hs-Troponin I Followed by CT Angiography Improves Acute Coronary Syndrome Risk Stratification Accuracy and Work-Up in Acute Chest Pain Patients: Results From ROMICAT II Trial

OBJECTIVES

This study compared diagnostic accuracy of conventional troponin/traditional coronary artery disease (CAD) assessment and highly sensitive troponin (hsTn) I/advanced CAD assessment for acute coronary syndrome (ACS) during the index hospitalization.

BACKGROUND

hsTnI and advanced assessment of CAD using coronary computed tomography angiography (CTA) are promising candidates to improve the accuracy of emergency department evaluation of patients with suspected ACS.

METHODS

We performed an observational cohort study in patients with suspected ACS enrolled in the ROMICAT II (Rule Out Myocardial Infarction/Ischemia using Computer Assisted Tomography) trial and randomized to coronary CTA who also had hsTnI measurement at the time of the emergency department presentation. We assessed coronary CTA for traditional (no CAD, nonobstructive CAD, ≥50% stenosis) and advanced features of CAD (≥50% stenosis, high-risk plaque features: positive remodeling, low <30-Hounsfield units plaque, napkin-ring sign, spotty calcium).

RESULTS

Of 160 patients (mean age: 53 ± 8 years, 40% women) 10.6% were diagnosed with ACS. The ACS rate in patients with hsTnI below the limit of detection (n = 9, 5.6%), intermediate (n = 139, 86.9%), and above the 99th percentile (n = 12, 7.5%) was 0%, 8.6%, and 58.3%, respectively. Absence of ≥50% stenosis and high-risk plaque ruled out ACS in patients with intermediate hsTnI (n = 87, 54.4%; ACS rate 0%), whereas patients with both ≥50% stenosis and high-risk plaque were at high risk (n = 13, 8.1%; ACS rate 69.2%) and patients with either ≥50% stenosis or high-risk plaque were at intermediate risk for ACS (n = 39, 24.4%; ACS rate 7.7%). hsTnI/advanced coronary CTA assessment significantly improved the diagnostic accuracy for ACS as compared to conventional troponin/traditional coronary CTA (area under the curve 0.84, 95% confidence interval [CI]: 0.80 to .88 vs. 0.74, 95% CI: 0.70 to 0.78; p < 0.001).

CONCLUSIONS

hsTnI at the time of presentation followed by early advanced coronary CTA assessment improves the risk stratification and diagnostic accuracy for ACS as compared to conventional troponin and traditional coronary CTA assessment. (Multicenter Study to Rule Out Myocardial Infarction/Ischemia by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).

Sensitive troponin assays in patients with suspected acute coronary syndrome: Results from the multicenter rule out myocardial infarction using computer assisted tomography II trial

BACKGROUND

Sensitive troponin (Tn) assays have been developed for the evaluation of patients with suspected acute coronary syndrome (ACS). We sought to compare the performance of a commercially available sensitive Tn I (sTnI) and precommercial highly sTnI (hsTnI) method to conventional Tn (cTn) assays.

METHODS

Among patients with acute chest pain but normal cTn in the emergency department of 6 centers, sTnI and hsTnI were measured at baseline, 2 and 4 hours after presentation. Diagnostic accuracy of sTnI and hsTnI relative to cTn for diagnosis during index hospitalization as well as their associations with coronary artery disease in patients randomized to coronary computed tomographic angiography (CTA) was assessed.

RESULTS

Overall, 322 patients were enrolled, of whom 161 had a CTA; 28 had ACS (8.7%), including 21 with unstable angina pectoris (UAP). Both sTnI and hsTnI values at baseline and second draw had significantly higher sensitivity for ACS and UAP than cTn and had significantly greater area under the receiver operator characteristic curve than cTn at first and second draws. Compared with cTn, 29% of ACS cases previously categorized as UAP were reclassified to acute myocardial infarction with sTnI or hsTnI. An hsTnI below limit of detection had 100% negative predictive value for ACS or significant coronary artery stenosis in those randomized to CTA.

CONCLUSIONS

In patients with acute chest discomfort, use of sTnI and hsTnI methods led to significant improvement in the early diagnostic accuracy for ACS, reclassifying one-third of UAP to myocardial infarction. Very low values for hsTnI excluded underlying coronary artery disease.

Coronary CT angiography versus standard evaluation in acute chest pain

BACKGROUND

It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes.

METHODS

In this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes.

RESULTS

The rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65).

CONCLUSIONS

In patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.).

Emergency department utilization after the implementation of Massachusetts health reform

STUDY OBJECTIVE

Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions.

METHODS

We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation.

RESULTS

Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%).

CONCLUSION

Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.

Differences in Triage Thresholds for Patients Presenting with Possible Acute Coronary Syndromes

BACKGROUND

Many studies have shown differences in cardiac care by racial/ethnic groups without accounting for institutional factors at the location of care.

OBJECTIVE

Exploratory analysis of the effect of hospital funding status (public vs private) on emergency department (ED) triage decision making for patients with symptoms suggestive of acute coronary syndromes (ACSs) and on the likelihood of ED discharge for patients with confirmed ACS.

STUDY DESIGN AND SETTING

Secondary analysis of data from a randomized controlled trial of 10,659 ED patients with possible ACS in five urban academic public and five private hospitals. The main outcome measures were the sensitivity and specificity of hospital admission for the presence of ACS at public and private hospitals and the adjusted odds of a patient with ACS not being hospitalized at public versus private hospitals.

RESULTS

Of 10,659 ED patients, 1,856 had confirmed ACS. For patients with suspected ACS, triage decisions at private hospitals were considerably more sensitive (99 vs 96%; p<.001) but less specific (30 vs 48%; p<.001) than at public hospitals. The difference between hospital types persisted after adjustment for multiple patient-level and hospital-level characteristics.

CONCLUSION

Significant differences in triage for patients with suspected ACS exist between public and private hospital EDs, even after adjustment for multiple patient demographic, clinical, and institutional factors. Further studies are needed to clarify the causes of the differences.

Acute coronary syndromes in the emergency department: diagnostic characteristics, tests, and challenges

Failure to diagnose patients who have acute coronary syndromes (ACSs)-either acute myocardial infarction (AMI) or unstable angina pectoris (UAP)-who present to the emergency department (ED) remains a serious public health issue. Better understanding of the pathophysiology of coronary artery disease has allowed the adoption of a unifying hypothesis for the cause of ACSs: the conversion of a stable atherosclerotic lesion to a plaque rupture with thrombosis. Thus, physicians have come to appreciate UAP and AMI as parts of a continuum of ACSs. This article reviews the state of the art regarding the diagnosis of ACSs in the emergency setting and suggests reasons why missed diagnosis continues to occur, albeit infrequently.

Clinical features, triage, and outcome of patients presenting to the ED with suspected acute coronary syndromes but without pain: a multicenter study

We studied the impact on triage and outcome of patients presenting to the emergency department (ED) with symptoms suggestive of an acute coronary syndromes (ACS) but without a complaint of pain. Data from a prospective clinical trial of patients with symptoms suggesting an ACS in the EDs of 10 US hospitals comparing patient demographics, clinical variables, and outcomes was used to perform a secondary analysis. Of 10,783 subjects, a final diagnosis of an ACS was confirmed in 24% of which 35% had acute myocardial infarction (AMI) and 65% unstable angina pectoris (UAP). Pain was absent in 6.2% of patients with acute ischemia and in 9.8% of those with AMI. Compared to similar patients who presented with pain, patients with painless ischemia were older, were more commonly women, had more cardiac and related diseases. Among patients with AMI, fewer patients without pain were admitted to critical care units compared to similar patients with pain. Among patients with AMI, logistic regression predicting lack of pain identified age, heart failure and diabetes, with only age and heart failure among all with ACS. After controlling for clinical features, lack of pain during acute ischemia predicted increased hospital mortality. We concluded that age and heart failure are independently associated with painless ACS, in addition to diabetes among those with AMI. Lack of pain predicts increased hospital mortality in patients with ACI through mechanisms that remain to be elucidated. There is a need for greater awareness in the general public of the different manifestations of ACS to enhance the recognition of and prompt response to their symptoms.

Acute resting myocardial perfusion imaging in patients with diabetes mellitus: results from the Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain (ERASE Chest Pain) trial

BACKGROUND

Resting myocardial perfusion imaging (MPI) improves the triage of patients presenting to the emergency department (ED) with symptoms suggestive of acute cardiac ischemia (ACI). In the ED setting the presence of diabetes mellitus (DM) is a predictor of ACI and hospitalization, but the role of resting MPI in patients with DM is unknown.

METHODS AND RESULTS

A secondary data analysis of a prospective, multicenter, randomized, controlled trial of ED evaluation strategies in patients with symptoms suggestive of ACI and normal or nondiagnostic electrocardiograms was performed. In the main trial 2475 patients were randomized to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented by results from resting MPI by use of single photon emission computed tomography (SPECT) technetium 99m sestamibi (n = 1215). Patients with diabetes (n = 341) were evaluated separately. Imaging results, final diagnoses, effect on triage, and prognostic value of the SPECT imaging were compared between diabetic and nondiabetic patients. Of the 341 patients with diabetes, 153 (45%) were randomized to the imaging strategy. Patients with DM had higher rates of hospitalization (66% vs 49.6%, P = .0001) and ACI (21.1% vs 12.0%, P < .001) than patients without DM. Among diabetic patients without ACI, the admission rate was 63% in the usual strategy group versus 54% in the imaging strategy group (relative risk [RR] = 0.91 [95% CI, 0.76-1.06]; P = .24). There was no difference in the magnitude of this reduced risk of admission compared with patients without DM (RR = 0.84 [95% CI, 0.77-0.92]; P = .0002 for patients without DM and P = .35 for interaction of diabetes and RR reduction).

CONCLUSIONS

Acute resting MPI with Tc-99m sestamibi is associated with improved triage decision making in symptomatic ED patients with diabetes.

The impact of electrocardiographic left ventricular hypertrophy and bundle branch block on the triage and outcome of ED patients with a suspected acute coronary syndrome: a multicenter study

We studied the impact on triage and outcome of the presence of left ventricular hypertrophy (LVH) and left/right bundle branch block (LBBB/RBBB) on the initial ED electrocardiogram (ECG) for patients with symptoms suggestive of an acute coronary syndrome (ACS). Secondary analysis of data from a prospective clinical trial of patients with chest pain or other symptoms suggesting ACS in six U.S. hospitals comparing patient demographics, clinical variables, and outcomes was used. Of 5,324 study patients, 3% had ECG-LVH, 3% had LBBB, 3% had RBBB, and 43% had ischemic ST segment or T wave abnormalities. Compared with patients without ST segment or T wave abnormalities, patients with ECG-LVH or BBB were older and were more likely to have a chief complaint of shortness of breath or a history of cardiac or related diseases. Patients with ECG-LVH or BBB had more diagnoses of congestive heart failure (CHF) and ACS compared with patients without these ECG abnormalities and were just as likely to have ACS as their diagnosis compared with patients with ischemic ST segment or T wave abnormalities. Having ECG-LVH or BBB did not alter the true-positive rate for ACS but increased the false-positive rate by almost 50%. Patients with ECG-LVH had approximately 3.5 times the 30-day mortality rate as those without these ECG abnormalities. It appears that for patients with symptoms suggestive of ACS, the presence of ECG-LVH or BBB did not alter the ability of ED clinicians to identify patients with ACS but was associated with a 50% higher false-positive admission rate compared with similar patients without these ECG abnormalities. With a short-term mortality rate 3.5 times that for patients without ECG-LVH, selected patients with ECG-LVH and symptoms suggesting ACS might benefit from hospitalization for further evaluation.

Diagnosis of acute cardiac ischemia

A better understanding of coronary syndromes allow physicians to appreciate UAP and AMI as part of a continuum of ACI. ACI is a life-threatening condition whose identification can have major economic and therapeutic importance as far as threatening dysrhythmias and preventing or limiting myocardial infarction size. The identification of ACI continues to challenge the skill of even experienced clinicians, yet physicians continue (appropriately) to admit the overwhelming majority of patients with ACI; in the process, they admit many patients without acute ischemia [2], overestimating the likelihood of ischemia in low-risk patients because of magnified concern for this diagnosis for prognostic and therapeutic reasons. Studies of admitting practices from a decade ago have yielded useful clinical information but have shown that neither clinical symptoms nor the ECG could reliably distinguish most patients with ACI from those with other conditions. Most studies have evaluated the accuracy of various technologies for diagnosing ACI, yet only a few have evaluated the clinical impact of routine use. The prehospital 12-lead ECG has moderate sensitivity and specificity for the diagnosis of ACI. It has demonstrated a reduction of the mean time to thrombolysis by 33 minutes and short-term overall mortality in randomized trials. In the general ED setting, only the ACI-TIPI has demonstrated, in a large-scale multicenter clinical trial, a reduction in unnecessary hospitalizations without decreasing the rate of appropriate admission for patients with ACI. The Goldman chest pain protocol has good sensitivity for AMI but was not shown to result in any differences in hospitalization rate, length of stay, or estimated costs in the single clinical impact study performed. The protocol's applicability to patients with UAP has not been evaluated. Single measurement of biomarkers at presentation to the ED has poor sensitivity for AMI, although most biomarkers have high specificity. Serial measurements can greatly increase the sensitivity for AMI while maintaining their excellent specificity. Biomarkers cannot identify most patients with UAP. Finally, diagnostic technologies to evaluate ACI in selected populations, such as echocardiography, sestamibi perfusion imaging, and stress ECG, may have very good to excellent sensitivity; however, they have not been sufficiently studied.

Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial

CONTEXT

Observational studies of acute myocardial perfusion imaging in emergency department (ED) patients with chest pain have suggested high sensitivity and negative predictive value for acute cardiac ischemia, but use of this method has not been prospectively tested.

OBJECTIVE

To assess whether incorporating acute resting perfusion imaging into an ED evaluation strategy for patients with suspected acute ischemia but no initial electrocardiogram (ECG) changes diagnostic of acute ischemia improves clinical decision making for initial ED triage.

DESIGN, SETTING, AND PATIENTS

Prospective, randomized controlled trial conducted at 7 academic medical centers and community hospitals between July 1997 and May 1999 among 2475 adult ED patients with chest pain or other symptoms suggestive of acute cardiac ischemia and with normal or nondiagnostic initial ECG results.

INTERVENTION

Patients were randomly assigned to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented with results from acute resting myocardial perfusion imaging using single-photon emission computed tomography with injection of 20 to 30 mCi of Tc-99m sestamibi (n = 1215), interpreted in real time by local staff physicians and with results provided to the ED physician for incorporation into clinical decision making.

MAIN OUTCOME MEASURE

Appropriateness of triage decision either to admit to hospital/observation or to discharge directly home from the ED.

RESULTS

Among patients with acute cardiac ischemia (ie, acute myocardial infarction [MI] or unstable angina; n = 329), there were no differences in ED triage decisions between those receiving standard evaluation and those whose evaluation was supplemented by a sestamibi scan. Among patients with acute MI (n = 56), 97% vs 96% were hospitalized (relative risk [RR], 1.00; 95% confidence interval [CI], 0.89-1.12), and among those with unstable angina (n = 273), 83% vs 81% were hospitalized (RR, 0.98; 95% CI, 0.87-1.10). However, among patients without acute cardiac ischemia (n = 2146), hospitalization was 52% with usual care vs 42% with sestamibi imaging (RR, 0.84; 95% CI, 0.77-0.92).

CONCLUSIONS

Sestamibi perfusion imaging improves ED triage decision making for patients with symptoms suggestive of acute cardiac ischemia without obvious abnormalities on initial ECG. In this study, unnecessary hospitalizations were reduced among patients without acute ischemia, without reducing appropriate admission for patients with acute ischemia.

Missed diagnoses of acute cardiac ischemia in the emergency department

BACKGROUND

Discharging patients with acute myocardial infarction or unstable angina from the emergency department because of missed diagnoses can have dire consequences. We studied the incidence of, factors related to, and clinical outcomes of failure to hospitalize patients with acute cardiac ischemia.

METHODS

We analyzed clinical data from a multicenter, prospective clinical trial of all patients with chest pain or other symptoms suggesting acute cardiac ischemia who presented to the emergency departments of 10 U.S. hospitals.

RESULTS

Of 10,689 patients, 17 percent ultimately met the criteria for acute cardiac ischemia (8 percent had acute myocardial infarction and 9 percent had unstable angina), 6 percent had stable angina, 21 percent had other cardiac problems, and 55 percent had noncardiac problems. Among the 889 patients with acute myocardial infarction, 19 (2.1 percent) were mistakenly discharged from the emergency department (95 percent confidence interval, 1.1 to 3.1 percent); among the 966 patients with unstable angina, 22 (2.3 percent) were mistakenly discharged (95 percent confidence interval, 1.3 to 3.2 percent). Multivariable analysis showed that patients who presented to the emergency department with acute cardiac ischemia were more likely not to be hospitalized if they were women less than 55 years old (odds ratio for discharge, 6.7; 95 percent confidence interval, 1.4 to 32.5), were nonwhite (odds ratio, 2.2; 1.1 to 4.3), reported shortness of breath as their chief symptom (odds ratio, 2.7; 1.1 to 6.5), or had a normal or nondiagnostic electrocardiogram (odds ratio, 3.3; 1.7 to 6.3). Patients with acute infarction were more likely not to be hospitalized if they were nonwhite (odds ratio for discharge, 4.5; 95 percent confidence interval, 1.8 to 11.8) or had a normal or nondiagnostic electrocardiogram (odds ratio, 7.7; 95 percent confidence interval, 2.9 to 20.2). For the patients with acute infarction, the risk-adjusted mortality ratio for those who were not hospitalized, as compared with those who were, was 1.9 (95 percent confidence interval, 0.7 to 5.2), and for the patients with unstable angina, it was 1.7 (95 percent confidence interval, 0.2 to 17.0).

CONCLUSIONS

The percentage of patients who present to the emergency department with acute myocardial infarction or unstable angina who are not hospitalized is low, but the discharge of such patients is associated with increased mortality. Failure to hospitalize is related to race, sex, and the absence of typical features of cardiac ischemia. Continued efforts to reduce the number of missed diagnoses are warranted.

Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial

BACKGROUND

Approximately 6 million U.S. patients present to emergency departments annually with symptoms suggesting acute cardiac ischemia. Triage decisions for these patients are important but remain difficult.

OBJECTIVE

To test whether computerized prediction of the probability of acute ischemia, used with electrocardiography, improves the accuracy of triage decisions.

DESIGN

Controlled clinical trial.

SETTING

10 hospital emergency departments in the midwestern, southeastern, and northeastern United States.

PATIENTS

10689 patients with chest pain or other symptoms suggestive of acute cardiac ischemia.

INTERVENTION

The probability of acute ischemia predicted by the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI), either automatically printed or not printed on patients' electrocardiograms.

MEASUREMENTS

Emergency department triage to a coronary care unit (CCU), telemetry unit, ward, or home. Other measurements were the bed capacity of the CCU relative to that of the telemetry unit; training or supervision status of the triaging physician; and patient diagnoses and outcomes based on clinical, electrocardiographic, and creatine kinase data.

RESULTS

For patients without cardiac ischemia, in hospitals with high-capacity CCUs and relatively low-capacity cardiac telemetry units, use of ACI-TIPI was associated with a reduction in CCU admissions from 15% to 12%, a change of -16% (95% CI, -30% to 0%), and an increase in emergency department discharges to home from 49% to 52%, a change of 6% (CI, 0% to 14%; overall P=0.09). Across all hospitals, for patients evaluated by unsupervised residents, use of ACI-TIPI was associated with a reduction in CCU admissions from 14% to 10%, a change of -32% (CI, -55% to 3%); a reduction in telemetry unit admissions from 39% to 31%, a change of -20% (CI, -34% to -2%); and an increase in discharges to home from 45% to 56%, a change of 25% (CI, 8% to 45%; overall P=0.008). Among patients with stable angina, in hospitals with high-capacity CCUs, use of ACI-TIPI was associated with a reduction in CCU admissions from 26% to 13%, a change of -50% (CI, -70% to -17%), and an increase in discharges to home from 20% to 22%, a change of 10% (CI, -29% to 71%; overall P=0.02). At hospitals with high-capacity telemetry units, use of ACI-TIPI was associated with a reduction in telemetry unit admissions from 68% to 59%, a change of -14% (CI, -27% to 1%), and an increase in emergency department discharges to home from 10% to 21%, a change of 100% (CI, 22% to 230%; overall P=0.02). Among patients with acute myocardial infarction or unstable angina, use of ACI-TIPI did not change appropriate admission (96%) to the CCU or telemetry unit at hospitals with high-capacity CCUs or telemetry units.

CONCLUSIONS

Use of ACI-TIPI was associated with reduced hospitalization among emergency department patients without acute cardiac ischemia. This result varied as expected according to the CCU and cardiac telemetry unit capacities and physician supervision at individual hospitals. Appropriate admission for unstable angina or acute infarction was not affected. If ACI-TIPI is used widely in the United States, its potential incremental impact may be more than 200000 fewer unnecessary hospitalizations and more than 100000 fewer unnecessary CCU admissions.

Syncytium induction in primary CD4+ T-cell lines from normal donors by human immunodeficiency virus type 1 isolates with non-syncytium-inducing genotype and phenotype in MT-2 cells

Human immunodeficiency virus type 1 (HIV-1) isolates classified as syncytium-inducing (SI) or non-SI (NSI) in the MT-2 T-cell line exhibit characteristic sequence differences in the V1-V2 and V3 regions of the env gene. Seven HIV-1 isolates were phenotyped as NSI or SI in the MT-2 cell line. Unexpectedly, all four NSI viruses induced large syncytia 4 to 8 days postinoculation in a panel of five primary CD4+ T-cell lines (including two clones) generated from the peripheral blood of normal donors by exposure to infectious HIV-1, inactivated HIV-1, or Epstein-Barr virus. The primary T-cell lines yielded neither HIV-1 provirus nor infectious HIV by PCR analysis or exhaustive coculture with phytohemagglutinin-treated blast cells. Three isolates (TC354, PK1, and PK2) were biologically cloned and retained their SI or NSI phenotypes in MT-2 and primary T-cell lines. The biologically cloned provirus DNA was also used to clone and sequence the relevant V2 and V3 regions of the env genes. The amino acid sequences of the V2 and V3 regions were characteristic of patterns already reported for the NSI, switch NSI, and SI phenotypes, respectively. This evidence precludes the possibility that these results were due to contamination of the NSI isolates with SI virus. The results unequivocally indicate that HIV-1 isolates with the NSI genotype and phenotype in MT-2 cells may actively induce syncytia in cloned CD4+ T cells in vitro and support the view that direct cytopathic effects may contribute to the steady decline in CD4+ T cells in asymptomatic HIV-1-seropositive patients without detectable SI virus.

Identification of the respiratory syncytial virus-induced immunosuppressive factor produced by human peripheral blood mononuclear cells in vitro as interferon-alpha

Respiratory syncytial virus (RSV) can inhibit the proliferative response of human peripheral blood mononuclear cells (PBMC) in vitro. This inhibition is mediated by an extracellular RSV-induced factor. In the present study, the factor was clearly identified as interferon (IFN)-alpha. The RSV-induced IFN-alpha bound strongly to PBMC and inhibited the anti-RSV proliferative response only when added within the first few days of stimulation. There was, however, no concomitant decrease in the production of interleukin (IL)-2 nor in the cell surface expression of CD25, CD71, and HLA-DR. Inhibition by RSV-induced IFN-alpha was unrelated to the levels of IL-1, -2, and -6 or of IFN-gamma induced by RSV in vitro or to the presence of IL-1 inhibitor, tumor necrosis factor-alpha, prostaglandin, or IL-10. Immunosuppression by IFN-alpha may significantly affect the outcome of infection and reinfection with RSV.

Diagnosis of human herpesvirus-6 infection in two patients with central nervous system complications

BACKGROUND

Although exanthem subitum (ES) is generally a mild, self-limiting disease of early childhood, some cases of ES are complicated by seizures and encephalopathy. The presence of human herpesvirus-6 (HHV-6) DNA in cerebrospinal fluid (CSF) of these patients suggests that HHV-6 can infect the central nervous system (CNS) causing encephalitis.

OBJECTIVES

To demonstrate HHV-6 infection in two patients with serious CNS complications. The patients, a child and an adult, failed to develop the characteristic rash normally associated with ES.

STUDY DESIGN

Peripheral blood mononuclear cells (PBMCs) and CSF were examined for the presence of HHV-6 or viral DNA, using virus isolation techniques and the polymerase chain reaction (PCR). Serum samples were tested by immunofluorescence (IF) and enzyme linked immuno-sorbent assay (ELISA) for the presence of anti-HHV-6 IgM and anti-HHV-6 IgG respectively.

RESULTS

HHV-6 was isolated from the PBMCs of the adult patient and the presence of virus in these cells was confirmed using electron microscopy. HHV-6 DNA was detected in CSF taken early during the infection in both patients, together with anti-HHV-6 IgM antibodies and increasing levels of anti-HHV-6 IgG.

CONCLUSIONS

The diagnosis of HHV-6 infection in these patients was confirmed either by virus isolation or by the detection of HHV-6 DNA in the CSF, and the results of serology. These cases show that HHV-6 infection may result in serious CNS complications, in children and adults.

Southern blot analysis of skin biopsies for human papillomavirus DNA: renal allograft recipients in south-eastern Queensland

The 104 skin biopsies from 34 patients who attended a Renal Transplant Unit in Brisbane over 12 months included 40 squamous cell carcinoma (SCC), 22 solar keratoses, 4 hyperkeratoses, 18 warts and 11 basal cell carcinoma (BCC). Human papillomavirus (HPV) DNA was identified by Southern blot hybridisation using, as individual probes, purified insert DNA from recombinant HPV 1, 2, 3 or 3/10, 4, 5 or 5/8, 7, 11, 16, 18 and 41 under relaxed conditions and characterised by restriction enzyme analysis and Southern blot hybridisation under more stringent conditions. Genomic HPV DNA was characterised in 7 skin biopsies from 4 renal allograft recipients (RARs): HPV 1A in a SCC (20 copies/cell) and a BCC (10 copies/cell) from the one patient, HPV 36 (20 copies/cell) in a SCC, HPV 1A [symbol: see text] 1000 copies/cell) in a wart and HPV 2B (200-800 copies/cell) in 3 warts from the one patient. Only HPV 1A in the SCC exhibited a significant degree of subtype variation. HPV DNA was identified in another 5 skin biopsies from another 4 RARs: HPV 3A in a wart and a hyperkeratosis, HPV 3/10-related DNA in 2 solar keratoses and HPV 5/8-related DNA in another (20-50 copies/cell). The incidence of HPV 5 (or 5-related HPVs) in RAR SCC was very low and that of HPV DNA in RAR warts was lower than that recorded elsewhere but this was not due to insensitivity of the assays. There was no evidence for a role for HPV in the aetiology of skin cancer in RARs in south-eastern Queensland but the possibility remains that as yet unidentified HPV types are involved.

Infectious respiratory syncytial virus (RSV) effectively inhibits the proliferative T cell response to inactivated RSV in vitro

The effect of respiratory syncytial virus (RSV) on the cellular immune response of human mononuclear cells in vitro was examined. Inhibition by RSV of the lymphocyte response to phytohemagglutinin in vitro was confirmed using cells from human umbilical cord blood. In addition, RSV significantly inhibited both the proliferative and T cell colony responses of human mononuclear cells to Epstein-Barr virus. An RSV-specific cellular immune response was induced in vitro by stimulation of mononuclear cells from RSV-seropositive donors with beta-propiolactone-inactivated RSV. This RSV-specific response was significantly inhibited by infectious RSV itself, and the inhibition was mediated by an extracellular factor produced by RSV-infected mononuclear cells. A similar inhibition in vivo of the RSV-induced cellular immune response may contribute significantly to delayed recovery from primary infection and to reduced resistance to subsequent infections.

Effects of cycloheximide on B-chronic lymphocytic leukaemic and normal lymphocytes in vitro: induction of apoptosis

A number of reports indicate that protein synthesis is a requirement for the occurrence of apoptosis. In this study, the effect of the protein synthesis inhibitor cycloheximide (CHM) on spontaneous apoptosis of B-chronic lymphocytic leukaemia (B-CLL) cells, previously shown to occur when they are cultured in RPMI-1640 medium with autologous or heterologous serum, was examined. No definite inhibition of apoptosis was observed. Indeed, CHM-treatment augmented apoptosis in the B-CLL cultures and also induced apoptosis of cultured normal peripheral blood lymphocytes. Augmentation was dose-dependent for B-CLL cells over the concentration range 10(-6) M (0.28 micrograms ml-1) to 10(-2) M (2800 micrograms ml-1), resulting in 9% to 98% apoptosis respectively by 24 h of culture (r = 0.619, P = 0.0008). Normal lymphocytes were affected by CHM over the range 10(-4) M to 10(-2) M, resulting in 7% to 74% apoptosis respectively (r = 0.794, P = 0.0001). Inhibition of protein synthesis in these cells by CHM was virtually complete at a concentration of 10(-3) M. The findings are in accord with some recent reports indicating that suppression of protein synthesis by CHM does not inhibit apoptosis in all circumstances. They also illustrate the marked susceptibility of B-CLL cells, compared with normal lymphocytes, to the induction of apoptosis by this drug. The manner in which CHM triggers apoptosis of some cell types is at present uncertain.

Interleukin-2 enhances production in 24 hours of infectious human immunodeficiency virus type 1 in vitro by naturally infected mononuclear cells from seropositive donors

When peripheral blood mononuclear cells from HIV-1 seropositive patients were treated with rIL-2 in vitro a rapid increase of 2-12 fold in production of extracellular infectious HIV-1 occurred, in 6 of 9 experiments. Overall, the increase in the 9 experiments was significant (p less than 0.01) and provides more direct evidence for an enhancing role of IL-2 in naturally infected cells.

Western blot analysis of antibody specificities in subacute sclerosing panencephalitis: reactivity to measles virus proteins produced in persistently infected cells

The specificity of serum antibodies from patients with subacute sclerosing panencephalitis (SSPE) and seropositive controls to measles virus proteins produced in acutely and persistently infected human cells was examined by western blot analysis. Sera from both SSPE patients and controls reacted to the H, N, and F1 virus proteins produced in acutely infected AV3 cells. However, while SSPE-derived sera reacted with the same proteins in persistently infected cells (AV3Al/MV), most control sera failed to react with the hemagglutinin protein produced in such cells (Hp). Most sera also reacted poorly with the M protein from either source, and the reactivity to the P protein was variable. Although the exact reason(s) for the different reactivities to the proteins were not determined, differences in antibody concentration did not appear to be responsible. The dramatic differences in the reactivity of SSPE and control sera to the Hp protein suggest that either the protein coevolves in persistent infections or multiple forms of the protein evolve in such infections and SSPE patients develop broad-spectrum humoral immunity as a consequence of exposure to them. Alternatively, over time there may be selective loss of some H-reactive antibody subsets by individuals who contract measles, but do not develop SSPE.

The value of MLA 144 culture fluid for the isolation of human immunodeficiency virus

Human immunodeficiency virus (HIV) was readily isolated by co-cultivation of patients' cells with phytohaemagglutinin-stimulated mononuclear cells from umbilical cord blood in 2 ml cultures in 24-well plates. Fluids from cultures of the MLA 144 cell line acted as an excellent source of interleukin-2, and promoted early replication of HIV in the primary cultures. Reverse transcriptase activity was commonly present at significant levels by 4-7 days. In contrast, recombinant IL-2 (recIL-2) did not promote early replication under these conditions. Adequate washing of the phytohaemagglutinin blasts was critical in this system, although others have reported it to be less important under other culture conditions. Cell concentrations and HIV: target cell ratios appeared not to play a major role in early outgrowth of virus. The particular sheep anti-alpha interferon tested resulted in a two-fold reduction in RT activity. Virus was readily transmitted in this simplified cheaper culture system.

Spontaneous programmed death (apoptosis) of B-chronic lymphocytic leukaemia cells following their culture in vitro

When B-chronic lymphocytic leukaemia (B-CLL) cells derived from peripheral blood were cultured in vitro, a substantial proportion of them spontaneously died by apoptosis. This type of cell death is morphologically and biochemically distinct from necrosis and has previously been found to occur under physiologic and certain pathologic conditions where cell deletion appears controlled and biologically meaningful. By 30 h of culture, approximately 20% of the unfractionated B-CLL cells were affected. There was no significant difference in the incidence of apoptosis in T-cell depleted and undepleted cultures or when either autologous or normal human serum was used. Furthermore, seeding densities of 2 x 10(6) and 5 x 10(5) cells/ml resulted in a similar incidence of apoptosis, indicating that cell density was unlikely to be a contributing factor in producing the death. The finding that B-CLL cells spontaneously die in vitro has at least two important implications. Firstly, previous work relating to some of the functions of B-CLL cells and their interactions with T cells may require re-evaluation. Secondly, an understanding of the mechanisms involved in the induction of apoptosis in this disease may have therapeutic consequences.

Detection of Epstein-Barr virus strain variants in lymphoblastoid cell lines 'spontaneously' derived from patients with rheumatoid arthritis, infectious mononucleosis and normal controls

'Spontaneous' lymphoblastoid cell lines (LCL) were established from patients with either rheumatoid arthritis (RA) or infectious mononucleosis (IM) or from healthy donors. Differences in Epstein-Barr virus (EBV) strains were determined by measuring the mol. wt. and expression of viral antigens in each of the LCLs. In addition to the previously reported EBV nuclear antigens, the LCLs also contained EBV-induced antigens with mol. wt. of 48K and 58K which were present in all but two of the lines. One of the differences observed between each of the groups of cell lines was their ability to produce viral antigens. Early and late antigens were identified by immunoblotting in most of the RA lines, two of the normal lines but none of the cell lines from patients with IM. Many of the IM cell lines were also found to express multiple EBNA1 antigens. The results demonstrate that a variety of wild-type EBV strains exist. However, the similarities observed in a number of the lines suggest that the diversity of strains may be limited.

The prevalence of antibodies to an Epstein-Barr virus-induced polypeptide (EBNA-2) in the sera of rheumatoid arthritic families

Using the protein immunoblot technique, antibodies to an Epstein-Barr virus-induced 92 kD polypeptide (EBNA-2) were more frequently present in the sera of patients with rheumatoid arthritis and their consanguineous relatives when compared with a control group. No association of anti-EBNA-2 antibody with the HLA-DR antigens was observed.

Reactions of sera from patients with rheumatoid arthritis, systemic lupus erythematosus and infectious mononucleosis to Epstein-Barr virus-induced polypeptides

P3HR-1 and Ramos cells induced with sodium butyrate and 12-O-tetradecanoylphorbol 13-acetate were used in the protein immunoblot technique to identify Epstein-Barr virus (EBV)-specific antibodies present in sera from clinically normal individuals and patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and infectious mononucleosis (IM). Sixteen EBV-specific polypeptides were detected ranging in mol. wt. from 22,000 (22K) to 140K. Many of the sera contained antibodies to different subsets of these antigens, and a high proportion expressed autoantibodies which reacted with cellular components from an EBV genome-negative cell line. About 50% of the sera from each category reacted with the 44K to 48K and 36K and 38K early antigen (EA) components. A high proportion of the SLE sera (64%) were found to contain anti-EA antibodies, suggesting an association between EBV and SLE. Almost all of the EBV-seropositive sera examined contained antibodies against a 22K late antigen, but none of the sera from IM patients reacted with this polypeptide.

Correlation between the presence of antibodies to the Epstein-Barr virus nuclear antigen type 2 and antibodies to the rheumatoid arthritis nuclear antigen in patients with rheumatoid arthritis

The incidence of antibodies to Epstein-Barr nuclear antigen type 2 (EBNA-2) was determined in sera from rheumatoid arthritis (RA) patients and control subjects, by protein immunoblotting. Sixty-eight percent of the RA patients and 48% of the controls possessed anti-EBNA-2 antibodies. The titer of anti-rheumatoid arthritis nuclear antigen (RANA) in RA patient sera showed a stronger correlation with serum reactions to EBNA-2 than with reactions to EBNA-1. Our results indicate that the presence of EBNA-2 may make a major contribution to the RANA reaction.

Induction of Epstein-Barr virus nuclear antigens

Lymphocytes were infected with the QIMR-WIL strain of Epstein-Barr virus, and the induction of Epstein-Barr virus-associated nuclear antigens was determined by using the protein immunoblot. There was a temporal increase in six antigens, with Epstein-Barr nuclear antigen 2 being detected 1 day after infection. The appearance of these antigens was shown to be independent of cellular DNA synthesis.

Identification of Epstein-Barr virus-induced polypeptides in P3HR-1 cells by protein immunoblot

The protein immunoblot technique was used to identify Epstein-Barr virus-specific antigens present in sodium butyrate-induced P3HR-1 cells. Using sera from patients with either nasopharyngeal carcinoma or arthritis, 16 polypeptides were detected ranging in molecular weight from 22K to 140K. Each of the anti-EA-, anti-VCA-positive sera were found to contain antibodies to different subsets of the antigens. A 72K protein was identified which was consistent with the nuclear antigen (EBNA), and culturing cells in the presence of disodium phosphonoacetate allowed identification of 140K and 22K antigens as late viral products. Treatment of cells with sodium butyrate revealed that expression of some antigens increased in parallel with the time of incubation of the cells in butyrate while other antigens either appeared early and then decreased in intensity or were only present after a number of days of butyrate treatment. One of the antigens which decreased with the time cells were treated with butyrate was EBNA.

Inhibition of growth of certain human tumour cell lines by a factor derived from human fibroblast-like cell lines. I. Demonstration by mixed culture and by use of cell washings

The growth of 7/9 Burkitt's lymphoma (BL) cell lines and 5/6 human melanoma cell lines was inhibited by certain human fibroblast-like cell lines, especially human myofibroblast cell lines. In contrast to BL lines, 3/5 lymphoblastoid cell lines were less susceptible and 3/4 human leukaemic lines were resistant. The effect was time- and concentration-dependent. Co-cultivation led to inhibition of tumour-cell growth within 3 days, but after removal from the fibroblasts, washing, and resuspending in fresh medium some tumour cells recovered and growth improved. The inhibitory activity was also demonstrated with washings of fibroblast-like cell lines, and was sensitive to pronase. The biological significance of this factor remains to be defined.

Identification of multiple Epstein-Barr virus-induced nuclear antigens with sera from patients with rheumatoid arthritis

By means of the protein immunoblot technique, the Epstein-Barr virus (EBV) nuclear antigen (EBNA) could be identified in a variety of EBV-transformed cell lines with anti-EBNA-positive sera from normal donors. The molecular weight of EBNA expressed in each of the cell lines varied between 70,000 and 75,000 and was dependent upon the strain of infecting virus. In contrast, 15 of 21 sera from patients with rheumatoid arthritis identified antigens in addition to EBNA. The most prominent of these antigens had molecular weights of 110,000 to 115,000 and 92,000. All of the EBV genome-positive cell lines except for QIMR-GOR and cell lines containing the P3HR-1 virus expressed these antigens. The antigens were not present in the EBV genome-negative Ramos and BJAB cell lines, nor were they identified with EBV seronegative sera, indicating that they were EBV related. There was no direct correlation between the presence of antibodies in sera to EBNA, viral capsid antigen or early antigen, and reaction with the 92,000-molecular-weight antigen in immunoblots, indicating that this antigen was distinct from previously described EBV-related antigens.

Factors influencing the human cytotoxic T cell response to autologous lymphoblastoid cell lines in vitro

Epstein-Barr virus (EBV)- and fetal calf serum (FCS)-specific cytotoxic human T cells can be generated in vitro, and have been shown to be HLA-antigen restricted. In the present work, peripheral blood mononuclear cells were stimulated with the gamma-irradiated autologous lymphoblastoid cell line (LCL) grown previously in FCS, human serum, or without serum. The induction and generation of cytotoxic T cells was carried out exclusively in culture medium containing autologous serum. With EBV-seronegative responders, FCS-grown stimulator LCL generated a FCS-specific cytotoxic T cell response. AB serum-grown LCL generated only a weak response, except at a high stimulatory dose, where the response tended to be essentially nonspecific. EBV-seropositive responders, in contrast, gave a typical secondary EBV-specific response regardless of the serum in which the LCL had been grown previously; no FCS response was detected. Dose-response and cold target inhibition studies confirmed these results. EBV immunity obviously plays a major role in the T cell response to the autologous LCL, which can no longer be viewed simply as a form of autologous mixed leucocyte reaction.

HLA-DR-antigen-associated restriction of EBV-specific cytotoxic T-cell colonies

EBV-specific cytotoxic T cells can be generated in vitro in a secondary response. Several previous studies with bulk cultures provided evidence that cytotoxicity was restricted by HLA-A,B-related antigens. In the present family study, the EBV-specific cytotoxic T-cell response of a normal EBV-seropositive donor was analysed in detail by T-cell colony formation. Peripheral blood mononuclear cells were stimulated by the gamma-irradiated autologous lymphoblastoid cell line (LCL) and 3 days later seeded into agarose. Colonies were harvested, amplified by addition of interleukin-2 (IL-2), and analysed for T-cell markers and specificity in 51Cr-release assays. Twenty-two colonies were studied: all colonies were OKT3+, five were predominantly OKT4+, 9 were OKT8+ and 8 were mixtures. As expected from previous work, the OKT8+ colonies were cytotoxic for the autologous LCL target and cytotoxicity was blocked by monoclonal antibody (W6/32) to the nonpolymorphic determinants of HLA-A,B,C antigens. Significantly, the OKT4+ colonies tested also showed specific cytotoxicity, but lysis of the autologous LCL was blocked by the monoclonal antibody (OKlal) to the non-polymorphic determinants of HLA-DR antigens. Two interesting patterns of specificity were seen in cytotoxicity tests on sibling LCL targets. In one pattern, targets bearing the A11, B5, DR7 haplotype were lysed, while those bearing the A1, B8, DR3 were not, indicating haplotype preference. In the other pattern, there was lysis of the autologous cell line but not of the sibling targets. These results including HLA-DR-associated restriction, haplotype preference and strict self-preference, further illustrate the complexity of the EBV-cytotoxic T-cell response.

A comparison of Epstein-Barr virus-specific T-cell immunity in malaria-endemic and -nonendemic regions of Papua New Guinea

Epstein-Barr virus genome-positive Burkitt's lymphoma is endemic in Africa and Papua New Guinea and in both countries the tumour is restricted to regions with holoendemic malaria. The present work has compared groups of healthy indigenous individuals living in malarious and non-malarious regions of Papua New Guinea for Epstein-Barr virus-specific T-cell-mediated immunity using the in vitro regression assay. Residents of the malarious region (55 tested), when compared with either residents of the non-malarious area (35 tested) or Caucasian controls (27 tested) showed a significant (p less than 0.0001) impairment of virus-specific T-cell immunity but no obvious disturbance (p greater than 0.05) of anti-viral antibody titres. These results may be important in explaining the postulated role of malarial infection as a co-factor in the pathogenesis of Burkitt's lymphoma.

Evidence for the involvement of HLA-DR antigens in restricted cytotoxicity by fetal calf serum-specific human T cells

Fetal calf serum (FCS) generated at least two distinct populations of human cytotoxic cells in vitro. One population expressed natural killer (NK) cell-like activity and lysed K562 and HSB-2 targets more effectively than autologous or allogeneic lymphoblastoid cell lines (LCLs). The other population contained FCS-specific cytotoxic T cells which preferentially lysed the autologous LCLs and showed minimal lysis of K562. E-rosette separation and cold target competition experiments clearly established that NK cells were not involved in the self-reactive lysis. Moreover, the lytic activity of the E-rosetted T cells was reduced by up to 95% when autologous target cells were grown in human AB serum rather than FCS, showing that FCS-associated determinants on targets were essential in the cytolytic phase. Autologous LCLs grown in FCS were also considerably stronger competitors than human serum-grown LCLs. The consistent self-preferred lysis suggested that HLA antigen-related restriction was involved, but the patterns of lysis did not implicate HLA-A or B antigens, and monoclonal antibody (W6/32) to an A, B, and C monomorphic determinant failed to block FCS-specific lysis. In contrast, monoclonal antibody (DA.2) to a monomorphic determinant of DR effectively blocked FCS-specific lysis. Cytotoxicity tests with a small panel of DR-typed donors indicated that strong cross-reactions were invariably associated with sharing of DR antigens, particularly DR2, and to a lesser but significant extent DR7. Although DR antigen sharing did not always result in lysis of allogeneic targets, the overall evidence strongly suggests that FCS-specific T-cell cytotoxicity in humans is restricted by products encoded by or associated with the DR genes.

Generation in vitro of EBV-induced specific cytotoxic T cells in autologous serum avoids complications due to self-preferred foetal calf serum-specific T-cell cytotoxicity

A previous report has established that in cultures of human mononuclear leukocytes, foetal calf serum (FCS) is capable of generating high levels of T cells preferentially cytotoxic for the autologous lymphoblastoid cell line (LCL). The present study compared the capacity of Epstein-Barr virus (EBV) to generate cytotoxic T cells in cultures of mononuclear cells grown in FCS in this system. Five EBV-seropositive and three seronegative donors were used and cultures were harvested at 14 days. With cultures from seropositive donors, whether grown in FCS or in autologous serum, EBV infection generated T cells cytotoxic for the autologous LCL; the response in uninfected control cultures was markedly lower. With seronegative donor cultures grown in FCS, there was virtually no difference in the capacity of T cells generated in infected or uninfected cultures to lyse the autologous LCL. Moreover, cells from seronegative donors cultured in human serum gave no detectable lysis of autologous LCL in either infected or uninfected cultures, clearly showing the absence of a response to EBV. This evidence shows that it is possible to distinguish the generation of specific cytotoxic T cells by FCS from generation by EBV, and with certain donors the apparently EBV-induced response may actually include a significant component induced by FCS in the medium. The cytotoxicity patterns of EBV-induced and FCS-induced T cells for autologous and allogeneic LCL targets showed a degree of parallelism, stressing the need for caution in interpretation of data obtained from cultures using FCS.

HLA antigen-related restriction of T lymphocyte cytotoxicity to Epstein-Barr virus

The specificity of cytotoxic T cells generated in Epstein-Barr virus (EBV)-infected lymphocyte cultures was investigated, using a 51Cr release assay. Potent cytotoxic T cells with preferred specificity directed to antigens expressed on autologous lymphoblastoid cell line (LCL) target cells were present in 14-day cultures of lymphocytes from EBV-seropositive donors and not from seronegative donors. Moreover, the cytotoxic patterns obtained with a panel of HLA antigen-related and unrelated LCL target cells, supported by unlabeled target inhibition tests, strongly indicate that T cell cytotoxicity to EBV is restricted to HLA antigens.

Long-term T-cell-mediated immunity to Epstein-Barr virus in man. IV. Development of T-cell memory in convalescent infectious mononucleosis patients

Under appropriate culture conditions, EB virus infection of lymphocytes from seropositive donors leads to regression of transformation, and this was shown previously to be due to activation in a secondary immune response to T lymphocytes inhibitory for the autologous lymphoblastoid cell line. Regression can be quantified by determining the number of cells required for its expression. To investigate the development of memory T cells with EB-virus specificity in the primary infection, a comparison was made of the capacity for regression of lymphocytes from 16 cases of infectious mononucleosis (IM) and 13 normal donors. With 9 normal seropositive donors a mean lymphocyte concentration of 4.6 X 10(5)/ml was required to achieve 50% regression. In contrast, with 8 cases of IM tested within 1 week of onset, a much higher mean lymphocyte concentration (3.7 X 10(6)/ml) was necessary. Six of these IM cases, and another not tested in the first week, were tested on several occasions between 5 and 23 weeks after onset, and showed a slight reduction in the mean cell concentration required for regression (1.5 X 10(6)/ml). Six additional were tested 23--83 weeks after onset by which time the cell concentration required for 50% regression (mean = 4.5 X 10(5)/ml) had reached the level shown by normal seropositive donors. Regression did not occur with lymphocytes from seronegative donors, even at the highest cell concentration. Recombination cultures of T-cell-depleted and T-cell-enriched lymphocyte populations from 3 IM cases in ratios of 1:7 to 7:1 showed that the failure of regression in acute IM was not due simply to lack of sufficient numbers of T cells. The results indicate that EB-virus-specific memory T-cell activity as detected by the regression test is absent in the acute phase of IM, becomes evident at low levels 5--23 weeks after onset, and reaches a maximum after about 6 months.

Long-term C-cell-mediated immunity to Epstein-Barr virus in man. II. Components necessary for regression in virus-infected leukocyte cultures

Regression of EB-virus-induced transformation occurs exclusively in cultures of leukocytes from seropositive donors. Studies have shown that the strength of regression could be assayed in terms of the proportion of T cells which must be added to the autologous EB virus-infected T-cell-depleted population in order to establish regression in the culture. The in vitro regression phenomenon was strongly T-cell-dependent but did not require the presence of either monocytes or, as a potential antigenic stimulus, the residual viral envelope material on the surface of virus-infected B cells. The T-cell-depleted population from seropositive donors sometimes transformed (7/60 cultures) without the experimental addition of virus. Regression appeared to be independent of cytotoxic mechanisms involving anti-viral antibodies and not to be mediated by soluble factors released into culture medium.

Long-term T-cell-mediated immunity to Epstein-Barr virus in man. III. Activation of cytotoxic T cells in virus-infected leukocyte cultures

Experiments have been conducted to determine the role played by immune T cells in the regression of EB-virus-induced transformation which is exclusively seen in leukocyte cultures from sero-positive donors. Kinetic studies suggest that, in virus-infected cultures from such donors, a population of T cells proliferates within the first 2 weeks apparently in response to the appearance of virus-infected B cells. This proliferation continues to some extent during the period of regression. Nonspecific induction of T-cell proliferation by PHA did not induce regression in virus-infected cultures from seronegative donors and acutally prevented the regression in seropositive donor cultures. T cells harvested from seropositive donor cultures 11-14 days post infection were generally much more inhibitory to the growth of the autologous EB-virus-transformed cell line than were T cells either freshly prepared from whole blood or harvested from corresponding uninfected cultures; this inhibitory activity was either absent or much diminished when assayed against allogeneic target cell lines. The results suggest that virus-specific memory T cells capable of mounting a cytotoxic response when properly challenged in vitro.

Human malignant melanoma cell lines

A series of 10 cell lines established from human malignant melanomas is described. The morphology varied but, in general, was epithelioid. Five produced visible melanin in culture but others produced melanin precursors. All lines were aneuploid and each had a distinctive human karyotype. One line appeared not to have the same sex as the patient but its karyotype was distinct from that of other lines.

Search for human tumour viruses by transfection: uptake of melanoma and Epstein-Barr virus DNA by human cells

In a model system, consistent transfection of chick embryo fibroblasts (CEF) by DNA from the XC cell line occurred, with recovery of infectious Rous sarcoma virus. The techniques were then applied in attempts to recover possible human tumour viruses. Even with various modifications of the XC technique, DNA from three human malignant melanoma cell lines failed to infect adult or foetal human fibroblasts, although melanoma DNA was taken up into nuclei of target cells. XC DNA did not transfect human foetal fibroblasts and melanoma DNA was ineffective in CEF. DNA from the Raji (Epstein-Barr virus non-producer) and QIMR-WIL (producer) lymphoblastoid cell lines did not transfect human cord blood lymphocytes or amnion cells. These broadly applicable techniques therefore failed to recover EB virus, the putative melanoma retrovirus, or other potential tumour virus.

Long-term T-cell-mediated immunity to Epstein-Barr virus in man. I. Complete regression of virus-induced transformation in cultures of seropositive donor leukocytes

Peripheral blood mononuclear cells from donors of known serological status with respect to EB virus were exposed to the virus in vitro and then cultured at various cell concentrations. All cultures from nine seronegative adult and 12 foetal donors gave rise to cell lines following subculture 4 weeks post infection. In contrast, seropositive donor cultures seeded at the higher cell concentrations developed foci of proliferating EBNA-positive cells within the first 1--2 weeks but thereafter regressed completely and subcultures made after 4 weeks never gave rise to cell lines. Out of 18 seropositive donors tested, 15 showed regression in all cultures seeded at 10(6) cells/ml and above, and with the other three donors a proportion of replicate cultures regressed. T-cell depletion and reconstitution experiments showed that the effect was absolutely dependent upon the presence in the cultures of T cells from these seropositive donors. The results strongly suggest that the regression phenomenon is an in vitro expression of long-term T-cell-mediated immunity to EB virus which the large majority, if not all, infected individuals possess.