Safety and immunogenicity of NYVAC-JEV and ALVAC-JEV attenuated recombinant Japanese encephalitis virus--poxvirus vaccines in vaccinia-nonimmune and vaccinia-immune humans.

A controlled, randomized, double-blind clinical trial evaluated whether two attenuated recombinant poxviruses with identical Japanese encephalitis virus (JEV) gene insertions, NYVAC-JEV and ALVAC-JEV, were safe and immunogenic in volunteers. Groups of 10 volunteers distinguished by vaccinia immune status received two doses of each vaccine. The vaccines appeared to be equally safe and well tolerated in volunteers, but more reactogenic than licensed formalin-inactivated JE and placebo vaccines given as controls. NYVAC-JEV and ALVAC-JEV vaccine recipients had frequent occurrence of local warmth, erythema, tenderness, and/or arm pain after vaccination. There was no apparent effect of vaccinia immune status on frequency or magnitude of local and systemic reactions. NYVAC-JEV elicited antibody responses to JEV antigens in recipients but ALVAC-JEV vaccine poorly induced antibody responses. However, NYVAC-JEV vaccine induced neutralizing antibody responses only in vaccinia-nonimmune recipients while vaccinia-immune volunteers failed to develop protective antibodies (5/5 vs. 0/5 seroconversion, p<0.01). These data suggest that preexisting immunity to poxvirus vector may suppress antibody responses to recombinant gene products.

Randomized dose-ranging study of the safety and efficacy of WR 238605 (Tafenoquine) in the prevention of relapse of Plasmodium vivax malaria in Thailand.

WR 238605 is an 8-aminoquinoline developed for the radical cure of Plasmodium vivax. Forty-four P. vivax-infected patients were randomly assigned to 1 of 4 treatment regimens: 3 groups received a blood schizonticidal dose of chloroquine followed by WR 238605: group A (n=15) received 300 mg daily for 7 days; group B (n=11), 500 mg daily for 3 days, repeated 1 week after the initial dose; group C (n=9), 1 dose of 500 mg. A fourth group (D; n=9) received chloroquine only. Among patients who completed 2-6 months of follow-up (n=23), there was 1 relapse in group B (day 120) and 1 in group C (day 112). Among patients treated with chloroquine only, there were 4 relapses (days 40, 43, 49, and 84). WR 238605 was safe, well tolerated, and effective in preventing P. vivax relapse.

Immunohistochemistry to identify Leishmania parasites in fixed tissues.

The definitive diagnosis of leishmaniasis currently depends on the identification of characteristic amastigote morphology in tissue, or isolation of promastigotes by culture. Histopathological identification can be difficult, and is variably sensitive; culture is considered "the gold standard", but is not uniformly diagnostic or available. In this study, we compared light microscopic immunohistochemistry (IHC) using a monoclonal anti-Leishmania antibody (G2D10) to standard hematoxylin and eosin (H&E) stain in the diagnosis of Leishmania on skin. Sixty-one archived specimens from patients suspected of being infected with Leishmania were used; 41 of these had leishmaniasis confirmed by culture. Although not statistically significant, both sensitivity and specificity were higher for IHC compared to H&E: 51% (95% CI: 35-67%) compared to 42% (CI: 26-58%; 2p=0.29) for sensitivity, and 100% (CI: 83-100%) compared to 85% (CI: 62-97%, 2p=0.25) for specificity, respectively. Furthermore, because organisms could be diagnosed by IHC at low power (x20-40), this assay was more rapid than H&E, in which parasite morphology could best be identified at oil immersion power. The G2D10 antibody has broad Leishmania species recognition, and offers promise as a simple, rapid diagnostic screen for leishmaniasis. Further study is underway to better characterize this antibody.

Successful double-blinded, randomized, placebo-controlled field trial of azithromycin and doxycycline as prophylaxis for malaria in western Kenya.

Azithromycin prevents malaria in animal models and early clinical trials. We determined the prophylactic efficacy of three antibiotic regimens given for 10 weeks (azithromycin, 250 mg daily; azithromycin, 1,000 mg weekly; and doxycycline, 100 mg daily) relative to that of placebo for 232 adult volunteers residing in an area of intense malaria transmission. Any confirmed parasitemia during the study was considered a prophylactic failure. Two hundred thirteen volunteers (92%) completed the study. The prophylactic efficacies were as follows: daily azithromycin, 82.7% (95% confidence interval [CI], 68.5%-91.1%); weekly azithromycin, 64.2% (95% CI, 47.1%-77.1%); and daily doxycycline, 92.6% (95% CI, 79.9%-97.5%). All regimens were well tolerated. We concluded that both 100 mg of doxycycline and 250 mg of azithromycin, given daily, were effective as prophylaxis for malaria in this setting. If studies with nonimmune volunteers confirm these results for semi-immune volunteers, a daily azithromycin regimen may have special utility for individuals with contraindications to treatment with doxycycline or other antimalarial agents.

A randomized, placebo-controlled study of oral cimetidine as an immunopotentiator of parenteral immunization with a group B meningococcal vaccine.

Cimetidine (CIM) is an H2-receptor antagonist with a long history of clinical use in peptic ulcer disease. In addition to its inhibitory effect upon gastric acid secretion, CIM can also block histamine-mediated immunosuppression by inhibiting H2 receptors on suppressor T cells. CIM results in immunoaugmentation of both cellular and humoral immunity by this mechanism and has been used clinically in the treatment of chronic infectious and neoplastic diseases. We postulated that orally administered CIM, like an adjuvant, could augment the immunologic response to a parenteral vaccine. To test this hypothesis, a randomized placebo (PLB)-controlled, double-blinded study in 14 healthy volunteers was performed using a Group B meningococcal outer membrane protein (OMP) vaccine administered twice, 6 weeks apart. Volunteers were randomized within pairs defined by their screening OMP antibody titers to receive either CIM or PLB which was administered for 5 days, beginning 2 days before each of the two immunizations. All 14 volunteers completed the study with excellent compliance. Sera were tested for anti-OMP and bactericidal antibodies. The groups were comparable in terms of gender distribution, age and baseline anti-OMP titers. Reactogenicity to the vaccine was mild and comparable between groups. There was little effect of CIM (over PLB) on anti-OMP or functional bactericidal antibody levels over time. Geometric means of maximum OMP antibody increase over baseline was 3.3-fold (95% CI: 1.8-6.3) for CIM and 2.4 for PLB (CI: 1.6-3.7). CIM had a corresponding 3.9-fold increase (CI: 1.9-8.3) in bactericidal antibody level compared to 2.2 for PLB (CI: 1.4-3.4). We conclude that oral CIM was not effective as an immunopotentiator of immunization with this group B meningococcal vaccine.

Enhancement of platelet deposition by cross-linked hemoglobin in a rat carotid endarterectomy model.

BACKGROUND: Purified human cross-linked hemoglobin, which is now being used in clinical trials, increases mean arterial pressure through binding of nitric oxide (NO). We postulated that binding of NO by cross-linked hemoglobin (alpha alpha Hb) could also increase platelet deposition at sites of subintimal injury. METHODS AND RESULTS: Male Sprague-Dawley rats were infused with alpha alpha Hb (0.88 g/kg, n = 8) or with the NO synthase inhibitor NG-monomethyl-L-arginine (L-NMMA, 30 mg/kg, n = 7) before undergoing microsurgical carotid endarterectomy. 111In-labeled platelets were infused after endarterectomy, and platelet deposition was measured 20 minutes later. In control endarterectomized rats (n = 8), mean platelet deposition was 7.7 +/- 0.7 x 10(6)/mm2. Platelet deposition was significantly increased above controls in rats that received alpha alpha Hb (13.2 +/- 0.9 x 10(6)/mm2, P = .0004) and in rats infused with L-NMMA (13.9 +/- 1.0 x 10(6)/mm2, P = .0002). The increase was prevented by infusion of L-arginine (150 mg/kg) immediately after alpha alpha Hb or L-NMMA. To determine whether aspirin (ASA) blocked the increased deposition induced by alpha alpha Hb, rats received oral ASA (10 mg/kg) 18 hours before endarterectomy. Platelet deposition in animals receiving ASA alone was 6.4 +/- 0.9 x 10(6)/mm2 (n = 8). This was significantly increased to 10.8 +/- 0.8 x 10(6)/mm2 (P = .002) for the ASA-treated group that received alpha alpha Hb at the time of endarterectomy (n = 8). The prolonged bleeding times induced by ASA were unaffected by the infusion of alpha alpha Hb. CONCLUSIONS: These data suggest that in a rat endarterectomy model, alpha alpha Hb increases platelet deposition at sites of subintimal injury by binding NO. Increased deposition induced by alpha alpha Hb can be prevented by administration of L-arginine but not by pretreatment with aspirin.

Antithrombotic effects of hirulog in a rat carotid endarterectomy model.

Although hirulog, a specific, direct inhibitor of thrombin, can prevent thrombosis in unstable angina and angioplasty without inducing excessive bleeding, it has not been used in a surgical setting. In the present study, the antithrombotic activity of hirulog was assessed in rats undergoing carotid endarterectomy. Three groups of anesthetized male Sprague-Dawley rats received either intravenous heparin (10 U/kg bolus followed by 90 U/kg/hr, n = 4), high-dose hirulog (0.8 mg/kg bolus followed by 2.2 mg/kg/hr, n = 7), or saline (n = 6) before endarterectomy and until termination of the protocol 30 min later. Platelet deposition, as measured by scanning electron microscopy, in rats receiving this high dose of hirulog was reduced by 63% (+/- 14%, SE) compared to controls (P = 0.004) and by 36% (+/- 16%) in heparinized rats (P - 0.07). Both groups had prolonged postsurgical bleeding. Infusion of hirulog at a lower dose (0.4 mg/kg bolus followed by 1.0 mg/kg/hr, n = 8) was not associated with prolonged bleeding; however, platelet deposition was reduced by only 16% (+/- 27%, P = 0.30), although 125I-fibrin deposition was reduced by 64% (+/- 11%, P = 0.004). In the high-dose hirulog group, plasma hirulog levels, as determined with a quantitative thrombin time, were three times higher (95% CI: 1.5-4.5 times) than in the group receiving the lower hirulog dose [11.6 +/- 2.3 (SE) micrograms/ml vs 3.9 +/- 0.6 micrograms/ml; P = 0.0022]. However, the mean activated partial thromboplastin time with the higher dose was similar to that of the lower dose (110 +/- 4 vs 90 +/- 13 sec, P - 0.09). The antithrombotic activity of hirulog can be maximized by titrating the dose, monitoring plasma drug levels, and possibly administering the drug after surgery to avoid prolonged bleeding.

Inhibition of platelet deposition by combined hirulog and aspirin in a rat carotid endarterectomy model.

PURPOSE: Hirulog, a thrombin-specific inhibitor, has shown efficacy in reducing arterial thrombosis in patients treated with aspirin who require angioplasty or have unstable angina. In this study, the effect of hirulog on reducing deposition of indium 111-labeled platelets was assessed in a surgical model of aspirin-treated rats undergoing carotid endarterectomy. METHODS: Animals were randomly assigned to one of five groups: control (no aspirin or hirulog); aspirin alone (10 mg/kg); aspirin plus low-dose hirulog (0.2 mg/kg bolus followed by 0.5 mg/kg/hr); aspirin plus medium-dose hirulog (0.4 mg/kg bolus followed by 1.0 mg/kg/hr); or aspirin plus high-dose hirulog (0.6 mg/kg bolus followed by 1.5 mg/kg/hr). Hirulog was infused before surgery and continued until termination of the experiment 30 minutes after endarterectomy. RESULTS: Platelet deposition in rats receiving aspirin alone was reduced by 19% +/- 23% SE (p = 0.26) compared with controls. Deposition in aspirin-treated groups receiving low-, medium-, and high-dose hirulog decreased in a dose-dependent manner by 37% +/- 20% (p = 0.048), 44% +/- 19% (p = 0.061), and 56% +/- 13% (p = 0.022), respectively. As the dose of hirulog was increased, the plasma hirulog levels and activated partial thromboplastin time ratios (final:initial) also increased in a dose-dependent manner. The mean plasma hirulog levels ranged from 0.74 +/- 0.08 micrograms/ml in the low-dose hirulog group to 2.55 +/- 0.08 micrograms/ml in the high-dose hirulog group, and the corresponding activated partial thromboplastin time ratios were 1.5 +/- 0.12 (p = 0.001) and 3.3 +/- 0.63 (p = 0.001). Bleeding was easily controlled by local hemostatic measures for all experimental groups. CONCLUSION: Hirulog causes significant decrease in 111In-labeled platelet deposition in aspirin-treated rats subjected to microsurgical endarterectomy at doses that allow surgical hemostasis to be easily established.

Protection against hepatitis A by an inactivated vaccine.

OBJECTIVE: To evaluate the safety and efficacy of a new inactivated hepatitis A vaccine. DESIGN: Double-blind randomized controlled trial stratified by community. SETTING: Community-based in Thailand. STUDY PARTICIPANTS: A total of 40,119 children, aged 1 to 16 years, attending 148 primary schools: 38,157 (95%) entered surveillance a mean of 138 days after receiving vaccine dose 1; 33,586 (84%) completed the controlled trial of 532 days; and 31,075 (81%) received crossover vaccine and remained under surveillance until day 844. INTERVENTION: Participants received hepatitis A vaccine or control hepatitis B vaccine starting January 7, 1991 (doses in months 0, 1, and 12), and crossed over to the alternate vaccine 18 months later. MAIN OUTCOME MEASURE: Cases of hepatitis A (symptoms, alanine aminotransferase levels of 45 U/L or higher, and IgM to hepatitis A virus) were identified by evaluating school absences of 2 or more days. RESULTS: There were no serious adverse reactions despite administration of more than 109,000 doses of hepatitis A vaccine. Among initially seronegative recipients of two doses of hepatitis A vaccine, the proportion with 20 mIU/mL or more of antibody to hepatitis A virus before and 5 months after a 1-year booster was 94% and 99%, respectively. Of 6976 episodes of illness during the controlled trial, there were 40 cases of hepatitis A; 38 were in the control group. Of the 40 cases, six, all in controls, occurred after the 1-year booster dose. Following two doses of hepatitis A vaccine (days 138 through 386), protective efficacy was 94% (95% confidence interval, 79% to 99%); cumulative efficacy including the postbooster period (days 138 to 532) was 95% (95% confidence interval, 82% to 99%). The two hepatitis A vaccine recipients who had symptomatic infections (257 and 267 days after dose 1) appeared to have been partially protected since their illnesses were brief and associated with only slight increases in alanine aminotransferase. CONCLUSIONS: Inactivated hepatitis A vaccine is safe; when administered in two doses, it protects against hepatitis A for at least 1 year.

Local immune response and protection in the guinea pig keratoconjunctivitis model following immunization with Shigella vaccines.

This study used the guinea pig keratoconjunctivitis model to examine the importance of route of administration (mucosal versus parenteral), frequency and timing of immunization (primary versus boosting immunization), and form of antigen given (live attenuated vaccine strain versus O-antigen-protein conjugate) on the production of protective immunity against Shigella infection. Since local immune response to the lipopolysaccharide (LPS) O-antigen of Shigella spp. is thought to be important for protection against disease, O-antigen-specific antibody-secreting cells (ASC) in the spleen and regional lymph nodes of immunized animals were measured by using an ELISPOT assay. Results indicated that protective efficacy was associated with a strong O-antigen-specific ASC response, particularly in the superficial ventral cervical lymph nodes draining the conjunctivae. In naive animals, a strong ASC response in the cervical lymph nodes and protection against challenge were detected only in animals that received a mucosal immunization. Protection in these animals was increased by a boosting mucosal immunization. While parenteral immunization alone with an O-antigen-protein conjugate vaccine did not protect naive animals against challenge, a combined parenteral-mucosal regimen elicited enhanced protection without the addition of a boosting immunization. Although O-antigen-specific serum immunoglobulin A titers were significantly higher in animals receiving a mucosal immunization, there was no apparent correlation between levels of serum antibody and protection against disease.

Association of protein S deficiency with thrombosis in a kindred with increased levels of plasminogen activator inhibitor-1.

OBJECTIVE: A single kindred in North America with venous thrombosis was described as having defective fibrinolysis because of increased levels of plasminogen activator inhibitor-1 (PAI-1). Our study describes the discovery of protein S deficiency in this kindred and its association with venous thromboembolism. DESIGN: A family study. SETTING: Community. PARTICIPANTS: Twenty-eight adults (ages 21 to 71 years) from three generations of the kindred; seven had a history of venous thromboembolism. MEASUREMENTS: Plasma levels of total and free protein S antigen, as well as the activities of protein S, protein C, PAI-1, and antithrombin III. RESULTS: Six of 7 persons (86%) with a history of venous thromboembolism were deficient in total and free protein S; of 21 asymptomatic members, 9 were deficient in protein S (P = 0.08). When compared with these 9 asymptomatic family members, the 6 persons with protein S deficiency and a history of thrombosis tended to smoke (P = 0.01) and to have higher triglyceride levels (P = 0.001). Overall, the mean PAI-1 activity in the 7 persons who had thrombosis was 7.9 kAU/L (AU/mL) and was 9.3 kAU/L (AU/mL) in the 21 persons who did not have thrombosis (95% CI, -9.9 to 7.0). CONCLUSIONS: In this kindred, a deficiency of total and free or functional protein S is the cause of thrombosis. Measurement of PAI-1 activity was not useful in the evaluation of familial thrombosis. The utility of the routine measurement of PAI-1 activity in the evaluation of familial thrombosis has not been established.

Comparison of beta-artemether and beta-arteether against malaria parasites in vitro and in vivo.

The antimalarial activity of beta-artemether and beta-arteether was compared in three test systems: in vitro against chloroquine-resistant and chloroquine-sensitive Plasmodium falciparum parasites, in mice infected with P. berghei, and in Aotus monkeys infected with chloroquine-resistant P. falciparum. In vitro, the mean 50% inhibitory concentration (IC50) for beta-artemether was 1.74 nM (range 1.34-1.81 nM), and this value for beta-arteether was 1.61 nM (range 1.57-1.92 nM). They were approximately 2.5-fold more potent than artemisinin, which had a mean IC50 of 4.11 nM (range 3.36-4.60 nM). In the mouse model, the 50% curative doses (CD50) of beta-artemether and beta-arteether had a mean value of 55 mg/kg (32-78 mg/kg). The 50% effective curative doses (ED50) in the Aotus monkey were 7.1 mg/kg (95% confidence interval [CI] = 3.7-13.5) for beta-artemether and 11.8 mg/kg (95% CI = 6.5-21.3) for beta-arteether. Overall, the activities of the two drugs were comparable.

CD4 lymphocyte decline and survival in human immunodeficiency virus infection. The Military Medical Consortium for Applied Retroviral Research.

The loss of the CD4 lymphocyte is the central pathophysiologic event in the progression of human immunodeficiency virus (HIV) infection. This retrospective study, based on review of data from deceased HIV patients followed in a single HIV clinic, was conducted to determine if the rate of CD4 lymphocyte decline was predictive of survival. Forty of 172 patients met defined criteria for inclusion in this study. For each patient, CD4-cell counts showed approximate exponential decline over time. A Cox regression analysis was used to assess the association of CD4 cell decline (half-life), race, age, gender, initial CD4-cell count, and treatment (anti-Pneumocystis carinii pneumonia prophylaxis and/or zidovudine vs. no therapy) on total survival (from initial CD4 cell count) and on remaining survival time after reaching a CD4 cell count of 100 (estimated). For all patients, the rate of CD4 cell decline was predictive of total survival (p = .009) but not for survival after reaching a count of 100 (p = .6). For patients who had never received therapy (6 patients), however, the CD4 half-life remained associated with survival time from 100 CD4 cells (p < .05) as opposed to the treated patients. Therapy was the single variable most predictive of both survival endpoints, resulting in an increase in median total survival of 27.2 mo (p < .00001) and of 15.4 mo from a CD4 cell count of 100 (p < .00004). Nonwhites had a slight survival disadvantage compared to whites (p = .08 overall; p = .02 from CD4 cell count of 100).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of ultrasound on tissue-type plasminogen activator-induced thrombolysis.

BACKGROUND: The efficacy of fibrinolytic therapy is limited by the small surface area of the clot that is available for the binding of the thrombolytic agent, such as tissue-type plasminogen activator (t-PA). We hypothesized that exposure of the clot to ultrasound during thrombolytic treatment could enhance lysis through perturbation of the thrombus, which would expose additional fibrin binding sites for t-PA. METHODS AND RESULTS: Whole human blood clots containing radiolabeled fibrinogen were incubated in vitro for 200 minutes with Tris-albumin buffer containing t-PA at concentrations ranging from 3 to 3,000 IU/ml. In paired experiments, one of the clots also was exposed to intermittent ultrasound (1 MHz, 1.75 W/cm2) throughout the experiment. The ultrasound was delivered as a 2-second exposure followed by a 2-second rest interval. The overall difference in mean clot lysis between thrombi receiving ultrasound and those receiving no ultrasound was significant (p less than 0.001) at all concentrations of t-PA. For clots incubated with t-PA at a concentration of 300 IU/ml, ultrasound increased the percent lysis at 200 minutes from 42 +/- 5% (mean +/- SEM) to 64 +/- 10%. In six paired experiments in a rabbit jugular vein thrombosis model, rabbits received 1 mg t-PA alone or t-PA and intermittent ultrasound (1 MHz, 1.75 W/cm2) for 200 minutes. For rabbits receiving ultrasound and t-PA, lysis was 55 +/- 11% at 100 minutes compared with 30 +/- 12% for rabbits receiving only t-PA. Lysis was 6 +/- 10% for rabbits (n = 4) receiving ultrasound alone. No evidence for tissue damage was noted in rabbits exposed to intermittent ultrasound. CONCLUSIONS: Exposure of whole blood clots in vitro to intermittent ultrasound combined with t-PA caused a significant enhancement of thrombolysis compared with t-PA alone. Intermittent ultrasound also showed a trend toward enhancement of t-PA-induced clot lysis in an animal thrombosis model. These data suggest that noninvasive intermittent ultrasound may be a useful adjunct to thrombolytic therapy.

Comparison between a one-point dilute phospholipid APTT and the dilute Russell viper venom time for verification of lupus anticoagulants.

In the present study, the dilute Russell viper venom time (RVVT) and the dilute phospholipid activated partial thromboplastin time (PL-APTT), which are two assays used for the verification of lupus anticoagulants (LA), were modified to increase standardization. The modified assays were then compared with respect to sensitivity and specificity in detecting LA in plasmas from 72 patients with a prolonged APTT. Modifications included utilizing a single dilution of phospholipid that was either bovine brain thromboplastin (Thrombofax) or liposomes comprised of phosphatidylcholine/phosphatidylserine, and expressing the results as a ratio of the clotting times of the mixture of patient and normal plasma/clotting time of normal plasma. In the RVVT, the correlation coefficient between assay results for liposomes and Thrombofax was 0.88 and in the PL-APTT, the correlation was 0.68. A positive test for LA was defined as a ratio of greater than or equal to 1.3 for the PL-APTT with liposomes and greater than or equal to 1.2 for the PL-APTT with Thrombofax and the RVVT with Thrombofax or liposomes. Regardless of the phospholipid source in the test system, the PL-APTT demonstrated higher sensitivity and the RVVT showed greater specificity in detecting patient plasmas that contained antiphospholipid antibodies.

Relative repellency of two formulations of N,N-diethyl-3-methylbenzamide (deet) and permethrin-treated clothing against Culex sitiens and Aedes vigilax in Thailand.

Field tests were conducted to compare the effectiveness of 2 repellent formulations of N,N-diethyl-3-methylbenzamide (deet) in combination with permethrin-impregnated military uniforms against Culex sitiens and Aedes vigilax in Thailand. Repellency was determined during a 2 h crepuscular period using volunteers who had been treated with repellents 6, 8, 10, and 12 h prior to the end of each test period. An extended-duration repellent formulation (EDRF) containing 35% deet repelled significantly more Ae. vigilax than 75% deet in ethanol. Although not statistically significant, the EDRF also resulted in fewer biting attempts by Cx. sitiens. Neither formulation provided complete protection against either species 4-12 h post-application, but both provided greater overall protection against Ae. vigilax. Volunteers who wore treated uniforms without repellents were attacked by significantly fewer mosquitoes than controls.

Correlation between lupus anticoagulants and anticardiolipin antibodies in patients with prolonged activated partial thromboplastin times.

PURPOSE: An increased incidence of thrombosis has been reported in patients with a prolonged activated partial thromboplastin time (APTT) due to a lupus anticoagulant (LA), which is an antibody to negatively charged phospholipids. The antiphospholipid antibodies can be quantitated in an enzyme-linked immunoabsorbent assay (ELISA) that utilizes cardiolipin as the antigen. With the development of the ELISA, two major areas of controversy have arisen. First, the correlation between assay results for LA and for the ELISA has varied widely among laboratories. Second, some investigators have described a correlation between high levels of anticardiolipin antibodies (ACA) and thrombotic disorders, whereas others have found no association between ACA levels and thrombosis in a general population of medical patients. To explore these issues further, the present study determined the sensitivity and specificity of an LA assay for detecting ACA in medical patients with a prolonged APTT. The association between the isotype and titer of ACA and thrombosis was examined in those patients positive for LA. PATIENTS AND METHODS: Plasma samples from 70 medical patients with a prolonged APTT by routine screening studies were tested for the presence of LA by dilution of phospholipid in an APTT system and for IgM and IgG ACA according to a standardized ELISA. Clinical records were reviewed for a history of thrombotic events by an investigator who had no knowledge of the laboratory results. RESULTS: The ACA assay gave positive results in 47 patients, 44 of whom also tested positive for LA. Thus, the sensitivity for the LA assay for detecting ACA was 94% (confidence interval, 82% to 99%). The result of the LA assay was negative in 20 of 23 patients who were ACA-negative. The specificity of the LA assay was 87% (confidence interval, 67% to 98%). Twelve of the 47 patients (26%) had a history of venous or arterial thrombosis. Of these patients, 75% tested in the high-positive range for IgG or IgM ACA, or both. Of the 35 patients without thrombosis, only 14% were in this range. Patients with thrombosis had either underlying systemic lupus erythematosus, lymphoma, or no apparent etiology for LA. There was no history of thrombosis in patients with LA associated with infection or medication. CONCLUSION: A test for LA in medical patients with a prolonged APTT can be sensitive and specific for ACA. Determination of ACA levels in patients who have LA that is not induced by medication or infection may define those patients at increased risk for thrombosis.

An in vitro micromethod for drug sensitivity testing of Leishmania.

We describe an in vitro microtest which is quantitative, rapid, and readily applicable to parasites isolated from all major forms of human leishmaniasis. It is based on drug-mediated inhibition of promastigote catabolism of a battery of simple 14C-substrates to 14CO2. Each test requires less than 1 microCi. The test is conducted in a serum-free, chemically defined medium containing 120 micrograms protein/ml, minimizing the possible interference of drug: serum protein interaction. Prior adaptation is not necessary to cultivate "difficult-to-grow" species. Leishmania sensitivity to pentavalent antimonials is detectable at micrograms levels below concentrations achievable in patients' sera.

Plasminogen activator and plasminogen activator inhibitor activities in a reference population.

The influence of age, gender, and aspirin ingestion on plasma levels of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) activities was studied in a reference population of 35 men and 35 women between the ages of 20 and 65 years. The t-PA values (mean +/- SD) in the women before and after 5 minutes of venous occlusion were 3.8 +/- 1.4 and 7.8 +/- 4.4 micrograms/L, respectively; in men these values were 3.3 +/- 1.2 and 8.8 +/- 8.9 micrograms/L. Men had higher mean PAI levels than did women (5.0 vs. 2.5 kU/L). T-PA showed an inverse relationship to PAI in both sexes. There was a negative correlation of t-PA levels with age, whereas PAI levels were positively correlated. The ingestion of a single dose of aspirin (650 mg) did not alter PAI or t-PA activities. This study indicates that factors such as age and sex may need to be considered when reference populations are developed for clinical studies of fibrinolysis.