Postoperative systemic inflammation after major abdominal surgery: patient-centred outcomes

Postoperative systemic inflammation is strongly associated with surgical outcomes, but its relationship with patient-centred outcomes is largely unknown. Detection of excessive inflammation and patient and surgical factors associated with adverse patient-centred outcomes should inform preventative treatment options to be evaluated in clinical trials and current clinical care. This retrospective cohort study analysed prospectively collected data from 3000 high-risk, elective, major abdominal surgery patients in the restrictive vs. liberal fluid therapy for major abdominal surgery (RELIEF) trial from 47 centres in seven countries from May 2013 to September 2016. The co-primary endpoints were persistent disability or death up to 90 days after surgery, and quality of recovery using a 15-item quality of recovery score at days 3 and 30. Secondary endpoints included: 90-day and 1-year all-cause mortality; septic complications; acute kidney injury; unplanned admission to intensive care/high dependency unit; and total intensive care unit and hospital stays. Patients were assigned into quartiles of maximum postoperative C-reactive protein concentration up to day 3, after multiple imputations of missing values. The lowest (reference) group, quartile 1, C-reactive protein ≤ 85 mg.l-1 , was compared with three inflammation groups: quartile 2 > 85 mg.l-1 to 140 mg.l-1 ; quartile 3 > 140 mg.l-1 to 200 mg.l-1 ; and quartile 4 > 200 mg.l-1 to 587 mg.l-1 . Greater postoperative systemic inflammation had a higher adjusted risk ratio (95%CI) of persistent disability or death up to 90 days after surgery, quartile 4 vs. quartile 1 being 1.76 (1.31-2.36), p < 0.001. Increased inflammation was associated with increasing decline in risk-adjusted estimated medians (95%CI) for quality of recovery, the quartile 4 to quartile 1 difference being -14.4 (-17.38 to -10.71), p < 0.001 on day 3, and -5.94 (-8.92 to -2.95), p < 0.001 on day 30. Marked postoperative systemic inflammation was associated with increased risk of complications, poor quality of recovery and persistent disability or death up to 90 days after surgery.

Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review

In some patients, the inflammatory-immune response to surgical injury progresses to a harmful, dysregulated state. We posit that postoperative systemic inflammatory dysregulation forms part of a pathophysiological response to surgical injury that places patients at increased risk of complications and subsequently prolongs hospital stay. In this narrative review, we have outlined the evolution, measurement and prediction of postoperative systemic inflammatory dysregulation, distinguishing it from a healthy and self-limiting host response. We reviewed the actions of glucocorticoids and the potential for heterogeneous responses to peri-operative corticosteroid supplementation. We have then appraised the evidence highlighting the safety of corticosteroid supplementation, and the potential benefits of high/repeated doses to reduce the risks of major complications and death. Finally, we addressed how clinical trials in the future should target patients at higher risk of peri-operative inflammatory complications, whereby corticosteroid regimes should be tailored to modify not only the a priori risk, but also further adjusted in response to markers of an evolving pathophysiological response.

Healthcare Utilization and Patients' Perspectives After Receiving a Positive Genetic Test for Familial Hypercholesterolemia

BACKGROUND

The MyCode Community Health Initiative (MyCode) is returning actionable results from whole exome sequencing. Familial hypercholesterolemia (FH) is an inherited condition characterized by premature cardiovascular disease.

METHODS

We used multiple methods to assess care in 28 MyCode participants who received FH results. Chart reviews were conducted on 23 individuals in the sample and 7 individuals participated semistructured interviews.

RESULTS

Chart reviews for 23 individuals with a Geisinger primary care provider found that 4 individuals (17% of 23) were at LDL-C (low-density lipoprotein cholesterol) goal (of either LDL-C <100 mg/dL for primary prevention and LDL-C <70 mg/dL for secondary prevention) and 17 individuals (74% of 23) were prescribed lipid-lowering therapy before genetic result disclosure. After disclosure of the genetic test result, 5 individuals (22% of 23) met their LDL-C goal and 18 individuals (78% of 23) were prescribed lipid-lowering therapy. Follow-up care about this result was not documented for 4 individuals (17% of 23). Changes to intensity of medication management were made for 8 individuals (47% of 17 individuals previously prescribed lipid-lowering therapy). Interviewed individuals (n=7) were not surprised by their result as all knew they had high cholesterol; however, individuals did not seem to discern FH as a separate condition from their high cholesterol.

CONCLUSIONS

Among individuals receiving genetic diagnosis of FH, >25% had no changes to lipid-lowering therapy, despite not being at LDL-C goal and learning their high cholesterol is related to a genetic condition requiring more aggressive treatment. Individuals and clinicians may have an inadequate understanding of FH as a distinct condition requiring enhanced medical management.

Intraoperative dexamethasone does not increase the risk of postoperative wound infection: a propensity score-matched post hoc analysis of the ENIGMA-II trial (EnDEX)

BACKGROUND

In a post hoc analysis of the ENIGMA-II trial, we sought to determine whether intraoperative dexamethasone was associated with adverse safety outcomes.

METHODS

Inverse probability weighting with estimated propensity scores was used to determine the association of dexamethasone administration with postoperative infection, quality of recovery, and adverse safety outcomes for 5499 of the 7112 non-cardiac surgery subjects enrolled in ENIGMA-II.

RESULTS

Dexamethasone was administered to 2178 (40%) of the 5499 subjects included in this analysis and was not associated with wound infection [189 (8.7%) vs 275 (8.3%); propensity score-adjusted relative risk (RR) 1.10; 95% confidence interval (CI) 0.89-1.34; P=0.38], severe postoperative nausea and vomiting on day 1 [242 (7.3%) vs 189 (8.7%); propensity score-adjusted RR 1.06; 95% CI 0.86-1.30; P=0.59], quality of recovery score [median 14, interquartile range (IQR) 12-15, vs median 14, IQR 12-16, P=0.10), length of stay in the postanaesthesia care unit [propensity score-adjusted median (IQR) 2.0 (1.3, 2.9) vs 1.9 (1.3, 3.1), P=0.60], or the primary outcome of the main trial. Dexamethasone administration was associated with a decrease in fever on days 1-3 [182 (8.4%) vs 488 (14.7%); RR 0.61; 95% CI 0.5-0.74; P<0.001] and shorter lengths of stay in hospital [propensity score-adjusted median (IQR) 5.0 (2.9, 8.2) vs 5.3 (3.1, 9.1), P<0.001]. Neither diabetes mellitus nor surgical wound contamination status altered these outcomes.

CONCLUSION

Dexamethasone administration to high-risk non-cardiac surgical patients did not increase the risk of postoperative wound infection or other adverse events up to day 30, and appears to be safe in patients either with or without diabetes mellitus.

CLINICAL TRIAL REGISTRATION

NCT00430989.

Preoperative Gastric Residual Volumes in Fasted Patients Measured by Bedside Ultrasound: A Prospective Observational Study

The purpose of this prospective observational study was to measure gastric volumes in fasted patients using bedside gastric ultrasound. Patients presenting for non-emergency surgery underwent a gastric antrum assessment, using the two-diameter and free-trace methods to determine antral cross-sectional area. Gastric residual volume (GRV) was calculated using a validated formula. Univariate and multivariable analyses were performed to examine any potential relationships between ‘at risk’ GRVs (>100 ml) and patient factors. Two hundred and twenty-two successful scans were performed; of these 110 patients (49.5%) had an empty stomach, nine patients (4.1%) had a GRV >100 ml, and a further six patients (2.7%) had a GRV >1.5 ml/kg. There was no significant relationship between ‘at risk’ GRV and obesity, diabetes mellitus, gastro-oesophageal reflux disease or opioid use, although our study had insufficient power to exclude an influence of one or more of these factors. Our results indicate that despite compliance with fasting guidelines, a small percentage of patients still have GRVs that pose a pulmonary aspiration risk. Anaesthetists should consider this background incidence when choosing anaesthesia techniques for their patients. While future observational studies are required to determine the role of preoperative bedside gastric ultrasound, it is possible that this technique may assist anaesthetists in identifying patients with ‘at risk’ GRVs.

Evaluation of the utility of the Vigileo FloTrac(™) , LiDCO(™) , USCOM and CardioQ(™) to detect hypovolaemia in conscious volunteers: a proof of concept study

It is important to detect and treat hypovolaemia; however, detection is particularly challenging in the conscious, spontaneously breathing patient. Eight healthy male volunteers were monitored using four minimally invasive monitors: Vigileo FloTrac(™) ; LiDCOrapid(™) ; USCOM 1A; and CardioQ(™) oesophageal Doppler. Monitor output and clinical signs were recorded during incremental venesection of 2.5% estimated blood volume aliquots to a total of 20% blood volume removed. A statistically significant difference from baseline stroke volume was detected after 2.5% blood loss using the LiDCO (p = 0.007), 7.5% blood loss using the USCOM (p = 0.019), and 12.5% blood loss using the CardioQ (p = 0.046) and the FloTrac (p = 0.028). Receiver operator characteristic curves for predicting > 10% blood loss had areas under the curve of 0.68-0.82. The minimally invasive cardiac output devices tested can detect blood loss by a reduction in stroke volume in awake volunteers, and may have a role in guiding fluid replacement in conscious patients with suspected hypovolaemia.

Psychosocial paediatric training in Iraq: perspectives of trainers and students

There is an absence of education regarding psychosocial issues in Iraqi paediatric training programmes. The aim of this study is to examine current knowledge and perspectives around these topics and to explore potential development in these programmes. 56 paediatric trainers and students at the Child Central Teaching Hospital, a hospital affiliated to the Al-Mustansyria medical college in Baghdad, responded to a questionnaire to evaluate knowledge and perspectives regarding psychosocial approaches to child and adolescent health as delivered presently via academic training and used in professional practice. The majority of the respondents reported having no training in psychosocial interventions. Using a scale from 0 ('not relevant') to 10 ('very important'), psychosocial issues were rated 7.1 in their relevance to everyday paediatric practice. On a scale of 0 ('very poor') to 10 ('totally adequate'), respondents rated formal current psychosocial training at 2.5. It is concluded that incorporating psychosocial approaches in paediatric training will lead to a broader base of knowledge in children's health and contribute to the promotion of multidisciplinary practice in Iraq.

Multisite comparison of mucociliary and cough clearance measures using standardized methods

BACKGROUND

A standardized protocol for measuring mucociliary (MCC) and cough clearance (CC) was developed and tested at the University of North Carolina at Chapel Hill, NC (UNC), Johns Hopkins University (JHU), and the University of Pittsburgh (Pitt).

METHODS

A total of 50 healthy nonsmoking adults with normal lung function were studied at the three sites: 30 [21 males/9 females (21M/9F)] at UNC, 10 (6M/4F) at JHU, and 10 (4M/6F) at Pitt. Subjects inhaled an aerosol of (99m)technetium sulfur colloid in 0.9% saline (mass median aerodynamic diameter=5.4 μm) under controlled breathing conditions (500 mL/sec, 30 breaths/min) by following a metronome and flow signal from a commercial dosimeter. Following inhalation, subjects sat in front of a gamma camera as sequential lung images were acquired for 60 min. Subjects then coughed 60 times, and images were acquired after each set of 20 coughs, i.e., at 70, 80, and 90 min. Subjects returned to the laboratory approximately 24 hr later for a final image of residual lung activity. Initial aerosol distribution was measured as a central/peripheral (C/P) ratio of activity. MCC/CC was expressed as the area under the retention versus time curve over 90 min (AUC90).

RESULTS

A multivariate analysis of clearance versus time with site and C/P as covariates showed no significant site-specific differences. Interestingly, MCC/CC was greater in females (n=19) versus males (n=31), with AUC90=0.84 ± 0.11 and 0.90±0.07, respectively (p=0.03), for the combined data set from all sites (not significant for any given site). There were no gender differences for either C/P ratio or 24-hr clearance.

CONCLUSIONS

This standardized protocol may prove beneficial in multicenter trials for testing new therapies that are designed to improve MCC/CC.

Autophobing on liquid subphases driven by the interfacial transport of amphiphilic molecules

We investigated the phenomenon of incomplete wetting of a high-energy liquid subphase by drops of pure amphiphilic molecules as well as drops of amphiphile solutions that are immiscible with the subphase. We show that amphiphiles escape across the contact line of the drop, move on the subphase/vapor interface, and form a submonolayer or full monolayer external to the drop. If this monolayer is sufficiently dense, then it can reduce the surface tension of the subphase, raise the contact angle of the drop, and prevent the drop from fully wetting the subphase. This phenomenon is called autophobing and has been extensively studied on solid substrates. For the liquid subphase studied here, we measure the surface tensions of the three relevant interfaces before and after the drop is deposited. The measured surface tension external to the drop shows that amphiphiles can move across the contact line and form a monolayer outside of the drop. In some cases, at equilibrium, the monolayer is in a sufficiently packed state to create the nonwetting condition. In other cases, at equilibrium the monolayer density is insufficient to lower the surface tension enough to achieve the nonwetting condition. Unlike on solid substrates where the formation of the monolayer external to the drop is kinetically hindered, the amphiphiles can move rapidly across the liquid subphase by Marangoni-driven surface transport, and local equilibrium is achieved. However, because the amphiphile inventory and subphase area are limited, the achievement of autophobing on a liquid subphase depends not only on the instrinsic subphase/amphiphile interaction but also on the total amphiphile inventory and area of the liquid subphase.

Helium-oxygen therapy for infants with bronchiolitis: a randomized controlled trial

OBJECTIVE

To compare nebulized racemic epinephrine delivered by 70% helium and 30% oxygen or 100% oxygen followed by helium-oxygen inhalation therapy via high-flow nasal cannula (HFNC) vs oxygen inhalation via HFNC in the treatment of bronchiolitis.

DESIGN

Prospective, randomized, controlled, single-blind trial.

SETTING

This study was conducted from October 1, 2004, through May 31, 2008, in the emergency department of an urban, tertiary care children's hospital. Patients Infants aged 2 to 12 months with a Modified Wood's Clinical Asthma Score (M-WCAS) of 3 or higher.

INTERVENTIONS

Patients initially received nebulized albuterol treatment driven by 100% oxygen. Patients were randomized to the helium-oxygen or oxygen group and received nebulized racemic epinephrine via a face mask. After nebulization, humidified helium-oxygen or oxygen was delivered by HFNC. After 60 minutes of inhalation therapy, patients with an M-WCAS of 2 or higher received a second delivery of nebulized racemic epinephrine followed by helium-oxygen or oxygen delivered by HFNC. Main Outcome Measure Degree of improvement of M-WCAS for 240 minutes or until emergency department discharge.

RESULTS

Of 69 infants enrolled, 34 were randomized to the helium-oxygen group and 35 to the oxygen group. The mean change in M-WCAS from baseline to 240 minutes or emergency department discharge was 1.84 for the helium-oxygen group compared with 0.31 for the oxygen group (P < .001). The mean M-WCAS was significantly improved for the helium-oxygen group compared with the oxygen group at 60 minutes (P = .005), 120 minutes (P < .001), 180 minutes (P < .001), and 240 minutes (P < .001).

CONCLUSION

Nebulized racemic epinephrine delivered by helium-oxygen followed by helium-oxygen inhalation therapy delivered by HFNC was associated with a greater degree of clinical improvement compared with that delivered by oxygen among infants with bronchiolitis. Trial Registration clinicaltrials.gov Identifier: NCT00116584.

Perioperative management of clopidogrel therapy: the effects on in-hospital cardiac morbidity in older patients with hip fractures

BACKGROUND

Increasing numbers of older patients prescribed clopidogrel are presenting for urgent hip fracture surgery. Best practice for the management of clopidogrel therapy is unknown, although delays to surgery are associated with increased mortality. We investigated the influence of perioperative management of clopidogrel therapy on in-hospital cardiac morbidity and transfusion in this population.

METHODS

Retrospective review of all patients aged >60 yr, admitted to a single centre with hip fractures between June 2005 and November 2008. Acute coronary syndrome (ACS) was defined as a raised plasma troponin concentration >0.04 µg litre(-1) associated with chest pain, new ECG changes, or both.

RESULTS

Of 1381 patients admitted with hip fractures, 114 were receiving regular clopidogrel therapy with a median age of 83.7 (60-98) yr. Clopidogrel was withheld perioperatively in 111 (98%) of these patients. Twenty-three patients (20.2%) suffered an ACS. Risk peaked for ACS [odds ratio (OR) 6.7 (95% confidence interval, CI, 1.7-25.8)] (P=0.006) between days 4 and 8 after clopidogrel withdrawal. The OR for requiring a blood transfusion during or after surgery peaked at day 1 after clopidogrel withdrawal [OR 2.31 (95% CI, 1.02-5.21)] (P=0.044).

CONCLUSIONS

The length of withdrawal of clopidogrel therapy perioperatively was associated with a significantly increased incidence of ACS. An association between shorter withdrawal and increased blood transfusion requirements was also seen. The study emphasizes the cardiovascular risks of routinely interrupting clopidogrel therapy in this at-risk population and that a more considered, individualized, evidenced-based approach is needed.

The potential for delivery of particulate matter through positive airway pressure devices (CPAP/BPAP)

BACKGROUND

Airborne particulate matter may induce health risk with inhalation. Special concerns exist for deployed military personnel with inhaled particulate matter in desert environments. Continuous positive airway pressure (CPAP) used in obstructive sleep apnea may facilitate inhalation of particulate matter. We evaluated the ability of commercial CPAP filter systems to eliminate inhalation of particulate matter.

METHODS

An ultrasonic medical nebulizer (DeVilbliss Ultraneb, DeVilbliss, Somerset, PA) atomized liquid producing "respirable" aerosol. Technetium-99m diethylene triamine pentaacetic acid dissolved in water was also aerosolized to quantify aerosol inhalation. A high efficiency particulate air (HEPA) filter placed at the patient-hose connection port in the bilevel positive airway pressure (BPAP) device captured the aerosol inbound to the patient. The HEPA filter provided a means to quantify aerosol dose delivered to a simulated patient. Commercial foam and ultrafine filters were assessed with aerosol to determine the simulated patient exposure.

RESULTS

Foam and ultrafine filters used together allowed 1.5% or less of aerosol volume to pass through the BPAP system. Foam filters alone allowed an average of 18.9% of aerosol delivered to pass through the BPAP system.

CONCLUSIONS

Foam and ultrafine filters used together in BPAP systems provide excellent aerosol filtration in this laboratory simulation of BPAP use.

Inhaled cyclosporine and pulmonary function in lung transplant recipients

BACKGROUND

Chronic rejection, manifesting as bronchiolitis obliterans, is the leading cause of death in lung transplant recipients. In our previously reported double-blinded, placebo-controlled trial comparing inhaled cyclosporine (ACsA) to aerosol placebo, the rate of bronchiolitis-free survival improved. However, an independent analysis of pulmonary function, a secondary endpoint of the trial, was not performed. We sought to determine the effect of ACsA, in addition to systemic immunosuppression, on pulmonary function.

METHODS

From 1998-2001, 58 patients were randomly assigned to inhale either 300 mg of ACsA (28 patients) or placebo aerosol (30 patients) 3 days a week for the first 2 years after transplantation. Longitudinal changes in pulmonary function of ACsA patients were compared to aerosol placebo patients. In another analysis, the rate of decline from 6-month maximum FEV(1) in randomized patients was compared to the rate of decline in patients receiving conventional immunosuppression from the Novartis transplant database (644 patients, 12 centers worldwide, transplanted from 1990-1995).

RESULTS

The average duration of ACsA and aerosol placebo was 400 days +/- 306 and 433 +/- 256, respectively. The change in FEV(1) of ACsA patients (adjusted for Cytomegalovirus (CMV) mismatch and transplant type, followed for a maximum duration of 4.6 years) was superior to the aerosol placebo controls (9.0 +/- 71.4 mL/year vs. -107.9 +/- 55.3, p = 0.007). The FEF(25-75) decreased by -220.3 +/- 117.7 L/(second x year) vs. -412.2 +/- 139.2, p = 0.07, respectively. Similarly, percent FEV(1) decline from maximal values was improved in ACsA patients compared to aerosol placebo and Novartis controls (ACsA -0.43 +/- 1.12%/year vs. aerosol placebo -4.08 +/- 1.4, p = 0.04; ACsA vs. Novartis -4.7 +/- 0.31, p = 0.007). Single-lung recipients receiving ACsA showed improvement in FEV(1) compared to Novartis controls (FEV(1) -0.8 +/- 1.8%/year vs. -4.94 +/- 0.4, p = 0.03) but double-lung recipients showed improvement compared to aerosol placebo controls only (FEV(1) -0.28 +/- 1.22%/year vs. -8.53 +/- 5.95, p = 0.048).

CONCLUSIONS

In this single center trial, ACsA appears to ameliorate important pulmonary function parameters in lung transplant recipients compared to aerosol placebo and historical control patients. Single- and double-lung transplant recipients may not respond uniformly to treatment, and ongoing randomized trials in lung transplant recipients using ACsA may help elucidate our findings.

Preparation and characterization of new challenge stocks of SIVmac32H J5 following rapid serial passage of virus in vivo

BACKGROUND

A new challenge stock of the simian immunodeficiency virus SIVmacJ5 has been produced following passage in vivo.

METHODS

SIVmacJ5 3/92 (J5M), was passaged serially through cynomolgus macaques (Macaca fascicularis) by intravenous inoculation of infected spleen cells isolated and prepared 14 days post-infection. Two challenge stocks, SIVmacJ5 S61MLN and SIVmacJ5 S62spl, were prepared by culture of lymphoid tissue ex vivo.

RESULTS

These virus stocks appeared better adapted for replication in M. fascicularis as demonstrated by a greater persistence of recoverable live virus from the periphery and increased pathology in lymphoid tissues 20 weeks post-challenge as detected by immunohistochemistry. Sequence analysis of the envelope gene from these stocks did not identify marked diversification of sequence as a result of this procedure.

CONCLUSIONS

These stocks display more robust peripheral persistence and tissue pathology in cynomolgus macaques and should prove valuable analysing recombinant vaccines based upon SIVmacJ5 transgenes.

Cryptococcus gattii infection causing fulminant intracranial hypertension

Cryptococcus neoformans variety gattii (C. gattii) causes infection in predominantly immunocompetent individuals. The majority of cases present with headache due to meningitis and its natural history normally follows an indolent course. We report a fatal case of fulminant cryptococcaemia culminating in severe intracranial hypertension due to C. gattii. Such cases of fulminant disease are rare and highlight a number of important therapeutic and diagnostic considerations. We discuss the atypical nature of this patient's illness, the major complications of C. gattii meningitis and the role of computed tomography (CT) in preventing serious sequelae from lumbar puncture. The management of intracranial hypertension (ICH) in critically ill patients is also reviewed.

Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: a randomized, controlled trial

BACKGROUND

Helium and oxygen mixtures (heliox) increase both pulmonary aerosol delivery and gas delivery relative to oxygen. We aimed to compare the effectiveness of a 70%:30% helium/oxygen (heliox)-driven continuous aerosol delivery versus 100% oxygen-driven delivery in the treatment of asthmatic children with moderate to severe exacerbations.

METHODS

We enrolled 30 children aged 2 to 18 years who presented to an urban, pediatric emergency department (ED) with moderate to severe asthma as defined by a pulmonary index (PI) score of > or =8. PI scores can range from 0 to 15. In this randomized, controlled, single-blind trial conducted in a convenience sample of children, all patients in the trial received an initial nebulized albuterol (5 mg) treatment driven by 100% oxygen and a dose of oral prednisone or prednisolone. Subsequently, patients were randomly assigned to receive continuously nebulized albuterol (15 mg/hour) delivered by either heliox or oxygen using a nonrebreathing face mask. The primary outcome measure was degree of improvement as assessed in blinded video-recorded PI scores over 240 minutes (at 30-minute intervals for the first 3 hours) or until ED discharge (if <240 minutes).

RESULTS

The mean change in PI score from baseline to 240 minutes or ED discharge was 6.67 for the heliox group compared with 3.33 for the oxygen group. Eleven (73%) patients in the heliox group were discharged from the hospital in <12 hours compared with 5 (33%) patients in the conventional group.

CONCLUSION

Continuously nebulized albuterol delivered by heliox was associated with a greater degree of clinical improvement compared with that delivered by oxygen among children with moderate to severe asthma exacerbations.

Effects of fenoldopam on renal blood flow and its function in a canine model of rhabdomyolysis

BACKGROUND AND OBJECTIVE

Our hypothesis was that fenoldopam, a selective DA1 agonist, would protect against rhabdomyolysis-induced renal injury.

METHODS

We studied the effects of intravenous fenoldopam (0.1-1.0 microg kg(-1) min(-1)) or saline on renal blood flow and function in 10 anaesthetized Labrador dogs in whom rhabdomyolysis and myoglobinuric acute renal failure had been induced by administration of glycerol 50% (10mL kg(-1)) intramuscularly. Haemodynamic measurements including renal blood flow and derived parameters of renal function including creatinine clearance were recorded before and for the 30 min following glycerol injection, and during the 3 h following commencement of each infusion. Serum malondialdehyde concentrations were measured before and 15 min after glycerol intramuscularly, and 30 and 150 min after commencement of the infusion.

RESULTS

In the fenoldopam group, creatinine clearance was less than placebo at 1 and 2 h after commencing the infusion (12.7 +/- 11.5 versus 31.3 +/- 9.9 mL min(-1), P = 0.04; 8.5 +/- 5.3 versus 20.1 +/- 7.4 mL min(-1), P = 0.03). A 140-fold increase in serum malondialdehyde concentration occurred in one dog (fenoldopam group).

CONCLUSION

Fenoldopam increased the severity of the renal injury in this canine model of myoglobinuric acute renal failure.

Antiplatelet and antithrombotic activity of RWJ-53308, a novel orally active glycoprotein IIb/IIIa antagonist

RWJ-53308 is a novel nonpeptide glycoprotein IIb/IIIa (GPIIb/IIIa) antagonist that inhibits fibrinogen binding to GPIIb/IIIa with an IC(50) of 0.4+/-0.3 nM. RWJ-53308 inhibits thrombin-induced platelet aggregation in human gel-filtered platelets (IC(50)=60+/-12 nM) and platelet aggregation in human platelet-rich plasma (PRP) in response to collagen, arachidonic acid, ADP, and SFLLRN-NH(2) (IC(50)=60+/-10, 150+/-30, 70+/-4, and 160+/-80 nM, respectively). The potency of RWJ-53308 in dog and guinea pig PRP is similar to human PRP. RWJ-53308 inhibits ex vivo collagen- and ADP-induced platelet aggregation in conscious dogs for up to 4 h following 0.3 mg/kg iv, and through 4 and 6 h following 1 and 3 mg/kg po. Oral bioavailability is 16+/-7%. RWJ-53308 reduces thrombus weight in a canine arteriovenous (AV) shunt model following intravenous (0.01-0.1 mg/kg) and oral (3 mg/kg) administration. In a guinea pig carotid artery pinch-injury model, RWJ-53308 completely suppresses thrombus-induced cyclic flow reductions (CFR) at 0.7 mg/kg iv. RWJ-53308 also blocks thrombus formation in photoactivation- and ferric chloride-induced models of thrombosis in guinea pigs at 0.3 and 1 mg/kg iv, respectively. In summary, RWJ-53308 is a potent orally active GPIIb/IIIa antagonist that may be useful for both acute and chronic treatment of arterial thrombotic disorders.

A case of pneumomediastinum in paediatric ARDS: to oscillate or not?

An 18-month-old was transferred (intubated and ventilated) to our hospital with staphylococcal tracheitis, which progressed to a necrotizing pneumonitis, complicated by surgical emphysema and pneumomediastinum. Maximum conventional ventilation on a Servo 300 failed. Treatment with high frequency oscillatory ventilation (for 10 days) with a permissive hypercarbia and hypoxaemia strategy to limit mean airway pressure facilitated recovery in our patient.

Mechanisms of protection induced by attenuated simian immunodeficiency virus. II. Lymphocyte depletion does not abrogate protection

To determine the role that cellular immune responses play in the protection conferred by vaccination with attenuated SIVmac32H (pC8), we have attempted to deplete macaques of their CD8+ cells prior to challenge with wild-type SIVmac32H (pJ5). In two of four pC8-infected macaques, N109 and N112, a transient partial depletion of CD8+ cells by antibody treatment was achieved. On the day of challenge peripheral CD2+CD4-CD8+ cell counts were reduced by 92 and 95%, respectively, in animals N109 and N112 and their lymph nodes revealed a 46 and 58% reduction, respectively, in CD2+CD4-CD8+ cells. Two other pC8-immunized macaques, N110 and N111, treated in the same way, did not show significant depletion of CD8+ cells. None of these four pC8-immunized animals became infected when challenged with 50 MID50 of pJ5. Treatment of a further four pC8-infected and protected macaques and two naive control animals with Campath-1H antibody successfully depleted peripheral CD3+ cell counts by >99% in all treated animals. Campath-1H depletion resulted in enhanced, longer lasting lymphoid depletion. Yet subsequent challenge with 20 MID50 of pJ5 still failed to infect the pC8-immunized animals. All eight of the naive controls, including two Campath-1H-treated animals, became infected following challenge. In summary, partial depletion of circulating CD8+ cells or total lymphocytes prior to challenge failed to abrogate the protection conferred by vaccination with pC8.

Evaluation of a candidate human immunodeficiency virus type 1 (HIV-1) vaccine in macaques: effect of vaccination with HIV-1 gp120 on subsequent challenge with heterologous simian immunodeficiency virus-HIV-1 chimeric virus

Human immunodeficiency virus type 1 (HIV-1) envelope vaccines can now be evaluated for efficacy in macaques by challenging with chimeric viruses in which the env, tat and rev genes of simian immunodeficiency virus (SIV) have been replaced by those of HIV-1. Most experiments have so far been conducted using gp120 molecules derived from T-cell-adapted LAI or MN strains of HIV-1, which predominantly use the CXCR-4 co-receptor. These vaccines protect against infection by apathogenic chimeric virus carrying the same envelope sequences. In the experiment described here, four macaques were vaccinated with W61D gp120 derived from a low passage Dutch isolate and capable of inhibiting the binding of MIP1beta to the co-receptor CCR-5. This vaccine was potent, inducing high titres of binding and neutralizing antibodies against the homologous HIV-1 and tenfold lower titres against a heterologous challenge virus (SHIV(SF33)) in which the env, tat and rev genes of SIV had been replaced by those of a San Francisco isolate, HIV-1(SF33). Despite strong immune responses to the vaccine there was no evidence that it protected against challenge with this chimeric virus. The antigenic divergence between vaccine and challenge virus or the increased virulence of the challenge virus may be responsible for the inability of this vaccine to protect against infection by SHIV(SF33).

Endogenous BDNF protein is increased in adult rat hippocampus after a kainic acid induced excitotoxic insult but exogenous BDNF is not neuroprotective

Systemic administration of the excitotoxin kainic acid to adult rats results in a well defined pattern of loss of the CA1 and CA3 pyramidal neurons of the hippocampus. Prior to this neuronal loss, brain-derived neurotrophic factor (BDNF) mRNA is substantially increased. We show here that BDNF protein is increased after excitotoxic insult in specific areas of the hippocampus, reaching maximal levels 24 h after the insult. BDNF protein levels in the hippocampus increase in direct relation to the severity of seizure. Up to 7 days after injection of kainic acid, levels of full-length TrkB protein were unchanged, whereas levels of truncated TrkB protein were significantly increased by 12 h. To determine whether elevations in BDNF protein levels are potentially beneficial to hippocampal neurons exposed to an excitotoxic stress, we infused exogenous BDNF prior to and during the period of neuronal death caused by kainic acid. We find that administration of high levels of exogenous BDNF does not affect severity of seizure, but does in fact, exacerbate the injury caused by kainic acid, specifically to CA3 pyramidal neurons. Although there was a trend toward sparing of CA1 pyramidal neurons on the side infused with BDNF, this was not significant. In the same paradigm, infusion of exogenous NT-3 had no effect.

Assessing the significance of reverse transcriptase activity in chick cell-derived vaccines

A recent publication reported the detection of low levels of the enzyme reverse transcriptase (RTase) in live viral vaccines prepared in chick embryo cells. The enzyme was detected using an assay with greatly increased sensitivity compared to more conventional methods. The authors have confirmed the observation of RTase activity and demonstrate that the activity is not dependent on the production of viral vaccines in chick cells but is present ubiquitously in chick embryonic fluids. The authors have also been unable to transmit the RTase activity from chick cells to a wide variety of cells of human, monkey, rabbit and turkey origin, suggesting that the activity is not associated with an avian agent capable of infecting these cells. It is concluded that the data available present no cause for concern over the safety of vaccines derived in chick cells and current WHO requirements for such vaccines remain appropriate.

Mechanisms of protection induced by attenuated simian immunodeficiency virus. IV. Protection against challenge with virus grown in autologous simian cells

Attenuated simian immunodeficiency virus (SIV) induces potent protection against infection with wild-type virus, but the mechanism of this immunity remains obscure. Allogeneic antibodies, which arise within animals as a result of SIV infection, might protect against challenge with exogenous SIV grown in allogeneic cells. To test this hypothesis, eight macaques were infected with attenuated SIV and subsequently challenged with wild-type SIV grown in autologous cells or heterologous cells. The results clearly demonstrated that animals infected with attenuated SIV are protected against wild-type SIV grown in autologous or heterologous cells. Thus, the hypothesis that live attenuated SIV protects by the induction of allogeneic antibodies is not tenable.

Early suppression of SIV replication by CD8+ nef-specific cytotoxic T cells in vaccinated macaques

In order to develop a successful subunit vaccine against infection with the human immunodeficiency virus (HIV), protective immune effector functions must be identified. Until now, there has been only indirect evidence that HIV-specific cytotoxic T lymphocytes (CTLs) fulfill this role. Using the macaque simian immunodeficiency virus (SIV) model, the protective potential of nef-specific CTLs, stimulated by vaccination, was examined in animals challenged with a high intravenous dose of the pathogenic simian immunodeficiency virus, SIVmac251(32H)(pJ5). An inverse correlation was found between the vaccine-induced nef-specific CTL precursor frequency and virus load measured after challenge. In addition, the early decline in viraemia, observed in both vaccinated and unvaccinated control animals was associated with the development of virus-specific CTL activity and not with the presence of virus-specific neutralizing antibodies. The results imply that vaccines that stimulate strong CTL responses could protect against HIV infection.

Fine analysis of humoral antibody response to envelope glycoprotein of SIV in infected and vaccinated macaques

To characterize the serological response to SIV envelope, induced by vaccination with different envelope immunogens or by SIV infection, plasma samples from 11 cynomolgus macaques infected with simian immunodeficiency virus (SIV) and from 16 macaques vaccinated with three different recombinant envelope proteins were analyzed by (1) ELISA, using a variety of antigens including overlapping peptides encompassing the entire sequence of the envelope protein of SIV, and (2) competition assays, using neutralizing monoclonal antibodies to SIV gp120. Seven regions of SIV envelope were predicted to be antigenic. Peptides representing four of these, in the second and third variable regions (V2 and V3) and the fourth constant (C4) region of gp120 and the Gnann region of gp41, were recognized by the majority of sera from infected and vaccinated animals. Additional antigenic regions were identified in the first and fourth variable domains (V1 and V4) and the carboxy terminus (C5) of gp120 and in three additional regions of gp41. Most infected and vaccinated animals made antibodies that competed with the binding of the three conformational MAbs. Among the vaccinated groups, antibodies induced by vaccination with precursor glycoproteins (gp140 or gp160) recognized several additional gp120 epitopes when compared with antibodies induced by external glycoprotein gp130. Sera from infected animals showed a more restricted gp120 response (17 of 46 peptides recognized) compared to animals vaccinated with precursor glycoproteins (31 peptides recognized). The converse was true for antibodies to gp41. Sera from animals vaccinated with recombinant gp140, produced in insect cells, were the only group that failed to compete with the binding of conformational MAbs. Finally, the development of antibodies to specific epitopes of gp120 and gp41 revealed differences between long-term survivors and nonsurvivors, implying that responses to specific epitopes may be important in conferring resistance to disease progression.

Passive immunization of cynomolgus macaques with immune sera or a pool of neutralizing monoclonal antibodies failed to protect against challenge with SIVmac251

In the first of two passive transfer experiments, three groups of four macaques were injected intraperitoneally with a normal serum pool, an immune serum pool (pool 1) collected 132-172 weeks postinfection with the 11/88 pool of SIVmac251, or with a pool of four neutralizing monoclonal antibodies (KK9, 17, 54, and 56) raised against gp120 of the 11/88 pool. Sera were given at a dose of 13 ml/kg whereas the MAb pool was given at 30 ml/kg. In a second experiment, a further four macaques were injected with an immune serum pool (pool 2) collected 12 weeks postinfection with simian-grown SIVmac251 at a dose of 19 ml/kg. Animals in both experiments were challenged with SIVmac251 grown in simian peripheral blood lymphocytes. Despite high levels of circulating antibodies in the serum of animals that received either the immune serum pools or the MAbs, all macaques became infected following challenge. The results described are in contrast to a previous report in which passive transfer of sera from animals infected with SIVsm successfully protected against challenge with the homologous virus grown in human PBMCs. Challenge with SIVmac251 grown in simian PBMCs may be the reason for these conflicting results. Nevertheless, the results suggest that in this model the presence of circulating neutralizing antibodies alone does not necessarily confer protection against challenge with SIVmac251 grown in simian cells.

The haemagglutinins of influenza A (H1N1) viruses in the 'O' or 'D' phases exhibit biological and antigenic differences

Influenza A (H1N1) viruses when initially isolated in mammalian cell cultures (MDCK cells) had different agglutination reactions with chicken and guinea-pig erythrocytes compared to the same viruses after passage. On first isolation the virus HA resembled the 'O' phase viruses described originally by Burnet and Bull and agglutinated mammalian but not avian erythrocytes. After passage, the virus HA resembled a classical 'D' phase virus and agglutinated both avian and mammalian erythrocytes. Monoclonal and polyclonal antisera detected antigenic differences between the HAs of the viruses in the 'O' and 'D' phases. The 'O' phase virus HA reacted preferentially with antibodies in post infection human antisera. Viruses in the 'O' phase replicated poorly in the allantoic cavity of embryonated hens' eggs whilst 'D' phase virus replicated in both MDCK cells and in embryonated hens' eggs. At least three distinguishable subpopulations of influenza A (H1N1) viruses may co-exist in clinical throat swab material, including viruses possessing HAs in the 'O' and 'D' phases and other 'D' phase viruses cultivable in embryonated hens' eggs but antigenically distinguishable from the corresponding 'D' phase virus in MDCK cells.

Immunisation of macaques with SIV env recombinants: specificity of T cell and antibody responses and evaluation of protective efficacy

Macaques were immunised with lentil lectin purified recombinant SIVmac (BK28) derived gp160 (rgp160) with or without live vaccinia (vac)-env (BK28) priming, followed by a final boost with solid matrix antibody antigen (SMAA)-gp160 (J5) complexes and challenged with the SIVmac molecularly cloned virus J5M. Rgp160 and vac-env plus gp160 induced strong Ab responses against the homologous virus. Live vac-env did not enhance or prolong the antibody response, however, T cell responses were stronger. Analysis of the specificity of the immune response demonstrated that sequence variation within SIVmac viruses can affect antibody and T cell recognition. A single booster immunisation with the heterologous SIVmac J5 env recombinant protein was not sufficient to protect against the molecularly cloned virus J5M. These findings further illustrate the difficulty of generating protective immunity with immunogens based on single sequence recombinants.

Studies on the specificity of the vaccine effect elicited by inactivated simian immunodeficiency virus

Inactivated, partially purified simian immunodeficiency virus (SIVmac) protected macaques from intravenous challenge with homologous and heterologous strains of SIV that had been grown on human cells but no protection against challenge with monkey peripheral blood mononuclear cell-grown SIVmac was afforded. Human immunodeficiency virus type 1 prepared in an analogous way to the SIVmac vaccine on the C8166 human T cell line protected macaques against challenge with human cell-grown SIVmac. These results suggest that protection may be mediated by xenoimmunization with the vaccine cell substrate proteins. All vaccinated macaques had anti-cell antibodies. Major reactivity to MHC class I antigens was found as well as to a 70-kD protein detectable only under nonreducing conditions.

Stimulation of specific immune responses to simian immunodeficiency virus using chimeric hepatitis B core antigen particles

Subunit approaches to vaccines against viral diseases have resulted in the development of a number of methods for presentation of defined epitopes to the immune system. We have exploited a highly immunogenic presentation system based on hepatitis B core antigen (HBcAg) particles to produce a number of candidate vaccines against simian immunodeficiency virus (SIV). Recombinant particles have been produced in bacteria which carry multiple copies of defined or predicted neutralizing epitopes of SIV at a number of different sites within the particle. In parallel, a number of synthetic peptide-based SIV vaccines have been produced based on homology to reported neutralizing epitopes in human immunodeficiency virus. Although potent immune responses were elicited against both particulate and peptide forms of the antigen, neutralizing antibodies were not induced as judged by available assays.

Identification of two neutralizing and 8 non-neutralizing epitopes on simian immunodeficiency virus envelope using monoclonal antibodies

Ten new monoclonal antibodies (MAbs) to SIV envelope were produced and characterized. Using a panel of 28 MAbs, 10 antibody binding sites on SIV envelope protein were identified. Seven sites were located in gp120 and three in gp41. Five sites in gp120 and two in gp41 were defined by overlapping peptides. The remaining two sites on gp120 and one on gp41 were distinguished by competition binding assays but could not be defined by overlapping peptides, suggesting that they were discontinuous or conformational epitopes. Five of the 28 MAbs consistently and reliably neutralized the infectivity of SIVmac251. Two of these bound to a peptide (aa171-190) in the V2 region. The remaining three MAbs bound to a conformational epitope on gp120. These two neutralizing epitopes on SIV are analogous to similar epitopes recently described in HIV-1. In contrast, three MAbs binding to the V3 region of SIV failed to neutralize infectivity, suggesting that this region in SIV may by functionally different from the V3 loop in HIV-1.

Restriction of serum antibody reactivity to the V3 neutralizing domain of HIV gp120 with progression to AIDS

OBJECTIVE

To identify epitopes on HIV-1 gp120 that correlate with disease resistance and/or prognostic indication.

DESIGN

The identification of epitopes on HIV-1 gp120 was determined by testing the reactivity by immunoblotting of anti-HIV-positive human sera against partially cleaved Chinese hamster ovary (CHO) cell-derived recombinant gp120. Cleavage of recombinant gp120 occurs in the V3 loop region resulting in 70 and 50K cleavage bands if the protein is subjected to sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) under reducing conditions. Antibodies reactive with the 120 Mr band alone on immunoblotting indicate that binding is restricted to this cleavage site. Reactivity to either of the cleavage products is independent of gp120 cleavage and indicates that binding occurs in sites other than the V3 cleavage region.

METHODS

A panel of anti-HIV-positive human sera was tested for virus neutralizing activity and reactivity by immunoblotting against CHO cell-derived gp120.

RESULTS

All sera reacted with the uncleaved from of gp120 but reacted either weakly or did not react with its cleavage products. There was a statistically significant correlation between serum reactivity to cleavage products and clinical stage of disease [Centers for Disease Control (CDC) criteria]. Sera of asymptomatic individuals (CDC stage II/III) were more likely to recognize either one or both of the cleavage products compared with sera from patients presenting with symptoms of disease (CDC stage IV). Furthermore, sera reacting with either one or both of the cleavage products were more likely to have higher neutralizing antibody titres than those that were unreactive.

CONCLUSIONS

There is a restriction of serum antibody reactivity (when tested by immunoblotting) to the V3 loop with progression to disease. Raised neutralizing antibody titres may be dependent on regions outside the V3 cleavage site.

Production and of monoclonal antibodies to simian immunodeficiency virus envelope glycoproteins

Eighteen monoclonal antibodies (MAb) to simian immunodeficiency virus (SIV) envelope have been characterized. All MAb were shown to bind to viral antigens on the surface of unfixed SIV-infected cells and to precipitate surface glycoproteins of SIVmac251. In Western blot 11 MAb bound to gp160 and gp120, five bound to gp160 and the transmembrane protein gp41 and two MAb did not react with denatured antigen. Preliminary competition assays identified the existence of six competition groups; two groups were within gp41 and four were within gp120. Of the latter four groups, three contained MAb with neutralizing activity. Two of the neutralizing MAb (KK5 and KK9) did not react with denatured antigen in Western blot suggesting that they may recognize conformational epitopes. Enzyme-linked immunosorbent-assay titres of MAb against SIVmac251 ranged from 10(2.4) to 10(5.6) and although similar titres were obtained with some MAb against other SIV and HIV antigens, the presence of isolate specific and shared group epitopes was demonstrated.

Direct isolation in eggs of influenza A (H1N1) and B viruses with haemagglutinins of different antigenic and amino acid composition

Influenza A (H1N1) and influenza B viruses from clinical samples were isolated in the amniotic cavity of embryonated hens' eggs by classical techniques and propagated in the allantoic cavity. Virus progeny from different eggs which had been inoculated with virus material from the same clinical sample possessed antigenically distinguishable haemagglutinins (HAs). Virus progeny of some eggs possessed HAs which were serologically identical to those of virus isolated in parallel in mammalian (MDCK) cells. These egg-grown viruses possessing HAs with the antigenic phenotype of mammalian cell-grown viruses appeared to be antigenically related to epidemic influenza virus because post-infection human sera reacted to high titre with the virus HA. Specific nucleotide changes were detected in the HAs of the viruses isolated directly in eggs at positions 163 and 189 for influenza A (H1N1) viruses or positions 141 and 196 to 198 for influenza B viruses. Egg-isolated viruses which possessed the antigenic phenotype of mammalian cell-grown viruses retained glycosylation sites at positions 163 and 196. The viruses isolated directly in embryonated hens' eggs which possessed the HA antigenic phenotype and glycosylation sites of MDCK cell-grown virus can, unlike the latter viruses themselves, be used as candidate influenza vaccine viruses.

A host-cell-selected variant of influenza B virus with a single nucleotide substitution in HA affecting a potential glycosylation site was attenuated in virulence for volunteers

An influenza B virus was passaged in man (virus A) and then in human embryo trachea (C) and into embryonated eggs (D) or directly into eggs (B). Virus A, B, and C had the same (cell-like) haemagglutinin phenotype on reaction with selected monoclonal antibodies while D had an "egg-like" phenotype. The viruses were administered at a dose of 1,000 TCD50 (for MDCK cells) by intranasal inoculation to groups of 27 or 28 volunteers. Viruses A, B, and C all produced disease in six to eight volunteers, whereas D produced no illness and only four volunteers were infected. The viruses shed by the volunteers were indistinguishable from those with which they were inoculated. The haemagglutinin genes of the viruses were sequenced and changes were detected indicating amino acid substitutions at position 196-198 in the attenuated egg-grown virus D whereby a potential glycosylation site present in the other viruses was lost.

Failure of influenza vaccine to prevent two successive outbreaks of influenza A H1N1 in a school community

Forty nine of the 149 boys (33%) at a preparatory school fell ill at the beginning of the autumn term 1986 with symptoms of influenza. One hundred and eighty two of the 470 pupils (39%) in the senior part of the same school had similar symptoms of influenza at the beginning of the spring term 1987. A new variant of influenza A H1N1 virus was isolated from both outbreaks and shown to be antigenically similar to A/Taiwan/1/86. The attack rate among pupils who had previously received trivalent influenza vaccine containing A/Chile/1/83 H1N1 antigen was not significantly different from the rate among those who had never been vaccinated. It is concluded that annual vaccination of all boarding school pupils may be inappropriate.

Protein and nucleic acid analysis of influenza B viruses isolated in Italy in 1984

Genomic and phenotypic analysis of 30 influenza B viruses, isolated in Italy in 1984, antigenically closely related to the B/USSR/100/83 prototype virus, was carried out using T1-oligonucleotide fingerprinting of total RNA and one-dimensional peptide mapping. The results of fingerprinting analysis indicated an oligonucleotide spot homology of 90-96%, corresponding to a nucleotide sequence variation of only 0.75-0.3%. All the strains appear to belong to the same evolutionary line. Nevertheless, heterogeneity was found at the structural and antigenic level, when the viruses were compared by peptide mapping and monoclonal antibody analysis. No correlation between the biochemical variability of the viruses and the epidemiological characteristics of the different strains was established, which is consistent with the hypothesis that distinct variants, arisen at different times from a parental strain, co-circulate during an epidemic, although the additional occurrence of random mutations during the evolution of the epidemic cannot be excluded.

In vitro response to influenza immunisation by peripheral blood mononuclear cells from patients with systemic lupus erythematosus and other autoimmune diseases

Reduced in vitro anti-influenza antibody response by peripheral blood mononuclear cells (PBMs) after vaccination was confirmed in a group of 28 patients with systemic lupus erythematosus (SLE), and also in 16 patients with some other autoimmune syndromes. This group of patients with SLE had higher serum anti-DNA binding, but there was no evidence of increased autoantibody production after vaccination, nor any clinical or laboratory evidence of flares in disease activity that are sometimes seen to follow intercurrent infection. Although a reduced in vitro antibody response may, to some extent, reflect redistribution of antibody producing cells, there appears to be more generalised impairment of the immune response in these patients, which cannot be accounted for by steroid/immunosuppressive therapy.

Serological studies with influenza A(H1N1) viruses cultivated in eggs or in a canine kidney cell line (MDCK)

Pairs of influenza A(H1N1) viruses cultivated from the same clinical specimen in canine kidney (MDCK) cells or in embryonated hens' eggs can frequently be distinguished by their reactions with monoclonal antibodies to haemagglutinin and with antibodies in ferret or human sera. Egg-adapted virus, further passaged in MDCK cultures remained "egg-like" in serological characteristics indicating that the differences in their serological reactions were not a direct result of host cell-dependent glycosylation of the haemagglutinin. Haemagglutination-inhibiting (HI) or virus neutralizing antibodies in human sera can be detected more frequently, and to higher titre, in tests employing virus grown exclusively in MDCK cells than in tests with virus adapted to growth in embryonated eggs. Striking differences were detected in the serological reactions in HI tests when sera from ferrets infected with egg-grown virus were tested against a series of strains of influenza A(H1N1) virus isolated in 1983 and adapted to growth in eggs. In contrast, sera from ferrets infected with MDCK-derived virus failed to distinguish serologically between the same viruses that had been passaged exclusively in MDCK cells and also revealed relatively small differences between their egg-adapted counterparts.It was concluded that the cell substrate used for virus isolation and cultivation is a factor that should be considered when interpreting the results of strain characterization of influenza A(H1N1) isolates and in sero-surveys using these viruses.