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Background: Elexacaftor–tezacaftor–ivacaftor has been shown to be safe and efficacious in people with cystic fibrosis and at least one F508del allele. Our aim was to identify a novel cystic fibrosis transmembrane conductance regulator (CFTR) modulator combination capable of further increasing CFTR-mediated chloride transport, with the potential for once-daily dosing. Methods: We conducted two phase 2 clinical trials to assess the safety and efficacy of a once-daily combination of vanzacaftor–tezacaftor–deutivacaftor in participants with cystic fibrosis who were aged 18 years or older. A phase 2 randomised, double-blind, active-controlled study (VX18-561-101; April 17, 2019, to Aug 20, 2020) was carried out to compare deutivacaftor monotherapy with ivacaftor monotherapy in participants with CFTR gating mutations, following a 4-week ivacaftor monotherapy run-in period. Participants were randomly assigned to receive either ivacaftor 150 mg every 12 h, deutivacaftor 25 mg once daily, deutivacaftor 50 mg once daily, deutivacaftor 150 mg once daily, or deutivacaftor 250 mg once daily in a 1:1:2:2:2 ratio. The primary endpoint was absolute change in ppFEV1 from baseline at week 12. A phase 2 randomised, double-blind, controlled, proof-of-concept study of vanzacaftor–tezacaftor–deutivacaftor (VX18-121-101; April 30, 2019, to Dec 10, 2019) was conducted in participants with cystic fibrosis and heterozygous for F508del and a minimal function mutation (F/MF genotypes) or homozygous for F508del (F/F genotype). Participants with F/MF genotypes were randomly assigned 1:2:2:1 to receive either 5 mg, 10 mg, or 20 mg of vanzacaftor in combination with tezacaftor–deutivacaftor or a triple placebo for 4 weeks, and participants with the F/F genotype were randomly assigned 2:1 to receive either vanzacaftor (20 mg)–tezacaftor–deutivacaftor or tezacaftor–ivacaftor active control for 4 weeks, following a 4-week tezacaftor–ivacaftor run-in period. Primary endpoints for part 1 and part 2 were safety and tolerability and absolute change in ppFEV1 from baseline to day 29. Secondary efficacy endpoints were absolute change from baseline at day 29 in sweat chloride concentrations and Cystic Fibrosis Questionnaire-Revised (CFQ-R) respiratory domain score. These clinical trials are registered with ClinicalTrials.gov, NCT03911713 and NCT03912233, and are complete. Findings: In study VX18-561-101, participants treated with deutivacaftor 150 mg once daily (n=23) or deutivacaftor 250 mg once daily (n=24) had mean absolute changes in ppFEV1 of 3·1 percentage points (95% CI –0·8 to 7·0) and 2·7 percentage points (–1·0 to 6·5) from baseline at week 12, respectively, versus –0·8 percentage points (–6·2 to 4·7) with ivacaftor 150 mg every 12 h (n=11); the deutivacaftor safety profile was consistent with the established safety profile of ivacaftor 150 mg every 12 h. In study VX18-121-101, participants with F/MF genotypes treated with vanzacaftor (5 mg)–tezacaftor–deutivacaftor (n=9), vanzacaftor (10 mg)–tezacaftor–deutivacaftor (n=19), vanzacaftor (20 mg)–tezacaftor–deutivacaftor (n=20), and placebo (n=10) had mean changes relative to baseline at day 29 in ppFEV1 of 4·6 percentage points (−1·3 to 10·6), 14·2 percentage points (10·0 to 18·4), 9·8 percentage points (5·7 to 13·8), and 1·9 percentage points (−4·1 to 8·0), respectively, in sweat chloride concentration of −42·8 mmol/L (–51·7 to –34·0), −45·8 mmol/L (95% CI –51·9 to –39·7), −49·5 mmol/L (–55·9 to –43·1), and 2·3 mmol/L (−7·0 to 11·6), respectively, and in CFQ-R respiratory domain score of 17·6 points (3·5 to 31·6), 21·2 points (11·9 to 30·6), 29·8 points (21·0 to 38·7), and 3·3 points (−10·1 to 16·6), respectively. Participants with the F/F genotype treated with vanzacaftor (20 mg)–tezacaftor–deutivacaftor (n=18) and tezacaftor–ivacaftor (n=10) had mean changes relative to baseline (taking tezacaftor–ivacaftor) at day 29 in ppFEV1 of 15·9 percentage points (11·3 to 20·6) and −0·1 percentage points (−6·4 to 6·1), respectively, in sweat chloride concentration of −45·5 mmol/L (−49·7 to −41·3) and −2·6 mmol/L (−8·2 to 3·1), respectively, and in CFQ-R respiratory domain score of 19·4 points (95% CI 10·5 to 28·3) and −5·0 points (−16·9 to 7·0), respectively. The most common adverse events overall were cough, increased sputum, and headache. One participant in the vanzacaftor–tezacaftor–deutivacaftor group had a serious adverse event of infective pulmonary exacerbation and another participant had a serious rash event that led to treatment discontinuation. For most participants, adverse events were mild or moderate in severity. Interpretation: Once-daily dosing with vanzacaftor–tezacaftor–deutivacaftor was safe and well tolerated and improved lung function, respiratory symptoms, and CFTR function. These results support the continued investigation of vanzacaftor–tezacaftor–deutivacaftor in phase 3 clinical trials compared with elexacaftor–tezacaftor–ivacaftor. Funding: Vertex Pharmaceuticals.

The synthesis and modification of fatty acids from carbohydrates are paramount for the production of lipids. Simultaneously, lipids are pivotal energy storage in human health. They are associated with various metabolic diseases and their production pathways are for instance candidate therapeutic targets for cancer treatments. The fatty acid de novo synthesis (FADNS) occurs in the cytoplasm, while the microsomal modification of fatty acids (MMFA) happens at the surface of the endoplasmic reticulum. The kinetics and regulation of these complex processes involve several enzymes. In mammals, those are the acetyl-CoA carboxylase (ACC), the fatty acid synthase (FAS), the very-long-chain fatty acid elongases (ELOVL 1-7), and the desaturases (delta family). Their mechanisms and expression in different organs have been studied for more than 50 years. However, modeling them in the context of complex metabolic pathways is still a challenge. Distinct modeling approaches can be implemented. Here we focus on dynamic modeling using ordinary differential equations based on kinetic rate laws. This requires a combination of knowledge on the enzymatic mechanisms and their kinetics, as well as the interactions between the metabolites, and between enzymes and metabolites. In this review, after recalling the modeling framework, we support the development of such a mathematical approach by reviewing the available kinetic information of the enzymes involved.

Human observers can reliably segment visual input and recognise objects. However, the underlying processes happen so quickly that they normally cannot be captured with fMRI. We used Emerging Images (EI), which contains a hidden object and extends the process of recognition, to investigate the involvement of early visual areas (V1, V2 and V3) and lateral occipital complex (LOC) in object recognition. The early visual areas were located with a retinotopy scan and the LOC with a localiser. The participants (N=8) then viewed an EI, followed by the hidden object’s silhouette (disambiguation), and then, the EI was repeated. BOLD responses before and after disambiguation were compared. The retinotopy parameters were used to back-project the BOLD response onto the visual field, creating spatially detailed maps of the activity change. V1 and V2 (but not V3) showed stronger response after disambiguation, while there was no difference in the LOC. The back-projections revealed no distinct pattern or changes in activity on object location, indicating that the activity in V1 and V2 is not specific for voxels corresponding to the object location. We found no difference before and after disambiguation in the LOC, which may be repetition suppression counteracting the effect of recognition.

BACKGROUND: Cystic fibrosis transmembrane conductance regulator (CFTR) modulators correct the basic defect caused by CFTR mutations. Improvements in health outcomes have been achieved with the combination of a CFTR corrector and potentiator in people with cystic fibrosis homozygous for the F508del mutation. The addition of elexacaftor (VX-445), a next-generation CFTR corrector, to tezacaftor plus ivacaftor further improved F508del-CFTR function and clinical outcomes in a phase 2 study in people with cystic fibrosis homozygous for the F508del mutation.METHODS: This phase 3, multicentre, randomised, double-blind, active-controlled trial of elexacaftor in combination with tezacaftor plus ivacaftor was done at 44 sites in four countries. Eligible participants were those with cystic fibrosis homozygous for the F508del mutation, aged 12 years or older with stable disease, and with a percentage predicted forced expiratory volume in 1 s (ppFEV1) of 40-90%, inclusive. After a 4-week tezacaftor plus ivacaftor run-in period, participants were randomly assigned (1:1) to 4 weeks of elexacaftor 200 mg orally once daily plus tezacaftor 100 mg orally once daily plus ivacaftor 150 mg orally every 12 h versus tezacaftor 100 mg orally once daily plus ivacaftor 150 mg orally every 12 h alone. The primary outcome was the absolute change from baseline (measured at the end of the tezacaftor plus ivacaftor run-in) in ppFEV1 at week 4. Key secondary outcomes were absolute change in sweat chloride and Cystic Fibrosis Questionnaire-Revised respiratory domain (CFQ-R RD) score. This study is registered with ClinicalTrials.gov, NCT03525548.FINDINGS: Between Aug 3 and Dec 28, 2018, 113 participants were enrolled. Following the run-in, 107 participants were randomly assigned (55 in the elexacaftor plus tezacaftor plus ivacaftor group and 52 in the tezacaftor plus ivacaftor group) and completed the 4-week treatment period. The elexacaftor plus tezacaftor plus ivacaftor group had improvements in the primary outcome of ppFEV1 (least squares mean [LSM] treatment difference of 10·0 percentage points [95% CI 7·4 to 12·6], pINTERPRETATION: Elexacaftor plus tezacaftor plus ivacaftor provided clinically robust benefit compared with tezacaftor plus ivacaftor alone, with a favourable safety profile, and shows the potential to lead to transformative improvements in the lives of people with cystic fibrosis who are homozygous for the F508del mutation.FUNDING: Vertex Pharmaceuticals.

Summary Background Tezacaftor–ivacaftor is an approved cystic fibrosis transmembrane conductance regulator (CFTR) modulator shown to be efficacious and generally safe and well tolerated over 8–24 weeks in phase 3 clinical studies in participants aged 12 years or older with cystic fibrosis homozygous for the Phe508del CFTR mutation (F/F; study 661-106 [EVOLVE]) or heterozygous for the Phe508del CFTR mutation and a residual function mutation (F/RF; study 661-108 [EXPAND]). Longer-term (>24 weeks) safety and efficacy of tezacaftor–ivacaftor has not been assessed in clinical studies. Here, we present results of study 661-110 (EXTEND), a 96-week open-label extension study that assessed long-term safety, tolerability, and efficacy of tezacaftor–ivacaftor in participants aged 12 years or older with cystic fibrosis who were homozygous or heterozygous for the Phe508del CFTR mutation. Methods Study 661-110 was a 96-week, phase 3, multicentre, open-label study at 170 clinical research sites in Australia, Europe, Israel, and North America. Participants were aged 12 years or older, had cystic fibrosis, were homozygous or heterozygous for Phe508del CFTR, and completed one of six parent studies of tezacaftor–ivacaftor: studies 661-103, 661-106, 661-107, 661-108, 661-109, and 661-111. Participants received oral tezacaftor 100 mg once daily and oral ivacaftor 150 mg once every 12 h for up to 96 weeks. The primary endpoint was safety and tolerability. Secondary endpoints were changes in lung function, nutritional parameters, and respiratory symptom scores; pulmonary exacerbations; and pharmacokinetic parameters. A post-hoc analysis assessed the rate of lung function decline in F/F participants who received up to 120 weeks of tezacaftor–ivacaftor in studies 661-106 (F/F) and/or 661-110 compared with a matched cohort of CFTR modulator-untreated historical F/F controls from the Cystic Fibrosis Foundation Patient Registry. Primary safety analyses were done in all participants from all six parent studies who received at least one dose of study drug during this study. This study was registered at ClinicalTrials.gov ( NCT02565914 ). Findings Between Aug 31, 2015, to May 31, 2019, 1044 participants were enrolled in study 661-110 from the six parent studies of whom 1042 participants received at least one dose of study drug and were included in the safety set. 995 (95%) participants had at least one TEAE; 22 (2%) had TEAEs leading to discontinuation; and 351 (34%) had serious TEAEs. No deaths occurred during the treatment-emergent period; after the treatment-emergent period, two deaths occurred, which were both deemed unrelated to study drug. F/F (106/110; n=459) and F/RF (108/110; n=226) participants beginning tezacaftor–ivacaftor in study 661-110 had improvements in efficacy endpoints consistent with parent studies; improvements in lung function and nutritional parameters and reductions in pulmonary exacerbations observed in the tezacaftor–ivacaftor groups in the parent studies were generally maintained in study 661-110 for an additional 96 weeks. Pharmacokinetic parameters were also similar to those in the parent studies. The annualised rate of lung function decline was 61·5% (95% CI 35·8 to 86·1) lower in tezacaftor–ivacaftor-treated F/F participants versus untreated matched historical controls. Interpretation Tezacaftor–ivacaftor was generally safe, well tolerated, and efficacious for up to 120 weeks, and the safety profile of tezacaftor–ivacaftor in study 661-110 was consistent with cystic fibrosis manifestations and with the safety profiles of the parent studies. The rate of lung function decline was significantly reduced in F/F participants, consistent with cystic fibrosis disease modification. Our results support the clinical benefit of long-term tezacaftor–ivacaftor treatment for people aged 12 years or older with cystic fibrosis with F/F or F/RF genotypes. Funding Vertex Pharmaceuticals Incorporated.

Since the end of January 2020, covid-19 is a group A infectious disease according to the Public Health Act (in Dutch: Wet publiekegezondheid or Wpg). To avert the risk of infection with covid-19, coercive measures can be imposed under this law. Almost at the same time, since January 1 2020, two new Dutch laws regulate the mandatory care for people with intellectual disability and dementia (the Care and Compulsion Act (in Dutch: Wet zorgendwang or Wzd) and for people with a mental disorder (the Mandatory Mental Health Care Act (in Dutch: Wet verplichte GGZ or Wvggz). Just like the Wpg, the Wzd and Wvggz allow coercion for the benefit of third parties. In this clinical lesson we describe the use of the Wpg, Wzd and Wvggz in order to avert covid-19 infection risk.

On 1 July 2020, the registration of organ and tissue donors in the Netherlands changed from an opt-in to an opt-out system. This means that everyone in the Netherlands will be registered as an organ and tissue donor unless they have registered a different choice in the donor register. The hope is that this new method for donor registration will lead to more donors. Only a small majority of members of the Senate and the House of Representatives in the Netherlands voted for the legislative amendment that enabled this new system to come into effect. In the Senate the amendment was defended on the grounds that it would do more justice to the autonomy of the deceased; the new law will, however, have to be defended from the principles of justice and solidarity by a government that feels responsibility towards those needing a donor organ.

In the late 1970s, the American bioethicists Tom Beauchamp and James Childress described the four ethical principles that should guide a physician's actions in individual patient care. These principles are: (a) respect for autonomy; (b) doing well (beneficence); (c) not harming (non-maleficence); and (d) justice. In many countries, the global outbreak of SARS-CoV-2 has led to overloaded healthcare systems due to large numbers of COVID-19 patients. In order to provide care to this high volume of patients, far-reaching measures are taken that affect everyone. These measures are not taken from an individual patient's perspective but in the interest of public health; nonetheless, they can directly affect the individual patient's interests. This article examines the extent to which Beauchamp and Childress' ethical principles may be compromised during the COVID-19 pandemic.

Mycobacterium microti belongs to the Mycobacterium tuberculosis complex (MTBC). It can cause pulmonary and extrapulmonary tuberculosis in humans. Compared to M. tuberculosis , which is the most prevalent subspecies of the MTBC, M. microti infection has a different etiology. Moreover, establishing the diagnosis with conventional bacteriology can be difficult. We will illustrate this with a case of an extrapulmonary tuberculosis of the hip caused by M .microti in an immunocompetent patient in The Netherlands.

PURPOSE: The purpose of this study is to assess the causes of uveitis in Indonesia and determine the importance of tuberculosis (TB) as a cause of uveitis. PATIENTS AND METHODS: Prospective cohort study examining 146 consecutive new human immunodeficiency virus-negative patients with active uveitis between June 2014 and May 2015. We assessed the anatomic locations and specific causes of uveitis, as well as associations with infectious and non-infectious systemic diseases. We determined the prevalence of positive QuantiFERON Tb Gold test (QFT) results in Indonesian patients with uveitis and calculated the number of patients with active systemic TB. RESULTS: Posterior and panuveitis were the most common anatomic entities (38% each). Infections represented the most frequent cause of uveitis (33%); the most prevalent were toxoplasmosis (19%) and active systemic TB (8%). The majority of patients were QFT positive (61%). A specific diagnosis could not be established in 45% of the patients. At first presentation to the ophthalmologist, the majority of patients (66%) had a visual acuity of less than finger counting at 3 m and already exhibited various complications of uveitis. When classifying the QFT-positive patients with unexplained uveitis into a TB-related group, the percentage of ‘TB-associated’ uveitis cases increased from 8–48%. Highly elevated QFT levels were observed in patients with uveitis of unknown cause and no signs of active systemic TB. CONCLUSIONS: In Indonesia, infectious uveitis was the most common type of uveitis and the leading causes consisted of toxoplasmosis and TB. The association observed between highly elevated QFT results and uveitis of otherwise unexplained origins indicates that a link exists between the latent TB infection and the development of uveitis.

Introduction: Treatment of MDRTB is complex: regimens require microbiological data; adverse events are frequent; availability of drugs and authorization for new drugs varies. The aim of this study was to scope the available national resources. Method: A survey to determine whether practising physicians could access MDRTB advice was sent to TBnet members by email. The ERS Office also contacted national respiratory societies. Questions included the name and contact details for their national advisory service, whether it was national policy to use the service for each patient with MDRTB and whether advice was required to access bedaquiline and delaminid. Results: 65 replies were received (14 were uninformative). 26/31 EU/EEA and 10/19 other countries in the WHO European Region were represented. 7 countries referred all MDRTB to a tertiary centre; 12 countries had tertiary referral centres that also gave advice to physicians treating MDRTB. 11 countries had an electronic system for advice, 6 with multidisciplinary team meetings to review patients’ progress. Lead clinicians were identified for a further 8 countries, one of which had no national advisory service and the other 7 had not responded by the time of abstract submission. For 18 (58%) countries, discussion of MDRTB by a national /regional committee was national policy and most (15/18) required consultation to use bedaquiline or delamanid. Electronic platforms had a wide range of functionality but few retained anonymised data and audited patient outcomes. Conclusion: MDRTB management is often concentrated in tertiary centres. Clinical governance, regarding audit and outcome, are at an early stage in managing MDRTB.

A considerable proportion of the world’s population is latently infected with Mycobacterium tuberculosis (MTB) complex (LTBI) but in low-incidence counties as the Netherlands (4.6 TB cases/100.000 /year) LTBI prevalence is predominantly found among the elder population and foreign-born residents. In resource-rich countries implementation of immunosuppressive therapies with “biologicals”, show a rapid rise with increased risk of LTBI progressing to, often serious forms of, active TB. Worldwide it is advised to screen all candidates for of immunosuppressive therapies for TB with a chest X-ray and LTBI with at least one test [interferon gamma release assays (IGRAs) and/or tuberculin skin tests (TSTs)]. Screening requires an acceptable balance between over-diagnosis and under-diagnosis, also because the tests are not perfect and can be false-negative and false-positive in populations almost without exposure. We developed a guideline advising a stratified pre-immunosuppression screening policy, using a questionnaire classifying candidates in three screening strategies, based upon their age, country of birth, documented TB contacts and tests in the past and other risk factors, such as profession and travel history. A very low risk group can start with immune therapy immediately and a very high risk group should receive preventive treatment for LTBI, both without the need for further testing. A medium risk group should be tested by TST and IGRA and receive preventive treatment if at least one test is positive. Since the questionnaire is not yet validated monitoring of this approach on a national level is needed to evaluate the performance of this stratified screening strategy, based upon risk analysis.

Purpose: To report on the prevalence and clinical implications of positive QuantiFERON-Gold (QFT-G) test results in the diagnostic evaluation of a large cohort of consecutive patients with uveitis in the Netherlands. Design: Retrospective cross-sectional study. Methods: This study included 710 consecutive patients who all underwent evaluation for uveitis including QFT-G testing. The ocular features, comorbidity, and abnormalities in diagnostic imaging and laboratory tests were registered for QFT-G–positive patients with uveitis. Results: Of all patients, 13% (92/710) were positive for QFT-G. Previously treated tuberculosis (TB) was documented in 2 patients. Of all 92 QFT-G–positive patients, culture-proven active TB was observed in 1 case. The proportion of patients with uveitis of unknown etiology was higher in QFT-G–positive than in the QFT-G–negative patients (54/92, 59% vs 238/618, 39%; P = .0004). The uveitis features of QFT-G–positive patients were mainly nonspecific. Of all QFT-G–positive patients with uveitis, 17 patients had chest imaging changes suggesting either TB or sarcoidosis. Twenty-nine QFT-G–positive patients with otherwise unexplained uveitis completed antituberculous therapy (29/710; 4% of all included patients) with beneficial effect in most cases. Conclusion: The QFT-G tested positive in 13% of patients with uveitis in the Netherlands, whereas only sporadic patients had a documented previous or active TB infection. The proportion of patients with unexplained uveitis was higher in QFT-G–positive patients. Though the association between uveitis and a positive QFT-G test might be coincidental, the majority of treated QFT-G–positive patients with otherwise unexplained severe uveitis cause had a beneficial response to antituberculous therapy.

An antibiotic approach directed at eradication of a new isolate of Pseudomonas aeruginosa can result in a significant reduction in exacerbation frequency in bronchiectasis patientshttp://ow.ly/L1Zl30nv1WS

We discuss two patients with infectious tuberculosis who underwent compulsory isolation and treatment without their consent. We describe the threat to the patient's rights, i.e. the right of freedom, the right of autonomy and the right of protection of the integrity of the body. We describe the application of the relevant laws and of the differing safeguards, and discuss the unlimited length of the Dutch Public Health Act orders. We refer to a Dutch statement and the WHO ethics guidelines on the implementation of their End TB Strategy. Forced isolation may be the last resort to protect society from patients with infectious diseases who do not comply with isolation measures, but compulsory treatment for tuberculosis patients is considered unacceptable. We suggest an amendment of the Dutch Public Health Act to enable better protection of the rights of tuberculosis patients.

QuantiFERON-Gold TB (QFT)-positive patients with undetermined cause of uveitis are problematic in terms of whether to diagnose and treat them for tuberculosis (TB). Here, we investigated whether peripheral blood expression of type 1 interferon (IFN)-inducible genes may be of use to stratify QFT-positive patients with uveitis into groups of high versus low risk of having active TB-associated uveitis. We recruited all new uveitis patients in Cipto Mangunkusumo Hospital, Jakarta, Indonesia for one year. We included 12 patients with uveitis and clinically diagnosed active pulmonary TB, 58 QFT-positive patients with uveitis of unknown cause, 10 newly diagnosed sputum-positive active pulmonary TB patients without uveitis and 23 QFT-negative healthy controls. Expression of 35 type 1 IFN-inducible genes was measured in peripheral blood cells from active pulmonary TB patients without uveitis and healthy controls. Differentially expressed genes were identified and used for further clustering analyses of the uveitis groups. A type-1 IFN gene signature score was calculated and the optimal cut-off value for this score to differentiate active pulmonary TB from healthy controls was determined and applied to QFT-positive patients with uveitis of unknown cause. Ten type 1 IFN-inducible genes were differentially expressed between active pulmonary TB and healthy controls. Expression of these 10 genes in QFT-positive patients with uveitis of unknown cause revealed three groups: 1); patients resembling active pulmonary TB, 2); patients resembling healthy controls, and 3); patients displaying an in-between gene expression pattern. A type 1 IFN gene signature score ≥5.61 displayed high sensitivity (100%) and specificity (91%) for identification of active TB. Application of this score to QFT-positive patients with uveitis of unknown cause yielded two groups with expected different likelihood (high vs. low) of having active-TB uveitis, and therefore may be useful in clinical management decisions.

Advanced age was the only risk factor for false-negative IGRAs in this study of active tuberculosis http://ow.ly/Cvp5G

PURPOSE: To evaluate clinical manifestations of patients with uveitis and scleritis of unknown origin and positive QuantiFERON-TB Gold In-Tube test (quantiferon) in a country not endemic for tuberculosis. DESIGN: Multicenter retrospective cohort study. METHODS: Retrospective review of the clinical, laboratory, and imaging data of 77 patients. Main outcome measures consisted of ocular and systemic features as well as results of laboratory examinations. RESULTS: Out of all, 60 of 71 (85%) were living for at least 6 months in tuberculosis-endemic regions. Location of uveitis was variable; posterior uveitis (29/77; 38%) was the most frequent. Two clinical entities were commonly noted: retinal occlusive vasculitis (21/77; 27%) and serpiginoid choroiditis (11/77; 14%). Antituberculosis treatment was completed in 32 patients; 29 of them (91%) achieved complete remission. Mean quantiferon level was 7.5 U/mL; 71% had values above 2 U/mL and 41% above 10 U/mL. We observed no associations between quantiferon levels and clinical and/or imaging features. Previous tuberculosis infection was diagnosed in 5 of 77 patients (6.5%), while hilar/mediastinal lymphadenopathy was found in 25 of 76 patients (33%). Of these, 12 were consistent with the diagnosis of sarcoidosis, 9 were typical for (prior) tuberculosis, and 4 were compatible with both diagnoses. CONCLUSIONS: Ocular features of patients with idiopathic uveitis and positive quantiferon were diverse, but retinal occlusive vasculitis and serpiginoid choroiditis were common. The quantiferon levels were usually highly elevated and 33% of patients exhibited lymphadenopathy, suggesting frequently the diagnosis of sarcoidosis. Ocular inflammation reacted favorably to antituberculosis treatment, although only a small minority had documented (prior) tuberculosis. (C) 2014 by Elsevier Inc. All rights reserved.

Introduction Small airway obstruction is important in the pathophysiology of cystic fibrosis (CF) lung disease. Additionally, many CF patients lose lung function in the long term as a result of respiratory tract exacerbations (RTEs). No trials have been performed to optimize mucolytic therapy during a RTE. We investigated whether specifically targeting dornase alfa to the small airways improves small airway obstruction during RTEs. Methods In a multi-center, double-blind, randomized controlled trial CF patients hospitalized for a RTE and on maintenance treatment with dornase alfa were switched to a smart nebulizer. Patients were randomized to small airway deposition (n = 19) or large airway deposition (n = 19) of dornase alfa for at least 7 days. Primary endpoint was forced expiratory flow at 75% of forced vital capacity (FEF75). Main Results Spirometry parameters improved significantly during admission, but the difference in mean change in FEF75 between treatment groups was not significant: 0.7 SD, P = 0.30. FEF25–75, FEV1, nocturnal oxygen saturation and diary symptom scores also did not differ between groups. Conclusions This study did not detect a difference if inhaled dornase alfa was targeted to small versus large airways during a RTE. However, the 95% confidence interval for the change in FEF75 was wide. Further studies are needed to improve the effectiveness of RTE treatment in CF. Pediatr Pulmonol. 2014; 49:154–161. © 2013 Wiley Periodicals, Inc.

Background: Because persistent inflammation plays a dominant role in cystic fibrosis (CF), we assessed systemic and local upper airway responses during and after pulmonary exacerbation. Methods: We followed a cohort of Psetidomonas aeruginosa-infected adult CF patients (n = 16) over time in pulmonary exacerbation and in stable disease. Interleukin (IL)-1 beta, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-17A, IL-22, interferon-gamma and TNF alpha levels were measured in sputum, nasal lavages and plasma. Results: In CF patients IL-6 and IL-10 levels in nasal lavages were significantly increased in exacerbation compared with stable disease. Systemic IL-6 significantly correlated with CRP levels and FEV1 (%predicted), independently of disease status. Systemic IL-10 also correlated significantly with CRP and FEV1 (%predicted), but only in exacerbation. Other cytokines tested did not discriminate between exacerbation and stable disease. Conclusions: Determination of IL-6 and IL-10 nasal lavages may provide a minimally invasive tool in the assessment of an exacerbation in CF. (C) 2013 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.

Latent tuberculosis infection (LTBI) screening and preventive treatment is one of the components of the World Health Organization (WHO) End TB strategy, and particularly relevant for low tuberculosis (TB) incidence countries, i.e. less than 100TB cases per million population. The Netherlands is such a low-incidence country with traditionally a strong emphasis on programmatic management of LTBI, e.g. examining contacts of infectious TB patients by the public health services. Increasingly, curative services are involved in LTBI management of clinical risk groups. The country recently adopted a five-year strategic national plan recommending LTBI screening of high-risk migrants populations. A monitoring and evaluation system is already in place to measure programme performance and guide policy. Research on LTBI screening of migrants is on-going and results should inform future decisions in scaling-up this intervention. Several challenges remain for programmatic LTBI management, such as securing financial resources and the right professional cadre for implementation; availability of screening tests and drugs; collecting additional data for monitoring and evaluation, in line with the WHO indicators for LTBI programmatic management; developing cultural-sensitive and client-centred education for migrants; reducing patient costs for LTBI screening and preventive treatment; and assessing cost-effectiveness and impact on TB epidemiology. Keywords: Elimination, Latent tuberculosis infection, Prevention, Screening, Tuberculosis, Municipal Public Health Service

Respiratory infections caused by respiratory viruses are common in paediatric cystic fibrosis (CF) patients and are associated with increased morbidity. There is only little data on the incidence of viral respiratory pathogens causing exacerbations in the adult CF patient population. In this observational pilot study we show, by using molecular as well as conventional techniques for viral isolation, that during 1 y a viral pathogen could be isolated in 8/24 (33%) adult CF patients who presented with a pulmonary exacerbation. This result shows that there is a considerable incidence of viral pathogens in pulmonary exacerbations in adult CF patients. Newly identified viruses such as pandemic influenza A/H1N1, human metapneumovirus, human bocavirus, and human coronavirus NL63 were not detected in our population, except for 1 human coronavirus NL63.

Introduction It is well known that pulmonary tuberculosis is associated with an increased risk of lung cancer. We investigated whether a history of pulmonary tuberculosis is an independent risk factor for lung cancer survival in Caucasian patients. Methods The data of the prospective population-based cohort of The Rotterdam Study were used. During a mean follow-up time of 18 years, there were 214 incident cases of pathology-proven lung cancer in a source population of 7983 study participants. History of tuberculosis was assessed at baseline by interviewers using standardized questionnaires. Associations of lung cancer survival with the occurrence of pulmonary tuberculosis were assessed using Cox's proportional hazard regression analysis adjusted for age, gender, pack-years, educational level and tumor stage. Results A history of tuberculosis was reported in 13 of the 214 subjects with lung cancer. The survival of patients with lung cancer was significantly shorter in subjects with a history of pulmonary tuberculosis (HR = 2.36, CI95%: 1.1–4.9), than in subjects without a history of pulmonary tuberculosis with a mean difference of 311 days. Conclusion The presence of a history of pulmonary tuberculosis may be an important prognostic factor in the survival of lung cancer.

Thirty-year-old observations report frequent asymptomatic Clostridium difficile carriage among cystic fibrosis (CF) patients. In this case-control study, we found more carriers among CF patients than controls (47% versus 11%), but most strains carried by CF patients were non-toxigenic (77% versus 17%). Among CF patients, carriers were younger, with more severe pulmonary disease than non-carriers. Strains belonged to multiple PCR-ribotypes, suggesting that these CF patients did not acquire strains from each other.

Objective: HIV-1 RNA levels in peripheral blood are strongly associated with progression to AIDS, CD4+ T-cell decline, or death. Their predictive value is reportedly independent of the predictive value of CD4+ T-cell counts. Because the interrelations between these parameters of HIV-1 infectin are poorly understood, we studied the kinetics and predictive value of serum HIV-1 RNA levels, CD4+ T-cell counts, and T-cell function. Design and methods: HIV RNA levels, CD4+ T-cell counts, and T-cell function were measured from seroconversion to AIDS in 123 homosexual men who seroconverted during a prospective study and were followers over 10 years. Results: Two patterns of median HIV-1 RNA levels were found during infection: a steady-state and a 'U-shaped' curve. Steady-state high RNA levels were related to rapid disease progression. For the U-shaped curve, there were groups with high and low RNA levels related to disease progression. At 1 year after seroconversion, RNA level was the only marker that was strongly predictive. Furthermore, decreasing RNA levels in the first year following seroconversion were related to better prognosis than stable low levels. Low CD4+ T-cell count and T-cell function became predictive of progression to AIDS at 2 and 5 years after seroconversion, respectively. Conclusions: With ongoing infection, the predictive value of low CD4+ T-cell count and T-cell function increases, whereas the predictive value of high HIV-1 RNA level decreases. These findings reflect the observation that infection with HIV progressively leads towards immune deficiency, which in later stages is most predictive of disease progression.

Methoxymorpholino doxorubicin (MMRDX) is an anthracycline analogue that is able to overcome tumor cell resistance to classical anthracyclines. Mechanisms for increased MMRDX cytotoxicity were analyzed in a small cell lung carcinoma cell line (GLC(4)), its 300-fold doxorubicin-resistant and multidrug resistance-associated protein (MRP)-over-expressing subline (GLC(4)/ADR), an ovarian carcinoma cell line (A2780) and its 100-fold doxorubicin resistant and P-glycoprotein (P-gp)-over-expressing subline A2780AD. Cross-resistance, measured with the MTT assay at MMRDX concentration resulting in 50% growth inhibition, was 1.8-fold in GLC(4)/ADR and 4.5-fold in A2780AD compared to their respective parental cell lines. Cellular MM RDX accumulation was equal in GLC(4) and GLC(4)/ADR and 2-fold lower in A2780AD compared to A2780. Doxorubicin fluorescence was analyzed with confocal laser scan microscopy. Fluorescence was nuclear in sensitive, and cytoplasmic in resistant, cell lines, while MMRDX fluorescence was found in the nucleus in all cell lines. Pre-incubation with the MRP blocker MK571 restored in GLC(4)/ADR cells the nuclear doxorubicin fluorescence pattern, as observed in GLC(4) cells. MMRDX, thus, can largely overcome cross-resistance in these P-gp- and MRP-overexpressing doxorubicin-resistant cell lines. Our results suggest that MMRDX is not a substrate for MRP-mediated resistance. (C) 1997 Wiley-Liss, Inc.

beta 2-microglobulin levels were determined in the serum of 18 initially asymptomatic HIV-1 p24 antigenaemic subjects who were treated with zidovudine (+/- acyclovir) and who were followed for 2 1/2 years. The median serum beta 2-microglobulin level at week 0 was 2.5 mg/l and decreased to 2.3 mg/l after 12 weeks of treatment (p = 0.001). A correlation was found between individual changes in serum beta 2-microglobulin levels and individual changes in serum p24 antigen levels during the first 48 weeks of treatment (p less than 0.05). Six out of 18 subjects progressed to AIDS after 60-126 weeks of treatment. In this group during a period of more than one year before disease progression median serum beta 2-microglobulin levels increased from 2.5 mg/l to 3.3 mg/l (p = 0.03) and median CD4+ cell counts decreased from 0.3 x 10(9)/l to 0.08 x 10(9)/l (p = 0.03), while in that period the pattern of serum p24 antigen levels was inconsistent. Although the variability in serum beta 2-microglobulin levels appeared to make this marker unsuitable for management decisions in individuals, a decline in beta 2-microglobulin levels was found to parallel a decline in p24 antigen levels during the early phase of zidovudine treatment. Moreover, after prolonged treatment, rising beta 2-microglobulin levels--in contrast to p24 antigen levels--were shown to have predictive value for disease progression.

Antibody-reactive peptide scanning (Pepscan) using overlapping nonapeptides and human sera as probes allows the identification of amino acids contributing significantly to antigen-antibody interaction. Five-hundred and two overlapping nonapeptides derived from the human immunodeficiency virus type 2 strain Rod (HIV-2Rod) external envelope glycoprotein gp125 were synthesized to serve as probes for reactivity with eight sera of HIV-2-infected individuals. Fifteen antibody-binding regions were identified, among which two amino-terminal regions [E3, amino acids (aa) 118 to 132; E4, aa 125 to 141] and four carboxy-terminal regions (E11, aa 303 to 324; E12, aa 340 to 358; E14, aa 436 to 452; E15, aa 486 to 507) were the most antigenic. The amino acids in binding sites E3 and E4 were highly variable among simian immunodeficiency virus (SIV), HIV-2 and HIV-1. The antibody-binding domains E14 and E15 were highly conserved among HIV-2 strains (94% and 86% identity of HIV-2Rod to HIV-2Isy and HIV-2NIHZ, respectively). Both domains had more amino acids in common with SIV (88% for E14, 64% for E15) than with HIV-1 (41% for E14, 45% for E15). Epidemiological studies revealed that the sera of African HIV-2-infected individuals bound the E11 and E15 peptides best (31%, 8/26). The sera of African HIV-1-infected individuals showed significant levels of cross-reactivity to the HIV-2 peptides, especially to the E15 peptide, whereas the sera of European HIV-1-infected individuals showed only moderate levels of cross-reactivity. If peptides covering the E15 epitope were used, African HIV-2-positive sera showed only a low level of cross-reactivity (4%) to E15 of HIV-1 and SIV. African HIV-1-positive sera bound the HIV-1 E15 peptide best (81%, 52/64), but showed high levels of cross-reactivity to SIV E15 (17%, 11/64) and HIV-2 E15 (25%, 16/64). European HIV-1-positive sera showed a high level of reactivity of HIV-1 E15 (91%, 50/55) and a low level of cross-reactivity to the HIV-2 (2%, 1/55), and none to the SIV E15 (0/55) peptide. These results indicate that the immunodominant regions of the HIV-2 external envelope (E11 and E15) align with the most immunodominant regions of HIV-1.

In three subgroups of a clinically and socially well defined group of Dutch homosexual men, the prevalence of human immunodeficiency virus type 1 (HIV-1) sequences in seronegative blood samples was studied using the polymerase chain reaction (PCR). In 19 seronegative partners of seropositive persons, no HIV-1 sequences were found by PCR in either early (1984/1985) or more recent (1987) samples. In 42 seronegative persons selected by their high risk for HIV-1 infection, none harbored HIV-1 sequences in either early (1985/1986) or late (1989) samples. In 15 people who seroconverted for HIV-1, only 2 samples collected 3 months before seroconversion were PCR-positive. These persons were also HIV antigen-positive at this time. These data suggest that a latent infection greater than 6 months does not occur and that the combination of HIV antibody and HIV antigen tests is appropriate and conclusive in most cases of HIV-1 infection.

Decreased T-cell reactivity in vitro is strongly associated with progression to AIDS and low CD4+ T-cell numbers. Low T-cell responses in vitro induced by CD3 monoclonal antibody (mAb) are predictive for progression to AIDS independent of low CD4+ T-cell counts and high HIV-1 RNA levels. We developed a whole-blood lymphocyte culture system in which T cells were stimulated by a combination of CD3 and CD28 mAb. Combined stimulation of CD28 a costimulatory molecule and CD3 considerably enhances T-cell responses in vitro and reduces variation coefficients which may increase the prognostic power of T-cell responses. A prospective study of HIV-1-infected homosexual men followed for 35 months. The predictive value of low T-cell responses to CD3 plus CD28 mAb relative to low CD4+ T-cell counts high HIV-1 RNA levels and the presence of syncytium-inducing (SI) HIV-1 variants was evaluated longitudinally in 202 HIV-1-infected homosexual men followed for 35 months. In multivariate analysis decreased T-cell responses at baseline were predictive of development of AIDS independent of low CD4+ T-cell numbers and high HIV-1 RNA levels. In a time-dependent model HIV-1 RNA levels lost their predictive value whereas low T-cell responses low CD4+ T-cell numbers and the presence of SI HIV-1 variants independently predicted AIDS. These data demonstrate that combined use of virological and immunological markers may be useful in monitoring disease progression and response to antiretroviral therapy. (authors)

Concentrations of soluble receptors for tumor necrosis factor (sTNFR-p55 and sTNFR-p75) and soluble T cell antigens CD25 and CD27 (sCD25 and sCD27) were measured in paired serum/cerebrospinal fluid (CSF) samples of 15 patients with AIDS dementia complex (ADC) and 15 HIV-infected control subjects (11 with other central nervous system (CNS) infections and four without CNS infection). In this study levels of sTNFR-p55, sTNFR-p75 and sCD25 were elevated in the CSF of ADC patients and of the 11 patients with other CNS infections, whereas CSF-levels of the specific T cell marker sCD27 were lower in patients with ADC as compared to the control subjects with and without other CNS infections. This pattern suggests a relative failure of eliciting a T cell-mediated immune response intrathecally in patients with ADC.

Activated complement factors within the lung may induce several local biological effects. In order to investigate local complement activation we have developed non-competitive two-site ELISAs of C3a and total C3 in bronchoalveolar lavage fluid (BALF). For the assay of C3a, both C3 and C3(H2O) were removed from the samples by precipitation with polyethylene glycol. It was necessary to add carrier proteins to BALF to remove C3 and C3(H2O) fully. The ELISA of C3a has the lowest limit of detection reported thus far, namely 0.045 nM (= 0.405 ng/ml). In BALF from healthy persons (n = 9) the C3a concentration was 0.20 nM (0.12-0.31 nM) (median, range). C3a was higher in BALF from patients with asthma or with sarcoidosis; asthma (n = 10), 0.45 nM (0.20-5.79 nM); sarcoidosis (n = 19), 1.31 nM (0.095-5.65 nM) (Mann-Whitney U test, p less than 0.005). In BALF from patients with Pneumocystis carinii pneumonitis (n = 10) the C3a concentration was 0.18 nM (0.07-0.57 nM). C3a concentrations in BALF may reflect local complement activation in the lung and/or diffusion into the lumen. This was studied by normalizing C3a concentrations in BALF into values for epithelial lining fluid (ELF), and calculating serum-to-ELF quotients of C3a, and C3a/total C3 quotients.

BACKGROUND: Heterozygosity for a 32-nucleotide deletion in the C-C chemokine receptor 5 gene (CCR5 delta 32) is associated with delayed disease progression in persons infected with HIV-1. OBJECTIVE: To compare the predictive value of CCR5 genotype with that of established markers in the clinical course of HIV-1 infection. DESIGN: Retrospective longitudinal study and nested case-control study. The latter included only long-term survivors, who were individually matched with progressors. SETTING: Amsterdam, the Netherlands. PARTICIPANTS: 364 homosexual men with HIV-1 infection. MEASUREMENTS: Polymerase chain reaction was used for CCR5 genotyping. Univariate and multivariate Cox proportional hazard analyses were done for disease progression with CCR5 genotype, CD4+ T-lymphocyte counts, T-lymphocyte function, HIV-1 biological phenotype (syncytium-inducing or non-syncytium-inducing HIV-1), and viral RNA load in serum as covariates. RESULTS: In the case-control study, 48% of long-term survivors were heterozygous for CCR5 delta 32 compared with 9% of progressors (odds ratio, 6.9 [95% CI, 1.9 to 24.8]). In the total study sample, CCR5 delta 32 heterozygotes had significantly delayed disease progression (P

Summary Chimpanzees infected with the HIV-1 strains HTLV-IIIB or LAV-1 in primary, secondary or tertiary passages developed neutralizing antibodies binding to variable domain V3 in the carboxyl terminal half of the external envelope (amino acids 309–317). Nonapeptide antigens reflecting either the HTLV-IIIB/LAV-1 neutralization epitope (IQRGPGRAF, designated 3B) or peptide analogues (ITKGPGRVI, designated RF; IQRGPGRVI, designated 3B/RF; ITKGPGRAF, designated RF/3B) were previously shown to be able to distinguish antibody populations in a polyclonal response of rabbits to these peptides. Sera from chimpanzees infected with the HIV-1 strains HTLV-IIIB and LAV-1 were tested for the presence of antibodies reactive to these nonapeptides. Sera from 3 chimpanzees infected with a primary LAV-1 or HTLV-IIIB passage, 2 chimpanzees infected with blood from the primary infected chimpanzees and from 1 chimpanzee infected with blood from a secondary passage animal, all bound peptides 3B and 3B/RF, sharing the sequence IQRGPGR, in equally high tires. In 2 primary passage animals and in 1 secondary passage animal, the capacity to bind to peptides 3B and 3B/RF was equally high, indicating clonality of these B-cell responses. Contrasting results were obtained with the sera from 1 primary, 1 secondary and 1 tertiary passage animal, showing stronger binding to the 3B/RF peptide than to the 3B peptide. The animals with antibodies binding strongly to the 3B peptide had an early HTLV-IIIB-induced cell-fusion-inhibiting (CFI) antibody response, while the animals with antibodies binding strongly to the 3B/RF peptide had a late HTLV-IIIB-induced CFI antibody response. This difference in binding to the 3B peptide might result from antigenic variation in the neutralization domain of the inoculum virus(es). The conservation of the antibody specificity for the neutralization epitope of the inoculum strain might open the way to type circulating virus strains by antibody specificity for a panel of peptide analogues derived from the V3 domain of the external envelope of distinct HIV-1 strains.

A cohort of 180 haemophiliacs followed between 1983 and 1986 and a cohort of 961 homosexual men followed between 1984 and 1986 were compared for the prevalence and incidence of HIV-1 antibody (HIV-1-Ab) seropositivity, the incidence of AIDS-related complex (ARC) and AIDS and the prevalence and incidence of serological and immunological markers for HIV-related disease progression. Among the haemophiliacs 23 (12.8%) patients were HIV-1-Ab seropositive at entry and 20 (12.7%) of the remaining 157 seroconverted for HIV-1-Ab during follow-up. Of the homosexual men 238 (24.8%) were HIV-1-Ab seropositive at entry and 68 (9.4%) of the 723 at entry seronegatives seroconverted during follow-up. Clinical follow-up of the HIV-1-Ab seropositive and seroconverted men was 59 months in the haemophiliac cohort and 60 months in the homosexual cohort. Among the HIV-1-Ab seropositive and seroconverted haemophiliacs and homosexual men the cumulative ARC/AIDS incidence was 2 and 18%, respectively. Occurrence of HIV-1-antigenaemia was more frequent among seropositive and seroconverted homosexual men (28%) than among haemophiliacs (7%) (p = 0.001). The groups did not differ significantly for the absence or loss of anti-HIV core antibodies or the occurrence of low CD4+ cell numbers. These data indicate a slower progression of HIV-related disease in seropositive haemophiliacs compared to seropositive homosexual men.

Sequential sera of homosexual men participating in a prospective study on the incidence of HIV-1 infection and risk factors for AIDS were tested for the presence of antibodies to a synthetic 17-mer (Neu21; KSIRIQRGPGRAFVTIG) representing a neutralization epitope as present on the LAV-1/HTLV-IIIB strain of HIV-1. Of 191 at entry, 143 (75%) HIV-1-seropositive men remained anti-Neu21-negative during the follow-up period of 36 months. Thirty-seven (19%) HIV-1-seropositive men were persistently anti-Neu21-positive. Eleven (6%) HIV-1 seropositive men seroconverted for anti-Neu21 during follow-up. Of 75 men developing antibodies to HIV-1, 17 (23%) developed antibodies to Neu21. The incidence of anti-Neu21 seroconversion (calculated as attack rate) after 36 months was significantly lower (P less than 0.00001) among HIV-1-seropositive individuals (8%) than among the 75 HIV-1 seroconverters tested (25%), indicating that seroconversion to this neutralization domain occurs early during infection. AIDS and AIDS-related complex were diagnosed in 17% of the anti-Neu21 negatives and in 11% of the anti-Neu21 positives; this difference was not significant. The presence of HIV-1 antigen (29 versus 28%), the absence of antibodies to core proteins (45 versus 46%) and low CD4+ cell numbers (34 versus 40%) were not seen more frequently among anti-Neu21 negatives than among anti-Neu21 positives. These results argue against a role for antibodies to this LAV-1/HTLV-IIIB neutralization domain in protection against disease progression.