Tick-Borne Encephalitis Virus Nonstructural Protein 1 IgG Enzyme-Linked Immunosorbent Assay for Differentiating Infection versus Vaccination Antibody Responses.

Tick-borne encephalitis virus (TBEV) is an important central nervous system (CNS) infection in Europe and Asia. It is a flavivirus in the tick-borne group. Effective vaccines against TBE are available in the affected countries. However, diagnosing TBE is challenging due to cross-reactive antibodies between different viruses of the genus Flavivirus, family Flaviviridae. Differentiation between infection-induced and vaccine-induced antibodies can be difficult and in many cases impossible, due to the increasing vaccination rate against TBEV. We present a new approach to detect antibodies against the TBEV nonstructural protein 1 (NS1) as a diagnostic marker, which is exclusively indicative for virus replication in natural infection, on the basis of an enzyme-linked immunosorbent assay (ELISA). A total of 188 anonymous serum samples from the National Consultant Laboratory for TBEV were included in our study. The assay was validated according to the European Laboratory Norm DIN EN ISO 15189 for diagnostic use. The ELISA for the detection of TBEV NS1 specific IgG class antibodies has demonstrated a sensitivity of >94% and a specificity of >93% in broadly cross-reacting sera from patients with vaccinations against flaviviral diseases and single or multiple flavivirus infections, respectively. The detection of anti-NS1 antibodies is feasible and facilitates reliable differentiation between different flavivirus infections, TBEV infection, and TBE vaccination.

Implementing an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a 200-bed community hospital in Germany.

BACKGROUND: Prescription of third-generation cephalosporins and fluoroquinolones has been linked to an increasing incidence of gram-negative bacteria producing extended-spectrum beta-lactamases, methicillin-resistant Staphylococcus aureus and nosocomial infection with Clostridium difficile. Antibiotic stewardship (ABS) programmes offer evidence-based tools to control antibiotic prescription rates and thereby influence the incidence of nosocomial infection and contain the development of multidrug-resistant bacteria, but there is limited experience with such programmes at community hospitals. METHODS: We implemented an ABS programme at a 200-bed community hospital and aimed at a > 30 % reduction of cephalosporin and fluoroquinolone consumption within 1 year. Pharmacy data were obtained to estimate hospital-wide drug use density expressed in WHO-ATC-defined daily doses (DDD) or hospital-adapted recommended daily doses (RDD) per 1,000 patient days. The effect of the ABS intervention on drug use density was analysed using interrupted time-series analysis for the periods between January 2011 and March 2013 as pre-intervention, and between April 2013 and March 2014 as post-intervention period. The CDI incidence was calculated based on microbiology laboratory data. RESULTS: Cephalosporin use (measured in RDD/1,000 patient days) decreased by 33 %, and fluoroquinolone use decreased by 31 %, respectively. Interrupted time-series analysis confirmed significant changes in the drug use density trends for both cephalosporins and fluoroquinolones after the intervention as well as for total antibiotic use that decreased by 11 % while no significant effect was noted for CDI incidence rates. CONCLUSION: ABS programmes can be effective in community hospitals and may help establish ecologically advantageous antibiotic strategies when needed.

[Pilot project of a pediatric antibiotic stewardship initiative at the Hauner children's hospital]. / Pilotprojekt einer pädiatrischen Antibiotic-Stewardship-Initiative am Dr. von Haunerschen Kinderspital - neue Wege der pädiatrischen Infektiologie.

The steady increase in antimicrobial resistance is of growing concern in healthcare. Antibiotic Stewardship [ABS] Strategies are important tools to control antibiotic use and -prevent antimicrobial resistance. An increasing number of institutions are developing ABS initiatives also in pediatrics. However, few data are available assessing the implementation and efficiency of these pediatric ABS programs.At the Dr. von Hauner Children's Hospital, Ludwig-Maximilian University, a tertiary care pediatric reference center, a pediatric ABS Team has been implemented. Key structural elements were the same as for adult patients, but antimicrobials agents selected for monitoring and appropriate clinical endpoints are different in pediatrics.Key features were: 1. prospective-audit with feedback and formulary restriction and 2. pre-authorization (also referred to as prior approval). The ABS team consisted of one pediatric infectious disease specialist, one clinical fellow in pediatric infectious diseases, and one clinical pharmacist with training in infectious diseases.With the implementation of a pediatric ABS strategy we could significantly influence antimicrobial consumption in our hospital. Cost-savings are estimated to be above 330 000 € per year, and concomitantly the use of broad-spectrum antibiotics and antifungal compounds was significantly reduced.Antibiotic Stewardship [ABS] Strategies may be an effective tool to control antibiotic use in the setting of a large tertiary pediatric teaching hospital. A national guideline for ABS initiatives may help to further improve rational use of antibiotics in the hospital setting.

Tick-borne encephalitis virus vaccination breakthrough infections in Germany: a retrospective analysis from 2001 to 2018.

OBJECTIVES: There are few data available regarding the clinical course of tick-borne encephalitis virus (TBEV) vaccination breakthrough infections. The published studies suggest that vaccination breakthrough infections may have a more severe course than native TBEV infection in unvaccinated individuals-potentially due to antibody-dependent enhancement. Here we report a large analysis of vaccination breakthrough infections. METHODS: This retrospective analysis was based on a national surveillance dataset spanning the years 2001-2018. Variables reflecting disease severity, such as 'CNS symptoms', 'myelitis', 'fatal outcome' and 'hospitalization' were analysed as well as general epidemiological variables. Cases were categorized as 'unvaccinated' or 'ever vaccinated', the latter category including cases with at least one dose of a TBEV vaccine. RESULTS: A total of 6073 notified TBEV infection cases were included in our analysis. Sufficient data on vaccination status were available for 95.1% of patients (5777/6073); of these, 5298 presented with a native infection. A total of (334/5777) cases developed an infection despite having been vaccinated at least once. Comparing unvaccinated patients with those with at least one vaccination, we find an odds ratio (OR) 2.73, (95% confidence interval (CI) 0.79-9.50) regarding the variable fatal outcome that did not reach statistical significance. Analysing the clinical variables 'CNS symptoms' and 'myelitis', there is no difference between these groups (OR 0.86, 95% CI 0.68-1.08; and OR 1.30, 95% CI 0.74-2.27 respectively). Patients who were vaccinated and had an assumed protection at symptom onset (n = 100) had a higher risk for the development of myelitic symptoms (OR 2.21, 95% CI 1.01-4.86]) than unvaccinated patients. CONCLUSION: Our findings could neither verify that vaccination breakthrough infections might cause a more severe disease than native infections nor prove a clear antibody-dependent enhancement phenomenon. It remains unclear whether the increased myelitis risk in a subgroup of vaccinated patients is a true effect or confounded.

Sequences involved in initiation of simian virus 40 late transcription in the absence of T antigen.

We analyzed the sequences involved in vivo in the initiation of simian virus 40 (SV40) late transcription occurring in the absence of both SV40 origin sequences and T antigen. The constituent elements of the SV40 late promoters have already been the subject of extensive studies. In vitro studies have resulted in the description of two putative domains of the late promoters. The first domain consists of an 11-base-pair (bp) sequence, 5'-GGTACCTAACC-3', located 25 nucleotides (nt) upstream of the SV40 major late initiation site (MLIS) (J. Brady, M. Radonovich, M. Vodkin, V. Natarajan, M. Thoren, G. Das, J. Janik, and N. P. Salzman, Cell 31:624-633, 1982). The second domain is located within the G-C-rich region (J. Brady, M. Radonovich, M. Thoren, G. Das, and N. P. Salzman, Mol. Cell. Biol. 4:133-141; U. Hansen and P. A. Sharp, EMBO J. 2:2293-2303). Our previous in vivo studies permitted us to define a domain of the late promoter which extends from nt 332 to nt 113 and includes the 72-bp enhancer sequences. Here, by using transfection of the appropriate chimeric plasmids into HeLa cells in conjunction with quantitative S1 nuclease analysis, we analyzed in more detail the sequences required for the control of SV40 late-gene expression occurring before the onset of viral DNA replication. We showed that the major late promoter element is in fact the 72-bp repeat enhancer element. This element was able to drive efficient late transcription in the absence of T antigen. Under our experimental conditions, removal of the G-C-rich region (21-bp repeats) entailed a significant increase in the level of late-gene expression. Moreover, translocation of this element closer to the MLIS (53 nt upstream of the MLIS) enhanced the level of transcripts initiated at natural late initiation sites. Our results suggest that the G-C-rich regions have to be positioned between the enhancer element and the initiation sites to stimulate transcription from downstream sites. Thus, the relative arrangement of the various promoter elements is a critical factor contributing to the situation in which the early promoter is stronger than late promoters before viral DNA replication.

Conversion through homologous recombination of the gene encoding Simian virus 40 115,000-molecular-weight super T antigen to a gene encoding a normal-size large T antigen variant.

We have previously cloned the gene encoding a 115,000-Mr super T antigen (115K super T antigen), an elongated form of the Simian virus 40 large T antigen, originating from the rat cell line V 11 F1 clone 1, subclone 7 (May et al., J. Virol. 45:901-913, 1983). DNA sequence analysis has shown that the 115K super T antigen gene contains notably an in-phase duplication of a sequence located in the region of tsA mutations. We have also shown that the 115K super T antigen gene is able to induce the formation of transformed foci in transfected rat cells. After rat cell cultures were transfected with the cloned gene encoding 115K super T antigen, we obtained a large number of transformants as reported in this paper. In these transformants, we detected a very high frequency of new T antigen variants, as shown by immunoprecipitation of the cell extracts with anti-simian virus 40 tumor serum followed by electrophoresis in sodium dodecyl sulfate-polyacrylamide gels. Based on these results and all of the data presently available, it appears likely that the input plasmid or cosmid DNAs containing the cloned gene were first subjected to recombination events that yield new variant T antigen genes before these recombinant genes become integrated. The new variant T antigens observed in the transformants were predominantly those comigrating with normal-size large T antigen. In fact, these latter variants appeared to be indistinguishable from wild-type large T antigen as judged by restriction mapping by Southern blotting of the total genomic DNA of the transformants. Models of intermolecular or intramolecular homologous recombination occurring between or within the input plasmid or input cosmid DNA molecules are proposed to account for the formation of such revertants.

Heart transplantation as salvage therapy for progressive prosthetic valve endocarditis due to methicillin-resistant Staphylococcus epidermidis (MRSE).

BACKGROUND: Prosthetic valve endocarditis (PVE) has the highest in-hospital mortality among all cases of infective endocarditis (IE), it is estimated at about 40 %. Orthotopic heart transplantation (OHT) as a measure of last resort, may be considered in selected cases where repeated surgical procedures and conservative efforts have failed to eradicate persistent or recurrent IE. Only few clinical data are available regarding this rare indication for OHT, since active IE has traditionally been considered as a contraindication for OHT. CASE PRESENTATION: We report on a 55 year old male patient who underwent prosthetic valve replacement with a mechanical valved conduit ten years ago and developed now persistent PVE with severe complications due to methicillin-resistant Staphylococcus epidermidis (MRSE). Repeated surgical procedures and conservative efforts have failed to eradicate the pathogen. Regarding the lack of curative options, salvage OHT was discussed as a measure of last resort. 28 months after the first diagnosis of PVE, the patient was successfully transplanted and is now doing well under close follow-up (6 months post-OHT). CONCLUSIONS: PVE remains a challenging condition regarding diagnosis and treatment. The presented case underscores the urgent need for an integrated and multidisciplinary approach to patients with suspected and definitive IE - especially in PVE. OHT might be a feasible measure of last resort in selected patients with IE. Our case report adds published clinical experience to this rarely performed procedure and consolidates previous findings.

Induction of apoptosis by transiently transfected metabolically stable wt p53 in transformed cell lines.

Biochemical and functional properties of wild-type (wt) and mutant p53 were studied under the same cellular environment by transient transfection. Exogenous wt p53 expressed in transformed cell lines was found to be as metabolically stable as mutant p53. Yet only mutant p53 bound to hsp70 whereas wt p53 did not, suggesting that the metabolic stability of p53 does not depend on its ability to form complexes with hsp70. The wt protein was expressed essentially in the nucleus, while mutant p53 showed both nuclear and cytoplasmic expression, as determined by immunofluorescence staining with PAb122. In addition, staining with PAb1801 revealed a number of strongly fluorescent cell fragments in cultures transfected by wt p53. Morphological features of apoptosis were observed in these cultures. Quantitative analysis by flow cytometry confirmed that only the cell population expressing wt p53 had a significant amount of cell debris. Thus, transient expression of a metabolically stable wt, but not mutant, p53 induces cell death by apoptosis. The present study demonstrates a model system to investigate the functional domains of p53 in the induction of apoptosis.

Sulfadiazine-related obstructive urinary tract lithiasis: an unusual cause of acute renal failure after kidney transplantation.

We report on the first case of acute renal failure related to obstructive urinary tract lithiasis involving sulfadiazine crystals in a kidney transplant recipient. This patient had disseminated toxoplasmosis which was treated by sulfadiazine (4 g/day) and pyrimethamine (50 mg/day). In the fourth week of anti-toxoplasmosis therapy, he presented with obstructive acute renal failure: the plasma creatinine level increased from 220 micromol/l to 547 micromol/l. Apercutaneous pyelography was conducted showing the presence of a lithiasis located at the junction between the graft ureter and the bladder. Six days later, he underwent surgery to retrieve an orange-colored, friable stone. Its spectrophotometric analysis confirmed that the stone consisted of N-acetyl sulfadiazine crystals.

[Surgical abstention in splenic injuries in children. Under what conditions?]. / L'abstention chirurgicale dans les traumatismes spléniques de l'enfant. A quelles conditions?

The authors report a series of 33 cases of documented splenic lesions which were not operated on. In their opinion non-surgical management is justified, thanks to the progress in ultrasonography and intensive care monitoring. They define out the modalities of this therapeutic choice.

[Failure of primary management of developmental dislocation of the hip: 31 years experience in Normandy]. / Echecs de la prise en charge initiale de la maladie luxante de la hanche en Haute-Normandie: analyse sur une période de 31 années consécutives (1968-1998).

PURPOSE OF THE STUDY: Primary management of developmental dislocation of the hip involves a series of events (clinical screening and detection, choice and interpretation of imaging studies, indication and proper execution of treatment). Each event has an important effect on outcome and failure may result from inadequate attention to any one. We analyzed the causes of failure observed over 31 years experience in our region. MATERIAL AND METHODS: We analyzed the files of children hospitalized in the Rouen Infantile Surgery Department from 1968 to 1998 for management of congenital dislocation of the hip diagnosed late (> 3 months) or for revision after inappropriate treatment. We identified 353 files. This series was retrospective from 1968 to 1985 (283 cases) and prospective from 1986 to 1998 (70 cases). RESULTS: Up through 1981, failed detection of developmental dislocation of the hip was identified in 10 to 27 children per year (mean 21.5). Since 1982, this rate has varied from 1 to 10 (mean 6.5). The number of children treated before the age of one year was 10.5 per year up through 1981 then 4.5 per year after 1982. The number of children treated after the age of one year was 11 per year through 1981 then 2 per year after 1982. Since 1986, treatment was undertaken for failure of primary management in 57 children after clinical diagnosis, in 3 children after radiological and ultrasonographic diagnosis, and in 11 children during the course of treatment. Standard x-ray studies systematically obtained at four months corrected the diagnosis in 24 children. The diagnosis was corrected after repeating the examination in 14 children before the age of one year. Correct diagnosis was established after the age of one year in 18 children. DISCUSSION: Although our University Department was the only referral center for pediatric surgery in our region during this period, these figures cannot be compared with the annual birth rate in the region (24,000 births/year) because the number of infants managed in other centers is unknown. Nevertheless, organizing regular follow-up by a pediatric orthopedic surgeon of all infants screened positive in the maternity ward enabled a 70% reduction in the number of failures since 1982. Systematic clinical screening, repeated regularly during the first year of life, has reduced the mean age of diagnosis. Neither ultrasonography nor radiography has replaced physical examination. Care must also be taken to avoid over reliance on ultrasound findings which do not correspond to clinical findings. Amongst the children treated late, 14% had undergone an inappropriate treatment for dislocation correctly identified during the neonatal period. Referring all children screened positive to a pediatric orthopedic surgeon should help reduce this rate.

[Urinary malformations in synostoses of the cervical vertebrae (Klippel-Feil syndrome). Apropos of 35 cases]. / Malformations urinaires dans les synostoses du rachis cervical (syndrome de Klippel-Feil). A propos de trente-cinq cas.

A study of 35 cases of congenital fusion of the cervical vertebrae demonstrated the high incidence of its association with urinary anomalies (52 per cent). More than half of these cases concerned unilateral kidney defects. The urinary anomalies are normally asymptomatic, but there is always the risk of chronic renal failure, and preventive surgery may be necessary. It is therefore advisable to make a systematic practice of obtaining ultrasound examinations and intravenous urograms. There are many other possible associated anomalies, which are often the first to be noted and lead to the discovery of the vertebral and urinary malformations. The authors define Klippel-Feil syndrome as the synostosis of two or more cervical vertebrae.

[Digestive duplications affecting the pharynx or fistulae of the fourth endo-branchial pouch. Four cases (author's transl)]. / Duplications digestives de localisation pharyngée ou fistules de la quatrième poche endo-branchiale.

Four cases of children with recurrent latero-cervical epithelial cystic tumours which where identified as exceptional derivatives of the 4th endobranchial pouch on the basis of their connections with the pharynx and in particular the piriform fossa. The opportunity is taken to review the characteristics of equally rare digestive, duplications and congenital diverticula at a cervical and buccopharyngeal level. This diagnosis was made initially in the first of these cases.

[Hepatitis B reactivation following immunosuppressive therapy and screening adherence: a neglected problem?]. / Hepatitis-B-Reaktivierung unter Chemotherapie und Screening-Adhärenz: ein unterschätztes Problem?

BACKGROUND: Current guidelines of the "Centers for Disease Control and Prevention [CDC]" recommend routine screening for Hepatitis B before cytotoxic or immunosuppressive therapies are initiated. The national German guideline "Prophylaxis, diagnosis and therapy of hepatitis B virus infection" is in line with the CDC recommendations and underscores general HBV screening before immunosuppression is induced. However, screening adherence and acceptance of these guidelines vary in different oncological specialities. To assess the HBV screening adherence a retrospective study was performed. PATIENTS AND METHODS: Data of 140 patients were analyzed retrospectively. 37 case-records did not meet inclusion criteria. Patients diagnosed with breast-cancer (n = 43) and Hodgkin's disease (n = 14) requiring chemotherapy were included, as well as patients receiving allogenic stem cell transplantation (SCTx) therapy (n = 22) or transarterial chemoembolization (TACE) therapy of the liver (n = 24). All included case-records were reviewed regarding HBV and HCV serology. RESULTS: In the TACE group three patients were screened for HBsAg. Four patients with breast cancer and five patients in the Hodgkin disease group were screened for HBsAg. In contrast, screening adherence was 100 % in the group of patients receiving allogenic stem cell transplantation therapy (n = 22). CONCLUSION: Apart from patients with allogenic stem cell transplantation, only some patients receiving immunosuppressive therapies had been screened for HBV infection. Our data indicate that standardized checklists may improve HBV screening previous to immunosuppressive therapies. These clinical structures have led to an almost optimal screening adherence in the high-risk group of allogenic SCTx patients.