Protein Enrichment of Familiar Foods as an Innovative Strategy to Increase Protein Intake in Institutionalized Elderly.

OBJECTIVE: To increase the protein intake of older adults, protein enrichment of familiar foods and drinks might be an effective and attractive alternative for oral nutritional supplements (ONS). We performed a pilot study to test whether these products could help institutionalized elderly to reach a protein intake of 1.2 gram per kg body weight per day (g/kg/d). DESIGN: Intervention study with one treatment group (no control group). Dietary assessment was done before and at the end of a 10-day intervention. SETTING: Two care facilities in Gelderland, the Netherlands: a residential care home and a rehabilitation center. PARTICIPANTS: 22 elderly subjects (13 women, 9 men; mean age 83.0±9.4 years). INTERVENTION: We used a variety of newly developed protein enriched regular foods and drinks, including bread, soups, fruit juices, and instant mashed potatoes. MEASUREMENTS: Dietary intake was assessed on two consecutive days before and at the end of the intervention, using food records filled out by research assistants. Energy and macronutrient intake was calculated using the 2013 Dutch food composition database. Changes in protein intake were evaluated using paired t-tests. RESULTS: Protein intake increased by 11.8 g/d (P=0.003); from 0.96 to 1.14 g/kg/d (P=0.002). This increase is comparable to protein provided by one standard portion of ONS. The intake of energy and other macronutrients did not change significantly. At the end of the intervention more elderly reached a protein intake level of 1.2 g/kg/d than before (9 vs 4). Protein intake significantly increased during breakfast (+3.7 g) and during the evening (+2.2 g). CONCLUSION: Including familiar protein enriched foods and drinks in the menu helped to meet protein recommendations in institutionalized elderly.

Elaboration of microbiological guidelines as an element of codes of hygienic practices for small and/or less developed businesses to verify compliance with hazard analysis critical control point.

Effective assurance of microbiological food safety practices in small and/or less developed businesses is not yet resolved. Although a start has been made by drafting hygiene codes, feasible methods for verifying manufacturing processes that rely on strict and meaningful criteria to be applied to process points are still lacking. This investigation is a model study with various types of ready-to-eat foods aimed at verifying adequate processing for safety and subsequent meticulous hygienic handling and safe storage of foods in small and/or less developed businesses by the use of quantitative methods for selected indicator organisms, as standardized by the International Organization for Standardization. The manufacture of the foods that were used in this study invariably included (i) a heat processing step that ensured a level of lethality of nonsporing organisms at least equivalent to the reduction of such organisms attained in the pasteurization of milk and (ii) effective means of prevention of postprocess recontamination and recolorization. The results of this study indicate that simple microbiological criteria used for this purpose, including aerobic mesophilic colony (standard plate) counts, Enterobacteriaceae counts, and, in some instances, enumeration of yeast propagules, allow adequate verification of good practices throughout. This verification through monitoring of samples taken during processing in small and/or less developed businesses was found to be an attractive alternative to the conventional examination of end products.

[Limited tuberculin screening participation amongst travellers to countries with high tuberculosis incidence; reason to consider BCG vaccination for some travellers]. / Beperkte deelname aan tuberculinescreening onder reizigers naar landen met hoge tuberculose-incidentie; reden om voor sommigen BCG-vaccinatie te overwegen.

OBJECTIVE: To determine the compliance amongst Dutch travellers to high tuberculosis-incidence countries with a screening procedure involving a tuberculin skin test before and after the trip. DESIGN: Prospective study. METHOD: Nine hundred and eighty-eight tuberculin-negative Dutch people who travelled to high tuberculosis-incidence countries for 3 to 12 months were studied for their compliance with an advised screening procedure of repeat tuberculin skin testing 2 to 4 months after return. At 2 of the 4 participating health services, data were also collected on extra calls made and the pertinent time investments. RESULTS: Five hundred and ninety-nine travellers (61%) were compliant with the screening procedure. Of those for whom the data was available (n = 417), 33% (98/300) of the compliant travellers required extra calls. These took an average of 30 min per extra traveller tested as a result. Compliance varied according to health service and was better amongst travellers to Africa. In addition, non-compliance was independently associated with male sex, work being the main travel purpose, and an undecided duration of travel on departure. CONCLUSIONS: Compliance of Dutch travellers with tuberculin skin-test screening is limited, particularly if no extra calls are issued. Bacillus Calmette-Guérin vaccination appears to be preferable for travellers with undecided travel duration and persons travelling for work on a frequent basis.

[Transmission of multiresistant tuberculosis in a Dutch hospital]. / Transmissie van multiresistente tuberculose in een Nederlands ziekenhuis.

Nosocomial transmission of multiresistant tuberculosis in the Netherlands is described for the first time in this article. It was detected by systematic country-wide DNA-fingerprinting. By the time the contact case (a man aged 35) developed disease he was residing in another part of the country. Contact-investigation by the Municipal Health Services involved revealed that the (HIV negative) contact case had been in contact with the index case (a man aged 27) during hospitalisation two years earlier. An analysis of the infection control measures applied, showed that inadequate treatment, early discharge from isolation and lack of bacteriological control (no sputum conversion documented) led to this hospital transmission.

Erythrocyte antibody screening in solid-phase: a comparison of two solid-phase microplate assays with the indirect antiglobulin test in polyethylene glycol for the detection of irregular erythrocyte antibodies.

The screening of a serum for irregular erythrocyte antibodies in the indirect antiglobulin test is a well-established technique. We compared the test results of two different solid-phase microplate indirect antiglobulin tests with a liquid-phase indirect antiglobulin test in tubes. Antibody screening with both solid-phase microplate techniques proved to be more sensitive than the liquid-phase indirect antiglobulin test. In addition, a difference in sensitivity between the two solid-phase techniques was observed: prior immobilization of test erythrocytes on the microplate followed by incubation with a serum and detection of sensitization with antihuman IgG-coated detector cells gave better test results than secondary immobilization on the microplate of test erythrocytes sensitized with antibodies and an antihuman globulin serum.

Transplantation of highly sensitized patients on the basis of acceptable HLA-A and B mismatches.

We think that the determination of acceptable mismatches is an efficient approach to increase the chance of finding a crossmatch-negative donor for highly sensitized patients. This approach has several advantages (4,5) namely: 1. There is no need for distribution of patient sera to other tissue typing centers. 2. Rather than performing crossmatches with all donors, most of which will be positive, selection is based on a predictable negative crossmatch. 3. Selection of potential donors is based on data obtained by the recipient centers, which has all the information concerning the patient's immunological background (transfusion, specific alloantibodies, autoantibodies) rather than on a negative crossmatch at another tissue typing center. 4. Selection is based on HLA-DR compatibility between donor and recipient, which is, both in our and other analyses (6), important for an optimal prognosis of graft survival in highly immunized patients. Of course, there are still patients for whom this protocol is not very helpful (rare HLA-types, hardly any or no acceptable mismatches). For these patients it might be that other approaches, including removal of circulating antibodies (7), may be the only solution.

Immunoglobulin genes, HLA-B8/DR3, and immune responsiveness to primary immunogen and mitogens in normal subjects.

The genetic regulation of immune responsiveness by genes from two independent, highly polymorphic genetic systems, namely immunoglobulin allotypes and human leukocyte antigens (HLA), was studied in 35 healthy Caucasian volunteers. The in vivo IgG class antibody response to the primary test immunogen alpha-helix pomatia hemocyanin (HPH) was increased in subjects with the Gm1,17;..;21 haplotype compared to that of the non-Gm1,17;..;21 group. The IgM-class response tended to be higher in the former group. Levels of in vivo IgA-class-specific anti-HPH antibodies tended to be higher in the group of individuals positive for HLA-B8/DR3 than in the non-B8/DR3 group. This difference was statistically significant only in the absence of the Gm1,17;..;21 haplotype. The in vitro lymphocyte proliferative response on mitogenic stimulation with phytohemagglutinin (1 micrograms/ml) and pokeweed mitogen (10 micrograms/ml) also appeared to be associated with both systems. The presence of the Gm1,17;..;21 haplotype was associated with decreased lymphocyte reactivity, whereas the B8/DR3 phenotype was associated with high responsiveness to these mitogens. However, in the presence of the Gm1,17;..;21 haplotype subjects positive for HLA-B8/DR3 did not respond better to mitogenic stimulation than those lacking this HLA haplotype. Our results imply that the immunogenetic make-up of test persons should be taken into account in the assessment of the immune status of individuals or groups of patients.

Expression of major histocompatibility complex antigens and replacement of donor cells by recipient ones in human liver grafts.

The disappearance of certain cell populations of donor origin and their replacement by recipient-specific cells constitutes a possible explanation for the relatively mild course of acute rejection despite lack of MHC compatibility in human orthotopic liver transplantation (OLT). In the present report, graft biopsies of 12 OLT patients from a total of 42 patients were studied for expression of MHC antigens after transplantation using monoclonal antibodies to HLA-ABC and HLA-DR. The patients were selected based upon donor-recipient mismatching for HLA-A2, B7, Drw52, or DQw1. Monoclonal antibodies to these 4 polymorphic HLA antigens and monoclonal antibodies to HLA-ABC and -DR were applied to frozen tissue sections and visualized using an immunoperoxidase technique. Expression of HLA-ABC and -DR on, respectively, hepatocytes and bile duct epithelium were observed in posttransplant graft conditions such as viral infections, cholangitis, and acute rejection. However, no specific pattern of MHC antigen distribution was observed for these various pathological graft conditions. Disappearance of DR-positive Kupffer cells of donor origin and immigration of recipient ones was encountered in the early posttransplant biopsies. This Kupffer cell replacement coincided with a reversible episode of acute rejection. The disappearance of highly immunogenic cellular components as HLA-DR positive Kupffer cells of graft origin may be one of the mechanisms contributing to the mild rejection response observed in human liver transplantation.

HLA-B POT: a new HLA-antigen within the B7-cross reactive group.

In this report, a new HLA-B locus antigen is described (tentatively called POT). The antigen has been identified with antisera against the antigens that belong to the B7-cross reacting group. In a collaborative study, based on exchange of cells and sera, it was confirmed by population and family studies that the antigen is distinct from B7, Bw42 or Bw73 and is associated with Bw6. In absorption experiments with EBV-transformed cell lines, the POT-antigens removes preferentially anti-B7, Bw42 and Bw73 activity and to a lesser extent antibodies reactive with the B40 CREG-antigens.

Kinetic analysis of the blood clearance and organ uptake curves of IgG-coated red cells in HLA-typed controls and patients with Wegener's granulomatosis.

Reticuloendothelial function and HLA type were studied in 22 controls and 15 patients with Wegener's granulomatosis (WG). IgG-coated red cells were injected intravenously and half-life times of blood disappearance and liver spleen uptake curves were related to the degree of antibody coating. Erythrocytes with 13,990 molecules of IgG per cell gave biexponential blood disappearance curves and were suitable for measuring splenic reticuloendothelial function. Half-life times thus obtained were not significantly different for individuals with the HLA-DR2 or DR3 phenotype. In WG patients with major disease activity, blood clearance of the injected cells was considerably decreased. Kinetic analysis of blood disappearance and spleen uptake curves revealed that this was partly due to a decrease in reversible trapping of the cells in the spleen. This suggests that a blocking effect of circulating immune complexes on splenic Fc receptors is not likely to be the sole cause of the observed hyposplenism.

HLA-DRw6 as a risk factor for active cytomegalovirus but not for herpes simplex virus infection after renal allograft transplantation.

To study genetically determined susceptibility to cytomegalovirus and herpes simplex virus infections in patients given renal transplants a prospective study was performed of 68 consecutive patients receiving their first cadaveric kidney allograft. The recipients positive for HLA-DRw6 showed a significantly increased incidence of active cytomegalovirus infection as early as the 10th week after transplantation (p less than 0.05). No relation with other human leucocyte antigens was found, nor did a correlation exist between HLA typing and the incidence of herpes simplex virus infections. Furthermore, recipients positive for HLA-DRw6 with secondary cytomegalovirus infections excreted infectious virus more often (p less than 0.01) and showed more clinical symptoms (p less than 0.01) than a comparable group of recipients negative for HLA-DRw6. These observations may have practical implications for the treatment of patients who have had renal transplant operations.

Maintenance of cytomegalovirus (CMV) latency and host immune responses of long term renal allograft survivors. II. Secondary CMV infections associated with impaired in vitro proliferative responses to mitogens, allogeneic lymphocytes and CMV infected cells.

The relationship between secondary cytomegalovirus (CMV) infections and host general cellular immunocompetence was investigated in 16 renal allograft recipients with minimal immunosuppressive treatment and excellent renal function. Results were compared with 19 CMV seropositive healthy controls. Significantly impaired immune responses were detected in the subgroup of nine recipients who experience at least 2 years before a secondary CMV infection. Their in vitro lymphocyte reactivity (LR) tests to phytohaemagglutinin (PHA, P = 0.01), pokeweed mitogen (PWM, P less than 0.05), microbial antigens (P less than 0.001) and to pooled allogeneic stimulator lymphocytes in the MLC test (P = 0.02) were lower than the controls. The MLC responses, however, increased with graft survival time (r = 0.8810, P = 0.01). This was positively correlated with the virus specific cellular immunity measurable by the LR responses to CMV infected target cells (r = 0.8333, P = 0.02). In contrast, long term renal allograft survivors who maintained their CMV infection in latency after transplantation (n = 7) showed normal responses to PWM, pooled lymphocytes and CMV infected target cells, whereas the responses to PHA and to bacterial antigens were less severely impaired (P less than 0.05 and P less than 0.001, respectively). This study of long term renal allograft survivors shows that a secondary CMV infection has a long lasting negative effect on immunity especially against alloantigens and CMV infected targets. However, in the data presented here it would be as acceptable to suggest that the patients are consistently relapsing with CMV because they initially had poor immune response and not vice versa.

Maintenance of cytomegalovirus (CMV) latency and host immune responses of long term renal allograft survivors. I. Prolonged suppression of in vitro lymphocyte responses against CMV infected fibroblasts related to previous secondary CMV infection.

Cytomegalovirus (CMV) specific humoral and cellular immunity was investigated in 16 renal allograft recipients with long term graft survival (26-122 months) who were shown to be CMV seropositive before transplantation. Results were compared with healthy individuals with latent CMV infections. Recipients (n = 9) who experienced a symptomatic secondary CMV infection shortly after transplantation (less than 6 months), showed a prolonged but finally temporary suppression of their in vitro lymphocyte memory responses against CMV infected fibroblasts (CMV-FF; median SI: 1.9), a persistence of high antibody titres against intracellular CMV antigens and most of them also had antibodies against CMV membrane antigens (CMV MA). In contrast the recipients (n = 7) who could maintain their CMV in latency after transplantation, had lower antibody titres and their in vitro memory lymphocyte responses against CMV-FF (median SI: 9.3) were comparable to those of the healthy controls (median SI: 11.6). The memory lymphocyte responses against purified CMV virions were depressed in both recipient groups. These results suggest that cellular immunity against CMV infected target cells constitute an important mechanism in maintaining CMV in latency after allografting.

HLA-B8/DR3 phenotype and the primary immune response.

Increased frequency of HLA-B8/DR3 has been reported in many organ-specific and systemic autoimmune diseases. Immune responsiveness in 11 normal subjects with and 22 without the B8/DR3 phenotype was studied. The IgA class immune response after immunization with the primary test immunogen alpha-Helix pomatia hemocyanin (HPH) was increased in B8/DR3-positive subjects compared to the non-B8/DR3 group. Also, IgG class antibody levels tended to be higher in the former group. The in vitro lymphocyte proliferative response to optimal concentrations of HPH did not differ between the groups nor did the response to allogeneic cells. Lymphocyte proliferation on stimulation with pokeweed mitogen and suboptimal concentration of phytohemagglutinin was increased in B8/DR3 individuals. It is concluded that the phenotype B8/DR3 is associated with a high humoral immune response.