Influenza in children – Diagnosis, treatment and prevention

Background: The burden of influenza on children is substantial. Although mortality rates are low, the incidence of influenza is highest in children, among whom also complications are frequent. A more accurate recognition of influenza in children could enable the rational use of antiviral drugs and help to avoid unnecessary courses of antibiotics. Limited data exists on the efficacy of oseltamivir treatment and the trivalent inactivated influenza vaccine (TIV) in children. Aims and methods: We sought for signs and symptoms that could help clinicians to diagnose influenza on clinical grounds in a case-control study in children <13 years of age. We further assessed the feasibility of different diagnostics methods during the early stage of the illness in children aged 1-3 years. The efficacy of early oseltamivir treatment (started <24h from the onset of symptoms) was evaluated in a randomized controlled trial (RCT) conducted in children 1-3 years of age, and the effectiveness of TIV to prevent laboratory-confirmed influenza was determined in a prospective, observational cohort study conducted among children aged 9 months to 3 years of age. Results: Fever was the only symptom predicting influenza in children. The sensitivity of conventionally used laboratory methods to detect influenza during the first 24h of illness was 92%. The sensitivity of the influenza rapid test in the same setting was 90% for influenza A and 25% for influenza B. Early oseltamivir treatment shortened the duration of the illness in children with influenza A by 3.5-4.0 days, but no efficacy was observed against influenza B. The effectiveness of TIV was 84% against the wellmatched influenza A, while no effectiveness against the mismatched influenza B was observed. Conclusions: Laboratory diagnostics are needed for a reliable diagnosis of influenza in children and were found sensitive already during the early stage of the illness. Early oseltamivir treatment was highly effective against influenza A, but no efficacy was seen against influenza B. TIV is effective also in young children if a good match between the vaccine and circulating strain is achieved.

Understanding the in vitro dissolution rate of glasses with respect to future clinical applications

Glass is a unique material with a long history. Several glass products are used daily in our everyday life, often unnoticed. Glass can be found not only in obvious applications such as tableware, windows, and light bulbs, but also in tennis rackets, windmill turbine blades, optical devices, and medical implants. The glasses used at present as implants are inorganic silica-based melt-derived compositions mainly for hard-tissue repair as bone graft substitute in dentistry and orthopedics. The degree of glass reactivity desired varies according to implantation situation and it is vital that the ion release from any glasses used in medical applications is controlled. Understanding the in vitro dissolution rate of glasses provides a first approximation of their behavior in vivo. Specific studies concerning dissolution properties of bioactive glasses have been relatively scarce and mostly concentrated to static condition studies. The motivation behind this work was to develop a simple and accurate method for quantifying the in vitro dissolution rate of highly different types of glass compositions with interest for future clinical applications. By combining information from various experimental conditions, a better knowledge of glass dissolution and the suitability of different glasses for different medical applications can be obtained. Thus, two traditional and one novel approach were utilized in this thesis to study glass dissolution. The chemical durability of silicate glasses was tested in water and TRIS-buffered solution at static and dynamic conditions. The traditional in vitro testing with a TRISbuffered solution under static conditions works well with bioactive or with readily dissolving glasses, and it is easy to follow the ion dissolution reactions. However, in the buffered solution no marked differences between the more durable glasses were observed. The hydrolytic resistance of the glasses was studied using the standard procedure ISO 719. The relative scale given by the standard failed to provide any relevant information when bioactive glasses were studied. However, the clear differences in the hydrolytic resistance values imply that the method could be used as a rapid test to get an overall idea of the biodegradability of glasses. The standard method combined with the ion concentration and pH measurements gives a better estimate of the hydrolytic resistance because of the high silicon amount released from a glass. A sensitive on-line analysis method utilizing inductively coupled plasma optical emission spectrometer and a flow-through micro-volume pH electrode was developed to study the initial dissolution of biocompatible glasses. This approach was found suitable for compositions within a large range of chemical durability. With this approach, the initial dissolution of all ions could be measured simultaneously and quantitatively, which gave a good overall idea of the initial dissolution rates for the individual ions and the dissolution mechanism. These types of results with glass dissolution were presented for the first time during the course of writing this thesis. Based on the initial dissolution patterns obtained with the novel approach using TRIS, the experimental glasses could be divided into four distinct categories. The initial dissolution patterns of glasses correlated well with the anticipated bioactivity. Moreover, the normalized surface-specific mass loss rates and the different in vivo models and the actual in vivo data correlated well. The results suggest that this type of approach can be used for prescreening the suitability of novel glass compositions for future clinical applications. Furthermore, the results shed light on the possible bioactivity of glasses. An additional goal in this thesis was to gain insight into the phase changes occurring during various heat treatments of glasses with three selected compositions. Engineering-type T-T-T curves for glasses 1-98 and 13-93 were stablished. The information gained is essential in manufacturing amorphous porous implants or for drawing of continuous fibers of the glasses. Although both glasses can be hot worked to amorphous products at carefully controlled conditions, 1-98 showed one magnitude greater nucleation and crystal growth rate than 13-93. Thus, 13-93 is better suited than 1-98 for working processes which require long residence times at high temperatures. It was also shown that amorphous and partially crystalline porous implants can be sintered from bioactive glass S53P4. Surface crystallization of S53P4, forming Na2O∙CaO∙2SiO2, was observed to start at 650°C. The secondary crystals of Na2Ca4(PO4)2SiO4, reported for the first time in this thesis, were detected at higher temperatures, from 850°C to 1000°C. The crystal phases formed affected the dissolution behavior of the implants in simulated body fluid. This study opens up new possibilities for using S53P4 to manufacture various structures, while tailoring their bioactivity by controlling the proportions of the different phases. The results obtained in this thesis give valuable additional information and tools to the state of the art for designing glasses with respect to future clinical applications. With the knowledge gained we can identify different dissolution patters and use this information to improve the tuning of glass compositions. In addition, the novel online analysis approach provides an excellent opportunity to further enhance our knowledge of glass behavior in simulated body conditions.

3D-tulostustekniikan hyödyntäminen diagnostisten pikatestien tuotekehityksessä

Pikamallinnustekniikat ovat kehittyneet viime vuosina nopeasti. Tämä antaa jo lähes rajat-tomat mahdollisuudet tuottaa 3D-tulostamalla erilaisia tuotteita. 3D-tulostuksen hyödyntä-minen on yleistynyt erityisesti teollisuuden ja teknologian aloilla. Tässä työssä tutkittiin miten 3D-tulostamista voidaan hyödyntää diagnostisten pikatestien tuotekehityksessä. Immunologinen lateral flow-testi on vasta-aineisiin perustuva, nopea ja helppokäyttöinen mittausmenetelmä pienten ainemäärien havaitsemiseen. Tässä työssä kehitettiin lateral flow-testikotelo, jonka suunnitteluun ja rakenteen mallintamiseen käytettiin 3D-tulostustekniikkaa. Testikotelon toimivuus lateral flow- testissä varmistettiin kehittämällä testikoteloon sopiva pikatesti, jonka suorituskykyä analysoitiin sekä visuaalisesti että Actim 1ngeni-lukulaitteella. Työ aloitettiin tutkimalla eri pikavalmistustekniikoita, joista testikotelon tulostamiseen valittiin SLA-tekniikka sen tulostustarkkuuden ja tuotteen pinnan laadun perusteella. Testikotelon suunnittelu aloitettiin määrittämällä millaisia ominaisuuksia testikotelolta haluttiin. Näitä ominaisuuksia olivat lateral flow-testin suojaaminen sekä testissä kulkevan näytteen virtauksen varmistamien. Lateral flow- testin kehityksessä hyödynnettiin osin aiemmin kehitetystä pikatestistä saatuja tietoja. Lateral flow- kasettitestin valmistusprosessi koostui seitsemästä eri prosessivaiheesta jotka olivat: Vasta-aineen/kontrollireagenssin konjugointi, näytetyynyn käsittely, konjugointityynyn käsittely, konjugointityynylle annostelu, membraanille annostelu, tikkujen laminointi ja leikkaus sekä kasettitestin kokoonpano. Kehitetyn lateral flow- kasettitestin toimivuus varmistettiin tutkimalla testin reaktiokinetiikkaa ja analyyttistä herkkyyttä sekä visuaalisesti että lukulaitteen avulla. Tutkimustulosten perusteella 3D-tulostus on erittäin hyödyllinen menetelmä pikatestien tuotekehityksessä suunniteltaessa testikotelorakenteita, näytteen annosteluvälineitä ja näiden yhdistelmiä.