Antibodies from Rabbits Immunized with HIV-1 Clade B SOSIP Trimers Can Neutralize Multiple Clade B Viruses by Destabilizing the Envelope Glycoprotein

The high viral diversity of HIV-1 is a formidable hurdle for the development of an HIV-1 vaccine. Elicitation of broadly neutralizing antibodies (bNAbs) would offer a solution, but so far immunization strategies have failed to efficiently elicit bNAbs. To overcome these obstacles, it is important to understand the immune responses elicited by current HIV-1 envelope glycoprotein (Env) immunogens. To gain more insight, we characterized monoclonal antibodies (MAbs) isolated from rabbits immunized with Env SOSIP trimers based on the clade B isolate AMC008. Four rabbits that were immunized three times with AMC008 trimer developed robust autologous and sporadic low-titer heterologous neutralizing responses. Seventeen AMC008 trimer-reactive MAbs were isolated using antigen-specific single B-cell sorting. Four of these MAbs neutralized the autologous AMC008 virus and several other clade B viruses. When visualized by electron microscopy, the complex of the neutralizing MAbs with the AMC008 trimer showed binding to the gp41 subunit with unusual approach angles, and we observed that their neutralization ability depended on their capacity to induce Env trimer dissociation. Thus, AMC008 SOSIP trimer immunization induced clade B-neutralizing MAbs with unusual approach angles with neutralizing effects that involve trimer destabilization. Optimizing these responses might provide an avenue to the induction of trimer-dissociating bNAbs. IMPORTANCE Roughly 32 million people have died as a consequence of HIV-1 infection since the start of the epidemic, and 1.7 million people still get infected with HIV-1 annually. Therefore, a vaccine to prevent HIV-1 infection is urgently needed. Current HIV-1 immunogens are not able to elicit the broad immune responses needed to provide protection against the large variation of HIV-1 strains circulating globally. A better understanding of the humoral immune responses elicited by immunization with state-of-the-art HIV-1 immunogens should facilitate the design of improved HIV-1 vaccine candidates. We identified antibodies with the ability to neutralize multiple HIV-1 viruses by destabilization of the envelope glycoprotein. Their weak but consistent cross-neutralization ability indicates the potential of this epitope to elicit broad responses. The trimer-destabilizing effect of the neutralizing MAbs, combined with detailed characterization of the neutralization epitope, can be used to shape the next generation of HIV-1 immunogens to elicit improved humoral responses after vaccination.

A study of the North Staffordsh i re you ng adult service forthe physically handicapped school leaver and young adult

Studies have shown that the expectations of physically disabled school leavers are low when they have nothing to do and they fail to develop even further. It has also been shown that where there is a service for young physically disabled school leavers, there is benefit for the young people. We performed an evaluation of our own service using a questionnaire and additionally looked at areas of unmet need. The study showed that the team's activities were useful, and young people obtained benefit from the service which they would not otherwise have had, for lack of proper assessment. It was realized that a number of services, which were requested, did not take place and these related to communication between our team and the community health service. We have adapted our service to address these problems and now plan to look more formally at ways to promote clients' desired lifestyles.

International consensus statement for the use of botulinum toxin treatment in adults and children with neurological impairments--introduction

Botulinum neurotoxin (BoNT) is most commonly used to reduce focal over-activity in skeletal muscle, although newer indications such as management of drooling, pain and tremor are emerging. Treatment of spasticity incorporating BoNT is usually part of an integrated multidisciplinary rehabilitation programme. Prior to initiating this therapy, specific functional limitations, goals and expected outcomes of treatment should be discussed with the patient/carers. Muscle selection and the order/priority of treatment should be agreed. Treatment goals may involve increasing active or passive function or the avoidance of secondary complications or impairment progression. This paper describes the basic science mechanisms of the action of BoNT and subsequent nerve recovery and introduces a supplement comprising the best available evidence and expert opinion from international panels on questions of assessment, indications, BoNT regimen, adjunctive therapy, expected outcomes and recommended monitoring. Speciality areas reviewed include Paediatric Lower Limb Hypertonicity, Paediatric Upper Limb Hypertonicity, Adult Lower Limb Hypertonicity, Adult Upper Limb Hypertonicity, Cervical Dystonia, Drooling and Pain and Niche Indications. There is good quality scientific evidence to support the efficacy of BoNT to reduce muscle over-activity in the limbs secondary to central nervous system disorders in adults and children, to address primary or secondary cervical dystonia, to reduce saliva flow and to treat some pain syndromes. There is emergent evidence for the efficacy of BoNT to reduce focal tremor, to treat other types of pain including neuropathic pain and also to improve function following treatment of focal muscle over-activity.

Cost-effectiveness modeling of intrathecal baclofen therapy versus other interventions for disabling spasticity

OBJECTIVE

To assess by simulation the cost-effectiveness of intrathecal baclofen (ITB) therapy compared with conventional medical treatments for patients with disabling spasticity and functional dependence caused by any neurological disease.

METHODS

Two models were created to simulate therapeutic strategies for managing severe spasticity, one with and one without the use of ITB, to assess various treatment sequences over 2 years based on current medical practices in France. Successful treatment at each evaluation was defined as a combination of: (1) the increased patient and caregiver satisfaction as assessed by goal attainment scaling (GAS), and (2) a decrease of at least 1 point on the Ashworth score. Probabilistic sensitivity analyses were performed using 5000 Monte-Carlo simulations taking into account specific distribution curves for direct costs and effectiveness parameters in each treatment option.

RESULTS

The model simulations suggest that including ITB as a first option strategy in the management of function of severely impaired patients with disabling spasticity results in a higher success rate (78.7% vs 59.3%; P < .001). In addition, the ITB therapy model revealed a lower cost (pound 59,391 vs pound 88,272; P < .001) and an overall more favorable cost-effectiveness ratio (pound 75,204/success vs pound 148,822/success; P < .001), compared with conventional medical management without ITB.

CONCLUSION

Within the assumptions of our modeling, ITB therapy evaluated by a combination of treatment success criteria at 6-month intervals over a 2-year period may be a cost-effective strategy compared to conventional medical management alone.

Clinical value of botulinum toxin in neurological indications

Botulinum toxin type-A (BoNT-A) prevents the release of acetylcholine at cholinergic junctions, thereby causing temporary muscle weakness lasting 3-4 months. It is now widely used to treat a broad range of clinical disorders characterized by muscle hyperactivity. BoNT-A has proved effective in the management of several neurological conditions and, in particular, in the management of movement disorders (e.g. blepharospasm, cervical dystonia, laryngeal dystonia, limb dystonia, hemifacial spasm, focal tics, tremor and other hyperkinetic disorders). As a treatment of spasticity, BoNT-A can improve mobility and dexterity as well as preventing the development of distressing and costly secondary complications. In cerebral palsy, BoNT-A is of value, being able to delay or even avoid surgery until motion patterns have become established.

Outcomes following childhood head injury: a population study

OBJECTIVES

To identify outcomes following head injury (HI) among a population of children admitted to one hospital centre and to compare outcomes between different severity groups.

METHODS

A postal follow up of children admitted with HI to one National Health Service Trust, between 1992 and 1998, was carried out. Children were aged 5-15 years at injury (mean 9.8), followed up at a mean of 2.2 years post-injury. Parents of 526 injured children (419 mild, 58 moderate, 49 severe) and 45 controls completed questionnaires. Outcomes were assessed using the King's Outcome Scale for Childhood Head Injury (KOSCHI).

RESULTS

Frequent behavioural, emotional, memory, and attention problems were reported by one third of the severe group, one quarter of the moderate, and 10-18% of the mild. Personality change since HI was reported for 148 children (28%; 21% mild HI, 46% moderate, 69% severe). There was a significant relationship between injury severity and KOSCHI outcomes. Following the HI, 252 (48%) had moderate disability (43% mild HI, 64% moderate, 69% severe), while 270 (51%) made a good recovery (57% mild HI, 36% moderate, 22% severe). There was a significant association between social deprivation and poor outcome (p = 0.002). Only 30% (158) of children received hospital follow up after the HI. All children with severe disability received appropriate follow up, but 64% of children with moderate disability received none. No evidence was found to suggest a threshold of injury severity below which the risk of late sequelae could be safely discounted.

CONCLUSIONS

Children admitted with mild HI may be at risk of poor outcomes, but often do not receive routine hospital follow up. A postal questionnaire combined with the KOSCHI to assess outcomes after HI may be used to identify children who would benefit from clinical assessment. Further research is needed to identify factors that place children with mild HI at risk of late morbidity.

Return to school after brain injury

AIMS

To examine return to school and classroom performance following traumatic brain injury (TBI).

METHODS

This cross-sectional study set in the community comprised a group of 67 school-age children with TBI (35 mild, 13 moderate, 19 severe) and 14 uninjured matched controls. Parents and children were interviewed and children assessed at a mean of 2 years post injury. Teachers reported on academic performance and educational needs. The main measures used were classroom performance, the Children's Memory Scale (CMS), the Wechsler Intelligence Scale for Children-third edition UK (WISC-III) and the Weschler Objective Reading Dimensions (WORD).

RESULTS

One third of teachers were unaware of the TBI. On return to school, special arrangements were made for 18 children (27%). Special educational needs were identified for 16 (24%), but only six children (9%) received specialist help. Two thirds of children with TBI had difficulties with school work, half had attention/concentration problems and 26 (39%) had memory problems. Compared to other pupils in the class, one third of children with TBI were performing below average. On the CMS, one third of the severe group were impaired/borderline for immediate and delayed recall of verbal material, and over one quarter were impaired/borderline for general memory. Children in the severe group had a mean full-scale IQ significantly lower than controls. Half the TBI group had a reading age > or =1 year below their chronological age, one third were reading > or =2 years below their chronological age.

CONCLUSIONS

Schools rely on parents to inform them about a TBI, and rarely receive information on possible long-term sequelae. At hospital discharge, health professionals should provide schools with information about TBI and possible long-term impairments, so that children returning to school receive appropriate support.

Physical therapy in spasticity

Physiotherapists are part of the rehabilitation team involved in the management of adult spasticity. Physical therapy is one part of the armoury in the fight against this disabling symptom of the upper motor neurone syndrome. Identifying the physiological changes brought about by physical therapy or physiotherapy, is difficult. As with many interventions in rehabilitation, this area is poorly studied and, until recently, there was little or no evidence for its effectiveness. The aim of this presentation is to identify key components of a physiotherapy approach and outline specific techniques. The key components considered are: education of the patient and their carers; the 'intervention cycle' - involving accurate assessment, careful measurement, intervention and evaluation; accurate goal setting and a staged stepwise approach over prolonged periods. The specific techniques used include treatments targeted at: muscle length changes, muscle strengthening and functional performance. Broadly these techniques can be divided into biomechanical, cognitive and neurophysiological, each being interdependent on the others. Physiotherapy combined with the other available treatments should meet the challenge arising from adult spasticity.

The management of pain in spasticity

Pain is a common feature of spasticity and muscle spasms and the reasons for this are discussed in this article. However, the causes of this spasticity have to be determined and for successful management, knowing the underlying mechanisms, which produce spasticity, is necessary. In addition to knowing the range of available treatments, one has to know their particular contribution to the overall management of the patient. The assessment and management of the spastic patient is multi-disciplinary and painful spasticity changes over time. This therefore requires repeated assessments and the direction of the treatment may also change. Pain may be a dominant feature, but is rarely the sole symptom. This article looks at a strategy for the overall management of the patient with the focus on managing pain.

A summary of spasticity management--a treatment algorithm

The muscle overactivity seen in spasticity results in limb stiffness and muscle spasm, to which there is both a neurogenic and a biomechanical component. Spasticity does not always cause harm and can assist in the rehabilitation process enabling a patient to stand when their limb weakness would not otherwise allow it. When it does cause harm, however, treatment is required. This aims to (i) prevent provocative factors (ii) treat muscle overactivity; and (iii) prevent complications. Untreated, limb contracture, pain and other complications occur and early management can be most effective. Treatment is essentially physical, but, when this is inadequate, pharmacological intervention may be required. A strategy has been devised which shows that the first choice pharmacological treatment of focal spasticity is botulinum toxin. Over the past decade, the choice of treatment has become more ambitious with the establishment of new technologies. Good management now depends on an understanding of their role and application in relation to the needs of individual patients. To this end, a treatment algorithm which covers the salient facts in patient assessment and gives the indications for the range of available treatments, is the best approach. The indications and limitations of the available treatments are discussed, along with their place in the overall management of the patients. The evidence base for much of what is done is not strong and this summary examines the activities of proven value and of consensus view.

Short-term sequelae of minor head injury (6 years experience of minor head injury clinic)

PURPOSE

It is known that post-concussive symptoms may persist after mild head injury. However, the majority of those patients are denied follow-up or support. A minor head injury clinic was thus established in North Staffordshire Hospital in 1993 to address these problems.

METHODS

Patients 16-65 years old attending hospital with minor head injury were invited to attend the clinic two weeks after presentation. A specialized brain injury nurse and/or assistant clinical psychologist assessed them. Patients with persistent symptoms were invited to a second assessment four weeks later.

RESULTS

One thousand two hundred and fifty-five patients were invited for first assessment, the most common cause of head injury was assault (454) followed by road traffic accident (334). Six hundred and sixteen patients did not attend the first assessment; most of non-attendees were those who had been assaulted (281). Six hundred and thirty-nine patients attended, (472) were male, their mean age was 33. Forty-three per cent of them had history of recent alcohol intake. One third had had a previous head injury. Although 391 attendees were in regular employment, 219 patients were unable to return to work 2 weeks after discharge (56%), and 49 people were still off sick 6 weeks after the injury. The most common complaints at both assessments were fatigue, headache, dizziness, irritability, sleep disturbances, poor concentration and poor memory in that order.

CONCLUSION

This study shows a significant number of patients with minor head injury still complaining of post concussive symptoms, which may contribute to a delay in return to work. The high incidence of non-attendance among the assaulted victims may indicate that this group needs to be more effectively targeted. Further study to look at the longer-term consequences of minor head injury is required in view of these findings.

A randomized, double-blind, placebo-controlled, dose-ranging study to compare the efficacy and safety of three doses of botulinum toxin type A (Dysport) with placebo in upper limb spasticity after stroke

BACKGROUND AND PURPOSE

We sought to define an effective and safe dose of botulinum toxin type A (Dysport) for the treatment of upper limb muscle spasticity due to stroke.

METHODS

This was a prospective, randomized, double-blind, placebo-controlled, dose-ranging study. Patients received either a placebo or 1 of 3 doses of Dysport (500, 1000, 1500 U) into 5 muscles of the affected arm. Efficacy was assessed periodically by the Modified Ashworth Scale and a battery of functional outcome measures.

RESULTS

Eighty-three patients were recruited, and 82 completed the study. The 4 study groups were comparable at baseline with respect to their demographic characteristics and severity of spasticity. All doses of Dysport studied showed a significant reduction from baseline of muscle tone compared with placebo. However, the effect on functional disability was not statistically significant and was best at a dose of 1000 U. There were no statistically significant differences between the groups in the incidence of adverse events.

CONCLUSIONS

The present study suggests that treatment with Dysport reduces muscle tone in patients with poststroke upper limb spasticity. Treatment was effective at doses of Dysport of 500, 1000, and 1500 U. The optimal dose for treatment of patients with residual voluntary movements in the upper limb appears to be 1000 U. Dysport is safe in the doses used in this study.

Study of the relationship between premorbid urinary incontinence and stroke functional outcome

OBJECTIVE

To examine functional outcome in stroke patients with premorbid incontinence of urine.

METHOD

Comparative study in stroke patients between premorbidly incontinent and continent groups. Both groups were subjected to structured interview, clinical examination and functional assessment at one week post stroke. Functional assessment was repeated six months later.

SUBJECTS

Eighty-six patients with first-time stroke younger than 80 years of age admitted to hospital, were divided into two groups according to their continence status.

OUTCOME MEASURE

The 20-point Barthel Index.

SETTING

Medical wards at North Staffordshire Teaching Hospitals.

RESULTS

Of 86 stroke patients (46 continent and 40 premorbidly incontinent), 19 died before six-month assessment, of whom 15 (79%) were premorbidly incontinent. Premorbid incontinence was the most significant variable predicting poor functional outcome (Barthel Index score <15) at six months, with a sensitivity of 82.6% and specificity of 86.4% and with age-corrected p-value of <0.001.

CONCLUSIONS

This study shows a significant relationship between premorbid incontinence and functional outcome at six months. However, other causes that could have contributed to the premorbid incontinence were not excluded. This point needs to be considered in future studies, which should also examine whether premorbid incontinence per se reflects an underlying predisposition for stroke.

Management of spasticity

Spasticity is a complex problem which can cause profound disability, alone or in combination with weakness, and can give rise to significant difficulties during rehabilitation. This article reviews a current approach to the management of spasticity.

A comparison of symptoms experienced following minor head injury and acute neck strain (whiplash injury)

The symptoms reported by patients who have experienced minor head or minor neck injury are compared. Symptoms were identified using a questionnaire-based out-patients interview. Rank order correlation analyses were carried out on data obtained at 2 and 6-12 weeks post-injury. Data on 24 head-injured and 29 neck-injured patients are presented. There was a significant rank order correlation at both assessments but neck injured patients reported more phobia (fear of travelling in car) and depression, and head-injured more dizziness. It is likely that neck-injury contributes to the symptomatology experienced after minor head injury, and vice-versa.

Sequelae of minor head injury: the natural history of post-concussive symptoms and their relationship to loss of consciousness and follow-up

The character and natural history of post-concussive symptoms were studied in two subject groups: patients admitted to hospital for observation following brief loss of consciousness (LOC) as a result of head injury and patients who attended the accident unit after head injury but not were not admitted. Follow-up data were obtained from the hospitalized group at standardized out-patient interview and from the non-hospitalized group by postal questionnaire. Two- and 12-week data are presented on 24 hospitalized and 58 non-hospitalized patients. The type and frequency of symptoms was similar in the two groups and rank ordering was significantly correlated. However, the reduction in symptom scores (number of symptoms) 12 weeks post-injury was significantly greater in the hospitalized than the non-hospitalized group. The possible significance of this is discussed.

Use of head injury instruction cards in accident centres

This study reports on the value of head injury instruction cards as purveyors of information to patients. Patients over 10 years old attending the North Staffordshire Royal Infirmary Accident and Emergency Department with a mild head injury were invited to attend a special brain injury follow-up clinic, where they were asked to complete a questionnaire. Patients failing to attend this clinic were contacted and asked to complete the questionnaire. This revealed that they were no less severely affected by the injury as the attenders. They were asked why they had not attended and a significant number of patients had no recall of being given a head injury instruction card on which the information of the follow-up clinic was given. Memory loss was the most likely cause of this and is more common than is widely appreciated in patients attending accident and emergency departments.

Not tarsal tunnel syndrome: a malignant "Triton" tumour of the tibial nerve

A 23 year old male patient presented with a venous thrombosis in the right calf. This was followed by symptoms, signs and electromyographic findings suggestive of a tarsal tunnel syndrome. Symptoms were briefly relieved by surgical division of the flexor retinaculum. Subsequently, patient developed swelling in the calf and was found to have a malignant ("Triton") tumour of the tibial nerve and required above knee amputation. In the absence of obvious foot or ankle deformity, caution should be exercised in making the diagnosis of tarsal tunnel syndrome.

Lone axillary nerve lesion due to closed non-dislocating injury of the shoulder

Two rugby players with a lone axillary nerve lesion are described. Neither suffered an overt dislocation of the shoulder nor was there any evidence of severe local injury. Recovery in both was complete by 1 year. Possible mechanisms of injury are discussed.

Endometriosis in adolescents

Traditional gynecologic opinion holds that endometriosis is rare in teenagers. However, several reports of this disease in teenagers have appeared over the past four decades, and in one study of a series of endometriosis patients, teenagers accounted for 8.5% of them. With these facts in mind, 43 consecutive laparoscopies were prospectively analyzed in symptomatic teenagers. A 65% incidence of endometriosis was found. The symptoms and physical findings are analyzed. The liberal use of diagnostic laparoscopy in selected symptomatic adolescents is recommended for the early diagnosis and aggressive preventive treatment of this common and potentially crippling illness.

Fetus papyraceus in twin pregnancy

Three cases of fetus papyraceus in twin pregnancy were seen over a 4-month period. They were associated with an antepartum stillbirth and intrauterine growth retardation of the larger twin. Two of the 3 mothers exhibited hypertension. It is concluded, therefore, that the appearance of a fetus papyraceus frequently indicates the presence of a hostile intrauterine environment. We suggest that serial ultrasonic examinations be performed to confirm the diagnosis of fetus papyraceus. In this way, appropriate therapy may be directed toward a better outcome for the second twin.