Filling the Gap - Improving Awareness and Practice in Hyponatraemia and the Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) in the Older Patient: A European Consensus View.

Introduction: Causes of hyponatraemia in older patients are multivariate and in the case of SIADH may often be drug induced. Diagnostic and treatment algorithms are unclear for this important age group. Methods: The author group identified 6 broad themes for consensus and formulated 42 separate consensus statements within these 6 themes. Statements were then circulated to geriatricians, general practitioners and other doctors to test agreement at the European level. Results: 64 responses were evaluated from around Europe. Agreement was achieved in 86% of the statements following amendment and redistribution of 6 of the statements. The survey and its feedback prompted the development of 13 recommendations related to the diagnosis and treatment of hyponatraemia including SIADH. Conclusion: The series of 13 recommendations developed here is intended to increase clarity for clinicians managing older patients with hyponatraemia and SIADH. Surprisingly, despite the lack of clear guidelines or recommendations for this age group consensus levels for the author-based statements were high among the respondents.

Highlighting clinical needs in Clostridium difficile infection: the views of European healthcare professionals at the front line.

BACKGROUND: Clostridium difficile infection (CDI) is the leading cause of infectious nosocomial diarrhoea in Europe. Despite increased focus, its incidence and severity are increasing in many European countries. AIM: We developed a series of consensus statements to identify unmet clinical needs in the recognition and management of CDI. METHODS: A consortium of European experts prepared a series of 29 statements representing their collective views on the diagnosis and management of CDI in Europe. The statements were grouped into the following six broad themes: diagnosis; definitions of severity; treatment failure, recurrence and its consequences; infection prevention and control interventions; education and antimicrobial stewardship; and National CDI clinical guidance and policy. These statements were reviewed using questionnaires by 1047 clinicians involved in managing CDI, who indicated their level of agreement with each statement. FINDINGS: Levels of agreement exceeded the 66% threshold for consensus for 27 out of 29 statements (93.1%), indicating strong support. Variance between countries and specialties was analysed and showed strong alignment with the overall consensus scores. CONCLUSION: Based on the consensus scores of the respondent group, recommendations are suggested for the further development of CDI services in order to reduce transmission and recurrence and to ensure that appropriate diagnosis and treatment strategies are applied across all healthcare settings.

Feline leukemia virus envelope sequences that affect T-cell tropism and syncytium formation are not part of known receptor-binding domains.

The envelope protein is a primary pathogenic determinant for T-cell-tropic feline leukemia virus (FeLV) variants, the best studied of which is the immunodeficiency-inducing virus, 61C. We have previously demonstrated that T-cell-tropic, cytopathic, and syncytium-inducing viruses evolve in cats infected with a relatively avirulent, transmissible form of FeLV, 61E. The envelope gene of an 81T variant, which encoded scattered single-amino-acid changes throughout the envelope as well as a 4-amino-acid insertion in the C-terminal half of the surface unit (SU) of envelope, was sufficient to confer the T-cell-tropic, cytopathic phenotype (J. L. Rohn, M. S. Moser, S. R. Gwynn, D. N. Baldwin, and J. Overbaugh, J. Virol. 72:2686-2696, 1998). In the present study, we examined the role of the 4-amino-acid insertion in determining viral replication and tropism of FeLV-81T. The 4-amino-acid insertion was found to be functionally equivalent to a 6-amino-acid insertion at an identical location in the 61C variant. However, viruses expressing a chimeric 61E/81T SU, containing the insertion together with the N terminus of 61E SU, were found to be replication defective and were impaired in the processing of the envelope precursor into the functional SU and transmembrane (TM) proteins. In approximately 10% of cultured feline T cells (3201) transfected with the 61E/81T envelope chimeras and maintained over time, replication-competent tissue culture-adapted variants were isolated. Compensatory mutations in the SU of the tissue culture-adapted viruses were identified at positions 7 and 375, and each was shown to restore envelope protein processing when combined with the C-terminal 81T insertion. Unexpectedly, these viruses displayed different phenotypes in feline T cells: the virus with a change from glutamine to proline at position 7 acquired a T-cell-tropic, cytopathic phenotype, whereas the virus with a change from valine to leucine at position 375 had slower replication kinetics and caused no cytopathic effects. Given the differences in the replication properties of these viruses, it is noteworthy that the insertion as well as the two single-amino-acid changes all occur outside of predicted FeLV receptor-binding domains.

In vivo evolution of a novel, syncytium-inducing and cytopathic feline leukemia virus variant.

Studies of feline leukemia virus (FeLV) have illustrated the importance of the genotype of the infecting virus in determining disease outcome. In FeLV infections, as in other retroviral infections, it is less clear how virus variants that evolve from the transmitted virus affect pathogenesis. We previously reported an analysis of the genotypic changes that occur in the viral envelope gene (env) in cats infected with a prototype transmissible FeLV clone, 61E (J. Rohn, M. Linenberger, E. Hoover, and J. Overbaugh, J. Virol. 68:2458-2467, 1994). In one cat, each variant (81T) had evolved, in addition to scattered amino acid changes, a four-amino-acid insertion with respect to 61E. This insertion was located at the same site in the extracellular envelope glycoprotein where the immunodeficiency-inducing molecular clone 61C possesses a six-amino-acid insertion critical for its pathogenic phenotype, although the sequences of the insertions were distinct. To determine whether acquisition of the four-amino-acid insertion was associated with a change in the replication or cytopathic properties of the virus, we constructed chimeras encoding 81T env genes in a 61E background. One representative chimeric virus, EET(TE)-109, was highly cytopathic despite the fact that it replicated with delayed kinetics in the feline T-cell line 3201 compared to the parental 61E virus. The phenotype of this virus was also novel compared to other FeLVs, including both the parental virus 61E and the immunodeficiency-inducing variant 61C, because infection of T cells was associated with syncytium formation. Moreover, in single-cycle infection assays, the 81T-109 envelope demonstrated receptor usage properties distinct from those of both 61E and 61C envelope. Thus, these studies demonstrate the evolution of a novel T-cell cytopathic and syncytium-inducing FeLV in the host. The 81T virus will be valuable for dissecting the mechanism of T-cell killing by cytopathic variants in the FeLV model.

Viral genetic variation, AIDS, and the multistep nature of carcinogenesis: the feline leukemia virus model.

Feline leukemia virus (FeLV) infection in cats serves as a valuable animal model system for understanding the mechanisms of human diseases such as cancer and immunodeficiency. We have used experimental infection with molecularly cloned viruses to isolate and characterize novel FeLV variants that evolved in vivo and that were associated with the development of thymic lymphoma. One variant, FeLV-81T, contained a mutated envelope gene that conferred cytopathicity, enhanced replication rate, and syncytium induction in feline T cells, and is reminiscent of immunodeficiency-inducing strains of FeLV. Another variant transduced a portion of the feline Notch2 gene, which was expressed as a novel truncated protein in the cell nucleus and which we believe functioned as an oncogene in the development of T cell malignancy. Understanding how FeLV variants that either stimulate or destroy lymphocytes evolve and interrelate during disease progression will help elucidate the mechanisms of retroviral pathogenicity.

Human foamy virus replication: a pathway distinct from that of retroviruses and hepadnaviruses.

Human foamy virus (HFV) is the prototype of the Spumavirus genus of Retroviridae. In all other retroviruses, the pol gene products, including reverse transcriptase, are synthesized as Gag-Pol fusion proteins and are cleaved to functional enzymes during viral budding or release. In contrast, the Pol protein of HFV is translated from a spliced messenger RNA and lacks Gag domains. Infectious HFV particles contain double-stranded DNA similar in size to full-length provirus, suggesting that reverse transcription has taken place in viral particles before new rounds of infection, reminiscent of hepadnaviruses. These data suggest that foamy viruses possess a replication pathway containing features of both retroviruses and hepadnaviruses but distinct from both.