The Correlation of Retinal Nerve Fiber Layer Thickness With Blood Pressure in a Chinese Hypertensive Population

To investigate the association between retinal nerve fiber layer (RNFL) thickness and blood pressure (BP) in subjects with systemic hypertension.Subjects with systemic hypertension on anti-hypertensive medications were screened by fundus photography and referred for glaucoma work-up if there was enlarged vertical cup-to-disc (VCDR) ratio ≥0.6, VCDR asymmetry ≥0.2, or optic disc hemorrhage. Workup included a complete ophthalmological examination, Humphrey visual field test, and RNFL thickness measurement by optical coherence tomography. The intraocular pressure (IOP) and RNFL thicknesses (global and quadrant) were averaged from both eyes and the means were correlated with: the systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) using Pearson correlation.Among 4000 screened hypertensive subjects, 133 were referred for glaucoma workup and 110 completed the workup. Of the 4000 screened subjects, 1.3% had glaucoma (0.9% had normal tension glaucoma [NTG], 0.2% had primary open angle glaucoma, and 0.2% had primary angle closure glaucoma), whereas 0.3% were NTG suspects. The SBP was negatively correlated with the mean superior RNFL thickness (P = 0.01). The DBP was negatively correlated with the mean global (P = 0.03), superior (P = 0.02), and nasal (P = 0.003) RNFL thickness. The MAP was negatively correlated with the mean global (P = 0.01), superior (P = 0.002), and nasal (P = 0.004) RNFL thickness while positively correlated with the mean IOP (P = 0.02).In medically treated hypertensive subjects, glaucoma was present in 1.3%, with NTG being most prevalent. MAP control may help with IOP lowering and RNFL preservation, although future prospective studies will be needed.Glaucoma is a chronic, progressive and irreversible optic neuropathy with characteristic anatomical and structural defects due to loss of the retinal ganglion cells. Loss of the retinal nerve fiber layer (RNFL) may precede visual field changes.^1,2 Various studies have demonstrated that up to 40–50% of the retinal ganglion cells need to be lost before visual field defects are observed in standard automated perimetry, which is still considered to be one of the gold standard investigations for glaucoma.^3,4 Assessment of RNFL thickness, on the other hand, is an objective test that has a high degree of correlation with visual field defects but at the same time able to detect earlier, pre-perimetric disease.^5,6Intraocular pressure (IOP) is still the most important modifiable risk factor of glaucoma progression. Vascular risk factors such as systemic hypertension, ocular perfusion pressure, hypercoagulability, carotid artery disease, and vasospasm have been extensively studied and it has been demonstrated that ocular hypoperfusion and systemic blood pressure play a vital role in the pathogenesis of glaucoma.^7–13 Some studies have demonstrated a positive association between systemic hypertension (HT) and glaucoma,^14–18 whereas others have demonstrated no significant association between the 2 entities.^19,20To our knowledge, very few studies have examined the association between RNFL thickness and BP.^21,22 The purpose of our study was to determine association between RNFL thickness with systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) in subjects with medically treated systemic HT.     

Outcome of Hepatitis E Virus Infection in Patients With Inflammatory Arthritides Treated With Immunosuppressants: A French Retrospective Multicenter Study

The clinical presentation and outcome of hepatitis E virus (HEV) infection in inflammatory rheumatic diseases are unknown. We aimed to investigate the severity of acute HEV infection and the risk of chronic viral replication in patients with inflammatory arthritides treated with immunosuppressive drugs.All rheumatology and internal medicine practitioners belonging to the Club Rhumatismes et Inflammation in France were sent newsletters asking for reports of HEV infection and inflammatory arthritides. Baseline characteristics of patients and the course of HEV infection were retrospectively assessed by use of a standardized questionnaire.From January 2010 to August 2013, we obtained reports of 23 cases of HEV infection in patients with rheumatoid arthritis (n = 11), axial spondyloarthritis (n = 5), psoriatic arthritis (n = 4), other types of arthritides (n = 3). Patients received methotrexate (n = 16), antitumor necrosis factor α agents (n = 10), rituximab (n = 4), abatacept (n = 2), tocilizumab (n = 2), and corticosteroids (n = 10, median dose 6 mg/d, range 2–20). All had acute hepatitis: median aspartate and alanine aminotransferase levels were 679 and 1300 U/L, respectively. Eleven patients were asymptomatic, 4 had jaundice. The HEV infection diagnosis relied on positive PCR results for HEV RNA (n = 14 patients) or anti-HEV IgM positivity (n = 9). Median follow-up was 29 months (range 3–55). Treatment included discontinuation of immunosuppressants for 20 patients and ribavirin treatment for 5. Liver enzyme levels normalized and immunosuppressant therapy could be reinitiated in all patients. No chronic infection was observed.Acute HEV infection should be considered in patients with inflammatory rheumatism and elevated liver enzyme values. The outcome of HEV infection seems favorable, with no evolution to chronic hepatitis or fulminant liver failure.Hepatitis E virus (HEV) infection is ubiquitous and is due to a small nonenveloped virus with a positive-sense, single-stranded RNA genome. The virus was discovered in the 1980s. Four major genotypes representing a single serotype have been recognized: HEV1 and HEV2 are restricted to humans and transmitted via contaminated water in developing countries; HEV3 and HEV4 infect humans, pigs, and other mammalian species and are responsible for sporadic cases of autochthonous HEV infection in Western countries. In this setting, HEV infection causes acute disease, mainly in middle-aged and older men. Such an infection might be mistaken for drug-induced liver injury.¹ Acute HEV infection might range in severity from subclinical to fulminant, in particular in the risk group of pregnant women, whose death rate in the course of HEV infection could approach 15% to 20%.^2,3 However, in the rest of the population and in immunosuppressed patients,⁴ acute HEV infection is usually asymptomatic. Thus, in a French study of kidney transplant recipients, acute HEV infection was asymptomatic in 14 of 16 patients (87.5%).⁵ Some extrahepatic manifestations of HEV infection were reported. Kamar et al⁶ reported neurologic disorders among 126 patients with HEV infection: inflammatory polyradiculopathy (n = 3), Guillain-Barre syndrome (n = 1), bilateral brachial neuritis (n = 1), encephalitis (n = 1), and ataxia/proximal myopathy (n = 1). Hematological disorders, notably acute immune thrombocytopenia,⁷ were also reported.Recent efforts to develop and standardize the HEV serology led to data showing increasingly recognized cases of HEV infection. HEV infection might correspond to about 10% of cases of non-A–D acute viral hepatitis in Western countries among nontravelers.⁸Another feature of HEV is its ability to cause chronic infection, defined as a persistent infection lasting >6 months, usually in severely immunocompromised patients.⁹ In 3 well-known circumstances of immunodeficiency—AIDS, kidney or liver transplantation, and haematological malignancies—HEV infection can develop into chronic infection.^10,11 In liver transplant recipients,¹² chronic infection with HEV can result in HEV-related cirrhosis.¹³ However, little is known about the incidence and severity of acute and chronic HEV infection in patients with inflammatory rheumatic diseases. We therefore addressed this issue of HEV infection in patients receiving treatment for inflammatory arthritides.     

Seroreactivity to a Large Panel of Field-Derived Plasmodium falciparum Apical Membrane Antigen 1 and Merozoite Surface Protein 1 Variants Reflects Seasonal and Lifetime Acquired Responses to Malaria

Parasite antigen diversity poses an obstacle to developing an effective malaria vaccine. A protein microarray containing Plasmodium falciparum apical membrane antigen 1 (AMA1, n = 57) and merozoite surface protein 1 19-kD (MSP1₁₉, n = 10) variants prevalent at a malaria vaccine testing site in Bandiagara, Mali, was used to assess changes in seroreactivity caused by seasonal and lifetime exposure to malaria. Malian adults had significantly higher magnitude and breadth of seroreactivity to variants of both antigens than did Malian children. Seroreactivity increased over the course of the malaria season in children and adults, but the difference was more dramatic in children. These results help to validate diversity-covering protein microarrays as a promising tool for measuring the breadth of antibody responses to highly variant proteins, and demonstrate the potential of this new tool to help guide the development of malaria vaccines with strain-transcending efficacy.Plasmodium falciparum uses antigenic variation to evade host immunity, including vaccine-induced immunity.^1,2 The protective immunity against P. falciparum malaria disease that is acquired after years of exposure is believed to reflect, in part, the gradual acquisition of allele-specific immune responses against a repertoire of parasite antigens, and, importantly, against diverse variants of these antigens.³ Apical membrane antigen 1 (AMA1) and merozoite surface protein 1 (MSP1) are immunogenic parasite surface antigens considered vital for erythrocyte attachment and invasion. Antibodies against these proteins are associated with protection against malaria, and several subunit AMA1 and MSP1 vaccines have been developed and tested.^1,4–6 Both AMA1 and MSP1₁₉, the C-terminus portion of the MSP1 protein used in subunit vaccines, are highly variable, with sequence diversity encoded by single nucleotide polymorphisms.^7,8 The highest prevalence of any one of the 440 AMA1 haplotypes observed from sequencing the ama1 gene among more than 1,400 field infections diagnosed during prospective incidence studies and vaccine trials was less than 4%.^1,8,9Although less extreme, MSP1₁₉ also has substantial diversity, with 17 haplotypes detected among more than 1,300 infections.⁷ Because vaccines that include dozens or hundreds of antigen variants are not feasible, malaria vaccine development would be aided by the identification of a manageable number of serodominant, cross-protective haplotypes among AMA1 and MSP1₁₉ variants. Developing such strain-transcending vaccines is hindered by the limited availability of diverse parasite antigens and the low throughput of standard assays such as enzyme-linked immunosorbent assay for measuring antibody responses.Protein microarrays offer the possibility of overcoming these obstacles to enable high throughput evaluations of seroreactivity to large numbers of antigen variants. Plasmodium falciparum proteins expressed in a cell-free Escherichia coli translation system and spotted onto microarrays are recognized by serum antibodies of persons exposed to malaria.^10–12 To date, this platform has been used to measure seroreactivity to large numbers of proteins derived from the genome of the P. falciparum reference strain 3D7.^10,12–14 To examine antibody responses to diverse variants of highly polymorphic P. falciparum antigens, we amplified, expressed and printed dozens of field-derived variants of AMA1 and MSP1₁₉ on a protein microarray.Antigen genes were amplified by polymerase chain reaction from DNA extracted from dried blood spots collected in a cohort study and an AMA1 vaccine trial in Mali, Africa. The resulting amplicons were analyzed by using the BigDye^® Terminator v3.1 Cycle Direct Sequencing Kit (Applied Biosciences, Foster City, CA).^4,8,15 Sequence contigs were compiled by using Sequencher software (Gene Codes, Ann Arbor, MI).^9,16 Sixty of the most prevalent AMA1 ectodomain haplotypes and 10 MSP1₁₉ haplotypes were selected for inclusion on the prototype protein microarray. Microarray construction has been described.¹⁷Serum samples were obtained from 18 adults 18–55 years of age enrolled in the control arm of a phase 1 trial of an AMA1-based vaccine conducted during 2004–2005 in Bandiagara, Mali.¹⁸ Similarly, serum samples were randomly obtained from 24 children 1–6 years of age enrolled in the control arm of a phase 1 trial of an AMA1-based malaria vaccine during 2006–2007 at the same site.^6,19 Bandiagara, Mali has high seasonal malaria transmission coinciding with the June–November rainy season, with entomologic inoculation rates of 50–150 infected bites/person/season.⁸ For each participant, paired serum samples from two time points corresponding to the pre-malaria (May–June) and post-malaria (December–January) seasons were probed in random order to eliminate batch and slide effects.Two microliters of serum from individual participant samples was diluted 1:200 with 10% E. coli lysate in blocking buffer and hybridized onto separate protein arrays overnight. Arrays were stained, washed, and scanned by using a Perkin-Elmer (Waltham, MA) ScanArray Express HT microarray scanner. Probing protocols have been described.^10,12,17 Fluorescence was quantified by using the ScanArray Express Suite (Perkin-Elmer). Median fluorescent intensities (MFIs) were calculated by using an adaptive capture feature to account for varying spot size, and the per-spot local background was subtracted.Raw MFIs were asinh-transformed to convert the MFI values to a Gaussian (normal) distribution, and biological variance contributed by seroreactivity to the E. coli components included in the translation protocol was subtracted by taking the average of eight empty vector, translated, negative controls (i.e., the no DNA controls). Residual non-biological variance between slides, batches, and individual arrays was corrected by using robust linear modeling (RLM) with respect to the negative and positive controls.²⁰ Asinh-transformed, RLM-scaled data were reverted to fluorescent intensities by sinh reverse-transformation and plotted on a heat map to show global trends (Figure 1).Open in a separate windowFigure 1.Heat map of seroreactivity to Plasmodium falciparum apical membrane antigen 1 (AMA1) and merozoite surface protein 1–19 (MSP1₁₉) variants. Each column represents serum from an individual Malian child or adult, or a malaria-naive North American adult, and each row represents an antigen variant. Gray, black, and red indicate low, moderate and high seroreactivity, respectively, to probed antigens. Four serial dilutions of IgG peptide were printed and probed as positive probing controls and used as a standardization parameter for robust linear model scaling as a measurement of total IgG. MFI = median fluorescent intensity.Parametric statistical hypotheses were tested on asinh-transformed, RLM-scaled data by using BioconductR (http://www.bioconductor.org/index.html, Excel (Microsoft, Redmond, WA), and SAS/STAT software (SAS Institute, Cary, NC). The magnitude of seroreactivity was measured by mean MFI using matched pair Student''s t tests (

Intestinal glucuronidation protects against chemotherapy-induced toxicity by irinotecan (CPT-11)

Camptothecin (CPT)-11 (irinotecan) has been used widely for cancer treatment, particularly metastatic colorectal cancer. However, up to 40% of treated patients suffer from severe late diarrhea, which prevents CPT-11 dose intensification and efficacy. CPT-11 is a prodrug that is hydrolyzed by hepatic and intestinal carboxylesterase to form SN-38, which in turn is detoxified primarily through UDP-glucuronosyltransferase 1A1 (UGT1A1)-catalyzed glucuronidation. To better understand the mechanism associated with toxicity, we generated tissue-specific Ugt1 locus conditional knockout mouse models and examined the role of glucuronidation in protecting against irinotecan-induced toxicity. We targeted the deletion of the Ugt1 locus and the Ugt1a1 gene specifically in the liver (Ugt1^ΔHep) and the intestine (Ugt1^ΔGI). Control (Ugt1^F/F), Ugt1^ΔHep, and Ugt1^ΔGI adult male mice were treated with different concentrations of CPT-11 daily for four consecutive days. Toxicities were evaluated with regard to tissue glucuronidation potential. CPT-11–treated Ugt1^ΔHep mice showed a similar lethality rate to the CPT-11–treated Ugt1^F/F mice. However, Ugt1^ΔGI mice were highly susceptible to CPT-11–induced diarrhea, developing severe and lethal mucositis at much lower CPT-11 doses, a result of the proliferative cell loss and inflammation in the intestinal tract. Comparative expression levels of UGT1A1 in intestinal tumors and normal surrounding tissue are dramatically different, providing for the opportunity to improve therapy by differential gene regulation. Intestinal expression of the UGT1A proteins is critical toward the detoxification of SN-38, whereas induction of the UGT1A1 gene may serve to limit toxicity and improve the efficacy associated with CPT-11 treatment.Colorectal cancer (CRC) is the third most commonly diagnosed cancer in the world (1, 2). Camptothecin (CPT)-11 (irinotecan) has been used alone or in combination with other drugs as the first-line therapeutic agent for metastatic CRC (3–5). However, its efficacy and safety are compromised because of severe late diarrhea, the side-effect resulting from CPT-11 bioactivation and subsequent metabolism, generally occurring more than 24 h after the administration of irinotecan (6–9). CPT-11 is a prodrug that is hydrolyzed by carboxylesterase (CES) activity to the active topoisomerase 1 inhibitor, SN-38 (10, 11). Inactivation and detoxification occur primarily by hepatic UDP-glucuronosyltransferase 1A1 (UGT1A1)-catalyzed glucuronidation to form the SN-38 glucuronide (SN-38G), which subsequently undergoes biliary excretion. In 2005 and 2010, the US Food and Drug Administration (FDA) updated the label for CPT-11 regarding the heightened risk of serious side effects for patients with the homozygous and heterozygous UGT1A1*28 allele (12, 13), recommending an initial dose reduction. Patients who carry the homozygous UGT1A1*28 alleles, identified as Gilbert’s syndrome, have reduced hepatic UGT1A1 expression (14, 15). However, the FDA’s recommendation has been questioned because Gilbert’s patients receiving CPT-11 therapy have been shown to experience toxicity to a lesser degree than previously anticipated (16, 17). After its excretion into the bile, SN-38G reaches the gastrointestinal tract, where it is subjected to bacterial β-glucuronidase β-linkage cleavage that produces a free SN-38 aglycone (18–21). Recent findings, using specific bacterial β-glucuronidase inhibitors to protect mice from CPT-11–induced late diarrhea, strongly suggest that the enterohepatic circulation of SN-38 plays an essential role in the delayed diarrhea (18, 22). Thus, glucuronidation of SN-38 both in the liver and the GI tract is not a simple detoxification reaction but a rather complex enzymatic process that is closely associated with drug detoxification, toxicity, and efficacy.Conventionally, the liver is considered the major organ for CPT-11 metabolism, abundantly expressing both CES and UGT enzymes. However, the intestinal tissue from both humans and rodents is also rich in these enzymes (10, 11, 23–25). The direct conversion of CPT-11 to SN-38 in the intestine is considered to be one of the mechanisms leading to intestinal toxicity (10, 26, 27). Alternatively, intestinal microflora-derived β-glucuronidase is capable of catalyzing SN-38G to generate free SN-38 through enterohepatic circulation (18). Thus, we are hypothesizing that levels of intestinal UGT1A activity play a key role in the metabolism of SN-38- and CPT-11–induced intestinal toxicity. Through the generation of tissue-specific Ugt1 locus conditional knockout animal models, we have directly examined the impact of tissue-specific UGT1A expression toward CPT-11–induced intestinal damage and clearance.     

Efficacy of Anakinra in Refractory Adult-Onset Still's Disease: Multicenter Study of 41 Patients and Literature Review

Adult-onset Still''s disease (AOSD) is often refractory to standard therapy. Anakinra (ANK), an interleukin-1 receptor antagonist, has demonstrated efficacy in single cases and small series of AOSD. We assessed the efficacy of ANK in a series of AOSD patients.Multicenter retrospective open-label study. ANK was used due to lack of efficacy to standard synthetic immunosuppressive drugs and in some cases also to at least 1 biologic agent.Forty-one patients (26 women/15 men) were recruited. They had a mean age of 34.4 ± 14 years and a median [interquartile range (IQR)] AOSD duration of 3.5 [2–6] years before ANK onset. At that time the most common clinical features were joint manifestations 87.8%, fever 78%, and cutaneous rash 58.5%. ANK yielded rapid and maintained clinical and laboratory improvement. After 1 year of therapy, the frequency of joint and cutaneous manifestations had decreased to 41.5% and to 7.3% respectively, fever from 78% to 14.6%, anemia from 56.1% to 9.8%, and lymphadenopathy from 26.8% to 4.9%. A dramatic improvement of laboratory parameters was also achieved. The median [IQR] prednisone dose was also reduced from 20 [11.3–47.5] mg/day at ANK onset to 5 [0–10] at 12 months. After a median [IQR] follow-up of 16 [5–50] months, the most important side effects were cutaneous manifestations (n = 8), mild leukopenia (n = 3), myopathy (n = 1), and infections (n = 5).ANK is associated with rapid and maintained clinical and laboratory improvement, even in nonresponders to other biologic agents. However, joint manifestations are more refractory than the systemic manifestations.Adult-Onset Still''s Disease (AOSD) is a systemic inflammatory disease of unknown origin characterized by daily high-spiking fevers, evanescent maculopapular rash, sore throat, arthritis and/or arthralgia, myalgia, serositis, lymphadenopathy, and hepatosplenomegaly. Laboratory evaluation typically demonstrates elevated acute-phase reactants, leukocytosis with neutrophil predominance, elevated levels of liver enzymes, and high levels of serum ferritin.^1,2AOSD is considered a complex autoinflammatory syndrome in which various environmental factors trigger an autoinflammatory systemic response in genetically predisposed individuals. Interleukin-1 (IL-1) appears to be implicated in AOSD pathogenesis as increased levels of this cytokine have been found in these patients compared to healthy controls.^3,4 Cytokine profile in AOSD sera is also characterized by the presence of interleukin-6 (IL-6), IL-18, tumor necrosis factor-α (TNF-α), and interferon-γ (IFN-γ).^5,6 Moreover, one of the major events in the pathogenesis of this syndrome seems to be a dysregulation of inflammasome complex and a related overproduction of active IL-1β promoted by IL-18.⁷The central role of the inflammasome complex may explain the intermittent course of the disease and the clinical and laboratory features that are found in genetically predisposed autoinflammatory syndromes.First-line treatment in AOSD has been classically based on nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. In an attempt to use the lowest possible dose of corticosteroids, other therapies, such as methotrexate, azathioprine, leflunomide, intravenous immunoglobulin, anti-TNF-α drugs, rituximab, or abatacept, are often given to achieve adequate control of the disease. However, the efficacy of these drugs is variable and they are not exempt from potential severe side effects.Anakinra (ANK) is a recombinant, nonglycosylated form of human IL-1 receptor that acts as a pure receptor antagonist binding tightly to the IL-1 receptor and preventing activation of this receptor by either IL-1β or IL-1α. Approved by the Food and Drug Administration (FDA) for the treatment of rheumatoid arthritis in 2001, its use in AOSD is supported by the pivotal role of IL-1β in this disease. In fact, ANK has been used for the treatment of AOSD with satisfactory results. However, in most cases information related to this issue was based on isolated cases reports or AOSD small series.^3,4,8–11Nevertheless, in an open, randomized, multicenter study that included 22 patients with AOSD taking prednisolone ≥10 mg/day, ANK induced more beneficial responses than disease-modifying antirheumatic drugs (DMARD).¹²Taking into account these considerations, our aim was to evaluate the efficacy of ANK in a large series of Spanish patients with AOSD refractory to other therapies.     

Jamestown Canyon Virus Disease in the United States—2000–2013

Jamestown Canyon virus (JCV) is a mosquito-borne orthobunyavirus in the California serogroup that can cause an acute febrile illness, meningitis, or meningoencephalitis. We describe epidemiologic and clinical features for JCV disease cases occurring in the United States during 2000–2013. A case of JCV disease was defined as an acute illness in a person with laboratory evidence of a recent JCV infection. During 2000–2013, we identified 31 cases of JCV disease in residents of 13 states. The median age was 48 years (range, 10–69) and 21 (68%) were male. Eleven (35%) case patients had meningoencephalitis, 6 (19%) meningitis, 7 (23%) fever without neurologic involvement, and 7 (23%) had an unknown clinical syndrome. Fifteen (48%) were hospitalized and there were no deaths. Health-care providers and public health officials should consider JCV disease in the differential diagnoses of viral meningitis and encephalitis, obtain appropriate specimens for testing, and report cases to public health authorities.Jamestown Canyon virus (JCV) is a mosquito-borne orthobunyavirus that causes an acute febrile illness, meningitis, or meningoencephalitis.^1–5 Although JCV is widely distributed throughout temperate North America, reports of human JCV infection in the United States are rare.¹ JCV was first isolated in 1961 from a pool of Culiseta inornata mosquitoes in Jamestown Canyon, CO.⁶ Since then, the virus has been isolated from various mosquito species (e.g., Aedes, Coquillettidia, Culex, and Culiseta species) in the northeastern, midwestern, and western United States.^6–19 JCV neutralizing antibodies have been found in various mammals throughout mainland North America,^13,20–36 and identified in humans throughout the United States.^{1–5,34,37–41}JCV is a member of the California serogroup viruses, which include La Crosse virus (LACV), California encephalitis virus, and snowshoe hare virus.⁴² Although the presence of anti-JCV immunoglobulin (Ig) M detected by enzyme-linked immunosorbent assay (ELISA) is usually evidence of a recent JCV infection, it also may indicate infection with another closely related California serogroup virus.^35,42,43 Plaque reduction neutralization tests (PRNTs) can be performed to measure virus-specific neutralizing antibodies and to potentially discriminate among cross-reacting antibodies from closely related California serogroup viruses.^44,45Prior to 2014, testing for JCV infection in the United States was performed at the Arboviral Diseases Branch of the Centers for Disease Control and Prevention (CDC) and at the Wadsworth Laboratory of the New York State Department of Health (NYSDOH). Since 2000, NYSDOH has been able to perform JCV PRNTs on acute and convalescent samples testing positive for California serogroup IgG antibodies by immunofluorescence assay. At the CDC, PRNTs have been used to detect JCV neutralizing antibodies since 1995. All samples testing positive or equivocal for LACV IgM antibodies by ELISA at the CDC have JCV PRNTs performed. A JCV IgM ELISA was developed at the CDC in 2010. Beginning in 2013, all samples submitted to the CDC for domestic arbovirus testing were routinely tested for JCV IgM antibodies by ELISA, and if positive, were confirmed by JCV PRNTs. We describe the demographic and clinical characteristics of laboratory-confirmed cases of JCV disease occurring in the United States during 2000–2013.     

Pinta: Latin America's Forgotten Disease?

Pinta is a neglected, chronic skin disease that was first described in the sixteenth century in Mexico. The World Health Organization lists 15 countries in Latin America where pinta was previously endemic. However, the current prevalence of pinta is unknown due to the lack of surveillance data. The etiological agent of pinta, Treponema carateum, cannot be distinguished morphologically or serologically from the not-yet-cultivable Treponema pallidum subspecies that cause venereal syphilis, yaws, and bejel. Although genomic sequencing has enabled the development of molecular techniques to differentiate the T. pallidum subspecies, comparable information is not available for T. carateum. Because of the influx of migrants and refugees from Latin America, U.S. physicians should consider pinta in the differential diagnosis of skin diseases in children and adolescents who come from areas where pinta was previously endemic and have a positive reaction in serological tests for syphilis. All stages of pinta are treatable with a single intramuscular injection of penicillin.The endemic treponematoses, pinta, yaws, and bejel, are caused by spiral-shaped, not-yet-cultivable bacteria of the genus Treponema.^1–3 These neglected infectious diseases (NIDs), for which there are no vaccines, present a diagnostic dilemma to physicians because their clinical manifestations must be differentiated from those of other diseases that affect the skin. Moreover, serological tests cannot differentiate the endemic treponematoses from each other or from venereal syphilis, which is caused by the closely related spirochete, Treponema pallidum subspecies pallidum. Unlike venereal syphilis, the endemic treponematoses are usually acquired by children or adolescents living in poor rural communities in tropical climates (see references ¹ and ² for maps showing the geographical distribution of endemic treponematoses). Whereas venereal syphilis has a global distribution and is transmitted primarily by sexual activity, the endemic treponematoses are transmitted by nonsexual, direct skin-to-skin contact with infectious lesions.Pinta, also known as mal del pinto or carate, is the most benign of the endemic treponematoses since it affects only the skin.^1–3 Pinta was first described in the sixteenth century in the Aztec and Carib Amerindians by Spanish conquistadors and missionaries.⁴ In the 1950s, there were an estimated 1 million cases of pinta in Mexico, Central America, and northern South America. Although pinta was most highly endemic in Mexico and Columbia, cases declined in these countries due to treatment campaigns and possibly due to improvements in living standards, access to health services, and hygiene.^4,5 The World Health Organization (WHO) lists 15 countries in Latin America where pinta was previously endemic. Because of the lack of surveillance data, the current prevalence of pinta is unknown. However, some findings suggest that pinta has not disappeared. For example, in 1982 and 1983, clinical evidence of pinta was discovered in 20% of the examined inhabitants of a remote village in Panama.⁶ In 1987 and 1993, pinta cases were reported in native Indians (Ticuna) living in the Amazon border region of Brazil, Columbia, and Peru.^7,8 Although the last reported case of pinta in Cuba was in 1975, an active, early pinta lesion was identified in a Cuban female who was visiting Austria in 1999.⁹ On the basis of these data, it is plausible that pinta has remained endemic in some remote areas of Latin America where access to health services is limited and living standards have not yet risen.^1,2Like syphilis, pinta is classified into stages (see references ^1–3 for pictures of the clinical stages of pinta). The primary stage is characterized by the presence of one or several papules or erythematous scaly plaques that develop about 3 weeks after infection. The body area most commonly affected is the exposed skin of the extremities. The papule or plaque, which is teeming with infectious treponemes, does not ulcerate, but expands to a diameter of 10 cm or greater. Regional lymphadenopathy is common. During early infection, serological tests for syphilis (STS) may be negative for antibodies to nontreponemal (cardiolipin) and treponemal antigens. Plaques may last for months to years and pigmentary changes may be observed in the plaques. The lesions may heal spontaneously or they may persist and become indistinguishable from the lesions of secondary pinta.The secondary stage usually appears several months after the initial manifestations of the primary stage.^1–3 Small disseminated lesions known as “pintids” may coalesce into plaques. The pintids change from an initial red color to brown, slate-blue, black, or gray colors. Different pigmentation may occur within a pintid. The secondary lesions can remain active and infectious for a long time, leading to extensive depigmentation. STS are positive in the majority of untreated cases.The late (tertiary) stage usually develops 2–5 years after initial infection and is characterized by pigmentary abnormalities (i.e., from dyschromic treponeme-containing lesions to achromic treponeme-free lesions), skin atrophy, and hyperkeratosis.^1–3 The degree of lesion pigmentation can be different in the same patient, resulting in a mottled appearance of the skin, which can persist lifelong. Lesions may turn into various colors (e.g., brown, gray-blue, or black). STS are positive in virtually all untreated cases.The etiological agent of pinta, Treponema carateum, was not identified until over 30 years after the 1905 discovery of the related agents of venereal syphilis and yaws.^4,10–12 Initially, it was thought that a pathogenic fungus caused pinta. However, two observations suggested otherwise. First, laboratory studies of pinta patients'' sera showed that the Wassermann test, an early STS, was positive in the majority of cases. Second, treatments that were effective against syphilis (i.e., mercury and arsenicals) were also effective against pinta. In August 1938, Sáenz and others¹⁰ using dark-field microscopy, demonstrated the presence of spirochetes that were morphologically indistinguishable from the T. pallidum subspecies in exudate from a Cuban pinta patient''s lesions. Subsequently, other investigators reported the presence of spirochetes in pinta lesions. Because the presence of these bacteria was insufficient to prove causality, León-Blanco performed skin inoculation experiments on himself and human volunteers with lesion exudate that contained the spirochetes and succeeded in reproducing the early manifestations of pinta.^4,12 León-Blanco also showed that some immunity to reinfection develops during pinta. Patients with late-stage pinta could not be reinfected, whereas patients whose early-stage pinta had been cured could be reinfected. Furthermore, León-Blanco and Briceno Ross and Iriarte demonstrated that syphilis and yaws patients, respectively, were not immune to infection with pinta, despite the antigenic similarity of the etiological agents.^4,11,12Because animal models are necessary to propagate the T. pallidum subspecies for experimental studies, several investigators attempted to determine if laboratory animals could be infected with T. carateum.¹¹ León-Blanco and Oteiza¹³ reported infection of one of the four rabbits that they inoculated intradermally with exudate from a pinta patient''s lesions. However, they were unable to successfully passage T. carateum from the rabbit''s lesion to other rabbits. Later, Kuhn and others¹⁴ demonstrated that chimpanzees could be infected intradermally and that these animals developed lesions similar to those of pinta patients. Unfortunately, T. carateum isolates are not available for study. Although phylogenetic data obtained via genomic sequencing have enabled the development of techniques to differentiate the T. pallidum subspecies, comparable information is not available for T. carateum.^1,2 Thus, despite the morphological and antigenic relatedness of the agents of pinta and syphilis, molecular knowledge of T. carateum is currently insufficient to warrant classification of this spirochete as a T. pallidum subspecies.Pinta can be treated with a single intramuscular injection of long-acting benzathine penicillin (1.2 MU for adults; 0.6 MU for children), which renders the lesions noninfectious in less than 24 hours.^1,3,11 Information is scant concerning the efficacy of other antibiotics. Although early pinta lesions heal within several months after penicillin administration, this treatment cannot reverse the skin changes of late pinta that can stigmatize those who were infected.⁴ Penicillin treatment was the mainstay for the “National Campaign to Eradicate Mal del Pinto” conducted in Mexico (1960s) and for the WHO campaign against the endemic treponematoses (1952–1964).^1,2,4 A national campaign against yaws that was conducted in Columbia in the 1950s resulted in an almost parallel decline in the incidence of both yaws and pinta, even though pinta was not specifically targeted.⁵ Despite the initial success of these campaigns, the endemic treponematoses, particularly yaws, have resurged due to the lack of sustained resources and political will. The WHO has initiated a campaign to eradicate yaws by 2020 that is based on mass treatment of endemic communities with an oral dose of azithromycin, a macrolide antibiotic with demonstrated efficacy against yaws.^1,2,15 If T. carateum is sensitive to azithromycin as is likely, this treatment strategy could have a concomitant effect on pinta in areas of Latin America where yaws and pinta may be co-endemic. Moreover, if the endemic treponematoses were rolled into the program area of the Pan American Health Organization''s (PAHO''s) Strategic Plan (2014–2019) that targets selected NIDs and focuses on strengthening national capacity for screening, treatment, and surveillance of NIDs, this could facilitate elimination of pinta and yaws in PAHO member countries and would aid WHO''s yaws eradication campaign (www.paho.org/hq/).The possibility of importation of NIDs such as the endemic treponematoses increases as record numbers of migrants and refugees from Latin America continue to enter the United States for economic or political reasons.^2,3,16 Accordingly, physicians should consider pinta in the differential diagnosis of skin diseases for Latin American children and adolescents who come from areas where pinta was previously endemic and have a positive reaction in STS.^3,16 This is critical to guide treatment as well as to avoid the inadvertent psychological harm and legal ramifications that can result from making an incorrect diagnosis of syphilis. Although pinta may be a forgotten disease, it is unlikely to be extinct.^9,17     

Response to the Critique by Hahn and Others Entitled “Conservation and Malaria in the Brazilian Amazon”

Hahn and others have recently criticized our study, “Conservation efforts may increase malaria burden in the Brazilian Amazon,” suggesting that results were flawed because of methodological limitations. Here, we briefly comment on some of their claims, showing that (1) several of their criticisms are misleading and others are incorrect, (2) they heavily criticize methods that they themselves have previously used, and (3) they selectively highlight some findings while ignoring others. We end this rebuttal by suggesting a way forward in this debate.Hahn and others¹ have recently written a perspective piece, which was published in The American Journal of Tropical Medicine and Hygiene, criticizing our study published in 2013.² Here, we respond to their critique, commenting and clarifying some of the points raised. Our response is organized in the same order as the issues were raised.Hahn and others¹ provide literature that supports their view that intact forests can help eliminate local malaria transmission. They¹ place special emphasis on a study that was based on a theoretical model parameterized to a different vector and applied to a completely different ecosystem (∼1,000 km away from our study region) on a region that has not had any reported malaria cases for the past 30 years.³ Unfortunately, Hahn and others¹ fail to acknowledge the large literature that support the opposite view regarding the role of forests, and most of those studies were conducted in the Brazilian Amazon.^4–10Hahn and others¹ claim that it is problematic to assume a constant population given that the Brazilian Amazon population increased from 2000 to 2010 by 23%. First, this statement is misleading, because the length of our study corresponds to less than one-half of this time interval. Second, population data arise from the Brazilian Census, which was conducted in 2000, 2007, and 2010. To account for fluctuation in population size, one would have to interpolate between three data points for each county, and it is not clear if this method is a better solution than adopting the 2007 population count for the 2004–2008 study period. Nevertheless, we performed our analysis again (this time using only 2007 malaria data) and found that our original conclusions hold (results available on request).Hahn and others¹ then criticize the fact that we excluded rural health facilities and the two easternmost states in the Brazilian Amazon (Maranhao and Tocantins). First, we did not have data from Maranhao and Tocantins, and therefore, these data were not excluded. Second, as explicitly mentioned in ref. 2, we excluded the rural health facilities because we did not have their spatial coordinates, thus precluding the assessment of the effect of proximity to forests. Third, the remark that we only accounted for 4.8% of the Brazilian Amazon region is misleading, because it ignores the fact that the human population in this region is highly clustered in the vicinities of established cities.^11,12 Even if we had the geographical location of all health facilities, it is likely that the sum of their catchment area would still only account for a small proportion of the overall area. To dispel any questions regarding selection bias, we use all (urban and rural) available data from 2007, this time assuming that all health facilities are located in the vicinity of the established cities. We find that the same results still hold, regardless of adoption of a 20- (as in the original analysis) or 50-km buffer size (which encompasses the great majority of the population in each county; results available on request).Hahn and others¹ suggest that our analysis suffers from the classic ecological fallacy. Any analysis that aggregates data potentially suffers from this problem. However, aggregate data is often the only available data, particularly at the spatial scale of our analysis. Examples of studies that rely on aggregate data abound (including studies by the critique authors themselves^13–15), providing important insights regarding large-scale drivers and spatial patterns of disease risk. Furthermore, our findings do corroborate the results of several entomological and epidemiological site-specific studies in the Brazilian Amazon. Hahn and others¹ then criticize the land use/land cover classification product that we used in our analysis. Interestingly, Hahn and others¹ have also used the same remote sensing product to implicate deforestation in malaria risk.¹⁴ Finally, Hahn and others¹ emphasize results from the works by Vittor and others^16,17 on Plasmodium vivax, while ignoring P. falciparum results from the same study, despite P. falciparum comprising approximately 40% of all detected infections. The PhD thesis of Vittor,¹⁸ which is the basis of the claims by Hahn and others,¹ indicates that P. falciparum prevalence was negatively associated with deforested land, and these results directly conflict with their mosquito and P. vivax data.^16,17 These Plasmodium results were never published in a peer-reviewed journal because of the low numbers of detected infections (110 infections of a total of 2,938 individuals examined). However, Hahn and others¹ do not hesitate to selectively report the results from P. vivax to support their claim.Hahn and others¹ say that we ignore the fate of the cleared forest in our analysis. However, they do so in their earlier analysis, which pointed to deforestation as an important malaria incidence driver.¹⁴ Furthermore, they assert that (1) deforestation results mainly from timber production and mining in Para rather than pasture/cattle ranching and soybean and (2) protected areas (PAs) tend to be located in areas of high deforestation pressure. These assertions are incorrect and shocking for anybody that knows this region.^19,20 Finally, Hahn and others¹ criticize us for not distinguishing among two very distinct types of PAs. Any type of aggregation can be criticized. For instance, one could take one step further and argue that the proposed classes are not enough because they exhibit considerable heterogeneity within themselves.²¹ We combined all PAs because we were not interested in comparing the effect of different classes of PAs on malaria risk.The role of biodiversity in decreasing disease risk has been and will probably continue to be the theme of a heated debate.^22–26 However, to criticize the methods we employed while also making use of them in their most recent study published in 2014²⁷ is, at a minimum, awkward. To effectively move this debate forward, we have to focus on more constructive ideas and suggestions. To this end, one of the critique authors (i.e., Amy Vittor) and I have partnered to reanalyze the mosquito data in refs. 16 and 17 and review the evidence regarding the role of forests in malaria risk, hoping to gain a more coherent picture of what is known about this important relationship. I invite the other authors of the critique to be part of this new exciting work.     

Improving the Management of Dysglycemia in Children in the Developing World

Improving the availability of point-of-care (POC) diagnostics for glucose is crucial in resource-constrained settings (RCS). Both hypo and hyperglycemia have an appreciable frequency in the tropics and have been associated with increased risk of deaths in pediatrics units. However, causes of dysglycemia, including hyperglycemia, are numerous and insufficiently documented in RCS. Effective glycemic control with glucose infusion and/or intensive insulin therapy can improve clinical outcomes in western settings. A non-invasive way for insulin administration is not yet available for hyperglycemia. We documented a few causes and developed simple POC treatment of hypoglycemia in RCS. We showed the efficacy of sublingual sugar in two clinical trials. Dextrose gel has been recently tested for neonate mortality. This represents an interesting alternative that should be compared with sublingual sugar in RCS. New studies had to be done to document dysglycemia mechanism, frequency and morbid-mortality, and safe POC treatment in the tropics.Recently, Michael Hawkes and colleagues¹ reported the performance of point-of-care (POC) tests to guide the management of 179 children with severe malaria in a resource-limited Ugandan hospital. They paired measurements of glucose using i-STAT and OneTouch Ultra glucometer and other measurements for lactate and hemoglobin. Despite the small sample size of children with hypoglycemia and the lack of gold standard methods, they concluded that diagnostic tools, although imperfect, may expedite clinical decision-making in the management of critically ill children in resource-constrained settings (RCS). We completely agree with the crucial need for improving the availability of point-of-care diagnostics for glucose, particularly in RCS where hypoglycemia is a common and underdiagnosed cause of death.^2–4 However, the sole diagnosis of dysglycemia is not sufficient if an access to effective therapy is not feasible, especially in the field for comatose children.For this purpose, we assessed the frequency of dysglycemia in sick children in non-malaria areas.² In the pediatric ward of a referral hospital in Madagascar, an appreciable frequency (10.9%) (95% confidence interval [CI], 8.1–14.3) of hyperglycemic children at admission carried an increased risk of death (risk ratio [RR]: 2.2, 95% CI: 1–4.7).² This association of hyperglycemia and increased mortality was described in rural Kenya and in a tertiary care hospital in India.^5,6 However, data on hyperglycemia frequency, causes, and mortality remains scarce in the tropics.^7,8 In the same study, we also found a 3.0% (95% CI, 1.6–5.2) prevalence of hypoglycemia among 420 consecutive children.² Hypoglycemia was associated with increased risk of deaths (RR: 19.4, 95% CI: 5.0–74.7) after multivariate analyses. The rate of hypoglycemia was consistent with reports from Tanzania⁹ but lower than rates reported in malaria areas.^5–7,10,11Hypoglycemia is a common and serious complication in children with severe malaria, and it also is indicative of mortality caused by this disease.^10,12 Depletion of glucose stores caused by starvation, parasite use of glucose, and cytokine-induced impairment of gluconeogenesis have been implicated.¹³ Hyperinsulinemia, secondary to parenteral quinine therapy, has been advanced as an iatrogenic cause and is well established in adults.^14,15 Hypoglycemia related to intoxication is probably another highly underestimated cause of death in the tropics. As an example, we investigated the seasonal epidemic of fatal encephalopathy in preschool children in Burkina Faso and related the deaths to the consumption of unripe ackee (Blighia sapida) fruit and hypoglycin, a potent lethal hypoglycemic agent present in unripe ackee.^16,17 There are numerous other causes that often remain undiagnosed. Moreover, hypoglycemia may be aggravated by several generally accepted risk factors such as the altered nutritional status, the severity of the infectious diseases, the young age, the delay in admittance to the hospital, the use of potentially toxic herbal preparations, and the lack of diagnostic facilities.^2,13Younger children and neonates are particularly susceptible to hypoglycemia, both in tropical and western countries.¹⁸ Undernourished children are prone to hypoglycemia any time their fragile nutritional balance is compromised. Delay in admittance to the hospital may impair glucose production and contribute to the worsening of hypoglycemia. We showed that the time of the last meal enhanced the depth of hypoglycemia.² In the tropics, prolonged delay of referral before both diagnosis and glucose administration increased the fasting period. Therefore, a period of prolonged fasting is considered as a risk factor because glycogen stores in the young child are limited, which can result in decreased hepatic glucose production.^3,19 Healthy adults are able to maintain normal plasma glucose levels up to 86 hours of fasting,⁹ although healthy children are not able to maintain a normal plasma glucose concentration during a fasting period of 24 hours and show a significant steeper decrease in plasma glucose concentration than adults. Therefore, the availability of POC tests must be extended to the primary health care settings for hypoglycemia detection at the consultation level. Moreover, repeated measurements should be advisable to detect late or recurrent hypoglycemia.Untreated hypoglycemia is a major cause of deaths in the tropics. Newborn hypoglycemia is probably underestimated completely as a result of the lack of safe and reliable POC diagnostic tests in maternity wards in resource-limited countries.¹ Despite considerable interest recently in neonate mortality in the new world, neonate hypoglycemia has been rarely documented in the tropics.^7,20–22 A rapid search in Medline using the terms “hypoglycemia,” “neonatal or neonates,” and “developing countries or low income” yields no more than 23 papers, although the same search found over 177,334 papers when dropping the terms “developing countries or low income.”Having an available POC test for hypoglycemia diagnostics resolves only one part of the problem, particularly in remote settings where dextrose infusion for young children is currently non-available or feasible. We proposed the use of the ordinary sugar powder administered by the sublingual route (SL), which benefits from an abundant absorption network for glucose.^23–25 This simple treatment is now recommended for the rapid on-site treatment of unripe Blighia sapida consumption.¹⁷ We also showed its efficacy in two clinical trials in resource-constrained settings in Mali and Burkina Faso. The SL absorption of glucose was faster than by the oral route (Figure 1).²⁴ An increase of 36 mg/dL (17.6–54.5) of blood glucose concentrations was obtained within 10 minutes and 64% of children reached blood glucose concentration higher than 3.3 mmol/L in 20 minutes. Indeed, the sublingual surface has a restricted absorption capacity that allows limited amounts of 0.2 g/kg to be absorbed in young infants. The saturation of the SL glucose carriers prevents the use of high doses and required repeated SL administration to by-pass this drawback.^23–25 Recently, evidence was given that 40% dextrose gel rubbed into the inside of the cheek is effective and well tolerated and could also be considered for first-line treatment to manage hypoglycemia in late preterm and term babies in the first 48 hours after birth.²⁶ The benefit of dextrose, the physiological D-isomer of glucose over the disaccharide sucrose, which required a split into glucose and fructose, is to be more rapidly and fully absorbed.²⁷ Dextrose gel reduces the admission rate to the intensive care unit (ICU), but its cost (US$2 per baby) and availability might be a limitation for resource-poor settings.²³ Sublingual administration of sugar should be proposed to health workers for the management of unconscious children hypoglycemic in out-of-hospital or when a dextrose infusion is not available. Further work is needed to increase the availability of this dextrose gel in the tropics and further trials to compare it with SL sugar.²³Open in a separate windowFigure 1.Mean delta of initial blood glucose concentration (g/L) after sublingual and oral sugar, and placebo (water) in young children in the tropics. Sixty-nine children (3–13 years of age) with blood glucose concentration < 3.9 mmol/L after overnight fasting randomly received 2.5 g of moistened sugar either orally or sublingually, oral water as placebo. Adapted from Barennes and others.²⁴In well-equipped intensive care, patients with or without diabetes have frequent dysglycemia, and hyperglycemia is associated with poor outcomes.²⁸ Several studies in western countries showed that a strict glycemic control is a safe and effective method for reducing the incidence of nosocomial infections in a predominantly non-diabetic, general surgical ICU patient population.^29,30 Effective glycemic control with glucose infusion and/or intensive insulin therapy showed improved clinical outcomes in critically ill term neonates.^31,32 Nevertheless, a recent multicenter trial has questioned the efficacy of a tight glucose control of hyperglycemia in critically ill children.³³ In RCS, the risk involved in hyperglycemia is probably underestimated and is rarely assessed outside of ICU.³⁰ Studies are needed for a better understanding of hyperglycemic outcomes and the necessity to initiate an early insulin therapy in severely ill hyperglycemic children admitted to pediatric emergency wards in the tropics. Therefore, recommendations of an intensive insulin therapy for hyperglycemia seem premature in primary health centers. Moreover, it requires a health system able to provide not only insulin and syringe but also ensure effective monitoring. A non-invasive way for insulin administration such as sublingual or nasal routes should be considered in the future.^34–36Finally, we conclude that increasing the availability of POC diagnostic tests is crucial but should be accompanied by increasing information on non-invasive treatment of dysglycemia. Sublingual sugar or ready to use dextrose gel being a good example of POC treatment of hypoglycemia, that will benefit all children.²⁶ New studies have to be done for hyperglycemia in children regarding diagnosis, understanding, and POC treatment in the tropics.     

Impact of prehypertension on left ventricular mass and QT dispersion in adult black Nigerians

The heterogeneity of individuals with blood pressure (BP) < 140/90 mmHg in terms of cardiovascular (CV) risk was reported as early as 1939 by Robinson and Brucer.1 BP in the range of 120–139/80–89 mmHg (labelled then as prehypertension) was observed to be associated with high risk of progression to hypertension (HT) and cardiovascular disease (CVD) later in life when compared with BP < 120/80 mm Hg.1The term prehypertension was adopted in May 2003 by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High blood Pressure (JNC-7) to describe BP range of 120–139/80–89 mmHg.2 The resuscitation of this terminology/concept in JNC-7 was a sequel to the documentation of a higher morbidity in individuals with prehypertension in landmark publications.3-5 Prehypertension (PHT) was defined in JNC-7 not only to emphasise the excess risk associated with BP in this range, but also to focus increased clinical and public health attention on prevention.2,6,7Prevalence rates of PHT among adults in the United States, Ghana and northern Nigeria have been reported to be 31, 40 and 58.7%, respectively.7-9 In most studies, including the ones above, PHT was more prevalent than hypertension.7-9 Though PHT is associated with increased risk of major CV events independently of other CV risk factors,10 most individuals (90%) with PHT have at least one cardiovascular risk factor such as dyslipidaemia, abdominal obesity, hyperinsulinaemia, impaired fasting glucose levels, insulin resistance, a prothrombotic state, tobacco use, endothelial dysfunction, and impaired vascular distensibility.6,7,9,10QT interval dispersion (QTd) (the difference between the longest and the shortest QT intervals on a surface ECG), when excessive, is associated with increased risk of cardiovascular morbidity and mortality in population studies, and many clinical conditions, including hypertension.11,12 This has been related to ventricular electrical instability, providing the necessary substrate for lethal ventricular arrhythmias.12,13 Greater QTd and left ventricular mass have been demonstrated in hypertensive individuals compared with normal individuals.11,13,14Considering the well-established, linear relationship between BP and the risk of cardiovascular events, the CV risk associated with PHT is intermediate between normotension and hypertension.2,03 Hence, electrocardiographic and echocardiographic indices of target-organ damage in PHT may also be intermediate between normotension and hypertension. The aims of this study were: (1) to compare the QTd and indices of left ventricular hypertrophy in adult black normal and prehypertensive subjects, and (2) to evaluate the relationship of QTd with electrocardiographic and echocardiographic indices in these subjects.     

Hematopoietic RIPK1 deficiency results in bone marrow failure caused by apoptosis and RIPK3-mediated necroptosis

Receptor-interacting serine/threonine-protein kinase 1 (RIPK1) is recruited to the TNF receptor 1 to mediate proinflammatory signaling and to regulate TNF-induced cell death. RIPK1 deficiency results in postnatal lethality, but precisely why Ripk1^−/− mice die remains unclear. To identify the lineages and cell types that depend on RIPK1 for survival, we generated conditional Ripk1 mice. Tamoxifen administration to adult RosaCreER^T2Ripk1^fl/fl mice results in lethality caused by cell death in the intestinal and hematopoietic lineages. Similarly, Ripk1 deletion in cells of the hematopoietic lineage stimulates proinflammatory cytokine and chemokine production and hematopoietic cell death, resulting in bone marrow failure. The cell death reflected cell-intrinsic survival roles for RIPK1 in hematopoietic stem and progenitor cells, because Vav-iCre Ripk1^fl/fl fetal liver cells failed to reconstitute hematopoiesis in lethally irradiated recipients. We demonstrate that RIPK3 deficiency partially rescues hematopoiesis in Vav-iCre Ripk1^fl/fl mice, showing that RIPK1-deficient hematopoietic cells undergo RIPK3-mediated necroptosis. However, the Vav-iCre Ripk1^fl/fl Ripk3^−/− progenitors remain TNF sensitive in vitro and fail to repopulate irradiated mice. These genetic studies reveal that hematopoietic RIPK1 deficiency triggers both apoptotic and necroptotic death that is partially prevented by RIPK3 deficiency. Therefore, RIPK1 regulates hematopoiesis and prevents inflammation by suppressing RIPK3 activation.The proinflammatory cytokine TNF stimulates receptor-interacting serine/threonine-protein kinase 1 (RIPK1) ubiquitination, NFκB and MAPK activation, and induction of apoptosis or necroptosis (1, 2). TNF signaling via TNF receptor 1 (TNFR1) is highly regulated and results in the recruitment of several adapter proteins including TNFR1-associated death domain (TRADD) protein, the E3 ubiquitin ligases cellular inhibitor of apoptosis protein-1 and -2 (cIAP1/2), and TNFR-associated factor 2 (TRAF2) or 5, and the serine threonine death domain-containing kinase RIPK1 (complex I) (1). We have demonstrated that the kinase activity of RIPK1 is not required for NFκB activation (3); rather, RIPK1 is modified by the addition of Lys63-linked and linear polyubiquitin chains (3–6). Polyubiquitinated RIPK1 then recruits NEMO/IκB kinase-γ (IKKγ) to mediate IKK activation and TAK1/TAB2/3 to mediate MAPK activation, resulting in antiapoptotic and proinflammatory gene expression (7, 8). Deubiquitination of RIPK1 by cylindromatosis (CYLD) results in the formation of a cytosolic complex containing TRADD, Fas-associated death domain protein (FADD), caspase-8, and RIPK1 (complex IIa) (2). Caspase-8 cleaves and inactivates RIPK1 and CYLD and stimulates apoptosis (9–11). In the absence of caspase-8 or the presence of caspase inhibitors, TNF family members and potentially other ligands stimulate the kinase activity of RIPK1 to induce necroptosis (9, 11–16). RIPK1 also is recruited to the Toll-like receptor adapter TRIF via the Rip homotypic interaction motif (RHIM) to mediate NFκB activation (17) and, under conditions of caspase-8 inhibition, initiates necroptosis (14, 16). Necrostatin-1 (Nec-1), an allosteric RIPK1 inhibitor, inhibits necroptosis induced by TNF or the TLR3 ligand poly I:C and abolishes the formation and activation of an RIPK1/3 complex (13–16, 18). Although the molecular details whereby RIPK1 initiates necroptosis are unclear, RIPK3 and the pseudo kinase MLKL appear to be required (2).Genetic studies in mice have revealed cross-regulation between the apoptotic and necroptotic pathways. For example, the FADD/caspase-8/FLICE-like inhibitory protein long form (FLIP_L) complex regulates RIPK1 and RIPK3 activity during development, because the embryonic lethality associated with a caspase-8 deficiency is completely rescued by the absence of RIPK3 (19, 20). Similarly, RIPK1 deficiency rescues FADD-associated embryonic lethality (21). Thus, in the absence of FADD or caspase-8, embryos succumb to RIPK1- and RIPK3-dependent necroptosis. However, Fadd^−/−/Ripk1^−/− mice, die perinatally (21, 22), as do Ripk1^−/− mice, revealing that RIPK1 has prosurvival roles beyond the regulation of the FADD/caspase-8/FLIP_L complex.We have demonstrated that complete RIPK1 deficiency results in increased TNF-induced cell death that can be rescued, in part, by the absence of the TNFR1 (22, 23). However, Ripk1^−/−Tnfr1^−/− animals still succumb (23), indicating that other death ligands/pathways contribute to the RIPK1-associated lethality. Consistent with this hypothesis, RIPK3 deficiency recently has been shown to rescue the perinatal lethality observed in Ripk1^−/−Tnfr1^−/− mice (24, 25). Similarly, combined caspase-8 and RIPK3 deficiency also rescues the RIPK1-associated lethality (24–26). Collectively, these genetic studies in mice reveal that the perinatal death of Ripk1^−/− mice reflects TNF-induced apoptosis and RIPK3-mediated necroptosis. The nature of the ligand(s) or the trigger(s) of RIPK3-mediated necroptosis in vivo remain unclear. However, Ripk1^−/− MEFs are prone to necroptosis induced by poly I:C or by treatment with type I or type II IFN (24, 25), suggesting that these pathways contribute. Although these studies reveal a regulatory role for RIPK1, the multiorgan cell death and inflammation observed in the complete and compound RIPK1-knockout strains have made it difficult to discern the specific tissues that require RIPK1 for survival.     

Sickle cell trait is not associated with chronic kidney disease in adult Congolese patients: a clinic-based,cross-sectional study

Chronic kidney disease (CKD) and end-stage renal disease (ESRD) are associated with significant cardiovascular (CV) and renal morbidity and mortality rates, with substantial economic burden.1,2 Therefore, early identification of CKD patients at high risk of progression is urgently needed for early and targeted treatment to improve patient care.1-3 Diabetes and hypertension are the primary risk factors for CKD and ESRD but do not fully account for CKD and ESRD risk.1-3 Marked variability in the incidence of CKD suggests that factors other than diabetes and hypertension contribute to its aetiology.4Family studies have suggested a genetic component to the aetiology of CKD and ESRD.5 In African Americans, high-risk common variants in the Apol1/MYH9 locus may explain up to 70% of the differences in ESRD rates between European and African Americans.5 While this finding has great implications for ESRD, the identification of additional risk factors for CKD, including genetic loci in association with estimated glomerular filtration rate (eGFR), may help to advance our understanding of the underpinnings of CKD in African Americans.5 In this era of identifying genetic risk factors for kidney disease, it may be appropriate to revisit one of the most common genetic disorders: sickle cell haemoglobinopathies.5In this regard, sickle cell trait (SCT), present in approximately 7–9% of African Americans, has been reported to be a potential candidate gene.6 However, conflicting reports exist as to whether SCT is a risk factor for the progression of nephropathy.6,7 Haemoglobin S (HbS) was selected for in Africa because of the protection it affords from malarial infection, a scenario similar to the protection from trypanosomal infection provided by heterozygosity for APOL1 nephropathy risk variants.6Whereas APOL1 contributes to risk for nephropathy in an autosomal recessive inheritance pattern, HbS reportedly had a dominant effect on risk, with SCT being associated with ESRD.6 In line with this finding, a few small studies on African Americans reported HbS as an independent risk factor for CKD and ESRD.8 However, other studies using a large sample of African Americans stated that SCT was not independently associated with susceptibility to ESRD in African Americans,6 highlighting the need for further studies in other populations such as those of sub-Saharan Africa where SCT is prevalent.Although SCT is very prevalent in black Africans,9 few studies have been conducted to assess the association between SCT and CKD.10 In Democratic Republic of Congo (DRC), the prevalence of CKD and SCT has been reported to be 12% and 17–24%, respectively.11-13 No study has evaluated the frequency of SCT among CKD patients to assess its association with reduced kidney function. Therefore, the aim of this clinic-based, cross-sectional study was to assess the potential association between SCT and CKD among adult Congolese patients.     

Betatrophin: The long awaited circulating factor from the liver promoting β-cell replication?

Regenerative therapy in diabetes with the capacity to reconstitute a functional β-cell mass sufficient for glycemic control holds the promise to effectively prevent the development of devastating late complications due to the unique ability of the β-cell to sense and regulate blood-glucose levels. An ability that cannot be mimicked by insulin replacement therapy or any other means of current treatment regiments for very large patient populations. Recently, Douglas A. Melton’s group from Harvard University reported the identification of a circulating protein secreted from the liver under insulin resistant states which is sufficient to dramatically and specifically increase the replication rate of β-cells in the mouse resulting in an increased functional β-cell mass over time. They re-named the factor betatrophin and described a number of exciting features of this molecule which suggested that it could be a potential candidate for development as a regenerative medicine in diabetes.¹ The official name of the gene encoding mouse betatrophin is Gm6484, but it has been annotated a number of times under different names: {"type":"entrez-nucleotide","attrs":{"text":"EG624219","term_id":"116865639","term_text":"EG624219"}}EG624219^2,3, RIFL⁴, Lipasin⁵ and ANGPTL8.⁶ The official human gene name is C19orf80, but it has also been annotated as TD26⁷, LOC55908⁸, as well as RIFL, Lipasin, ANGPTL8 and betatrophin.     

Prevalence of Melioidosis in Patients with Suspected Pulmonary Tuberculosis and Sputum Smear Negative for Acid-Fast Bacilli in Northeast Thailand

The clinical and radiological features of pulmonary melioidosis can mimic tuberculosis. We prospectively evaluated 118 patients with suspected pulmonary tuberculosis who were acid-fast bacilli (AFB) smear negative at Udon Thani Hospital, northeast Thailand. Culture of residual sputum from AFB testing was positive for Burkholderia pseudomallei in three patients (2.5%; 95% confidence interval [CI] 0.5–7.3%). We propose that in melioidosis-endemic areas, residual sputum from AFB testing should be routinely cultured for B. pseudomallei.Melioidosis is a serious infectious disease caused by the Tier 1 Select Agent and Gram-negative bacillus, Burkholderia pseudomallei.¹ Naturally acquired melioidosis is highly endemic in northeast Thailand where it is the third most common cause of death caused by infectious diseases after human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and tuberculosis,² and in northern Australia where it is the commonest cause of fatal community-acquired bacteremic pneumonia.³ Melioidosis is also increasingly reported from many countries across Asia, regions of South America, various Pacific and Indian Ocean islands, and some countries in Africa including Nigeria, Gambia, Kenya, and Uganda.¹ Death from melioidosis reaches 80% in those who are not treated with effective antimicrobial drugs.⁴Melioidosis can manifest with a variety of clinical presentations including sepsis, pneumonia, arthritis, and internal organ abscesses, and has been termed “the great mimicker” because it can be confused with a range of diseases. The most notable example is tuberculosis, with an estimated 10% of melioidosis patients presenting with chronic respiratory symptoms and chest radiography mimicking pulmonary tuberculosis.⁵ In reported cases, failure of clinical improvement after the administration of anti-tuberculosis drugs led to bacteriological culture of sputum, broncho-alveolar lavage, or blood and the detection of B. pseudomallei.^6–8 Although it is clear that melioidosis can mimic clinical features of tuberculosis, patients presenting with suspected tuberculosis in Thailand where melioidosis is highly endemic are not systematically screened for melioidosis. Here, we evaluated the use of culturing sputum samples taken from individuals in Thailand with suspected tuberculosis that were smear negative for acid-fast bacilli (AFB) to detect B. pseudomallei.     

PML plays both inimical and beneficial roles in HSV-1 replication

After entry into the nucleus, herpes simplex virus (HSV) DNA is coated with repressive proteins and becomes the site of assembly of nuclear domain 10 (ND10) bodies. These small (0.1–1 μM) nuclear structures contain both constant [e.g., promyelocytic leukemia protein (PML), Sp100, death-domain associated protein (Daxx), and so forth] and variable proteins, depending on the function of the cells or the stress to which they are exposed. The amounts of PML and the number of ND10 structures increase in cells exposed to IFN-β. On initiation of HSV-1 gene expression, ICP0, a viral E3 ligase, degrades both PML and Sp100. The earlier report that IFN-β is significantly more effective in blocking viral replication in murine PML^+/+ cells than in sibling PML^−/− cells, reproduced here with human cells, suggests that PML acts as an effector of antiviral effects of IFN-β. To define more precisely the function of PML in HSV-1 replication, we constructed a PML^−/− human cell line. We report that in PML^−/− cells, Sp100 degradation is delayed, possibly because colocalization and merger of ICP0 with nuclear bodies containing Sp100 and Daxx is ineffective, and that HSV-1 replicates equally well in parental HEp-2 and PML^−/− cells infected at 5 pfu wild-type virus per cell, but poorly in PML^−/− cells exposed to 0.1 pfu per cell. Finally, ICP0 accumulation is reduced in PML^−/− infected at low, but not high, multiplicities of infection. In essence, the very mechanism that serves to degrade an antiviral IFN-β effector is exploited by HSV-1 to establish an efficient replication domain in the nucleus.Several prominent events take place after the entry of herpes simplex virus (HSV) DNA into the nucleus of newly infected cells. Thus, viral DNA becomes coated by repressive proteins, the function of which is to block viral gene expression (1–6); nuclear domain 10 (ND10) bodies colocalize with the viral DNA (7, 8); α or immediate early viral genes are expressed; and one viral protein, ICP0, degrades promyelocytic leukemia protein (PML) and Sp100, two key constituents of ND10 bodies in conjunction with the UbcH5A ubiquitin-conjugating enzyme (9–11). What is left of the ND10 bodies is infiltrated by viral proteins and becomes the viral replication compartment (12–15).ND10 bodies range between 0.1 and 1 μM in diameter. The composition of ND10 bodies varies depending on the cellular function or in response to stress, such as that resulting from virus infection (16–19). Among the constant components of ND10 are PML, Sp100, and death-domain associated protein (Daxx). PML has been reported to be critical for the recruitment of components and for the organization of the ND10 bodies (18–23). The function of ND10 bodies may vary under different cellular conditions and may also depend on their composition.A key question that remains unanswered is the function of ND10 bodies in infection, and in particular, why HSV has evolved a strategy that specifically targets PML and Sp100 for degradation. Two clues that may ultimately shed light on the function of ND10 is that exposure of cells to IFN leads to an increase in the number of ND10 bodies and an increase in PML (16, 24–26). The second clue emerged from the observation reported earlier by this laboratory is that pretreatment of murine PML^+/+ cells with IFN-β led to a drastic reduction in virus yields. In contrast, exposure of PML^−/− cells to IFN-β led to a significantly smaller decrease in virus yields (27). The results suggest PML is an antiviral effector of IFN-β, but many questions regarding the function of PML remain unanswered (28).In this study, we constructed a PML^−/− cell line (1D2) derived from HEp-2 cells. The first part of this report centers on the structure of ND10 bodies bereft of PML and the interaction of these bodies with ICP0. In the second part, we report on the replication of HSV-1 in PML^−/− cells. Here we show that HSV-1 replication and the accumulation of ICP0 are significantly reduced in PML^−/− cells exposed to low ratios of virus per cell. HSV has evolved a strategy to take advantage of PML before its degradation.     

iRhoms 1 and 2 are essential upstream regulators of ADAM17-dependent EGFR signaling

The metalloproteinase ADAM17 (a disintegrin and metalloprotease 17) controls EGF receptor (EGFR) signaling by liberating EGFR ligands from their membrane anchor. Consequently, a patient lacking ADAM17 has skin and intestinal barrier defects that are likely caused by lack of EGFR signaling, and Adam17^−/− mice die perinatally with open eyes, like Egfr^−/− mice. A hallmark feature of ADAM17-dependent EGFR ligand shedding is that it can be rapidly and posttranslationally activated in a manner that requires its transmembrane domain but not its cytoplasmic domain. This suggests that ADAM17 is regulated by other integral membrane proteins, although much remains to be learned about the underlying mechanism. Recently, inactive Rhomboid 2 (iRhom2), which has seven transmembrane domains, emerged as a molecule that controls the maturation and function of ADAM17 in myeloid cells. However, iRhom2^−/− mice appear normal, raising questions about how ADAM17 is regulated in other tissues. Here we report that iRhom1/2^−/− double knockout mice resemble Adam17^−/− and Egfr^−/− mice in that they die perinatally with open eyes, misshapen heart valves, and growth plate defects. Mechanistically, we show lack of mature ADAM17 and strongly reduced EGFR phosphorylation in iRhom1/2^−/− tissues. Finally, we demonstrate that iRhom1 is not essential for mouse development but regulates ADAM17 maturation in the brain, except in microglia, where ADAM17 is controlled by iRhom2. These results provide genetic, cell biological, and biochemical evidence that a principal function of iRhoms1/2 during mouse development is to regulate ADAM17-dependent EGFR signaling, suggesting that iRhoms1/2 could emerge as novel targets for treatment of ADAM17/EGFR-dependent pathologies.ADAM17 (a disintegrin and metalloprotease 17) is a membrane-anchored metalloproteinase that controls two major signaling pathways with important roles in development and disease, the EGF receptor (EGFR) pathway and the proinflammatory tumor necrosis factor α (TNF-α) pathway (1–5). Mice lacking ADAM17 resemble mice with defects in EGFR signaling in that they have open eyes at birth, enlarged semilunar heart valves, and enlarged hypertrophic zones in long bone growth plates, most likely caused by a lack of ADAM17-dependent release of the EGFR ligands transforming growth factor α (TGF-α) and heparin-binding epidermal growth factor (HB-EGF) (3, 6–14). In humans, defects in skin and intestinal barrier protection have been reported in a patient lacking ADAM17 (15) and in patients treated with EGFR inhibitors (16, 17), and similar skin defects were recently identified in a patient with defective EGFR signaling (18). Mouse models of ADAM17/EGFR signaling appear to recapitulate these mechanisms, because defects in skin barrier protection can be observed by inactivating either ADAM17 or the EGFR in keratinocytes (19), as well as in mice expressing very low levels of ADAM17, which also have increased susceptibility to intestinal inflammation (20). A hallmark feature of ADAM17 is its rapid response to various activators of cellular signaling pathways (21–23), which is presumably important to allow a rapid response to injury and to maintain the skin and intestinal barrier. The rapid activation of ADAM17 is controlled by its transmembrane domain whereas the cytoplasmic domain is dispensable in this context (22), suggesting that ADAM17 is regulated by one or more other membrane proteins, yet the underlying mechanism has remained enigmatic.Recent studies have shown that the maturation and function of ADAM17 in myeloid cells depend on inactive Rhomboid 2 (iRhom2), a catalytically inactive member of the Rhomboid family of seven membrane-spanning intramembrane serine proteinases (24–28). Myeloid cells lacking iRhom2 release very little TNF-α in response to activation of Toll-like receptor 4 by lipopolysaccharide (LPS) (24, 26, 28). Therefore, mice lacking iRhom2 are protected from the detrimental effects of TNF-α in mouse models for septic shock and inflammatory arthritis, similar to conditional knockout mice lacking ADAM17 in myeloid cells (11, 26, 29). However, iRhom2^−/− (iR2^−/−) mice are viable with no evident spontaneous pathological phenotypes (26, 29), whereas Adam17^−/− (A17^−/−) mice die shortly after birth (3). A major unresolved question has therefore been whether iRhom2 and the related iRhom1 are the long-sought-after regulators of the function of ADAM17-dependent EGFR signaling in vivo. Here we generate iRhom1^−/− (iR1^−/−) mice, which are viable and healthy, and report that iR1/2^−/− double knockout mice closely resemble mice lacking ADAM17 or the EGFR, providing the first genetic evidence, to our knowledge, that the principal function of iRhoms1/2 during mouse development is to control ADAM17/EGFR signaling.