Comparison of antipsychotic drug use among Dutch Youth before and after implementation of the Youth Act (2010-2019)

OBJECTIVE

The Dutch law on youth care (the Youth Act) was implemented from 2015 onwards. One of the government's aims by implementing this new policy was de-medicalization of youths by separating youth mental healthcare from the rest of the healthcare system. A previous study conducted by our research group showed that prevalence rates of antipsychotic drug prescriptions stabilized among Dutch youth in the period 2005-2015, just before the introduction of the Youth Act. In our study, we aimed to describe antipsychotic drug use among Dutch children aged 0-19 years old before and after implementation of the Youth Act (2010-2019).

METHODS

We analyzed prescription data of 7405 youths aged 0-19 years using antipsychotic drugs between 2010 and 2019, derived from a large Dutch community pharmacy-based prescription database (IADB.nl).

RESULTS

Prevalence rates of antipsychotic drug use per thousand youths decreased significantly in youths aged 7-12 years old in 2019 compared to 2015 (7.9 vs 9.0 p < 0.05). By contrast, prevalence rates increased in adolescent females in 2019 compared to 2015 (11.8 vs 9.5 p < 0.05). Incidence rates increased significantly in adolescent youths in 2019 compared to 2015 (3.9 vs 3.0 p < 0.05), specifically among adolescent girls (4.2 per thousand in 2019 compared to 3.0 per thousand in 2015). Dosages in milligram declined for the most commonly prescribed antipsychotic drugs during the study period. The mean duration of antipsychotic drug use in the study period was 5.7 (95% CI 5.2-6.2) months.

CONCLUSION

Despite the aim of the Youth Act to achieve de-medicalization of youths, no clear reduction was observed in prevalence rates of antipsychotic drugs or treatment duration in all subgroups. Prevalence rates even increased in adolescent females.

An explorative study of school performance and antipsychotic medication

BACKGROUND

Antipsychotic therapy can reduce severe symptoms of psychiatric disorders, however, data on school performance among children on such treatment are lacking. The objective was to explore school performance among children using antipsychotic drugs at the end of primary education.

METHODS

A cross-sectional study was conducted using the University Groningen pharmacy database linked to academic achievement scores at the end of primary school (Dutch Cito-test) obtained from Statistics Netherlands. Mean Cito-test scores and standard deviations were obtained for children on antipsychotic therapy and reference children, and statistically compared using analyses of covariance. In addition, differences in subgroups as boys versus girls, ethnicity, household income, and late starters (start date within 12 months of the Cito-test) versus early starters (start date > 12 months before the Cito-test) were tested.

RESULTS

In all, data from 7994 children could be linked to Cito-test scores. At the time of the Cito-test, 45 (0.6 %) were on treatment with antipsychotics. Children using antipsychotics scored on average 3.6 points lower than the reference peer group (534.5 ± 9.5). Scores were different across gender and levels of household income (p < 0.05). Scores of early starters were significantly higher than starters within 12 months (533.7 ± 1.7 vs. 524.1 ± 2.6).

CONCLUSION

This first exploration showed that children on antipsychotic treatment have lower school performance compared to the reference peer group at the end of primary school. This was most noticeable for girls, but early starters were less affected than later starters. Due to the observational cross-sectional nature of this study, no causality can be inferred, but the results indicate that school performance should be closely monitored and causes of underperformance despite treatment warrants more research.

Antibiotic use during pregnancy and asthma in preschool children: the influence of confounding

BACKGROUND

A recent study suggested that early-life intestinal microbiota may play an important role in the development of childhood asthma, indicating that antibiotics taken during early life or in late pregnancy may be associated with childhood asthma.

OBJECTIVE

This study aims to assess the association between prenatal antibiotic use and asthma in preschool children using data from the prescription database IADB.nl. To assess the influence of potential confounding, we conducted both a case-sibling and a case-control study and compared the results.

METHODS

We conducted a case-sibling study in which 1228 children with asthma were compared to 1228 siblings without asthma, using data from the prescription database IADB.nl. In addition, a case-control study was conducted. Asthma in preschool children was defined as ≥ 3 prescriptions for anti-asthma medication within a year before the fifth birthday. Conditional logistic regression was used to estimate crude and adjusted odds ratios (aORs).

RESULTS

In both the case-sibling and case-control analysis, the use of antibiotics in the third trimester of pregnancy was associated with an increased risk of asthma in preschool children (aOR 1.37; 95% CI 1.02-1.83 and aOR 1.40; 95% CI 1.15-1.47). Time-trend analyses showed that results were not influenced by a time trend in antibiotic exposure. A significant association between exposure to antibiotics in any trimester of pregnancy and the development of asthma in preschool children was observed in the case-control analysis only (aOR 1.46; 95% CI 1.34-1.59).

CONCLUSION

Antibiotic use in the third trimester of pregnancy was associated with a small increased risk of asthma in preschool children. This association was robust to time-invariant confounding or exposure time trends, further supporting the important role for early-life intestinal microbiota in the development of childhood asthma.

[Antidepressant guidelines poorly adhered to in young people]

OBJECTIVE

To examine if Dutch physicians adhere to the national guidelines on the treatment of depression in children and adolescents.

DESIGN

Retrospective database research.

METHOD

Data on children and adolescents aged between 6 and 17 years were selected from the IADB, a Dutch database of filled prescriptions. We examined whether children and adolescents were prescribed fluoxetine as recommended by the guideline, and whether the starting dose was in accordance with the guideline.

RESULTS

Of 2942 children and adolescents in whom antidepressant treatment was initiated, the proportion prescribed fluoxetine increased from 10.1% in 1994-2003 to 19.7% in 2010-2014. However, paroxetine (1994-2003) and citalopram (2004-2014) were the most frequently prescribed antidepressants. Starting doses were guideline-concordant in 58% of children, 31% of preadolescents and 16% of adolescents. Sixty percent of all adolescents were prescribed an adult starting dose.

CONCLUSION

Guideline adherence was poor. In contrast to the guidelines, physicians preferred citalopram to fluoxetine in children and adolescents with depression. Furthermore, adolescents often received an adult starting dose. These results suggest that dedicated effort is necessary to improve guideline adherence.

Identification of Dutch children diagnosed with atopic diseases using prescription data: a validation study

Purpose

The aim of this study is to validate medication proxies for the identification of children diagnosed with atopic disorders that can be applied in various types of epidemiological research.

Methods

Records of 7439 children, aged between 0 and 10 years, in the period 2001 until 2010, were retrieved from the Registration Network Groningen database, a general practitioners database in the north-eastern part of the Netherlands. The sensitivity and positive predictive value (PPV) of 22 medication proxies for the identification of children diagnosed with atopic disorders (asthma, atopic dermatitis, and allergic rhinitis) were computed using the registered diagnoses as gold standards. In addition, different capture periods (1 year, half year, and length of study period) for the detection of prescriptions were tested for all the medication proxies.

Results

The highest PPV (0.84, 95 % CI 0.81–0.87) in combination with a sufficient sensitivity value (0.54, 95 % CI 0.50–0.57) for the identification of children diagnosed with asthma was yielded for the medication proxy, ≥2 prescriptions for anti-asthma medication within 1 year, including 1 inhaled steroid. PPV and sensitivity were even higher in the age group 6–10 years. The proxies designed for the identification of children diagnosed with atopic dermatitis and allergic rhinitis yielded only high PPVs (≥0.75) in combination with low sensitivity values (≤0.22). Altering the capture period for the detection of prescriptions to half a year or the length of the study period only affected sensitivity values.

Conclusion

Children diagnosed with asthma can be identified reliably with a range of medication proxies. The use of prescription data for the identification of children diagnosed with atopic dermatitis and allergic rhinitis is questionable.

Does a cardiovascular event change adherence to statin treatment in patients with type 2 diabetes? A matched cohort design

OBJECTIVE

To be effective, adherence to statin treatment is essential. We assessed the effect of an apparent first cardiovascular event on statin adherence rates in type 2 diabetes patients.

RESEARCH DESIGN AND METHODS

A matched cohort study was conducted among type 2 diabetes patients initiating statin treatment for primary prevention in the Groningen University IADB.nl pharmacy database. Patients who had a drug-treated cardiovascular event (index date) after statin initiation were matched to a reference patient without such an event with similar gender, age at statin initiation, initiation date, follow-up period and adherence level before the event. Adherence rates were measured as percentages of days covered (PDC), and shifts in adherence levels (non-adherent/partially adherent/fully adherent) and rates around the event were evaluated.

RESULTS

We could match 375 of the 855 eligible index patients to a reference patient. Index patients had on average a PDC of 81% after the index date; reference patients had a PDC of 71% (p < 0.001) while both had a PDC of 79% before the index date. Index patients were 4.5 times more likely than reference patients to shift from non-adherent to fully adherent (95% CI 1.1-18.8) and 1.8 times more likely to shift from partially adherent to fully adherent (95% CI 1.2-2.6). In the index group, 26% of patients became more adherent after the first cardiovascular event. In contrast, 20% of patients became less adherent.

LIMITATIONS

Medication proxies were used, which could have caused misclassification. Furthermore, a substantial group of index patients could not be matched to a reference patient due to small ranges in matching criteria.

CONCLUSIONS

The occurrence of a drug-treated cardiovascular event appeared to avert the declining statin adherence rate observed in diabetes patients without such an event. On the other hand, one in five patients became less adherent after the event, indicating that there are still important benefits to achieve.

Did introduction of pneumococcal vaccines in the Netherlands decrease the need for respiratory antibiotics in children? Analysis of 2002 to 2013 data

To estimate the effect of the introduction of the 7- and 10-valentpneumococcal vaccines in 2006 and 2011, respectively in the Netherlands, we assessed respiratory antibiotic use in one to nine year-old children between 2002 and 2013. Seasonal autoregressive integrated moving-average models were applied to estimate the percentage reduction in respiratory antibiotic use. When compared with the pre-vaccination period, the proportion of respiratory antibiotic prescriptions fell by 4.94% (95% CI: 4.63 to 5.26) and 9.02% (95% CI: 2.83 to 14.82) after the introduction of the 7-valent vaccine in children aged three and four years, respectively. After the introduction of the 10-valent vaccine, we observed a reduction of 13.04% (95% CI: 2.76 to 22.23), 20.31% (95% CI: 13.50 to 26.58), 16.92% (95% CI: 3.07 to 28.80), 22.34% (95% CI: 3.73 to 37.35), 23.75% (95% CI: 2.37 to 40.44) in two, three, four, six and seven year-old children, respectively. Thus, our results indicate a reduction in respiratory antibiotic prescriptions in young children after introduction of the pneumococcal vaccines. As only children in our study population aged one and two years born after March 2011 had received the 10-valent vaccine, the effects of the 10-valent vaccine in children aged three to nine years likely reflect the effects of the 7-valent vaccine and herd immunity.

Prenatal exposure to acid-suppressive drugs and the risk of allergic diseases in the offspring: a cohort study

BACKGROUND

Recent studies reported increased risks for the development of asthma in children after prenatal exposure to acid-suppressive drugs. As a result of common pathogenesis, associations could also be present for other allergic diseases.

METHODS

Using the prescription database IADB.nl, we conducted a cohort study amongst 33 536 children in the Netherlands, with a maximum follow-up of 8 years. Maternal exposure was defined as ≥1 dispensed prescription for proton pump inhibitors (PPIs) and/or Histamine 2-antagonists (H2As) during pregnancy. Children were considered to have a drug-treated allergic disease if they received either ≥2 prescriptions for dermal (atopic dermatitis), inhaled (asthma) or nasal (allergic rhinitis) steroids within a 12-month period. Clustered Cox proportional hazard regression was used to estimate crude and adjusted hazard ratios (aHR) with 95% confidence intervals (95% CI).

RESULTS

The aHR for the development of any allergic disease was 1.37 (95% CI: 1.14-1.66) for children exposed to PPIs or H2As. Prenatal exposure to PPIs and/or H2As was associated with atopic dermatitis, asthma and allergic rhinitis with aHRs of 1.32 (95% CI 1.06-1.64), 1.57 (95% CI 1.20-2.05) and 2.40 (95% CI 1.42-4.04), respectively. The aHR for the development of two or more (aHR 2.13 95% CI: 1.43-3.19) and three allergic diseases (aHR 5.18 95% CI: 2.16-12.42) were even more elevated after prenatal exposure to PPIs or H2As.

CONCLUSION

Prenatal exposure to PPIs and H2As appeared associated with an increased risk for the development of atopic dermatitis, asthma and allergic rhinitis in the offspring, especially with the development of multiple allergic diseases. Because our study has limitations inherent to observational studies, prospective studies are now warranted to confirm our findings.

In utero exposure to antidepressants and the use of drugs for pulmonary diseases in children

Purpose

The use of antidepressants during pregnancy is common. Some studies suggest an association between in utero exposure to antidepressants and the occurrence of pulmonary diseases like asthma later in life. Serotonin reuptake inhibitors (SSRIs) as well tricyclic antidepressants (TCAs) are thought to be involved in the development of the respiratory rhythm generator (RRG) and the maturation of the formation of surfactant. In this study the use of drugs for pulmonary diseases in children who were exposed to antidepressants in utero were compared with non-exposed children.

Methods

The pharmacy prescription database IADB.nl was used for a cohort study in which the use of drugs for pulmonary disease in children after in utero exposure to antidepressants (TCAs, SSRIs) was compared with children with no antidepressant exposure in utero. Drugs for pulmonary diseases were applied as a proxy for disturbed development of the respiratory tract.

Results

A small though significant increase in the incidence risk ratio (IRR) of the use of drugs for pulmonary disease was found after any-time in utero exposure to SSRIs, adjusted for maternal use of antibiotics, of 1.17 (95 % CI 1.16–1.18). An increase was also seen when we looked specifically for the use of SSRIs in at least the first trimester (IRR = 1.18, 95 % CI 1.17–1.20). An increased IRR in the use of drugs for pulmonary disease was also seen when children were exposed to TCAs, but this was not statistically significant. However, in both groups our sample size was rather small. The effect size is modest and may also be confounded by maternal smoking.

Conclusions

In utero exposure to SSRIs leads to a statistically significant increase in the use of drugs for pulmonary diseases, especially when exposure occurred during the first trimester of pregnancy. The increase in the use of drugs for pulmonary disease may also be related to other factors. Therefore, further study is recommended.

Storage-related changes in erythrocyte band 3: not a case for the Diego blood group antigens

Removal of erythrocytes from the circulation is mediated by the immune system. Changes in structure and function of band 3, a major membrane protein of the erythrocyte, trigger the binding of antibodies to a band 3-derived neoantigen, senescent cell antigen, on erythrocytes aged in vivo. This mechanism probably is also involved in determining the survival of erythrocytes after transfusion. Band 3 is the carrier of the Diego blood group system, and subtle changes in the three-dimensional conformation of the same extracellular loops of band 3 determine Diego blood group activity as well as senescent cell antigen activity. Therefore we used the Diego blood group system to probe these changes with a combination of serological and immunochemical methods. Our data indicate that changes in band 3 structure during storage under blood bank conditions, as shown by immunoblot analysis, are not detectable as changes in expression of Diego antigens in intact cells. This makes it unlikely that immunological removal of erythrocytes after transfusion is mediated by reactions involving the Diego blood group system.

Testing a new mechanism for left interventricular septal pacing: the transseptal route; a feasibility and safety study

AIMS

To prove the feasibility and safety of left interventricular septal pacing.

BACKGROUND

Right ventricular apical pacing is an established but haemodynamically less favourable pacing method compared with transvenous left ventricular pacing. Alternatively, we propose a simple septal screw-in lead for left interventricular septal pacing.

METHODS

A pacemaker lead with a long insulated screw with the two distal windings forming an active tip was implanted from the right side of the interventricular septum to the subendocardial left side in six goats. A special guiding sheath enabled stable, easy, and swift implantation of the lead. The implantation was performed using fluoroscopy together with. normal and contrast echocardiography (via the long pre-shaped sheath) and electrocardiographic signals (His-bundle recordings in conjunction with atrial and ventricular intracardiac signals). The screw was also positioned at other locations along the free wall, and at the interventricular septum to assess possible adverse effects at other sites.

RESULTS

An average of 2.2 +/- 1.5 positions per goat was attempted. No adverse effects were noticed during implantation or at necropsy. In two goats, the final position was at the junction of the right ventricular wall and the interventricular septum. Parameters at the final positions were as follows: the pacing threshold was 1.3 +/- 1.0 V at 0.5 ms; the pacing impedance was 1022 +/- 463 omega at 4.8 V and 0.5 ms. R-wave amplitudes were 17.6 +/- 7.6 mV.

CONCLUSION

Left interventricular septal pacing is feasible. In our study it was safely performed in six goats. The pacing threshold was low, and the stability of the lead system was good. Implantations in humans and animals and haemodynamic evaluations are needed to reveal the potential benefits of this new form of left interventricular septal pacing.

Validation of the NucliSens Extractor in combination with the hepatitis C virus Cobas Amplicor 2.0 assay in four laboratories in the Netherlands utilizing nucleic acid amplification technology for blood screening

BACKGROUND AND OBJECTIVES

Since July 1 1999, four laboratories in the Netherlands have been routinely screening plasma minipools for the release of labile blood components utilizing hepatitis C virus nucleic acid amplification technology (HCV NAT). This report describes the performance evaluation of the HCV NAT method and the quality control results obtained during 6 months of routine screening.

MATERIALS AND METHODS

Plasma minipools of 48 donations were prepared on a Tecan Genesis robot. HCV RNA was isolated from 2 ml of plasma by using the NucliSens Extractor and amplified and detected with the Cobas HCV Amplicor 2.0 test system. For validation of the test system the laboratories used viral quality control (VQC) reagents of CLB.

RESULTS

Initial robustness experiments demonstrated consistent detection of PeliSpy HCV RNA samples of 140 genome equivalents/ml (geq/ml) in each station of the installed Nuclisens Extractors. Further 'stress' tests with a highly viraemic sample of approximately 5 x 10(6) geq/ml did not contaminate negative samples processed on all Extractor stations in subsequent runs. In the validation period prior to July 1999, 1021 pools were tested with the following performance characteristics: 0.1%, initially false reactive; 0.89%, failure of internal control detection; 0.97%, no eluate generated by the Extractor; and 100% reactivity of the PeliSpy 140 geq/ml control in 176 Extractor runs and a 98% reactivity rate of the PeliSpy 38 geq/ml control in 102 test runs. By testing the PeliCheck HCV RNA genotype 1 dilution panels 49 times, an overall 95% detection limit of 30 geq/ml ( approximately 8 IU/ml) and a 50% detection limit of 5 geq/ml was found by the four laboratories. In the first 6 months of routine screening, the minimum requirement for invalid results (2%) was exceeded with some batches of silica and NucliSens Extractor cartridges. From November 1999 to February 2000, the manufacturer (Organon Teknika) improved the protocol for silica absorption of the Nuclisens Extractor -- the cartridge design as well as the software of the Extractor. During the next 6 months of observation in 2000, the percentages of false initial reactives and invalids were 0.05% and 1.4%, respectively, in 8962 pools tested. Of these invalid results, 0.74% and 0.66% were caused by Extractor failure and negative internal control signals, respectively. The PeliSpy HCV RNA 'stop or go' run control of 140 geq/ml was 100% reactive, but invalid in 16/1375 (1.2%) of cases. The PeliSpy run control of 38 geq/ml for monitoring sensitivity of reagent batches was reactive in 95% of 123 samples tested.

CONCLUSIONS

Each of the four HCV NAT laboratories in the Netherlands have achieved similar detection limits that are well below the sensitivity requirements of the regulatory bodies. After improvement of the NucliSens Extractor procedure, the robustness of the test system has proved to be acceptable for routine screening and timely release of all labile blood components.

Not peripheral parasitaemia but the level of soluble parasite antigen in plasma correlates with vaccine efficacy against Babesia canis

Groups of five dogs were vaccinated against Babesia canis using soluble parasite (SPA) antigens from in vitro cultures. Although vaccination did not significantly alter peripheral parasitaemia upon challenge, protected animals had lower levels of SPA in the plasma after a challenge infection. The severity of anaemia correlated with the SPA-load during the post-challenge period in that high levels of SPA were associated with low haematocrit values. In addition, it was found that recovery was associated with the production of antibodies against SPA. The results suggest that SPA induce anaemia during B. canis infection, and that vaccination with SPA results in antibody production that can neutralize the effects of SPA after a challenge infection.

Strain variation limits protective activity of vaccines based on soluble Babesia canis antigens

Groups of five dogs were immunized with vaccines containing soluble parasite antigens (SPA) derived from in vitro culture of Babesis canis parasites, either obtained commercially (Pirodog) or produced at laboratory scale. Both vaccines generated antibodies that reacted with parasitised erythrocytes (PE). Upon challenge infection with homologous parasites, protection was evident from less severe decreases of haematocrit values, and reduced morbidity. Vaccinated animals, however, were not protected against challenge infection with heterologous B. canis parasites. Recovery from challenge infection coincided with the production of antibodies against parasitized erythrocytes. The results suggest that SPA from B. canis carry strain-specific determinants that are crucial for inducing protection in dogs against challenge infection, and explain vaccination failures in the field.

Vaccination of dogs against Babesia canis infection using antigens from culture supernatants with emphasis on clinical babesiosis

Groups of five dogs were vaccinated with Babesia canis antigens from in vitro culture in combination with saponin as adjuvant. Protection against challenge infection was evident as diminished clinical disease, decrease in parasitaemia, and a less marked fall in haematocrit values. Recovery from infection occurred at the time a memory immune response became effective (from Days 5 to 6 after challenge infection onwards). The effect was dose dependent, the highest antigen dose being most effective. A lysate of normal erythrocytes did not have protective activity, indicating that a parasite component was responsible for protection. Unlike the malaria situation, disease was not associated with elevated levels of tumour necrosis factor in the plasma, nor with hypoglycaemia. Disease appeared to be the result of the activity of a parasite product, which could have triggered reactions which led to sequestration of erythrocytes from the peripheral venous blood. As a result, the packed cell volume decreased, and organs such as lymph nodes and spleen became congested. As soon as immunity had developed there was a rapid increase in the peripheral erythrocyte number, and congestion of the spleen diminished, indicative of restored capillary blood flow. The results further suggest that vaccination with a soluble parasite product blocks the trigger of this pathological process.

Experimental challenge of sheep 18 months after vaccination with a live (S48) Toxoplasma gondii vaccine

Sheep can be immunised against toxoplasma abortion with a live vaccine composed of S48 tachyzoites. In this study the immunity induced in sheep was examined 18 months after vaccination. Seventy-three sheep were divided into three groups. Group 1 was vaccinated and 18 months later, when they were 90 days pregnant, the 27 sheep were challenged orally with Toxoplasma gondii oocysts. These ewes produced significantly more live lambs, after a significantly longer gestation period, than the 34 unvaccinated, challenged ewes in group 2. In addition there was less placental damage and fewer lambs were born with antibody to the parasite in the vaccinated group than in group 2. The 12 ewes in group 3 served as unvaccinated, unchallenged control animals. The degree of protection induced by the S48 tachyzoites was as good 18 months after vaccination as previously observed six months after vaccination.

Vaccination of dogs against Babesia canis infection using parasite antigens from in vitro culture

Groups of five dogs were vaccinated with different Babesia canis vaccine formulations. It appeared that partial protection against challenge infection was obtained when using parasite antigens from in vitro culture in combination with saponin. Protection was evident as a decrease in parasitaemia after challenge and was associated with the presence of serum antibodies against Babesia parasites. In addition, parasite antigen derived from in vitro culture supernatant exhibited more protective activity than somatic parasite antigen, in that a less marked fall of haematocrit values was found after challenge infection. The fall of haematocrit value observed in the animals immunized with somatic parasite antigen was not different from that observed in the adjuvant control group.

Replication of human immunodeficiency virus type 1 in primary dendritic cell cultures

The ability of the human immunodeficiency virus type 1 (HIV-1) to replicate in primary blood dendritic cells was investigated. Dendritic cells compose less than 1% of the circulating leukocytes and are nondividing cells. Highly purified preparations of dendritic cells were obtained using recent advances in cell fractionation. The results of these experiments show that dendritic cells, in contrast to monocytes and T cells, support the active replication of all strains of HIV-1 tested, including T-cell tropic and monocyte/macrophage tropic isolates. The dendritic cell cultures supported much more virus production than did cultures of primary unseparated T cells, CD4+ T cells, and adherent as well as nonadherent monocytes. Replication of HIV-1 in dendritic cells produces no noticeable cytopathic effect nor does it decrease total cell number. The ability of the nonreplicating dendritic cells to support high levels of replication of HIV-1 suggests that this antigen-presenting cell population, which is also capable of supporting clonal T-cell growth, may play a central role in HIV pathogenesis, serving as a source of continued infection of CD4+ T cells and as a reservoir of virus infection.

Vaccination of sheep with a live incomplete strain (S48) of Toxoplasma gondii and their immunity to challenge when pregnant

Sixty-four ewes were vaccinated with tachyzoites of an incomplete strain (S48) of Toxoplasma gondii grown either in the peritoneal cavity of mice (group 1) or vero cell culture (group 2) and 30 ewes (group 3) were not vaccinated. All the ewes were mated 77 days later and challenged orally with 2000 sporulated oocysts at 89 to 90 days of gestation. Ten additional unvaccinated (group 4) and 10 vaccinated (group 5) control ewes were not challenged. The unvaccinated ewes developed a characteristic febrile response to challenge while in the vaccinated ewes the fever commenced earlier but was less severe and of shorter duration. After challenge, the antibody titres against T gondii rose rapidly to high values in the vaccinated ewes while the ewes in group 3 responded more slowly. Only eight of the 45 fetuses/lambs (17.8 per cent) from group 3 were viable compared with 72.3 per cent of those in group 1 and 80.8 per cent of those in group 2. Gestation in the unvaccinated challenged ewes was shortened and the mean birthweight of their single, viable offspring was significantly lower than the weight of single lambs from the vaccinated (groups 1 and 2) and control ewes (groups 4 and 5). Examination of precolostral sera showed that almost two-thirds of the lambs from the vaccinated ewes were infected in utero. The 20 control ewes appeared clinically normal at all times and lambed normally. The two vaccine preparations were equally effective.

Rex-dependent nucleolar accumulation of HTLV-I mRNAs

The regulator of virion protein expression (Rex) of the human T-cell leukemia virus type I (HTLV-I) modulates the pattern and level of spliced and unspliced retroviral mRNA species in the cytoplasm. The elucidation of the molecular basis for this regulation is likely to throw light on new regulatory mechanisms of the host cell. We have investigated the possibility that Rex acts to direct unspliced viral RNA to the nucleolus. To test this possibility, we used in situ hybridization to detect HTLV-I envelope protein (env) transcripts formed in the nucleolus in the presence and absence of the Rex protein. The HTLV-I env sequences are normally removed by splicing from the HTLV-I RNA in the absence of Rex. The experiments presented here show that the accumulation of HTLV-I env sequences in the nucleolus is significantly increased in the presence of Rex. The results raise the possibility that Rex directs unspliced viral mRNA to the nucleolus whence it is exported to the cytoplasm for translation. The association between the nucleolus and retroviral mRNA was lost in purified nucleoli after cellular fractionation.

Short dwell times reduce the local defence mechanism of chronic peritoneal dialysis patients

The effect of different intraperitoneal dwell times on the phagocytic capacity of the effluent-derived macrophages in 6 peritoneal dialysis patients was studied. The number of peritoneal cells increased after longer dwell times, and a significant increase in the percentage of macrophages phagocytosing opsonized sheep red blood cells [( IgG]SRBC) and unopsonized latex beads was determined when the dwell time increased from 1.5 to 15 h. Thus, the total phagocytic capacity of the effluent-derived macrophages dramatically increased with prolonged dwell times. In addition, the IgG concentration showed a five-fold increase following long intraperitoneal dwell times. The increasing IgG levels were accompanied by an increase, however not significant (p less than 0.06), in the opsonic activity of the effluents. The increase in local phagocytic and opsonic capacity following longer intraperitoneal dwell times must be taken in consideration by dialysis fluid exchange schedules of peritoneal dialysis patients.

[Is there a future for vaccines against gastrointestinal helminths?]

Vaccines against gastro-intestinal helminths have a large market potential, but they also generally have a narrow range of activity. This is a major drawback in the competition with the broad-spectrum anthelmintics and there is still a long way to go before molecular (recombinant) vaccines will appear on the market. Major problems are the induction of protective gut-mucosal immunity with subunit vaccines and the differences in genetic background within host populations, which largely determine the efficacy of vaccination. As yet the changes for vaccines against blood- and tissue parasites, comprising a number of veterinary important protozoa, seem to be better.

Chemotaxis of the peritoneal cells and the detection of a chemo-attractant in the effluent from peritoneal dialysis patients

The migration of peritoneal cells from 25 continuous ambulatory peritoneal dialysis patients and eight healthy women undergoing laparoscopy were studied. Peritoneal cells of continuous ambulatory peritoneal dialysis patients migrated to commonly used chemoattractants, like N-formyl-methionyl-leucyl-phenyl-alanine-methyl- ester and casein, but they also migrated to high concentrations of recombinant interleukin-1 alpha and to endotoxin (lipopolysaccharide). In the peritoneal effluent from continuous ambulatory peritoneal dialysis patients a rather heat stable chemoattractant was found with a molecular weight of 40-200 kDa with an optimal activity at approximately 125 kDa. The chemoattractant is a protein and is not complement factor 5a or interleukin-1 and was only found in peritoneal effluent from continuous ambulatory peritoneal dialysis patients, but not in peritoneal fluid from healthy women undergoing laparoscopy. Therefore, peritoneal dialysis might induce the generation of a chemoattractant. The optimal chemotactic response of peritoneal cells from continuous ambulatory peritoneal dialysis patients to N-formyl-methionyl-leucyl-phenyl-alanine-methyl- ester in medium could be enhanced by replacing the medium by peritoneal effluent. So the chemotaxis of peritoneal cells to the factor in the peritoneal effluent is caused by another mechanism, which might involve different cell surface receptor populations, than the chemotactic response to N-formyl-methionyl-leucyl-phenyl-alanine-methyl-ester.

HLA-DR expression on human peritoneal macrophages in vivo and in vitro

Qualitative, semi-quantitative (immuno-electronmicroscopy), and quantitative (radioimmunoassay) measurements were made of the in vivo and in vitro expression of HLA-DR on continuous ambulatory peritoneal dialysis (CAPD) patients' peritoneal macrophages (M phi) and on healthy persons' blood monocytes (MO). In vivo, great variation is seen in both the qualitative and (semi-) quantitative expression of HLA-DR in peritoneal M phi. After culturing for 5 to 20 h, CAPD patients' M phi with low to intermediate numbers of HLA-DR molecules per cell (25-80 x 10(3] showed a two- to threefold enhancement of HLA-DR expression. This enhancement was determined for the total peritoneal cell (PC) population and for the adherent subpopulation of peritoneal M phi and blood MO. CAPD patients whose cells initially had high numbers of HLA-DR molecules (80-110 x 10(3] showed no or only slight enhancement of HLA-DR expression when cultured.

Most CD4+ T cells from human immunodeficiency virus-1 infected patients can undergo prolonged clonal expansion

We have addressed the capacity of HIV-1 infection to alter the growth of primary CD4+ T cells, but at the clonal level. Single T cells were expanded in the presence of PHA, IL-2, and small numbers of accessory dendritic cells. We report two new findings. First, T cells from seropositive individuals, even those with AIDS and markedly reduced CD4+ counts, exhibit a normal cloning efficiency, and proliferative capacity. This result is in contrast to two prior reports of a low cloning efficiency in CD4+ T cells from HIV-1-infected patients. Second, when we added high doses of exogenous HIV-1 to T cell clones from control subjects, we observed infection but not cytotoxicity or loss of CD4+ cells, following addition of virus stocks at days 0, 3, and/or 7 of clonal growth. The same HIV-1 isolates markedly reduced CD4+ T cells in bulk mononuclear cultures. When tested at day 11, HIV-1 mRNA was expressed in some cells of exogenously infected clones by in situ hybridization; when tested at day 18, several clones could transactivate a TAT-sensitive cell line. These findings suggest that the loss of CD4+ T cells in infected individuals is not the inevitable result of the activation of latent infection, or spread of a productive infection, during clonal growth.

Isolation and partial characterisation of a potentially pathogenic cysteine proteinase from adult Dictyocaulus viviparus

Dictyocaulus viviparus adult worms feed on pulmonary tissues and cause significant pathology in the bovine host. In this report, acidic extracts of these organisms were examined for cysteine proteinase activity. A soluble thiol-dependent proteinase with native molecular weight of approximately 25 kDa was isolated and partially purified. This enzyme had maximal activity at acidic pH and showed inhibitor susceptibilities similar to the vertebrate acidic cysteine proteinases. When stored at 4 degrees C, it was stable at pH 5.0 for at least 10 days and at pH 7.0 for at least 24 h. The D. viviparus cysteine proteinase was capable of degrading type I collagen and hemoglobin. It is suggested that this enzyme may be involved in the nutrition of this parasite and/or have the potential to contribute to bronchial pathology in cattle.

Peritoneal dialysis fluid induces change of mononuclear phagocyte proportions

Peritoneal macrophages from uninfected continuous ambulatory peritoneal dialysis (CAPD) patients in general show two different, endogenous peroxidase activity (PA) patterns: exudate and negative. This suggests, in accordance with the animal model, that these macrophages are changed proportionately in CAPD patients. This chronic change may be caused by mechanical stimulation alone (massage) or the composition of the dialysis fluid used. Therefore in the rat model both physiological saline and commercial dialysis fluid were intraperitoneally (i.p.) administrated. Our results on the PA-pattern of peritoneal macrophages do indicate that a single i.p. administration of commercial dialysis fluid induced an acute exudate, especially when compared with the minor saline effect. These results are confirmed by the percentage of macrophages positive for a differentiation antigen recognized by the monoclonal antibody ED2. In addition the percentage of Fc-receptor positive peritoneal cells is more enhanced after i.p. injection of dialysis fluid when compared with the saline effect. These findings strongly suggest that the dialysis fluid used in peritoneal dialysis patients is the inducer of exudate peritoneal macrophages in these patients.

Distinct subpopulations of elicited human macrophages in peritoneal dialysis patients and women undergoing laparoscopy: a study on peroxidatic activity

The endogenous peroxidatic activity (PA) pattern of peritoneal macrophages from 24 continuous ambulatory peritoneal dialysis (CAPD) patients and from five healthy women undergoing laparoscopy was studied. In general, the macrophages showed two different PA patterns in vivo: exudate and negative macrophages. However, two of 24 CAPD patients showed resident macrophages, the first described in vivo in man. Since, in general, the examined human peritoneal macrophages are exudate and PA-negative, this suggests, in accordance with the animal model system, that a chronic sterile inflammation exists in the peritoneal cavity of CAPD patients and healthy women undergoing laparoscopy. After 2 hr culture, blood monocytes and peritoneal macrophages transformed into cells with the characteristics of exudate-resident and resident macrophages, so isolation procedures that include short periods of culture can change the developmental stage of human monocytes and macrophages.

Use of ELISA to assess lungworm infection in calves

The enzyme-linked immunosorbent assay (ELISA) technique was applied to the detection of lungworm infections in calves. In experimentally infected animals different responses to larval and adult worm antigens were observed. The response to adult worm antigens was delayed in vaccinated animals when infection occurred by the gradual uptake of infective larvae from contaminated pasture. A serological survey in The Netherlands demonstrated a high incidence of lungworm infection in both vaccinated and unvaccinated herds. There was a good correlation between anti-adult worm and anti-larval ELISA-titres. ELISA appeared to be a useful technique for assessing the level of lungworm infection in a herd.

The fieldmaster 101 PR automatic visual field screener--technical evaluation and clinical results

The perimetric concept and the technical construction of the Fieldmaster 101 PR were evaluated. 64 eyes of patients and 10 normal subjects were examined. We conclude that the Fieldmaster is a well-engineered instrument, using an inefficient test strategy. The presentation of visual field results could be improved. Clinical results of the patient examinations are presented.

A case of Acanthamoeba keratitis in The Netherlands

A severe kerato-iritis of the right eye of a 36-year-old healthy man constituted a diagnostic and therapeutic problem. More than seven months after the onset of his complaints a cornea transplantation was carried out because a large abscess had developed in the stroma of the cornea and perforation was feared. Amoebae, belonging to the free-living genus Acanthamoeba, were found in the excised corneal disc. Similar infections have been described earlier in the USA, in England and in Germany. The case described here is the first well documented one in the Netherlands. The case history and identification of the amoeba are described. Data from the literature on epidemiology, pathogenicity and treatment are discussed.

A seroepidemiological study of amebiasis in Surinam by the enzyme-linked immunosorbent assay (ELISA)

Sera from nine populations in Surinam, South America, were screened for antibodies against Entamoeba histolytica by the enzyme-linked immunosorbent assay (ELISA) technique and a precipitin test (gel diffusion or counterimmunoelectrophoresis). In two small surveys in 1974 and 1978, a high rate of clinically significant ELISA titers was found in a rather isolated group of Amerindians living near the Brazilian border, predominately in the youngest age groups. Amerindians living near the coast showed a low level of seropositivity. Low levels were also found in Bush Negro villages in the interior of Surinam and in Hindustani school children from the savannah area. A high frequency of ELISA titers greater than or equal to 320, indicating a high rate of invasive amebiasis, was detected in persons in a mental institution in Paramaribo. It is concluded that the ELISA, which is much more sensitive than the precipitin tests, is a useful screening test for assessing the prevalence of invasive amebiasis on an epidemiological scale.

Virulence of bacteria-associated, Crithidia-associated, and axenic Entamoeba histolytica: experimental hamster liver infections with strains from patients and carriers

Experimental infections of the hamster liver were carried out with five strains from patients with clinical amoebiasis and ten strains from asymptomatic carriers. Inocula of comparatively small size (12000-36000 amoebae) were injected under the liver capsule. 1. The virulence of the patient strains varied from 21-96% (see article) and declined sharply within 7-15 weeks after elimination of the associated bacterial flora. The virulence of the carrier strains varied from 0-100%, probably fluctuating with changes in the concomitant bacterial flora (Table 1). 2. The interrelation between size of inoculum, period of bacteria-free growth, and virulence was demonstrated with a Crithidia-associated patient strains (Table 2). 3. A patient strain showed a faster decrease of virulence during axenic than in Crithidia-associated cultivation (Table 3). 4. Two successive passages through hamster liver resulted in a marked increase of virulence of two bacteria-free strains, lasting for several months (Table 4). 5. A significant enhancement of virulence of Crithidia-associated and axenic amoebae by reassociation with a mixed bacterial flora during two weeks, followed by elimination of the bacteria, was demonstrated with two strains. The restored virulence was lost again within a few weeks (Table 5). 6. The virulence of an attenuated patient strain did not become manifest by adding large numbers of dead amoebae to the inoculum (Table 6). 7. The pathology of the different lesions caused in the hamster liver by the amoebae is described, including one of a granulomatous type, frequently found after inoculation with bacteria-free amoebae. 8. In an attempt to explain the occurrence of strains differing in pathogenicity an hypothesis is put forward based on the idea of selection of virulence and avirulent amoebae.

Monoxenic and axenic cultivation of carrier and patient strains of Entamoeba histolytica

All of five strains of Entamoeba histolytica, isolated from symptomatic cases of amoebiasis, could be adapted to axenic growth on the TP-S-1 medium of Diamond (1968). Four axenic strains were started from amoeba-Crithidia cultures; one could be axenized directly after isolation from a case of cutaneous amoebiasis. Attempts to monoxenize, resp. axenize strains, isolated from Dutch, asymptomatic carriers, were less successful. Only three out of ten strains could be submitted to bacteria-free growth. These three strains, however, originated probably from a recent case of intestinal amoebiasis. The results, suggesting that highly virulent strains can be easier cultivated bacteria-free than those with low or no virulence, are further discussed. The yield of axenic amoebae per tube fluctuates largely depending on many factors such as the strain, the number of transfers (i.e. degree of establishment), the quality of Panmede liver digest and serum in the TP-S-1 medium, and the care of manipulating the cultures. For optimal growth, a more acid medium was required in an amoeba-Crithidia culture than in an axenic culture. Multinucleated, giant amoebae were frequently observed in axenic cultures.