PROcalcitonin and NEWS2 evaluation for Timely identification of sepsis and Optimal use of antibiotics in the emergency department (PRONTO): protocol for a multicentre, open-label, randomised controlled trial

INTRODUCTION

Sepsis is a common, potentially life-threatening complication of infection. The optimal treatment for sepsis includes prompt antibiotics and intravenous fluids, facilitated by its early and accurate recognition. Currently, clinicians identify and assess severity of suspected sepsis using validated clinical scoring systems. In England, the National Early Warning Score 2 (NEWS2) has been mandated across all National Health Service (NHS) trusts and ambulance organisations. Like many clinical scoring systems, NEWS2 should not be used without clinical judgement to determine either the level of acuity or a diagnosis. Despite this, there is a tendency to overemphasise the score in isolation in patients with suspected infection, leading to the overprescription of antibiotics and potentially treatment-related complications and rising antimicrobial resistance. The biomarker procalcitonin (PCT) has been shown to be useful in specific circumstances to support appropriate antibiotics prescribing by identifying bacterial infection. PCT is not routinely used in the care of undifferentiated patients presenting to emergency departments (EDs), and the evidence base of its optimal usage is poor. The PROcalcitonin and NEWS2 evaluation for Timely identification of sepsis and Optimal (PRONTO) study is a randomised controlled trial (RCT) in adults with suspected sepsis presenting to the ED to compare standard clinical management based on NEWS2 scoring plus PCT-guided risk assessment with standard clinical management based on NEWS2 scoring alone and compare if this approach reduces prescriptions of antibiotics without increasing mortality.

METHODS AND ANALYSIS

PRONTO is a parallel two-arm open-label individually RCT set in up to 20 NHS EDs in the UK with a target sample size of 7676 participants. Participants will be randomised in a ratio of 1:1 to standard clinical management based on NEWS2 scoring or standard clinical management based on NEWS2 scoring plus PCT-guided risk assessment. We will compare whether the addition of PCT measurement to NEWS2 scoring can lead to a reduction in intravenous antibiotic initiation in ED patients managed as suspected sepsis, with at least no increase in 28-day mortality compared with NEWS2 scoring alone (in conjunction with local standard care pathways). PRONTO has two coprimary endpoints: initiation of intravenous antibiotics at 3 hours (superiority comparison) and 28-day mortality (non-inferiority comparison). The study has an internal pilot phase and group-sequential stopping rules for effectiveness and futility/safety, as well as a qualitative substudy and a health economic evaluation.

ETHICS AND DISSEMINATION

The trial protocol was approved by the Health Research Authority (HRA) and NHS Research Ethics Committee (Wales REC 2, reference 20/WA/0058). In England and Wales, the law allows the use of deferred consent in approved research situations (including ED studies) where the time dependent nature of intervention would not allow true informed consent to be obtained. PRONTO has approval for a deferred consent process to be used. Findings will be disseminated through peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

ISRCTN54006056.

The Transcriptome of Paired Major and Minor Salivary Gland Tissue in Patients With Primary Sjögren's Syndrome

Background

While all salivary glands (SGs) can be involved in primary Sjögren’s syndrome (pSS), their respective role in pathogenesis remains unclear. Our objective was to assess immunopathway activation in paired parotid and labial gland tissue from biopsy-positive and biopsy-negative pSS and non-SS sicca patients.

Methods

Paraffin-embedded, paired parotid and labial salivary gland tissue and peripheral blood mononuclear cells were obtained from 39 pSS and 20 non-SS sicca patients. RNA was extracted, complementary DNA libraries were prepared and sequenced. For analysis of differentially expressed genes (DEGs), patients were subdivided based on fulfillment of ACR-EULAR criteria and histopathology.

Results

With principal component analysis, only biopsy-positive pSS could be separated from non-SS sicca patients based on SG gene expression. When comparing the transcriptome of biopsy-positive pSS and biopsy-negative non-SS sicca patients, 1235 and 624 DEGs (FDR<0.05, log2FC<-1 or >1) were identified for parotid and labial glands, respectively. The number of DEGs between biopsy-negative pSS and non-SS sicca patients was scarce. Overall, transcript expression levels correlated strongly between parotid and labial glands (R² = 0.86, p-value<0.0001). Gene signatures present in both glands of biopsy-positive pSS patients included IFN-α signaling, IL-12/IL-18 signaling, CD3/CD28 T-cell activation, CD40 signaling in B-cells, DN2 B-cells, and FcRL4+ B-cells. Signature scores varied considerably amongst pSS patients.

Conclusion

Transcriptomes of paired major and minor SGs in pSS were overall comparable, although significant inter-individual heterogeneity in immunopathway activation existed. The SG transcriptome of biopsy-negative pSS was indistinguishable from non-SS sicca patients. Different patterns of SG immunopathway activation in pSS argue for personalized treatment approaches.

IL-17A Recruits Rab35 to IL-17R to Mediate PKCα-Dependent Stress Fiber Formation and Airway Smooth Muscle Contractility

IL-17A is a critical proinflammatory cytokine for the pathogenesis of asthma including neutrophilic pulmonary inflammation and airway hyperresponsiveness. In this study, by cell type-specific deletion of IL-17R and adaptor Act1, we demonstrated that IL-17R/Act1 exerts a direct impact on the contraction of airway smooth muscle cells (ASMCs). Mechanistically, IL-17A induced the recruitment of Rab35 (a small monomeric GTPase) and DennD1C (guanine nucleotide exchange factor [GEF]) to the IL-17R/Act1 complex in ASMCs, resulting in activation of Rab35. Rab35 knockdown showed that IL-17A-induced Rab35 activation was essential for protein kinase Cα (PKCα) activation and phosphorylation of fascin at Ser39 in ASMCs, allowing F-actin to interact with myosin to form stress fibers and enhance the contraction induced by methacholine. PKCα inhibitor or Rab35 knockdown indeed substantially reduced IL-17A-induced stress fiber formation in ASMCs and attenuated IL-17A-enhanced, methacholine-induced contraction of airway smooth muscle. Taken together, these data indicate that IL-17A promotes airway smooth muscle contraction via direct recruitment of Rab35 to IL-17R, followed by PKCα activation and stress fiber formation.

Assessing the risk of drug crystallization in vivo

INTRODUCTION

Low intrinsic solubility leading to poor oral bioavailability is a common challenge in drug discovery that can often be overcome by formulation strategies, however, it remains a potential limitation that can pose challenges for early risk assessment and represent a significant obstacle to drug development. We identified a selective inhibitor (BMS-986126) of the IL-1 receptor-associated kinase 4 (IRAK4) with favorable properties as a lead candidate, but with unusually low intrinsic solubility of <1 μg/mL.

METHODS

Conventional histopathology identified the issue of crystal formation in vivo. Subsequent investigative work included confocal Raman micro-spectroscopy, MALDI-MS, polarized light microscopy of fresh wet-mount tissue scrapings and transmission electron microscopy.

RESULTS

BMS-986126 was advanced into a 2-week toxicology study in rats. The main finding in this study was minimal granulomatous inflammation in the duodenum, associated with the presence of birefringent crystals at the highest dosage of 100 mg/kg/day. Considering the safety margin, and the single location of the lesion, BMS-986126 was further progressed into IND-enabling toxicology studies where tolerability deteriorated with increasing dosing duration. Birefringent crystals and granulomatous inflammation were detected in multiple organs at dosages ≥20 mg/kg/day. Raman spectroscopy confirmed the identity of the crystals as BMS-986126. Therefore, follow up investigations were conducted to further characterize drug crystallization and to evaluate detection methods for their potential to reliably detect in vivo crystallization early.

DISCUSSION

The purpose of our efforts was to identify critical factors influencing in vivo drug crystallization and to provide a preliminary assessment (based on one compound) which method would be best suited for identifying crystals. Results indicated a combination of methods was required to provide a complete assessment of drug crystallization and that a simple technique, scraping of freshly collected tissue followed by evaluation under polarizing light was suitable for detecting crystals. However, dosing for 2 weeks was required for crystals to grow to a clearly detectable size.

TLR-stimulated IRAKM activates caspase-8 inflammasome in microglia and promotes neuroinflammation

NLRP3 inflammasome plays a critical spatiotemporal role in the pathogenesis of experimental autoimmune encephalomyelitis (EAE). This study reports a mechanistic insight into noncanonical NLRP3 inflammasome activation in microglia for the effector stage of EAE. Microglia-specific deficiency of ASC (apoptosis-associated speck-like protein containing a C-terminal caspase-activation and recruitment [CARD] domain) attenuated T cell expansion and neutrophil recruitment during EAE pathogenesis. Mechanistically, TLR stimulation led to IRAKM-caspase-8-ASC complex formation, resulting in the activation of caspase-8 and IL-1β release in microglia. Noncanonical inflammasome-derived IL-1β produced by microglia in the CNS helped to expand the microglia population in an autocrine manner and amplified the production of inflammatory cytokines/chemokines. Furthermore, active caspase-8 was markedly increased in the microglia in the brain tissue from patients with multiple sclerosis. Taken together, our study suggests that microglia-derived IL-1β via noncanonical caspase-8-dependent inflammasome is necessary for microglia to exert their pathogenic role during CNS inflammation.

Act1 is a negative regulator in T and B cells via direct inhibition of STAT3

Although Act1 (adaptor for IL-17 receptors) is necessary for IL-17-mediated inflammatory responses, Act1- (but not Il17ra-, Il17rc-, or Il17rb-) deficient mice develop spontaneous SLE- and Sjögren's-like diseases. Here, we show that Act1 functions as a negative regulator in T and B cells via direct inhibition of STAT3. Mass spectrometry analysis detected an Act1-STAT3 complex, deficiency of Act1 (but not Il17ra-, Il17rc-, or Il17rb) results in hyper IL-23- and IL-21-induced STAT3 activation in T and B cells, respectively. IL-23R deletion or blockade of IL-21 ameliorates SLE- and Sjögren's-like diseases in Act1-/- mice. Act1 deficiency results in hyperactivated follicular Th17 cells with elevated IL-21 expression, which promotes T-B cell interaction for B cell expansion and antibody production. Moreover, anti-IL-21 ameliorates the SLE- and Sjögren's-like diseases in Act1-deficient mice. Thus, IL-21 blocking antibody might be an effective therapy for treating SLE- and Sjögren's-like syndrome in patients containing Act1 mutation.

Abstract 2707: Integrated analysis of colorectal carcinoma by co-extraction of RNA, DNA and protein from FFPE tumor samples

Background: Integrated analysis of multi-omic data is important in understanding oncogenesis, pathology, and drug mechanism of action. Formalin-fixed, paraffin-embedded (FFPE) tissues comprise the bulk of archival specimens in hospitals and clinical trials. Commercial kits are commonly used to extract RNA, DNA, or protein for biomarker studies; however, high-quality extractions are challenging due to crosslinking. We explored the feasibility of performing proteomic, transcriptomic, and genetic analysis from limited FFPE samples collected in clinical trials through a pilot study in colorectal cancer (CRC) and normal tissue.

Methods: Qiagen kits were employed, with some modifications, to extract nucleic acid and protein from FFPE sample lysates that would be amenable to next-generation sequencing and liquid chromatography/mass-spectrometry (LC/MS) proteomic profiling. Commercially sourced FFPE slides from CRC biopsies and normal colon, heart, and skin samples were processed (n = 10 each; ~600-mm2 by 5-μm/slice). RNA-seq library preparation was performed using the Illumina® TruSeq Access kit. Label-free LC/MS proteomic analysis was carried out using trypsin/Lys-C-digested protein fragments on an EASY-nLC™ 1200 coupled to a Q Exactive™ Plus (Thermo Fisher). MS data were processed with MaxQuant to estimate protein abundance (Cox and Mann, Nat Biotech 2008).

Results: Of 40 samples tested, 38 yielded quantifiable nucleic acid and protein of sufficient quality for transcriptional and proteomic analyses. Mean RNA yield was ~300 ng (150 ng-1.2 µg). RNA degradation was significant, with a mean DV&gt;200 of 45% (Agilent Bioanalyzer). Mean DNA yield was 530 ng, with a mean fragment size of 2 kb. Mean protein yield was 50 µg (1 µg-300 µg). RNA libraries had a mapping rate range of 85%-90% and a coding rate range of 70%-80%; ~16,000 genes were reliable detected (log2 TPM &gt; 1). The number of unique proteins detected ranged from 3,000 to 4,000 for CRC, normal colon, and heart samples; skin samples averaged 1,000 proteins and had the lowest overall yield. Correlation of RNA and protein expression for the same genes was weak (Spearman's rho ~0.3-0.4) at the per-sample level but statistically significant. Using linear models, we identified differentially expressed transcripts and proteins between the CRC and normal colon samples. Pathway enrichment analysis of both modalities indicated changes in cell cycle, which is consistent with rapid growth of tumor cells. Changes in nucleoside metabolism, extracellular matrix remodeling, and innate immune response were more apparent at the protein level.

Conclusion: We found that multi-omic analysis was feasible with FFPE samples, and proteomics can be used to validate RNA results. Additionally, proteomics reveal post-translational events, such as extracellular matrix remodeling, that provide unique insights into cancer pathology.

Citation Format: Vishal Patel, Ji Gao, Mingyi Liu, Aiqing He, Xi-Tao Wang, Kathryn Vanderlaag, Ariella Sasson, Stefan Kirov, Sunil Kuppasani, Omar J. Jabado, Kandasamy Ravi, Ashok Dongre, Julie Carman, Heidi LeBlanc. Integrated analysis of colorectal carcinoma by co-extraction of RNA, DNA and protein from FFPE tumor samples [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2707.

IL-17A-Induced PLET1 Expression Contributes to Tissue Repair and Colon Tumorigenesis

This study identifies a novel mechanism linking IL-17A with colon tissue repair and tumor development. Abrogation of IL-17A signaling in mice attenuated tissue repair of dextran sulfate sodium (DSS)-induced damage in colon epithelium and markedly reduced tumor development in an azoxymethane/DSS model of colitis-associated cancer. A novel IL-17A target gene, PLET1 (a progenitor cell marker involved in wound healing), was highly induced in DSS-treated colon tissues and tumors in an IL-17RC-dependent manner. PLET1 expression was induced in LGR5⁺ colon epithelial cells after DSS treatment. LGR5⁺PLET1⁺ marks a highly proliferative cell population with enhanced expression of IL-17A target genes. PLET1 deficiency impaired tissue repair of DSS-induced damage in colon epithelium and reduced tumor formation in an azoxymethane/DSS model of colitis-associated cancer. Our results suggest that IL-17A-induced PLET1 expression contributes to tissue repair and colon tumorigenesis.

Discovery and structure-based design of 4,6-diaminonicotinamides as potent and selective IRAK4 inhibitors

The identification of small molecule inhibitors of IRAK4 for the treatment of autoimmune diseases has been an area of intense research. We discovered novel 4,6-diaminonicotinamides which potently inhibit IRAK4. Optimization efforts were aided by X-ray crystal structures of inhibitors bound to IRAK4. Structure activity relationship (SAR) studies led to the identification of compound 29 which exhibited sub-micromolar potency in a LTA stimulated cellular assay.

B cells from African American lupus patients exhibit an activated phenotype

Systemic lupus erythematosus (SLE) is a complex systemic autoimmune disease driven by both innate and adaptive immune cells. African Americans tend to present with more severe disease at an earlier age compared with patients of European ancestry. In order to better understand the immunological differences between African American and European American patients, we analyzed the frequencies of B cell subsets and the expression of B cell activation markers from a total of 68 SLE patients and 69 normal healthy volunteers. We found that B cells expressing the activation markers CD86, CD80, PD1, and CD40L, as well as CD19⁺CD27^-IgD^- double-negative B cells, were enriched in African American patients vs. patients of European ancestry. In addition to increased expression of CD40L, surface levels of CD40 on B cells were lower, suggesting the engagement of the CD40 pathway. In vitro experiments confirmed that CD40L expressed by B cells could lead to CD40 activation and internalization on adjacent B cells. To conclude, these results indicate that, compared with European American patients, African American SLE patients present with a particularly active B cell component, possibly via the activation of the CD40/CD40L pathway. These data may help guide the development of novel therapies.

Evaluating the impact of a child injury prevention project

This article describes an evaluation study which assessed the effectiveness of a child injury prevention project in deprived localities. The initiative took place across the Bumley, Pendle and Rossendale Primary Care Trust locality in East Lancashire. Families with children under five years of age living within this locality participated in the study. The intervention consisted of a home safety consultation and the provision and fitting of low-cost safety equipment to 1234 families and their homes within Sure Start programme areas that chose to access the Home Safety Equipment Scheme. In addition to this targeted work in these programme areas, a population-wide education and information campaign was provided across the whole locality. Rates of attendance at an accident and emergency (A&E) department by children aged less than five years of age following an injury were used to assess the outcome of the intervention. Results showed that over two years the proportion of children attending an A&E department reduced at a faster rate in the intervention than in the non-intervention wards, thereby reducing the health inequalities gap. It was therefore concluded that targeted work with parents of young children living in disadvantaged areas, together with the provision and fitting of low-cost safety equipment, can improve health and reduce inequalities among the local under-five population.

Anatomically Based Modelling of the Human Skull and Jaw

We present here an anatomically based model of the human masticatory system that provides a framework for simulating the complex chewing process. The initial motivation for creating this model was the desire to have a computational model of the human jaw that can be used to simulate the action of simple bites, and to calculate the stresses and forces on the teeth that are involved. The model created also provides a platform that can be used to investigate other features of the masticatory system. To construct this global model, individual models of the bones of the skull and jaw were created from generic data sets. Geometric models of the muscles of mastication were also created and attached to the appropriate bones. To complete this initial model, representations of the crowns of the teeth were created and a basic model of the temporomandibular joint (TMJ) was included. The finite element method was used to solve for the stresses and strains created by the loading conditions during a clenching simulation involving the mandible bone. The model presented here is also discussed in relation to a model of the entire musculo-skeletal system being developed as part of the Physiome Project.

Occurrence of infectious upper respiratory tract disease and response to vaccination in horses on six sentinel premises in northern Colorado

REASONS FOR PERFORMING STUDY

Horses vaccinated against common agents of infectious upper respiratory disease (IURD) may not have detectable serum antibody and may not be protected from clinical disease.

OBJECTIVES

The objectives of this study were to 1) investigate the serological response of horses to vaccination against influenza virus (H3N8 and H7N7) and equine herpesviruses (EHV) in a field setting and 2) evaluate associations among vaccination status, serum antibody concentrations, and occurrences of IURD in monitored horses.

METHODS

In this study, horses on 6 Colorado premises were vaccinated parenterally against influenza virus and EHV, and serological response evaluated. Horses were monitored, and biological samples collected from individuals with clinical IURD and control horses.

RESULTS

Of 173 horses, 61 (35.3%), 21 (12.1%) and 4 (2.3%) seroconverted in response to vaccination against EHV, influenza virus H7N7 and influenza virus H3N8, respectively.

CONCLUSIONS

Outbreaks of IURD in study horses were associated with influenza virus H3N8 and Streptococcus equi infection, and serological response to vaccination with conventional products was poor.

POTENTIAL RELEVANCE

These results confirm that horses may not respond with detectable serological responses to conventional vaccination against common respiratory viruses and, therefore, suggest that alternate methods of protecting horses against common respiratory viruses should be sought.

Detection of cold-adapted vaccine-strain influenza virus using two commercial assays

Because of the contagious nature of influenza virus it is necessary to identify infected individuals after the virus is introduced into a population. The aim of this study was to characterise influenza virus detection with commercially available assays after intranasal vaccinating horses with cold-adapted influenza virus. Seven horses were vaccinated and placed with 3 unvaccinated horses. Nasal secretion samples were evaluated using 2 antigen detection assays. All 10 horses were positive in the Flu OIA assay during the study period, but only one horse was positive on one sample using the Directigen Flu A assay. Horses were most likely to be positive during the first 3 days following vaccination, and several horses were intermittently positive for several days after this. Obtaining positive test results from nonvaccinated, incontact horses suggests they became infected with vaccine-strain virus that was shed by vaccinated horses. These results are important for the correct interpretation of influenza antigen detection tests in situations when this modified-live intranasal vaccine has been used.

Detection and identification of Mycoplasma from bovine mastitis infections using a nested polymerase chain reaction

A polymerase chain reaction (PCR) test was compared with culture for the detection and diagnosis of bovine Mycoplasma intramammary infection. The PCR test was applied to 24-hour Mycoplasma enrichment cultures of milk from cows with suspected mastitis and from bulk tank milk. In comparison to culture, the sensitivity and specificity of the PCR method were 96.2% and 99.1% for individual cow milk and 100% and 99.8% for the bulk tank milk, respectively. However, in discrepant cases where PCR was positive and culture was negative, the PCR test was correct; subsequent PCR tests and culturing of the individual cow's milk yielded positive results. The PCR test simultaneously detected and differentiated among 11 bovine Mycoplasma species.

Evaluation of serologic and viral detection methods for diagnosing feline herpesvirus-1 infection in cats with acute respiratory tract or chronic ocular disease

OBJECTIVE

To determine the value of virus isolation (VI), immunofluorescent antibody (IFA) assay, serum neutralization (SN), and ELISA for the diagnosis of clinical feline herpesvirus-1 (FHV-1) infection in cats.

ANIMALS

46 clinically normal cats, 17 cats with signs of acute respiratory tract disease, and 38 cats with signs of chronic ocular disease.

PROCEDURE

Conjunctival swabs for VI, conjunctival scrapings for IFA testing, and venous blood samples for SN or ELISA testing were obtained from all cats.

RESULTS

FHV-1 was detected in 10.9 and 28.3% of clinically normal cats and in 18.2 and 33.3% of cats with FHV-1-associated disease by VI and the IFA assay, respectively. There were no significant differences in the viral detection rate between cats with acute respiratory tract disease and cats with chronic ocular disease or between diseased cats and clinically normal cats; however, FHV-1 was never detected by both methods in clinically normal cats. Overall FHV-1 seroprevalence was 97% when tested by ELISA and 66% when tested by SN. Seroprevalence did not vary significantly among the 3 groups for either serologic test. Magnitude of SN and ELISA titers varied greatly but independently of presence or absence of clinical signs of FHV-1-associated disease. Sensitivity, specificity, and positive and negative predictive values were assessed for VI and the IFA assay--jointly and individually--and for each SN and ELISA titer magnitude. Values never all exceeded 50%.

CLINICAL IMPLICATIONS

Because FHV-1 can be detected commonly in clinically normal cats by the IFA assay or VI, neither test appears to aid in the clinical diagnosis of FHV-1 infection. Seroprevalence does not appear to vary between affected and clinically normal cats. SN, ELISA, VI, and the IFA assay appear to be of limited value in the diagnosis of FHV-1-associated disease in cats. Concurrent assessment of the IFA assay and VI results may permit exclusion of FHV-1 as an etiologic agent if results of both tests are negative.

Enzyme-linked immunosorbent assay for detection of feline herpesvirus 1 IgG in serum, aqueous humor, and cerebrospinal fluid

Feline herpesvirus 1 (FHV) is an important cause of feline ocular and respiratory disease, but the role the virus plays in central nervous system disease of cats has not been explored. The study described here was performed to validate an indirect enzyme-linked immunosorbent assay (ELISA) to detect FHV-specific IgG antibodies for use in feline epidemiologic, ocular, and central nervous system disease studies. The indirect IgG ELISA was applied to serum, aqueous humor, and cerebrospinal fluid from cats. Serum FHV IgG ELISA results were compared with those of serum neutralization in client-owned cats and laboratory-housed cats following vaccination. Of the 100 client-owned cats tested by ELISA, 97 had detectable FHV IgG; 95 had titers >32. The FHV IgG ELISA was more sensitive than serum neutralization and could be used with aqueous humor and cerebrospinal fluid. Cats with inflammatory central nervous system or ocular diseases had significant leakage of serum proteins into aqueous humor and cerebrospinal fluid, necessitating use of cutoff values derived from serum when these fluids were assessed.

Distinct mechanism for antidepressant activity by blockade of central substance P receptors

The localization of substance P in brain regions that coordinate stress responses and receive convergent monoaminergic innervation suggested that substance P antagonists might have psychotherapeutic properties. Like clinically used antidepressant and anxiolytic drugs, substance P antagonists suppressed isolation-induced vocalizations in guinea pigs. In a placebo-controlled trial in patients with moderate to severe major depression, robust antidepressant effects of the substance P antagonist MK-869 were consistently observed. In preclinical studies, substance P antagonists did not interact with monoamine systems in the manner seen with established antidepressant drugs. These findings suggest that substance P may play an important role in psychiatric disorders.

Monitoring and detection of acute viral respiratory tract disease in horses

OBJECTIVE

To develop a system to monitor and detect acute infections of the upper respiratory tract (i.e., nares, nasopharynx, and pharynx) in horses and to assess the association among specific viral infections, risk factors, and clinical signs of disease.

DESIGN

Prospective study.

ANIMALS

151 horses with clinical signs of acute infectious upper respiratory tract disease (IURD) from 56 premises in Colorado.

PROCEDURE

Health management data, blood samples, and nasal or nasopharyngeal swab samples were obtained for 151 horses with clinical signs of acute IURD. Of these horses, 112 had an additional blood sample obtained during convalescence and were considered to have complete sample sets. Samples were tested for evidence of respiratory tract infection by use of ELISA, virus isolation, and serologic testing of paired serum samples.

RESULTS

Viral infections were identified in 65 horses with complete sample sets; influenza virus infection was identified in 43 horses, equine herpesvirus (EHV) infection in 18, and mixed influenza virus and EHV infections in 4. On 14 premises, samples were obtained from more than 1 affected horse. Viral infections were identified in horses on 11 of 14 premises. Equine herpesviruses were isolated from 10 horses. A relationship was not found between vaccination history and identification of EHV or influenza virus infections. An infection with EHV was less likely to be identified in horses with initial (acute) antibody titers > 1:16 to EHV.

CLINICAL IMPLICATIONS

Influenza virus (specifically, A/equine/2) was the most common virus associated with acute IURD. Use of multiple diagnostic tests and obtaining samples from more than 1 horse in an outbreak may improve detection of viral infections.

Concurrent outbreaks of Salmonella Typhimurium in South Australia

The Communicable Disease Control Branch of the South Australian Health Commission received 45 laboratory notifications of Salmonella between 23 December 1996 and 17 January 1997. A rapid screening test, undertaken by the Institute of Medical and Veterinary Sciences, Adelaide, was the first indication that this was more than one outbreak, prompting the establishment of separate investigations. Three Salmonella Typhimurium (S. Typhimurium) phage types were subsequently identified. Investigations are continuing into an outbreak of S. Typhimurium phage type (PT) 64, while investigations failed to identify any association between four cases of PT 44. As of 12 February 1997, 71 notifications had been confirmed as S. Typhimurium PT 135. Epidemiological investigations found this outbreak was associated with consumption of bread rolls with a meat filling distributed through local Asian grocery stores from a home-based manufacturer. The product was voluntarily withdrawn and there have been no new cases of PT 135.

Use of isolated immature-stage B cells to understand negative selection and tolerance induction at the molecular level

Encounter with antigen by newly developing antigen receptor-positive B cells leads to negative selection. This process positions the B cell antigen receptor (BCR) in a central role for initiating the process of negative selection and suggests developmental regulation of its signaling. The observation that immature B cells are more susceptible to negative selection than are mature B cells has been demonstrated in a number of in vitro and in vivo model systems and support the idea of developmental regulation of BCR-initiated responses. Since identical antigen receptors are expressed on immature and mature B cells, the critical fate-determining distinction between these developmental stages must lie downstream of the receptor-ligand interaction itself, in the form of different BCR-linked signaling processes or with different secondary events occurring subsequent to BCR cross-linking. To address the first possibility, our laboratory and others have sought to define the differences in BCR-mediated signal transduction in immature and mature B lymphocytes. In this review article we will discuss current in vitro systems to study this question in primary, nontransformed murine B lymphocytes. In addition, we will discuss our previously published work in order to illustrate how these model systems have been useful in beginning to unravel the molecular basis for immune B cell negative selection and tolerance.

Risperidone in the treatment of negative symptoms of schizophrenia: a meta-analysis

Risperidone has antiserotonergic and antidopaminergic properties that may make it more effective than conventional antipsychotic agents in the treatment of the negative symptoms of schizophrenia. Clinical trials in chronic schizophrenic patients have shown trends in favor of risperidone in the control of negative symptoms compared with haloperidol, perphenazine or zuclopenthixol, but the differences were not consistently statistically significant. A meta-analysis of the pooled results from six double-blind trials showed that risperidone at doses ranging from 4 to 8 mg/day had a significantly (p < 0.004) higher negative symptom response rate, defined as the percentage of patients with a 20% or more reduction in scores on the negative subscale of the Positive and Negative Syndrome Scale, than patients receiving active controls. The combined patient population treated with 4-8 mg/day of risperidone was 1.43 times more likely to have had a clinical response on the negative symptom subscale than the combined population treated with haloperidol, perphenazine or zuclopenthixol.

Comparison of methods for estimation of Toxoplasma gondii-specific antibody production in the aqueous humor of cats

Intraocular production of Toxoplasma gondii-specific antibody in cats has been estimated by comparing the ratio of T gondii-specific antibody in aqueous humor and serum with the ratio of total immunoglobulins in serum and aqueous humor (Goldmann-Witmer coefficient; aqueous antibody coefficient; C value). It has been proposed that in human beings, comparison of the ratio of T gondii-specific antibody in aqueous humor and serum with the ratio of antibodies against a nonocular pathogen in serum and aqueous humor is more accurate than methods using total immunoglobulin quantification. We developed an ELISA for detection of calicivirus-specific antibodies in the serum and aqueous humor of cats. By evaluating calicivirus-specific antibody concentrations in the aqueous humor of healthy and diseased cats, calicivirus was assessed as a nonintraocular pathogen. The ratio of T gondii-specific antibodies in the aqueous humor and serum and the ratio of calicivirus-specific antibodies in serum and aqueous humor were evaluated as a means of estimating intraocular T gondii-specific antibody production. A field strain of feline calicivirus was isolated, cultured, and purified. A calicivirus-specific IgG ELISA was developed for detection of feline calicivirus-specific IgG in serum and aqueous humor. Calicivirus-specific IgG was measured in the serum and aqueous humor from 3 groups of control cats. Results suggested that calicivirus is a nonintraocular pathogen in cats and that calicivirus IgG detected in aqueous humor is attributable to leakage across a damaged blood-ocular barrier.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of an immunoperoxidase technique to detect equine herpesvirus-1 antigen in formalin-fixed paraffin-embedded equine fetal tissues

An indirect immunoperoxidase (IP) procedure using the avidin-biotin-peroxidase complex detection technique was developed to detect viral equine herpesvirus-1 (EHV-1) antigen in formalin-fixed paraffin-embedded tissues from aborted equine fetuses. The procedure was applied to liver, lung, and other tissues from 20 cases of confirmed or suspected EHV-1-induced abortions. Specific staining was observed in tissue sections from EHV-1-infected fetuses. Positive IP staining was present in tissues of 7 cases that were also positive by fluorescent antibody (FA) and virus isolation (VI) and that had typical histologic lesions. There was no IP staining in 7 cases that had no histologic lesions and negative FA and VI results. Five cases had typical histologic lesions and positive results in only 1 laboratory test; 3 were positive by VI and 2 by FA. Liver of 1 case was positive by IP, but tissues were too autolytic for other tests to be evaluated.

Serologic prevalence of selected infectious diseases in cats with uveitis

Serologic evidence of infection by Toxoplasma gondii, feline leukemia virus, feline coronaviruses, or feline immunodeficiency virus (FIV) is commonly found in cats with uveitis. Serum samples from 124 cats with uveitis were assayed by use of ELISA for the detection of T gondii-specific immunoglobulin M (IgM), IgG, and circulating antigens (Ag), as well as an ELISA for feline leukemia virus Ag, an ELISA for antibodies to FIV, and an indirect fluorescent antibody assay for antibodies to feline coronaviruses. Serologic evidence of infection by 1 or more of the infectious agents was detected in 83.1% of the samples. Serologic evidence of T gondii infection, defined as the detection of T gondii-specific IgM, IgG, or Ag in serum, was found in 74.2% of the samples. The seroprevalence of T gondii infection was significantly greater in cats with uveitis than in healthy cats from a similar geographic area. Serum samples from cats with serologic evidence of both T gondii and FIV infections were more likely to contain T gondii-specific IgM without IgG than samples from cats with serologic evidence of T gondii infection alone. Cats with serologic evidence of FIV and T gondii coinfection had a higher T gondii-specific IgM titer geometric mean and a lower T gondii-specific IgG titer geometric mean than did cats with serologic evidence of T gondii infection alone. Serologic evaluation for T gondii infection should include assays that detect IgM, IgG, and Ag, particularly in cats coinfected with FIV.

Detection of cattle infected with bovine viral diarrhea virus using nucleic acid hybridization

A ribonucleic acid (RNA) hybridization assay to identify cattle infected by bovine viral diarrhea virus (BVDV) is described. The RNA probe was derived from the coding region at the 3' end of the genome of the NADL strain of BVDV. Total RNA from infected cell cultures or peripheral blood leukocytes from suspect animals was extracted and applied to nylon membranes with a slot blot apparatus. Peripheral blood leukocytes were tested concurrently for BVDV by virus isolation. The results of hybridization and virus isolation were in agreement for 92% of the cases. When compared with virus isolation, hybridization had a sensitivity of detection of 59.5% and a specificity of 95%. Cross-reactivity to RNA extracts of border disease virus-infected cells was noted. No cross-reactivity was detected to other common bovine viruses (bovine herpesvirus-1, bovine respiratory syncytial virus, parainfluenza-3 virus, and bluetongue virus), to viruses classified in related families (equine arteritis virus and Venezuelan equine encephalitis virus), or to viruses having similar genomic organization (dengue virus type 2 and Japanese encephalitis virus).

Neonatal suppression with anti-Ia antibody. III. In vivo responses to the type 2 antigen TNP-Ficoll

We studied the response to thymus-independent type 2 (type 2) Ag in mice suppressed from birth with anti-Ia antibody. Although these mice have significantly reduced numbers of surface IgM+ cells and reduced or absent levels of Ia-restricted Th cell activity, their IgM antibody response to the type 2 Ag TNP-Ficoll was unaffected whereas that to the prototypic thymus-dependent Ag SRBC was predictably eliminated. These data suggest that an in vivo antibody response can be made to type 2 Ag in the absence of Ia-dependent cellular interactions. The surface IgM+IgD-Ia- B cells that are found in the anti-Ia antibody-suppressed mouse may represent an expanded population of Ia-independent, type 2 Ag-sensitive B cells normally present as a smaller proportion of the splenic lymphocyte population. Thymus-dependent responses, which have been shown to have an absolute requirement for an Ia-dependent interaction, are absent in these animals.

Neonatal suppression with anti-Ia antibody. III. In vivo responses to the type 2 antigen TNP-Ficoll

We studied the response to thymus-independent type 2 (type 2) Ag in mice suppressed from birth with anti-Ia antibody. Although these mice have significantly reduced numbers of surface IgM+ cells and reduced or absent levels of Ia-restricted Th cell activity, their IgM antibody response to the type 2 Ag TNP-Ficoll was unaffected whereas that to the prototypic thymus-dependent Ag SRBC was predictably eliminated. These data suggest that an in vivo antibody response can be made to type 2 Ag in the absence of Ia-dependent cellular interactions. The surface IgM+IgD-Ia- B cells that are found in the anti-Ia antibody-suppressed mouse may represent an expanded population of Ia-independent, type 2 Ag-sensitive B cells normally present as a smaller proportion of the splenic lymphocyte population. Thymus-dependent responses, which have been shown to have an absolute requirement for an Ia-dependent interaction, are absent in these animals.

Use of an immunoperoxidase test for the detection of bovine herpesvirus-1 in aborted fetal tissue

An indirect immunoperoxidase (IP) procedure using a specific monoclonal antibody and an avidin-biotin-peroxidase complex was developed and applied to detect virus antigen in formalin-fixed, paraffin-embedded tissue sections. This IP procedure was compared with currently used diagnostic tests for detection of virus-induced abortions caused by bovine herpesvirus-1 (BHV-1). The IP procedure was applied to detect BHV-1 antigen in sections of liver and lung from 87 aborted fetuses. Sixteen of these cases were positive for viral antigen by IP staining. Sections from both liver and lung were positive in 15 of the 16 cases. A fluorescent antibody test (FA), which was applied to acetone-fixed frozen sections of liver and lung, gave positive results on 12 of the 87 fetuses, 11 of which were also positive by IP. Seven of the 12 FA-positive cases were positive on both sections of liver and lung. When FA and IP were compared. FA had a sensitivity of 67% and IP had a sensitivity of 94%. Virus was isolated from one of the 67 cases tested. The tissues in which antigen was most frequently detected by IP were liver, lung, and kidney. Distinct multifocal staining was seen in positive sections of all these tissues.

Epitope specificity of the bovine antibody response to the gIII glycoprotein of bovine herpesvirus type 1

A panel of monoclonal antibodies (MAbs) to BHV-1, specific for gI and gIII glycoproteins and for a nonglycosylated core protein p100, was used to examine the epitope specificity of the immune response to the virus in naturally exposed and experimentally infected cattle. Sera from experimentally infected calves were analyzed in a competition ELISA (C-ELISA). Antibody to an epitope on gIII appeared as early as 4 days post infection, although virus-neutralizing antibody did not appear until day 8 or later. Antibody production peaked at 13 to 18 days post infection but the level of antibody to each gIII epitope varied. Competition by sera from cattle naturally exposed to BHV-1 was analyzed as a function of the virus neutralization (VN) titer of these sera. Competition with most of the MAbs correlated linearly with neutralization titer. However, competition with 2 of the MAbs, one specific for gIII and one specific for gI, was maximal even at the lowest neutralization titer, and competition with another MAb, specific for a non-glycosylated core protein, p100, was negative. Selected sera from the naturally exposed group were also examined by radioimmunprecipitation, and were shown to react predominantly with gI, gIII and gIV glycoproteins and in a few shown to react predominantly with gI, gIII and gIV glycoproteins and in a few MAbs were determined, and it was found that neutralization was enhanced by certain combinations. A mutually exclusive relationship between neutralization enhancement and competition for binding by MAbs (as determined by reciprocal C-ELISA) indicated an epitope-specific, rather than antibody-specific, mechanism for neutralization enhancement.

Detection of cytopathic and noncytopathic bovine viral diarrhea virus in cell culture with an immunoperoxidase test

Bovine viral diarrhea virus (BVDV) antigen was detected in cell culture with an indirect immunoperoxidase (IP) procedure using a specific monoclonal antibody, and an avidin-biotin-peroxidase complex. Cytopathic and noncytopathic strains of the virus showed similar patterns of IP staining until 3 days post-infection. At six days post-infection, intensity of staining decreased in cell cultures infected with noncytopathic virus, but not with cytopathic virus. The IP procedure detected BVDV antigen in cells used to isolate virus from tissues of aborted bovine fetuses and peripheral blood lymphocytes of adult cattle. Immunoperoxidase detected BVDV isolates from 10 of 44 cases of abortion of which seven of these were noncytopathic. Noncytopathic BVDV isolates from the peripheral blood lymphocytes of 7 of 65 animals were identified.

Evaluation of an antigen-capture ELISA for the detection of bovine herpesvirus type 1 shedding from feedlot cattle

A total of 457 nasal swab specimens from cases of respiratory disease in 2 feed lots were evaluated for the detection of bovine herpesvirus Type 1 (BHV-1) by ELISA. Thirty-three were found to be positive for BHV-1 by the recovery of infectious virus and 21 of these were positive by ELISA, yielding a sensitivity of 64%. Fifteen other virus isolations were made and included bovine viral diarrhea viruses, rhinoviruses and parainfluenza Type 3 viruses; none of these cases were positive with the BHV-1 ELISA. Specificity of the ELISA was 100%. Eighty percent of the specimens with BHV-1 titers greater than 10(5) TCID50 were detected by ELISA; the median amount of virus in positive specimens that were detected by ELISA was 7 X 10(5) TCID50 and the median amount of virus in specimens not detected was 1.5 X 10(4) TCID50. BHV-1 infection was most frequently diagnosed in feedlot cattle that had been in the feedlot for 40-80 days. Approximately half of the infected cattle were carrying virus-neutralizing antibodies in their serum.

Intussusception in a premature infant simulating necrotising enterocolitis

Intussusception in older infants is manifested by bloody stools, colicky abdominal pain and a palpable abdominal mass. In neonates the symptoms are often restricted to vomiting, guaiac positive stools and abdominal distension. These symptoms closely mimic necrotising enterocolitis. Surgical treatment of necrotising enterocolitis should be postponed until perforation of the gastrointestinal tract has occurred, whereas, prompt surgical treatment is recommended for intussusception. We report a case of intussusception that simulated necrotising enterocolitis in a 740 grammes premature infant in the second week of life. The clinical and radiographic features are described and the difficulty in distinction between the two conditions is emphasised. Neonatologists and paediatric surgeons should always include intussusception in the differential diagnosis of abdominal distension and guaiac positive stools in small premature infants.

Interferon-gamma suppresses B cell stimulation factor (BSF-1) induction of class II MHC determinants on B cells

The data presented in this manuscript extend our previous observations that recombinant interferon-gamma (reIFN-gamma) can suppress anti-immunoglobulin (anti-Ig)-stimulated B cell proliferation, and demonstrate that reIFN-gamma can also suppress B cell stimulation factor type 1 (BSF-1)-stimulated increases in expression of MHC class II molecules (Ia) on B cells. This suppression is most effective when relatively low concentrations of BSF-1 are employed, but is still very substantial even when optimal concentrations of BSF-1 were used. This suppression is also observed when size-separated small B cells which are devoid of detectable macrophages or NK cells are cultured with BSF-1 and reIFN-gamma, thus suggesting that IFN-gamma-mediated inhibition is a consequence of a direct effect on the B cells. Incubation of B cells with reIFN-gamma for 24 hr before their culture with BSF-1 did not prevent BSF-1-stimulated increases in sIa. This finding supports the contention that the effect of IFN-gamma is not mediated via the stimulation of "suppressor" influences in these cell cultures. The inhibition of B cell activation by IFN-gamma occurs within the first 3 hr after the onset of culture, as demonstrated by the inability of antibody to IFN-gamma to totally reverse the IFN-gamma-mediated suppressive effects on B cell proliferation if it is added later than 3 hr after the onset of culture. These results suggest a role for IFN-gamma in down-regulating the ability of B cells to function as antigen-presenting cells in non-cognate T cell-dependent responses.

Interferon-gamma suppresses B cell stimulation factor (BSF-1) induction of class II MHC determinants on B cells

The data presented in this manuscript extend our previous observations that recombinant interferon-gamma (reIFN-gamma) can suppress anti-immunoglobulin (anti-Ig)-stimulated B cell proliferation, and demonstrate that reIFN-gamma can also suppress B cell stimulation factor type 1 (BSF-1)-stimulated increases in expression of MHC class II molecules (Ia) on B cells. This suppression is most effective when relatively low concentrations of BSF-1 are employed, but is still very substantial even when optimal concentrations of BSF-1 were used. This suppression is also observed when size-separated small B cells which are devoid of detectable macrophages or NK cells are cultured with BSF-1 and reIFN-gamma, thus suggesting that IFN-gamma-mediated inhibition is a consequence of a direct effect on the B cells. Incubation of B cells with reIFN-gamma for 24 hr before their culture with BSF-1 did not prevent BSF-1-stimulated increases in sIa. This finding supports the contention that the effect of IFN-gamma is not mediated via the stimulation of "suppressor" influences in these cell cultures. The inhibition of B cell activation by IFN-gamma occurs within the first 3 hr after the onset of culture, as demonstrated by the inability of antibody to IFN-gamma to totally reverse the IFN-gamma-mediated suppressive effects on B cell proliferation if it is added later than 3 hr after the onset of culture. These results suggest a role for IFN-gamma in down-regulating the ability of B cells to function as antigen-presenting cells in non-cognate T cell-dependent responses.

Wheat gluten challenge in schizophrenic patients

Eight chronic schizophrenic patients were maintained on a diet free of gluten, cereal grains, and milk (CM-F diet) and challenged in a double-blind manner with dietary wheat gluten and placebo. While on the CM-F diet, each patient received a daily challenge of 30 g of gluten for 5 weeks and a placebo challenge for 8 weeks. No deterioration in clinical status as measured by the BPRS was noted on gluten challenge. Serum alpha 1 acid glycoprotein measurement demonstrated no evidence of inflammatory response to gluten challenge. The data suggest that sensitivity to dietary gluten is not characteristic of young chronic schizophrenic patients.