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Abstract Background Over the last 20 years, malaria incidence has decreased across the Greater Mekong Sub-region (GMS) and the emergence of artemisinin resistance has stimulated efforts to accelerate regional elimination. In the GMS, the malaria transmission is focused increasingly in forested zones. This article describes forest-going activities and examines forest workers’ attitudes to and experiences of malaria prevention and control in north-eastern Cambodia. Methods In Stung Treng Province, Cambodia, 19 in-depth interviews were conducted in villages with participants recently diagnosed with uncomplicated falciparum malaria who reported working in forests. Two focus group discussions with respondents’ forest-working peers were held. Interviews and focus groups were audio-recorded transcribed, and translated for thematic analysis. Results Forest work is an essential source of income for respondents. Many combine it with farming, which influences the timing and duration of forest visits. Forest activities include logging and collecting other forest products, particularly malva nuts. Men log year-round, whereas gathering forest products is seasonal and can involve entire families. Forest workers sleep chiefly in unimpregnated hammock nets in make-shift encampments. Respondents are concerned about symptomatic malaria, but unfamiliar with the concept of asymptomatic infection. They view the forest as an area of potential malaria infection and seek to protect themselves from mosquito bites through wearing long-sleeved clothes, using repellents, and lighting fires. Forest workers express a willingness to self-test and self-administer anti-malarials. Conclusions Forest workers’ behaviour and perceptions of risk indicate that improvements are needed to current control measures. There is potential to: better target distribution of impregnated hammock nets; offer curative or presumptive treatment while in forests; and expand access to screening. Establishing the efficacy and feasibility of prophylaxis for forest workers in the GMS is a priority.

Background: Across the Greater Mekong Sub-region, malaria persists in isolated communities along international borders. Arts and drama have been used to reach to communities in Cambodia to engage them in malaria research, prevention and control. The “Village Drama Against Malaria” (VDAM) project was conducted in north eastern and western Cambodia: Stung Treng; Battambang and Pailin provinces during 2016 to 2019. In total, VDAM reached 55 rural villages, 2,378 student participants and 43,502 audience members. Methods: This article presents the results of two stakeholder-led evaluation workshops in which participants collaboratively developed theories of change to better understand the potential and actual impact of arts and drama-based activities on malaria in these communities. The workshops had a particular focus on identifying areas for monitoring and evaluation so that impact can be measured. Workshop participants included village malaria workers, community leaders, professional and student drama performers, and representatives from the local health authorities and the national malaria control programme. Results: Five broad areas were identified as relevant for monitoring and evaluation: logistical and practical challenges; embeddedness and reach of engagement; health knowledge and confidence of young people; effectiveness of communications; impact on malaria. These areas align well with the monitoring and evaluation conducted to date and point to additional opportunities for data collection. Conclusions: The findings from these workshops will inform future engagement strategies, for example, we may engage a smaller number of young people but over a longer period and more in-depth.

Abstract Background Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymopathy worldwide. Primaquine is the only licensed drug that effectively removes Plasmodium vivax hypnozoites from the human host and prevents relapse. While well tolerated by most recipients, primaquine can cause haemolysis in G6PD deficient individuals and is, therefore, underused. Rapid diagnostic tests (RDTs) could permit ascertainment of G6PD status outside of laboratory settings and hence safe treatment in remote areas. The performance of the fluorescent spot test (Trinity, Ireland; FST) and a G6PD RDT (Carestart, USA) against spectrophotometry were assessed. Methods Participants were enrolled during cross-sectional surveys in Laos and by purposive sampling in Cambodia. FST and RDT were performed during village surveys and 3 mL of venous blood was collected for subsequent G6PD measurement by spectrophotometry. Results A total of 757 participants were enrolled in Laos and 505 in Cambodia. FST and RDT performed best at 30% cut-off activity and performed significantly better in Laos than in Cambodia. When defining intermediate results as G6PD deficient, the FST had a sensitivity of 100% (95%CI 90–100) and specificity of 90% (95%CI 87.7–92.2) in Laos and sensitivity of 98% (94.1–99.6) and specificity of 71% (95%CI 66–76) in Cambodia (p

Abstract Helicobacter fennelliae (H. fennelliae) is associated with human gastroenteritis; however, H. fennelliae was isolated and confirmed by phenotypic and genotypic identification from a non-diarrheal child stool sample in Cambodia. Antimicrobial susceptibility testing demonstrated that this isolate had a high minimal inhibitory concentration against macrolides and quinolones, which are first-line antibiotic treatment choices for Campylobacter infections. Consequently, macrolides and quinolones were likewise expected to be ineffective against Campylobacter-like organisms such as H. fennelliae. This isolate warranted further genetic characterization to better understand associated antibiotic resistance mechanisms. Resistant pathogens from asymptomatic diarrheal cases are likely underestimated, and as such colonized individuals may spread resistant organisms to local community members and the environment.

This article describes our experience using art and theatre to engage rural communities in western Cambodia to understand malaria and support malaria control and elimination. The project was a pilot science–arts initiative to supplement existing engagement activities conducted by local authorities. In 2016, the project was conducted in 20 villages, involved 300 community members and was attended by more than 8000 people. Key health messages were to use insecticide-treated bed-nets and repellents, febrile people should attend village malaria workers, and to raise awareness about the risk of forest-acquired malaria. Building on the experience and lessons learnt in the year prior, the 2017 project which was conducted in 15 villages involved 600 community members and attracted more than 12,000 people. In addition to the malaria theme, upon discussion with local health authorities, secondary theme (infant vaccination) was added to the 2017 project. We learnt the following lessons from our experience in Cambodia: involving local people including children from the beginning of the project and throughout the process is important; messages should be kept simple; it is necessary to take into consideration practical issues such as location and timing of the activities; and that the project should offer something unique to communities.

Abstract Two mass drug administrations (MDA) against falciparum malaria were conducted in 2015–16, one as operational research in northern Cambodia, and the other as a clinical trial in western Cambodia. During an April 2017 workshop in Phnom Penh the field teams from Médecins Sans Frontières and the Mahidol-Oxford Tropical Medicine Research Unit discussed lessons for future MDAs.

BACKGROUND:Between 2013 and 2017, targeted malaria elimination (TME), a package of interventions that includes mass drug administration (MDA)-was piloted in communities with reservoirs of asymptomatic P. falciparum across the Greater Mekong sub-Region (GMS). Coverage in target communities is a key determinant of the effectiveness of MDA. Drawing on mixed methods research conducted alongside TME pilot studies, this article examines the impact of the community engagement, local social context and study design on MDA coverage. METHODS AND FINDINGS:Qualitative and quantitative data were collected using questionnaire-based surveys, semi-structured and in-depth interviews, focus group discussions, informal conversations, and observations of study activities. Over 1500 respondents were interviewed in Myanmar, Vietnam, Cambodia and Laos. Interview topics included attitudes to malaria and experiences of MDA. Overall coverage of mass anti-malarial administration was high, particularly participation in at least a single round (85%). Familiarity with and concern about malaria prompted participation in MDA; as did awareness of MDA and familiarity with the aim of eliminating malaria. Fear of adverse events and blood draws discouraged people. Hence, community engagement activities sought to address these concerns but their impact was mediated by the trust relationships that study staff could engender in communities. In contexts of weak healthcare infrastructure and (cash) poverty, communities valued the study's ancillary care and the financial compensation. However, coverage did not necessarily decrease in the absence of cash compensation. Community dynamics, affected by politics, village conformity, and household decision-making also affected coverage. CONCLUSIONS:The experimental nature of TME presented particular challenges to achieving high coverage. Nonetheless, the findings reflect those from studies of MDA under implementation conditions and offer useful guidance for potential regional roll-out of MDA: it is key to understand target communities and provide appropriate information in tailored ways, using community engagement that engenders trust.

Background: Countries in Southeast Asia are working to eliminate multidrug-resistant falciparum malaria, a major cause of mortality in tropical regions. Malaria is declining but transmission persists in many rural areas and among forest workers and isolated populations. In these remote communities, conventional health services and education are limited. Mobilising and educating these populations require new approaches as many people are illiterate and do not attend village meetings. This article describes a qualitative study to assess the feasibility of a drama project as a community engagement strategy. Methods: A drama project was conducted in twenty villages in Cambodia with three key messages: to use insecticide-treated bednets and repellents, to get early diagnosis and treatment, and to learn about risks of forest-acquired malaria. Qualitative interviews were conducted with the drama team members, village malaria workers, local health staffs and villagers, to explore the feasibility of using drama to engage the community and the associated challenges. Results: 29 people were interviewed, which included 18 semi-structured interviews and one focus group discussion. Analysis of the interviews resulted in development of the following seven themes: i) exposure to malaria and engagement activities, ii) readiness and barriers to participation, iii) understanding and learning about malaria using drama, iv) entertainment value and engagement method preferences, v) challenges to community engagement, vi) future participation and vii) sustainability. The event saw a very positive response, with an encouraging average participation rate of 66%. The project faced several challenges including logistic problems, rescheduling due to raining season, and time- and budget-constraints. Conclusions: Our evaluation demonstrated that the drama project was feasible in promoting awareness and understanding of malaria prevention and control. Audience members perceived drama as entertaining and as the preferred choice of engagement activity. Participatory drama could be considered as part of the community engagement for malaria elimination.

Background: Countries in Southeast Asia are working to eliminate multidrug-resistant falciparum malaria, a major cause of mortality in tropical regions. Malaria is declining but transmission persists in many rural areas and among forest workers and isolated populations. In these remote communities, conventional health services and education are limited. Mobilising and educating these populations require new approaches as many people are illiterate and do not attend village meetings. This article describes a qualitative study to assess the feasibility of a drama project as a community engagement strategy. Methods: A drama project was conducted in twenty villages in Cambodia with three key messages: to use insecticide-treated bednets and repellents, to get early diagnosis and treatment, and to learn about risks of forest-acquired malaria. Qualitative interviews were conducted with the drama team members, village malaria workers, local health staffs and villagers, to explore the feasibility of using drama to engage the community and the associated challenges. Results: 29 people were interviewed, which included 18 semi-structured interviews and one focus group discussion. Analysis of the interviews resulted in development of the following seven themes: i) exposure to malaria and engagement activities, ii) readiness and barriers to participation, iii) understanding and learning about malaria using drama, iv) entertainment value and engagement method preferences, v) challenges to community engagement, vi) future participation and vii) sustainability. The event saw a very positive response, with an encouraging average participation rate of 66%. The project faced several challenges including logistic problems, rescheduling due to raining season, and time- and budget-constraints. Conclusions: Our evaluation demonstrated that the drama project was feasible in promoting awareness and understanding of malaria prevention and control. Audience members perceived drama as entertaining and as the preferred choice of engagement activity. Participatory drama could be considered as part of the community engagement for malaria elimination.

Little is known about circulation of influenza and other respiratory viruses in remote populations along the Thai-Cambodia border in western Cambodia. We screened 586 outpatients (median age 5, range 1-77) presenting with influenza-like-illness (ILI) at 4 sentinel sites in western Cambodia between May 2010 and December 2012. Real-time reverse transcriptase (rRT) PCR for influenza was performed on combined nasal and throat specimens followed by viral culture, antigenic analysis, antiviral susceptibility testing and full genome sequencing for phylogenetic analysis. ILI-specimens negative for influenza were cultured, followed by rRT-PCR for enterovirus and rhinovirus (EV/RV) and EV71. Influenza was found in 168 cases (29%) and occurred almost exclusively in the rainy season from June to November. Isolated influenza strains had close antigenic and phylogenetic relationships, matching vaccine and circulating strains found elsewhere in Cambodia. Influenza vaccination coverage was low (

The active metabolites of primaquine, in particular 5-hydroxyprimaquine, likely responsible for the clearance of dormant hypnozoites, are produced through the hepatic CYP450 2D6 (CYP2D6) enzymatic pathway. With the inherent instability of 5-hydroxyprimaquine, a stable surrogate, 5,6-orthoquinone, can now be detected and measured in the urine as part of primaquine pharmacokinetic studies. This study performed CYP450 2D6 genotyping and primaquine pharmacokinetic testing, to include urine 5,6-orthoquinone, in 27 healthy adult Cambodians, as a preliminary step to prepare for future clinical studies assessing primaquine efficacy for Plasmodium vivax infections. The CYP2D6 *10 reduced activity allele was found in 57% of volunteers, and the CYP2D6 genotypes were dominated by *1/*10 (33%) and *10/*10 (30%). Predicted phenotypes were evenly split between Normal Metabolizer (NM) and Intermediate Metabolizer (IM) except for one volunteer with a gene duplication and unclear phenotype, classifying as either IM or NM. Median plasma primaquine (PQ) area under the curve (AUC) was lower in the NM group (460 h*ng/mL) compared to the IM group (561 h*ng/mL), although not statistically significant. Similar to what has been found in the US study, no 5,6-orthoquinone was detected in the plasma. The urine creatinine-corrected 5,6-orthoquinone AUC in the NM group was almost three times higher than in the IM group, with peak measurements (T max ) at 4 h. Although there is variation among individuals, future studies examining the relationship between the levels of urine 5,6-orthoquinone and primaquine radical cure efficacy could result in a metabolism biomarker predictive of radical cure.

Information on causative diarrheal pathogens and their associated antimicrobial susceptibility remains limited for Cambodia. This study describes antimicrobial resistance patterns for Shigella and nontyphoidal Salmonella isolates collected in Cambodia over a 5-year period. Multidrug resistance was shown in 98% of Shigella isolates, with 70%, 11%, and 29% of isolates being resistant to fluoroquinolones, azithromycin, and cephalosporin, respectively. As many as 11% of Shigella isolates were resistant to nearly all oral and parenteral drugs typically used for shigellosis, demonstrating extreme drug resistance phenotypes. Although a vast majority of nontyphoidal Salmonella isolates remained susceptible to cephalosporins (99%) and macrolides (98%), decreased susceptibility to ciprofloxacin was found in 67% of isolates, which is notably higher than previous reports. In conclusion, increasing antimicrobial resistance of Shigella and nontyphoidal Salmonella is a major concern for selecting empirical treatment of acute infectious diarrhea in Cambodia. Treatment practices should be updated and follow local antimicrobial resistance data for the identified pathogens.

The effect of fat saponification and the inclusion or exclusion of blood in slaughterhouse mixtures were assessed in terms of anaerobic digestion performance. Mixtures of animal by-products (ABP) were collected for 1 year, whereby following the daily activity and waste generation at a slaughterhouse facility, seasonal fluctuations were found. The blood content of ABP mixtures was variable, affecting both the methane yield and the production rate (287.8-320.5 NL CH4 kg COD -1 and 80.3-94.7 and NL CH4 kg COD -1 d -1 , respectively). The saponification of fatty ABP materials was studied to assess the methane production rate, singularly or combined, with and without the addition of blood. Data showed that saponification significantly reduced the lag phase, from 2.2 to 1.5 days in winter mixtures and from 1.5 to 0.9 days in summer mixtures (all with blood), and from 0.3 to 0.1 days in summer mixtures without blood. Finally, the percentage of energy demand at the slaughterhouse potentially covered by net biogas energy was estimated, finding that the facility could be 100% energy self-sufficient in winter, whereas this would be reduced to 85% in the summer due to different methane yields of ABP mixtures based on season., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Clinical failure of primaquine (PQ) has been demonstrated in people with CYP450 2D6 genetic polymorphisms that result in reduced or no enzyme activity. The distribution of CYP2D6 genotypes and predicted phenotypes in the Cambodian population is not well described. Surveys in other Asian countries have shown an approximate 50% prevalence of the reduced activity CYP2D6 allele *10, which could translate into increased risk of PQ radical cure failure and repeated relapses, making interruption of transmission and malaria elimination difficult to achieve. We determined CYP2D6 genotypes from 96 volunteers from Oddor Meanchey Province, Cambodia, an area endemic for Plasmodium vivax . We found a 54.2% frequency of the *10 allele, but in approximately half of our subjects, it was paired with a normal activity allele, either *1 or *2. The prevalence of *5, a null allele, was 9.4%. Overall predicted phenotype percentages were normal metabolizers, 46%; intermediate metabolizers, 52%; and poor metabolizers, 1%.

Background: Primaquine is an approved radical cure treatment for Plasmodium vivax malaria but treatment can result in life-threatening hemolysis if given to a glucose-6-phosphate dehydrogenase deficient (G6PDd) patient. There is a need for reliable point-of-care G6PD diagnostic tests., Objectives: To evaluate the performance of the CareStart™ rapid diagnostic test (RDT) in the hands of healthcare workers (HCWs) and village malaria workers (VMWs) in field settings, and to better understand user perceptions about the risks and benefits of PQ treatment guided by RDT results., Methods: This study enrolled 105 HCWs and VMWs, herein referred to as trainees, who tested 1,543 healthy adult male volunteers from 84 villages in Cambodia. The trainees were instructed on G6PD screening, primaquine case management, and completed pre and post-training questionnaires. Each trainee tested up to 16 volunteers in the field under observation by the study staff., Results: Out of 1,542 evaluable G6PD volunteers, 251 (16.28%) had quantitative enzymatic activity less than 30% of an adjusted male median (8.30 U/g Hb). There was no significant difference in test sensitivity in detecting G6PDd between trainees (97.21%), expert study staff in the field (98.01%), and in a laboratory setting (95.62%) (p = 0.229); however, test specificity was different for trainees (96.62%), expert study staff in the field (98.14%), and experts in the laboratory (98.99%) (p < 0.001). Negative predictive values were not statistically different for trainees, expert staff, and laboratory testing: 99.44%, 99.61%, and 99.15%, respectively. Knowledge scores increased significantly post-training, with 98.7% willing to prescribe primaquine for P.vivax malaria, an improvement from 40.6% pre-training (p < 0.001)., Conclusion: This study demonstrated ability of medical staff with different background to accurately use CareStart™ RDT to identify G6PDd in male patients, which may enable safer prescribing of primaquine; however, pharmacovigilance is required to address possible G6PDd misclassifications., Competing Interests: The authors have declared that no competing interests exist.

The thickness of the subcutaneous fat (SFT) is a very important parameter in the ham, since determines the process the ham will be submitted. This study compares two methods to predict the SFT in slaughter line: an automatic system using an SVM model (Support Vector Machine) and a manual measurement of the fat carried out by an experienced operator, in terms of accuracy and economic benefit. These two methods were compared to the golden standard obtained by measuring SFT with a ruler in a sample of 400 hams equally distributed within each SFT class. The results show that the SFT prediction made by the SVM model achieves an accuracy of 75.3%, which represents an improvement of 5.5% compared to the manual measurement. Regarding economic benefits, SVM model can increase them between 12 and 17%. It can be concluded that the classification using SVM is more accurate than the one performed manually with an increase of the economic benefit for sorting., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The thickness of the subcutaneous fat in hams is one of the most important factors for the dry-curing process and largely determines its final quality. This parameter is usually measured in slaughterhouses by a manual metrical measure to classify hams. The aim of the present study was to propose an automatic classification method based on data obtained from a carcass automatic classification equipment (AutoFom) and intrinsic data of the pigs (sex, breed, and weight) to simulate the manual classification system. The evaluated classification algorithms were decision tree, support vector machines (SVM), k-nearest neighbour and discriminant analysis. A total of 4000 hams selected by breed and sex were classified as thin (0-10 mm), standard (11-15 mm), semi-fat (16-20 mm) and fat (>20 mm). The most reliable model, with a percentage of success of 73%, was SVM with Gaussian kernel, including all data available. These results suggest that the proposed classification method can be a useful online tool in slaughterhouses to classify hams., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Mass drug administration (MDA) to interrupt malaria transmission requires the participation of entire communities. As part of a clinical trial in western Cambodia, four villages received MDA in 2015-2016. Before approaching study communities, a collaboration was established with the local health authorities, village leaders, and village malaria workers. Formative research guided the development of engagement strategies. In each village, a team of volunteers was formed to explain MDA to their neighbors and provide support during implementation. Public mobilization events featuring drama and music were used to introduce MDA. Villages comprised groups with different levels of understanding and interests; therefore, multiple tailored engagement strategies were required. The main challenges were explaining malaria transmission, managing perceptions of drug side effects, and reaching mobile populations. It was important that local leaders took a central role in community engagement. Coverage during each round of MDA averaged 84%, which met the target for the trial.

The drainage of vertical foam films governs their lifetime. For a foam film supported on a rectangular solid frame, when the interface presents a low resistance to shear, the drainage dynamics involves a complex flow pattern at the film scale, leading to a drainage time proportional to the frame width. Using an original velocimetry technique, based on fluorescent foam films and photobleaching, we measure the horizontal and vertical components of the velocity in a draining film, thus providing the first quantitative experimental evidence of this flow pattern. Upward velocities up to 10  cm/s are measured close to the lateral menisci, whereas a slower velocity field is obtained in the center of the film, with comparable downwards and horizontal components. Scaling laws are proposed for all characteristic velocities, coupling gravitational effects, and capillary suction.

Senegalese sole (Solea senegalensis) has been considered since the 1990's to be a promising flatfish species for diversifying European marine aquaculture. However, pathogen outbreaks leading to high mortality rates can impair Senegalese sole commercial production at the weaning phase. Different approaches have been shown to improve fish immunocompetence; with this in mind the objective of the work described herein was to determine whether increased levels of dietary vitamin A (VA) improve the immune response in early juveniles of Senegalese sole. For this purpose, Senegalese sole were reared and fed with Artemia metanauplii containing increased levels of VA (37,000; 44,666; 82,666 and 203,000 total VA IU Kg(-1)) from 6 to 60 days post-hatch (early juvenile stage). After an induced bacterial infection with a 50% lethal dose of Photobacterium damselae subsp. damselae, survival rate, as well as underlying gene expression of specific immune markers (C1inh, C3, C9, Lgals1, Hamp, LysC, Prdx1, Steap4 and Transf) were evaluated. Results showed that fish fed higher doses of dietary VA were more resistant to the bacterial challenge. The lower mortality was found to be related with differential expression of genes involved in the complement system and iron availability. We suggest that feeding metamorphosed Senegalese sole with 203,000 total VA IU Kg(-1) might be an effective, inexpensive and environmentally friendly method to improve Senegalese sole immunocompetence, thereby improving survival of juveniles and reducing economic losses., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The world population is growing quickly and there is a need to make sustainable protein available through an integrated approach that includes marine aquaculture. Seafood is already a highly traded commodity but the production from capture fisheries is rarely sustainable, which makes mollusc culture more important. However, an important constraint to its continued expansion is the potential for trade movements to disseminate pathogens that can cause disease problems and loss of production. Therefore, this review considers legislative and regulatory aspects of molluscan health management that have historically attempted to control the spread of mollusc pathogens. It is argued that the legislation has been slow to react to emerging diseases and the appearance of exotic pathogens in new areas. In addition, illegal trade movements are taken into account and possible future developments related to improvements in areas such as data collection and diagnostic techniques, as well as epidemiology, traceability and risk analysis, are outlined., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Dihydroartemisinin-piperaquine has been adopted as first-line artemisinin combination therapy (ACT) for multidrug-resistant Plasmodium falciparum malaria in Cambodia because of few remaining alternatives. We aimed to assess the efficacy of standard 3 day dihydroartemisinin-piperaquine treatment of uncomplicated P falciparum malaria, with and without the addition of primaquine, focusing on the factors involved in drug resistance., Methods: In this observational cohort study, we assessed 107 adults aged 18-65 years presenting to Anlong Veng District Hospital, Oddar Meanchey Province, Cambodia, with uncomplicated P falciparum or mixed P falciparum/Plasmodium vivax infection of between 1000 and 200,000 parasites per μL of blood, and participating in a randomised clinical trial in which all had received dihydroartemisinin-piperaquine for 3 days, after which they had been randomly allocated to receive either primaquine or no primaquine. The trial was halted early due to poor dihydroartemisinin-piperaquine efficacy, and we assessed day 42 PCR-corrected therapeutic efficacy (proportion of patients with recurrence at 42 days) and evidence of drug resistance from the initial cohort. We did analyses on both the intention to treat (ITT), modified ITT (withdrawals, losses to follow-up, and those with secondary outcomes [eg, new non-recrudescent malaria infection] were censored on the last day of follow-up), and per-protocol populations of the original trial. The original trial was registered with ClinicalTrials.gov, number NCT01280162., Findings: Between Dec 10, 2012, and Feb 18, 2014, we had enrolled 107 patients in the original trial. Enrolment was voluntarily halted on Feb 16, 2014, before reaching planned enrolment (n=150) because of poor efficacy. We had randomly allocated 50 patients to primaquine and 51 patients to no primaquine groups. PCR-adjusted Kaplan-Meier risk of P falciparum 42 day recrudescence was 54% (95% CI 45-63) in the modified ITT analysis population. We found two kelch13 propeller gene mutations associated with artemisinin resistance--a non-synonymous Cys580Tyr substitution in 70 (65%) of 107 participants, an Arg539Thr substitution in 33 (31%), and a wild-type parasite in four (4%). Unlike Arg539Thr, Cys580Tyr was accompanied by two other mutations associated with extended parasite clearance (MAL10:688956 and MAL13:1718319). This combination triple mutation was associated with a 5·4 times greater risk of treatment failure (hazard ratio 5·4 [95% CI 2·4-12]; p<0·0001) and higher piperaquine 50% inhibitory concentration (triple mutant 34 nM [28-41]; non-triple mutant 24 nM [1-27]; p=0·003) than other infections had. The drug was well tolerated, with gastrointestinal symptoms being the most common complaints., Interpretation: The dramatic decline in efficacy of dihydroartemisinin-piperaquine compared with what was observed in a study at the same location in 2010 was strongly associated with a new triple mutation including the kelch13 Cys580Tyr substitution. 3 days of artemisinin as part of an artemisinin combination therapy regimen might be insufficient. Strict regulation and monitoring of antimalarial use, along with non-pharmacological approaches to malaria resistance containment, must be integral parts of the public health response to rapidly accelerating drug resistance in the region., Funding: Armed Forces Health Surveillance Center/Global Emerging Infections Surveillance and Response System, Military Infectious Disease Research Program, National Institute of Allergy and Infectious Diseases, and American Society of Tropical Medicine and Hygiene/Burroughs Wellcome Fund., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Emerging antimalarial drug resistance in mobile populations remains a significant public health concern. We compared two regimens of dihydroartemisinin-piperaquine in military and civilians on the Thai-Cambodian border to evaluate national treatment policy., Methods: Efficacy and safety of two and three-day regimens of dihydroartemisinin-piperaquine were compared as a nested open-label evaluation within a malaria cohort study in 222 otherwise healthy volunteers (18% malaria-infected at baseline). The first 80 volunteers with slide-confirmed Plasmodium falciparum or vivax malaria were randomized 1:1 to receive either regimen (total dose 360 mg dihydroartemisinin and 2880 mg piperaquine) and followed weekly for up to 6 months. The primary endpoint was malaria recurrence by day 42. Volunteers with vivax infection received primaquine at study discharge with six months follow-up., Results: Eighty patients (60 vivax, 15 falciparum, and 5 mixed) were randomized to dihydroartemisinin-piperaquine. Intention-to-treat all-species efficacy at Day 42 was 85% for the two-day regimen (95% CI 69-94) and 90% for the three-day regimen (95% CI 75-97). PCR-adjusted falciparum efficacy was 75% in both groups with nearly half (45%) still parasitemic at Day 3. Plasma piperaquine levels were comparable to prior published reports, but on the day of recrudescence were below measurable in vitro piperaquine IC50 levels in all falciparum treatment failures., Conclusions: In the brief period since introduction of dihydroartemisinin-piperaquine, there is early evidence suggesting declining efficacy relative to previous reports. Parasite IC50 levels in excess of plasma piperaquine levels seen only in treatment failures raises concern for clinically significant piperaquine resistance in Cambodia. These findings warrant improved monitoring of clinical outcomes and follow-up, given few available alternative drugs., Trial Registration: ClinicalTrials.gov NCT01280162.

Retinoic acid (RA), the main active metabolite of vitamin A, regulates vertebrate morphogenesis through signaling pathways not yet fully understood. Such process involves the specific activation of retinoic acid and retinoid X receptors (RARs and RXRs), which are nuclear receptors of the steroid/thyroid hormone receptor superfamily. Teleost fish are suitable models to study vertebrate development, such as skeletogenesis. Cell systems capable of in vitro mineralization have been developed for several fish species and may provide new insights into the specific cellular and molecular events related to vitamin A activity in bone, complementary to in vivo studies. This work aims at investigating the in vitro effects of RA (0.5 and 12.5 μM) on proliferation, differentiation and extracellular matrix (ECM) mineralization of two gilthead seabream bone-derived cell lines (VSa13 and VSa16), and at identifying molecular targets of its action through gene expression analysis. RA induced phenotypic changes and cellular proliferation was inhibited in both cell lines in a cell type-dependent manner (36-59% in VSa13 and 17-46% in VSa16 cells). While RA stimulated mineral deposition in VSa13 cell cultures (50-62% stimulation), it inhibited the mineralization of extracellular matrix in VSa16 cells (11-57% inhibition). Expression of hormone receptor genes (rars and rxrs), and extracellular matrix-related genes such as matrix and bone Gla proteins (mgp and bglap), osteopontin (spp1) and type I collagen (col1a1) were differentially regulated upon exposure to RA in proliferating, differentiating and mineralizing cultures of VSa13 and VSa16 cells. Altogether, our results show: (i) RA affects proliferative and mineralogenic activities in two fish skeletal cell types and (ii) that during phenotype transitions, specific RA nuclear receptors and bone-related genes are differentially expressed in a cell type-dependent manner., (Crown Copyright © 2013. Published by Elsevier Ltd. All rights reserved.)

Background: Despite recent malaria containment and control efforts leading to reduced incidence, Cambodia remains endemic for both Plasmodium vivax and multidrug-resistant Plasmodium falciparum malaria. Little has been reported in the peer-reviewed literature regarding the burden of severe malaria (SM) in Cambodia., Methods: Medical records for all patients admitted to the Battambang Referral Hospital (BRH) with an admitting or discharge diagnosis of SM from 2006 to 2009 (suspected SM cases) were reviewed. Those meeting the case definition of SM according to retrospective chart review and investigator assessment of probable cases, based on published national guidelines available at the time, were analysed for trends in demographics, mortality and referral patterns., Results: Of the 537 suspected SM cases at BRH during the study period, 393 (73%) met published WHO criteria for SM infection. Despite limited diagnostic and treatment facilities, overall mortality was 14%, with 7% mortality in children 14 and under, but 19% in adults (60% of cases). Cerebral malaria with coma was relatively rare (17%), but mortality was disproportionately high at 35%. Mean time to hospital presentation was five days (range one to 30 days) after onset of symptoms. While patients with delays in presentation had worse outcomes, there was no excess mortality based on treatment referral times, distance travelled or residence in artemisinin-resistance containment (ARC) Zone 1 compared to Zone 2., Conclusions: Despite limitations in diagnosis and treatment, and multiple confounding co-morbidities, mortality rates at BRH were similar to reports from other countries in the region. Interventions to improve access to early diagnosis and effective treatment, combined with modest improvements in intensive care, are likely to reduce mortality further. Patients referred from Zone 1 did not have excess mortality compared to Zone 2 ARC areas. A steep decrease in SM cases and deaths observed in the first half of 2009 has since continued, indicating some success from containment efforts despite the emergence of artemisinin resistance in this area.

It is well known that the transboundary spread of infectious diseases is aided by trade in live animals and the consequences can be severe if, as a result, a pathogen broadens its host range to new species. Trade in aquatic animal species is increasing, and aquaculture is also expanding to meet the growing human population's demands for animal protein. Moreover, it is clear that aquaculture has created potential new pathways by which pathogens and diseases may be introduced or spread to new areas. The risk of pathogen transfer is generally considered greater for the movement of live aquatic animals than for the movement of processed and dead products. The currently available health standards support the concept of minimising the risk of disease and pathogen incursion while, at the same time, avoiding unjustifiable or unnecessary impediments to trade. Nevertheless, the international spread of diseases through the movement of animals still occurs, despite these standards. Consequently, this paper considers the evidence linking international trade in aquatic animals and aquatic animal-derived products with the transmission and spread of diseases. The authors provide examples of pathogen transfer leading to disease spread and considerthe situation of emerging diseases, as well as the need for a holistic approach to deal with risk-based threats at their source.

Background: Vitamin A (VA) has a key role in vertebrate morphogenesis, determining body patterning and growth through the control of cell proliferation and differentiation processes. VA regulates primary molecular pathways of those processes by the binding of its active metabolite (retinoic acid) to two types of specific nuclear receptors: retinoic acid receptors (RARs) and retinoid X receptors (RXRs), which promote transcription of downstream target genes. This process is well known in most of higher vertebrates; however, scarce information is available regarding fishes. Therefore, in order to gain further knowledge of fish larval development and its disruption by nutritional VA imbalance, the relative expression of some RARs and RXRs, as well as several genes involved in morpho- and skeletogenesis such as peroxisome proliferator-activated receptors (PPARA, PPARB and PPARG); retinol-binding protein (RBP); insulin-like growth factors I and II (IGF1 and IGF2, respectively); bone morphogenetic protein 2 (Bmp2); transforming growth factor β-1 (TGFB1); and genes encoding different extracellular matrix (ECM) proteins such as matrix Gla protein (mgp), osteocalcin (bglap), osteopontin (SPP1), secreted protein acidic and rich in cysteine (SPARC) and type I collagen α1 chain (COL1A1) have been studied in gilthead sea bream., Results: During gilthead sea bream larval development, specific expression profiles for each gene were tightly regulated during fish morphogenesis and correlated with specific morphogenetic events and tissue development. Dietary hypervitaminosis A during early larval development disrupted the normal gene expression profile for genes involved in RA signalling (RARA), VA homeostasis (RBP) and several genes encoding ECM proteins that are linked to skeletogenesis, such as bglap and mgp., Conclusions: Present data reflects the specific gene expression patterns of several genes involved in larval fish RA signalling and skeletogenesis; and how specific gene disruption induced by a nutritional VA imbalance underlie the skeletal deformities. Our results are of basic interest for fish VA signalling and point out some of the potential molecular players involved in fish skeletogenesis. Increased incidences of skeletal deformities in gilthead sea bream fed with hypervitaminosis A were the likely ultimate consequence of specific gene expression disruption at critical development stages.

The discharge of catchment-management water from the Ranger uranium (U) mine into Magela Creek upstream of the Ramsar-listed Magela Floodplain in Kakadu National Park is an important part of the mine's water-management system. Because U is one of the primary toxicants associated with this water, a receiving-water trigger value (TV), based on chronic toxicity data from five local native species, was derived for U. To strengthen the data set underpinning the derivation of the TV, the chronic toxicity of U to two additional tropical freshwater species, duckweed Lemna aequinoctialis (96-hour growth rate), and pulmonate gastropod, Amerianna cumingi (96-hour reproduction), was determined. The fate of U within the test systems was an important component of the study because analysis of U concentrations during the snail tests indicated that a substantial proportion of U (approximately 25%) was being lost from the test solutions when integrated during the entire test duration. Analysis of the snails and their food for U indicated that only a small proportion that was lost from solution was being taken up by the snails. Therefore, the majority of U that was lost was considered unavailable to the snails, and thus the exposure concentrations used to calculate the toxicity estimates were adjusted downward. Integrating the loss of U from the L. aequinoctialis test solutions over time showed that only a small proportion (6% to 13%) was lost during the test: Of that, almost half (2-5%) was taken up by the plants (constituting exposure). Uranium was only moderately toxic to L. aequinoctialis, with no observed-effect concentrations, lowest observed-effect concentrations, and inhibition concentrations causing 10% and 50% effects (IC10 and IC50) values of 226, 404, 207, and 1435 microg/l, respectively. A. cumingi was found to be more sensitive to U than L. aequinoctialis, with NOEC, LOEC, IC10, and IC50 values of 60, 61, 15, and 278 microg/l, respectively. The data for these two additional species will be used to revise the current TV for U in Magela Creek.

SK&F 96365 was used in a Neuroblastoma (Neuro-2a) cell based assay to determine the production of maitotoxin-like (MTX-like) compounds in two strains of Gambierdiscus spp. A 2.5 hour assay was effective for the detection of the MTX-induced toxic effects with a concentration that inhibited 50% cell viability (IC(50)) equivalent to 3.38 nM MTX. Evidence was found for the production of MTX-like compounds in both Gambierdiscus strains studied at concentrations of 404 and 36.7 nmoles MTX equivalence per 10(6) cells. The assay is proposed as an efficient approach to the detection and quantification of MTX-like compounds in Gambierdiscus spp., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Alfacs Bay is a N.W. Mediterranean estuary important for mussel (Mytilus galloprovincialis) aquaculture. During studies at the site, fiberglass particles were detected. The presence of fiberglass occurred naturally in the water throughout the study period (November 2006 to July 2007). An investigation was undertaken into its role in the feeding behavior of the local mussels. Fiberglass was present in all types of mussel samples. Rejection, which we would have expected for the whole study period, was only evident during the second season studied. To our knowledge, this is the first report of the ingestion of fiberglass by a marine organism. Our novel finding indicates the need to investigate fiberglass ingestion by marine organisms at different levels of the food web and the possible implications for human health and the health of the organisms themselves. In addition, we propose the use of mussels as sentinel organisms to monitor fiberglass contamination in marine ecosystems.

The suitability and sensitivity of two neural cell models, NG108-15 and Neuro-2a, to different marine toxins were evaluated under different incubation and exposure times and in the presence or absence of ouabain and veratridine (O/V). NG108-15 cells were more sensitive to pectenotoxin-2 than Neuro-2a cells. For saxitoxin, brevetoxin-3, palytoxin, okadaic acid and dinophysistoxin-1 both cell types proved to be sensitive and suitable for toxicity evaluation. For domoic acid preliminary results were presented. Setting incubation time and exposure time proved to be critical for the development of the assays. In order to reduce the duration of the assays, it was better to reduce cell time incubation previous to toxin exposure than exposure time. For palytoxin, after 24h of growth, both cell types were sensitive in the absence of O/V. When growth time previous to toxin exposure was reduced, both cell types were unsensitive to palytoxin when O/V was absent. Although dinophysistoxin-1 and okadaic acid are both phosphatase inhibitors, these toxins did not respond similarly in front of the experimental conditions studied. Both cell types were able to identify Na-channel acting toxins and allowed to quantify the effect of saxitoxin, brevetoxin-3, palytoxin, okadaic acid, dinophysistoxin-1 and pectenotoxin-2 under different experimental conditions.

Nisin, an amphipathic antibiotic peptide, is produced by a number of strains of Lactococcus lactis subsp. lactis. It has been employed as a food preservative as it has a high antibacterial activity with a relatively low toxicity for humans. Nisin is known to exert a high antibacterial activity against Gram-positive but not Gram-negative bacteria. However, purified nisin Z was found to show an antibacterial activity both against Gram-positive and Gram-negative bacteria. To clarify the mechanisms of activity, nisin Z and purified nisin Z were tested for their antibacterial activities in a high-salt environment. The activity of nisin Z against Staphylococcus aureus was stable even in the presence of NaCl at 100 mM, showing ca. 2log colony-forming unit (CFU) reduction. In contrast, the activity of nisin Z against Escherichia coli was highly sensitive to the same concentration of NaCl, and CFU reduction was not observed. Furthermore, purified nisin Z caused the permeabilisation both of S. aureus and E. coli cytoplasmic membranes. The permeabilisation of E. coli but not S. aureus cytoplasmic membranes was remarkably reduced in a high-salt environment. Moreover, vancomycin inhibited the nisin Z-induced permeabilisation of the S. aureus cytoplasmic membrane. These results suggest that nisin Z utilises two distinct mechanisms of antibacterial activity: a high-salt-sensitive mechanism for E. coli and a high-salt-insensitive mechanism for S. aureus.

This study was performed to evaluate the isomer-specific cytotoxic effects of conjugated linoleic acid (CLA) on rat hepatoma dRLh-84 cells in vitro. A 10trans,12cis (10t,12c)-CLA showed a strong cytotoxic effect on dRLh-84 cells in culture, whereas no such effect was observed with 9cis,11trans (9c,11t)-CLA or linoleic acid. The optimum concentration for induction of cytotoxicity by 10t,12c-CLA was 5 to 10 microM, but the effect was alleviated at higher concentrations. Coincubation with oleic or palmitoleic acid and 10t,12c-CLA cancelled the cytotoxic effect, but other major saturated or polyunsaturated fatty acids and eraidic acid did not interfere with 10t,12c-CLA-induced cytotoxity. The cytotoxic effect was also alleviated by alpha-tocopherol (alpha-toc) and alpha-tocotrienol but not by any other antioxidant reagent examined. Significant cytotoxicity of 10t,12c-CLA was detected after only a 15-min incubation, and the most noticeable effect was seen after 3 h. After incubation with 10t,12c-CLA at 10 microM, an additional 90 microM of 10t,12c-CLA or 100 microM of alpha-toc was also able to alleviate the cytotoxicity. When cells were treated with 10 microM 10t,12c-CLA for more than 48 h, treatment with additional CLA or alpha-toc could not prevent cell death.

Previous studies have shown the physiological significance of dietary conjugated linoleic acid (CLA) in various experimental animals and in human beings. One of the important problems to better elucidate is the difference between triglyceride (TG) and free (FFA) dietary CLA. Here, using splenocytes, this study assesses how TG- and FFA-CLA modulate immunoglobulin and various cytokine productions. In this study, C57BL/6N mice were fed an experimental diet containing 0% CLA, 0.1 or 1% FFA-CLA, or 0.1 or 1% TG-CLA for 3 weeks. The production of immunoglobulin tended to be up-regulated by 1% FFA-CLA. As a result of protein array analysis using the supernatant from splenocytes cultured with no CLA, 1% FFA-CLA, and TG-CLA, some cytokine production was shown to be remarkably regulated by dietary FFA- and TG-CLA. A total of 32 cytokines were examined, and 11-14 produced cytokines that were 2-fold up-regulated as compared with control for FFA- or TG-CLA, respectively. Especially, the production of IL-9 and MCP-5 and other cytokines was remarkably up-regulated by both FFA- and TG-CLA. In addition, seven cytokines were 2-fold down-regulated by TG-CLA. These data show that there is a slight but significant difference between the functionalities of FFA- and TG-CLA.

We evaluated the effect of conjugated linoleic acid (CLA) isomers on the growth factor-induced proliferation of human breast cancer MCF-7 cells. When MCF-7 cells were cultured in RPMI 1640 medium supplemented with 1% fetal bovine serum (FBS), CLA inhibited the proliferation and notably cis9, trans11 (c9,t11)-CLA showed the strongest effect. However, cells barely grew when cultured with 1% charcoal-treated FBS (cFBS). Proliferation was promoted in cFBS cultured cells by the addition of 17beta-estradiol (E2), insulin, and epidermal growth factor (EGF). Trans10, cis12 (T10,c12)-CLA inhibited cell proliferation induced by E2 and insulin, but not by EGF. T10,c12-CLA also exhibited cell-killing activity when cells were induced with insulin. On the other hand, c9,t11-CLA was shown to have no effect on MCF-7 cell proliferation induced by and of these three growth factors. In conclusion, although both c9, t11 and t10, c12-CLA can inhibit the proliferation of MCF-7 cells, our results suggested that they have separate mechanisms and different targets of actions.

We showed the inhibitory effect of oleic and palmitoleic acids (OA and POA) on this trans10, cis12 (10t, 12c)-CLA induced cytotoxic activity. When cells were cultured in the presence of 10t, 12c-CLA, this potent cytotoxic effect on dRLh-84 cells was clearly obvious when compared to the control vehicle group. It was revealed that the levels of cellular OA and POA levels decreased upon cis9, trans11 (9c,11t) or 10t, 12c-CLA treatment in a time course dependent manner. OA or POA demonstrates a dose dependent inhibition of the 10t, 12c-CLA induced cytotoxicity. Notable nuclear fragmentation or activation of caspase-3 and 9 by 10t, 12c-CLA in dRLh-84 was counteracted by treatment with OA or POA. Results also suggest that 10t, 12c-CLA induced apoptosis can be inhibited by treatment with OA or POA.