Fairness and Distributive Justice by 3- to 5-Year-Old Tibetan Children

We asked whether young children raised in an environment strongly promoting compassion for others, as in the case of Tibetan Buddhism, would show less proclivity toward self-maximizing in sharing. We replicated the procedure of Rochat et al. with a group of 3- and 5-year-old Tibetan children living in exile and attending a traditional Buddhist school where the Dalai Lama resides. We report that Tibetan children, like children of seven other cultures, start from a marked self-maximizing propensity at 3 years of age, becoming significantly more fair by 5 years. These data confirm that the developing sense of equity by young children is comparable in the context of a compassion-based culture.

A canarypox vector-expressing cytomegalovirus (CMV) phosphoprotein 65 induces long-lasting cytotoxic T cell responses in human CMV-seronegative subjects

The major matrix phosphoprotein 65 (pp65) of cytomegalovirus (CMV) is an important target of HLA-restricted cytotoxic T cells (CTL) after natural infection. A canarypox-CMV pp65 recombinant was studied for its ability to induce CMV pp65-specific CTL, helper T lymphocytes, and antibodies in a phase I clinical trial. Twenty-one CMV-seronegative adult volunteers were randomized to receive immunizations at months 0, 1, 3, and 6 with either canarypox-CMV pp65 or placebo. In canarypox-CMV pp65-immunized subjects, pp65-specific CTL were elicited after only 2 vaccinations and were present at months 12 and 26 in all subjects tested. Cell-depletion studies indicated that the CTL were phenotype CD8(+). Peripheral blood mononuclear cells proliferated in response to stimulation with purified pp65, and antibodies specific for pp65 also were detected. Canarypox-CMV pp65 is the first recombinant vaccine to elicit CMV-specific CTL responses, which suggests the potential usefulness of this approach in preventing disease caused by CMV.

Recombinant CD4-IgG2 in human immunodeficiency virus type 1-infected children: phase 1/2 study. The Pediatric AIDS Clinical Trials Group Protocol 351 Study Team

The use of recombinant CD4-IgG2 in pediatric human immunodeficiency virus type 1 (HIV-1) infection was evaluated by single and multidose intravenous infusions in 18 children in a phase 1/2 study. The study drug was well tolerated, and dose proportionality was observed in terms of area under time-concentration curve and peak serum concentration. Acute decreases of >0.7 log(10) copies/mL in serum HIV-1 RNA concentration were seen in 4 of the 6 children treated with 4 weekly 10 mg/kg doses. At 14 days after treatment, 3 children had sustained reductions in serum HIV-1 RNA; the other children had rebounded to baseline levels or above. By 28 days after therapy, the peak HIV-1 cellular infectious units was reduced in all 6 children, including the 2 who had experienced an earlier transient increase in values. Thus, recombinant CD4-IgG2 treatment of HIV-1-infected children appears to be well tolerated and capable of reducing HIV-1 burden.

The Ohio Substance Abuse Monitoring Network: constructing and operating a statewide epidemiologic intelligence system

Working with the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) and researchers at the University of Akron, Wright State University's Center for Interventions, Treatment, and Addictions Research developed the Ohio Substance Abuse Monitoring (OSAM) Network to provide a statewide summary of substance abuse trends. Ten key informants across the state collect qualitative and statistical data on substance abuse trends in their regions and prepare biannual reports. The OSAM network has a rapid response capability through which key informants can investigate special issues related to substance abuse identified by ODADAS and provide policymakers with timely, statewide reports. Within 12 months after operations began, the key informants produced reports on drug abuse trends and rapid response issues for the state. These reports prepared policymakers to respond more effectively to prevention and substance abuse treatment needs.

Lymphoproliferative responses to recombinant HIV-1 envelope antigens in neonates and infants receiving gp120 vaccines. AIDS Clinical Trial Group 230 Collaborators

Children of mothers infected with human immunodeficiency virus type 1 (HIV-1) were immunized at birth and at 1, 3, and 5 months with 1 of 3 doses of recombinant gp120 vaccines prepared from SF-2 or MN strains of HIV-1. A total of 126 children were not infected; 21 received adjuvant only. Vaccine recipients developed lymphoproliferative responses on >/=2 occasions, responding more often to homologous HIV-1 antigens than did adjuvant recipients (56% vs. 14%; P<.001). Responses were appreciated after 2 immunizations and were maintained for >84 weeks after the last immunization. An accelerated immunization schedule (birth, 2 weeks, 2 months, and 5 months) with the lowest dose of the SF-2 vaccine produced responses in all 11 vaccinees by 4 weeks. Responses to heterologous envelope antigens were also detected. Immune responses to vaccination are achievable at an age when some infection (perinatal or breast milk exposure related) may be prevented.

CoMFA-based prediction of agonist affinities at recombinant D1 vs D2 dopamine receptors

We have previously shown that using agonist affinity at recombinant receptors selectively expressed in clonal cells as the dependent variable in three-dimensional quantitative structure-activity relationship studies (3D-QSAR) presents a unique opportunity for accuracy and precision in measurement. Thus, a comparison of affinity's structural determinants for a set of compounds at two different recombinant dopamine receptors represents an attainable goal for 3D-QSAR. A molecular database of bound conformations of 16 structurally diverse agonists was established by alignment with a high-affinity template compound for the D1 receptor, 3-allyl-6-bromo-7,8-dihydroxy-1-phenyl-2,3,4, 5-tetrahydro-1H-benzazepin. A second molecular database of the bound conformations of the same compounds was established against a second template for the D2 receptor, bromocriptine. These aligned structures suggested three-point pharmacophore maps (one cationic nitrogen and two electronegative centers) for the two dopamine receptors, which differed primarily in the height of the nitrogen above the plane of the catechol ring and in the nature of the hydrogen-bonding region. The ln(1/KL) values for the low-affinity agonist binding conformation at recombinant D1 and D2 dopamine receptors stably expressed in C6 glioma cells were used as the target property for the CoMFA (comparative molecular field analysis) of the 16 aligned structures. The resulting CoMFA models yielded cross-validated R2 (q2) values (standard error of prediction) of 0. 879 (1.471, with five principal components) and 0.834 (1.652, with five principal components) for D1 and D2 affinity, respectively. The simple R2 values (standard error of the estimate) were 0.994 (0.323) and 0.999 (0.116), respectively, for D1 and D2 receptor. F values were 341 and 2465 for D1 and D2 models, respectively, with 5 and 10 df. The predictive utility of the CoMFA model was evaluated at both receptors using the dopamine agonists, apomorphine and 7-OH-DPAT. Predictions of KL were accurate at both receptors. Flexible 3D searches of several chemical databases (NCI, MDDR, CMC, ACD, and Maybridge) were done using basic pharmacophore models at each receptor to determine the similarity of hit lists between the two models. The D1 and D2 models yielded different lists of lead compounds. Several of the lead compounds closely resembled high-affinity training set compounds. Finally, homology modeling of agonist binding to the D2 receptor revealed some consistencies and inconsistencies with the CoMFA-derived D2 model and provided a possible rationale for features of the D2 CoMFA contour map. Together these results suggest that CoMFA-homology based models may provide useful insights concerning differential agonist-receptor interactions at related receptors. The results also suggest that comparisons of CoMFA models for two structurally related receptors may be a fruitful approach for differential QSAR.

Novel and selective 5-HT2C/2B receptor antagonists as potential anxiolytic agents: synthesis, quantitative structure-activity relationships, and molecular modeling of substituted 1-(3-pyridylcarbamoyl)indolines

The synthesis, biological activity, and molecular modeling of a novel series of substituted 1-(3-pyridylcarbamoyl)indolines are reported. These compounds are isosteres of the previously published indole urea 1 (SB-206553) and illustrate the use of aromatic disubstitution as a replacement for fused five-membered rings in the context of 5-HT2C/2B receptor antagonists. By targeting a region of space previously identified as sterically allowed at the 5-HT2C receptor but disallowed at the 5-HT2A receptor, we have identified a number of compounds which are the most potent and selective 5-HT2C/2B receptor antagonists yet reported. 46 (SB-221284) was selected on the basis of its overall biological profile for further evaluation as a novel, potential nonsedating anxiolytic agent. A CoMFA analysis of these compounds produced a model with good predictive value and in addition good qualitative agreement with both our 5-HT2C receptor model and our proposed binding mode for this class of ligands within that model.

The University of Massachusetts Medical Center office-based continuity experience: are we preparing pediatrics residents for primary care practice?

OBJECTIVE

Surveys of residency graduates and employers have suggested that residency programs do not prepare residents well for practice. Since 1988, pediatric residents at the University of Massachusetts have been paired one-on-one with an office-based pediatrician for their 3-year continuity experience. This survey was conducted to determine if graduates of such a program are prepared to enter pediatric practice.

METHODOLOGY

Graduates of the program from 1991 through 1995 who entered primary care practice were surveyed about their preparedness for practice. The questionnaire was also sent to the residents' first employers. The 32 questions were directed to overall sense of preparedness, ability to manage the pace of practice, common illnesses, common behavior problems, anticipatory guidance, office management, and subspecialty problems.

RESULTS

Data from all 25 residents who entered practice and the employers of 20 of the 25 residents were obtained and analyzed. Both groups rated overall resident preparedness to be "well-prepared" or "very well-prepared" and gave high scores on working at the pace of practice, diagnosing and treating common illnesses, diagnosing and treating common behavior problems, and providing anticipatory guidance. Areas in which residents were considered to be less well-prepared included anticipatory guidance about nutrition, managing problems by telephone, office management, gynecology, and orthopedics.

CONCLUSIONS

The results suggest that continuity experiences in office practices are associated with preparation for the pace and types of visits that occur commonly in primary care practice, abilities which previous surveys of residency alumni and employers have found lacking. Some areas may benefit from a formal curriculum which may be implemented in the office practice, at the medical center, or at both sites. Preceptors may benefit from faculty development and continuing medical education that is directed not only at teaching skills but also at content areas which were not addressed in their own residencies.

Ganciclovir treatment of symptomatic congenital cytomegalovirus infection: results of a phase II study. National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group

Congenital cytomegalovirus (CMV) infection occurs in approximately 1% of newborns in the United States. A phase II evaluation was done of ganciclovir for the treatment of symptomatic congenital CMV infection. Daily doses of 8 or 12 mg/kg were administered in divided doses at 12-h intervals for 6 weeks. Clinical and laboratory evaluations sought evidence of toxicity, quantitative virologic responses in urine, plasma drug concentrations, and clinical outcome. A total of 14 and 28 babies received 8 and 12 mg/kg/day, respectively. Five additional babies received ganciclovir on a compassionate plea basis. Significant laboratory abnormalities included thrombocytopenia (< or = 50,000/mm3) in 37 babies and absolute neutropenia (< or = 500 mm3) in 29 babies. Quantitative excretion of CMV in the urine decreased; however, after cessation of therapy, viruria returned to near pretreatment levels. Hearing improvement or stabilization occurred in 5 (16%) of 30 babies at 6 months or later, indicating efficacy.

Thrombolysis and Q wave versus non-Q wave first acute myocardial infarction: a GUSTO-I substudy. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries Investigators

OBJECTIVES

We assessed the outcomes of patients with a first myocardial infarction with ST segment elevation, with and without the development of abnormal Q waves after thrombolysis.

BACKGROUND

Prethrombolytic era studies report conflicting short-versus long-term mortality in the overall non-Q wave population, probably related to its heterogeneity.

METHODS

Patients with no electrocardiographic (ECG) confounding factors or evidence of previous infarction were included. Q wave infarction was defined as a Q wave duration > or = 30 ms in lead aVF; R wave > or = 40 ms in lead V1; any Q wave or R wave < or = 10 ms and < or = 0.1 mV in lead V2; or Q wave > or = 40 ms in at least two of the following leads: I, aVL, V4, V5 or V6. In-hospital clinical events and mortality at 30 days and 1 year were assessed.

RESULTS

No Q waves developed in 4,601 (21.3%) of the 21,570 patients. This group comprised more women and had a lower Killip class, lower weight and less anterior baseline ST elevation. The non-Q wave group had less in-hospital cardiogenic shock (2.1% vs. 3.3%, p < 0.0001), less heart failure (8.5% vs. 13.9%, p < 0.0001) and a trend toward less stroke (0.7% vs. 1.0%, p = 0.07) but an increased use of angioplasty (28% vs. 24%, p = 0.0001). The unadjusted mortality rate in the non-Q wave group was lower at 30 days (0.9% vs. 1.8%, p = 0.0001) and 1 year (2.7% vs. 4.2%, p = 0.0001), as was the adjusted 30-day mortality rate (4.8% vs. 5.3%, p < 0.0001).

CONCLUSIONS

Patients with no ECG confounding factors or evidence of previous infarction who do not develop Q waves after thrombolysis have a better 30-day and 1-year prognosis than patients with a Q wave infarction.

Educating pediatric residents in community settings

Pediatric training programs have recently witnessed a renewed emphasis on community-based experiences. This change can be attributed partly to the need for a more appropriate foundation for careers in general pediatrics and partly to a call for more generalist physicians as a result of health care reform. Community experiences provide optimal sites for residents to learn community-based primary care, practice management, collaboration with patient care teams, and advocacy on behalf of children's issues. The literature of the past year has focused on the theoretical issues, curricular components, and practical demands of implementing such experiences.

Drug-induced up-regulation of dopamine D2 receptors on cultured cells

Ligand-induced up-regulation of recombinant dopamine D2 receptors was assessed using C6 glioma cells stably expressing the short (415-amino-acid; D2s) and long (444-amino-acid; D2L) forms of the receptor. Overnight treatment of C6-D2L cells with N-propylnorapomorphine (NPA) caused a time- and concentration-dependent increase in the density of receptors, as assessed by the binding of radioligand to membranes prepared from the cells, with no change in the affinity of the receptors for the radioligand. The effect of 10 microM NPA was maximal after 10 h, at which time the density of D2L receptors was more than doubled. The agonists dopamine and quinpirole also increased the density of D2L receptors. The receptor up-regulation was not specific for agonists, because the antagonists epidepride, sulpiride, and domperidone caused smaller (30-60%) increases in receptor density. Prolonged treatment with 10 microM NPA desensitized D2L receptors, as evidenced by a reduced ability of dopamine to inhibit adenylyl cyclase, whereas treatment with sulpiride was associated with an enhanced responsiveness to dopamine. The magnitude of NPA-induced receptor up-regulation in each of four clonal lines of C6-D2L cells (mean increase, 80%) was greater than in all four lines of C6-D2S cells (33%). Inactivation of pertussis toxin-sensitive G proteins had no effect on the basal density of D2L receptors or on the NPA-induced receptor up-regulation. Treatment with 5 micrograms/ml of cycloheximide, on the other hand, decreased the basal density of receptors and attenuated, but did not prevent, the NPA-induced increase.(ABSTRACT TRUNCATED AT 250 WORDS)

Reinventing vital statistics. The impact of changes in information technology, welfare policy, and health care

Vital statistics offers a case study in the potential of new information technology and reengineering to achieve better public sector performance. New technology--notably the shift from a paper to an electronic process for recording vital events and transmitting the data to public agencies--is creating opportunities to produce more timely, accurate, and useful information. The furthest advanced innovation is the electronic birth certificate. At the same time, changes in welfare policy and health care--including efforts to establish paternity at the time of birth and to improve health care outcomes--are creating pressures for more policy-relevant data about vital events. In addition, the rise of integrated health plans and health information networks is radically altering the organizational context of vital statistics. On the basis of a State-by-State survey of vital statistics officials, the authors estimate that at the end of 1994, 58 percent of all births in the United States were being recorded on an electronic birth certificate and communicated to a public agency electronically. Nearly all respondents reported that the electronic birth certificate brought improvements in both timeliness and accuracy of data. Achieving the full promise of the new technology, however, will require more fundamental changes in institutions and policies and a reconceptualization of the birth certificate as part of a broader perinatal information system.

Induced hyporesponsiveness in rat Kupffer cells is not specific for lipopolysaccharide

The phenomenon of lipopolysaccharide (LPS)-induced hyporesponsiveness has been reported to occur in macrophage cell lines and primary cells. Hyporesponsiveness was evidenced by a diminution or lack of production of tumour necrosis factor-alpha (TNF-alpha) after sequential doses of LPS. In order to characterize the hyporesponsive state in Kupffer cells, the production of TNF-alpha was quantified after varying the concentration of a primary low dose of LPS prior to a challenge with a high, normally stimulatory dose of LPS. The kinetics of establishment of the hyporesponsive state and the effect of varying the bacterial serotype and genus of the challenge dose were determined. The specificity of the hyporesponsive state for LPS was examined. Our results demonstrate that complete hyporesponsiveness with no detectable production of TNF-alpha (< 30 pg/ml) was achieved after a primary dose > or = 10 ng/ml. Establishment of the hyporesponsive state took place within 6 hr. Induction of hyporesponsiveness was not dependent upon the serotype or genus of the challenge dose of LPS and was not specific for LPS. Complete hyporesponsiveness was induced after a primary dose (10 micrograms/ml) of the Gram-positive bacterium Corynebacterium parvum (Cp) and was evident upon challenge with 100 micrograms/ml Cp. The data indicate that the mechanisms by which LPS and Cp induce hyporesponsiveness are not identical in that a primary dose of LPS (10 ng/ml) induced only partial hyporesponsiveness upon challenge with Cp (100 micrograms/ml). These studies improve our understanding of Kupffer cell function.

ECG myocardial infarct size: a gender-, age-, race-insensitive 12-segment multiple regression model. I: Retrospective learning set of 100 pathoanatomic infarcts and 229 normal control subjects

In this early study of ongoing work with multiple regression modeling for mapping myocardial infarct (MI) into 12 left ventricular (LV) segments, promising results have been presented using electrocardiographic (ECG) QRS variables that are gender, age, and race insensitive (GARI), the GARI-QRS 12-segment multiple regression model. These include Q, R, and S duration, expressed as percentage total QRS duration, and R/Q duration, R/Q amplitude, R/S duration, and R/S amplitude variables. For version I, building 12 regression models using 68 single and 32 multiple MIs, the GARI-QRS variables correlated with pathoanatomic MI in each of 12 segments with r values ranging from .67 to .88. In version II of the model, using all MIs and 229 normal subjects, r = .73-.91. Version II predictions of MI in 12 LV segments for each subject were used to calculate the predicted total percentage LV infarct, which correlated well with that found at autopsy. The r values found were .81 for all single MIs, .73 for multiple MIs, and .80 for all MIs taken together. With refinements of the input ECG variables to include (1) improvement in the GARI-QRS variables, (2) adding a significant number of subjects with hypertrophies and conduction defects with and without MI to an expanded learning set, and (3) applying the enhanced 12-LV-segment regression models to a similar test set, it is to be expected that these regression models can be improved even further in such a way as to be applicable to general clinical populations using routine computerized ECG analysis programs.

Persistence of cell-mediated and humoral immune responses in healthy children immunized with live attenuated varicella vaccine

Two hundred fourteen healthy seronegative children immunized with various doses of Oka/Merck varicella vaccine were studied for persistence of varicella-zoster virus (VZV)-specific lymphocyte proliferation and antibodies to VZV as determined by a glycoprotein (gp) ELISA. Of the 140 vaccinees tested for VZV-specific lymphocyte proliferation, 94% had positive responses, with a mean stimulation index of 8.9 (range, 3.0-44.6). Of 214 tested by gpELISA, 95% were positive for up to 6 years after immunization; the geometric mean titer was 30.2 (range, 1.3-3510.0). Of 122 individuals tested both by ELISA and for VZV-specific lymphocyte proliferation, 91% had persistence of both responses. Persistence of cellular and humoral immune responses in a large percentage of vaccinees for up to 6 years after immunization with Oka/Merck varicella vaccine suggests that protection against severe varicella is likely to be similarly long-lasting.

The effect of decreasing amounts of live virus, while antigen content remains constant, on immunogenicity of Oka/Merck varicella vaccine

The purpose of the study was to establish the minimum immunizing dose of stored Oka/Merck varicella vaccine and mimic effects of prolonged storage of vaccine at freezer temperatures. Ninety children were randomized to one of three groups: group A (1770 pfu/dose), group B (400-500 pfu/dose), or group C (80-160 pfu/dose). Seroconversion rates for groups A-C were 97%, 96%, and 92%, respectively. Group A and B vaccinees had higher antibody titers at 1 year than did group C subjects (P = .01). The difference between groups B and C approached significance (P = .058). At 1 year after immunization, 73%, 83%, and 80% in groups A-C, respectively, demonstrated cell-mediated responses. Since freshly reconstituted vaccine contains 1770 pfu/dose, vaccine failure from loss of potency is unlikely if vaccine is stored properly and administered promptly after reconstitution.

Delayed type hypersensitivity to human cytomegalovirus

A skin test for immunity to human cytomegalovirus (HCMV) is described in which skin induration is measured after intradermal injection of antigen derived from heat-inactivated Towne strain HCMV or of envelope prepared from the virus. Randomly selected healthy young adult males and females were prescreened for evidence of past infection with HCMV using serologic tests. Each individual was inoculated with heat inactivated whole virion HCMV antigen prepared from serum-free supernatants of HCMV-infected MRC-5 cells, non-infected MRC-5 cell lysates, and Candida extract. HCMV seropositive individuals developed positive skin reactions to both the Candida extract and the HCMV test antigen. No response was observed at the MRC-5 cell lysate inoculation site. The envelope antigen also elicited a response in seropositive individuals. Seronegative individuals who were negative to the HCMV intradermal antigen at the start of the study developed a positive response 1 week after subcutaneous immunization with live attenuated Towne strain HCMV. This response also correlated with the onset of in vitro proliferation responses to HCMV antigens by peripheral blood lymphocytes obtained from the immunized individuals. Furthermore, skin test and lymphocyte proliferation responses remained positive when tested up to 93 days post-immunization. In guinea pig experiments with HCMV, those animals immunized with purified HCMV or a virus envelope preparation developed strong skin reactions to intradermal injection of each of those antigens. In contrast, no reaction was observed in immune animals, either to viral capsid antigen or uninfected cell-lysate antigen, and no reactions were observed to any HCMV antigen in non-immune animals.

Linear single-dose pharmacokinetics of ganciclovir in newborns with congenital cytomegalovirus infections. NIAID Collaborative Antiviral Study Group

The pharmacokinetic characteristics of ganciclovir were determined in neonates (age range, 2 to 49 days) after an 1-hour intravenous infusion of a single dose of either 4 mg/kg (n = 14) or 6 mg/kg (n = 13). Twenty-seven newborns with symptomatic cytomegalovirus inclusion disease were enrolled in this open phase I-II pharmacokinetics, safety, and tolerance trial of ganciclovir at one of two doses. Ganciclovir disposition was best described by a one-compartment open model with zero-order input and first-order elimination. The mean elimination half-life (t1/2) for both dose groups was 2.4 hours. The mean apparent volume of distribution (Vd) was 669 +/- 70 ml/kg for the 4 mg/kg group and 749 +/- 59 ml/kg for the 6 mg/kg group. The mean total body clearance (CL) for the 4 mg/kg and 6 mg/kg groups was 189 +/- 28 ml/hr/kg and 213 +/- 21 ml/hr/kg, respectively. No significant differences were observed in Vd or CL between the two groups. The Vd, expressed in milliliters, increased with increasing patient weight (r = 0.689; p = 0.0001). The CL, expressed in milliliters per hour per kilogram, increased with increasing age (r = 0.413; p = 0.032). No significant differences were observed between the two dose groups for the area under the curve normalized for dose (AUC/Dose) or the maximum plasma concentration normalized for dose (Cmax/Dose), indicating that ganciclovir exhibited linear pharmacokinetics in these neonates.

Predictors of morbidity and mortality in neonates with herpes simplex virus infections. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group

BACKGROUND

In a controlled trial comparing acyclovir with vidarabine in the treatment of neonatal herpes simplex virus (HSV) infection, we found no significant difference between the treatments in adjusted mortality and morbidity. Hence, we sought to define for the entire cohort (n = 202) the clinical characteristics that best predicted the eventual outcome in these neonates.

METHODS

Data were gathered prospectively at 27 centers between 1981 and 1988 in infants less than one month of age who had virologically confirmed HSV infection. We examined the outcomes by multivariate analyses of 24 variables. Disease was classified in one of three categories based on the extent of the involvement at entry into the trial: infection confined to skin, eyes, or mouth; encephalitis; or disseminated infection.

RESULTS AND CONCLUSIONS

There were no deaths among the 85 infants with localized HSV infection. The mortality rate was significantly higher in the 46 neonates with disseminated infection (57 percent) than in the 71 with encephalitis (15 percent). In addition, the risk of death was increased in neonates who were in or near coma at entry (relative risk, 5.2), had disseminated intravascular coagulopathy (relative risk, 3.8), or were premature (relative risk, 3.7). In babies with disseminated disease, HSV pneumonitis was also associated with greater mortality (relative risk, 3.6). In the survivors, morbidity was most frequent in infants with encephalitis (relative risk, 4.4), disseminated infection (relative risk, 2.1), seizures (relative risk, 3.0), or infection with HSV type 2 (relative risk, 4.9). With HSV infection limited to the skin, eyes, or mouth, the presence of three or more recurrences of vesicles was associated with an increased risk of neurologic impairment as compared with two or fewer recurrences.

A controlled trial comparing vidarabine with acyclovir in neonatal herpes simplex virus infection. Infectious Diseases Collaborative Antiviral Study Group

BACKGROUND

Despite the use of vidarabine, herpes simplex virus (HSV) infection in neonates continues to be a disease of high morbidity and mortality. We undertook a controlled trial comparing vidarabine with acyclovir for the treatment of neonatal HSV infection.

METHODS

Babies less than one month of age with virologically confirmed HSV infection were randomly and blindly assigned to receive either intravenous vidarabine (30 mg per kilogram of body weight per day; n = 95) or acyclovir (30 mg per kilogram per day; n = 107) for 10 days. Actuarial rates of mortality and morbidity among the survivors after one year were compared overall and according to the extent of the disease at entry into the study (infection confined to the skin, eyes, or mouth; encephalitis; or disseminated disease).

RESULTS

After adjustment for differences between groups in the extent of disease, there was no difference between vidarabine and acyclovir in either morbidity (P = 0.83) or mortality (P = 0.27). None of the 85 babies with disease confined to the skin, eyes, or mouth died. Of the 31 babies in this group who were treated with vidarabine and followed for a year, 88 percent (22 of 25) were judged to be developing normally after one year, as compared with 98 percent (45 of 46) of the 54 treated with acyclovir (95 percent confidence interval for the difference, -4 to 24). For the 71 babies with encephalitis, mortality was 14 percent with vidarabine (5 of 36) and with acyclovir (5 of 35); of the survivors, 43 percent (13 of 30) and 29 percent (8 of 28), respectively, were developing normally after one year (95 percent confidence interval for the difference, -11 to 39). For the 46 babies with disseminated disease, mortality was 50 percent (14 of 28) with vidarabine and 61 percent (11 of 18) with acyclovir (95 percent confidence interval for the difference, -20 to 40); of the survivors, 58 percent (7 of 12) and 60 percent (3 of 5), respectively, were judged to be developing normally after one year (95 percent confidence interval for the difference, -40 to 50). Both medications were without serious toxic effects.

CONCLUSIONS

In this multicenter, randomized, blinded study there were no differences in outcome between vidarabine and acyclovir in the treatment of neonatal HSV infection. The study lacked statistical power to determine whether there were sizable differences within the subgroups of those with localized HSV, encephalitis, or disseminated disease.

Isolated gA/gB glycoprotein complex of human cytomegalovirus envelope induces humoral and cellular immune-responses in human volunteers

Three human cytomegalovirus (HCMV) seronegative individuals were immunized with a single dose of HCMV envelope; two individuals developed neutralizing antibodies. Two naturally HCMV seropositive and three HCMV seronegative human volunteers were immunized with a major glycoprotein complex, gA/gB, of HCMV that had been purified by immunoadsorbent column chromatography. After a single injection of the gA/gB preparation, the naturally seropositive individuals developed higher titres of neutralizing antibodies and temporarily higher HCMV-specific lymphocyte proliferation (HCMV-LP) responses in vitro. The seronegative individuals developed neutralizing antibodies after the third injection of gA/gB, which were present only transiently, but showed a rapid reappearance and increase in titre after the fourth injection. At 1 year after the first injection, the neutralizing antibody titres were still comparable with those of the naturally seropositive individuals. HCMV-LP responses to HCMV in the initially seronegative individuals developed after the second or third injection with the gA/gB preparation and remained positive during the 1-year observation period. These results show that the gA/gB protein induces both humoral and cellular immune responses in humans, and might serve as the basis of a subunit vaccine.

Significance of epididymal and ductal anomalies associated with testicular maldescent

Epididymal abnormalities have long been found in conjunction with cryptorchid testicles. The aim of this study was to document the different types of epididymal and ductal anomalies in relation to the position of the cryptorchid testis and to determine their clinical significance. Exploration was performed on 187 cryptorchid testes in 174 boys. The position of the testis and the epididymal and ductal anomalies were documented at operation. A biopsy was taken from the testis or atretic spermatic cord structures for light microscopy. Epididymal, ductal and/or testicular anomalies were detected in 43 per cent of the 187 testes, including anomalies of ductal fusion, anomalies of ductal suspension and anomalies associated with absent or vanishing testes. Biopsy of the testes with severe anomalies of ductal fusion showed preservation of germ cells in 69 per cent and diminished germ cells in 31 per cent. The higher the arrest of testicular descent, the more grossly abnormal was the associated ductal system. Early successful orchiopexy alone may not ensure subsequent fertility despite the presence of normal germ cells.

A comparative study of herpes simplex infections in renal transplant and leukemic patients

Herpes simplex virus (HSV) reactivation and lesion formation were studied in 68 renal transplant recipients and 30 leukemic patients. Antibody titers to HSV were determined, and seropositive patients were examined three times weekly for up to one month. Surveillance cultures were taken for oral HSV, and HSV culture and cytology were done for all oral lesions found. In a smaller number of patients, immune responses were determined. HSV reactivation was similar in the transplant and leukemic groups (46.8% vs. 50%), but a significant difference in the incidence of HSV lesion formation was noted between the two groups. Of the transplant patients in whom HSV reactivated, 31.8% developed HSV lesions; of leukemic patients in whom HSV reactivated, 100% developed HSV lesions. Differences in the incidence of formation of HSV lesions in these groups of immunosuppressed patients suggest that reactivation of HSV and formation of HSV lesions may involve different mechanisms. Low levels of antibody-dependent cellular cytotoxicity were noted in leukemic patients and may contribute to increased formation of HSV lesions in this group.

Immune responses to isolated human cytomegalovirus envelope proteins

A group of envelope proteins of human cytomegalovirus, gA protein (L. Pereira, M. Hoffman, M. Tatsuno, and D. Dondero, Virology 139:73-86, 1984; L. Pereira, p. 383-404, in B. Roizman, ed., The herpesviruses, vol. 3, 1985), and two protein mixtures (58,000-molecular-weight [58K]-66K and 130K-66K), separated by serial columns prepared with anti-gA immunoglobulin G from sera of immunized guinea pigs, induced neutralizing antibodies and a cellular immune response in the animals. The gA is a disulfide-linked protein complex consisting of high-molecular-weight (greater than 200K), 130K-150K, and 55K-58K proteins.

A team approach to pharmacologic treatment of chronic schizophrenia

The authors describe a therapeutic approach to the pharmacologic treatment of the schizophrenic patient. This team approach relies on interaction between the patient, the patient's family, and the clinician, and helps to eliminate blaming behavior that often demoralizes all parties involved. The authors maintain that neuroleptic therapy can control the positive symptoms of schizophrenia. However, they point out that neuroleptics may cause side effects and may interfere with improvement in negative symptoms and interpersonal relationships. The authors suggest that reduced-dosage strategies may prove the most effective way to prevent relapse, while minimizing the side effects of neuroleptics.

HCMV envelope antigens induce both humoral and cellular immunity in guinea pigs

Antibody and cellular immunity were measured in guinea pigs immunized with whole virion, with nucleocapsids of human cytomegalovirus or with solubilized antigens containing virus envelope proteins. All the three types of immunogens induced the production of humoral antibody as well as cytomegalovirus (CMV)-specific cellular immunity. In immunization experiments envelope antigen was as effective as immunization with whole virion.

Human natural killer cells analyzed by B73.1, a monoclonal antibody blocking Fc receptor functions. I. Characterization of the lymphocyte subset reactive with B73.1

We describe the production of the monoclonal antibody B73.1, reacting with a subset of human lymphocytes and, in about one-half of the donors, with neutrophilic polymorphonuclear leukocytes. In the peripheral blood from normal adult donors, 14.6 +/- 8.5% of the lymphocytes react with B73.1 antibody. The B73.1(+) lymphocyte subset does not bear markers of typical T or B cells and corresponds to the lymphocyte subset containing antibody-dependent killer (K) and natural killer (NK) cells. We demonstrate that: a) virtually all lymphocytes with K/NK cytotoxic activity are found in the lymphocyte subpopulation bearing the B73.1-defined antigen; b) the B73.1(+) lymphocyte subset bears the combination of antigens known to be present on K/NK cells; and c) there is a positive correlation between the level of cytotoxicity and the actual number of B73.1(+) lymphocytes in individual donors. We also report the distribution of B73.1(+) lymphocytes according to donor age and tissue types. The use of the B73.1 antibody in quantitating the actual number of K/NK cells and in performing functional studies on spontaneous cytotoxicity is discussed.

Human natural killer cells analyzed by B73.1, a monoclonal antibody blocking Fc receptor functions. I. Characterization of the lymphocyte subset reactive with B73.1

We describe the production of the monoclonal antibody B73.1, reacting with a subset of human lymphocytes and, in about one-half of the donors, with neutrophilic polymorphonuclear leukocytes. In the peripheral blood from normal adult donors, 14.6 +/- 8.5% of the lymphocytes react with B73.1 antibody. The B73.1(+) lymphocyte subset does not bear markers of typical T or B cells and corresponds to the lymphocyte subset containing antibody-dependent killer (K) and natural killer (NK) cells. We demonstrate that: a) virtually all lymphocytes with K/NK cytotoxic activity are found in the lymphocyte subpopulation bearing the B73.1-defined antigen; b) the B73.1(+) lymphocyte subset bears the combination of antigens known to be present on K/NK cells; and c) there is a positive correlation between the level of cytotoxicity and the actual number of B73.1(+) lymphocytes in individual donors. We also report the distribution of B73.1(+) lymphocytes according to donor age and tissue types. The use of the B73.1 antibody in quantitating the actual number of K/NK cells and in performing functional studies on spontaneous cytotoxicity is discussed.

A non-x-linked syndrome with susceptibility to severe Epstein-Barr virus infections

Three siblings developed severe (two) or fatal (one) infectious mononucleosis. This family differed from previously described kindreds with a susceptibility to overwhelming Epstein-Barr virus infections in that: (1) both males and females were affected; (2) they had a history of the recurrent bacterial infections; (3) they produced the full spectrum of antibodies to EBV in the expected range of titers; and (4) survivors recovered completely. Two of these youths, but not their parents or an unaffected sibling with mild IM, had a deficiency of natural killer activity that did not respond to preincubation of their peripheral blood mononuclear cells with interferon. NK activity may have an important role in controlling infections with EBV.

The bacteriologically battered baby: another case of Munchausen by proxy

We present a case in which a mother who had had self-inflicted infections as a teenager also caused life-threatening infections in her year-old child. After testing for and treating various immunologic deficiencies without success, it was apparent that the infection was caused by contamination of intravenous sites. Strict isolation of the patient, with restricted and observed visitations by the mother, was the critical step in stopping the infections. Because the woman took her child to several emergency departments, this case is presented to alert emergency personnel to this entity and to explain some of the dynamics and the social issues that cause the problem.

The relationship of single words to two-word sentences

The relationship between the single-word utterances and 2-word sentences of 12 children was examined as part of a longitudinal study of language development. Children whose single-word utterances usually named objects produced sentences which named many objects. Children whose single words were frequently interjections produced sentences which expressed desire for an object. 2-word sentences seem to have some of their structural and functional roots in the single-word phase.