Solid Organ Transplantation From Hepatitis B Virus–Positive Donors: Consensus Guidelines for Recipient Management

Use of organs from donors testing positive for hepatitis B virus (HBV) may safely expand the donor pool. The American Society of Transplantation convened a multidisciplinary expert panel that reviewed the existing literature and developed consensus recommendations for recipient management following the use of organs from HBV positive donors. Transmission risk is highest with liver donors and significantly lower with non‐liver (kidney and thoracic) donors. Antiviral prophylaxis significantly reduces the rate of transmission to liver recipients from isolated HBV core antibody positive (anti‐HBc+) donors. Organs from anti‐HBc+ donors should be considered for all adult transplant candidates after an individualized assessment of the risks and benefits and appropriate patient consent. Indefinite antiviral prophylaxis is recommended in liver recipients with no immunity or vaccine immunity but not in liver recipients with natural immunity. Antiviral prophylaxis may be considered for up to 1 year in susceptible non‐liver recipients but is not recommended in immune non‐liver recipients. Although no longer the treatment of choice in patients with chronic HBV, lamivudine remains the most cost‐effective choice for prophylaxis in this setting. Hepatitis B immunoglobulin is not recommended.     

Tim-3 enhances FcεRI-proximal signaling to modulate mast cell activation

T cell (or transmembrane) immunoglobulin and mucin domain protein 3 (Tim-3) has attracted significant attention as a novel immune checkpoint receptor (ICR) on chronically stimulated, often dysfunctional, T cells. Antibodies to Tim-3 can enhance antiviral and antitumor immune responses. Tim-3 is also constitutively expressed by mast cells, NK cells and specific subsets of macrophages and dendritic cells. There is ample evidence for a positive role for Tim-3 in these latter cell types, which is at odds with the model of Tim-3 as an inhibitory molecule on T cells. At this point, little is known about the molecular mechanisms by which Tim-3 regulates the function of T cells or other cell types. We have focused on defining the effects of Tim-3 ligation on mast cell activation, as these cells constitutively express Tim-3 and are activated through an ITAM-containing receptor for IgE (FcεRI), using signaling pathways analogous to those in T cells. Using a variety of gain- and loss-of-function approaches, we find that Tim-3 acts at a receptor-proximal point to enhance Lyn kinase-dependent signaling pathways that modulate both immediate-phase degranulation and late-phase cytokine production downstream of FcεRI ligation.T cell, or transmembrane, immunoglobulin domain and mucin domain (Tim-3) is a type I membrane protein expressed on a variety of innate and adaptive immune cell types. Tim-3 is often referred to as a checkpoint receptor due to its apparent inhibitory function on T cells and its association with activation-induced T cell exhaustion in tumors and chronic viral infection (Sánchez-Fueyo et al., 2003; Jones et al., 2008; Fourcade et al., 2010; Jin et al., 2010; Sakuishi et al., 2010). Recent studies, however, suggest a more nuanced picture of Tim-3 function in T cells, depending on the setting, e.g., acute versus chronic stimulation (Ferris et al., 2014; Gorman and Colgan, 2014). In addition to CD4 and CD8 T cells, Tim-3 is also expressed on other immune cell types, such as NK cells, macrophages, DCs, and mast cells, but its function on these cell types is less clear. Tim-3 blockade was shown to enhance macrophage function in response to sepsis (Yang et al., 2013), and also to regulate antigen (Ag) presentation by DCs, partly through Btk and c-Src (Maurya et al., 2014). On the other hand, Tim-3 expression on monocytes infiltrating the CNS during EAE was shown to promote inflammation (Anderson et al., 2007).Mast cells are first-line defenders against allergens and invading pathogens as a result of their proximity to the external environment. Cross-linking of IgE bound to the high-affinity IgE receptor FcεRI by Ag leads to the release of preformed mediators and de novo synthesis of proinflammatory and antiinflammatory mediators and cytokines, which together serve to regulate hypersensitivity, autoimmunity, cardiovascular disease, and tumor progression (Kalesnikoff and Galli, 2008). In addition to their well-known pathological roles in allergic responses, mast cells also contribute to defense against bacteria, helminthes, and tumors (Abraham and St John, 2010). It was reported that mast cells constitutively express cell surface Tim-3, and that cross-linking of Tim-3 could enhance cytokine production of IgE-sensitized and Ag-stimulated BM-derived mast cells (BMMCs) and peritoneal mast cells (pMCs) without affecting degranulation (Nakae et al., 2007). TGF-β has been shown to up-regulate expression of Tim-3 in tumor-infiltrating mast cells and a human mast cell line, through a mitogen-activated protein kinase Erk-kinase (MEK)–dependent pathway (Wiener et al., 2006; Yoon et al., 2011). Although previous data suggest that Tim-3 is a positive regulator of mast cell activation, the molecular mechanisms behind the contribution of Tim-3 to mast cell function are still unknown. Importantly, there was until now no genetic evidence addressing the function of Tim-3 in these cells. Given the important role of mast cells as sentinels in both allergic and nonallergic diseases, it is of interest to explore Tim-3 activity on this cell type and how antibody (Ab) modulation can affect its function.Here, we demonstrate through multiple approaches that Tim-3 functions to enhance proximal FcεRI signaling in mast cells. Cross-linking of Tim-3 with multiple independent antibodies enhanced mast cell degranulation and cytokine release in a dose-dependent manner. Acute knock-down or genetic deficiency of Tim-3 rendered mast cells less responsive to Ag cross-linking of FcεRI, resulting in decreased degranulation and cytokine production. The cytoplasmic tail of Tim-3 was required for co-stimulatory signal transduction in mast cells, together with FcεRI signaling pathways. This was shown in part with the use of recently reported Nur77-GFP transgenic models, which have not previously been used for the study of FcεRI signaling. Collectively, our data demonstrate that Tim-3 acts at a receptor-proximal level to intensify activation of FcεRI-dependent signaling pathways upon Ag cross-linking, while maintaining the threshold for negative signaling of Lyn.     

Impact of the Combination of Daptomycin and Trimethoprim-Sulfamethoxazole on Clinical Outcomes in Methicillin-Resistant Staphylococcus aureus Infections

Complicated Staphylococcus aureus infections, including bacteremia, are often associated with treatment failures, prolonged hospital stays, and the emergence of resistance to primary and even secondary therapies. Daptomycin is commonly used as salvage therapy after vancomycin failure for the treatment of methicillin-resistant S. aureus (MRSA) infections. Unfortunately, the emergence of daptomycin resistance, especially in deep-seated infections, has been reported, prompting the need for alternative or combination therapy. Numerous antibiotic combinations with daptomycin have been investigated clinically and in vitro. Of interest, the combination of daptomycin and trimethoprim-sulfamethoxazole (TMP-SMX) has proved to be rapidly bactericidal in vitro to strains that are both susceptible and nonsusceptible to daptomycin. However, to date, there is limited clinical evidence supporting the use of this combination. This was a multicenter, retrospective case series of patients treated with the combination of daptomycin and TMP-SMX for at least 72 h. The objective of this study was to describe the safety and effectiveness of this regimen in clinical practice. The most commonly stated reason that TMP-SMX was added to daptomycin was persistent bacteremia and/or progressive signs and symptoms of infection. After the initiation of combination therapy, the median time to clearance of bacteremia was 2.5 days. Microbiological eradication was demonstrated in 24 out of 28 patients, and in vitro synergy was demonstrated in 17 of the 17 recovered isolates. Further research with this combination is necessary to describe the optimal role and its impact on patient outcomes.     

Identification of an updated set of prescribing-safety indicators for GPs

Background

Medication error is an important contributor to patient morbidity and mortality and is associated with inadequate patient safety measures. However, prescribing-safety tools specifically designed for use in general practice are lacking.

Aim

To identify and update a set of prescribing-safety indicators for assessing the safety of prescribing in general practice, and to estimate the risk of harm to patients associated with each indicator.

Design and setting

RAND/UCLA consensus development of indicators in UK general practice.

Method

Prescribing indicators were identified from a systematic review and previous consensus exercise. The RAND Appropriateness Method was used to further identify and develop the indicators with an electronic-Delphi method used to rate the risk associated with them. Twelve GPs from all the countries of the UK participated in the RAND exercise, with 11 GPs rating risk using the electronic-Delphi approach.

Results

Fifty-six prescribing-safety indicators were considered appropriate for inclusion (overall panel median rating of 7–9, with agreement). These indicators cover hazardous prescribing across a range of therapeutic indications, hazardous drug–drug combinations and inadequate laboratory test monitoring. Twenty-three (41%) of these indicators were considered high risk or extreme risk by 80% or more of the participants.

Conclusion

This study identified a set of 56 indicators that were considered, by a panel of GPs, to be appropriate for assessing the safety of GP prescribing. Twenty-three of these indicators were considered to be associated with high or extreme risk to patients and should be the focus of efforts to improve patient safety.     

Simultaneous quantification of ten key Kratom alkaloids in Mitragyna speciosa leaf extracts and commercial products by ultra‐performance liquid chromatography−tandem mass spectrometry

Kratom (Mitragyna speciosa) is a psychoactive plant popular in the United States for the self‐treatment of pain and opioid addiction. For standardization and quality control of raw and commercial kratom products, an ultra‐performance liquid chromatography?tandem mass spectrometry (UPLC?MS/MS) method was developed and validated for the quantification of ten key alkaloids, namely: corynantheidine, corynoxine, corynoxine B, 7‐hydroxymitragynine, isocorynantheidine, mitragynine, mitraphylline, paynantheine, speciociliatine, and speciogynine. Chromatographic separation of diastereomers, or alkaloids sharing same ion transitions, was achieved on an Acquity BEH C18 column with a gradient elution using a mobile phase containing acetonitrile and aqueous ammonium acetate buffer (10mM, pH 3.5). The developed method was linear over a concentration range of 1–200 ng/mL for each alkaloid. The total analysis time per sample was 22.5 minutes. The analytical method was validated for accuracy, precision, robustness, and stability. After successful validation, the method was applied for the quantification of kratom alkaloids in alkaloid‐rich fractions, ethanolic extracts, lyophilized teas, and commercial products. Mitragynine (0.7%–38.7% w/w), paynantheine (0.3%–12.8% w/w), speciociliatine (0.4%–12.3% w/w), and speciogynine (0.1%–5.3% w/w) were the major alkaloids in the analyzed kratom products/extracts. Minor kratom alkaloids (corynantheidine, corynoxine, corynoxine B, 7‐hydroxymitragynine, isocorynantheidine) were also quantified (0.01%–2.8% w/w) in the analyzed products; however mitraphylline was below the lower limit of quantification in all analyses.     

Functional STAT3 deficiency compromises the generation of human T follicular helper cells

T follicular helper (Tfh) cells are critical for providing the necessary signals to induce differentiation of B cells into memory and Ab-secreting cells. Accordingly, it is important to identify the molecular requirements for Tfh cell development and function. We previously found that IL-12 mediates the differentiation of human CD4(+) T cells to the Tfh lineage, because IL-12 induces naive human CD4(+) T cells to acquire expression of IL-21, BCL6, ICOS, and CXCR5, which typify Tfh cells. We have now examined CD4(+) T cells from patients deficient in IL-12Rβ1, TYK2, STAT1, and STAT3 to further explore the pathways involved in human Tfh cell differentiation. Although STAT1 was dispensable, mutations in IL12RB1, TYK2, or STAT3 compromised IL-12-induced expression of IL-21 by human CD4(+) T cells. Defective expression of IL-21 by STAT3-deficient CD4(+) T cells resulted in diminished B-cell helper activity in vitro. Importantly, mutations in STAT3, but not IL12RB1 or TYK2, also reduced Tfh cell generation in vivo, evidenced by decreased circulating CD4(+)CXCR5(+) T cells. These results highlight the nonredundant role of STAT3 in human Tfh cell differentiation and suggest that defective Tfh cell development and/or function contributes to the humoral defects observed in STAT3-deficient patients.     

Importance of day 21 BM chimerism in sustained neutrophil engraftment following double-unit cord blood transplantation

Delayed or failed engraftment remains a concern after cord blood transplantation (CBT) even when using double-unit grafts. Therefore, we analyzed the association between BM assessment performed approximately 21 days after transplantation, and the speed and success of sustained donor-derived neutrophil engraftment in 56 myeloablative double-unit CBT (DCBT) recipients. Overall, the cumulative incidence of sustained neutrophil engraftment was 95% (95% confidence intervals (CI): 89-100). Of the percentage of myeloid precursors, the BM cellularity and the total donor chimerism the total donor chimerism percentage had the most critical association with the speed and success of engraftment. DCBT recipients who were 100% donor achieved a 98% engraftment rate at a median of 22 days. This compared with 100% engraftment in patients who were 90-99% donor, but at a delayed median of 29 days and only 68% engraftment in patients <90% donor at a median of 37 days (P=0.001). Multivariate analysis was performed in the subgroup of patients who had not engrafted at the time the BM analysis was performed, the subgroup of most clinical concern. This confirmed donor chimerism was predictive of subsequent neutrophil recovery (P=0.004). These findings demonstrate the importance of the day 21 BM chimerism determinations after DCBT.     

Rates and determinants of HIV-attributable mortality among rural female sex workers in Northern Karnataka, India

Female sex workers (FSWs) have among the highest rates of HIV infection in India. However, little is known about their HIV-specific mortality rates. In total, 1561 FSWs participated in a cohort study in Karnataka. Outcome data (mortality) were available on 1559 women after 15 months of follow-up. To gather details on deaths, verbal autopsy (VA) questionnaires were administered to key informants. Two physicians reviewed the VA reports and assigned underlying causes of death. Forty-seven deaths were reported during the follow-up (overall mortality rate was 2.44 per 100 person-years), with VA data available on 45 women. Thirty-five (75.6%) of these women were known to be HIV-positive, but only 42.5% were on antiretroviral therapy (ART). Forty deaths were assessed to be HIV-related, for an HIV-attributable mortality rate of 2.11 deaths per 100 person-years. Absence of a current regular partner (incidence rate ratio: 2.79; 95% confidence interval [CI]: 1.39-5.60) and older age (1.06; 1.01-1.11) were associated with increased HIV-attributable mortality. Reported duration in sex work was not related to HIV-attributable mortality. We found a high HIV-related mortality rate among this cohort of FSWs; nearly 10 times that of national mortality rates among women of a similar age group. Older age, but not reported duration in sex work, was associated with increased mortality, and suggests HIV acquisition prior to self-reported initiation into sex work. Despite significant efforts, there remain considerable gaps in HIV prevention near or before entry into sex work, as well as access and uptake of HIV treatment among FSWs.