Diagnostic test accuracy of screening tools for post-traumatic stress disorder among refugees and asylum seekers: A systematic review and meta-analysis

Background

Refugees and asylum seekers often experience traumatic events resulting in a high prevalence of post-traumatic stress disorder (PTSD). Undiagnosed PTSD can have detrimental effects on resettlement outcomes. Immigration medical exams provide an opportunity to screen for mental health conditions in refugee and asylum seeker populations and provide links to timely mental health care.

Objective

To assess the diagnostic accuracy of screening tools for PTSD in refugee and asylum seeker populations.

Methods

We systematically searched Medline, Embase, PsycINFO, CENTRAL and CINAHL up to 29 September 2022. We included cohort-selection or cross-sectional study designs that assessed PTSD screening tools in refugee or asylum seeker populations of all ages. All reference standards were eligible for inclusion, with a clinical interview considered the gold standard. We selected studies and extracted diagnostic test accuracy data in duplicate. Risk of bias and applicability concerns were addressed using QUADAS-2. We meta-analyzed findings using a bivariate random-effects model. We partnered with a patient representative and a clinical psychiatrist to inform review development and conduct.

Results

Our review includes 28 studies (4,373 participants) capturing 16 different screening tools. Nine of the 16 tools were developed specifically for refugee populations. Most studies assessed PTSD in adult populations, but three included studies focused on detecting PTSD in children. Nine studies looked at the Harvard Trauma Questionnaire (HTQ) with diagnostic cut-off points ranging from 1.17 to 2.5. Meta-analyses revealed a summary point sensitivity of 86.6% (95%CI 0.791; 0.917) and specificity of 78.9% (95%CI 0.639; 0.888) for these studies. After evaluation, we found it appropriate to pool other screening tools (Posttraumatic Stress Disorder Checklist, the Impact of Event Scale, and the Posttraumatic Diagnostic Scale) with the HTQ. The area under the curve for this model was 79.4%, with a pooled sensitivity of 86.2% (95%CI 0.759; 0.925) and a specificity of 72.2% (95%CI 0.616; 0.808).

Conclusions

Our review identified several screening tools that perform well among refugees and asylum seekers, but no single tool was identified as being superior. The Refugee Health Screener holds promise as a practical instrument for use in immigration medical examinations because it supports the identification of PTSD, depression, and anxiety across diverse populations. Future research should consider tool characteristics beyond sensitivity and specificity to facilitate implementation in immigration medical exams.

Registration

Open Science Framework: 10.17605/OSF.IO/PHNJV.

Never Let a Crisis Go to Waste

The adage "Never let a good crisis go to waste," widely attributed to Winston Churchill (Gruère 2019), has echoed throughout the COVID-19 pandemic. It aptly describes the rapid uptake of virtual care since March 2020 and other developments that it has inspired, including renewed attention to health information and data governance, interoperability, health equity, appropriateness and cross-border licensure.

[Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]

The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.

Funding Long-Term Care in Canada: Issues and Options

Canada's aging population is likely to result in increased health and long-term care (LTC) costs. It is estimated that between 2012 and 2046, LTC cost liability could reach almost $1.2 trillion. Many Canadians are unaware of the potential burden of LTC expenditures, and there is no consensus on who should pay for them. There are four possible options: (1) general tax revenues; (2) social insurance (employer/employee contributions); (3) private purchase of LTC insurance; and (4) private savings. This paper reviews these options as they have materialized to date in Canada and other countries. Despite the growing acuity of this issue, it seems unlikely that a universal, publicly funded approach to LTC will emerge in Canada. It is clear that federal and provincial/territorial governments must continue to explore policy options for LTC funding including public education, prevention and mitigation strategies and provision for tax-sheltered savings specifically for LTC.

Public Spending on Health Services and Policy Research in Canada: A Reflection on Thakkar and Sullivan Comment on "Public Spending on Health Service and Policy Research in Canada, the United Kingdom, and the United States: A Modest Proposal"

Vidhi Thakkar and Terrence Sullivan have done a careful and thought-provoking job in trying to establish comparable estimates of public spending on health services and policy research (HSPR) in Canada, the United Kingdom and the United States. Their main recommendation is a call for an international collaboration to develop common terms and categories of HSPR. This paper raises two additional questions that have an international comparative dimension: There is little doubt that public spending on HSPR represents more than the "tip of the iceberg," but how much more? And how do the countries fare on the uptake of HSPR by decision-makers? I have long speculated that probably as much or more is spent by provincial/territorial governments, regional health authorities, hospitals and other agencies on HSPR activities carried out by consultants in Canada than by the federal, provincial/territorial granting agencies. Support for this contention is provided in a paper by Penno and Gauld on spending on external consultancies by New Zealand's District Health Boards (DHBs). Their estimate of the amount spent on consultancies in 2014/15 represents 80% of the amount spent on research by the Health Research Council of New Zealand in 2015. In terms of the uptake of research Jonathan Lomas pioneered the concept of linking researchers with decisionmakers when he became the founding Chief Executive Officer (CEO) of the Canadian Health Services Research Foundation (CHSRF) in 1997. An early assessment was promising, and it would be interesting to know if other countries have tried this. Most assessments of research uptake and impact are short-term in nature. It might be insightful to assess HSPR developments over the long term, such as prospective reimbursement through diagnosis related groups (DRGs) that has been evolving internationally for more 40+ years. In the short term the prospects for a major infusion of funding in HSPR in Canada are not promising, although there have been welcome investments in the Canadian Foundation for Healthcare Improvement (formerly CHSRF).

Public and Professional Insights on End-of-Life Care: Results of the 2016 Health Care in Canada Survey

A new dimension has been added to Canadian Medicare ߝ exemption from prosecution for physicians, nurse practitioners and assistants providing medical assistance in dying for competent and informed adult patients with a grievous and irremediable medical condition causing intolerable physical or psychological suffering, irreversible decline in capabilities and reasonably foreseeable natural death. To define stakeholders' perceptions on all contemporary end-of-life care options, we analyzed data from the 2016 Health Care in Canada Survey comprising representative samples of the adult public (n = 1,500), physicians (n = 102), nurses (n = 102), pharmacists (n = 100), administrators (n = 100) and allied health professionals (n = 100). Among the public, enhanced pain management, hospice/palliative care and home/family care were all supported at, or above, the 80th percentile; medically assisted death was supported by 70%. Among all professionals, hospice/palliative care, pain management and home care garnered >90% support; support for medically assisted death ranged from 58% (physicians) to 79% (allied professionals). In terms of priority to implement available options, medically assisted death was rated first by 46% of the public, overall, and by 69% of the sub-group who strongly supported it, followed by enhanced pain management (45%) and home care (42%). Among professionals, top implementation priorities (range: 57ߝ61%) were: enhanced pain management, hospice/palliative care and home care support. Priority for medically assisted death ranged between 25% and 41%, although among professionals who strongly supported it, it was their top priority (52%). When asked to balance patients' right to access assisted death, versus some professionals' reluctance to provide it, 42% of the public and the majority of professionals thought providers should be allowed to opt out if they referred patients to another willing provider. And many professionals perceive some risk of either legal or regulatory reprisal if they assist in patients' deaths. In summary, there is substantial contemporary support for all components of end-of-life care among all stakeholders. However, non-lethal care modalities remain generally preferred, perhaps, at least in part, because medical professionals have a pervasive concern of going in harm's way by participating in assisted death, or by refusing. Things can be better.

Patient-Centred Care in Canada: Key Components and the Path Forward

Canadians' health and its care continue to evolve. Chronic diseases affect more than 50% of our aging population, but the majority of public and professional stakeholders retain a sense of care quality. An emergent issue, however, is generating an increasingly wide debate. It is the concept of patient-centred care, including its definition of key components, and efficacy. To advance the evidence base, the 2013-2014 and 2016 Health Care in Canada (HCIC) surveys measured pan-stakeholder levels of support and implementation priorities for frequently proposed components of patient centricity in healthcare. The public's highest rated component was timely access to care, followed by perceived respect and caring in its delivery, with decisions made in partnership among patients and professional providers, and within a basic belief that care should be based on patients' needs versus their ability to pay. Health professionals' levels of support for key components largely overlapped the public's levels of support for key components, with an additional accent on care influenced by an evidence base and expert opinion. In terms of priority to actually implement enhanced patient-centred care options, timely access was universally dominant among all stakeholders. Caring, respectful care, also retained high implementation priority among both the public and professionals, as did care decisions made in partnership, and, among professionals, care driven by research and expert opinion. Low priorities, for both the public and professionals, were the actual measurements of patient-centred care delivery and its impact on outcomes. In summary, there is remarkable concordance among all stakeholders in terms of favoured interventions to enhance patient-centred care, namely, timely access, caring, partnering and communicative delivery of evidence-based care. Unfortunately, the lack of contemporary imperative around the value of measuring and reporting actual use and outcomes of favoured interventions means uncertainty of their efficacy will persist for the foreseeable future. Things can be better.

Assessing the prospects for physician supply and demand in Canada: Wishing it was rocket science

"It's not rocket science" is an often used phrase to describe tasks that are not very difficult. Although rocketry has proven to be an exacting science with highly predictable results, the same cannot be said for physician workforce planning in Canada. The "boom" in physician supply in the 1960s and 1970s was followed by a "bust" in the early 1990s and a further boom in the 2000s. A large generational shift in the physician population is anticipated between now and 2030; the proportion of "boomers" (1946-1964) will drop from 43% to 16% of the practising profession. Canada has not been alone in increasing physician supply. Any judgement as to whether too many or too few physicians are being trained must consider the drivers and mitigators of both supply and demand. Although there are current concerns about a shortage of practice opportunities for some specialties, the available data do not indicate a physician surplus on the horizon in Canada.

[Progressive multifocal leukoencephalopathy]

Progressive multifocal leukoencephalopathy (PML) is a disease of immunosuppressed patients caused by the JC polyomavirus (JCPyV). Due to the elevated risk in patients treated with natalizumab for multiple sclerosis (MS) and also treatment with other biologicals for different indications, the relevance of PML has increased in recent years. This article summarizes the published knowledge on the biology and pathogenesis of PML with a focus on the role of cerebrospinal fluid diagnostics in the work-up for PML and the current PML case definition. Current recommendations regarding risk management are discussed, as are possible therapies and prevention.

Policy Capacity for Health Reform: Necessary but Insufficient: Comment on "Health Reform Requires Policy Capacity"

Forest and colleagues have persuasively made the case that policy capacity is a fundamental prerequisite to health reform. They offer a comprehensive life-cycle definition of policy capacity and stress that it involves much more than problem identification and option development. I would like to offer a Canadian perspective. If we define health reform as re-orienting the health system from acute care to prevention and chronic disease management the consensus is that Canada has been unsuccessful in achieving a major transformation of our 14 health systems (one for each province and territory plus the federal government). I argue that 3 additional things are essential to build health policy capacity in a healthcare federation such as Canada: (a) A means of "policy governance" that would promote an approach to cooperative federalism in the health arena; (b) The ability to overcome the "policy inertia" resulting from how Canadian Medicare was implemented and subsequently interpreted; and (c) The ability to entertain a long-range thinking and planning horizon. My assessment indicates that Canada falls short on each of these items, and the prospects for achieving them are not bright. However, hope springs eternal and it will be interesting to see if the July, 2015 report of the Advisory Panel on Healthcare Innovation manages to galvanize national attention and stimulate concerted action.

Reliable LC3 and p62 autophagy marker detection in formalin fixed paraffin embedded human tissue by immunohistochemistry

Autophagy assures cellular homeostasis, and gains increasing importance in cancer, where it impacts on carcinogenesis, propagation of the malignant phenotype and development of resistance. To date, its tissue-based analysis by immunohistochemistry remains poorly standardized. Here we show the feasibility of specifically and reliably assessing the autophagy markers LC3B and p62 (SQSTM1) in formalin fixed and paraffin embedded human tissue by immunohistochemistry. Preceding functional experiments consisted of depleting LC3B and p62 in H1299 lung cancer cells with subsequent induction of autophagy. Western blot and immunofluorescence validated antibody specificity, knockdown efficiency and autophagy induction prior to fixation in formalin and embedding in paraffin. LC3B and p62 antibodies were validated on formalin fixed and paraffin embedded cell pellets of treated and control cells and finally applied on a tissue microarray with 80 human malignant and non-neoplastic lung and stomach formalin fixed and paraffin embedded tissue samples. Dot-like staining of various degrees was observed in cell pellets and 18/40 (LC3B) and 22/40 (p62) tumors, respectively. Seventeen tumors were double positive for LC3B and p62. P62 displayed additional significant cytoplasmic and nuclear staining of unknown significance. Interobserver-agreement for grading of staining intensities and patterns was substantial to excellent (kappa values 0.60 - 0.83). In summary, we present a specific and reliable IHC staining of LC3B and p62 on formalin fixed and paraffin embedded human tissue. Our presented protocol is designed to aid reliable investigation of dysregulated autophagy in solid tumors and may be used on large tissue collectives.

Comparison of human metapneumovirus, respiratory syncytial virus and Rhinovirus respiratory tract infections in young children admitted to hospital

Respiratory Syncytial Virus (RSV), Human metapneumovirus (HMPV), and Rhinoviruses (RV) are frequent causes of respiratory tract infections in young children. We compared laboratory and clinical findings in children with comparable age distribution and hospitalized due to RSV, HMPV or RV infections. Viral pathogens were detected by a quantitative real time PCR from nasopharyngeal aspirates. No significant differences in the admission diagnosis, laboratory parameters, patient demographics and treatment measures between the three viral causes of respiratory illness were found. No correlation between viral load and disease severity was observed however, there was a significantly lower concentration of the nasopharyngeal interleukin 8 (IL‐8) in children with RV compared to HMPV and RSV, indicating a milder proinflammatory reaction. Moreover, RV‐infected children had significantly lower body temperature, higher leucocyte counts in peripheral blood, and a tendency to have a shorter stay in hospital than children with either HMPV or RSV infection. Taken together, clinical presentation of the infections with RSV, HMPV, and RV is similar among children of the same age group and not clearly distinguishable by standard clinical or laboratory findings. Therefore, virus specific testing should be included regularly for routine diagnosis of children with respiratory tract infections. J. Med. Virol. 87:275–280, 2015. © 2014 Wiley Periodicals, Inc.

Canadian physicians' responses to cross border health care

Background

The idea for this survey emanated from desk research and two meetings for researchers that discussed medical tourism and out-of-country health care, which were convened by some of the authors of this article (VR, CP and RL).

Methods

A Cross Border Health Care Survey was drafted by a number of the authors and administered to Canadian physicians via the Canadian Medical Association’s e-panel. The purpose of the survey was to gain an understanding of physicians’ experiences with and views of their patients acquiring health care out of country, either as medical tourists (paying out-of-pocket for their care) or out-of-country care patients funded by provincial/territorial public health insurance plans. Quantitative and qualitative results of the survey were analyzed.

Results

631 physicians responded to the survey. Diagnostic procedures were the top-ranked procedure for patients either as out-of-country care recipients or medical tourists. Respondents reported that the main reason why patients sought care abroad was because waiting times in Canada were too long. Some respondents were frustrated with a lack of information about out-of-country procedures upon their patients’ return to Canada. The majority of physician respondents agreed that it was their responsibility to provide follow-up care to medical travellers on return to Canada, although a substantial minority disagreed that they had such a responsibility.

Conclusions

Cross-border health care, whether government-sanctioned (out-of-country-care) or patient-initiated (medical tourism), is increasing in Canada. Such flows are thought likely to increase with aging populations. Government-sanctioned outbound flows are less problematic than patient-initiated flows but are constrained by low approval rates, which may increase patient initiation. Lack of information and post-return complications pose the greatest concern to Canadian physicians. Further research on both types of flows (government-sanctioned and patient-initiated), and how they affect the Canadian health system, can contribute to a more informed debate about the role of cross-border health care in the future, and how it might be organized and regulated.

The healthcare quality agenda in Canada

Sullivan et al. have captured several important themes. One of the reasons that healthcare has been slow to adopt a culture of quality has been that it has taken a long time to recognize that quality is a continuous journey along several dimensions. Following advances in the early 1990s on appropriateness and effectiveness, there has been a decade-long preoccupation with accessibility that still remains an issue. Patient-centredness is one of the most recent dimensions to receive attention, and the overall goal of quality - improved patient outcomes - needs considerable work. Measurement and reporting are fundamental to quality improvement, but the provincial and territorial governments have not lived up to their Health Accord commitments to regular reporting on common indicators. At least six provinces have established health quality councils, but it remains to be seen if this bottom-up approach will lead to a common reporting framework that will support benchmarking. Canada would likely benefit from a pan-Canadian approach to innovation in healthcare quality.

[Progressive multifocal leukoencephalopathy under natalizumab. Initial possibilities for risk stratification?]

Natalizumab (Tysabri®) is the first monoclonal antibody approved for the treatment of relapsing forms of multiple sclerosis (MS) but while treatment is highly efficient, it carries the risk of progressive multifocal leukoencephalopathy (PML). Based on reports of confirmed cases of PML, the risk of PML might increase beyond 24 months of treatment. Thus, attempts to stratify patients treated with natalizumab into those carrying higher or lower risk for developing PML are currently being undertaken. Among these strategies JC virus serology might potentially be the first tool available. As a large variety of methods have been published resulting in controversial results for JC virus seroprevalence, standardized testing will be mandatory when applying this method in clinical practice. In addition, risk management strategies for the seropositive majority of patients need to be redefined and optimized further.

Induction maintenance concept for HAART as initial treatment in HIV infected infants

Background

Early initiated antiretroviral therapy (ART) in HIV infected infants leads to improved long-term viral suppression and survival. Guidelines recommend initiating therapy with a triple ART consisting of two nucleoside reverse transcriptase inhibitors (NRTIs) and either one additional non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI). Compared to older children and adults, viral relapse is seen more frequently in infants receiving triple ART. We now address the possibility of a more potent ART with a quadruple induction and triple maintenance therapy.

Methods

We examine the longitudinal course in four HIV infected infants, who were referred from other centers and could not be recruited to multicentre trials. We introduced ART initially consisting of two NRTIs, one NNRTI and one PI and later discontinued the PI at the age of 12 months maintaining a triple regime consisting of two NRTIs and one NNRTI.

Results

Provided that therapy adherence was maintained we observed an effective sustained decline of viral load and significant CD4 cell reconstitution even after switching to a triple regime. No drug associated toxicity was seen.

Conclusion

We suggest that a four drug therapy might be a possible initial therapy option in HIV infected infants, at least in those with a high viral load, followed by a maintenance triple regime after 12 months of therapy.

Value for money: putting the patient first

Canadians spend more on healthcare than people in most other countries. We are fifth in the OECD in terms of health spending per capita, and eighth out of 28 countries in terms of health spending as a percentage of GDP. Given these facts, it is appropriate to discuss the issue of value for money in healthcare. In their paper, McGrail et al. present four challenges to improving value for money in Canadian healthcare: a lack of analysis of the hospital sector; the need to learn from rate variation analysis; the slow uptake of the electronic health record (EHR); and the need to measure health outcomes. Our paper addresses each of these points, but also proposes that a broader outlook is needed to come to grips with this question. It is essential to go beyond supply-side cost control, and also take into account the needs of the patient. Moreover, we need to look beyond our borders to learn how other countries have been able to evolve universal publicly funded health systems without long waiting times.

Comparison of hemagglutination inhibition assay, an ELISA-based micro-neutralization assay and colorimetric microneutralization assay to detect antibody responses to vaccination against influenza A H1N1 2009 virus

The hemagglutination inhibition (HI) assay has been the main method used to investigate immune responses to vaccination against influenza H1N1 (2009) virus. However microneutralization tests (MNT) have been shown to be more sensitive and more specific. In this study, the three methods of choice: (i) the HI assay, (ii) an ELISA-based conventional MNT and (iii) a colorimetric MNT in terms of their ability to detect antibody responses in serum pairs collected from 43 healthy individuals before and 21 days after vaccination were compared. The colorimetric MNT was established yielding intra- and inter-run imprecisions of 7.5% and 12.4%, respectively. Testing of antisera to seasonal influenza viruses demonstrated the assay to be specific for antibodies to influenza H1N1 (2009) virus. A good correlation between the three methods was found, being highest for the ELISA-MNT and the colorimetric MNT (r=0.714 for geometric mean titers (GMT) and r=0.695 for titer increases). Similar rates of fourfold titer increases were detected: 95.3% in the ELISA-MNT vs. 93.0% in colorimetric MNT and 95.3% in HI assay. The ELISA-based MNT demonstrated the highest titer range leading to the highest postvaccination GMT and the highest titer increase (>50-fold). The lowest GMTs were measured with the HI assay, while the colorimetric MNT detected the highest GMT in prevaccination sera. Taken together, similar seroconversion rates were obtained with the three assays. The ELISA-MNT appeared to be the best method to compare absolute pre- and postvaccination GMTs. The colorimetric MNT, being less labour-intensive than the ELISA-MNT, seems to be a suitable tool in vaccination studies.

Prospective, comprehensive, and effective viral monitoring in children undergoing allogeneic hematopoietic stem cell transplantation

Major advances in the monitoring and treatment of viral infections after hematopoietic stem cell transplantation (HSCT) have been achieved over the last decade. The appropriate extent of viral monitoring and antiviral therapy remains controversial, and reports in pediatric patients receiving allogeneic unmanipulated hematopoietic stem cells (HSCs) are sparse. A total of 40 pediatric patients who underwent HSCT with either peripheral blood stem cells (PBSCs, n = 30) or bone marrow (BM; n = 10) were prospectively monitored every week for viral DNAemia (VDNA) by simultaneous detection of cytomegalovirus (CMV), Epstein-Barr virus (EBV), human herpesvirus 6 (HHV6), human adenovirus (ADV), and polyoma BK virus (BKV) using real-time TaqMan polymerase chain reaction (PCR). All patients received prophylactic acyclovir and preemptive ganciclovir (GCV) when 500 copies/microg DNA (EBV/HHV6) or >1 copy/microg DNA (CMV) were detected on 2 consecutive measurements. VDNA occurred in 25 of 40 recipients (CMV, 11/40 patients [28%]; EBV, 19/40 [48%]; HHV6, 2/40 [5%]; ADV/BKV, 1/40) and was found exclusively after neutrophil engraftment and in most cases up to day +100. Recurrent VDNA (P = .028) and (readily treatable) viral disease (P = .003) were observed predominantly in patients suffering from nonmalignant diseases, a cohort characterized by delayed lymphocyte engraftment. VDNA occurred more frequently in HLA-mismatched HSCT and in the 24 of 40 patients receiving antithymocyte globulin (ATG). The incidence of EBV, but not that of CMV, was increased in the ATG group. Yet, in these patients, viral loads of both EBV and CMV were higher, but with prompt initiation of preemptive GCV, no posttransplantation lymphoproliferative disorder or other life-threatening morbidities occurred. HHV6 was typically detected at low viral loads (<10(2) copies/microg DNA), with only 5% of HSC recipients fulfilling our HHV6 criteria for triggering GCV treatment. In multivariate analysis, ATG treatment, HLA mismatch, recipient CMV seropositivity, and stem cell source, but not severe acute graft-versus-host disease were identified as independent risk factors for VDNA. This comprehensive viral monitoring program with defined thresholds for initiation of preemptive GCV effectively prevents the development of critical viral disease, even in high-risk patients receiving ATG.

Expression plasmids are only useful for the investigation of co-receptor tropism and fusion capacity of short HIV-1 envelope domains

Expression vectors have been used widely to identify functionally important domains in HIV-1 glycoproteins. Env domains such as the V3 loop were amplified by polymerase chain reaction (PCR) and inserted into plasmids carrying the backbone of an HIV-1 reference strain like NL4-3. The hypothesis of the present approach was that cloning large domains of wild type envelopes yields constructs that are non-functional in co-receptor-expressing HeLaCD4 cells, in contrast to laboratory-adapted HIV-1 strains. The background for this assumption was that primary HIV-1 virions are frequently less infectious and lack fusion capacity in HeLaCD4 cells compared to laboratory-adapted (LA) viruses. To address this hypothesis, env domains of different length were amplified from a panel of X4-tropic HIV-1 clinical isolates cultured in peripheral blood lymphocytes (PBLs) and cloned into the backbone of NL4-3 env. Constructs bearing either the V3 loops or 312 nucleotides of the intracellular trunk (ICT) of gp41 led to a similar fusion capacity as NL4-3. In contrast, none of the plasmids carrying the 2322 N-terminal nucleotides of primary isolates led to similar syncytium formation. These results have an effect on studies that investigate pathogenic effects of Env regions with chimeric constructs in the backbone of HIV reference envelopes.

SEN Virus infection in HIV/HCV coinfected patients

BACKGROUND

Chronic Hepatitis C Virus (HCV) infection is currently one of the most relevant coinfections in HIV positive patients. The influence of SEN Virus (SENV) on the outcome of HCV therapy in HIV/HCV coinfected patients who underwent combination therapy with pegylated interferon (PEG-IFN) and ribavirin is unclear.

METHODS

SENV DNA was determined by polymerase chain reaction in 67 HIV/HCV coinfected patients, 77 HIV monoinfected patients, 95 treatment naive HCV monoinfetcted patients, and 122 healthy blood donors. Quantitative analysis was done for SENV H DNA.

RESULTS

SENV DNA was detected in 8 of 67 (12%) HIV/HCV coinfected patients, in 9 of 77 (11.7%) HIV monoinfected patients, in 21 of 95 (22%) HCV monoinfected patients, and 12 of 122 (9.8%) healthy blood donors. HIV monoinfected patients showed the highest mean SENV H DNA level. The mean SENV H DNA was significantly lower in HIV/HCV coinfected patients compared to all other groups. The sustained virological response rates to combination therapy of HCV in HIV/HCV coinfected patients did not differ between patients with detectable SENV 5/8 (62.5%) and without SENV 28/59 (47.5%; p = 0.47). We found no significant difference in SENV H DNA pretreatment levels between nonresponders and responders to combination therapy (112 +/- 144 copies vs. 8 +/- 7 copies/ml; p = 0.27).

CONCLUSION

Coinfection with HCV may reduce SENV H replication in HIV positive patients and results in significantly lower SENV H DNA levels in HIV/HCV coinfected patients. SENV infection has no influence on the outcome of HCV combination therapy in HIV/HCV coinfected patients.

Quantitative detection of norovirus excretion in pediatric patients with cancer and prolonged gastroenteritis and shedding of norovirus

Although chronic courses of norovirus infection have been described in immunocompromised patients, little is known about noroviral shedding and correlation with clinical symptoms in these patients. In this report, the quantitative courses of norovirus excretion in nine pediatric patients with hematologic and oncologic disorders and prolonged gastroenteritis were investigated. In a retrospective study multiple fecal samples from nine pediatric cancer patients were examined by a one-step real-time PCR. Clinical data of the patients were reviewed and virological data were correlated with clinical symptoms. All nine patients presented with prolonged illness and prolonged noroviral shedding. Vomiting and diarrhea were associated with high norovirus concentrations and norovirus excretion declined slowly in the patients. Retrospectively, initial PCR-testing for norovirus was performed with a median of 7 days after onset of symptoms. This finding hints at the difficulty of obtaining early diagnosis of the infection in these children. The patients were shedding high norovirus concentration over a long period of time. Results of sequential quantitative PCR-testing for norovirus correlated with clinical symptoms. Both clinical symptoms and quantitative PCR-testings help to define the severity of norovirus infection and to estimate the risk for transmission. To prevent the spread of the disease, usage of virocidal disinfectants and isolation procedures should be maintained as long as patients are positive for noroviruses. Since vomiting is frequent in pediatric patients with oncological conditions, a screening program for rapid detection of norovirus infection in this group of patients should be considered.

Severe combined immunodeficiency signalized by eosinophilia and lymphopenia in rotavirus infected infants

BACKGROUND

Severe combined immunodeficiency (SCID) is a heterogeneous disease consisting of several different subtypes. Most subtypes present during infancy and without treatment, infections usually lead to early death. Diagnosis of SCID can be difficult as new subtypes are expected to be discovered soon. Late diagnosis is associated with a poorer outcome. Infections like rotavirus enteritis cannot be cleared in children with SCID due to impaired immunity. The aim of our study was to identify clues in children with rotavirus enteritis that aid to diagnose SCID early.

PATIENTS AND METHODS

Total white blood counts in a cohort of SCID patients with persistent rotavirus infection at diagnosis (n=18) were compared to total white blood counts in matched control patients without SCID but with rotavirus infection.

RESULTS

Relative and absolute lymphopenia and eosinophilia were more common in SCID patients (p<0.005).

CONCLUSION

In infants with rotavirus infection, a full blood count should be performed: Eosinophilia and/or lymphopenia raise a high suspicion of SCID.

Akute Retinanekrose

Acute retinal necrosis (ARN) is a rare entity caused by Herpes viruses. An immunocompromised background and the complications of ARN mostly lead to a poor visual outcome. Confirmation of the early diagnosis through polymerase chain reaction and antibody detection from aqueous or vitreous taps is recommended to improve the medical management and prevent disease progression with an increased risk of complications. Favourable outcomes are possible by means of combined antiviral systemic and intravitreal strategies with Acyclovir, Foscarnet and Ganciclovir. We report on the relevant literature recommendations and our own experience.

Trends in infections in children with malignant disease in 2000: comparison of data of 1980/81

Children with cancer have an overall chance of survival of 70-80%. Despite significant advances in supportive care during the last years, infections remain a major cause of therapy-associated morbidity and death. Between January and December 2000, oncology patients (ONC) treated on a pediatric oncology ward after chemotherapy (n = 109), loco-regional thermochemotherapy (n = 13), or hematopoietic stem cell (HSCT) transplantation (n = 35) suffered a total of 249 febrile infectious complications (HSCT 40/ONC 209). These episodes were analyzed retrospectively and compared with 125 ONC patients with 133 febrile infections in 1980/81. The relative incidence of fever of unknown origin (FUO) decreased from 1980/81 to 2000 (p <.001). The frequency of bloodstream infections (BSI) in febrile episodes was comparable in both periods with 37% (50/135) in 1980 and 29% (72/249) in 2000. In both periods, gram-positive bacteria were the most frequent organisms, whereas gram-negative organisms were detected in approximately 20% of BSI. In 1980/81 microbiologically (MDI) or clinically documented infections (CDI) were not detected, whereas in 2000 27% of all infectious were MDI/CDI. During the last 20 years, improved diagnostic tools have resulted in an increased detection rate of infectious agents causing febrile episodes in pediatric cancer patients. The comparison of the two observation periods did not reveal a change in the microbiologic spectrum. Despite the fact that in 2000 more patients were treated with intensified chemotherapy because of relapse, infection-related mortality was unchanged compared to 1980/81. This observation may indicate a sufficient preemptive antibacterial therapy followed by better diagnostic tools and goal-oriented treatment.

A prescription for Ontario's Wait Time Strategy

After a late start, Ontario is well on its way to implementing an ambitious Wait Time Strategy that has already begun to show some tangible improvements in access to the five priority areas. This commentary argues that in addition to the supporting tools identified in the lead essay, a sustainable wait time strategy must encompass prevention and demand management, address shortages in health human resources, provide patients with recourse to a safety valve and promote interprovincial standards and cooperation. Care will also be needed to ensure ongoing support and engagement of organized medicine, realigning incentives to support patient care and extending the reach of health information systems into the community.

Passing the baton--toward making a case for a Canadian centre for health leadership

This paper demonstrates that the average tenure of current senior leaders in the health sector has declined sharply over the last three decades, and is substantially shorter than that of leaders in the private and public arenas. It offers potential reasons for this downward trend, and sets out the broad parameters for a Canadian Centre for Health Leadership, which could help better identify, develop, support, and celebrate leadership in health and healthcare in Canada.

Chlamydia pneumoniae, herpes simplex virus and cytomegalovirus in symptomatic and asymptomatic high-grade internal carotid artery stenosis. Does infection influence plaque stability?

BACKGROUND

Current debates are focused on inflammatory processes in atherosclerotic lesions as a possible pathomechanism for destabilization and thrombembolism. In this prospective study the role of systemic and local infection in patients with high-grade internal carotid artery stenosis (ICA) was evaluated.

PATIENTS AND METHODS

Serum antibody titers of 109 consecutive patients, who underwent surgery for ICA stenosis (asymptomatic n = 40, symptomatic n = 69) were prospectively measured for Chlamydia pneumoniae (Cpn) (IgA and IgG), Herpes simplex virus (HSV) (IgG, IgM) and Cytomegalovirus (CMV) (IgG, IgM) respectively. 53 carotis plaques of this group (asymptomatic n = 17, symptomatic n = 36) could be analyzed by polymerase chain reaction (PCR) for Cpn-, HSV- and CMV-DNA presence.

RESULTS

Seropositivity was found in 61,5% for Cpn, 91,7% for HSV and 72,5% CMV respectively. No significant relation was found between symptomatic and asymptomatic patients as well as no difference was seen for presence of IgA antibodies against Cpn comparing both groups. Plaque-PCR revealed Cpn in 7 cases (13,2%), HSV in 2 cases (3,8%) and no CMV had been detected. Again, no significant relationship was found concerning symptomatic and asymptomatic patients. All 9 PCR-positive plaques displayed lesions of "complicated atherosclerosis" as central fibrous necrosis and calcification or plaque bleeding and surface thrombosis.

CONCLUSIONS

Our results do not support the hypothesis that systemic Cpn, HSV or CMV- infection or evidence of Cpn-, HSV- or CMV-DNA in carotid plaques causes plaque destabilization and cerebral thromboembolism. Plaque infection could only be observed in cases with advanced atherosclerosis.