vigorous than uninfected grasses and that the proportion of infected individuals is greater in older populations. In this study individual plants or genotypes of the grass Danthonia spicata (L.) Beauv. Infected by the fungus Atkinsonella hypoxylon (Peck) Diehl. were compared with uninfected genotypes from the same population. Danthonia spicata typically bears dimorphic chasmogamous and cleistogamous flowers but in the study population infected plants were partially sterilized, producing only cleistogamous flowers; uninfected plants produced chasmogamous and cleistogamous flowers. Two experimental comparisons were conducted by propagating infected and uninfected genotypes into clones, or ramets, which were then planted back into their native site. Infected ramets had higher survival and growth rates, but lower flower production, than uninfected ramets both in random field transects and in field competition studies between D. spicata and the grass Anthoxanthum odoratum L. The results indicate infected individuals have higher survival and growth rates but reduced fecundity compared to uninfected individuals.

Trehalose-containing lipooligosaccharides. A new class of species-specific antigens from Mycobacterium

Mycobacterium kansasii is characterized by the presence of seven species-specific neutral lipooligosaccharide antigens. All react with hyperimmune anti-M. kansasii serum in enzyme-linked immunosorbent assays, and the more glycosylated members also react by gel diffusion. Both the native glycolipids and their inherent oligosaccharides were purified and the major features of their unique structures determined by acetolysis, partial acid cleavage, 1H-NMR and 13C-NMR, and chemical ionization and electron impact mass spectrometry of the permethylated products. They have in common a tetraglucose "core," beta-D-Glcp-(1 leads to 3)-beta-D-Glcp-(1 leads to 4)- alpha-D-Glcp(1 leads to 1)-alpha-D-Glcp where Glcp is glucopyranose, distinguished by the presence of an alpha,alpha-trehalose substituent. Variable residues of xylose, 3-O-methylrhamnose, fucose, and a novel N-acyl aminosugar, (4,6-dideoxy-2-O-methyl-3-C-methyl-4-(2'-methoxypropionamido)hexose; proof of this structure is not given) are linked to the core and the resulting oligosaccharides are acylated with 2,4-dimethyltetradecanoyl and acetyl functions to present a familial arrangement. Related but species-specific lipooligosaccharides typify Mycobacterium szulgai and apparently a host of other atypical mycobacteria. Thus, the antigenicity, and perhaps other features such as pathogenesis and drug resistance, of most atypical mycobacteria may be rationalized in terms of these new found cell wall lipooligosaccharides and the previously described glycopeptidolipids.

Partial resolution of tardive dyskinesia with treatment of co-existing thyrotoxicosis

Neuroleptic-induced tardive dyskinesia improved after treatment of thyrotoxicosis. Neuroleptic blood levels indicated that the improvement was not caused by masking of the symptoms by rising drug levels. Dopamine metabolite measurements suggested that the thyrotoxicosis caused an increase in the sensitivity of caudate neurons to dopamine, rather than a change in release of dopamine.