Production of a Sindbis/Eastern Equine Encephalitis chimeric virus inactivated cell culture antigen.

Eastern Equine Encephalitis virus (EEEV) is a medically important pathogen that can cause severe encephalitis in humans, with mortality rates ranging from 30 to 80%. Unfortunately there are no antivirals or licensed vaccines available for human use, and laboratory diagnosis is essential to differentiate EEEV infection from other pathogens with similar clinical manifestations. The Arboviral Diseases Branch (ADB) reference laboratory at the CDC Division of Vector-Borne Diseases (DVBD) produces reference antigens used in serological assays such as the EEEV immunoglobulin M antibody-capture enzyme-linked immunosorbent assay (MAC-ELISA). However, EEEV is classified as a HHS select agent and requires biosafety level (BSL) three containment, limiting EEEV antigen production in non-select agent and BSL-2 laboratories. A recombinant Sindbis virus (SINV)/EEEV has been constructed for use under BSL-2 conditions and is not regulated as a select agent. Cell culture production of inactivated EEEV antigen from SINV/EEEV for use in the EEEV MAC-ELISA is reported here. Cell culture conditions and inactivation procedures were analyzed for SINV/EEEV using a recently developed antigen production algorithm, with the MAC-ELISA as the performance indicator.

Development of an algorithm for production of inactivated arbovirus antigens in cell culture.

Arboviruses are medically important pathogens that cause human disease ranging from a mild fever to encephalitis. Laboratory diagnosis is essential to differentiate arbovirus infections from other pathogens with similar clinical manifestations. The Arboviral Diseases Branch (ADB) reference laboratory at the CDC Division of Vector-Borne Diseases (DVBD) produces reference antigens used in serological assays such as the virus-specific immunoglobulin M antibody-capture enzyme-linked immunosorbent assay (MAC-ELISA). Antigen production in cell culture has largely replaced the use of suckling mice; however, the methods are not directly transferable. The development of a cell culture antigen production algorithm for nine arboviruses from the three main arbovirus families, Flaviviridae, Togaviridae, and Bunyaviridae, is described here. Virus cell culture growth and harvest conditions were optimized, inactivation methods were evaluated, and concentration procedures were compared for each virus. Antigen performance was evaluated by the MAC-ELISA at each step of the procedure. The antigen production algorithm is a framework for standardization of methodology and quality control; however, a single antigen production protocol was not applicable to all arboviruses and needed to be optimized for each virus.

Prescribing for comorbid disease in a palliative population: focus on the use of lipid-lowering medications.

BACKGROUND: The balance of benefit versus burden of ongoing treatments for comorbid disease in palliative populations as death approaches needs careful consideration given their particular susceptibility to adverse drug effects. AIM: To provide descriptive data regarding the medications being prescribed to patients who have a life-limiting illness at the time of referral to a palliative care service in regional Australia, with particular focus on lipid-lowering medications. METHODS: A prospective case note review of 203 patients reporting the number of medications prescribed and, for lipid-lowering medications, the indication and level of prevention sought (primary, secondary, tertiary). Rates were compared by performance status, disease phase and comorbidity burden. RESULTS: Mean number of regular medications prescribed was 7.2, with higher rates observed in those patients with a non-malignant primary diagnosis (rate ratio 1.28, confidence interval (CI) 1.11-1.50) or poorer performance status (rate ratio 1.37, CI 1.11-1.69) and lower rates for those in the terminal phase of disease (rate ratio 0.48, CI 0.30-0.76). Over one fifth of patients were prescribed a lipid-lowering medication, and two fifths of these prescriptions were for primary prevention of cardiovascular disease. Patients in the highest quartile of Charlson Comorbidity Index score were 4.6 (CI 2.06-10.09) times more likely to be prescribed a lipid-lowering medication than those in the lowest quartile. CONCLUSIONS: Polypharmacy is prevalent for this group of patients, placing them at high risk of drug-drug and drug-host interactions. Prescribing may be driven by risk factors and disease guidelines rather than a rational, patient-centred approach.

Haemagglutinin and nucleoprotein replicon particle vaccination of swine protects against the pandemic H1N1 2009 virus.

The recent emergence of the pandemic H1N1 (pH1N1) and H3N2 variant influenza A viruses (IAV) in 2009 and 2011-2012, respectively, highlight the zoonotic potential of influenza viruses and the need for vaccines capable of eliciting heterosubtypic protection. In these studies, single-cycle, propagation-defective replicon particle (RP) vaccines expressing IAV haemagglutinin (HA) and nucleoprotein (NP) genes were constructed and efficacy was evaluated in homologous and heterologous pig challenge studies with the pH1N1 2009 influenza virus (A/California/04/2009). Homologous HA RP vaccination eliminated virus shedding and decreased pulmonary pathology in pigs following pH1N1 2009 challenge. An RP vaccine expressing an H3N2-derived NP gene was able to decrease nasal shedding and viral load following heterosubtypic pH1N1 2009 challenge in pigs. These studies indicate that although homologous vaccination of swine remains the most effective means of preventing IAV infection, other vaccine alternatives do offer a level of heterosubtypic protection, and should continue to be evaluated for their ability to provide broader protection.

Fetal listing for organ transplantation in Canada.

This article presents an ethical and legal examination of whether a fetus should be listed to receive a transplanted organ. To date, relatively little discussion of this question has found its way into either the clinical or ethics literature. This article is divided into four sections. The first section analyzes the most common reasons against fetal listing offered by the nonclinicians with whom the author spoke. The two reasons involve the legal concepts of rights and best interests. Pivotal ethical foundations of the Canadian health system are also discussed so as to help develop a compatible allocation process for Canadian transplant programs. The second section analyzes common concerns raised in the author's discussions with clinicians. The third section presents four cardiac transplant scenarios to illustrate how relevant and sequential criteria for deciding whether, and in what circumstances, an available heart can be defensibly allocated to a fetus. The last section summarizes the decision process that reflects the preceding sections' analysis. Recognizing that the four scenarios do not exhaust the likely situations wherein a fetus and an infant might qualify for the same organ, the article closes with a recommendation that it be considered a catalyst for further analysis.

West Nile virus infection and serologic response among persons previously vaccinated against yellow fever and Japanese encephalitis viruses.

It is hypothesized that previous heterologous flaviviral exposure may modulate clinical illness among persons infected with West Nile virus (WNV). Little is known about the serological response in such persons. In summer 2003, a WNV outbreak occurred in Colorado, the location of the Centers for Disease Control and Prevention, Division of Vector-Borne Infectious Diseases (DVBID). DVBID employees, most previously vaccinated with yellow fever virus (YFV) or Japanese encephalitis virus (JEV) vaccines, were studied to determine whether previous vaccination affected symptom development among those subsequently infected with WNV during the outbreak, as well as their serological response. Serum samples collected in December 2003 and previously banked samples were tested using the plaque reduction neutralization test (PRNT) against WNV, Saint Louis encephalitis virus, dengue- 4 virus, JEV, and YFV. Specimens shown to have WNV antibody by PRNT were tested by IgM and IgG enzymelinked immunosorbent assays (ELISAs). Ten (9%) of 113 serosurvey participants had WNV neutralizing antibody titers in December 2003. PRNT titers from previous specimens showed that one of the ten had seroconverted to WNV before 2003. Of the remaining nine participants, seven reported illness in the summer of 2003, two of which were unvaccinated and five previously vaccinated. In the December 2003 specimens, five persons previously unvaccinated or vaccinated only against YFV had a fourfold or greater neutralizing titer with WNV than with other flaviviruses, whereas no persons previously vaccinated against JEV or JEV and YFV showed a similar difference in neutralizing titers. Eight of nine persons infected in 2003 had negative or indeterminate WNV MAC-ELISA results in the December 2003 sample; the ninth person was vaccinated against YFV one month previously, and was also YFV positive by MAC-ELISA. We conclude that previous flaviviral vaccination does not markedly affect the development of WNV fever and that the IgM antibody response in patients without neuroinvasive WNV disease is transient.

Vaccine-preventable disease susceptibility in a young adult Micronesian population.

Current US military recruit vaccination policy presumes that recruits have had a complete childhood immunization series. This assumption may not be appropriate for recruits from Micronesia, who may have had limited access to modern health care, including immunization programs. During 1988 and 1990, a cross-sectional serosurvey was conducted among 66 US military recruits, 56 from the Federated States of Micronesia and 10 from the Republic of the Marshall Islands, collectively referred to as Micronesia. Antibody seronegativity levels for 12 vaccine-preventable (or potentially so) diseases were: measles (52%), mumps (14%), rubella (21%), varicella (38%), diphtheria (39%) tetanus (0%), polio type 1 (4%), polio type 2 (0%), polio type 3 (14%), hepatitis A (9%), hepatitis B (17%), and hepatitis C (98%). Compared with Army recruits in general, Micronesian recruits were significantly more likely to be seronegative for measles and varicella and seropositive for hepatitis types A and B. Personal histories of disease were felt to be inadequate in predicting antibody status.

Influence of sleep state on the response to hypercapnia in fetal lambs.

The effect of sleep state on the respiratory response to hypercapnia was studied in 14 chronic fetal sheep, 125-140 days gestation. Fetal PaCO2 was raised by 11 to 34 Torr by gradually increasing the maternal FICO2 to 0.09. Fetal sleep state was monitored. Fetal breathing (FB) was analysed in terms of frequency (f), tracheal pressure (TP) and ventilation equivalent (VEq) = sigma TP /min. In 16 out of 17 experiments on apneic fetuses in NREM sleep, the fetuses switched to REM sleep and in 14 instances began to breathe within 2 1/2 min thereafter. The PaCO2 at which apneic fetuses started breathing was 54.8 +/- 8.4 Torr (mean +/- SD). In 4 out of 10 trials on breathing fetuses in REM sleep the fetuses switched to NREM sleep and stopped breathing before removal of the CO2 stimulus. During REM sleep hypercapnia stimulated FB by an increase in TP and by a reduction in the number and duration of apneic pauses. It is concluded that in the fetal lamb CO2 stimulates breathing only during REM sleep and that this stimulus is superimposed on the basic mechanism that stimulated spontaneous FB during this sleep state.

Effect of carotid chemoreceptor denervation on breathing in utero and after birth.

The influence of the carotid bodies on fetal breathing activity in utero and on the establishment of postnatal breathing was studied. The electrocorticogram, the electromyogram of the lateral rectus and postural muscles, and tracheal and arterial pressures were monitored on chronically prepared intact and carotid sinus-denervated fetal lambs. The denervated fetuses required a longer time for recovery from the operation, but thereafter the sleeping and breathing behavior was similar to that of the control group. Four of the carotid sinus-denervated fetuses were allowed to be delivered spontaneously, and all established regular postnatal respiration despite conclusive evidence of nonfunctional carotid bodies. These experiments indicate that the fetal carotid chemoreceptors are not essential for the spontaneous intrauterine breathing activity during rapid-eye-movement sleep nor for the establishment of effective breathing at birth.

Respiratory response to somatic stimulation in fetal lambs during sleep and wakefulness.

1. The respiratory response to electrical stimulation of the nose, tail, gum and fibular nerve (nonspecific somatic stimulation) was tested in chronically instrumented fetal lambs during sleep and wakefulness. 2. The respiratory response to somatic stimulation was greatest during REM sleep, lowest during NREM sleep, and intermediate during the awake state (AW). 3. Respiratory responses could follow electrical somatic stimulation up to 2 Hz in any sleep state without changing sleep state. 4. The fetal breathing (FB) response to repetitive stimulation depended on the initial sleep state and whether or not the sleep state was affected by the stimulation. Five patterns of response were seen: a) NREM leads to NREM (initial sleep state and sleep state at end of stimulation)--FB was initiated and did not continue beyond the duration of the stimulation. b) NREM leads to REM sleep--FB was initiated and continued beyond the time of stimulation. c) REM leads to REM sleep--spontaneous FB was enhanced and continued beyond the time of stimulation. d) REM leads to NREM sleep--spontaneous FB was enhanced but did not continue beyond the time of stimulation. e) NREM, REM sleep, Awake leads to Awake--FB was initiated or enhanced and continued beyond the time of stimulation until the onset of NREM sleep.

Sleep, wakefulness and the monosynaptic reflex in fetal and newborn lambs.

1. Electrocorticogram (ECoG), electromyogram (EMG) of the lateral rectus and antigravity muscles (neck and masseter) and breathing activity (FB) were monitored in chronically prepared fetal sheep of 125-140 days gestation and in newborn lambs up to 11 days postnatal age. 2. Awake state (AW), non-rapid eye movement sleep (NREM) and rapid eye movement sleep (REM) were defined using standard criteria for ECoG, eye movements and postural muscle tone. 3. The percentage of time the fetuses spent in each state was: NREM sleep 53%, REM sleep 41.4%, and AW 5.6%. 4. Spontaneous intrauterine breathing activity occurred only during REM sleep, but 35% of REM sleep was not associated with FB. 5. Gasps (isolated deep inspirations) appeared occasionally throughout the recording and were not related to any specific sleep state or wakefulness. 6. In the fetus, the monosynaptic reflex (MSR) induced by direct electrical stimulation of the fibular nerve was enhanced by about 75% during REM sleep compared to NREM and AW. In the newborn lamb the adult pattern of suppression of MSR during REM sleep was not seen until several days after birth.

Enhanced fetal erythrocyte carbonic anhydrase activity by hydrocortisone.

The present experiments were undertaken to study the effect of exogenous corticosteroids on carbonic anhydrase (CA) activity in fetal erythrocytes. Rabbit fetuses from 24 days of gestation to term (31 days) were injected intraperitoneally with either 0.2 ml of 0.9% saline or 2.5 mg hydrocortisone succinate. Nonoperated, noninjected animals served as controls. Carbonic anhydrase activity measured at 24 hr after injection was increased in the saline-injected group at all ages studies when compared with the noninjected fetuses. A marked increase (2- to 7-fold) in enzyme activity was demonstrated after steroid injection at 24 but not 48 hr after treatment. An increase in CA activity was also demonstrated after incubating fetal erythrocytes for 2, 4, and 8 hr in the presence of hydrocortisone succinate. It is suggested that low CA activity in infants with hyaline membrane disease (HMD) may reflect lack of enhancement by steroid.

Respiratory effects of H+ and dinitrophenol injections into the brain stem subarachnoid space of fetal lambs.

Mock cerebrospinal fluid (pH 5.37-8.38) or 2,4-dinitrophenol (DNP) (0.15-1.5 mg) was injected into the subarachnoid space of the ventral brain stem of exteriorized fetal sheep. Changes in pH on the ventral surface of the medulla did not stimulate respiratory efforts or induce significant cardiovascular changes. The respiratory response to DNP injections ranged from no response to prolonged rhythmic ventilation that was independent of the peripheral chemoreceptors or the control arterial pH and blood gas tensions. This inconsistency suggests an effector site somewhat removed from the immediate surface of the medulla. The heart rate and blood pressure were not affected. It is concluded that increased H+ concentration in the extracellular fluid of the fetal ventral medulla does not initiate respiration, and any respiratory response to metabolic inhibitors applied to this area therefore is not attributable to a secondary change in surface pH.