Complicated Treatment Course of Severe Asymptomatic Hypertriglyceridemia: A Case Report and Literature Review

BACKGROUND Close observation, statins, fibrate treatment, and lifestyle changes can safely manage asymptomatic individuals with severe hypertriglyceridemia (HTG) and minimal risk of symptom development. However, the risk of medication-induced liver injury in patients taking statin-fibrate makes management more challenging, and may require hospital admission and close monitoring with follow-up. CASE REPORT We present a rare case of a 43-year-old man with asymptomatic severe HTG exceeding 11.370 mg/dL with mixed hyperlipidemia, managed initially with high-intensity statins and fibrate. However, due to the concurrent use of statin and fibrates, the patient subsequently developed an acute liver injury. Hence, the oral medications had to be stopped, and the patient was admitted to the hospital for an insulin drip. Even during the hospital course, the patient's triglyceride (TG) levels showed resistance to the recommended dose of insulin and he required a higher insulin dose. He was discharged on fenofibrate and subcutaneous insulin to keep the TG level under 500. Fibrate was stopped, and high-intensity statin was used as primary prevention with lifestyle modifications. CONCLUSIONS This instance highlights the necessity of increased cognizance and cooperative endeavors in handling severe asymptomatic HTG. Our results highlight the significance of further research into the management of severe asymptomatic HTG in cases of injury to the liver. This work adds essential knowledge to the ongoing discussion about managing a rare case complicated by acute liver injury.

Cocaine-Induced Acute Extremity Compartment Syndrome: A Rare Case Report

There is a dearth of research connecting acute extremities compartment syndrome to cocaine. Here, we present a case of a forty-year-old guy who is actively using cocaine and comes to the emergency room with excruciating right leg pain and swelling. Physical examination revealed substantial tachycardia, lack of dorsalis pedis pulses, stiff and painful calf muscles, and absence of plantar reflexes in the right lower extremities after sleeping on his right leg. A positive urine drug screen for cocaine, severe rhabdomyolysis, and acute renal damage warranted further laboratory testing. A diagnosis of compartment syndrome was established based on the lack of dorsalis pedis pulses in the right lower extremity and radiographic evidence of oedematous alterations in the calf muscles with perimuscular edema. For this case, acute renal injury was done, and treatment with fluid, hemodialysis, and right lower extremity double-compartment fasciotomies have been used. After that, his clinical situation improved, and no other dialysis sessions were required. Cocaine usage has been linked to rhabdomyolysis; nevertheless, compartment syndrome is an extremely uncommon consequence, particularly in the absence of severe damage or extended immobility.

Invited Article: A precise instrument to determine the Planck constant, and the future kilogram

A precise instrument, called a watt balance, compares mechanical power measured in terms of the meter, the second, and the kilogram to electrical power measured in terms of the volt and the ohm. A direct link between mechanical action and the Planck constant is established by the practical realization of the electrical units derived from the Josephson and the quantum Hall effects. We describe in this paper the fourth-generation watt balance at the National Institute of Standards and Technology (NIST), and report our initial determination of the Planck constant obtained from data taken in late 2015 and the beginning of 2016. A comprehensive analysis of the data and the associated uncertainties led to the SI value of the Planck constant, h = 6.626 069 83(22) × 10(-34) J s. The relative standard uncertainty associated with this result is 34 × 10(-9).

Bridging classical and quantum mechanics

Using a watt balance and a frequency comb, a mass-energy equivalence is derived. The watt balance compares mechanical power measured in terms of the meter, the second, and the kilogram to electrical power measured in terms of the volt and the ohm. A direct link between mechanical action and the Planck constant is established by the practical realization of the electrical units derived from the Josephson and the quantum Hall effects. By using frequency combs to measure velocities and acceleration of gravity, the unit of mass can be realized from a set of three defining constants: the Planck constant h, the speed of light c, and the hyperfine splitting frequency of 133Cs.

Detailed molecular characterisation of acute myeloid leukaemia with a normal karyotype using targeted DNA capture

Advances in sequencing technologies are giving unprecedented insights into the spectrum of somatic mutations underlying acute myeloid leukaemia with a normal karyotype (AML-NK). It is clear that the prognosis of individual patients is strongly influenced by the combination of mutations in their leukaemia and that many leukaemias are composed of multiple subclones, with differential susceptibilities to treatment. Here, we describe a method, employing targeted capture coupled with next-generation sequencing and tailored bioinformatic analysis, for the simultaneous study of 24 genes recurrently mutated in AML-NK. Mutational analysis was performed using open source software and an in-house script (Mutation Identification and Analysis Software), which identified dominant clone mutations with 100% specificity. In each of seven cases of AML-NK studied, we identified and verified mutations in 2-4 genes in the main leukaemic clone. Additionally, high sequencing depth enabled us to identify putative subclonal mutations and detect leukaemia-specific mutations in DNA from remission marrow. Finally, we used normalised read depths to detect copy number changes and identified and subsequently verified a tandem duplication of exons 2-9 of MLL and at least one deletion involving PTEN. This methodology reliably detects sequence and copy number mutations, and can thus greatly facilitate the classification, clinical research, diagnosis and management of AML-NK.

The use of adrenaline autoinjectors by children and teenagers

BACKGROUND

Although adrenaline is recommended as first line treatment for anaphylaxis, it is often not utilized. There has been a debate about when adrenaline autoinjectors should be prescribed and how many should be dispensed.

OBJECTIVES

To see how many adrenaline autoinjectors were used during anaphylactic reactions and to determine why they were not used in situations where they were clinically indicated.

METHODS

Patients were recruited prospectively at 14 paediatric allergy clinics throughout UK. Participants completed a questionnaire covering demographic data, atopic status and details of allergic reactions in the previous year and reasons for using more than one device.

RESULTS

A total of 969 patients were recruited of whom 466 (48.1%, 95% CI: 37.9-58.2) had had at least one reaction in the previous year; 245 (25.3%, 95% CI: 16.2-34.4) of these reactions were anaphylaxis. An adrenaline autoinjector was used by 41 (16.7%, 95% CI: 11.7-21.3) participants experiencing anaphylaxis. Thirteen participants received more than one dose of adrenaline, for nine of these a health professional gave at least one. The commonest reasons for using more than one were severe breathing difficulties (40%), lack of improvement with first dose (20%) and miss-firing (13.3%). The commonest reasons for not using adrenaline in anaphylaxis were 'thought adrenaline unnecessary' (54.4%) and 'unsure adrenaline necessary' (19.1%). Many with wheeze did not use their autoinjector.

CONCLUSIONS AND CLINICAL RELEVANCE

Adrenaline is used by only a minority of patients experiencing anaphylaxis in the community. Thirteen of the 41 patients with anaphylaxis who used their autoinjector needed another dose of adrenaline. Further research is needed to consider how to best encourage the usage of adrenaline when clinically indicated in anaphylaxis.

Optical Properties of Anatase, Rutile and Amorphous Phases of TiO2 Thin Films Grown at Room Temperature by RF Magnetron Sputtering

Anatase (A), rutile (R) and amorphous phase TiO2 thin films have been prepared by RF magnetron sputtering on unheated glass substrates by controlling the total pressure of sputtering gases (Ar + O2) and the substrate bias. The crystal structures of the films were confirmed by x-ray diffraction and Raman scattering. The analysis of optical absorption data for A- TiO2 film shows an energy bandgap (Eg) of 3.2 eV (indirect extrapolation) and ∼ 3.5 eV (direct extrapolation). On the other hand, R-TiO2 film shows Eg ∼ 2.9 eV (indirect) and 3.2 eV (direct). The latter film also shows the presence of amorphous regions with Eg ∼ 3.0 eV (indirect) and 3.8 eV (direct). The bandgap of both the films, obtained using indirect extrapolation, has a value range consistent with the previous measurements.

Vietnamese community screening for hepatitis B virus and hepatitis C virus

Asian Americans represent an important cohort at high risk for viral hepatitis. To determine the prevalence of Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infection and HBV vaccination in a Vietnamese community, a total of 322 Vietnamese subjects from a local doctor's office and annual Vietnamese Health Fair were included in this study. Demographic and clinical data were collected. 2.2% of the screened cohort tested positive for anti-HCV and 9.3% tested positive for HBsAg. Unlike HBV-positive subjects, HCV-positive subjects had significantly higher liver enzymes (P = 0.0045 and P = 0.0332, respectively). The HBV-positive group was more likely to report jaundice (P = 0.0138) and a family history of HBV (P = 0.0115) compared to HBV-negative subjects. Forty-eight patients (15.5%) reported a family history of liver disease (HBV, HCV, HCC, cirrhosis, other). Of this 48, 68.8% reported no personal history of HBV vaccination and 77.1% reported no family history of vaccination for HBV. Among the 183 subjects without a family history of liver disease, 156 (85.2%) reported no personal history of vaccination and 168 (91.8%) reported no family history of vaccination. HBV vaccination rates in those reporting a family history of liver disease were significantly higher (P =0.020). There was a high prevalence of HBV infection in this community screening. Nevertheless, the rate for HBV vaccination was low. The low prevalence of abnormal liver enzymes in HBV-positive subjects emphasizes the need for screening to be triggered by risk factors and not by abnormal liver enzymes.

Screening for hepatitis B, C and non-alcoholic fatty liver disease: a survey of community-based physicians

BACKGROUND

Screening guidelines for hepatitis B (HBV) and hepatitis C viruses (HCV) as well as a position statement for non-alcoholic fatty liver disease (NAFLD) have been put forth by different sources, but awareness of these guidelines and their impact on the physician practices have not been assessed.

AIM

To assess the attitudes of primary care physicians (PCPs), gastroenterologists (GEs) and hepatologists (HEPs) regarding screening for HBV, HCV and NAFLD.

DESIGN

A survey questionnaire was sent to community-based PCPs and GEs to assess issues related to HBV, HCV and NAFLD. The same questionnaire was sent to hepatologists (HEPs). The questionnaire contained 10 items related to demographic and practice patterns of these physicians, 35 items related to HBV, 35 items related to HCV and 29 items related to NAFLD.

RESULTS

A total of 214 physicians (103 PCPs, 59 GEs and 52 HEPs) completed the survey. A majority of PCPs, GEs and HEPs agreed on most screening issues for these causes of liver disease. Nevertheless, within group comparison of physicians (guideline aware versus guideline unaware) showed significant differences in accurate response between those who were aware of guidelines and those who were not aware.

CONCLUSIONS

A large percentage of PCPs and GEs were unaware of official guidelines for viral hepatitis B and hepatitis C. Those aware of guidelines were more likely to screen appropriately and avoid unnecessary testing. More needs to be done to assess awareness and the impact implementation of guidelines in hepatology.

[Anatomic bases of the infrahyoid flap: vascular pedicles and innervation]

The infrahyoid flap is used in head and neck reconstruction, especially in oral defect. This study is designed to determine vascular pedicles and innervation of the infrahyoid muscles and flap.

MATERIALS AND METHOD

The neck regions of 12 injected cadavers were investigated bilaterally.

RESULTS

The arterial pedicles of the infrahyoid muscles are the superior and inferior thyroid arteries. The arterial pedicles of the flap are the superior thyroid artery. The venous pedicles of the muscles and flap are the superior thyroid, lingual and facial veins. The infrahyoid flap is innervated by the ansa cervicalis.

CONCLUSION

The infrahyoid flap seems to be an excellent flap for oral, oropharynx and superior facial part reconstruction. It can be harvested easily in the same operation area.

The immunologic aspects of poxvirus oncolytic therapy

The concept of using replicating oncolytic viruses in cancer therapy dates to the beginning of the twentieth century. However, in the last few years, an increasing number of pre-clinical and clinical trials have been carried out with promising preliminarily results. Novel, indeed, is the suggestion that viral oncolytic therapy might not operate exclusively through an oncolysis-mediated process but additionally requires the "assistance" of the host's immune system. Originally, the host's immune response was believed to play a predominant obstructive role against viral replication, hence limiting the anti-tumor efficacy of viral vectors. Recent data, however, suggest that the immune response may also play a key role in promoting tumor destruction in association with the oncolytic process. In fact, immune effector pathways activated during oncolytic virus-induced tumor rejection seem to follow a similar pattern to those observed when the broader phenomenon of immune-mediated tissue-specific rejection occurs in other immune-related pathologies. We recently formulated the "Immunologic Constant of Rejection" hypothesis, emphasizing commonalties in transcriptional patterns observed when tissue-destruction occurs: whether with a favorable outcome, such as in tumor rejection and pathogen clearance; or a destructive one, such as in allograft rejection or autoimmunity. Here, we propose that a similar mechanism induces clearance of virally infected tumors and that such a mechanism is primarily dependent on innate immune functions.

The NGDO Co-ordination Group for Onchocerciasis Control

Since the beginning of the donation of Mectizan by Merck & Co., Inc., non-governmental development organizations (NGDO) have been actively involved in the mass distribution of this drug to control onchocerciasis. In 2006, the network of NGDO involved in onchocerciasis control assisted in the treatment of over 62 million people. The current strategy that is used for distribution in Africa, community-directed treatment with ivermectin (CDTI), is very well suited for integration with other health activities. NGDO have been the pioneers in integrating comprehensive eye care, insecticide-treated nets for malaria, the control of multiple 'neglected' tropical diseases, and vitamin-A supplementation. These expanded activities bring with them new challenges, which need to be addressed by all partners and where the NGDO will play an active role.

[Dercum's disease: a severe complication in a rare disease. A case report]

Dercum's disease or adiposis dolorasa is unusual and unknown. Four symptoms are typical. It is characterized by painful subcutaneous fatty tumors in postmenopausal woman. We present this disease through the study of an uncommon clinical case: a sceptic choc following the "steato-cutaneous-necrosis" of a fatty tumor. The disease remains rare. The etiology is to this day unknown and different hypothesis (endocrinous, metabolic, genetics) are put forward. Multiple complications can occur but severe septicemia is rare. The treatment can be medical (loss of weight, corticoids, intravenous lidocaine) or surgical (surgical excision or liposuction).

NMR imaging of the honeybee brain

NMR microscopy provides non-invasively distinct soft-tissue contrast in small biological samples. We were able to visualize the three-dimensional structure of the honeybee brain in its natural shape in the intact head capsule. Thus, in addition to acquiring detailed information about the shapes and volumes of the different brain compartments, we were able to show their relative orientations toward each other within the head capsule. Since the brain was lightly fixed but not dehydrated, and stayed attached to the head capsule and its internal structures, the NMR experiments exhibited larger volumes and a more natural stereo geometry of the various brain structures compared to confocal laser microscopy experiments on dissected, dehydrated and cleared brains.

Antibody responses to the repetitive Plasmodium falciparum antigen Pf332 in humans naturally primed to the parasite

Antibodies to the degenerate repeats of EB200, a part of the Plasmodium falciparum antigen Pf332, are protective in monkeys. To analyse the prevalence, magnitude and specificity of antibodies to EB200 in malaria-exposed humans, the IgG antibody reactivity with recombinant EB200 protein as well as with crude malaria antigen was determined in Senegalese donors (n = 100; 4-87 years). Antibody reactivity with EB200 was low or absent in children below 15 years but was prevalent and significantly higher in older donors. In comparison, all individuals displayed reactivity with a crude malaria antigen preparation, which also increased with age. The reactivity with the crude malaria antigen was correlated to the reactivity with EB200, suggesting that the low levels of IgG to EB200 found in some adult donors reflected a limited degree of recent exposure to parasites rather than a selective non-responsiveness to Pf332. Comparison of serological and clinical data showed that high levels of antibodies to crude malaria antigen and to EB200 were predictive of fewer future clinical attacks of malaria. A reactivity pattern very similar to that found in Senegalese donors was observed in Liberian adults where 80% of the sera showed reactivity with EB200 and all peptides were recognized by between 60 and 100% of the donors. This strong reactivity with EB200-derived overlapping peptides suggests that the epitopes in EB200, to a large extent, are linear. In the light of previous data on the parasite neutralizing capacity of antibodies to Pf332, the present results emphasize the potential interest of Pf332-derived sequences for inclusion in a subunit vaccine against P. falciparum malaria.

Comparative immunization study using RNA and DNA constructs encoding a part of the Plasmodium falciparum antigen Pf332

Development of nucleic acid-based vaccines against parasitic diseases shows great promise, although certain concerns about safety aspects of conventional DNA vaccines have been raised. This study presents a comparison of antibody responses induced in mice by DNA and RNA-based immunization with vectors encoding a part of the P. falciparum antigen Pf332. Two types of plasmids were used, one conventional DNA plasmid containing a cytomegalovirus promoter and one suicidal DNA plasmid encoding the Semliki Forest virus (SFV) replicase. RNA, encoding the SFV replicase and the relevant antigen, was delivered either as naked RNA or packaged in SFV suicide particles. In general, the antibody responses induced by the DNA plasmids were low and peaking after three injections, the conventional plasmid giving the highest responses. Also the RNA delivered in SFV particles consistently induced antibody responses, although comparatively low. Analyses of the ratio of immunoglobulin (Ig)G1/IgG2a subclasses in the responses indicated that all plasmids resulted in a bias for a Th2-type of response, while the SFV-particles elicited a Th1 type of response. Importantly, all these immunogens induced an immunological memory, which could be efficiently activated by a booster injection with the corresponding protein, with unchanged patterns of IgG subclasses.

Plasmid vaccine expressing granulocyte-macrophage colony-stimulating factor attracts infiltrates including immature dendritic cells into injected muscles

Plasmid-encoded GM-CSF (pGM-CSF) is an adjuvant for genetic vaccines; however, little is known about how pGM-CSF enhances immunogenicity. We now report that pGM-CSF injected into mouse muscle leads to a local infiltration of potential APCs. Infiltrates reached maximal size on days 3 to 5 after injection and appeared in several large discrete clusters within the muscle. Immunohistological studies in muscle sections from mice injected with pGM-CSF showed staining of cells with the macrophage markers CD11b, Mac-3, IA(d)/E(d) and to the granulocyte marker GR-1 from day 1 through day 14. Cells staining with the dendritic cell marker CD11c were detected only on days 3 to 5. Muscles injected with control plasmids did not stain for CD11c but did stain for CD11b, Mac-3, IA(d)/E(d), and GR-1. No staining was observed with the APC activation markers, B7.1 or CD40, or with markers for T or B cells. These findings are consistent with the infiltrating cells in the pGM-CSF-injected muscles being a mixture of neutrophils, macrophages, and immature dendritic cells and suggest that the i.m. APCs may be enhancing immune responses to coinjected plasmid Ags. This hypothesis is supported by data showing that 1) separation of injections with pGM-CSF and Ag-expressing plasmid into different sites did not enhance immune responses and 2) immune enhancement was associated with the presence of CD11c+ cells in the infiltrates. Thus, pGM-CSF enhancement may depend on APC recruitment to the i.m. site of injection.

Characterization of antibody responses to a Plasmodium falciparum blood-stage antigen induced by a DNA prime/protein boost immunization protocol

The humoral immune responses elicited by priming with a DNA plasmid and boosting with either the plasmid or the corresponding recombinant protein in alum adjuvant were compared. The plasmid DNA encoded a sequence (M3) derived from the Plasmodium falciparum antigen Pf155/RESA, and the recombinant protein consisted of the identical malarial sequence fused to an albumin-binding region (BB) of streptococcal protein G. Mice of different genetic backgrounds (CBA, Balb/c and C57Bl/6) were primed with plasmid DNA and boosted with either plasmid or recombinant protein. In all strains of mice, boosting with protein elicited higher anti-M3 antibody levels than obtained by boosting with plasmid, yet the kinetics and longevity of the secondary responses were comparable. Antiserum obtained after protein boosting displayed an immunoglobulin (Ig)G subclass profile skewed to the IgG1 isotype, regardless of the mouse strain. In contrast, mice receiving a second injection with plasmid responded with a more mixed IgG subclass profile. Inclusion of a P. falciparum circumsporozoite protein-derived T-helper epitope (CS.T3) in the immunization plasmid as well as in the fusion protein, did not significantly change the humoral responses to M3. The results show the potential of DNA vaccination for the purpose of priming an antibody response against the malarial blood-stage antigen Pf155/RESA. When combined with a protein boost, this DNA priming results in high-titred and long-lasting anamnestic responses.

Limited genetic diversity of Plasmodium falciparum in field isolates from Honduras

The genetic diversity displayed by Plasmodiumfalciparum field isolates, the occurrence of variant forms of the parasite at different frequencies in different geographic areas, and the complexity of the infections represent major obstacles for the development of effective malaria control measures. However, since most of the existing studies have been performed in regions where P. falciparum transmission is high, little is known about the diversity and complexity of parasite populations circulating in areas of low malaria endemicity. We investigated the extent of genetic polymorphism in P. falciparum field isolates from Honduras, a region where its transmission is low and seasonal. Allelic diversity was analyzed in the highly polymorphic parasite genes encoding the merozoite surface proteins- (MSP-1) and -2 (MSP-2) and the glutamate-rich protein (GLURP) by the polymerase chain reaction. Gene polymorphism was also assessed in the EB200 region derived from the highly size polymorphic Pf332 gene. Limited size polymorphism was detected in all genes analyzed, with four and three variants for the MSP-1 and MSP-2 alleles, respectively, and two size variants for the GLURP and Pf332 genes. Moreover, based on the studied genetic markers, most infections consisted of only a few genetically distinct parasite clones. These results suggest that the P. falciparum parasite populations circulating in this region are genetically homogeneous and point to an association between the extent of parasite genetic diversity and the intensity of malaria transmission.

Differential induction of immunoglobulin G subclasses by immunization with DNA vectors containing or lacking a signal sequence

The route and method used to immunize mice with antigen-expressing DNA plasmids have an impact on the resulting T-helper cell response and IgG subclass distribution. Previous findings further indicate that the intracellular targeting of expressed antigens influences the differentiation of naive T-cells into either a Th1 or a Th2 type of response. In the present study, we analyzed the levels of IgG1 and IgG2a antibodies, as correlates of Th2 and Th1 responses, respectively, after intramuscular injection of mice with plasmids encoding a chimeric protein containing a Plasmodium falciparum blood stage antigen expressed in two different forms. One plasmid expresses the antigen in a secreted form as it is preceded by a signal sequence while expression from the other plasmid, lacking this sequence, results in cytoplasmic localization of the antigen. Mice immunized with the plasmid encoding secreted antigen responded with predominantly IgG1 antibodies. In contrast, sera from mice immunized with the plasmid expressing cytosolic protein displayed a mixed IgG1/IgG2a profile. In line with previous findings, our results suggest that the intracellular targeting of proteins expressed by DNA plasmids is an important factor for the differentiation of Th cells and the resulting subclass pattern of IgG responses.

What is core? Guidelines for the core curriculum in paediatrics

A key point that the UK General Medical Council addressed in its recommendations on the undergraduate medical education was the concept of 'core curriculum' (General Medical Council 1993). Although enthusiastic for the idea of reducing factual overload, many medical teachers found themselves facing the task of how to define what a core curriculum is, what should be included and why. Predictably, our initial response is to include common and important topics, but how common is common, and how does one determine the relative importance of topics? We do not claim to have unravelled all the ambiguities surrounding the subject nor to have resolved all the controversies that are inevitably encountered. We hope, however, to describe some of the principles that governed our approach and put forward some guidelines, that may contribute to the debate.

Comparative study of DNA-based immunization vectors: effect of secretion signals on the antibody responses in mice

The presence of a signal sequence preceding the gene encoding a target antigen in a DNA vaccine should facilitate secretion of the in vivo translated antigen. The immune responses elicited upon injection with such a vector could differ from those induced by the same vector lacking a signal sequence. In the present study, the humoral responses elicited in mice immunized with two plasmids, either containing or lacking the human tissue plasminogen activator signal sequence, were compared. Both plasmids encode the chimeric antigen ZZN4, containing a malaria antigen Pf332-derived sequence (N4) linked to a bacterial fusion partner (ZZ). In vitro transfection of COS cells with each plasmid and treatment of the transfectants with brefeldin A confirmed that secretion of ZZN4 via the endoplasmic reticulum and Golgi pathway only occurred in cells transfected with the signal peptide-encoding plasmid. Repeated intramuscular injections of mice with either of the plasmids elicited comparable antibody responses to ZZN4 with regard to kinetics, specific IgG levels and persistence. These results indicate that in vivo transfection of muscle cells by either of these two plasmids generated comparable levels of antigen available for B-cell recognition and for uptake by antigen-presenting cells, despite the differential intracellular targeting of the encoded antigen. The relevance of these findings for the design of DNA vaccine vectors is discussed.

Predominance of H-2d- and H-2k-restricted T-cell epitopes in the highly repetitive Plasmodium falciparum antigen Pf332

Genetic restriction of immune responses to malaria antigens is an important issue for a better comprehension of malaria immunity as well as for development of subunit vaccines. To experimentally define the major histocompatibility complex restriction of immune responses to the highly repetitive Plasmodium falciparum high-molecular-weight antigen Pf332, H-2-congenic mice were immunized with EB200, a recombinant fragment of Pf332 consisting of degenerate repeat motifs. Strong B- and T-cell responses were elicited in H-2d and H-2k mice whereas responses in H-2b, H-2q and H-2s mice were of lower magnitude. The T-cell specificity elicited by EB200 was defined by in vitro proliferative responses to a panel of overlapping peptides spanning EB200. Dominant epitopes were identified for H-2d and H-2k mice, respectively, and an additional epitope was recognized by all five mouse strains. Selected EB200-derived peptides were further investigated for their ability to elicit T-cell help when injected as multiple antigen peptides. Defined H-2d- and H-2k-restricted T-cell epitopes generated high antibody levels in the respective mouse strains, as did several peptides lacking defined epitopes indicating the presence of additional H-2d- and H-2k-restricted, cryptic or subdominant T-cell epitopes in EB200. The biased H-2 restriction pattern of T-cell epitopes in Pf332 and, as previously reported, in structurally related repeats in the malaria antigens Pf11.1 and Pf155/RESA may be explained by a shared motif for H-2d and H-2k class II-restricted T-cell epitopes, as revealed by alignment of these sequences.

A novel expression system for Salmonella typhimurium allowing high production levels, product secretion and efficient recovery

A novel expression system for heterologous production in Salmonella typhimurium, taking advantage of the promoter, signal sequence and two IgG-binding domains (ZZ) from staphylococcal protein A, has been investigated. The production of two different fusion proteins, ZZ-M3 and ZZ-M5, was characterized in terms of production levels, product localization (periplasma or culture medium) and product quality after affinity purification. High expression levels and efficient product secretion were obtained, making the system attractive for vaccine development. The potential use of S. typhimurium as host for heterologous production in biotechnology is discussed.

Surface display compared to periplasmic expression of a malarial antigen in Salmonella typhimurium and its implications for immunogenicity

Two different expression systems were investigated for the production of an 80 amino acid polypeptide, M3, from the C-terminus of the Plasmodium falciparum blood stage antigen Pf155/RESA in an attenuated Salmonella typhimurium vaccine strain. Upon expression, the malarial polypeptide was targeted either to the periplasm as a soluble fusion protein containing two IgG-binding domains (ZZ) from the staphylococcal protein A or, to the bacterial surface as an insert within a chimeric outer membrane protein A (OmpA) derived from Escherichia coli and Shigella dysenteriae. Both the ZZM3 and the OmpAM3 proteins were stably expressed in the periplasm or on the surface of Salmonella, respectively. The ZZ expression system yielded 10-100 times more malarial immunogen than did the OmpA system. Live recombinant Salmonella expressing ZZM3 or OmpAM3 were used to immunize mice intraperitoneally. Both the ZZM3 and OmpAM3 genes persisted for up to three weeks in bacteria isolated from different lymphoid organs. Bacteria expressing ZZM3 induced antibodies to M3, ZZ and to the Pf155/RESA antigen whereas, bacteria producing OmpAM3 induced similar levels of antibodies reactive with M3 but not with Pf155/RESA. Both recombinants induced a memory response of antibodies reactive with both M3 and Pf155/RESA. The high levels of M3 produced by the ZZ expression system make it suitable for the expression of heterologous antigens in Salmonella. Nevertheless, in spite of the quantitative difference in M3 expression, the ZZ and OmpA constructs elicited comparable immune responses to M3.

Efficiency of protective sealants for glass ionomer cements

This study compared the efficiency of protective sealants for glass ionomer cements. Scotchbond 2, Visar Seal, an experimental light activated silicone and Ketac Glaze were evaluated using liquid scintillation spectrometry. The results showed that Ketac Glaze was a very effective sealant for the newly placed glass ionomer cement and the resin component of Scotchbond 2 is in the same range.

Dietitians' development of an enteral nutrition management package

Several dietitians at the Royal Victoria Hospital, Montreal, examined current hospital practices in enteral feeding and defined three major areas of concern that are known to influence the management of enterally-fed patients. These concerns deal with physicians' perceptions, nursing management and cost. In order to address these concerns and consequently improve the management of enterally-fed patients, an Enteral Nutrition Management Package consisting of an order form, flow sheet and monitoring record was developed. The package provides standardized guidelines for enterally-fed patients and emphasizes the need for monitoring patients' clinical progress. The usefulness of the package is dependent upon the participation of every member of the health care team including the physician, nurse and dietitian. The development of the package is the result of initiative taken by clinical dietitians in addressing patient care concerns in enteral nutrition within a multidisciplinary system.

Ultrasonic study of normal and fractured bone

Ultrasonic velocity measurement in bone can be used as a clinical tool that will accurately and objectively monitor the progress of fracture healing. This technique may provide a rational basis for evaluating the effectiveness of various modalities in clinical treatment. The eventual goal of this technique is to determine the status of healing fractures, prescribe appropriate treatment, give the rationale for the timing and form of a rehabilitative program that would accelerate the patient's return to productivity. An instrument has been developed to measure ultrasonic velocity in the long bones of the extremities. Serial measurements of tibial fractures and the measurement of a large group of normals shows no statistically significant differences in ultrasonic measurements have been found on the basis of race, sex, or pregnancy among normals. But a numerically small but statistically significant variation with age was found. While the number of fracture cases observed was small, the evidence is clear that ultrasonic measurement in fractured tibia may give a more reliable indication of the general pattern of healing response than the clinical and roentgenographic examination.