Deltamethrin and transfluthrin select for distinct transcriptomic responses in the malaria vector Anopheles gambiae

BACKGROUND

The widespread use of pyrethroid insecticides in Africa has led to the development of strong resistance in Anopheles mosquitoes. Introducing new active ingredients can contribute to overcome this phenomenon and ensure the effectiveness of vector control strategies. Transfluthrin is a polyfluorinated pyrethroid whose structural conformation was thought to prevent its metabolism by cytochrome P450 monooxygenases in malaria vectors, thus representing a potential alternative for managing P450-mediated resistance occurring in the field. In this study, a controlled selection was used to compare the dynamics of resistance between transfluthrin and the widely used pyrethroid deltamethrin in the mosquito Anopheles gambiae. Then, the associated molecular mechanisms were investigated using target-site mutation genotyping and RNA-seq.

METHODS

A field-derived line of An. gambiae carrying resistance alleles at low frequencies was used as starting material for a controlled selection experiment. Adult females were selected across 33 generations with deltamethrin or transfluthrin, resulting in three distinct lines: the Delta-R line (selected with deltamethrin), the Transflu-R line (selected with transfluthrin) and the Tiassale-S line (maintained without selection). Deltamethrin and transfluthrin resistance levels were monitored in each selected line throughout the selection process, as well as the frequency of the L1014F kdr mutation. At generation 17, cross-resistance to other public health insecticides was investigated and transcriptomes were sequenced to compare gene transcription variations and polymorphisms associated with adaptation to each insecticide.

RESULTS

A rapid increase in resistance to deltamethrin and transfluthrin was observed throughout the selection process in each selected line in association with an increased frequency of the L1014F kdr mutation. Transcriptomic data support a broader response to transfluthrin selection as compared to deltamethrin selection. For instance, multiple detoxification enzymes and cuticle proteins were specifically over-transcribed in the Transflu-R line including the known pyrethroid metabolizers CYP6M2, CYP9K1 and CYP6AA1 together with other genes previously associated with resistance in An. gambiae.

CONCLUSION

This study confirms that recurrent exposure of adult mosquitoes to pyrethroids in a public health context can rapidly select for various resistance mechanisms. In particular, it indicates that in addition to target site mutations, the polyfluorinated pyrethroid transfluthrin can select for a broad metabolic response, which includes some P450s previously associated to resistance to classical pyrethroids. This unexpected finding highlights the need for an in-depth study on the adaptive response of mosquitoes to newly introduced active ingredients in order to effectively guide and support decision-making programmes in malaria control.

Semi-field evaluation of the space spray efficacy of Fludora Co-Max EW against wild insecticide-resistant Aedes aegypti and Culex quinquefasciatus mosquito populations from Abidjan, Côte d'Ivoire

BACKGROUND

Space spraying of insecticides is still an important means of controlling Aedes and Culex mosquitoes and arboviral diseases. This study evaluated the space spray efficacy of Fludora Co-Max EW, (water-based insecticide space spray combining flupyradifurone and transfluthrin with film forming aqueous spray technology (FFAST)), against wild insecticide-resistant Aedes aegypti and Culex quinquefasciatus mosquitoes from Abidjan, Côte d'Ivoire, compared with K-Othrine EC (deltamethrin-only product), in small-scale field trials.

METHODS

Wild Ae. aegypti and Cx. quinquefasciatus mosquito larvae were collected in Abidjan, Côte d'Ivoire from August to December 2020. Mosquito larvae were reared in the laboratory until the adult stage. Fludora Co-Max EW and K-Othrine EC were tested against emerged adult females (F₀ generation) using ultra-low volume cold fogging (ULV) and thermal fogging (TF) delivery technology, both outdoors and indoors in Agboville, Côte d'Ivoire. Specifically, cages containing 20 mosquitoes each were placed at distances of 10, 25, 50, 75 and 100 m from the spraying line for outdoor spraying, and at ceiling, mid-height and floor levels for indoor house spraying. Knockdown and mortality were recorded at each checkpoint and compared by treatments.

RESULTS

Overall, Fludora Co-Max EW induced significantly higher knockdown and mortality effects in the wild insecticide-resistant Ae. aegypti and Cx. quinquefasciatus compared with K-Othrine EC. In both species, mortality rates with Fludora Co-Max EW were > 80% (up to 100%) with the ULV spray outdoors at each distance checkpoint (i.e. 10-100 m), and 100% with the ULV and TF sprays indoors at all checkpoints (i.e. ceiling, mid-height and floor). K-Othrine EC induced high mortality indoors (97.9-100%), whereas mortality outdoors rapidly declined in Ae. aegypti from 96.7% (10 m) to 36.7% (100 m) with the ULV spray, and from 85.0% (10 m) to 38.3% (100 m) with the TF spray. Fludora Co-Max EW spray applied as ULV spray outdoors had higher knockdown and higher killing effects on Ae. aegypti and Cx. quinquefasciatus than when applied as TF spray. Fludora Co-Max EW performed better against Cx. quinquefasciatus than against Ae. aegypti.

CONCLUSIONS

Fludora Co-Max EW induced high mortality and knockdown effects against wild insecticide-resistant Ae. aegypti and Cx. quinquefasciatus Abidjan strains and performed better than K-Othrine EC. The presence of flupyradifurone and transfluthrin (with new and independent modes of action) and FFAST technology in the current Fludora Co-Max EW formulation appears to have broadened its killing capacity. Fludora Co-Max EW is thus an effective adulticide and may be a useful tool for Aedes and Culex mosquito and arbovirus control in endemic areas.

Exposure of Anopheles gambiae larvae to a sub-lethal dose of an agrochemical mixture induces tolerance to adulticides used in vector control management

The heavy use of pesticides in agricultural areas often leads to the contamination of nearby mosquito larvae breeding sites. Exposure to complex mixtures of agrochemicals can affect the insecticide sensitivity of mosquito larvae. Our study objective was to determine whether agrochemical residues in Anopheline larval breeding sites can affect the tolerance of adults to commonly used adulticides. We focussed on Fludora® Fusion, a vector control insecticide formulation combining two insecticides (deltamethrin and clothianidin) with different modes of action. An. gambiae larvae were exposed to a sub-lethal dose of a mixture of agrochemical pesticides used in a highly active agricultural area on the Ivory Coast. Comparative bioassays with Fludora Fusion mixture and its two insecticide components (deltamethrin and clothianidin) were carried out between adult mosquitoes exposed or not to the agrochemicals at the larval stage. A transcriptomic analysis using RNA sequencing was then performed on larvae and adults to study the molecular mechanisms underlying the phenotypic changes observed. Bioassays revealed a significantly increased tolerance of adult females to clothianidin (2.5-fold) and Fludora Fusion mixture (2.2-fold) following larval exposure to agrochemicals. Significantly increased tolerance to deltamethrin was not observed suggesting that insecticide exposure affects the adult efficacy of the Fludora Fusion mixture mainly through mechanisms acting on clothianidin. Transcriptomic analysis revealed the potential of agrochemicals to induce various resistance mechanisms including cuticle proteins, detoxification action and altered insecticide sequestration. These results suggest that although the Fludora Fusion mixture is effective for adult vector control, its efficacy may be locally affected by the ecological context. The present study also suggests that, although the complex interactions between the use of agrochemicals and vector control insecticides are difficult to decipher in the field, they still must be considered in the context of insecticide resistance management programmes.

Towards understanding transfluthrin efficacy in a pyrethroid-resistant strain of the malaria vector Anopheles funestus with special reference to cytochrome P450-mediated detoxification

Malaria vector control interventions rely heavily on the application of insecticides against anopheline mosquitoes, in particular the fast-acting pyrethroids that target insect voltage-gated sodium channels (VGSC). Frequent applications of pyrethroids have resulted in resistance development in the major malaria vectors including Anopheles funestus, where resistance is primarily metabolic and driven by the overexpression of microsomal cytochrome P450 monooxygenases (P450s). Here we examined the pattern of cross-resistance of the pyrethroid-resistant An. funestus strain FUMOZ-R towards transfluthrin and multi-halogenated benzyl derivatives, permethrin, cypermethrin and deltamethrin in comparison to the susceptible reference strain FANG. Transfluthrin and two multi-fluorinated derivatives exhibited micromolar potency - comparable to permethrin - to functionally expressed dipteran VGSC in a cell-based cation influx assay. The activity of transfluthrin and its derivatives on VGSC was strongly correlated with their contact efficacy against strain FUMOZ-R, although no such correlation was obtained for the other pyrethroids due to their rapid detoxification by the resistant strain. The low resistance levels for transfluthrin and derivatives in strain FUMOZ-R were only weakly synergized by known P450 inhibitors such as piperonyl butoxide (PBO), triflumizole and 1-aminobenzotriazole (1-ABT). In contrast, deltamethrin toxicity in FUMOZ-R was synergized > 100-fold by all three P450 inhibitors. The biochemical profiling of a range of fluorescent resorufin and coumarin compounds against FANG and FUMOZ-R microsomes identified 7-benzyloxymethoxy-4-trifluoromethylcoumarin (BOMFC) as a highly sensitive probe substrate for P450 activity. BOMFC was used to develop a fluorescence-based high-throughput screening assay to measure the P450 inhibitory action of potential synergists. Azole fungicides prochloraz and triflumizole were identified as extremely potent nanomolar inhibitors of microsomal P450s, strongly synergizing deltamethrin toxicity in An. funestus. Overall, the present study contributed to the understanding of transfluthrin efficacy at the molecular and organismal level and identified azole compounds with potential to synergize pyrethroid efficacy in malaria vectors.

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Transfluthrin and derivatives lack cross-resistance in resistant Anopheles funestus.

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Pyrethroid resistance in An. funestus is strongly synergized by azole fungicides.

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BOMFC is a highly active fluorescent probe substrate for microsomal cytochrome P450 monooxygenases in An. funestus.

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Azole fungicides are nanomolar inhibitors of microsomal cytochrome P450 monooxygenases in An. funestus.

Residual efficacy of Fludora Fusion against Anopheles arabiensis in simple huts in Ethiopia

Emergence and spread of malaria vectors resistant to the available insecticides required a new and efficacious insecticide. Residual efficacy of Fludora® Fusion was evaluated against insecticide susceptible Anopheles arabiensis in ten circular huts similar to the residential huts. Fludora® Fusion WP-SB 56.25, FICAM WP80 and Clothianidin WG70 were sprayed, by experienced technician, on interior wall surfaces: paint, dung, smooth mud, and rough mud. WHO cone bioassays were carried out a month after spraying and thereafter on monthly intervals for 12 months. Knockdown was recorded at 60 minutes and mortality at 24 hours, 48 hours and 72 hours holding time post-exposure. Fludora Fusion induced 100% An. arabiensis mortality during the first four months post-treated on all surface types at 24 hours holding time post-exposure. Its activity remained over 80% from the fifth to the twelfth month post-treated on the surfaces with the exception of two assessment points, at seventh month and eleventh month, on paint and smooth mud surfaces. FICAM induced 100% mortality rate during the first 4 months and 92% mortality during the fifth month post-treatment on painted surfaces. Its activity was over 96% mortality 1-month post-treatment on smooth mud and rough mud surfaces and 92% mortality 2-month post-treatment on dung surfaces. Clothianidin caused 89% and 86% mortality 1-month post-treatment on smooth mud and rough mud surfaces. Fludora Fusion can be used as alternative indoor residual insecticide spraying against An. arabiensis in Ethiopia.

Experimental evolution supports the potential of neonicotinoid-pyrethroid combination for managing insecticide resistance in malaria vectors

The introduction of neonicotinoids for managing insecticide resistance in mosquitoes is of high interest as they interact with a biochemical target not previously used in public health. In this concern, Bayer developed a combination of the neonicotinoid clothianidin and the pyrethroid deltamethrin (brand name Fludora Fusion) as a new vector control tool. Although this combination proved to be efficient against pyrethroid-resistant mosquitoes, its ability to prevent the selection of pyrethroid and neonicotinoid resistance alleles was not investigated. In this context, the objective of this work was to study the dynamics and the molecular mechanisms of resistance of An. gambiae to the separated or combined components of this combination. A field-derived An. gambiae line carrying resistance alleles to multiple insecticides at low frequencies was used as a starting for 33 successive generations of controlled selection. Resistance levels to each insecticide and target site mutation frequencies were monitored throughout the selection process. Cross resistance to other public health insecticides were also investigated. RNA-seq was used to compare gene transcription variations and polymorphisms across all lines. This study confirmed the potential of this insecticide combination to impair the selection of resistance as compared to its two separated components. Deltamethrin selection led to the rapid enrichment of the kdr L1014F target-site mutation. Clothianidin selection led to the over-transcription of multiple cytochrome P450s including some showing high homology with those conferring neonicotinoid resistance in other insects. A strong selection signature associated with clothianidin selection was also observed on a P450 gene cluster previously associated with resistance. Within this cluster, the gene CYP6M1 showed the highest selection signature together with a transcription profile supporting a role in clothianidin resistance. Modelling the impact of point mutations selected by clothianidin on CYP6M1 protein structure showed that selection retained a protein variant with a modified active site potentially enhancing clothianidin metabolism. In the context of the recent deployment of neonicotinoids for mosquito control and their frequent usage in agriculture, the present study highlights the benefit of combining them with other insecticides for preventing the selection of resistance and sustaining vector control activities.

Assessing the anti-resistance potential of public health vaporizer formulations and insecticide mixtures with pyrethroids using transgenic Drosophila lines

BACKGROUND

Insecticide resistance-and especially pyrethroid resistance-is a major challenge for vector control in public health. The use of insecticide mixtures utilizing alternative modes of action, as well as new formulations facilitating their uptake, is likely to break resistance and slow the development of resistance.

METHODS

We used genetically defined highly resistant lines of Drosophila melanogaster with distinct target-site mutations and detoxification enzymes to test the efficacy and anti-resistance potential of novel mixture formulations (i.e. Fludora^® Fusion consisting of deltamethrin and clothianidin), as well as emulsifiable concentrate transfluthrin, compared to alternative, currently used pyrethroid insecticide formulations for vector control.

RESULTS

The commercial mixture Fludora^® Fusion, consisting of both a pyrethroid (deltamethrin) and a neonicotinoid (clothianidin), performed better than either of the single active ingredients against resistant transgenic flies. Transfluthrin, a highly volatile active ingredient with a different molecular structure and primary exposure route (respiration), was also efficient and less affected by the combination of metabolic and target-site resistance. Both formulations substantially reduced insecticide resistance across different pyrethroid-resistant Drosophila transgenic strains.

CONCLUSIONS

The use of mixtures containing two unrelated modes of action as well as a formulation based on transfluthrin showed increased efficacy and resistance-breaking potential against genetically defined highly resistant Drosophila flies. The experimental model remains to be validated with mosquito populations in the field. The possible introduction of new transfluthrin-based products and mixtures for indoor residual spraying, in line with other combination and mixture vector control products recently evaluated for use in public health, will provide solutions for better insecticide resistance management.

Heart rate and blood lactate responses during the cross-country test of 2-star to 5-star eventing competitions

The objective of this retrospective study was to evaluate the physiological demands of cross-country competitions at different levels. Heart rates (HR) and post exercise blood lactate concentrations (LAC) measured between 2010 and 2019 in response to 1,463 cross-country competitions (437 at 2-star, 703 at 3-star, 313 at 4-star and 10 at 5-star level) in 294 horses were analysed. The effect of competition level, mean velocity, height profile, total distance, number of jumping efforts, climate, age, sex, percentage of Thoroughbred blood and performance level on HR, LAC, HR recovery and LAC disappearance rates was evaluated by Linear Mixed Effects Models. Mean HR and LAC significantly increased from 2-star to 4-star level (P<0.001). Each 30 m/min increase in mean velocity was associated with a 3 beats/min increase in HR (P<0.001) and a 41% increase in LAC (P<0.001) and each 30 m increase in cumulative elevation with a 2 beats/min increase in HR (P<0.001) and a 32% increase in LAC (P<0.001). Each 20 m increase in mean distance per jumping effort was associated with a 1 beat/min decrease in HR (P<0.01) and a 13% decrease in LAC (P<0.001). Compared to Warmbloods, horses with 75% Thoroughbred blood had 4 beats/min lower HRs (P<0.05) and 34% lower LAC values (P<0.001). Each 5 years increase in age was associated with a 4 beats/min decrease in HR (P<0.001, only in mares) and an 11% decrease in LAC (P<0.01). The HRs during the first 3 minutes of recovery were higher at warmer and more humid conditions (P<0.05). The rate of LAC disappearance was higher in horses with higher percentages of Thoroughbred blood (P<0.05).

Preexisting cognitive impairment in intracerebral hemorrhage

OBJECTIVES

Preexisting cognitive impairment is a predictor of cognitive decline after ischemic stroke, but evidence in intracerebral hemorrhage (ICH) is limited. We aimed to determine the prevalence of premorbid cognitive impairment in patients with ICH.

MATERIALS AND METHODS

We included patients with acute ICH. Pre-ICH cognitive impairment was determined based on the results of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) that uses information from close relatives. Patients were assessed as having been cognitively impaired with an IQCODE score of ≥3.44; an IQCODE ≥4.00 indicated pre-ICH dementia. CT and MRI images were reviewed to determine the extent of white matter lesions and to measure the radial width of the temporal horn as marker of brain atrophy. We investigated differences of cardiovascular risk factors and imaging data between patients with and without pre-ICH cognitive impairment using correlation analyses, uni- and multivariable regression models. Functional neurological state was assessed using the modified Rankin Scale (mRS). The mRS was dichotomized at the level of 3, and a premorbid mRS of 0-2 was considered as functional independency.

RESULTS

Among the 89 participants, median age was 70 years (interquartile range 58-78) and 52 (58.4%) were male. IQCODE indicated pre-ICH cognitive impairment in 18.0% (16 of 89), and 83.1% were functionally independent before ICH. Cognitive impairment was associated with a premorbid mRS≥3 (chi squared test, P=0.009). In multivariable analysis, prior stroke/transient ischemic attack (OR 18.29, 95%-CI 1.945-172.033, P=.011) and hematoma volume (OR 0.90, 95%-CI 0.812-0.991, P=.033) were independently associated with pre-ICH cognitive impairment.

CONCLUSIONS

In conclusion, cognitive impairment frequently precedes ICH. A higher frequency of cerebrovascular events suggests a role of vascular processes in the development of cognitive impairment before ICH.

Discovery of Rigidified α,β-Unsaturated Imines as New Resistance-breaking Insecticides for Malaria Vector Control

During our continuous search for new resistance-breaking insecticides applicable to malaria vector control, a new class of α,β-unsaturated imines was identified by applying the principle of conformational rigidification as a powerful tool for compound optimisation. Herein we describe the successful synthesis of these compounds and their biological test results. Our lead compound 16 from this insecticidal class outperforms market standards, notably for the control of mosquito strains that exhibit either metabolic or target-site resistance to these established insecticides. In our model system for insecticide-treated mosquito nets the compound reveals long-lasting efficacy for up to several months.

Peri-procedural silent cerebral infarcts after left atrial appendage occlusion

BACKGROUND AND PURPOSE

To determine the rate of peri-interventional silent brain infarcts after left atrial appendage occlusion (LAAO).

METHODS

In this prospective, uncontrolled single-center pilot study, consecutive patients with atrial fibrillation undergoing LAAO between July 2013 and January 2016 were included. The Amplatzer Cardiac Plug, WATCHMAN or Amulet device was used. A neurological examination and cranial magnetic resonance imaging (MRI) were performed within 48 h before and after the procedure. MRI was evaluated for new diffusion-weighted imaging (DWI) hyperintensities, cerebral microbleeds (CMBs) and white-matter lesions (WMLs).

RESULTS

Left atrial appendage occlusion was performed in 21 patients (mean age, 73.2 ± 9.5 years). Main reasons for LAAO were previous intracerebral hemorrhage (n = 11) and major systemic bleeding (n = 6). No clinically overt stroke occurred peri-interventionally. After the intervention, one patient had a small cerebellar hyperintensity on DWI (4.8%; 95% confidence interval, 0.0-14.3) that was not present on the MRI 1 day before the procedure. Among 11 patients with available MRI just before LAAO, there were no significant changes in the number of CMBs and the severity of WMLs after LAAO.

CONCLUSIONS

This study of peri-interventional MRI in LAAO suggests a low rate of silent peri-procedural infarcts in this elderly population. Confirmation in larger studies is needed.

Contact Bioassays with Phenoxybenzyl and Tetrafluorobenzyl Pyrethroids against Target-Site and Metabolic Resistant Mosquitoes

Background

Mosquito strains that exhibit increased tolerance to the chemical class of compounds with a sodium channel modulator mode of action (pyrethroids and pyrethrins) are typically described as “pyrethroid resistant”. Resistance to pyrethroids is an increasingly important challenge in the control of mosquito-borne diseases, such as malaria or dengue, because one of the main interventions (the distribution of large numbers of long-lasting insecticide-treated bed nets) currently relies entirely on long-lasting pyrethroids. Increasing tolerance of target insects against this class of insecticides lowers their impact in vector control. The current study suggests that the level of metabolic resistance depends on the structure of the molecule and that structurally different compounds may still be effective because detoxifying enzymes are unable to bind to these uncommon structures.

Methods

Treated surface contact bioassays were performed on susceptible Aedes aegypti, East African knockdown resistance (kdr) Anopheles gambiae (strain RSP-H) and metabolically resistant Anopheles funestus (strain FUMOZ-R) with different pyrethroids, such as cypermethrin, ß-cyfluthrin, deltamethrin, permethrin and transfluthrin (alone and in combination with the synergist piperonyl butoxide). The nonfluorinated form of transfluthrin was also assessed as a single agent and in combination with piperonyl butoxide.

Results

Although the dosages for pyrethroids containing a phenoxybenzyl moiety have exhibited differences in terms of effectiveness among the three tested mosquito species, the structurally different transfluthrin with a polyfluorobenzyl moiety remained active in mosquitoes with upregulated P450 levels. In trials with transfluthrin mixed with piperonyl butoxide, the added synergist exhibited no efficacy-enhancing effect.

Conclusion

The results of this study suggest that transfluthrin has the potential to control P450-mediated metabolically resistant mosquitoes because the structural formula of transfluthrin differs from that of the tested pyrethroids, which are used in vector control. The P450-detoxifying enzymes of the Anopheles funestus FUMOZ-R mosquitoes seem to bind preferably at the phenoxybenzyl moiety and appear to be unable to degrade transfluthrin with its tetrafluorobenzyl moiety. Inhibition of the class of monooxygenases by piperonyl butoxide revealed no increase of efficacy of the pure transfluthrin compound, which also indicates that the P450 enzymes potentially do not impact the efficacy of transfluthrin.

In vivo and in vitro characterization of a Plasmodium liver stage-specific promoter

Little is known about stage-specific gene regulation in Plasmodium parasites, in particular the liver stage of development. We have previously described in the Plasmodium berghei rodent model, a liver stage-specific (lisp2) gene promoter region, in vitro. Using a dual luminescence system, we now confirm the stage specificity of this promoter region also in vivo. Furthermore, by substitution and deletion analyses we have extended our in vitro characterization of important elements within the promoter region. Importantly, the dual luminescence system allows analyzing promoter constructs avoiding mouse-consuming cloning procedures of transgenic parasites. This makes extensive mutation and deletion studies a reasonable approach also in the malaria mouse model. Stage-specific expression constructs and parasite lines are extremely valuable tools for research on Plasmodium liver stage biology. Such reporter lines offer a promising opportunity for assessment of liver stage drugs, characterization of genetically attenuated parasites and liver stage-specific vaccines both in vivo and in vitro, and may be key for the generation of inducible systems.

Prevalence of atrial fibrillation and association of previous antithrombotic treatment in patients with cerebral microbleeds

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMBs) are associated with an increased risk of intracerebral hemorrhage. The impact of oral anticoagulation (OAC) on CMBs is not well characterized. Our aim was to assess the prevalence of CMBs in stroke and transient ischaemic attack (TIA) patients with atrial fibrillation (AF) and to analyze the implications of previous treatment with OAC.

METHODS

In this retrospective analysis on data from a prospectively recruiting stroke registry, patients with ischaemic stroke or TIA with brain magnetic resonance imaging including susceptibility weighted imaging were consecutively enrolled during a 3-year period. For each patient cardiovascular risk factors, AF history and recent diagnosis of AF, present use of OAC and antiplatelets, the National Institute of Health Stroke Scale and the premorbid modified Rankin Scale score were recorded. Two independent raters identified CMBs according to consensus criteria. CMB location was classified as lobar, deep or in the posterior fossa.

RESULTS

In all, 785 patients (mean age 63.9 ± 14.2 years) were included. At least one CMB was detected in 186 (23.7%) patients. CMBs were significantly more frequent in patients with AF (30.5% vs. 22.4%). Patients with previous OAC treatment were more likely to have CMBs (36.7% vs. 22.8%, P = 0.03) and abundant CMBs (n > 10) were more frequent in anticoagulated patients even after adjustment for age. However, age was the only independent factor predicting CMBs (P = 0.001).

CONCLUSIONS

Cerebral microbleeds are common in elderly AF patients with acute ischaemic stroke. Previous OAC is associated with a higher number of CMBs predominantly in the lobar location. Establishing a causal relationship requires prospective longitudinal investigation.

Prevalence of renal dysfunction in ischaemic stroke and transient ischaemic attack patients with or without atrial fibrillation

BACKGROUND AND PURPOSE

Chronic kidney disease (CKD) is associated with a higher risk of stroke and atrial fibrillation (AF). There are limited data on the comorbidity of renal dysfunction and AF in stroke patients. Our aim was to determine the frequency of kidney dysfunction in ischaemic stroke patients with and without AF.

METHODS

In a prospectively collected, single center cohort of acute ischaemic stroke and transient ischaemic attack (TIA) patients, glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease equation on admission. Renal function was graded into five categories (cat.): cat. 1, eGRF ≥90 ml/min/1.73 m(2); cat. 2, 60-89; cat. 3, 30-59; cat. 4, 15-29; cat. 5, <15. The diagnosis of AF was based on medical history, a 12-lead electrocardiogram (ECG) and 24-h Holter or continuous ECG monitoring.

RESULTS

In total, 2274 patients (1727 stroke, 547 TIA; median age 71.0) were included. Median eGFR was 78.6 ml/min/1.73 m(2) (interquartile range 61/95); 21.1% were in cat. 3, 2.1% in cat. 4, 0.7% in cat. 5. In all, 535 patients (23.5%) suffered from AF; 28.0% of these were in cat. 3, 2.6% and 0.8% in cat. 4 and cat. 5, respectively. In multivariable analysis, age [odds ratio (OR) 1.1], diabetes (OR 1.8), heart failure (OR 1.7) and AF (OR 1.4) were independently associated with kidney dysfunction (eGFR < 60).

CONCLUSIONS

Renal dysfunction is far more common in stroke patients than in the general population and more common in AF-related stroke. These findings may have implications for the choice of anticoagulants.

Intracerebral hemorrhage during anticoagulation with vitamin K antagonists: a consecutive observational study

Intracerebral hemorrhage (ICH) is the most devastating complication of oral anticoagulation (OAC). As the number of patients on long-term OAC is expected to rise, the proportion of intracerebral hemorrhage related to OAC (OAC-ICH) in relation to spontaneous ICH (spont-ICH) is expected to increase as well. We determined the proportion of OAC-ICH in consecutive stroke patients and explored differences between OAC-ICH and spont-ICH regarding initial volume, hematoma expansion and outcome. Our prospective study consecutively enrolled patients with supra- and infratentorial ICH. The National Institute of Health Stroke Scale Score and the modified Rankin Scale (mRS) score at baseline and after 3 months, medical history and demographic variables were recorded. All admission and follow-up CTs/MRIs were analysed regarding ICH volume using the ABC/2-method. Intraventricular hemorrhage (IVH) was quantified using the Graeb score. Within 19 months, 2,282 patients were admitted to our ER. 206 ICH patients were included. Overall, 24.8 % of all ICH were related to OAC. Compared to patients with spont-ICH, OAC-ICH patients were older (p = 0.001), more frequently had initial extension of ICH into the ventricles (p = 0.05) or isolated primary IVH (p = 0.03) and a higher Graeb score upon admission (p = 0.01). In contrast, initial ICH volume (p = 0.16) and ICH expansion (p = 0.9) in those receiving follow-up imaging (n = 152) did not differ between the two groups. After correction for age, there was a trend towards poorer outcome in OAC-ICH (p = 0.08). One-fourth of all ICH are related to OAC. Initial extension of ICH into the ventricles and primary IVH are more frequent in OAC-ICH. The rate of hematoma expansion in OAC-ICH patients is similar to non-anticoagulated ICH patients.

Does the STAF score help detect paroxysmal atrial fibrillation in acute stroke patients?

BACKGROUND AND PURPOSE

Detecting paroxysmal atrial fibrillation (pAF) soon after acute cerebral ischaemia has a major impact on secondary stroke prevention. Recently, the STAF score, a composite of clinical and instrumental findings, was introduced to identify stroke patients at risk of pAF. We aimed to validate this score in an independent study population.

METHODS

Consecutive patients admitted to our stroke unit with acute ischaemic stroke were prospectively enrolled. The diagnostic work-up included neuroimaging, neuroultrasound, baseline 12-channel electrocardiogram (ECG), 24-h Holter ECG, continuous ECG monitoring, and echocardiography. Presence of AF was documented according to the medical history of each patient and after review of 12-lead ECG, 24-h Holter ECG, or continuous ECG monitoring performed during the stay on the ward. Additionally, a telephone follow-up visit was conducted for each patient after 3 months to inquire about newly diagnosed AF. Items for each patient-age, baseline NIHSS, left atrial dilatation, and stroke etiology according to the TOAST criteria - were assessed to calculate the STAF score.

RESULTS

Overall, 584 patients were enrolled in our analysis. AF was documented in 183 (31.3%) patients. In multivariable analysis, age, NIHSS, left atrial dilatation, and absence of vascular etiology were independent predictors for AF. The logistic AF-prediction model of the STAF score revealed fair classification accuracy in receiver operating characteristic curve analysis with an area under the curve of 0.84. STAF scores of ≥5 had a sensitivity of 79% and a specificity of 74% for predicting AF.

CONCLUSION

The value of the STAF score for predicting the risk of pAF in stroke patients is limited.

Postoperative memory prediction in left temporal lobe epilepsy: the Wada test is of no added value to preoperative neuropsychological assessment and MRI

The contribution of the Wada test (intracarotid amytal procedure, IAP) to predicting postoperative memory outcome in left temporal lobe epilepsy (LTLE) is becoming increasingly controversial when preoperative neuropsychological evaluation and MRI findings are available. We retrospectively analyzed 59 patients with LTLE who underwent en bloc temporal lobe resection. All patients had valid bilateral IAP test results, complete pre- and postoperative neuropsychological evaluation, and MRI grading on a 5-point scale integrating T 2 signal increase and degree of atrophy. Thirty percent of patients showed postoperative memory decline. Multiple regression analysis revealed that significant predictors of decline [F(2.56)=22.71, P<0.001, r(2)=0.448] included preoperative memory learning score [t=-5.89, P<0.001] and MRI classification [t=3.10, P<0.003], but not IAP scores. The IAP is of no added value in the prediction of postoperative memory outcome in LTLE in the presence of comprehensive neuropsychological and MRI data.

Sonographic monitoring of mass effect in stroke patients treated with hypothermia. Correlation with intracranial pressure and matrix metalloproteinase 2 and 9 expression

Severe stroke leads to subsequent cerebral oedema. Patients with severe stroke develop midline shift (MLS) which can be measured by transcranial duplex sonography (TCD). We measured MLS with TCD in 30 patients with large infarction in the territory of the middle cerebral artery (MCA). All of the examined patients had intracranial pressure (ICP) measure devices and the ICP at the time of the TCD was recorded. MLS was also determined on CT scan on day 4. Ten of the 30 patients were treated with hypothermia. We also determined matrix metalloproteinase 2 (MMP2) and matrix metalloproteinase 9 (MMP9) in serum by zymography. MLS measured by TCD correlated significantly with MLS on CT. In addition there was a strong correlation between the ICP measured at the time of TCD and MLS. In patients treated with hypothermia MLS was less pronounced. MMP9 and MMP2 showed a characteristic time course and had strong associations with MLS. We confirm earlier reports that TCD is a reliable noninvasive method for serially monitoring patients with intracranial lesions. Hypothermia reduces MMP9 activity as well as MLS. TCD may reduce the need for repetitive CT scans in neurological critically ill patients.

Gene expression in human peripheral blood mononuclear cells upon acute ischemic stroke

BACKGROUND AND PURPOSE

Ischemic stroke provokes a systemic inflammatory response. The purpose of this study was to characterize this response on the gene expression level in circulating mononuclear leukocytes from acute ischemic stroke (AIS) patients.

METHODS

RNA from peripheral blood mononuclear cells (PBMCs) of AIS patients (24 + 2 hours after onset of symptoms) was analyzed with Affymetrix U133A GeneChips using a pooled design. We compared the gene expression signature from AIS patients (n = 20), stroke survivors (n = 15), patients with acute traumatic brain injury (ATBI, n = 15) and healthy control subjects without vascular risk factors (n = 15).

RESULTS

Expression levels of 9682 probe sets with present calls on each GeneChip were compared. Between AIS patients and stroke survivors or between AIS patients and ATBI patients there were no significant differences in expression values of single genes after correction for multiple testing. However, comparison of the PBMC expression profiles from AIS patients and healthy subjects revealed significantly different expression (p = 0.012) of a single probe set, specific for phosphodiesterase 4 D (PDE4D). In order to detect modest expression differences in multiple genes with a presumed cumulative effect we studied the gene expression of functional groups of genes by global statistical tests. Analysis of 11 gene groups revealed differential expression between AIS patients and healthy subjects for genes involved in the inflammatory response (GeneOntology GO:0006954). Genes encoding the N-formyl peptide receptor-like 1 (FPRL1), interleukin-1 receptor antagonist (IL1RN) and complement component 3a receptor 1 (C3AR1) contributed most to the observed difference.

CONCLUSIONS

This transcriptome analysis did not identify significant changes between circulating mononuclear cells from AIS patients 24 hours after stroke and closely matched stroke survivors. However, comparing AIS patients with healthy control subjects revealed measurable differences in PDE4D and in inflammatory response genes when considered as a set.

Expression and processing of Plasmodium berghei SERA3 during liver stages

Cysteine proteases mediate liberation of Plasmodium berghei merozoites from infected hepatocytes. In an attempt to identify the responsible parasite proteases, we screened the genome of P. berghei for cysteine protease-encoding genes. RT-PCR analyses revealed that transcription of four out of five P. berghei serine repeat antigen (PbSERA) genes was strongly upregulated in late liver stages briefly before the parasitophorous vacuole membrane ruptured to release merozoites into the host cell cytoplasm, suggesting a role of PbSERA proteases in these processes. In order to characterize PbSERA3 processing, we raised an antiserum against a non-conserved region of the protein and generated a transgenic P. berghei strain expressing a TAP-tagged PbSERA3 under the control of the endogenous promoter. Immunofluorescence assays revealed that PbSERA3 leaks into the host cell cytoplasm during merozoite development, where it might contribute to host cell death or activate host cell proteases that execute cell death. Importantly, processed PbSERA3 has been detected by Western blot analysis in cell extracts of schizont-infected cells and merozoite-infected detached hepatic cells.

The liver stage of Plasmodium berghei inhibits host cell apoptosis

Plasmodium berghei is the causative agent of rodent malaria and is widely used as a model system to study the liver stage of Plasmodium parasites. The entry of P. berghei sporozoites into hepatocytes has extensively been studied, but little is known about parasite-host interaction during later developmental stages of the intracellular parasite. Growth of the parasite far beyond the normal size of the host cell is an important stress factor for the infected cell. Cell stress is known to trigger programmed cell death (apoptosis) and we examined several apoptotic markers in P. berghei-infected cells and compared their level of expression and their distribution to that of non-infected cells. As none of the apoptotic markers investigated were found altered in infected cells, we hypothesized that parasite infection might confer resistance to apoptosis of the host cell. Treatment with peroxide or serum deprivation induced apoptosis in non-infected HepG2 cells, whereas P. berghei-infected cells appeared protected, indicating that the parasite interferes indeed with the apoptotic machinery of the host cell. To prove the physiological relevance of these results, mice were infected with high numbers of P. berghei sporozoites and treated with tumour necrosis factor (TNF)-alpha/D-galactosamine to induce massive liver apoptosis. Liver sections of these mice, stained for degraded DNA, confirmed that infected cells containing viable parasites were protected from programmed cell death. However, in non-treated control mice as well as in TNF-alpha-treated mice a small proportion of dead intracellular parasites with degraded DNA were detected. Most hepatocytes containing dead parasites provoked an infiltration of immunocompetent cells, indicating that these cells are no longer protected from cell death.

The cooperation of B-Myb with the coactivator p300 is orchestrated by cyclins A and D1

B-Myb is a highly conserved member of the Myb family of transcription factors whose activity is regulated during the cell cycle. Previous work has shown that the activity of B-Myb is stimulated by cyclin A/Cdk2-dependent phosphorylation whereas interaction of B-Myb with cyclin D1 inhibits its activity. Here, we have investigated the role of p300 as a coactivator for B-Myb. We show that B-Myb-dependent transactivation is stimulated by p300 as a result of interaction between B-Myb and p300. We have mapped the sequences responsible for the interaction of B-Myb and p300 to the E1A-binding region of p300 and the transactivation domain of B-Myb, respectively. Furthermore, our data suggest that phosphorylation of B-Myb stimulates its acetylation by p300 and that the acetylation of B-Myb is necessary for the full stimulation of its transactivation potential by p300. We have also studied the effect of cyclin D1 on the cooperation of B-Myb and p300. Based on our results we propose that cyclin D1 inhibits the activity of B-Myb by interfering with the interaction of B-Myb and p300. The data reported here provide novel insight into the mechanisms by which the activity of B-Myb is regulated during the cell cycle. Taken together they suggest that the coactivator p300 plays an important role in this regulation and that the cooperation of B-Myb and p300 is orchestrated by cyclins A and D1.