Performance of lateral flow device and galactomannan for the detection of Aspergillus species in bronchoalveolar fluid of patients at risk for invasive pulmonary aspergillosis.

Early diagnosis of invasive pulmonary aspergillosis (IPA) remains difficult due to the variable performance of the tests used. We compared the performance characteristics of Aspergillus lateral flow device (LFD) in bronchoalveolar lavage (BAL) vs. BAL-galactomannan (GM), for the diagnosis of IPA. 311 BAL specimens were prospectively collected from patients who underwent bronchoscopy from January to May 2013. Patients at risk for IPA were divided into haematological malignancy (HEM) and non-HEM groups: solid organ transplants (SOT) (lung transplant (LT) and non-LT SOT); chronic steroid use (CSU); solid tumour (STU) and others. We identified 96 patients at risk for IPA; 89 patients (93%) were in the non-HEM groups: SOT 57 (LT, 46, non-LT SOT, 11); CSU 21; STU 6, other 5. Only three patients met criteria for IA (two probable; one possible). Overall sensitivity (SS) was 66% for both and specificity (SP) was 94% vs. 52% for LFD and GM respectively. LFD and GM performance was similar in the HEM group (SS 100% for both and SP 83% vs. 100% respectively). LFD performance was better than GM among non-HEM SOT patients (P = 0.02). Most false-positive GM results occurred in the SOT group (50.8%), especially among LT patients (56.5%). LFD performance was superior with an overall SP of 95.6% in SOT (P < 0.002) and 97% in LT patients (P = 0.0008). LFD is a rapid and simple test that can be performed on BAL to rule out IPA.

Phylogenetic framework and molecular signatures for the class Chloroflexi and its different clades; proposal for division of the class Chloroflexia class. nov. [corrected] into the suborder Chloroflexineae subord. nov., consisting of the emended family Oscillochloridaceae and the family Chloroflexaceae fam. nov., and the suborder Roseiflexineae subord. nov., containing the family Roseiflexaceae fam. nov.

The phylum "Chloroflexi" contains highly divergent groups of bacteria. To understand the evolutionary relationships among these bacteria, phylogenetic trees were constructed based upon concatenated sequences for 20 conserved proteins and comparative genomic analyses were carried out to identify molecular markers (conserved signature indels or CSIs) that are specific for different clades of Chloroflexi. In phylogenetic trees based upon either concatenated protein sequences or the 16S rRNA gene, species from the class Chloroflexi and the order Chloroflexales formed strongly supported clades. The species from these clades are also clearly distinguished from other bacteria based upon 5 and 9 identified CSIs, respectively, in important proteins that were specific for these clades. Additionally, three CSIs that were specific for the genus Chloroflexus and four CSIs specific for the genus Roseiflexus were also identified. In phylogenetic trees, the species Oscillochloris trichoides (family Oscillochloridaceae) formed a strongly supported clade with the species from the genus Chloroflexus (and with Chloronema in the 16S rRNA gene tree). A specific relationship of O. trichoides to the Chloroflexus spp. is also strongly supported by 7 CSIs that are uniquely shared by the species from these genera but not found in Roseiflexus or any other bacteria. In addition to their phylogenetic clustering and shared presence of many novel CSIs, the species from the genera Chloroflexus and Oscillochloris (and also Chloronema) also differ from species of the genera Roseiflexus (and Heliothrix) by their green color, shared presence of the chlorosomes and Bchl c (in addition to Bchl a and d in some species), by their fatty acid profiles, and by the presence of ß- and γ-carotenes and quinone MK-10. Based upon these observations, we propose division of the order Chloroflexales into two suborders: the first of these suborders Chloroflexineae subord. nov. is comprised of the family Oscillochloridaceae (emended to include the genus Chloronema) and a new family Chloroflexaceae fam. nov. consisting of the genus Chloroflexus. The second suborder Roseiflexineae subord. nov. contains a new family Roseiflexaceae fam. nov. comprised of the genera Roseiflexus and Heliothrix; orange-red bacteria lacking chlorosomes and Bchl c and differing from the Chloroflexineae in their carotenoids, quinones and fatty acid profiles. Additionally, we also provide here formal descriptions of the class Chloroflexia class. nov. [corrected], and of the orders Chloroflexales ord. nov. and Herpetosiphonales ord. nov. Lastly, our phylogenetic and comparative analyses provide either no or very weak support for a grouping together of the different classes (viz. Chloroflexi, Thermomicrobia, Dehalococcoidetes, Anaerolineae, Caldilineae and Ktedonobacteria) that are currently part of the phylum Chloroflexi. However, a specific grouping of the classes Chloroflexi and Thermomicrobia (as well as 'Thermobaculum') is supported by both phylogenetic means and the identified CSIs. Based upon these results, it is suggested that the phylum Chloroflexi "sensu stricto" should be comprised only of the classes Chloroflexi and Thermomicrobia and the other four classes (viz. Dehalococcoidetes, Anaerolineae, Caldilineae and Ktedonobacteria), which are at present part of this "superphylum" should be regarded as taxa related to the phylum Chloroflexi "sensu stricto", awaiting more detailed investigations to clarify their relationships to each other and other phyla of bacteria.

Canadian DOs: International Expansion of Osteopathic Medical Education North of the Border.

CONTEXT: The growth of osteopathic medicine in the United States has led to a vibrant expansion of the profession internationally. Canadian students represent the majority of international applicants and matriculants to US colleges of osteopathic medicine (COMs); however, to our knowledge, no studies have explored this population. OBJECTIVE: To gain a better understanding of Canadian students attending US colleges of osteopathic medicine by examining their residency training preference, visa preference, intent to practice in the United States or Canada, receptiveness to incorporating osteopathic manipulative medicine into practice, specialty preference, estimated debt incurred, and effect of debt on specialty choice. METHODS: A 10-question electronic survey was sent to Canadian osteopathic medical students in the 17 COMs and branch campuses that accept international applicants. The initial survey pool consisted of frst-, second-, third-, and fourth-year medical students (classes of 2014-2017) compiled from a database managed by the Canadian Osteopathic Medical Student Association. RESULTS: Of the 102 students contacted, 66 (65%) completed the survey. Respondents had a strong desire to practice in Canada (44 [67%]) but were considering an Accreditation Council on Graduate Medical Education (ACGME) or dually accredited residency program in the United States (46 [70%] and 15 [23%], respectively) that would sponsor an H1B visa. Respondents were receptive to incorporating osteopathic manipulative medicine into practice (44 [67%]). Most respondents chose non-primary care specialties (40 [61%]) and incurred a debt of more than $200,000 (44 of 65 [68%]); however, debt had a limited infuence on respondents' choice of specialty (χ23=1.911; P=.591). CONCLUSION: Most respondents planned to complete ACGME training, to return to Canada to practice medicine, and to practice in a non-primary care specialty. As a growing population that will play a large role in the expansion and reception of the profession internationally, Canadian osteopathic medical students and US-trained Canadian DOs merit further examination.