Oral bait handout as a method to access roaming dogs for rabies vaccination in Goa, India: A proof of principle study

Rabies has profound public health, social and economic impacts on developing countries, with an estimated 59,000 annual human rabies deaths globally. Mass dog vaccination is effective at eliminating the disease but remains challenging to achieve in India due to the high proportion of roaming dogs that cannot be readily handled for parenteral vaccination. Two methods for the vaccination of dogs that could not be handled for injection were compared in Goa, India; the oral bait handout (OBH) method, where teams of two travelled by scooter offering dogs an empty oral bait construct, and the catch-vaccinate-release (CVR) method, where teams of seven travel by supply vehicle and use nets to catch dogs for parenteral vaccination. Both groups parenterally vaccinated any dogs that could be held for vaccination. The OBH method was more efficient on human resources, accessing 35 dogs per person per day, compared to 9 dogs per person per day through CVR. OBH accessed 80% of sighted dogs, compared to 63% by CVR teams, with OBH accessing a significantly higher proportion of inaccessible dogs in all land types. All staff reported that they believed OBH would be more successful in accessing dogs for vaccination. Fixed operational team cost of CVR was four times higher than OBH, at 127 USD per day, compared to 34 USD per day. Mean per dog vaccination cost of CVR was 2.53 USD, whilst OBH was 2.29 USD. Extrapolation to a two week India national campaign estimated that 1.1 million staff would be required using CVR, but 293,000 staff would be needed for OBH. OBH was operationally feasible, economical and effective at accessing the free roaming dog population. This study provides evidence for the continued expansion of research into the use of OBH as a supplementary activity to parenteral mass dog vaccination activities in India.

Cardiovascular causes of sudden unexpected death in children and adolescents (0-17 years) : A nationwide autopsy study in the Netherlands

Background

Little is known about the causes of unexpected death in minors (0–17 years). In young adults an important cause is cardiovascular disease, with primary arrhythmogenic disorders, atherosclerotic events, cardiomyopathies and myocarditis as main contributors. The aim of this autopsy study was to determine the contribution of cardiovascular disease to unexpected death in minors.

Methods and results

In the Netherlands, systematic investigation of all cases of unexplained death in minors was compulsory in a nationwide governmental project during a 15-month period. Autopsies were performed according to a standardised protocol (autopsy rate 85%). A cardiovascular cause of death was found in 13/56 cases (23%). In the group <1 year, the main cardiovascular causes were various congenital defects (n = 3) and myocarditis (n = 2). In the 1–9 year group, no cardiovascular causes were found. In the 10–14 year group, hypertrophic cardiomyopathy (n = 1) and ruptured ascending aortic aneurysm (n = 1) were among the observed cardiovascular causes. In 14/56 (25%) cases autopsy revealed no structural abnormalities that could explain the sudden death, mostly in the group <1 year.

Conclusion

This national cohort with a high autopsy rate reveals a high incidence (23%) of cardiovascular diseases as the pathological substrate of sudden unexpected death in children. Another high percentage of minors (25%) showed no structural abnormalities, with the possibility of a genetic arrhythmia. These findings underline the importance of systematic autopsy in sudden death in minors, with implications for cardiogenetic screening of relatives.

Electronic supplementary material

The online version of this article (10.1007/s12471-018-1152-y) contains supplementary material, which is available to authorized users.

Field Studies Evaluating Bait Acceptance and Handling by Dogs in Navajo Nation, USA

Mass parenteral vaccination remains the cornerstone of dog rabies control. Oral rabies vaccination (ORV) could increase vaccination coverage where free-roaming dogs represent a sizeable segment of the population at risk. ORV's success is dependent on the acceptance of baits that release an efficacious vaccine into the oral cavity. A new egg-flavored bait was tested alongside boiled bovine intestine and a commercially available fishmeal bait using a hand-out model on the Navajo Nation, United States, during June 2016. A PVC capsule and biodegradable sachet were tested, and had no effect on bait acceptance. The intestine baits had the highest acceptance (91.9%; 95% confidence interval (CI), 83.9%⁻96.7%), but the fishmeal (81.1%; 95% CI, 71.5%⁻88.6%) and the egg-flavored baits (77.4%; 95% CI, 72.4%⁻81.8%) were also well accepted, suggesting that local bait preference studies may be warranted to enhance ORV's success in other areas where canine rabies is being managed. Based on a dyed water marker, the delivery of a placebo vaccine was best in the intestine baits (75.4%; 95% CI, 63.5%⁻84.9%), followed by the egg-flavored (68.0%; 95% CI, 62.4%⁻73.2%) and fishmeal (54.3%; 95% CI, 42.9%⁻65.4%) baits. Acceptance was not influenced by the supervision or ownership, or sex, age, and body condition of the dogs. This study illustrates that a portion of a dog population may be orally vaccinated as a complement to parenteral vaccination to achieve the immune thresholds required to eliminate dog rabies.

The influence of soyfibre supplemented tube feeding on the occurrence of diarrhoea in postoperative patients

We investigated the occurrence of diarrhoea in postoperative patients on tube feeding, with or without soyfibre supplementation. The patients also received antibiotic treatment. 60 postoperative patients were assigned to either a fibre free formula diet (FFF) or a soyfibre supplemented formula diet (SSF). The tube feeding was supplied continuously through a nasogastric or a jejunal tube (mean volume 1775 ml a day). The consistency and frequency of the bowel evacuations were recorded for a period of 5 days. A daily diarrhoea score (DS) was obtained by adding a consistency score (formed stools 1, loose 3, and watery 5 points) for every evacuation. The major finding of this study is that the total DS of the FFF group was 1.7 times higher than the SSF group (ANOVA, p = 0.05). We conclude that soyfibre enriched tube feeding has a beneficial and significant influence on the occurrence of diarrhoea in a selected group of postoperative patients.

Highly resistant gram-negative microorganisms: incidence density and occurrence of nosocomial transmission (TRIANGLe Study)

OBJECTIVES

The objectives of this study were to determine the incidence density and the occurrence of horizontal spread of highly resistant gram-negative rods (HR-GNRs) in Dutch hospitals. The factors that influence these outcome measures were also investigated.

METHODS

All patients with HR-GNRs, as determined by sample testing, who were hospitalized in 1 of 18 hospitals during a 6-month period (April through October 2007) were included in this study. For all available isolates, the species was identified, susceptibility was determined (including the presence of extended-spectrum β-lactamases [ESBLs]), and molecular typing was performed. On the basis of a combination of species identification, molecular typing, and epidemiological data, the occurrence of nosocomial transmission was determined.

RESULTS

The mean incidence density of patients with HR-GNRs was 55 per 100,000 patient-days (cumulative incidence, 39 per 10,000 patients admitted). A facility being a university hospital was a statistically significant (P = .03) independent determinant of a higher incidence of patients with HR-GNRs. The majority of HR-GNR isolates were ESBL producers. The adjusted transmission index-the ratio between secondary and primary cases-in the participating hospitals ranged from 0.0 to 0.2. The overall adjusted transmission index of HR-GNRs was 0.07. No determinants for a higher transmission index were identified.

DISCUSSION

The nosocomial transmission rate of HR-GNRs was relatively low in all hospitals where well-established transmission-based precautions were used. The incidence density of patients with HR-GNRs was higher in university hospitals, probably due to the patient population and the complexity of the care provided.

Abstract P6-11-08: A Comparison of Chemotherapeutic Treatment Practice in Metastatic Breast Cancer (MBC) in Belgium (BE) and The Netherlands (NL)

Introduction: Current treatment recommendations provide limited guidance for chemotherapy (CT) of MBC, while physicians have many options to choose from. We undertook a retrospective survey to describe and compare actual CT approaches to MBC in clinical practice in two neighboring European countries, BE and NL.

Methods: 20 BE and 18 NL hospitals collected data for 490 and 434 patients (pts), respectively, diagnosed with MBC in 2003-2009 and treated with ≥1 CT regimen. Demographic, disease and treatment data of the last 25 consecutively treated pts per hospital were included in each survey. The NL survey required age ≥70 yrs at MBC diagnosis, the BE survey had no upper age limit. We compared patient characteristics and treatment policies between both cohorts (BE vs. NL, for all comparisons). Results: BE patients were older at MBC diagnosis (median 60 vs. 56 yrs) and had M1 tumor status at primary diagnosis more frequently (26 vs. 20%). Average year of MBC diagnosis was 2005 for both countries. There were no striking differences in ER/PR positivity (61/50 vs. 64/47%), HER2/neu overexpression (27 vs. 31%), triple negative status (12 vs. 15%), or cardiac co-morbidity. Prior hormonal (22 vs. 12%), hormonal + adjuvant CT (32 vs. 26%), and total adjuvant CT (58 vs. 51%) had been given more frequently in the BE cohort. In pts receiving adjuvant CT, anthracyclines had been used more frequently in the NL cohort (61 vs. 78%). Pts in the BE and NL cohort received up to 10 and 6 lines of CT, respectively. 79 vs. 73% and 55 vs. 43% of pts received 2 and 3 lines of CT, respectively. BE pts received far more monotherapy in first line (46 vs. 25%), but not in second (66 vs. 65%) and third line (65 vs. 63%). Drugs used most frequently for monotherapy in lines 1-3 were the same in BE and NL: docetaxel (40 vs. 38%) and capecitabine (13 vs. 26%) in line 1; docetaxel (27 vs. 38%) and capecitabine (23 vs. 16%) in line 2; capecitabine (30 vs. 30%) and vinorelbine (16 vs. 19%) in line 3. The most frequently used CT combinations were very different: FEC (40%)vs. FAC (24%) in first line, FEC (7%) vs. CMF (14%) in second line, and non-pegylated liposomal doxorubicin/cyclophosphamide (6%) vs. CMF (15%) in third line.

Many different CT regimens for MBC were used throughout all lines (e.g. &gt; 20 regimens in first line) in both countries. Overall, 81 vs. 71% of pts received a taxane and/or an anthracycline in first line, 57 vs. 60% in second line, and 43 vs. 29% in third line. 33 vs. 36% were re-challenged with an anthracycline after having received anthracycline-based (neo) adjuvant CT.

Physician-assessed response (52 vs. 53%) and stable disease rates (22 vs. 26%) to first-line CT were similar.

Conclusions: Daily treatment practice of MBC differs considerably between BE and NL, in particular with respect to monotherapy vs. combination CT in first line, specific combination regimens used in lines 1-3, and the number of subsequent lines employed. More adjuvant treatment appeared to have been given to Belgian pts. Despite these differences, reported response rates were remarkably similar. Although a wide variety of CT regimens are used in MBC in BE and NL, anthracyclines and taxanes are the cornerstones in both countries.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-11-08.

Human rabies due to lyssavirus infection of bat origin

Rabies is a fatal viral encephalitis and results from infection with viruses belonging to the genus Lyssavirus. Infection usually results from a bite from a dog infected with classical rabies virus. However, a small number of cases result from contact with bats. It is within bats that most lyssavirus variants, referred to as genotypes, are found. The lyssaviruses found in bats have a distinct geographical distribution and are often restricted to specific bat species. Most have been associated with rabies in humans and in some cases spill-over to domestic animals. Many diagnostic techniques are unable to differentiate rabies virus from other genotypes so it is possible that some human and animal cases go unreported. Furthermore, current vaccines have limited efficacy against some genotypes.

Analysis of vaccine-virus-associated rabies cases in red foxes (Vulpes vulpes) after oral rabies vaccination campaigns in Germany and Austria

To eradicate rabies in foxes, almost 97 million oral rabies vaccine baits have been distributed in Germany and Austria since 1983 and 1986, respectively. Since 2007, no terrestrial cases have been reported in either country. The most widely used oral rabies vaccine viruses in these countries were SAD (Street Alabama Dufferin) strains, e.g. SAD B19 (53.2%) and SAD P5/88 (44.5%). In this paper, we describe six possible vaccine-virus-associated rabies cases in red foxes (Vulpes vulpes) detected during post-vaccination surveillance from 2001 to 2006, involving two different vaccines and different batches. Compared to prototypic vaccine strains, full-genome sequencing revealed between 1 and 5 single nucleotide alterations in the L gene in 5 of 6 SAD isolates, resulting in up to two amino acid substitutions. However, experimental infection of juvenile foxes showed that those mutations had no influence on pathogenicity. The cases described here, coming from geographically widely separated regions, do not represent a spatial cluster. More importantly, enhanced surveillance showed that the vaccine viruses involved did not become established in the red fox population. It seems that the number of reported vaccine virus-associated rabies cases is determined predominantly by the intensity of surveillance after the oral rabies vaccination campaign and not by the selection of strains.

Experimental infection of serotine bats (Eptesicus serotinus) with European bat lyssavirus type 1a

The serotine bat (Eptesicus serotinus) accounts for the vast majority of bat rabies cases in Europe and is considered the main reservoir for European bat lyssavirus type 1 (EBLV-1, genotype 5). However, so far the disease has not been investigated in its native host under experimental conditions. To assess viral virulence, dissemination and probable means of transmission, captive bats were infected experimentally with an EBLV-1a virus isolated from a naturally infected conspecific from Germany. Twenty-nine wild caught bats were divided into five groups and inoculated by intracranial (i.c.), intramuscular (i.m.) or subcutaneous (s.c.) injection or by intranasal (i.n.) inoculation to mimic the various potential routes of infection. One group of bats was maintained as uninfected controls. Mortality was highest in the i.c.-infected animals, followed by the s.c. and i.m. groups. Incubation periods varied from 7 to 26 days depending on the route of infection. Rabies did not develop in the i.n. group or in the negative-control group. None of the infected bats seroconverted. Viral antigen was detected in more than 50% of the taste buds of an i.c.-infected animal. Shedding of viable virus was measured by virus isolation in cell culture for one bat from the s.c. group at 13 and 14 days post-inoculation, i.e. 7 days before death. In conclusion, it is postulated that s.c. inoculation, in nature caused by bites, may be an efficient way of transmitting EBLV-1 among free-living serotine bats.

Detection of high levels of European bat lyssavirus type-1 viral RNA in the thyroid gland of experimentally-infected Eptesicus fuscus bats

Two common bat lyssavirus species have been identified in many European countries: European bat lyssavirus type-1 and -2 (EBLV-1 and EBLV-2). Only limited knowledge on the susceptibility of the natural EBLV-hosts, insectivorous bats, to lyssavirus infection is available. Our study was undertaken to evaluate the susceptibility and pathology associated with an EBLV-1 infection in Eptesicus fuscus following different routes of virus inoculation including intracranial (n = 6), intramuscular (n = 14), oral (n = 7) and intranasal (n = 7). Blood and saliva samples were collected from all bats on a monthly basis. Four bats inoculated intracranially developed rabies with a mean of 11 days to death, whilst seven bats inoculated intramuscularly developed rabies, with an extended incubation period prior to death. We did not observe any mortality in the oral (p.o.) or intranasal (i.n.) groups and both groups had detectable levels of virus neutralizing antibodies (data not shown). Virus shedding was demonstrated in the saliva by virus isolation and the detection of viral RNA in ill bats, particularly immediately prior to the development of disease. In addition, the presence of virus and viral RNA was detected in the thyroid gland in bats challenged experimentally with EBLV-1, which exceeded that detected in all other extra-neural tissue. The significance of detecting EBLV-1 in the thyroid gland of rabid bats is not well understood. We speculate that the infection of the thyroid gland may cause subacute thyroiditis, a transient form of thyroiditis causing hyperthyroidism, resulting in changes in adrenocortical activity that could lead to hormonal dysfunction, thereby distinguishing the clinical presentation of rabies in the rabid host.

Susceptibility of North American big brown bats (Eptesicus fuscus) to infection with European bat lyssavirus type 1

The aim of this study was to determine the susceptibility of insectivorous bats (using the big brown bat as a model) to infection with European bat lyssavirus type 1a (EBLV-1a), to assess the dynamics of host immune responses and to evaluate the opportunity for horizontal viral transmission within colonies. Two isolates of EBLV-1a, originating from Slovakia (EBLV-1aSK) and Germany (EBLV-1aGE), were tested. Four different routes of inoculation were used with isolate EBLV-1aSK [10(4.8) mouse intracerebral median lethal dose (MICLD(50)) in 50 mul]: intramuscular (i.m.) in the deltoid area or masseter region, per os (p.o.) and intradermal (i.d.) scratches. Isolate EBLV-1aGE (10(3.2) and 10(2.2) MICLD(50) in 20 mul) was inoculated via the intranasal (i.n.), i.m. (low- and high-dose groups, into pectoral muscles); p.o. and intracerebral (i.c.) routes. None of the bats infected by the i.n., p.o. or i.d. route with either virus isolate developed disease during the experiments (91 or 120 days, respectively). Incubation periods were 9-12 days for i.c.-inoculated bats (66 % mortality), 12-33 days for bats inoculated i.m. with the higher dose (23-50 % mortality) and 21-58 days in bats inoculated i.m. with the lower dose of virus (57 % mortality). Virus or viral RNA in bat saliva was detected occasionally, as early as 37 days before death. All i.d.-inoculated and the majority of i.m.-inoculated bats seroconverted within 7-10 days of inoculation. These observations suggest that exposure of bats to varying doses of EBLV-1 from rabid conspecifics via natural (i.d.) routes could lead to an abortive infection and serve as a natural mode of immunization resulting in the presence of virus-neutralizing antibodies in free-ranging bats.

Epidemiology of rabies in Southeast Europe

Rabies remains endemic within a number of countries in Southeast Europe including Romania, Bulgaria and Turkey. With the probable expansion of the European Union eastwards, it is likely that rabies elimination programs will be increased to reduce the burden of disease in new accession countries. A clear understanding of the epidemiology of the virus in this area of Europe is vital before such programs are introduced. With the exception of Turkey, the red fox (Vulpes vulpes) is the principal disease reservoir in Southeastern Europe. However, cases of rabies in the dog (Canis familiaris) are regularly reported. In contrast to Northern Europe, the raccoon dog (Nyctereutes procyonoides) does not appear to be a vector in the south. This study summarises the current rabies situation in Southeast Europe and demonstrates the phylogenetic relationships between the viruses in a number of the countries within the region. Rabies virus RNA was extracted from original samples and a fragment of the nucleoprotein gene amplified by reverse-transcriptase PCR. Automated sequencing was used to derive nucleoprotein gene sequences and these were used to prepare a molecular phylogeny of rabies viruses in Southeast Europe. In Bulgaria, the dog is the main vector bringing rabies into contact with humans and livestock. However, other species may also act as reservoirs for the disease, complicating the development of elimination strategies. The fox is the principal reservoir species for rabies in Romania although cases in dogs are regularly reported. Despite a gradual decline in dog rabies, urban pockets of the disease remain in many regions of Turkey. Furthermore, there is some evidence that the fox has been a significant vectorfor rabies and may be responsible for increases in rabies in cattle in the Aegean region of the country. Throughout the region there is evidence for cross-border movement of rabies by both wildlife and canine vectors.

Should Medical Research Have a Place in Future Clinical Training?

Aim: To determine the attitudes of training grade (Senior House Officer – SHO, Specialist Registrar – SpR) and non-training grade doctors (both Staff Grade and senior or Consultant level) towards the place of research in the curriculum for junior doctors and also the pursuit of research by senior (but non-academic) clinicians. Materials and Methods: A survey of a range of doctors from differing grades (above) was sent to all doctors of the employing Trust (comprising most of the regional training scheme) with a number of fixed questions but also an opportunity to provide free-text responses. Percentages of the fixed responses were estimated and free-text responses were grouped into main themes and miscellaneous items. Results: Despite much criticism of the current protected research time for higher trainees in psychiatry in the UK and the anticipated abolition of this within the new training structure after August 2007, we found surprising and strong support for structured research training, experience and the opportunity to pursue this at senior level even for non-academic clinical consultants. Conclusions: Urgent review of the new training grade curriculum is needed with emphasis on how to address the research opportunities for trainees and seniors without compromising clinical, teaching and managerial obligations. A better use of such opportunities was strongly supported rather than the proposed abolition, which seems to be fast approaching. Key words: New Curriculum, Opportunities, Strategies, Survey

Should medical research have a place in future clinical training?

AIM

To determine the attitudes of training grade (Senior House Officer - SHO, Specialist Registrar - SpR) and non-training grade doctors (both Staff Grade and senior or Consultant level) towards the place of research in the curriculum for junior doctors and also the pursuit of research by senior (but non-academic) clinicians.

MATERIALS AND METHODS

A survey of a range of doctors from differing grades (above) was sent to all doctors of the employing Trust (comprising most of the regional training scheme) with a number of fixed questions but also an opportunity to provide free-text responses. Percentages of the fixed responses were estimated and free-text responses were grouped into main themes and miscellaneous items.

RESULTS

Despite much criticism of the current protected research time for higher trainees in psychiatry in the UK and the anticipated abolition of this within the new training structure after August 2007, we found surprising and strong support for structured research training, experience and the opportunity to pursue this at senior level even for non-academic clinical consultants.

CONCLUSIONS

Urgent review of the new training grade curriculum is needed with emphasis on how to address the research opportunities for trainees and seniors without compromising clinical, teaching and managerial obligations. A better use of such opportunities was strongly supported rather than the proposed abolition, which seems to be fast approaching.

An algorithm for the clinical assessment of nutritional status in hospitalized patients

Upon admission to hospital, 30–50% of patients either are or become malnourished. There is no generally accepted definition of malnutrition or guidelines on the best way to establish nutritional status. We consider it self-evident that the nursing staff have an important role in screening patients at risk of malnutrition on admission and thereafter at regular times. This is why we developed the nursing nutritional screening form (NNSF). The NNSF was tested by nurses, dietitians and clinicians, in pairs, to establish the extent of agreement in two phases on sixty-nine and forty patients. Later, the form was used in practice by nursing staff on five wards (334 patients). Based on the results of the NNSF, patients were referred to a dietitian. The dietitian established whether the patient was indeed at risk, or was actually malnourished, using a complete nutritional history. The degree of concurrence within pairs was reasonable to good. The same applied to the concurrence between nursing staff and dietitians, but concurrence between clinicians and nursing staff was less. In total, 334 patients were screened and sixty-nine of them were referred to the dietitian. It was established that 86% of the referred patients were potentially at risk of malnutrition or were malnourished. Without the NNSF, 39% (n27) of the patients referred to the dietitian would not have been referred, or would have been referred much later. The NNSF makes it possible for nurses to detect malnourished patients or patients at risk of malnutrition at an early stage of their hospitalization.

Repair of a salivary duct fistula in a horse without using a stent

A salivary duct fistula in a horse was repaired surgically without using a stent. Seventeen months after the operation the skin incision had healed without complications and the fistula had not recurred.

Epidemiology of bat rabies in Germany

Rabies in European bats was first reported in Germany in 1954. In concordance with Denmark and the Netherlands, Germany has reported one of the highest numbers (n = 187) of European bat lyssavirus (EBLV)-positive cases in bats in Europe so far (1954-2005). A combined descriptive epidemiological and phylogenetic analysis on bat rabies and prevailing EBLVs is presented, comprising the past 50 years. So far, only the two lineages of EBLV-1 (genotype 5), a and b, have been detected. Although only 50% of the rabies-positive bats have been identified by species, the Serotine bat (Eptesicus serotinus) is the bat species most frequently infected. Single rabies cases have also been detected in a further five indigenous bat species. There is proven evidence for a substantial bias in the frequency of bat rabies cases in the north of Germany, with an endemic cluster in the northwesternmost low-lying plain areas adjacent to the Netherlands and Denmark. Improvements to bat rabies surveillance and research are discussed.

Wildlife rabies in Western Turkey: the spread of rabies through the western provinces of Turkey

The incidence of rabies has decreased in Turkey during recent years. However, an increasing number of rabies cases have been reported in the Aegean (western) region of Turkey. The virus appears to have maintained a foothold in the urban areas of the province of Izmir with only three cases per year being reported during the mid-1990s. Since 2001, the virus has been recorded in the previously rabies-free provinces of Manisa and Aydin. During this epizootic, cases have been reported in both dogs and foxes, and there has been an unusually high incidence of rabies in domestic livestock, especially cattle. This report describes the development of this epizootic and a preliminary phylogenetic study which suggests that the source of this epizootic was likely to have been the residual cases within Izmir rather than a fresh introduction of rabies from foci to the north (Istanbul) and the Eastern provinces of Turkey.

Cross reactive antigenicity in orally vaccinated foxes and raccoon dogs against European Bat Lyssavirus type 1 and 2

For the first time, the effectiveness of oral rabies vaccines against European Bat Lyssaviruses Type 1 (EBLV-1) and Type 2 (EBLV-2) by means of cross-neutralization assays was investigated. Sera from orally vaccinated red foxes (Vulpes vulpes) and raccoon dogs (Nyctereutes procyonoides) with the Street Alabama Dufferin (SAD) B19 and SAD P5/88 live-modified vaccine viruses were used to study the cross reactive antigenicity against CVS-11 (genotype 1), EBLV-1 (genotype 5) and EBLV-2 (genotype 6). For comparison, similar crossneutralization assays with sera from EBLV-1 and EBLV-2 infected ferrets (Mustela putorius furo) and/or foxes were conducted. Sera from animals vaccinated with the two oral rabies vaccines were reactive against CVS-11 (homologous virus), EBLV-1 and EBLV-2 (heterologous virus). There was a positive relationship among the virus neutralising antibody titres (VNA); high VNA titres against CVS-11 also resulted in high VNA titres against each EBLV, whereas in general, the VNA-titres obtained with homologous virus were statistically higher than those with the heterologous virus except for SAD P5/88 vaccinated raccoon dogs. No significant difference was found between EBLV-1 and EBLV-2 VNA titres. A similar trend was observed when the results of the cross-neutralization data of the foxes and ferrets inoculated i.m. with EBLV-1 and/or EBLV-2 was analysed. Based on the similarity of the EBLV-VNA titres obtained in our study questions were raised on whether the genetic distance of genotype 5 & 6 within phylogroup 1 really does reflect their antigenetic characteristics or whether this is a feature of attenuated live vaccine viruses. This broad cross protection, however, demonstrated that the representatives of attenuated SAD strains of oral rabies vaccines currently used in Germany are most likely able to protect the reservoir species, red fox and raccoon dog, against EBLV-1 and EBLV-2 infection.

Rabies in Red Foxes (Vulpes vulpes) Experimentally Infected with European Bat Lyssavirus Type 1

The susceptibility of red foxes (Vulpes vulpes) to European bat lyssavirus type 1 (EBLV-1) infection was examined. Eight foxes were inoculated intramuscularly (i.m.) with 10(4.9) foci-forming units (FFU) (n = 4) and 10(5.1) FFU (n = 4) and observed for up to 90 days. All foxes showed manifestations of a neurologic disorder (e.g. seizures, myoclonus, agitation), starting as early as 5 days post-infection (p.i.). Subsequently, all animals showed improvement followed by one or more relapses. One fox was killed 3 days after it recovered, 26 days post-infection. Two other foxes were also killed 38 and 54 days post-infection after severe neurologic signs returned. All foxes developed a humoral immune response against EBLV-1 as determined in serum and brain tissues. However, no rabies virus antigen was detected in the brain, other tissues and secretions examined (e.g. salivary gland, saliva, tonsils, lungs) by using different standard diagnostic techniques [fluorescent antibody test, reverse transcription polymerase chain reaction (RT-PCR), rabies tissue culture inoculation test], with the exception of one fox in which EBLV-1 RNA was detected by RT-PCR in only the spinal cord. Brain tissues showed moderate to severe multifocal, mononuclear encephalomyelitis in the three foxes that were killed during the observation period, although no EBLV-1 virus was detectable in these tissues.

Susceptibility of ferrets (Mustela putorius furo) to experimentally induced rabies with European Bat Lyssaviruses (EBLV)

Twenty ferrets (Mustela putorius furo) were inoculated by intramuscular (i.m.) injection with European Bat Lyssaviruses (EBLV) type-1 and 2 using 10(4.0) foci-forming units (FFU) EBLV-2 (n = 6), 10(4.0) FFU EBLV-1 (n = 7) and 10(6.0) FFU EBLV-1 (n = 7). Furthermore, 15 mice received 10(2.5) FFU EBLV-2 (n = 5), 10(2.5) FFU EBLV-1 (n = 5) and 10(4.5) FFU EBLV-1 (n = 5) by i.m. inoculation. All ferrets and mice receiving the higher dose of EBLV-1 succumbed to infection. In contrast, only three of seven ferrets and two of five mice inoculated experimentally with the lower EBLV-1 dose died. By comparison, all of the EBLV-2 infected ferrets and four of five mice survived infection. All 20 infected ferrets seroconverted. Using sensitive molecular tools, the virus was detected in different tissues, but it could not be found in any saliva samples taken during the 84-day observation period.

Oral Vaccination against Rabies and the Behavioural Ecology of the Red Fox (Vulpes vulpes)

As a result of oral vaccination of foxes (Vulpes vulpes) against rabies, this virus disease has almost been completely eradicated from West- and Central Europe. In most countries, vaccine baits were distributed twice a year: during spring (March to May) and autumn (September to October). This strategy has shown to be able to control and eventually eradicate rabies. However, it remains to be clarified if this is the most cost-effective strategy. Astonishingly, the behavioural ecology of the target species, the red fox, did receive only limited attention selecting the periods when baits should be distributed. Considering the behavioural ecology and rabies epidemiology of foxes, territory owners seem to play a key role in the spread and maintenance of rabies. Thus, oral vaccination campaigns should be targeted primarily at these animals. It is suggested that the optimal timing for bait distribution in Europe is late autumn (November) or early winter (December), depending on the prevailing climatic conditions. Additional campaigns, when financially feasible, can be implemented in order to maintain a high vaccination coverage during the remaining year. Furthermore, different baiting strategies can be selected in case of re-infection or persistent residual foci.

Origin of maternally transferred antibodies against rabies in foxes (Vulpes vulpes)

During previous experiments, maternal antibodies against rabies were detected in the sera of fox cubs whelped by orally immunised vixens. These antibodies appear to be transferred exclusively via the colostrum. No evidence of maternally transferred immunity in the form of immunoglobulin G was found in 80 fox embryos collected from 19 rabies-immune vixens originating from areas where oral rabies vaccine baits had been distributed.

Thermo-stability of the oral rabies virus vaccines SAD B19 and SAD P5/88

The thermo-stability of two widely used oral rabies vaccine viruses, SAD B19 and SAD P5/88, was examined under various laboratory and field conditions. In the laboratory, both vaccine viruses were kept at 35 degrees C and titrated after 3 days. The titer of both vaccine viruses was also determined after 4 and 7 days when stored at 20 degrees C. Furthermore, vaccine baits were placed in three different micro-environments during two successive 21-day observation periods (11.9.01-2.10.01 and 2.10.01-23.10.01); (i) wooded area--location A, (ii) grassy meadow--location B, and (iii) barren soil--location C. Baits were re-collected 0, 3, 6, 9, 12, 15 and 21 days after distribution and the vaccine virus was subsequently titrated. The temperature stress for the vaccine baits was highest at location C, followed by location B and the lowest at location A. The vaccine baits were exposed to higher temperatures and higher temperature fluctuations at location B and C during trial I than during trial II. However, for both vaccines the loss of titer was more pronounced during trial II than during trial I. It is therefore suggested that under the given climatic conditions, the stability of the virus was hardly influenced by the temperatures and temperature fluctuations.

Magnetic resonance imaging in children with anorectal malformations: embryologic implications

PURPOSE

The aim of this study was to evaluate the spectrum of developmental anomalies in the caudal region of patients with anorectal malformations (ARM) and relate them to the new insights in the embryogenesis of this region.

METHODS

Forty-nine patients with ARM were investigated with magnetic resonance imaging (MRI); 24 preoperatively (preop) and 25 postoperatively (postop). Of this group, 17 patients had a high (or intermediate) ARM, 28 a low ARM, and 4 a cloacal malformation (CM). The evaluation of the imaging studies included the level and type of ARM (preop); the developmental state of the sphincter muscle complex (SMC); and the associated anomalies of spinal cord, spine, and urogenital system. The anomalies detected were ordered and related to recent embryologic observations in the caudal region.

RESULTS

With MRI, the level of ARM was depicted effectively in 23 of 24 patients (96%) investigated preop, including 5 of 9 clinically proven fistulae in those with high ARM and CM (56%). Maldevelopment of the SMC was observed in 14 of 49 patients (29%). Associated anomalies of spinal cord and spine were found in 51% of patients, more frequently in those with high ARM, low ARM with fistulae, and cloacal malformations. Associated anomalies of the urogenital system were found in 37% of patients.

CONCLUSIONS

As illustrated by the current study, MRI has become indispensable for the visualization of the nature of congenital ARM and associated anomalies. Moreover, MRI aids in understanding the morphology and pathogenesis of these complex congenital malformations. Based on the MRI and recent embryologic observations, a new and simplified classification of ARM is introduced, including a more appropriate nomenclature.

Safety studies of the oral rabies vaccine SAD B19 in striped skunk (Mephitis mephitis)

Safety of the modified live rabies virus vaccine, SAD B19, was studied in striped skunks (Mephitis mephitis). Seven skunks received 10(7.9) foci formatting units by direct oral administration. In four cages, a vaccinated animal was placed with a control animal, the other three vaccinated skunks were housed individually. Saliva and nasal swabs were collected 1, 2, 4, 24, 48, and 72 hr post-vaccination. From all vaccinated and control animals (n = 11) blood samples were collected 0, 28, 56, 84, and 296 days post-vaccination. Three of seven vaccinated skunks seroconverted. None of the control animals had detectable levels of rabies virus neutralizing antibodies. Also no vaccine virus was isolated from the nasal and saliva swabs collected from any animal. Thus, SAD B19 was innocuous for skunks in our study after direct oral administration at field concentration.

Comparative immunogenicity and efficacy studies with oral rabies virus vaccine SAD P5/88 in raccoon dogs and red foxes

A comparative study of immunogenicity and efficacy of the oral rabies virus vaccine SAD P5/88 in raccoon dogs and foxes was conducted. The raccoon dogs received 10(6.9) (n = 6), 10(6.3) (n = 6) or 10(5.7) FFU SAD P5/88 (n = 5) by direct oral application, and subsequently all animals seroconverted. The foxes received 10(7.2) (n = 4), 10(6.2) (n = 4), 10(5.2) (n = 4) and 10(4.2) FFU SAD P5/88 (n = 5) by the same route. On days 106 and 196 post vaccination 10 raccoon dogs and 16 foxes were challenged with a relevant street virus, respectively. All 10 raccoon dogs vaccinated with 10(6.3) (n = 5) or 10(5.7) FFU SAD P5/88 (n = 5) survived the challenge, whereas all control animals (n = 5) died of rabies. Two foxes vaccinated with 10(4.2) FFU and one fox vaccinated with 10(5.2) FFU died of rabies on day 7, 17 and 12 post infection, respectively. Also all control foxes succumbed to rabies. Our findings demonstrate that SAD P5/88 is not only an effective vaccine for oral vaccination of foxes but also for that of raccoon dogs.

Maternal immunity against rabies in raccoon dogs

The objective of the study was to examine possible maternally transferred antibodies (maAb) against rabies in raccoon dogs. Ten cubs born from a rabies-immune animal were bled on days 31, 36, 43, 50, 57 and 64 post partum. The geometric mean titres of the cubs were 1.19, 1.18, 0.45, 0.25, 0.25 and 0.16 IU/ml, respectively. Up to 36 days post partum maAb were detected in all cubs at levels > or = 0.5 IU/ml and at day 56 post partum all animals had maAb levels < 0.5 IU/ml. Based on the results of this study, it is suggested that vaccine baits should not be distributed before July if the vaccination campaign is aimed at immunizing young raccoon dogs as well.

[Reduced risk of complications associated with severe acute (necrotizing) pancreatitis by administration of antibiotics; results from a literature review]

OBJECTIVE

To determine the role of antibiotics in patients with acute pancreatitis.

DESIGN

Literature review.

METHOD

A Medline search for randomised clinical trials (RCTs) during the period 1990-1999 was carried out using the key words 'pancreatitis', 'acute' and 'antibiotics'. Outcome measures were pancreas-related infection, sepsis and death.

RESULTS

Four RCTs were identified. Control groups were not given antibiotics. Based on the pooled data, the differences in risk in favour of the groups treated with various antibiotics were as follows: -14% (95% CI: -26(-)-1; p = 0.04) for pancreas infections, -25% (95% CI: -39(-)-12; p = 0.0002) for sepsis and -13% (95%-BI: -22(-)-3; p = 0.007) for death.

CONCLUSION

Administration of antibiotics to patients with severe acute (necrotising) pancreatitis reduces the risk of serious complications.

Is it possible to orally vaccinate juvenile red foxes against rabies in spring campaigns?

The rabies antibody status of juvenile foxes (Vulpes vulpes) was evaluated in large-scale, long-term oral vaccination campaigns. Between 9% (n = 659) and 21% (n = 42) of the juvenile foxes examined in 1993-94 and 1997, respectively, showed rabies virus neutralizing antibody (nAb)-titers > or = 0.5 IU/ml following bait distribution in spring. The presence of nAb may be due to either the passive transfer of maternal antibodies, or active immunization derived from spring vaccination campaigns. The latter alternative is supported by the finding of nAb throughout late spring and the summer months, and the finding of the tetracycline (TC) biomarker, used in the vaccine-baits, in 27% (n = 43) and 37% (n = 155) of juveniles in 1993-94 and 1997, respectively. It was not possible to distinguish nAb originating from passive immunity from that arising from active immunization. However, biological data on the whelping period of red foxes, on dynamics of maternal antibodies and the timing of oral vaccination, gave evidence that a superposition of these processes is likely. Evidence from these studies suggests that oral vaccination coinciding with the spring perinatal period may produce immunity in both parents and only in a certain percentage of the offspring simultaneously. This phenomenon should be useful in further enhancing the efficacy of oral vaccination in red foxes.

Absence of apolipoprotein E4 genotype, good gallbladder motility and presence of solitary stones delay rather than prevent gallstone recurrence after extracorporeal shock wave lithotripsy

BACKGROUND/AIMS

Extracorporeal shock wave lithotripsy (ESWL) with adjuvant bile salt dissolution therapy may be successful in selected gallstone patients, but the considerable risk of recurrence is a major drawback. Apolipoprotein E4 genotype and impaired gallbladder motility have been identified as major risk factors for recurrence during short-term follow up. We have now examined their relevance during long-term follow up.

METHODS

Eighty-four cholesterol gallstone patients (55 solitary and 29 multiple (two to ten) stones) were followed prospectively up to 10 years after complete stone disappearance. Various potential risk factors for recurrence were evaluated.

RESULTS

Gallstone recurrence was found in up to 80% of patients at 10 years follow-up. Absence of the apolipoprotein epsilon4 allele, initial solitary stones, good gallbladder emptying (i.e. minimal postprandial volume < or = 6 ml) and 2-year postdissolution ursodeoxycholic acid prophylaxis (in ten patients) all delayed but did not prevent recurrence. In contrast, regular use of non-steroidal anti-inflammatory drugs (NSAIDs) was identified as an independent protective factor, with greatly decreased recurrence (at 10 years: 58 vs 93% in non-NSAID users, P = 0.03).

CONCLUSIONS

Non-apolipoprotein E4 genotype, presence of solitary stones and good gallbladder emptying delay rather than prevent recurrence after initially successful ESWL. Regular use of NSAIDs may prevent recurrence.

Immunogenicity and efficacy of the oral rabies vaccine SAD B19 in foxes

Studies on the immunogenicity and efficacy of SAD B19 attenuated rabies virus vaccine in foxes under laboratory conditions were conducted. Twenty-seven foxes (Vulpes vulpes) were offered a vaccine bait containing 10(6.3) FFU/ml SAD B19. Blood samples were collected 60, 110 and 190 days post-vaccination. On day 190 post vaccination the animals and 14 controls were challenged with a canid street rabies virus. Twenty-four of the 26 vaccinated foxes (92.3%) survived the challenge, whereas all the controls died from rabies. The two vaccinated foxes that did not survive the challenge did not show any detectable level of rabies neutralizing antibodies at any time after vaccination. The geometric mean titres (GMT) of foxes that seroconverted after vaccination were 43.5, 33.9 and 43.5 IU/ml 60, 110 and 190 days post-vaccination, respectively. Furthermore, to test the vaccine virus under sub-optimal conditions five naive and nine previously vaccinated vixens received 2 ml SAD B19 (10(6.7) FFU/ml) by direct administration of the vaccine virus into the oral cavity shortly before or during pregnancy. All vixens seroconverted above the threshold of 0.5 IU/ml. No booster effect was observed in the immune response of the previously vaccinated animals.

Optimising spring oral vaccination campaigns of foxes against rabies

To optimise spring vaccination campaigns the following set of data has been analysed; (i) population dynamics of the red fox, (ii) onset and progress of the reproductive season, and (iii) maternal immunity and the immune response of fox cubs to oral vaccination. The field data originated from foxes caught in Bavaria, Germany. The results of our analysis clearly demonstrate that certain periods during spring are less suitable for bait distribution. If the objective of a vaccination campaign is to reach only the adult foxes, it is suggested to conduct the campaign during the first half of March. If also young foxes are to be vaccinated, baits should not be distributed before the end of May in previously baited areas, because a large segment of the young fox population can not be vaccinated effectively before this date as a result of maternally transferred immunity. In areas vaccinated for the first time, baits can be distributed earlier, since 5 weeks old cubs are already immunocompetent.

[Clinical evaluation of the Biocomp-implant system. Results after 1,3 and 5 years in a general practice]

A population of 107 consecutive patients was treated with a new HA-coated, screw-type dental implant (n = 384 implants), the Biocomp implant. Treatment was performed in a general dental practice by one and the same dentist. The implants were utilized for various types of prosthetic constructions, sometimes in challenging conditions with respect to patient selection, jaw bone quantity and quality. A clinical and radiographical evaluation was performed after 1, 3 and 5 years. After 5 years, the chance on implant survival was 87.1% (standard error 3.4%). Implant loss occurred predominantly within the first 1.5 year after implant placement. Particularly short implants, placed in the atrofic maxilla, frequently failed. Biocomp implants that served as abutments for an overdenture in the edentulous mandible or as a single tooth replacement in the upper anterior region had an excellent prognosis.