A multi-site, international laboratory study to assess the performance of penicillin susceptibility testing of Staphylococcus aureus.

OBJECTIVES: There is clinical uncertainty over the optimal treatment for penicillin-susceptible Staphylococcus aureus (PSSA) infections. Furthermore, there is concern that phenotypic penicillin susceptibility testing methods are not reliably able to detect some blaZ-positive S. aureus. METHODS: Nine S. aureus isolates, including six genetically diverse strains harbouring blaZ, were sent in triplicate to 34 participating laboratories from Australia (n = 14), New Zealand (n = 6), Canada (n = 12), Singapore (n = 1) and Israel (n = 1). We used blaZ PCR as the gold standard to assess susceptibility testing performance of CLSI (P10 disc) and EUCAST (P1 disc) methods. Very major errors (VMEs), major error (MEs) and categorical agreement were calculated. RESULTS: Twenty-two laboratories reported 593 results according to CLSI methodology (P10 disc). Nineteen laboratories reported 513 results according to the EUCAST (P1 disc) method. For CLSI laboratories, the categorical agreement and calculated VME and ME rates were 85% (508/593), 21% (84/396) and 1.5% (3/198), respectively. For EUCAST laboratories, the categorical agreement and calculated VME and ME rates were 93% (475/513), 11% (84/396) and 1% (3/198), respectively. Seven laboratories reported results for both methods, with VME rates of 24% for CLSI and 12% for EUCAST. CONCLUSIONS: The EUCAST method with a P1 disc resulted in a lower VME rate compared with the CLSI methods with a P10 disc. These results should be considered in the context that among collections of PSSA isolates, as determined by automated MIC testing, less than 10% harbour blaZ. Furthermore, the clinical relevance of phenotypically susceptible, but blaZ-positive S. aureus, remains unclear.

Characterizing Enzyme Cooperativity with Imaging SAMDI-MS.

This paper describes a method that combines a microfluidic device and self-assembled monolayers for matrix-assisted laser desorption/ionization mass spectrometry (SAMDI) mass spectrometry to calculate the cooperativity in binding of calcium ions to peptidylarginine deiminase type 2 (PAD2). This example uses only 120 µL of enzyme solution and three fluidic inputs. This microfluidic device incorporates a self-assembled monolayer that is functionalized with a peptide substrate for PAD2. The enzyme and different concentrations of calcium ions are flowed through each of eight channels, where the position along the channel corresponds to reaction time and position across the channel corresponds to the concentration of Ca2+ . Imaging SAMDI (iSAMDI) is then used to determine the yield for the enzyme reaction at each 200 µm pixel on the monolayer, providing a time course for the reactions. Analysis of the peptide conversion as a function of position and time gives the degree of cooperativity (n) and the concentration of ligand required for half maximal activity (K0.5 ) for the Ca2+ - dependent activation of PAD2. This work establishes a high-throughput and label-free method for studying enzyme-ligand binding interactions and widens the applicability of microfluidics and matrix-assisted laser desorption/ionization mass spectrometry (MALDI) imaging mass spectrometry.

Provider Perception of Time During Trauma Resuscitation: A Prospective Quantitative Trauma Video Review Analysis.

INTRODUCTION: Delays in transition to the next phase of care result in increased mortality. Prehospital literature suggests emergency medical service technicians underestimate transport times by as much as 20%. What remains unknown is clinician perception of time during the trauma resuscitation. We sought to determine if clinicians have an altered perception of time. We hypothesized that clinicians underestimate time, resulting in delay of care. METHODS: Clinicians at a large level 1 trauma center completed a post-trauma activation survey on the perceived elapsed time to complete three specific resuscitation endpoints. The primary study endpoint was the time to the next phase of care, defined as leaving the trauma bay to go to the operating room, interventional radiology, computerized tomography or time of death. The data from the surveys were linked and compared with recorded videos of the resuscitations. The difference in perceived versus actual time, along with confounding variables, was used to assess the impact of perception of time on the time to the next phase of care using a stepwise multivariate linear model. RESULTS: There were 284 complete surveys and videos, culminating in 543 time points. The median perceived versus actual time (minutes [interquartile range]) to the next phase of care was 20 [10-25] versus 26 [19-40] (P < 0.001). Overall, clinicians underestimated time by 28%, such that if the resuscitation lasted 20 min, the clinician's perception was that 14.4 min elapsed. Differences in the perceived versus actual time in the procedure group impacted time to the next phase of care (P = 0.01). CONCLUSIONS: Clinicians have significant gaps in the perception of time during trauma resuscitations. This misperception occurs during procedures and correlates with an increase in the length of time to the next phase of care.

Remdesivir for the treatment of patients in hospital with COVID-19 in Canada: a randomized controlled trial.

BACKGROUND: The role of remdesivir in the treatment of patients in hospital with COVID-19 remains ill defined in a global context. The World Health Organization Solidarity randomized controlled trial (RCT) evaluated remdesivir in patients across many countries, with Canada enrolling patients using an expanded data collection format in the Canadian Treatments for COVID-19 (CATCO) trial. We report on the Canadian findings, with additional demographics, characteristics and clinical outcomes, to explore the potential for differential effects across different health care systems. METHODS: We performed an open-label, pragmatic RCT in Canadian hospitals, in conjunction with the Solidarity trial. We randomized patients to 10 days of remdesivir (200 mg intravenously [IV] on day 0, followed by 100 mg IV daily), plus standard care, or standard care alone. The primary outcome was in-hospital mortality. Secondary outcomes included changes in clinical severity, oxygen- and ventilator-free days (at 28 d), incidence of new oxygen or mechanical ventilation use, duration of hospital stay, and adverse event rates. We performed a priori subgroup analyses according to duration of symptoms before enrolment, age, sex and severity of symptoms on presentation. RESULTS: Across 52 Canadian hospitals, we randomized 1282 patients between Aug. 14, 2020, and Apr. 1, 2021, to remdesivir (n = 634) or standard of care (n = 648). Of these, 15 withdrew consent or were still in hospital, for a total sample of 1267 patients. Among patients assigned to receive remdesivir, in-hospital mortality was 18.7%, compared with 22.6% in the standard-of-care arm (relative risk [RR] 0.83 (95% confidence interval [CI] 0.67 to 1.03), and 60-day mortality was 24.8% and 28.2%, respectively (95% CI 0.72 to 1.07). For patients not mechanically ventilated at baseline, the need for mechanical ventilation was 8.0% in those assigned remdesivir, and 15.0% in those receiving standard of care (RR 0.53, 95% CI 0.38 to 0.75). Mean oxygen-free and ventilator-free days at day 28 were 15.9 (± standard deviation [SD] 10.5) and 21.4 (± SD 11.3) in those receiving remdesivir and 14.2 (± SD 11) and 19.5 (± SD 12.3) in those receiving standard of care (p = 0.006 and 0.007, respectively). There was no difference in safety events of new dialysis, change in creatinine, or new hepatic dysfunction between the 2 groups. INTERPRETATION: Remdesivir, when compared with standard of care, has a modest but significant effect on outcomes important to patients and health systems, such as the need for mechanical ventilation. Trial registration: ClinicalTrials.gov, no. NCT04330690.

Risk Behaviors and Experiences Among Youth Experiencing Homelessness-Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts, 2019.

Youth experiencing homelessness experience violence victimization, substance use, suicide risk, and sexual risk disproportionately, compared with their stably housed peers. Yet few large-scale assessments of these differences among high school students exist. The youth risk behavior survey (YRBS) is conducted biennially among local, state, and nationally representative samples of U.S. high school students in grades 9-12. In 2019, 23 states and 11 local school districts included a measure for housing status on their YRBS questionnaire. The prevalence of homelessness was assessed among states and local sites, and relationships between housing status and violence victimization, substance use, suicide risk, and sexual risk behaviors were evaluated using logistic regression. Compared with stably housed students, students experiencing homelessness were twice as likely to report misuse of prescription pain medicine, three times as likely to be threatened or injured with a weapon at school, and three times as likely to report attempting suicide. These findings indicate a need for intervention efforts to increase support, resources, and services for homeless youth.

Monthly Trauma Training and Simulation Are Associated With Improved Resident Skill and Leadership.

BACKGROUND: Training for trauma procedures has been limited to infrequent courses with little data on longitudinal performance, and few address procedural and leadership skills with granular assessment. We implemented a novel training program that emphasized an assessment of trauma resuscitation and procedural skills. OBJECTIVE: This study aimed to determine whether this program could demonstrate improvement in both skill sets in surgical trainees over time. METHODS: This was a prospective, observational study at a Level I trauma center between November 2018 and May 2019. A procedural skill and simulation program was implemented to train and evaluate postgraduate year (PGY) 1-5 residents. All residents participated in an initial course on procedures such as tube thoracostomy and vascular access, followed by a final evaluation. Skills were assessed by the Likert scale (1-5, 5 noting mastery). PGY 3s and above were additionally evaluated on resuscitation. A paired t test was performed on repeat learners. RESULTS: A total of 40 residents participated in the structured procedural skills and simulation program. Following completion of the program, PGY-2 scores increased from a Mdn [interquartile range, IQR] 3.0 [2.5-4.0] to 4.5 [4.2-4.5]. The PGY-3 scores increased from a Mdn [IQR] 3.95 [3.7-4.6] to 4.8 [4.6-5.0]. Eighteen residents underwent repeat simulation training, with Mdn [IQR] score increases in PGY 2s (3.7 [2.5-4.0] to end score 4.47 [4.0-4.5], p = .03) and PGY 3s (3.95 [3.7-4.6] to end score 4.81 [4.68-5.0], p = .04). Specific procedural and leadership skills also increased over time.

A Randomized Controlled Trial of an Electronic Clinical Decision Support Tool for Inpatient Antimicrobial Stewardship.

BACKGROUND: The weighted incidence syndromic combination antibiogram (WISCA) is an antimicrobial stewardship tool that utilizes electronic medical record data to provide real-time clinical decision support regarding empiric antibiotic prescription in the hospital setting. The aim of this study was to determine the impact of WISCA utilization for empiric antibiotic prescription on hospital length of stay (LOS). METHODS: We performed a crossover randomized controlled trial of the WISCA tool at 4 hospitals. Study participants included adult inpatients receiving empiric antibiotics for urinary tract infection (UTI), abdominal-biliary infection (ABI), pneumonia, or nonpurulent cellulitis. Antimicrobial stewardship (ASP) physicians utilized WISCA and clinical guidelines to provide empiric antibiotic recommendations. The primary outcome was LOS. Secondary outcomes included 30-day mortality, 30-day readmission, Clostridioides difficile infection, acquisition of multidrug-resistant gram-negative organism (MDRO), and antibiotics costs. RESULTS: In total, 6849 participants enrolled in the study. There were no overall differences in outcomes among the intervention versus control groups. Participants with cellulitis in the intervention group had significantly shorter mean LOS compared to participants with cellulitis in the control group (coefficient estimate = 0.53 [-0.97, -0.09], P = .0186). For patients with community acquired pneumonia (CAP), the intervention group had significantly lower odds of 30-day mortality compared to the control group (adjusted odds ratio [aOR] .58, 95% confidence interval [CI], .396, .854, P = .02). CONCLUSIONS: Use of WISCA was not associated with improved outcomes for UTI and ABI. Guidelines-based interventions were associated with decreased LOS for cellulitis and decreased mortality for CAP.

Mask Use and Ventilation Improvements to Reduce COVID-19 Incidence in Elementary Schools - Georgia, November 16-December 11, 2020.

To meet the educational, physical, social, and emotional needs of children, many U.S. schools opened for in-person learning during fall 2020 by implementing strategies to prevent transmission of SARS-CoV-2, the virus that causes COVID-19 (1,2). To date, there have been no U.S. studies comparing COVID-19 incidence in schools that varied in implementing recommended prevention strategies, including mask requirements and ventilation improvements* (2). Using data from Georgia kindergarten through grade 5 (K-5) schools that opened for in-person learning during fall 2020, CDC and the Georgia Department of Public Health (GDPH) assessed the impact of school-level prevention strategies on incidence of COVID-19 among students and staff members before the availability of COVID-19 vaccines.† Among 169 K-5 schools that participated in a survey on prevention strategies and reported COVID-19 cases during November 16-December 11, 2020, COVID-19 incidence was 3.08 cases among students and staff members per 500 enrolled students.§ Adjusting for county-level incidence, COVID-19 incidence was 37% lower in schools that required teachers and staff members to use masks, and 39% lower in schools that improved ventilation, compared with schools that did not use these prevention strategies. Ventilation strategies associated with lower school incidence included methods to dilute airborne particles alone by opening windows, opening doors, or using fans (35% lower incidence), or in combination with methods to filter airborne particles with high-efficiency particulate absorbing (HEPA) filtration with or without purification with ultraviolet germicidal irradiation (UVGI) (48% lower incidence). Multiple strategies should be implemented to prevent transmission of SARS-CoV-2 in schools (2); mask requirements for teachers and staff members and improved ventilation are important strategies that elementary schools could implement as part of a multicomponent approach to provide safer, in-person learning environments. Universal and correct mask use is still recommended by CDC for adults and children in schools regardless of vaccination status (2).

Safety of Erector Spinae Plane Blocks in Patients With Chest Wall Trauma on Venous Thromboembolism Prophylaxis.

BACKGROUND: Current guidelines for severe rib fractures recommend neuraxial blockade in addition to multimodal pain therapies. While the guidelines for venous thromboembolism prevention recommend chemoprophylaxis, these medications must be held for neuraxial blockade placement. Erector spinae plane block (ESPB) is a newly described block for thoracic pain control. Advantages include its quick learning curve and potential for less bleeding complications. We describe the use of ESPB for rib fractures in patients on chemoprophylaxis. We hypothesize that ESPB can be performed in this patient population without holding chemoprophylaxis. MATERIALS AND METHODS: This was a retrospective observational cohort study of a level 1 trauma center from 9/2016 to 12/2018. All patients with trauma with rib fractures undergoing neuraxial blockade or ESPB were included. Demographics, chemoprophylaxis and anticoagulation regimens, outcomes, and complications were collected. RESULTS: Nine hundred sixty-four patients with rib fracture(s) were admitted. Of these, 73 had a pain management consult. Thirteen had epidural catheters and 25 had ESPBs placed. There was no difference in demographics, injury patterns, bleeding complications, or venous thromboembolism rates among the groups. Patients with ESPB were less likely to have a dose of chemoprophylaxis held because of placement of a catheter (25% versus 100%, P < 0.00001). Three patients with ESPB were on oral anticoagulation on admission, and two were able to continue their regimen during placement. CONCLUSIONS: ESPB can be safely placed in patients on chemoprophylaxis. It should be considered over traditional blocks in patients with blunt chest wall trauma because of its technical ease and ability to be performed with chemoprophylaxis.

On being a client with posttraumatic stress disorder: Interactions with treatment providers and institutional barriers.

Premature dropout from psychological treatment for posttraumatic stress disorder (PTSD) is common. Little research has sought to understand perceptions of treatment and barriers to treatment in this population. This study analyzed anonymous posts among an online community of individuals with PTSD (93 forum users comprising 158 posts regarding treatment providers and 40 forum users comprising 50 posts regarding institutional barriers). Results indicated that individuals with PTSD desire greater clarity about expectations for treatment, collaboration toward treatment goals, open discussion of client-therapist boundaries, and increased validation among therapists in response to trauma disclosure. Individuals with PTSD also reported multiple systemic issues that were barriers to treatment including a lack of available services in their area, being placed on a waitlist for long periods of time, the cost of treatment as a financial burden, and poor crisis response in emergency rooms. Findings indicated areas of growth for treatment providers which will help inform future treatment studies in improving care and treatment adherence among individuals with PTSD.

CDC Deployments to State, Tribal, Local, and Territorial Health Departments for COVID-19 Emergency Public Health Response - United States, January 21-July 25, 2020.

Coronavirus disease 2019 (COVID-19) is a viral respiratory illness caused by SARS-CoV-2. During January 21-July 25, 2020, in response to official requests for assistance with COVID-19 emergency public health response activities, CDC deployed 208 teams to assist 55 state, tribal, local, and territorial health departments. CDC deployment data were analyzed to summarize activities by deployed CDC teams in assisting state, tribal, local, and territorial health departments to identify and implement measures to contain SARS-CoV-2 transmission (1). Deployed teams assisted with the investigation of transmission in high-risk congregate settings, such as long-term care facilities (53 deployments; 26% of total), food processing facilities (24; 12%), correctional facilities (12; 6%), and settings that provide services to persons experiencing homelessness (10; 5%). Among the 208 deployed teams, 178 (85%) provided assistance to state health departments, 12 (6%) to tribal health departments, 10 (5%) to local health departments, and eight (4%) to territorial health departments. CDC collaborations with health departments have strengthened local capacity and provided outbreak response support. Collaborations focused attention on health equity issues among disproportionately affected populations (e.g., racial and ethnic minority populations, essential frontline workers, and persons experiencing homelessness) and through a place-based focus (e.g., persons living in rural or frontier areas). These collaborations also facilitated enhanced characterization of COVID-19 epidemiology, directly contributing to CDC data-informed guidance, including guidance for serial testing as a containment strategy in high-risk congregate settings, targeted interventions and prevention efforts among workers at food processing facilities, and social distancing.

Comparison of Appendectomy for Perforated Appendicitis With and Without Abscess: A National Surgical Quality Improvement Program Analysis.

BACKGROUND: Outcomes of appendectomy stratified by type of complicated appendicitis (CA) features are poorly researched, and the evidence to guide operative versus nonoperative management for CA is lacking. This study aimed to determine laparoscopic-to-open conversion risk, postoperative abscess risk, unplanned readmission risk, and length of hospital stay (LOS) associated with appendectomy in patients with perforated appendicitis without abscess (PA) and perforated appendicitis with abscess (PAWA) compared with a control cohort of nonperforated appendicitis (NPA). METHODS: The 2016-2017 National Surgical Quality Improvement Program Appendectomy-targeted database identified 12,537 (76.1%) patients with NPA, 2142 (13.0%) patients with PA, and 1799 (10.9%) patients with PAWA. Chi-squared analysis and analysis of variance were used to compare categorical and continuous variables. Binary logistic and linear regression models were used to compare risk-adjusted outcomes. RESULTS: Compared with NPA, PA and PAWA had higher rates of conversion (0.8% versus 4.9% and 6.5%, respectively; P < 0.001), postoperative abscess requiring intervention (0.6% versus 4.8% and 7.0%, respectively; P < 0.001), readmission (2.8% versus 7.7% and 7.6%, respectively; P < 0.001), and longer median LOS (1 day versus 2 days and 2 days, respectively; P < 0.001). PA and PAWA were associated with increased odds of postoperative abscess (odds ratio [OR]: 7.18, 95% confidence interval [CI]: 5.2-9.8 and OR: 9.94, 95% CI: 7.3-13.5, respectively), readmission (OR: 2.70, 95% CI: 2.1-3.3 and OR: 2.66, 95% CI: 2.2-3.3, respectively), and conversion (OR: 5.51, 95% CI: 4.0-7.5 and OR: 7.43, 95% CI: 5.5-10.1, respectively). PA was associated with an increased LOS of 1.7 days and PAWA with 1.9 days of LOS (95% CI: 1.5-1.8 and 1.7-2.1, respectively). CONCLUSIONS: Individual features of CA were independently associated with outcomes. Further research is needed to determine if surgical management is superior to nonoperative management for CA.

Changes in liver stiffness after ART initiation in HIV-infected Nigerian adults with and without chronic HBV.

BACKGROUND: There are limited data from sub-Saharan Africa on long-term liver fibrosis changes in HIV- and HIV/HBV-infected individuals. OBJECTIVES: To assess the effects of ART on liver stiffness measurement (LSM) using transient elastography (TE) in HIV- and HIV/HBV-infected Nigerian adults and examine factors associated with fibrosis regression. METHODS: We included ART-naive HIV- and HIV/HBV-infected adults (≥18 years) enrolled in a prospective, longitudinal study of liver disease between July 2011 and February 2015 at Jos University Teaching Hospital HIV Care and Treatment Centre in Nigeria. Patients initiated ART and had TE at baseline and follow-up (year 3). LSM cut-offs for Metavir scores were 5.9, 7.6 and 9.4 kPa for moderate fibrosis, advanced fibrosis and cirrhosis, respectively. We used multivariable regression to identify factors associated with TE (≥1 Metavir) stage decline. RESULTS: A total of 106 HIV- and 71 HIV/HBV-infected patients [70.5% female and median age = 34 years (IQR = 29-42 years)] were studied. Baseline LSM and median LSM decline were significantly higher in HIV/HBV- versus HIV-infected patients; 41% of HIV/HBV-infected patients regressed ≥1 Metavir stage versus 17% of HIV-infected patients (P < 0.01); LSM scores at year 3 were not significantly different between HIV- and HIV/HBV-infected patients. In multivariable analyses, patients with baseline CD4+ T cells ≥200 (versus <200) cells/mm3 and lower BMIs were more likely to experience LSM stage decline. CONCLUSIONS: HBV coinfection does not attenuate LSM declines in HIV-infected patients after ART initiation despite being a risk factor for more advanced liver disease prior to therapy. The inverse association between BMI and TE stage decline needs further investigation.

Investigation of low molecular weight peptides (<1 kDa) in chicken meat and their contribution to meat flavor formation.

BACKGROUND: Low molecular weight peptides (LMWPs) (<1 kDa) generated in meat during chilled conditioning can act as flavor precursors in the Maillard reaction with a potential contribution to key volatile organic compound (VOC) formation upon heating. Liquid chromatography/quadrupole time-of-flight mass spectrometry (LC/QTOF-MS) successfully detected 44 LMWPs in chicken breast and thigh muscles stored at 4 °C for up to 6 days. Carnosine (350 mg per 100 g), glutathione (GSH, 20 mg per 100 g) (concentrations based on reported values in the literature) and cysteine glycine (Cys Gly, 5 mg per 100 g) (concentration based on results from LC/QTOF-MS) were used in model systems containing ribose (25 mg per 100 g). The three model systems were heated at 180 °C for 2 h at pH 6.3. VOCs were measured by simultaneous distillation solvent extraction/gas chromatography/mass spectrometry. RESULTS: Of 33 VOCs detected, 26 were significantly different (P ≤ 0.05) between the three peptides. The majority of nitrogen-containing volatiles, pyrazines and pyridines, dominated the carnosine mixture, while sulfur-containing VOCs dominated the GSH and Cys Gly peptide mixtures. CONCLUSION: Known key aroma compounds such as thiazole (meaty), 2-methyl-3-furanthiol (beef and meat), 2-furfurylthiol (roasted), dihydro-2-methyl-3(2H)-thiophenone (meaty), 2-acetylthiazole (meaty and roasted) and pyrazine (meaty) were detected under conditions specific to aged and thermally treated chicken, suggesting a potential contribution to the overall sensory quality of cooked meat. © 2018 Society of Chemical Industry.

High-Throughput Enzyme Kinetics with 3D Microfluidics and Imaging SAMDI Mass Spectrometry.

Microfluidic systems are important for performing precise reagent manipulations and reducing material consumption in biological assays. However, optical detection methods limit analyses to fluorescent or UV-active compounds and traditional 2D fluidic designs have limited degrees of freedom. This article describes a microfluidic device that has three inputs and performs 2592 distinct enzyme reactions using only 150 µL of reagent with quantitative characterization. This article also introduces imaging self-assembled monolayers for matrix-assisted laser desorption/ionization mass spectrometry (iSAMDI-MS) to map reaction progress, by immobilization of the product onto the floor of the microfluidic channel, into an image that is used for calculating the Michaelis constant ( Km). This approach expands the scope of imaging mass spectrometry, microfluidic detection strategies, and the design of high-throughput reaction systems.

An Immobilized Enzyme Reactor for Spatiotemporal Control over Reaction Products.

This paper describes a microfluidic chip wherein the position and order of two immobilized enzymes affects the type and quantity of reaction products in the flowing fluid. Assembly of the chip is based on a self-assembled monolayer presenting two orthogonal covalent capture ligands that immobilize their respective fusion enzyme. A thiol-tagged substrate is flowed over a region presenting the first enzyme-which generates a product that is efficiently transferred to the second enzyme-and the second enzyme's product binds to an adjacent thiol capture site on the chip. The amount of the three possible reaction products is quantified directly on the chip using self-assembled monolayers for matrix-assisted laser desorption/ionization mass spectrometry, revealing that the same microsystem can be spatiotemporally arranged to produce different products depending on the device design. This work allows for optimizing multistep biochemical transformations in favor of a desired product using a facile reaction and analytical format.

Rsx is a metatherian RNA with Xist-like properties in X-chromosome inactivation.

In female (XX) mammals, one of the two X chromosomes is inactivated to ensure an equal dose of X-linked genes with males (XY). X-chromosome inactivation in eutherian mammals is mediated by the non-coding RNA Xist. Xist is not found in metatherians (marsupials), and how X-chromosome inactivation is initiated in these mammals has been the subject of speculation for decades. Using the marsupial Monodelphis domestica, here we identify Rsx (RNA-on-the-silent X), an RNA that has properties consistent with a role in X-chromosome inactivation. Rsx is a large, repeat-rich RNA that is expressed only in females and is transcribed from, and coats, the inactive X chromosome. In female germ cells, in which both X chromosomes are active, Rsx is silenced, linking Rsx expression to X-chromosome inactivation and reactivation. Integration of an Rsx transgene on an autosome in mouse embryonic stem cells leads to gene silencing in cis. Our findings permit comparative studies of X-chromosome inactivation in mammals and pose questions about the mechanisms by which X-chromosome inactivation is achieved in eutherians.

Time Requirements for Acquisition of Hepatitis C Virus Therapy in HIV/HCV Coinfected Patients.

Background: The process of obtaining approval for hepatitis C virus (HCV) treatment may be time consuming and complicated due to prior authorizations and the need to appeal denials. Pharmacists are poised to play a critical role in the acquisition and management of oral direct acting antivirals (DAAs) for the treatment of HCV infection; however, the time expended in this activity requires assessment. Objective: The objective of this study was to assess time expenditures by pharmacists to acquire DAAs for HCV therapy. Methods: Patients were enrolled in the Northwestern University Viral Hepatitis Registry, a prospective, observational cohort of ambulatory, adult patients living with human immunodeficiency virus (HIV) coinfected with chronic hepatitis B and/or C virus, and recruited since 2013 from the Infectious Disease Center at Northwestern Memorial Hospital, Chicago, IL. Patients were included in the current study if they were referred to the pharmacist for HCV DAA acquisition, drug-drug interaction management, and adherence counseling between February 1, 2014, and April 30, 2015. Patient demographics, virus-specific characteristics, and time required to secure HCV DAA treatment, counsel patients, and follow-up therapy were collected. Results: Among 54 HIV/HCV coinfected patients referred for treatment, all eventually received approval for DAA therapy. However, 87% (n = 47) required prior authorization. Pharmacists dedicated 2.1 hours/patient (interquartile range 1.5-2.8 hours; range 0.75-6.5 hours) to manage DAA therapy. Conclusion: Successful acquisition of HCV DAA therapy relied heavily on pharmacist effort, reflecting the vital role that pharmacists play in this process. Dedicated resources for medication access should be considered to ensure timely DAA acquisition.

Hepatitis B virus sequencing and liver fibrosis evaluation in HIV/HBV co-infected Nigerians.

OBJECTIVES: Molecular characteristics of hepatitis B virus (HBV), such as genotype and genomic mutations, may contribute to liver-related morbidity and mortality. The association of these characteristics with liver fibrosis severity in sub-Saharan Africa is uncertain. We aimed to characterise molecular HBV features in human immunodeficiency virus (HIV)/HBV co-infected Nigerians and evaluate associations between these characteristics and liver fibrosis severity before and after antiretroviral therapy (ART) initiation. METHODS: HIV/HBV co-infected Nigerians underwent liver fibrosis estimation by transient elastography (TE) prior to and 36 months after ART initiation. Basal core promoter/precore (BCP/PC) and preS1/preS2/S regions of HBV were sequenced from baseline plasma samples. We evaluated associations between HBV mutations and liver fibrosis severity by univariate and multivariable regression. RESULTS: At baseline, 94 patients underwent TE with median liver stiffness of 6.4 (IQR 4.7-8.7) kPa. Patients were predominantly infected with HBV genotype E (45/46) and HBe-antigen negative (75/94, 79.8%). We identified BCP A1762T/G1764A in 15/35 (43%), PC G1896A in 20/35 (57%), 'a' determinant mutations in 12/45 (26.7%) and preS2 deletions in 6/16 (37.5%). PreS2 mutations were associated with advanced fibrosis in multivariable analysis. At follow-up, median liver stiffness was 5.2 (IQR 4.1-6.6) kPa. No HBV molecular characteristics were associated with lack of fibrosis regression, although HIV virologic control, body mass index (BMI) and baseline CD4+ T-cell count were associated with a decline in fibrosis stage. CONCLUSION: Frequent BCP/PC and preS1/preS2/S mutations were found in ART-naïve HIV/HBV co-infected Nigerians. Median liver stiffness declined after initiation of ART, regardless of pre-ART HBV mutational pattern or virologic characteristics.

High rates of hepatitis C virus (HCV) cure using direct-acting antivirals in HIV/HCV-coinfected patients: a real-world perspective.

OBJECTIVES: There are few data on the real-world experience of FDA-approved oral hepatitis C virus (HCV) direct-acting antiviral (DAA) drug combinations in HIV/HCV-coinfected patients. We evaluated the safety and efficacy of DAA therapies in a cohort of HIV/HCV patients in a large urban clinic in Chicago. METHODS: HIV/HCV-coinfected adults (≥18 years) enrolled in the Northwestern University Viral Hepatitis Registry between January 2013 and June 2015 were analysed. Treated patients received one of the following DAA combinations: sofosbuvir/ledipasvir, sofosbuvir/ribavirin, sofosbuvir/simeprevir or paritaprevir/ritonavir/ombitasvir/dasabuvir ±â€Šribavirin. The primary outcome was sustained virological response at 12 weeks after DAA completion (SVR12). RESULTS: Seventy-seven HIV/HCV patients were evaluated for DAA therapy. Most patients were male (62/77, 81%) and infected with HCV genotype 1 (67/77, 87%). Some 32/77 (42%) were cirrhotic and 29/77 (38%) had received prior treatment with an IFN-containing regimen. DAA therapy was more likely to be started in Caucasians than persons of other ethnicities (P = 0.01). The overall SVR12 rate was 92% in 52 patients who completed therapy and had follow-up by the end of the study: sofosbuvir/simeprevir, 32/33 (97%); sofosbuvir/ribavirin, 4/7 (57%); sofosbuvir/ledipasvir, 11/11 (100%); and paritaprevir/ritonavir/ombitasvir/dasabuvir, 1/1 (100%). Four patients relapsed after therapy with sofosbuvir/simeprevir (n = 1) or sofosbuvir/ribavirin (n = 3). Adverse events were uncommon and did not result in DAA treatment interruption or discontinuation. CONCLUSIONS: The HCV DAA combinations of sofosbuvir/ledipasvir and sofosbuvir/simeprevir were highly effective and well tolerated in this diverse population of HIV/HCV-coinfected patients, many of whom had advanced liver disease. HIV coinfection should not be considered a barrier to successful HCV treatment with DAAs.