Post mass-immunization measles outbreak in Taoyuan County, Taiwan: dynamics of transmission, vaccine effectiveness, and herd immunity

OBJECTIVES

Analysis of national surveillance data and a seroepidemiologic investigation were conducted to elucidate the causes and epidemiologic characteristics of a measles outbreak in Taoyuan, Taiwan, 1994.

METHODS

Measles cases were identified through a national surveillance system. Reported cases and their physician or school nurses were interviewed to trace additional suspect cases and were sampled for serologic diagnosis. Measles-specific IgG and IgM were assayed. A confirmed case was defined as being positive for measles IgM test but not having received measles vaccination within the previous 3 months.

RESULTS

The outbreak began in Taoyuan City in December 1993 and continued to spread in primary schools and kindergartens, but caused only sporadic cases in neighboring towns. Among 42 confirmed cases, 15 (38%) were primary school children and 16 (38%) were kindergarten children. Among 24 confirmed cases with a vaccination record, 7 had one dose of vaccination, 4 had two doses of vaccination, and 13 (54%) were unvaccinated. The overall measles susceptible proportion at a kindergarten before the outbreak was 8.1% (17/209) and the overall measles cumulative incidence among susceptibles was 0.65 (11/17).

CONCLUSIONS

A measles vaccination coverage of 82% with the first dose at 9 months of age and 63% with the second dose (measles, mumps, and rubella) at 15 months was inadequate to block measles virus circulation in Taoyuan City in 1994. The city center, with a growing population, represents a high risk as an epicenter for measles outbreaks. Measles outbreaks may occur in a school population with 92% herd immunity.

Thiotepa, busulfan and cyclophosphamide as a preparative regimen for allogeneic transplantation for advanced chronic myelogenous leukemia

Thirty-six adults with chronic myelogenous leukemia (CML) in second or greater chronic phase, accelerated phase, or blast crisis underwent marrow or blood stem cell transplantation from an HLA-matched sibling using high-dose thiotepa, busulfan and cyclophosphamide (TBC) as the preparative regimen. All evaluable patients engrafted and had complete donor chimerism. One patient failed to clear meningeal leukemia, and one patient had one of 30 metaphases positive for the Philadelphia chromosome at 2 months post transplant. The remainder of the patients studied had eradication of CML documented by cytogenetics and/or Southern blot for BCR gene rearrangement, and 13 of 15 patients studied became negative for the BCR gene rearrangement by polymerase chain reaction. Three-year relapse rate is 42% (95% CI, 19-64%). The relapse rate was significantly lower for patients transplanted without blast crisis (9% vs 100%, P < 0.001). Eight (22%, 95% CI, 10-39%) patients had severe or fatal veno-occlusive disease (VOD). Elevated liver enzymes within 1 month prior to transplantation and transplantation using marrow were significantly associated with the occurrence of VOD. Three-year survival is 28% (95% CI, 13-43%). Survival was significantly higher for patients transplanted without blast crisis (45% vs 0%, P = 0.01). TBC is an effective preparative regimen for CML in accelerated phase but not refractory blast crisis, and it should be used with caution in patients with prior hepatopathy who have an increased risk of severe VOD.

Risperidone and associated amenorrhea: a report of 5 cases

BACKGROUND

We report a 5-case series in which risperidone use in usual or lower-than-usual doses was unexpectedly associated with amenorrhea.

CASE REPORTS

On regimens of risperidone (1-8 mg/day), 5 psychiatric patients with various diagnoses developed amenorrhea with elevated serum prolactin levels (mean = 121.7 ng/mL; range, 61.2-229.8 ng/mL). In 4 of 5 cases, menstruation resumed only when risperidone was withdrawn, and in 1 case, menstruation restarted when the dose was tapered. Follow-up serum prolactin levels dropped to a mean of 17.2 ng/mL (range, 6.4-37.6 ng/mL).

CONCLUSION

These findings indicate that the occurrence of amenorrhea during risperidone treatment may be related to elevated serum prolactin levels. This phenomenon may be due either to the dopamine D2 blocking effect of risperidone or to the large individual variability in the rate at which risperidone is metabolized.

Primary cutaneous nocardiosis

A case of primary cutaneous nocardiosis due to Nocardia asteroides occurring in a steroid-dependent asthmatic with no history of trauma is presented. He had a 5 month history of painful nodules on his right shin and calf. He was initially treated with a 6 week course of oral cephalexin 500 mg four times daily, followed by a 2 week course of minocycline 100 mg twice daily with worsening of the infection. A 12 week course of oral clarithromycin 500 mg twice daily led to complete resolution. A discussion of the problems associated with antimicrobial susceptibility testing and nocardia resistance is presented.

Natural autoantibody to galectin-9 in normal human sera

Antibodies to certain self-antigens are detected in normal individuals as well as in patients with autoimmune diseases. Natural autoantibodies found in normal human sera are thought to act as an immune regulator, a functional controller of specific proteins, or the first-line defense against pathogenic microorganisms. In the course of screening human pancreatic islet cDNA library with human sera, we found that autoantibodies to galectin-9 and its unique isoform are present in normal healthy individuals. Galectin-9 antibody was detected in all 44 human sera tested by the immunoprecipitation assays, suggesting a widespread presence of galectin-9 autoantibodies in humans. The reactivity of the sera to galectin-9 was not inhibited by lactose or endoglycosidase treatment, indicating that the reactivity was not due to a nonspecific lectin-carbohydrate interaction. We also demonstrated by RT-PCR that galectin-9 and its isoform are expressed in a variety of human tissues such as pancreatic islets, liver, lung, and tonsils as well as HeLa and Jurkat cell lines. Thus, although it has been reported previously that human galectin-9 is expressed mainly in immune cells and tissues, the current work suggests that the expression of galectin-9 and its isoform is not tissue-restricted and natural autoantibodies against them are present in normal human sera. The significance of these autoantibodies needs to be studied further.

Construction and analysis of a library for random insertional mutagenesis in Streptococcus pneumoniae: use for recovery of mutants defective in genetic transformation and for identification of essential genes

To explore the use of insertion-duplication mutagenesis (IDM) as a random gene disruption mutagenesis tool for genomic analysis of Streptococcus pneumoniae, a large mutagenic library of chimeric plasmids with 300-bp inserts was constructed. The library was large enough to produce 60,000 independent plasmid clones in Escherichia coli. Sequencing of a random sample of 84 of these clones showed that 85% of the plasmids had inserts which were scattered widely over the genome; 80% of these plasmids had 240- to 360-bp inserts, and 60% of the inserts targeted internal regions of apparent open reading frames. Thus, the library was both complex and highly mutagenic. To evaluate the randomness of mutagenesis during recombination and to test the usefulness of the library for obtaining specific classes of nonessential genes, this library was used to seek competence-related genes by constructing a large pneumococcal transformant library derived from 20,000 mutagenic plasmids. After we screened the mutants exhaustively for transformation defects, 114 competence-related insertion mutations were identified. These competence mutations hit most previously known genes required for transformation as well as a new gene with high similarity to the Bacillus subtilis competence gene comFA. Mapping of the mutation sites at these competence loci showed that the mutagenesis was highly random, with no apparent hot spots. The recovery of a high proportion of competence genes and the absence of hot spots for mutational hits together show that such a transformant library is useful for finding various types of nonessential genes throughout the genome. Since a promoterless lacZ reporter vector was used for the construction of the mutagenic plasmid library, it also serves as a random transcriptional fusion library. Finally, use of a valuable feature of IDM, directed gene targeting, also showed that essential genes, which can be targets for new drug designs, could be identified by simple sequencing and transformation reactions. We estimate that the IDM library used in this study could readily achieve about 90% genome coverage.

Molecular flexibility profiling using NMR spectroscopy

Molecular flexibility is a factor that is not extensively studied in most pharmaceutical research efforts. When it is, the level of effort is high involving the preparation of detailed models supported by either molecular dynamics simulations and/or Nuclear Magnetic Resonance data. While these studies are both powerful and illuminating, they cannot be routinely applied in a drug discovery setting as they are time and expertise intensive. Yet there seems to be little doubt that at least in some cases, molecular flexibility plays a key role in complex formation. A simple, rapid and generally applicable flexibility profiling protocol was applied to two model systems and data describing the internal mobility of carbon atoms were obtained. The protocol utilizes the Model Free approach and NMR data to characterize the internal molecular dynamics of these compounds. The first model system consisted of fluorene and diphenylmethane where the anticipated flexibility trends were observed in the data providing a link between chemical intuition and the experimental results. Data on a second model system, which consisted of two Paclitaxel analogs, showed predictable patterns including dynamical phenyl and methyl groups and a relatively immobile taxane core. Subtle differences in the internal dynamics within the taxane core suggest that it cannot be considered as a rigid structure. Key advantages of using this approach are that no prior knowledge or supposition of dynamical features is required, the protocol can be carried out in most medicinal chemistry laboratories and the data obtained provide a common, empirically derived reference point to discuss the effects of molecular flexibility on activity.

Correlation of bcl-2 rearrangement with clinical characteristics and outcome in indolent follicular lymphoma

The t(14;18) translocation, which involves the bcl-2 oncogene, occurs in follicular lymphomas (FL) at two common sites: the major breakpoint region (MBR) and the minor cluster region (mcr). The biological and clinical significance of these breakpoints is unknown. The bcl-2 breakpoint site was determined in 247 previously untreated patients (49% men; median age 52 years) with indolent FL (155 grade I, 83 grade II, and 8 grade III) to correlate it with pretreatment characteristics, response, and outcome. The bcl-2 breakpoint site was determined by a polymerase chain reaction method of peripheral blood (all cases), bone marrows (149 cases), and fresh lymph node biopsy specimens (68 cases). The breakpoint site occurred at MBR in 175 cases (71%) and at mcr in 27 (11%). In 45 cases (18%), no breakpoint was detected (germline). No significant relationship was found between the rearrangements and the expression of BLC-2 and BAX proteins. Patients' germline for MBR and mcr tended to present more frequently with stage IV disease and higher beta2-microglobulin (beta2M) levels, whereas mcr-rearranged patients presented more frequently with early stage and normal beta2M. The complete response rate of germline patients was significantly lower than that of MBR and mcr patients. An estimated 3-year failure-free survival (FFS) for mcr, MBR, and germline cases was 95%, 76%, and 57%, respectively (P <.001). The bcl-2 breakpoint site was independent of serum beta2M and lactate dehydrogenase in its correlation with FFS. In conclusion, the bcl-2 rearrangement site is an important prognostic factor in indolent FL, useful to identify patients who may require different treatment.

LC/MS applications in drug development

The combination of high-performance liquid chromatography and mass spectrometry (LC/MS) has had a significant impact on drug development over the past decade. Continual improvements in LC/MS interface technologies combined with powerful features for structure analysis, qualitative and quantitative, have resulted in a widened scope of application. These improvements coincided with breakthroughs in combinatorial chemistry, molecular biology, and an overall industry trend of accelerated development. New technologies have created a situation where the rate of sample generation far exceeds the rate of sample analysis. As a result, new paradigms for the analysis of drugs and related substances have been developed. The growth in LC/MS applications has been extensive, with retention time and molecular weight emerging as essential analytical features from drug target to product. LC/MS-based methodologies that involve automation, predictive or surrogate models, and open access systems have become a permanent fixture in the drug development landscape. An iterative cycle of "what is it?" and "how much is there?" continues to fuel the tremendous growth of LC/MS in the pharmaceutical industry. During this time, LC/MS has become widely accepted as an integral part of the drug development process. This review describes the utility of LC/MS techniques for accelerated drug development and provides a perspective on the significant changes in strategies for pharmaceutical analysis. Future applications of LC/MS technologies for accelerated drug development and emerging industry trends are also discussed.

Expression of Mad1 protein inhibits proliferation of cancer cells and inversely correlated with Myc protein expression in primary gastric cancer

We performed immunohistochemical assay for Mad1 and Myc protein in 76 gastric cancer tissues. Cancers with reduced Mad1 expression had high proliferative index (S and G2/M-phase) and there was inverse correlation between Mad1 and Myc expression in the same cancer cells. There was no significant correlation between expression of Mad1 and cell differentiation or extent of the disease. There was a trend that reduced expression of Mad1 was associated with poor survival of the patients. Mad1 may influence biologic behavior of cancer cell by inhibiting transcriptional activity of Myc and reduced levels of Mad1 expression seem to be associated with carcinogenesis in human gastric cancer.

Reduced expression of p27Kip1 protein is associated with poor clinical outcome of breast cancer patients treated with systemic chemotherapy and is linked to cell proliferation and differentiation

The cyclin-dependent kinase inhibitor p27Kip1 is a negative regulator of cell proliferation. Its expression is known to be altered in a proteasome-dependent manner without changes in DNA level. Reduced expression of p27Kip1 is associated with aggressive behavior in a variety of human cancers. We investigated expression of p27Kip1 protein in human breast cancer using immunohistochemistry to assess its biologic implication along with cell-cycle analysis by flow cytometry. A total of 68 patients with invasive ductal cancer received adjuvant chemotherapy with cyclophosphamide, methotrexate, and 5-FU every 3 weeks for six cycles. In epithelial cells of normal and benign breast disease, expression of p27Kip1 was well preserved while its expression markedly decreased in breast cancer (45 of 68). Expression of p27Kip1 is significantly reduced in poorly differentiated cancers and in the advanced stage of the disease. Levels of p27Kip1 expression correlated with cell populations in G0/G1 phase of the cell cycle. In survival analysis, p27Kip1 was useful to predict disease free survival but not overall survival of the patients after adjuvant chemotherapy. In summary, p27Kip1 seems to have a role in the cell proliferation and differentiation process during carcinogenesis of breast cancer. The results of the present study suggest that p27Kip1 can be used in predicting response to systemic chemotherapy in a subset of patients with breast cancer.

123I-IPT brain SPECT study in essential tremor and Parkinson's disease

OBJECTIVE

To investigate nigral neuronal damage in patients with isolated postural tremor and those with postural and rest tremor without parkinsonism.

METHODS

Using [123I]-N-(3-iodopropen-2-yl)-2 -carbomethoxy-3beta-(4-chlorophenyl) tropane SPECT, we measured the basal ganglia-occipital cortex/occipital cortex ([BG-OCC]/OCC) uptake ratios in 21 control subjects and patients with isolated postural tremor (n = 9), postural and rest tremor (n = 6), and PD (n = 11).

RESULTS

In the patients with PD, the means (+/-SD) of the (BG-OCC)/OCC ratios of the ipsilateral (2.35+/-0.37) and the contralateral (1.97+/-0.33) sides to the more severely affected limbs were significantly lower than the mean of the bilateral (BG-OCC)/OCC ratios of the age-matched control subjects (3.83+/-0.66). The mean (+/-SD) of the bilateral (BG-OCC)/OCC ratios of the patients with isolated postural tremor (3.60+/-0.83) was comparable with that of the age-matched control subjects. However, the mean (+/-SD) of the bilateral (BG-OCC)/OCC ratios of the patients with postural and rest tremor (2.61+/-0.18) was lower than that of the control subjects (p < 0.05). The mean of the bilateral (BG-OCC)/OCC ratios of the patients with postural and rest tremor was comparable with that of the side ipsilateral to the severely affected limbs of the patients with PD. However, it was higher than that of the side contralateral to the limbs more severely affected by PD. Four of the six patients with postural and rest tremor had (BG-OCC)/OCC ratios lower than 2 standard deviations from the mean of the age-matched control subjects.

CONCLUSIONS

Later in their clinical courses, some patients with postural tremor may acquire rest tremor in association with mild substantia nigra neuronal loss.

Prevention of collagen-induced arthritis in mice by a polyphenolic fraction from green tea

Identification of common dietary substances capable of affording protection or modulating the onset and severity of arthritis may have important human health implications. An antioxidant-rich polyphenolic fraction isolated from green tea (green tea polyphenols, GTPs) has been shown to possess anti-inflammatory and anticarcinogenic properties in experimental animals. In this study we determined the effect of oral consumption of GTP on collagen-induced arthritis in mice. In three independent experiments mice given GTP in water exhibited significantly reduced incidence of arthritis (33% to 50%) as compared with mice not given GTP in water (84% to 100%). The arthritis index also was significantly lower in GTP-fed animals. Western blot analysis showed a marked reduction in the expression of inflammatory mediators such as cyclooxygenase 2, IFN-gamma, and tumor necrosis factor alpha in arthritic joints of GTP-fed mice. Histologic and immunohistochemical analysis of the arthritic joints in GTP-fed mice demonstrated only marginal joint infiltration by IFN-gamma and tumor necrosis factor alpha-producing cells as opposed to massive cellular infiltration and fully developed pannus in arthritic joints of non-GTP-fed mice. The neutral endopeptidase activity was approximately 7-fold higher in arthritic joints of non-GTP-fed mice in comparison to nonarthritic joints of unimmunized mice whereas it was only 2-fold higher in the arthritic joints of GTP-fed mice. Additionally, total IgG and type II collagen-specific IgG levels were lower in serum and arthritic joints of GTP-fed mice. Taken together our studies suggest that a polyphenolic fraction from green tea that is rich in antioxidants may be useful in the prevention of onset and severity of arthritis.

Prognostic value of DNA flow cytometry in stomach cancer: a 5-year prospective study

The role of DNA flow cytometry in the prediction of prognosis for patients with stomach cancer remains to be defined. Thus we studied prospectively the role of DNA flow cytometry as a prognosis indicator in stomach cancer patients in a high-incidence area. Between November 1990 and December 1992, primary stomach cancer tissues were obtained from the surgical specimens from 217 patients (148 male, 69 female). DNA flow cytometric analyses of DNA ploidy and S-phase fraction were performed and the results were correlated with patient survival. The median age of the patients was 55 years (range 24-78). Aneuploid cell population was found in 114 of 217 samples (53%). Tumour S-phase fraction was obtained in 96 of 103 diploid tumours (93%) and 61 of 114 aneuploid tumours (54%). After median follow-up of 66.1 months, the patients with tumours with an S-phase fraction over 17% had significantly worse survival rates than patients with tumours with S-phase fractions of lower than 8% or 8-17% (45% vs 59% and 63% of patients surviving, P = 0.007). Tumour ploidy status did not correlate with patient survival. Multivariate analyses showed that the TNM stage remained the most important prognostic indicator. The tumour S-phase fraction was also an independent prognostic indicator (relative risk 2.300, 95% CI, 1.252-4.223). Tumour S-phase fraction obtained by DNA flow cytometry is an independent prognostic indicator for the survival of the patients with stomach cancer.

Failure to demonstrate Borna disease virus genome in peripheral blood mononuclear cells from psychiatric patients in Korea

RNA, extracted from peripheral blood mononuclear cells (PBMC) obtained from 81 Korean psychiatric patients (39 with schizophrenia, 33 with bipolar affective disorders and nine with major depression), was analyzed for a 391-nucleotide, highly conserved region of the p24 protein-encoding ORF II of Borna disease virus (BDV), using nested reverse transcription-polymerase chain reaction (RT-PCR). BDV genomic RNA was not detected in PBMC from any of the 81 Korean psychiatric patients. These data do not support an etiologic association between BDV infection and neuropsychiatric disorders in humans.

A simplified and standardized neutralization enzyme immunoassay for the quantification of measles neutralizing antibody

A simplified and standardized neutralization enzyme immunoassay (Nt-EIA) was developed to detect measles virus growth in Vero cells and to quantify measles neutralizing antibody. Heat-inactivated sera were diluted serially 4-fold and tested in duplicate. The 50% reduction point (50%RP) of virus growth was calculated using the Reed-Muench formula and the neutralizing antibody titre of test sera was converted into mIU/ml by comparing their 50%RP with that of the international standard serum. The optimal virus input and incubation time were found to be 50-100 plaque forming unit (PFU)/well and 64-72 h, respectively. The simplified Nt-EIA had a good reproducibility with only 3.7-4.2% of duplicate tests having a ratio > 4 in an evaluation of intra assay variation and the coefficients of variance were 2-9% in an evaluation of inter assay variation. In addition, the simplified Nt-EIA had a high sensitivity(98.6%), specificity (100%) and agreement (98.8%) in qualitative comparison with plaque reduction neutralization test (PRNT). In quantitative comparison, the correlation coefficient between Nt-EIA and PRNT was 0.83 without log transformation or 0.77 after log transformation and 90% of 61 positive sera had a ratio < 4 between antibody titre tested by the two methods. The simplified Nt-EIA is thus a suitable alternative to the PRNT for the quantification of measles neutralizing antibody.

Frequency of spinocerebellar ataxia types 1,2,3,6,7 and dentatorubral pallidoluysian atrophy mutations in Korean patients with spinocerebellar ataxia

Autosomal dominant cerebellar ataxias (ADCAs) are a heterogeneous group of disorders characterized by degenerative symptoms in the cerebellum, spinal cord, and brain stem. Six different genes have been reported to be associated with ADCA, and the length of trinucleotide repeats of these genes is correlated with the age at onset and severity of symptoms. Although there are strong hereditary effects in these disorders, most of the studies carried out in heterogeneous populations and in small groups obscure the true incidence of these diseases. We examined the frequency of six types of ADCAs in 87 unrelated Korean patients with progressive ataxia and compared the results to the frequencies in other ethnic groups. Spinocerebellar ataxia (SCA) type 2 was the most frequent hereditary ataxia (12.6%) and types 3 and 6 accounted for 4.6% and 6.9% of ataxia patients, respectively. Dentatorubral pallidoluysian atrophy was also found in three patients (3.4%). No instances of SCA types 1 or 7 were detected. These findings show the striking contrast to the white population and a difference from Japanese findings. Our results demonstrate that dentatorubral pallidoluysian atrophy should be included in the differential diagnosis of Korean patients with spinocerebellar ataxia, and that there are strong hereditary effects in patients with ADCAs.

Para-incisional tattooing with electrocautery

The authors present a technique using electrocautery diathermy to make surgical tattoos. This method has been used in over 300 patients who underwent head and neck surgery at Aberdeen Royal Infirmary and Albany Medical College, New York, over a period of five years. A wide variety of operative procedures such as total laryngectomies and neck dissections were performed. The electrocautery surgical tattoos have a major advantage of persisting until the end of the operative procedure by which time other types of tattoos have faded. The technique is widely available, inexpensive, and has to date been complication free.

Apoptosis of pancreatic beta-cells detected in accelerated diabetes of NOD mice: no role of Fas-Fas ligand interaction in autoimmune diabetes

Autoreactive T lymphocytes probably cause pancreatic beta-cell death by inducing apoptosis. To visualize apoptotic beta-cells in vivo, we accelerated diabetes of NOD mice with cyclophosphamide (CY) or adoptive transfer. We also studied whether Fas-mediated apoptosis is involved in the development of diabetes by administrating anti-Fas ligand (FasL) Ab and by grafting Fas-deficient neonatal pancreas from NOD-lpr/lpr mice. Apoptotic cells were clearly shown 8 days after CY treatment. Beta-cell apoptosis was also observed after adoptive transfer but in a different kinetic pattern. Anti-FasL Ab administration failed to inhibit diabetes after CY treatment or adoptive transfer, while it inhibited Con A-induced hepatitis. Fas-deficient neonatal pancreata were destroyed by lymphocytic infiltration in diabetic NOD mice. Our results clearly demonstrate apoptosis of beta-cells in accelerated diabetes and indicate that Fas-FasL interaction is not involved in diabetes of NOD mice, contrary to the previous reports.