Risk of hospitalization and death for healthcare workers with COVID-19 in nine European countries, January 2020-January 2021.

This article presents and compares coronavirus disease 2019 attack rates for infection, hospitalization, intensive care unit (ICU) admission and death in healthcare workers (HCWs) and non-HCWs in nine European countries from 31st January 2020 to 13th January 2021. Adjusted attack rate ratios in HCWs (compared with non-HCWs) were 3.0 [95% confidence interval (CI) 2.2-4.0] for infection, 1.8 (95% CI 1.2-2.7) for hospitalization, 1.9 (95% CI 1.1-3.2) for ICU admission and 0.9 (95% CI 0.4-2.0) for death. Among hospitalized cases, the case-fatality ratio was 1.8% in HCWs and 8.2% in non-HCWs. Differences may be due to better/earlier access to treatment, differential underascertainment and the healthy worker effect.

Timing of two versus three doses of quadrivalent HPV vaccine and associated effectiveness against condyloma in Sweden: a nationwide cohort study.

OBJECTIVE: To assess incidence of condyloma after two doses of quadrivalent human papillomavirus (qHPV) vaccine, by time since first vaccine dose, in girls and women initiating vaccination before age 20 years. DESIGN: Register-based nationwide open cohort study. SETTING: Sweden. PARTICIPANTS: Girls and women initiating qHPV vaccination before age 20 years between 2006 and 2012. The study cohort included 264 498 girls, of whom 72 042 had received two doses of qHPV vaccine and 185 456 had received all three doses. MAIN OUTCOME MEASURE: Incidence rate ratios (IRRs) of condyloma estimated by time between first and second doses of qHPV in months (m) and age at vaccination, adjusted for attained age. RESULTS: For girls first vaccinated with two doses before the age of 17 years, the IRR of condyloma for 0-3 months between the first and second doses was 1.96 (95% CI 1.43 to 2.68) as compared with the standard three-dose schedule. The IRRs were 1.27 (95% CI 0.63 to 2.58) and 4.36 (95% CI 2.05 to 9.28) after receipt of two doses with 4-7 months and 8+ months between doses, respectively. For women first vaccinated after the age of 17 years, vaccination with two doses of qHPV vaccine and 0-3 months between doses was associated with an IRR of 2.12 (95% CI 1.62 to 2.77). For an interval of 4-7 months between doses, the IRR did not statistically significantly differ to the standard three-dose schedule (IRR=0.81, 95% CI 0.36 to 1.84). For women with 8+ months between dose 1 and dose 2 the IRR was 3.16 (95% CI 1.40 to 7.14). CONCLUSION: A two-dose schedule for qHPV vaccine with 4-7 months between the first and second doses may be as effective against condyloma in girls and women initiating vaccination under 20 years as a three-dose schedule. Results from this nationwide study support immunogenicity data from clinical trials.

The immunogenetics of narcolepsy associated with A(H1N1)pdm09 vaccination (Pandemrix) supports a potent gene-environment interaction.

The influenza A(H1N1)pdm09 vaccination campaign from 2009 to 2010 was associated with a sudden increase in the incidence of narcolepsy in several countries. Narcolepsy with cataplexy is strongly associated with the human leukocyte antigen (HLA) class II DQB1*06:02 allele, and protective associations with the DQB1*06:03 allele have been reported. Several non-HLA gene loci are also associated, such as common variants of the T-cell receptor-α (TRA), the purinergic receptor P2RY11, cathepsin H (CTSH) and TNFSF4/OX40L/CD252. In this retrospective multicenter study, we investigated if these predisposing gene loci were also involved in vaccination-associated narcolepsy. We compared HLA- along with single-nucleotide polymorphism genotypes for non-HLA regions between 42 Pandemrix-vaccinated narcolepsy cases and 1990 population-based controls. The class II gene loci associations supported previous findings. Nominal association (P-value<0.05) with TRA as well as suggestive (P-value<0.1) associations with P2RY11 and CTSH were found. These associations suggest a very strong gene-environment interaction, in which the influenza A(H1N1)pdm09 strain or Pandemrix vaccine can act as potent environmental triggers.

Increased ß-haemolytic group A streptococcal M6 serotype and streptodornase B-specific cellular immune responses in Swedish narcolepsy cases.

BACKGROUND: Type 1 narcolepsy is a neurological disorder characterized by excessive daytime sleepiness and cataplexy associated with the HLA allele DQB1*06:02. Genetic predisposition along with external triggering factors may drive autoimmune responses, ultimately leading to the selective loss of hypocretin-positive neurons. OBJECTIVE: The aim of this study was to investigate potential aetiological factors in Swedish cases of postvaccination (Pandemrix) narcolepsy defined by interferon-gamma (IFNγ) production from immune cells in response to molecularly defined targets. METHODS: Cellular reactivity defined by IFNγ production was examined in blood from 38 (HLA-DQB1*06:02(+) ) Pandemrix-vaccinated narcolepsy cases and 76 (23 HLA-DQB1*06:02(+) and 53 HLA-DQB1*06:02(-) ) control subjects, matched for age, sex and exposure, using a variety of different antigens: ß-haemolytic group A streptococcal (GAS) antigens (M5, M6 and streptodornase B), influenza (the pandemic A/H1N1/California/7/09 NYMC X-179A and A/H1N1/California/7/09 NYMC X-181 vaccine antigens, previous Flu-A and -B vaccine targets, A/H1N1/Brisbane/59/2007, A/H1N1/Solomon Islands/3/2006, A/H3N2/Uruguay/716/2007, A/H3N2/Wisconsin/67/2005, A/H5N1/Vietnam/1203/2004 and B/Malaysia/2506/2004), noninfluenza viral targets (CMVpp65, EBNA-1 and EBNA-3) and auto-antigens (hypocretin peptide, Tribbles homolog 2 peptide cocktail and extract from rat hypothalamus tissue). RESULTS: IFN-γ production was significantly increased in whole blood from narcolepsy cases in response to streptococcus serotype M6 (P = 0.0065) and streptodornase B protein (P = 0.0050). T-cell recognition of M6 and streptodornase B was confirmed at the single-cell level by intracellular cytokine (IL-2, IFNγ, tumour necrosis factor-alpha and IL-17) production after stimulation with synthetic M6 or streptodornase B peptides. Significantly, higher (P = 0.02) titres of serum antistreptolysin O were observed in narcolepsy cases, compared to vaccinated controls. CONCLUSION: ß-haemolytic GAS may be involved in triggering autoimmune responses in patients who developed narcolepsy symptoms after vaccination with Pandemrix in Sweden, characterized by a Streptococcus pyogenes M-type-specific IFN-γ cellular immune response.

Responses of fetal ovine systemic and umbilical arteries to angiotensin II.

Angiotensin II (ANG II) contracts umbilical arteries and has been hypothesized to regulate fetal blood pressure primarily by altering umbilical vascular resistance. To determine whether systemic arteries in term fetal sheep are sensitive to ANG II, isometric contraction of endothelium-intact isolated fetal renal, mesenteric, and umbilical arteries in response to ANG II was studied. ANG II (10(-7) M) elicited contractile responses in all three vessels (43 +/- 8%, 99 +/- 21%, and 105 +/- 5% of the maximal response seen with 90 mM KCl for renal, mesenteric, and umbilical arteries, respectively). The time course of the contractile responses differed among the vessels: renal and mesenteric arteries exhibited rapid transient contraction followed by relaxation, whereas umbilical artery displayed a more slowly developing but sustained contraction (1 +/- 0%, 3 +/- 1%,and 93 +/- 4% of maximal contractile response at 5 min, for renal, mesenteric, and umbilical arteries, respectively). The AT1 receptor antagonist, losartan (10(-6) M), abolished contractile responses in renal and mesenteric arteries but only slowed the contraction in umbilical artery in response to ANG II and had no effect on maximal tension. AT2 receptor blockade (PD 123319, 10(-7) M) had no significant effect on the response to ANG II in any vessel. Indomethacin (10(-6) M) significantly potentiated contraction to ANG II in renal and mesenteric but not umbilical arteries. Northern and Western blot analyses demonstrated the presence of AT1 mRNA and protein in all three vessels. Immunostaining for the AT1 receptor was present in endothelium and the tunica media. These findings demonstrate the AT1 receptor is present and functionally active in fetal systemic arteries and are consistent with previous findings that the umbilical circulation displays a greater responsiveness to ANG II than the systemic vasculature.

Ontogeny of CLCN3 chloride channel gene expression in human pulmonary epithelium.

Human fetal bronchopulmonary epithelia secrete liquid, and this chloride (Cl)-dependent process is important for normal lung growth. At the time of birth there is a maturational transition from a secretory to an absorptive phenotype. The pathways for Cl exit from the apical membrane which are required for fetal lung liquid secretion are unknown but are thought to be independent of the cystic fibrosis transmembrane conductance regulator. We determined the ontogeny of expression of the CLCN family of voltage-dependent Cl channel genes (CLCN2 through 6, K(a) and K(b)) in the human lung to identify potential pathways for pulmonary liquid secretion. Only CLCN3 and CLCN6 messenger RNA were detected by Northern analysis of fetal whole lung tissue. Ribonuclease protection assays confirmed the expression of CLCN3 and also revealed expression of CLCN2. The ontogeny of expression of these two channels was similar, peaking in midgestation and declining postnatally. In situ hybridization localized the CLCN2 and CLCN3 messages to airway and distal pulmonary epithelia and to pulmonary blood vessels. We conclude that CLCN3 is expressed in human airway epithelia and expression is developmentally regulated. The contribution of these channels to pulmonary epithelial liquid transport and lung development remains to be determined.

Role of Cl(-) channels in alpha-adrenoceptor-mediated vasoconstriction in the anesthetized rat.

In vitro studies have provided evidence that Cl(-) ion currents are important for activation of vascular smooth muscle contraction. The stilbene, 4,4'-diisothiocyanatostilbene-2,2'-disulfonic acid (DIDS), disrupts Cl(-) metabolism by blocking Cl(-) channels and by inhibiting Cl(-) bicarbonate exchange. The aims of this study were to: (i) characterize the hemodynamic responses produced by DIDS in pentobarbital anesthetized rats, and (ii) examine vasoconstrictor responses to norepinephrine before and after administration of DIDS. DIDS (2.5-50 micromol/kg, 92.5 micromol/kg total dose, i.v.) produced dose-dependent but transient reductions in mean arterial blood pressure and in hindquarter, renal and mesenteric vascular resistances. Prior to the administration of DIDS, norepinephrine (1. 0-5.0 microgram/kg, i.v.) produced dose-dependent increases in mean arterial pressure, renal resistance and mesenteric resistance, but decreases in hindquarter resistance that were inversely related to dose. After administration of DIDS, the peak pressor responses produced by norepinephrine were either slightly diminished (1.0, 2.5 microgram/kg) or unchanged (5.0 microgram/kg). Peak norepinephrine-induced changes in hindquarter and renal vascular resistance were unaffected by DIDS, while increases in mesenteric resistance were augmented. The total norepinephrine-induced increases in mean arterial pressure (mm Hgxs) were markedly reduced by DIDS. These effects of DIDS on norepinephrine-induced responses were similar, but not identical to those of the voltage-sensitive Ca(2+) channel blocker, nifedipine (500 nmol/kg, i.v.). These findings suggest that DIDS may interfere with norepinephrine-induced depolarization of resistance arteries, thereby preventing activation of voltage-sensitive Ca(2+) channels.

Complex RNA processing of TDRKH, a novel gene encoding the putative RNA-binding tudor and KH domains.

The sequence from a human EST (IMAGE:259322) with homology to the nucleotide-sensitive chloride conductance regulator (ICln) was used to screen a human aortic cDNA library. The probe sequence was from a region of the EST lacking homology to ICln, and the goal was to isolate an ICln-like gene. A 2843bp cDNA clone with an open reading frame coding for a 561 amino acid protein was isolated. This clone had no homology to ICln. PROSITE analysis of the putative protein sequence reveals one tudor and two K homology (KH) domains. The gene has therefore been named TDRKH. Both KH and tudor motifs are involved in binding to RNA or single-strand DNA. PCR analysis demonstrated that TDRKH is alternatively spliced in several ways and alternatively polyadenylated at multiple sites. Northern analysis confirmed the presence of messages of multiple lengths with predominant bands at 2.8 and 4.0 kb and also demonstrated that TDRKH is widely expressed in human tissues. Within an intron of TDRKH, there is a region with 90% homology to ICln. This sequence, which is incorporated into the alternatively spliced message represented by IMAGE:259322, contains a 2 bp deletion that disrupts the ICln reading frame and therefore represents an ICln pseudogene. The TDRKH gene was mapped to the Epidermal Differentiation Complex (EDC) at chromosome 1q21 by radiation hybrid mapping and STS content of genomic clones from that region. The EDC contains a large cluster of related genes involved in terminal differentiation of the epidermis. It remains to be determined whether TDRKH has a specific role in epithelial function.

Endothelium modulates anion channel-dependent aortic contractions to iodide.

Anion currents contribute to vascular smooth muscle (VSM) membrane potential. The substitution of extracellular chloride (Cl) with iodide (I) or bromide (Br) initially inhibited and then potentiated isometric contractile responses of rat aortic rings to norepinephrine. Anion substitution alone produced a small relaxation, which occurred despite a lack of active tone and minimal subsequent contraction of endothelium-intact rings (4.2 +/- 1.2% of the response to 90 mM KCl). Endothelium-denuded rings underwent a similar initial relaxation but then contracted vigorously (I > Br). Responses to 130 mM I (93.7 +/- 1.9% of 90 mM KCl) were inhibited by nifedipine (10(-6) M), niflumic acid (10(-5) M), tamoxifen (10(-5) M), DIDS (10(-4) M), and HCO(-)(3)-free buffer (HEPES 10 mM) but not by bumetanide (10(-5) M). Intact rings treated with N(omega)-nitro-L-arginine (10(-4) M) responded weakly to I (15.5 +/- 2.1% of 90 mM KCl), whereas hemoglobin (10(-5) M), indomethacin (10(-6) M), 17-octadecynoic acid (10(-5) M), and 1H-[1,2, 4]oxadiazole[4,3-a]quinoxalin-1-one (10(-6) M) all failed to augment the response of intact rings to I. We hypothesize that VSM takes up I primarily via an anion exchanger. Subsequent I efflux through anion channels having a selectivity of I > Br > Cl produces depolarization. In endothelium-denuded or agonist-stimulated vessels, this current is sufficient to activate voltage-dependent calcium channels and cause contraction. Neither nitric oxide nor prostaglandins are the primary endothelial modulator of these anion channels. If they are regulated by an endothelium-dependent hyperpolarizing factor it is not a cytochrome P-450 metabolite.

A prospective study of the use of a dobutamine stress test to identify outcome in patients with sepsis, severe sepsis, or septic shock.

OBJECTIVE: To more clearly define the relationship between an oxygen flux test, oxygen supply dependency, and outcome in patients with sepsis, severe sepsis, or septic shock. DESIGN: Prospective, interventional clinical trial. SETTING: A teaching hospital general intensive care unit in London, UK. PATIENTS: A total of 36 patients with sepsis, severe sepsis, or septic shock were studied during a 10-month period. INTERVENTIONS: After resuscitation, patients were given an intravenous infusion of dobutamine at 10 microg/kg/min for 1 hr. Cardiac and respiratory variables were measured before the infusion and then while the infusion was in progress. Any patient who was able to increase his or her oxygen consumption by >15% was designated a responder to the test. MEASUREMENTS AND MAIN RESULTS: Hemodynamic, oxygen transport, and lactate measurements were made at baseline and after 1 hr of the dobutamine infusion. All patients were then followed up until hospital discharge. Responders to this test had a hospital mortality of 14%, whereas nonresponders had a mortality of 91% (p<.01). The responders were characterized by being younger (p<.05), having higher Acute Physiology and Chronic Health Evaluation III scores (p<.05), and having a greater requirement for inotropic support (p<.05). After the test, the responders had significantly higher oxygen delivery (p<.01) and oxygen consumption (p<.05) than the nonresponders, as well as a significantly greater temperature increase as a result of the infusion (p<.05). The nonresponders were unable to increase either oxygen delivery or oxygen consumption to the dobutamine. This test was highly predictive of outcome (p<.0001). The identification of an increase in both oxygen delivery and oxygen consumption (oxygen supply dependency) was not associated with a poor outcome. CONCLUSION: A dobutamine oxygen flux test provides evidence of the intrinsic function of cells. The inability of these cells to increase oxidative metabolism during sepsis, as indicated by the dobutamine test, is associated with a high mortality.

Expression of CLCN voltage-gated chloride channel genes in human blood vessels.

Chloride (Cl) ion channels play a critical role in the response of both vascular smooth muscle (VSM) and endothelial (ENDO) cells to agonist stimulation. In VSM, agonist-induced Cl currents produce membrane depolarization, resulting in calcium influx through voltage-sensitive channels. ENDO cells also activate Cl currents after either agonist application or perturbation of cell volume. Although some of these currents have been characterized biophysically, the genes involved have not been identified. The CLCN family of voltage-dependent Cl channel genes comprises nine members (CLCN1-7, Ka and Kb) which demonstrate quite diverse functional characteristics while sharing significant sequence homology. We used Northern-blot analysis to study the expression of these Cl channel genes in cultured human aortic and coronary VSM cells and in aortic ENDO cells. CLCN3 is by far the most abundant CLC channel mRNA in both VSM and ENDO cells. Lower levels of expression are seen for CLCN2, CLCN4, CLCN5 and CLCN6. Expression levels were similar in VSM and ENDO cells except for CLCN4 which was more highly expressed in ENDO cells. In situ hybridization was used to confirm the expression of CLCN3 in intact human fetal lung. CLCN3 message was seen in VSM and ENDO cells of both large and small pulmonary vessels, indicating that their detection by Northern blotting was not an artifact of cell culture. CLCN3 is also expressed in pulmonary epithelial and bronchial smooth muscle cells but not in chondrocytes or pulmonary interstitial cells. Recent studies suggest that CLCN3 may encode the swelling-induced Cl conductance. We used whole cell patch clamp recording to demonstrate swelling-induced Cl currents in these cultured VSM cells. This suggests that the CLCN3 protein is expressed; however, the functional role of this current in VSM remains to be determined.

Faecal peritonitis causes oedema and neuronal injury in pig cerebral cortex.

Encephalopathy is a common complication of sepsis. However, little is known about the morphological changes that occur in the brain during sepsis. Faecal peritonitis was induced in pigs that were killed 8 h later and frontal cortex samples were taken immediately after death. The tissue was investigated using light and electron microscopy and compared with frontal cortex samples taken from sham-operated controls. Septic pigs had 49.5% more perimicrovessel oedema than sham pigs. However, the tight junctions between cerebral microvessel endothelial cells appeared morphologically intact in both septic and sham pigs. Sepsis also resulted in neuronal injury, disruption of astrocytic end-feet and swollen, rounded erythrocytes. These morphological changes may be sufficient to underlie the clinical features seen in septic encephalopathy.

Chloride ion currents contribute functionally to norepinephrine-induced vascular contraction.

Norepinephrine (NE) increases Cl- efflux from vascular smooth muscle (VSM) cells. An increase in Cl- conductance produces membrane depolarization. We hypothesized that if Cl- currents are important for agonist-induced depolarization, then interfering with cellular Cl- handling should alter contractility. Isometric contraction of rat aortic rings was studied in a bicarbonate buffer. Substitution of extracellular Cl- with 130 mM methanesulfonate (MS; 8 mM Cl-) did not cause contraction. NE- and serotonin-induced contractions were potentiated in this low-Cl- buffer, whereas responses to K+, BAY K 8644, or NE in the absence of Ca2+ were unaltered. Substitution of Cl- with I- or Br- suppressed responses to NE. Inhibition of Cl- transport with bumetanide (10(-5) M) or bicarbonate-free conditions (10 mM HEPES) inhibited NE- but not KCl-induced contraction. The Cl--channel blockers DIDS (10(-3) M), anthracene-9-carboxylic acid (10(-3) M), and niflumic acid (10(-5) M) all inhibited NE-induced contraction, whereas tamoxifen (10(-5) M) did not. Finally, disruption of sarcoplasmic reticular function with cyclopiazonic acid (10(-7) M) or ryanodine (10(-5) M) prevented the increase in the peak response to NE produced by low-Cl- buffer. We conclude that a Cl- current with a permeability sequence of I- > Br- > Cl- > MS is critical to agonist-induced contraction of VSM.

The endothelium modulates the contribution of chloride currents to norepinephrine-induced vascular contraction.

Activation of a Cl- current is critical to agonist-induced activation of rat aortic smooth muscle contraction. Substituting extracellular Cl- with 130 mM methanesulfonate (8 mM Cl-) increases the contractile response to norepinephrine (NE) but not to KCl. We hypothesized that endothelial factors modulate this effect. Removing the endothelium (rubbing) or treatment with N-nitro L-arginine (L-NNA) markedly increased the potentiation of NE-induced contraction by low-Cl- buffer. Indomethacin had no effect. The previously demonstrated ability of Cl--channel blockers (DIDS, anthracene-9-carboxylic acid, niflumic acid) or Cl- transport inhibitors (bumetanide, bicarbonate-free buffer) to inhibit responses to NE was not altered by L-NNA. Low-Cl- buffer alone did not contract intact rings but produced nifedipine-sensitive contractile responses after rubbing or L-NNA treatment. These data suggest that the Cl- conductance of smooth muscle in intact blood vessels is low but increases with withdrawal of reduced nitric oxide (NO') or agonist stimulation. Rubbing or L-NNA increased the sensitivity of rings to KCl but not to NE. Nifedipine reduced both sensitivity and maximum response to NE in intact vessels. L-NNA increased the maximum response to NE in nifedipine-treated rings without changing sensitivity. We conclude that although NO' affects both the voltage-dependent and voltage-independent components of contraction, sensitivity to NE is determined by the voltage-dependent portion. The voltage change required for a full response to NE is dependent on activation of a Cl- current that may be under the tonic regulatory influence of NO'.

Linkage of infantile Bartter syndrome with sensorineural deafness to chromosome 1p.

Bartter syndrome (BS) is a family of disorders manifested by hypokalemic hypochloremic metabolic alkalosis with normotensive hyperreninemic hyperaldosteronism. We evaluated a unique, inbred Bedouin kindred in which sensorineural deafness (SND) cosegregates with an infantile variant of the BS phenotype. Using a DNA-pooling strategy, we screened the human genome and successfully demonstrated linkage of this unique syndrome to chromosome 1p31. The genes for two kidney-specific chloride channels and a sodium/hydrogen antiporter, located near this region, were excluded as candidate genes. Although the search for the disease-causing gene in this family continues, this linkage further demonstrates the genetic heterogeneity of BS. In addition, the cosegregation of these phenotypes allows us to postulate that a single genetic alteration may be responsible for the SND and the BS phenotype. The identification and characterization of this gene would lead to a better understanding of the normal physiology of the kidney and the inner ear.