Scaling up electronic village registers for measuring vital statistics in rural villages in Malawi.

Setting: Eighty-three villages without electricity in Mtema Traditional Authority, Lilongwe District, Malawi. Objectives: To describe 1) the expansion of the electronic village register (EVR) to 83 villages in Mtema Traditional Authority, 2) the challenges encountered and changes made to render the system robust and user-friendly, 3) the value propositions developed to increase the system's desirability, and 4) the results of the village register. Design: Descriptive study. Results: After the deployment of the EVR in one village in 2013, the system was extended to 83 villages with modifications to render it more robust and user-friendly. These changes included modifications to the power, connectivity and work stations, better battery security and a single modular electronics panel. Value propositions of the EVR for the village headmen included daily postings of news/sports items and sockets for charging mobile phones and lanterns. Of the 47 559 residents registered, 48% were male, 14% were aged 0-4 years, 43% were aged 15-44 years and 4% were aged ⩾65 years. Between 1 April 2016 and 31 March 2017, 976 births and 177 deaths were recorded. The total equipment cost per village was US$2430. Conclusion: An electronic village birth and death registration system can function in an area with no communication or electricity infrastructure.

Contexte : Quatre-vingt-trois villages sans électricité dans la zone d'autorité traditionnelle de Mtema, district de Lilongwe, Malawi.Objectif: Décrire 1) l'expansion du registre électronique de village (EVR) aux 83 villages de la zone d'autorité traditionnelle Mtema, 2) les défis rencontrés et les modifications effectuées pour rendre le système robuste et convivial, 3) les propositions de valeur élaborées pour augmenter la désirabilité du système, et 4) les résultats du registre de village.Schéma : Etude descriptive.Résultats : Après le déploiement de l'EVR dans un village en 2013, le système a été étendu à 83 villages, avec des modifications visant à la rendre plus robuste et plus convivial. Ces changements ont inclus des modifications du courant, de la connectivité et des stations de travail, une meilleure sécurité au niveau des piles et un panneau électronique modulaire unique. Les propositions de valeur de l'EVR pour les autorités du village ont inclus des affichages quotidiens relatifs aux actualités/aux sports et des prises pour charger les téléphones mobiles et les lanternes. Sur les 47 559 résidents enregistrés, 48% étaient des hommes, 14% avaient de 0 à 4 ans, 43% avaient de 15 à 44 ans et 4%, ≥65 ans. Entre le 1er avril 2016 et le 31 mars 2017, 976 naissances et 177 décès ont été enregistrés. Le coût total de l'équipement a été de US$2430 par village.Conclusion : Un système d'enregistrement électronique villageois des naissances et des décès peut fonctionner dans une zone dépourvue d'infrastructures de communication ou d'électricité.

Marco de referencia: Ochenta y tres aldeas que no cuentan con suministro eléctrico en la Autoridad Tradicional de Mtema de la provincia de Lilongwe, en Malawi.Objetivos: Describir los siguientes aspectos: 1) la ampliación del registro de aldea electrónico (EVR) a 83 aldeas de la Autoridad Tradicional de Mtema; 2) las dificultades encontradas y las modificaciones introducidas con el objeto de lograr un sistema de mayor solidez y utilización más sencilla; 3) las propuestas de valor formuladas con miras a hacer más atractiva la utilización del sistema; y 4) los resultados del registro de aldea electrónico.Métodos: Fue este un estudio descriptivo.Resultados: Tras la introducción del EVR en una aldea en el 2013, se amplió el sistema a 83 aldeas con modificaciones que aportaban mayor solidez y facilidad de utilización. Los cambios abordaron la potencia de la alimentación, la conectividad y las estaciones de trabajo, una mayor seguridad de las baterías y un tablero modular electrónico único. Las propuestas de valor sobre el EVR dirigidas a los jefes de aldea fueron la publicación diaria de noticias y deportes y la alimentación de las tomas para cargar los teléfonos móviles y las linternas. De los 47 559 residentes registrados, 48% eran de sexo masculino, 14% tenían entre 0 y 4 años de edad, 43% entre 15 y 44 años y 4% ≥65 años. Del 1° de abril del 2016 al 31 de marzo del 2017 se registraron 976 nacimientos y 177 defunciones. El costo total del equipo por aldea fue de US$2430.Conclusión: Un sistema electrónico de registro de los nacimientos y las defunciones puede funcionar en una zona que no cuenta con infraestructura de comunicaciones ni suministro eléctrico.

Managing and monitoring chronic non-communicable diseases in a primary health care clinic, Lilongwe, Malawi.

SETTING: Patients with chronic non-communicable diseases attending a primary health care centre, Lilongwe, Malawi. OBJECTIVE: Using an electronic medical record monitoring system, to describe the quarterly and cumulative disease burden, management and outcomes of patients registered between March 2014 and June 2015. DESIGN: A cross-sectional study. RESULTS: Of 1135 patients, with new registrations increasing each quarter, 66% were female, 21% were aged ⩾65 years, 20% were obese, 53% had hypertension alone, 18% had diabetes alone, 12% had asthma, 10% had epilepsy and 7% had both hypertension and diabetes. In every quarter, about 30% of patients did not attend the clinic and 19% were registered as lost to follow-up (not seen for ⩾1 year) in the last quarter. Of those attending, over 90% were prescribed medication, and 80-90% with hypertension and/or diabetes had blood pressure/blood glucose measured. Over 85% of those with epilepsy had no seizures and 60-75% with asthma had no severe attacks. Control of blood pressure (41-51%) and diabetes (15-38%) was poor. CONCLUSION: It is feasible to manage patients with non-communicable diseases in a primary health care setting in Malawi, although more attention is needed to improve clinic attendance and the control of hypertension and diabetes.

Contexte : Les patients atteints de maladies chroniques non transmissibles fréquentant un centre de santé primaire et soignés à Lilongwe, Malawi.Objectif : Se servant d'un système électronique de suivi des dossiers médicaux, décrire le poids trimestriel et cumulé des maladies, la prise en charge et le pronostic des patients enregistrés entre mars 2014 et juin 2015.Schéma : Une étude transversal.Résultats : De 1135 patients nouvellement enregistrés avec une augmentation chaque trimestre, 66% étaient des femmes, 21% avaient plus de 65 ans, 20% étaient obèses, 53% avaient une hypertension isolée, 18% avaient un diabète isolé, 12% avaient de l'asthme, 10% avaient une épilepsie et 7% avaient à la fois hypertension et diabète. Chaque trimestre, environ 30% des patients ne se sont pas présentés au centre de santé et 19% ont été enregistrés comme perdus de vue (pas vus depuis au moins 1 an) au cours du dernier trimestre. Parmi ceux qui se sont présentés, plus de 90% ont eu une prescription de médicaments et 80% à 90% des patients atteints d'hypertension et/ou de diabète ont eu une mesure de tension artérielle/de glycémie. Plus de 85% des patients avec épilepsie n'ont pas eu de convulsions et 60­75% des patients atteints d'asthme n'ont pas eu de crise grave. Le contrôle de la tension artérielle (41­51%) et du diabète (15­38%) a été médiocre.Conclusion : Il est possible de prendre en charge les patients atteints de maladies chroniques non transmissibles dans un contexte de centre de santé primaire au Malawi, mais il faut accorder plus d'attention à l'amélioration de la fréquentation du centre et au contrôle de l'hypertension et du diabète.

Marco de referencia: Los pacientes con diagnóstico de enfermedades crónicas no transmisibles que acuden a un centro de atención primaria de salud en Lilongwe, Malawi.Objetivo: Utilizando un sistema de electrónico seguimiento de las historias clínicas, describir la carga de morbilidad trimestral y acumulada, el tratamiento y el desenlace clínico de los pacientes registrados de marzo del 2014 a junio del 2015.Método: Fue este un estudio transversal.Resultados: Se registraron 1135 pacientes y los casos nuevos registrados aumentaron en cada trimestre. De estos pacientes el 66% era de sexo femenino, la 21% de los pacientes tenía 65 años de edad o más, el 20% era obeso, contaba con un diagnóstico exclusivo de hipertensión el 53%, de diabetes el 18%, de asma el 12%, epilepsia el 10% y 7% de los pacientes presentaba hipertensión y diabetes. En cada trimestre, cerca de 30% de los pacientes no acudió al centro y el 19% se registró como perdidos durante el seguimiento (no acudieron en un año o más) en el último trimestre. De los pacientes que acudieron al centro, más del 90% recibió recetas de medicamentos y se midió la tensión arterial y la glucemia en 80% a 90% de los pacientes con diagnóstico de hipertensión, diabetes o ambos. Más del 85% de los pacientes con epilepsia no presentó convulsiones y de 60% a 75% de los pacientes con asma no sufrió crisis graves. Se observó una regulación deficiente de la tensión arterial (de 41% a 51%) y de la diabetes (de 15% a 38%).Conclusión: Es factible tratar a los pacientes con enfermedades no transmisibles en el marco de la atención primaria de salud en Malawi, pero se precisan esfuerzos encaminados a estimular la asistencia y mejorar el control de la hipertensión y la diabetes.

Cohort analysis of antenatal care and delivery outcomes in pregnancy: a basis for improving maternal health.

Cohort analysis has been the cornerstone of tuberculosis (TB) monitoring and evaluation for nearly two decades; these principles have been adapted for patients with the human immunodeficiency virus/acquired immune-deficiency syndrome on antiretroviral treatment and patients with diabetes mellitus and hypertension. We now make the case for using cohort analyses for monitoring pregnant women during antenatal care, up to and including childbirth. We believe that this approach would strengthen the current monitoring and evaluation systems used in antenatal care by providing more precise information at regular time intervals. Accurate real-time data on how many pregnant women are enrolled in antenatal care, their characteristics, the interventions they are receiving and the outcomes for mother and child should provide a solid basis for action to reduce maternal mortality.

Une analyse de cohorte a été la pierre angulaire du suivi et évaluation de la tuberculose pendant près de deux décennies ; ces principes ont été adaptés aux patients atteints de virus de l'immunodéficience humaine/syndrome de l'immunodéficience acquise sous traitement antiretroviral, ainsi qu'aux patients ayant un diabète et une hypertension. Nous recommandons maintenant l'utilisation d'analyse de cohorte pour le suivi des femmes enceintes en consultation prénatale et jusqu'à l'accouchement inclus. Nous pensons que cette approche renforcerait le système actuel de suivi et évaluation utilisé en consultation prénatale en fournissant des informations plus précises à intervalles réguliers. Des données exactes en temps réel sur le nombre de femmes enceintes enrôlées en consultation prénatale, leurs caractéristiques, l'intervention mise en place et les résultats vis-à-vis de la mère et de l'enfant, devraient fournir une solide base d'action visant à diminuer la mortalité maternelle.

El análisis de cohortes ha constituido la piedra angular del seguimiento y de la evaluación de la tuberculosis durante cerca de dos decenios; estos principios se adaptaron a los pacientes coinfectados por el virus de la inmunodeficiencia humana y la síndrome de la inmunodeficiencia adquirida que reciben tratamiento antirretrovírico y a los pacientes con diabetes e hipertensión. En el presente artículo se defiende la oportunidad de utilizar los análisis de cohortes en el seguimiento de las embarazadas durante el cuidado prenatal, hasta incluir el nacimiento. Se propone que esta estrategia reforzaría los sistemas de seguimiento y evaluación que se practican actualmente en la atención prenatal, pues aportaría información más precisa y a intervalos regulares. Obtener los datos exactos y en tiempo real sobre la forma como las embarazadas se inscriben a la atención prenatal, sus características, las principales intervenciones que reciben y los desenlaces de la madre y el niño aportaría fundamentos sólidos a las actividades encaminadas a disminuir la mortalidad materna.

'Task shifting' in an antiretroviral clinic in Malawi: can health surveillance assistants manage patients safely?

Malawi has a critical shortage of clinicians and nurses. This study evaluated whether health surveillance assistants (HSAs) could provide antiretroviral therapy (ART) efficiently and safely for stable patients. HSAs could identify patients with previously established criteria requiring clinical management, including ART initiates, children and patients on second-line treatment. HSAs were not capable of correctly identifying current complications, including potentially severe side effects and toxicities, and inappropriately referred stable patients to clinicians, reducing efficiency. While task shifting to HSAs appears promising, to be safe and efficient, additional clinical training is needed before potentially task shifting stable ART patient care to less skilled health care cadres.

Le Malawi connait un manque critique de cliniciens et d'infirmières. Cette étude a évalué dans quelle mesure les assistants de surveillance de santé (HSA) pourraient distribuer un traitement antirétroviral (ART) de manière efficiente et sûre à des patients en état stable. Les HSA pourraient identifier les patients répondant à des critères préalablement établis, exigeant une prise en charge clinique, notamment les débuts d'ART, les enfants et les patients sous traitement de deuxième ligne. Les HSA n'ont pas été capables d'identifier correctement les complications courantes, notamment les effets collatéraux potentiellement graves et les toxicités ; ils n'ont pas référé de manière appropriée les patients stables aux cliniciens, ce qui a réduit leur efficience. Alors que le transfert de tâches vers les HSA paraît prometteur, pour qu'il soit sûr et efficient, une formation clinique complémentaire s'impose avant de transférer la tâche des soins aux patients ART stables à des cadres de la santé de moindre compétence.

Malaui afronta una grave escasez de personal médico y de enfermería. En el presente estudio se investigó si los auxiliares de vigilancia de la salud (HSA) podrían realizar un suministro eficaz y seguro del tratamiento antirretrovírico (ART) a los pacientes estables. Los ayudantes de vigilancia sanitaria podrían detectar a los pacientes que precisan manejo médico con base en criterios establecidos antes, como los pacientes que comenzaron recientemente el ART, los niños y los pacientes que reciben medicamentos de segunda línea. Los HSA no pudieron reconocer las complicaciones frecuentes, ni las reacciones adversas y las toxicidades que podrían ser graves y remitieron a los médicos, sin razón válida, pacientes estables con lo cual se redujo su eficacia. Si bien la delegación de tareas a los HSA podría parecer prometedora, a fin de velar por la seguridad y la eficiencia de la iniciativa, es preciso impartir una mayor capacitación clínica antes de confiar al personal sanitario menos calificado la atención de pacientes estables que reciben el ART.

The relative involvement of Th1 and Th2 associated immune responses in the expulsion of a primary infection of Heligmosomoides polygyrus in mice of differing response phenotype.

T helper cell (Th1 and Th2) associated responses were examined following a primary infection with the gastrointestinal nematode Heligmosomoides polygyrus in five inbred strains of mice with different resistance phenotypes. Levels of (i) mast cell protease, (ii) specific IgE, (iii) nitric oxide and (iv) specific IgG2a, as markers of Th2 and Th1 associated responses, respectively, were determined in sera and intestinal fluids and correlated with worm burdens. The "fast" responder (resistant) strains SWR and SJL produced strong Th2 and Th1 associated responses respectively in a mutually exclusive fashion. The F1 hybrid (SWRxSJL) F1, showed rapid expulsion of the parasite and expressed both intense Th1 and Th2 responses, suggesting synergism between Th1 and Th2 activity in these mice. The results indicate that both Th2 and Th1 responses operate in mice following a primary infection with H. polygyrus and that each Th response may be involved to a greater or lesser degree within certain strains. Resistance to H. polygyrus was found to correlate only to the intensity of either the gut-associated mastocytosis or nitric oxide production in these strains but not to either specific IgE or IgG2a titres. Chronic infections in the "slow" response phenotype mouse strains CBA and C57BL/10, were associated with both poor Th2 and poor Th1-associated responses attributed to a general parasite-mediated immunosuppression of the host immune response to infection.

Hypogalactosylation of serum IgG in patients with ANCA-associated systemic vasculitis.

The triad of small vessel vasculitides (SVV) comprise Wegener's granulomatosis (WG), microscopic polyangiitis (MPA) and Churg-Strauss syndrome (CS). All three are associated with presence of circulating IgG antineutrophil cytoplasm antibodies (ANCA) which target autoantigens contained, primarily, within neutrophil azurophilic granules. The widely accepted model of pathogenesis suggests that ANCA activate cytokine-primed neutrophils within the microvasculature, leading to by-stander damage to endothelial cells, and rapid escalation of inflammation with recruitment of mononuclear cells. Activation may be initiated, in vitro, by the coligation of the PR3 or MPO antigen, translocated to the cell surface, and FcgammaRIIa/FcgammaRIIIb receptors. This suggests that the IgG subclass profile of ANCA and, possibly, its glycosylation status could influence the inflammatory mechanisms activated. The glycosylation status of total IgG isolated from the sera of patients with WG (13), MPA (6) and CSS (1) was determined by analysis of the released oligosaccharides. A deficit in IgG galactosylation is demonstrated for all patient samples, compared to controls. The mean percentage values for the agalactosylated (G0) oligosaccharides were 57% (SD +/- 9.71), 47% (SD +/- 4.25) and 28% (SD +/- 4.09) for WG, MPO and control samples, respectively. The G0 levels for polyclonal IgG isolated from the sera of both WG and MPA patients were significantly increased compared to controls (P < 0.0001). The major glycoform present therefore is agalactosylated (G0) IgG. In previous studies the G0 glycoform of IgG has been shown to bind and activate mannan binding lectin, and hence to activate the complement cascade, and to facilitate mannose receptor binding and the uptake of IgG complexes by macrophages and dendritic cells. Both of these activities could impact on the processing and presentation of self-antigens in autoimmune disease.

Heterogeneity in the granulomatous response to mycobacterial infection in patients with defined genetic mutations in the interleukin 12-dependent interferon-gamma production pathway.

Patients with genetic lesions in the Type-1 cytokine/cytokine receptor pathway exhibit a selective susceptibility to severe infections with poorly pathogenic mycobacteria and non-typhi salmonella spp. These experiments of nature demonstrate that IL-12-dependent IFNgamma production is critical for granuloma formation and therefore host immunity against such pathogens. The essential role of granuloma formation for protective immunity to these organisms is emphasized by the differing granuloma forming capabilities and resultant clinical sequelae observed in these patients which seems to reflect their ability to produce or respond to IFNgamma (Fig. 9). At one pole of this spectrum, represented by the complete IFNgammaR1/2 deficient patients, there is a complete absence of mature granuloma formation, whereas with the less severe mutations (i.e. partial IFNgammaR1/2, complete IL-12p40 and complete IL-12Rbeta1 deficiency), granuloma formation is very heterogenous with wide variations in composition being observed. This suggests that in the latter individuals, who produce partial but suboptimal IFNgamma responses, other influences, including pathogen virulence and host genotype may also affect the type and scale of the cellular response elicited.

Effect of oxygen radicals and differential expression of catalase and superoxide dismutase in adult Heligmosomoides polygyrus during primary infections in mice with differing response phenotypes.

The ability of oxygen radicals to kill Heligmosomoides polygyrus adult worms was examined by assessing parasite survival following incubation with hydrogen peroxide and acetaldehyde/xanthine oxidase, generators of H2O2 and H2O2/O2(-), respectively. H. polygyrus worms could tolerate levels of < 0.25 mM hydrogen peroxide and < 0.5 mM/20 mU acetaldehyde/xanthine oxidase for 20 h, but, at higher concentrations, marked sex-dependent susceptibility was observed, with males being more sensitive to H2O2 and O2(-) than female worms. The ability to evade free radical-mediated damage was also evaluated by measuring superoxide dismutase (SOD) and catalase levels in worms isolated at different time points from four strains of mice with differing resistance phenotypes. Levels of both catalase and SOD in female worms isolated from 'rapid'[(SWRxSJL)F1], 'fast' (SWR) or 'intermediate' (BALB/c), but not 'slow' (C57BL/10), responder mice showed a strain-dependent increase with time. Moreover, male worms were rejected faster than female worms in the 'rapid', 'fast' and 'intermediate' responder strains of mice. The results suggest that host-derived free radicals can damage adult worms and that female worms can increase production of their scavenging enzymes in response to the immune onslaught that eventually leads to worm expulsion in mice with 'fast', 'rapid' or 'intermediate' response phenotypes.

Antineutrophil cytoplasm autoantibodies from patients with systemic vasculitis activate neutrophils through distinct signaling cascades: comparison with conventional Fcgamma receptor ligation.

In systemic vasculitis, interactions between antineutrophil cytoplasm autoantibodies (ANCAs) and neutrophils initiate endothelial and vascular injury. ANCAs directed against either myeloperoxidase (MPO) or proteinase 3 (PR3) can activate cytokine-primed neutrophils by binding cell surface-expressed MPO or PR3, with the concurrent engagement of Fcgamma receptors (FcgammaR). Because roles for phospholipase D (PLD) and phosphatidylinositol 3 kinase (PI3K) have been demonstrated in FcgammaR activation of neutrophils, this study investigated the hypothesis that ANCA stimulation of neutrophils involved a similar engagement of FcgammaR and activation of PLD and PI3K. Pretreatment of tumor necrosis factor (TNF) alpha-primed neutrophils with antibodies against FcgammaRII and FcgammaRIII inhibited MPO-ANCA and PR3-ANCA induced superoxide generation, confirming that FcgammaR ligation is involved in ANCA-mediated neutrophil activation. However, although stimulation of TNF-alpha-primed neutrophils by conventional FcgammaR ligation, either using antibody-mediated cross-linking of FcgammaR or aggregated IgG, induced PLD activation, ANCA stimulation did not. Moreover, although ANCA-induced neutrophil activation results in significant PI3K activation-as assessed by phosphatidylinositol 3,4,5-triphosphate generation-conventional FcgammaR ligation, but not ANCA, activates the p85/p110 PI3K subtype. Inhibition of ANCA-induced superoxide generation with pertussis toxin suggests that ANCAs activate the p101/p110gamma PI3K isoform. In addition, the kinetics of activation of protein kinase B differs between conventional FcgammaR ligation and ANCA stimulation of neutrophils. These results demonstrate that though ligation of FcgammaRIIa and FcgammaRIIIb may be necessary, it is likely that ANCAs require other membrane cofactors for neutrophil activation.

Diagnosis of defects in the type 1 cytokine pathway.

Patients with inherited defects in the interleukin-12 (IL-12)-dependent, 'high-output' interferon-gamma (IFN-gamma) pathway exhibit selective susceptibility to poorly pathogenic mycobacterial and salmonella infections. This review summarises the extended clinical spectrum seen in this group of patients and indicates a strategy for the identification of putative defects in the type 1 cytokine pathway.

Unusual T cell receptor phenotype V gene usage of gamma delta T cells in a line derived from the peripheral nerve of a patient with Guillain-Barré syndrome.

Guillain-Barré syndrome is considered to be an immune mediated disorder but the relative role of T cells and antibodies in its pathogenesis is unclear. As gut infection with Campylobacter jejuni is the most common antecedent infection it is possible that gut derived T lymphocytes might play a part in the development of the syndrome. The T cell receptor phenotype (TCR) of a nerve gamma delta T cell line obtained from a sural nerve biopsy taken from a patient with a demyelinating form of GBS was determined using polymerase chain reaction (PCR) and flow cytometry (FACS). This TCR was compared with the phenotype preferentially expressed in the peripheral blood of the same patient. The T cell nerve line was found to express V gamma 8/delta 1 which represents an unusual T cell subset normally found on lymphocytes resident in epithelial tissue such as the gut. The peripheral blood gamma delta T lymphocytes from the patient were of the V gamma 9/delta 2 subset, which is the phenotype predominantly expressed in the peripheral blood of healthy subjects. In conclusion, the presence of this unusual population of V gamma 8/delta 1(+) lymphocytes in nerve would be consistent with a pathogenetic role for gut associated lymphocytes in the pathogenesis of Guillain-Barré syndrome associated with C jejuni.

The relationship between circulating and intestinal Heligmosomoides polygyrus-specific IgG1 and IgA and resistance to primary infection.

Specific serum and intestinal immunoglobulin (Ig)G1 and IgA responses to Heligmosomoides polygyrus were measured in a panel of seven inbred mouse strains which exhibit 'rapid' (<6 weeks (SWRxSJL)F1), 'fast' (<8 weeks, SJL and SWR), 'intermediate' (10-20 weeks, NIH and BALB/c) or 'slow' (>25 weeks, C57BL/10 and CBA) resolution of primary infections. Mice with 'rapid', 'fast' or 'intermediate' response phenotypes produced greater serum and intestinal antibody responses than those with 'slow' phenotypes. The F1 hybrids ((SWRxSJL)F1) of two 'fast' responder strains showed the earliest antibody response with maximum titres evident within 6 weeks of infection. There was a negative correlation between the serum IgG1 responses and worm burdens in individual mice within a number of mouse strains, and also between serum IgG1 and IgA responses and worm burdens in the 'rapid' ((SWRxSJL)F1) responder strain. The presence of IgG1 in the gut was found to be due to local secretion rather than plasma leakage. Using Western immunoblotting, serum IgG1 from 'rapid' and 'fast' responder but not 'slow' responder mice was found to react with low molecular weight antigens (16-18 kDa) in adult worm excretory/secretory products.

Stimulation of peripheral blood lymphocytes with Campylobacter jejuni generates a gammadelta T cell response in patients with Guillain-Barrésyndrome.

In three patients whose Guillain-Barré syndrome (GBS) was preceded by gastrointestinal infection due to Campylobacter jejuni, gammadelta T cells were generated from peripheral blood in response to in vitro stimulation with C. jejuni. In one of the patients, where a diagnostic sural nerve biopsy was performed, gammadelta T cells were also isolated following culture of the nerve tissue. Studies with healthy volunteers and C. jejuni gastroenteritis patients also showed preferential enrichment for gammadelta T cells in peripheral blood cells stimulated with C. jejuni, although the response was significantly lower than that seen in GBS patients. In two out of three GBS patients and all of the controls, gammadelta T cell receptor (TCR) gene usage was shown to be Vgamma9/Vdelta2+. In the GBS patient where nerve-infiltrating gammadelta T cells were isolated, these and C. jejuni-specific peripheral blood cells had similar TCR gene usage, predominantly consisting of Vgamma5/Vdelta1+ cells. Sequencing the Vdelta1 products from nerve and peripheral blood showed similarities in CDR3 length, but the single Vdelta1 sequence obtained from nerve was not identified in peripheral blood. These results suggest that the generation of gammadelta T cells is part of a normal immune response to C. jejuni, which, in patients with GBS, may contribute to the pathogenesis of their inflammatory neuropathy.

Isolation and characterisation of T lymphocytes from sural nerve biopsies in patients with Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy.

OBJECTIVES: To characterise cultured T lymphocytes from nerve biopsies in patients with Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS: Sural nerve biopsies, obtained from six patients with Guillain-Barré syndrome, four with CIDP, and six controls with other neuropathies, were cultured with 20 U/ml recombinant interleukin-2 (IL-2) for eight weeks. Flow cytometry was used to determine the phenotype of cultured T lymphocytes. Their proliferative responses to a range of bacterial antigens were also examined. RESULTS: T cell lines were established from four of six patients with Guillain-Barré syndrome, one of four with CIDP, one patient with peripheral nerve vasculitis, and none of five controls with non-inflammatory neuropathies. One of these T cell lines from a patient with Guillain-Barré syndrome, preceded by Campylobacter jejuni infection, consisted entirely of gamma delta TCR+ T lymphocytes. The peripheral blood of this patient also contained an increased frequency of gamma delta T cells when stimulated with C jejuni. The nerve derived T cell lines failed to show a proliferative response to bacterial antigens or to a preparation of myelin proteins. CONCLUSIONS: A new technique to isolate T cells from nerve biopsies in patients with Guillain-Barré syndrome and CIDP is reported. This technique may prove to be a useful tool in the investigation of the pathogenesis of other inflammatory neuropathies such as peripheral nerve vasculitis. The isolation of a gamma delta TCR+ nerve T cell line is of interest because of the possibility that these cells might respond to glycolipid epitopes common to C jejuni and peripheral nerve gangliosides.

Differential expression of glutathione S-transferase (GST) by adult Heligmosomoides polygyrus during primary infection in fast and slow responding hosts.

Glutathione S-transferase (GST) specific enzymatic activity, assayed with the model substrate 1-chloro-2,4-dinitrobenzene, was 45% higher in adult Heligmosomoides polygyrus passaged through a slow responder mouse strain, C57/BL10 compared to worms passaged through a fast-responder strain (SWR x SJL) F1. Western analysis using polyclonal antisera raised to purified H. polygyrus GSTs did not appear to positively correlate the expression of GST protein with functional enzymatic activity. However, western blotting did indicate a sex-linked expression pattern of GST protein, with male worms expressing a higher ratio of the 24 kDa to the 23 kDa GST family than female worms.

Glutathione binding proteins in the gastrointestinal nematode Heligmosomoides polygyrus.

A glutathione-affinity matrix was used to identify glutathione-dependent protein(s) in somatic extracts of the nematode Heligmosomoides polygyrus. Polypeptides of 70-80 kDa were retained by the affinity matrix following the elution of H. polygyrus glutathione S-transferases by 5 mM glutathione. The 70-80-kDa polypeptides were subsequently eluted from the matrix by the addition of 20 mM glutathione and these polypeptides did not show glutathione S-transferase activity. The high-affinity H. polygyrus glutathione-binding proteins may be related to the uncharacterized purification hindering factors previously demonstrated during the isolation of glutathione S-transferases in several other helminths.

Glutathione S-transferases from the gastrointestinal nematode Heligmosomoides polygyrus and mammalian liver compared.

Glutathione S-transferases have been partially characterised from the gastrointestinal nematode Heligmosomoides polygyrus. Two major subunit families were purified (24 and 23 kDa) with N-terminal homology to the mammalian Alpha family. Four dimeric forms of GST were purified from the nematode by glutathione-affinity chromatography, two major enzymes (pI 8.1, 5.0) and two minor forms (pI 5.8, 5.3). The purified GST pool could neutralize model and lipid peroxides via peroxidase activity but not peroxidation derived reactive carbonyls via glutathione transferase activity. Antisera raised to the pooled nematode GSTs appeared to recognize other Strongylida GSTs more strongly on Western blotting compared to mammalian GSTs.

Immunological relationships during primary infection with Heligmosomoides polygyrus: Th2 cytokines and primary response phenotype.

The primary immune response to infection with Heligmosomoides polygyrus was studied in mice differing in response phenotype (fast-SWR, intermediate-NIH, slow-CBA). Marked IgG1 and IgE but not IgG2a antibody responses were detected in infected mice and the former were more intense in fast compared with slow responder strains. Mastocytosis, MMCP-1, and the secretion of cytokines by mesenteric lymph node cells, following stimulation in vitro by Con A, were also more intense initially in SWR mice. Secretion of IL-4 declined in all strains by the 4th week of infection, irrespective of response phenotype. IL-10 was only produced briefly by SWR mice. However, the temporal patterns of secretion of IL-3 and IL-9 clearly distinguished fast from slow responder phenotypes. Following initial intense secretion of IL-3, production declined in all strains but in the 5-6th weeks enhanced secretion was evident in SWR and NIH mice and was sustained until week 10 p.i. In contrast, CBA mice never recovered from the initial down-regulation in weeks 3-4 and secretion declined to background levels by week 6 p.i. despite the continued presence of adult worms. Temporal changes in the secretion of IL-9 were very similar: secretion declined in CBA mice by week 6 p.i., whilst SWR and NIH mice continued to secrete high amounts. We suggest that fast and slow responder mice differ not only in their initial responsiveness to parasite antigens but also in their ability to sustain a Th2 response to the parasite and we propose that the latter is in part determined by their different susceptibilities to parasite-mediated immunomodulation. Only the fast responder strains can sustain a Th2 response of sufficient intensity to facilitate expulsion of adult worms.

Immunological relationships during primary infection with Heligmosomoides polygyrus (Nematospiroides dubius): downregulation of specific cytokine secretion (IL-9 and IL-10) correlates with poor mastocytosis and chronic survival of adult worms.

Mice were infected either with Trichinella spiralis (day 0), Heligmosomoides polygyrus (day-14) or concurrently with both species and were killed in groups, together with naïve control mice, on 2 occasions (day 8 and 15 post infection with T. spiralis, corresponding to days 22 and 29 p.i. with H. polygyrus). The expulsion of T. spiralis was slowed significantly in concurrently infected mice and this was associated with a reduced mastocytosis and lower serum mucosal mast cell protease levels. Mesenteric lymph node (MLN) lymphocytes from all three experimental groups secreted IL-3 and IL-4 in copious amounts when stimulated in vitro by Concanavalin A (Con-A), but the secretion of high levels of IL-9 and IL-10 was essentially confined to mice infected with T. spiralis alone. It is suggested that adult H. polygyrus selectively modulate cytokine secretion by Th2 cells within the MLN during infection and that this is brought about as a direct consequence of the mechanism employed by H. polygyrus to depress mucosal inflammatory responses in order to facilitate its own survival.