Cost-effectiveness of measles control during elimination in Ontario, Canada, 2015

BackgroundGiven that measles is eliminated in Canada and measles immunisation coverage in Ontario is high, it has been questioned whether Ontario's measles outbreak response is worthwhile.AimOur objective was to determine cost-effectiveness of measles containment protocols in Ontario from the healthcare payer perspective.MethodsWe developed a decision-analysis model comparing Ontario's measles containment strategy (based on actual 2015 outbreak data) with a hypothetical 'modified response'. The modified scenario assumed 10% response costs with reduced case and contact tracing and no outbreak-associated vaccinations; it was based on local and provincial administrative and laboratory data and parameters from peer-reviewed literature. Short- and long-term health outcomes, quality-adjusted life years (QALYs) and costs discounted at 1.5%, were estimated. We conducted one- and two-way sensitivity analyses.ResultsThe 2015 outbreak in Ontario comprised 16 measles cases and an estimated 3,369 contacts. Predictive modelling suggested that the outbreak response prevented 16 outbreak-associated cases at a cost of CAD 1,213,491 (EUR 861,579). The incremental cost-effectiveness ratio was CAD 739,063 (EUR 524,735) per QALY gained for the outbreak response vs modified response. To meet the commonly accepted cost-effectiveness threshold of CAD 50,000 (EUR 35,500) per QALY gained, the outbreak response would have to prevent 94 measles cases. In sensitivity analyses, the findings were robust.ConclusionsOntario's measles outbreak response exceeds generally accepted cost-effectiveness thresholds and may not be the most efficient use of public health resources from a healthcare payer perspective. These findings should be balanced against benefits of increased vaccine coverage and maintaining elimination status.

Measles Outbreak with Unique Virus Genotyping, Ontario, Canada, 2015

The province of Ontario continues to experience measles virus transmissions despite the elimination of measles in Canada. We describe an unusual outbreak of measles in Ontario, Canada, in early 2015 that involved cases with a unique strain of virus and no known association among primary case-patients. A total of 18 cases of measles were reported from 4 public health units during the outbreak period (January 25–March 23, 2015); none of these cases occurred in persons who had recently traveled. Despite enhancements to case-patient interview methods and epidemiologic analyses, a source patient was not identified. However, the molecular epidemiologic analysis, which included extended sequencing, strongly suggested that all cases derived from a single importation of measles virus genotype D4. The use of timely genotype sequencing, rigorous epidemiologic investigation, and a better understanding of the gaps in surveillance are needed to maintain Ontario’s measles elimination status.

Myositiden bei Systemischer Sklerose, Lupus und Sjögren-Syndrom

Diese Übersichtsarbeit fokussiert auf die Overlap- und undifferenzierten Myopathien, welche bei der Systemischen Sklerose (SSc), dem systemischen Lupus erythematodes (SLE) und dem Sjögren Syndrom beobachtet werden. Am häufigsten findet sich ein Myositis-Overlap bei der SSc. Da eine einheitliche Definition nicht existiert, schwanken die Angaben über die Prävalenz stark. Grundsätzlich aber sind myopathische Symptome bei der diffusen SSc deutlich häufiger als bei der limitierten Unterform. Es werden 2 myopathische Muster bei der SSc beschrieben: die „einfache“ Myopathie (milde proximale Muskelschwäche, eine normale oder nur leicht erhöhte Creatinkinase (CK) und polyphasische Potenziale im EMG von normaler Dauer und Amplitude) sowie die „komplizierte“ Myopathie (mit mindestens 3 von 4 Befunden: symmetrische Schwäche, bioptischer Nachweis eines entzündlichen Infiltrates, EMG-Veränderungen, Erhöhung der Muskelenzyme im Serum). Neuere Befunde der sogenannten Blood Oxygenation Level Dependent (BOLD) Magnetresonanztomografie legen jedoch nahe, dass die bei SSc im Muskel beobachtete Mikroangiopathie zu einer dynamischen, d. h. sich erst bei Kraftausdauer manifestierenden Muskelschwäche führen könnte. Im Allgemeinen wird angenommen, dass Patienten mit “komplizierter” Myopathie und histologisch nachgewiesener Myositis im Vergleich zur „einfachen“ Mypoathie besser auf eine immunsuppressive Therapie ansprechen. Empfohlen wird eine Glucokortikosteroid-Therapie in möglichst geringer Dosierung, da Steroide eine lebensbedrohliche renale Krise triggern können. Beim SLE werden Myalgien oder eine Muskelschwäche von bis zu 70% der Patienten beklagt, schwere Paresen und Muskelatrophien sind jedoch selten. Eine Myositis, definiert als Muskelschwäche mit begleitender CK-Erhöhung und charakteristischen EMG oder inflammatorischen Biopsiebefunden, wurde bei 6,5% der Patienten beobachtet und war in ungefähr der Hälfte der SLE Patienten bereits Teil der Initialmanifestation. Die Lupus-Myositis wird als milde Erkrankung beschrieben, obwohl sie allerdings von Rezidiven mit abwechselnden Remissionen geprägt ist. Evidenz-basierte Therapieempfehlungen existieren nicht. In der Praxis hat sich jedoch neben Kortikosteroiden der Einsatz von Methotrexat oder Azathioprin bewährt. Beim Sjögren-Syndrom wird die Prävalenz der Myositis zwischen 3 und 7% beziffert, unspezifische Myalgien wurden bei einem Drittel der Patienten beobachtet. Die Muskelsymptome korrelieren beim Sjögren-Syndrom nur schlecht mit den Biopsie-Ergebnissen, welche eine sogar noch häufigere Prävalenz der Myositis nahe legen. Allerdings ist die Ausprägung der Muskelschwäche beim Sjögren-Syndrom meist relativ mild und nur langsam progredient. Bereits geringe Initialdosen von Prednison führen in aller Regel zu einer lang anhaltenden Remission mit nur geringer Rezidivrate. Einheitliche Kriterien zur Klassifikation und Verlaufsbeurteilung der Overlap-Myositis fehlen. Eine Standardisierung der diagnostischen Methoden aller involvierten Fachdisziplinen sowie eine länderübergreifende Harmonisierung der Myositis-Definitionen und der Erfassungsgrundlagen in Registern wären wichtig.

GotFlu channel: an online syndromic surveillance tool supporting college health practice and public health work

OBJECTIVE

Develop a tool to ease the burden of H1N1 influenza on a campus clinic by promoting self-care, generating medical notes, and identifying vulnerable students.

PARTICIPANTS

Students at Brock University, a mid-sized urban campus; Brock's Student Health Services; and Niagara Public Health.

METHODS

Students accessed a controlled portal of Brock's Web site and self-identified onset/offset of influenza-like symptoms. Daily sign-in numbers were monitored and nonidentifiable aggregate data transferred to the local public health unit.

RESULTS

There was concordance among the number of college students signing in, local school absenteeism rates, and local rates of laboratory-confirmed influenza. Many visits to the campus health clinic were averted, 1,432 students used the tool.

CONCLUSION

The online, real-time surveillance tool was effective in monitoring influenza activity on campus, providing timely health advice, decreasing unnecessary visits to the campus medical clinic, and assisting local public health in surveillance activities.

Endothelial survival factors and spatial completion, but not pericyte coverage of retinal capillaries determine vessel plasticity

Pericyte loss and capillary regression are characteristic for incipient diabetic retinopathy. Pericyte recruitment is involved in vessel maturation, and ligand-receptor systems contributing to pericyte recruitment are survival factors for endothelial cells in pericyte-free in vitro systems. We studied pericyte recruitment in relation to the susceptibility toward hyperoxia-induced vascular remodeling using the pericyte reporter X-LacZ mouse and the mouse model of retinopathy of prematurity (ROP). Pericytes were found in close proximity to vessels, both during formation of the superficial and the deep capillary layers. When exposure of mice to the ROP was delayed by 24 h, i.e., after the deep retinal layer had formed [at postnatal (p) day 8], preretinal neovascularizations were substantially diminished at p18. Mice with a delayed ROP exposure had 50% reduced avascular zones. Formation of the deep capillary layers at p8 was associated with a combined up-regulation of angiopoietin-1 and PDGF-B, while VEGF was almost unchanged during the transition from a susceptible to a resistant capillary network. Inhibition of Tie-2 function either by soluble Tie-2 or by a sulindac analog, an inhibitor of Tie-2 phosphorylation, resensitized retinal vessels to neovascularizations due to a reduction of the deep capillary network. Inhibition of Tie-2 function had no effect on pericyte recruitment. Our data indicate that the final maturation of the retinal vasculature and its resistance to regressive signals such as hyperoxia depend on the completion of the multilayer structure, in particular the deep capillary layers, and are independent of the coverage by pericytes.

Analysis of human telomerase reverse transcriptase mRNA (hTERT) expression in myxoid liposarcomas using LightCycler real-time quantitative reverse transcriptase-polymerase chain reaction

We describe a convenient, nonradioactive reverse transcription--polymerase chain reaktion (RT-PCR) method for the rapid and accurate quantitative detection of the human telomerase catalytic subunit human telomerase reverse transcriptase (hTERT) mRNA. The LightCycler TeloTAGGG hTERT Quantification Kit (Roche Molecular Biochemicals) was designed to be used for the highly sensitive and quantitative detection of hTERT mRNA relative to the house-keeping gene porphobilinogen deaminase (PBGD). As a tumor progression model, we investigated 26 myxoid liposarcomas (11 pure myxoid grade I, 15 myxoid/round cell grade II/III) for the hTERT expression level and compared the results of the new method with former measurements performed in silver-stained polyacrylamide gels. Both methods revealed similar results, with real-time RT-PCR being the more accurate quantification technique, which also saves time and material. Elevated hTERT expression (cut-off ratio x 100 at 1.3) was an indicator of round cell components and hence for tumor progression in myxoid liposarcoma. The new method is capable of differentiating between pure myxoid and myxoid/round cell liposarcomas for hTERT-expression more accurately.

High telomerase activity and high HTRT mRNA expression differentiate pure myxoid and myxoid/round-cell liposarcomas

Molecular markers characterizing the transition of a myxoid to a more round-cell liposarcoma have not been described. To examine whether telomerase activity, hTRT and hTR mRNA expression were associated with tumor progression in myxoid liposarcoma, we investigated a total of 28 myxoid liposarcomas (13 pure myxoid tumors, 14 mixed-type tumors, and 1 pure round-cell variant) from 19 patients. Telomerase activity was detected by using the fluorescent PCR-based TRAP-assay. Expression of hTRT and hTR mRNAs was determined by the semi-quantitative RT-PCR. On the basis of only one tumor sample per patient, telomerase activity was found in 9 of 9 myxoid/round-cell liposarcomas and in 3 of 10 pure myxoid tumors. Elevated hTRT expression was found in 13 of 17 liposarcomas. All telomerase-positive tumors showed hTRT expression, whereas there were 3 cases showing hTRT expression without telomerase activity. HTR mRNA expression was elevated in all 19 liposarcomas. Thus, only the levels of telomerase activity and of hTRT mRNA expression differentiated pure myxoid liposarcoma and myxoid/round-cell liposarcoma (p < 0.003 and p = 0.029, respectively). We believe that high levels of telomerase activity and of hTRT expression are associated with tumor progression from low-grade pure myxoid to higher-grade malignant round-cell liposarcoma, and may consequently represent a useful prognostic marker for this histological sub-type of soft-tissue tumors.

Myxoid liposarcoma with transition to round-cell lesion-cell cycle regulator genes and telomerase activity characterizing tumor progression: a case report

A mixed myxoid/round cell liposarcoma was macrodissected in its 2 histologic components and investigated for genetic differences between its low-grade myxoid and the high-grade round-cell region. For both, we failed to detect p53 gene mutations, loss of heterozygosity at the p53 or Rb genes, and p53 protein expression. The round-cell component showed a high telomerase activity, and an elevated c-myc mRNA and protein expression. The myxoid component was characterized by a lack of telomerase activity and low c-myc mRNA expression, and immunohistochemistry failed to detect the c-myc protein. There was a higher Mib-1 proliferation index in the round-cell portion. The same specific translocation t(12;16) and the fusion transcript type II in both components confirmed the close relationship between myxoid and round-cell liposarcomas. Telomerase activity and increased c-myc expression seem to be helpful molecular markers for characterizing tumor progression in myxoid liposarcoma.

Prognostic significance of telomerase activity in soft tissue sarcomas

Only few reports on the prognostic significance of telomerase activity in human cancer exist. To find a new prognostic marker in soft tissue tumors, we investigated 60 soft tissue sarcomas of different histology and six benign tumors for telomerase activity. Telomerase activity was measured by using the non-radioactive PCR-based TRAP-assay. PCR products were analyzed on an automated fluorescence sequencer. Tumors of grade-II and grade-III histology showed a significantly poorer prognosis. Both disease-free (p<0.03) and the overall survival (p<0.02) were reduced in the highly malignant sarcoma patients. We found telomerase activity in 38.3% of the cases, there being a correlation with a more aggressive behavior of soft tissue sarcomas. Telomerase activity correlated with the grade of malignancy (p=0.04), but not with sex (p=0.64) or age (p=0. 48) of the patients. The total survival was significantly reduced in patients with telomerase-positive sarcomas (p=0.04). Both of the patients having grade I tumors with telomerase activity died of disease, whereas 10 of 11 patients with telomerase-negative grade I tumors are still alive. Only one of the benign tumors showed telomerase activity. We suggest that telomerase activity is a potential prognostic factor in malignant soft tissue tumors. Despite the histological heterogeneity of soft tissue tumors, single entities should be assessed for telomerase activity.

Polymorphic enzymes of xenobiotic metabolism as modulators of acquired P53 mutations in bladder cancer

Occurrence or specific types of mutations found in oncogenes or tumor suppressor genes may partially be determined by activities of toxifying or detoxifying enzymes, such as glutathione S-transferases (GST) M1 and T1, arylamine N-acetyltransferase (NAT2), microsomal epoxide hydrolase, and the cytochrome P-450 enzymes 2D6, 1A1, 2A6, and 2E1. In an explorative observational study, 69 bladder cancer patients were analysed for acquired mutations in the p53 tumor suppressor gene. The same patients were studied for the polymorphic traits of xenobiotic metabolism given above which were characterized from blood cell DNA by molecular methods. In 20 patients, single point mutations in p53 were detected whereas five patients carried two mutations; thus in total 25 mutations were detected. Twelve of these were G:C-->A:T transitions, six were A:T-->G:C transitions and seven were transversions (three G:C-->T:A, two A:T-->T:A, one G:C-->C:G, and one A:T-->C:G). There was no correlation between the types of p53 mutations and lifetime smoking or occupational history. In correlation with xenobiotic metabolism, 86% of the seven transversion mutations were found in homozygously deficient individuals for GSTM1 compared to only 44% of GSTM1 deficiency in the carriers of the 18 transition mutations of p53 (p = 0.06). A similar trend was seen for NAT2: six of the seven carriers of transversion mutations had two slow NAT2 alleles. No apparent associations were seen for the other polymorphic traits which were studied. In conclusion, low or deficient activities of two conjugating enzymes of foreign compound metabolism, GSTM1 and NAT2, may influence types of acquired mutations in p53 in bladder cancer.

[The radiologic picture of pathomorphological changes in the intestinal wall in Crohn disease in relation to the course of the disease]

Crohn's disease has highly variable presentation in the x-ray examination depending on the stage of the gut wall inflammation. Our series showed that the lesions concern mainly the ileocecal region with involvement of the terminal ileum in 72.4% and of the cecum in 56.2% of the cases. In patients who required only conservative treatment mainly "cobble stone"-lesions, pseudopolyps and pseudodiverticuli could be demonstrated. Patients who needed surgical therapy showed in the first place stenosis, spicules and fistulae. Of all the studied patients 59% had to be assigned to surgery and of these 62% showed signs of relapse. The recurrence of disease occurred in 88% at the site of the anastomosis mainly in the first two years after operation. Differences in the frequency of relapse after the first or the second operation could not be seen.

The anticonvulsant effects of propranolol and beta-adrenergic blockade

The anticonvulsant activity of racemic and (+)-propranolol was studied in rats. Neither drug changed the current to produce a minimal seizure in 50% of animals. Both drugs were effective in the maximal electroshock seizure test, the (+) isomer being more potent than the racemic form. Since the (+) isomer is practically devoid of beta-adrenergic blocking activity, the anticonvulsant effects of propranolol do not result from beta-adrenergic blockade.

Isoelectric focusing of glutathione S-transferases from rat liver and kidney

The glutathione S-transferases that were purified to homogeneity from liver cytosol have overlapping but distinct substrate specificities and different isoelectric points. This report explores the possibility of using preparative electrofocusing to compare the composition of the transferases in liver and kidney cytosol. Hepatic cytosol from adult male Sprague-Dawley rats was resolved by isoelectric focusing on Sephadex columns into five peaks of transferase activity, each with characteristic substrate specificity. The first four peaks of transferase activity (in order of decreasing basicity) are identified as transferases AA, B, A and C respectively, on the basis of substrate specificity, but the fifth peak (pI6.6) does not correspond to a previously described transferase. Isoelectric focusing of renal cytosol resolves only three major peaks of transferase activity, each with narrow substrate specificity. In the kidney, peak 1 (pI9.0) has most of the activity toward 1-chloro-2,4-dinitrobenzene, peak 2 (pI8.5) toward p-nitrobenzyl chloride, and peak 3 (pI7.0) toward trans-4-phenylbut-3-en-2-one. Renal transferase peak 1 (pI9.0) appears to correspond to transferase B on the basis of pI, substrate specificity and antigenicity. Kidney transferase peaks 2 (pI8.5) and 3 (pI7.0) do not correspond to previously described glutathione S-transferases, although kidney transferase peak 3 is similar to the transferase peak 5 from focused hepatic cytosol. Transferases A and C were not found in kidney cytosol, and transferase AA was detected in only one out of six replicates. Thus it is important to recognize the contribution of individual transferases to total transferase activity in that each transferase may be regulated independently.