Control of heterologous hepatitis C virus infection in chimpanzees is associated with the quality of vaccine-induced peripheral T-helper immune response

Prophylactic hepatitis C virus (HCV) vaccine trials with human volunteers are pending. There is an important need for immunological end points which correlate with vaccine efficacy and which do not involve invasive procedures, such as liver biopsies. By using a multicomponent DNA priming-protein boosting vaccine strategy, naïve chimpanzees were immunized against HCV structural proteins (core, E1, and E2) as well as a nonstructural (NS3) protein. Following immunization, exposure to the heterologous HCV 1b J4 subtype resulted in a peak of plasma viremia which was lower in both immunized animals. Compared to the naïve infection control and nine additional historical controls which became chronic, vaccinee 2 (Vac2) rapidly resolved the infection, while the other (Vac1) clearly controlled HCV infection. Immunization induced antibodies, peptide-specific gamma interferon (IFN-gamma), protein-specific lymphoproliferative responses, IFN-gamma, interleukin-2 (IL-2), and IL-4 T-helper responses in both vaccinees. However, the specificities were markedly different: Vac2 developed responses which were lower in magnitude than those of Vac1 but which were biased towards Th1-type cytokine responses for E1 and NS3. This proof-of-principle study in chimpanzees revealed that immunization with a combination of nonstructural and structural antigens elicited T-cell responses associated with an alteration of the course of infection. Our findings provide data to support the concept that the quality of the response to conserved epitopes and the specific nature of the peripheral T-helper immune response are likely pivotal factors influencing the control and clearance of HCV infection.

Estimating the sensitivity and specificity of matching name-based with non-name-based case registries

Because non-name-based case registries have recently been used for reporting human immunodeficiency virus infection, this study attempted to define the sensitivity, specificity and accuracy of case registry matches using non-name-based registries. The AIDS, sexually transmitted disease (STD), and tuberculosis (TB) case registries were matched using all available information to establish the standard. The registries were then matched again using five increasingly less specific criteria to compare sensitivity, specificity and accuracy. The registries were then also transformed into non-name-based codes as if they were the HIV registry and matched again. With name-based registries, sensitivities increased as the matching criteria became less exacting, while the accuracy declined slightly. Specificities remained close to 100% due to the relatively small number of matched cases. Results from matches of non-name-based registry matches were similar to those of the name-based registry matches. Non-name reporting can be used for data matching with acceptable accuracy.

Allogeneic whole-cell vaccine: a phase I/II study in men with hormone-refractory prostate cancer

OBJECTIVE

To establish the safety and toxicity of an allogeneic human tumour cell vaccine in patients with hormone-refractory prostate cancer, and to determine any biochemical, immunological or clinical response to vaccination.

PATIENTS AND METHODS

Sixty patients with hormone-refractory prostate cancer were recruited and randomly allocated into four equal groups. Three cell lines (from a bank of four) were administered initially every 2 weeks and then monthly, in conjunction with the immunostimulant Mycobacterium vaccae (SRL-172), each group receiving a different combination of the four cell lines. The patients' serum prostate-specific antigen (PSA) levels were monitored regularly, and the immune response to the vaccine measured using nonspecific intracellular cytokines and specific humoral and cell-mediated assays.

RESULTS

The vaccine was safe and well tolerated with no major side-effects. Whilst several patients had a decline in PSA from the entry level, there was no significant decrease that could be attributed solely to the vaccine. However, the immunological data were more encouraging, with several patients from each arm of the trial having an increase in cytokine production, increases in specific antibodies and evidence of T-cell proliferation in response to the vaccinations.

CONCLUSION

The failure of the vaccine to produce a PSA response in the patients in the trial is not surprising considering the stage of the disease. The high PSA levels on entry indicate that the burden of disease was probably high and thus this was an extremely challenging group of patients in which to try and elicit a response through immunotherapy. However, the immunological evidence of a response to the vaccine was encouraging and suggests that further exploration of immunotherapy in less advanced disease may yield more encouraging clinical responses.

Management of urethritis in health maintenance organization members receiving care at a multispecialty group practice in Massachusetts

BACKGROUND

Cost containment has led to a concern that health maintenance organization-insured patients presenting with complaints of urethritis may be treated without being tested.

GOAL

To determine the proportion of men presenting with symptoms of urethritis who are tested for Chlamydia trachomatis and Neisseria gonorrhoeae.

STUDY DESIGN

Reviews were performed on 196 randomly selected patient records with an outpatient visit and a diagnostic code consistent with urethritis between 1995 and 1997. Data were collected on demographics, diagnostic testing, and treatment.

RESULTS

Diagnostic testing for C trachomatis and N gonorrhoeae was performed, respectively, in 92.3% and 83.2% of the men presenting at an initial visit with complaints of urethritis. Altogether, 98.2% of the patients who met the Centers for Disease Control criteria for documenting urethritis were tested for C trachomatis and N gonorrhoeae.

CONCLUSION

Diagnostic testing for C trachomatis and N gonorrhoeae is nearly universal in this multispecialty group practice setting, facilitating surveillance and public health efforts.

A filarial nematode-secreted product signals dendritic cells to acquire a phenotype that drives development of Th2 cells

Although exogeneous "danger" signals such as LPS can activate APC to produce a Th1 response, the nature of events initiating a Th2 response is controversial. We now show that pathogen-derived products have the capacity to induce bone marrow-derived dendritic cell cultures to acquire a phenotype that promotes the differentiation of naive CD4+ T cells toward either a Th1 or Th2 phenotype. Thus, LPS-matured dendritic cells (DC1) promote a Th1 response (increased generation of IFN-gamma and reduced production of IL-4) by Ag-stimulated CD4+ T cells from the DO.11.10 transgenic mouse expressing a TCR specific for an OVA peptide (OVA323-339). In contrast, a phosphorylcholine-containing glycoprotein, ES-62, secreted by the filarial nematode, Acanthocheilonema viteae, which generates a Th2 Ab response in vivo, is found to induce the maturation of dendritic cells (DC2) with the capacity to induce Th2 responses (increased IL-4 and decreased IFN-gamma). In addition, we show that the switch to either Th1 or Th2 responses is not effected by differential regulation through CD80 or CD86 and that a Th2 response is achieved in the presence of IL-12.

A new system for sternal intraosseous infusion in adults

BACKGROUND

Intraosseous (IO) infusion provides an alternative route for the administration of fluids and medications when difficulty with peripheral or central lines is encountered during resuscitation of critically ill and injured patients.

OBJECTIVE

To report the first 50 uses of a new system for emergency IO infusion into the sternum in adults, the Pyng F.A.S.T.1 IO infusion system.

METHODS

Six emergency departments and five prehospital emergency medical services (EMS) sites in Canada and the United States provided clinical and/or research data on their use of the IO system in a pilot study of success rates, insertion times, and complications. Indications for use included adult patient, urgent need for fluids or medications, and unacceptable delay or inability to achieve standard vascular access. A basic data set was standardized for all sites, and some sites collected additional data.

RESULTS

The overall success rate for achieving vascular access with the system was 84%. Success rates were 74% for first-time users, and 95% for experienced users. Failure to achieve vascular access occurred most frequently in patients (5 of 9) described subjectively by the user as "very obese," in whom there was a thick layer of tissue overlying the sternum. Mean time to achieve vascular access was 77 seconds. Flow rates of up to 80 mL/min were reported for gravity drip, and more than 150 mL/min by syringe bolus. Pressure cuffs were also used successfully, although fluid rate was controlled by clamping the line. Further research on flow rates is needed. No complications or complaints were reported at two-month follow-up.

CONCLUSION

These early data indicate that sternal IO infusion using the new F.A.S.T.1 IO system may provide rapid, safe vascular access and may be a useful technique for reducing unacceptable delays in the provision of emergency treatment.

Dual in-plane electronic speckle pattern interferometry system with electro-optical switching and phase shifting

A dual in-plane electronic speckle pattern interferometry (ESPI) system has been developed for in situ measurements. The optical setup is described here. The system uses an electro-optical switch to change between the illumination directions for x and y sensitivity. The ability of the electro-optic device to change the polarization of the laser light forms the basis of this switch. The electro-optic device is a liquid-crystal layer cemented between two optically flat glass plates. An electric field can be set up across the layer by application of a voltage to electrodes. The speckle interferometry system incorporates two additional liquid-crystal devices to facilitate phase shifting, and the overall system is controlled by advanced software, which allows switching between the two perpendicular planes in quasi real time. The fact that there are no moving parts is an advantage in any ESPI system for which mechanical stability is vital.

Equine herpesvirus type 1 infects dendritic cells in vitro: stimulation of T lymphocyte proliferation and cytotoxicity by infected dendritic cells

Equine herpesvirus type 1 (EHV-1) causes respiratory disease, abortion and myeloencephalopathy in horses. As with other herpesviruses, cell-mediated immunity is considered important for both recovery and protection. Although virus-specific T-cell proliferation and cytotoxicity can be detected following in vivo infection, little is known about the role of antigen presenting cells such as dendritic cells (DCs) in these processes. Peripheral blood DCs were shown to express the viral glycoprotein gB perinuclearly following exposure to EHV-1 in vitro, demonstrating EHV-1 replication within them. Co-culture of infected DCs or their supernatants with a susceptible cell line (RK13) demonstrated that EHV-1 infection was productive. In vitro-infected DCs showed cytopathic effects, including loss of viability and syncytial formation. However, they were superior to other antigen presenting cells in stimulating both peripheral blood T-cell proliferation and cytotoxicity. Although ponies which had been intranasally infected with EHV-1 exhibited T-cell proliferation to live virus presented on DCs, the responses began to decline as early as 15 weeks and cease at 22 weeks post-in vivo infection. Cytotoxic responses were not detected 35 weeks after the first intranasal infection but were seen again 7 weeks following a second infection. These findings show that equine DCs, which are infected with EHV-1 in vitro, can stimulate memory T-cell responses but appear unable to circumvent the short-lived memory response found following this infection in vivo.

Effects of toluidine blue and destaining reagents used in sexual assault examinations on the ability to obtain DNA profiles from postcoital vaginal swabs

Toluidine blue is an important tool to detect and document genital and perianal injuries following sexual assault. Application of toluidine blue dye and its subsequent removal from unstained areas by means of a destaining reagent, such as diluted acetic acid or a lubricant has been shown to increase the detection rate of posterior fourchette lacerations from 16% to 40% in adult rape victims. Currently, limited information on toluidine blue positive findings in sexually active control groups imposes some limitation on the interpretation of these injuries. Because injuries could otherwise be attributed to improper handling of an examination speculum or the improper insertion of the examining finger, the toluidine blue test should be performed prior to any digital or speculum examination and thus prior to the collection of forensic evidence. For forensic DNA identity testing, it becomes pertinent to determine whether toluidine blue and the destaining reagents used in a sexual assault examination have an adverse effect on the recovery of high molecular weight DNA from postcoital vaginal swabs and thereby have an impact on restriction fragment length polymorphism (RFLP) analysis or PCR-based tests. It is known that some of the lubricants used can have a destructive effect on sperm motility. In order to investigate the potential effects, postcoital vaginal swabs were taken 6 h after sexual intercourse and exposed directly to 1% toluidine blue in aqueous solution, 1-10% acetic acid, and various surgical and vaginal lubricants. Subsequently, the DNA was isolated and DNA identity typing (RFLP and PCR-based) was performed. The results demonstrate, that these reagents have no negative effect on the ability to obtain DNA profiles, either RFLP or PCR-based, from shallow and deep vaginal swabs. The quantity and quality of extractable high molecular weight DNA obtained was comparable with that from uncontaminated postcoital vaginal swabs. RFLP patterns and PCR-based typing results on the D1S80, HUMTH01, TPOX, and CSF1PO loci were consistent with the uncontaminated control swabs and the corresponding whole blood samples of the donors. Therefore, evidentiary material inadvertently contaminated with these reagents can be successfully typed.

The importance of social histories for assessing sexually transmitted disease risk

BACKGROUND

Although identifying risk groups for sexually transmitted diseases based on age or race may be useful for targeting screening efforts, clinicians should recognize that even members of most "low-risk" groups include some individuals at higher risk of infection.

GOAL OF THIS STUDY

This case series of generally older people with sexually transmitted diseases illustrates how assumptions regarding age and risk group can lead to missed opportunities for sexually transmitted disease prevention.

STUDY DESIGN

Records were compiled from two clusters of patients with sexually transmitted diseases seen at a Springfield, Mass., health center between March and September 1992.

RESULTS

Nine patients with a sexually transmitted disease (one with syphilis/human immunodeficiency virus co-infection, one with herpes/human immunodeficiency virus co-infection, two with human immunodeficiency virus infections, and five with syphilis) are described. Eight of the patients are linked epidemiologically.

CONCLUSIONS

A social history is essential during a medical encounter for sexually transmitted disease prevention purposes. Relying on assumptions regarding risk groups, as well as sexual activity, age, or other medical conditions, may lead to a patient's level of risk of infection going unrecognized. Discomfort associated with asking the sensitive questions involved in a social history also is a barrier to recognizing risks or infections. Non-judgmental sexual histories are appropriate when evaluating all patients.

The loss of the sense of reality in incest and child sexual abuse: a psychoanalytic perspective

This article takes a psychoanalytic perspective on incest and child sexual abuse. It concentrates on what could be called "the loss of the sense of reality" that is experienced by the victim of incest. The position in which a child of five is placed when she is sexually abused by her father is considered; this is followed by detailed material from the analysis of a woman who had an incestuous relationship with her brother. Transference and counter-transference difficulties that arise in work with abused patients are explored. A theoretical explanation of the damaging effects of an incestuous relationship is outlined.

Myelodysplastic syndrome as a late complication following autologous bone marrow transplantation for non-Hodgkin's lymphoma

PURPOSE

To determine the incidence, natural history, and risk factors associated with myelodysplastic syndrome (MDS) occurring as a late complication following autologous bone marrow transplantation for patients with non-Hodgkin's lymphoma.

METHODS

We retrospectively reviewed the charts of all 262 patients who underwent autologous bone marrow transplantation for non-Hodgkin's lymphoma at the Dana-Farber Cancer Institute from 1982 through 1991. Although patients received a variety of treatments before they were eligible for transplant, identical myeloablative therapy (cyclophosphamide 60 mg/kg/d for 2 days plus total-body irradiation twice daily for 3 days) was administered in each case. By collecting data on pretransplant and early posttransplant variables, we attempted to identify risk factors for the development of MDS.

RESULTS

The crude overall incidence of posttransplant MDS or acute myeloid leukemia (AML) was 7.6%. The actuarial risk at 6 years was 18% +/- 9%. The median time of onset was 31 months (range, 10 to 101) after transplant or 69 months (range, 27 to 141) after initial treatment for lymphoma. Pretreatment variables predictive for the development of MDS (univariate analysis) included prolonged interval between initial treatment and the transplant procedure (P = .003), increased duration of exposure to chemotherapy (P = .019) or to alkylating agents (P = .045), and use of radiation therapy (P = .032) or pelvic radiation (P = .003) before transplant.

CONCLUSION

MDS is a potential complication of autologous bone marrow transplantation for non-Hodgkin's lymphoma; bone marrow stem-cell damage sustained before the transplant may be the most important risk factor.

A phase II study of continuous infusion recombinant human granulocyte-macrophage colony-stimulating factor as an adjunct to autologous bone marrow transplantation for patients with non-Hodgkin's lymphoma in first remission

Recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) clearly hastens myeloid recovery in patients with relapsed hematologic malignancies undergoing autologous bone marrow transplantation (ABMT). In efforts to further improve neutrophil engraftment and shorten hospital stay in ABMT patients, rhGM-CSF was administered by a potentially more potent route (continuous infusion) to non-Hodgkin's lymphoma (NHL) patients with better BM reserve (first remission). Time to myeloid engraftment was compared with that of NHL patients treated in first remission at our institution on a similar ABMT protocol but without growth factor support (controls). Median neutrophil engraftment (absolute neutrophil count, 500 cells/microL) in first remission patients treated with rhGM-CSF was 14 days, compared with 22 days in controls (P = .0001). Hospital stays were also significantly reduced for rhGM-CSF patients (P = .0003). Platelet engraftment did not differ between the two groups. Persistent fever and generalized serositis were the primary toxicities. rhGM-CSF, delivered by this route, was efficacious but more toxic than 2-hour rhGM-CSF infusions previously reported by other investigators. Future alterations in both dose and schedule may retain comparable efficacy yet diminish toxicity.

An investigation of the abnormal metabolic status of synovial fluid from patients with rheumatoid arthritis by high field proton nuclear magnetic resonance spectroscopy

The 1H Hahn spin-echo NMR profiles of rheumatoid synovial fluids have been investigated and compared with those of matched serum samples. In addition to markedly elevated lactate and diminished glucose concentrations, inflammatory synovial fluids contained (i) substantially lower levels of NMR-detectable chylomicron-and very-low-density-lipoprotein-associated triacylglycerols which appear to have a shortened mean chain-length, and (ii) high concentrations of ketone bodies (predominantly 3-D-hydroxybutyrate), relative to those of corresponding paired serum samples. These observations confirm the abnormal metabolic status of the inflamed rheumatoid joint and provide evidence for an increased utilisation of lipids for fuel therein.

Sulphydryl reactivity of the HLA-B27 epitope: accessibility of the free cysteine studied by flow cytometry

HLA-B27 has an unpaired cysteine on or near its serologically defined spondylitis associated epitope, and it has been argued that its sulphydryl side chain may be chemically reactive. In a previous study it was shown that chemical treatment of HLA-B27 cells with the sulphydryl binding agent p-chloromercuriphenylsulphonic acid (pCMPSA) specifically reduced binding of antibodies to HLA-B27 by up to 80%, as measured in a cellular enzyme linked immunosorbent assay (CELISA). The effect of sulphydryl blockade on intact B27 cells was investigated using flow cytometry. Compared with the CELISA, inhibition required higher concentrations of pCMPSA, and the degree of inhibition produced by a greater than or equal to 30 microM solution of pCMPSA as measured by flow cytometry (median 28.9%) was significantly lower than that measured by CELISA (median 73.6%; p = 1.6 x 10(-6)). Analysis of unfixed, cell surface HLA-B27 by flow cytometry suggests that on most B27 molecules the unpaired sulphydryl site is not available. On the basis of this evidence for modification after translation, a new 'altered self' hypothesis is proposed for the part which HLA-B27 plays in inflammatory disease.

Influence of an intravenous dose of aurothiomalate on the status of low-molecular-mass endogenous metabolites in blood plasma: a proton nuclear magnetic resonance (NMR) study

The effect of aurothiomalate on the status of a wide range of low-molecular-mass endogenous metabolites in blood plasma obtained from animals treated with an intravenous dose of this second-line agent (150 mg/kg) has been assessed by high field proton Hahn spin-echo NMR spectroscopy. As well as modulating the effective concentrations of NMR-detectable biomolecules, aurothiomalate induces a time-dependent decrease in plasma levels of triacylglycerols with a corresponding elevation in the concentration of the ketone body 3-D-hydroxybutyrate, indicating an increased utilisation of fats for energy in rats treated with this 1:1 gold(I)-thiolate complex. These observations may reflect the toxic side-effects that are associated with aurothiomalate treatment.

Nursing management of the patient with Chlamydia trachomatis infection

Information on the recognition and management of clinical syndromes commonly caused by Chlamydia should be widely disseminated. Clinicians must be able to make risk assessments on their patients who may have asymptomatic disease. Because chlamydial infections are often undiagnosed, infected patients continue to spread the organisms to their sexual partners and to neonates. Sexual contacts of patients with Chlamydia or gonorrhea should receive treatment regimens effective against both organisms. Patients who are infected with gonorrhea should receive treatment regimens effective against both organisms. Chlamydia culture is the gold standard for detection of the organism. Antigen detection methods have been developed that offer a low-cost alternative to culture, but these tests are not ideal. Chlamydia tests are not a substitute for clinical experience and risk assessment by the nurse practitioner.

The development and implementation of a hospital safety and sanitation task force

We have found that the above activities are facilitated by utilizing a computerized filing program. The computer formal provides quick, concise reports and statistical data analysis. The formation catalogued can be easily analysis. The information catalogued can be easily categorized and analyzed. The time invested in organizational meetings concerning committee membership, guideline review and creating an efficient incident coding scheme was essential to the success of the project. Problems seem to arise when several different departments share a common space for different activities. For example, medication room sanitation throughout the hospital was suboptimal probably related to the fact that Nursing, Pharmacy and General Stores all utilized the area. No individual department felt it was their sole responsibility to ensure appropriate sanitation. Through the efforts of the task force, we were able to facilitate cooperation among the departments with each doing their share. As a result, medication rooms are now cleaner, neater and therefore safer. Additional incidents have been corrected since the original tabulation of this report. A priority goal is to facilitate corrective action in a more timely manner. It is critical that surveys should not be intended to be "white glove inspections" with criticisms placed on specific departments. This can be accomplished by informing department managers of the intent of the surveys and by allowing staff to participate in all activities. In addition, the support and cooperation of administration is a major factor in the potential success of a program of this nature. As a result of the interdisciplinary team approach, the general safety environment for patients, visitors, employees and volunteers has significantly been improved at our institution.

Intracerebral toxoplasmosis in patients with acquired immune deficiency syndrome

The acquired immune deficiency syndrome (AIDS) is a recently described T-cell deficiency predisposing patients to a spectrum of opportunistic infections. Kaposi's sarcoma, and other neoplasms. It appears primarily among homosexual males and intravenous drug abusers, but is now being observed in other groups as well. The authors describe six adult patients with AIDS who developed intracranial toxoplasmosis. In four patients, diagnosis was made by brain biopsy, and in one by serology. These patients received a 90-day course of therapy with sulfadiazine, pyrimethamine, or both when tolerated, and improved neurologically. In one patient, the brain biopsy was nondiagnostic and the organism was identified at autopsy. On computerized tomographic and pathological follow-up studies the organism appeared to be eradicated by therapy. Early aggressive diagnostic study and prompt institution of therapy are imperative for reversal of neurological deficits. Despite cure of toxoplasmosis, the prognosis in patients with AIDS is poor; the mortality in this series was 67%. Isolation precautions should be taken by those caring for such patients.

Giant cell tumor of the skull: a report of two cases

Giant cell tumor of the skull is an extremely rare clinical entity. We describe two patients with this neoplasm and review the pertinent literature relating to its biology, treatment, and prognosis.

Acromegaly and spinal stenosis. Case report

Spinal stenosis is a well defined clinical entity that is occasionally encountered in patients with acromegaly. Persistent elevation of growth hormone promotes hypertrophy of the bones and ligaments, resulting in widening of the thoracolumbar vertebral bodies, and developmental narrowing of the spinal canal. This report describes the case of a 54-year-old acromegalic man with a 30-year history of low-back pain. Who developed symptoms of spinal stenosis. This case and two similar cases from the literature are discussed, and the appropriate therapeutic approaches reviewed.

Management of extracranial carotid stenosis and intracranial aneurysms

Twenty patients with extracranial carotid stenosis and intracranial aneurysms are reviewed. Fifteen of these patients had transient ischemic attacks (TIA's) and incidental aneurysms. The other five presented with symptoms referrable to an aneurysm, and angiography revealed significant carotid stenosis. None of the patients who presented with TIA's and underwent endarterectomy suffered subarachnoid hemorrhage. However, those patients who presented with symptoms referrable to an aneurysm and underwent endarterectomy seem to be at greater risk for subarachnoid hemorrhage.