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New studies of COVID–19 are constantly updating best practices in clinical care. Often, it is impractical to apply recommendations based on high-income country investigations to resource limited settings in low- and middle-income countries (LMICs). We present a set of pragmatic recommendations for the management of anticoagulation and thrombotic disease for hospitalized patients with COVID-19 in LMICs. In the absence of contraindications, we recommend prophylactic anticoagulation with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for all hospitalized COVID-19 patients in LMICs. If available, we recommend LMWH over UFH for venous thromboembolism (VTE) prophylaxis to minimize risk to healthcare workers. We recommend against the use of aspirin for VTE prophylaxis in hospitalized COVID-19 and non–COVID-19 patients in LMICs. Because of limited evidence, we suggest against the use of “enhanced” or “intermediate” prophylaxis in COVID-19 patients in LMICs. Based on current available evidence, we recommend against the initiation of empiric therapeutic anticoagulation without clinical suspicion for VTE. If contraindications exist to chemical prophylaxis, we recommend mechanical prophylaxis with intermittent pneumatic compression (IPC) devices or graduated compression stockings (GCS) for hospitalized COVID-19 patients in LMICs. In LMICs, we recommend initiating therapeutic anticoagulation for hospitalized COVID-19 patients, in accordance with local clinical practice guidelines, if there is high clinical suspicion for VTE, even in the absence of testing. If available, we recommend LMWH over UFH or Direct oral anticoagulants for treatment of VTE in LMICs to minimize risk to healthcare workers. In LMIC settings where continuous intravenous UFH or LMWH are unavailable or not feasible to use, we recommend fixed dose heparin, adjusted to body weight, in hospitalized COVID-19 patients with high clinical suspicion of VTE. We suggest D-dimer measurement, if available and affordable, at the time of admission for risk stratification, or when clinical suspicion for VTE is high. For hospitalized COVID-19 patients in LMICs, based on current available evidence, we make no recommendation on the use of serial D-dimer monitoring for the initiation of therapeutic anticoagulation. For hospitalized COVID-19 patients in LMICs receiving intravenous therapeutic UFH, we recommend serial monitoring of partial thromboplastin time or anti-factor Xa level, based on local laboratory capabilities. For hospitalized COVID-19 patients in LMICs receiving LMWH, we suggest against serial monitoring of anti-factor Xa level. We suggest serial monitoring of platelet counts in patients receiving therapeutic anticoagulation for VTE, to assess risk of bleeding or development of heparin induced thrombocytopenia.

Objective Evaluate host and pathogen factors associated with mortality in those with hospital acquired infections (HAI) in a tertiary intensive care unit in Brazil. Methods Observational and analytical cohort single center study in a general intensive care unit (ICU) in Northeastern Brazil between January 2016 and August 2018, including those over 18 years of age admitted to the ICU found to have a HAI. Results A total of 165 patients were included, with a mean age of 72 years and male predominance (53.3%) and observed mortality of 46%. Mortality in those with HAI was significantly associated with older age, increased ICU length of stay and readmission to the ICU in univariate analysis. Multivariate analysis revealed that development of septic shock and obtundation during ICU admission was significantly associated with an increased risk of death (OR: 6.94, 95% CI 1.23-39.27, OR: 2.48, 95% CI 1.17-5.29, respectively). A trend towards mortality risk was noted in those with increased age and prior cardiovascular disease. Surprisingly, mortality risk was independent of site of infection, type of pathogen and antibiotic resistance. Furthermore, having more than one HAI over the course of the ICU admission did not impact mortality. Conclusion Risk of death in those with HAI is associated with obtundation and septic shock, in addition to vasopressor use. Host factors, rather than pathogen-specific characteristics or infecting site, impact risk of death related to HAI in the ICU.

Background Severity stratification scores developed in intensive care units (ICUs) are used in interventional studies to identify the most critically ill. Studies that evaluate accuracy of these scores in ICU patients admitted with pneumonia are lacking. This study aims to determine performance of severity scores as predictors of mortality in critically ill patients admitted with pneumonia. Methods Prospective cohort study in a general ICU in Brazil. ICU severity scores (Simplified Acute Physiology Score 3 [SAPS 3] and Sepsis-Related Organ Failure Assessment [qSOFA]), prognostic scores of pneumonia (CURB-65 [confusion, urea, respiratory rate, blood pressure, age] and CRB-65 [confusion, respiratory rate, blood pressure, age]), and clinical and epidemiological variables in the first 6 hours of hospitalization were analyzed. Results Two hundred patients were included between 2015 and 2018, with a median age of 81 years (interquartile range, 67–90 years) and female predominance (52%), primarily admitted from the emergency department (65%) with community-acquired pneumonia (CAP, 80.5%). SAPS 3, CURB-65, CRB-65,and qSOFA all exhibited poor performance in predicting mortality. Multivariate regression identified variables independently associated with mortality that were used to develop a novel pneumonia-specific ICU severity score (Pneumonia Shock score) that outperformed SAPS 3, CURB-65, and CRB-65. The Shock score was validated in an external multicenter cohort of critically ill patients admitted with CAP. Conclusions We created a parsimonious score that accurately identifies patients with pneumonia at highest risk of ICU death. These findings are critical to accurately stratify patients with severe pneumonia in therapeutic trials that aim to reduce mortality.

BackgroundVisceral leishmaniasis is an opportunistic disease in HIV-1 infected individuals, although not yet recognized as a determining factor for AIDS diagnosis. The growing geographical overlap of HIV-1 and Leishmania infections is an emerging challenge worldwide, as co-infection increases morbidity and mortality for both. Here, we determined the prevalence of people living with HIV (PWH) with a previous or ongoing infection by Leishmania infantum in Bahia, Brazil and investigated the virological and immunological factors associated with co-infection.Methodology and Principal FindingsWe adopted a two-stage cross-sectional cohort (CSC) design (CSC-I, n=5,346 and CSC-II, n=317) of treatment-naïve HIV-1-infected individuals in Bahia, Brazil. In CSC-I, samples collected at the time of HIV-1 diagnosis between 1998 and 2013 were used for serological screening for leishmaniasis by an in-house immunoassay (ELISA) with SLA (Soluble Leishmania Antigen), resulting in a prevalence of previous or ongoing infection of 16.27%. Next, 317 PWH were prospectively recruited from July 2014 to December 2015 with collection of sociodemographic and clinical data. Serological validation by two different immunoassays confirmed a prevalence of 15.46% and 8.20% by anti-SLA, and anti-HSP70 serology, respectively, whereas 4.73% were double-positive (DP). Stratification of these 317 individuals in DP and double-negative (DN) revealed a significant reduction of CD4+ counts and CD4+/CD8+ ratios and a tendency of increased viral load in the DP group, as compared to DN. No statistical differences in HIV-1 subtype distribution were observed between the two groups. However, we found a significant increase of CXCL10/IP-10 (p=0.0076) and a tendency of increased CXCL9/MIG (p=0.061) in individuals with DP serology for L. infantum, demonstrating intensified immune activation in this group. These findings were corroborated at the transcriptome level in independent Leishmania- and HIV-1-infected cohorts (Swiss HIV Cohort and Piaui Northeast Brazil Cohort), indicating that CXCL10 transcripts are shared by the IFN-dominated immune activation gene signatures of both pathogens and positively correlated to viral load in untreated PWH.Conclusions/SignificanceThis study demonstrated a high prevalence of PWH with L. infantum seropositivity in Bahia, Brazil, linked to IFN-mediated immune activation and a significant decrease in CD4+ levels. Our results highlight the urgent need to increase awareness and define public health strategies for the management and prevention of HIV-1 and L. infantum co-infection.AUTHOR SUMMARYMore than 1 billion people live in areas endemic for leishmaniasis and are at risk of infection, which includes one third of the 38 million people living with HIV (PWH) worldwide. Leishmaniasis is a neglected tropical disease caused by infection with Leishmania parasites, transmitted by bites from infected sand flies. HIV/Leishmania co-infection is increasing worldwide, especially in Southern Europe and Brazil, due to both human and ecological factors (migration, climate change, deforestation). This study demonstrates that a worryingly high number (one out of 6) of PWH in Bahia (Northeast Brazil) show previous or ongoing infection with the parasite Leishmania infantum, determined by antibodies detection against this parasite in PWH. Using a rigorous study design with data collection over 18 years in >5500 PWH, we found similarly high numbers (16.3% and 15.5%) of PWH with antibodies against Leishmania infantum in two consecutive cohorts. Moreover, PWH with antibodies against Leishmania infantum in Bahia, Brazil displayed a worse immune profile, with lower CD4 immune cells numbers and immune activation mediated by interferon, which we confirmed in independent HIV- and Leishmania-infected cohorts from other geographic areas. Our results underscore the need to raise awareness and define public health strategies to prevent HIV/Leishmania co-infection, since therapeutic failure and mortality are strongly increased in co-infected PWH, even with antiretroviral therapy as standard of care.

Zika virus (ZIKV) is a mosquito-borne Flavivirus with a positive-sense RNA genome, which are generally transmitted through the bite of an infected Aedes mosquito. ZIKV infections could be associated with neurological sequelae that, and otherwise produces similar clinical symptoms as other co-circulating pathogens. Past infection with one member of the Flavivirus genus often induces cross-reactive antibodies against other flaviruses. These attributes complicate the ability to differentially diagnose ZIKV infection from other endemic mosquito-borne viruses, making it both a public health issue as well as a diagnostic challenge. We report the results from serological analyses using arbovirus-specific peptides on 339 samples that were previously collected from 6 countries. Overall, we found that our multiplexed peptide-based ELISA was highly efficient for identifying ZIKV antibodies as early as 2 weeks post infection, and that it correlates with microneutralization, plaque reduction neutralization tests (PRNTs) and commercial tests for ZIKV in previously characterized samples. We observed that seropositivity varied by patient cohort, reflecting the sampling period in relation to the 2015–2016 ZIKV outbreak. This work evaluates the accuracy, specificity, and sensitivity of our peptide-based ELISA method for detecting ZIKV antibodies from geographically diverse regions. These findings can contribute to ongoing serological methods development and can be adapted for use in future studies.

Introduction New oral anticoagulants (NOACs) are approved for use in nonvalvular atrial fibrillation (AF). Objectives This study aimed to evaluate the efficacy and safety of NOACs compared with warfarin in AF and valvular heart disease (VHD). Methods We identified randomized controlled trials (RCTs) and post-hoc analyses comparing NOACs and warfarin in AF and VHD, including biological and mechanical heart valves (MHV). Through systematic review and meta-analysis, with the aid of the “Rev Man” program 5.3, the primary effectiveness endpoints were stroke and systemic embolism (SE). The primary safety outcome was major bleeding, and the secondary outcome included intracranial hemorrhage. Data were analyzed using risk ratios (RRs) and 95% confidence intervals (CIs), and heterogeneity was assessed using the I2 statistic. Results Six RCTs were included, involving 13,850 patients with AF and VHD. NOACs significantly reduced the risk of stroke/SE (RR 0.78; 95% CI 0.66–0.91; P = 0.002) and intracranial hemorrhage (RR 0.51; 95% CI 0.33–0.79; P = 0.003) and lowered the risk of major bleeding (RR 0.77; 95% CI 0.58–1.02; P = 0.07) compared with warfarin. Conclusions The efficacy and safety of NOACs as thromboprophylaxis for AF and VHD are similar to those of warfarin. Electronic supplementary material The online version of this article (10.1007/s40268-019-0274-z) contains supplementary material, which is available to authorized users.

Antiretroviral therapy (ART) has represented a major advancement in the care of people living with HIV (PLWHH), resulting in significant reductions in morbidity and mortality through immune reconstitution and attenuation of homeostatic disruption. Importantly, restoration of immune function in PLWH with opportunistic infections occasionally leads to an intense and uncontrolled cytokine storm following ART initiation known as immune reconstitution inflammatory syndrome (IRIS). IRIS occurrence is associated with the severe and rapid clinical deterioration that results in significant morbidity and mortality. Here, we detail the determinants underlying IRIS development in PLWH, compiling the available knowledge in the field to highlight details of the inflammatory responses in IRIS associated with the most commonly reported opportunistic pathogens. This review also highlights gaps in the understanding of IRIS pathogenesis and summarizes therapeutic strategies that have been used for IRIS.

ObjectiveThis study aimed to assess the performance of a commonly used ICU severity score (SAPS3) and determine whether an alternative scoring system may be more accurate across all age strata.MethodsRetrospective cohort study in a general ICU in Brazil. A secondary analysis was performed with clinical and epidemiological data, present in the first 24 hours of unit admission. Then, a binary logistic regression, followed by cross-validation, was made to develop a novel prognostic tool. ICU mortality was the primary outcome evaluated.ResultsA total of 3042 patients were included over the study period between August 2015 and July 2018 with a median age of 67 ± 18.4 years. SAPS3 performed fairly in prediction of ICU mortality, particularly in the 80 years or older subset. Multivariable regression identified variables independently associated with mortality that were used to develop the Age Calibrated ICU Score (ACIS) tool that performed similarly to SAPS3 across age categories, being slightly superior in the very elderly population (AUC 0.80 vs 0.72).ConclusionsThe ACIS offers a robust and simple tool to predict ICU mortality, particularly in an increasingly elderly critical care population.

1Instituto Goncalo Moniz, FIOCRUZ, Salvador, Brazil, 2Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil, 3Division of Infectious Diseases and Pulmonary Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego, CA, USA, 4Instituto Aggeu Magalhaes, FIOCRUZ, Recife, Brazil, 5Faculdade de Ceilândia, Universidade de Brasilia, (FCE-UnB), Brasilia, Brazil and 6Hospital Geral Roberto Santos, Salvador, Brazil

Background Chikungunya virus (CHIKV) has caused worldwide epidemics that impose a major burden on health systems. Approximately half of infected individuals develop chronic debilitating arthralgia, affecting their quality of life. Here, we identified the relevant clinical and demographic variables in the acute phase of CHIKV infection prospectively linked to chronic arthralgia to elaborate a prognostic scoring system. Methods Acute CHIKV infection cases (n = 134) confirmed by serology or molecular test were examined, Author summary Debilitating articular pain frequently occurs as a consequence of Chikungunya virus infection, affecting individuals' quality of life for a long time. Here we present a simple tool to predict people at risk to remain with long-term articular pain after Chikungunya infection. We evaluated 134 patients acutely affected by Chikungunya virus searching for characteristics previously described as related to persistent symptoms. We examined about 80% of those individuals after one year to identify those with persistent arthralgia. We detected five features that represent good predictors and developed a scoring system named SHERA (www.sheracalculator.com/shera), the acronyms of Sex (female), Hypertension, Edema, Retroocular pain and Age (>26y). SHERA can correctly predict 8 out of every 10 Chikungunya infected individuals that will persist with articular pain symptoms at least one year after disease onset. These results were confirmed in the second group of patients from another city affected by Chikungunya outbreak. The easy-to-use scoring system can be applied in areas with limited access to health support, helping to identify the ones who will need special care and benefit from early intervention.

Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq) (APOIO A PESQUISAS EM ANDAMENTO SOBRE VIRUS ZIKA E IMPLEMENTACAO E MANUTENCAO DE BIOBANCOS - 439967/2016 - 3 e PROEP 420765/2017 -4), Financiadora de Estudos e Projetos (FINEP) (MCTIC/FINEP/FNDCT 01/201 6 ZIKA - 0416006000), Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior (CAPES), Fundacao de Amparo a Pesquisa do Estado da Bahia (FAPESB) and Programa de Pesquisa Para o SUS (PPSUS) - no.003/2017.

Advances in the understanding of the human microbiome outside of the ICU have led investigators to consider the role of the microbiome in critical illness. The picture that is being elucidated is one of dysbiosis occurring at multiple sites in the critically ill patient. This review describes the changes that occur in the various microbiomes of a critically ill patient, the implications of these changes and shows how advances in the understanding of dysbiosis may lead to microbiome-targeted therapies.Critically ill patients undergo dysbiosis at several organ sites including the skin, gastrointestinal system and the lungs with loss of microbial diversity and a propensity for potentially pathogenic organisms to dominate a particular microbiome. These microbiome changes appear to be predictive of clinical outcome. While the use of fecal microbial transplantation has been demonstrated to be an effective treatment for recurrent Clostridium difficile infection, the use of fecal microbial transplantation and other microbiome modifying therapies may have a role in managing critical illness in the ICU.A growing understanding of the microbiome in the critically ill may modify current dogma regarding the pathogenesis of sepsis and other life-threatening conditions seen in the ICU, thereby fundamentally changing antibiotic stewardship and the management of the critically ill patient.

Background: Pleural effusions constitute one of the most frequent pathologies encountered in the pulmonary service of Maputo Central Hospital (MCH) in Mozambique. Bleomycin and talc are commonly used for pleurodesis, but cost prohibitive, therefore we aimed to retrospectively compare the efficacy and safety of sodium hydroxide (NaOH) with bleomycin for pleurodesis. Methods: Case records of pleurodesis using bleomycin and NaOH from 2002 to 2013 were reviewed. Standard of care for pleurodesis for recurrent pleural effusions at MCH was developed using the materials available. NaOH remained the agent of choice until 2006 when bleomycin became available. Clinical data regarding general complications, rate of success and lung expansion were noted for every patient who underwent pleurodesis at MCH during this time frame. Results: Review of pleurodesis at MCH revealed 24 cases using bleomycin and 23 cases using NaOH as the sclerosing agent. Patient characteristics were balanced between the two groups with majority of pleural effusions malignant in etiology. Conclusions: There was no statistically significant difference between the use of bleomycin and NaOH as defined by lung expansion. General complications were observed less frequently in 2 (10%) of patients treated with NaOH compared with 8 (38%) of patients using bleomycin. Only three patients presented with recurrent pleural effusion after pleurodesis with NaOH. NaOH may offer a low cost alternative sclerosing agent for resource limited areas.

OBJECTIVE:ICU severity scores such as the Sequential Organ Failure Assessment (SOFA) determine neurologic dysfunction based on the Glasgow Coma Scale, a tool that may be limited in a critically ill population. It remains unknown whether alternative methods to assess for neurologic dysfunction, such as FOUR and RASS, are superior. This study aimed to determine the predictive performance of a modified SOFA tool in a large Brazilian ICU cohort. DESIGN:Prospective cohort single center study. SETTING:Mixed surgical and medical ICU in Salvador, Bahia, Brazil between August 2015 and December 2018. PATIENTS:All acutely ill ICU admissions, other than postoperative patients or those with insufficient data, were eligible for study inclusion. MEASUREMENTS AND MAIN RESULTS:2147 patients were admitted to the ICU, of which 999 meeting inclusion criteria were included in the final analysis with a median age of 72 years (IQR 58-83) and a female predominance 545 (54%). The SOFA score using GCS, RASS and FOUR for the neurologic component performed marginally in the ability to predict general ICU mortality (SOFAGCS AUC 0.74 vs SOFARASS AUC 0.71 and SOFAFOUR AUC 0.67), with SOFAFOUR performing significantly lower compared to either SOFARASS and SOFAGCS (p

Background Tuberculosis (TB)-associated Immune reconstitution inflammatory syndrome (TB-IRIS) is an aberrant inflammatory response in TB patients with advanced human immunodeficiency virus coinfection, after antiretroviral therapy commencement. Case presentation We present a rare case of a 51-year-old woman living with HIV who developed a series of TB-IRIS events occurring at multiple sites sequentially, highlighting the clinical complexity in diagnosis and management. Conclusion This case illustrates how complicated a clinical scenario of successive TB-IRIS episodes can be, in terms of clinical management.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

Background: The emergence of the Chikungunya virus (CHIKV) has resulted in worldwide epidemics that impose a major burden on health systems. Infection is often characterized by chronic debilitating arthralgia in approximately half of infected individuals, resulting in long-term effects on patients' quality of life. The early identification of affected individuals at risk of chronic implications may help direct efforts to attenuate the physical and emotional impact of infection, thereby reducing the socio-economic impact of outbreaks. Some predictive markers of chronic disease risk have been identified, yet their application is limited in clinical settings. Here, we prospectively identified the relevant clinical and demographic variables in the acute phase of Chikungunya infection that were linked to the persistence of arthralgia one year later in an attempt to elaborate a prognostic scoring system. Methods: Individuals with acute CHIKV infection (n=133), confirmed by serology or molecular test, were examined

Introduction Mechanical heart valves (MHV) are extremely durable, but they require permanent use of anticoagulation to prevent thromboembolic events. The only approved therapeutic options are vitamin K antagonists (VKAs), such as warfarin. As a drug class, clinical management is difficult, therefore new alternatives need to be evaluated. Methods RIWA is a phase II/III, prospective, open-label, randomized, pilot study designed to investigate oral rivaroxaban 15 mg twice daily compared with dose-adjusted warfarin for the prevention of stroke (ischemic or hemorrhagic) and systemic embolism in patients with MHV, from August 2018 to December 2019. Patients will undergo transesophageal echocardiography at the beginning and the end of the study (follow-up time 90 days). On an explanatory basis, all events will be analyzed, including stroke, peripheral systemic embolism, valve thrombosis, significant bleeding and death. Discussion Warfarin and similar VKAs are standard therapy for patients with an MHV. Even with the appropriate use of therapy, the incidence of thromboembolic events is high at 1–4% per year. Furthermore, bleeding risk is significant, ranging from 2 to 9% per year. The new frontier to be overcome in relation to use of the new oral anticoagulants is undoubtedly in patients with MHV. A significant portion of people with MHV worldwide will benefit if noninferiority of these new agents is confirmed. Trial Registration ClinicalTrials.gov identifier: NCT03566303. Recruitment Status: Recruiting. First Posted: 25 June 2018. Last Update Posted: 25 June 2018.

Immune reconstitution inflammatory syndrome (IRIS) occurs in up to 40% of individuals co-infected with pulmonary tuberculosis (PTB) and HIV, primarily upon antiretroviral therapy (ART) initiation. Phenotypic changes in T-cells during TB-IRIS and their relationship with systemic inflammation are not fully understood. In this prospective cohort study, we followed 48 HIV-positive patients with PTB from South India before and after ART initiation, examining T-lymphocyte subsets and inflammatory biomarkers in peripheral blood. Quantification of naïve (CD27+CD45RO−) as well as effector memory CD4+ T cells (CD27−CD45RO+) at weeks 2–6 after ART initiation could distinguish TB-IRIS from non-IRIS individuals. Additional analyses revealed that ART reconstituted different quantities of CD4+ T lymphocyte subsets with preferential expansion of CXCR3+ CCR6− cells in TB-IRIS patients. Moreover, there was an expansion and functional restoration of central memory (CD27+CD45RO+) CXCR3+CCR6− CD4+ lymphocytes and corresponding cytokines, with reduction in CXCR3−CCR6+ cells after ART initiation only in those who developed TB-IRIS. Together, these observations trace a detailed picture of CD4+ T cell subsets tightly associated with IRIS, which may serve as targets for prophylactic and/or therapeutic interventions in the future.

Background Fine needle aspiration cytology (FNAC) is an important diagnostic tool in a range of medical settings. It is fast, quick and a highly accurate diagnostic method and can be used, in settings with minimal laboratory infrastructures. Methods In this report, we describe the experience in the use of FNAC since it is introduction in 1996 in the Anatomical Pathology Service of the Maputo Central Hospital (MCH), along with more detailed data referring to 2009-2010. Results The number of FNAC analyses increased gradually from 269 (4.1% of all pathologic tests of the Service) in 1996, when it was introduced in Mozambique, to 3234 (17% of all tests) in 2010. Lymph nodes were the organs most frequently biopsied, followed by breast and soft tissues. Inflammatory conditions, especially tuberculosis, were the most frequent diagnoses (22.2% of the cases), followed by hyperplastic conditions (20.6%), benign tumors (13.4%) and malignant tumors (12.3%). Conclusion Our results clearly demonstrate that even in an environment with poor laboratory resources, it is possible to establish a FNAC clinic that can provide a quick and precise diagnosis for clinicians to aid in early treatment interventions, especially in inflammatory diseases which were the majority of our cases.

Background Worldwide, about 11% of Tuberculosis (TB) cases occur in people living with HIV (PLHIV) and it is the leading cause of death in this population. An important step towards reducing the incidence and mortality of TB in PLHIV is to reduce the time from onset of symptoms to treatment. Factors related to TB treatment delay therefore need to be understood. Methods Using data from a prospective cohort study of patients diagnosed with TB at the National Institute of Infectious Disease, at the Oswaldo Cruz Foundation, Rio de Janeiro, Brazil we conducted a survival analysis to identify factors associated with patient and health care treatment delay. In our analysis we included patients who were co-infected with TB and HIV (n = 201). Patients were followed during the course of their TB treatment and information regarding duration of symptoms, sociodemographics and clinical characteristics were collected at the baseline visit. Results The median time from onset of initial symptoms to prescription of TB treatment (total delay) was 82 days. From initiation of symptoms to first visit at INI clinic (patient delay), the median was 51 days. From first visit to initiation of treatment (health care delay) the median was 16 days. Illiteracy was associated with greater patient delay [Hazard Ratio (HR) = 2.25, CI 95% 1.29–3.94]. Having had a previous episode of TB (HR = 0.53, CI 95% 0.37–0.74) and being married (HR = 0.71, CI 95% 0.54–0.94) were inversely related to patient delay. Illiteracy was also associated with greater health care delay (HR = 2.83, CI 95% 1.25–5.47) in contrast to high viral load (HR = 0.37, CI 95% 0.24–0.54) and weight loss greater than 10% (HR = 0.54, CI 95% 0.37–0.8), both of which were inversely related to health care delay. Conclusions This study highlights the existence of factors that lead to greater risk of delayed treatment of TB among patients co-infected with HIV and TB. These include factors that can be assessed through targeted interventions which have implications for improving treatment outcomes and, through reduced duration of infectiousness, reduce the incidence of TB in Brazil.

Saccharomyces cerevisiaeis increasingly being promoted as a nutritional supplement by health food enthusiasts and is also recommended as prophylaxis against antibiotic-associated diarrhea. However, severe opportunistic infections due toS. cerevisiaehave been reported in patients with chronic disease, cancer, and immunosuppression. Fungemia, endocarditis, pneumonia, peritonitis, urinary tract infections, skin infections, and esophagitis have been described. It is important to consider infections due toS. cerevisiaein appropriate clinical settings. Here, we describe the first case ofS. cerevisiaelaryngitis in a patient with a history of laryngeal carcinoma who also had oral lesions.

Introduction. Case reports have emerged with identification of Gordonia bronchialis infections including sternal wound infections and foreign bodies such as central lines and shunts. Case presentation. We present a case that demonstrates the need to consider Gordonia infection as a cause of sternal wound infection and highlights the utility of novel diagnostics to aid in the identification of unusual pathogens that can cause post-operative infections. We report here the first successful use of ceftaroline for treatment of a G. bronchialis sternal wound infection. Conclusion. There are only case reports and in vitro assays to date to guide treatment of this infection, and we now add ceftaroline as a new drug to consider, though adequate surgical debridement is paramount.

Since the re-emergence of Zika virus in 2014 and subsequent association with microcephaly, much work has focused on the development of a vaccine to halt its spread throughout the world. The mosquito vector that transmits this virus is widespread and responsible for the spread of other arboviridae including Dengue. Current diagnostic methods rely on serologic testing that are complicated by cross reactivity and therefore unable to distinguish Zika from Dengue infection in the absence of virus isolation. We performed an in silico analysis to identify potential epitopes that may stimulate a unique T-lymphocyte response to distinguish prior infection with Zika or Dengue. From this analysis, we not only identified epitopes unique to Zika and Dengue, but also identified epitopes unique to each Dengue serotype. These peptides contribute to a pool of peptides identified for vaccine development that can be tested in vitro to confirm immunogenicity, absence of homology and global population coverage. The current lack of accurate diagnostic testing hampers our ability to understand the scope of the epidemic, implications for vaccine implementation and complications related to monoinfection and co-infection with these two closely related viruses.

Recent viral outbreaks highlight the need for reliable, yet broadly deployable diagnostics for detection of epidemic and emerging pathogens. In this study we designed and optimized methods to visually detect viral nucleic acid by isothermal amplification and SYBR dye intercalation. We designed and tested loop-mediated isothermal amplification (LAMP) primers and lyophilized reactions to optimize the detection of Zaire Ebola Virus (ZEBOV) and further evolved the LAMP platform to allow room-temperature storage for deployment in resource limited settings. Our results demonstrated excellent sensitivity and specificity for viral nucleic acid sequences with lower limits of detection of less than 100 copies. Moreover, lyophilized reaction mixtures retained activity for prolonged periods under dry conditions at room temperature. This approach offers a way for detection of emerging viruses in resource limited settings.

There was considerable discussion about the importance of antibiotic stewardship at the American Thoracic Society meeting in San Francisco in May 2016. Extensive literature in critical care suggests that use of early empiric antibiotics for the treatment of suspected sepsis and septic shock is crucial to clinical outcomes with delays in therapy being associated with increased mortality (1,2).

Background The objective of this paper is to summarise and critically review the available data about onchocerciasis in Mozambique, in order to report epidemiological and clinical aspects related to the disease and identify gaps in knowledge. The paper is intended to raise awareness of the existence and importance of this disease and to define research priorities. Methods We examined the scarce epidemiological data at our disposal: two diagnostic studies in 1997 and 1998 (first reports on the existence of onchocerciasis in Mozambique), and two Rapid Epidemiological Mapping of Onchocerciasis (REMO) surveys in 2001 and 2007. We examined differences in study designs and methodologies as well as the differing geographical locations to explain the divergence in findings among the studies. Results Evidence indicates that onchocerciasis is hypoendemic in Mozambique (with national and imported cases), but still largely remains an undiagnosed illness. There is no awareness of the clinical aspects of the disease and nor of the differential diagnosis with lepromatous leprosy and dermatitis caused by Scabies spp. The use of skin biopsy and a symptom screening questionnaire, combined with nodule rate, in the first two studies may have captured even atypical or subacute presentations. Both REMO surveys relied solely on nodule detection and in the six years between the two studies, the prevalence of nodules detected more than doubled. Conclusions The epidemiology and clinical aspects of the disease are unknown in Mozambique. Since the last REMO took place in 2007 and since the population is subject to large-scale movement and displacement, it is important to develop tools to identify and analyse populations that are at high risk for onchocerciasis. Cases of onchocerciasis may be misdiagnosed as leprosy or scabies that fail to improve despite being subjected to treatment against leprosy. Techniques to enable a differential diagnosis need to be established by training health professionals on the recognition of this undiagnosed disease. It is equally necessary to identify the blackfly vectors and where they breed.

Editorials 4. Delclaux C, L’Her E, Alberti C, et al: Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive air- way pressure delivered by a face mask: A randomized controlled trial. JAMA 2000; 284:2352–2360 5. Demoule A, Girou E, Richard JC, et al: Benefits and risks of suc- cess or failure of noninvasive ventilation. Intensive Care Med 2006; 6. Esteban A, Frutos-Vivar F, Muriel A, et al: Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med 2013; 188:220–230 7. Frat JP, Thille AW, Mercat A, et al; FLORALI Study Group; REVA Network: High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015; 372:2185–2196 8. Carteaux G, Millan-Guilarte T, De Prost N, et al: Failure of Noninvasive Ventilation for De Novo Acute Hypoxemic Respiratory Failure: Role of Tidal Volume. Crit Care Med 2016; 44:282–290 9. L’Her E, Deye N, Lellouche F, et al: Physiologic effects of noninvasive ventilation during acute lung injury. Am J Respir Crit Care Med 2005; 10. Dreyfuss D, Saumon G: Ventilator-induced lung injury: Lessons from experimental studies. Am J Respir Crit Care Med 1998; 11. Jiang TX, Reid WD, Belcastro A, et al: Load dependence of second- ary diaphragm inflammation and injury after acute inspiratory loading. Am J Respir Crit Care Med 1998; 157:230–236 12. Vassilakopoulos T, Divangahi M, Rallis G, et al: Differential cytokine gene expression in the diaphragm in response to strenuous resistive breathing. Am J Respir Crit Care Med 2004; 170:154–161 13. Toumpanakis D, Kastis GA, Zacharatos P, et al: Inspiratory resistive breathing induces acute lung injury. Am J Respir Crit Care Med Improved Outcomes in Critically Ill Patients With AIDS: How Does This Trend Continue?* “Success needs no explanation. Failure does not have one that matters.” –Jesse Jackson Daniel A. Sweeney, MD Division of Pulmonary, Critical Care and Sleep Medicine University of California, San Diego La Jolla, CA Kevan Akrami, MD Division of Infectious Diseases University of California, San Diego La Jolla, CA; and Critical Care Medicine Department Clinical Center National Institutes of Health Bethesda, MD Atul Malhotra, MD Division of Pulmonary, Critical Care and Sleep Medicine University of California, San Diego La Jolla, CA I n this issue of Critical Care Medicine, Huson et al (1) thoughtfully describe the clinical characteristics and out- comes of patients with AIDS admitted to Dutch ICUs *See also p. 291. Key Words: acquired immunodeficiency syndrome; antiretroviral therapy; intensive care; mortality; noninvasive ventilation Dr. Malhotra received support for article research from the National Insti- tutes of Health (NIH). The remaining authors have disclosed that they do not have any potential conflicts of interest. The opinions expressed in this article are the authors’ own and do not represent any position or policy of the NIH, the Department of Health and Human Services, or the U.S. government. Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001492 www.ccmjournal.org during the era of combination antiretroviral therapy (cART) from 1997 to 2014. Their findings show that major progress has been made during this time period such that patients with AIDS being treated in ICUs now have mortality rates approach- ing that of patients without AIDS. Although it could be argued that this success story needs no explanation, the true impact of this study may lie with the questions it raises. This study chal- lenges care providers to search for the treatment modifications that may explain this trend so as to promote further improve- ment in the care of critically ill patients with AIDS. Huson et al (1) performed a retrospective analysis of 1,127 AIDS patients and 4,479 controls (non-AIDS patients matched for age, sex, and admission type [medical or surgical and planned or unplanned]) treated in Dutch ICUs from 1997 to 2014. In general, AIDS patients had significantly more comorbidities, were more acutely ill based on Acute Physiology and Chronic Health Evalu- ation (APACHE) II scores, and were more likely to be admitted with another infection—typically a respiratory infection or sepsis. Not surprisingly, AIDS patients experienced a higher overall mor- tality rate than controls (28.2% vs 17.8%; p < 0.0001). More interesting and encouraging than these data are the favorable trends that were identified in critically ill AIDS patients from 1999 to 2014. Although the mortality rate for both AIDS and non-AIDS patients declined over the study period (39–16% and 22–14%, respectively), the aver- age annual percentage change was greater for patients with AIDS than controls (–6.0 [–8.0 to –3.9] vs –2.1 [–4.1 to –0.1]; p = 0.02). This greater decline in mortality among AIDS patients coincided with a downward trend in the proportion of AIDS patients being admitted with a respiratory infection. Further anal- yses suggest that decline in mortality was largely a function of the improved outcome in the subset of AIDS patients admitted with an infectious diagnosis. Using standardized mortality rates to control February 2016 • Volume 44 • Number 2 Copyright © 2016 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Zika virus (ZIKV) is an emerging mosquito-borne flavivirus linked to devastating neurologic diseases. Immune responses to flaviviruses may be pathogenic or protective. Our understanding of human immune responses to ZIKV in vivo remains limited. Therefore, we performed a longitudinal molecular and phenotypic characterization of innate and adaptive immune responses during an acute ZIKV infection. We found that innate immune transcriptional and genomic responses were both cell type- and time-dependent. While interferon stimulated gene induction was common to all innate immune cells, the upregulation of important inflammatory cytokine genes was primarily limited to monocyte subsets. Additionally, genomic analysis revealed substantial chromatin remodeling at sites containing cell-type specific transcription factor binding motifs that may explain the observed changes in gene expression. In this dengue virus-experienced individual, adaptive immune responses were rapidly mobilized with T cell transcriptional activity and ZIKV neutralizing antibody responses peaking 6 days after the onset of symptoms. Collectively this study characterizes the development and resolution of an in vivo human immune response to acute ZIKV infection in an individual with pre-existing flavivirus immunity., Author summary Zika virus (ZIKV) is an emerging flaviviral infection that causes significant clinical disease. It is estimated that approximately one half of the world’s population is at risk for ZIKV infection. There are only a limited number of studies describing the human immune response to ZIKV infection. Carlin et al. combined conventional and genomic approaches to longitudinally analyze the innate and adaptive immune responses to acute ZIKV infection and its resolution in a person who was infected while traveling in Venezuela during the 2016 ZIKV epidemic year. Genome-wide sequencing in individual cell types revealed that although many populations respond to interferon stimulation, only specific cell populations within peripheral blood mononuclear cells upregulate important inflammatory cytokine gene expression. Additionally, analysis of open chromatin using ATAC-seq suggests that chromatin remodeling at sites containing cell-type specific transcription factor binding motifs may help us understand changes in gene expression. Consistent with previous reports, this individual with prior exposure to dengue virus (DENV), rapidly developed neutralizing anti-ZIKV responses that were cross-reactive with multiple DENV serotypes. Collectively this study combines traditional and genomic approaches to characterize the cell-type specific development of an in vivo human immune response to acute ZIKV infection.

Myotonic dystrophy (DM), the most common adult-onset muscular dystrophy, is caused by CTG or CCTG microsatellite repeat expansions. Expanded DM mRNA microsatellite repeats are thought to accumulate in the nucleus, sequester Muscleblind proteins, and interfere with alternative mRNA splicing. Muscleblind2 (Mbnl2) is a member of the family of Muscleblind RNA binding proteins (that also include Mbnl1 and Mbnl3) that are known to bind CTG/CCTG RNA repeats. Recently, it was demonstrated that Mbnl1-deficient mice have characteristic features of human DM, including myotonia and defective chloride channel expression. Here, we demonstrate that Mbnl2-deficient mice also develop myotonia and have skeletal muscle pathology consistent with human DM. We also find defective expression and mRNA splicing of the chloride channel (Clcn1) in skeletal muscle that likely contributes to the myotonia phenotype. Our results support the hypothesis that Muscleblind proteins and specifically MBNL2 contribute to the pathogenesis of human DM. Developmental Dynamics 237:403– 410, 2008. © 2008 Wiley-Liss, Inc.

The proto-oncogene c-myc has a central role in multiple processes important for embryonic development, including cell proliferation, growth, apoptosis, and differentiation. We have investigated the role of c-myc in neural crest by using Wnt1-Cre-mediated deletion of a conditional mutation of the c-myc gene. c-myc deficiency in neural crest resulted in viable adult mice that have defects in coat color, skull frontal bone, and middle ear ossicle development. Physiological hearing studies demonstrated a significant hearing deficit in the mutant mice. In this report, we focus on the craniofacial and hearing defects. To further examine neural crest cells affected by c-myc deficiency, we fate mapped Wnt1-Cre expressing neural crest cells using the ROSA26 Cre reporter transgene. The phenotype obtained demonstrates the critical role that c-myc has in neural crest during craniofacial development as well as in providing a model for examining human congenital skull defects and deafness.

Background. Bacteraemia is a common cause of fever among patients presenting to hospitals in sub-Saharan Africa. The worldwide rise of antibiotic resistance makes empirical therapy increasingly difficult, especially in resource-limited settings. Objectives. To describe the incidence of bacteraemia in febrile adults presenting to Maputo Central Hospital (MCH), an urban referral hospital in the capital of Mozambique, and characterise the causative organisms and antibiotic susceptibilities. We aimed to describe the antibiotic prescribing habits of local doctors, to identify areas for quality improvement. Methods. Inclusion criteria were: (i) ≥18 years of age; (ii) axillary temperature ≥38°C or ≤35°C; (iii) admission to MCH medical wards in the past 24 hours; and (iv) no receipt of antibiotics as an inpatient. Blood cultures were drawn from enrolled patients and incubated using the BacT/Alert automated system (bioMerieux, France). Antibiotic susceptibilities were tested using the Kirby-Bauer disc diffusion method. Results. Of the 841 patients enrolled, 63 (7.5%) had a bloodstream infection. The most common isolates were Staphylococcus aureus , Escherichia coli , and non-typhoidal Salmonella . Antibiotic resistance was common, with 20/59 (33.9%) of all bacterial isolates showing resistance to ceftriaxone, the broadest-spectrum antibiotic commonly available at MCH. Receipt of insufficiently broad empirical antibiotics was associated with poor in-hospital outcomes (odds ratio 8.05; 95% confidence interval 1.62 - 39.91; p=0.04). Conclusion. This study highlights several opportunities for quality improvement, including educating doctors to have a higher index of suspicion for bacteraemia, improving local antibiotic guidelines, improving communication between laboratory and doctors, and increasing the supply of some key antibiotics.

Lbx2 is a member of the ladybird family of homeobox genes. The first murine ortholog identified, Lbx1, is required for hypaxial musculature and dorsal spinal cord neuron development. The second murine ortholog, Lbx2, is expressed in the developing urogenital and nervous systems. To elucidate the function of Lbx2, we generated a gene-targeted allele of Lbx2 in mice. Lbx2 deficiency did not impair mouse development, and Lbx2 null mice appeared healthy and fertile. Replacement of Lbx2 by the lacZ gene provides a valuable histological marker for Lbx2-expressing cells. Given the important role of Pax3 in neural crest, we intercrossed our Lbx2 deficient mice with Splotch Pax3 mutant mice to determine if Pax3 affects Lbx2 expression. There was reduced Lbx2 expression in dorsal root ganglia and cranial nerve ganglia with Pax3 deficiency, but not in the genital tubercle. This suggested that Pax3 is required for Lbx2 expression in affected neural crest-derived tissues.