Increase in invasive group A streptococcal infections and emergence of novel, rapidly expanding sub-lineage of the virulent Streptococcus pyogenes M1 clone, Denmark, 2023.

A highly virulent sub-lineage of the Streptococcus pyogenes M1 clone has been rapidly expanding throughout Denmark since late 2022 and now accounts for 30% of the new invasive group A streptococcal infections. We aimed to investigate whether a shift in variant composition can account for the high incidence rates observed over winter 2022/23, or if these are better explained by the impact of COVID-19-related restrictions on population immunity and carriage of group A Streptococcus.

Feasibility of prehospital identification of non-ST-elevation myocardial infarction by ECG, troponin and echocardiography.

BACKGROUND: Prehospital identification and selection of treatment strategy in patients with suspected non-ST-elevation myocardial infarction (NSTEMI) is challenging. The aim of this study was to evaluate the feasibility and diagnostic accuracy of prehospital ECG, troponin T (TnT) and transthoracic echocardiography (TTE) acquired by paramedics in early identification of NSTEMI. METHODS: Consecutive patients requesting an ambulance from Sorlandet Hospital, Norway due to chest pain between November 2017 and January 2020 were screened for inclusion in the study. One ambulance was equipped with ECG recorder, point-of-care TnT test and TTE scanner, and six paramedics were given necessary training. ECG, TnT result and TTE images were acquired prehospitally and transferred to an in-hospital cardiologist. NSTEMI was suspected in patients with ischaemic ECG changes, elevated TnT or myocardial regional wall motion abnormalities (RWMA) at TTE. RESULTS: A total of 253 patients were included in the study. ECG was interpretable by cardiologists in 243 (96%), TnT in 238 (94%) and TTE images in 240 (95%) patients. NSTEMI was the discharge diagnosis in 22 (9%) of these patients. Four (18%) patients with NSTEMI had ischaemic ECG changes, elevated TnT and RWMA at TTE. Eight (36%) patients with NSTEMI had positive findings at two of the diagnostic methods, six (27%) patients had positive findings at one, and four (18%) patients had no positive findings in any of the diagnostic methods. In three patients (14%) with NSTEMI, RWMA was the only positive test. The negative and positive predictive values for RWMA were 42% and 96%, respectively. CONCLUSIONS: Prehospital acquisition of ECG, TnT and interpretable TTE images by paramedics were feasible in most patients with chest pain. Based on these examinations, it was possible to identify the majority of cases with NSTEMI prehospitally and admit the patients directly to a hospital with facilities for percutaneous coronary intervention (PCI) for further treatment. TRIAL REGISTRATION NUMBER: NCT04223986.

Placebo effects in allergen immunotherapy-An EAACI Task Force Position Paper.

The placebo (Latin "I will please") effect commonly occurs in clinical trials. The psychological and physiological factors associated with patients' expectations about a treatment's positive and negative effects have yet to be well characterized, although a functional prefrontal cortex and intense bidirectional communication between the central nervous system and the immune system appear to be prerequisites for a placebo effect. The use of placebo raises certain ethical issues, especially if patients in a placebo group are denied an effective treatment for a long period of time. The placebo effect appears to be relatively large (up to 77%, relative to pretreatment scores) in controlled clinical trials of allergen immunotherapy (AIT), such as the pivotal, double-blind, placebo-controlled (DBPC) randomized clinical trials currently required by regulatory authorities worldwide. The European Academy of Allergy and Clinical Immunology (EAACI) therefore initiated a Task Force, in order to better understand the placebo effect in AIT and its specific role in comorbidities, blinding issues, adherence, measurement time points, variability and the natural course of the disease. In this Position Paper, the EAACI Task Force highlights several important topics regarding the placebo effect in AIT such as a) regulatory aspects, b) neuroimmunological and psychological mechanisms, c) placebo effect sizes in AIT trials, d) methodological limitations in AIT trial design and e) potential solutions in future AIT trial design. In conclusion, this Position Paper aims to examine the methodological problem of placebo in AIT from different aspects and also to highlight unmet needs and possible solutions for future trials.

State-of-the-art in marketed adjuvants and formulations in Allergen Immunotherapy: A position paper of the European Academy of Allergy and Clinical Immunology (EAACI).

Since the introduction of allergen immunotherapy (AIT) over 100 years ago, focus has been on standardization of allergen extracts, with reliable molecular composition of allergens receiving the highest attention. While adjuvants play a major role in European AIT, they have been less well studied. In this Position Paper, we summarize current unmet needs of adjuvants in AIT citing current evidence. Four adjuvants are used in products marketed in Europe: aluminium hydroxide (Al(OH)3 ) is the most frequently used adjuvant, with microcrystalline tyrosine (MCT), monophosphoryl lipid A (MPLA) and calcium phosphate (CaP) used less frequently. Recent studies on humans, and using mouse models, have characterized in part the mechanisms of action of adjuvants on pre-existing immune responses. AIT differs from prophylactic vaccines that provoke immunity to infectious agents, as in allergy the patient is presensitized to the antigen. The intended mode of action of adjuvants is to simultaneously enhance the immunogenicity of the allergen, while precipitating the allergen at the injection site to reduce the risk of anaphylaxis. Contrasting immune effects are seen with different adjuvants. Aluminium hydroxide initially boosts Th2 responses, while the other adjuvants utilized in AIT redirect the Th2 immune response towards Th1 immunity. After varying lengths of time, each of the adjuvants supports tolerance. Further studies of the mechanisms of action of adjuvants may advise shorter treatment periods than the current three-to-five-year regimens, enhancing patient adherence. Improved lead compounds from the adjuvant pipeline are under development and are explored for their capacity to fill this unmet need.

Pollen season is reflected on symptom load for grass and birch pollen-induced allergic rhinitis in different geographic areas-An EAACI Task Force Report.

BACKGROUND: The effectiveness of allergen immunotherapy (AIT) in seasonal and perennial allergic rhinitis (AR) depends on the definition of pollen exposure intensity or time period. We recently evaluated pollen and symptom data from Germany to examine the new definitions of the European Academy of Allergy and Clinical Immunology (EAACI) on pollen season and peak pollen period start and end. Now, we aim to confirm the feasibility of these definitions to properly mirror symptom loads for grass and birch pollen-induced allergic rhinitis in other European geographical areas such as Austria, Finland and France, and therefore their suitability for AIT and clinical practice support. METHODS: Data from twenty-three pollen monitoring stations from three countries in Europe and for 3 years (2014-2016) were used to investigate the correlation between birch and grass pollen concentrations during the birch and grass pollen season defined via the EAACI criteria, and total nasal symptom and medication scores as reported with the aid of the patient's hay-fever diary (PHD). In addition, we conducted a statistical analysis, together with a graphical investigation, to reveal correlations and dependencies between the studied parameters. RESULTS: The analysis demonstrated that the definitions of pollen season as well as peak pollen period start and end as proposed by the EAACI are correlated to pollen-induced symptom loads reported by PHD users during birch and grass pollen season. A statistically significant correlation (slightly higher for birch) has been found between the Total Nasal Symptom and Medication Score (TNSMS) and the pollen concentration levels. Moreover, the maximum symptom levels occurred mostly within the peak pollen periods (PPP) following the EAACI criteria. CONCLUSIONS: Based on our analyses, we confirm the validity of the EAACI definitions on pollen season for both birch and grass and for a variety of geographical locations for the four European countries (including Germany from a previous publication) analyzed so far. On this basis, the use of the EAACI definitions is supported in future clinical trials on AIT as well as in daily routine for optimal patient care. Further evaluation of the EAACI criteria in other European regions is recommended.

2019 ARIA Care pathways for allergen immunotherapy.

Allergen immunotherapy (AIT) is a proven therapeutic option for the treatment of allergic rhinitis and/or asthma. Many guidelines or national practice guidelines have been produced but the evidence-based method varies, many are complex and none propose care pathways. This paper reviews care pathways for AIT using strict criteria and provides simple recommendations that can be used by all stakeholders including healthcare professionals. The decision to prescribe AIT for the patient should be individualized and based on the relevance of the allergens, the persistence of symptoms despite appropriate medications according to guidelines as well as the availability of good-quality and efficacious extracts. Allergen extracts cannot be regarded as generics. Immunotherapy is selected by specialists for stratified patients. There are no currently available validated biomarkers that can predict AIT success. In adolescents and adults, AIT should be reserved for patients with moderate/severe rhinitis or for those with moderate asthma who, despite appropriate pharmacotherapy and adherence, continue to exhibit exacerbations that appear to be related to allergen exposure, except in some specific cases. Immunotherapy may be even more advantageous in patients with multimorbidity. In children, AIT may prevent asthma onset in patients with rhinitis. mHealth tools are promising for the stratification and follow-up of patients.

Low Cost and Flexible UAV Deployment of Sensors.

This paper presents a platform for airborne sensor applications using low-cost, open-source components carried by an easy-to-fly unmanned aircraft vehicle (UAV). The system, available in open-source , is designed for researchers, students and makers for a broad range of exploration and data-collection needs. The main contribution is the extensible architecture for modularized airborne sensor deployment and real-time data visualisation. Our open-source Android application provides data collection, flight path definition and map tools. Total cost of the system is below 800 dollars. The flexibility of the system is illustrated by mapping the location of Bluetooth beacons (iBeacons) on a ground field and by measuring water temperature in a lake.

Efficacy of 2 months of allergen-specific immunotherapy with Bet v 1-derived contiguous overlapping peptides in patients with allergic rhinoconjunctivitis: Results of a phase IIb study.

BACKGROUND: An immunotherapy formulation consisting of 3 contiguous overlapping peptides (COPs) derived from Bet v 1, the major birch pollen allergen, showed good clinical tolerability in a previous phase I/IIa clinical trial. OBJECTIVES: We sought to evaluate the efficacy and safety of allergen-specific immunotherapy using 2 dose regimens of Bet v 1 COPs versus placebo in subjects with birch pollen-induced allergic rhinoconjunctivitis. METHODS: A randomized, double-blind, placebo-controlled phase IIb clinical trial was performed to assess the efficacy of Bet v 1 COP immunotherapy during the 2013 birch pollen season. Before the season, Bet v 1 COPs (50 and 100 µg in aluminum hydroxide) or placebo (saline and aluminum hydroxide) were administered as 5 subcutaneous injections to 239 adults with allergic rhinoconjunctivitis to birch pollen. Bet v 1 COPs at 25 or 50 µg were administered on day 1, and 50 or 100 µg was administered on days 8, 15, 29, and 57, respectively. Patients were monitored for adverse events during the treatment period and assessed for combined rhinoconjunctivitis symptom and medication scores, as well as quality of life. RESULTS: Rhinoconjunctivitis symptom and medication scores improved in both Bet v 1 COP-treated groups, reaching statistical significance over placebo in the 50-µg group (least squares mean, -0.23; 26% improvement; P = .015). Both active groups showed significant improvement in quality of life and nighttime nasal symptom scores, supporting the primary end point findings. Bet v 1 COP injections were well tolerated, with a higher frequency of systemic adverse events in the 100-µg group. CONCLUSION: Two months of preseasonal immunotherapy with 3 COPs derived from Bet v 1 at a 50-µg dose showed promising efficacy, small risk for systemic reactions, and immunomodulatory changes in this single-season, dose-finding, phase IIb trial in patients allergic to birch pollen.

100 years of immunotherapy: the Monaco charter. under the high patronage of His Serene Highness Prince Albert II of Monaco.

Aims of the Monaco Charter: (1) to present the current evidence on the efficacy and safety of allergen-specific immunotherapy (SIT) and to address the reasons for its underuse in clinical practice; (2) to develop strategies to increase the awareness about the benefits and the hazards of SIT in allergic patients, lay public and healthcare professionals not trained in allergy, and (3) to make SIT accessible and affordable to eligible patients.

Alpha-1-antitrypsin is produced by human neutrophil granulocytes and their precursors and liberated during granule exocytosis.

Alpha-1-antitrypsin (A1AT) is an important inhibitor of neutrophil proteases including elastase, cathepsin G, and proteinase 3. Transcription profiling data suggest that A1AT is expressed by human neutrophil granulocytes during all developmental stages. A1AT has hitherto only been found associated with azurophile granules in neutrophils indicative of A1AT expression being restricted to the promyelocyte stage. We examined the localization and production of A1AT in healthy donor neutrophils and found A1AT to be a constituent of all granule subtypes and to be released from neutrophils following stimulation. A1AT is produced at all stages of myeloid maturation in the bone marrow. The production increases as neutrophils enter circulation and increases further upon migration to tissues as observed in skin windows and when blood neutrophils are incubated with granulocyte colony-stimulating factor. Neutrophils from patients with A1AT-deficiency carrying the (PI)ZZ mutation in the A1AT gene appeared structurally and functionally normal, but A1AT produced in leukocytes of these patients lacked the ability to bind proteases efficiently. We conclude that A1AT generation and release from neutrophils add significantly to the antiprotease levels in tissues during inflammation. Impaired binding of neutrophil A1AT to serine proteases in patients with (PI)ZZ mutations may enhance their susceptibility to the development of emphysema.

Fine-scale movement patterns and habitat selection of little owls (Athene noctua) from two declining populations.

Advances in bio-logging technology for wildlife monitoring have expanded our ability to study space use and behavior of many animal species at increasingly detailed scales. However, such data can be challenging to analyze due to autocorrelation of GPS positions. As a case study, we investigated spatiotemporal movements and habitat selection in the little owl (Athene noctua), a bird species that is declining in central Europe and verges on extinction in Denmark. We equipped 6 Danish food-supplemented little owls and 6 non-supplemented owls in the Czech Republic with high-resolution GPS loggers that recorded one position per minute. Nightly space use, measured as 95% kernel density estimates, of Danish male owls were on average 62 ha (± 64 SD, larger than any found in previous studies) compared to 2 ha (± 1) in females, and to 3 ± 1 ha (males) versus 3 ± 5 ha (females) in the Czech Republic. Foraging Danish male owls moved on average 4-fold further from their nest and at almost double the distance per hour than Czech males. To create availability data for the habitat selection analysis, we accounted for high spatiotemporal autocorrelation of the GPS data by simulating correlated random walks with the same autocorrelation structure as the actual little owl movement trajectories. We found that habitat selection was similar between Danish and Czech owls, with individuals selecting for short vegetation and areas with high structural diversity. Our limited sample size did not allow us to infer patterns on a population level, but nevertheless demonstrates how high-resolution GPS data can help to identify critical habitat requirements to better formulate conservation actions on a local scale.

Point-of-care ultrasound (POCUS) practices in the helicopter emergency medical services in Europe: results of an online survey.

BACKGROUND: The extent to which Point-of-care of ultrasound (POCUS) is used in different European helicopter EMS (HEMS) is unknown. We aimed to study the availability, perception, and future aspects of POCUS in the European HEMS using an online survey. METHOD: A survey about the use of POCUS in HEMS was conducted by a multinational steering expert committee and was carried out from November 30, 2020 to December 30, 2020 via an online web portal. Invitations for participation were sent via email to the medical directors of the European HEMS organizations including two reminding notes. RESULTS: During the study period, 69 participants from 25 countries and 41 different HEMS providers took part in the survey. 96% (n = 66) completed the survey. POCUS was available in 75% (56% always when needed and 19% occasionally) of the responding HEMS organizations. 17% were planning to establish POCUS in the near future. Responders who provided POCUS used it in approximately 15% of the patients. Participants thought that POCUS is important in both trauma and non-trauma-patients (73%, n = 46). The extended focused assessment sonography for trauma (eFAST) protocol (77%) was the most common protocol used. A POCUS credentialing process including documented examinations was requested in less than one third of the HEMS organizations. CONCLUSIONS: The majority of the HEMS organizations in Europe are able to provide different POCUS protocols in their services. The most used POCUS protocols were eFAST, FATE and RUSH. Despite the enthusiasm for POCUS, comprehensive training and clear credentialing processes are not available in about two thirds of the European HEMS organizations. Due to several limitations of this survey further studies are needed to evaluate POCUS in HEMS.

The secretory leukocyte protease inhibitor (SLPI) and the secondary granule protein lactoferrin are synthesized in myelocytes, colocalize in subcellular fractions of neutrophils, and are coreleased by activated neutrophils.

The secretory leukocyte protease inhibitor (SLPI) re-establishes homeostasis at sites of infection by virtue of its ability to exert antimicrobial activity, to suppress LPS-induced cellular immune responses, and to reduce tissue damage through inhibition of serine proteases released by polymorphonuclear neutrophil granulocytes (PMNs). Microarray analysis of bone marrow (BM) populations highly enriched in promyelocytes, myelocytes/metamyelocytes (MYs), and BM neutrophils demonstrates a transient, high mRNA expression of SLPI and genuine secondary granule proteins (GPs) in MYs. Consistent with this finding, immunostaining of BM cells showed SLPI and the secondary GP lactoferrin (LF) to be present in cells from the myelocyte stage and throughout neutrophil differentiation. Subcellular fractionation studies demonstrated the colocalization of SLPI and LF in subcellular fractions highly enriched in secondary granules. Finally, exocytosis studies demonstrated a corelease of SLPI and LF within minutes of activation. Collectively, these findings strongly indicate that SLPI is localized in secondary granules of PMNs. However, the amount of SLPI detected in PMNs is low compared with primary keratinocytes stimulated by growth factors involved in wound healing. This implicates that neutrophil-derived SLPI might not contribute essentially to re-establishment of homeostasis at sites of infection but rather, exert physiologically relevant intracellular activities. These might include the protection of secondary GPs against proteolytic activation and/or degradation by proteases, which might be dislocated to secondary granules at minute amounts as a consequence of spillover.

Correction: Effect of early measles vaccine on pneumococcal colonization: A randomized trial from Guinea-Bissau.

[This corrects the article DOI: 10.1371/journal.pone.0177547.].

Tissue Thickness Effects on Immunohistochemical Staining Intensity of Markers of Cancer.

High-quality patient samples are required for reliable immunohistochemistry test outcomes that provide a significant benefit for patient care. Among the preanalytic variables in tissue handling, tissue thickness is thought to be easily controlled; however, whether the thickness of the tissue effects the staining intensity for antibody immunohistochemistry has not been quantitatively demonstrated. To investigate, we cut multiblock tissue sections of tonsil, liver, and kidney at 2, 4, 6, and 8 µm thicknesses. Interferometry measurements of the sectioned paraffin showed a <1 µm variation within a preset microtome thickness. Sections were then immunostained with antibodies targeting different cellular localizations; Ki-67 and BCL6 (nuclear), CD7 (membranous), and cytokeratin (cytoplasmic). A pathologist annotated regions of interest for each marker and performed brightfield and whole-slide visual scoring. Then a pixel-wise processing algorithm determined intensity of each pixel in these regions of interest and binned them into predetermined 0, 1+, 2+, or 3+ intensities. Visual scores from brightfield and whole-slide images were highly correlated to the percentage of pixels in each intensity bin. A stepwise increase was observed in pathologist scores and algorithmically defined percentage of pixels in each bin with increasing thickness demonstrating that changes in preset section thickness impacts staining intensity. The use of tissue thickness outside vendors' recommendations might change the intensity including the proportion of positive and negative cells and eventually the overall diagnosis outcome. Therefore, we recommend that tissue be consistently cut within the middle of thickness range specified by the assay manufacturer.

The role of point of care ultrasound in prehospital critical care: a systematic review.

BACKGROUND: In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers. METHODS AND RESULTS: By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting. CONCLUSION: Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations - a large part of these needs to be supervised.

How strong is the evidence that immunotherapy in children prevents the progression of allergy and asthma?

PURPOSE OF REVIEW: The purpose of this review is to describe the scientific evidence that specific immunotherapy can prevent the development of asthma in patients suffering from rhinoconjunctivitis as well as reduce the number of new allergies developing. RECENT FINDINGS: Proposed strategies for the prevention of the development of allergic rhinoconjunctivitis and asthma include allergen avoidance, pharmacological treatment (antihistamines and steroids) and specific immunotherapy. Long-term follow-up on immunotherapy studies demonstrates that specific immunotherapy for 3 years shows persistent long-term effects on clinical symptoms after termination of treatment and long-term, preventive effects on later development of asthma in children with seasonal rhinoconjunctivitis. It is so far the only treatment for allergic diseases that has been shown to be able to prevent worsening of disease and development of asthma. Also, specific immunotherapy seems to reduce the development of new allergic sensitivities as measured by the skin prick test as well as specific IgE measurements. SUMMARY: Specific immunotherapy is the only treatment that interferes with the basic pathophysiological mechanisms of the allergic disease and thereby carries the potential for changes in the long-term prognosis of respiratory allergy. Specific immunotherapy should be recognized not only as first-line therapeutic treatment for allergic rhinoconjunctivitis, but also as secondary preventive treatment for respiratory allergic diseases.

Automating the Incremental Evolution of Controllers for Physical Robots.

Evolutionary robotics is challenged with some key problems that must be solved, or at least mitigated extensively, before it can fulfill some of its promises to deliver highly autonomous and adaptive robots. The reality gap and the ability to transfer phenotypes from simulation to reality constitute one such problem. Another lies in the embodiment of the evolutionary processes, which links to the first, but focuses on how evolution can act on real agents and occur independently from simulation, that is, going from being, as Eiben, Kernbach, & Haasdijk [2012, p. 261] put it, "the evolution of things, rather than just the evolution of digital objects.…" The work presented here investigates how fully autonomous evolution of robot controllers can be realized in hardware, using an industrial robot and a marker-based computer vision system. In particular, this article presents an approach to automate the reconfiguration of the test environment and shows that it is possible, for the first time, to incrementally evolve a neural robot controller for different obstacle avoidance tasks with no human intervention. Importantly, the system offers a high level of robustness and precision that could potentially open up the range of problems amenable to embodied evolution.