Influenza vaccination in 18 developed countries, 1980-1992

Influenza continues to be an important cause of preventable morbidity and mortality. Although influenza vaccine is widely recommended for older high-risk individuals, no studies have compared its use in different countries. We gathered information on influenza vaccine distribution in 18 developed countries for the period 1980-1992. During the 1980s there was a > or = 10-fold difference in annual per capita vaccine distribution among these countries, and in 1992 the difference was still more than 7-fold. Several countries demonstrated large increases in vaccine use over the study period, some showing substantial increases in specific years. Thirteen of the 18 countries recommend influenza vaccination for all elderly persons and 11 countries provide reimbursement for vaccination through national or social health insurance. These countries tend to have higher levels of vaccine use. Historical, economic and political factors also affect vaccination practices and policies, but their relationships to differences in vaccine use between countries are not known. A better understanding of why the use of influenza vaccine varies among countries will be important if its protective benefits are to be fully realized.

Evidence of feline immunodeficiency virus replication in cultured Kupffer cells

OBJECTIVE

To determine if cultured feline Kupffer cells (KC) are as permissive for feline immunodeficiency virus (FIV) as cultured human liver macrophages are for HIV. Two types of infection likely to be relevant to the in vivo situation were used. KC were infected with either free virus or autologous infected peripheral blood mononuclear cells (PBMC).

METHODS

Feline KC were isolated by centrifugal elutriation from collagenase-perfused liver; cultured cells were characterized by their morphological appearance and their erythrophagocytotic properties. After infection, viral replication was measured by enzyme-linked immunosorbent assay, reverse transcriptase activity, immunofluorescence assay, in situ hybridization and electron microscopic observations.

RESULTS

Three days after isolation, 85% of cultured KC were able to internalize red blood cells; 45% were CD4-positive and 65% expressed a 24 kD protein thought to be a receptor for FIV (CD9). After the addition of autologous infected PBMC or cell-free supernatant of chronically infected IRC4 cells to KC cultures, a peak of viral replication was detected at day 28. Antigen revealed by immunofluorescence assay was present in only 0.4%, and viral RNA was detected by in situ hybridization in 2% of the infected cells.

CONCLUSIONS

FIV can replicate in cultured feline KC without inducing any cytopathic effect, which suggests that these cells may play a role in the physiopathology of FIV infection.

[Complex perianal fistula: diagnosis and treatment]

After a detailed discussion of the question of perianal fistulas, the authors use their own experience to examine complex perianal fistulas (trans-sphincteric with involvement of the puborectal muscle, high intersphincteric, extrasphincteric and supersphincteric) which represent 5-15% of cases. They affirm that elective treatment consists of surgical silk to ensure the optimal drainage of the fistula and provoke sclerosis of adjacent tissues, followed after 9 weeks by either the slow section of the fistula using a silicone ligature or direct fistulotomy. No cases of incontinence or recidivation were observed using this method in 29 cases treated between 1990 and 1992 who were followed up for between 6-24 months.

Increased plasma pancreastatin-like immunoreactivity levels in non-obese patients with essential hypertension

DESIGN

Pancreastatin, a novel peptide, is known to inhibit insulin secretion and to have a glycogenolytic effect, and is present in many endocrine and chromaffin cells. Both the plasma insulin levels and the adrenergic activity accompanying insulin resistance have been shown to be increased in hypertensive subjects. Our working hypothesis was that pancreastatin might play a role in these pathological phenomena.

METHODS

We studied the plasma pancreastatin level in non-obese essential hypertensive patients in response to an intravenous glucose load. We further measured the responses to the glucose challenge of insulin, glucagon, catecholamines and free fatty acids, as well as other factors related to insulin resistance (i.e. lipoproteins and apolipoproteins). We separated the hypertensive patients into three groups according to their response to an oral glucose-tolerance test: normoinsulinaemic, hyperinsulinaemic and glucose-intolerant. Matched normotensive control subjects were also studied.

RESULTS

Pancreastatin levels did not change in the control group after the glucose challenge. However, all hypertensive patients showed an increase in plasma pancreastatin levels after glucose loading. The normoinsulinaemic hypertensive patients also had elevated basal pancreastatin levels. The increase in pancreastatin levels was in the ranking: normoinsulinaemic > hyperinsulinaemic > glucose-intolerant. The pancreastatin: insulin ratio showed that the secretion of pancreastatin and insulin may be regulated differently. Basal free fatty acid and glucagon levels were found to be elevated both in the hyperinsulinaemic and in the glucose-intolerant group. Fasting triglycerides levels were increased in all of the hypertensive patients. Other risk factors for coronary artery disease were also found to be altered: elevated very low-density lipoprotein-cholesterol and decreased high-density lipoprotein-cholesterol, with ranking: normoinsulinaemic < hyperinsulinaemic < glucose-intolerant.

CONCLUSIONS

These results show an increase in pancreastatin levels in hypertensive patients, suggesting that pancreastatin might play a role in the pathophysiology of essential hypertension.

The elimination of indigenous measles, mumps, and rubella from Finland by a 12-year, two-dose vaccination program

BACKGROUND

In the 1970s measles, mumps, and rubella were rampant in Finland, and rates of immunization were inadequate. In 1982 a comprehensive national vaccination program began in which two doses of a combined live-virus vaccine were used.

METHODS

Public health nurses at 1036 child health centers administered the vaccine to children at 14 to 18 months of age and again at 6 years, and also to selected groups of older children and young adults. Vaccination was voluntary and free of charge. In follow-up studies, we focused on rates of vaccination, reasons for noncompliance, adverse reactions, immunogenicity, persistence of antibody, and incidence of the three diseases. Since 1987, paired serum samples have been collected from all patients with suspected cases of measles, mumps, or rubella.

RESULTS

Over a period of 12 years, 1.5 million of the 5 million people in Finland were vaccinated. Coverage now exceeds 95 percent. The vaccine was efficient and safe, even in those with a history of severe allergy. No deaths or persistent sequelae were attributable to vaccination. The most frequent complication requiring hospitalization was acute thrombocytopenic purpura, which occurred at a rate of 3.3 per 100,000 vaccinated persons. The 99 percent decrease in the incidence of the three diseases was accompanied by an increasing rate of false positive clinical diagnoses. In 655 vaccinated patients with clinically diagnosed disease, serologic studies confirmed the presence of measles in only 0.8 percent, mumps in 2.0 percent, and rubella in 1.2 percent. The few localized outbreaks were confined to patients in the partially vaccinated age groups. There are now fewer than 30 sporadic cases of each of the three diseases per year, and those are probably imported.

CONCLUSIONS

Over a 12-year period, an immunization program using two doses of combined live-virus vaccine has eliminated indigenous measles, mumps, and rubella from Finland. Serologic studies show that most reported sporadic cases are now due to other causes, but a continued high rate of vaccination coverage is essential to prevent outbreaks resulting from exposure to imported disease.

Receptors for pancreastatin in rat liver membranes: molecular identification and characterization by covalent cross-linking

High affinity binding sites for pancreastatin were identified for the first time, and their molecular characterization was performed with rat liver membranes. Using rat 125I-pancreastatin, we have studied the interaction of pancreastatin with liver membranes. Cross-linking of the tracer to the membranes was performed using the bifunctional reagent dithiobis(succinimidyl propionate). Analysis of binding under equilibrium conditions indicated the existence of one class of binding sites, with a Bmax of 15 fmol/mg of protein and an apparent Kd of 0.2 nM. The cross-linking of 125I-pancreastatin to liver membranes revealed a single band of M(r) 40,000, corresponding to the 125I-pancreastatin-receptor complex. The labeling of this complex was inhibited in the presence of rat pancreastatin (10(-10) to 10(-7) M) and in the presence of guanyl-5'-ylimidodiphosphate (10(-7) to 10(-4) M). Pretreatment of rat liver membranes with pertussis toxin did not affect pancreastatin binding or the inhibition by guanyl-5'-ylimidodiphosphate of pancreastatin binding. The specificity of pancreastatin binding was further assessed by displacement experiments with pancreastatin from other species and vasopressin. The binding of the pancreastatin-receptor complexes to Sepharose coupled to different lectins showed the glycoprotein nature of the pancreastatin receptor. These results strongly suggest that rat liver possesses a specific pancreastatin receptor, a glycoprotein of M(r) 35,000 that is coupled to a pertussis toxin-insensitive G protein in the plasma membrane.

Diminished insulin receptors on erythrocyte ghosts in nonobese patients with essential hypertension independent of hyperinsulinemia

Hypertension is associated with insulin resistance and dyslipidemia in a syndrome named X. Epidemiologic evidence also supports a link between hyperinsulinemia and blood pressure (BP), independent of obesity and non-insulin-dependent diabetes mellitus. To assess the possible role of insulin receptors in this syndrome, we studied insulin binding by erythrocyte ghosts in patients with moderate essential hypertension with or without fasting or postglucose hyperinsulinemia. We measured plasma glucose and insulin before and at 30, 60, and 120 min after administration of 75 g glucose in 62 hypertensive patients and 20 matched normotensive controls. Both groups had comparable age (mean 45 years) and waist/hip ratios (mean 0.88). Patients undergoing antihypertensive treatment did not receive antihypertensive medication for 3 weeks. Patients with fasting or postglucose hyperglycemia were excluded from the study. Insulin binding to erythrocyte ghosts was significantly decreased (p < 0.001) to almost half the values of controls (6.5% specific binding) in both patients with hyperinsulinemic (3.2% specific binding) and those with normoinsulinemic (3.9% specific binding) hypertension. Scatchard analysis demonstrated that this was due to a lesser number of insulin receptors. These data indicate that patients with essential hypertension can show decreased erythrocyte insulin receptors without detectable hyperinsulinemia.

[Complications of hepatic hydatidosis]

Fifty cases of complicated hydatid cyst of the liver on a total of 250 cases of hydatid cyst observed were analyzed. The Authors describe the several complications observed (compression, infection, rupture into biliary tract or into the thorax or into the peritoneal cavity, the diagnostic and therapeutic procedures. Total mortality was about 7.6% (3 cases) 2 patient died for intraperitoneal rupture and one for rupture in the biliary tract. Surgical treatment should be as radical as possible performing total or subtotal pericystectomy, hepatic resection is reserved to selected cases. Drainage by Kehr tube of biliary tract is necessary of rupture of the cyst in the biliary tract, while we limit the indication for a papillostomy to the sphincter duct stenosis.

[Tracheostomy: indications, techniques, and complications]

The authors report their experience relative to 46 tracheostomies performed over a 10-year period. In 6 cases the indication for a tracheostomy was a post-traumatic respiratory failure; in 20 cases a chronic respiratory insufficiency, in 6 cases a malignant neoplasm of the larynx; in 10 cases a postoperative respiratory insufficiency; in 4 cases for tongue and/or neck wounds. The authors stress the importance of a correct indication, the use of large volume-low pressure cuffs and an appropriate surgical technique to prevent complication of tracheostomy.

[Hydatid choleperitoneum: a rare complication of hepatic hydatid disease]

The authors report their experience relative to hydatid choleperitoneum which is a rare complication of hydatid hepatic disease (one case of 236 operated). They underline how such pathology constitutes a clinic and anatomopathological case, well characterized and different from those offered by other complications of this hepatic disease. They draw attention moreover on how preoperative diagnosis is often difficult and consequently how the surgical therapeutic technique requires a very careful examination of anatomic relations of the lesion and recognize, as a chiefly foundation, a radical treatment of hepatic disease and whenever possible, the removal of the pseudomembrane of encystment.

Lipoproteins and their genetic variation in subjects with and without angiographically verified coronary artery disease

To examine the concentration of serum lipoproteins and the association of their genetic variation with the occurrence of coronary artery disease (CAD), composite serum lipoprotein profiles including lipoprotein(a) (Lp[a]), apolipoprotein (apo) E phenotypes, and apo B Xba I genotypes were determined in patients with angiographically verified CAD (CAD+ group, n = 111) and in subjects with no angiographic evidence of CAD (CAD- group, n = 46). In addition, we determined the concentrations of serum lipids, lipoproteins, and apolipoproteins in 96 healthy controls. Both CAD- and CAD+ groups had lower concentrations of apos A-I and A-II but higher concentrations of serum total and very low density lipoprotein triglyceride and very low density lipoprotein cholesterol than did healthy controls. The mean concentrations of serum total and low density lipoprotein cholesterol and the median values of Lp(a) were similar in the CAD+ and CAD- groups, both having higher concentrations of low density lipoprotein cholesterol and apo B than the healthy controls. Irrespective of gender, patients with CAD had significantly lower serum high density lipoprotein cholesterol than did those without CAD (1.48 +/- 0.40 versus 1.16 +/- 0.29 mmol/l, p less than 0.001). In women, the mean serum total and very low density lipoprotein triglyceride concentration was also higher in the CAD+ than in the CAD- group. The frequency of the apo E4 allele (epsilon 4) was significantly higher in the CAD+ group (0.293) than in the CAD- group (0.174; p less than 0.001). The frequencies of the two apo B alleles, X1 (Xba I restriction site absent) and X2 (Xba I restriction site present), were similar in the two groups. Stepwise discriminant analysis revealed that in men, serum high density lipoprotein cholesterol had the highest power to discriminate for CAD. In addition, the concentration of plasma apo B levels and the occurrence of apo E phenotypes were independently associated with CAD in men. In women, the only independent factor associated with CAD after adjustment for beta-blocker and diuretics usage was the concentration of serum triglycerides.

HIV-induced deletion of antigen-specific T cell function is MHC restricted

When antigen-specific T cells are pulsed by antigen-presenting cells (APC) in the presence of HIV they are functionally deleted following subsequent exposure to syngeneic APC in the absence of HIV. Recombinant soluble HIV envelope (gp120) is able to induce a similar effect which, unlike that induced by HIV, is reversible. Neither HIV nor gp120 affect the ability to respond to IL-2. Thus it is only antigen-specific responses involving the T cell receptor pathways and CD4/MHC class II interaction that appear to be inhibited by HIV-1 and gp120. Furthermore, the functional impairment caused by HIV-1 is specific to the T cells that respond to the antigen in co-culture with HIV, as there is no apparent effect on 'bystander'-activated T cells specific for another antigen. Antigen-specific T cell lines may be deleted by a signalling mechanism which involves molecules other than gp120/CD4 but still requires MHC class II restriction.

Increase of vaccination coverage by mass media and individual approach: intensified measles, mumps, and rubella prevention program in Finland

In the 1970s, mass vaccination projects were started in various parts of the world against measles and congenital rubella, with eradication as the final goal. In many developing and industrial countries, including Finland, the elimination of measles failed because of low vaccination coverage. In Finland, a combined measles, mumps, and rubella (Virivac) vaccination program was started in 1982. Computerized recording of the vaccinated children was considered necessary and was integrated with the population registry to identify the hard-to-reach families. Several interventions improved compliance: a mass media campaign and notification of nonvaccinated children to local health professionals and parents. All successive campaigns increased vaccination coverage significantly, with the notification of parents about their nonvaccinated child being especially effective. A vaccination coverage of over 96% was achieved, which theoretically prevents measles, mumps, and rubella transmission.

Viral antibodies in multiple sclerosis. A nationwide co-twin study

Serum viral antibody titers against 21 viruses were studied in 19 of 23 same-sex twin pairs with multiple sclerosis derived from the Finnish Twin Cohort. Thorough neurologic examinations showed two monozygotic pairs to be concordant, whereas all dizygotic pairs were discordant. Special attention was given to measles, mumps, and rubella viruses, against which the antibody levels were determined with the complement fixation, hemagglutination inhibition, hemolysis-ingel, and enzyme immunoassay methods. Epstein-Barr virus antibody levels were determined by enzyme assay. In pairwise comparisons, the measles, mumps, and Epstein-Barr virus-IgG antibody levels were more often elevated in the patients with multiple sclerosis, compared with the healthy co-twins. The same antibody levels were more often above the median in the diseased twin, compared with the healthy twin, but the difference was not significant. No human T-cell lymphotropic virus type I antibodies were found in any of the individuals examined. The total IgG, IgA, and IgM levels did not differ between the diseased and healthy subjects. The HLA types, severity of the disease, and cell-mediated immunity parameters did not influence antibody levels.

[Perforation of the colon]

The paper reports personal observations relating to 111 cases of colonic perforation. Etiopathogenesis and different surgical approaches are discussed and results are compared. Hartmann's operation is identified as the best solution in cases of colonic perforation with diffuse peritonitis. In cases of localized peritonitis, excellent results may be obtained by operating immediately.

MS and SLE in twins of successive generations

During a nationwide twin study on multiple sclerosis (MS) in Finland a dizygotic pair discordant for MS was found. The affected co-twin had dizygotic twin daughters. The affected co-twin of the second generation had systemic lupus erythematosus (SLE). Both pairs were thoroughly examined. No evidence of CNS involvement in the healthy co-twins was found. In pairwise comparisons, virus-specific IgG antibodies to measles and mumps were significantly increased in the MS patient whereas the same was true for rubella in the SLE patient. Both MS and SLE patient expressed HLA alleles most often found to be associated with these disorders. Reversed CD4/CD8 ratios were observed in both MS and SLE patient. No difference in interleukin-2 receptor expression were found but gamma-interferon secretion in the MS patient showed marked increase whereas that of the SLE patient was of the same magnitude as in the healthy members. A different triggering stimulus rather than the dissimilarity in the immunogenetic predisposition may be decisive as to whether or not they develop MS or SLE.

[Emergency surgery in icterus]

Obstructive jaundice may be, still today, a surgical emergency. After the analysis of the serious syndrome following a persistent cholestasis, the authors discuss new technological diagnostic procedures and indications, pros and cons of the use of P.T.D. (Percutaneous Transhepatic Drainage). Finally, they underline emergency cases and proper surgical management, on the basis of their personal experience, as well.

Apoprotein E polymorphism and coronary artery disease. Increased prevalence of apolipoprotein E-4 in angiographically verified coronary patients

Several studies have indicated that genetic polymorphism of apolipoprotein (apo) E is related to coronary artery disease (CAD). We therefore determined the apo E phenotype in 91 consecutive Finnish men with angiographically confirmed CAD. The apo E phenotype distribution differed significantly from that observed in the Finnish population (p less than 0.05). In the patient group, the frequency of the epsilon 4 allele was 0.324, which is 1.4-fold higher than in the normal Finnish population and twice as high as in other Caucasian populations. Serum lipoproteins and postheparin plasma lipase activities did not display any significant variation according to apo E phenotype. These studies confirm and extend, in a population with high epsilon 4 allele frequency, the previous data on the impact of the epsilon 4 allele on the risk of CAD and suggest that the high epsilon 4 allele frequency in the Finnish population may be one factor contributing to Finns' increased susceptibility to CAD.

Fatal encephalitis caused by a bat-borne rabies-related virus. Clinical findings

The clinical findings are described in the first reported European case of fatal encephalitis of bat origin caused by a rabies-related virus. A bat zoologist developed the symptoms of rabies 51 days after his last exposure to a bat bite. The clinical disease of 23 days duration was a combination of the paralytic and 'furious' forms of rabies. Serial BAEP and EEG recordings, CT and MR scans of the brain, as well as CSF findings, demonstrated severe ascending destruction of the brain. An unusual progression from isolated brainstem death to cortical brain death occurred. Neuropathologically, the brain showed severe lytic changes. The presence of rabies-related virus antigens in brain smears was shown using a panel of fluorescent antibodies. The virus was inoculated into and isolated from suckling mice. The virus had a close resemblance to European bat rabies isolates, which belong to the group of rabies-related viruses. Of particular concern is whether the virus can spread from bats to terrestrial animals and whether the European type of bat rabies constitutes a danger to man.

Treatment of acromioclavicular disruptions: trial of a simple surgical approach

Following the Allman and the Zlotsky and Ballard classifications, 85 cases of acromioclavicular disruptions (ACD) have been treated. Types I and II have been conservatively managed, while type III was treated by a special surgical technique described in the text. Types I and II were reviewed by a questionnaire form and type III was assessed clinically and radiologically, with good results according to a score rating made for the review.