A phase II, randomised clinical trial to demonstrate the non-inferiority of low-dose MF59-adjuvanted pre-pandemic A/H5N1 influenza vaccine in adult and elderly subjects

BACKGROUND

Effective planning and preparedness against a possible future A/H5N1 influenza pandemic is a major global challenge. Because dose sparing strategies are required to meet the global demand for vaccine, efforts have focused on the development of adjuvanted vaccine formulations of relatively lower antigen content.

AIM

This study aimed to demonstrate the non-inferiority of a low-antigen-dose (3.75 μ) [DOSAGE ERROR CORRECTED] A/H5N1 pre-pandemic vaccine compared with a licensed, higher-dose (7.5 mg) formulation in adult and elderly subjects. Immunogenicity was assessed according to European and U.S. licensure criteria.

METHODS

A total of 722 subjects were randomized in equal numbers to receive either the licensed or low-dose formulation. All subjects received two vaccine doses administered three weeks apart. Immunogenicity was assessed three weeks after the administration of each vaccine dose by hemagglutination inhibition (HI), single radial haemolysis (SRH) and microneutralization assays (MN). Local and systemic reactions were assessed over a seven day period post-vaccination. Adverse events were recorded throughout.

RESULTS

The low-dose vaccine was demonstrated to be non-inferior to the licensed formulation in terms of antibody titres against the vaccine strain. All three European licensure criteria were met by adult subjects in response to the low-dose vaccine; two criteria were met by the elderly age group. Cross-reactive antibodies were detected against the heterologous A/H5N1 antigen strains A/Indonesia/05/05 and A/turkeyTurkey/01/05. Both vaccines were generally well tolerated by both age groups.

CONCLUSION

These data demonstrate that a low antigen dose in combination with MF59 adjuvant is adequate for the routine pre-pandemic immunization of adult and elderly subjects.

Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy

Skin and soft-tissue infections (SSTIs) are among the most common bacterial infections, posing considerable diagnostic and therapeutic challenges and resulting in significant morbidity and mortality among patients as well as increased healthcare costs. eight members of the SSTI working group of the Italian Society of infectious Diseases prepared a draft of the statements, grading the quality of each piece of evidence after a careful review of the current literature using MEDLINE database and their own clinical experience. Statements were graded for their strength and quality using a system based on the one adopted by the Infectious Diseases Society of America (IDSA). The manuscript was successively reviewed by seven members of the SSTI working group of the international Society of Chemotherapy, and ultimately re-formulated by all e xperts. the microbiological and clinical aspects together with diagnostic features were considered for uncomplicated and complicated SSTIs. Antimicrobial therapy was considered as well -both empirical and targeted to methicillin-resistant Staphylococcus aureus (MRSA) and/or other main pathogens.

Secondary hemophagocytosis in 3 patients with organic acidemia involving propionate metabolism

Hemophagocytic lymphohistiocytosis (HLH) may develop secondary to infections, malignancies, immune deficiency syndromes, and rheumatologic and metabolic disorders. Associations between HLH and inborn errors of metabolism, including lysinuric protein intolerance, multiple sulfatase deficiency, galactosemia, Gaucher disease, Pearson syndrome, and galactosialidosis, have previously been reported in the literature. In this report the authors present 3 children with disorders of propionate metabolism--1 with methylmalonic acidemia and 2 with propionic acidemia--who developed secondary HLH during their metabolic attacks. All patients fulfilled the 5 HLH criteria of the Histiocyte Society. Familial HLH was ruled out by molecular analysis. Plasma exchange was performed for 2 of them. Unfortunately 1 died of multiorgan failure despite intensive therapy. This is the first report of such an association.

Plasma protein oxidation is correlated positively with plasma iron levels and negatively with hemolysate zinc levels in sickle-cell anemia patients

INTRODUCTION

Sickle-cell anemia (SCA) is a disease of high oxidative stress. The oxidative medium of SCA was evaluated by protein oxidation parameters and their correlation with lipids and ions were investigated both in the plasma and in the erythrocyte.

METHODS

Blood samples were obtained from 15 steady-state patients with SCA, 10 carriers, and 10 controls. Plasma protein carbonyl, total sulfhydryl, total cholesterol, triglyceride, phospholipids, and bilirubin levels were determined by spectrophotometric methods. Plasma copper, zinc, and iron levels were determined by atomic absorption spectrophotometry. Levels of cholesterol, triglyceride, and ions were also determined in the hemolysate lipid extract.

RESULTS

Patients had increased protein carbonyl and decreased total sulfhydryl levels compared with controls. Plasma cholesterol levels were lower than controls, and triglyceride levels were higher than carriers in patients with SCA. Plasma iron and hemolysate copper were higher in patients than carriers and controls. Plasma protein carbonyl levels were found to be correlated with plasma iron and hemolysate zinc levels in the patient group.

CONCLUSION

Alterations of proteins, lipids, and ions in the plasma and erythrocyte of steady-state patients with SCA were demonstrated. Some of these alterations are related with each other and with the oxidative stress observed in the disease.

Gated myocardial perfusion scintigraphy in children with sickle cell anemia: correlation with echocardiography

OBJECTIVES

The heart is one of the organs affected by sickle cell anemia (SCA). This prospective study has aimed to evaluate myocardial perfusion and left ventricle (LV) function in children with SCA by gated myocardial perfusion scintigraphy (G-MPS) and to compare the results with echocardiographic parameters.

METHODS

Forty-three patients with SCA were evaluated by G-MPS and echocardiography. Myocardial perfusion and motion with thickening function were analyzed both visually and quantitatively. End-diastolic (EDV), end-systolic volumes (ESV), ejection fraction (EF), lung-to-heart (L/H) ratio were also calculated.

RESULTS

None of the patients showed stress perfusion impairment in G-MPS. LV dilatation in 15 patients was observed both by G-MPS and echocardiography. EF values were within normal limits. Correlation between EF values calculated by two methods was not statistically significant. However, LV dilatation detected by both methods and EDV-ESV values in G-MPS were correlated to end-diastolic and end-systolic diameters calculated in echocardiography (p<0.05). M-Mode echocardiography revealed higher myocardial performance index (LV-MPI) in patients with LV dilatation. There was also a significant relationship between LV dilatation and frequent blood transfusions (>5/years) and acute chest syndrome (p<0.05).

CONCLUSION

Myocardial perfusion impairment in children with SCA is not frequently observed. Thus, performing the scintigraphy only in patients with cardiac symptoms should be considered. Since EF values of the children with SCA are not deteriorated in early stages, LV-MPI and LV dilatation should be considered as a significant parameter other than EF or perfusion data.

A neonatal case of left ventricular noncompaction associated with trisomy 18

A neonatal case of left ventricular non-compaction associated with trisomy 18: Left ventricular noncompaction (LVNC) is a rare congenital cardiomyopathy and exact etiology is still unknown. Trisomy 18 is the second most common autosomal trisomy in live-born infants. LVNC has been described in association with other dysmorphic features, association with trisomy 18 has not been reported previously in a neonate. LVNC broadens the cardiac anomalies associated with trisomy 18.

Anemia and neutropenic fever with high dose diazoxide treatment in a case with hyperinsulinism due to Munchausen by proxy

BACKGROUND

The etiology of hyperinsulinemic hypoglycemia in adolescents is similar to that of adults. Patients resistant to medical treatment may undergo pancreatectomy. Diazoxide is the mainstay of medical treatment. Rarely bone marrow suppression is reported due to diazoxide.

PATIENT

An adolescent with severe hyperinsulinemic hypoglycemia was referred for pancreatectomy after she was treated with high doses of diazoxide, octreotide and glucose. She developed anemia and febrile neutropenia in the course of diazoxide treatment that resolved with cessation of medication. The cause of the hyperinsulinemia proved to be classical Munchausen by proxy.

CONCLUSION

This is the first report of bone marrow suppression involving erythroid series by diazoxide. Follow-up of blood count may be considered in patients on high dosages since anemia may be dose dependent. Munchausen by proxy poses a serious threat to children with significant morbidity and mortality. Awareness and a high index of suspicion in clinical settings with unusual causes are the mainstay for the diagnosis.

Resistance patterns in Turkey

Resistance to antimicrobial agents in Gram-positive and Gram-negative bacteria is common in Turkey. In this review, resistance to several antimicrobial agents in this country is discussed for bacteria which have gained clinical importance in recent years. Among Gram-positives, staphylococci are of major importance because of their high level of resistance to many agents in the hospital and the community. Methicillin resistance in different hospitals ranges from 13% to 37%. High-level resistance to gentamicin occur in enterococci and resistance to glycopeptides have not been reported in these isolates. S. pneumoniae resistance to penicillin have been observed in Turkey as 47% in Hacettepe University and most of the resistant isolates were from children with severe underlying diseases. In reports from other hospitals, the level of resistance was lower because of a different patient population. In Gram-negative bacilli, aminoglycoside resistance is a significant problem in the treatment of severe infections in our country. The most common mechanism of resistance in our isolates is the plasmid-mediated enzymatic modification of these agents. Extended-broad spectrum beta-lactamases have been detected in Klebsiella spp. and Salmonella spp. in Turkey. In a Pseudomonas strain, an extended-spectrum variant of OXA-10 was identified. Some isolates were also shown to produce plasmid mediated PER-1 enzymes. Due to resistance problems encountered in many hospitals, restriction control measures have been started in some hospitals in order to limit the antibiotic use and our hope is the country-wide application of these precautions as soon as possible.

A European survey of antibiotic management of methicillin-resistant Staphylococcus aureus infection: current clinical opinion and practice

Although the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) varies across Europe, healthcare-associated MRSA infections are common in many countries. Despite several national guidelines, the approach to treatment of MRSA infections varies across the continent, and there are multiple areas of management uncertainty for which there is little clinical evidence to guide practice. A faculty, convened to explore some of these areas, devised a survey that was used to compare the perspectives of infection specialists from across Europe on the management of MRSA infections with those of the faculty specialists. The survey instrument, a web-based questionnaire, was sent to 3840 registered delegates of the 19th European Congress of Clinical Microbiology and Infectious Diseases, held in April 2009. Of the 501 (13%) respondents to the survey, 84% were infection/microbiology specialists and 80% were from Europe. This article reports the survey results from European respondents, and shows a broad range of opinion and practice on a variety of issues pertaining to the management of minor and serious MRSA infections, such as pneumonia, bacteraemia, and skin and soft tissue infections. The issues include changing epidemiology, when and when not to treat, choice of treatment, and duration and route of treatment. The survey identified areas where practice can be improved and where further research is needed, and also identified areas of pan-European consensus of opinion that could be applied to European guidelines for the management of MRSA infection.

Evaluation of cardiovascular complications with 99mTc tetrofosmin gated myocardial perfusion scintigraphy in patients with thalassemia major

OBJECTIVE

Iron overload limits the life expectancy of thalassaemic patients by causing cardiac toxicity. Iron also plays a catalytic role in the pathogenesis of atherosclerosis. The aim of this study was to evaluate the role of (99m)Tc Tetrofosmin gated myocardial perfusion scintigraphy (GMPS) in the detection of cardiac dysfunction in patients with thalassemia major.

MATERIALS AND METHODS

Forty two patients with homozygous beta-thalassemia were enrolled in the study. Myocardial perfusion and wall motion were analysed in all patients (mean age 17 +/- 5.28) and 34 age-matched controls using GMPS. Clinical data, liver function tests, hemoglobin, ferritin, low density lipoprotein (LDL) and cholesterol levels, and the total number and frequency of transfusions were collected from patient records.

RESULTS

97.6 % and 78.5 % of patients had normal myocardial perfusion and wall motion respectively. Nine out of 42 thalassaemic patients had abnormal left ventricular wall motion; half of these had septal hypokinesia. No significant correlation was found between the total number of transfusions, serum ferritin levels and left ventricular ejection fraction (p = 0.442 and p = 1.00, respectively). Echocardiography revealed systolic dysfunction in 5 out of 9 patients with wall motion abnormality. LDL was normal in 38 out of 42 patients and cholesterol levels were normal in 37 out of 42 patients.

CONCLUSIONS

Regional wall motion abnormalities can be seen in patients with thalassemia major. This early damage is frequently located in the septum and can be detected by GMPS. Serum ferritin levels and the number of blood transfusions are inadequate as predictors of myocardial dysfunction.