Influenza gain-of-function experiments: their role in vaccine virus recommendation and pandemic preparedness.

In recent years, controversy has arisen regarding the risks and benefits of certain types of gain-of-function (GOF) studies involving avian influenza viruses. In this article, we provide specific examples of how different types of data, including information garnered from GOF studies, have helped to shape the influenza vaccine production process-from selection of candidate vaccine viruses (CVVs) to the manufacture and stockpiling of safe, high-yield prepandemic vaccines for the global community. The article is not written to support a specific pro- or anti-GOF stance but rather to inform the scientific community about factors involved in vaccine virus selection and the preparation of prepandemic influenza vaccines and the impact that some GOF information has had on this process.

[Microcirculatory changes over the tender points in fibromyalgia patients after acupuncture therapy (measured with laser-Doppler flowmetry)]. / Anderung der Durchblutung über den tender points bei Fibromyalgie-Patienten nach einer Akupunkturtherapie (gemessen mit der Laser-Doppler-Flowmetrie).

Apart from widespread pain which is the main symptom of fibromyalgia, a great variety of functional and vegetative changes occur in the presence of this disease. Such changes include alterations in microcirculation, which may cause pain. A preliminary study demonstrated a reduction in regional blood flow above "tender points" in fibromyalgia patients compared with healthy controls. A consensus statement of the National Institutes of Health (NIH) states that acupuncture is a sufficient adjuvant method to treat patients with fibromyalgia. The aim of the present study was to determine parameters to measure the effectiveness of a specific treatment modality (such as acupuncture) in addition to the patient's subjective assessment of acupuncture treatment. Twenty patients with fibromyalgia according to the ACR and the Müller/Lautenschläger criteria were included in the study. Acupuncture was performed and adapted to individual needs in accordance with a specific protocol. Five representative "tender points" were examined before and after therapy by laser flowmetry, and the data were compared with temperature measurement and dolorimetry. Increased blood flow was registered above all "tender points" after acupuncture. Skin temperature had increased in 10/12 tender points by a mean of 0.45 degree C. The number of "tender points" were reduced from 16.1 to 13.8 after therapy. The pain threshold increased in 10/12 "tender points". These data suggest that acupuncture is a useful method to treat patients with fibromyalgia. Besides normalisation of clinical parameters, the improvement in microcirculation above "tender points" may alleviate pain.

Abnormal microcirculation and temperature in skin above tender points in patients with fibromyalgia.

OBJECTIVE: Skin temperature and skin blood flow were studied above different tender points in 20 patients with fibromyalgia (FM) and 20 healthy controls. METHODS: Blood flow was measured by laser Doppler flowmetry and skin temperature was measured with an infrared thermometer. RESULTS: In the skin above the five tender points examined in each subject, we found an increased concentration of erythrocytes, decreased erythrocyte velocity and a consequent decrease in the flux of erythrocytes. A decrease in temperature was recorded above four of the five tender points. CONCLUSION: Vasoconstriction occurs in the skin above tender points in FM patients, supporting the hypothesis that FM is related to local hypoxia in the skin above tender points.

Hepatitis A in New South Wales, Australia from consumption of oysters: the first reported outbreak.

Between 22 January and 4 April 1997, 467 hepatitis A cases were reported to the New South Wales Health Department, Australia. To identify the cause of the outbreak, we conducted a matched case-control study, and an environmental investigation. Among 66 cases and 66 postcode-matched controls, there was a strong association between illness and consumption of oysters (adjusted odds ratio 42; 95 % confidence interval 5-379). More than two-thirds of cases reported eating oysters, including one third of cases and no controls who reported eating oysters in the Wallis Lake area. A public warning was issued on 14 February, and Wallis Lake oysters were withdrawn from sale. Hepatitis A virus was subsequently identified in oyster samples taken from the lake. Hepatitis A virus poses a special risk to consumers who eat raw oysters because it can survive for long periods in estuaries and cause severe disease.

Formation of a carcinogenic aromatic amine from an azo dye by human skin bacteria in vitro.

Azo dyes represent the major class of dyestuffs. They are metabolised to the corresponding amines by liver enzymes and the intestinal microflora following incorporation by both experimental animals and humans. For safety evaluation of the dermal exposure of consumers to azo dyes from wearing coloured textiles, a possible cleavage of azo dyes by the skin microflora should be considered since, in contrast to many dyes, aromatic amines are easily absorbed by the skin. A method for measuring the ability of human skin flora to reduce azo dyes was established. In a standard experiment, 3x10(11) cells of a culture of Staphylococcus aureus were incubated in synthetic sweat (pH 6.8, final volume 20 mL) at 28 degrees C for 24 h with Direct Blue 14 (C.I. 23850, DB 14). The reaction products were extracted and analysed using HPLC. The reduction product o-tolidine (3,3'-dimethylbenzidine, OT) could indeed be detected showing that the strain used was able to metabolise DB 14 to the corresponding aromatic amine. In addition to OT, two further metabolites of DB 14 were detected. Using mass spectrometry they were identified as 3,3'-dimethyl-4-amino-4'-hydroxybiphenyl and 3, 3'-dimethyl-4-aminobiphenyl. The ability to cleave azo dyes seems to be widely distributed among human skin bacteria, as, under these in vitro conditions, bacteria isolated from healthy human skin and human skin bacteria from strain collections also exhibited azo reductase activity. Further studies are in progress in order to include additional azo dyes and coloured textiles. At the moment, the meaning of the results with regard to consumer health cannot be finally assessed.

The arteriovenous impulse system in total hip arthroplasty.

BACKGROUND: Despite the continuing high incidence of deep vein thrombosis after total hip arthroplasty, currently available mechanical thromboprophylactic systems are not sufficiently utilised in Germany. PATIENTS AND METHODS: Duplex-sonographic measurements of the maximum venous flow velocity (V. femoralis) in 10 healthy individuals performed with a leg orientation synonymous to that during total hip arthroplasty were compared to figures obtained during an out-stretched leg position. Additionally, duplex-sonography was conducted on 9 patients intra-operatively during total hip replacement to complete the study. All investigations were executed both with and without application of the A-V Impulse System (AVIS), a mechanical thromboprophylactic procedure. RESULTS: In contrast to the out-stretched leg position, a decreased venous peak flow velocity during surgery as well as in the operation-identical leg orientation was demonstrated in the absence of AVIS. However, by means of AVIS, a significant increase in the venous peak flow velocity (p < 0.01) was achieved for both situations. Additionally, an increased vessel diameter of the V. femoralis communis was observed in 75% of patients due to the leg orientation stipulated for hip replacement surgery. CONCLUSION: The data suggest that the A-V Impulse System can effectively accelerate the venous reflux-flow during operations involving hip replacements and thus provide an early preventative therapy for deep vein thrombosis after a surgical procedure.

[Retrograde intravenous perfusion as ultima ratio in potential amputation patients with peripheral arterial occlusive disease]. / Retrograde intravenöse Perfusion als ultima ratio bei amputationsgefährdeten Patienten mit einer peripheren arteriellen Verschlusskrankheit.

In 21 patients with critical ischemia and/or inflammation of the leg facing possible amputation, retrograde intravenous perfusion (RVP) was used to administer fibrinolytics, vasodilators and antibiotics. Amputation was avoided in 15 patients. In 4 patients, RVP was interrupted due to unsuitable veins for putting in cannulas. After introducing a 3-in-1-Block (Winnie) for analgesia, 7 courses of treatment at least were reached before unbearable pain became a reason for stopping therapy. RVP should, therefore, be considered as the last resort in the treatment of critical ischemia and/or inflammation of the leg of patients facing possible amputation.

A large outbreak of acute gastroenteritis associated with astrovirus among students and teachers in Osaka, Japan.

In June 1991, a large outbreak of acute nonbacterial gastroenteritis occurred among students and teachers at 10 primary and 4 junior high schools in Katano City, Osaka, Japan. The outbreak affected > 4700 persons, lasted 5 days, and was believed to have been linked to contaminated food from a common supplier. Astrovirus, identified as the etiologic agent, was detected by direct electron microscopy in 10 of 38 fecal samples obtained from patients with diarrhea. Detection was confirmed by solid-phase immune electron microscopy (IEM), EIA, reverse transcription-polymerase chain reaction, and virus isolation in CaCo-2 cells. Several patients who had astrovirus in their stool also demonstrated a significant antibody response to a reference strain of astrovirus by IEM and EIA and to their own isolate by IEM. Astrovirus can be an important agent of epidemic acute nonbacterial gastroenteritis in school-aged children and adults in Japan.

Application of PCR to detect Norwalk virus in fecal specimens from outbreaks of gastroenteritis.

Norwalk virus (NV) and other small round-structured viruses (SRSVs) are frequent causes of gastroenteritis outbreaks. The recent cloning and sequencing of the NV genome has made it possible to detect NV and Norwalk-related viruses from fecal specimens by reverse transcription (RT)-PCR. We applied this technique to the examination of a total of 139 fecal specimens from 19 outbreaks characterized by NV serology, including 56 samples from 7 NV outbreaks, 36 from 6 Norwalk-related virus outbreaks, and 47 from 6 outbreaks with SRSVs visualized by electron microscopy that were serologically unrelated to NV. Three primer pairs were evaluated: two pairs in the polymerase region of NV and one pair near the 3' end of the genome. When one set of primers (primer pair 51-3) from the polymerase region was used, 40% of all samples were positive by RT-PCR and specimens from the NV outbreaks were more likely to be positive (64%) than those from outbreaks associated with Norwalk-related viruses (44%) or SRSVs (8%). To determine the relationship of the outbreak strains to NV, we compared the sequences of a 145-base portion of the polymerase gene from 10 specimens obtained from five different outbreaks characterized as NV by serology. No two outbreak strains had the same sequence in this 145-base portion of the polymerase gene, and the identities of the nucleotide and amino acid sequences of these products compared with the sequences of the corresponding region of NV ranged from 62 to 79% and 69 to 90%, respectively. Because of sequence diversity in the polymerase region, the successful application of RT-PCR to investigations of outbreaks of suspected NV-associated gastroenteritis will depend on the use of either multiple primer pairs or primers made against regions of the genome that are more conserved.

[Optimizing analgesia and procedure of retrograde venous perfusion in treatment of patients with peripheral arterial occlusive diseases]. / Optimierung der Analgesie und Verfahrensweise der retrograden Venenperfusion bei Behandlung von Patienten mit peripheren arteriellen Durchblutungsstörungen.

Description of the 3-in-1-Block (Winnie) as an effective method of anaesthesia in retrograde venous perfusion as one therapy in arterial occlusive disease. Additional recommendations are given to achieve a homogeneous distribution of the substances in the limb.

Enteric viruses and diarrhea in HIV-infected patients. Enteric Opportunistic Infections Working Group.

BACKGROUND: Diarrhea occurs frequently among persons with the acquired immunodeficiency syndrome, but the cause often remains unknown. We used a group of diagnostic assays to determine which viruses were etiologic agents of diarrhea in a group of persons infected with the human immunodeficiency virus (HIV). METHODS: Stool and serum specimens were obtained from HIV-infected patients enrolled in a longitudinal study in Atlanta. Fecal specimens from patients with diarrhea and from control patients without diarrhea were screened by electron microscopy, polyacrylamide-gel electrophoresis, and enzyme immunoassays for rotaviruses, enteric adenoviruses, caliciviruses, picobirnaviruses, and astroviruses. Paired serum samples were tested for antibody responses to Norwalk virus and picobirnavirus. RESULTS: Viruses were detected in 35 percent of 109 fecal specimens from patients with diarrhea but in only 12 percent of 113 specimens from those without diarrhea (P < 0.001). Specimens from patients with diarrhea were more likely than those from patients without diarrhea to have astrovirus (12 percent vs. 2 percent, P = 0.003); picobirnavirus (9 percent vs. 2 percent, P = 0.017); caliciviruses, including small round structured viruses (6 percent vs. 1 percent, P = 0.062); and adenoviruses (9 percent vs. 3 percent, P = 0.047). They were also more likely to have a mixed viral infection (6 percent vs. 0 percent, P = 0.006). With the use of polyacrylamide-gel electrophoresis to analyze concentrated RNA extracts from stool, picobirnavirus was detected in fecal specimens from 6 of the 65 patients with diarrhea and was associated with prolonged viral shedding and chronic diarrhea. No rotaviruses, enteric adenoviruses, or instances of seroconversion to positivity for Norwalk virus were observed. CONCLUSIONS: Novel enteric viruses such as astrovirus and picobirnavirus may be more important etiologic agents of diarrhea in HIV-infected patients than previously recognized and may be more common than either bacterial or parasitic enteropathogens.

Prevalence of enteric viruses among hospital patients with AIDS in Kinshasa, Zaire.

Diarrhoea is the most common manifestation of acquired immunodeficiency syndrome (AIDS) in Africa. Numerous parasitic or bacterial agents have been implicated, but a pathogen-specific aetiology has not been found. Enteric viruses (i.e., rotavirus, small round structured viruses, coronavirus, and adenovirus) were detected by enzyme-linked immunosorbent assay or electron microscopy in faecal specimens of 17% of 198 consecutive adult admissions to a general medical ward of an urban hospital in Kinshasa, Zaire. Overall, 57% of patients were seropositive for infection with human immunodeficiency virus (HIV) 1; of these, 50% were classified as World Health Organization AIDS stage IV. The prevalence of enteric viruses in stool specimens did not differ significantly between patients with and without HIV infection, and was not associated with acute or chronic diarrhoea, or constitutional symptoms. However, a trend (P = 0.14) towards greater frequency of virus in stools from patients in the lower 3 quintiles of the CD4/CD8 T cell ratio was seen. This trend approached statistical significance (P = 0.07) with stratification by HIV infection. Although we found no evidence in this population to support a major pathogenic role for these viruses alone in the enteropathy of AIDS, increased viral shedding was weakly associated with immunodeficiency.

PIP: During July-October 1989 in Zaire, a physician examined and took blood and stool samples from 198 adult patients at Mama Yemo Hospital in central Kinshasa to learn the prevalence of enteric viruses and their link to diarrhea, immunosuppression, and wasting among HIV infected and uninfected patients. In Kinshasa, diarrhea is prevalent and heterosexual intercourse is the main mode of HIV transmission. 57.6% of the patients were infected with HIV. 50% of the HIV-positive patients had AIDS. 93% of all HIV-positive patients either had AIDS (stage IV) or advanced stage III disease. 49% of them died while in the hospital. 22% of the HIV-negative patients died while in the hospital. 17% of all adult patients studied were infected with at least 1 enteric virus, especially rotavirus. Enteric viruses were isolated from both HIV infected and uninfected patients (17% and 18%, respectively). State of immunocompromise did not significantly affect viral shedding, but fewer patients in the less immunocompromised stages shed viruses than did those in the advanced stages of immunocompromise (3 vs. 72 patients). When examining the ratio of circulating CD4 and CD8 T cells in HIV-infected patients, however, there was a trend toward greater frequency of enteric viruses (p = .07). Chronic diarrhea was significantly associated with HIV seropositivity (p 0.01), HIV stage (p .001), and CD4/CD8 T cell ratio (p .01). Acute diarrhea was not associated with any of the above, however. These findings suggest that enteric viruses were not a significant cause of diarrhea, but they were isolated somewhat more often in patients of advanced immunosuppression.

An outbreak of Norwalk-like gastroenteritis associated with contaminated drinking water at a caravan park.

During the 1989 Christmas holiday period, a large outbreak of gastroenteritis occurred among persons staying at a caravan park in southern New South Wales. Review of local hospital records found that 77 per cent of patients presenting with infective diarrhoea between 29 December and 3 January had stayed at the caravan park. In a retrospective cohort study we compared rates of illness among caravan park patrons exposed to different water sources. Stools were tested for pathogens and convalescent sera for viral antibodies. Rain and reticulated river water sampled from the caravan park were tested for bacteria and viruses. Of 351 persons interviewed at the caravan park, 305 (87 per cent) reported an illness characterised by diarrhoea, vomiting and abdominal pain. Of 196 persons who used reticulated river water for drinking or ablutions, 175 (89 per cent) became ill compared with 47 of 72 persons (65 per cent) who did not use this water (relative risk 1.4, 95 per cent confidence interval 1.2 to 1.6). The outbreak was probably caused by a 27-28 nm small round structured virus found in the stool from one ill person. High levels of faecal coliforms in the reticulated river water and enterovirus in sediment samples suggest that the outbreak was caused by sewage contaminating the reticulated river water through a break in the pipe directly over the underground water tanks. To prevent such outbreaks, poor water and sewerage system layouts should be avoided and nonpotable water should be clearly labelled. Where feasible, all camping-ground water should stem from town supplies.

Outbreak of human calicivirus gastroenteritis in a day-care center in Sydney, Australia.

Between January and March 1988, an outbreak of gastroenteritis occurred among children and staff at a day-care center in Sydney, New South Wales, Australia. Over an 11-week period, 53 persons had 101 episodes of gastroenteritis; some patients had 5 separate episodes. The principal etiologic agent in the outbreak, human calicivirus (HCV), was detected by electron microscopy in 32% of fecal specimens from children and staff members with symptoms but in only 8% of asymptomatic individuals (P less than 0.01). HCV was confirmed by both an enzyme immunoassay and solid-phase immune electron microscopy. HCV infection was a particular problem in infants, who had the highest age-specific attack rates, had the greatest symptomatic/asymptomatic infection ratio, and were most likely to have a second symptomatic episode. The mode of transmission of this virus was not identified, and extensive efforts to control the 11-week outbreak had little effect. Prolonged excretion of HCV by some symptomatic patients and high rates of asymptomatic infection may have contributed to the extended duration of the outbreak. HCV may be a common cause of gastroenteritis in children that is under-recognized because of insensitive methods of detection.

Recovery of viruses and bacteria in waters off Bondi beach: a pilot study.

A pilot study was conducted between February and April, 1989, on the occurrence of sewage-derived viruses and bacteria in the beach and nearshore waters off Bondi, Sydney. Enteroviruses were isolated from 41% of a total of 66 sewage, sea-water, grease and sediment samples. Poliovirus vaccine strains accounted for 78% of the isolates. Adenoviruses were isolated four times and coxsackievirus B was isolated twice in samples that were collected away from the bathing area. Rotavirus and hepatitis A virus were not detected. The number of faecal coliforms, faecal streptococci, Aeromonas hydrophila and Clostridium perfringens in the sewage ranged from 10(4) to 10(7) cfu/100 mL. An initial reduction of 10(2)-10(3) in bacterial counts was observed in the plume (the effluent's initial dilution zone) and a further reduction of 10(2)-10(4) in counts in samples that were collected away from the plume. Salmonella spp. were detected in one-third of the samples and low numbers of Campylobacter jejuni were found in the sewage and plume. Salmonella serotypes that were associated with the sewage and plume were distinct from those in the stormwater and beachwater, indicating that stormwater may be an important source of pollution on Bondi beach.

Acute diarrhoea in adults: a prospective study.

A prospective study of 74 adults with acute diarrhoea was carried out in Sydney in 1984-1985 to determine the infective agents that were involved and their relationship to clinical, epidemiological and laboratory features. Thirty-four potential pathogens were identified in 32 (43.2%) patients. These included, in order of frequency: Campylobacter spp., rotavirus, Clostridium difficile, Salmonella enteritidis, Aeromonas hydrophila, Vibrio parahaemolyticus, adenovirus, a small round virus and Giardia lamblia. A seasonal trend was noted; the majority of Campylobacter isolations occurred in summer. The patients with Cl. difficile infection formed a distinct group, and experienced a subacute onset of diarrhoea after antibiotic administration, with few systemic symptoms. Except in these patients, the clinical and epidemiological features, together with results of faecal microscopy, were not a reliable predictor of the nature of the pathogens that were identified. While most patients with diarrhoea can be treated supportively, stool culture is an important procedure in patients with severe or protracted illness when specific antimicrobial therapy is contemplated.

[Rare malposition of a temporary pacemaker]. / Seltene Fehllage eines temporären Schrittmachers.

An unusual, pericardial malposition of an introducible electrode catheter in cardiopulmonary reanimation is described.

Infectious gastroenteritis in Norfolk Island and recovery of viruses from drinking water.

A high incidence of gastroenteritis in both islanders and tourists has been recorded in recent years on Norfolk Island--a popular tourist resort for Australians and New Zealanders. No bacterial cause has been found. However, electron microscopic examination of 28 faecal specimens revealed viruses associated with gastroenteritis in 21 (75%). No viruses were isolated in cell cultures. Bore water is used for drinking purposes on the island and 32 samples from 15 bores were examined for viruses by electron microscopy and culture as well as for bacterial contamination. Seven polioviruses (all type 1 vaccine strain) and adenoviruses 1 and 5 were isolated in cell cultures. In addition one rotavirus, one adenovirus and two small round viruses were detected by electron microscopy. Six of 21 samples tested showed unacceptably high levels of bacteria for drinking water. The deep ground water has apparently become contaminated with sewage effluent and is almost certainly the main cause of the high level of gastroenteritis on the island.