Pleural Effusion and Malnutrition Are Associated With Worse Early Outcomes After Liver Transplant.

INTRODUCTION: Pulmonary complications after liver transplantation (LT) have previously been associated with longer hospital stays and ventilator time, and higher mortality. This study reports the outcomes for a specific pulmonary complication, pleural effusion, in LT recipients. METHODS: Records from a single transplant center were analyzed retrospectively for all adult LT patients. Patients with documented pleural effusion by radiographic imaging within 30 days pre- or post-transplant were considered as cases. Outcomes included length of hospital stay, discharge disposition, hospital readmission, discharge with home oxygen, and 1-year survival. RESULTS: During the 4-year study period, 512 LTs were performed, with 107 patients (21%) developing a peri-transplant pleural effusion. In total, 49 patients (10%) had a pre-transplant effusion, 91 (18%) had a post-transplant effusion, and 32 (6%) had both. Characteristics associated with the presence of any pleural effusion included an increasing model for end-stage liver disease score, re-transplantation, diagnosis of alcoholic liver disease, low protein levels, and sarcopenia. Effusion patients had longer hospital stays (17 vs 9 days, P < .001) and higher likelihood of discharge to a care facility (48% vs 21%, P < .001). Ninety-day readmission occurred in 69% of effusion patients (vs 44%, P < .001). One-year patient survival with any effusion was 86% (vs 94%, P < .01). CONCLUSIONS: Overall, 21% of recipients developed a clinically significant peri-transplant pleural effusion. Pleural effusion was associated with worse outcomes for all clinical measures. Risk factors for the development of pleural effusion included higher MELD score (>20), re-transplantation, alcoholic liver disease, and poor nutrition status, including poor muscle mass.

Addressing the global snakebite crisis with geo-spatial analyses - Recent advances and future direction.

Venomous snakebite is a neglected tropical disease that annually leads to hundreds of thousands of deaths or long-term physical and mental ailments across the developing world. Insufficient data on spatial variation in snakebite risk, incidence, human vulnerability, and accessibility of medical treatment contribute substantially to ineffective on-ground management. There is an urgent need to collect data, fill knowledge gaps and address on-ground management problems. The use of novel, and transdisciplinary approaches that take advantage of recent advances in spatio-temporal models, 'big data', high performance computing, and fine-scale spatial information can add value to snakebite management by strategically improving our understanding and mitigation capacity of snakebite. We review the background and recent advances on the topic of snakebite related geospatial analyses and suggest avenues for priority research that will have practical on-ground applications for snakebite management and mitigation. These include streamlined, targeted data collection on snake distributions, snakebites, envenomings, venom composition, health infrastructure, and antivenom accessibility along with fine-scale models of spatio-temporal variation in snakebite risk and incidence, intraspecific venom variation, and environmental change modifying human exposure. These measures could improve and 'future-proof' antivenom production methods, antivenom distribution and stockpiling systems, and human-wildlife conflict management practices, while simultaneously feeding into research on venom evolution, snake taxonomy, ecology, biogeography, and conservation.

Further definition of the proximal 19p13.3 microdeletion/microduplication syndrome and implication of PIAS4 as the major contributor.

The proximal 19p13.3 microdeletion/microduplication (prox19p13.3del/dup) syndrome is a recently described disorder with common clinical features including developmental delay, intellectual disability, speech delay, facial dysmorphic features with ear defects, anomalies of the hands and feet, umbilical hernia and hypotonia. While deletions are associated with macrocephaly, patients with duplications have microcephaly. The smallest region of overlap in multiple patients (113.5 kb) included three genes and one pseudogene, with a suggested major role of PIAS4 in determination of the phenotype and head size in these patients. Here, we refine the prox19p13.3del/dup with four additional patients: two with microdeletions, one with microduplication and one family with single-nucleotide nonsense variant in PIAS4. The patient with the PIAS4 loss of function variant displayed a phenotype quite similar to deletion patients -including the macrocephaly and many other core features of the syndrome. Patient's SNV was inherited from her mother who is similarly affected. Thus, our data indicate that PIAS4 is a major contributor to the proximal 19p13.3del/dup syndrome phenotype. In summary, we report the first patient with a pathogenic variant in PIAS4- and three additional rearrangements at the proximal 19p13.3 locus. These observations add further evidence about the molecular basis of this microdeletion/microduplication syndrome.

Estimating snakebite incidence from mathematical models: A test in Costa Rica.

BACKGROUND: Snakebite envenoming is a neglected public health challenge that affects mostly economically deprived communities who inhabit tropical regions. In these regions, snakebite incidence data is not always reliable, and access to health care is scare and heterogeneous. Thus, addressing the problem of snakebite effectively requires an understanding of how spatial heterogeneity in snakebite is associated with human demographics and snakes' distribution. Here, we use a mathematical model to address the determinants of spatial heterogeneity in snakebite and we estimate snakebite incidence in a tropical country such as Costa Rica. METHODS AND FINDINGS: We combined a mathematical model that follows the law of mass action, where the incidence is proportional to the exposed human population and the venomous snake population, with a spatiotemporal dataset of snakebite incidence (Data from year 1990 to 2007 for 193 districts) in Costa Rica. This country harbors one of the most dangerous venomous snakes, which is the Terciopelo (Bothrops asper, Garman, 1884). We estimated B. asper distribution using a maximum entropy algorithm, and its abundance was estimated based on field data. Then, the model was adjusted to the data using a lineal regression with the reported incidence. We found a significant positive correlation (R2 = 0.66, p-value < 0.01) between our estimation and the reported incidence, suggesting the model has a good performance in estimating snakebite incidence. CONCLUSIONS: Our model underscores the importance of the synergistic effect of exposed population size and snake abundance on snakebite incidence. By combining information from venomous snakes' natural history with census data from rural populations, we were able to estimate snakebite incidence in Costa Rica. The model was able to fit the incidence data at fine administrative scale (district level), which is fundamental for the implementation and planning of management strategies oriented to reduce snakebite burden.

PIAS4 is associated with macro/microcephaly in the novel interstitial 19p13.3 microdeletion/microduplication syndrome.

Array comparative genomic hybridization (aCGH) is a powerful genetic tool that has enabled the identification of novel imbalances in individuals with intellectual disability (ID), autistic disorders and congenital malformations. Here we report a 'genotype first' approach using aCGH on 13 unrelated patients with 19p13.3 submicroscopic rearrangement (11 deletions and 2 duplications) and review cases in the literature and in public databases. Shared phenotypic features suggest that these patients represent an interstitial microdeletion/microduplication syndrome at 19p13.3. Common features consist of abnormal head circumference in most patients (macrocephaly with the deletions and microcephaly with the duplications), ID with developmental delay (DD), hypotonia, speech delay and common dysmorphic features. The phenotype is associated with at least a ~0.113 Mb critical region harboring three strong candidate genes probably associated with DD, ID, speech delay and other dysmorphic features: MAP2K2, ZBTB7A and PIAS4, an E3 ubiquitin ligase involved in the ubiquitin signaling pathways, which we hypothesize for the first time to be associated with head size in humans.

Mutations in the human UBR1 gene and the associated phenotypic spectrum.

Johanson-Blizzard syndrome (JBS) is a rare, autosomal recessive disorder characterized by exocrine pancreatic insufficiency, typical facial features, dental anomalies, hypothyroidism, sensorineural hearing loss, scalp defects, urogenital and anorectal anomalies, short stature, and cognitive impairment of variable degree. This syndrome is caused by a defect of the E3 ubiquitin ligase UBR1, which is part of the proteolytic N-end rule pathway. Herein, we review previously reported (n = 29) and a total of 31 novel UBR1 mutations in relation to the associated phenotype in patients from 50 unrelated families. Mutation types include nonsense, frameshift, splice site, missense, and small in-frame deletions consistent with the hypothesis that loss of UBR1 protein function is the molecular basis of JBS. There is an association of missense mutations and small in-frame deletions with milder physical abnormalities and a normal intellectual capacity, thus suggesting that at least some of these may represent hypomorphic UBR1 alleles. The review of clinical data of a large number of molecularly confirmed JBS cases allows us to define minimal clinical criteria for the diagnosis of JBS. For all previously reported and novel UBR1 mutations together with their clinical data, a mutation database has been established at LOVD.

Diagnosis of familial Wolf-Hirschhorn syndrome due to a paternal cryptic chromosomal rearrangement by conventional and molecular cytogenetic techniques.

The use of conventional cytogenetic techniques in combination with fluorescent in situ hybridization (FISH) and single-nucleotide polymorphism (SNP) microarrays is necessary for the identification of cryptic rearrangements in the diagnosis of chromosomal syndromes. We report two siblings, a boy of 9 years and 9 months of age and his 7-years- and 5-month-old sister, with the classic Wolf-Hirschhorn syndrome (WHS) phenotype. Using high-resolution GTG- and NOR-banding karyotypes, as well as FISH analysis, we characterized a pure 4p deletion in both sibs and a balanced rearrangement in their father, consisting in an insertion of 4p material within a nucleolar organizing region of chromosome 15. Copy number variant (CNV) analysis using SNP arrays showed that both siblings have a similar size of 4p deletion (~6.5 Mb). Our results strongly support the need for conventional cytogenetic and FISH analysis, as well as high-density microarray mapping for the optimal characterization of the genetic imbalance in patients with WHS; parents must always be studied for recognizing cryptic balanced chromosomal rearrangements for an adequate genetic counseling.

Infection and seroconversion of susceptible animals introduced into a babesiosis endemic area.

The study aimed to determine the incubation period of Babesia sp. infection in naive cattle and to monitor the serological response once exposed to natural Boophilus microplus (Rhipicephalus microplus)-infested paddocks. The study was carried out on a farm located in Veracruz, Mexico. Five groups of five steers were relocated every 3 months from a tick-free area to a tick-infested paddock. Animals were introduced in October, January, April, July, and October. Blood samples were taken daily until day 21 to determine packed cell volume (PCV), percentage of parasitized erythrocytes (PPE), and antibody titers to Babesia bigemina and B. bovis by the indirect fluorescent antibody procedure. Detection of Babesia in blood was also performed by species-specific PCR. The estimated incubation period was 6-14 days post introduction to paddocks (PIP), with fever (41 degrees C) for at least 3 days. PCV decreased by >25% and Babesia parasites were observed during the clinical phase of the disease. The highest individual PPEs (0.44% and 0.22% for B. bovis and B. bigemina, respectively) were observed from animals introduced in October. The four other groups showed a mean PPE ranging from 0.002-0.146% at day 14 PIP. All animals were detected as PCR positive between 8-14 days PIP. The highest antibody titers were 1:3328. The environmental conditions were favorable throughout the year for tick reproduction as the farm showed enzootic stability and hyperendemic conditions for bovine babesiosis. In this type of farm, strategic tick control could be accompanied by babesiosis vaccination, particularly for cattle relocated from tick-free areas.

Bovine babesiosis live vaccine production: use of gamma irradiation on the substrate.

Gamma irradiation on bovine serum and red blood cells (RBC) allows proliferation and growth of in vitro-cultured Babesia sp., and has potential application to inactivate contaminating viruses and bacteria from the substrate. Gamma irradiation with 25 kGy in a source of (60)Co was able to inactivate infectious bovine rinotracheitis (IBR) and bovine viral diarrhea (BVD) viruses in artificially contaminated serum; besides, bacteria were also eliminated. In vitro culture of Babesia bovis (B. bovis) in modified substrate, by adding irradiated serum with (60)Co at 25 kGy was propagated from 24-well culture plates to 225 cm(2) tissue culture flasks, and percentages of parasitized erythrocytes (PPE) from 2.4% to 8.8% were obtained. Infected RBC adapted to Irrad S were transferred to the irradiated substrate in vitro culture system, by using serum irradiated at 25 kGy and RBC from 10 to 70 Gy. The PPE ranged from 3.1 to 11. Culture of Babesia bigemina (B. bigemina) was established with Irrad S (25 kGy); its propagation was achieved in tissue culture flasks reaching PPE from 0.5 to 4.3 with no statistical difference (P > 0.05) when compared to the nonirradiated control culture (1.2-4.8). B. bigemina-infected RBCs were transferred to the modified culture system by adding irradiated serum and RBC (25 kGy and 70 Gy, respectively). PPE obtained in culture flasks were from 0.8 to 4.2. The results indicate that gamma irradiation is a suitable method to inactivate potential viral contamination and eliminate bacteria from bovine serum, to produce a live attenuated vaccine through the in vitro culture.

Field challenge of cattle vaccinated with a combined Babesia bovis and Babesia bigemina frozen immunogen.

To determine the optimal dose of a combined, frozen immunogen containing in vitro culture-derived strains of Babesia bovis and Babesia bigemina, twenty-four 14-month-old Bos taurus steers from a Boophilus microplus-free area in Northern Mexico were used in this experiment. Cattle were randomly allocated into six groups with four animals each, and were intramuscularly inoculated as follows: group 1 (control animals) were administered with normal bovine erythrocytes; group 2 received 1 x 10(7) B. bovis- and B. bigemina-infected erythrocytes as a combined fresh immunogen. Groups 3-6 were inoculated with a combined frozen immunogen containing (previous to cryopreservation at -196 degrees C) 1 x 10(7), 5 x 10(7), 1 x 10(8), and 5 x 10(8) infected erythrocytes of each parasite species, respectively. Four months after immunization, principal and control animals were translocated to a bovine babesiosis endemic zone for field challenge. This was carried out by introducing the experimental cattle to tick-infested pastures for 30 days without ixodicide treatment. Cattle were monitored from day 8 postintroduction to the field (PIF) by recording the manifestation of clinical disease, rectal temperature values (RT), packed cell volume index (PCV), and percent of parasitized erythrocytes (PPE). At challenge, all experimental cattle became infected with both Babesia bovis and B. bigemina. However, except for two animals from group 6, none of the vaccinated animals showed signs of acute clinical babesiosis; therefore, no treatment was instituted. Out of six animals showing acute clinical babesiosis (four group 1 controls and two group 6 vaccinates), two animals (one from each group) died, despite babesiacide treatment, as they manifested classical cerebral babesiosis caused by B. bovis. Regardless of the dose or type of immunogen used (combined fresh or frozen), 90% of vaccinated cattle were determined to be protected against the virulent Babesia sp. field isolates. Nevertheless, by evaluating clinical parameters, such as average of maximum drop in PVC index (28.5%), average duration of parasitemia (3 days for B. bovis; 8.5 days for B. bigemina), and average duration of RT values > or = 39.5 degrees C (2 days), animals receiving 1 x 10(8) infected erythrocytes, as combined frozen immunogen, were more efficaciously protected against challenge with virulent B. bovis and B. bigemina field isolates.

Molecular epidemiology of bovine anaplasmosis

Bovine anaplasmosis presents a worldwide distribution. However, specific models for studying the epidemiology of the disease are not available. Epidemiological modeling encounters some difficulties due to a lack of culturing techniques for Anaplasma marginales, the causative agent, as well as for the lack of typing techniques to characterize strains. The chronic carrier state and the population dynamics of mechanical and biological vector also create difficulties. In addition, conventional serology and blood smear diagnostic techniques fail to detect all chronica carriers. Fortunately the needs for the accurate typing of isolates and for detecting chronica carriers made it possible to encourage the development of new tools based on molecular epidemiology principles. A. marginali isolates can now be typed by using panels of monoclonal antibodies, and the genes coding for some major surface proteins can be expressed or analyzed by looking at the nucleotide arrangement level. In the same manner, the latest techniques for detecting A. marginale chronic infections use DNA and RNA probes, and PCR-based methods to detect A. marginali DNA from bovine blood samples with extremely low rickettsaemias. Currently all these new epidemiological tools are being incroporated to experimental models to analyze their applicability for epidemiological studies in the near future

Evaluation of a colorimetric Babesia bigemina-DNA probe within an epidemiological survey

An epidemiological survey was conducted in south east Mexico, in an effort to establish the serological reactivity and carrier status to Babesia bigemina of an indigenous cattle population. The prevalance was obtained through the Indirect Fluorescent Antibody Test (IFAT), using an in vitro culture-derived B. bigemina antigen. A specific, digoxigenin-coupled, ~6kb B. bigemina-DNA probe (BBDP), was used to indicate the presence of the parasite. Serum samples from 925 animals of all ages, were obtained within the three regions (I, II, III) of the state of Yucatan and tested by IFAT. In addition, whole blood samples draw from 136 of the same animals of region II were analyzed using the BBDP. Positive IFAT (IFAT+) reactions were observed in 531 sera for a 57% overall prevalence. Regional values were: I = 157 + (56%), II = 266 + (68%) and III = 108 + (42%). Only 32 (23%) of the blood samples tested with BBDP showed distinctive hybridization signal, in contrast with 100 (73%) IFAT + animals. The responses distribution for IFAT vs. BBDP was: +/+ 23, +/- 77, -/+ 9 and -/- 27 respectively. It was found that the analytical sinsitivity of BBDP appears to be low for its utilization is widespread epidemiological surveys. It was considered, however, that the colorimetric probe mifht to be useful to safely detect transmission prone carriers, since it is able to detect parasitemias as low as 0.001

Diagnostico de la zona endemica de hidroarsenicismo cronico en la Provincia del Chaco

Diagnostico del Hidroarsenicismo cronico endemico y medidas preventivas a ser tomadas por las autoridades para evitar la alta incidencia de esta patologia en el territorio del Chaco, especialmente en las zonas aridas, carentes de rios