In vivo topical gene therapy for recessive dystrophic epidermolysis bullosa: a phase 1 and 2 trial

Recessive dystrophic epidermolysis bullosa (RDEB) is a lifelong genodermatosis associated with blistering, wounding, and scarring caused by mutations in COL7A1, the gene encoding the anchoring fibril component, collagen VII (C7). Here, we evaluated beremagene geperpavec (B-VEC), an engineered, non-replicating COL7A1 containing herpes simplex virus type 1 (HSV-1) vector, to treat RDEB skin. B-VEC restored C7 expression in RDEB keratinocytes, fibroblasts, RDEB mice and human RDEB xenografts. Subsequently, a randomized, placebo-controlled, phase 1 and 2 clinical trial (NCT03536143) evaluated matched wounds from nine RDEB patients receiving topical B-VEC or placebo repeatedly over 12 weeks. No grade 2 or above B-VEC-related adverse events or vector shedding or tissue-bound skin immunoreactants were noted. HSV-1 and C7 antibodies sometimes presented at baseline or increased after B-VEC treatment without an apparent impact on safety or efficacy. Primary and secondary objectives of C7 expression, anchoring fibril assembly, wound surface area reduction, duration of wound closure, and time to wound closure following B-VEC treatment were met. A patient-reported pain-severity secondary outcome was not assessed given the small proportion of wounds treated. A global assessment secondary endpoint was not pursued due to redundancy with regard to other endpoints. These studies show that B-VEC is an easily administered, safely tolerated, topical molecular corrective therapy promoting wound healing in patients with RDEB.

Hyaluronan synthesis inhibition impairs antigen presentation and delays transplantation rejection

A coat of pericellular hyaluronan surrounds mature dendritic cells (DC) and contributes to cell-cell interactions. We asked whether 4-methylumbelliferone (4MU), an oral inhibitor of HA synthesis, could inhibit antigen presentation. We find that 4MU treatment reduces pericellular hyaluronan, destabilizes interactions between DC and T-cells, and prevents T-cell proliferation in vitro and in vivo. These effects were observed only when 4MU was added prior to initial antigen presentation but not later, consistent with 4MU-mediated inhibition of de novo antigenic responses. Building on these findings, we find that 4MU delays rejection of allogeneic pancreatic islet transplant and allogeneic cardiac transplants in mice and suppresses allogeneic T-cell activation in human mixed lymphocyte reactions. We conclude that 4MU, an approved drug, may have benefit as an adjunctive agent to delay transplantation rejection.

Natural Tr1-like cells do not confer long-term tolerogenic memory

IL-10-producing Tr1 cells promote tolerance but their contributions to tolerogenic memory are unclear. Using 10BiT mice that carry a Foxp3-eGFP reporter and stably express CD90.1 following IL-10 production, we characterized the spatiotemporal dynamics of Tr1 cells in a house dust mite model of allergic airway inflammation. CD90.1+Foxp3-IL-10+ Tr1 cells arise from memory cells and rejoin the tissue-resident memory T-cell pool after cessation of IL-10 production. Persistent antigenic stimulation is necessary to sustain IL-10 production and Irf1 and Batf expression distinguishes CD90.1+Foxp3-IL-10+ Tr1 cells from CD90.1+Foxp3-IL-10- ‘former’ Tr1. Depletion of Tr1-like cells after primary sensitization exacerbates allergic airway inflammation. However, neither transfer nor depletion of former Tr1 cells influences either Tr1 numbers or the inflammatory response during subsequent allergen memory re-challenge weeks later. Together these data suggest that naturally-arising Tr1 cells do not necessarily give rise to more Tr1 upon allergen re-challenge or contribute to tolerogenic memory. This phenotypic instability may limit efforts to re-establish tolerance by expanding Tr1 in vivo.

4-Methylumbelliferyl glucuronide contributes to hyaluronan synthesis inhibition

4-Methylumbelliferone (4-MU) inhibits hyaluronan (HA) synthesis and is an approved drug used for managing biliary spasm. However, rapid and efficient glucuronidation is thought to limit its utility for systemically inhibiting HA synthesis. In particular, 4-MU in mice has a short half-life, causing most of the drug to be present as the metabolite 4-methylumbelliferyl glucuronide (4-MUG), which makes it remarkable that 4-MU is effective at all. We report here that 4-MUG contributes to HA synthesis inhibition. We observed that oral administration of 4-MUG to mice inhibits HA synthesis, promotes FoxP3⁺ regulatory T-cell expansion, and prevents autoimmune diabetes. Mice fed either 4-MUG or 4-MU had equivalent 4-MU:4-MUG ratios in serum, liver, and pancreas, indicating that 4-MU and 4-MUG reach an equilibrium in these tissues. LC-tandem MS experiments revealed that 4-MUG is hydrolyzed to 4-MU in serum, thereby greatly increasing the effective bioavailability of 4-MU. Moreover, using intravital 2-photon microscopy, we found that 4-MUG (a nonfluorescent molecule) undergoes conversion into 4-MU (a fluorescent molecule) and that 4-MU is extensively tissue bound in the liver, fat, muscle, and pancreas of treated mice. 4-MUG also suppressed HA synthesis independently of its conversion into 4-MU and without depletion of the HA precursor UDP-glucuronic acid (GlcUA). Together, these results indicate that 4-MUG both directly and indirectly inhibits HA synthesis and that the effective bioavailability of 4-MU is higher than previously thought. These findings greatly alter the experimental and therapeutic possibilities for HA synthesis inhibition.

The bone marrow is patrolled by NK cells that are primed and expand in response to systemic viral activation

The bone marrow hosts NK cells whose distribution, motility and response to systemic immune challenge are poorly understood. At steady state, two-photon microscopy of the bone marrow in Ncr1^gfp/+ mice captured motile NK cells interacting with dendritic cells. NK cells expressed markers and effector molecules of mature cells. Following poly (I:C) injection, RNA-Seq of NK cells revealed three phases of transcription featuring immune response genes followed by posttranscriptional processes and proliferation. Functionally, poly (I:C) promoted upregulation of granzyme B, enhanced cytotoxicity in vitro and in vivo, and, in the same individual cells, triggered proliferation. Two-photon imaging revealed that the proportion of sinusoidal NK cells decreased, while at the same time parenchymal NK cells accelerated, swelled and divided within the bone marrow. MVA viremia induced similar responses. Our findings demonstrate that the bone marrow is patrolled by mature NK cells that rapidly proliferate in response to systemic viral challenge while maintaining their effector functions.

Active dissemination of cellular antigens by DCs facilitates CD8+ T-cell priming in lymph nodes

Antigen (Ag) specific activation of naïve T cells by migrating dendritic cells (DCs) is a highly efficient process, although the chances for their colocalization in lymph nodes (LNs) appear low. Ag presentation may be delegated from Ag-donor DCs to the abundant resident DCs, but the routes of Ag transfer and how it facilitates T-cell activation remain unclear. We visualized CD8⁺ T cell-DC interactions to study the sites, routes, and cells mediating Ag transfer in mice. In vitro, Ag transfer from isolated ovalbumin (OVA)⁺ bone marrow (BM) DCs triggered widespread arrest, Ca²⁺ flux, and CD69 upregulation in OT-I T cells contacting recipient DCs. Intravital two-photon imaging revealed that survival of Ag-donor DCs in LNs was required for Ag dissemination among resident CD11c⁺ DCs. Upon interaction with recipient DCs, CD8⁺ T cells clustered, upregulated CD69, proliferated and differentiated into effectors. Few DCs sufficed for activation, and for efficient Ag dissemination lymphocyte function associated antigen 1 (LFA-1) expression on recipient DCs was essential. Similar findings characterized DCs infected with a replication-deficient OVA-expressing Vaccinia virus known to downregulate MHC-I. Overall, active Ag dissemination from live incoming DCs helped activate CD8⁺ T cells by increasing the number of effective presenting cells and salvaged T-cell priming when Ag-donor DCs could not present Ag.

Heparanase of murine effector lymphocytes and neutrophils is not required for their diapedesis into sites of inflammation

Heparanase, the exclusive mammalian heparan sulfate-degrading enzyme, has been suggested to be utilized by leukocytes to penetrate through the dense basement membranes surrounding blood venules. Despite its established role in tumor cell invasion, heparanase function in leukocyte extravasation has never been demonstrated. We found that TH1/TC1-type effector T cells are highly enriched for this enzyme, with a 3.6-fold higher heparanase mRNA expression compared with naive lymphocytes. Using adoptive transfer of wild-type and heparanase-deficient effector T cells into inflamed mice, we show that T-cell heparanase was not required for extravasation inside inflamed lymph nodes or skin. Leukocyte extravasation through acute inflamed skin vessels was also heparanase independent. Furthermore, neutrophils emigrated to the inflamed peritoneal cavity independently of heparanase expression on either the leukocytes or on the endothelial and mesothelial barriers, and overexpression of the enzyme on neutrophils did not facilitate their emigration. However, heparanase absence significantly reduced monocyte emigration into the inflamed peritoneal cavity. These results collectively suggest that neither leukocyte nor endothelial heparanase is required for T-cell and neutrophil extravasation through inflamed vascular barriers, whereas this enzyme is required for optimal monocyte recruitment to inflamed peritoneum.

Three Clusters of Bacillus Pseudobacteremia Related to a Radiometric Blood Culture Analyzer

During a ten-month period from September 1981 to July 1982 three episodes of pseudobacteremia due to Bacillus species occurred at this 550-bed institution. The first involved eight isolates, the second 11, and the third seven isolates of the organism, all with the same antibiogram.

The patients involved did not exhibit clinical signs of septicemia, and in only one case was more than one specimen per patient positive when multiple blood samples were obtained. Occasional blood cultures of Bacillus species identified in between clusters revealed a different antibiogram.

Extensive epidemiologic investigation of patient locations, phlebotomists, and time of cultures yielded no common source. Components involved in the transport and processing of blood cultures, including the radiometric blood culture processor, were also sampled but without recovery of the organism. After the last episode, a layer of dust was noted inside the machine, and culture of this dust grew Bacillus spp. with the same antibiogram as those found in the blood cultures. The filter from an air conditioning unit in close proximity to the machine grew several species of Bacillus.

It is presumed that Bacillus spores in the dust were introduced into the blood culture bottles following the heat sterilization of the gas sampling (inoculation/removal) needles.

Modification of the cover of the machine was undertaken to prevent access of dust bearing microbes to the inside of the machine. In addition, maintenance now includes regular disinfection/cleaning of the “floor” of the machine, and more frequent changes of the air conditioner filter.

Luminal bacteria recruit CD103+ dendritic cells into the intestinal epithelium to sample bacterial antigens for presentation

CD103+ dendritic cells (DCs) carry bacteria from the small intestine and can present antigens to T cells. Yet they have not been recorded sampling luminal bacteria or presenting bacterial antigens in mesentery lymph nodes. We used 2-photon microscopy in live Cx3cr1(+/gfp) ×Cd11c-YFP mice to study these processes. At steady state, sparse CD103+ DCs occupied the epithelium. They patrolled among enterocytes while extending dendrites toward the lumen, likely using tight-junction proteins to penetrate the epithelium. Challenge with Salmonella triggered chemokine- and toll-like receptor (TLR)-dependent recruitment of additional DCs from the lamina propria (LP). The DCs efficiently phagocytosed the bacteria using intraepithelial dendrites. Noninvasive bacteria were similarly sampled. In contrast, CD103+ DCs sampled soluble luminal antigen inefficiently. In mice harboring CD103+ DCs, antigen-specific CD8 T cells were subsequently activated in MLNs. Intestinal CD103+ DCs are therefore equipped with unique mechanisms to independently complete the processes of uptake, transportation, and presentation of bacterial antigens.

DC mobilization from the skin requires docking to immobilized CCL21 on lymphatic endothelium and intralymphatic crawling

Dendritic cells (DCs) must travel through lymphatics to carry skin antigens into lymph nodes. The processes controlling their mobilization and migration have not been completely delineated. We studied how DCs in live mice respond to skin inflammation, transmigrate through lymphatic endothelium, and propagate in initial lymphatics. At steady state, dermal DCs remain sessile along blood vessels. Inflammation mobilizes them, accelerating their interstitial motility 2.5-fold. CCR7-deficient BMDCs crawl as fast as wild-type DCs but less persistently. We observed discrete depositions of CCL21 complexed with collagen-IV on the basement membrane of initial lymphatics. Activated DCs move directionally toward lymphatics, contact CCL21 puncta, and migrate through portals into the lumen. CCR7-deficient DCs arrive at lymphatics through random migration but fail to dock and transmigrate. Once inside vessels, wild-type DCs use lamellipodia to crawl along lymphatic endothelium and, sensing lymph flow, proceed downstream. DCs start drifting freely only in collecting lymphatics. These results demonstrate in vivo that the CCL21-CCR7 axis plays a dual role in DC mobilization: promoting both chemotaxis and arrest of DCs on lymphatic endothelium. Intralymphatic crawling, in which DCs combine active adhesion-based migration and directional cues from lymph flow, represents a new step in DC mobilization which may be amenable to regulation.

Clinical Management Factors Contribute to the Decision for Contralateral Prophylactic Mastectomy (CPM)

INTRODUCTION:Rates of CPM are reported to be increasing, yet factors driving this trend are unclear. We performed this analysis to determine if increasing rates of CPM are being driven by increased recognition of risk factors for contralateral breast cancer (CBC) or by treatment factors related to the index lesion.METHODS:From 1997-2005, 2967 patients with Stage 0-III primary unilateral breast cancer underwent mastectomy at MSKCC and were entered into a prospectively maintained database. Demographic, tumor and treatment factors were abstracted and comparisons made between patients who did and did not undergo CPM within one year of treatment for their index cancer. Generalized estimating equations were used to fit logistic regression models to identify independent predictors of CPM.RESULTS:The overall rate of CPM was 13.8%(n=408), increasing from 6.7% in 1997 to 24.4% in 2005 (p<0.0001). The median age of CPM pts was 44.9 vs 53.2 in the non-CPM group (p<.001) and only 7% of CPM pts were non-white compared to 25% of non-CPM pts (p<.001). Although 69% of CPM pts had a family history (FH) of breast cancer (vs 40% non-CPM; p<.001) only 8% had 2 or more first degree relatives affected. Genetic testing was performed in 29% of CPM pts; of those 37 (31%) were positive. The use of MRI increased from 1.3% to 36.3%of cases over the study period. MRI at diagnosis (43% vs 16%) and MRI generated biopsy in the contralateral or bilateral breasts (29% vs 4%) were strongly associated with CPM (p<.0001). Prior attempts at breast conservation (BCT) (28% vs 16%; p<.001) were more common in the CPM group, but number of attempts did not differ between groups. Patients undergoing CPM were more likely to have DCIS versus an invasive histology (p<0.0001), and of those with invasive disease, CPM patients had smaller tumors (1.2cm vs. 1.8cm, p<0.0001) and were more likely to be node negative (53% vs 43%, p<0.0001). ER, PR, and HER2 status were not associated with CPM. CPM rates among surgeons ranged from 9.8% to 26%. Multivariate analysis of predictors of CPM for 2387 patients with complete data is shown in the Table.VariableORp95%CIWhite race3.6<0.00012.4-5.4Age<502.3<0.00011.8-3.1FH breast cancer2.9<0.00012.3-3.7MRI at Dx2.2<0.00011.7-2.8BCT attempted1.60.000081.2-2.1Reconstruction3.2<0.00012.3-4.5DCIS histology1.40.021.1-1.9*adjusted for surgeonCONCLUSIONS: Factors associated with clinical management of the index cancer such as preoperative MRI with the potential for additional biopsy, failed attempt at BCT, and breast reconstruction were strongly associated with CPM. Age and FH were also independent predictors; however the FH profiles of CPM pts in this series do not support increased recognition of mutation carriers and truly high risk FH as a major cause of increasing rates of CPM. The lack of association with ER status, which results in treatment that decreases the risk of CBC, provides additional support that patients may be choosing CPM for reasons other than future risk. These data suggest that the need for additional procedures during management of the index cancer may be contributing to the increasing use of CPM among a relatively moderate risk patient population. Efforts to optimize BCT and minimize unnecessary tests may help to curb this trend.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 38.

Chronic lung disease and cystic fibrosis phenotype in prolidase deficiency: a newly recognized association

Six families with prolidase deficiency (PD) and chronic lung disease are reported, a previously unrecognized association. In one family with a classic cystic fibrosis (CF) phenotype, no evidence for CF Transmembrane Conductance Regulator (CFTR)-related mutations could be found. Chronic lung disease and CFTR-mutation negative CF may be associated with PD.

Nutritional upregulation of p85alpha expression is an early molecular manifestation of insulin resistance

AIMS/HYPOTHESIS

We sought to define early molecular alterations associated with nutritionally induced insulin resistance in humans.

METHODS

Insulin sensitivity was assessed using a hyperinsulinaemic-euglycaemic clamp in eight healthy women while on an isocaloric diet and after 3 days of overfeeding (50% above eucaloric diet). Expression of phosphatidylinositol (PI) 3-kinase subunits p85alpha and p110 was assessed and measurements were made of IRS-1-associated PI 3-kinase activity, tyrosine and serine phosphorylation of IRS-1, and serine and threonine phosphorylation of p70S6 kinase. Measurements were made in skeletal muscle biopsies obtained before and after overfeeding.

RESULTS

Three days of overfeeding resulted in a reduction of insulin sensitivity accompanied by: (1) increased expression of skeletal muscle p85alpha; (2) an alteration in the ratio of p85alpha to p110; (3) a decrease in the amount of IRS-1-associated p110; and (4) a decrease in PI 3-kinase activity. Increases in expression of p85alpha and in the p85alpha:p110 ratio demonstrated a highly significant inverse correlation with insulin sensitivity, and changes in PI 3-kinase activity correlated with changes in insulin sensitivity. Tyrosine and serine phosphorylation of IRS-1 and serine and threonine phosphorylation of p70S6 kinase were unaffected by 3 days of overfeeding.

CONCLUSIONS/INTERPRETATION

We identified a novel mechanism of nutritionally induced insulin resistance in healthy women of normal weight. We conclude that increased expression of p85alpha may be one of the earliest molecular alterations in the mechanism of the insulin resistance associated with overfeeding.

Profile and prognosis of febrile elderly patients with bacteremic urinary tract infection

OBJECTIVE

To describe the profile of elderly patients with bacteremic urinary tract infections (UTI) and correlate clinical and laboratory findings with the outcome in order to identify independent predictors of mortality.

METHODS

This retrospective study took place in a large community-based, geriatric hospital and included 191 patients aged 75-105 years with urine and blood cultures simultaneously positive for bacterial organisms. Records were analysed for demographic information, clinical and laboratory data over a 29 month period. Mortality was assessed and was correlated with these findings.

RESULTS

Most of the patients (80.1%) had community-acquired infection. Gram-negative organisms accounted for 87.6% of bacterial isolates, with Escherichia coli accounting for 46.1% of cases. Non-Escherichia coli Gram-negative organisms were highly resistant to two common urinary tract antibiotics (gentamicin and ceftriaxone). Patients with chronic urinary catheter had Gram-negative bacteria significantly less sensitive to ciprofloxacin, gentamycin, ampicillin and ceftriaxon than patients without catheter (p<0.05). In-hospital mortality was 33%. Multiple logistic regression analysis revealed that mortality was significantly related to the number of underlying diagnoses (p<0.0203), cognitive status (p<0.0003), length of hospitalization (p<0.0397), low level of serum albumin (p<0.0021), high neutrophil count (p<0.0001) and high level of lactate dehydrogenase (p<0.0351). Fatality was not associated with advanced age in the very old.

CONCLUSION

Bacteremic UTI in the elderly has a high mortality rate. In frail elderly patients with age-associated multiple severe underlying disorders and cognitive impairment, early recognition of bacteremic UTI and prompt, appropriate treatment are critical in reducing the mortality.

Risk factors for recurrence of Clostridium difficile-associated diarrhea in the elderly

Risk factors that influence the recurrence of nosocomial Clostridium difficile-associated diarrhea (CDAD) were determined in an 18-month follow-up study in a subacute geriatric department. A case-control study was conducted, comparing 43 patients with recurrent C. difficile-associated diarrhea (RCDAD) (case patients) with 38 patients who had only 1 episode of CDAD (control patients). The mean age of patients was 81.6 +/- 7.2 y (range 64-95 y). All cases with CDAD were receiving antibiotic therapy. RCDAD occurred in 53.1% of patients. Risk factors for RCDAD included fecal incontinence (p < or = 0.04), longer duration of fever from admission until first episode of CDAD (p < or = 0.02) and H2-antagonist treatment (p < or = 0.02). This study shows that RCDAD is a common clinical event in elderly hospitalized patients and may be predictable in some groups of patients.

[Effect of optic aberrations, caused by ablation pattern decentration after laser vision correction, on visual acuity]

The aim of this work was to study the effects of subclinical ablation pattern decentration on the quality of vision after photorefractive laser surgery. Optical high order spherical and coma-like aberrations of 30 eyes were evaluated before, 1 and 3 months after photorefractive surgery (PRK and LASIK). Relationship between the size and shape of the light spot on the retina during transmission of paraxial beams through the eye and the ablation zone decentrations was estimated. The results are presented for pupil diameters of 1 and 6 mm both at the center of the retina along the optical axis and at a distance of 0.5 mm from the center. Decentration of ablation zone by less than 1 mm makes the principal contribution to induction of higher order aberrations. The relative increase factor is 3.9 and 5.1 for the coma-like and spherical aberrations, respectively. At such decentrations spatial resolution of the eye decreases as the pupil size increases, which is most pronounced even at a slight distance from the visual axis but inside the fovea.

Treatment of the jaundiced patient with breast carcinoma: case report and alternate therapeutic strategies

BACKGROUND

Breast carcinoma in the setting of liver metastases and jaundice raises a complex therapeutic dilemma. Not only is the prognosis poor but toxicity related to treatment can be unpredictable due to altered drug clearance. Guidelines built around dose reduction have been suggested but often do not address the varied presentations in clinical medicine. Bilirubin exceeding 5.0 mg% often is considered an absolute contraindication to the administration of chemotherapeutic agents dependent on hepatic metabolism.

METHODS

A 55-year-old woman with metastatic breast carcinoma to the liver and hyperbilirubinemia was treated with sequential, empiric chemotherapy agents with the goal of preventing severe toxicity through dose reduction, avoidance of combination therapy, divided doses (weekly therapy), and selection of drugs less dependent on hepatic clearance. Several attempts did not yield a regimen with a successful response, but toxicity was minimal. Eventually, a successful schedule and dose of an agent cleared by liver metabolism was individualized for the patient.

RESULTS

After eight cycles of low dose weekly doxorubicin chemotherapy, the patient's symptoms resolved, bilirubin level normalized, and performance status returned to baseline. The patient remained on treatment and was alive 12 months later.

CONCLUSIONS

The authors propose that altering a drug schedule by dividing doses may minimize toxicity, maintain dose intensity, and represent an alternative strategy for the treatment of patients with hepatic impairment.

Dental instrument and device sterilization and disinfection practices

Dental instruments and devices require sterilization or high-level disinfection. An evaluation of the implementation of such processes was undertaken. Eleven thousand questionnaires on methods used to sterilize and disinfect dental instruments were sent to dental practices and 1391 (13%) were returned for evaluation. Sixty-eight percent of respondents believed they were sterilizing their instruments, however, some of the liquid chemical products used were not suitable for sterilizing instruments, and 12% of respondents used incorrect contact times. Forty-nine percent of respondents did not challenge autoclaves with biological spores to check their function at an acceptable frequency. There were similar product and timing problems when a high-level liquid chemical disinfection was attempted. Although the return sample was small, problems were identified that can and should be corrected. This study demonstrates that the potential for person-to-person transmission of infectious agents such as the human immunodeficiency virus (HIV) and hepatitis B and C viruses via inadequately sterilized dental instrument exists depending on the prevalence of HIV in the dental practice area.

Measles: lessons from an outbreak

BACKGROUND

Measles outbreaks continue to be a problem for infection control in hospitals--patients, personnel, and employee health service. Guidelines for measles outbreaks are not clear for medical personnel in the hospital.

METHODS

Outbreak investigation in a university-affiliated teaching hospital.

RESULTS

Four primary cases resulted in 607 staff exposures and two secondary cases. Forty-seven medical personnel were furloughed and 88 were vaccinated for measles. Minimal serologic criteria for immunity were found to be inadequate in the outbreak setting.

CONCLUSIONS

We found that serologic guidelines for assessing immunity to measles are inadequate. During the outbreak, we arbitrarily doubled the acceptable enzyme-linked immunosorbent assay titers that we would consider protective, > or = 2, to decrease the possibility of further secondary cases. Employees with enzyme-linked immunosorbent assay measles titers less than 2 and without a definite history of natural measles were revaccinated with a measles vaccine. This strategy takes advantage of the anamnestic response that revaccination would confer in persons with low antibody titer.

Varicella zoster and herpes simplex virus infections

There are six herpes viruses, three of which, the varicella-zoster virus and the herpes simplex viruses types 1 and 2, are of particular concern to patients and staff in critical care units. These viruses, especially in their reactivated states, may present atypically in critically ill and immune-suppressed patients, and, by the time the diagnosis is made, exposures of other patients and clinicians may have occurred. Pregnancy and immunosuppressed states can result in severe, even life-threatening varicella-zoster virus infections in susceptible adults. Similarly, nosocomial herpes simplex virus infections can have serious consequences for exposed patients and staff. An additional problem after herpes simplex virus infection is the potential of lifelong and possibly frequent recurrences. In this article, the manifestations, modes of transmission, and treatment will be discussed. Special emphasis will be placed on describing the types of patients who are at high risk of presenting with varicella-zoster virus or herpes simplex virus infection so that physicians and nurses can use appropriate preventive measures to avert nosocomial infections in patients and staff.

Fifth disease and other parvovirus B19 infections

Parvovirus B19 is the etiologic agent in three diseases with clinically different presentations and implications. The first and most common disease is erythema infectiosum or fifth disease. Symptoms may vary somewhat between affected children and adults. A second type of presentation occurs in infected people who require a greater than normal replacement of red blood cells, and a third infection may affect a developing fetus. Because there is no effective treatment or vaccine, physicians and nurses should conscientiously observe universal precautions to avoid acquisition of B19 infection from patients.

Colonization and bacteremia related to duration of triple-lumen intravascular catheter placement

The increased use of triple-lumen catheters has brought with it an increase in sepsis. We undertook a study to determine whether this increase was related to the length of time a catheter was in place. Culture of the fluid in each of the three lumens of all triple-lumen catheters in the medical intensive care units was done daily for a 6-month period. In 14 of 31 catheters, 28 of 93 lumens showed bacterial or fungal growth. A temporal relationship between the time a catheter was placed and the onset of catheter colonization and patient sepsis was established (p less than 0.01). Catheter colonization preceded sepsis in three of four patients who became bacteremic with the same organisms that were cultured from the lumens and the catheter tips. As a result of this study, centrally placed intravascular lines are now changed every 7 days in our institution with a noticeable decrease in line-related sepsis.

How to handle blood and body fluids

Blood and body fluids and Universal Precautions have become part of the everyday vocabulary in health care. How body fluids are handled by individuals depends on their perception of risk for acquiring an infection from these substances and is not always based on sound knowledge. An understanding of how infections are acquired and the role of blood and body fluids as part of the risk is necessary if nurses and others are to use appropriate precautionary measures. Those parameters are discussed in this article.

Significance of fever in hospital employees

Hospital employees are exposed to a variety of occupationally related hazards that can be categorized as infectious or noninfectious. Lost work time often results from these problems. Infection control practitioners receive many telephone calls of inquiry about these employees in terms of their transmissible infections. Little has been written concerning fever in the employee health setting. To determine the frequency of febrile illness in hospital employees, we conducted a prospective study of the employee health service from January to December 1987. Winthrop-University Hospital is a 533-bed community teaching hospital with approximately 2400 employees. During 1987, 2974 visits were made to the employee health service. Of these, 879 (30%) were for occupationally related illness or injury. Oral temperatures of greater than or equal to 100 degrees F were noted in 25 (2.8%) of the 879 visits. Fever occurred predominantly in employees with infections. Upper respiratory tract infection accounted for 268 of 544 (49%) visits for infection. In addition, 11 of 22 (50%) febrile episodes were related to upper respiratory tract infections. A total of 963 work days were lost because of illness or injury. Of these, 743 (77%) were related to an infectious illness; 67 sick days (7%) were attributed to infections with a febrile response. We conclude that fever is uncommon in our employee health care population and that upper respiratory tract infections were the single most common cause of fever. When an employee had a febrile illness, the lost work time was 9% of the total time loss because of infection.