Predicting the need of aortic valve surgery in patients with chronic aortic regurgitation: a comparison between cardiovascular magnetic resonance imaging and transthoracic echocardiography

To compare the ability of cardiac magnetic resonance tomography (CMR) and transthoracic echocardiography (TTE) to predict the need for valve surgery in patients with chronic aortic regurgitation on a mid-term basis. 66 individuals underwent assessment of aortic regurgitation (AR) both in CMR and TTE between August 2012 and April 2017. The follow-up rate was 76% with a median of 5.1 years. Cox proportional hazards method was used to assess the association of the time-to-aortic-valve-surgery, including valve replacement and reconstruction, and imaging parameters. A direct comparison of most predictive CMR and echocardiographic parameters was performed by using nested-factor-models. Sixteen patients (32%) were treated with aortic valve surgery during follow-up. Aortic valve insufficiency parameters, both of echocardiography and CMR, showed good discriminative and predictive power regarding the need of valve surgery. Within all examined parameters AR gradation derived by CMR correlated best with outcome [χ² = 27.1; HR 12.2 (95% CI: 4.56, 36.8); (p < 0.0001)]. In direct comparison of both modalities, CMR assessment provided additive prognostic power beyond echocardiographic assessment of AR but not vice versa (improvement of χ² from 21.4 to 28.4; p = 0.008). Nested model analysis demonstrated an overall better correlation with outcome by using both modalities compared with using echo alone with the best improvement in the moderate to severe AR range with an echo grade II out of III and a regurgitation fraction of 32% in CMR. This study corroborates the capability of CMR in direct quantification of AR and its role for guiding further treatment decisions particularly in patients with moderate AR in echocardiography.

Hepatitis E virus seroprevalence, seroincidence and seroreversion in the German adult population

A steep rise in Hepatitis E diagnoses is currently being observed in Germany and other European countries. The objective of this study was (i) to assess whether this trend mirrors an increase in infection pressure or is caused by increased attention and testing and (ii) estimate individual and population-based Hepatitis E Virus (HEV) seroconversion and seroreversion rates for Germany. We measured anti-HEV IgG prevalence in 10 407 adults participating in two linked, population-representative serosurveys (total n = 12 971) conducted in 1998 and 2010. In this period, we found a moderate but statistically significant decline of overall anti-HEV IgG prevalence from 18.6% to 15.3%. At both time points, seroprevalence increased with age and peaked in persons born between 1935 and 1959 suggesting a past period of increased infection pressure. Paired samples of individuals participating in 1998 and 2010 (n = 2564) revealed respective seroconversion and seroreversion rates of 6.2% and 22.6% among seronegative and seropositive individuals during 12 years, or 5.2 and 2.9 per 1000 inhabitants per year. This corresponds to a total of 417 242 [95%CI: 344 363-495 971] new seroconversions per year in the German population. While anti-HEV seroprevalence has decreased in the last decade, infection pressure and seroincidence remains high in Germany. Continuously rising numbers of Hepatitis E diagnoses in Europe are likely due to an increased awareness of clinicians and indicate that still there is a gap between incident and diagnosed cases. Studies on the true burden of the disease, specific risk factors and sources of autochthonous infections as well as targeted prevention measures are urgently needed.

Steep rise in norovirus cases and emergence of a new recombinant strain GII.P16-GII.2, Germany, winter 2016

Since early November 2016, the number of laboratory-confirmed norovirus infections reported in Germany has been increasing steeply. Here, we report the detection and genetic characterisation of an emerging norovirus recombinant, GII.P16-GII.2. This strain was frequently identified as the cause of sporadic cases as well as outbreaks in nine federal states of Germany. Our findings suggest that the emergence of GII.P16-GII.2 contributed to rising case numbers of norovirus gastroenteritis in Germany.

Flow-assisted basophil activation tests in immediate drug hypersensitivity: two decades of Antwerp experience

The last two decades have witnessed that flow-assisted analysis of in vitro-activated basophils can constitute a valuable adjunct in the in vitro diagnostic approach of immediate drug hypersensitivity reactions (IDHR). This article summarises the current experience with the basophil activation test in the diagnosis of IDHR, with particular focus on allergy to curarising neuromuscular blocking agents, antibiotics (β-lactams and fluoroquinolones), iodinated radiocontrast media and opiates.

Hepatitis E virus antibody prevalence in hunters from a district in Central Germany, 2013: a cross-sectional study providing evidence for the benefit of protective gloves during disembowelling of wild boars

Background

In Germany, 17 % of the general human population have antibodies to hepatitis E virus (HEV) (recomLine HEV-IgG/IgM immunoassay [Mikrogen GmbH]). Wild boars represent an animal reservoir for HEV genotype 3, which is the common genotype in Germany. We estimated the seroprevalence among hunters with contact to wild boars to identify factors that may be associated with past or present HEV infection.

Methods

In 2013, the local veterinarian authority in a district in Central Germany attended meetings of hunters who provided blood specimens and completed a questionnaire collecting information on age, sex, hunting-related activities and consumption of wild boar meat. Specimens of wild boars were taken during drive hunts in this district during the season 2012/2013. All specimens were tested for HEV RNA and anti-HEV IgM and IgG antibodies. Log-binomial regression was used to estimate prevalence ratios (PR) for the hunters.

Results

Of 126 hunters (median age 55; 94 % male) 21 % tested positive for anti-HEV IgG antibodies (95 % confidence interval [CI] 13–28 %) (recomWell HEV IgG assay [Mikrogen GmbH]). Anti-HEV prevalence was highest in the age group of the 70–79-year-olds (67 %; 95 % CI 39–95 %). Wild boars showed an average anti-HEV prevalence of 41 %. HEV RNA was detected in 4/22 (18 %) liver specimens and in 1/22 (4.5 %) muscle specimens. Most wild boars were tested positive for HEV RNA (3/10; 30 %) and HEV-specific antibodies (7/15; 47 %) in the southwestern part of the district. Hunters preferring this hunting ground had a lower anti-HEV prevalence when gloves were frequently used during disembowelling of wild boars compared to hunters using gloves never or infrequently (age-adjusted PR 0.12; 95 % CI 0.02–0.86).

Conclusions

Hunters may benefit from wearing gloves when in contact with blood or body fluids of HEV animal reservoirs. Anti-HEV prevalence among the hunters of this study did not significantly differ from that of the general population suggesting that other factors play a major role in the epidemiology of HEV in Germany.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1199-y) contains supplementary material, which is available to authorized users.

Large and prolonged food-borne multistate hepatitis A outbreak in Europe associated with consumption of frozen berries, 2013 to 2014

In May 2013, Italy declared a national outbreak of hepatitis A, which also affected several foreign tourists who had recently visited the country. Molecular investigations identified some cases as infected with an identical strain of hepatitis A virus subgenotype IA. After additional European Union/European Economic Area (EU/EEA) countries reported locally acquired and travel-related cases associated with the same outbreak, an international outbreak investigation team was convened, a European outbreak case definition was issued and harmonisation of the national epidemiological and microbiological investigations was encouraged. From January 2013 to August 2014, 1,589 hepatitis A cases were reported associated with the multistate outbreak; 1,102 (70%) of the cases were hospitalised for a median time of six days; two related deaths were reported. Epidemiological and microbiological investigations implicated mixed frozen berries as the vehicle of infection of the outbreak. In order to control the spread of the outbreak, suspected or contaminated food batches were recalled, the public was recommended to heat-treat berries, and post-exposure prophylaxis of contacts was performed. The outbreak highlighted how large food-borne hepatitis A outbreaks may affect the increasingly susceptible EU/EEA general population and how, with the growing international food trade, frozen berries are a potential high-risk food.

Molecular allergy diagnosis: status anno 2015

IgE antibodies play a key role in type I allergic reactions. Today, different in vitro immunoassays for allergen-specific IgE antibodies are available. However, some major issues should be taken into account for correct interpretation of specific IgE (sIgE) antibody results, as these assays do not demonstrate absolute positive and negative predictive values. Therefore, additional diagnostic tests are needed to make the correct diagnosis. During the last two decades significant progress in biochemistry and molecular biology enabled the detection and quantification of sIgE antibodies to allergen protein components and epitope-emulating peptides, also called molecular allergy diagnosis or component resolved diagnosis (CRD). In contrast to conventional sIgE antibody assays, molecular allergy diagnosis makes it possible to discriminate between genuine allergy and merely sensitisation, to establish personalized sensitization patterns and to assess the individual risk of severity of an allergic reaction and finally it helps us to predict the natural course. In this review the use of CRD in inhalant, food, latex and hymenoptera venom allergy will be discussed. The primary focus will be on the most relevant clinical applications of CRD rather than to describe all the currently available allergen components and epitopes. Appropriate experience of our own research group is provided.

QCD and strongly coupled gauge theories: challenges and perspectives

We highlight the progress, current status, and open challenges of QCD-driven physics, in theory and in experiment. We discuss how the strong interaction is intimately connected to a broad sweep of physical problems, in settings ranging from astrophysics and cosmology to strongly coupled, complex systems in particle and condensed-matter physics, as well as to searches for physics beyond the Standard Model. We also discuss how success in describing the strong interaction impacts other fields, and, in turn, how such subjects can impact studies of the strong interaction. In the course of the work we offer a perspective on the many research streams which flow into and out of QCD, as well as a vision for future developments.

Large multistate outbreak of norovirus gastroenteritis associated with frozen strawberries, Germany, 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

[Epidemiology of hepatitis A, B, and C among adults in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1)]

Ten years after seroepidemiological data were obtained in the German National Health Interview and Examination Survey 1998 (GNHIES98), German Health Interview and Examination Survey (DEGS1) data contribute to a population-based, representative surveillance of hepatitis A and B immunity and of the serological markers for hepatitis C in Germany. The prevalence of antibodies against the hepatitis A virus is 48.6 %. In comparison to the situation 10 years ago, seroprevalence is significantly higher among 18- to 39-year-old adults and is significantly lower in those aged 50-79 years. The association between age and seroprevalence has changed, indicating a decrease in naturally acquired hepatitis A immunity. Individual and population immunity has to be achieved through vaccination. Prevalence of hepatitis B antibodies indicates that 5.1 % of adults have been exposed to the virus, significantly fewer than 10 years ago (7.9 %). Prevalence of hepatitis B surface antibodies indicates that 22.9 % of adults have been vaccinated against hepatitis B. Vaccination coverage has increased in all age groups and is highest in the younger age groups. These positive trends can be attributed to the general recommendation since 1995 to vaccinate against hepatitis B. For hepatitis C, the prevalence of antibodies in the general population is 0.3 %. Germany thus remains a low-HCV-endemic country. An English full-text version of this article is available at SpringerLink as supplemental.

Component-resolved diagnosis of wasp (yellow jacket) venom allergy

BACKGROUND

Wasp venom allergy is a potentially life-threatening condition with serious consequences of diagnostic error.

OBJECTIVE

To assess whether component-resolved diagnosis, using non-glycosylated recombinant allergen components from yellow jacket can add to the diagnosis of wasp venom allergy.

METHODS

In total, 148 patients with a wasp (yellow jacket) allergy were included, 91 with unequivocal tests, 26 with double positivity of serum-specific IgE (sIgE) to both venoms, 21 with discrepant sIgE and skin test results and finally 10 having their diagnosis only confirmed by basophil activation test (negative sIgE and skin test results). Specific IgE to recombinant species-specific allergen components Ves v 1 and Ves v 5 from yellow jacket, Api m 1 from honeybee and Ves v 5 complemented wasp venom were tested by ImmunoCAP.

RESULTS

Overall, combined use of sIgE to rVes v 1 and rVes v 5 allowed correct diagnosis in 139 of the 148 patients (94%) and rApi m 1 was demonstrable in only one patient. Supplementing the traditional yellow jacket allergosorbent with rVes v 5 allowed to correctly diagnose wasp allergy in patients sensitized to Ves v 5 but demonstrating a negative sIgE to wasp venom.

CONCLUSION

Component-resolved diagnoses with the wasp-specific recombinant allergen components Ves v 1 and Ves v 5 is a reliable method to diagnose yellow jacket allergy and can help to take out the sting of difficult cases. However, as the number of patients with doubt after conventional tests is small, larger collaborative studies are needed to draw more definitive conclusions. Whether the rVes v 5 supplemented yellow jacket allergosorbent constitutes an asset in the diagnostic management of wasp venom allergy remains to be further established.

Sensitization to the mammalian oligosaccharide galactose-alpha-1,3-galactose (alpha-gal): experience in a Flemish case series

BACKGROUND

Recent observations have disclosed that the galactose-alpha (1,3)-galactose (alpha-gal) moiety of non-primate glycoproteins can constitute a target for meat allergy.

OBJECTIVE

To describe adults with allergic reactions to mammalian meat, dairy products and gelatin. To investigate whether patients could demonstrate sensitization to activated recombinant human coagulation factor VII ectapog alpha that is produced in baby hamster kidney cells.

METHODS

Ten adults with mammalian meat, dairy products and gelatin allergies were examined using quantification of specific IgE and/or skin prick test for red meat, milk, milk components, gelatin, cetuximab and eptacog alpha.

RESULTS

Most patients demonstrate quite typical clinical histories and serological profiles, with anti-alpha-gal titers varying from less than 1% to over 25% of total serum IgE. All patients demonstrate negative sIgE for gelatin, except the patient with a genuine gelatin allergy. All patients also demonstrated a negative sIgE to recombinant milk components casein, lactalbumin and lactoglobulin. Specific IgE to eptacog was positive in 5 out of the 9 patients sensitized to alpha-gal and none of the 10 control individuals.

CONCLUSION

This series confirms the importance of the alpha-gal carbohydrate moiety as a potential target for allergy to mammalian meat, dairy products and gelatin (oral, topical or parenteral) in a Flemish population of meat allergic adults. It also confirms in vitro tests to mammalian meat generally to be more reliable than mammalian meat skin tests, but that diagnosis can benefit from skin testing with cetuximab. Specific IgE to gelatin is far too insensitive to diagnose alphaa-gal related gelatin allergy. IgE binding studies indicate a potential risk of alpha-gal-containing human recombinant proteins produced in mammalians.

Increase in hepatitis A in tourists from Denmark, England, Germany, the Netherlands, Norway and Sweden returning from Egypt, November 2012 to March 2013

Since November 2012, there has been an increase in reported cases of hepatitis A in tourists returning from Egypt in several European countries. As of 24 April, 80 HAV cases in travellers with symptom onset after 1 November 2012 visiting different areas in Egypt have been reported. Four cases from Norway, six cases from the Netherlands and five cases from England share an identical hepatitis A viral RNA sequence. This increase in cases suggests that vaccination recommendations for travellers to hepatitis A endemic countries should be reinforced.

Puumala virus outbreak in Western Thuringia, Germany, 2010: epidemiology and strain identification

In 2010, the highest annual number of human Puumala virus (PUUV) infections was reported in Germany since hantavirus surveillance started in 2001. The increase in annual case numbers was especially marked in western Thuringia. We combined results of case-based hantavirus surveillance in humans and serological and molecular investigations in the rodent reservoir to describe the epidemiological situation and to identify the putative outbreak strain. A 5-fold increase in notified hantavirus cases compared to the previous annual maximum was observed in western Thuringia in 2010. Disease incidence varied tremendously within a small geographical area with case patients' places of residence clustering around beech-dominated broad leaf forest patches. Investigations in the rodent reservoir revealed a novel Puumala virus (PUUV) subtype, which is clearly distinct from strains collected in other PUUV endemic regions of Germany. It can be assumed that in regions in western Thuringia where hantavirus cases occurred in 2010 or previous outbreak years, PUUV has been present in the environment for a long time. Further studies are needed to elucidate the population dynamics and hantavirus prevalence of the rodent reservoir and driving ecological factors.

IgE-mediated allergy to pholcodine and cross-reactivity to neuromuscular blocking agents: Lessons from flow cytometry

BACKGROUND

Immunoglubulin E antibody-mediated allergic reactions to opioids are rare and difficult to document correctly.

OBJECTIVE

Assessment of the basophil activation test in the diagnosis of IgE-mediated allergy to the antitussive pholcodine and associated sensitizations to neuromuscular blocking agents (NMBA).

METHODS

Three patients with a suspected IgE-mediated allergy to pholcodine were investigated using skin tests, quantification of specific IgE, and flow cytometric activation of basophils.

RESULTS AND CONCLUSION

Flow cytometric activation of basophils, with simultaneous analysis of CD63 appearance and median histamine content per cell, is the only technique capable to correctly document pholcodine allergy. The negative predictive value of basophil activation tests might help to elucidate on the controversial putative cross-reactivity between pholcodine and NMBA.

Nutritional content and a phase-I safety clinical trial of a herbal-nutritional supplement (IMUNITI) with putative immune-modulating properties

The relationship between HIV and AIDS and poor nutrition has been well established. Poor nutrition hastens the progression of HIV infection to AIDS. The rising pandemic of HIV and AIDS and high toxicity associated with anti-retroviral use are major factors that have compelled research to explore traditional herbal medicines as potential alternatives or supplements to anti-retroviral agents. A Phase I clinical trial was conducted on IMUNITI Wellness Pack, a herbal product with putative immune-modulating properties. The product is a combination of 7 herbal preparations, minerals, vitamins, and a specially formulated soya-maize meal porridge and a bottle of water purifier. The aim was to evaluate the safety and tolerability of IMUNITI, with a purpose of developing it for use in HIV-infected patients. The phase I study was conducted at the MRC clinic in Botha's hill and the study lasted 5 weeks from date of participant dosing. The study was a randomised blinded placebo-controlled phase I clinical trial conducted on 48 healthy males. The participants were randomly divided into 4 groups of 12. The 3 groups received different escalating doses of IMUNITI while the forth group received placebo tablets. Participants consumed IMUNITI daily for a period of 5 weeks. Assessments were done at baseline, week 1 and week 5 to determine the safety parameters in all participants. In this study, IMUNITI did not show any safety concerns. In all study participants, there were no significant changes above the upper limit of the reference ranges of the laboratory tests for full blood count, INR, renal and biochemical safety parameters. IMUNITI was well tolerated. Furthermore, the nutritional content analysis of IMUNITI showed that it is a high kilojoule, high protein content product which contains a mixture of sugars, vitamins, traces of calcium, phosphorus and minerals.

Allergy to chlorhexidine: beware of the central venous catheter

The example reported here illustrates the frequent belief that "innocent" products such as central venous catheters do not produce allergic reactions. However, they might be impregnated with chlorhexidine and elicit serious life-threatening anaphylaxis in patients with allergy to this antiseptic agent.

A national cross-sectional study on socio-behavioural factors that influence physicians' decisions to begin antimicrobial therapy

PURPOSE

Current efforts to prevent antimicrobial resistance include limiting antimicrobial use, providing education about appropriate use, and developing better point-of-care tests, but what do physicians actually think of rational prescribing and potential interventions? We tried to ascertain which factors can influence a physician's decision to start antimicrobial therapy on a patient, and their opinions on measures to promote rational prescribing.

METHODS

We conducted a nationwide, cross-sectional survey of 10,600 physicians from medical registries of all known board-certified physicians in Germany.

RESULTS

Among respondents (n = 3,492; 33%; detailed non-response bias analysis included), 90% indicated that they decide to start antimicrobial therapy on a patient at least weekly, and 66% reported that they decide daily. We identified correlates for deciding to start antimicrobial therapy on a patient. Predictors were status as a hospital physician (odds ratio (OR) 1.29 (95% confidence interval (CI) 1.00-1.68)), male physician (OR 1.81 (95% CI 1.42-2.31)), being age 50-59 (OR 1.56 (95% CI 1.10-2.21)), and practising in states in the former East Germany (OR 1.60 (95% CI 1.15-2.21)). Each specialist was significantly less likely to decide to start a course of antimicrobial therapy than ENTs and urologists. Other predictors were agreeing to prescribe to be on the safe side (OR 1.34 (95% CI 1.03-1.76)), believing that the quality of prescribing practice improves after receiving continuing education from pharmaceutical companies (OR 1.43 (95% CI 1.11-1.84)), and having experience with failed therapy for resistant pathogens (OR 2.42 (95% CI 1.83-3.19)).

CONCLUSIONS

Physicians in our sample decide to start antimicrobial therapy on a patient, and they value intervention to support prudent use, for example continuing education, practice guidelines and implementation of surveillance measures. Socio-behavioural factors, regional variation, gender, and age merit further research to promote rational antimicrobial prescribing and explore related influencing factors.

Enhanced surveillance during a large outbreak of bloody diarrhoea and haemolytic uraemic syndrome caused by Shiga toxin/verotoxin-producing Escherichia coli in Germany, May to June 2011

Germany has a well established broad statutory surveillance system for infectious diseases. In the context of the current outbreak of bloody diarrhoea and haemolytic uraemic syndrome caused by Shiga toxin/ verotoxin-producing Escherichia coli in Germany it became clear that the provisions of the routine surveillance system were not sufficient for an adequate response. This article describes the timeline and concepts of the enhanced surveillance implemented during this public health emergency.

Immunogenicity and safety of recombinant rabies viruses used for oral vaccination of stray dogs and wildlife

Rabies is a zoonotic disease and stray dogs, wild carnivores and bats are the natural reservoirs of rabies. Oral immunization with live vaccines is the only practical approach to eradicate rabies in free ranging terrestrial animals. We have developed the double glycoprotein (G) rabies virus (RV) variant SPBNGAS-GAS that has great promise to be used as a live-attenuated vaccine. Oral immunization of rodents and several target animal species with this double G RV variant resulted in the induction of protective immunity, superior to that induced by a single RV G variant (SPBNGAS). The high oral efficacy of SPBNGAS-GAS is likely because of its increased ability to infect monocytes or immature dendritic cells (DCs), thereby inducing their conversion into mature DCs. Furthermore, infection of DCs with the double G variant resulted in a strong up-regulation of the expression of genes related to the NFjB signalling pathway including IFN-α and IFN-β, which might underlie the protection conferred by this live RV vaccine. A potential problem associated with the use of live RVs for oral vaccination could rest in the possibility of reversion to the pathogenic phenotype because of the high mutation rate characteristic for all RNA viruses. In this respect, the presence of a second non-pathogenic G gene decreases considerably the risk of reversion to the pathogenic phenotype because a nonpathogenic G is dominant over a pathogenic G in determining the pathogenicity of the double G RV variant. Because of its excellent efficacy and safety, the SPBNGAS-GAS vaccine may provide a distinct advantage over other live RV vaccine in its ability to vaccinate a broad range of mammalian species.

[Investigation of a family cluster of influenza A/H1N1 infections in Germany, 2009]

INTRODUCTION

On May 3, 2009, a first case of influenza A/H1N1 infection occurred in the federal state of Saxony-Anhalt, Germany. In order to stop the possible spread of the virus and to study the epidemiological and clinical characteristics of the infection, an investigation was launched by the local health authorities and the RKI.

METHODS

Standardised questionnaires were used to assess demographic and clinical data. Specimens were collected from case patients and close contacts and were analysed for influenza A/H1N1 using real-time PCR.

RESULTS

The index patient showed fever and coughing 3.5 days after returning from a holiday in Mexico. The local health authorities were informed on May 3, and measures were rapidly implemented. These measures included a trace-back of possible contact persons, isolation of the case and close contacts, prophylactic treatment with Oseltamivir. Virological investigations showed that the case shedded viral genome up until the last day of antiviral therapy. Viral genome was also detected in the spouse and the son of the patient. Both showed no symptoms under a prophylactic treatment with antiviral medication. No viral genome was detected in three other family members, and in six other contact persons outside of the family.

DISCUSSION

The spread of the virus was contained due to the fast response of the local health authorities. Two secondary cases occurred in the family. These cases remained asymptomatic, possibly due to antiviral prophylaxis. Epidemiological and virological results suggest that the influenza A/H1N1 virus has a longer incubation period and that viral shedding may probably be prolonged when compared with seasonal influenza.

Role of virus-induced neuropeptides in the brain in the pathogenesis of rabies

Rabies virus (RABV) infection is characterized by the rapid neuronal spread of RABV into the CNS before a protective immune response is raised. Therefore, a typical feature of RABV infection is the paucity of inflammatory reactions in the brain. Here we examined whether the induction of immunosuppressive neuropeptides, in particular CGRP, may contribute to the ability of RABV to evade immune responses. RABV infection of mice caused a strong induction of calcitonin gene-related peptide (CGRP) in neurons and fibres in the neocortex as well as in the dentate gyrus and CA1 region of the hippocampus although RABV did not infect neurons in which CGRP expression was upregulated. Neuropeptide Y (NPY) or vasoactive intestinal peptide (VIP) expressing neurons also were not infected by RABV. In contrast, somatostatin neurons were infected by RABV. There was evidence for an RABV-induced increase of VIP and somatostatin but not of NPY. To test how CGRP expression is related to TNFalpha-induced enhancement of CNS innate and adaptive immunity during RABV infection, we used recombinant RABVs that contained either an active (SPBN-TNFalpha(+)) or an inactive (SPBN-TNFalpha(-)) TNFalpha gene. As compared to SPBN-TNFalpha(-), infection with SPBN-TNFalpha(+) attenuated the induction of CGRP but simultaneously enhanced induction of the invariant chain of MHC II, microglial activation and T cell infiltration. In conclusion, distinct neuropeptidergic neurons in the brain are remarkably spared from RABV infection suggesting a pivotal role of neuropeptides during CNS virus infection. Given the inhibitory effect of CGRP on antigen presentation, we propose that the strong RABV-induced upregulation of CGRP in the brain may contribute to the mechanism by which RABV escapes immune detection. Targeting the expression of neuropeptides, in particular CGRP, that are induced during RABV infection may open a new avenue for therapeutic intervention in human rabies.

[Care for the elderly with frequent falls: the fall clinic in Zeeuws-Vlaanderen, the Netherlands]

A fall-clinic forms part of the fall-prevention program in Zeeuws-Vlaanderen. In this paper it is explained how elderly who are prone to falling are examined in the fall-clinic to find the underlying cause of their fall problem. The complete examination is termed the fall-risk analysis (FRA). In a six year period 121 elderly visited the fall-clinic. On average they were 78 +/- 8 years of age (mean +/- standarddeviation) and 76% was female. An insufficient muscle force of the hip flexors was the most prominent limitation that could be related to the increased fall risk. Based on the FRA on average 4.3 +/- 1.7 actions were proposed, where a referral to a specialist or physical therapist was most frequently proposed. The fall-clinic is integrated into existing structures of the Dutch health care services. Additional attention is given to case finding by means of district-nurses and family physicians. In this way a highly qualitative health care chain is being created for the falling elderly.

Effect of conformational aspects on the movement of the equine back

The relationship between structure and function is important in the judgement of the horse. Twenty sound riding horses walked and trotted on a treadmill. The movement of the backs of each of the horses was measured using a commercially available movement analysis system. Morphometric, spatiotemporal and kinematic information were correlated to investigate the effect of conformation on movement. Taller and heavier horses seem to have longer thoracic and lumbar backs, and are wider at the pelvis. Horses with longer strides extended and flexed their backs in the caudal saddle region to a greater extent at the walk, but not the trot. Horses with greater angle of L5 tend to extend and flex this region of the back more. At the walk and trot, a long thoracic back results in greater lumbar lateral bending. A negative relationship was found between the curvature of mid-thoracic back and the amount of lateral bending of L1 and L3 and axial rotation of the pelvis at the trot. There are clear relationships between back conformation and movement that may be important to the orthopaedic health of the horse. Further understanding of the relationships between conformation, movement and injury may provide an objective basis for the evaluation of future performance and soundness.

Repeatability of back kinematics in horses during treadmill locomotion

We tested the hypothesis that repeatability of a standardised protocol for quantifying back kinematics is sufficiently high not to prevent its use in the clinical evaluation of horses with back problems. We investigated the extent to which differences between laboratories may affect the results when a standardised protocol is used. As a clinical tool, movement analysis techniques are helpful for the objective and quantitative assessment of kinematics. Knowledge about the repeatability of the kinematic data is very important. The present study investigates the repeatability of back kinematics in 10 sound horses over 5 successive days and in 2 laboratories (5 horses at each location). Measurements were performed on the treadmill during the walk and the trot. The between-stride, between-day and between-horse repeatability were determined. A high degree of between-stride and between-day repeatability was observed in the spatiotemporal parameters and in the time-angle diagrams of thoracic and lumbar vertebrae, the sacrum and the hindlimb during both the walk and trot. Much more variability was found between horses, with the highest degree of dissimilarity in the lateral bending rotation of the L1 vertebra. For range of motion values, the between-day coefficient of variability was <14% and the between-horse coefficient of variability was up to 4 times higher. Small differences were found in range of motion values between the 2 laboratories. It is concluded that an analysis of back kinematics in the horse can provide highly repeatable data, warranting clinical use.

Silver-haired bat rabies virus variant does not induce apoptosis in the brain of experimentally infected mice

To examine whether induction of apoptosis plays a role in the pathogenesis of street rabies, we compared the distribution of viral antigens, histopathology, and the induction of apoptosis in the brain of mice infected with a street rabies virus (silver-haired bat rabies virus, SHBRV) and with a mouse-adapted laboratory rabies virus strain (challenge virus standard, CVS-24). Inflammation was identified in the meninges, but not in the parenchyma of the brain of mice infected with either CVS-24 or SHBRV. Necrosis was present in numerous cortical, hippocampal, and Purkinje neurons in CVS-24-infected mice, but only minimal necrosis was identified in mice infected with SHBRV. Likewise, extensive terminal deoxynucleotidyl transferase-mediated dUTP-digoxigenin nick end-labeling (TUNEL) staining was observed in the brain of mice infected with CVS-24 but little or none in the brain of mice infected with SHBRV. Rabies virus antigens were distributed similarly in the CNS infected with either virus. However, the expression of the glycoprotein (G) is more widespread and the staining of G is generally stronger in CVS- than SHBRV-infected mice, whereas the expression of rabies virus nucleoprotein (N) is similar in mice infected with either CVS or SHBRV. The positive TUNEL staining thus correlates with the high level of G expression in CVS-infected mouse brain. Northern blot hybridization revealed that the ratio between the N and G transcripts is similar in brains infected with either virus, indicating that the reduced expression of G protein is not caused by reduced transcription in SHBRV-infected animals. Taken together, these observations suggest that apoptosis is not an essential pathogenic mechanism for the outcome of a street rabies virus infection and that other pathologic processes may contribute to the profound neuronal dysfunction characteristic of street rabies.

Overexpression of cytochrome C by a recombinant rabies virus attenuates pathogenicity and enhances antiviral immunity

The pathogenicity of individual rabies virus strains appears to correlate inversely with the extent of apoptotic cell death they induce and with the expression of rabies virus glycoprotein, a major inducer of an antiviral immune response. To determine whether the induction of apoptosis by rabies virus contributes to a decreased pathogenicity by stimulating antiviral immunity, we have analyzed these parameters in tissue cultures and in mice infected with a recombinant rabies virus construct that expresses the proapoptotic protein cytochrome c. The extent of apoptosis was strongly increased in primary neuron cultures infected with the recombinant virus carrying the active cytochrome c gene [SPBN-Cyto c(+)], compared with cells infected with the recombinant virus containing the inactive cytochrome c gene [SPBN-Cyto c(-)]. Mortality in mice infected intranasally with SPBN-Cyto c(+) was substantially lower than in SPBN-Cyto c(-)-infected mice. Furthermore, virus-neutralizing antibody (VNA) titers were significantly higher in mice immunized with SPBN-Cyto c(+) at the same dose. The VNA titers induced by these recombinant viruses paralleled their protective activities against a lethal rabies virus challenge infection, with SPBN-Cyto c(+) revealing an effective dose 20 times lower than that of SPBN-Cyto c(-). The strong increase in immunogenicity, coupled with the marked reduction in pathogenicity, identifies the SPBN-Cyto c(+) construct as a candidate for a live rabies virus vaccine.