Human placental membrane as a wound cover for chronic diabetic foot ulcers: a prospective, postmarket, CLOSURE study.

OBJECTIVE: To evaluate the safety and efficacy of a chorioamniotic allograft, used as a wound cover for chronic foot ulcers, in patients with diabetes. METHODS: A multicentre, prospective, postmarket study where eligible patients received up to 11 weekly wound cover applications. Computerised planimetry was used to calculate the diabetic foot ulcer (DFU) area each week. The primary endpoint of the study was wound closure assessment. Secondary endpoints included DFU recurrence and morbidity. RESULTS: A total of 63 patients with 64 ulcers were enrolled, after successful completion of a two-week run-in period. Patients were predominantly male and had risk factors for delayed healing. Mean baseline DFU area was 3.8cm2 (standard deviation (SD): 4.8). After 12 weeks, a total of 19 (40%) DFUs had closed. Results varied by size category, 'small' (≤2.0cm2), 'medium' (>2.0-4.0 cm2), and 'large' (>4.0-25.0 cm2), with higher percentage closure in the 'small' DFU group, compared with the 'medium' and 'large' DFUs (57%, 33%, and 10%, respectively). Of those DFUs that closed, the average closure time was 6.5 weeks. There were no unanticipated adverse events. CONCLUSION: Known risk factors for healing, including DFU size, location and duration, affected the outcomes. However, the results are in line with the literature and support the use of the chorioamniotic allograft in chronic and complex cases.

Experimental and natural vertical transmission of West Nile virus by California Culex (Diptera: Culicidae) mosquitoes.

Culex (Diptera: Culicidae) mosquitoes, the primary summer vectors of West Nile virus (family Flaviviridae, genus Flavivirus, WNV), also may serve as overwintering reservoir hosts. Detection of WN viral RNA from larvae hatched from eggs deposited by infected females during late summer and fall may provide evidence for the vertical passage of WNV to overwintering cohorts. To determine whether vertical transmission to the overwintering generation occurs in populations of Culex mosquitoes throughout California, larvae from naturally infected females were tested by family for WN viral RNA by real-time quantitative reverse transcription-polymerase chain reaction during August through October 2011. Viral RNA was detected in 34 of 934 Culex tarsalis Coquillett and Cx. pipiens complex females that laid viable egg rafts. From these egg rafts, first-instar larvae from nine families tested positive, yielding an overall field vertical transmission rate of 26% (n = 34). To determine whether the WNV may be lost transtadially during development to the adult stage, first-instar larvae and adult progeny from experimentally infected Cx. pipiens complex females were assessed for the presence and quantity of WN viral RNA. Most (approximately 75%) WNV infections were lost from positive families during larval development to the adult stage. In field and laboratory studies, only infected mothers with mean cycle threshold scores < or = 20 vertically transmitted WNV to larval progeny, adult progeny, or both. In summary, vertical transmission of WNV was detected repeatedly in naturally infected Culex mosquitoes collected throughout California during late summer and fall, with females having high titered infections capable of passing WNV onto their progeny destined for overwintering.

Detection of persistent west nile virus RNA in experimentally and naturally infected avian hosts.

To determine whether West Nile virus (WNV) persistent infection in avian hosts may potentially serve as an overwintering mechanism, House Sparrows and House Finches, experimentally and naturally infected with several strains of WNV, and two naturally infected Western Scrub-Jays were held in mosquito-proof outdoor aviaries from 2007-March 2008. Overall, 94% (n = 36) of House Sparrows, 100% (n = 14) of House Finches and 2 Western Scrub-Jays remained WNV antibody positive. When combined by species, 37% of the House Sparrows, 50% of the House Finches, and 2 Western Scrub-Jays were WNV RNA positive at necropsy, up to 36 weeks post-infection. Infectious WNV was not detected. Our study supports the hypothesis that some avian hosts support the long-term persistence of WNV RNA, but it remains unresolved whether these infections relapse to restart an avian-arthropod transmission cycle and thereby serve as an overwintering mechanism for WNV.

Efficacy of three vaccines in protecting Western Scrub-Jays (Aphelocoma californica) from experimental infection with West Nile virus: implications for vaccination of Island Scrub-Jays (Aphelocoma insularis).

The devastating effect of West Nile virus (WNV) on the avifauna of North America has led zoo managers and conservationists to attempt to protect vulnerable species through vaccination. The Island Scrub-Jay (Aphelocoma insularis) is one such species, being a corvid with a highly restricted insular range. Herein, we used congeneric Western Scrub-Jays (Aphelocoma californica) to test the efficacy of three WNV vaccines in protecting jays from an experimental challenge with WNV: (1) the Fort Dodge West Nile-Innovator(®) DNA equine vaccine, (2) an experimental DNA plasmid vaccine, pCBWN, and (3) the Merial Recombitek(®) equine vaccine. Vaccine efficacy after challenge was compared with naïve and nonvaccinated positive controls and a group of naturally immune jays. Overall, vaccination lowered peak viremia compared with nonvaccinated positive controls, but some WNV-related pathology persisted and the viremia was sufficient to possibly infect susceptible vector mosquitoes. The Fort Dodge West Nile-Innovator DNA equine vaccine and the pCBWN vaccine provided humoral immune priming and limited side effects. Five of the six birds vaccinated with the Merial Recombitek vaccine, including a vaccinated, non-WNV challenged control, developed extensive necrotic lesions in the pectoral muscle at the vaccine inoculation sites, which were attributed to the Merial vaccine. In light of the well-documented devastating effects of high morbidity and mortality associated with WNV infection in corvids, vaccination of Island Scrub-Jays with either the Fort Dodge West Nile-Innovator DNA vaccine or the pCBWN vaccine may increase the numbers of birds that would survive an epizootic should WNV become established on Santa Cruz Island.

Repeated West Nile virus epidemic transmission in Kern County, California, 2004-2007.

West Nile virus (WNV) has remained epidemic in Kern County, CA, since its introduction in 2004 through 2007 when the human case annual incidence increased from 6-8 to 17 per 100,000, respectively. The 2007 increase in human infection was associated with contradicting surveillance indicators, including severe drought, warm spring but cool summer temperature anomalies, decreased rural and urban mosquito abundance but increased early season infection in urban Culex quinquefasciatus Say, moderate avian "herd immunity," and declines in the catch of competent (western scrub-jay and house finch) and noncompetent (California quail and mourning dove) avian species. The decline in these noncompetent avian hosts may have increased contact with competent avian hosts and perhaps humans. The marked increase in home foreclosures and associated neglected swimming pools increased urban mosquito production sites, most likely contributing to the urban mosquito population and the WNV outbreak within Bakersfield. Coalescing five surveillance indicators into a risk assessment score measured each half month provided 2- to 6-wk early warning for emergency planning and was followed consistently by the onset of human cases after reaching epidemic conditions. St. Louis encephalitis virus (SLEV) antibody was detected rarely in wild birds but not mosquitoes or sentinel chickens, indicating that previously infected birds were detected in Kern County, but SLEV reintroduction was not successful. In contrast, western equine encephalitis virus (WEEV) was detected during 3 of 5 yr in Culex tarsalis Coquillett, sentinel chickens, and wild birds, but failed to amplify to levels where tangential transmission was detected in Aedes mosquitoes or humans. A comparison of transmission patterns in Kern County to Coachella Valley in the southeastern desert of California showed the importance of mosquito phenology and spatial distribution, corvids, or other avian "super spreaders" and anthropogenic factors in WNV epidemiology.

DIFFERENTIAL IMPACT OF WEST NILE VIRUS ON CALIFORNIA BIRDS.

The strain of West Nile virus (WNV) currently epidemic in North America contains a genetic mutation elevating its virulence in birds, especially species in the family Corvidae. Although dead American Crows (Corvus brachyrhynchos) have been the hallmark of the epidemic, the overall impact of WNV on North America's avifauna remains poorly understood and has not been addressed thoroughly in California. Here, we evaluate variation by species in the effect of WNV on California birds from 2004 to 2007 by using (1) seroprevalence in free-ranging birds, (2) percentage of carcasses of each species reported by the public that tested positive for WNV, (3) mortality determined from experimental infections, and (4) population declines detected by trend analysis of Breeding Bird Survey (BBS) data. Using Bayesian linear models, we extrapolate trends in BBS data from 1980-2003 (pre-WNV) to 2004-2007 (post-WNV). We attribute significant declines from expected abundance trends in areas supporting epiornitics to WNV transmission. We combine risk assessed from each of the four data sets to generate an overall score describing WNV risk by species. The susceptibility of California avifauna to WNV varies widely, with overall risk scores ranging from low for the refractory Rock Pigeon (Columba livia) through high for the susceptible American Crow. Other species at high risk include, in descending order, the House Finch (Carpodacus mexicanus), Black-crowned Night-Heron (Nycticorax nycticorax), Western Scrub-Jay (Aphelocoma californica), and Yellow-billed Magpie (Pica nuttalli). Our analyses emphasize the importance of multiple data sources in assessing the effect of an invading pathogen.

Delinquent mortgages, neglected swimming pools, and West Nile virus, California.

Adjustable rate mortgages and the downturn in the California housing market caused a 300% increase in notices of delinquency in Bakersfield, Kern County. This led to large numbers of neglected swimming pools, which were associated with a 276% increase in the number of human West Nile virus cases during the summer of 2007.

Role of California (Callipepla californica) and Gambel's (Callipepla gambelii) quail in the ecology of mosquito-borne encephalitis viruses in California, USA.

Gambel's and California quail were infected repeatedly whenever western equine encephalomyelitis virus (WEEV), St. Louis encephalitis virus (SLEV), and (WNV) West Nile virus were active during summer in California. The timing of virus appearance and quail infection coincided well with the appearance of chicks in nature, leading us to hypothesize that large coveys containing these non-immune birds could be important in focal virus amplification in rural settings. However, experimental infection studies with chicks, juveniles, and adults of both quail species using sympatric strains of WEEV, SLEV, and WNV indicated that only immature birds were competent hosts for WEEV, producing viremias sufficiently elevated to efficiently infect Culex tarsalis mosquitoes. Quail were less competent hosts for WNV and were incompetent for SLEV. Large populations of quail that frequently are infected with SLEV or WNV, but produce low to moderate viremias, may serve as dead end hosts for these viruses. Due to their abundance and repeated infection, these birds may attenuate virus amplification in rural areas of California and possibly could be one reason why WNV epidemics seem to occur more frequently in urban and periurban than in rural landscapes.