Switch to Sirolimus-based immunosuppresion in stable renal transplant recipients

Purpose: Sirolimus (SRL) has been used to replace calcineurin inhibitors (CNI) for various indications including CNI-induced toxicity. The aim of this study was to evaluate the efficacy and safety of switching from CNI to SRL in stable renal transplant recipients (RTR) with low grade proteinuria (<1 g/24 h). Methods and materials: Between 2001 and 2007, 41 patients (20 females, 21 males; mean age 47 ± 13) were switched after a median time post-transplantation of 73.5 months (range 0.2-273.2 months). Indications for switch were CNI nephrotoxicity (39%), thrombotic micro-angiopathy (14.6%), post-transplantation cancer (24.4%), CNI neurotoxicity (7.4%), or others (14.6%). Mean follow-up after SRL switch was 23.8±16.3 months. Mean SRL dosage and through levels were 2.4 ± 1.1 mg/day and 8 ± 2.2 ug/l respectively. Immunosuppressive regiments were SRL + mycophenolate mofetil (MMF) (31.7%), SRL + MMF + prednisone (36.58%), SRL + prednisone (19.51%), SRL + Azathioprine (9.75%), or SRL alone (2.43%). Results: Mean creatinine decreased from 164 to 143 μmol/l (p <0.03), mean estimated glomerular filtration rate (eGFR) increased significantly from 50.13 to 55.01 ml/minute (p <0.00001), mean systolic and diastolic blood pressure decreased from 138 to 132 mm Hg (p <0.03) and from 83 to78 mm Hg (p <0.01), but mean proteinuria increased from 0.21 to 0.63 g/24 h (p <0.001). While mean total cholesterolemia didn't increased significantly from 5.09 to 5.56 mmol/l (p = 0.06). The main complications after SRL switch were dermatitis (19.5%), urinary tract infections (24.4%), ankle edema (13.3%), and transient oral ulcers (20%). Acute rejection after the switch occurred in 7.3% of patients (n = 3), and 2 acute rejections were successfully treated with corticosteroids and 1 did not respond to treatment (not related to switch). SRL had to be discontinued in 17% of patients (2 nephrotic syndromes, 2 severe edema, 1 acute rejection, 1 thrombotic micro-angiopathy, and 1 fever). Conclusion: In conclusion, we found that switching from CNI to SRL in stable RTR was safe and associated with a significant improvement of renal function and blood pressure. Known side-effects of SRL led to drug discontinuation in less than 20% of patients and the acute rejection rate was 7.3%. This experience underlines the importance of patient selection before switching to SRL, in particular regarding preswitch proteinuria.

PFAPA syndrome is not sporadic disease

Résumé de thèseLe syndrome de PFAPA est une maladie fébrile récurrente décrite pour la première fois en 1987 par Marshall et col. Elle est caractérisée par une fièvre périodique, une stomatite aphteuse, une pharyngite et des adénopathies. Ce syndrome débute dans les premières années de vie et est connu pour disparaître spontanément en principe avant l'adolescence. Hormis un traitement de prednisone en début de crise, aucun traitement n'a pu montrer une efficacité thérapeutique ou curative.L'origine et l'étiologie de cette maladie sont encore inconnues à ce jour et le diagnostic reste un diagnostic d'exclusion qui repose sur des critères définis par différents groupes depuis 1987. Dans le cadre du Working Party periodic fever de la Société Européenne de Rhumatologie pédiatrique (PreS), un groupe a été établi et celui-ci a mis en place un registre de patients atteints de PFAPA afin d'analyser cette maladie et de mieux définir les critères diagnostic. Le Dr Michael Hofer a été nommé chairman de ce groupe et a introduit rapidement les patients romands dans cet outil de travail.L'introduction des patients romands dans la base de données ainsi créée, nous a suggéré une susceptibilité familiale qui nous a poussés à investiguer ce point de manière plus approfondie. Nous avons donc regroupé tous les patients lausannois et ceux de collègues bordelais ayant un diagnostic avéré de PFAPA. Nous avons ensuite interrogé, au cours d'un entretien téléphonique, les familles de ces enfants grâce à un questionnaire standardisé. Celui-ci a été testé et validé sur des patients sains d'une consultation de pédiatrie générale.Nous avons ensuite réunie toutes ces informations et séparés les patients en deux groupes AF+ (anamnèse familiale positive pour une fièvre récurrente) et AF- (anamnèse familiale négative pour une fièvre récurrente). Nous avons établi des comparaisons entre les 2 différents groupes en reprenant les caractéristiques de ces patients depuis le registre PFAPA dans lequel ils sont tous inclus. Les analyses ont été contrôlées et validées par le centre d'épidémiologie clinique grâce aux méthodes statistiques reconnues.Les résultats obtenus et qui sont détaillés dans l'article, permettent de suspecter une origine familiale et par là même, potentiellement génétique, à cette maladie d'étiologie inconnue. Jusqu'à présent aucune prépondérance familiale n'avait pu être mise en évidence dans les autres études sur le sujet. Pourtant cette maladie fait partie du groupe des fièvres récurrentes qui ont pour beaucoup déjà un diagnostic génétique.Notre étude ouvre donc des perspectives non seulement de recherche sur l'éventuelle cause génétique mais pourrait également permettre une meilleure compréhension de la maladie, de ses diverses présentations ainsi que par la suite de nouvelles possibilités thérapeutiques.

Corticosterone shifts reproductive behaviour towards self-maintenance in the barn owl and is linked to melanin-based coloration in females.

Trade-offs between the benefits of current reproduction and the costs to future reproduction and survival are widely recognized. However, such trade-offs might only be detected when resources become limited to the point where investment in one activity jeopardizes investment in others. The resolution of the trade-off between reproduction and self-maintenance is mediated by hormones such as glucocorticoids which direct behaviour and physiology towards self-maintenance under stressful situations. We investigated this trade-off in male and female barn owls in relation to the degree of heritable melanin-based coloration, a trait that reflects the ability to cope with various sources of stress in nestlings. We increased circulating corticosterone in breeding adults by implanting a corticosterone-releasing-pellet, using birds implanted with a placebo-pellet as controls. In males, elevated corticosterone reduced the activity (i.e. reduced home-range size and distance covered within the home-range) independently of coloration, while we could not detect any effect on hunting efficiency. The effect of experimentally elevated corticosterone on female behaviour was correlated with their melanin-based coloration. Corticosterone (cort-) induced an increase in brooding behaviour in small-spotted females, while this hormone had no detectable effect in large-spotted females. Cort-females with small eumelanic spots showed the normal body-mass loss during the early nestling period, while large spotted cort-females did not lose body mass. This indicates that corticosterone induced a shift towards self-maintenance in males independently on their plumage, whereas in females this shift was observed only in large-spotted females.

Characteristics of infections associated with external ventricular drains of cerebrospinal fluid.

OBJECTIVES: Manifestations of external ventricular drain (EVD) - associated infections overlap with those of the underlying neurosurgical conditions. We analyzed characteristics of EVD-associated infections. METHODS: We included patients aged ≥18 years with EVD-associated infections from 1997 to 2008, using modified CDC criteria for nosocomial infections. Hospital charts were reviewed retrospectively and the in-hospital outcome was evaluated. RESULTS: Forty-eight patients with EVD-associated infections were included (median age, 52 years, range 20-74 years). The median EVD-indwelling time was 7 days (range, 1-39 days) and EVD-associated infection occurred 6 days after insertion (range, 1-17 days). In 23% of patients, meningitis occurred 1-10 days after EVD removal. Fever >38 °C was present in 79% of patients, but Glasgow Coma Scale (GCS) scores were reduced in only 29%, and headache, vomiting and/or neck stiffness were present in only 31%. The median cerebrospinal fluid (CSF) leukocyte count was higher at onset of EVD-associated infection than at EVD insertion (175 × 10(6)/l versus 46 × 10(6)/l, p = 0.021), but other CSF parameters did not differ significantly. The most commonly implicated organisms were coagulase-negative staphylococci (63%) and Propionibacterium acnes (15%). CONCLUSIONS: Fever and increased CSF leukocytes should raise the suspicion of EVD-associated infection, which may occur up to 10 days after removal of EVD.

Prise en charge par le praticien des infections après transplantation d'organes solides [Management of infection after organ transplantation by the primary care physician]

The primary care physician is frequently consulted in first line for infectious complications in organ transplant recipients. Many infections without signs of severity can nowadays be managed on an outpatient basis. However, a number of clinical situations specific to transplant recipients may require special attention and knowledge. In particular, the general practitioner must be aware of the potential interactions between immunosuppressive and antimicrobial therapies, the risk of renal dysfunction as a consequence of diarrhea or urinary tract infection, and the diagnostic of CMV disease as a cause of fever without obvious source occurring several months after transplantation. Collaboration with the transplantation specialists is recommended in order to assure an optimal management of these patients.

Binding of Lassa virus perturbs extracellular matrix-induced signal transduction via dystroglycan.

The arenavirus Lassa virus (LASV) causes a severe haemorrhagic fever with high mortality in man. The cellular receptor for LASV is dystroglycan (DG). DG is a ubiquitous receptor for extracellular matrix (ECM) proteins, which cooperates with β1 integrins to control cell-matrix interactions. Here, we investigated whether LASV binding to DG triggers signal transduction, mimicking the natural ligands. Engagement of DG by LASV resulted in the recruitment of the adaptor protein Grb2 and the protein kinase MEK1 by the cytoplasmic domain of DG without activating the MEK/ERK pathway, indicating assembly of an inactive signalling complex. LASV binding to cells however affected the activation of the MEK/ERK pathway via α6β1 integrins. The virus-induced perturbation of α6β1 integrin signalling critically depended on high-affinity LASV binding to DG and DG's cytoplasmic domain, indicating that LASV-receptor binding perturbed signalling cross-talk between DG and β1 integrins.

History of biological warfare and bioterrorism.

Bioterrorism literally means using microorganisms or infected samples to cause terror and panic in populations. Bioterrorism had already started 14 centuries before Christ, when the Hittites sent infected rams to their enemies. However, apart from some rare well-documented events, it is often very difficult for historians and microbiologists to differentiate natural epidemics from alleged biological attacks, because: (i) little information is available for times before the advent of modern microbiology; (ii) truth may be manipulated for political reasons, especially for a hot topic such as a biological attack; and (iii) the passage of time may also have distorted the reality of the past. Nevertheless, we have tried to provide to clinical microbiologists an overview of some likely biological warfare that occurred before the 18th century and that included the intentional spread of epidemic diseases such as tularaemia, plague, malaria, smallpox, yellow fever, and leprosy. We also summarize the main events that occurred during the modern microbiology era, from World War I to the recent 'anthrax letters' that followed the World Trade Center attack of September 2001. Again, the political polemic surrounding the use of infectious agents as a weapon may distort the truth. This is nicely exemplified by the Sverdlovsk accident, which was initially attributed by the authorities to a natural foodborne outbreak, and was officially recognized as having a military cause only 13 years later.

How critical is timing for the diagnosis of influenza in general practice?

QUESTIONS UNDER STUDY: The diagnostic significance of clinical symptoms/signs of influenza has mainly been assessed in the context of controlled studies with stringent inclusion criteria. There was a need to extend the evaluation of these predictors not only in the context of general practice but also according to the duration of symptoms and to the dynamics of the epidemic. PRINCIPLES: A prospective study conducted in the Medical Outpatient Clinic in the winter season 1999-2000. Patients with influenza-like syndrome were included, as long as the primary care physician envisaged the diagnosis of influenza. The physician administered a questionnaire, a throat swab was performed and a culture acquired to document the diagnosis of influenza. RESULTS: 201 patients were included in the study. 52% were culture positive for influenza. By univariate analysis, temperature >37.8 degrees C (OR 4.2; 95% CI 2.3-7.7), duration of symptoms <48 hours (OR 3.2; 1.8-5.7), cough (OR 3.2; 1-10.4) and myalgia (OR 2.8; 1.0-7.5) were associated with a diagnosis of influenza. In a multivariable logistic analysis, the best model predicting influenza was the association of a duration of symptom <48 hours, medical attendance at the beginning of the epidemic (weeks 49-50), fever >37.8 and cough, with a sensitivity of 79%, specificity of 69%, positive predictive value of 67%, negative predictive value of 73% and an area under the ROC curve of 0.74. CONCLUSIONS: Besides relevant symptoms and signs, the physician should also consider the duration of symptoms and the epidemiological context (start, peak or end of the epidemic) in his appraisal, since both parameters considerably modify the value of the clinical predictors when assessing the probability of a patient having influenza.

No association between ApoE polymorphism and febrile seizures.

Seizures associated with fever are a common pediatric problem, affecting about 2-7 % of children between 3 months and 5 years of age. Differentiation of febrile seizures from acute symptomatic seizures secondary to central nervous system infections or seizures associated with fever in children with epilepsy is essential to provide appropriate treatment and follow-up care. Here, we tested the hypothesis that children who exhibit simple febrile seizures during early childhood, but do not develop epileptic seizures later in life, might preferentially carry the ApoE2 allele of the gene coding for the apolipoprotein E. We did not find any differences in the distribution of ApoE alleles or genotypes between individuals who exhibited simple febrile seizures (n = 93) and age-matched, typically developing subjects (n = 80). We found that the observed allele and genotype frequencies did not deviate from Hardy-Weinberg equilibrium, which suggests that the frequencies of ApoE alleles and genotypes are stable in the Swiss population from which our samples were derived. Across both groups of subjects (n = 173), we found an ApoE2 allele frequency of 0.064, an ApoE3 frequency of 0.829 and an ApoE4 frequency of 0.107. Our findings are consistent with previous reports of the distribution of ApoE polymorphism for European subjects free of any neurological disorders, and show that the different alleles of the gene coding for the apolipoprotein E are not associated with the occurrence of simple febrile seizures.

Epidemiology and phylogenetic analysis of West Nile virus in Ontario, Canada, 2002-2003 /

Since the discovery of West Nile (WN) virus in the Western Hemisphere many surveillance programs have been implemented to monitor the epidemiology and genetic variation of WN virus in North America. This project was based on the WN virus Adult Mosquito Identification and Diagnostic Program conducted at Brock University for Ontario, Canada, during the 2002 and 2003 transmission seasons. There are three sections to this thesis. The first section investigated which mosquito species carry WN virus in Ontario, Canada throughout the 2002-2003 transmission seasons. It was found that from the 2002 data, eight mosquito species were detected with WN virus (Aedes vexans, Anopheles punctipennis, Coquilleltidia perlurbans, Culex salinarius, Cx. pipiens, Cx. resluans, Ochlerolalus Irivillalus and Och. Iriserialus) and 7.19% of the total mosquito pools tested were found to be WN virus positive (129 positive poolsll, 793 total pools tested). In 2003, WN virus was detected in only five mosquito species (Ae. vexans, Cx. salinarius, Och. Iriserialus, Cx. pipiens and Cx. resluans) and 1.42% of the total mosquito pools tested were WN virus positive (101 positive poolsl7,1 01 total pools tested). WN virus positive mosquito pools were detected 3-4 weeks earlier in 2002 compared to 2003 data. The second section investigated the actual infection rate (IR) of clearly identified Cx. pipiens and Cx. resluans from the 2002 outbreak. It was found that significantly more ex. resluans were infected with WN virus compared to ex. pipiens. The third section investigated the degree of variability of the WN virus genome. A 879 nucleotide section of the WN virus genome was amplified from 21 American Crows and 20 adult female mosquitoes from Ontario, Canada, and compared to the homologous region of the original New York 1999 Chilean Flamingo sequence (NY99FL). Seventy-two nucleotides from Ontario WN virus sequences showed variability compared to NY99FL with 10 synapotypic changes. Phylogenetic analysis revealed a close relationship between Ontario and US WN virus sequences.

Transmission of West Nile virus in the Niagara Region among a population at risk for exposure

Background. West Nile Virus (WNV), a mosquito-borne flavivirus, is one of an increasing number of infectious diseases that have been emerging or re-emerging in the last two decades. Since the arrival ofWNV to Canada to present date, the Niagara Region has only reported 30 clinical cases, a small number compared to the hundreds reported in other regions of similar conditions. Moreover, the last reported human case in Niagara was in 2006. As it has been demonstrated that the majority of WNV infections are asymptomatic, the question remains whether the lack of clinical cases in Niagara truly reflects the lack of transmission to humans or if infections are still occurring but are mostly asymptomatic. Objectives. The general objective of this study was to establish whether or not active WNV transmission could be detected in a human population residing in Niagara for the 2007 transmission season. To fullfil this objective, a cross-sectional seroprevalence study was designed to investigate for the presence of anti-WNV antibodies in a sample of Mexican migrant agricultural workers employed in farms registered with the Seasonal Agricultural Workers Program (SAWP). Due to the Mexican origin of the study participants, three specific research objectives were proposed: a) determine the seroprevalence ofanti-WNV antibodies as well as anti-Dengue virus antibodies (a closely related virus prevalent in Mexico and likely to confound WNV serology); b) analyze risk factors associated with WNV and Dengue virus seropositivity; and c) assess the awareness of study participants about WNV infection as well as their understanding of the mode of transmission and clinical importance of the infection. Methodology: After obtaining ethics clearance from Brock University, farms were visited and workers invited to participate. Due to time constraints, only a small number of farms were enrolled with a resulting convenience and non-randomized study sample. Workers' demographic and epidemiological data were collected using a standardized questionnaire and blood samples were drawn to determine serum anti-WNV and anti- Dengue antibodies with a commercial ELISA. All positive samples were sent to the National Microbiology Laboratory in Winnipeg, Manitoba for confirmation with the Plaque Reduction Neutralization Test (PRNT). Data was analyzed with Stata 10.0. Antibody determinations were reported as seroprevalence proportions for both WNV and Dengue. Logistic regression was used to analyze risk factors that may be associated with seropositivity and awareness was reported as a proportion of the number of individuals possessing awareness over the total number of participants. Results and Discussion. In total 92 participants working in 5 farms completed the study. Using the commercial ELISA, seropositivity was as follows: 2.2% for WNV IgM, 20.7% for WNV IgG, and 17.1 % for Dengue IgG. Possible cross-reactivity was demonstrated in 15/20 (75.0%) samples that were positive for both WNV IgG and Dengue IgG. Confirmatory testing with the PRNT demonstrated that none of the WNV ELISA positive samples had antibodies to WNV but 13 samples tested positive for anti-Dengue antibodies (14.1 % Dengue sereoprevalence). The findings showed that the ELISA performance was very poor for assessing anti-WNV antibodies in individuals previously exposed to Dengue virus. However, the ELISA had better sensitivity and specificity for assessing anti-Dengue antibodies. Whereas statistical analysis could not be done for WNV seropositivity, as all samples were PRNT negative, logistic regression demonstrated several risk factors for Dengue exposure_ The first year coming to Canada appeared to be significantly associated with increased exposure to Dengue while lower socio-economic housing and the presence of a water basin in the yard in Mexico appeared to be significantly associated with a decreased exposure to Dengue_ These seemingly contradictory results illustrate that in mobile populations such as migrant workers, risk factors for exposure to Dengue are not easily identified and more research is needed. Assessing the awareness of WNV and its clinical importance showed that only 23% of participants had some knowledge of WNV, of which 76% knew that the infection was mosquito-borne and 47% recognized fever as a symptom. The identified lack of understanding and awareness was not surprising since WNV is not a visible disease in Mexico. Since WNV persists in an enzootic cycle in Niagara and the occurrence of future outbreaks is unpredictable, the agricultural workers remain at risk for transmission. Therefore it important they receive sufficient health education regarding WNV before leaving Mexico and during their stay in Canada. Conclusions. Human transmission of WNV could not be proven among the study participants even when due to their occupation they are at high risk for mosquito bites. The limitations of the study sample do not permit generalizable conclusions, however, the study findings are consistent with the absence of clinical cases in the Niagara Region, so it is likely that human transmission is indeed neglible or absent. As evidenced by our WNV serology results, PRNT must be utilized as a confirmatory test since false positivity occurs frequently. This is especially true when previous exposure to Dengue virus is likely.

Letter from George Cran regarding a Christian mission in India, 1803.

George Cran was the son of a farmer in the parish of Forgue in Aberdeen Shire, Scotland. He became a member of the church at Huntley, Scotland where his devotion to God inspired him to become a Sunday school teacher. He subsequently became a member of the London Missionary Society. In 1801 he was sent to study at the seminary in Gosport, England where he spent two to three years. His desire was to preach Christ to the “heathens”. Messrs. Ringeltaube, Des Granges and Cran were designated to work in India. No ships for the East India Company would grant passage to missionaries due to the open hostility of the government therefore they set sail from Copenhagen on April 20, 1804 and reached Tranquebar on December 5th, 1805. Cran and Des Granges were designated to supervise the churches in Tinnevelly and they were to begin a mission among the northern Circars. This would have meant that they would have to work in two different places which would have separated them by over 500 miles. The society didn’t seem to be aware of the vast hindrances that the missionaries had to face. Cran and Des Granges decided instead to work in Vizagapatam where they were welcomed by many of the European residents. They conducted English services for which they were paid a monthly salary by the governor. They also conducted services for the natives and opened a school for native children. By November of 1806 a mission house had been built and a “charity” school for Eurasian children was opened. Cran and Des Granges were also diligently studying the native language and they began to translate the Bible into Telugu (spoken by the Hindus who live along the lower basins of the Kistna and Godaveri Rivers). In November of 1808 Cran was almost killed by a fever which left him severely weakened. He was only partially recovered, but accepted an invitation by the general who commanded the local district to accompany him on a journey around the province. The journey proved to be too much for Cran and he died on January 6th, 1809. He is buried at Chicacole, India. He is remembered for his successful work at Vizagapatam and his translation of the Bible. The fact that it was 27 years after the arrival of Cran before a single native was converted attests to the fact that this was a very difficult undertaking. The London Missionary Society was formed in 1795 in England by evangelical Anglicans and nonconformists. It is a non-denominational society and now forms part of the Council for World Mission. with information from The Voice of God to the Churches a Sermon on the Death of George Cran, Augustus Des Granges and Jonathan Brain by David Bogue and The History of the London Missionary Society 1795-1895 by Richard Lovett

Modeling short-range ballistic missile defense and Israel's Iron Dome system

This paper develops a model of short-range ballistic missile defense and uses it to study the performance of Israel’s Iron Dome system. The deterministic base model allows for inaccurate missiles, unsuccessful interceptions, and civil defense. Model enhancements consider the trade-offs in attacking the interception system, the difficulties faced by militants in assembling large salvos, and the effects of imperfect missile classification by the defender. A stochastic model is also developed. Analysis shows that system performance can be highly sensitive to the missile salvo size, and that systems with higher interception rates are more “fragile” when overloaded. The model is calibrated using publically available data about Iron Dome’s use during Operation Pillar of Defense in November 2012. If the systems performed as claimed, they saved Israel an estimated 1778 casualties and $80 million in property damage, and thereby made preemptive strikes on Gaza about 8 times less valuable to Israel. Gaza militants could have inflicted far more damage by grouping their rockets into large salvos, but this may have been difficult given Israel’s suppression efforts. Counter-battery fire by the militants is unlikely to be worthwhile unless they can obtain much more accurate missiles.

Letter to Robert Dickson from John Hamilton

Letter to Robert Dickson from John Hamilton who was in Brighton. He says that he has had scarlet fever. He speaks of his travels to the Giant’s Causeway and Londonderry. He says that his poor brother-in-law is not getting any better. The writing on this letter goes in 2 directions in order to save paper (3 ½ pages, handwritten), Sept. 5, 1834.

Credibility and Signaling in Disinflation- a Cross Country Examination

This paper develops a model of money demand where the opportunity cost of holding money is subject to regime changes. The regimes are fully characterized by the mean and variance of inflation and are assumed to be the result of alternative government policies. Agents are unable to directly observe whether government actions are indeed consistent with the inflation rate targeted as part of a stabilization program but can construct probability inferences on the basis of available observations of inflation and money growth. Government announcements are assumed to provide agents with additional, possibly truthful information regarding the regime. This specification is estimated and tested using data from the Israeli and Argentine high inflation periods. Results indicate the successful stabilization program implemented in Israel in July 1985 was more credible than either the earlier Israeli attempt in November 1984 or the Argentine programs. Government’s signaling might substantially simplify the inference problem and increase the speed of learning on the part of the agents. However, under certain conditions, it might increase the volatility of inflation. After the introduction of an inflation stabilization plan, the welfare gains from a temporary increase in real balances might be high enough to induce agents to raise their real balances in the short-term, even if they are uncertain about the nature of government policy and the eventual outcome of the stabilization attempt. Statistically, the model restrictions cannot be rejected at the 1% significance level.