Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

BACKGROUND

Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.

OBJECTIVES

To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.

METHODS

Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital.

RESULTS

A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.

CONCLUSION

Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

Aptamer proteomics for biomarker discovery in heart failure with reduced ejection fraction

Background

Though current heart failure (HF) biomarkers are highly prognostic, systematically characterizing associations between circulating proteins and risk of subsequent events may improve clinical risk prediction and illuminate new biological pathways. Large-scale assays measuring thousands of proteins now enable unbiased proteomic investigation in clinical trials.

Purpose

To identify and replicate serum proteins associated with HF events in patients with chronic HF with reduced ejection fraction (HFrEF), and to develop and validate a proteomic risk score.

Methods

Serum levels of 4076 proteins were measured at baseline in the ATMOSPHERE (n=1261, 487 events over 6 years) and PARADIGM-HF (n=1257, 287 events over 4 years) trials of chronic HFrEF using a modified aptamer-based proteomics assay. Proteins associated with the primary endpoint, HF hospitalization or cardiovascular death, were identified in the ATMOSPHERE discovery cohort (false discovery rate<0.05) by Cox regression adjusted for age, sex, treatment arm, and anticoagulant use, and replicated in PARADIGM-HF (Bonferroni-corrected p<0.05). A proteomic risk score was derived in ATMOSPHERE using Cox LASSO penalized regression and evaluated in PARADIGM-HF compared to the MAGGIC clinical risk score and N-terminal pro-B-type natriuretic peptide (NT-proBNP). For proteins associated with the primary endpoint, pathway analysis was conducted using Ingenuity Pathway analysis and an exploratory two-sample Mendelian randomization was performed using genetic and outcome data from both trials and protein quantitative trait loci from deCODE to infer which identified proteins contribute to HF prognosis.

Results

We identified 377 serum proteins associated with the primary endpoint in ATMOSPHERE and replicated 167 in PARADIGM-HF. Prognostic proteins included known HF biomarkers Growth Differentiation Factor 15, NT-proBNP, and Angiopoietin-2, and also a previously unrecognized HF biomarker: Sushi, Von Willebrand Factor Type A, EGF And Pentraxin Domain Containing 1 (SVEP1) (HR 1.60 [95% CI 1.44–1.79] per standard deviation [SD], p=2x10–17) (Table 1). Proteins related to hepatic fibrosis, granulocyte adhesion, and inhibition of matrix metalloproteinases were over-represented. A 64-protein risk score derived in ATMOSPHERE predicted clinical events in PARADIGM-HF with greater discrimination (c-statistic 0.70) than the MAGGIC clinical score (c-statistic 0.61), NT-proBNP (c-statistic 0.65), or both (c-statistic 0.66) (Figure 1). Genetically predicted levels of NT-proBNP, WISP2, FSTL1, and CTSS were associated with the primary endpoint by Mendelian randomization.

Conclusions

We identify SVEP1, an extracellular matrix protein known to cause inflammation in vascular smooth muscle cells, as a previously unrecognized HF biomarker. A 64-protein score improved risk discrimination compared with NT-proBNP and may assist in identifying high-risk patients for clinical trials or disease management programs.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The ATMOSPHERE and PARADIGM-HF trials were sponsored by Novartis

OP0182 SECUKINUMAB IN GIANT CELL ARTERITIS: THE RANDOMISED, PARALLEL-GROUP, DOUBLE-BLIND, PLACEBO-CONTROLLED, MULTICENTRE PHASE 2 TitAIN TRIAL

Background

Little is known about glucocorticoid-sparing agents in giant cell arteritis (GCA) except for IL-6 inhibition. Secukinumab (SEC) has shown significant improvements in the signs and symptoms of IL-17A driven medical conditions such as plaque psoriasis, psoriatic arthritis, and axial spondyloarthritis.1,2 It has a favourable long-term safety profile.1,2

Objectives

TitAIN is the first randomised controlled trial investigating the potential efficacy, safety, and tolerability of SEC in GCA patients (pts).

Methods

This phase 2, randomised, double-blind, placebo (PBO) controlled, multicentre, proof-of-concept trial enrolled pts (aged ≥50 years) with new onset (diagnosed within 6 weeks (wks) of baseline) or relapsing (diagnosed >6 wks from baseline) GCA, naïve to biological therapy. Pts were randomised (1:1) to SEC 300 mg or PBO initially administered wkly (5 doses) and every 4 wks thereafter through Wk 48 (last dose), in combination with a 26-wk prednisolone taper regimen starting from baseline. Proportion of GCA pts in sustained remission until Wk 28 was the primary endpoint assessed by a Bayesian analysis of the posterior distribution with non-responder imputation. Other key endpoints included proportion of GCA pts in sustained remission until Wk 52 (based on study data with non-responder imputation) and time to first GCA flare after baseline.

Results

Out of 52 randomised pts (SEC, n=27; PBO, n=25), 71.2% (n=37) completed study treatment (SEC, 81.5%; PBO, 60.0%). Overall, 42 (80.8%) pts had new onset GCA and 10 (19.2%) pts had relapsing GCA at baseline. Proportion (posterior median with 95% credibility interval) of GCA pts in sustained remission until Wk 28 was higher with SEC, 70.1% (51.6%-84.9%), than with PBO, 20.3% (12.4%-30.0%); odds ratio (posterior median with 95% credibility interval), 9.31 (3.54-26.29) (Table 1). Until Wk 52, proportion (95% confidence interval) of GCA pts in sustained remission were 59.3% (38.8%-77.6%) in SEC group and 8.0% (1.0%-26.0%) in PBO group (Table 1). Median (95% confidence interval) time to first GCA flare after baseline was not reached for GCA pts treated with SEC and was 197.0 (101.0-280.0) days for PBO (Figure 1). Overall, treatment-emergent adverse events (AEs) occurred in 98.1% (SEC vs PBO, 100.0% vs 96.0%) and serious AEs in 32.7% (SEC vs PBO, 22.2% vs 44.0%) pts. Two pts in each SEC and PBO groups had AEs that led to study drug discontinuation and 1 pt in each group had AEs that led to death (not treatment-related). There were no new or unexpected safety signals identified with SEC treatment.

Table 1.

Proportion of GCA patients with sustained remission (Full analysis set) until Week 28 and 52

Proportion of ptsSecukinumab (N=27)Placebo (N=25)Median percentage (95% credibility interval), Wk 2870.1% (51.6%, 84.9%)20.3% (12.4%, 30.0%)Percentage (95% confidence interval), Wk 5259.3% (38.8%, 77.6%)8.0% (1.0%, 26.0%)

The full analysis set comprises all pts to whom study treatment has been assigned by randomisation and who received at least one dose of randomised study treatment (secukinumab or placebo).

GCA, giant cell arteritis; N, number of pts in each treatment group in the full analysis set, pts, patients; Wk, Week

Figure 1.

Kaplan-Meier plot of time to first GCA flare from baseline up to Week 52 (Full analysis set)

Conclusion

SEC demonstrated a higher sustained remission rate and longer time to first GCA flare vs PBO through 52 wks in pts with GCA. This proof-of-concept phase 2 study supports further development of SEC as a potential treatment in combination with 26 wk glucocorticoid taper for pts with GCA.

References

[1]Mease PJ, et al. ACR Open Rheumatol. 2020;2(1):18-25

[2]Baraliakos X, et al. RMD Open. 2019;5:e001005

Disclosure of Interests

Nils Venhoff Speakers bureau: AbbVie, Novartis, Bristol-Myers-Squibb, Chugai, Roche, Vifor, Consultant of: AbbVie, Chugai, Novartis, Vifor, Grant/research support from: Bristol-Myers-Squibb, Novartis, Wolfgang A. Schmidt Speakers bureau: Abbvie, Chugai, Medac, Novartis, Roche, Sanofi, Consultant of: Advisory board member: Abbvie, Chugai, GlaxoSmithKline, Novartis, Roche, Sanofi, Grant/research support from: principle investigator in GCA trials: Abbvie, GlaxoSmithKline, Novartis, Sanofi, Raoul Bergner Speakers bureau: Abbvie, Bristol Myers Squibb, Chugai, Novartis, Roche, Consultant of: Advisory board member: Gilead, GlaxoSmithKline, Vifor, Jürgen Rech Speakers bureau: Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, MSD; Novartis, Roche, Sanofi, Sobi, UCB, Consultant of: Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, MSD, Novartis, Roche, Sanofi, Sobi, UCB, Leonore Unger Paid instructor for: Novartis, Hans-Peter Tony Consultant of: Abbvie, BMS, Chugai, Gilead, Lilly, Novartis, Roche, Sanofi, Meryl Mendelson Shareholder of: Novartis Pharmaceuticals Corporation, Employee of: Novartis Pharmaceuticals Corporation, Christian Sieder Employee of: Novartis Pharma GmbH, Meron Maricos Employee of: Novartis Pharma GmbH, Jens Thiel Speakers bureau: Novartis, GSK, Bristol-Myers-Squibb, Roche, AstraZeneca, Vifor, Consultant of: Novartis, Janssen, GSK; research grants: Bristol-Myers-Squibb, Novartis

COVID-19 vaccine hesitancy and anti-vaxxers - supporting healthcare workers to navigate the unvaccinated: Reflections from clinical practice

An important step in preparation for the fourth COVID-19 wave is to provide healthcare workers (HCWs) with skills to facilitate behaviour change in vaccine-hesitant patients. Convincing members of the public who are vaccine hesitant rather than anti-vaxxers should be the focus of our efforts. Our experience is that vaccine-hesitant individuals and anti-vaxxers are generally distinct cohorts, with differing reasons for their vaccine reluctance. If we are to truly address hesitancy, we must take time to understand the reasons for an individual's hesitancy. Developing a conceptual framework and skills for HCWs during encounters with unvaccinated individuals will be important not only for shifting some to get vaccinated, but also to manage the complex emotions that HCWs will undoubtedly be forced to confront during the fourth wave.

Study reporting quality among interventions to reduce antibiotic use is a barrier to evidence-informed policymaking on antimicrobial resistance: systematic review

Background

Countries are currently seeking evidence-informed policy options to address antimicrobial resistance (AMR). While rigorous evaluations of AMR interventions are the ideal, they are far from the current reality. Additionally, poor reporting and documentation of AMR interventions impede efforts to use evidence to inform future evaluations and policy interventions.

Objectives

To critically evaluate reporting quality gaps in AMR intervention research.

Methods

To evaluate the reporting quality of studies, we conducted a descriptive synthesis and comparative analysis of studies that were included in a recent systematic review of government policy interventions aiming to reduce human antimicrobial use. Reporting quality was assessed using the SQUIRE 2.0 checklist of 18 items for reporting system-level interventions to improve healthcare. Two reviewers independently applied the checklist to 66 studies identified in the systematic review.

Results

None of the studies included complete information on all 18 SQUIRE items (median score = 10, IQR = 8–11). Reporting quality varied across SQUIRE items, with 3% to 100% of studies reporting the recommended information for each SQUIRE item. Only 20% of studies reported the elements of the intervention in sufficient detail for replication and only 24% reported the mechanism through which the intervention was expected to work.

Conclusions

Gaps in the reporting of impact evaluations pose challenges for interpreting and replicating study results. Failure to improve reporting practice of policy evaluations is likely to impede efforts to tackle the growing health, social and economic threats posed by AMR.

COVID-19 vaccines - less obfuscation, more transparency and action

Letter by Venter et al. on editorial  by Schoub (Dial down the rhetoric over COVID-19 vaccines. S Afr Med J 2021;111(6):522-523. https://doi.org/10.7196/SAMJ.2021.v111i6.15740).

Association between minimum inhibitory concentration, beta-lactamase genes and mortality for patients treated with piperacillin/tazobactam or meropenem from the MERINO study

INTRODUCTION

This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial.

METHODS

Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations.

RESULTS

320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam non-susceptible breakpoint (MIC > 16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% CI 2.8 - 87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3% - 15%) and 8% (95% CI 2% - 15%) for the original PA population and the post-hoc MA populations, which reduced to 5% (95% CI -1% - 10%) after excluding strains with piperacillin/tazobactam MIC values > 16 mg/L. Isolates co-harboring ESBL and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-mortality of 14% (95% CI 2% - 28%).

CONCLUSION

After excluding non-susceptible strains, the 30-day mortality difference was from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA co-harboring ESBLs suggests meropenem remains the preferred choice for definitive treatment of ceftriaxone non-susceptible E. coli and Klebsiella.

Building resilient and responsive research collaborations to tackle antimicrobial resistance-Lessons learnt from India, South Africa, and UK

Research, collaboration, and knowledge exchange are critical to global efforts to tackle antimicrobial resistance (AMR). Different healthcare economies are faced with different challenges in implementing effective strategies to address AMR. Building effective capacity for research to inform AMR-related strategies and policies is recognised as an important contributor to success. Interdisciplinary, intersector, as well as international collaborations are needed to span global to local efforts to tackle AMR. The development of reciprocal, long-term partnerships between collaborators in high-income and in low- and middle-income countries (LMICs) needs to be built on principles of capacity building. Using case studies spanning local and international research collaborations to codesign, implement, and evaluate strategies to tackle AMR, we have evaluated and build upon the ESSENCE criteria for capacity building in LMICs. The first case study describes the local codesign and implementation of antimicrobial stewardship (AMS) in the state of Kerala in India. The second case study describes an international research collaboration investigating AMR surgical patient pathways in India, the UK, and South Africa. We describe the steps undertaken to develop robust, agile, and flexible AMS research and implementation teams. Notably, investing in capacity building ensured that the programmes described in these case studies were sustained through the current severe acute respiratory syndrome coronavirus pandemic. Describing the strategies adopted by a local and an international collaboration to tackle AMR, we provide a model for capacity building in LMICs that can support sustainable and agile AMS programmes.

COVID-19 antibody testing: From hype to immunological reality

The potential role for serological tests in the current COVID-19 pandemic has generated very considerable recent interest across many sectors worldwide, inter alia pathologists seeking additional weapons for their armoury of diagnostic tests; epidemiologists seeking tools to gain seroprevalence data that will inform improved models of the spread of disease; research scientists seeking tools to study the natural history of COVID-19 disease; vaccine developers seeking tools to assess vaccine efficacy in clinical trials; and companies and governments seeking tools to aid return-to-work decision-making. However, much of the local debate to date has centred on questions surrounding whether regulatory approval processes are limiting access to serological tests, and has not paused to consider the intrinsically limiting impact of underlying fundamental biology and immunology on where and how different COVID-19 serological tests can usefully be deployed in the response to the current pandemic. We review, from an immunological perspective, recent experimental evidence on the time-dependency of adaptive immune responses following SARS-CoV-2 infection and the impact of this on the sensitivity and specificity of COVID-19 antibody tests made at different time points post infection. We interpret this scientific evidence in terms of mooted clinical applications for current COVID-19 antibody tests in identifying acute infections, in confirming recent or past infections at the individual and population level, and in detecting re-infection and protective immunity. We conclude with guidance on where current COVID-19 antibody tests can make a genuine impact in the pandemic.

Strengthening the science of addressing antimicrobial resistance: a framework for planning, conducting and disseminating antimicrobial resistance intervention research

Antimicrobial resistance (AMR) has the potential to threaten tens of millions of lives and poses major global economic and development challenges. As the AMR threat grows, it is increasingly important to strengthen the scientific evidence base on AMR policy interventions, to learn from existing policies and programmes, and to integrate scientific evidence into the global AMR response.While rigorous evaluations of AMR policy interventions are the ideal, they are far from the current reality. To strengthen this evidence base, we describe a framework for planning, conducting and disseminating research on AMR policy interventions. The framework identifies challenges in AMR research, areas for enhanced coordination and cooperation with decision-makers, and best practices in the design of impact evaluations for AMR policies.This framework offers a path forward, enabling increased local and global cooperation, and overcoming common limitations in existing research on AMR policy interventions.

Developing core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus approach

OBJECTIVES

With increasing global interest in hospital antimicrobial stewardship (AMS) programmes, there is a strong demand for core elements of AMS to be clearly defined on the basis of principles of effectiveness and affordability. To date, efforts to identify such core elements have been limited to Europe, Australia, and North America. The aim of this study was to develop a set of core elements and their related checklist items for AMS programmes that should be present in all hospitals worldwide, regardless of resource availability.

METHODS

A literature review was performed by searching Medline and relevant websites to retrieve a list of core elements and items that could have global relevance. These core elements and items were evaluated by an international group of AMS experts using a structured modified Delphi consensus procedure, using two-phased online in-depth questionnaires.

RESULTS

The literature review identified seven core elements and their related 29 checklist items from 48 references. Fifteen experts from 13 countries in six continents participated in the consensus procedure. Ultimately, all seven core elements were retained, as well as 28 of the initial checklist items plus one that was newly suggested, all with ≥80% agreement; 20 elements and items were rephrased.

CONCLUSIONS

This consensus on core elements for hospital AMS programmes is relevant to both high- and low-to-middle-income countries and could facilitate the development of national AMS stewardship guidelines and adoption by healthcare settings worldwide.

Antibiotic stewardship in low- and middle-income countries: the same but different?

BACKGROUND

Antibiotic resistance (ABR) is a quickly worsening problem worldwide, also in low- and middle-income countries (LMICs). Appropriate antibiotic use in humans and animals, i.e. antibiotic stewardship (ABS), is one of the cornerstones of the World Health Organization's global action plan for ABR. Many LMICs are in the process of developing stewardship programs.

AIMS

We highlight challenges for ABS initiatives in LMICs, give an outline of (inter)national recommendations and demonstrate examples of effective, contextualized stewardship interventions.

SOURCES

We searched PubMed for articles on ABS interventions in humans in LMICs. Relevant websites and experts were consulted for additional sources.

CONTENT

Evidence on effective and feasible stewardship interventions in LMICs is limited, and challenges for implementation of interventions are numerous. Nevertheless, several initiatives at the international and local levels in Latin America, Africa and Asia have shown that ABS effective interventions are feasible in LMICs, although contextualization is essential.

IMPLICATIONS

Specific guidance for setting up antimicrobial stewardship programs in LMICs should be developed. Strategic points might need to be progressively addressed in LMICs, such as (a) ensuring availability of diagnostic testing, (b) providing dedicated education in ABR both for healthcare workers and the general public, (c) creating or strengthening (inter)national agencies towards better regulations and audit on production, distribution and dispensing of drugs, (d) strengthening healthcare facilities, (e) exploring a broader synergism between policy makers, academia, professional bodies and civil society and (f) designing and studying easy and scalable ABS interventions for both hospital and community settings.

Opportunities for system level improvement in antibiotic use across the surgical pathway

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement.

Sleep quality, sleep duration and physical activity in obese adolescents: effects of exercise training

BACKGROUND

Decreased sleep duration and altered sleep quality are risk factors for obesity in youth. Structured exercise training has been shown to increase sleep duration and improve sleep quality.

OBJECTIVES

This study aimed at evaluating the impact of exercise training for improving sleep duration, sleep quality and physical activity in obese adolescents (OB).

METHODS

Twenty OB (age: 14.5 ± 1.5 years; body mass index: 34.0 ± 4.7 kg m(-2) ) and 20 healthy-weight adolescents (HW) completed an overnight polysomnography and wore an accelerometer (SenseWear Bodymedia) for 7 days. OB participated in a 12-week supervised exercise-training programme consisting of 180 min of exercise weekly. Exercise training was a combination of aerobic exercise and resistance training.

RESULTS

Sleep duration was greater in HW compared with OB (P < 0.05). OB presented higher apnoea-hypopnoea index than HW (P < 0.05). Physical activity (average daily metabolic equivalent of tasks [METs]) by accelerometer was lower in OB (P < 0.05). After exercise training, obese adolescents increased their sleep duration (+64.4 min; effect size: 0.88; P = 0.025) and sleep efficiency (+7.6%; effect size: 0.76; P = 0.028). Physical activity levels were increased in OB as evidenced by increased steps per day and average daily METs (P < 0.05). Improved sleep duration was associated with improved average daily METs (r = 0.48, P = 0.04).

CONCLUSION

The present study confirms altered sleep duration and quality in OB. Exercise training improves sleep duration, sleep quality and physical activity.

Impact of exercise training without caloric restriction on inflammation, insulin resistance and visceral fat mass in obese adolescents

BACKGROUND

Exercise training has been shown to improve cardiometabolic health in obese adolescents.

OBJECTIVES

Evaluate the impact of a 12-week exercise-training programme (without caloric restriction) on obese adolescents' cardiometabolic and vascular risk profiles.

METHODS

We measured systemic markers of oxidation, inflammation, metabolic variables and endothelial function in 20 obese adolescents (OB) (age: 14.5 ± 1.5 years; body mass index: 34.0 ± 4.7 kg m(-2) ) and 20 age- and gender-matched normal-weight adolescents (NW). Body composition was assessed by magnetic resonance imagery. Peak aerobic capacity and maximal fat oxidation were evaluated during specific incremental exercise tests. OB participated in a 12-week exercise-training programme.

RESULTS

OB presented lower peak aerobic capacity (24.2 ± 5.9 vs. 39.8 ± 8.3 mL kg(-1)  min(-1) , P < 0.05) and maximal fat oxidation compared with NW (P < 0.05). OB displayed greater F2t-Isoprostanes (20.5 ± 6.7 vs. 13.4 ± 4.2 ng mmol(-1) creatinine), Interleukin-1 receptor antagonist (IL-1Ra) (1794.8 ± 532.2 vs. 835.1 ± 1027.4 pg mL(-1) ), Tumor Necrosis Factor-α (TNF-α) (2.1 ± 1.2 vs. 1.5 ± 1.0 pg mL(-1) ), Soluble Tumor Necrosis Factor-α Type II Receptor (sTNFαRII), leptin, insulin, homeostasis model assessment of insulin resistance, version 2 (HOMA2-IR), high-sensitive C-reactive protein, triglycerides and lower adiponectin and high-density lipoprotein cholesterol (all P < 0.05). After exercise training, despite lack of weight loss, VO2peak (mL.kg(-1) .min(-1) ) and maximal fat oxidation increased (P < 0.05). IL-1Ra and IFN-gamma-inducible protein 10 (IP-10) decreased (P < 0.05). Insulin and HOMA2-IR decreased (14.8 ± 1.5 vs. 10.2 ± 4.2 μUI mL(-1) and 1.9 ± 0.8 vs. 1.3 ± 0.6, respectively, P < 0.05). Change in visceral fat mass was inversely associated with change in maximal fat oxidation (r = -0.54; P = 0.024). The subgroup of participants that lost visceral fat mass showed greater improvements in triglycerides, insulin resistance and maximal fat oxidation.

CONCLUSION

Our data confirms the role of exercise training on improving the inflammatory profile and insulin resistance of OB in the absence of weight loss. However, those who lost a greater amount of visceral fat mass showed greater benefits in terms of insulin profile, triglycerides and maximal fat oxidation.

Detection on four continents of dengue fever cases related to an ongoing outbreak in Luanda, Angola, March to May 2013

In April 2013, ten cases of dengue fever in travellers returning from Luanda, Angola, to five countries on four continents, were reported to the globally distributed GeoSentinel Surveillance network. Dengue virus serotype 1 was identified in two cases. The findings indicate that a major dengue outbreak is currently ongoing in Luanda. This report illustrates how cases from an emerging arboviral epidemic focus can spread internationally and highlights the risk of dissemination of a vector-borne disease into receptive areas

Acute generalised exanthematous pustulosis secondary to cotrimoxazole or tenofovir

Cutaneous adverse drug reactions are a common complication of antiretroviral therapy and of drugs used to treat opportunistic infections. We present a rare case of acute generalised exanthematous pustulosis secondary to cotrimoxazole or tenofovir.

Enhanced diagnosis of HIV-1-associated tuberculosis by relating T-SPOT.TB and CD4 counts

The sensitivity of the tuberculin skin test is impaired in HIV-1-infected persons. Enzyme-linked immunospot-based detection of immune sensitisation may be less affected. Furthermore, the quantitative response can be related to the CD4 count, potentially improving specificity for active disease. The T-SPOT.TB assay was performed on HIV-1-infected participants, 85 with active tuberculosis (TB) and 81 healthy patients (non-TB). The ratio of the sum of the 6-kDa early secretory antigenic target and culture filtrate protein 10 response to the CD4 count (spot-forming cell (SFC)/CD4) was calculated. Using the manufacturer's guidelines, active TB was diagnosed with 76% sensitivity and 53% specificity. Using an SFC/CD4 ratio of 0.12, sensitivity (80%) and specificity (62%) improved. The quantitative T-cell response increased with increasing smear-positivity in the active TB group (p = 0.0008). In the non-TB group, the proportion of persons scored positive by T-SPOT.TB assay was lower in the group with a CD4 count of <200 cells·mm(-3) (p = 0.029). The ratio of the summed T-cell response to CD4 count improved the diagnostic accuracy of the T-SPOT.TB assay in HIV-1-infected persons, and a ratio of SFC/CD4 of >0.12 should prompt investigation for active disease. A strong association between the degree of sputum positivity and T-SPOT.TB score was found. The sensitivity of the T-SPOT.TB assay in active disease may be less impaired by advanced immunosuppression.

Quantitative trait loci and interaction effects responsible for variation in female postmating mortality in Drosophila simulans and D. sechellia introgression lines

Mating appears to inflict a cost to Drosophila females, resulting in a reduction of their lifespan shortly after mating. Males from different chromosome extracted lines differ significantly in their detrimental effects on postmating female survival, and seminal fluid proteins produced in the male accessory glands are at least partially responsible for the effect. This suggests that there is a genetic basis underlying the male inflicted effect on female's postmating mortality. However, the genes responsible for this effect remain elusive. Using males from introgression lines between D. simulans and D. sechellia genomes and a quantitative trait locus (QTL) mapping approach, we identified chromosomal regions that affect postmating mortality of females. We found a second chromosome QTL with an effect on average female lifespan after mating and a third chromosome QTL with an effect on postmating female mortality rate. Under the general observation of a faster divergence of sex-related genes among closely related species, it is predicted that genes for reproductive traits other than hybrid sterility will show evidence of epistatic effects when brought into a heterospecific background. We detected a significant epistatic genetic effect on postmating female mortality rate that supports this prediction.

The use of thalidomide in the treatment of intracranial tuberculomas in adults: two case reports

We present two cases of tuberculous meningitis (TBM) in adults complicated by focal neurological deficits which showed progression whilst on steroids. In case 1 an MRI demonstrated multiple ring-enhancing lesions compressing the optic chiasm leading to a bitemporal hemianopia. After the introduction of thalidomide serial imaging and field perimetry at 6, 9, 12 and 24 months into treatment showed progressive improvement. In case 2, two months into anti-tuberculous treatment with steroids, the patient developed fluctuating right sided paralysis with the MRI demonstrating a large ring-enhancing mass encasing the left internal carotid and middle cerebral arteries. Thalidomide was introduced as an immunomodulatory adjunct and subsequently the patient made a complete neurological recovery. The immunomodulatory effects of thalidomide may have a role in the acute and chronic management of TBM complicated by intracranial tuberculomas.

Fever in the immunocompromised host

A broad classification of immune defects provides a framework for the approach to fever in the immunocompromised host. Practical, historical, and physical examination findings are reviewed, and common clinical scenarios are highlighted. A general initial work-up and treatment plan are outlined.

Detection of endogenous human cytomegalovirus in CD34+ bone marrow progenitors

The cellular sites and mechanisms of human cytomegalovirus (HCMV) latency are still poorly defined. Although evidence suggests that peripheral blood monocytes are one site of latency in the healthy carrier, it is unlikely that monocytes represent a site of primary HCMV infection. Consequently, we have analysed CD34+ bone marrow progenitors, precursors of monocytes, to determine whether they are a site of HCMV carriage in normal virus carriers. For the first time, we demonstrate the presence of endogenous HCMV within bone marrow progenitors in the absence of HCMV lytic gene expression. These findings are consistent with previous evidence showing that the permissiveness of myeloid cells for HCMV is critically dependent on the differentiation state of the cell.

Patients with HIV infection and end-stage renal disease

There has been a steady increase in the number of dialysis patients with human immunodeficiency viral (HIV) infection. HIV-associated nephropathy (HIVAN) is the most common cause of end-stage renal disease in this patient population. Although the major potential category of risk of HIV transmission is from the dialysis patient to staff, there are no data to indicate that this has occurred. Dialysis of patients with HIV infection is challenging and requires effective care to prolong survival.