Visualisation of intra-cardiac structures and radiofrequency lesions using intracardiac echocardiography.

AIMS: Fluoroscopy does not allow identification specific anatomical landmarks during electrophysiological studies. Intra-cardiac echocardiography permits visualization of these structures with excellent accuracy, but the optimal method has not been fully described. The aim of this study was to assess the capability of intra-cardiac echocardiography for the visualization of such structures using two different approaches. We also assessed its capability for the evaluation of radio frequency lesions 20 min after catheter ablation of the cavo-tricuspid isthmus. METHODS: Intra-cardiac echocardiography was performed using a 9 MHz rotating transducer in eight consecutive patients (age range: 37-76 years) after radio frequency ablation of the cavo-tricuspid isthmus. The ultrasound catheter was inserted through the femoral vein into the superior vena cava and was pulled back to the inferior vena cava. The echo catheter was then reinserted through the subclavian vein and advanced into the right ventricular apex and was pulled back from the right ventricular to the superior vena cava. Qualitative evaluation and intra-cardiac measurements were performed off-line. RESULTS: The fossa ovalis, the tricuspid valve, and the terminal crest were visible in all patients regardless of the method of introduction of the echo catheter. Left-sided structures were less accurately seen by intra-cardiac echocardiography. The horizontal diameter of the fossa ovalis was 8.9+/-1.8mm. The cavo-tricuspid isthmus was visible using the femoral approach in three patients. The isthmus could be visualized in all patients, and in three patients together with the ostium of the coronary sinus, using the subclavian approach. radio frequency lesions were not visible 20 min after ablation. Additionally, both the left and right ventricles could be seen using the subclavian approach. CONCLUSIONS: The subclavian approach is feasible, safe and superior to visualize the isthmus. Twenty minutes after radio frequency ablation of the cavo-tricuspid isthmus radio frequency lesions are not visible using intra-cardiac echocardiography.     

Characterization of the pseudorabies virus-specific immunoglobulin M response and evaluation of its diagnostic use in pigs with preexisting immunity to the virus.

Despite preexisting immunity to pseudorabies virus (PRV), pigs may become infected and may or may not show clinical signs of disease. To investigate whether detection of immunoglobulin M (IgM) antibodies to PRV is suitable for diagnosis of recent infection in pigs with (or without) preexisting immunity, the IgM responses of pigs were examined after both experimental and natural infections. Upon inoculation of seronegative pigs with a low dose of a mildly virulent strain of PRV, IgM was first detectable at day 7 postinoculation (p.i.), reached a maximum at day 14 p.i., and became undetectable again at about days 32 to 36 p.i. In inoculated pigs with maternal antibodies against PRV, the IgM response began later and ended sooner, and peak titers were also lower. In immune pigs with maternally derived antibodies, there was apparently no correlation between the virulence of the inoculated strain and the IgM response. The suitability of the IgM enzyme-linked immunosorbent assay (ELISA) for detection of recent infection in the field was compared with that of the virus neutralization (VN) assay and with an ELISA which specifically detects antibodies directed to glycoprotein I (gI) of PRV. Paired sera were obtained from pigs suspected of PRV infection in an area endemic for PRV infection in which vaccination against PRV is often applied. Practically all pigs had antibodies to PRV in the acute phase of the disease. Compared with the VN assay, the specificity of the IgM ELISA was high but its sensitivity was low. However, all three serotests apparently failed to detect some PRV infections. The IgM ELISA appeared to be especially useful as a diagnostic aid for detection of recent infections in pigs with high levels of neutralizing and gI antibodies, probably maternally derived, in the acute phase of the disease. Such pigs may fail to develop a significant rise in VN antibody titer. The IgM ELISA may be the only serotest for monitoring infections in such pigs.     

Stimulation of bone resorption by inflamed nasal mucosa, dermonecrotic toxin-containing conditioned medium from Pasteurella multocida, and purified dermonecrotic toxin from P. multocida.

The effects of inflamed nasal mucosa from pigs with atrophic rhinitis (AR), cell extract from Bordetella bronchiseptica, conditioned medium from Pasteurella multocida, and purified dermonecrotic toxin (DNT) from P. multocida on mouse fetal long bones in organ culture were studied. Inflamed nasal "AR mucosa" stimulated the release of 45Ca from prelabeled cultures, while histologically the formation of calcified matrix was impaired as well. B. bronchiseptica cell extract only transiently increased 45Ca release, but also impaired the formation of matrix. 45Ca release was also stimulated by DNT-containing conditioned medium from P. multocida and by purified DNT. The effect of DNT was biphasic: low doses (1 to 25 ng/ml) slightly stimulated bone resorption, higher doses were inhibitory. The stimulatory action of DNT on 45Ca release was accompanied by an increase in numbers of preosteoclasts and osteoclasts. The significance of these findings for the pathogenesis of AR is discussed.     

Vaccination of pigs against pseudorabies virus with plasmid DNA encoding glycoprotein D

We analysed the ability of a plasmid carrying the gene encoding glycoprotein D (gD) of pseudorabies virus (PRV) to induce humoral and cell-mediated immune responses and assessed the protection provided by PRV-gD DNA vaccination against challenge infection with PRV. Immunization with plasmid PRV-gD induced neutralizing antibodies and lymphocyte proliferative responses both in mice and pigs. Moreover, when challenged with virulent PRV six weeks following the last immunization, PRV-gD DNA vaccinated pigs excreted virus for a significantly shorter period and showed less clinical symptoms than pigs vaccinated with a control plasmid. Thus, in the target animal, DNA vaccination with PRV-gD DNA induces protective immunity against challenge infection.     

Mucosal and systemic immunity against poliovirus in mice transgenic for the poliovirus receptor: the poliovirus receptor is necessary for a virus-specific mucosal IgA response

In view of the planned eradication of poliovirus, the suitability of transgenic mice bearing the human receptor for poliovirus (PVRtg mice) as a nonprimate animal model to study mucosal immunity against poliovirus was investigated. After intraperitoneal (ip) priming followed by ip or oral booster with live poliovirus, PVRtg mice had detectable IgA and IgG responses. The IgA response was restricted to PVRtg mice and could not be induced by oral immunization. After ip priming, PVRtg mice did shed virus in the stool, whereas control mice did not. Moreover, the amount of virus shed in the stools of PVRtg mice that had an IgA response after immunization was significantly lower than that of nonimmunized mice. A virus-specific mucosal IgA response is dependent on expression of the poliovirus receptor and is influenced by the route of immunization and the virus strain. PVRtg mice are a suitable model for the study of poliovirus-specific immunity and protection against poliovirus infection.     

The effectiveness of interventions to reduce the household economic burden of illness and injury: a systematic review

Objective

To determine the nature, scope and effectiveness of interventions to reduce the household economic burden of illness or injury.

Methods

We systematically reviewed reports published on or before 31 January 2014 that we found in the CENTRAL, CINAHL, Econlit, Embase, MEDLINE, PreMEDLINE and PsycINFO databases. We extracted data from prospective controlled trials and assessed the risk of bias. We narratively synthesized evidence.

Findings

Nine of the 4330 studies checked met our inclusion criteria – seven had evaluated changes to existing health-insurance programmes and two had evaluated different modes of delivering information. The only interventions found to reduce out-of-pocket expenditure significantly were those that eliminated or substantially reduced co-payments for a given patient population. However, the reductions only represented marginal changes in the total expenditures of patients. We found no studies that had been effective in addressing broader household economic impacts – such as catastrophic health expenditure – in the disease populations investigated.

Conclusion

In general, interventions designed to reduce the complex household economic burden of illness and injury appear to have had little impact on household economies. We only found a few relevant studies using rigorous study designs that were conducted in defined patient populations. The studies were limited in the range of interventions tested and they evaluated only a narrow range of household economic outcomes. There is a need for method development to advance the measurement of the household economic consequences of illness and injury and facilitate the development of innovative interventions to supplement the strategies based on health insurance.     

IL-13 genetic polymorphism identifies children with late wheezing after respiratory syncytial virus infection

BACKGROUND: The nature of wheezing after respiratory syncytial virus lower respiratory tract infection (RSV LRTI) is usually transient. However, some children will develop persistent or late wheezing. OBJECTIVE: We hypothesized that early and late postbronchiolitis wheezing are determined by distinct clinical, immunologic, and genetic variables. METHODS: A cohort of 101 children hospitalized for RSV LRTI was prospectively followed for 6 years. During RSV LRTI, cytokine studies were performed and genetic polymorphisms were determined. Parents performed daily log registration of respiratory symptoms during the first 3 years of follow-up and again at age 6 years during the winter season. RESULTS: Distinctive associations for early and late postbronchiolitis wheezing were found. We previously showed that airflow limitation during RSV LRTI as well as convalescent monocyte IL-10 production are associated with early wheezing. These variables were not associated with late wheezing. On the other hand, atopic family history was not associated with early wheezing, but it was associated with late wheezing. Most importantly, the IL-13 Gln allele was associated with late wheezing (odds ratio 3.27, 95% confidence interval 1.32-8.06), but it was not associated with early wheezing. CONCLUSION: This study revealed distinct clinical, immunologic, and genetic determinants of early and late wheezing after RSV LRTI, indicating distinct pathophysiological mechanisms. We conclude that late wheezing at age 6 years, but not early postbronchiolitis wheezing, is an asthmatic phenomenon and genetically related to a functional IL-13 polymorphism. CLINICAL IMPLICATIONS: After RSV LRTI, wheezing at age 6 years is not related to early postbronchiolitis wheezing and represents a distinct disease entity.     

Protection of children born to hepatitis-B-infected mothers

The vaccination schedule implemented on 1 March 2003 for the approximately 1000 Dutch children per year born to hepatitis-B-virus-infected mothers is under discussion. The Health Council of The Netherlands and TNO have both published reports which reveal that the current schedule does not fulfil its objectives, as too many children are completely missed and many of the vaccinated children do not receive their scheduled vaccinations on time. Furthermore, doubts have been expressed about the effectiveness of the present vaccination schedule. In line with one of the schedules proposed by the Health Council we suggest the introduction of a 4-dose vaccination, in which the first vaccination is given immediately after the birth of the child. The subsequent vaccinations can then take place after 2, 4 and 11 months. These are the ages at which other children are also vaccinated against hepatitis B in accordance with the Dutch national vaccination programme. Furthermore, we advise an improved surveillance to ensure compliance with the individual vaccination schedules for these children. If data from the hepatitis-B screening of pregnant women, the regional vaccination registers, and the vaccinations actually administered are linked, then it will be possible to take swift action if a child is late for a hepatitis-B vaccination. In our opinion, this can best be achieved if a single national organisation is made responsible for the entire process, starting from the collection of the hepatitis-B data of pregnant women up to concluding the scheme, whether or not the serologic response is checked.