[Posttraumatic stress disorder : Risk factors, phenomenology, early recognition and management]. / Posttraumatische Belastungsstörung : Risikofaktoren, Phänomenologie, Früherkennung und Management.

Posttraumatic stress disorder is characterized by the symptom levels intrusion, avoidance and hyperarousal as a reaction to an exceptionally threatening event. It is a well-investigated and well-treatable mental condition; however, the frequently accompanying disturbances in sleep, cognition, affect and especially avoidance behavior represent substantial hurdles in the trauma surgery treatment as well in occupational reintegration. Basic knowledge about risk factors and the clinical phenomenology also enable early identification by the primary trauma surgeon or the accident insurance consultant (D-physician) and if necessary to initiate a qualified psychotraumatologically founded treatment.

[Psychological care in the intensive care unit : Task areas, responsibilities, requirements, and infrastructure]. / Psychologische Versorgung auf der Intensivstation : Tätigkeitsbereiche, Aufgaben, Anforderungen und Ausstattung.

The relatively high rates of mental stress among critically ill patients and their relatives implies the necessity of conceptually and financially embedded psychological care in intensive care units (ICUs). Professional associations also recommend the involvement of psychological professionals and screening of mental symptoms in critically ill patients. Intensive care medicine psychologists and psychotherapists take this as an opportunity to describe the content and goals of psychological care. Task areas are care for patients and relatives as well as staff support. Goals of psychological support in the ICU are detection of mental symptoms in patients and their treatment, psychological first aid for relatives in crisis situations, and support of the staff in terms of communication with patients and relatives as well as regarding development and maintenance of an adaptive coping style for dealing with emotionally challenging situations. Psychological care in the ICU is offered by psychologists, psychotherapists, or physicians with a psychotherapeutic qualification. The psychologist is integrated into the ICU team and has a proactive, resource-oriented, and supportive orientation. Psychological support can be an enrichment and a relief, both in the interdisciplinary treatment of patients as well as in the care of relatives, and also represent a resource for the team.

GSK-3-specific inhibitor-supplemented hESC medium prevents the epithelial-mesenchymal transition process and the up-regulation of matrix metalloproteinases in hESCs cultured in feeder-free conditions.

Feeder-free culture induces spontaneous differentiation of human embryonic stem cells (hESCs), identified as an epithelial to mesenchymal transition (EMT). The maintenance of pluripotency of hESCs in feeder-free cultures through the activation of the WNT pathway using a glycogen synthase kinase (GSK)-3-specific inhibitor (BIO) was reported. The aim of this study was to determine the effect of BIO on the EMT process. In contrast with those grown in feeder-free conditions with control medium, hESC colonies cultured with BIO-supplemented hESC medium did not show any fibroblast-like cells at the periphery. Transmission electron microscopy, relative quantitative real-time RT-PCR and immunostaining analyses showed the presence of epithelial features and a diminution of mesenchymal features in the BIO-treated hESCs such as a strong E-cadherin expression, the down-regulation of Vimentin, Snail and Slug expressions and a cytoplasmic beta-catenin expression. An up-regulation of matrix metalloproteinases (MMP) MMP-2, MMP-9, MT-1MMP (membrane-type 1 MMP) and EMMPRIN (extracellular MMP inducer) expression was also found associated with the EMT occurring in feeder-free hESCs cultures using mouse embryonic fibroblasts conditioned medium (MEF CM). The presence of BIO clearly down-regulated the expression of these MMPs. This study showed that BIO, a GSK-3-specific inhibitor, prevents the EMT process which is associated with the feeder-free hESC culture. Nevertheless, BIO was not sufficient to expand hESCs in a long-term culture system.

Epithelial-mesenchymal transition process in human embryonic stem cells cultured in feeder-free conditions.

Feeder-free human embryonic stem cell (hESC) culture is associated with the presence of mesenchymal-like cells appearing at the periphery of the colonies. The aim of this study was to identify this early differentiation process. Long-term feeder-free hESC cultures using matrigel and conditioned medium from mouse and from human origin revealed that the appearance of mesenchymal-like cells was similar regardless of the conditioned medium used. Standard characterization confirmed the preservation of hESC properties, but the feeder-free cultures could not be maintained longer than 37 passages. The early differentiation process was characterized in the short term after switching hESCs cultured on feeders to feeder-free conditions. Transmission electron microscopy showed an epithelium-like structure inside the hESC colonies, whereas the peripheral cells revealed the acquisition of a rather mesenchymal-like phenotype. Immunochemistry analysis showed that cells at the periphery of the colonies had a negative E-cadherin expression and a positive Vimentin expression, suggesting an epithelial-mesenchymal transition (EMT). Nuclear staining of beta-catenin, positive N-cadherin and negative Connexin 43 expression were also found in the mesenchymal-like cell population. After RT-PCR analysis, Slug and Snail, both EMT-related transcription factors, were detected as up-regulated in the mesenchymal-like cell population. Taken together, our data suggest that culturing hESCs in feeder-free conditions enhances an early differentiation process identified as an EMT.

Derivation of human embryonic stem cell lines from embryos obtained after IVF and after PGD for monogenic disorders.

BACKGROUND: Human embryonic stem (hES) cells are pluripotent cells usually derived from the inner cell mass (ICM) of blastocysts. Because of their ability to differentiate into all three embryonic germ layers, hES cells represent an important material for studying developmental biology and cell replacement therapy. hES cell lines derived from blastocysts diagnosed as carrying a genetic disorder after PGD represent in vitro disease models. METHODS: ICMs isolated by immunosurgery from human blastocysts donated for research after IVF cycles and after PGD were plated in serum-free medium (except VUB01) on mouse feeder layers. RESULTS: Five hES cell lines were isolated, two from IVF embryos and three from PGD embryos. All lines behave similarly in culture and present a normal karyotype. The lines express all the markers considered characteristic of undifferentiated hES cells and were proven to be pluripotent both in vitro and in vivo (ongoing for VUB05_HD). CONCLUSIONS: We report here on the derivation of two hES cell lines presumed to be genetically normal (VUB01 and VUB02) and three hES cell lines carrying mutations for myotonic dystrophy type 1 (VUB03_DM1), cystic fibrosis (VUB04_CF) and Huntington disease (VUB05_HD).

Repeated oral once daily intake of increasing doses of the novel synthetic genistein product Bonistein in healthy volunteers.

Bonistein is a new product consisting of > 99.5 % synthetic genistein, an isoflavone with phyto-oestrogenic properties, which might be a safe and efficacious alternative for the prevention of post-menopausal bone loss to the traditional hormone replacement therapy. A randomised, open-labelled and sequential-group phase I study was performed to assess safety, tolerability and pharmacokinetic characteristics of oral administrations of Bonistein. Thirty healthy volunteers received in three subsequent groups 30, 60 or 120 mg once daily for 14 days. For the pharmacokinetic profiles of Bonistein, blood samples were taken on study Days 1 (after first dose) and 14 (steady state). Repeated intake of Bonistein was well tolerated. A total of 33 adverse events were reported, mainly of mild intensity. No relevant changes in clinical laboratory or vital signs were observed. The pharmacokinetic characteristics of Bonistein revealed comparable results for extent and rate of absorption on Days 1 and 14. Both AUC and C (max) values of Bonistein increased in proportion with the dose.

A new Coenzyme Q10 tablet-grade formulation (all-Q) is bioequivalent to Q-Gel and both have better bioavailability properties than Q-SorB.

Commercial Coenzyme Q10 (CoQ10, ubiquinone) formulations are often of poor intestinal absorption. We investigated the bioavailability of DSM Nutritional Products Ltd. (Kaiseraugst, Switzerland) CoQ10 10% TG/P (all-Q), a new tablet-grade formulation, with CoQ10 Q-Gel Softsules based on the Bio-Solv technology (Tishcon Corp., Salisbury, MD; marketed by Epic4Health, Smithtown, NY) and Q-SorB (Nature's Bounty, Bohemia, NY). Twelve healthy male subjects participated in a randomized, three-period crossover bioequivalence study. Plasma CoQ10 was determined from pre-dose until +36 hours. To compare bioavailability, corrected maximum concentration (Cmax) and area under the curve from 0 to +14 hours [AUC(0-14 h)] were assessed and tested for bioequivalence. The bioequivalence ranges of 0.8-1.25 hour x microg/mL for AUC(0-14 h) and 0.75-1.33 microg/mL for Cmax were applied. In summary, the kinetic profiles of all CoQ10 preparations revealed a one-peak plasma concentration-time course. Highest Cmax values were seen after Q-Gel application, whereas time to Cmax was nearly identical across all treatments. The AUC(0-14 h) values were highest for Q-Gel, narrowly followed by all-Q. The tests for bioequivalence showed a bioequivalence between Q-Gel and all-Q, and both preparations were found to have better bioavailability properties than Q-SorB. Although all-Q and Q-Gel have equivalent bioavailability properties, all-Q can be directly used in tablets, while this is not the case for Q-Gel or other similar forms.

Epigallocatechin gallate (EGCG) (TEAVIGO) does not impair nonhaem-iron absorption in man.

A number of studies have shown that tea catechins can inhibit intestinal iron absorption, mostly iron in the nonhaem form. This randomized, double-blind, placebo-controlled, 3-periods cross-over study examined the degree of inhibition of nonhaem iron absorption by pure crystalline epigallocatechin gallate (EGCG). The study was designed to show the maximum inhibitory action of EGCG by selecting 30 healthy women with low iron stores. Treatments were 150 mg, 300 mg EGCG and placebo each for 8 consecutive study days with a wash-out period of 14 days between treatments. Iron incorporation was assessed by supplying 57Fe orally and 58Fe intravenously. Differences in fractional nonhaem iron absorption between the treatments were evaluated by using two-sided ANOVA. Results showed a relative nonhaem iron absorption reduction of 14% with 150mg EGCG and 27% for 300mg EGCG treatment compared to placebo. Differences were statistically significant (p < or = 0.05) between the placebo and the 300mg EGCG treatments and between the 150 and 300 mg EGCG treatments. The inverse relation between EGCG dose and fractional nonhaem iron absorption was linear (p = 0.0002). In this study the magnitude of the inhibitory action of EGCG on nonhaem iron absorption was found to be much lower than that reported in the literature for black tea and similar compounds. The doses of EGCG in supplements, which will be lower than those used in this study, are not expected to have any health relevant effects on iron absorption in subjects with normal iron stores.

Bonistein (synthetic genistein), a food component in development for a bone health nutraceutical.

In the discussion of the risk-benefit relation of the hormone replacement therapy (HRT) for elder women phytochemicals with estrogenic activity received a great deal of attention. Phytoestrogens are naturally occurring compounds with structural similarity to 17beta-estradiol. Especially genistein, an isoflavone most abundant in soy, possess a high and selective binding-affinity to the mammalian estrogen receptors. It has been found, that genistein exert in humans both: weak estrogenic and anti-estrogenic effects, similar to the SERMs. Consequently, it was concluded, that genistein might provide an alternative to prevent postmenopausal bone-loss and ameliorate menopausal symptoms without side-effects similar to HRT. Pre-clinical experiments and results from clinical pilot studies with pure genistein confirmed its efficacy in these indications. Nevertheless, currently some open issues still exist to recommend its intake thoughtlessly. Bonistein, pure synthetic genistein developed by DSM Nutritional Products, was tested extensively in appropriate models for bone health. A battery of toxicological studies was conducted to determine safe intake levels. In the early clinical development pharmacokinetic studies were performed in healthy volunteers and in postmenopausal women. Now large-scale studies are in preparation to investigate Bonistein's efficacy in postmenopausal bone-loss and climacteric syndrome.

Pharmacodynamics of moxifloxacin and levofloxacin simulating human serum and lung concentrations.

Fluoroquinolones are known to penetrate well into the infectious foci such as lung mucosa, epithelial lining fluid and alveolar macrophages achieving higher target site concentrations than the corresponding serum levels. In order to integrate the in vitro antibacterial activity and pharmacokinetics of moxifloxacin and levofloxacin, their bactericidal efficacy was assessed by simulating human serum and lung tissue concentrations using Streptococcus pneumoniae, Staphylococcus aureus and Klebsiella pneumoniae as indicator organisms. The bacteria were exposed to fluctuating moxifloxacin and levofloxacin concentrations simulating the drug levels in serum, lung mucosa, epithelial lining fluid and alveolar macrophages. The following parameters were deduced from the kill curves: area under the bactericidal kill curve normalized to the initial inoculum (AUBKC norm), the time needed to reduce the inoculum by 3 log(10) titers, and the initial bactericidal activity. In general, all these three parameters were for all the bacterial isolates having been exposed to moxifloxacin concentration dependent. In contrast, beyond a levofloxacin concentration of optimal bactericidal effect, higher drug concentrations did not further augment the bactericidal activity of levofloxacin. These data demonstrate that not all fluoroquinolones share the same pharmacodynamic targets needed to maximize their antibacterial effect.

Effect of pH on the in vitro activity of and propensity for emergence of resistance to fluoroquinolones, macrolides, and a ketolide.

Antibiotic activity against common respiratory pathogens can be affected by the pH of the medium (in vitro) or the bodily fluid (in vivo) in which bacteria are present. The ionized fraction of an antibiotic is not able to efficiently penetrate bacterial or mammalian membranes, reducing the quantity of molecules able to exert their antibacterial effect resulting in elevated MIC values This study shows that the activity of macrolide antibiotics is particularly sensitive to acidic conditions, whereas a ketolide and fluoroquinolones are much less affected. Furthermore, induction of spontaneous and multistep macrolide resistance is greatly increased in acidic medium. In contrast, telithromycin and moxifloxacin did not induce resistance at any pH. Antibiotics which are less likely to induce resistance in vitro may also be less likely to induce the development of resistance in patients with respiratory tract infections.

Inhibitory effects of various micro-organisms on the growth of Helicobacter pylori.

AIMS: To examine the in vitro influence of various bacteria species on Helicobacter pylori (Hp) growth. METHODS AND RESULTS: The effects of 29 micro-organisms on 31 Hp strains were determined using two modified 'cross streak' methods. Staphylococcus epidermidis, Staphylococcus aureus, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Morganella morganii, Serratia marcescens, Bacteroides fragilis, Fusobacterium nucleatum and Clostridium difficile showed the strongest inhibition. The inhibitory effects varied, depending on the bacteria spp. and Hp strains, and were method dependent. The cagA status of Hp strains did not correlate with the extent of inhibition. CONCLUSIONS: Helicobacter pylori is inhibited by a significant number of commensal bacteria species as well as opportunistic human pathogens. The success and progress of Hp infection may be influenced by the bacterial flora present, while the difficulty in cultivating Hp from the oral mucosa and faeces may be the result of antagonistic bacterial interaction. SIGNIFICANCE AND IMPACT OF THE STUDY: This study provides valuable data on the sensitivity of Hp to a variety of intestinal and oral commensals as well as opportunistic human pathogens. Hp's varying pathogenicity and the specific localization of infection may be the result of these sensitivities. These results can also serve as a basis for further studies to identify the inhibitory substances and make them available for therapeutic use.

Plasma-kinetic characteristics of purified and isolated green tea catechin epigallocatechin gallate (EGCG) after 10 days repeated dosing in healthy volunteers.

This randomized, double-blind, placebo-controlled study assessed the safety, tolerability, and plasma-kinetic behavior of 94% pure crystalline epigallocatechin gallate (EGCG) after ten days' repeated dosing in 36 healthy male volunteers. Each of the three treatment groups consisted of 12 subjects; nine of them received oral EGCG in one dose of 200, 400, or 800 mg daily, and three received a placebo. Blood samples for plasma-kinetic EGCG characterization were taken on day 1 and day 10. Kinetic parameters for rate and extent, elimination half-lives, and accumulation factor (R) were determined and compared between day 1 and day 10 for each dosage group. Orally administered EGCG is rapidly absorbed from the gut. Dose linearity was applied for single-dose application (day 1). After repeated dosing (day 10) dose linearity was applied between the 200 mg and 400 mg group. Dose escalation to 800 mg was more than dose-proportional in rate and extent, and statistically different from the 200 mg and 400 mg group. An increase in elimination half-life (t1/2.z) and in the accumulation factor (R) in the 800 mg dosage group indicates dose-dependent saturation of capacity-limited excretion routes or an increase of hepato-duodenal re-circulation. Ten days' repeated administration of oral doses of EGCG of up to 800 mg per day were found to be safe and very well tolerated.

Increased serum resistance in Klebsiella pneumoniae strains producing extended-spectrum beta-lactamases.

The aim of this study was to determine whether there is an association between serum resistance, O serotypes, and the production of extended-spectrum beta-lactamases (ESBLs) in Klebsiella pneumoniae. Ninety ESBL-producing and 178 non-ESBL-producing K. pneumoniae isolates gathered in five European countries were O serotyped and tested for sensitivity to the serum's bactericidal effect. The frequency of serum-resistant isolates was higher among ESBL-producing strains (30%; 27/90 isolates) than among non-ESBL-producing strains (17.9%; 32/178 isolates) (P = 0.037; odds ratio [OR] = 1.96; 95% confidence interval [95% CI] = 1.08 to 3.53). Although O1 was the most common O serotype in both Klebsiella groups, its frequency among ESBL-producing strains was significantly higher (59%; 53/90 isolates) than among non-ESBL producers (36%; 64/178 isolates) (P = 0.0006; OR = 2.5; 95% CI = 1.52 to 4.29). Furthermore, the prevalence of the O1 serotype was higher among serum-resistant strains of both ESBL-producing (74%; 20/27isolates) and non-ESBL producers (75%; 24/32 isolates) than among serum-sensitive ESBL producers (52.4%; 33/63 isolates) and non-ESBL producers (27.4%; 40/146 isolates). Serum resistance among ESBL-producing strains (36%; 17/47 isolates) versus non-ESBL-producing strains (16%; 27/166 isolates) was also significantly higher after the exclusion of clonal strains (P = 0.0056; OR = 2.9; 95% CI = 1.41 to 6.01). Sixteen ESBL types were detected, among which the frequency of serum resistance was significantly lower among the SHV-producing strains (9/48 isolates) than among the TEM producers (16/35 isolates) (P = 0.016; OR = 3.65; CI = 1.3 to 9.7). Curing ESBL-coding plasmids did not influence the serum resistance of the bacteria; all six plasmid-cured derivatives maintained serum resistance. The present findings suggest that ESBL-producing strains have a greater pathogenic potential than non-ESBL-producing strains, but the linkage between O serotypes, serum resistance, and ESBL production remains unclear at this stage.

Impairment of respiratory burst in polymorphonuclear leukocytes by extended-spectrum beta-lactamase-producing strains of Klebsiella pneumoniae.

The ability of extended-spectrum beta-lactamase (ESBL)-producing and non-ESBL-producing Klebsiella pneumoniae strains to induce a respiratory burst in polymorphonuclear leukocytes (PMNLs) was investigated. Ninety ESBL-producing and 178 non-ESBL-producing Klebsiella pneumoniae isolates were serotyped and their ability to induce a respiratory burst in PMNLs tested by monitoring the cells' chemiluminescence (CL) response. The percentage of isolates inducing high levels of CL response (CL>75%) was significantly higher among non-ESBL producers (52%) than among ESBL producers (32.2%) ( P<0.0001; OR=3.396; 95%CI=2.036-5.664). The median CL response was significantly higher among the non-ESBL producers (76.9%) than among the ESBL producers (52.6%) ( P=0.034). The two groups did not differ in their ability to resist intracellular killing by PMNLs ( P>0.05), with strains inducing high levels of CL response having significantly lower survival rates (31.8% vs. 42.4%) than strains inducing low levels of CL response (164% vs. 200%) ( P<0.01). The frequencies of the K2 and the K25 serotypes were significantly higher among ESBL-producing strains (17.8% and 22.2%, respectively) than among the non-ESBL producers (6.2% and 1.7%, respectively) ( P=0.0057 and P<0.0001). Of the 77 Klebsiella K serotypes, 71 were detectable among the non-ESBL producers, but only 24 were detectable among the ESBL producers. ESBL-producing Klebsiella pneumoniae strains might have a greater pathogenic potential by virtue of their ability to escape the phagocytic activity of PMNLs.

Chlamydia pneumoniae infection and restenosis in patients with coronary heart disease.

BACKGROUND: The aim of this study was to establish whether Chlamydia pneumoniae is implicated in the development of restenosis in patients with coronary heart disease (CHD) after percutaneous transluminal coronary angioplasty (PTCA). PATIENTS AND METHODS: 67 patients were selected for study after they underwent control angiography after PTCA. Sera were tested for anti-chlamydial antibodies with a genus specific ELISA and a species-specific microimmunofluorescence test (MIFT). Oropharyngeal specimens were examined for the presence of antigen with a Chlamydia immunofluorescence test (IFT), C. pneumoniae IFT and semi-nested PCR. In addition, anamnestic findings were also included. To determine the general level of antibodies, an age- and sex matched control group of 180 persons was also examined for Chlamydia and C. pneumoniae serology. RESULTS: Coronary angiography revealed that 31 of the 67 patients had developed a restenosis. There was no significant correlation between serological and angiographic findings. However, the MIFT showed a higher positive rate, especially in IgA, in the restenosis group. C. pneumoniae was detected in the oropharynx by PCR and/or IFT in 20.8% and 16.0% of the cases in patients with and without a restenosis. PCR found more C. pneumoniae-positive cases in the restenosis patients than IFT. No association was found between the detection of Chlamydia antigen and serology. The women with restenosis were more frequently smokers (p = 0.012). Men with restenosis were significantly older (p = 0.015). C. pneumoniae serology based on the rELISA or the MIFT did not show any correlation with restenosis. CONCLUSION: No evidence was found to suggest that positive C. pneumoniae serology is a risk factor for the development of restenosis. However, whether the species-specific serological test, especially for IgA-antibodies, and the detection of C. pneumoniae in oropharyngeal specimens by PCR might be reliable diagnostic markers in these cases remains to be determined.

A single ascending dose study of epigallocatechin gallate in healthy volunteers.

This randomized, double-blind, placebo-controlled study assessed the safety, tolerability and plasma kinetic behaviour of single oral doses of 94% pure crystalline bulk epigallocatechin gallate (EGCG) under fasting conditions in 60 healthy male volunteers. In each group of 10 subjects, eight received oral EGCG in single doses of 50 mg, 100 mg, 200 mg, 400 mg, 800 mg or 1600 mg, and two received placebo. Blood samples were taken at intervals until 26 h later. The area under the concentration-time curve from 0 h to infinity (AUC(0-infinity)), the maximum plasma concentration (Cmax) of EGCG, the time taken to reach the maximum concentration (Tmax), and the terminal elimination half-life (t1/2z) of EGCG were determined. Safety and tolerability were assessed. In each dosage group, the kinetic profile revealed rapid absorption with a one-peak plasma concentration versus time course, followed by a multiphasic decrease consisting of a distribution phase and an elimination phase. The mean AUC(0-infinity) of total EGCG varied between 442 and 10,368 ng.h/ml. The according mean Cmax values ranged from 130 to 3392 ng/ml and were observed after 1.3-2.2 h. The mean t1/2z values were seen between 1.9 and 4.6 h. Single oral doses of EGCG up to 1600 mg were safe and very well tolerated.

[Serotonin syndrome]. / Le syndrome sérotoninergique.

The serotonin syndrome is a hyperserotoninergic state resulting from an excess of intrasynaptic 5-hydroxytryptamine, induced by multiple psychotropic agents, but also non psychiatric drugs. It is a potentially dangerous and sometimes lethal condition. The clinical manifestations usually include cognitive, neuromuscular and autonomic features and are mediated by the action of serotonin on various subtypes of receptors. The main differential diagnosis is the neuroleptic malignant syndrome. Treatment is mainly supportive. No pharmacological agent has been definitely demonstrated really effective. However, reports of cases treated with the 5-HT2 blockers, including cyproheptadine or chlorpromazine have suggested that these agents could have some efficacy. Serotonin syndrome is a toxic condition which requires heightened clinical awareness among physicians in order to prevent, recognize, and treat the condition promptly.

New LightCycler PCR for rapid and sensitive quantification of parvovirus B19 DNA guides therapeutic decision-making in relapsing infections.

Detection of parvovirus B19 DNA offers diagnostic advantages over serology, particularly in persistent infections of immunocompromised patients. A rapid, novel method of B19 DNA detection and quantification is introduced. This method, a quantitative PCR assay, is based on real-time glass capillary thermocycling (LightCycler [LC]) and fluorescence resonance energy transfer (FRET). The PCR assay allowed quantification over a dynamic range of over 7 logs and could quantify as little as 250 B19 genome equivalents (geq) per ml as calculated for plasmid DNA (i.e., theoretically >or=5 geq per assay). Interrater agreement analysis demonstrated equivalence of LC-FRET PCR and conventional nested PCR in the diagnosis of an active B19 infection (kappa coefficient = 0.83). The benefit of the new method was demonstrated in an immunocompromised child with a relapsing infection, who required an attenuation of the immunosuppressive therapy in addition to repeated doses of immunoglobulin to eliminate the virus.