Mumps antibody levels among students before a mumps outbreak: in search of a correlate of immunity

BACKGROUND

In 2006, a mumps outbreak occurred on a university campus despite ≥ 95% coverage of students with 2 doses of measles-mumps-rubella (MMR) vaccine. Using plasma samples from a blood drive held on campus before identification of mumps cases, we compared vaccine-induced preoutbreak mumps antibody levels between individuals who developed mumps (case patients) and those who did not develop mumps (nonpatients).

METHODS

Preoutbreak samples were available from 11 case patients, 22 nonpatients who reported mumps exposure but no mumps symptoms, and 103 nonpatients who reported no known exposure and no symptoms. Antibody titers were measured by plaque reduction neutralization assay using Jeryl Lynn vaccine virus and the outbreak virus Iowa-G/USA-06 and by enzyme immunoassay (EIA).

RESULTS

Preoutbreak Jeryl Lynn virus neutralization titers were significantly lower among case patients than unexposed nonpatients (P = .023), and EIA results were significantly lower among case patients than exposed nonpatients (P = .007) and unexposed nonpatients (P = .009). Proportionately more case patients than exposed nonpatients had a preoutbreak anti-Jeryl Lynn titer < 31 (64% vs 27%, respectively; P = .065), an anti-Iowa-G/USA-06 titer < 8 (55% vs 14%; P = .033), and EIA index standard ratio < 1.40 (64% vs 9%; P = .002) and < 1.71 (73% vs 14%, P = .001).

DISCUSSION

Case patients generally had lower preoutbreak mumps antibody levels than nonpatients. However, titers overlapped and no cutoff points separated all mumps case patients from all nonpatients.

Patterns of chlamydia/gonorrhea positivity among voluntarily screened New York City public high school students

PURPOSE

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are common sexually transmitted infections that disproportionately affect adolescents. Annual screening for CT for sexually active female adolescents is recommended. In 2006, New York City began conducting CT/GC education, screening, and treatment in public high schools. We examine 3-year programmatic outcomes and the relationship between sexual activity, screening, and CT/GC positivity.

METHODS

We describe the epidemiology of students who screened and those infected with CT/GC. Univariate, bivariate, and multivariate logistic regression analyses were performed to assess relationships between sex, race/ethnicity, age, sexual activity, and screening status; and the relationship between sexually transmitted infection positivity and sexual activity.

RESULTS

Between July 2006 and June 2009, we educated 57,418 students and screened 27,353 (47.6%) for CT/GC; 1,736 (6.3%) students were reported to be infected with either organism. Students who screened positive were more likely to be females (8.9%), report black race (8.3%) and be ≥16 years of age (6.6%-9.7%). Screening rates were 70.6% for students who were sexually active, 27.9% for those who had never had sex, and 47.3% for those who did not respond to the sexual activity question; CT/GC positivity was 7.2%, 1.4%, and 6.1%, respectively.

CONCLUSIONS

Black, older adolescent females were most likely to screen positive for CT/GC in this population. A large proportion of students who did not answer the sexual activity question chose to screen for CT/GC and screened positive. School screening programs should offer screening to all students regardless of reported sexual activity. Programs should target females and older adolescents.

Triage of the child with abdominal pain: A clinical algorithm for emergency patient management

OBJECTIVE

To create a simplified clinical algorithm for the triage of children with abdominal pain.

DESIGN

Retrospective analysis.

SETTING

Emergency room at the Children's Hospital of Eastern Ontario, Ottawa, Ontario.

METHODS

A data mining methodology (rough sets analysis) was applied to a randomized data set obtained from 175 emergency room admission charts of patients. Patients were placed into two diagnostic decision classes: appendicitis confirmed by a pathological report, and resolution (this classification implied the resolution of all clinical complaints and physical findings, with no pathological diagnosis and no operative procedure).

RESULTS

Nine clinical symptoms and signs were identified as being important in the management of children with abdominal pain. A clinically based algorithm for the triage of such children was developed.

CONCLUSIONS

It is possible to develop a clinical algorithm for the triage of children with abdominal pain that can also be used by nonmedical professionals. A template for such an algorithm can be used as the basis for diagnosing other paediatric emergencies, such as chest pain, headaches and joint pain.

[Coronary embolism due to an adherent right atrium thrombus through a patent foramen ovale]

This observation relates to the discovery of native coronary paradoxical embolism secondary to thrombus adherent to the right atrium through a patent foramen ovale (PFO). A patient of 64 years, with a history of mitral regurgitation not followed, was hospitalized for acute respiratory distress due to a mitral insufficiency (MI) with a ruptured chordae and pulmonary embolism. Coronary angiography was performed and revealed two typical images of coronary embolism associated to a non-atheromatous coronary tree. The patient underwent a mitral valve replacement. After the establishment of cardiopulmonary bypass, adherent fibrin and cruoric thrombus of the right atrium and a PFO were found. The analysis of the valves did not reveal any arguments for infective endocarditis. A CT scan, performed as the patient remained unconscious after surgery, showed several cerebral infarcts. Paradoxical embolism coronary was diagnosed in front of the combination of adherent thrombus in the right atrium, pulmonary embolism and systemic coronary and cerebral embolism with a PFO. Coronary embolism rarely happens. It is mainly due to three causes: iatrogenic origin in most cases, direct causes due to micro emboli, particularly from infectious endocarditis and paradoxical embolic origin. There are two types of right atrial thrombus; the most common is the mobile thrombus from the peripheral venous system. The other one, which is more rare, is the adherent thrombus, which occurs in situ. Coronary embolism of paradoxical origin represents a small proportion of the causes of coronary embolism. However, this diagnosis must be considered.

[Primary myxoid mediastinal liposarcoma]

Mediastinal liposarcomas (LPS) are rare tumours. We report a case of primary myxoid LPS in a 22-year-old woman suffering from cough, dyspnoea on exercise and asthenia for 3 weeks. Thoracic MRI showed a large tumour on the right side. After neoadjuvant chemotherapy, a complete resection was performed, followed by adjuvant thoracic irradiation. Eighteen months after the diagnosis, no sign of recurrence was detected. Mediastinal LPS include a heterogeneous group of bulky tumours, the progression of which depends on the histological type. The prognosis is dominated by the operability of the tumour. Adjuvant therapies are not established.

Is staging beneficial for Fowler-Stephens orchiopexy? A systematic review

PURPOSE

Fowler and Stephens showed that by dividing the spermatic vessels a high intra-abdominal testis could be placed in the scrotum. Testicular atrophy is a potential complication of this technique. We conducted a systematic review to determine whether single or 2-stage Fowler-Stephens orchiopexy results in better testicular viability.

MATERIALS AND METHODS

We searched electronic databases, clinical trial registries and gray literature. We included reports describing boys younger than 18 years with a primary outcome of "testicular viability and position." We performed a meta-analysis using random effects models. Heterogeneity was assessed using forest plot and I(2) statistic.

RESULTS

We identified 1,807 citations and included 61 articles. Single stage Fowler-Stephens orchiopexy was discussed in 9 articles, a 2-stage procedure in 36 and both approaches in 16. There were no randomized controlled trials, and most studies were cohort or case series. The pooled estimate of success rates was 80% for single stage Fowler-Stephens orchiopexy (95% CI 75 to 86) and 85% for 2-stage Fowler-Stephens orchiopexy (95% CI 81 to 90). The pooled odds ratio of single stage vs 2-stage Fowler-Stephens orchiopexy was 2.0 (95% CI 1.1 to 3.9) favoring the 2-stage procedure. There was no difference in the success rate between laparoscopic and open techniques in either single or 2-stage Fowler-Stephens orchiopexy. There was no evidence of asymmetry on the funnel plot. There were no complications reported with single stage, while ileus, hematoma and infection were the most common complications with 2-stage Fowler-Stephens orchiopexy.

CONCLUSIONS

Both techniques have a fairly high success rate but 2-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach (85% vs 80%, OR 2 in favor of 2-stage). Laparoscopic and open techniques had the same success rate. However, the level of evidence of the studies was low, and a study of a more robust design, such as a randomized controlled trial, should be performed.

A Phase I Trial of a Pegylated Liposomal Anthracycline (Doxil TM) and Lapatinib Combination in the Treatment of Metastatic Breast Cancer: Dose-Escalation Results of an Anthracycline and Lapatinib Combination Trial

Background: Liposomal formulations such as pegylated liposomal doxorubicin (PLD) were developed to improve the therapeutic index and overall benefit of the anthracyclines (A). Lapatinib (L) is a selective and highly competitive inhibitor of ErbB1 and ErbB2 tyrosine kinases. The combination of conventional doxorubicin and an ErbB2 targeting agent (trastuzumab) was effective but led to an unacceptable risk of cardiac toxicity. The combination of PLD and L however may be effective with less cardiac risk. Methods: This is an open-label, phase I, dose-escalation trial of PLD at 20, 30, 45 and 60 mg/m2 IV every 4 weeks (maximum of 8 doses) and L, 1500 mg po daily until progression in patients (pts) with metastatic breast cancer (MBC). EGFR and/or ErbB2 positivity was not required. Prior chemotherapy, endocrine therapy and trastuzumab were allowed however prior A use was limited to 240 mg/m2 of doxorubicin or 600 mg/m2 of epirubicin. Initially, prior EGFR targeting therapies were not allowed however the trial was subsequently amended to allow prior lapatinib. Concomitant CYP3A4 inducers/ inhibitors were not allowed. A left ventricular ejection fraction (LVEF) of ≥ 50% was required. The primary objective was to evaluate the safety, tolerability and feasibility of the combination of PLD and L, particularly with respect to cardiac safety. MUGAs were performed at entry and every 8 weeks thereafter. Results: 16 patients (PLD: 20 mg/m2 - 4 pts; 30 mg/m2 - 3 pts; 45 mg/m2 – 6 pts; 60 mg/m2- 3 pts) with a mean age of 53 yrs (range, 33-68) have been treated for a total of 30 treatment cycles. Dose-limiting toxicity (DLT) was not reached. One pt experienced an LVEF drop to &lt; 50% after 4 cycles however this was accompanied by a pericardial effusion felt to be secondary to progressive disease. Adverse events observed include: grade IV- mucus plugging and knee pain in 1 pt each; grade III- fatigue and hand-foot-syndrome (HFS) in 2 pts each and edema, diarrhea, dizziness, headache, stomatitis and skin toxicity in 1 pt each; grade I/II in ≥2 pts- anemia, leucopenia, fatigue, shortness of breath, pain, nausea, stomatitis, anorexia, diarrhea, increased alkaline phosphatase or transaminases, hypoalbuminemia and hyperglycemia. Preliminary response data in 11 evaluable pts reveals 1 PR, 3 SD, and 8 PD. Event-free and overall survival curves are as shown.Conclusions: In the first 16 pts treated, the combination of PLD and L has been well tolerated without treatment-related cardiac toxicity. One pt experienced an LVEF drop to &lt; 50%, however this was felt likely to be disease-related. DLT was not reached however grade 3 HFS occurred in 2 out of 3 pts in the 60 mg/m2 cohort. A pharmacokinetic interaction cohort at the 45 mg/m2 dose is planned.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3096.

Single amino acid changes in the mumps virus haemagglutinin–neuraminidase and polymerase proteins are associated with neuroattenuation

It has previously been shown that three amino acid changes, one each in the fusion (F; Ala/Thr-91→Thr), haemagglutinin–neuraminidase (HN; Ser-466→Asn) and polymerase (L; Ile-736→Val) proteins, are associated with attenuation of a neurovirulent clinical isolate of mumps virus (88-1961) following serial passage in vitro. Here, using full-length cDNA plasmid clones and site-directed mutagenesis, it was shown that the single amino acid change in the HN protein and to a lesser extent, the change in the L protein, resulted in neuroattenuation, as assessed in rats. The combination of both amino acid changes caused neuroattenuation of the virus to levels previously reported for the clinical isolate following attenuation in vitro. The amino acid change in the F protein, despite having a dramatic effect on protein function in vitro, was previously shown to not be involved in the observed neuroattenuation, highlighting the importance of conducting confirmatory in vivo studies. This report provides additional supporting evidence for the role of the HN protein as a virulence factor and, as far as is known, is the first report to associate an amino acid change in the L protein with mumps virus neuroattenuation.

Coping with a diagnosis of C trachomatis or N gonorrhoeae: psychosocial and behavioral correlates

The current study sought to add to the stress and coping literature by examining whether coping responses are elicited from a diagnosis of chlamydia or gonorrhea and, if so, whether active or passive coping responses are associated with particular psychological factors and prevention behaviors. Data from 259 urban, minority participants recently diagnosed with chlamydia or gonorrhea were analyzed. Results indicated that denial was associated with having more baseline depressive symptoms and with having more one-time partners at follow-up. Problem-focused coping was associated with more consistent condom use at follow-up. Important sex and ethnicity differences were found. Intervention implications are discussed.

Mumps outbreaks in vaccinated populations: are available mumps vaccines effective enough to prevent outbreaks?

Increased reports of mumps in vaccinated populations prompted a review of the performance of mumps vaccines. The effectiveness of prior vaccination with 1 dose of vaccine ranged from 72.8% to 91% for the Jeryl Lynn strain, from 54.4% to 93% for the Urabe strain, and from 0% to 33% for the Rubini strain. Vaccine effectiveness after 2 doses of mumps vaccine was reported in 3 outbreaks and ranged from 91% to 94.6%. There was evidence of waning immunity, which is a likely factor in mumps outbreaks, aggravated by possible antigenic differences between the vaccine strain and outbreak strains. Inadequate vaccine coverage or use of the Rubini vaccine strain accounted for the majority of outbreaks reviewed; however, some outbreaks could not be prevented, despite high vaccination coverage with 2 doses of the Jeryl Lynn vaccine strain. Our findings indicate the need for more-effective mumps vaccines and/or for review of current vaccination policies to prevent future outbreaks.

Iatrogenic anterior diaphragmatic hernia in childhood

Congenital anterior diaphragmatic hernias (ADH) account for 2 - 6 % of diaphragmatic defects, whereas acquired ADH are rare. These hernias are most often the result of blunt or penetrating trauma. This is the first report of iatrogenic ADH in childhood. Two children with asymptomatic, iatrogenic ADH were diagnosed at 6 and 12 months of age, respectively. Both had undergone previous cardiac surgery requiring pericardial drainage. The ADH was seen on an incidental chest X-ray in one patient, and during a laparoscopic-assisted gastrostomy in the other. Both were successfully repaired laparoscopically. Subxiphoid pericardial drains may result in iatrogenic ADH. A high index of suspicion after cardiac surgery is necessary to avoid missing this potentially serious complication. Laparoscopy is a useful tool in both the diagnosis and repair of this condition.

Laparoscopic-assisted colostomy in children

INTRODUCTION

Colostomy morbidity has been reported to be as high as 50%. Laparoscopic-assisted colostomy (LAC) is associated with decreased colostomy complication. LAC is recommended for stoma formation in adults but has not been previously reported in children. In this paper, we report on our initial experience with LAC in children.

MATERIALS AND METHODS

Using a two- to four-port (3.5-mm) technique, LAC was performed in a female with an imperforate anus and 2 male patients with complicated Hirschsprung's disease (HD), respectively. Data collected included operative time, time to recover bowel function, and morbidity. Close follow-up was done until stoma closure.

RESULTS

The operative time was 144 minutes in the HD patients (including concomitant laparoscopic biopsies and a leveling colostomy) and 40 minutes in the imperforate anus patient. Median time to passage of both flatus and stool was 40 hours (range, 24-48). Time to commence feeds postop was 40 hours (range, 24-48). The median time of follow-up was 3 months (range, 2-9) until the stoma was taken down. No complications have occurred to date.

CONCLUSIONS

LAC is safe and easily performed in neonates and infants. It facilitates accurate stoma placement and orientation. It allows additional bowel mobilization, especially in HD. In accordance with the adult experience, LAC seems to obviate stoma-related complications. Encouraged by our initial low morbidity rate, a prospective evaluation of this technique is planned.

Analysis of structural changes in normal and aneurismal human aortic tissues using FTIR microscopy

Aortic aneurisms are frequently asymptomatic but can induce dramatic complications. The diagnosis is only based on the aortic diameter and not on a structural and compositional basis. In this preliminary study, we propose infrared microspectroscopy to nondestructively probe normal and aneurismal human aortas. Spectra from 19 human ascending aortic biopsies (10 normal and 9 aneurismal) were acquired using infrared microspectroscopy. A 1500 x 150 microm(2) area of each 7-microm thick cryosection was investigated using a 30-microm spatial resolution with a total of about 200 spectra per sample. Spectral differences between normal and aneurismal tissues were mainly located in spectral regions related to proteins, such as elastin and collagen, and proteoglycans (1750-1000 cm(-1)). Tissue heterogeneity and sample classification have been evaluated using hierarchical cluster analysis of individual or mean spectra and their second derivative. Using spectral range related to proteins, 100% of good classification was obtained whereas the proteoglycan spectral range was less discriminant. This in vitro study demonstrates the potential of such technique to differentiate between normal and aneurismal aortas using selected spectral ranges. Future investigations will be focused on these specific spectral regions to determine the role of elastin and collagen in the discrimination of normal and pathological aortas.

Mumps

Mumps is a common childhood infection caused by the mumps virus. The hallmark of infection is swelling of the parotid gland. Aseptic meningitis and encephalitis are common complications of mumps together with orchitis and oophoritis, which can arise in adult men and women, respectively; other complications include deafness and pancreatitis. Clinical diagnosis can be based on the classic parotid swelling; however, this feature is not present in all cases of mumps and can also occur in various other disorders. Laboratory diagnosis is based on isolation of virus, detection of viral nucleic acid, or serological confirmation (generally presence of IgM mumps antibodies). Mumps is vaccine-preventable, and one dose of mumps vaccine is about 80% effective against the disease. Routine vaccination has proven highly effective in reducing the incidence of mumps, and is presently used by most developed countries; however, there have been outbreaks of disease in vaccinated populations. In 2005, a large epidemic peaked in the UK, and in 2006 the American midwest had several outbreaks. In both countries, the largest proportion of cases was in young adults. In the UK, susceptible cohorts too old to have been vaccinated and too young to have been exposed to natural infections were the primary cause of the mumps epidemic. In the USA, effectiveness and uptake in combination appear not to have been sufficient to obtain herd immunity for mumps in populations such as college students.