Transmission of yellow fever vaccine virus through blood transfusion and organ transplantation in the USA in 2021: report of an investigation

BACKGROUND

In 2021, four patients who had received solid organ transplants in the USA developed encephalitis beginning 2-6 weeks after transplantation from a common organ donor. We describe an investigation into the cause of encephalitis in these patients.

METHODS

From Nov 7, 2021, to Feb 24, 2022, we conducted a public health investigation involving 15 agencies and medical centres in the USA. We tested various specimens (blood, cerebrospinal fluid, intraocular fluid, serum, and tissues) from the organ donor and recipients by serology, RT-PCR, immunohistochemistry, metagenomic next-generation sequencing, and host gene expression, and conducted a traceback of blood transfusions received by the organ donor.

FINDINGS

We identified one read from yellow fever virus in cerebrospinal fluid from the recipient of a kidney using metagenomic next-generation sequencing. Recent infection with yellow fever virus was confirmed in all four organ recipients by identification of yellow fever virus RNA consistent with the 17D vaccine strain in brain tissue from one recipient and seroconversion after transplantation in three recipients. Two patients recovered and two patients had no neurological recovery and died. 3 days before organ procurement, the organ donor received a blood transfusion from a donor who had received a yellow fever vaccine 6 days before blood donation.

INTERPRETATION

This investigation substantiates the use of metagenomic next-generation sequencing for the broad-based detection of rare or unexpected pathogens. Health-care workers providing vaccinations should inform patients of the need to defer blood donation for at least 2 weeks after receiving a yellow fever vaccine. Despite mitigation strategies and safety interventions, a low risk of transfusion-transmitted infections remains.

FUNDING

US Centers for Disease Control and Prevention (CDC), the Biomedical Advanced Research and Development Authority, and the CDC Epidemiology and Laboratory Capacity Cooperative Agreement for Infectious Diseases.

Transfusion-Transmitted Cache Valley Virus Infection in a Kidney Transplant Recipient With Meningoencephalitis

BACKGROUND

Cache Valley virus (CVV) is a mosquito-borne virus that is a rare cause of disease in humans. In the fall of 2020, a patient developed encephalitis 6 weeks following kidney transplantation and receipt of multiple blood transfusions.

METHODS

After ruling out more common etiologies, metagenomic next-generation sequencing (mNGS) of cerebrospinal fluid (CSF) was performed. We reviewed the medical histories of the index kidney recipient, organ donor, and recipients of other organs from the same donor and conducted a blood traceback investigation to evaluate blood transfusion as a possible source of infection in the kidney recipient. We tested patient specimens using reverse-transcription polymerase chain reaction (RT-PCR), the plaque reduction neutralization test, cell culture, and whole-genome sequencing.

RESULTS

CVV was detected in CSF from the index patient by mNGS, and this result was confirmed by RT-PCR, viral culture, and additional whole-genome sequencing. The organ donor and other organ recipients had no evidence of infection with CVV by molecular or serologic testing. Neutralizing antibodies against CVV were detected in serum from a donor of red blood cells received by the index patient immediately prior to transplant. CVV neutralizing antibodies were also detected in serum from a patient who received the co-component plasma from the same blood donation.

CONCLUSIONS

Our investigation demonstrates probable CVV transmission through blood transfusion. Clinicians should consider arboviral infections in unexplained meningoencephalitis after blood transfusion or organ transplantation. The use of mNGS might facilitate detection of rare, unexpected infections, particularly in immunocompromised patients.

SARS-CoV-2 infection risk among vaccinated and unvaccinated household members during the Alpha variant surge - Denver, Colorado, and San Diego, California, January-April 2021

BACKGROUND

COVID-19 vaccination reduces SARS-CoV-2 infection and transmission. However, evidence is emerging on the degree of protection across variants and in high-transmission settings. To better understand the protection afforded by vaccination specifically in a high-transmission setting, we examined household transmission of SARS-CoV-2 during a period of high community incidence with predominant SARS-CoV-2 B.1.1.7 (Alpha) variant, among vaccinated and unvaccinated contacts.

METHODS

We conducted a household transmission investigation in San Diego County, California, and Denver, Colorado, during January-April 2021. Households were enrolled if they had at least one person with documented SARS-CoV-2 infection. We collected nasopharyngeal swabs, blood, demographic information, and vaccination history from all consenting household members. We compared infection risks (IRs), RT-PCR cycle threshold values, SARS-CoV-2 culture results, and antibody statuses among vaccinated and unvaccinated household contacts.

RESULTS

We enrolled 493 individuals from 138 households. The SARS-CoV-2 variant was identified from 121/138 households (88%). The most common variants were Alpha (75/121, 62%) and Epsilon (19/121, 16%). There were no households with discordant lineages among household members. One fully vaccinated secondary case was symptomatic (13%); the other 5 were asymptomatic (87%). Among unvaccinated secondary cases, 105/108 (97%) were symptomatic. Among 127 households with a single primary case, the IR for household contacts was 45% (146/322; 95% Confidence Interval [CI] 40-51%). The observed IR was higher in unvaccinated (130/257, 49%, 95% CI 45-57%) than fully vaccinated contacts (6/26, 23%, 95% CI 11-42%). A lower proportion of households with a fully vaccinated primary case had secondary cases (1/5, 20%) than households with an unvaccinated primary case (66/108, 62%).

CONCLUSIONS

Although SARS-CoV-2 infections in vaccinated household contacts were reported in this high transmission setting, full vaccination protected against SARS-CoV-2 infection. These findings further support the protective effect of COVID-19 vaccination and highlight the need for ongoing vaccination among eligible persons.

Epidemiology of Dengue, Chikungunya, and Zika Virus Disease in U.S. States and Territories, 2017

Dengue, chikungunya, and Zika viruses, primarily transmitted by Aedes species mosquitoes, have caused large outbreaks in the Americas, leading to travel-associated cases and local mosquito-borne transmission in the United States. We describe the epidemiology of dengue, chikungunya, and noncongenital Zika virus disease cases reported from U.S. states and territories in 2017, including 971 dengue cases, 195 chikungunya cases, and 1,118 Zika virus disease cases. Cases of all three diseases reported from the territories were reported as resulting from local mosquito-borne transmission. Cases reported from the states were primarily among travelers, with only seven locally acquired mosquito-transmitted Zika virus disease cases reported from Texas (n = 5) and Florida (n = 2). In the territories, most dengue cases (n = 508, 98%) were reported from American Samoa, whereas the majority of chikungunya (n = 39, 100%) and Zika virus disease (n = 620, 93%) cases were reported from Puerto Rico. Temporally, the highest number of Zika virus disease cases occurred at the beginning of the year, followed by a sharp decline, mirroring decreasing case numbers across the Americas following large outbreaks in 2015 and 2016. Dengue and chikungunya cases followed a more seasonal pattern, with higher case numbers from July through September. Travelers to the United States and residents of areas with active virus transmission should be informed of both the ongoing risk from dengue, chikungunya, and Zika virus disease and personal protective measures to lower their risk of mosquito bites and to help prevent the spread of these diseases.

Travel-Associated and Locally Acquired Dengue Cases - United States, 2010-2017

Dengue is a potentially fatal acute febrile illness caused by any of four mosquito-transmitted dengue viruses (DENV-1 to DENV-4) belonging to the family Flaviviridae and endemic throughout the tropics. Competent mosquito vectors of DENV are present in approximately one half of all U.S. counties. To describe epidemiologic trends in travel-associated and locally acquired dengue cases in the United States, CDC analyzed cases reported from the 50 states and District of Columbia to the national arboviral surveillance system (ArboNET). Cases are confirmed by detection of 1) virus RNA by reverse transcription-polymerase chain reaction (RT-PCR) in any body fluid or tissue, 2) DENV antigen in tissue by a validated assay, 3) DENV nonstructural protein 1 (NS1) antigen, or 4) immunoglobulin M (IgM) anti-DENV antibody if the patient did not report travel to an area with other circulating flaviviruses. When travel to an area with other flaviviruses was reported, IgM-positive cases were defined as probable. During 2010-2017, totals of 5,009 (93%) travel-associated and 378 (7%) locally acquired confirmed or probable dengue cases were reported to ArboNET. Cases were equally distributed between males and females, and median age was 41 years. Eighteen (three per 1,000) fatal cases were reported, all among travelers. Travelers should review country-specific recommendations (https://wwwnc.cdc.gov/travel/notices/watch/dengue-asia) for reducing their risk for DENV infection, including using insect repellent and staying in residences with air conditioning or screens on windows and doors.

Zika Virus Infection Among U.S. Pregnant Travelers - August 2015-February 2016

After reports of microcephaly and other adverse pregnancy outcomes in infants of mothers infected with Zika virus during pregnancy, CDC issued a travel alert on January 15, 2016, advising pregnant women to consider postponing travel to areas with active transmission of Zika virus. On January 19, CDC released interim guidelines for U.S. health care providers caring for pregnant women with travel to an affected area, and an update was released on February 5. As of February 17, CDC had received reports of nine pregnant travelers with laboratory-confirmed Zika virus disease; 10 additional reports of Zika virus disease among pregnant women are currently under investigation. No Zika virus-related hospitalizations or deaths among pregnant women were reported. Pregnancy outcomes among the nine confirmed cases included two early pregnancy losses, two elective terminations, and three live births (two apparently healthy infants and one infant with severe microcephaly); two pregnancies (approximately 18 weeks' and 34 weeks' gestation) are continuing without known complications. Confirmed cases of Zika virus infection were reported among women who had traveled to one or more of the following nine areas with ongoing local transmission of Zika virus: American Samoa, Brazil, El Salvador, Guatemala, Haiti, Honduras, Mexico, Puerto Rico, and Samoa. This report summarizes findings from the nine women with confirmed Zika virus infection during pregnancy, including case reports for four women with various clinical outcomes. U.S. health care providers caring for pregnant women with possible Zika virus exposure during pregnancy should follow CDC guidelines for patient evaluation and management. Zika virus disease is a nationally notifiable condition. CDC has developed a voluntary registry to collect information about U.S. pregnant women with confirmed Zika virus infection and their infants. Information about the registry is in preparation and will be available on the CDC website.

West Nile Virus and Other Nationally Notifiable Arboviral Diseases - United States, 2014

Arthropod-borne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes and ticks. West Nile virus (WNV) is the leading cause of domestically acquired arboviral disease in the United States (1). However, several other arboviruses also cause sporadic cases and seasonal outbreaks. This report summarizes surveillance data reported to CDC in 2014 for WNV and other nationally notifiable arboviruses, excluding dengue. Forty-two states and the District of Columbia (DC) reported 2,205 cases of WNV disease. Of these, 1,347 (61%) were classified as WNV neuroinvasive disease (e.g., meningitis, encephalitis, or acute flaccid paralysis), for a national incidence of 0.42 cases per 100,000 population. After WNV, the next most commonly reported cause of arboviral disease was La Crosse virus (80 cases), followed by Jamestown Canyon virus (11), St. Louis encephalitis virus (10), Powassan virus (8), and Eastern equine encephalitis virus (8). WNV and other arboviruses cause serious illness in substantial numbers of persons each year. Maintaining surveillance programs is important to help direct prevention activities.

West nile virus and other arboviral diseases - United States, 2013

Arthropod-borne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes and ticks. West Nile virus (WNV) is the leading cause of domestically acquired arboviral disease in the United States. However, several other arboviruses also cause sporadic cases and seasonal outbreaks of neuroinvasive disease (i.e., meningitis, encephalitis, and acute flaccid paralysis). This report summarizes surveillance data reported to CDC in 2013 for WNV and other nationally notifiable arboviruses, excluding dengue. Forty-seven states and the District of Columbia reported 2,469 cases of WNV disease. Of these, 1,267 (51%) were classified as WNV neuroinvasive disease, for a national incidence of 0.40 per 100,000 population. After WNV, the next most commonly reported cause of arboviral disease was La Crosse virus (LACV) (85 cases), followed by Jamestown Canyon virus (JCV), Powassan virus (POWV), and eastern equine encephalitis virus (EEEV) (eight). WNV and other arboviruses continue to cause serious illness in substantial numbers of persons annually. Maintaining surveillance remains important to help direct and promote prevention activities.

West Nile virus and other arboviral diseases--United States, 2012

Arthropod-borne viruses (arboviruses) are transmitted to humans primarily through the bites of infected mosquitoes and ticks. West Nile virus (WNV) is the leading cause of domestically acquired arboviral disease in the United States. However, several other arboviruses also cause sporadic cases and seasonal outbreaks of neuroinvasive disease (e.g., meningitis, encephalitis, and acute flaccid paralysis). In 2012, CDC received reports of 5,780 nationally notifiable arboviral disease cases (excluding dengue). A large multistate outbreak of WNV disease accounted for 5,674 (98%) of reported cases, the highest number reported since 2003. Other reported etiologies included Eastern equine encephalitis virus (EEEV), Powassan virus (POWV), St. Louis encephalitis virus (SLEV), and California serogroup viruses such as La Crosse virus (LACV) and Jamestown Canyon virus (JCV). Arboviruses continue to cause serious illness in substantial numbers of persons in the United States. Maintaining surveillance remains important to identify outbreaks and guide prevention efforts.

Medical risk factors for severe West Nile Virus disease, United States, 2008-2010

We conducted enhanced surveillance to identify medical risk factors for severe illness (i.e., hospitalization or death) and neuroinvasive disease (i.e., encephalitis or meningitis) among all West Nile virus disease cases reported from selected states from 2008 to 2010. Of the 1,090 case-patients included in the analysis, 708 (65%) case-patients were hospitalized, 641 (59%) case-patients had neuroinvasive disease, and 55 (5%) case-patients died. Chronic renal disease (adjusted odds ratio [aOR] = 4.1; 95% confidence interval [CI] = 1.4-12.1), history of cancer (aOR = 3.7; 95% CI = 1.8-7.5), history of alcohol abuse (aOR = 3.0; 95% CI = 1.3-6.7), diabetes (aOR = 2.2; 95% CI = 1.4-3.4), and hypertension (aOR = 1.5; 95% CI = 1.1-2.1) were independently associated with severe illness on multivariable analysis. Although the same medical conditions were independently associated with encephalitis, only hypertension was associated with meningitis. The only condition independently associated with death was immune suppression. Prevention messages should be targeted to persons with these conditions.

West nile virus RNA not detected in urine of 40 people tested 6 years after acute West Nile virus disease

West Nile virus (WNV) causes an acute infection that is usually cleared by an effective immune response after several days of viremia. However, a recent study detected WNV RNA in the urine of 5 of 25 persons (20%) tested several years after their initial acute WNV disease. We evaluated an established cohort of 40 persons >6 years after initial infection with WNV. Urine collected from all participants tested negative for WNV RNA by reverse-transcription polymerase chain reaction and transcription-mediated amplification. Prospective studies are needed to determine if and for how long WNV persists in urine following WNV disease.

Laboratory testing practices for West Nile virus in the United States

We surveyed state public health and commercial diagnostic reference laboratories regarding current testing practices for West Nile virus (WNV). The majority of WNV testing is now performed in commercial diagnostic reference laboratories using commercially available Food and Drug Administration-cleared kits labeled for the presumptive diagnosis of WNV. However, only 25% of surveyed state public health or commercial diagnostic reference laboratories currently have the capacity to perform the recommended confirmatory testing. These findings indicate the need for both manufacturers and laboratories to monitor the performance of these WNV test kits. Further, clinicians should be aware of the limitations of these kits and the need for additional testing to confirm a diagnosis of WNV disease.

Surveillance for human West Nile virus disease - United States, 1999-2008

PROBLEM/CONDITION

West Nile virus (WNV) is an arthropod-borne virus (arbovirus) in the family Flaviviridae and is the leading cause of arboviral disease in the United States. An estimated 80% of WNV infections are asymptomatic. Most symptomatic persons develop an acute systemic febrile illness that often includes headache, myalgia, arthralgia, rash, or gastrointestinal symptoms. Less than 1% of infected persons develop neuroinvasive disease, which typically presents as encephalitis, meningitis, or acute flaccid paralysis.

REPORTING PERIOD

1999-2008.

DESCRIPTION OF SYSTEM

WNV disease is a nationally notifiable disease with standardized case definitions. State and metropolitan heath departments report cases to CDC through ArboNET, an electronic passive surveillance system. Variables collected include patient age, sex, race, county and state of residence, date of illness onset, clinical syndrome, and outcome of illness.

RESULTS

During 1999-2008, a total of 28,961 confirmed and probable cases of WNV disease, including 11,822 (41%) WNV neuroinvasive disease cases, were reported to CDC from 47 states and the District of Columbia. No cases were reported from Alaska, Hawaii, Maine, or any U.S. territories. A total of 93% of all WNV patients had illness onset during July-September. The national incidence of WNV neuroinvasive disease peaked in 2002 (1.02 cases per 100,000 population) and was stable during 2004-2007 (mean annual incidence: 0.44; range: 0.39-0.50). In 2008, the incidence was 0.23 per 100,000 population, compared with 0.41 in 2007 and 0.50 in 2006. During 1999-2008, the highest incidence of neuroinvasive disease occurred in West North Central and Mountain states. Neuroinvasive disease incidence increased with increasing age, with the highest incidence (1.35 cases per 100,000 population) occurring among persons aged >or=70 years. The hospitalization rate and case-fatality ratio increased with increasing age among persons with neuroinvasive disease.

INTERPRETATION

The stability in reported incidence of neuroinvasive disease during 2004-2007 might represent an endemic level of WNV transmission. Whether the incidence reported in 2008 represents a decrease that will continue is unknown; variations in vectors, avian amplifying hosts, human activity, and environmental factors make predicting future WNV transmission levels difficult.

PUBLIC HEALTH ACTION

Surveillance of WNV disease is important for detecting and monitoring seasonal epidemics and targeting prevention and control activities. Public health education programs should focus on older persons, who are at increased risk for neurologic disease and poor clinical outcomes. In the absence of an effective human vaccine, WNV disease prevention depends on community-level mosquito control and household and personal protection measures.

Rapid assessment of mosquitoes and arbovirus activity after floods in southeastern Kansas, 2007

A rapid assessment was conducted in July-August 2007 to determine the impact of heavy rains and early summer floods on the mosquitoes and arbovirus activity in 4 southeastern Kansas counties. During 10 days and nights of collections using different types and styles of mosquito traps, a total of 10,512 adult female mosquitoes representing 29 species were collected, including a new species record for Kansas (Psorophora mathesoni). High numbers of Aedes albopictus were collected. Over 4,000 specimens of 4 Culex species in 235 species-specific pools were tested for the presence of West Nile, St. Louis, and western equine encephalitis viruses. Thirty pools representing 3 Culex species were positive for West Nile virus (WNV). No other arboviruses were detected in the samples. Infection rates of WNV in Culex pipiens complex in 2 counties (10.7/1,000 to 22.6/1,000) and in Culex salinarius in 1 county (6.0/1,000) were sufficiently high to increase the risk of transmission to humans. The infection rate of WNV in Culex erraticus was 1.9/1,000 in one county. Two focal hot spots of intense WNV transmission were identified in Montgomery and Wilson counties, where infection rates in Cx. pipiens complex were 26/ 1,000 and 19.9/1,000, respectively. Despite confirmed evidence of WNV activity in the area, there was no increase in human cases of arboviral disease documented in the 4 counties for the remainder of 2007.

Epidemiology of neuroinvasive arboviral disease in the United States, 1999-2007

From 1999-2007, the most common causes of neuroinvasive arboviral disease in the United States, after West Nile virus (WNV), were California (CAL) serogroup viruses, St. Louis encephalitis virus (SLEV), and eastern equine encephalitis virus (EEEV). The CAL serogroup virus disease was primarily reported from Appalachia and the upper Midwest, SLEV disease from southern states, and EEEV disease from areas along the Atlantic and Gulf coasts. Children accounted for 88% of CAL serogroup virus disease, whereas 75% of SLEV disease occurred among older adults. The EEEV disease had the highest case-fatality rate (42%). The incidence of CAL serogroup virus and EEEV disease remained stable before and after the detection of WNV in the United States in 1999. The SLEV disease declined 3-fold after 1999; however, SLEV disease has occurred in sporadic epidemics that make trends difficult to interpret. The CAL serogroup virus, SLEV, and EEEV disease are persistent public health concerns in the United States warranting ongoing prevention efforts.

West Nile virus quantification in feces of experimentally infected American and fish crows

To better understand the potential environmental health risk presented by West Nile virus (WNV)-contaminated feces, we quantified the amount of WNV present in the feces of experimentally infected American crows (Corvus brachyrhynchos) and fish crows (Corvus ossifragus). Peak fecal titers ranged from 10(3.5) to 10(8.8) plaque-forming units (PFU)/g for 10 American crows and from 10(2.3) to 10(6.4) PFU/g for 10 fish crows. The presence of infectious WNV in bird feces indicates a potential for direct transmission of WNV. Thus, handlers of sick or dead birds should take appropriate precautions to avoid exposure to fecal material.

The epidemic of West Nile virus in the United States, 2002

Since 1999, health officials have documented the spread of West Nile virus across the eastern and southern states and into the central United States. In 2002, a large, multi-state, epidemic of neuroinvasive West Nile illness occurred. Using standardized guidelines, health departments conducted surveillance for West Nile virus illness in humans, and West Nile virus infection and illness in non-human species. Illnesses were reported to the Centers for Disease Control and Prevention (CDC) through the ArboNET system. In 2002, 39 states and the District of Columbia reported 4,156 human West Nile virus illness cases. Of these, 2,942 (71%) were neuroinvasive illnesses (i.e., meningitis, encephalitis, or meningoencephalitis) with onset dates from May 19 through December 14; 1,157 (28%) were uncomplicated West Nile fever cases, and 47 (1%) were clinically unspecified. Over 80% of neuroinvasive illnesses occurred in the central United States. Among meningitis cases, median age was 46 years (range, 3 months to 91 years), and the fatality-to-case ratio was 2%; for encephalitis cases (with or without meningitis), median age was 64 years (range, 1 month to 99 years) and the fatality-to-case ratio was 12%. Neuroinvasive illness incidence and mortality, respectively, were significantly associated with advanced age (p = 0.02; p = 0.01) and being male (p < 0.001; p = 0.002). In 89% of counties reporting neuroinvasive human illnesses, West Nile virus infections were first noted in non-human species, but no human illnesses were reported from 77% of counties in which non-human infections were detected. In 2002, West Nile virus caused the largest recognized epidemic of neuroinvasive arboviral illness in the Western Hemisphere and the largest epidemic of neuroinvasive West Nile virus ever recorded. It is unknown why males appeared to have higher risk of severe illness and death, but possibilities include higher prevalence of co-morbid conditions or behavioral factors leading to increased infection rates. Several observations, including major, multi-state West Nile virus epidemics in 2002 and 2003, suggest that major epidemics may annually reoccur in the United States. Non-human surveillance can warn of early West Nile virus activity and needs continued emphasis, along with control of Culex mosquitoes.

A systematic approach to the complete study of a signaling molecule: ribosomal p90rsk as an example

Ribosomal p90rsk is a kinase of central importance in transducing mitogenic signals from an activated receptor to the cell nucleus and for protein synthesis. Here, we analyze the optimal steps to fully describe this kinase in both normal neutrophils and leukemic cell lines. These are: (i) immunological analyses (immunoblotting and immunoprecipitation); (ii) enzyme activity assays (in vitro and "in-gel"); and (iii) immunobiochemical combination methods (immunoprecipitation/kinase assay, immunoprecipitation/"in-gel" assay and ion exchange chromatography/immunoblotting). For the enzyme assays, we describe a novel method to measure ribosomal p90rsk kinase activity "in-gel", based on a renatured-protein method that allows for the direct quantitation of enzyme activity. Finally, we present an algorithm that can be readily implemented to the quantification of the extent of stimulation of a kinase in response to a particular extracellular stimuli. In our case, it was found that activation of p90rsk was higher in proliferating leukemic cells than in mature neutrophils, indicating that a suppression of key signal transduction links could contribute to the maturational arrest typical of acute leukemia. All the techniques and strategies described here for p90rsk could be easily extrapolated to the study of any signal transduction molecule, provided it has a phosphotransferase activity.

An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties

Abdominoplasty is a popular body-contouring procedure. In this study the authors review retrospectively 199 abdominoplasty patients during a 15-year period to identify factors that affect overall outcome. Patients included 190 women and 9 men. The complication rate was 32% with few major complications (1.4%). The revision rate was 43%, and was related to fine-tuning the aesthetic appearance. Patients were divided into four groups based on tobacco use and history of diabetes and hypertension. There was no significant difference in revision rates or major complications between the subgroups. Minor complication rates, however, were significantly higher in smokers and patients with diabetes and/or hypertension. Complication and revision rates in patients undergoing intra-abdominal procedures combined with abdominoplasty were not significantly different from those patients undergoing abdominoplasty alone. A patient survey revealed symptom improvement in 95% of patients. Eighty-six percent of patients were satisfied with their result, and 86% would recommend abdominoplasty to a friend. The authors conclude that abdominoplasty is a safe and satisfying procedure, whether performed alone or in conjunction with another procedure. Patients are pleased with the outcome and have improvement in their symptoms, with minimal health risk. There is, however, a significant incidence of minor complications, related primarily to wound healing. These complications are increased significantly in smokers and patients with diabetes and/or hypertension. Revision rates are not different significantly between the subgroups. When complications do occur or revisions are required, they are minor and managed easily in an office setting.

Presence of a phospholipase D (PLD) distinct from PLD1 or PLD2 in human neutrophils: immunobiochemical characterization and initial purification

Utilizing the transphosphatidylation reaction catalyzed by phospholipase D (PLD) in the presence of a primary alcohol and the short-chain phospholipid PC8, we have characterized the enzyme from human neutrophils. A pH optimum of 7.8-8.0 was determined. PIP(2), EDTA/EGTA, and ATP were found to enhance basal PLD activity in vitro. Inhibitory elements were: oleate, Triton X-100, n-octyl-beta-glucopyranoside, divalent cations, GTPgammaS and H(2)O(2). The apparent K(m) for the butanol substrate was 0.1 mM and the V(max) was 6.0 nmol mg(-1) h(-1). Immunochemical analysis by anti-pan PLD antibodies revealed a neutrophil PLD of approximately 90 kDa and other bands recognized minimally by anti-PLD1 or anti-PLD2 antibodies. The 90-kDa protein is tyrosine-phosphorylated upon cell stimulation with GM-CSF and formyl-Met-Leu-Phe. Protein partial purification using column liquid chromatography was performed after cell subfractionation. Based on the enzyme's regulatory and inhibitory factors, and its molecular weight, these data indicate an enzyme isoform that might be different from the mammalian PLD1/2 forms described earlier. The present results lay the foundation for further purification of this granulocyte PLD isoform.

Phospholipase D (PLD) is present in Leishmania donovani and its activity increases in response to acute osmotic stress

We report here that the signaling molecule phospholipase D (PLD) is present in the parasitic protozoan Leishmania donovani. In vitro enzymatic activity is dependent on Ca2+ and Mg2+ ions, its basal activity is stimulated by phosphatidyl-inositol-4,5-bisphosphate (PIP2) and its pH optima are pH 8.0 and pH 6.0. PLD activity increases 3-fold about 5 min after an abrupt decrease in osmolality from 317 mOsm (isosmotic) to 155 mOsm and increases 1.5-fold in response to an abrupt increase in osmolality to 617 mOsM. Cells grown for > 24 h under the anisosmotic conditions showed only marginal changes in activity compared to the controls grown under isosmotic conditions, indicating an adaptation to long-term exposure to hypo- or hyper-osmolarity. Immunologically, two isoforms, PLD1 and PLD2, are present. An analysis of in vitro PLD activity in anti-PLD immunocomplexes revealed that either hypotonic (cell swelling) or hypertonic stress (cell shrinking) causes an increase in PLD1 activation but a reduction in PLD2 activity. The interplay between these two isoforms results in a predominance for PLD1 in the observed increase when measuring total PLD activity. Finally, the increase in enzymatic activity in acute hyposmotic shock is accompanied by tyrosyl phosphorylation of the PLD1 isoform, suggesting a role for protein tyrosine kinase in the control of PLD activity in response to osmotic stress.

MAP kinase upregulation after hematopoietic differentiation: role of chemotaxis

Mitogen-activated protein kinase (MAPK) isoform p42 is known to be active in exponentially growing cells at several points of the cell cycle. A high basal activity was present in three cell lines representative of immature myeloid cells tested: uHL-60, AML-14, and MPD. However, DMSO-induced differentiation of HL-60 cells (dHL-60) and subsequent expression of the neutrophilic phenotype occurred with a concomitant reduction on the basal level of MAPK activity. Simultaneously, extracellular stimuli like the cytokine granulocyte/macrophage colony-stimulating factor (GM-CSF) induced a fast (<10 min) and robust response. In terms of MAPK activity, the more mature the cell was, the higher the corresponding activity, in the three differentiation series considered: AML-14 < 3D10; MPD < G-MPD; uHL-60 < dHL-60 < neutrophils. Interestingly, peripheral blood neutrophils expressed the highest (16-fold) MAPK activation level in response to GM-CSF. Finally, using the specific MAPK inhibitor PD-98059, we demonstrated that MAPK activation is needed for neutrophil chemotaxis toward interleukin-8 and its priming by GM-CSF. Since neutrophils are terminally differentiated cells, GM-CSF does not serve a purpose in proliferation, and it must trigger the recruitment of selective signal transduction pathways particular to that final stage that includes enhanced physiological functions such as chemotaxis.

Human cell line that differentiates to all myeloid lineages and expresses neutrophil secondary granule genes

The aim of this study was to characterize a human leukemic cell line that appears capable of spontaneous differentiation to all myeloid lineages. The MPD cell line was derived using standard tissue culture techniques from the peripheral blood of a patient with an aggressive nonchronic myelogenous leukemia myeloproliferative disorder. Immunophenotyping, cytogenetic analysis, reverse transcriptase polymerase chain reaction, Northern blotting, immunoblotting, and colony assays were used to characterize the line and to assess its ability to express lineage-specific genes representative of advanced differentiation.Light microscopic morphologic analysis of the MPD cell line suggests that it has the unique property of spontaneous differentiation to mature-appearing neutrophils, macrophages, eosinophils, and basophils in proportions that approximate those found in normal bone marrow or peripheral blood. It was demonstrated that this cell line is capable of producing lineage-specific mRNA and granule proteins of at least two myeloid lineages, neutrophil and eosinophil, including neutrophil secondary granule proteins, which are not expressed in other available human cell lines. MPD cells were found to be capable of producing differentiated myeloid colonies (neutrophil, eosinophil, macrophge, mixed) in semisolid medium. The ability of MPD cells to express genetic programs associated with advanced differentiation of multiple myeloid lineages will make it a valuable tool for the study of the processes underlying lineage commitment and the regulation of expression of lineage-specific genes.

Direct inhibition of in vitro PLD activity by 4-(2-aminoethyl)-benzenesulfonyl fluoride

While conducting a purification protocol of phospholipase D (PLD) from human granulocytes, we observed that PLD activity was inhibited by a commonly-used protease inhibitor cocktail. Of the six inhibitors present in the cocktail, the serine protease inhibitor, 4-(2-aminoethyl)-benezensulfonyl fluoride (AEBSF), was found to be the sole inhibitor of PLD. AEBSF caused a loss of neutrophil and purified plant PLD activities in vitro, but not in intact cells at the concentrations used, nor did it affect the related phospholipases A(2) and C, that were utilized as specificity controls. The compound AEBSNH(2), which has the fluoride replaced by an -NH(2) group, failed to affect PLD activity as did other compounds structurally related to AEBSF with known protease inhibitory capabilities. Finally, basal- and agonist-stimulated PLD activity was inhibited in phosphatidylcholine-specific anti-PLD immunoprecipitates (IC(50) = 75 microM). These results suggest that AEBSF, in an effect probably unrelated to its anti-proteolytic ability, directly interferes with PLD enzymatic activity, making it a significant compound to begin analyzing the role of PLD in mammalian cell signaling.

Lung herniation into the neck associated with congenital absence of the sternocleidomastoid muscle

This is a case report and literature review involving congenital absence of the sternocleidomastoid muscle (SCM) and simultaneous herniation of the left lung into the neck. To date there have been eight cases of absence of the SCM muscle, but no records of lung herniation alone or in combination with SCM muscle absence. Included is the management course taken to correct this patient's defect, CAT scans of the neck, fluoroscopic imaging of the lung and neck, and photographic documentation of the defect.

Reduction mammaplasty: an outcome analysis

Reduction mammaplasty is usually performed to relieve painful symptoms and physical signs of macromastia. Justification for reduction mammaplasty should be based on the probability of relieving these clinical signs and symptoms. This retrospective study involved four surgeons who performed a variety of breast reduction procedures and was designed to determine if preoperative symptoms were resolved after reduction mammaplasty. We surveyed 285 women who had reduction mammaplasties from 1988 to 1993. Data from these surveys and the patients' charts were reviewed. A total of 185 patients (65%) returned completed surveys and were included in this study for analysis. Mean age was 40 years with an average follow-up of 3 years. The most common preoperative complaint was shoulder grooving (90%), followed by back pain (82%), shoulder pain (78%), and neck pain (65%). Average amount of breast tissue removed was 855 gm from each breast. Preoperative complaints were substantially reduced after surgery, regardless of the presurgical body mass. Most patients (97%) had improvement of symptoms, and 59% were asymptomatic. Only 3% had no change in their symptoms and none were worse. The complication rate was 45% with fat necrosis/infection being the most common complication (22%). The majority of patients (95%) were either happy or very happy with the surgery, and 98% would recommend surgery to a friend. Our data indicate that reduction mammaplasty relieves preoperative symptoms associated with macromastia.

Treatment of cleft palate associated with Robin sequence: appraisal of risk factors

Mandibular hypoplasia, airway obstruction, and a typical wide U-shaped cleft palate comprise the Robin sequence. Although much has been written regarding the treatment of these patients in the neonatal period, the literature reveals little information regarding later care of the cleft palate in these patients. The purpose of this study is to examine patients with the Robin sequence and evaluate the risk of postsurgical problems and outcome related to the neonatal period. Thirty-six patients with the Robin sequence presenting from 1972 through 1990 were reviewed. A majority of patients had feeding and respiratory difficulties, to varying degrees, following birth. These problems were treated successfully by maneuvers ranging from positioning to two infants who eventually required tracheostomy. Thirty-four patients had palate repair. Age at repair averaged 16.2 months, and one third of patients had associated anomalies. Infants who experienced problems following palatoplasty were those who had histories of severe difficulties and complications in the early months of life. In addition, patients with associated congenital anomalies has significantly more problems at the time of palate repair than those without anomalies. Those patients with the Robin sequence, who historically had minimal difficulty following birth, experienced few complications at the time of palate repair. Of the 34 patients with repaired palates, 23 demonstrated sufficient follow-up to allow for evaluation of speech outcome. Satisfactory or normal speech production was noted in 65.4%. This is not significantly different from that observed in all patients undergoing cleft palate repair during this same time period (74.9%). Secondary pharyngoplasty procedures were required in 17.4%.(ABSTRACT TRUNCATED AT 250 WORDS)

Orthognathic surgery in the cleft lip and palate patient

Orthognathic surgery for the cleft lip and palate patient should be designed to achieve good facial aesthetics and a stable, functional occlusion. Maxillary and mandibular osteotomies, which benefit cleft lip and palate patients with associated dentofacial deformities, should be modified to meet the needs of the individual patient. Soft-tissue correction of the upper lip and nose adds to the overall aesthetic result, but should be performed as a separate procedure.

Comparison of Nasometer and listener judgments of nasality in the assessment of velopharyngeal function after pharyngeal flap surgery

This study examined the relationship between nasalance scores as derived from the Model 6200 Nasometer and listener judgments of perceived nasality for individuals with pharyngeal flaps. Sixteen individuals with pharyngeal flaps read a speech sample consisting of seven sentences for which associated nasalance scores were obtained. In addition, 10 trained listeners were asked to judge the subjects' audiorecorded speech samples for the degree of both hypernasality and hyponasality using two 6-point scales. The mean judges' ratings of hypernasality did not increase systematically with increasing nasalance scores or with decreasing hyponasality ratings. However, as the nasalance scores associated with nasal loaded sentences increased, a systematic decrease in listener perception of hyponasality occurred.

One-stage closure of the entire primary palate

Timing of the closure of the anterior palate and alveolus is a subject of debate. Late repair of this defect is complicated by high fistula formation and subjects the patient to the problems of palate fistula for extended periods of time. We have utilized a single procedure performed when the child is 3 months of age that completely closes the anterior hard palate and alveolus along with the cleft lip. Our series consisted of 61 consecutive patients with unilateral clefts of the primary and secondary palate. Mucosal turnover flaps from the vomer along with lateral nasal mucosal flaps provide the nasal lining. A buccal sulcus flap with a Veau flap completes the oral repair. Ninety-five percent (58 of 61) of the patients had complete and stable closure of their anterior palate and alveolus after 1 year. The incidence of fistula formation in our series (3 of 61) is much lower than that reported with the utilization of other protocols. Excellent exposure of the anterior palate and alveolar defect during lip repair, early restoration of anatomic relationships, establishment of a good nostril floor and sill, and very low fistula formation are among the benefits of this procedure. The increase in operative time is considered minimal in light of aforementioned advantages.

Surgical-orthodontic correction of transverse maxillary deficiency

A conservative osteotomy of the zygomaticomaxillary buttress in combination with a rapid palatal expansion appliance is a dependable technique for the treatment of horizontal maxillary deficiency in adults. This procedure has been used successfully in 56 patients in our series, but 17 patients (30 per cent) required a midpalatal osteotomy. In two patients, overexpansion was not achieved because of necrosis of the mucosa. In three other patients, expansion had to proceed at a slower pace because of mucosal ulceration. There have been no other complications. The procedure is indicated mainly in those patients with a horizontal deficiency who do not require subsequent surgery, but for some patients it may be the preliminary procedure. Twelve patients (21 per cent) had subsequent orthognathic surgery. Follow-up has been from 1 to 12 years and there has been no relapse. In our opinion, the zygomaticomaxillary buttress is the primary area of resistance to lateral movement of the maxilla by rapid maxillary expansion appliances.

Surgical-orthodontic correction of transverse maxillary deficiency

A conservative osteotomy of the zygomaticomaxillary buttress in combination with a rapid palatal expansion appliance is a dependable technique for the treatment of horizontal maxillary deficiency in adults. This procedure has been used successfully in 56 patients in our series, but 17 patients (30 percent) required a midpalatal osteotomy. In two patients, overexpansion was not achieved because of necrosis of the mucosa. In three other patients, expansion had to proceed at a slower pace because of mucosal ulceration. There have been no other complications. The procedure is indicated mainly in those patients with a horizontal deficiency who do not require subsequent surgery, but for some patients it may be the preliminary procedure. Twelve patients (21 per cent) had subsequent orthognathic surgery. Follow-up has been from 1 to 12 years and there has been no relapse. In our opinion, the zygomaticomaxillary buttress is the primary area of resistance to lateral movement of the maxilla by rapid maxillary expansion appliances.

Mandibular prognathism

The use of the vertical subcondylar osteotomy for correction of uncomplicated mandibular prognathism is reviewed. Techniques for use in more complicated cases such as when a set back of greater than 10 mm is required are also described.

Soft-tissue manifestations of aesthetic defects of the jaws: diagnosis and treatment

Treatment planning for patients with dentofacial deformities should include a skeletal and a soft-tissue analysis. This article collates and summarizes several different soft-tissue analyses. In addition, it correlates the anticipated soft-tissue profile changes with various skeletal and soft-tissue surgical procedures.

Management of dog bite avulsions of the lip vermilion

A conservative approach allowing the wounds to heal by secondary intention has been used in 14 patients. The results have been very satisfactory, and only six of the 14 patients required minor scar revisions.

The syndrome of inappropriate secretion of antidiuretic hormone in the pharyngeal flap operation

A prospective study was undertaken to determine whether there was a relationship between the pharyngeal flap operation and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). From August 1982 to November 1983, 25 patients underwent pharyngeal flap procedures. They were compared to a control group made up of five patients who underwent major cleft lip revisions. Twelve of the twenty-five patients (48%) who underwent pharyngeal flap procedures had inappropriately elevated serum ADH levels, low serum osmolality, and hyponatremia in the postoperative period. There was a statistically significant (p less than 0.001) drop in the serum sodium levels in the pharyngeal flap group from the preoperative to postoperative period. There was neither a statistically significant change in the serum sodium levels nor inappropriate elevation of ADH levels in the control group. Two patients who underwent pharyngeal flap procedures developed SIADH. To our knowledge this complication has not been reported in association with the pharyngeal flap operation. No specific causes were found that would explain why SIADH developed.

Surgical orthodontic correction of transverse maxillary deficiency: a simplified approach

Osteotomy of the zygomaticomaxillary buttress in combination with a rapid palatal exapnsion appliance is a dependable technique for the treatment of horizontal maxillary deficiency in adults. This procedure has been used in 18 patients with excellent expansion in 17. In one patient, expansion was discontinued prior to overcorrection because of pressure necrosis on the palate related to the appliance. This was the only complication. The procedure is indicated mainly in those patients with a horizontal deficiency who do not require subsequent surgery, but for some patients it may be the preliminary procedure. Three patients in this series had subsequent orthognathic surgery. Follow-up has been from 1 to 6 years, and there has been no relapse. In our opinion, the zygomaticomaxillary buttress is the primary area of resistance to lateral movement of the maxilla by rapid maxillary expansion appliances.

The combined surgical and orthodontic treatment of mandibular prognathism

Patients with severe mandibular prognathism are best managed with a combined orthodontic-surgical approach. In our patients, the orthodontic treatment consisted of six to eighteen months of presurgical preparation, which in some patients may accentuate the dental deformity. This is done to provide two well-aligned dental arches that will fit accurately at surgery. The surgical procedure used was an oblique subcondylar osteotomy. This was followed by six to eight months of orthodontic treatment to complete dental alignment. Thirty patients were treated using this combined approach, with excellent results and few complications.

Does infection play a role in breast capsular contracture?

The formation of capsular contracture around silicone implants continues to be the most common complication of augmentation mammaplasty. To date, the etiologic factors in the formation of capsular contractures have remained inconclusive. In the present study, the role of subclinical infection with S. epidermidis as a cause of capsular contracture was evaluated in 16 rabbits using miniature silicone implants. All the implants on the side contaminated with varying concentrations of S. epidermidis developed breast capsular contractures. Using Baker's classification, they were graded III or IV, while the controls were all considered to be either grade I or II. Grossly, the capsules on the contaminated side were firm, fibrous, and 2 to 3 times thicker than the controls, and this was confirmed histologically using micrometry. Implants contaminated with 10(7) bacteria uniformly extruded. The present study seems to indicate that subclinical infection with Staphylococcus epidermidis may be one of the causes of capsular contracture around breast implants.

Surgical intervention in complications of acute leukemia

Aggressive chemotherapy has dramatically increased the number and duration of remissions in acute leukemia. Concomitant with improved survival has been an increased incidence of complications necessitating surgery in patients with chemotherapy-induced pancytopenia. In the past, patients such as the three described here rarely survived, whether managed conservatively or surgically. All three of these achieved partial or complete remisson. In view of our experience plus reports in the literature, we feel that aggressive surgical intervantion can result in a greater percentage of patients surviving the complications of therapy, and this in turn can lead to a higher incidence of complete remission.

The effects of Surgicel on bone formation

The subperiosteal implantation of Surgicel has been advocated for the stimulation of bone formation by some authors. A clinical trial in five patients demonstrated no radiographic evidence of bone formation after 12 months. An experimental model was designed in the rabbit. This study also demonstrated no radiographic or histologic evidence of bone formation with the use of subperiosteal Surgicel. The further use of Surgicel for the stimulation of bone formation is not recommended.