Transcriptomic response and immunological responses to chimpanzee adenovirus- and MVA viral-vectored vaccines for RSV in healthy adults.

Cohorts of healthy younger adults (18-50yrs) and healthy older adults (60-75yrs) were immunized intramuscularly or intranasally with an adenovirus-vectored RSV vaccine (PanAd3-RSV) as a prime dose and boosted with PanAd3-RSV or a poxvirus-vectored vaccine (MVA-RSV) encoding the same insert. Whole blood gene expression was measured at baseline, 3- and 7-days post vaccination. Intramuscular prime vaccination with PanAd3-RSV induced differential expression of 643 genes (DEGs, FDR < 0.05). Intranasal prime vaccination with PanAd3-RSV did not induce any differentially expressed genes (DEGs) in blood samples at 3 days post vaccination. Intranasally primed participants showed greater numbers of DEGS on boosting than intramuscularly primed participants. The most highly enriched biological processes related to DEGs after both prime and boost vaccination were type-1 interferon related pathways, lymphocytic and humoral immune responses.

Humoral and cellular immunity to RSV in infants, children and adults.

BACKGROUND: Respiratory syncytial virus (RSV) causes respiratory disease throughout life. Here we report differences in naturally acquired immunity with age and presumed exposure. METHODS: A longitudinal, non-interventional, observational study was performed in healthy adults (20 paediatric healthcare workers and 10 non-healthcare workers), children (10 aged 3-6 years) and infants (5 aged 2-4 months and 20 aged 6-12 months). Blood samples were analysed for RSV-neutralising antibody titre, F/Ga/Gb-specific antibody titres, F-specific IgG/IgA memory B-cell frequencies and T-cell production of IFNγ, IL-4, IL-13 and IL-17. RESULTS: Serum G-specific antibody titres were significantly lower in infants and children than adults. However, serum titres of F-specific and RSV-neutralising antibody and IFNγ-producing T-cell frequencies were low or absent in the infants, but comparable between children and adults. Interestingly, F-specific memory IgA B-cells could not be detected in paediatric samples and in samples from non-healthcare workers, but recordable IgA memory B-cells were found in 9/18 paediatric healthcare workers and 2/8 non-healthcare workers at the end of the RSV season. These responses waned 4-6 months later. By contrast, F-specific IgG memory B-cells were detectable in samples from all adults without significant variation across time points. T-cells producing IL-4, IL-13 and IL-17 responses were not detectable in peripheral blood from a subset of volunteers. CONCLUSIONS: Repeated RSV exposure in early life generates immune responses that are inversely related to frequency of severe disease. Induction of F-specific antibody and cellular immune responses through infant vaccination might help to accelerate the development of protective immune responses at an early age. Clinicaltrials.gov reference NCT01563692 and NCT01640652.

La disociación en niños y adolescentes: la variabilidad en la expresión clínica a propósito de dos casos / Dissociation in children and adolescents: the variability in clinical expression in relation to two cases

El término disociación ha pasado de constituir una entidad nosológica a ser relegado a un síntoma, apareciendo disgregado en las diferentes clasificaciones internacionales actuales, lo que lo lleva a ser un concepto teórico, confuso y generador de controversia. El diagnóstico por exclusión que esto implica, hace que sea un trastorno infradiagnosticado en la práctica clínica, lo que trae consigo la escasez de publicaciones, especialmente en población infanto-juvenil. Se debe entender cómo la respuesta a un fenómeno postraumático expresándose clínicamente dependiendo de la propia resiliencia del sujeto. Se exponen dos casos clínicos contrapuestos (disociación mente-mente vs mentecuerpo) que han necesitado ingreso hospitalario. Se precisarían más publicaciones sobre esta patología, para ofrecer a los clínicos un enfoque amplio que facilite el diagnóstico de la disociación como entidad mórbida y no únicamente como diagnóstico de exclusión, así como su tratamiento y pronóstico

The term dissociation has gone from being a nosological conception to being relegated to a symptom, appearing nowadays, disintegrated into different international classifications, which leads to a theoretical, confusing and controversial concept generator. The diagnosis of exclusion that this entails, makes it an underdiagnosed disorder in clinical practice, which brings about the shortage of publications, especially in child population. It should be understood as the response to a post-traumatic phenomenon, variably expressed depending on the resiliency of the subject. We expose two counterposed clinical cases (mind-mind vs mind-body dissociation) that needed hospitalization. More publications focused on this disease are needed to offer clinicians a wide focus to help on diagnosis, treatment and prognosis as a disorder and not being only an exclusion-diagnosis syndrome

Safety and immunogenicity of novel respiratory syncytial virus (RSV) vaccines based on the RSV viral proteins F, N and M2-1 encoded by simian adenovirus (PanAd3-RSV) and MVA (MVA-RSV); protocol for an open-label, dose-escalation, single-centre, phase 1 clinical trial in healthy adults.

INTRODUCTION: Respiratory syncytial virus (RSV) infection causes respiratory disease throughout life, with infants and the elderly at risk of severe disease and death. RSV001 is a phase 1 (first-in-man), open-label, dose-escalation, clinical trial of novel genetic viral-vectored vaccine candidates PanAd3-RSV and modified vaccinia virus Ankara (MVA)-RSV. The objective of RSV001 is to characterise the (primary objective) safety and (secondary objective) immunogenicity of these vaccines in healthy younger and older adults. METHODS AND ANALYSIS: Heterologous and homologous 'prime'/boost combinations of PanAd3-RSV and single-dose MVA-RSV are evaluated in healthy adults. 40 healthy adults aged 18-50 years test one of four combinations of intramuscular (IM) or intranasal (IN) PanAd3-RSV prime and IM PanAd3 or IM MVA-RSV boost vaccination, starting at a low dose for safety. The following year an additional 30 healthy adults aged 60-75 years test either a single dose of IM MVA-RSV, one of three combinations of IN or IM PanAd3-RSV prime and PanAd3-RSV or MVA-RSV boost vaccination used in younger volunteers, and a non-vaccinated control group. Study participants are self-selected volunteers who satisfy the eligibility criteria and are assigned to study groups by sequential allocation. Safety assessment includes the daily recording of solicited and unsolicited adverse events for 1 week after vaccination, as well as visit (nursing) observations and safety bloods obtained at all scheduled attendances. Laboratory measures of RSV-specific humoral and cellular immune responses after vaccination will address the secondary end points. All study procedures are performed at the Centre for Clinical Vaccinology and Tropical Medicine (CCVTM), Oxford, UK. ETHICS AND DISSEMINATION: RSV001 has clinical trial authorisation from the Medicines and Healthcare Products Regulatory Agency (MHRA) and ethics approval from NRES Berkshire (reference 13/SC/0023). All study procedures adhere to International Conference on Harmonisation (ICH) Good Clinical Practice guidelines. The results of the trial are to be published in peer-reviewed journals, conferences and academic forums. TRIAL REGISTRATION NUMBER: NCT01805921.

Why a carefully designed, nurse-led intervention failed to meet expectations: the case of the Care Programme for Palliative Radiotherapy.

PURPOSE OF THE RESEARCH: Implement and evaluate the Care Programme for Palliative Radiotherapy (CPPR) in the Outpatient Clinic of the Department of Radiotherapy, Erasmus MC-Cancer Institute, Rotterdam, The Netherlands. METHODS: Participatory Action Research (PAR). Qualitative descriptive design: participatory observations, semi-structured interviews with patients and professionals and focus groups with professionals; content analysis of documents. SAMPLE: Patients with impending paraplegia due to metastatic spinal cord compression, nurse practitioners (NPs), nurse manager, staff and ward nurses, radiographers, radiotherapists and medical doctors. KEY RESULTS: After a shift from inpatient to outpatient radiotherapy treatment, patients and healthcare professionals perceived shortcomings in the oncological chain care. The CPPR was developed in a participative way giving a key role to the NP. Evaluation after implementation of the programme showed that patients and professionals were predominantly positive about its effects. However, implementation was not sustained due to lack of institutional and managerial support. CONCLUSIONS: The technological innovation far preceded the organisational changes needed to provide innovative, patient-centred care. Implementing this programme with a central role for the NP was seen as the solution to the problems identified. However, in spite of the systematic approach using PAR, the programme was not successful in bringing about sustained improvements. NPs fulfil a valuable role in the care and support of patients with palliative care needs but need institutional support. More attention should have paid to the organisational context. Involve all relevant actors; use a participatory approach to enhance commitment; ensure the support of management during the whole project.

Kinetics of the neutralizing antibody response to respiratory syncytial virus infections in a birth cohort.

The kinetics of respiratory syncytial virus (RSV) neutralizing antibodies following birth, primary and secondary infections are poorly defined. The aims of the study were to measure and compare neutralizing antibody responses at different time points in a birth cohort followed-up over three RSV epidemics. Rural Kenyan children, recruited at birth between 2002 and 2003, were monitored for RSV infection over three epidemic seasons. Cord and 3-monthly sera, and acute and convalescent sera following RSV infection, were assayed in 28 children by plaque reduction neutralization test (PRNT). Relative to the neutralizing antibody titers of pre-exposure control sera (1.8 log10 PRNT), antibody titers following primary infection were (i) no different in sera collected between 0 and 0.4 months post-infection (1.9 log10 PRNT, P=0.146), (ii) higher in sera collected between 0.5 and 0.9 (2.8 log10 PRNT, P<0.0001), 1.0-1.9 (2.5 log10 PRNT, P<0.0001), and 2.0-2.9 (2.3 log10 PRNT, P<0.001) months post-infection, and (iii) no different in sera collected at between 3.0 and 3.9 months post-infection (2.0 log10 PRNT, P=0.052). The early serum neutralizing response to secondary infection (3.02 log10 PRNT) was significantly greater than the early primary response (1.9 log10 PRNT, P<0.0001). Variation in population-level virus transmission corresponded with changes in the mean cohort-level neutralizing titers. It is concluded that following primary RSV infection the neutralizing antibody response declines to pre-infection levels rapidly (~3 months) which may facilitate repeat infection. The kinetics of the aggregate levels of acquired antibody reflect seasonal RSV occurrence, age, and infection history.

The natural history of respiratory syncytial virus in a birth cohort: the influence of age and previous infection on reinfection and disease.

This study aimed to quantify the effect of age, time since last infection, and infection history on the rate of respiratory syncytial virus infection and the effect of age and infection history on the risk of respiratory syncytial virus disease. A birth cohort of 635 children in Kilifi, Kenya, was monitored for respiratory syncytial virus infections from January 31, 2002, to April 22, 2005. Predictors of infection were examined by Cox regression and disease risk by binomial regression. A total of 598 respiratory syncytial virus infections were identified (411 primary, 187 repeat), with 409 determined by antigen assay and 189 by antibody alone (using a "most pragmatic" serologic definition). The incidence decreased by 70% following a primary infection (adjusted hazard ratio = 0.30, 95% confidence interval: 0.21, 0.42; P < 0.001) and by 59% following a secondary infection (hazard ratio = 0.41, 95% confidence interval: 0.22, 0.73; P = 0.003), for a period lasting 6 months. Relative to the age group <6 months, all ages exhibited a higher incidence of infection. A lower risk of severe disease following infection was independently associated with increasing age (P < 0.001) but not reinfection. In conclusion, observed respiratory syncytial virus incidence was lowest in the first 6 months of life, immunity to reinfection was partial and short lived, and disease risk was age related.

Nestling development and the timing of tick attachments.

Parasites exposed to fast-developing hosts experience a variety of conditions over a short time period. Only few studies in vertebrate-ectoparasite systems have integrated the timing of ectoparasite infestations in the host's development into the search for factors explaining ectoparasite burden. In this study we examined the temporal pattern of attachment in a nidicolous tick (Ixodes arboricola) throughout the development of a songbird (Parus major). In the first experiment, we exposed bird clutches at hatching to a mix of the 3 tick instars (larvae, nymphs and adults), and monitored the ticks that attached in relation to the average broods' age. In a complementary experiment we focused on the attachment in adult female ticks--the largest and most significant instar for the species' reproduction--after releasing them at different moments in the nestlings' development. Our observations revealed a positive association between the size of the attached instar and the broods' age. Particularly, adult females were less likely to be found attached to recently hatched nestlings, which contrasts with the smaller-sized larvae and nymphs. These differences suggest either an infestation strategy that is adapted to host physiology and development, or a result of selection by the hosts' anti-tick resistance mechanisms. We discuss the implications of our results in terms of tick life-history strategies.

Novel mitochondrial DNA length variants and genetic instability in a family with diabetes and deafness.

We have identified two locations with novel multiplasmic length variants in the mitochondrial DNA of a family with diabetes and deafness. At nt568 in the D-loop, the 6-bp polycytidine tract was found to be variable in length up to a total of 12 residues. A second region with length variants was found at nt8281 in the intergenic COII-tRNA(Lys) region, which consists of two copies of the 9-bp repeat CCCCCTCTA. Only the second repeat occurs in a heteroplasmic C(9-14)A form with both T residues largely deleted. In addition, the mtDNA contained a number of new homoplasmic point mutations. Both length variants are stably inherited in a maternal way with no major changes in their length distribution. In contrast, during culture of fibroblasts from the proband the average length of the polycytidine tracts is increased at both locations indicating a fibroblast-specific genetic instability. Cybrid cells containing mtDNA from the proband proliferate less efficient than cybrids with wild-type mtDNA in co-culture experiments, suggesting functional consequences of the mtDNA length variants or the additional homoplasmic point mutations. Since oxygen consumption was not severely affected, these mutation seem less detrimental for mitochondrial function than the A3243G diabetogenic mutation and most other pathogenic mtDNA mutations. The contribution of mtDNA length variants to the phenotype of members of this family is discussed.

Function of local networks in palliative care: a Dutch view.

BACKGROUND: Although network formation is considered an effective method of stimulating the integrated delivery of palliative care, scientific evidence on the usefulness of network formation is scarce. In 1998 the Ministry of Health of The Netherlands started a 5-year stimulation program on palliative care by founding and funding six regional Centres for the Development of Palliative Care. These centers were structured around pivotal organizations such as university hospitals and comprehensive cancer centers. As part of the stimulation program a locoregional network model was introduced within each center for the Development of Palliative Care to integrate palliative care services in the Dutch health care system. OBJECTIVE: We performed a study on network formation in the southwestern area of The Netherlands with 2.4 million inhabitants. The study aimed to answer the following questions: (1) how do networks in palliative care develop, which care providers participate and how do they function? (2) which are the achievements of the palliative care networks as perceived by their participants? (3) which are the success factors of the palliative care networks according to their participants and which factors predict the achievements? DESIGN: Between September 2000 and January 2004 eight local palliative care networks in the region of the Center for Development of Palliative Care-Rotterdam (southwestern area of The Netherlands) were closely followed to gain information on their characteristics and developmental course. MEASUREMENTS: At the start of the study semistructured interviews were held with the coordinators of the eight networks. The information from these interviews and from the network documents were used to constitute a questionnaire to assess the opinions and experiences of the network participants. RESULTS: According to the vast majority of responders, the most important reason to install the networks was the lack of integration between the existing local health care services. The networks were initiated to stimulate mutual collaboration, improve accessibility to health care services and increase the quality of these services. The most important achievements obtained by the palliative care networks were: increase in personal contacts between colleagues in a region, improved engagement and collaboration between participating organizations, enhanced insight in the health care provisions, joined initiatives for the development of new care products, and organization of patient-tailored care. Important success factors for the networks were deemed: fruitful mutual contacts, regular funding and the collective development of care products. By logistic regression analyses, the collective development of new care products and the organization of case discussions between caregivers from different health care services turned out to be the most important predictors for success of the palliative care networks. CONCLUSIONS: Projects that stimulate the communication between professionals appear to improve the mutual collaboration between individual participants and between the participating organizations, which consequently enhances the quality of palliative care.

Accidentes de tráfico atendidos por una unidad de soporte vital avanzado. Análisis de factores pronósticos / Road traffic accidents assisted by an advanced vital support unit. Analysis of prognostic factors

Objetivos: Describir los accidentes de tráfico atendidos por una Unidad de Soporte Vital Avanzado (USVA), la magnitud que éstos representan en nuestra actividad así como determinar aquellos factores que permitan predecir la mortalidad. Métodos: Estudio observacional descriptivo en el que se han recogido de forma prospectiva los accidentes de tráfico que han requerido la atención de la USVA de A Coruña (España) durante el período de un año. Resultados: Se encontraron diferencias significativas entre profundidad del coma, medido con la escala de Glasgow (GCS), y la mortalidad. Las variables asociadas estadísticamente con la mortalidad al realizar el análisis de regresión logística fueron el GCS (OR= 0,77) y el traumatismo torácico (OR= 3,37). Conclusiones: Bajos valores en la escala de Glasgow y tener traumatismo torácico se muestran como los factores relacionados con una mayor mortalidad (AU)

Range of planning in music performance.

Two factors influence the range of planning in music performance; the structural content of musical events and the serial distances between them. In this experiment, pianists memorized and performed polyphonic music (which contained multiple simultaneous voices) in which the serial distance and phrase structure between the entrances of 2 musical voices were varied. The distance between each musical element and its influence on other elements was assessed in production errors and interonset timing measures. Errors and timing measures offered converging evidence for interactive effects of serial distance and phrase structure; intervening phrase boundaries reduced the serial distances over which musical elements influenced one another. These findings suggest structural as well as linear constraints on the planning of complex sequences.

Separate structural elements within internal transcribed spacer 1 of Saccharomyces cerevisiae precursor ribosomal RNA direct the formation of 17S and 26S rRNA.

Structural features of Internal Transcribed Spacer 1 (ITS1) that direct its removal from Saccharomyces cerevisiae pre-rRNA during processing were identified by an initial phylogenetic approach followed by in vivo mutational analysis of specific structural elements. We found that S. cerevisiae ITS1 can functionally be replaced by the corresponding regions from the yeasts Torulaspora delbrueckii, Kluyveromyces lactis and Hansenula wingei, indicating that structural elements required in cis for processing are evolutionarily conserved. Despite large differences in size, all ITS1 regions conform to the secondary structure proposed by Yeh et al. [Biochemistry 29 (1990) 5911-5918], showing five domains (I-V; 5'-->3') of which three harbour an evolutionarily highly conserved element. Removal of most of domain II, including its highly conserved element, did not affect processing. In contrast, highly conserved nucleotides directly downstream of processing site A2 in domain III play a major role in production of 17S, but not 26S rRNA. Domain IV and V are dispensable for 17S rRNA formation although an alternative, albeit inefficient, processing route to mature 17S rRNA may be mediated by a conserved region in domain IV. Each of these two domains is individually sufficient for efficient production of 26S rRNA, suggesting two independent processing pathways. We conclude that ITS1 is organized into two functionally and structurally distinct halves.

Units of knowledge in music performance.

The units of knowledge that form cognitive plans for music performance were examined in production errors. In Experiment 1, pianists performed multivoice homophonic music (containing strong across-voice associations) and polyphonic music (containing strong within-voice associations). Pitch errors reflected more chordal (across-voice) units in homophonic performances and more single-note units in polyphonic performances. Error instructions were harmonically and diatonically related to their intended pitches more often than chance, which demonstrates retrieval-based influences on planning. In Experiment 2, pianists conceptualized one of several voices as melody. Both the melody and the voice controlled by outer right-hand fingers (a common location of melody) contained fewer errors, which implies that there are conceptual, retrieval-based, and articulatory influences on units of knowledge that contribute to planning music performance.

Adaptive monitoring in the ICU: a dynamic and contextual study.

The wealth of physiological data made available by current medical monitoring systems can be used efficiently only if the monitoring system is capable of relieving human personnel of relatively low-level tasks by performing intelligent data interpretation, contextual analysis and advice tasks. The system described in this paper can choose the variables to which most processing time will be devoted on the basis of the evolution of the patient.

A system to study transcription by yeast RNA polymerase I within the chromosomal context: functional analysis of the ribosomal DNA enhancer and the RBP1/REB1 binding sites.

We have developed a novel system to study transcription by yeast RNA polymerase I (Pol I) of mutated rDNA units within the chromosomal context. For this, complete rDNA units carrying specific oligonucleotide tags in both the 17S and 26S rRNA genes were integrated into the chromosomal rDNA locus. Using this novel system, we analysed the action of the rDNA enhancer in stimulating transcription within the chromosomal context. We found that the enhancer acts as a stimulatory element in both directions, mainly on its two most proximal rRNA operons. Deletion of the sequences between the enhancer and the Pol I promoter in the tagged, integrated unit indicated that this part of the intergenic spacer contains no other transcriptional regulatory elements for Pol I. We also applied the system to study the function of the rDNA binding protein RBP1/REB1. For this purpose, we analysed tagged units in which either one or both of the binding sites for this protein have been inactivated. We found that mutations of both binding sites strongly diminish the transcription of the adjacent operon. The protein is hypothesized to play a crucial role in keeping the chromosomal rDNA units in an optimal spatial configuration by anchoring consecutive enhancers and promoters to the nucle(ol)ar matrix.

Functional analysis of internal transcribed spacer 2 of Saccharomyces cerevisiae ribosomal DNA.

Using the previously described "tagged ribosome" (pORCS) system for in vivo mutational analysis of yeast rDNA, we show that small deletions in the 5'-terminal portion of ITS2 completely block maturation of 26 S rRNA at the level of the 29 SB precursor (5.8 S rRNA-ITS2-26 S rRNA). Various deletions in the 3'-terminal part, although severely reducing the efficiency of processing, still allow some mature 26 S rRNA to be formed. On the other hand, none of the ITS2 deletions affect the production of mature 17 S rRNA. Since all of the deletions severely disturb the recently proposed secondary structure of ITS2, these findings suggest an important role for higher order structure of ITS2 in processing. Analysis of the effect of complete or partial replacement of S. cerevisiae ITS2 with its counterpart sequences from Saccharomyces rosei or Hansenula wingei, points to helix V of the secondary structure model as an important element for correct and efficient processing. Direct mutational analysis shows that disruption of base-pairing in the middle of helix V does not detectably affect 26 S rRNA formation. In contrast, introduction of clustered point mutations at the apical end of helix V that both disrupt base-pairing and change the sequence of the loop, severely reduces processing. Since a mutant containing only point mutations in the sequence of the loop produces normal amounts of mature 26 S rRNA, we conclude that the precise (secondary and/or primary) structure at the lower end of helix V, but excluding the loop, is of crucial importance for efficient removal of ITS2.

Automated sampling and analysis in research product synthesis.

The information obtained about relevant reaction parameters can be greatly increased by monitoring concentration changes during a reaction. To achieve this goal, a fully automated system was designed which handles both sampling and analysis. The sampling system takes samples at predefined intervals, and also performs a number of tasks such as dilution, neutralization, filtration and analysis.The examples show the universal applicability of the device regarding to solvents, reaction media and reaction type. It is also demonstrated that the information, included in the concentration profiles, greatly increases our knowledge about the reaction. This increase in information, in conjunction with other data,for example calorimetry, could be used for reaction simulation software.

Foetos: an expert system for fetal assessment.

Assessment of the fetus in a high-risk pregnancy uses a variety of tests for screening and continued detection of in utero compromise. This paper describes Foetos, an expert system designed to help clinical personnel to interpret several fetal assessment tests: fetal biophysical profile, contraction stress test, and nonstress tests. Foetos has been built using the knowledge engineering tool Genie, which adopts a mixed frame- and rule-based approach to represent the clinical knowledge in the field. Foetos includes diagnostic, prognostic, and therapeutic structures, based on heuristic interpretation of such tests and contextual structures which relate interpretation to the overall clinical picture. The results of initial retrospective and prospective program validation are included in the report. These results show a substantial level of agreement between Foetos' recommendations and clinical management. Interpretation of the results indicates that the obstetrical field could be an area of interest for the application of AI techniques.

Connection of electronic medical devices in ICU according to the standard 'MIB'.

In the daily routine of an SICU, particularly in cardiac surgery, the nurses are to an increasing extent confronted with problems of connecting and using medical instruments as well as with documentation of the data of these instruments. An increasing number of user errors is to be expected. Use of advanced computer technology can help avoid such errors. In this paper the system 'ALODIN' is presented which is developed in our institutions according to the IEEE standard 'Medical Information Bus' (MIB). ALODIN-I will be part of a CCCS (computerized critical care system) which is installed in the clinic for cardiovascular surgery at Medical School Hannover.