A field-expedient algorithmic approach to the clinical management of chemical and biological casualties.

Warriors on the modern battlefield face considerable danger from possible attack with chemical and biological weapons. Aggravating this danger is the fact that medical resources at the lowest echelons of care, already likely to be strained to capacity during modern conventional combat, are at present inadequate to handle large numbers of chemical or biological casualties. Complicating this problem further is the austere nature of diagnostic modalities available at lower echelons. With this in mind, and given the urgency required to adequately manage chemical and biological casualties, it is likely that such casualties will initially require significant empiric care in the absence of a definitive diagnosis. Such care under field conditions, often rendered by relatively inexperienced medical personnel, might best be provided using an algorithmic approach. We have developed such an algorithm.

Immunization against potential biological warfare agents.

The intentional release of biological agents by belligerents or terrorists is a possibility that has recently attracted increased attention. Law enforcement agencies, military planners, public health officials, and clinicians are gaining an increasing awareness of this potential threat. From a military perspective, an important component of the protective pre-exposure armamentarium against this threat is immunization. In addition, certain vaccines are an accepted component of postexposure prophylaxis against potential bioterrorist threat agents. These vaccines might, therefore, be used to respond to a terrorist attack against civilians. We review the development of vaccines against 10 of the most credible biological threats.

Malignant otitis externa with optic neuritis.

Malignant otitis externa is a serious condition that presents difficulties in treatment, and also in monitoring its progress. A case of malignant otitis externa with optic neuritis is presented that remained refractory to standard treatment but was cured by adjuvant hyperbaric oxygen therapy. This is the only reported case that has survived this disease with optic neuritis. The usefulness of imaging techniques in this condition is discussed, as well as the ESR, in evaluating the effectiveness of treatment.

HLA-DQA2 (DX alpha) polymorphism and insulin dependent diabetes.

A certain HLA-DQA2 locus TaqI fragment, DX alpha"U", has been reported to be associated with insulin-dependent diabetes mellitus (IDDM). Reports of various studies in this vein have ranged from stating that the association of DQA2"U" with IDDM exists even among subjects positive for HLA-DR3 and -DR4 to stating that the association of DQA2"U" with diabetes can be attributed to linkage disequilibrium between the DQA2"U" and some component(s) on the affected haplotypes. Using a synthetic 97-base probe corresponding to a portion of an intron of DQA2, in a Southern blot analysis of IDDM and control subjects from Wisconsin, we were able to confirm the association of DQA2"U" with diabetes. However, among DR3 subjects there was no significant association between DQA2"U" and diabetes (p = 0.26). Although there was a (nonsignificant) association of IDDM with DQA2"U" among DR4-positive subjects (p = 0.14), this can be completely attributed to linkage disequilibrium between DQA2"U" and DQw8. We also sequenced most of the second exon (corresponding to the alpha 1 domain of the DQA2 glycoprotein) from five individuals that were homozygous for either DQA2"U" or DQA2"L." The only polymorphisms observed were a "silent" mutation at position 36 and one example of a difference that would result in a change of amino acid at position 41.

Allelic T-cell receptor alpha complexes have little or no influence on susceptibility to type 1 diabetes.

We performed a multiple-affected-sib study to determine if T-cell receptor alpha-chain alleles affect susceptibility to insulin-dependent diabetes mellitus. Restriction fragment length polymorphisms were used to follow the segregation of allelic T-cell receptor alpha complexes within the families. The segregation of T-cell receptor alpha alleles in 29 multiplex families revealed no significant tendency for affected sibs to share T-cell receptor alpha-chain alleles more often than would be expected by chance alone (p greater than 0.2). In contrast, the same type of analysis for HLA alleles easily detected the well-known linkage of insulin-dependent diabetes mellitus susceptibility to the HLA complex (p = 0.003). We suggest that the importance of HLA alleles in insulin-dependent diabetes mellitus susceptibility and the lack of importance of T-cell receptor alpha alleles result from the different strategies by which HLA and T-cell receptor molecules achieve antigen-binding diversity: multiple loci and allelic diversity in the case of HLA; combinatorial, junctional, and N-region diversity in the case of the T-cell receptor. In this paper we also describe three new restriction fragment length polymorphisms of the T-cell receptor alpha complex and a new method for testing the significance of linkage in multiple-affected-sib studies.

A diabetes-susceptible HLA haplotype is best defined by a combination of HLA-DR and -DQ alleles.

HLA-DR4 is associated with insulin-dependent diabetes mellitus (IDDM) in many populations. Many recent studies suggest that the DR4 effect is really due to DQ3.2, an allele of the nearby DQB1 locus. We used T cell clones, MAb, and allele-specific oligonucleotides to test IDDM and control subjects for DR4 subtypes (Dw4, Dw10, Dw13, and Dw14) and for DR4-associated DQB1 alleles (DQ3.1 and DQ3.2). We find that (a) IDDM is approximately equally associated with alleles of the DRB1 locus (Dw4 and Dw10, combined relative risk, RR = 6.4) and the DQB1 locus (DQ3.2, RR = 5.9); and (b) there is significant interaction, in a statistical sense, between these DR and DQ alleles in IDDM. The only IDDM-associated DR4 haplotypes were those carrying the IDDM-associated alleles at both loci (RR = 12.1); haplotypes with Dw4 or 10 but not DQ3.2, or vice versa, had a RR less than 1. Alternative explanations include: (a) that susceptibility requires specific allelic products of both DR and DQ loci; (b) that the combination of certain DR and DQ alleles marks haplotypes with the true susceptibility allele at a third locus; or (c) that Dw4 and 10 mark haplotypes with an allele at another locus that interacts with DQ3.2. As discussed, this third locus is unlikely to be DQA1 (DQ alpha). The data thus are not easily reconciled with an exclusive effect of HLA-DQ. This information increases our ability to predict IDDM by genetic typing: in the population studied, heterozygotes DR3/[DQ3.2, Dw4] or DR3/[DQ3.2, Dw10] had a relative risk of 38.0 and an absolute risk of 1 in 15.

Lack of interaction of HLA and IgG heavy chain allotypes in insulin-dependent diabetes mellitus.

Because of conflicting previous reports showing the presence or absence of Gm-HLA interaction in insulin-dependent diabetes mellitus (IDDM), we report results for a group of Wisconsin families having 2 or more siblings with IDDM. Although this study is very similar to one by Field et al., who found HLA-Gm interaction in IDDM, we find no evidence for such an interactive effect p = 0.33). We discuss published data on HLA-Gm interaction in IDDM, and conclude that overall there is little reason to postulate such an interaction.

T-cell-defined DR4 subtypes as markers for type 1 diabetes.

In most populations studied, HLA-DR4, a DRB1 (formerly DR beta I) allele, is increased in frequency among patients with insulin-dependent diabetes mellitus (IDDM). Using T-cells, one can distinguish five subtypes of DR4 (Dw4, Dw10, Dw13, Dw14, and Dw15). Two of these (Dw4 and Dw10) are IDDM-associated in the populations studied here. Therefore, Dw4 and Dw10 could be causative or merely markers for a linked diabetes allele. If they are causative, one might expect them to share some unique structural element or at least to associate consistently with IDDM in different populations. Published sequence data show no structural element unique to Dw4 and Dw10; moreover, the associations of these DR4-Dw subtypes with diabetes vary considerably in different populations. Thus the DRB1 locus probably cannot account for the DR4 association in IDDM. The strong linkage disequilibrium between IDDM and Dw4 and Dw10 suggests that the diabetes susceptibility locus should be in the vicinity of the DR region or the DQ region of the HLA complex. Alternative hypotheses are discussed, relating DR- and DQ-region alleles to IDDM. We further postulate that the evolutionary event that produced the Dw10 allele occurred on a Dw4 haplotype that happened to carry a diabetes susceptibility allele at another locus.

Functional polymorphism of the HLA-DR beta III chain.

Several clusters of class II HLA genes contribute to variation in human antigen-presenting capacity. In the HLA-DR cluster, most of the variation is due to the highly polymorphic DR beta I gene. Recent work by others has shown some nucleotide and implied amino acid sequence variation in DR beta III chains, but this variation is not known to be functionally significant. We show here that two proliferating human T-cell clones define three allelic variants of DR beta III (assignment to DR beta III based on blocking of proliferation by selected monoclonal antibodies). Thus, the DR beta III locus encodes at least three alleles that are distinguishable by human T cells and most probably contribute to the human antigen-presenting repertoire. The three DR beta III alleles subdivide the "supertypic" HLA antigen DRw52 into subtypes provisionally called DRw52.1-52.3. The DR3 haplotypes studied to date have been either DRw52.1 or 52.2; DR5 haplotypes have all (23 of 23) been 52.2; DRw6 haplotypes have included all three DRw52 subtypes, nearly half being 52.3. Our data, combined with other published data, imply that DRw8 must either have a fourth DRw52 subtype or be DR beta III null.

A minor subset of HLA-DR3 haplotypes is preferentially increased in type 1 (insulin-dependent) diabetes.

We have been using human T-lymphocyte clones specifically sensitized to detect leucocyte antigens of Type 1 (insulin-dependent) diabetic patients in the hope of detecting novel HLA antigens associated with Type 1 diabetes. We previously described two such clones which define a new class II HLA antigen, Boston-1 (BO1). BO1 is found mainly on cells of persons with particular HLA-DR antigens and, of potential significance for diabetes, BO1 identifies a distinctive subset of DR3 haplotypes. We report here that BO1+ DR3 haplotypes are overrepresented in Type 1 diabetes. That is, significantly more of the DR3-positive subjects are BO1-positive in the patient group (31%) than in the control group (8%), suggesting that a diabetes-susceptibility gene may be more common on the BO1+ than on the BO1- DR3 haplotypes. Alternative interpretations are also discussed.

A particular subset of HLA-DR4 accounts for all or most of the DR4 association in type I diabetes.

Two human T-lymphocyte clones, derived from a mixed leukocyte culture (MLC) with stimulating cells from a type I diabetic patient, define a subset of HLA-DR4, tentatively called "DR4S." In testing of 69 random type I diabetic subjects and 69 random controls, 79% (37/47) of DR4-positive patients, but only 44% (8/18) of DR4-positive controls, had DR4S (P less than 0.01). The relative risk of type I diabetes for DR4S+ individuals was 8.8, while that for DR4+ DR4S- individuals was only 1.0. Thus, in the population tested, DR4S accounts for all or most of the increased frequency of HLA-DR4 in type I diabetes.