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Human ascariasis is a major neglected tropical disease caused by the nematodeAscaris lumbricoides. We report a 296 megabase (Mb) reference-quality genome comprised of 17,902 protein-coding genes derived from a single, representativeAscarisworm. An additional 68 worms were collected from 60 human hosts in Kenyan villages where pig husbandry is rare. Notably, the majority of these worms (63/68) possessed mitochondrial genomes that clustered closer to the pig parasiteAscaris suumthan toA. lumbricoides. Comparative phylogenomic analyses identified over 11 million nuclear-encoded SNPs but just two distinct genetic types that had recombined across the genomes analyzed. The nuclear genomes had extensive heterozygosity, and all samples existed as genetic mosaics with eitherA. suum-like orA. lumbricoides-like inheritance patterns supporting a highly interbredAscarisspecies genetic complex. As no barriers appear to exist for anthroponotic transmission of these ‘hybrid’ worms, a one-health approach to control the spread of human ascariasis will be necessary.

Co-infection with soil-transmitted helminths (STH) and Plasmodium spp. parasites is a common occurrence in tropical low-income countries, but the consequences of this interaction remain poorly understood. Here, we performed a multi-omic analysis on peripheral blood and fecal samples from 130 individuals in Tierralta, Córdoba, Colombia who were infected with P. vivax alone (n = 33), co-infected with P. vivax and STH (n = 27), infected with STH alone (n = 39) or were infected with neither P. vivax nor STH (n = 31). In addition to Complete Blood Count (CBC) with differential, transcriptional profiling of peripheral blood samples was performed by RNA-Seq, fecal microbial communities were determined by 16S ribosomal RNA gene sequencing and circulating cytokine levels were measured by bead-based immunoassays. Differences in blood cell counts were driven primarily by P. vivax infection, including an increased percentage of neutrophils that was associated with a transcriptional signature of neutrophil activation in the blood. P. vivax infection was also associated with increased levels of IL-6, IL-8 and IL-10, and these cytokine levels were not affected by STH co-infection. Surprisingly, P. vivax infection was more strongly associated with changes in the microbiome than STH infection. Children infected with P. vivax exhibited elevated Bacteroides and reduced Prevotella and Clostridiaceae, but these differences were not observed in individuals co-infected with STH. We also observed that P. vivax parasitemia was higher in the STH-infected population. When we used machine learning to identify the most important predictors of P. vivax parasite burden from all measured variables, bacterial taxa were the strongest predictors of parasitemia levels. In contrast, circulating TGF-β was the strongest predictor of T. trichiura egg burden. This study provides unexpected evidence that the gut microbiota may have a stronger link with P. vivax than with STH infection.

Background With the expansion of soil transmitted helminth (STH) intervention efforts and the corresponding decline in infection prevalence, there is an increased need for sensitive and specific STH diagnostic assays. Previously, through next generation sequencing (NGS)-based identification and targeting of non-coding, high copy-number repetitive DNA sequences, we described the development of a panel of improved quantitative real-time PCR (qPCR)-based assays for the detection of Necator americanus, Ancylostoma duodenale, Ancylostoma ceylanicum, Trichuris trichiura, and Strongyloides stercoralis. However, due to the phenomenon of chromosome diminution, a similar assay based on high copy-number repetitive DNA was not developed for the detection of Ascaris lumbricoides. Recently, the publication of a reference-level germline genome sequence for A. lumbricoides has facilitated our development of an improved assay for this human pathogen of vast global importance. Methodology/Principal findings Repurposing raw DNA sequence reads from a previously published Illumina-generated, NGS-based A. lumbricoides germline genome sequencing project, we performed a cluster-based repeat analysis utilizing RepeatExplorer2 software. This analysis identified the most prevalent repetitive DNA element of the A. lumbricoides germline genome (AGR, Ascaris germline repeat), which was then used to develop an improved qPCR assay. During experimental validation, this assay demonstrated a fold increase in sensitivity of ~3,100, as determined by relative Cq values, when compared with an assay utilizing a previously published, frequently employed, ribosomal internal transcribed spacer (ITS) DNA target. A comparative analysis of 2,784 field-collected samples was then performed, successfully verifying this improved sensitivity. Conclusions/Significance Through analysis of the germline genome sequence of A. lumbricoides, a vastly improved qPCR assay has been developed. This assay, utilizing a high copy-number repeat target found in eggs and embryos (the AGR repeat), will improve prevalence estimates that are fundamental to the programmatic decision-making process, while simultaneously strengthening mathematical models used to examine STH infection rates. Furthermore, through the identification of an optimal target for PCR, future assay development efforts will also benefit, as the identity of the optimized repeat DNA target is likely to remain unchanged despite continued improvement in PCR-based diagnostic technologies., Author summary With an at-risk population in the billions, Ascaris lumbricoides is a pathogen of great global importance. In recent years, efforts to control the spread of this parasitic helminth have expanded, resulting in declining infection rates and worm burdens in some regions. While immeasurably important for global health, these declines have also served to expose the shortcomings of traditional diagnostic methods, as low-levels of pathogen generate a need for more sensitive tools, and microscopy-based techniques are proving ill-suited to the task at hand. Thankfully, improved sensitivity can be achieved through the careful selection of optimal repetitive DNA targets for PCR. However, previous attempts to identify such targets in A. lumbricoides were unsuccessful, largely due to chromosome diminution, an unusual phenomenon occurring in the Ascaridida, whereby large portions of the germline genome are reproducibly eliminated during early development, resulting in their absence in larvae or adult worms. As the stool-based molecular diagnosis of A. lumbricoides infection is primarily dependent upon the identification of egg-derived DNA, utilizing genomic DNA from adult worms for molecular target selection eliminates germline candidates and results in suboptimal target sequence choices. Recently, the publication of a pre-diminution germline genome of A. lumbricoides has provided us with an opportunity to re-evaluate target selection, facilitating the development of a novel quantitative real-time PCR assay with greatly improved sensitivity (~3100-fold as determined by relative Cq value) over previously developed assays that were based on ribosomal repeat DNA sequences with lower copy numbers.

Background Pertuzumab combined with trastuzumab and docetaxel is the standard first-line therapy for HER2-positive metastatic breast cancer, based on results from the phase III CLEOPATRA trial. PERUSE was designed to assess the safety and efficacy of investigator-selected taxane with pertuzumab and trastuzumab in this setting. Patients and methods In the ongoing multicentre single-arm phase IIIb PERUSE study, patients with inoperable HER2-positive advanced breast cancer (locally recurrent/metastatic) (LR/MBC) and no prior systemic therapy for LR/MBC (except endocrine therapy) received docetaxel, paclitaxel or nab-paclitaxel with trastuzumab [8mg/kg loading dose, then 6mg/kg every 3weeks (q3w)] and pertuzumab (840mg loading dose, then 420mg q3w) until disease progression or unacceptable toxicity. The primary end point was safety. Secondary end points included overall response rate (ORR) and progression-free survival (PFS). Results Overall, 1436 patients received at least one treatment dose (initially docetaxel in 775 patients, paclitaxel in 589, nab-paclitaxel in 65; 7 discontinued before starting taxane). Median age was 54years; 29% had received prior trastuzumab. Median treatment duration was 16months for pertuzumab and trastuzumab and 4months for taxane. Compared with docetaxel-containing therapy, paclitaxel-containing therapy was associated with more neuropathy (all-grade peripheral neuropathy 31% versus 16%) but less febrile neutropenia (1% versus 11%) and mucositis (14% versus 25%). At this preliminary analysis (52 months' median follow-up), median PFS was 20.6 [95% confidence interval (CI) 18.9–22.7] months overall (19.6, 23.0 and 18.1months with docetaxel, paclitaxel and nab-paclitaxel, respectively). ORR was 80% (95% CI 78%–82%) overall (docetaxel 79%, paclitaxel 83%, nab-paclitaxel 77%). Conclusions Preliminary findings from PERUSE suggest that the safety and efficacy of first-line pertuzumab, trastuzumab and taxane for HER2-positive LR/MBC are consistent with results from CLEOPATRA. Paclitaxel appears to be a valid alternative taxane backbone to docetaxel, offering similar PFS and ORR with a predictable safety profile. ClinicalTrials.gov NCT01572038.

Background: First-line (1L) docetaxel+trastuzumab+pertuzumab (THP) for HER2-positive metastatic breast cancer (MBC) significantly improved progression-free survival (PFS) and overall survival in the phase III CLEOPATRA trial, and led to the approval of this regimen. PERUSE (NCT01572038) was designed to assess the safety and efficacy of investigator's choice of taxane+HP for 1L locally recurrent (LR)/MBC, and allows exploration of safety and efficacy in a larger population. Methods: PERUSE is a multicenter, single-arm phase IIIb study. Patients (pts) with Eastern Cooperative Oncology Group performance status ≤2 and no prior systemic therapy for LR/MBC (except endocrine therapy) receive T, paclitaxel (PAC), or nab-PAC plus H (8 mg/kg→6 mg/kg every 3 weeks [q3w]) and P (840 mg→420 mg q3w) until disease progression (PD) or unacceptable toxicity. The primary endpoint is safety. Secondary endpoints include best overall response (BOR) and PFS. Results: The safety/ITT population includes 1436 pts at data cutoff (1 Apr 2016). Median follow-up was 17.2 mo (range, Most pts discontinued taxanes for 'other' reasons (25%), adverse events (AEs; 16%), PD, or investigator decision (15% each); H, for PD or AEs (46% and 7%); and P, for PD or AEs (46% and 8%). Grade ≥3 treatment-emergent AEs (TEAEs) of interest are shown in table 1. Serious TEAEs were reported in 282 (36%) pts on T, 185 (31%) on PAC, and 21 (32%) on nab-PAC. Preliminary efficacy by taxane is shown in table 2. Table 1Pts, n (%)TPACNab-PAC n=775n=589n=65Neutropenia110 (14)31 (5)1 (2)Diarrhea62 (8)50 (8)4 (6)Febrile neutropenia81 (10)7 (1)0Fatigue21 (3)10 (2)1 (2)Asthenia16 (2)10 (2)0Peripheral neuropathy10 (1)15 (3)0Anemia11 (1)12 (2)2 (3)Left ventricular dysfunction1 ( Table 2 TPACNab-PACBOR, based on pts with measureable disease at baseline, n (%)n=659n=482n=53Complete72 (11)80 (17)4 (8)Partial442 (67)319 (66)38 (72)Stable disease112 (17)62 (13)8 (15)PD18 (3)12 (2)2 (4)Missing15 (2)9 (2)1 (2)PFS, ITT populationn=775n=589n=65Pts with events, n (%)439 (57)324 (55)40 (62)Median, mo (95% confidence interval)19.6 (17.4–22.6)24.8 (20.7–27.0)18.1 (11.9–34.2)25th–75th percentile, mo9.4–not reached (NR)10.2–NR7.9–NR Conclusion: The preliminary findings of this large, single-arm study suggest that safety and efficacy of 1L taxane+HP for HER2-positive LR/MBC are in keeping with the results of the phase III CLEOPATRA study. There was less febrile neutropenia with PAC/nab-PAC+HP compared with THP, and preliminary PFS was similar to that seen in the CLEOPATRA study for all taxane+HP combinations. Citation Format: Bachelot T, Puglisi F, Ciruelos E, Peretz-Yablonski T, Schneeweiss A, Easton V, Lindegger N, Restuccia E, Miles D. Preliminary safety and efficacy of first-line pertuzumab combined with trastuzumab and taxane therapy for HER2-positive locally recurrent/metastatic breast cancer (PERUSE) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-04.

Background: First-line (1L) docetaxel+trastuzumab+pertuzumab (THP) is approved for HER2-positive metastatic breast cancer (MBC), based on superior progression-free (PFS) and overall survival vs TH in the phase III CLEOPATRA trial. Predefined CLEOPATRA subgroup analyses suggested that THP use should not be limited by patient (pt) age: toxicity was increased but efficacy was similar in pts ≥65 vs Methods: In this multicentre, single-arm phase IIIb study, pts with ECOG PS ≤2 and no prior systemic therapy for LR/MBC (except endocrine therapy) receive investigator's choice of T, paclitaxel (PAC), or nab-PAC + H (8→6 mg/kg q3w) + P (840→420 mg q3w) until disease progression/unacceptable toxicity. The primary endpoint is safety. Secondary endpoints include PFS, estimated using the Kaplan–Meier method. Results: At data cutoff (1 Apr 2016), 1436 pts were included in the safety/ITT populations. 312 pts (22%) were aged ≥65 at study entry; they were more likely to have comorbidities than the Proportions of pts with visceral and hormone receptor-positive disease were similar (78% vs 74% and 65% vs 64%, respectively). Median duration of chemotherapy was similar but median exposure to antibodies was shorter in the ≥65 vs Interruptions/discontinuations due to treatment-emergent adverse events (TEAEs) were more common in pts ≥65 compared with pts TEAEs related to taxanes, H, and P were generally similar in pts aged ≥65 and Serious TEAE rates and most common grade ≥3 TEAEs of interest are shown in table 1. Table 1Pts, n (%) Preliminary median PFS at the time of this analysis was 23.2 mo in the Conclusion: Preliminary findings with 1L taxane+HP in this large cohort of LR/MBC pts show that pts aged ≥65 years had more comorbidities and poorer PS at study entry compared with those aged Citation Format: Miles D, Schneeweiss A, Peretz-Yablonski T, Ciruelos E, Puglisi F, Easton V, Lindegger N, Restuccia E, Bachelot T. Preliminary safety and efficacy of first-line pertuzumab combined with trastuzumab and taxane therapy in patients ≥65 years with HER2-positive locally recurrent/metastatic breast cancer: Subgroup analyses of the PERUSE study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-07.

Malaria caused by Plasmodium vivax is a highly prevalent infection world-wide, that was previously considered mild, but complications such as anemia have been highly reported in the past years. In mice models of malaria, anti-phosphatidylserine (anti-PS) autoantibodies, produced by atypical B-cells, bind to uninfected erythrocytes and contribute to anemia. In human patients with P. falciparum malaria, the levels of anti-PS, atypical B-cells and anemia are strongly correlated to each other. In this study, we focused on assessing the relationship between autoantibodies, different B-cell populations and hemoglobin levels in two different cohorts of P. vivax patients from Colombia, South America. In a first longitudinal cohort, our results show a strong inverse correlation between different IgG autoantibodies tested (anti-PS, anti-DNA and anti-erythrocyte) and atypical memory B-cells (atMBCs) with hemoglobin in both P. vivax and P. falciparum patients over time. In a second cross-sectional cohort, we observed a stronger relation between hemoglobin levels, atMBCs and autoantibodies in complicated P. vivax patients compared to uncomplicated ones. Altogether, these data constitute the first evidence of autoimmunity associating with anemia and complicated P. vivax infections, suggesting a role for its etiology through the expansion of autoantibody-secreting atMBCs., Author summary Malaria is one of the top global infections causing high mortality and morbidity every year. Plasmodium vivax is the most prevalent malarial infection, particularly in the region of the Americas. Complications associated with P. vivax, such as anemia, are a growing reported phenomenon, but the mechanisms leading to them are poorly understood. Here, we report the first evidence of autoantibodies and Atypical Memory B-cells correlating with anemia in two different cohorts of P. vivax patients, particularly during complicated infections. These findings point to Atypical Memory B-cells as key pathological players, possibly through the secretion of autoantibodies, and attributes a role for autoimmunity in mediating complications during P. vivax infections.

BACKGROUND: The open-label randomized phase III TANIA trial (NCT01250379) evaluated 2nd-line BEV-containing therapy in BEV-pretreated LR/mBC. The primary objective was met: 2nd-line PFS was statistically significantly improved in patients (pts) receiving further BEV (hazard ratio [HR] 0.75, 95% CI 0.61–0.93; p=0.0068) [von Minckwitz, Lancet Oncol 2014]. We report final efficacy, safety, and health-related quality of life (HRQoL) results. METHODS: Eligible pts had HER2-negative LR/mBC that had progressed on/after 1st-line BEV plus chemotherapy (CT). Pts were randomized to receive 2nd-line CT (investigator's choice) either alone or combined with BEV (15 mg/kg q3w or 10 mg/kg q2w) until disease progression (PD), unacceptable toxicity, or consent withdrawal. At 2nd PD, pts in the CT arm received 3rd-line CT without BEV (no crossover); pts initially randomized to BEV–CT received 3rd-line BEV–CT. Secondary endpoints included 3rd-line PFS, 2nd- and 3rd-line PFS (from randomization to 3rd PD/death), overall survival (OS), HRQoL, and safety. HRQoL was assessed using FACT-B at baseline, every 8/9 weeks (depending on treatment schedule) during 2nd-line therapy, and at the time of 2nd PD. Prespecified HRQoL analyses included differences between treatment arms in mean change from baseline for each FACT-B subscale. RESULTS: At the time of data cut-off for the prespecified final analysis (April 30, 2015, 24 months after the last pt was randomized), median follow-up was 32.1 vs 30.9 months in the CT vs BEV–CT arms, respectively. All pts had stopped study treatment. Of the 494 pts randomized to 2nd-line therapy, 234 began 3rd-line therapy (105 initially randomized to CT; 129 from the BEV–CT arm, of whom 17 received CT without BEV). The most commonly selected 3rd-line CT was vinorelbine (33% of CT pts vs 31% of BEV–CT pts). EndpointNo. of events/pts (%)Median, months (95% CI)Stratified HR (95% CI)p-value CTBEV–CTCTBEV–CT 3rd-line PFS99/105 (94)124/129 (96)2.9 (2.2-3.9)3.8 (2.4-5.1)0.79 (0.59-1.06)0.10802nd- and 3rd-line PFS177/247 (72)206/247 (83)10.7 (9.2-12.5)12.8 (10.7-14.5)0.85 (0.68-1.05)0.1349OS156/247 (63)163/247 (66)18.7 (15.4-21.2)19.7 (17.6-21.0)0.96 (0.76-1.21)0.7253 Subgroup analyses of 3rd-line PFS and OS according to stratification factors were consistent with the overall ITT result. Before study closure, 68% and 61% of pts in the 3rd-line ITT population CT and BEV–CT arms, respectively, received further CT. 3rd-line safety results showed no new safety signals. At week 8/9, mean change from baseline for all FACT-B subscales was CONCLUSIONS: Although BEV given after PD on 1st-line BEV-containing therapy showed improvement in 2nd-line PFS, no OS benefit was demonstrated. No new safety signals were observed. There were no differences in HRQoL between treatment arms, suggesting that the PFS benefit with BEV is achieved with maintained HRQoL. Citation Format: Vrdoljak E, Marschner N, Zielinski C, Gligorov J, Cortes J, Puglisi F, Aapro M, Fallowfield L, Fontana A, Inbar M, Kahan Z, Welt A, Lévy C, Brain E, Pivot X, Putzu C, Gonzalez-Martin A, Ebel K, Easton V, von Minckwitz G. Final results of the TANIA randomized phase III trial of bevacizumab (BEV) after progression on 1st-line BEV therapy for HER2-negative locally recurrent/metastatic breast cancer (LR/mBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-14-01.

In recent years, an increased focus has been placed upon the possibility of the elimination of soil-transmitted helminth (STH) transmission using various interventions including mass drug administration. The primary diagnostic tool recommended by the WHO is the detection of STH eggs in stool using the Kato-Katz (KK) method. However, detecting infected individuals using this method becomes increasingly difficult as the intensity of infection decreases. Newer techniques, such as qPCR, have been shown to have greater sensitivity than KK, especially at low prevalence. However, the impact of using qPCR on elimination thresholds is yet to be investigated. In this paper, we aim to quantify how the sensitivity of these two diagnostic tools affects the optimal prevalence threshold at which to declare the interruption of transmission with a defined level of confidence. A stochastic, individual-based STH transmission model was used in this study to simulate the transmission dynamics of Ascaris and hookworm. Data from a Kenyan deworming study were used to parameterize the diagnostic model which was based on egg detection probabilities. The positive and negative predictive values (PPV and NPV) were calculated to assess the quality of any given threshold, with the optimal threshold value taken to be that at which both were maximised. The threshold prevalence of infection values for declaring elimination of Ascaris transmission were 6% and 12% for KK and qPCR respectively. For hookworm, these threshold values are lower at 0.5% and 2% respectively. Diagnostic tests with greater sensitivity are becoming increasingly important as we approach the elimination of STH transmission in some regions of the world. For declaring the elimination of transmission, using qPCR to diagnose STH infection results in the definition of a higher prevalence, than when KK is used., Author summary Soil-transmitted helminths are categorised as a neglected tropical disease and comprise four dominant species (two hookworms, Trichuris trichuria & Ascaris lumbricoides) that affect the poorest people in the world. The World Health Organisation (WHO) has made great strides in reducing the morbidity induced by STH infections in pre-school aged and school-aged children through mass drug administration. Many countries are now considering moving from morbidity reduction in school-aged children to community-wide treatment with the aim of transmission elimination. These helminths reproduce sexually within a human host and therefore both male and female worms must be present to produce fertilized eggs. The density of female and male worms below which mating success is too low to sustain parasite populations is defined as the ‘breakpoint’ in transmission. Both the prevalence and intensity of infection are very low as this breakpoint is approached when worm numbers are highly aggregated in their distribution within the human host population. Consequently, it becomes increasingly challenging to identify infected individuals using standard microscopic diagnostic tools (such as Kato-Katz). New and more sensitive molecular diagnostics tools, such as qPCR, are a necessity in settings where communities are moving towards the interruption of transmission. This paper demonstrates that the threshold to declare interruption of transmission is 50% lower when microscopic techniques are applied compared with molecular techniques.

Programmed DNA elimination is a developmentally regulated process leading to the reproducible loss of specific genomic sequences. DNA elimination occurs in unicellular ciliates and a variety of metazoans, including invertebrates and vertebrates. In metazoa, DNA elimination typically occurs in somatic cells during early development, leaving the germline genome intact. Reference genomes for metazoa that undergo DNA elimination are not available. Here, we generated germline and somatic reference genome sequences of the DNA eliminating pig parasitic nematode Ascaris suum and the horse parasite Parascaris univalens. In addition, we carried out in-depth analyses of DNA elimination in the parasitic nematode of humans, Ascaris lumbricoides, and the parasitic nematode of dogs, Toxocara canis. Our analysis of nematode DNA elimination reveals that in all species, repetitive sequences (that differ among the genera) and germline-expressed genes (approximately 1000–2000 or 5%–10% of the genes) are eliminated. Thirty-five percent of these eliminated genes are conserved among these nematodes, defining a core set of eliminated genes that are preferentially expressed during spermatogenesis. Our analysis supports the view that DNA elimination in nematodes silences germline-expressed genes. Over half of the chromosome break sites are conserved between Ascaris and Parascaris, whereas only 10% are conserved in the more divergent T. canis. Analysis of the chromosomal breakage regions suggests a sequence-independent mechanism for DNA breakage followed by telomere healing, with the formation of more accessible chromatin in the break regions prior to DNA elimination. Our genome assemblies and annotations also provide comprehensive resources for analysis of DNA elimination, parasitology research, and comparative nematode genome and epigenome studies.

Background Understanding and quantifying the sources and implications of error in the measurement of helminth egg intensity using Kato-Katz (KK) and the newly emerging “gold standard” quantitative polymerase chain reaction (qPCR) technique is necessary for the appropriate design of epidemiological studies, including impact assessments for deworming programs. Methods Repeated measurements of Ascaris lumbricoides infection intensity were made from samples collected in western Kenya using the qPCR and KK techniques. These data were combined with data on post-treatment worm expulsions. Random effects regression models were used to quantify the variability associated with different technical and biological factors for qPCR and KK diagnosis. The relative precision of these methods was compared, as was the precision of multiple qPCR replicates. Results For both KK and qPCR, intensity measurements were largely determined by the identity of the stool donor. Stool donor explained 92.4% of variability in qPCR measurements and 54.5% of observed measurement variance for KK. An additional 39.1% of variance in KK measurements was attributable to having expelled adult A. lumbricoides worms following anthelmintic treatment. For qPCR, the remaining 7.6% of variability was explained by the efficiency of the DNA extraction (2.4%), plate-to-plate variability (0.2%) and other residual factors (5%). Differences in replicate measurements by qPCR were comparatively small. In addition to KK variability based on stool donor infection levels, the slide reader was highly statistically significant, although it only explained 1.4% of the total variation. In a comparison of qPCR and KK variance to mean ratios under ideal conditions, the coefficient of variation was on average 3.6 times larger for KK highlighting increased precision of qPCR. Conclusions Person-to-person differences explain the majority of variability in egg intensity measurements by qPCR and KK, with very little additional variability explained by the technical factors associated with the practical implementation of these techniques. qPCR provides approximately 3.6 times more precision in estimating A. lumbricoides egg intensity than KK, and could potentially be made more cost-effective by testing each sample only once without diminishing the power of a study to assess population-level intensity and prevalence. Electronic supplementary material The online version of this article (doi:10.1186/s13071-017-2164-y) contains supplementary material, which is available to authorized users.

Congenital Talipes Equinovarus (CTEV) is one of the most common congenital limb deformities. We reviewed the records of infants who had received treatment for structural CTEV between 1 January 2007 and 30 November 2012. This was cross-referenced with the prenatal scans of mothers over a corresponding period of time. We investigated the sensitivity, specificity, and positive and negative predictive values of the fetal anomaly scan for the detection of CTEV and explored whether the publication of Fetal Anomaly Screening Programme guidelines in 2010 affected the rate of detection. During the study period there were 95 532 prenatal scans and 34 373 live births at our hospital. A total of 37 fetuses with findings suggestive of CTEV were included in the study, of whom 30 were found to have structural CTEV at birth. The sensitivity of screening for CTEV was 71.4% and the positive predictive value was 81.1%. The negative predictive value and specificity were more than 99.5%. There was no significant difference between the rates of detection before and after publication of the guidelines (p = 0.5). We conclude that a prenatal fetal anomaly ultrasound screening diagnosis of CTEV has a good positive predictive value enabling prenatal counselling. The change in screening guidance has not affected the proportion of missed cases. This information will aid counselling parents about the effectiveness and accuracy of prenatal ultrasound in diagnosing CTEV. Cite this article: Bone Joint J 2014;96-B:984–8.

The effects of intensive glucose control on cardiovascular events in patients with long-standing type 2 diabetes mellitus remain uncertain.We randomly assigned 1791 military veterans (mean age, 60.4 years) who had a suboptimal response to therapy for type 2 diabetes to receive either intensive or standard glucose control. Other cardiovascular risk factors were treated uniformly. The mean number of years since the diagnosis of diabetes was 11.5, and 40% of the patients had already had a cardiovascular event. The goal in the intensive-therapy group was an absolute reduction of 1.5 percentage points in the glycated hemoglobin level, as compared with the standard-therapy group. The primary outcome was the time from randomization to the first occurrence of a major cardiovascular event, a composite of myocardial infarction, stroke, death from cardiovascular causes, congestive heart failure, surgery for vascular disease, inoperable coronary disease, and amputation for ischemic gangrene.The median follow-up was 5.6 years. Median glycated hemoglobin levels were 8.4% in the standard-therapy group and 6.9% in the intensive-therapy group. The primary outcome occurred in 264 patients in the standard-therapy group and 235 patients in the intensive-therapy group (hazard ratio in the intensive-therapy group, 0.88; 95% confidence interval [CI], 0.74 to 1.05; P=0.14). There was no significant difference between the two groups in any component of the primary outcome or in the rate of death from any cause (hazard ratio, 1.07; 95% CI, 0.81 to 1.42; P=0.62). No differences between the two groups were observed for microvascular complications. The rates of adverse events, predominantly hypoglycemia, were 17.6% in the standard-therapy group and 24.1% in the intensive-therapy group.Intensive glucose control in patients with poorly controlled type 2 diabetes had no significant effect on the rates of major cardiovascular events, death, or microvascular complications with the exception of progression of albuminuria (P = 0.01) [added]. (ClinicalTrials.gov number, NCT00032487.)

Background Although chronic morbidity in humans from soil transmitted helminth (STH) infections can be reduced by anthelmintic treatment, inconsistent diagnostic tools make it difficult to reliably measure the impact of deworming programs and often miss light helminth infections. Methods Cryopreserved stool samples from 796 people (aged 2–81 years) in four villages in Bungoma County, western Kenya, were assessed using multi-parallel qPCR for 8 parasites and compared to point-of-contact assessments of the same stools by the 2-stool 2-slide Kato-Katz (KK) method. All subjects were treated with albendazole and all Ascaris lumbricoides expelled post-treatment were collected. Three months later, samples from 633 of these people were re-assessed by both qPCR and KK, re-treated with albendazole and the expelled worms collected. Results Baseline prevalence by qPCR (n = 796) was 17 % for A. lumbricoides, 18 % for Necator americanus, 41 % for Giardia lamblia and 15 % for Entamoeba histolytica. The prevalence was

This randomized phase 2 study explored the feasibility of delivering four to six cycles of the dose-intensified regimen FEC-100 (5-fluorouracil, epirubicin, and cyclophosphamide) to elderly patients with stage II-III breast cancer, using pegfilgrastim for neutrophil support. Sixty patients aged 65-77 years received single 6mg doses of pegfilgrastim on day 2 of FEC-100, either as primary prophylaxis (all cycles: PP), or as secondary prophylaxis (all cycles following a neutropenic event: SP). Neutropenic events (a composite endpoint that included grade 3 neutropenia+fever, grade 4 neutropenia, infectious complication requiring systemic anti-infectives and chemotherapy dose delay/reduction) occurred in 24/30 (80%) of the PP and 21/29 (72%) of the SP group in the first cycle. Most patients received all chemotherapy cycles at full dose on schedule (26/30 [87%] PP; 20/29 [69%] SP). These data indicate that delivery of FEC-100 is feasible with pegfilgrastim support in elderly breast cancer patients.

Context: Antimicrobial use has been associated with increasing antimicrobial resistance. There is an urgent need for judicious use of antimicrobials. Informational feedback has been shown to result in changes in behavioural practices of physicians in certain healthcare settings. We conducted this study to see if the passive informational feedback can reduce in antimicrobial usage in a tertiary care centre. Aims: The study was undertaken to evaluate if the feedback to clinicians on their own antibiotic prescription results in any change in their antibiotic prescription habits. Settings and Design: The study was conducted at a tertiary care setting involving 33 units of different specialties. These units were split into 10 groups based on specialty and were allocated randomly to the control (16 units) and intervention (17 units) arms of the study. This study was a prospective intervention to assess the effect of prescribing feedback on clinical prescribing practices. Materials and Methods: In the intervention arm, information on resistance rates and antibiotic-prescribing patterns was provided to all doctors. Behavioural change was assessed by comparing baseline prescribing rates of each unit with prescribing rates after the intervention. In the control arm, only information on monthly resistance rates was provided. Statistical Analysis : Change in the antimicrobial prescribing rates in the treatment group was assessed by using a Student′s t-test. Results: The mean antibiotic use for all the specialties was 189 DDDs/100BDs. The prospective intervention did not elicit any effect on the antibiotic prescribing practices of the physicians. Low prescribers continued to prescribe antibiotics at a low rate, and high prescribers continued to prescribe at a high rate. Conclusions: In view of unfavourable results of passive intervention in the above study, active intervention may be more effective.

Background: Chemotherapy (including paclitaxel) remains the predominant treatment for metastatic TNBC but clinical outcomes remain poor. Therefore, new therapeutic approaches are needed. Atezolizumab blocks the binding of PD-L1 to its receptors PD-1 and B7.1, thus restoring tumor-specific T cell immunity. TNBC is a rational target for atezolizumab therapy due to high PD-L1 expression on tumor-infiltrating immune cells (IC) and elevated T cell tumor infiltration. Furthermore, combining chemotherapy with atezolizumab is hypothesized to enhance anti-tumor immune response via neoantigen release. Atezolizumab alone and in combination with nab-paclitaxel has demonstrated promising clinical benefit in metastatic TNBC and was well tolerated, with no exacerbation of chemotherapy-associated adverse events. Atezolizumab in combination with nab-paclitaxel is being further investigated as 1L TNBC treatment in IMpassion130. IMpassion131 is a global, multi-center, randomized, double-blind, placebo-controlled study comparing the efficacy and safety of 1L atezolizumab + paclitaxel vs placebo + paclitaxel in patients with untreated, inoperable, locally advanced or metastatic TNBC. (NCT03125902) Methods: Eligibility criteria include patients with inoperable, locally advanced or metastatic TNBC, histologically confirmed; de novo or recurrent disease after early breast cancer treated with chemotherapy ≥ 12 months prior; eligible for taxane monotherapy; no prior chemotherapy or targeted systemic therapy for inoperable locally advanced or metastatic disease; ECOG PS 0-1 and measurable disease by RECIST v1.1. Exclusion criteria include known symptomatic CNS disease, prior immunotherapy and a history of autoimmune disease. Approximately 495 patients will be randomized 2:1 to receive atezolizumab (840 mg) or placebo (q2w; days 1 and 15 of 28-day cycle) plus paclitaxel (90 mg/m2; days 1, 8, 15 of 28-day cycle) until disease progression. Stratification factors are PD-L1 expression on tumor-infiltrating IC (IC0 < 1% vs IC1/2/3 ≥ 1% with VENTANA SP142 IHC assay), prior taxane therapy, presence of liver metastases and geographical region. The primary endpoint is progression-free survival (PFS) measured by RECIST v1.1. Key secondary endpoints include overall survival (OS), 12- and 18-month OS rates, 12-month PFS rate, objective response rate, duration of response, and safety. Tumor biopsies will be collected at baseline, on treatment and at disease progression to assess for biomarkers of treatment response and immune escape. Citation Format: Miles D, André F, Gligorov J, Verma S, Xu B, Cameron D, Barrios CH, Schneeweiss A, Easton V, Ghazi Y, O'Shaughnessy J. IMpassion131: A phase III study comparing 1L atezolizumab with paclitaxel vs placebo with paclitaxel in treatment-naive patients with inoperable locally advanced or metastatic triple negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-01-01.

Granulocyte colony-stimulating factors (G-CSFs) reduce febrile neutropaenia (FN) incidence but may be used inconsistently in current practice (CP). This study compared the efficacy of pegfilgrastim primary prophylaxis (PPP) with CP neutropaenia management in breast cancer. Individual patient data (N = 2282) from 11 clinical trials and observational studies using chemotherapy regimens with 15% FN risk and PPP (6 mg, all cycles) or CP (no G-CSF or any cycle G-CSF/pegfilgrastim) were included in an integrated analysis. Most patients received docetaxel-containing regimens. A generalised linear mixed model was fitted (N = 2210). Neutropaenia prophylaxis (PPP versus CP), age and disease stage influenced the incidence of FN. Overall, FN was less frequent with PPP than with CP (odds ratio [OR]: 0.124; 95% confidence interval [CI]: 0.08, 0.194; P < 0.0001). Odds for cycle 1 FN, dose reductions >= 15% and FN-related hospitalisation were also significantly lower with PPP. These data support PPP in breast cancer patients receiving chemotherapy with moderately high/high FN risk. (C) 2008 Elsevier Ltd. All rights reserved.

Extensive small-cell lung cancer (SCLC) is commonly treated with multiple cycles of chemotherapy. Reducing the time interval between cycles of chemotherapy (dose-dense chemotherapy) may improve outcomes in the treatment of extensive SCLC, as it has in other chemosensitive malignancies. To evaluate the feasibility of dose-dense chemotherapy in patients with extensive SCLC, this study evaluates a dose-dense doxorubicin/cyclophosphamide/etoposide (ACE) regimen, supported by the once-per-cycle administration of the hematopoietic growth factor pegfilgrastim. Patients received up to six 14-day cycles of ACE chemotherapy (doxorubicin 40 mg/m,(2) cyclophosphamide 1000 mg/m(2), etoposide 120 mg/m(2) on day 1 IV, plus oral etoposide 240 mg/m(2) daily on days 2-3). On day 4 of each cycle, patients received pegfilgrastim 6 mg by subcutaneous injection. Of 30 patients enrolled, 27 started chemotherapy and received pegfilgrastim. Full-dose, on-schedule chemotherapy was given to all 22 patients starting cycle 2, and in 107 (88%) of 121 cycles. Eighteen of the 27 patients (67%) received full-dose, on-schedule chemotherapy for all 6 cycles. The overall response rate was 17/27 (63%). Nine patients (33%) experienced hematologic toxicities that investigators considered severe or life-threatening. Four patients (15%) had febrile neutropenia. Full-dose, on-schedule dose-dense ACE chemotherapy is feasible with once-per-cycle pegfilgrastim support in extensive SCLC.

EORTC/ASCO guidelines recommend primary prophylaxis (PP) with granulocyte colony stimulating factor (G-CSF) when the risk of chemotherapy (CT)-induced febrile neutropenia (FN) is ≥20%. Without G-CSF prophylaxis, FN risk in patients with non-Hodgkin’s lymphoma (NHL) receiving CHOP is up to 50%, and over 50% of FN occurs in cycle 1. Physicians often delay/reduce dose to manage neutropenia, potentially compromising CT efficacy. We identified 3 prospective clinical trials that assessed PP of neutropenia with pegfilgrastim (Neulasta®) 6 mg once per cycle in NHL patients receiving CHOP or CHOP-like regimens ± rituximab. In a retrospective integrated analysis, data from the 3 trials were combined to evaluate the efficacy and safety of PP with pegfilgrastim in a large NHL population. The primary outcome measure was the proportion of patients developing FN. In all, 280 patients started the first cycle of CT, of whom 275 (98%) received pegfilgrastim as PP and were included in the present analyses. The proportion of patients experiencing FN over all cycles was relatively low (15%), and approximately half of FN cases occurred during cycle 1 (Table). WHO grade 3/4 hematological toxicities occurred in the following proportions of patients: white blood cell count (WBC) To conclude, in this population, PP of FN with pegfilgrastim was associated with a relatively low occurrence of FN (15%) and a high proportion of patients achieving RDI ≥90%. These data support the use of pegfilgrastim 6 mg as PP against FN and neutropenic complications in NHL patients receiving CHOP-like CT, particularly the elderly for whom risk of FN and hospitalization is greatest. These findings support current ASCO/EORTC guideline recommendations. Patients starting each cycle, n (%) Patients with, n (%) [95% CI] FN RDI ≥90% *Data from one study only Cycle 1 275 (100) 20 (7) [4, 10] 250 (91) [88, 94] Cycle 2 259 (94) 7 (3) [1, 5] 225 (87) [83, 91] Cycle 3 244 (89) 7 (3) [1, 5] 202 (83) [78, 88] Cycle 4 221 (80) 8 (4) [1, 6] 174 (79) [73, 84] Cycle 5 173 (63) 2 (1) [0, 3] 132 (76) [70, 83] Cycle 6 158 (57) 5 (3) [0, 6] 132 (84) [78, 89] Cycle 7* 23 (13) 0 18 (78) [61, 95] Cycle 8* 19 (11) 0 15 (79) [61, 97] All cycles 275 (100) 41 (15) [11, 19] 228 (83) [78, 87]

The German Hodgkin’s Lymphoma Study Group has previously demonstrated that dose-escalated BEACOPP chemotherapy administered every 21 days with filgrastim significantly improved failure-free and overall survival compared to COPP-ABVD in patients with advanced Hodgkin’s Lymphoma (Diehl et al, Annals of Oncology 1998). An alternative approach to dose escalation is reduction of cycle length to 14 days. BEACOPP given every 14 days (BEACOPP-14) with filgrastim has been demonstrated to be feasible and effective with moderate acute toxicity (Sieber et al, JCO 2003). The aim of this study was to explore the feasibility of pegfilgrastim to support full delivery of BEACOPP-14 in high-risk Hodgkin’s lymphoma. All patients received BEACOPP-14 for up to 8 cycles. Patients were randomised to receive a single, 6mg, subcutaneous dose of pegfilgrastim on day 4 (d4) or 8 (d8) of each cycle. Primary endpoints were proportion of chemotherapy cycles given at planned dose and on time and proportion of patients receiving all administered cycles of chemotherapy at planned dose and on time. A cycle was considered “on time” if it started ≤ 17 days after the start of the previous cycle, and at “planned dose” if a dose of >75% was administered for each myelosuppresive agent. Secondary endpoints included incidence of severe neutropenia (SN: absolute neutrophil count [ANC] 70% patients in cycle 6, and >50% of patients in cycle 8 received chemotherapy at planned dose on time in both groups. Over all cycles administered, 33% d4 and 40% d8 patients received chemotherapy at planned dose and on time. Nine of 21 patients (43%) in the d4 group compared to 15/20 patients (75%) in the d8 group had at least one incidence of SN. Serious adverse events reported by more than one subject were pneumonia, fever, febrile neutropenia, anaemia and syncope, which were similar in incidence between groups. At least 85% of patients had a response to BEACOPP-14, the remaining patients (d4: 14%, d8: 15%) had no response recorded. This exploratory study suggests that full delivery of BEACOPP-14 with pegfilgrastim administered on d4 or d8 is feasible. The safety profile for the 2 groups was similar although the incidence of SN in the d4 group may indicate that administration of pegfilgrastim immediately after the end of myelosuppressive chemotherapy could offer enhanced protection against SN.

The greatly increased prospective fault MVA at many switching stations, due to the rapid growth of interconnections on many systems during the last 15 years, has necessitated the design of circuit-breakers of larger capacity. This in turn has made desirable improved facilities for technical investigations and for proving the rating of the breakers.The paper discusses the mechanical and electrical factors which affect the design of alternators supplying power for switchgear testing. A review is made of several methods of increasing the output of such alternators, and the merits of each are critically examined.

The classic arrangement of a direct-driven d.c. exciter has proved, in general, a reliable, economic and satisfactory source of excitation supply for turbogenerators of moderate output. With increasing rating of individual units, the excitation power required exceeded that practicable for a direct-coupled d.c. machine and gearing was introduced to permit operation at a lower speed. These two factors, higher output and lower speed, inevitably resulted in greater physical size, with problems of access for maintenance purposes. Economics dictate that larger base-load units should operate for the maximum period between planned shutdowns and provide a stimulus to develop alternative sources of excitation power. The rotating-field a.c. exciter with static rectifier has been extensively adopted and forms the major feature of the paper; other schemes in use only on smaller units or on special or prototype machines are also discussed.