Cohort-Specific Peptide Reagents Broaden Depth and Breadth Estimates of the CD8 T Cell Response to HIV-1 Gag Potential T Cell Epitopes.

An effective HIV vaccine will need to stimulate immune responses against the sequence diversity presented in circulating virus strains. In this study, we evaluate breadth and depth estimates of potential T-cell epitopes (PTEs) in transmitted founder virus sequence-derived cohort-specific peptide reagents against reagents representative of consensus and global sequences. CD8 T-cells from twenty-six HIV-1+ PBMC donor samples, obtained at 1-year post estimated date of infection, were evaluated. ELISpot assays compared responses to 15mer consensus (n = 121), multivalent-global (n = 320), and 10mer multivalent cohort-specific (n = 300) PTE peptides, all mapping to the Gag antigen. Responses to 38 consensus, 71 global, and 62 cohort-specific PTEs were confirmed, with sixty percent of common global and cohort-specific PTEs corresponding to consensus sequences. Both global and cohort-specific peptides exhibited broader epitope coverage compared to commonly used consensus reagents, with mean breadth estimates of 3.2 (global), 3.4 (cohort) and 2.2 (consensus) epitopes. Global or cohort peptides each identified unique epitope responses that would not be detected if these peptide pools were used alone. A peptide set designed around specific virologic and immunogenetic characteristics of a target cohort can expand the detection of CD8 T-cell responses to epitopes in circulating viruses, providing a novel way to better define the host response to HIV-1 with implications for vaccine development.

Comprehensive epitope mapping using polyclonally expanded human CD8 T cells and a two-step ELISpot assay for testing large peptide libraries.

The genetic diversity of circulating HIV-1 strains poses a major barrier to the design, development and evaluation of HIV-1 vaccines. The assessment of both vaccine- and natural infection-elicited T cell responses is commonly done with multivalent peptides that are designed to maximally capture the diversity of potential T cell epitopes (PTEs) observed in natural circulating sequences. However, depending on the sequence diversity of viral subtypes and number of the HIV immunogens under investigation, PTE estimates, including HLA-guided computational methods, can easily generate enormous peptide libraries. Evaluation of T cell epitope specificity using such extensive peptide libraries is usually limited by sample availability, even for high-throughput and robust epitope mapping techniques like ELISpot assays. Here we describe a novel, two-step protocol for in-vitro polyclonal expansion of CD8 T cells from a single vial of frozen PBMC, which facilitated the screening 441 HIV-1 Gag peptides for immune responses among 32 HIV-1 positive subjects and 40 HIV-1 negative subjects for peptide qualification. Using a pooled-peptide mapping strategy, epitopes were mapped in two sequential ELISpot assays; the first ELISpot screened 33 large peptide pools using CD8 T cells expanded for 7 days, while the second step tested pool-matrix peptides to identify individual peptides using CD8 T cells expanded for 10 days. This comprehensive epitope screening established the breadth and magnitude of HIV-1 Gag-specific CD8 T cells and further revealed the extent of immune responses to variable/polymorphic epitopes.

Aggressive intracerebral tuberculoma in a 1-year-old child: A case report with literature review.

The incidence of central nervous system tuberculosis is a rare entity that accounts about 1% of all tuberculosis and remains a major health problem in developing countries. We report a case of 1-year-old baby boy who presented with a three-week history of vomiting, seizure and progressive right-sided weakness. Brain magnetic resonance imaging performed on the admission day revealed a large lesion measuring (4.3*3.5cm) involving the left thalamus with extensive perilesional edema producing enfacement of third ventricle, midline shifting and obstructive hydrocephalus.

Septic Embolic Stroke Followed by Hemorrhage and Brain Abscess in a Patient with Systemic Infections: A Case Report and Literature Review.

We report a case of 50-year-old man with a severe acute ischemic stroke followed by intracerebral hemorrhage and brain abscess due to systemic infection. His initial intracranial radiographic findings were normal but three days later MRI scan of the brain revealed well-defined rounded cystic lesion on the T2-weighted and T1-weighted images in the right basal ganglia; the lesion presented an area of diffusion restriction on DWI; lately the lesion was confirmed to be an early stage of cerebral abscess. A week later the patient was noted to have worsening neurological status and left extremity weakness, and emergency brain CT scan revealed massive intracerebral hemorrhage in the right occipital lobe; he underwent intracranial hematoma evacuation surgery. The hematoma was removed successfully, and the systemic infections were treated with antibiotics.

A mixed-methods study of maternal near miss and death after emergency cesarean delivery at a referral hospital in Somaliland.

OBJECTIVE: To explore maternal near miss and death after emergency cesarean delivery in Somaliland, including the impact of the prerequisite for family consent. METHODS: A facility-based, mixed-methods study was conducted to assess all maternal near misses and deaths recorded at a referral hospital that provided services to women from all regions of Somaliland. The data sources comprised a quantitative prospective cross-sectional study using the WHO near-miss tool (performed from August 1 to December 31, 2015) and qualitative interviews with 17 healthcare providers working at the referral hospital who were in direct contact with the women in labor (performed from January 15 to March 15, 2015). RESULTS: Of the 138 maternal near misses and deaths recorded, 50 (36%) were associated with emergency cesarean delivery. The most frequent maternal complication was severe pre-eclampsia (n=17; 34%), and the most frequent underlying causes were hypertensive disorders (n=31; 62%) and obstetric hemorrhage (n=15; 30%). Healthcare providers were often prevented from performing emergency cesarean delivery until the required consent had been received from the woman's extended family. CONCLUSION: Maternity care in Somaliland must be improved, and the issue of legal authority for consent examined, to ensure both safe and timely provision of emergency cesarean delivery.

Species concepts in Cercospora: spotting the weeds among the roses.

The genus Cercospora contains numerous important plant pathogenic fungi from a diverse range of hosts. Most species of Cercospora are known only from their morphological characters in vivo. Although the genus contains more than 5 000 names, very few cultures and associated DNA sequence data are available. In this study, 360 Cercospora isolates, obtained from 161 host species, 49 host families and 39 countries, were used to compile a molecular phylogeny. Partial sequences were derived from the internal transcribed spacer regions and intervening 5.8S nrRNA, actin, calmodulin, histone H3 and translation elongation factor 1-alpha genes. The resulting phylogenetic clades were evaluated for application of existing species names and five novel species are introduced. Eleven species are epi-, lecto- or neotypified in this study. Although existing species names were available for several clades, it was not always possible to apply North American or European names to African or Asian strains and vice versa. Some species were found to be limited to a specific host genus, whereas others were isolated from a wide host range. No single locus was found to be the ideal DNA barcode gene for the genus, and species identification needs to be based on a combination of gene loci and morphological characters. Additional primers were developed to supplement those previously published for amplification of the loci used in this study. TAXONOMIC NOVELTIES: New species - Cercospora coniogrammes Crous & R.G. Shivas, Cercospora delaireae C. Nakash., Crous, U. Braun & H.D. Shin, Cercospora euphorbiae-sieboldianae C. Nakash., Crous, U. Braun & H.D. Shin, Cercospora pileicola C. Nakash., Crous, U. Braun & H.D. Shin, Cercospora vignigena C. Nakash., Crous, U. Braun & H.D. Shin. Typifications: epitypifications - Cercospora alchemillicola U. Braun & C.F. Hill, Cercospora althaeina Sacc., Cercospora armoraciae Sacc., Cercospora corchori Sawada, Cercospora mercurialis Pass., Cercospora olivascens Sacc., Cercospora violae Sacc.; neotypifications - Cercospora fagopyri N. Nakata & S. Takim., Cercospora sojina Hara.

Use of a palliative care order set to improve resident comfort with symptom management in palliative care.

Although one-fourth of all medicare dollars are spent during the last year of life, symptom management for terminal hospitalized patients has continued to be inadequate. Quality end-of-life care is often overlooked, seldom taught and rarely measured within Internal Medicine Residency Programmes. We studied the effects of a palliative care order set and educational e-mail on resident comfort. Survey of residents showed that only 54% were comfortable across nine aspects of palliative care. Three months after release, 88% of residents were using the order set and 63% believed it increased their comfort with palliative care. Resident comfort managing palliative symptoms increased an average 10% (P = 0.02). First-year residents exposed to this order set increased in comfort from 40% to 65% (P < 0.0001), which significantly surpassed the 48% of second-year residents who reported being comfortable (P = 0.002). Introducing a palliative care order set improves resident comfort with symptom management in dying patients.

Inter-individual differences in novelty-seeking behavior in rats predict differential responses to desipramine in the forced swim test.

RATIONALE: Antidepressant medications are effective only in a subpopulation of patients with depression, and some patients respond to certain drugs, but not others. The biological bases for these clinical observations remain unexplained. OBJECTIVE: To investigate individual differences in response to antidepressants, we have examined the effects of the norepinephrine reuptake inhibitor desipramine (DMI) and the selective serotonin reutake inhibitor fluoxetine (FLU) in the forced swim test (FST) in rats that differ in their emotional behavior. METHODS: As response to novelty correlates with numerous other measures of emotionality and substance abuse, we contrasted animals that are high responders (HR) in a novel environment with animals that are low responders (LR) and asked whether the two groups exhibit differential responses to DMI (10mg/kg) and FLU (20mg/kg). RESULTS: At the behavioral level, DMI caused a significant decrease in immobility in LR animals only, while FLU caused a significant reduction in immobility in both groups. Moreover, at the neural level, DMI treatment led to a decrease in FST-induced c-fos messenger RNA levels in medial prefrontal cortex (PFC) and paraventricular nucleus of the hypothalamus (PVN) in LR but not HR animals. CONCLUSIONS: Taken together, our results suggest that the HR-LR model is a useful tool to investigate individual differences in responses to norepinephrine reuptake inhibitors (NRIs) and that a differential activation of PFC and/or PVN could underlie some of the inter-individual differences in the efficacy of NRIs.

Hemoglobin H disease in the Al-Qatif Region of Saudi Arabia.

BACKGROUND: The Al-Qatif region in the Eastern province of Saudi Arabia has the highest prevalence of a-thalassemia genes in the Kingdom. Hemoglobin H (Hb H) disease, however, has been rarely reported. We decided therefore to verify the rarity of the disease, and characterize the presenting features in cases identified. PATIENTS AND METHODS: All patients seen in Qatif Central Hospital between September 1988 and November 1990 with low red cell indices were screened for Hb H disease, and those found positive had clinical data compiled from their hospital records and analyzed. RESULTS: Thirty-nine cases of Hb H were diagnosed. The mean age of the patients was 18 years. The mean hemoglobin was 13.5 g/dl for neonates and 7.6 g/dl for the others. The mean Hb Bart's level was 27.5% in neonates and the mean Hb H level in others was 11.1%. In addition to low red cell indices, all patients had a high red cell distribution width (RDW) mean of 25.6%. The main clinical signs were jaundice and hepatosplenomegaly. Concurrent glucose-6-phosphate dehydrogenase (G6PD) deficiency was seen in 28.2% of patients. CONCLUSION: Hemoglobin H disease is not uncommon in the Al-Qatif region of Saudi Arabia. The red cell indices may mimic iron deficiency, which should be excluded by the presence of jaundice and organomegaly. The condition often co-exists with G6PD deficiency.

Seroprevalence of hepatitis A virus markers in Eastern Saudi Arabia.

OBJECTIVE: To record and update the sero-epidemiological status of Hepatitis A virus in Eastern Saudi Arabia. To investigate the main viral etiology of clinical hepatitis in children and discuss the possibility of introducing a Hepatitis A virus vaccine in this Province. METHODS: Examining serum specimens by Enzyme Linkage Immuno-Sorbet Assay technique for these parameters: Immunoglobulin M anti-hepatitis A virus, total immunoglobulin anti-hepatitis A virus, and in selected cases we checked for hepatitis B surface antigen and anti-hepatitis C virus. The study was carried out in the Virology Diagnostic Labs, of Dammam Regional Laboratories & Blood Bank, Dammam. A total of 12,357 serum samples were collected from 5876 healthy children, 5798 healthy adults, and 683 from clinically diagnosed hepatitis in children. The period of study was 12 years from February 1987 to January 1999. RESULTS: Hepatitis A virus prevalence showed 3% for pre-school age, 80% in older children and 93% in adults, while total prevalence was 86%. Breaking down the prevalence among children showed 3% in the <6 years age group, 62% in the 6 - <8 years age group, 71% in the 8 - <10 years age group, 83% in the 10 - <12 years age group and 93% in the 12 - <18 years age group. While the grand total among children was 78%. The prevalence of hepatitis viruses causing clinical hepatitis in children showed: 65% for hepatis A virus, 21% for hepatitis B virus, 7% for hepatitis C virus, 2% for double infection of hepatitis B virus + hepatitis C virus and 5% for non A, non B, non C. CONCLUSION: Hepatitis A virus infection starts dramatically high in school-age children, and then rises gradually with an increase in age. This reflects that our region is of pattern I class. There is no difference in the prevalence due to seasons of year, climate or sex. Hepatitis A virus is the leading cause of clinical hepatitis in children, followed by hepatitis B virus and hepatitis C virus. There is a possibility of starting to introduce hepatitis A virus vaccine among pre-school age children, as well as among hepatitis A virus negative adults that live in a higher socioeconomic environment within the country, which can be considered as islands of pattern II among pattern I areas.

Patterns of resistance to antituberculous drugs in Eastern Province, Saudi Arabia.

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Splenic abscess and sickle cell disease.

This is a report of our experience with 10 cases of splenic abscess in patients with sickle cell disease (SCD). All presented with fever and abdominal pain and were found to have a tender enlarged spleen. Two were found to have a ruptured spleen and five of them were septicemic on presentation. Although both ultrasound and CT-scan of the abdomen were of diagnostic value, we found CT-scan more accurate and reliable in the diagnosis of splenic abscess. Ultrasound and/or CT-scan should be used routinely in the evaluation of SCD patients who present with fever and abdominal pain, especially if they have a tender enlarged spleen. Diagnostic aspiration under CT-scan or ultrasound guidance should be used in doubtful cases to differentiate between splenic abscess and a large splenic infarct. All our patients were managed by peri operative antibiotics and splenectomy with no mortality. Salmonella was the commonest causative organism. Although CT-guided aspiration of splenic abscess is being advocated recently, we feel splenectomy should be the treatment of choice in patients with SCD as there is no point in preserving a non-functioning spleen that is present in the majority of patients. CT-guided aspiration may be employed as a temporary measure for those patients who are at high surgical risk with unilocular abscess.

Sensorineural hearing loss in homozygous sickle cell disease in Qatif, Saudi Arabia.

Sensorineural hearing loss (SNHL) is a known complication of sickle cell disease (SCD). There is a paucity of information on this problem in Sausi SCD patients. A prospective controlled study was conducted over 27 months in Qatif Central Hospital. One hundred patients with sickle cell anemia (SCA), aged five to 40 years, were studied. The control group consisted of 100 healthy individuals. A detailed history, otologic and audiologic examinations were carried out on both groups. Further investigations to rule out local retrocochlear pathology were performed on those having unilateral SNHL. No case of SNHL was detected in the control group, while it was recorded in 19 (19%) of SCA patients, 13 males and six females. There was a significant association between the SNHL and the onset of first vaso-occlusive crisis at six years of age or less. There was no significant difference in the frequency of SNHL between children and adults. Twenty-one percent of patients who had SNHL completely recovered. Patients with SCD need a careful regular hearing assessment. Those detected to have SNHL need a careful plan implemented by both the clinician and otolaryngologist for proper care of this important complication.

Splenectomy in patients with sickle-cell disease.

BACKGROUND: Splenic complications of sickle-cell disease (SCD) are associated with morbidity, and in some it may lead to mortality. This paper presents our experience with 43 patients with SCD who had splenectomy as part of their management. PATIENTS AND METHODS: The records of 43 patients with SCD who had splenectomy were examined for age at operation, sex, hemoglobin (Hb) electrophoresis, indication for splenectomy, pre- and postoperative medications, operative procedures, and postoperative complications. RESULTS: The indications for splenectomy were acute splenic sequestration crisis (ASSC) in 21 patients, hypersplenism in 15, and splenic abscess in 7. In 17 patients, the spleen was also found to be massively enlarged causing discomfort and intervening with everyday activity. For those with hypersplenism, there was a significant postoperative increase in total Hb (P < 0.0001), hematocrit (P < 0.0001), white blood cells (P < 0.0001), and platelet count (P < 0.0001). CONCLUSIONS: With careful perioperative management and proper follow-up, splenectomy in patients with SCD is beneficial in reducing their transfusion requirements and its attendant risks, eliminating the discomfort from mechanical pressure of the enlarged spleen, avoiding the risks of ASSC, and managing splenic abscess.

Splenectomy and acute splenic sequestration crises in sickle cell disease.

Acute splenic sequestration crises (ASSC) is one of the complications of sickle cell disease (SCD) that can be life-threatening due to loss of blood volume. Over a 5-year period, we have treated 19 patients ranging in age from 4 to 32 years with ASSC. There were 14 males and 5 females; 17 had homozygous SCD and the other 2 had sickle thalassemia. Two patients presented with severe anemia and acute circulatory collapse; 1 of them developed residual weakness of his limbs and decreased visual acuity. Nine patients underwent splenectomy after major episodes of sequestration while the remaining 10 had recurrent minor episodes of sequestration. The clinical features and the role of splenectomy are discussed.

Cholelithiasis in children with sickle cell disease.

Abdominal ultrasonography was performed on 305 children with sickle cell disease (SCD) (285 SS and 20 S-beta-thalassemia) to establish the prevalence of cholelithiasis in Saudi children with SCD. Their ages ranged from 1 to 18 years (mean 10.45 years). Gallstones were demonstrated in 60 children, giving a prevalence of 19.7%. An additional 50 patients (16.4%) had only biliary sludge. The youngest patient with gallstones was 3 years old. There was a correlation between the presence of gallstones and increasing age. Patients with gallstones were also found to have higher serum bilirubin levels, but their hemoglobin, hematocrit, reticulocyte count, hemoglobin S, and hemoglobin F levels were not significantly different from those of patients without gallstones.