Preclinical immunogenicity and efficacy of a candidate COVID-19 vaccine based on a vesicular stomatitis virus-SARS-CoV-2 chimera

Background

To investigate a vaccine technology with potential to protect against coronavirus disease 2019 (COVID-19) and reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with a single vaccine dose, we developed a SARS-CoV-2 candidate vaccine using the live vesicular stomatitis virus (VSV) chimeric virus approach previously used to develop a licensed Ebola virus vaccine.

Methods

We generated a replication-competent chimeric VSV-SARS-CoV-2 vaccine candidate by replacing the VSV glycoprotein (G) gene with coding sequence for the SARS-CoV-2 Spike glycoprotein (S). Immunogenicity of the lead vaccine candidate (VSV∆G-SARS-CoV-2) was evaluated in cotton rats and golden Syrian hamsters, and protection from SARS-CoV-2 infection also was assessed in hamsters.

Findings

VSV∆G-SARS-CoV-2 delivered with a single intramuscular (IM) injection was immunogenic in cotton rats and hamsters and protected hamsters from weight loss following SARS-CoV-2 challenge. When mucosal vaccination was evaluated, cotton rats did not respond to the vaccine, whereas mucosal administration of VSV∆G-SARS-CoV-2 was found to be more immunogenic than IM injection in hamsters and induced immunity that significantly reduced SARS-CoV-2 challenge virus loads in both lung and nasal tissues.

Interpretation

VSV∆G-SARS-CoV-2 delivered by IM injection or mucosal administration was immunogenic in golden Syrian hamsters, and both vaccination methods effectively protected the lung from SARS-CoV-2 infection. Hamsters vaccinated by mucosal application of VSV∆G-SARS-CoV-2 also developed immunity that controlled SARS-CoV-2 replication in nasal tissue.

Funding

The study was funded by Merck Sharp & Dohme, Corp., a subsidiary of Merck & Co., Inc., Rahway, NJ, USA, and The International AIDS Vaccine Initiative, Inc. (IAVI), New York, USA. Parts of this research was supported by the Biomedical Advanced Research and Development Authority (BARDA) and the Defense Threat Reduction Agency (DTRA) of the US Department of Defense.

Pregnant women & vaccines against emerging epidemic threats: Ethics guidance for preparedness, research, and response

Zika virus, influenza, and Ebola have called attention to the ways in which infectious disease outbreaks can severely - and at times uniquely - affect the health interests of pregnant women and their offspring. These examples also highlight the critical need to proactively consider pregnant women and their offspring in vaccine research and response efforts to combat emerging and re-emerging infectious diseases. Historically, pregnant women and their offspring have been largely excluded from research agendas and investment strategies for vaccines against epidemic threats, which in turn can lead to exclusion from future vaccine campaigns amidst outbreaks. This state of affairs is profoundly unjust to pregnant women and their offspring, and deeply problematic from the standpoint of public health. To ensure that the needs of pregnant women and their offspring are fairly addressed, new approaches to public health preparedness, vaccine research and development, and vaccine delivery are required. This Guidance offers 22 concrete recommendations that provide a roadmap for the ethically responsible, socially just, and respectful inclusion of the interests of pregnant women in the development and deployment of vaccines against emerging pathogens. The Guidance was developed by the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies (PREVENT) Working Group - a multidisciplinary, international team of 17 experts specializing in bioethics, maternal immunization, maternal-fetal medicine, obstetrics, pediatrics, philosophy, public health, and vaccine research and policy - in consultation with a variety of external experts and stakeholders.

Arsenic efflux in Enterobacter cloacae RSN3 isolated from arsenic-rich soil

In the present study, bacterial isolates were screened for arsenic resistance efficiency. Environmental isolates were isolated from arsenic-rich soil samples (i.e., from Rajnandgaon district of Chhattisgarh state, India). Amplification and sequencing of 16S rRNA gene revealed that the isolates were of Bacillus firmus RSN1, Brevibacterium senegalense RSN2, Enterobacter cloacae RSN3, Stenotrophomonas pavanii RSN6, Achromobacter mucicolens RSN7, and Ochrobactrum intermedium RSN10. Arsenite efflux gene (arsB) was successfully amplified in E. cloacae RSN3. Atomic absorption spectroscopy (AAS) analysis showed an absorption of 32.22% arsenic by the RSN3 strain. Furthermore, results of scanning electron microscopy (SEM) for morphological variations revealed an initial increase in the cell size at 1 mM sodium arsenate; however, it was decreased at 10 mM concentration in comparison to control. This change of the cell size in different metal concentrations was due to the uptake and expulsion of the metal from the cell, which also confirmed the arsenite efflux system.

Unprecedented pace and partnerships: the story of and lessons learned from one Ebola vaccine program

INTRODUCTION

The Ebola epidemic in West Africa from 2014 to 2016 was unique in its size, location, and duration; this article reviews the experiences and lessons learned for one vaccine candidate developed during the outbreak and discusses critical gaps that still exist today which will need to be addressed for successful end to end emerging infectious disease vaccine product development in the future.

AREAS COVERED

Through the formation of numerous international partnerships, the rVSVΔG-ZEBOV-GP vaccine advanced through Phase I/II/III clinical trials which resulted in favorable Phase III efficacy results. Key lessons learned that could be used to facilitate future vaccine development efforts include sufficient preclinical work in relevant animal models, innovative partnerships created to pool resources and expertise, and 'hyper' coordination and communication among partners to build trust and ensure an adequate regulatory package needed to license a vaccine.

EXPERT COMMENTARY

As evidenced by the 2014-2016 outbreak in West Africa as well as the two other most recent outbreaks in the Democratic Republic of the Congo in 2018, there is an urgent need to develop new models for emerging infection vaccine development where trusted partners come together and where the development of vaccines is a shared responsibility conducted in advance of the next crisis.

Antibodies to Toxin B Are Protective Against Clostridium difficile Infection Recurrence

BACKGROUND

Although newer studies have evaluated risk factors for recurrent Clostridium difficile infection (CDI), the vast majority did not measure important biomarkers such as endogenous anti-toxin A and anti-toxin B antibody levels.

METHODS

Data from the placebo group of a phase 2 trial testing monoclonal antibodies to C. difficile toxins A and B for preventing CDI recurrence (rCDI) were analyzed to assess risk factors associated with rCDI. Patients with symptomatic CDI taking metronidazole or vancomycin were enrolled. The primary outcome was rCDI within 84 days of treatment start. Univariate and multivariate logistic regression was used to examine associations between potential risk factors and rCDI. At baseline, demographic and clinical characteristics were recorded; endogenous antibody levels were assessed using 2 enzyme-linked immunosorbent assays.

RESULTS

A predictor of recurrence was age ≥65 years, and an antibody-mediated immune response to toxin B appears to be protective against rCDI.

CONCLUSIONS

Our findings demonstrate the importance of clinical as well as immunological risk factors in rCDI and provide more robust evidence for the protective effects of antibody to toxin B in the prevention of rCDI.

CLINICAL TRIALS REGISTRATION

NCT00350298.

Biventricular Non-Compaction Cardiomyopathy

Left ventricular non-compaction (spongy myocardium) is one of the most misclassified cardiomyopathies. It is characterised by an excessively prominent trabecular meshwork of myocardium and deep intertrabecular myocardium due to an arrest in the compaction process of the myocardial fibres. It could be isolated i.e. without any other structural heart defects or associated with congenital heart defects. The clinical manifestations are variable heart failure, arrhythmia, thromboembolic phenomena depending on extent of non-compaction of cardiac segment.

Combined oral contraceptive use increases HPV persistence but not new HPV detection in a cohort of women from Thailand

BACKGROUND

Women diagnosed with cervical cancer report longer duration and more recent use of combined oral contraceptives (COCs). It is unclear how COC use impacts risk of cervical carcinogenesis.

METHODS

We estimated the risk of new human papillomavirus (HPV) DNA detection and persistence among 1135 human immunodeficiency virus (HIV)-negative women aged 20-37 years from Thailand who were followed for 18 months at 6-month intervals. Type-specific HPV DNA, demographic information, hormonal contraceptive use, sexual behavior, genital tract coinfection, and Papanicolaou test results were assessed at baseline and each follow-up.

RESULTS

Women who reported current COC use during follow-up were less likely to clear HPV infection compared with nonusers, independent of sexual behavior, and Papanicolaou test diagnosis (AHR: 0.67 [95% CI: .49-.93]). Similar associations were not observed among women reporting current use of depomedroxyprogesterone acetate (DMPA). Neither COC nor DMPA use was significantly associated with new HPV DNA detection.

CONCLUSIONS

These data do not support the hypothesis that contraceptive use is associated with cervical cancer risk via increased risk of HPV acquisition. The increased risk of HPV persistence observed among current COC users suggests a possible influence of female sex hormones on host response to HPV infection.

Development and validation of the Influenza Intensity and Impact Questionnaire (FluiiQ™)

OBJECTIVE

Clinical trials of new agents to reduce the severity and impact of influenza require accurate assessment of the effect of influenza infection. Because there are limited high-quality adult influenza Patient Reported Outcomes (PRO) measures, the aim was to develop and validate a simple but comprehensive questionnaire for epidemiological research and clinical trials.

METHODS

Construct and item generation was guided by the literature, concept mapping, focus groups, and interviews with individuals with laboratory-confirmed influenza and expert physicians. Items were administered to 311 people with influenza-like illness (ILI) across 25 US sites. Analyses included classic psychometrics, structural equation modeling (SEM), and Rasch analyses.

RESULTS

Concept mapping generated 149 concepts covering the influenza experience and clustered into symptoms and impact on daily activities, emotions, and others. Items were drafted using simplicity and brevity criteria. Eleven symptoms from the literature underwent review by physicians and patients, and two were removed and one added. The symptoms domain factored into systemic and respiratory symptoms, whereas the impact domains were unidimensional. All domains displayed good internal consistency (Cronbach α ≥ 0.8) except the three-item respiratory domain (α = 0.48). A five-factor SEM indicated excellent fit where systemic, respiratory, and daily activities domains differentiated patients with ILI or confirmed influenza. All scales were responsive over time.

CONCLUSIONS

Patient and clinician consultations resulted in an influenza PRO measure with high validity and good overall evidence of reliability and responsiveness. The Influenza Intensity and Impact Questionnaire (FluiiQ™) will improve the evaluation of existing and future agents designed to prevent or control influenza infection by increasing the breadth and depth of measurement in this field.

Kinetics of DNA load predict HPV 16 viral clearance

INTRODUCTION

While high HPV 16 viral load measured at a single time point is associated with cervical disease outcomes, few studies have assessed changes in HPV 16 viral load on viral clearance.

OBJECTIVE

To measure the association between changes in HPV 16 viral load and viral clearance in a cohort of Thai women infected with HPV 16.

STUDY DESIGN

Fifty women (n=50) between the ages of 18-35 years enrolled in a prospective cohort study were followed up every three months for two years. Women positive for HPV 16 DNA by multiplex TaqMan assay at two or more study visits were selected for viral load quantitation using a type-specific TaqMan based real-time PCR assay. The strength of the association of change in viral load between two visits and viral clearance at the subsequent visit was assessed using a GEE model for binary outcomes.

RESULTS

At study entry, HPV 16 viral load did not vary by infection outcome. A >2 log decline in viral load across two study visits was found to be strongly associated with viral clearance (AOR: 5.5, 95% CI: 1.4-21.3). HPV 16 viral load measured at a single time point was not associated with viral clearance.

CONCLUSIONS

These results demonstrate that repeated measurement of HPV 16 viral load may be a useful predictor in determining the outcome of early endpoints of viral infection.

The association of hormonal contraceptive use and HPV prevalence

Women diagnosed with cervical cancer report longer duration and more recent use of combined oral contraceptives (COCs). It is unclear whether COC use is associated with upstream events of human papillomavirus (HPV) infection prior to development of clinical disease. The objective of our study was to assess the association of contraceptive use on the risk for prevalent HPV infection in a cohort of long-term hormonal contraceptive (HC) users. One thousand and seventy (n = 1,070) HIV-negative women aged 20-37 from Thailand enrolled in a prospective study of the natural history of HPV. Baseline HPV genotype information, recency and duration of HC use, sexual behavior, other sexually transmitted infection (STI) information and cervical cytology and histology were assessed. At enrollment, 19.8% and 11.5% of women were infected with any HPV or any high-risk (HR)-HPV, respectively. After adjustment for age, current and past sexual risk behaviors, STI history and cytology, the use of COCs for >6 years was found to be associated with an increased risk of infection with any HPV [prevalence ratio (PR): 1.88 (1.21, 2.90)] and any HR-HPV [PR: 2.68 (1.47, 4.88)] as compared to never users. Recent, long-term COC use was associated with an increased risk for prevalent HPV infection independent of sexual behavior and cervical abnormalities. No similar association was observed for recent or long duration use of progestin-only contraceptives (i.e., depomedroxyprogesterone acetate). These data suggest that COC use may impact early upstream events in the natural history of HPV infection.

International epidemiology of human pre-existing adenovirus (Ad) type-5, type-6, type-26 and type-36 neutralizing antibodies: correlates of high Ad5 titers and implications for potential HIV vaccine trials

Replication-defective adenoviruses have been utilized as candidate HIV vaccine vectors. Few studies have described the international epidemiology of pre-existing immunity to adenoviruses. We enrolled 1904 participants in a cross-sectional serological survey at seven sites in Africa, Brazil, and Thailand to assess neutralizing antibodies (NA) for adenovirus types Ad5, Ad6, Ad26 and Ad36. Clinical trial samples were used to assess NA titers from the US and Europe. The proportions of participants that were negative were 14.8% (Ad5), 31.5% (Ad6); 41.2% (Ad26) and 53.6% (Ad36). Adenovirus NA titers varied by geographic location and were higher in non-US and non-European settings, especially Thailand. In multivariate logistic regression analysis, geographic setting (non-US and non-European settings) was statistically significantly associated with having higher Ad5 titers; participants from Thailand had the highest odds of having high Ad5 titers (adjusted OR=3.53, 95% CI: 2.24, 5.57). Regardless of location, titers of Ad5NA were the highest and Ad36 NA were the lowest. Coincident Ad5/6 titers were lower than either Ad5 or Ad6 titers alone. Understanding pre-existing immunity to candidate vaccine vectors may contribute to the evaluation of vaccines in international populations.

Confirmation and quantitation of human papillomavirus type 52 by Roche Linear Array using HPV52-specific TaqMan E6/E7 quantitative real-time PCR

Human papillomavirus type 52 is highly prevalent in Asia and Africa and accounts for 2-3% of total cervical cancer burden worldwide. The Roche Molecular Systems HPV Linear Array (RMS-LA uses multiple type (i.e. mixed) probes to detect DNA from HPV 52 infection which limits the assay's ability to determine HPV 52 status in the presence of HPV 33, 35, or 58 infection. This report presents a simple to use and highly reproducible HPV 52 type-specific quantitative real-time PCR (RT-PCR) assay based on Taqman chemistry for detection and quantification of HPV 52 DNA from cervical swab specimens. Mixed probe positive cervical swab specimens collected from rural and urban women in Thailand (n=68) were used to determine assay agreement and differences in HPV 52 DNA viral load across cytological diagnosis. Forty-eight specimens were determined to be HPV 52 positive by RMS-LA with 94% (n=45) confirmed positive by Taqman assay (kappa: 0.86, 95% CI: 0.74, 0.99). Higher median viral load was observed among women with a Pap diagnosis of >=ASCUS vs. normal/inflammation (8510 copies/1000 cell equivalents vs. 279 copies/1000 cell equivalents, p<0.05). Accurate ascertainment of infection status is important in understanding HPV 52's role in the etiology of cervical cancer as well as for the development of type-specific vaccines.

Autonomic failure in primary amyloidosis

Amyloidosis is an uncommon plasma cell dyscrasia affecting Multisystem, characterized by deposition of amyloid proteins in extracellular spaces and the tissues. Reported incidence of amyloidosis is 8 cases per million per year. Deposition of amyloid fibrils occurs in peripheral nerves in 20% of the cases in Primary Amyloidosis. Though. polyneuropathy is one of the presenting manifestations in cases of Primary Amyloidosis, pure autonomic failure without involving peripheral nerves is not a documented entity. Here, we present a case of Primary Amyloidosis presenting as Pure Autonomic Failure (Dysautonomia).

White paper on academic emergency medicine in India: INDO-US Joint Working Group (JWG)

Emergency Medicine (EM) is a new discipline for India. As Medical Council of India (MCI) makes progress in recognizing the need to develop EM residency training programs in India it is important that there exist an established training model for future faculty, residents and medical students. This INDO-US white paper makes a serious attempt to recognize the opportunities and challenges in developing academic emergency medicine in India. The contents of this white paper address the overall scenario and are not targeted towards a person, physician, body, hospital or any other associated entity. This paper emphasizes the importance of MCI recognized training in Emergency Medicine for physicians in India.

Detection of HIV vaccine-induced cell-mediated immunity in HIV-seronegative clinical trial participants using an optimized and validated enzyme-linked immunospot assay

An effective vaccine for HIV is likely to require induction of T-cell-mediated immune responses, and the interferon-gamma (IFNgamma) enzyme-linked immunospot (ELISPOT) assay has become the most commonly used assay for measuring these responses in vaccine trials. We optimized and validated the HIV ELISPOT assay using an empirical method to establish positivity criteria that results in a < or =1% false-positive rate. Using this assay, we detected a broad range of HIV-specific ELISPOT responses to peptide pools of overlapping 20mers, 15mers, or 9mers in study volunteers receiving DNA- or adenovirus vector-based HIV vaccines and in HIV-seropositive donors. We found that 15mers generally had higher response magnitudes than 20mers and lower false-positive rates than 9mers. These studies show that our validated ELISPOT assay using 15mer peptide pools and the positivity criteria of > or =55 spots per 10(6) cells and > or =4-fold over mock (negative control) is a sensitive and specific assay for the detection of HIV vaccine-induced cell-mediated immunity.

Estimating the Benefit of an HIV‐1 Vaccine That Reduces Viral Load Set Point

Vaccines designed to induce cell-mediated immune responses against human immunodeficiency virus (HIV)-1 are being developed. Such vaccines are unlikely to provide sterilizing immunity but may be associated with reduced viral set points after infection. We modeled the potential impact of a vaccine that reduces viral set point after infection, using natural history data from 311 HIV-1 seroconverters. Log-normal parametric regression models were used to estimate the log median time to events of interest. Relative times were estimated for those with viral load set points of 30,000 copies/mL (reference group) versus those with lower viral set points. The time to key clinical events in the course of HIV-1 disease progression was significantly extended for those with viral set points 0.5-1.25 log(10) copies/mL lower than the reference group. By quantifying the anticipated clinical benefits associated with a reduction in viral set point, these findings support the use of virologic end points in HIV-1 vaccine trials.

Pulsed underwater corona discharges as a source of strong oxidants: *OH and H2O2

Because of undesirable side effects of chemical methods pulsed underwater corona discharges are emerging as a potential future advanced oxidation process (AOP) for water disinfection. In pulsed corona discharges a discharge channel is created, which contains a non-thermal plasma with a low degree of ionisation and low electron densities, but with electron energies of up to 10 eV. It has been demonstrated that electrons with this energy can dissociate water and oxygen molecules and produce various reactive radicals (*OH, H*, O*, HO2*), molecular species (H2O2, H2, O2), ultraviolet radiation and shock waves. It is supposed that the combination of all effects leads to a very efficient killing of microorganisms. To understand this in detail and to improve the efficiency of the overall system there is the need to develop suitable diagnostic methods for the quantitative determination of the various oxidants produced during the discharge. In this paper we present preliminary experimental results obtained with different chemical probes for *OH radicals, and H2O2 produced by pulsed corona discharges.

Cross-Clade Reactivity of HIV-1-Specific T-cell Responses in HIV-1-Infected Individuals From Botswana and Cameroon

An effective HIV type 1 (HIV-1) vaccine will likely require elicitation of broadly reactive cell-mediated immune (CMI) responses against divergent HIV-1 clades. We compared anti-HIV-1 T-cell immune responses among 363 unvaccinated adults infected with diverse HIV-1 clades. Response rates to clade B Gag and/or clade B Nef in Botswana (95%) and Cameroon (98%) were similar when compared with those in countries previously studied, including Brazil (92%), Thailand (96%), South Africa (96%), Malawi (100%), and the United States (100%). Substantial cross-clade cell-mediated immune responses in Botswana and Cameroon confirm previous findings in a larger, more genetically diverse collection of HIV-1 samples.

API consensus guidelines for use of antiretroviral therapy in adults (API-ART guidelines). Endorsed by the AIDS Society of India

With rational use of antiretroviral therapy (ART), human immunodeficiency virus (HIV) infection has been transformed into a chronic manageable illness like diabetes and hypertension. These guidelines provide information on state of art, evidence based approach for use of ART in Indian context. When to initiate ART? Antiretroviral therapy is indicated for all symptomatic HIV infected persons regardless of CD4 counts and plasma viral load (PVL) levels. In asymptomatic patients, ART should be offered when the CD4 counts < 200/mm3 and should be considered in patients with CD4 counts between 200-250/mm3. Therapy is not recommended for patients with CD4 count more than 350/ mm3. Involvement of patient in all treatment decisions and assessing readiness is critical before initiating ART. What to start with? A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen is recommended for antiretroviral naïve patients. The choice between nevirapine and efavirenz is based on differences in adverse events profiles; cost and availability of convenient fixed dose combinations and need for concomitant use of rifampicin. A backbone of 2-nucleoside reverse transcriptase inhibitors (NRTIs) is combined with the NNRTI. Various combinations and ART strategies not to be used in clinical practice has been enlisted. How to follow up? Recommendations have been made for baseline evaluation and monitoring of patients on ART. These include guidelines on laboratory and clinical evaluation. A plasma viral load at 6 months after initiation of first-line ART is strongly recommended. Yearly estimation of lipid profile has been recommended. How to identify and manage ART failure? The guidelines recognize the issue of identifying ART failure late if only CD4 counts are used for monitoring. In the absence of resistance testing various second-line regimens have been enlisted. A boosted protease inhibitor based regimen is recommended in this situation to be combined with 2-NRTIs. Special situations Recommendations have been made for use of ART in HIV-TB, HIV-HBV, and HIV-HCV co-infected patients. In patients with active TB and a CD4 count < 200/mm3, initiation of ART is recommended as soon as the anti-TB treatment is tolerated. Efavirenz is the only ARV drug, which can be safely used with rifampicin. In pregnancy use of single dose nevirapine for reducing risk of mother to child transmission of HIV is not recommended, because of the risk of development of resistance. For post-exposure prophylaxis taking ART treatment history of the source patient is crucial in designing an effective regimen.

Exercise ECG testing--is it obsolete?

Role of exercise ECG Testing has become controversial with the emergence of so many non-invasive imaging modalities. In spite of that, Exercise ECG Testing still remains the best modality as an initial test for evaluation of chest pain, prognostication and risk stratification of coronary artery disease, rehabilitation following myocardial infarction and various re-vascularization procedures. Further, the test has also been used in other cardiovascular diseases other than coronary artery disease.

Cross‐Reactivity of Anti–HIV‐1 T Cell Immune Responses among the Major HIV‐1 Clades in HIV‐1–Positive Individuals from 4 Continents

BACKGROUND

The genetic diversity of human immunodeficiency virus type 1 (HIV-1) raises the question of whether vaccines that include a component to elicit antiviral T cell immunity based on a single viral genetic clade could provide cellular immune protection against divergent HIV-1 clades. Therefore, we quantified the cross-clade reactivity, among unvaccinated individuals, of anti-HIV-1 T cell responses to the infecting HIV-1 clade relative to other major circulating clades.

METHODS

Cellular immune responses to HIV-1 clades A, B, and C were compared by standardized interferon- gamma enzyme-linked immunospot assays among 250 unvaccinated individuals, infected with diverse HIV-1 clades, from Brazil, Malawi, South Africa, Thailand, and the United States. Cross-clade reactivity was evaluated by use of the ratio of responses to heterologous versus homologous (infecting) clades of HIV-1.

RESULTS

Cellular immune responses were predominantly focused on viral Gag and Nef proteins. Cross-clade reactivity of cellular immune responses to HIV-1 clade A, B, and C proteins was substantial for Nef proteins (ratio, 0.97 [95% confidence interval, 0.89-1.05]) and lower for Gag proteins (ratio, 0.67 [95% confidence interval, 0.62-0.73]). The difference in cross-clade reactivity to Nef and Gag proteins was significant (P<.0001).

CONCLUSIONS

Cross-clade reactivity of cellular immune responses can be substantial but varies by viral protein.

Acute pancreatitis and diabetic ketoacidosis in non-diabetic person while on treatment with sodium valproate, chlorpromazine and haloperidol

A nondiabetic young male patient in hypomanic phase of bipolar disorder on maintenance treatment with sodium valproate, developed transient episode of acute pancreatitis and diabetic ketoacidosis after addition of chlorpromazine and halopridol. It subsided completely within six weeks and his blood sugar was normal without any antidiabetic therapy. Simultaneous occurrence of acute pancreatitis and diabetic ketoacidosis is reported as a very rare complication of combination of antipsychotic drugs sodium valproate, chlorpromazine and haloperidol. Blood sugar should be periodically monitored in patients on sodium valproate and antipsychotic medication.

Predicting mortality in stroke

Physicians are faced with the task of predicting the immediate and long term outcome in stroke patients. It is also important to efficiently and optimally utilize resources. We used APACHE III scoring system or predicting in hospital outcome in patients with stroke. We found it to be sensitive (>90%) and resonably specific (73%) in predicting short term, in-hospital mortality, in our study group.

Test of HIV incidence shows continuing HIV transmission in homosexual/bisexual men in England and Wales

It has been suggested that HIV incidence will decrease with the increased use of antiretroviral Therapy (ART) in HIV infected homosexual/bisexual men. HIV incidence was measured using a sensitive/less sensitive assay technique, at a time when combination ART was widespread. The Serological Testing Algorithm for Recent HIV Seroconversion (STARHS)13 technique was applied to syphilis test specimens collected from homosexual/bisexual men attending 15 sexually transmitted infections (STI) clinics which participated in an unlinked anonymous serosurvey of HIV infection during 1998. The HIV incidence rate was adjusted to compensate for patients who had a repeat syphilis test within the same year. Leftover syphilis test sera from 6202 men had been unlinked and anonymised, of which 415 were HIV positive. Sera from 412 (99.3%) patients were available. The STARHS assay showed 62 to have been recently infected with HIV (approximately in the last four months), giving an incidence of 3.33% per annum (95% CI: 2.06%-5.27%). The highest incidence was seen in those aged 35-44 years. About 46% of all HIV-infected homosexual/bisexual men were probably receiving combination ART at this time. If 10% of those on treatment were misclassified as recent infections the incidence would have been 2.58% per annum (95% CI: 1.53%-4.24%). In homosexual/bisexual men having syphilis tests at STI clinics in the UK during 1998 the incidence of HIV infection was between two and three per hundred per year. Treatment with combination ART of almost a half of homosexual/bisexual men who are HIV infected in the population is compatible with appreciable continuing HIV transmission among those at high behavioural risk. Public health surveillance systems for those at high risk for HIV infection should, as soon as possible, incorporate the STARHS methodology for monitoring recent HIV incidence.

The national CD4 surveillance scheme for England and Wales

This paper describes a national surveillance scheme, began in 1995, designed to monitor immunosuppression associated with HIV infection in adults in England and Wales. Currently 60 out of 64 (94%) laboratories performing CD4 cell counts participate in the scheme. The database contains over 42,000 patient records with over 300,000 counts, taken between April 1984 and March 2000. Approximately half of the patient records in the CD4 database match with patient records in the UK database of diagnosed HIV infections; a large proportion of the unmatched patients in the CD4 database may not be HIV-infected. Close to 50% of both men who have sex with men and injecting drug users and two-thirds of those who acquired their infection heterosexually had CD4 cell counts below 350 cells/mm3 at the time of HIV diagnosis. The National CD4 Surveillance Scheme provides important information regarding the epidemiology of HIV infection such as the changes in patterns of early and late diagnosis. It should continue to be used in conjunction with the other HIV surveillance systems to present as complete a picture of the epidemic as possible.

What a test for recent infection might reveal about HIV incidence in England and Wales

BACKGROUND

A laboratory method has been developed that detects recent HIV infection and allows incidence to be estimated by testing single stored antibody-positive specimens. A theoretical exploration of the method's surveillance utility was carried out.

METHODS

Using various data sources, HIV incidence rates were postulated. The confidence intervals (CI) for these postulated incidences were calculated using the expected number of recent infections for each postulated incidence, the actual number tested for HIV, and the known number of HIV-1 positives. A test for trend was used to determine when an important change in incidence could be recognized.

RESULTS

If the incidence was 5% per annum (p.a.) in homosexual/bisexual men attending sexually transmitted diseases (STD) clinics in London, 64 recent infections would be expected in the 392 HIV-seropositive specimens and, if observed, would result in a 95% CI of 3.1-7.9% p.a. for the incidence rate. An incidence of 1% p.a. in pregnant women would be most unlikely as this would require detection of 193 recent infections, 26 more than the total 167 HIV-seropositive specimens found in 1997. In African women attending STD clinics in London, 30% of prevalent infections would be classified as recent if the incidence was 5% p.a. Further, if the incidence in homosexual/bisexual men were to fall by 50% over 3 years, a decrease of this magnitude would be recognized as significant within 2 years.

CONCLUSIONS

The detuned assay will increase the information from HIV serosurveys even where prevalence and incidence are relatively low. Existing surveillance systems should be redesigned to take full advantage of the method.

CD4 cell counts in adults with newly diagnosed HIV infection: results of surveillance in England and Wales, 1990-1998. CD4 Surveillance Scheme Advisory Group

OBJECTIVES

To describe the distribution and changes in CD4 cell counts (both initial and subsequent) in HIV-infected persons over time and determine the factors influencing these counts.

DESIGN

Reports were requested from laboratories measuring CD4 cell counts in England and Wales. Initial counts were analysed and median counts were followed over time.

METHODS

Time trends and the relationship between initial CD4 cell count and age, sex, and HIV risk category were studied using quantile regression methods or chi-square tests.

RESULTS

Between 1990 and 1998, 9553 adults were newly diagnosed with HIV infection and had a CD4 cell count within 6 months of HIV diagnosis. Over 50% of initial CD4 cell counts in each major risk category were below 350 cells/mm3. Older age (P < 0.001), male sex (P < 0.013) and heterosexual risk (P < 0.001) were independently associated with lower initial CD4 cell counts. For heterosexually infected adults, the median initial CD4 cell count was significantly negatively associated with the year of diagnosis (P = 0.03) and the median age increased through the time period examined (P < 0.001), whereas for men who have sex with men (MSM), there was no significant change in these values over time. For each year cohort of newly diagnosed individuals, the median CD4 cell count in subsequent years decreased until 1996 and then increased thereafter, consistent with a treatment effect.

CONCLUSION

Across all major risk groups, a large proportion of HIV-infected adults are being diagnosed late in the course of HIV disease. For the heterosexually infected, the data suggest an ageing cohort effect, whereas for MSM the data are consistent with continuing transmission.

Silent myocardial ischaemia and cardiac autonomic neuropathy in diabetics

Treadmill exercise electrocardiography was performed in 47 patients of diabetes to detect latent coronary artery disease. Eighteen patients (36.3%) were found positive on treadmill test. All forty seven subjects were evaluated for cardiac autonomic neuropathy. The incidence of cardiac autonomic neuropathy in treadmill positive group was 72.2% as compared to 31.0% in treadmill negative group, (p < 0.01). Nine patients from the positive group and 4 patients from the negative group were subjected for coronary angiography, which revealed significant CAD in 8 and 1 subjects in both groups respectively. It is concluded that the incidence of silent myocardial ischaemia in diabetics is very high and cardiac autonomic neuropathy seems to be the most probable reason for absence of pain.

Anatomical note. Venous segmentation in the spleen of the sheep

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Hepatovenous segments in the human liver

The patterns of hepatovenous segments in 95 human livers have been studied after preparing corrosion casts of the hepatic veins in 72 specimens and taking X-rays of 23 livers after injecting barium sulphate into the hepatic veins. Five hepatovenous segments were seen in every specimen: left, middle, right, paracaval and caudate. The sizes of corresponding hepatovenous segments were similar in 77.9% of livers; in the remainder increased or decreased size, at the expense of neighbouring segments, was observed.

Study of venous segments in the spleens of buffalo and dog

By preparing the corrosion cast of the splenic vein and its intrasplenic tree, venous segments have been observed in the spleens of buffalo and dog. The buffalo spleen showed the presence of two venous segments (a dorsal and a ventral) in 85% of cases and three (a dorsal, an intermediate and a ventral) in 15% of cases. The spleen of the dog revealed only two venous segments (a dorsal and a ventral) in all the specimens. The results are compared with descriptions available in the literature.

Arterial segmentation in the spleen of the sheep (Ovis aries)

Forty corrosion casts of the splenic artery and its tree were used to study segmentation in the sheep spleen. Twenty eight spleens (70%) had two arterial segments, a right and a left. One spleen (2.5%) had a visceral and a parietal segment. Eleven spleens (27.5%) showed no arterial segmentation, the artery ramifying irregularly.

Segmentation in the dog spleen. A study by corrosion cast

40 corrosion casts of the dog splenic artery were prepared to observe the vascular segments in the dog spleen. 39 specimens (97.5%) revealed the presence of two segments, a dorsal and a ventral one. However, in 1 specimen (2.5%) no segmentation was seen.