Timing of treatment initiation of direct-acting antivirals for HIV/HCV coinfected and HCV monoinfected patients.

Direct-acting antiviral therapy is safe and cost-effective for the treatment of hepatitis C virus (HCV) infection. However, variability in drug payment rules represents a barrier to treatment that may disproportionately affect certain populations. We conducted a retrospective cohort study among HIV/HCV coinfected and HCV monoinfected patients using Kaplan-Meier and Fisher's exact test to analyze the time from the prescription of a direct-acting antiviral agent to delivery to the patient. Variables with significance p < .20 in univariate analysis were included in a Cox regression model. Factors associated with faster treatment were Infectious Diseases office setting (p = .01), public insurance payer (p = .01), and initial approval of requested regimen (p = .01). The presence of other liver disease was associated with delay in treatment (p = .05). Unrestrictive Medicare and Medicaid regulations resulted in more rapid delivery of medication compared to private payers. Fibrosis level, Child-Pugh class and HIV status did not significantly change time to treatment.

Partnering with parents in interprofessional leadership graduate education to promote family-professional partnerships.

Evidence supports the benefits to families of relationships with professionals that build on the concept of partnership, but there are few studies in the literature of strategies involving joint education for parents and professionals to enhance the capacity of parents of children with special healthcare needs to be effective interprofessional partners. Since 2007, parents of children with special healthcare needs have participated alongside graduate students from five different profession-based training programmes in a structured interprofessional leadership programme. The aims of this summative evaluation study were to elicit the influences of this training model on parents' capacity to partner with both health professionals and other parents and explore features of the training that facilitated these partnership skills. Using qualitative analysis, a semi-structured interview, guided by sensitising concepts informing leadership development, was conducted with 17 of the 23 parents who participated in the training. Transcriptions of the interviews were used for creating codes and categories for analysis. Parents described how the programme enhanced abilities to see other points of view, skills in communicating across professions, skills in conflict management, and feelings of confidence and equality with providers that influenced their relationships with their own providers and their capacity to assist other parents in addressing challenges in the care of their children. Parents reported that building concrete skills, organised opportunities to hear other viewpoints, structured time for learning and self-reflection, and learning in the context of a trusting relationship facilitated the development of partnership skills. These findings suggest that the leaders of interprofessional training programmes should involve parents and graduate students as equal partners to enhance partnership skills.

Longitudinal assessment of hematopoietic abnormalities after autologous hematopoietic cell transplantation for lymphoma.

PURPOSE: Autologous hematopoietic cell transplantation (HCT) is being increasingly used as an effective treatment strategy for patients with relapsed or refractory Hodgkin's lymphoma (HL) or non-Hodgkin's lymphoma (NHL) but is associated with therapy-related myelodysplasia and acute myeloid leukemia (t-MDS/AML) as a major cause of nonrelapse mortality. The phenomenon of hematopoietic reconstitution after autologous HCT and the role of proliferative stress in the pathogenesis of t-MDS/AML are poorly understood. PATIENTS AND METHODS: Using a prospective longitudinal study design, we evaluated the nature and timing of alterations in hematopoietic progenitors and telomere length after HCT in patients undergoing autologous HCT at City of Hope Cancer Center (Duarte, CA). RESULTS: A significant reduction in primitive and committed progenitors was observed before HCT compared with healthy controls. Further profound and persistent reduction in primitive progenitors but only transient reduction in committed progenitors were seen after HCT. Primitive progenitor frequency in pre-HCT marrow and peripheral-blood stem cells predicted for primitive progenitor recovery after HCT. Shortening of telomere length was observed in marrow cells early after HCT, with subsequent restoration to pre-HCT levels. Patients within this cohort who developed t-MDS/AML had reduced recovery of committed progenitors and poorer telomere recovery, possibly indicating a functional defect in primitive hematopoietic cells. CONCLUSION: Our studies suggest that hematopoietic regeneration after HCT is associated with increased proliferation and differentiation of primitive progenitors. Increased proliferative stress on stem cells bearing genotoxic damage could contribute to the pathogenesis of t-MDS/AML. Extended follow-up of a larger number of patients is required to confirm whether alterations in progenitor and telomere recovery predict for increased risk of t-MDS/AML.

Infection of endothelial cells with Anaplasma marginale and A. phagocytophilum.

Anaplasma marginale and A. phagocytophilum are obligate intracellular, tick-borne pathogens that target erythrocytes and neutrophil granulocytes, respectively. Because ticks do not directly tap blood vessels, an intermediate tissue may mediate infection of blood cells. We considered that vascular endothelium interacts with circulating blood cells in vivo, and could be involved in pathogenesis and dissemination of the organisms. We used light and electron microscopy and immune labeling to show that A. phagocytophilum invaded rhesus (RF/6A), human (HMEC-1, MVEC), as well as bovine (BCE C/D-1b) endothelial cell lines, whereas A. marginale infected rhesus and bovine endothelial cells. A. marginale formed large intracellular inclusions that appeared smooth and solid at first, and subsequently coalesced into discrete granules. A. phagocytophilum formed numerous smaller inclusions in each cell. Within 1-3 weeks, the monolayers were destroyed, and lysed cultures were diluted onto fresh monolayers. Electron microscopy demonstrated uneven distribution of A. marginale inside large inclusions, with reticulated forms grouped more tightly than denser cells, whereas in A. phagocytophilum individual organisms appeared more evenly spaced. Specific polyclonal and monoclonal antibodies both labeled A. marginale and A. phagocytophilum in endothelial cells, and oligonucleotide primers complimentary to either A. marginale or A. phagocytophilum amplified their expected target from these cultures. In conclusion, we demonstrate that relevant microvascular endothelium is susceptible to anaplasmas in vitro and may present a link that could explain development of the immune response and persistent infection.

Rickettsiella-like bacteria in Ixodes woodi (Acari: Ixodidae).

We examined a parthenogenetic strain of the hard tick Ixodes woodi Bishopp for the presence of endosymbiotic bacteria. Electron microscopic examination revealed the ovarian tissues and Malpighian tubules were infected with pleomorphic bacteria. Two basic types were observed: a larger granular cell and a smaller condensed cell. Cloning and sequence analysis of polymerase chain reaction (PCR) amplified 16S rRNA gene yielded a single sequence from bacteria present in I. woodi tissues. Phylogenetic analysis of the nearly complete 16S rDNA indicated that the ticks were infected with an endosymbiont belonging to the gamma subdivision of the Proteobacteria. It clustered with the insect pathogenic species Rickettsiellagrylli (Vago and Martoja 1963) and the animal pathogen Coxiella burnetii (Derrick 1939) Philip 1948. Our results suggest that the I. woodi females harbored a single endosymbiotic bacterium related to selected Rickettsiella species and to C burnetii.

Gender issues in suicide rates, trends and methods among youths aged 15-24 in 15 European countries.

BACKGROUND: No recent cross-country examinations for youth suicide trends and methods for Europe were found. AIM: The aim of the study is to specify differences in suicide rates, trends and methods used among 15-24 years olds by gender across 15 European countries. METHOD: Data for 14,738 suicide cases in the age group 15-24 in 2000-2004/5 were obtained and analysed. RESULTS: Suicide rates ranged 5.5-35.1 for males and 1.3-8.5 for females. Statistically significant decline since 2000 was observed in Germany, Scotland, Spain, and England for males and in Ireland for females. Hanging was most frequently used for both genders, followed by jumping and use of a moving object for males and jumping and poisoning by drugs for females. Male suicides had a higher risk than females of using firearms and hanging and lower risk of poisoning by drugs and jumping. There were large differences between single countries. LIMITATIONS: The limitations of the study are the small numbers of specific suicide methods in some countries as well as the re-categorisation of ICD-9 codes into ICD-10 in England, Ireland and Portugal. Further, the use of suicides (X60-X84) without events of undetermined deaths (Y10-Y34) continues to be problematic considering the possibility of "hidden suicides". CONCLUSIONS: The present study shows that suicide rates among young males are decreasing since 2000 in several European countries. Analysis of suicide methods confirms that there is a very high proportion of hanging in youths, which is extremely difficult to restrict. However, besides hanging there are also high rates of preventable suicide methods and reducing the availability of means should be one of the goals of suicide prevention.

Factors influencing in vitro infectivity and growth of Rickettsia peacockii (Rickettsiales: Rickettsiaceae), an endosymbiont of the Rocky Mountain wood tick, Dermacentor andersoni (Acari, Ixodidae).

Rickettsia peacockii, a spotted fever group rickettsia, is a transovarially transmitted endosymbiont of Rocky Mountain wood ticks, Dermacentor andersoni. This rickettsia, formerly known as the East Side Agent and restricted to female ticks, was detected in a chronically infected embryonic cell line, DAE100, from D. andersoni. We examined infectivity, ability to induce cytopathic effect (CPE) and host cell specificity of R. peacockii using cultured arthropod and mammalian cells. Aposymbiotic DAE100 cells were obtained using oxytetracycline or incubation at 37 degrees C. Uninfected DAE100 sublines grew faster than the parent line, indicating R. peacockii regulation of host cell growth. Nevertheless, DAE100 cellular defenses exerted partial control over R. peacockii growth. Rickettsiae existed free in the cytosol of DAE100 cells or within autophagolysosomes. Exocytosed rickettsiae accumulated in the medium and were occasionally contained within host membranes. R. peacockii multiplied in other cell lines from the hard ticks D. andersoni, Dermacentor albipictus, Ixodes scapularis, and Ixodes ricinus; the soft tick Carios capensis; and the lepidopteran Trichoplusia ni. Lines from the tick Amblyomma americanum, the mosquito Aedes albopictus, and two mammalian cell lines were non-permissive to R. peacockii. High cell densities facilitated rickettsial spread within permissive cell cultures, and an inoculum of one infected to nine uninfected cells resulted in the greatest yield of infected tick cells. Cell-free R. peacockii also were infectious for tick cells and centrifugation onto cell layers enhanced infectivity approximately 100-fold. The ability of R. peacockii to cause mild CPE suggests that its pathogenicity is not completely muted. An analysis of R. peacockii-cell interactions in comparison to pathogenic rickettsiae will provide insights into host cell colonization mechanisms.

Rickettsia monacensis sp. nov., a spotted fever group Rickettsia, from ticks (Ixodes ricinus) collected in a European city park.

We describe the isolation and characterization of Rickettsia monacensis sp. nov. (type strain, IrR/Munich(T)) from an Ixodes ricinus tick collected in a city park, the English Garden in Munich, Germany. Rickettsiae were propagated in vitro with Ixodes scapularis cell line ISE6. BLAST analysis of the 16S rRNA, the citrate synthase, and the partial 190-kDa rickettsial outer membrane protein A (rOmpA) gene sequences demonstrated that the isolate was a spotted fever group (SFG) rickettsia closely related to several yet-to-be-cultivated rickettsiae associated with I. ricinus. Phylogenetic analysis of partial rompA sequences demonstrated that the isolate was genotypically different from other validated species of SFG rickettsiae. R. monacensis also replicated in cell lines derived from the ticks I. ricinus (IRE11) and Dermacentor andersoni (DAE100) and in the mammalian cell lines L-929 and Vero, causing cell lysis. Transmission electron microscopy of infected ISE6 and Vero cells showed rickettsiae within the cytoplasm, pseudopodia, nuclei, and vacuoles. Hamsters inoculated with R. monacensis had immunoglobulin G antibody titers as high as 1:16,384, as determined by indirect immunofluorescence assay. Western blot analyses demonstrated that the hamster sera cross-reacted with peptides from other phylogenetically distinct rickettsiae, including rOmpA. R. monacensis induced actin tails in both tick and mammalian cells similar to those reported for R. rickettsii. R. monacensis joins a growing list of SFG rickettsiae that colonize ticks but whose infectivity and pathogenicity for vertebrates are unknown.