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Background. Chronic pulmonary aspergillosis (CPA) is a severe, progressive respiratory infection characterized by multiple pulmonary cavities and increased levels of antibodies to Aspergillus species. We report the first use of posaconazole in patients with CPA. Methods. A retrospective study was performed. A composite clinical and radiological evaluation was used to assess response to posaconazole therapy. The rates of clinical response and failure after 6 and 12 months of therapy were determined. Kaplan-Meier survival models were developed to describe the time to clinical response and failure. The underlying diagnosis, the type of therapy (primary or salvage), Aspergillus antibody titer, and posaconazole serum concentrations were assessed as covariates. Aspergillus species were identified and minimum inhibitory concentrations (MICs) of triazoles were determined using standard techniques. Results. There were 79 patients that initially received posaconazole 400 mg twice per day. The median age of patients was 61 years, and 57% were male. Response to posaconazole was observed in 61% of patients at 6 months and in 46% at 12 months. Kaplan-Meier plots showed that the first response to posaconazole was observed in some patients only after approximately 1 year of therapy. Covariates were not significant. Adverse reactions were observed in 12 patients (15%) (nausea in 5, rash in 5, headache in 1, and lethargy in 1), leading to withdrawal of treatment for 9 patients. Aspergillus species were recovered from 22 patients. A posaconazole MIC of >8 mg/L was found in 4 isolates; in 1 of these isolates, this emerged during therapy. Treatment failed in all 4 patients from whom these 4 isolates had been recovered. Conclusion. Posaconazole is a safe and partially effective treatment for CPA. Prospective comparative studies are now required.

Background Pseudomonas aeruginosa and Aspergillus fumigatus frequently co-colonise the airways of patients with cystic fibrosis (CF). This study aimed to assess the impact of short-term administration of intravenous antipseudomonal antibiotics during CF exacerbations on the presence of Aspergillus. Methods Pre- and post-antibiotic sputum samples from 26 adult patients with CF and chronic Pseudomonas colonisation were analysed for the presence of Aspergillus by fungal culture, real-time PCR and galactomannan antigen (GM). Lung function (forced expiratory volume in 1 s and forced vital capacity % predicted) and blood levels of total IgE, specific A fumigatus IgE and specific A fumigatus IgG were measured at the start and end of antibiotics. Respiratory viral real-time PCR and bacterial community profiling using ribosomal intergenic spacer analysis (RISA) were performed to estimate concurrent changes in the lung microbiome. Results Aspergillus PCR and GM were more sensitive than culture in detecting Aspergillus species (culture 8%, GM 31%, PCR 77%). There was a significant decline in the presence of Aspergillus, measured both by PCR and GM index, following antibacterial therapy (PCR: median increase in crossing threshold 1.7 (IQR 0.5–3.8), p<0.001; GM: median fall in GM index 0.7 (IQR 0.4–1.6), p=0.016). All patients improved clinically with a significant increase in lung function (p<0.0001). RISA community analysis showed large changes in bacterial community similarity in 67% of patients following antibiotics. Viral RT-PCR demonstrated the presence of a concurrent respiratory virus in 27% of patients. Conclusions Intravenous antibiotics targeting Pseudomonas during CF pulmonary exacerbations have a negative impact on the presence of Aspergillus in sputum samples.

[18F]Fluorodexyglucose (FDG) positron emission tomography (PET) scans have significantly improved the diagnosis and staging of lung cancer, but false-positive scans are known to occur due to inflammatory and infectious diseases. Recognition of the conditions leading to false-positive scans is important. Single or multiple pulmonary nodules, with or without cavitation, are classical findings in acute and chronic pulmonary aspergillosis. Clinical features of pulmonary aspergillosis are very similar to those of lung cancer. This report highlights pulmonary aspergillosis as an alternative diagnosis to lung cancer in patients with positive [18F]FDG PET scans and the need to strive for presurgical histological diagnosis.

This collaborative article presents a review of chronic pulmonary aspergillosis (CPA) from the perspective of a multidisciplinary team comprising of respiratory physicians, radiologists, mycologists, dietitians, pharmacists, physiotherapists and palliative care specialists. The review synthesises current knowledge on CPA, emphasising the intricate interplay between clinical, radiological, and microbiological aspects. We highlight the importance of assessing each patient as multidisciplinary team to ensure personalised treatment strategies and a holistic approach to patient care.

The authors assess the utility and limitations of “minimalist stabilization”—small-scale interventions designed to stabilize a partner government engaged in violent conflict—and propose policy recommendations concerning when minimalist stabilization missions may be appropriate and the strategies most likely to make such interventions successful, as well as the implications for U.S. Army force structure debates and partnership strategies.

The Internet is a new battleground between governments that censor online content and those who advocate freedom for all to browse, post, and share information online. This report examines how Internet freedom may transform state-society relations in nondemocratic regimes, using case studies of China, Egypt, Russia, and Syria, and also draws parallels between Internet freedom and Radio Free Europe programs during the Cold War.

In the coming decade, NATO faces growing fiscal austerity and declining defense budgets. This study analyzes the impact of planned defense budget cuts on the capabilities of seven European members of NATO: the United Kingdom, France, Germany, Italy, Spain, the Netherlands, and Poland. The authors assess the implications of the cuts for NATO capabilities and strategy and for U.S. policy.