Validation of a new Aspergillus real-time PCR assay for direct detection of Aspergillus and azole resistance of Aspergillus fumigatus on bronchoalveolar lavage fluid.

Azole resistance in Aspergillus fumigatus is increasingly reported. Here, we describe the validation of the AsperGenius, a new multiplex real-time PCR assay consisting of two multiplex real-time PCRs, one that identifies the clinically relevant Aspergillus species, and one that detects the TR34, L98H, T289A, and Y121F mutations in CYP51A and differentiates susceptible from resistant A. fumigatus strains. The diagnostic performance of the AsperGenius assay was tested on 37 bronchoalveolar lavage (BAL) fluid samples from hematology patients and 40 BAL fluid samples from intensive care unit (ICU) patients using a BAL fluid galactomannan level of ≥1.0 or positive culture as the gold standard for detecting the presence of Aspergillus. In the hematology and ICU groups combined, there were 22 BAL fluid samples from patients with invasive aspergillosis (IA) (2 proven, 9 probable, and 11 nonclassifiable). Nineteen of the 22 BAL fluid samples were positive, according to the gold standard. The optimal cycle threshold value for the presence of Aspergillus was <36. Sixteen of the 19 BAL fluid samples had a positive PCR (2 Aspergillus species and 14 A. fumigatus samples). This resulted in a sensitivity, specificity, and positive and negative predictive values of 88.9%, 89.3%, 72.7%, and 96.2%, respectively, for the hematology group and 80.0%, 93.3%, 80.0%, and 93.3%, respectively, in the ICU group. The CYP51A real-time PCR confirmed 12 wild-type and 2 resistant strains (1 TR34-L98H and 1 TR46-Y121F-T289A mutant). Voriconazole therapy failed for both patients. The AsperGenius multiplex real-time PCR assay allows for sensitive and fast detection of Aspergillus species directly from BAL fluid samples. More importantly, this assay detects and differentiates wild-type from resistant strains, even if BAL fluid cultures remain negative.

Efficacy of IFN-λ1 to protect human airway epithelial cells against human rhinovirus 1B infection.

Impaired interferon (IFN) production has been observed in various obstructive respiratory diseases. This contributes to enhanced sensitivity towards viral infections triggering acute exacerbations. To compensate for this impaired host IFN response, there is need to explore new therapeutic strategies, like exogenous administration of IFNs as prophylactic treatment. In the present study, we examined the protective potential of IFN-λ1 and compared it with the previously established protecting effect of IFN-ß. A549 cells and human primary bronchial epithelial cells were first treated with either IFN-ß (500 IU/ml) or IFN-λ1 (500 ng/ml) for 18 h. For infection, two approaches were adopted: i) Continuous scenario: after pre-treatment, cells were infected immediately for 24 h with human rhinovirus 1B (HRV1B) in IFN-containing medium, or were cultured for another 72 h in IFN-containing medium, and then infected for 24 h with HRV1B, ii) Pre-treatment scenario: IFN-containing medium was replaced after 18 h and cells were infected for 4 h either immediately after pre-treatment or after additional culturing for 72 h in IFN-free medium. The protective effect was evaluated in terms of reduction in the number of viral copies/infectious progeny, and enhanced expression of IFN-stimulated genes (ISGs). In both cell types and in both approaches, IFN-λ1 and IFN-ß treatment resulted in pronounced and long-lasting antiviral effects exemplified by significantly reduced viral copy numbers and diminished infectious progeny. This was associated with strong up-regulation of multiple ISGs. However, in contrast to the IFN-ß induced expression of ISGs, which decreased over time, expression of ISGs induced by IFN-λ1 was sustained or even increased over time. Here we demonstrate that the protective potential of IFN-λ1 is comparable to IFN-ß. Yet, the long-lasting induction of ISGs by IFN-λ1 and most likely less incitement of side effects due to more localized expression of its receptors could make it an even more promising candidate for prophylactic treatment than IFN-ß.

The host immune response contributes to Haemophilus influenzae virulence.

BACKGROUND: There is compelling evidence that infections with non-typeable Haemophilus influenzae (NTHi) are associated with exacerbations in COPD patients. However, NTHi has also been isolated frequently during clinically stable disease. In this study we tested the hypothesis that genetically distinct NTHi isolates obtained from COPD patients differ in virulence which could account for dissimilarities in the final outcome of an infection (stable vs. exacerbation). RESULTS: NTHi isolates (n = 32) were obtained from stable COPD patients, or during exacerbations. Genetically divergent NTHi isolates were selected and induction of inflammation was assessed as an indicator of virulence using different in vitro models. Despite marked genomic differences among NTHi isolates, in vitro studies could not distinguish between NTHi isolates based on their inflammatory capacities. Alternatively, when using a whole blood assay results demonstrated marked inter-, but not intra-individual differences in cytokine release between healthy volunteers irrespective of the origin of the NTHi isolate used. CONCLUSION: Results suggest that the individual immune reactivity might be an important predictor for the clinical outcome (exacerbation vs. no exacerbation) following NTHi infection.

Interferon-ß induces a long-lasting antiviral state in human respiratory epithelial cells.

OBJECTIVES: Interferon-ß (IFNß) induces strong antiviral effects and is therefore an attractive agent to prevent or reduce the incidence of virus-mediated exacerbations in asthmatic or chronic obstructive pulmonary disease (COPD) patients. We therefore investigated the effects of prophylactic IFNß on respiratory epithelial cells infected with rhinovirus (RV). METHODS: A549 cells and primary bronchial epithelial cells (PBECs) were exposed for 18 h to IFNß. Then, IFNß was either removed or maintained in the supernatant for the rest of the experiment and cells were infected with RV-1B at t = 0 or 72 h after the initial exposure to IFNß. RESULTS: Viral RNA levels were decreased in both cell types. Furthermore, both viral RNA and infectious virus levels in the supernatant of infected A549 cells were still significantly reduced at 72 h after removal of IFNß. This pronounced antiviral pre-treatment effect was associated with increased expression of the antiviral genes IFN-stimulated protein of MR15000 (ISG15) and Myxovirus resistance 1 (Mx1) and the effect was maintained even when IFNß levels in the supernatant of A549 cells were undetectable. CONCLUSIONS: These data show that IFNß has not only a strong, but also a long-lasting protective effect against RV infection of respiratory epithelium.

The type I interferon response during viral infections: a "SWOT" analysis.

The type I interferon (IFN) response is a strong and crucial moderator for the control of viral infections. The strength of this system is illustrated by the fact that, despite some temporary discomfort like a common cold or diarrhea, most viral infections will not cause major harm to the healthy immunocompetent host. To achieve this, the immune system is equipped with a wide array of pattern recognition receptors and the subsequent coordinated type I IFN response orchestrated by plasmacytoid dendritic cells (pDCs) and conventional dendritic cells (cDCs). The production of type I IFN subtypes by dendritic cells (DCs), but also other cells is crucial for the execution of many antiviral processes. Despite this coordinated response, morbidity and mortality are still common in viral disease due to the ability of viruses to exploit the weaknesses of the immune system. Viruses successfully evade immunity and infection can result in aberrant immune responses. However, these weaknesses also open opportunities for improvement via clinical interventions as can be seen in current vaccination and antiviral treatment programs. The application of IFNs, Toll-like receptor ligands, DCs, and antiviral proteins is now being investigated to further limit viral infections. Unfortunately, a common threat during stimulation of immunity is the possible initiation or aggravation of autoimmunity. Also the translation from animal models to the human situation remains difficult. With a Strengths-Weaknesses-Opportunities-Threats ("SWOT") analysis, we discuss the interaction between host and virus as well as (future) therapeutic options, related to the type I IFN system.

CpG and poly(I:C) stimulation of dendritic cells and fibroblasts limits herpes simplex virus type 1 infection in an IFNß-dependent and -independent way.

Viral activation of toll-like receptors (TLRs) on dendritic cells (DCs) leads to production of various cytokines, including antiviral type I interferons (IFNs). Synthetic ligands specific for TLRs are also able to induce the production of type I IFNs (IFNα/ß) by DCs, suggesting that these ligands have potential as antiviral drugs. In this in vitro study we extensively investigated the antiviral activity of various TLR ligands. Mouse bone marrow (BM) cells were differentiated into plasmacytoid and conventional DCs (pDCs and cDCs), stimulated with various TLR ligands and tested the antiviral abilities of collected supernatants in an in vitro herpes simplex virus type 1 (HSV-1) infection model. We observed a significant IFNß-, (but not IFNα-) dependent reduction in HSV-1 infection when a mixed pDC/cDC population was stimulated with the TLR9 ligand CpG. In the absence of pDCs, TLR stimulation resulted in less pronounced antiviral effects. The most pronounced antiviral effect was observed when both DC subsets were stimulated with poly(I:C). A similar noticeable antiviral effect was observed when fibroblasts (L929 cells) were stimulated directly with poly(I:C). These poly(I:C)-mediated antiviral effects were only partially IFNß-mediated and probably TLR independent. These data demonstrate that TLR ligands are not only able to produce type I IFN but can indeed act as antiviral drugs. In particular poly(I:C), which exerts its antiviral effects even in the absence of DCs, may become a promising drug e.g. to prevent respiratory infections by topical intranasal application.

Recovery from psychotic illness: a 15- and 25-year international follow-up study.

BACKGROUND: Poorly defined cohorts and weak study designs have hampered cross-cultural comparisons of course and outcome in schizophrenia. AIMS: To describe long-term outcome in 18 diverse treated incidence and prevalence cohorts. To compare mortality, 15- and 25-year illness trajectory and the predictive strength of selected baseline and short-term course variables. METHODS: Historic prospective study. Standardised assessments of course and outcome. RESULTS: About 75% traced. About 50% of surviving cases had favourable outcomes, but there was marked heterogeneity across geographic centres. In regression models, early (2-year) course patterns were the strongest predictor of 15-year outcome, but recovery varied by location; 16% of early unremitting cases achieved late-phase recovery. CONCLUSIONS: A significant proportion of treated incident cases of schizophrenia achieve favourable long-term outcome. Sociocultural conditions appear to modify long-term course. Early intervention programmes focused on social as well as pharmacological treatments may realise longer-term gains.

Psychometric properties of the schedules for clinical assessment in neuropsychiatry (SCAN-2.1).

BACKGROUND: The Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the successor of the ninth version of the Present State Examination (PSE-9), is one of the latest instruments developed by the World Health Organisation for the assessment of psychiatric disorders. So far, the psychometric properties have only been established for certain sections of the instrument. The present study is the first to test the psychometric properties of SCAN-2.1 for most of the disorders covered by the SCAN, and was carried out prior to a survey conducted in the Nijmegen Health Area (the Netherlands). METHODS: Interviewers were psychology graduates with little clinical experience. Two designs were used. In one design, pairs of independent live interviews with the same respondent were compared (test-retest situation). In the other, ten videotaped interviews by experts were rated by each of the interviewers (standardized situation), and the outcomes were compared with those of the other interviewers as well as with a reference score. RESULTS: In the test-retest situation the kappa coefficient for diagnostic caseness was qualified as substantial (0.62) and for diagnostic categories and diagnostic groups as moderate to good (0.24 to 0.64). In the standardized situation using videotaped interviews by experts, sensitivity as well as specificity proved to be substantial to almost perfect. The agreement per interviewer with regard to the reference diagnoses ranged from 87% (diagnostic group) to 94% (diagnostic caseness). Agreement on the syndrome level (without duration and interference criteria of DSM-IV) was excellent. CONCLUSIONS: Although the instrument is traditionally used by experienced clinicians, this study shows that less experienced (but well trained) interviewers can apply SCAN reliably. Special attention should be paid to the items without explicit interview questions, as they tend to be more sensitive to neglect than the items with interview questions.

The prehistory of psychiatry in Ethiopia.

Ethiopian psychiatry has changed considerably during the last few years with an increasing number of Ethiopian doctors and nurses trained in psychiatry. In the paper is given an outline of the history of psychiatry in Ethiopia from 1965 onwards. Important improvements in the Amanuel Mental Hospital in Addis Ababa which for long was the only psychiatric facility in the country, the establishment of the Department of Psychiatry at the Medical Faculty of the University of Addis Ababa and the introduction of psychiatry in the curriculum of the medical faculty are important steps. Recently training of nurses and doctors in psychiatry has led to the establishment of psychiatric clinics in 26 district hospitals throughout the country staffed with psychiatric nurses supervised by psychiatrists from Amanuel Hospital in Addis Ababa. The development of psychiatric research in Ethiopia is also outlined.

Stability and change in needs of patients with schizophrenic disorders: a 15- and 17-year follow-up from first onset of psychosis, and a comparison between 'objective' and 'subjective' assessments of needs for care.

Need for care was studied in a Dutch incidence cohort of patients with schizophrenic disorders 15 and 17 years from first onset of psychosis. Long-term course of the disorders varied from complete remission and full community participation to chronic psychosis and long-term hospital stay. Fifty patients were assessed twice with the Needs For Care Assessment Schedule (NFCAS, Brewin and Wing 1989); at the latter follow-up an assessment was also made using the Camberwell Assessment of Need (CAN, Phelan et al. 1995). The NFCAS is an investigator- or professional-based instrument which provides an 'objective' assessment of needs. Need for care was recorded in 22 areas of clinical and social functioning. Comparison of the two assessments over a 2-year period demonstrated a high stability on the individual items (mean 88%, mostly concerning the absence of a problem twice), but did not show the expected stability of need status among this group of patients with chronic disorders. One in five patients (22%) had no needs at all on both occasions and 56% of the patients showed a change in needs. There was more negative than positive change: 28% suffered from new unmet needs at the 17-year follow-up, while only 12% had improved their status to no needs. About one-third (36%) had at least one unmet need, mostly regarding psychotic symptoms, dyskinesia or underactivity. The CAN provides a 'subjective' assessment of needs according to the view of patients themselves. The problems patients reported most commonly were in the areas of day-time activities, social relationships and information on their condition and treatment, for all which they asked for more help than they received. This patient-based instrument produces slightly higher numbers of problems and unmet needs, and a lower ratio between met and unmet needs. There is an overall percentage of 21% of disagreement between patient and investigator view regarding the unmet need status. Agreement between the two instruments on the nature of the problems with unmet needs was lacking altogether.

Natural course of schizophrenic disorders: a 15-year followup of a Dutch incidence cohort.

Data are presented on the 15-year natural course of schizophrenia and other nonaffective functional psychoses in a cohort of 82 first-contact cases from a circumscribed area in the Netherlands. The subjects were suffering from functional psychosis with International Classification of Diseases-Ninth Revision (ICD-9) diagnoses 295, 297, or 298.3-9 (broad definition of schizophrenia) on entry. Standardized assessments of psychopathology, psychological impairments, negative symptomatology, social disability, and use of mental healthcare were used. The study reveals a pattern of chronicity and relapses with a high risk of suicide: Two-thirds of the subjects had at least one relapse and after each relapse 1 of 6 subjects did not remit from the episode; 1 of 10 committed suicide; and 1 of 7 had at least one episode with affective psychotic symptoms that started on average 6 years after the onset of the schizophrenic disorder. Diagnoses were reclassified in five patients, according to DSM-III-R criteria for a bipolar disorder. The predictive power--in terms of time in psychosis and in partial or full remission--of demographic, illness, and treatment variables at onset of the illness was very limited. Insidious onset and delays in mental health treatment are risk factors that predict a longer duration of first or subsequent episodes. The importance of mental health treatment in regard to outcome is probably subject to change because an early warning and intervention strategy could prevent further damage and deterioration. Our data support the need for an adequate relapse prevention program as a priority for our mental health services.

Assessment of the need for care 15 years after onset of a Dutch cohort of patients with schizophrenia, and an international comparison.

Assessment of needs for care is crucial in the evaluation of ongoing changes from institutional care to various forms of day- and outpatient treatment. Do patients really do better in the community and are they adequately cared for? The 15-year follow-up of a Dutch incidence cohort of patients with schizophrenia and other functional non-affective psychoses showed that 47 (out of 63) patients had positive ratings of symptoms and disabilities. They were assessed by means of the Needs for Care Assessment Schedule, which articulates the problems and corresponding interventions resulting in a judgement of met or unmet need for treatment or assessment. There was a mean of 2.1 clinical problems and 2.1 social problems per patient. Few problems were considered to generate unmet needs: 14% of the clinical problems and only 7% of the social problems. Nevertheless, 32% of the patients had one or more unmet needs. These results were compared with data from six research centres in the United Kingdom (Camberwell, Oxford and South Glamorgan), Canada (Montreal), Italy (Verona) and Finland (Tampere). Despite differences in health care settings in the four countries, the ratio of met to unmet needs (about 4-5 to 1) among chronic, mostly schizophrenic patients is more or less the same with the exception of an apparently underserved hostel population in Oxford and the Finnish patient population probably due to high expectations with respect to independent community living.

Time trends in the care-based incidence of schizophrenia.

BACKGROUND: Several studies have suggested a declining first-admission rate for schizophrenia. This study examines the care-based incidence of schizophrenia in a Dutch register area. METHOD: Data from Groningen psychiatric case register were used to compare first-admission rates for schizophrenia over 1976-90 with those of other functional psychoses, and to consider various potential biases. RESULTS: Diagnostic habits probably affected time trends in incidence rates. Using a broader definition of schizophrenia, no evidence was found for a decrease in the incidence of schizophrenia. Although first admissions to intramural services showed a (non-significant) decrease, this effect seemed to be neutralised when all mental health services were taken into account. CONCLUSIONS: Care-based studies of time trends in psychiatric disorders should embrace all mental health services. Furthermore, unless a diagnostic classification system with univocal criteria is used, bias caused by changing diagnostic habits cannot be ruled out.

Assessment of the prevalence of psychiatric disorder in young adults.

BACKGROUND: The effectiveness of different assessment procedures for determining prevalence rates of psychiatric disorder in young adults was investigated. METHOD: In a two-stage multi-method procedure, the Young Adult Self-Report, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), the Structured Interview for Personality Disorders (Revised), and the Global Assessment of Functioning (GAF) Scale were used to assess prevalence rates in 706 19-24-year-olds from the general population. Furthermore, individuals' subjective perception of distress and referral to mental health services were assessed. RESULTS: The prevalence of any SCAN/DSM-III-R disorder was 19.3% (95% confidence interval: 11.2-27.4%). Most subjects who received a SCAN/DSM-III-R diagnosis were only mildly impaired. The highest prevalence rates of dysfunctioning (GAF score below 61) without referral to mental health services were for dissociative disorder (2.3%), sleep disorder (2.1%), alcohol dependence (1.3%) and affective disorder (1.8%). CONCLUSION: Instruments that assess functional impairment in addition to DSM-III-R diagnoses are indispensable in prevalence studies.

Costs and benefits of hospital and day treatment with community care of affective and schizophrenic disorders.

BACKGROUND: A randomised controlled trial of day treatment with community care for patients with schizophrenic and affective disorders, referred for in-patient psychiatric treatment, was conducted to evaluate patterns of treatment and the course of illness with its psychosocial consequences over a period of two years. METHOD: Seventy patients, of whom 34 had affective and 36 had schizophrenic disorder, were assigned to the experimental condition (day treatment with ambulatory and domiciliary care), and 33 patients, of whom 16 had affective and 17 had schizophrenic disorder, were assigned to the control condition of standard clinical care. RESULTS: Day treatment with community care was feasible for 40.6% of the affective patients and 33.3% of the schizophrenic patients. The direct treatment costs of both disorders, based on numbers of in- and day-patient days and out-patient contacts over two years, appeared more or less the same. Patients benefited equally from day treatment as from in-patient treatment, although there were some gains in self-care and in functioning in the household among experimentals. Although schizophrenics were socioeconomically worse off, and also suffered from more (severe) symptoms and social disabilities than the affective patients at entry into the study, they were similar at two years. This finding is unexpected, compared with other follow-up studies. Extra cost for patients and families were not observed. Patients and their families in the experimental condition were significantly more satisfied with the treatment. Experimental patients spent much more time at home during admission, remained much less time in secluded wards, and were more compliant with treatment. CONCLUSIONS: Day treatment could be considered a cost-effective alternative to in-patient treatment.

Positive life change and recovery from depression and anxiety. A three-stage longitudinal study of primary care attenders.

BACKGROUND: The objective was to examine the relationship between positive life change (PLC) and recovery from depression and anxiety. Following Brown et al (1988, 1992), we hypothesised: (a) that an excess of PLC would be found in the 3-month period before recovery compared with base rates ('excess hypothesis') and (b) that fresh-start and anchoring subtypes of PLC would trigger recovery from depression and anxiety respectively ('specificity hypothesis'). METHOD: One hundred and seventy primary care patients with a depressive and/or anxiety disorder, selected from 1994 consecutive attenders, were assessed at baseline and at 1-year and 3.5-year follow-ups on life change (LEDS) and psychopathology (PSE and Course Interview). RESULTS: Our results appeared to confirm the excess hypothesis regarding depression and anxiety (twofold excess was found prior to recovery), but not regarding mixed anxiety/depression. They did not support the specificity hypothesis. CONCLUSIONS: PLC facilitates recovery but is neither a necessary nor sufficient condition for remission. Difficulty reduction is the most important recovery-enhancing factor.

Efficacy of psychiatric day treatment. Course and outcome of psychiatric disorders in a randomised trial.

The course of the psychopathology and social functioning in an experimental day-treatment group referred for inpatient psychiatric treatment is compared with that of a control group receiving standard inpatient care. During a follow-up period of 2 years subjects were interviewed three times. The interview comprised information about psychiatric symptoms, psychological functions, psychiatric diagnosis and social-role functioning. Apart from these discrete assessments an effort was made to map episodes of illness throughout the follow-up period. Upon entry the groups did not differ in terms of psychopathology or social functioning. At follow-up both groups had improved significantly with respect to symptomatology, psychological and social functioning. The extent to which the groups improved did not differ significantly regarding pathology, but self-care improved more in the experimental group. The average duration of episodes of illness was similar for the experimental and control group. During the 2-year follow-up patients suffered from a well-defined disorder during an average of 11 months. The fact that approximately 40% of them were still a psychiatric case after 2 years further underscores the severity of their pathology.