Using the Eat Sleep Console Model to Promote Optimal Care and Outcomes for Infants With Neonatal Abstinence Syndrome: A Nurse-Driven, Multidisciplinary Initiative.

BACKGROUND: A nurse led a team of providers in a quality improvement (QI) project to positively impact inpatient care and outcomes for infants with neonatal abstinence syndrome (NAS). The Eat Sleep Console (ESC) model was implemented to promote rooming-in and family-centered care as part of a nonpharmacological treatment approach. PURPOSE: To compare the ESC model with the traditional Finnegan treatment approach to describe differences in infants' pharmacotherapy use (morphine), length of stay (LOS), weight loss, consumption of mother's own milk by any feeding method within 24 hours of discharge, Neonatal Intensive Care Unit (NICU) use, and Pediatric Unit utilization. METHODS: The QI project was conducted at a single hospital site with more than 1700 deliveries per year in the Midwestern United States. A comparative effectiveness study design was used to evaluate the ESC model. RESULTS: The ESC model impacted care and outcomes for infants with NAS, contributing to a significant reduction in morphine treatment, decrease in LOS among morphine-treated infants, increase in weight loss in infants who did not require morphine treatment, less NICU use, and greater Pediatric Unit utilization. A nonsignificant increase was found in the number of infants who consumed their mother's own milk by any feeding method in the 24-hour period prior to discharge. IMPLICATIONS FOR PRACTICE AND RESEARCH: Results may be helpful for hospitals striving to optimize care for infants exposed to opioids, using assessments of eating, sleeping, and consoling to guide individualized treatment decisions and to reduce morphine use.

Neutrophils use superoxide to control bacterial infection at a distance.

Understanding the roles of neutrophils and macrophages in fighting bacterial infections is a critical issue in human pathologies. Although phagocytic killing has been extensively studied, little is known about how bacteria are eliminated extracellularly in live vertebrates. We have recently developed an infection model in the zebrafish embryo in which leukocytes cannot reach the injected bacteria. When Escherichia coli bacteria are injected within the notochord, both neutrophils and macrophages are massively recruited during several days, but do not infiltrate the infected tissue presumably because of its tough collagen sheath. Nevertheless, the bacteria are killed during the first 24 hours, and we report here that neutrophils, but not macrophages are involved in the control of the infection. Using genetic and chemical approaches, we show that even in absence of phagocytosis, the bactericidal action relies on NADPH oxidase-dependent production of superoxide in neutrophils. We thus reveal a host effector mechanism mediated by neutrophils that eliminates bacteria that cannot be reached by phagocytes and that is independent of macrophages, NO synthase or myeloperoxidase.

Mycobacterium abscessus-Induced Granuloma Formation Is Strictly Dependent on TNF Signaling and Neutrophil Trafficking.

Mycobacterium abscessus is considered the most common respiratory pathogen among the rapidly growing non-tuberculous mycobacteria. Infections with M. abscessus are increasingly found in patients with chronic lung diseases, especially cystic fibrosis, and are often refractory to antibiotic therapy. M. abscessus has two morphotypes with distinct effects on host cells and biological responses. The smooth (S) variant is recognized as the initial airway colonizer while the rough (R) is known to be a potent inflammatory inducer associated with invasive disease, but the underlying immunopathological mechanisms of the infection remain unsolved. We conducted a comparative stepwise dissection of the inflammatory response in S and R pathogenesis by monitoring infected transparent zebrafish embryos. Loss of TNFR1 function resulted in increased mortality with both variants, and was associated with unrestricted intramacrophage bacterial growth and decreased bactericidal activity. The use of transgenic zebrafish lines harboring fluorescent macrophages and neutrophils revealed that neutrophils, like macrophages, interact with M. abscessus at the initial infection sites. Impaired TNF signaling disrupted the IL8-dependent neutrophil mobilization, and the defect in neutrophil trafficking led to the formation of aberrant granulomas, extensive mycobacterial cording, unrestricted bacterial growth and subsequent larval death. Our findings emphasize the central role of neutrophils for the establishment and maintenance of the protective M. abscessus granulomas. These results also suggest that the TNF/IL8 inflammatory axis is necessary for protective immunity against M. abscessus and may be of clinical relevance to explain why immunosuppressive TNF therapy leads to the exacerbation of M. abscessus infections.

Morphogenesis and cell fate determination within the adaxial cell equivalence group of the zebrafish myotome.

One of the central questions of developmental biology is how cells of equivalent potential-an equivalence group-come to adopt specific cellular fates. In this study we have used a combination of live imaging, single cell lineage analyses, and perturbation of specific signaling pathways to dissect the specification of the adaxial cells of the zebrafish embryo. We show that the adaxial cells are myogenic precursors that form a cell fate equivalence group of approximately 20 cells that consequently give rise to two distinct sub-types of muscle fibers: the superficial slow muscle fibers (SSFs) and muscle pioneer cells (MPs), distinguished by specific gene expression and cell behaviors. Using a combination of live imaging, retrospective and indicative fate mapping, and genetic studies, we show that MP and SSF precursors segregate at the beginning of segmentation and that they arise from distinct regions along the anterior-posterior (AP) and dorsal-ventral (DV) axes of the adaxial cell compartment. FGF signaling restricts MP cell fate in the anterior-most adaxial cells in each somite, while BMP signaling restricts this fate to the middle of the DV axis. Thus our results reveal that the synergistic actions of HH, FGF, and BMP signaling independently create a three-dimensional (3D) signaling milieu that coordinates cell fate within the adaxial cell equivalence group.

Dynamics of macrophage polarization support Salmonella persistence in a whole living organism.

Numerous intracellular bacterial pathogens interfere with macrophage function, including macrophage polarization, to establish a niche and persist. However, the spatiotemporal dynamics of macrophage polarization during infection within host remain to be investigated. Here, we implement a model of persistent Salmonella Typhimurium infection in zebrafish, which allows visualization of polarized macrophages and bacteria in real time at high resolution. While macrophages polarize toward M1-like phenotype to control early infection, during later stages, Salmonella persists inside non-inflammatory clustered macrophages. Transcriptomic profiling of macrophages showed a highly dynamic signature during infection characterized by a switch from pro-inflammatory to anti-inflammatory/pro-regenerative status and revealed a shift in adhesion program. In agreement with this specific adhesion signature, macrophage trajectory tracking identifies motionless macrophages as a permissive niche for persistent Salmonella. Our results demonstrate that zebrafish model provides a unique platform to explore, in a whole organism, the versatile nature of macrophage functional programs during bacterial acute and persistent infections.

Risk of mortality among patients with alcohol-associated hepatitis in the US from 2007 to 2021.

BACKGROUND/AIMS: Alcohol-associated hepatitis (AH) mortality and risk factors have not been carefully studied in real-world settings. We examined the rate, temporal trend, and risk factors of mortality in AH. METHODS: We conducted a cohort study of individuals with AH diagnoses using medical claims data from Optum's Clinformatics® Data Mart (CDM). Participants were individuals covered by Medicare Advantage and commercial insurance policies. Cases were identified using diagnostic codes. Cox regressions were used to estimate 90 and 180-day mortality rates by hospitalization status. RESULTS: The cohort included 32,001 patients (72% men) who had at least one year of continuous insurance coverage prior to AH diagnoses. Of these, 20,912 were hospitalized within seven days of diagnosis. Ninety and 180-day mortality rates were 12.0% (95% CI [11.6%, 12.5%]) and 16.0% (95% CI [15.4%, 16.5%]), respectively, for the hospitalized patients and 3.1% (95% CI [2.8%, 3.4%]) and 5.1% (95% CI [4.6%, 5.5%]) for the non-hospitalized patients. Pre-existing liver disease, even in a mild form, was associated with an increased risk of death. In hospitalized patients, a history of mild liver disease was associated with a 24% increase in 180-day mortality risk (HR = 1.24, 95% CI: [1.14, 1.36]). Moderate-to-severe liver disease was associated with a more than doubled risk (HR = 2.33, 95% CI: [2.12, 2.56]). CONCLUSIONS: History of liver disease was associated with significantly increased AH mortality. The finding highlights the chronic disease context of AH and suggests that prior diagnosis of liver disease should be considered for prognosis and targeted prevention.

Fgf-dependent glial cell bridges facilitate spinal cord regeneration in zebrafish.

Adult zebrafish show a remarkable capacity to regenerate their spinal column after injury, an ability that stands in stark contrast to the limited repair that occurs within the mammalian CNS post-injury. The reasons for this interspecies difference in regenerative capacity remain unclear. Here we demonstrate a novel role for Fgf signaling during glial cell morphogenesis in promoting axonal regeneration after spinal cord injury. Zebrafish glia are induced by Fgf signaling, to form an elongated bipolar morphology that forms a bridge between the two sides of the resected spinal cord, over which regenerating axons actively migrate. Loss of Fgf function inhibits formation of this "glial bridge" and prevents axon regeneration. Despite the poor potential for mammalian axonal regeneration, primate astrocytes activated by Fgf signaling adopt a similar morphology to that induced in zebrafish glia. This suggests that differential Fgf regulation, rather than intrinsic cell differences, underlie the distinct responses of mammalian and zebrafish glia to injury.

Segmentation-based tracking of macrophages in 2D＋time microscopy movies inside a living animal.

The automated segmentation and tracking of macrophages during their migration are challenging tasks due to their dynamically changing shapes and motions. This paper proposes a new algorithm to achieve automatic cell tracking in time-lapse microscopy macrophage data. First, we design a segmentation method employing space-time filtering, local Otsu's thresholding, and the SUBSURF (subjective surface segmentation) method. Next, the partial trajectories for cells overlapping in the temporal direction are extracted in the segmented images. Finally, the extracted trajectories are linked by considering their direction of movement. The segmented images and the obtained trajectories from the proposed method are compared with those of the semi-automatic segmentation and manual tracking. The proposed tracking achieved 97.4% of accuracy for macrophage data under challenging situations, feeble fluorescent intensity, irregular shapes, and motion of macrophages. We expect that the automatically extracted trajectories of macrophages can provide pieces of evidence of how macrophages migrate depending on their polarization modes in the situation, such as during wound healing.

Molecular Actors of Inflammation and Their Signaling Pathways: Mechanistic Insights from Zebrafish.

Inflammation is a hallmark of the physiological response to aggressions. It is orchestrated by a plethora of molecules that detect the danger, signal intracellularly, and activate immune mechanisms to fight the threat. Understanding these processes at a level that allows to modulate their fate in a pathological context strongly relies on in vivo studies, as these can capture the complexity of the whole process and integrate the intricate interplay between the cellular and molecular actors of inflammation. Over the years, zebrafish has proven to be a well-recognized model to study immune responses linked to human physiopathology. We here provide a systematic review of the molecular effectors of inflammation known in this vertebrate and recapitulate their modes of action, as inferred from sterile or infection-based inflammatory models. We present a comprehensive analysis of their sequence, expression, and tissue distribution and summarize the tools that have been developed to study their function. We further highlight how these tools helped gain insights into the mechanisms of immune cell activation, induction, or resolution of inflammation, by uncovering downstream receptors and signaling pathways. These progresses pave the way for more refined models of inflammation, mimicking human diseases and enabling drug development using zebrafish models.

Quantifying patient experiences with therapeutic neurorehabilitation technologies: a scoping review.

PURPOSE: Neurorehabilitation technologies are a novel approach to providing rehabilitation for patients with neurological conditions. There is a need to explore patient experiences. This study aimed; 1) To identify available questionnaires that assess patients' experiences with neurorehabilitation technologies, and 2) where reported, to document the psychometric properties of the identified questionnaires. MATERIALS AND METHODS: Four databases were searched (Medline, Embase, Emcare and PsycInfo). The inclusion criteria were all types of primary data collection that included neurological patients of all ages who had experienced therapy with neurorehabilitation technologies and completed questionnaires to assess these experiences. RESULTS: Eighty-eight publications were included. Fifteen different questionnaires along with many self-developed scales were identified. These were categorised as; 1) self-developed tools, 2) specific questionnaire for a particular technology, and 3) generic questionnaires originally developed for a different purpose. The questionnaires were used to assess various technologies, including virtual reality, robotics, and gaming systems. Most studies did not report any psychometric properties. CONCLUSION: Many tools have been used to evaluate patient experiences, but few were specifically developed for neurorehabilitation technologies and psychometric data was limited. A preliminary recommendation would be use of the User Satisfaction Evaluation Questionnaire to evaluate patient experience with virtual reality systems.Implications for Rehabilitation:Fifteen unique tools evaluating patient experiences with neurorehabilitation technology were identifiedThe User Satisfaction Evaluation and ArmAssist Usability Assessment were designed specifically for therapeutic neurorehabilitation technologyFor all identified tools, psychometric data were poorly reported or not availableA preliminary recommendation is to use the User Satisfaction Evaluation Questionnaire for evaluating virtual reality systems.

An arginase 2 promoter transgenic line illuminates immune cell polarisation in zebrafish.

Innate immune responses to inflammation and infection are complex and represent major challenges for developing much needed new treatments for chronic inflammatory diseases and drug-resistant infections. To be ultimately successful, the immune response must be balanced to allow pathogen clearance without excess tissue damage, processes controlled by pro- and anti-inflammatory signals. The roles of anti-inflammatory signalling in raising an appropriate immune response are underappreciated, representing overlooked potential drug targets. This is especially true in neutrophils, a difficult cell type to study ex vivo owing to a short lifespan, dogmatically seen as being highly pro-inflammatory. Here, we have generated and describe the first zebrafish transgenic line [TgBAC(arg2:eGFP)sh571] that labels expression of the anti-inflammatory gene arginase 2 (arg2) and show that a subpopulation of neutrophils upregulate arginase soon after immune challenge with injury and infection. At wound-healing stages, arg2:GFP is expressed in subsets of neutrophils and macrophages, potentially representing anti-inflammatory, polarised immune cell populations. Our findings identify nuanced responses to immune challenge in vivo, responses that represent new opportunities for therapeutic interventions during inflammation and infection.

Identification of a pharyngeal mucosal lymphoid organ in zebrafish and other teleosts: Tonsils in fish?

The constant exposure of the fish branchial cavity to aquatic pathogens causes local mucosal immune responses to be extremely important for their survival. Here, we used a marker for T lymphocytes/natural killer (NK) cells (ZAP70) and advanced imaging techniques to investigate the lymphoid architecture of the zebrafish branchial cavity. We identified a sub-pharyngeal lymphoid organ, which we tentatively named "Nemausean lymphoid organ" (NELO). NELO is enriched in T/NK cells, plasma/B cells, and antigen-presenting cells embedded in a network of reticulated epithelial cells. The presence of activated T cells and lymphocyte proliferation, but not V(D)J recombination or hematopoiesis, suggests that NELO is a secondary lymphoid organ. In response to infection, NELO displays structural changes including the formation of T/NK cell clusters. NELO and gill lymphoid tissues form a cohesive unit within a large mucosal lymphoid network. Collectively, we reveal an unreported mucosal lymphoid organ reminiscent of mammalian tonsils that evolved in multiple teleost fish families.

Identification and Evaluation of the Growth Promotion of Endophytic Bacteria on in vitro Potato Plants.

<b>Background and Objective:</b> Isolation and investigation of plant growth promoting bacteria on potato plants can provide significant information for the application of beneficial bacteria in potato production. This study aims to isolate and characterize endophytic bacteria isolated from potato roots. In addition, the potential application of endophytes in promoting potato growth under <i>in vitro</i> conditions was also investigated. <b>Materials and Methods:</b> The roots from 15 healthy potato plants were excised and surface sterilized by NaOCl and finally rinsed by sterilized water. The confirmed surface-sterilized roots were then aseptically cut into small fragments and spread onto the isolation media, followed by incubation at 27°C for up to 3 days. Six isolates that showed differences in colony morphology were selected for further investigation. All isolates were screened for IAA production, nitrogen fixation, and phosphate solubilization. <b>Results:</b> Five of the isolates were identified as <i>Bacillus</i> and isolate 30 was identified as <i>Paenibacillus alvei</i>. All isolates exhibited good IAA production. While Iso-27 had no nitrogen fixation activity, Iso-28 showed the highest level of nitrogen fixation activity (3.59 mg L¹), four isolates (Iso-9, Iso-10, Iso-11, Iso-28) could solubilize phosphate, ranging from 49.64 g L¹ to 67.98 mg L¹. After being inoculated with <i>in vitro</i> potato plants, isolates 9, 10, 28, 30, improved the stalk length, root number, fresh mass and dried mass of the potato plants. <b>Conclusion:</b> The four isolates can potentially be applied in <i>in vitro</i> potato culture.

Ontogenetic Changes in Blood Osmolality During the Postembryonic Development of Zebrafish (Danio rerio).

The zebrafish Danio rerio is a teleost model species widely used in developmental genetics, biomedical studies, toxicology, and drug screening. Despite the interest of this species in research, little is known through indirect observations about its blood osmolality, which is a key parameter for diverse experiments. In this study, we directly measured blood osmolality using nano-osmometry at different stages of zebrafish postembryonic development. We found that blood osmolality is close to 240 mOsm·kg-1 in early larvae. It progressively increased to ∼270 mOsm·kg-1 during the larval development before reaching ∼300 mOsm·kg-1 after metamorphosis in juveniles and later in adults. These ontogenetic changes in blood osmolality illustrate the physiological changes in osmoregulation associated with postembryonic development, including metamorphosis. These values are of practical interest for adjusting the osmolality of fixatives and cell and tissue culture media for research using zebrafish as a model.

Preparing sequencing grade RNAs from a small number of FACS-sorted larvae macrophages isolated from enzyme free dissociated zebrafish larvae.

Macrophages are phagocytic cells from the innate immune system that are critical for tissue homeostasis and form the first line of host defense against invading pathogens. The zebrafish larva is an exquisite model to decipher the transcriptional response of macrophages after injury. We used a macrophage reporter line in which an mfap4 promoter drives the expression of a farnesylated mCherry fluorescent protein to label macrophages and we performed tissue dissociation, cell isolation by Fluorescence Activated Cell sorting and RNA preparation. The two bottlenecks are (i) the dissociation of the embryos that often relies on cell suspension steps that alter the activation status of immune cells, and (ii) obtaining high RNA integrity for gene expression analysis from a small number of isolated macrophages. Here, we describe (i) the dissociation of cells from whole Tg(mfap4:mCherry-F) zebrafish larvae using an enzyme-free and osmotically controlled buffer, (ii) the sorting of fluorescent macrophages by FACS and (iii) the preparation of high quality RNAs for meaningful gene expression analysis from a small number of isolated macrophages.•An optimized protocol in 5 steps to extract high quality RNAs from zebrafish macrophages.•A cell dissociation method using an enzyme-free and osmotically controlled buffer to prevent the alteration of macrophage activation status and limit cell mortality.•Production of high integrity RNAs from a small number of isolated macrophages.

Macrophages undergo a behavioural switch during wound healing in zebrafish.

In response to wound signals, macrophages are immediately recruited to the injury where they acquire distinct phenotypes and functions, playing crucial roles both in host defense and healing process. Although macrophage phenotypes have been intensively studied during wound healing, mostly using markers and expression profiles, the impact of the wound environment on macrophage shape and behaviour, and the underlying mechanisms deserve more in-depth investigation. Here, we sought to characterize the dynamics of macrophage recruitment and behaviour during aseptic wounding of the caudal fin fold of the zebrafish larva. Using a photo-conversion approach, we demonstrated that macrophages are recruited to the wounded fin fold as a single wave where they switch their phenotype. Intravital imaging of macrophage shape and trajectories revealed that wound-macrophages display a highly stereotypical set of behaviours and change their shape from amoeboid to elongated shape as wound healing proceeds. Using a pharmacological inhibitor of 15-lipoxygenase and protectin D1, a specialized pro-resolving lipid, we investigated the role of polyunsaturated fatty acid metabolism in macrophage behaviour. While inhibition of 15-lipoxygenase using PD146176 or Nordihydroguaiaretic acid (NDGA) decreases the switch from amoeboid to elongated shape, protectin D1 accelerates macrophage reverse migration and favours elongated morphologies. Altogether, our findings suggest that individual macrophages at the wound switch their phenotype leading to important changes in behaviour and shape to adapt to changing environment, and highlight the crucial role of lipid metabolism in the control of macrophage behaviour plasticity during inflammation in vivo.

RNA-binding proteins, RNA granules, and gametes: is unity strength?

Changes in mRNA translation and degradation represent post-transcriptional processes operating during gametogenesis and early embryogenesis to ensure regulated protein synthesis. Numerous mRNA-binding proteins (RBPs) have been described in multiple animal models that contribute to the control of mRNA translation and decay during oogenesis and spermatogenesis. An emerging view from studies performed in germ cells and somatic cells is that RBPs associate with their target mRNAs in RNA-protein (or ribonucleoprotein) complexes (mRNPs) that assemble in various cytoplasmic RNA granules that communicate with the translation machinery and control mRNA storage, triage, and degradation. In comparison with Xenopus, Caenorhabditis elegans, or Drosophila, the composition and role of cytoplasmic RNA-containing granules in mammalian germ cells are still poorly understood. However, regained interest for these structures has emerged with the recent discovery of their role in small RNA synthesis and transposon silencing through DNA methylation. In this review, we will briefly summarize our current knowledge on cytoplasmic RNA granules in murine germ cells and describe the role of some of the RBPs they contain in regulating mRNA metabolism and small RNA processing during gametogenesis.

Macrophage morphological plasticity and migration is Rac signalling and MMP9 dependant.

In vitro, depending on extracellular matrix (ECM) architecture, macrophages migrate either in amoeboid or mesenchymal mode; while the first is a general trait of leukocytes, the latter is associated with tissue remodelling via Matrix Metalloproteinases (MMPs). To assess whether these stereotyped migrations could be also observed in a physiological context, we used the zebrafish embryo and monitored macrophage morphology, behaviour and capacity to mobilise haematopoietic stem/progenitor cells (HSPCs), as a final functional readout. Morphometric analysis identified 4 different cell shapes. Live imaging revealed that macrophages successively adopt all four shapes as they migrate through ECM. Treatment with inhibitors of MMPs or Rac GTPase to abolish mesenchymal migration, suppresses both ECM degradation and HSPC mobilisation while differently affecting macrophage behaviour. This study depicts real time macrophage behaviour in a physiological context and reveals extreme reactivity of these cells constantly adapting and switching migratory shapes to achieve HSPCs proper mobilisation.

Pseudomonas aeruginosa OprF plays a role in resistance to macrophage clearance during acute infection.

While considered an extracellular pathogen, Pseudomonas aeruginosa has been reported to be engulfed by macrophages in cellular and animal models. However, the role of macrophages in P. aeruginosa clearance in vivo remains poorly studied. The major outer membrane porin OprF has been recently shown to be involved in P. aeruginosa fate within cultured macrophages and analysis of an oprF mutant may thus provide insights to better understand the relevance of this intramacrophage stage during infection. In the present study, we investigated for the first time the virulence of a P. aeruginosa oprF mutant in a vertebrate model that harbors functional macrophages, the zebrafish (Danio rerio) embryo, which offers powerful tools to address macrophage-pathogen interactions. We established that P. aeruginosa oprF mutant is attenuated in zebrafish embryos in a macrophage-dependent manner. Visualization and quantification of P. aeruginosa bacteria phagocytosed by macrophages after injection into closed cavities suggested that the attenuated phenotype of oprF mutant is not linked to higher macrophage recruitment nor better phagocytosis than wild-type strain. Using cultured macrophages, we showed an intramacrophage survival defect of P. aeruginosa oprF mutant, which is correlated with elevated association of bacteria with acidic compartments. Notably, treatment of embryos with bafilomycin, an inhibitor of acidification, increased the sensibility of embryos towards both wild-type and oprF mutant, and partially suppressed the attenuation of oprF mutant. Taken together, this work supports zebrafish embryo as state-of-the-art model to address in vivo the relevance of P. aeruginosa intramacrophage stage. Our results highlight the contribution of macrophages in the clearance of P. aeruginosa during acute infection and suggest that OprF protects P. aeruginosa against macrophage clearance by avoiding bacterial elimination in acidified phagosomes.

Occurrence of foamy macrophages during the innate response of zebrafish to trypanosome infections.

A tightly regulated innate immune response to trypanosome infections is critical to strike a balance between parasite control and inflammation-associated pathology. In this study, we make use of the recently established Trypanosoma carassii infection model in larval zebrafish to study the early response of macrophages and neutrophils to trypanosome infections in vivo. We consistently identified high- and low-infected individuals and were able to simultaneously characterise their differential innate response. Not only did macrophage and neutrophil number and distribution differ between the two groups, but also macrophage morphology and activation state. Exclusive to high-infected zebrafish, was the occurrence of foamy macrophages characterised by a strong pro-inflammatory profile and potentially associated with an exacerbated immune response as well as susceptibility to the infection. To our knowledge, this is the first report of the occurrence of foamy macrophages during an extracellular trypanosome infection.