Publications

Central Role of the Spleen in Malaria Parasite Clearance

In acute malaria, red blood cells (RBCs) that have been parasitized, but no longer contain a malaria parasite, are found in the circulation (ring-infected erythrocyte surface antigen [RESA]-RBCs). These are thought to arise by splenic removal of dead or damaged intraerythrocytic parasites and return of the intact RBCs to the circulation. In a study of 5 patients with acute falciparum malaria who had previously undergone splenectomy, it was found that none of these 5 patients had any circulating RESA-RBCs, in contrast to the uniform finding of RESA-RBCs in all patients with acute malaria and intact spleens. Parasite clearance after artesunate treatment was markedly prolonged, although the parasites appeared to be dead and could not be cultured ex vivo. These observations confirm the central role of the spleen in the clearance of parasitized RBCs after antimalarial treatment with an artemisinin derivative. Current criteria for high-grade antimalarial drug resistance that are based on changes in parasitemia are not appropriate for asplenic patients.

Red cell selectivity in malaria: a study of multiple-infected erythrocytes

To characterize red cell susceptibility to invasion in malaria, a selectivity index (SI) was calculated as the ratio of observed number of multiple-infected red cells to that expected from a random process (Poisson distribution). In patients with falciparum malaria (n = 100) SI decreased with increasing parasitaemia (P < 0·001), and correlated inversely with plasma lactate concentrations, chosen prospectively as a measure of disease severity (r = −0·36, P < 0·001). For parasitaemias <5%, the SI was lower in patients with severe malaria (geometric mean 1·35; 95% confidence interval 1· 01– 1·80) than in uncomplicated malaria (2·31; 1·89-2-81; P=0·003), despite similar parasite counts. The geometric mean (range) SI in vivax malaria (n = 20), 7·69 (1·67, 29·75), was significantly greater than that in falciparum malaria at comparable parasitaemias (≤2%), 2·44 (0·45, 14·05), P < 0·001, suggesting that about 13% of circulating erythrocytes were susceptible to invasion by Plasmodium vivax. This translates into susceptibility for about 2 weeks after emergence from the bone marrow, if age is the sole determinant of this process. In falciparum malaria selectivity was inversely proportional to severity; lack of selectivity could reflect either a 'favourable' host red cell phenotype, or an indiscriminate parasite population. Both are dangerous for the host.

The threat of antimalarial drug resistance

The battle between man and malaria has continued for thousands of years. Antimalarial drugs are essential weapons to fight the disease, but their efficacy is threatened by drug resistance which continues to emerge creating a major obstacle to malaria control and jeopardizing renewed hopes for elimination. As 2016 is the first year under WHO Global Technical Strategy for Malaria 2016–2030, it is a good time to ponder the progress of both sides and plan for the future.

A pharmacokinetic-pharmacodynamic assessment of the hepatic and bone-marrow toxicities of the new trypanoside fexinidazole

Fexinidazole is a novel oral treatment for Trypanosoma brucei gambiense human African trypanosomiasis: g -HAT. Fexinidazole is also active against other kinetoplastid parasites, notably T. cruzi the causative agent of Chagas disease. During the course of a dose ranging assessment in chronic indeterminate Chagas disease, delayed neutropenia and significant increases in hepatic transaminases were observed and clinical investigations were suspended. We retrospectively analyzed all available pharmacokinetic and pharmacodynamic data on fexinidazole in normal healthy volunteers and in patients with chronic Chagas disease and g -HAT, in order to assess the determinants of toxicity. A population pharmacokinetic model was fitted to plasma concentration data on the bioactive fexinidazole sulfone metabolite from three phase I studies, two g -HAT phase II/III field trials and one Chagas phase-II field trial (n=462 total). Bayesian exposure-response models were then fitted to hematological and liver related pharmacodynamic outcomes in chronic Chagas patients. Neutropenia, reductions in platelet counts, and elevations in liver transaminases were all found to be exposure and thus dose dependent in patients with chronic Chagas disease. Clinically insignificant transient reductions in neutrophil and platelet counts consistent with these exposure-response relationships were observed in the g -HAT trials. In contrast, no evidence of hepatotoxicity was observed in the g -HAT trials. Fexinidazole treatment results in a dose dependent liver toxicity and transient bone marrow suppression in Chagas disease. Regimens of shorter duration should be trialled for Chagas. The currently recommended regimen for sleeping sickness provides exposures within a satisfactory safety margin for bone marrow suppression and does not cause hepatotoxicity.

Variation in virulence of dengue virus

No abstract is provided for this article.

DOES CHLOROQUINE CAUSE HYPOGLYCAEMIA IN THE ABSENCE OF CLINICAL MALARIA?

No abstract is provided for this article.

Fluid Replacement in Dengue Shock Syndrome: A Randomized, Double‐Blind Comparison of Four Intravenous‐Fluid Regimens

Dengue hemorrhagic fever and dengue shock syndrome (DSS) are major causes of childhood morbidity and mortality in many tropical countries. Increased intravascular permeability leading to shock is the cardinal feature of DSS. Fluid resuscitation to counteract massive plasma leakage is the mainstay of treatment. A double-blind, randomized trial comparing four intravenous-fluid regimens for acute resuscitation of 50 children with DSS was conducted. Colloids (dextran 50 or the protein digest gelafundin 35,000) restored cardiac index and blood pressure and normalized hematocrit more rapidly than crystalloids (Ringer's lactate or 0.9%-weight/volume saline). Dextran 70 provided the most rapid normalization of the hematocrit and restoration of the cardiac index, without adverse effects, and may be the preferred solution for acute resuscitation in DSS. Further large-scale double-blind trials are required to provide an evidence-based approach to the management of DSS.

A Simple Scoring System to Differentiate between Relapse and Re-Infection in Patients with Recurrent Melioidosis

Melioidosis is an important cause of morbidity and mortality in East Asia. Recurrent melioidosis occurs in around 10% of patients following treatment either because of relapse with the same strain or re-infection with a new strain of Burkholderia pseudomallei. Distinguishing between the two is important but requires bacterial genotyping. The aim of this study was to develop a simple scoring system to distinguish re-infection from relapse.In a prospective study of 2,804 consecutive adult patients with melioidosis presenting to Sappasithiprasong Hospital, NE Thailand, between 1986 and 2005, there were 141 patients with recurrent melioidosis with paired strains available for genotyping. Of these, 92 patients had relapse and 49 patients had re-infection. Variables associated with relapse or re-infection were identified by multivariable logistic regression and used to develop a predictive model. Performance of the scoring system was quantified with respect to discrimination (area under receiver operating characteristic curves, AUC) and categorization (graphically). Bootstrap resampling was used to internally validate the predictors and adjust for over-optimism.Duration of oral antimicrobial treatment, interval between the primary episode and recurrence, season, and renal function at recurrence were independent predictors of relapse or re-infection. A score of < 5 correctly identified relapse in 76 of 89 patients (85%), whereas a score > or = 5 correctly identified re-infection in 36 of 52 patients (69%). The scoring index had good discriminative power, with a bootstrap bias-corrected AUC of 0.80 (95%CI: 0.73-0.87).A simple scoring index to predict the cause of recurrent melioidosis has been developed to provide important bedside information where rapid bacterial genotyping is unavailable.

Cooperative Breeding

Cooperative breeders are animals where parents are assisted in protecting and provisioning their young by helpers that seldom or never breed themselves. Systems of this kind occur in birds, mammals and some fish, and have usually evolved from ancestors with monogamous breeding systems. Helpers are often previous offspring of breeders and are usually closely related to the young they help to raise though, in some systems, they can also be unrelated immigrants. Their contributions commonly enhance the growth and survival of juveniles and reduce the workload of their parents, increasing their fecundity. Cooperative breeding systems appear to have evolved where the costs of dispersal are high, helping provides substantial fitness benefits to related recipients or to helpers themselves and the fitness costs of helping are low.

Thiamin supplementation does not reduce the frequency of adverse events after anti-malarial therapy among patients with falciparum malaria in southern Laos

In a recent study one third of Lao patients presenting with uncomplicated Plasmodium falciparum malaria had biochemical evidence of thiamin deficiency, which was associated with a higher incidence of adverse events. Thiamin supplementation might, therefore, reduce adverse events in this population. An exploratory, double-blind, parallel group, placebo-controlled, superiority trial of thiamin supplementation in patients of all ages with uncomplicated and severe falciparum malaria was conducted in Xepon District, Savannakhet Province, southern Laos. Patients were randomly assigned to either oral thiamin 10 mg/day for 7 days immediately after standard anti-malarial treatment then 5 mg daily until day 42, or identical oral placebo. After interim analyses when 630 patients (314 in thiamin and 316 in placebo groups) had been recruited, the trial was discontinued on the grounds of futility. On admission biochemical thiamin deficiency (alpha ≥ 25%) was present in 27% of patients and 9% had severe deficiency (alpha > 31%). After 42 days of treatment, the frequency of thiamin deficiency was lower in the thiamin (2%, 1% severe) compared to the placebo (11%, 3% severe) groups (p < 0.001 and p = 0.05), respectively. Except for diarrhoea, 7% in the placebo compared to 3% in the thiamin group (p = 0.04), and dizziness on day 1 (33% vs 25%, p = 0.045), all adverse events were not significantly different between the groups (p > 0.05). Clinical, haematological, and parasitological responses to treatment did not differ significantly between the two groups. Thiamin supplementation reduced biochemical thiamin deficiency among Lao malaria patients following anti-malarial drug treatment, but it did not reduce the frequency of adverse events after anti-malarial therapy or have any detected clinical or parasitological impact. ISRCTN 85411059

Antimicrobial resistance in commensal opportunistic pathogens isolated from non-sterile sites can be an effective proxy for surveillance in bloodstream infections

Antimicrobial resistance (AMR) surveillance in bloodstream infections (BSIs) is challenging in low/middle-income countries (LMICs) given limited laboratory capacity. Other specimens are easier to collect and process and are more likely to be culture-positive. In 8102 E. coli BSIs, 322,087 E. coli urinary tract infections, 6952 S. aureus BSIs and 112,074 S. aureus non-sterile site cultures from Oxfordshire (1998–2018), and other (55,296 isolates) rarer commensal opportunistic pathogens, antibiotic resistance trends over time in blood were strongly associated with those in other specimens (maximum cross-correlation per drug 0.51–0.99). Resistance prevalence was congruent across drug-years for each species (276/312 (88%) species-drug-years with prevalence within ± 10% between blood/other isolates). Results were similar across multiple countries in high/middle/low income-settings in the independent ATLAS dataset (103,559 isolates, 2004–2017) and three further LMIC hospitals/programmes (6154 isolates, 2008–2019). AMR in commensal opportunistic pathogens cultured from BSIs is strongly associated with AMR in commensal opportunistic pathogens cultured from non-sterile sites over calendar time, suggesting the latter could be used as an effective proxy for AMR surveillance in BSIs.

Clinical malaria in the tropics

Although malaria has been largely eradicated from temperate countries, it is on the increase in the tropics. Infection with Plasmodium falciparum affects a vast number of people and kills over a million annually. Severe malaria is a multisystem disease affecting particularly the central nervous system (causing coma and convulsions), the kidneys (resulting in acute tubular necrosis), and the liver (contributing to lactic acidosis and hypoglycaemia). Acute pulmonary oedema (acute respiratory distress syndrome) may occur in adults particularly in association with renal impairment. In children these symptoms are rare, whereas hypoglycaemia, lactic acidosis and severe anaemia are more common. Malaria should be suspected in any febrile patient living in or returning from the tropics, and a blood smear examined. Chloroquine has been the mainstay of antimalarial treatment for the past 40 years, but resistance in P. falciparum is now widespread throughout the tropics and has recently been recognised in P. vivax from Oceania. Sulfadoxine-pyrimethamine resistance is also common. Fortunately, quinine, and the newly introduced compounds, halofantrine and mefloquine, can be relied upon nearly everywhere. The most rapidly acting and effective of all antimalarial drugs, artemisinin and its derivatives, have come from China. They offer a genuine prospect of reducing mortality from malaria in the tropics.

Effects of lactation on feeding behaviour and habitat use in wild Red deer hinds

In many mammals, the energetic costs of lactation double a female's daily energy requirements on her activity budgets, food choice and ranging behaviour–but the effects of lactation have rarely been documented. In this paper, the ecological consequences of lactation in free‐ranging Red deer ( Cervus elaphus ) hinds on the lsle of Rhum is examined by comparing the feeding behaviour, habitat use and ranging behaviour of hinds that were supporting calves (milk hinds) with hinds that did not have calves (yeld hinds). In summer, milk hinds graze for approximately two hours longer per day then yeld hinds. This difference has disappeared by the latter half of the winter, when the grazing budgets of milk and yeld hinds are similar. Both in summer and winter milk hinds spend more time grazing on the most strongly selected plant communities (short, herb‐rich greens) where standing crops are low but food quality is comparatively high. Inter‐year variation in habitat use by milk hinds is also closely related to variation in rainfall—while this is not the case among yeld hinds. Both in summer and winter, yeld hinds range more widely than milk hinds.

Urinary catecholamine excretion in tetanus

Summary Imperfect understanding of the pathophysiology of tetanus has limited therapeutic advances. Autonomic disturbance is a major cause of mortality and is believed to be associated with catecholamine release, predominantly norepinephrine. We measured epinephrine and norepinephrine concentrations in 24‐h urine collections from tetanus and critically ill patients suffering from other severe diseases. In patients with severe tetanus, mean (SD) epinephrine was 164.18 (129.37) nmol.day −1 compared with 45.18 (37.74) nmol.day −1 in mild‐moderate disease (p = 0.008). In the severe group, mean (SD) norepinephrine was 411.64 (208.5), and 121.00 (81.81) nmol.day −1 in moderately ill patients (p &lt; 0.001). Compared with critically ill control patients, median epinephrine was 331.77 in tetanus patients and 89.70 nmol.day −1 in controls (p &lt; 0.001). Median norepinephrine concentration was 788.02 nmol.day −1 in tetanus and 300.05 nmol.day −1 in control patients, p = 0.006. The study finds a novel result of increased epinephrine excretion in tetanus and confirms that catecholamine excretion in tetanus exceeds that in other critically ill patients. These results should be considered in designing more effective therapeutic strategies.

Quantitative bacteriology of Typhoid fever in Vietnam

ING & INDEXING

COMPARISON OF TWO REGIMENS OF ARTEMETHER-LUMEFANTRINE FOR THE TREATMENT OF UNCOMPLICATED PLASMODIUM FALCIPARUM MALARIA IN PREGNANT WOMEN IN THE DEMOCRATIC REPUBLIC OF CONGO

The spread of artemisinin-resistant Plasmodium falciparum in the Greater Mekong subregion: a molecular epidemiology observational study

BackgroundEvidence suggests that the PfKelch13 mutations that confer artemisinin resistance in falciparum malaria have multiple independent origins across the Greater Mekong subregion, which has motivated a regional malaria elimination agenda. We aimed to use molecular genotyping to assess antimalarial drug resistance selection and spread in the Greater Mekong subregion.MethodsIn this observational study, we tested Plasmodium falciparum isolates from Myanmar, northeastern Thailand, southern Laos, and western Cambodia for PfKelch13 mutations and for Pfplasmepsin2 gene amplification (indicating piperaquine resistance). We collected blood spots from patients with microscopy or rapid test confirmed uncomplicated falciparum malaria. We used microsatellite genotyping to assess genetic relatedness.FindingsAs part of studies on the epidemiology of artemisinin-resistant malaria between Jan 1, 2008, and Dec 31, 2015, we collected 434 isolates. In 2014–15, a single long PfKelch13 C580Y haplotype (−50 to +31·5 kb) lineage, which emerged in western Cambodia in 2008, was detected in 65 of 88 isolates from northeastern Thailand, 86 of 111 isolates from southern Laos, and 14 of 14 isolates from western Cambodia, signifying a hard transnational selective sweep. Pfplasmepsin2 amplification occurred only within this lineage, and by 2015 these closely related parasites were found in ten of the 14 isolates from Cambodia and 15 of 15 isolates from northeastern Thailand. C580Y mutated parasites from Myanmar had a different genetic origin.InterpretationOur results suggest that the dominant artemisinin-resistant P falciparum C580Y lineage probably arose in western Cambodia and then spread to Thailand and Laos, outcompeting other parasites and acquiring piperaquine resistance. The emergence and spread of fit artemisinin-resistant P falciparum parasite lineages, which then acquire partner drug resistance across the Greater Mekong subregion, threatens regional malaria control and elimination goals. Elimination of falciparum malaria from this region should be accelerated while available antimalarial drugs still remain effective.FundingThe Wellcome Trust and the Bill and Melinda Gates Foundation.

Development and Validation of a Solid-Phase Extraction-Liquid Chromatographic Method for Determination of Amoxicillin in Plasma

A bioanalytic method for the determination of amoxicillin in plasma by hydrophilic interaction solid-phase extraction and liquid chromatography has been developed and validated. Plasma was precipitated with acetonitrile before samples were loaded onto a zwitterionic hydrophilic interaction liquid chromatography (ZIC-HILIC) solid-phase extraction column. Amoxicillin was analyzed by liquid chromatography on an Aquasil (150 x 4.6 mm) LC column with mobile-phase acetonitrile: phosphate buffer (pH 2.5; 0.1 mol/L) (7:93, v/v) and UV detection at 230 nm. A regression model using 1/concentration weighting was found the most appropriate for quantification. The intraassay precision for plasma was 3.3% at 15.0 microg/mL and 10.9% at 0.200 microg/mL. The interassay precision for plasma was 1.8% at 15.0 microg/mL and 7.5% at 0.200 microg/mL. The total-assay precision for plasma over 4 days using a total of 20 replicates was 13.2%, 5.5%, and 3.8% at 0.200 microg/mL, 3.00 microg/mL, and 15.0 microg/mL, respectively. The lower limit of quantification and the limit of detection were 0.050 microg/mL and 0.025 microg/mL, respectively, for 100 microL plasma. Long-term storage stability studies of amoxicillin in plasma indicate that a temperature of -80 degrees C is necessary to prevent degradation of amoxicillin.