Evaluation of the Efficacy of Doxycycline, Ciprofloxacin, Levofloxacin, and Co-trimoxazole Using In Vitro and In Vivo Models of Q Fever.

Q fever, caused by the intracellular pathogen Coxiella burnetii, is traditionally treated using tetracycline antibiotics, such as doxycycline. Doxycycline is often poorly tolerated, and antibiotic-resistant strains have been isolated. In this study, we have evaluated a panel of antibiotics (doxycycline, ciprofloxacin, levofloxacin, and co-trimoxazole) against C. burnetii using in vitro methods (determination of MIC using liquid and solid media; efficacy assessment in a THP cell infection model) and in vivo methods (wax moth larvae and mouse models of infection). In addition, the schedule for antibiotic treatment has been evaluated, with therapy initiated at 24 h pre- or postchallenge. Both doxycycline and levofloxacin limited overt clinical signs during treatment in the AJ mouse model of aerosol infection, but further studies are required to investigate the possibility of disease relapse or incomplete bacterial clearance after the antibiotics are stopped. Levofloxacin was well tolerated and therefore warrants further investigation as an alternative to the current recommended treatment with doxycycline.

Foreign Medical Teams in support of the Ebola outbreak: a UK military model of pre-deployment training and assurance.

We discuss the training methodology developed and utilised to prepare UK military medical teams to establish an Ebola Treatment Centre in Sierra Leone. We highlight the process of identifying and mitigating nosocomial risk in the Pre-Deployment Training process, encompassing the challenges of developing, training and assuring a capability at pace, which deployed to deliver high quality clinical care to patients with Ebola Virus Disease.

Leptospirosis in a British soldier after travel to Borneo.

Undifferentiated febrile illness in a returning soldier is a common problem encountered by serving medical officers. A 32-year-old soldier presented to Birmingham Heartlands Hospital with fever and acute kidney injury after return from Borneo. Leptospirosis was suspected and empirical antibiotics were started before subsequent confirmation by serology and PCR. Leptospirosis is common in South-East Asia, and troops exercising in jungle areas, and in the UK, are at risk. Advice, including inpatient management when appropriate, is available from the UK Role 4 Military Infectious Diseases and Tropical Medicine Service.

People with diagnosed HIV infection not attending for specialist clinical care: UK national review.

BACKGROUND: Regular clinical care is important for the well-being of people with HIV. We sought to audit and describe the characteristics of adults with diagnosed HIV infection not reported to be attending for clinical care in the UK. METHODS: Public Health England (PHE) provided clinics with lists of patients diagnosed or seen for specialist HIV care in 2010 but not linked to a clinic report or known to have died in 2011. Clinics reviewed case-notes of these individuals and completed questionnaires. A nested case-control analysis was conducted to compare those who had remained in the UK in 2011 while not attending care with individuals who received specialist HIV care in both 2010 and 2011. RESULTS: Among 74,418 adults living with diagnosed HIV infection in the UK in 2010, 3510 (4.7%) were not reported as seen for clinical care or died in 2011. Case note reviews and outcomes were available for 2255 (64%) of these: 456 (20.2%) remained in the UK and did not attend care; 590 (26.2%) left UK; 508 (22.6%) received care in the UK: 73 (3.2%) died and 628 (27.8%) had no documented outcome. Individuals remaining in the UK and not attending care were more likely to be treatment naïve than those in care, but duration since HIV diagnosis was not significant. HIV/AIDS related hospitalisations were observed among non-attenders. CONCLUSION: Retention in UK specialist HIV care is excellent. Our audit indicates that the 'true' loss to follow up rate in 2011 was <2.5% with no evidence of health tourism. Novel interventions to ensure high levels of clinic engagement should be explored to minimise disease progression among non-attenders.

Infective endocarditis in the military patient.

Infective endocarditis (IE) is a potentially fatal cardiac infection associated with an inhospital mortality rate of up to 22%. Fifty per cent of IE cases develop in patients with no known history of valve disease. It is therefore important to remain vigilant to the possibility of the diagnosis in patients with a febrile illness and unknown source. From a military perspective, our patients are unique due to the breadth of pathogens they are exposed to, and blood-culture-negative IE is a risk. In particular, there should be awareness of Coxiella burnetii as a possible causative pathogen. In this review we incorporate the latest consensus from systematic reviews and publications identified by a literature search through Medline. We describe the diagnosis and management of IE with particular reference to the military population.

One Health: opportunities for Defence Engagement (Health).

The One Health concept continues to gain traction as a necessary approach to tackle emerging threats to human, animal and environmental health but has not yet been adopted within Defence Engagement (Health). The health of humans, animals and ecosystems are closely interlinked. The One Health concept recognises this interdependence and seeks to balance and optimise the health of all three through an integrated and unifying approach. With a focus on zoonoses, vectorborne disease, antimicrobial resistance and food safety it encourages collaboration, communication, coordination and capacity building. The UK has made commitments to the One Health approach in the Global Health and Security Agenda, and the Integrated Review. This article explores how the One Health approach could and should be adopted within Defence Engagement (Health) activity to offer the potential for high-impact, low-risk activity while facilitating long-term relationship building.

Multiple Targets, One Goal: Compounding life-extending effects through Polypharmacology.

Analysis of lifespan-extending compounds suggested the most effective geroprotectors target multiple biogenic amine receptors. To test this hypothesis, we used graph neural networks to predict such polypharmacological compounds and evaluated them in C. elegans. Over 70% of the selected compounds extended lifespan, with effect sizes in the top 5% compared to the DrugAge database. This reveals that rationally designing polypharmacological compounds enables the design of geroprotectors with exceptional efficacy.

Sexual health and HIV in the Army.

Sexual acquisition of infections has always been an important part of military history and although disease patterns have changed over time, the problem has not gone away. This article will look at how to recognise infection, the general principles of management, where to access guidance and how to get specialised help within the complexities of the military environment.

Fungal Planet description sheets: 154-213.

Novel species of microfungi described in the present study include the following from South Africa: Camarosporium aloes, Phaeococcomyces aloes and Phoma aloes from Aloe, C. psoraleae, Diaporthe psoraleae and D. psoraleae-pinnatae from Psoralea, Colletotrichum euphorbiae from Euphorbia, Coniothyrium prosopidis and Peyronellaea prosopidis from Prosopis, Diaporthe cassines from Cassine, D. diospyricola from Diospyros, Diaporthe maytenicola from Maytenus, Harknessia proteae from Protea, Neofusicoccum ursorum and N. cryptoaustrale from Eucalyptus, Ochrocladosporium adansoniae from Adansonia, Pilidium pseudoconcavum from Greyia radlkoferi, Stagonospora pseudopaludosa from Phragmites and Toxicocladosporium ficiniae from Ficinia. Several species were also described from Thailand, namely: Chaetopsina pini and C. pinicola from Pinus spp., Myrmecridium thailandicum from reed litter, Passalora pseudotithoniae from Tithonia, Pallidocercospora ventilago from Ventilago, Pyricularia bothriochloae from Bothriochloa and Sphaerulina rhododendricola from Rhododendron. Novelties from Spain include Cladophialophora multiseptata, Knufia tsunedae and Pleuroascus rectipilus from soil and Cyphellophora catalaunica from river sediments. Species from the USA include Bipolaris drechsleri from Microstegium, Calonectria blephiliae from Blephilia, Kellermania macrospora (epitype) and K. pseudoyuccigena from Yucca. Three new species are described from Mexico, namely Neophaeosphaeria agaves and K. agaves from Agave and Phytophthora ipomoeae from Ipomoea. Other African species include Calonectria mossambicensis from Eucalyptus (Mozambique), Harzia cameroonensis from an unknown creeper (Cameroon), Mastigosporella anisophylleae from Anisophyllea (Zambia) and Teratosphaeria terminaliae from Terminalia (Zimbabwe). Species from Europe include Auxarthron longisporum from forest soil (Portugal), Discosia pseudoartocreas from Tilia (Austria), Paraconiothyrium polonense and P. lycopodinum from Lycopodium (Poland) and Stachybotrys oleronensis from Iris (France). Two species of Chrysosporium are described from Antarctica, namely C. magnasporum and C. oceanitesii. Finally, Licea xanthospora is described from Australia, Hypochnicium huinayensis from Chile and Custingophora blanchettei from Uruguay. Novel genera of Ascomycetes include Neomycosphaerella from Pseudopentameris macrantha (South Africa), and Paramycosphaerella from Brachystegia sp. (Zimbabwe). Novel hyphomycete genera include Pseudocatenomycopsis from Rothmannia (Zambia), Neopseudocercospora from Terminalia (Zambia) and Neodeightoniella from Phragmites (South Africa), while Dimorphiopsis from Brachystegia (Zambia) represents a novel coelomycetous genus. Furthermore, Alanphillipsia is introduced as a new genus in the Botryosphaeriaceae with four species, A. aloes, A. aloeigena and A. aloetica from Aloe spp. and A. euphorbiae from Euphorbia sp. (South Africa). A new combination is also proposed for Brachysporium torulosum (Deightoniella black tip of banana) as Corynespora torulosa. Morphological and culture characteristics along with ITS DNA barcodes are provided for all taxa.

Use of axenic media to determine antibiotic efficacy against coxiella burnetii.

The traditional methods of measuring minimum inhibitory concentration (MIC) of antibiotics against Coxiella burnetii are time-consuming and technically difficult. The discovery of axenic media for C. burnetii culture provided an opportunity to determine the feasibility of using both broth dilution and an antimicrobial gradient method (Etest) as a convenient method of measuring MICs. The MICs for a range of antibiotics that have proven or potential use in the treatment of Q fever, namely doxycycline, ciprofloxacin, levofloxacin, moxifloxacin and co-trimoxazole, were measured. It was possible to measure MICs using both microdilution and Etest methods. MICs obtained were comparable to those from other methods. This study demonstrates the potential use of a relatively simple test to measure MIC in an organism that is difficult to culture.

Enhanced case management can be delivered for patients with EVD in Africa: Experience from a UK military Ebola treatment centre in Sierra Leone.

BACKGROUND: Limited data exist describing supportive care management, laboratory abnormalities and outcomes in patients with Ebola virus disease (EVD) in West Africa. We report data which constitute the first description of the provision of enhanced EVD case management protocols in a West African setting. METHODS: Demographic, clinical and laboratory data were collected by retrospective review of clinical and laboratory records of patients with confirmed EVD admitted between 5 November 2014 and 30 June 2015. RESULTS: A total of 44 EVD patients were admitted (median age 37 years (range 17-63), 32/44 healthcare workers), and excluding those evacuated, the case fatality rate was 49% (95% CI 33%-65%). No pregnant women were admitted. At admission 9/44 had stage 1 disease (fever and constitutional symptoms only), 12/44 had stage 2 disease (presence of diarrhoea and/or vomiting) and 23/44 had stage 3 disease (presence of diarrhoea and/or vomiting with organ failure), with case fatality rates of 11% (95% CI 1%-58%), 27% (95% CI 6%-61%), and 70% (95% CI 47%-87%) respectively (p = 0.009). Haemorrhage occurred in 17/41 (41%) patients. The majority (21/40) of patients had hypokalaemia with hyperkalaemia occurring in 12/40 patients. Acute kidney injury (AKI) occurred in 20/40 patients, with 14/20 (70%, 95% CI 46%-88%) dying, compared to 5/20 (25%, 95% CI 9%-49%) dying who did not have AKI (p = 0.01). Ebola virus (EBOV) PCR cycle threshold value at baseline was mean 20.3 (SD 4.3) in fatal cases and 24.8 (SD 5.5) in survivors (p = 0.007). Mean national early warning score (NEWS) at admission was 5.5 (SD 4.4) in fatal cases and 3.0 (SD 1.9) in survivors (p = 0.02). Central venous catheters were placed in 37/41 patients and intravenous fluid administered to 40/41 patients (median duration of 5 days). Faecal management systems were inserted in 21/41 patients, urinary catheters placed in 27/41 and blood component therapy administered to 20/41 patients. CONCLUSIONS: EVD is commonly associated life-threatening electrolyte imbalance and organ dysfunction. We believe that the enhanced levels of protocolized care, scale and range of medical interventions we report, offer a blueprint for the future management of EVD in resource-limited settings.

Evidence for immunoglobulin Fc receptor-mediated prostaglandin2 and platelet-activating factor formation by cultured rat mesangial cells.

The possibility of Fc-dependent uptake of IgG immune complexes was examined in subcultured rat mesangial cells free of monocytes. 195Au-labeled colloidal gold particles were coated either with BSA only or with BSA followed by rabbit anti-BSA-IgG or the F(ab')2 fragment of the IgG. Mesangial cells preferentially took up 195Au particles covered with BSA-anti-BSA-IgG over those covered with BSA or the F(ab')2 fragment. This uptake was a time-dependent and saturable process inhibitable by sodium azide or cytochalasin B. Using phase-contrast microscopy in the light reflectance mode, it was established that essentially all mesangial cells took up IgG-coated gold particles. By electron microscopy the process was shown to consist of vesicular uptake with delivery to endosomes. Mesangial binding-uptake of the IgG-covered particles was associated with stimulation of PGE2 synthesis and production of platelet-activating factor, a lipid mediator of inflammation. To characterize the potential Fc receptor for IgG we used the rosetting technique with sheep red blood cells coated with IgG subclass-specific mouse monoclonal antibodies. 50% of mesangial cells exhibited rosetting with red cells coated with mouse IgG2a, whereas negligible rosetting was observed with IgG2b or IgG1. Competition experiments confirmed the specificity of IgG2a binding. We conclude that cultured rat mesangial cells exhibit specific receptors for IgG and that occupancy of Fc receptors results in endocytosis and is associated with generation of PGE2 and platelet-activating factor. These observations may be of significance for immune-mediated glomerular diseases.

The Red Queen Hypothesis and plant/pathogen interactions.

The Red Queen Hypothesis (RQH) explains how pathogens may maintain sexual reproduction in hosts. It assumes that parasites become specialized on common host genotypes, reducing their fitness. Such frequency-dependent selection favors sexual reproduction in host populations. Necessary conditions are that resistance and virulence are genotype specific so that host genotype frequencies respond to changes in pathogen genotype frequencies, and vice versa. Empirical evidence on the genetic basis of disease, variation in resistance and virulence, and patterns of infection in sexual and asexual plants support certain features of the hypothesis. However, gene-for-gene interactions are generally not consistent with the RQH because they do not result in cycling of gene frequencies, unlike a matching allele mechanism. A conclusion of whether the RQH can explain the maintenance of sexual reproduction cannot be reached at present. Nevertheless, the RQH theory has shed light on many aspects of plant/pathogen interactions important for reducing pathogen damage in agricultural systems.

Albumin and fatty acid effects on the stimulated production of 1-O-hexadecyl-2-acetyl-sn-glycero-3-phosphocholine (PAF) by human polymorphonuclear leukocytes.

Production of platelet-activating factor (PAF) during opsonized zymosan stimulation of human polymorphonuclear leukocytes is dependent on the concentration of extracellular albumin and on the presence of exogenous fatty acids. Fatty acid-free albumin caused a concentration-dependent increase in PAF synthesis up to 5% albumin concentrations (w/v) where the amount of PAF produced was three- to four-fold higher than in controls containing no albumin. The addition of free fatty acids, particularly arachidonic acid and palmitic acid, to 5% fatty acid-free albumin media caused a concentration-dependent decrease in PAF synthesis. A 50% inhibition of PAF synthesis was observed at an arachidonic acid concentration of 120 microM and at a palmitic acid concentration of 100 microM. The inhibition of PAF production by palmitic acid was also dependent on the concentration of extracellular albumin. In 0.5% fatty acid-free albumin media, a palmitic acid concentration of 40 microM produced a 50% inhibition in PAF synthesis. The addition of palmitic acid did not affect the release of endogenous arachidonic acid during stimulation. In contrast, the addition of stearic acid up to 120 microM in 5% fatty acid-free albumin media had no effect on PAF production. The different inhibitory effects of palmitic acid and stearic acid on PAF production may be related to differences in intracellular utilization of these two fatty acids during cell stimulation.

Binding of platelet activating factor to albumin.

Binding of platelet activating factor (1-O-alkyl-2-O-acetyl-sn-glycero-3-phosphocholine) to albumin is an important facet of the biological activity of this phospholipid. Measurement of that binding has been hampered by the physical nature of the lipid, which made estimation of the free and bound concentrations difficult. With the use of ultracentrifugation to generate an albumin gradient and to produce a region free of protein, the successful measurement of free PAF and PAF bound to albumin was accomplished. This study has demonstrated that PAF binds to albumin at four binding sites and that the average equilibrium dissociation constant for this binding is 1.10(-7) M. Consideration of these data has led to the hypothesis that the receptor active form of PAF is the albumin-PAF complex, rather than free PAF.

Biosynthesis of platelet activating factor and 1-O-acyl analogues by endothelial cells.

Mass spectrometric procedures have been used to measure 1-O-alkyl-2-O-acetyl-glycero-3-phosphocholine (PAF) and a structural analogue, 1-O-acyl-2-O-acetyl-glycero-3-phosphocholine, biosynthesis in stimulated human umbilical vein endothelial cells (HUVEC). The primary species of acetylated glycerophosphocholine detected were of the 1-O-acyl type, rather than PAF. The amounts of PAF synthesized were much less than reported in earlier studies. In addition, mass spectrometric procedures were used to profile the molecular species of glycerophosphocholine in HUVEC and to determine those species which have arachidonate in the sn-2 position. The pattern of the occurrence of arachidonate in the sn-2 position is very similar to the pattern of synthesis of the acetylated glycerophosphocholines. These results suggest that 1-O-acyl-2-O-acetyl-glycero-3-phosphocholines may have significant but unappreciated biological activities. These results also support the view that glycerophosphocholine molecular species which have arachidonate esterified at the sn-2 position are the immediate precursors for the hydrolysis-acetylation steps which result in the synthesis of sn-2 acetylated glycerophosphocholines, including PAF.

A model for the extracellular release of PAF: the influence of plasma membrane phospholipid asymmetry.

Recent studies suggesting that cellular activation leads to enhanced transbilayer movement of phospholipids and loss of plasma membrane phospholipid asymmetry lead us to hypothesize that such events may govern the release of PAF, a potent, but variably release, lipid mediator synthesized by numerous inflammatory cells. To model these membrane events, we studied the transbilayer movement of PAF across the human erythrocyte and erythrocyte ghost plasma membrane, membranes with documented phospholipid asymmetry which can be deliberately manipulated. Utilizing albumin to extract outer leaflet PAF, transbilayer movement of PAF was shown to be significantly enhanced in erythrocytes and ghosts altered to lose membrane asymmetry when compared to movement in those with native membrane asymmetry. Verification of membrane changes was demonstrated using merocyanine 540 (MC540), a dye which preferentially stains loosely packed or hydrophobic membranes, and acceleration of the modified Russell's viper venom clotting assay by externalized anionic phospholipids. Utilizing the erythrocyte ghost loaded with PAF in either the outer or the inner leaflet, enhanced transbilayer movement to the opposite leaflet was seen to accompany loss of membrane asymmetry. Studies utilizing ghosts loaded with albumin intracellularly demonstrated that 'acceptor' molecules binding PAF further influence the disposition of PAF across the plasma membrane. Taken together, these findings suggest that the net release of PAF from activated inflammatory cells will depend on localization of PAF to the plasma membrane, transbilayer movement, which is facilitated by alteration of membrane phospholipid asymmetry, and removal from the membrane by extracellular and intracellular 'acceptor' molecules.

Effects of platelet activating factor and related lipids on phase transition of dipalmitoylphosphatidylcholine.

Recent evidence localizing the inflammatory mediator, platelet activating factor, (PAF, 1-O-alkyl-2-acetyl-sn-glycero-3-phosphocholine) to the membranes of stimulated neutrophils raises the possibility that PAF may, in addition to its activities as a mediator, alter the physical properties of membranes. Accordingly, the effects of PAF and related alkyl ether and acyl analogs on phase transition thermodynamics of dipalmitoylphosphatidylcholine (DPPC) were studied using fluorescence polarization of the fluorescent probe, 1,6-diphenyl-1,3,5-hexatriene (DPH). PAF, its ester analog (1-palmitoyl-2-acetylphosphatidylcholine) and both the corresponding alkyl and acyl lysophospholipid analogs (each at a concentration of 10 mol%) significantly decreased the phase transition temperature and broadened the phase transition of DPPC (P less than 0.05). The relative potency of the lipids in causing this effect was ester-PAF greater than or equal to PAF greater than or equal to lyso-PAF greater than lyso-PC suggesting that the fluidization of the synthetic membranes was attributable to both the 2-position acetyl group and the 1-position alkyl linkage. Furthermore, using various related compounds, increases in chain length and degree of unsaturation in the 2-position were shown to enhance the depression in transition temperature and broadening of the phase transition. Phase transition thermodynamics were also assessed using differential scanning calorimetry. Similar depression in the phase transition temperature was measured for PAF and both the alkyl and acyl lysophospholipids. Broadening of the phase transition for DPPC by the various analogs was assessed by calculation of transition peak width and cooperative unit. Data from fluorescence polarization and differential scanning calorimetry provide similar though not identical results and support the hypothesis that the unique features of PAF may alter membrane physical properties and could ultimately explain some of its biologic actions.

Effects of platelet activating factor on calcium-lipid interactions and lateral phase separations in phospholipid vesicles.

Recent studies localizing the inflammatory mediator, platelet activating factor (PAF, 1-O-alkyl-2-acetyl-sn-glycero-3-phosphocholine), to the membranes of stimulated neutrophils, raise the possibility that PAF may, in addition to its activities as a mediator, alter the physical properties of membranes. This, and the increasing evidence that calcium-lipid interactions may have central importance in membrane organizational structure and in functions of cell homeostasis and stimulus-response coupling, prompted us to study the effects of PAF on calcium-lipid interactions in lipid vesicles. Using fluorescence polarization of dansylated probes located in the glycerol portion of the membrane bilayer, PAF (at a concentration as low as 1 mol%) was shown to reduce membrane rigidification significantly during calcium-induced lateral phase separations. This effect of PAF was structurally dependent on both the 1-position alkyl linkage and the 2-position acetyl group as shown by studies of related lipid analogs. Furthermore, using a self-quenching probe, it was shown that inhibition of lateral phase separation did not account for this reduction in the calcium-induced membrane rigidification attributed to PAF. Data suggest that PAF at low concentrations may alter phospholipid head packing and, thereby, change membrane surface features during calcium-lipid interactions, effects which may ultimately explain some of its biological actions.

Use of an ultraviolet tracer in simulation training for the clinical management of Ebola virus disease.

In October 2014 the UK military deployed to Sierra Leone to provide care for healthcare workers affected by Ebola virus disease. A training package designed by the Army Medical Services Training Centre prepared the deploying personnel in the required infection prevention and control measures. The training used ultraviolet tracer to provide validation of the skills required when treating patients with Ebola and to confirm subsequent decontamination. This training construct provided useful feedback to clinicians on their infection control measures and would be useful in the context of any infection spread by droplets and fomites.