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Assistant Professor, University of the Virgin Islands

In mice that had recovered from an influenza an infection arrhythmias definition purchase tenormin 100 mg mastercard, immunity to reinfection was abrogated by the intranasal instillation of anti-IgA antibodies heart attack arm pain 50 mg tenormin, however not antiIgG or IgM (Renegar and Small arrhythmia low blood pressure tenormin 50 mg online, 1991a) arrhythmia interpretation practice tenormin 50 mg buy generic on-line, and intravenous passive switch of IgA resulted in IgA in nasal secretions that protected mice from intranasal problem with influenza (Renegar and Small, 1991b). Moreover, recombinant IgA is enough to prevent influenza transmission in a guinea pig model (Seibert et al. During transcytosis by way of mucosal epithelial cells, an additional polypeptide secretory part is added to dimeric IgA and the resulting molecule is identified as secretory IgA (S-IgA). Dimeric and S-IgA are 7�10 occasions extra environment friendly than monomeric IgA at neutralizing influenza viruses (Renegar et al. Dimeric and S-IgA are represented by two subclasses, IgA1 and IgA2, with covalently or noncovalently joined dimers, respectively. S-IgA can be immune to proteolysis and can neutralize viruses inside epithelial cells and transport viruses which have passed the epithelial barrier to the lamina propria back to the lumen (Sato and Kiyono, 2012). S-IgA could subsequently be useful in preventing viruses from breaching the mucosal barrier, whereas avoiding immunopathology by not activating inflammatory responses immediately and by limiting the number of antigen�antibody complexes in the lamina propria that may trigger inflammation. The Fc receptor for IgG mediates transport of IgG throughout epithelial barriers by transcytosis, permitting the transudation of IgG from the serum into the lung the place it is in a position to neutralize viruses (Spiekermann et al. This explains why passively transferred IgG is effective at preventing extreme disease from respiratory infections in experimental animals and why serum IgG antibodies are the principle correlate of protection for parentally administered inactivated influenza vaccines in humans (Section Respiratory Virus Vaccines). Respiratory Virus Reinfection Viruses that can cause repeated infection are typically characterized both by a failure to induce sturdy immunity or by vital antigenic diversity in the face of protecting immune responses. Influenza viruses can reinfect hosts because the antigenic sites evolve and drift to avoid neutralization by prior immunity. Infection induces a robust homosubtypic neutralizing antibody response in healthy individuals that contributes to recovery and safety from repeat influenza virus infection with homologous virus or an antigenically comparable virus (Wrammert et al. Moreover, natural infection can result in long-lasting immunity to the infecting virus. For example, when the influenza A H1N1 subtype reemerged in 1977, the most prone members of the inhabitants have been these born after the time when related H1N1 viruses had beforehand circulated, the 1950s (Shortridge et al. However, as a outcome of influenza viruses endure antigenic drift and shift, the effective period of safety might last solely until an antigenic variant emerges. These research are actually being reproduced with experimental human challenge an infection (DeVincenzo et al. Most reinfections are restricted to the higher respiratory tract, except topics are immunocompromised. Reinfections may be the consequence of a extremely prevalent and contagious virus, efficient evasion of native and innate immunity, or a steep gradient for transudation of antibody from the serum to the nasal epithelium (Graham, 2011). However, amongst respiratory viruses, licensed vaccines are available just for influenza. However, a systemic immune response can be protective if it is sufficiently strong, similar to that induced by inactivated influenza vaccines administered by the i. Moreover, reaching an appropriate balance between sufficient attenuation and immunogenicity, particularly in younger infants who must be vaccinated in the face of maternal antibody, is a problem. This section describes licensed vaccines in addition to vaccines which are at present in improvement. Influenza Vaccination stays the first technique for the prevention and management of influenza (Lambert and Fauci, 2010). As described in Section Immune Responses to Respiratory Virus Infection, after an influenza infection, each cellmediated immunity and systemic and mucosal neutralizing antibodies are produced. Whereas cell-mediated immunity contributes considerably to the clearance of a major influenza virus an infection, and may ameliorate disease brought on by reinfection, neutralizing antibodies play an essential role in preventing reinfection. This section focuses on licensed vaccines and the immune responses they elicit, as decided from medical trial data. Owing to antigenic drift in circulating viruses (discussed in Section Virology), an influenza vaccine from one season is in all probability not efficient in subsequent seasons. Each year, the strains which are to be included within the vaccine for the following influenza season are chosen and vaccine seed viruses are generated (Lambert and Fauci, 2010). If the yield of the vaccine virus in eggs is poor, they might be "egg-adapted" by way of serial passage. The inactivated vaccine viruses are treated with formalin or -propriolactone and "cut up" with detergents earlier than being formulated for scientific use, with or without thimerosal as a preservative (Fiore et al. Until 2013, seasonal influenza vaccines were trivalent, containing two subtypes of influenza A viruses (H1N1 and H3N2) and one influenza B virus. However, from the 2013 winter season in the Northern Hemisphere, quadrivalent vaccines, containing two subtypes of influenza A viruses and two strains of influenza B viruses, have turn into obtainable. It takes a number of months from the generation of a seed virus to the manufacture and distribution of a vaccine. Typically, for seasonal influenza within the Northern Hemisphere, manufacturers amplify vaccine viruses and inactivate or purify them between February and late summer season and formulate and distribute them for administration in the fall before the anticipated peak of the influenza season (Lambert and Fauci, 2010). In 2009, the H1N1 pandemic virus emerged in April, when the manufacture of seasonal trivalent vaccines was already under method. A monovalent H1N1 vaccine was produced as shortly as possible along with the seasonal vaccines, but the monovalent vaccine was not out there for widespread use till after the pandemic had peaked in the Northern Hemisphere and was not available in any respect during the 2009 winter season within the Southern Hemisphere (Broadbent and Subbarao, 2011; Skowronski et al. One means of accelerating capacity is to transfer towards using cell tradition instead of eggs for vaccine production, and several corporations are investigating this. However, in unprimed individuals, for instance, youngsters, it could take four weeks or longer for serum antibody ranges to peak after vaccination (Brokstad et al. Moreover, ranges of IgA in nasal wash specimens correlated with safety towards challenge with wild-type influenza viruses (Clements et al. However, the extent to which the cellular immune response is protective in opposition to an infection is unknown because the recall response is likely to happen after the peak of viral replication (Subbarao et al. Elderly people usually have a considerably decreased antibody response to influenza vaccination (Goodwin et al. In a quantitative evaluate of 4492 aged topics, 42%, 51%, and 35% seroconverted to H1N1, H3N2, and influenza B vaccination, respectively, compared to 60%, 62%, and 58% in younger subjects (Goodwin et al. The impaired capability of the aged to mount an enough immune response to influenza vaccines has been attributed to immunosenescence. Impaired perform of costimulatory molecules, altered secretion of inflammatory cytokines, and diminished function of natural killer cells, macrophages, and neutrophils have been observed within the aged, as well as a decreased proliferative capability of B cells and impaired T cell reminiscence recall (Sullivan et al. In addition, thymic involution and a decline in T cell output are features of advancing age. This, together with a lifetime of publicity to a selection of pathogens, leads to a discount within the na�ve T cell pool and a relative increase in the proportion of reminiscence T cells in the elderly compared with young adults. Postlicensure research have shown enhanced immune responses in this age group, compared to the standard dose (Sullivan et al. Although mobile immune responses are mounted during a secondary influenza infection (Woodland et al. The objective of parenteral immunization with inactivated influenza vaccines is to induce adequate serum antibody titers to limit influenza disease. This protection is mediated by serum IgG that transudes into the lower respiratory tract, neutralizing virus. After two doses, full protection was achieved and was associated with maturation of the antibody response (Lau et al. Lower antibody titers are associated with an elevated danger of illness, although a particular antibody titer that may assure safety from an infection has not been identified. However, antibody titers that correlate with protection in healthy adults may not translate to scientific improvements in influenza outcomes in the aged (Gorse et al. Respiratory Virus Vaccines Chapter fifty nine 1147 Adjuvanted Influenza Vaccines Adjuvants are added to vaccine formulations to enhance immune responses to the antigen in the vaccine. Aluminum salts (alum) are probably the most generally and traditionally used adjuvants worldwide. They act by capturing antigens on the injection web site, so the antigen is slowly processed and offered by the immune system (the so-called depot effect), and so they cause mild cell damage and inflammation that promotes a Th2 immune enhancement (Tetsutani and Ishii, 2012). Neither appears to act through a depot effect; as a substitute they induce a local and transient proinflammatory cytokine and chemokine response on the injection website and draining lymph nodes that recruit immune cells from the circulation. The local cytokine response was paralleled by an enhanced recruitment of monocytes and granulocytes within the draining lymph node (Morel et al. These are less broadly used because of increased reactogenicity and antagonistic events (Fiore et al.

Syndromes

• Take proper care of your nails.
• Steppage gait -- foot drop where the foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking
• Nausea and vomiting
• Shock (pale color, lethargy, sweating)
• Aortic valve
• The pain cannot be controlled.

Lactobacilli are gram-positive micro organism that are regular residents of the oro-gastrointestinal and vaginal tract and are also utilized in meals fermentation and preservation paediatric blood pressure chart uk 100 mg tenormin cheap fast delivery. Their typically regarded as secure for people standing has led to reports by which lactobacilli producing antibody fragments blood pressure pulse buy tenormin 100 mg low price. Stable and contained expression systems have been developed allowing reworked lactobacilli to be administered to people (Martin et al hypertension questionnaires 100 mg tenormin discount overnight delivery. The antibody fragment could be expressed in lactobacilli isolated from the oral heart attack heartburn 100 mg tenormin generic fast delivery, gastrointestinal, or vaginal tract to defend different mucosal surfaces. The use of genetically engineered antibody fragments produced and regionally delivered by bacteria in the mucosal websites may thus present an efficient remedy at low price, significantly in growing nations. We will summarize printed knowledge on the usage of antibodies for prophylaxis and remedy against chosen pathogens that infect the oral, pulmonary, gastrointestinal, and vaginal tracts Tables 1�4). We additionally wish to highlight the safety conferred by different forms of antibodies that are being developed, produced, and delivered using completely different approaches and applied sciences. Oral Pathogens Streptococcus mutans Streptococcus mutans is a normal resident of the human oral cavity recognized as one of the main etiologic brokers of caries. Passive immunization against caries was developed using oral administration of antibody preparation against complete cells of Str. Because the practical mAb was solely detected on the teeth for under as much as three days after software, it was speculated that the ecological area of interest vacated by Str. This mAb was subsequently re-engineered as a chimeric IgA/IgG Ab with a rabbit secretory component for expression in tobacco vegetation. Administration of fresh lactobacilli expressing surface anchored scFv in ingesting water decreased Str. Porphyromonas gingivalis Porphyromonas gingivalis, a gram-negative anaerobe present in subgingival plaque, was identified as a significant etiologic agent of chronic periodontitis (Marcotte and Lavoie, 1998). Passive Immunization Chapter 71 1419 hydrolytic activity in vitro (Yokoyama et al. Topical software of the mAb in patients with periodontitis prevented recolonization with Po. Furthermore, in infants and younger kids, Hib causes bacteremia, pneumonia, and acute bacterial meningitis. This product, administered intramuscularly, was protecting against Hib bacteremia and meningitis, and pneumococcal otitis in infants (Santosham et al. One possibility is thus to develop mAbs that focus on the capsular polysaccharide of the serotypes causing most an infection and to give the mAbs as a mix. Intraperitoneal administration of mAbs to the capsular polysaccharide protects mice against a deadly systemic or intranasal problem with Str. Their efficacy may depend on their capacity to agglutinate and alter the expression of gene concerned in quorum sensing, tricking the micro organism to kill each other (fratricide) (Fabrizio et al. The slim vary of antifungal brokers, the toxicity of a few of the medicine, and the emergence of resistant strains of Can. Antibodies from cows immunized with complete Candida organisms and purified mannan prevented the adherence of Can. Efungumab (Mycograb) was developed as a human recombinant scFv antibody fragment towards a heat shock protein (hsp90) for the therapy of invasive Candida an infection together with amphotericin B (Matthews and Burnie, 2001; Matthews et al. Despite these points, efungumab demonstrated an important proof of precept for the event of mAbs with antifungal exercise. Administration of polyclonal antibody preparations derived from wholesome human donors immunized with Ps. The multiple clades and subclades of influenza viruses and excessive mutation rate during infection constitute a considerable drawback for human vaccine growth (Stephenson et al. Systemic administration of polyclonal antibodies towards influenza virus has been proven to be protecting in human and mouse models of infection (Kong and Zhou, 2006; Lu et al. The antibody, developed by Crucell (The Netherlands), is currently present process a section I scientific trial fusing a single intravenous dose. Respiratory syncytial virus has lately been found to have a excessive prevalence within the elderly and in immunocompromised adults, particularly bone marrow and lung transplant recipients, leading to considerable morbidity and mortality (Hynicka and Ensor, 2012). The two glycosylated surface proteins, F and G, are essential for the infectivity and pathogenesis of the virus and elicit manufacturing of neutralizing antibodies by the host (Hall, 2000). Some studies thus showed a lower in colonization and signs (Ando and Nakamura, 1991; Casswall et al. A full human antibody derived from the scFv (Abba3-IgG) prevented the adherence of H. Rotavirus Rotavirus is the most important etiologic agent of severe diarrhea in younger kids, accounting for an estimated 500,000 deaths each year mainly within the growing world. There is thus a necessity for different methods to complement vaccination methods in situations the place efficacy of vaccination alone may not be enough (Marcotte et al. Studies in humans and mice recommend a job of secretory IgA and serum IgG antibodies in safety in opposition to rotavirus (Coulson et al. Several studies have proven that passive immunization utilizing hyperimmune polyclonal bovine colostrum or hyperimmunized hen egg yolk Ig is protecting in animal fashions and humans (Davidson et al. Novel approaches to the prevention and remedy of rotavirus-induced diarrhea are being developed to cut back the medical and financial burden in both developed and creating nations. Gastrointestinal Pathogens Helicobacter pylori Helicobacter pylori infection is liable for chronic gastritis and peptic ulcer disease and is related to an elevated threat of creating stomach most cancers (Suerbaum and Michetti, 2002). Although antimicrobial therapy is on the market, the price of antibiotic therapy and the looks of antibiotic resistance suggest that an efficient different prevention strategy could be of great profit, notably in developing countries. Furthermore, mice given mouse mAbs towards Helicobacter or virulence factor (urease) on the time of the preliminary problem are protected from an infection (Blanchard et al. Antibodies from cows or chickens immunized with whole cell lysates or urease inhibit the adherence of H. Oral administration of these antibody preparations additionally reduces colonization by H. However, medical studies on the effect of oral administration of colostrum antibodies and IgY antibodies in opposition to H. Clostridium difficile Clostridium difficile is a spore-forming, anaerobic bacterium that could also be a leading reason for antibiotic-associated diarrhea in hospitals and long-term care facilities (Redelings et al. The toxins may conceivably be neutralized within the lower gastrointestinal tract, thereby preventing the critical first step in Cl. Oral administration of rooster IgY and bovine antibody directed against toxin A and B was protective in the hamster mannequin of infection (Kelly et al. The limited proof in oral immunotherapy in medical settings has probably been hampered by the high Ig dose necessities and the related prices. As an alternate, neutralizing single-domain antibodies derived from llamas are at present being developed against toxins A and B (Hussack et al. The incontrovertible fact that secretory Igs in breast milk shield neonates and young infants against diarrhea is important for considering and testing passive immunotherapy to handle this an infection (Loureiro et al. Intraperitoneal injection of mAbs in opposition to Shiga toxin reduces systemic issues and prolongs survival in mice and gnotobiotic pigs intestinally infected with E. This could possibly be because of differences in the specificity of the antibody preparations. A better approach would possibly thus be to generate antibodies particular for virulence components. The similar three mAbs are being assessed as a gel-formulated microbicide in a phase I scientific trial (Morris et al. These antibodies could be used as a combination with antibodies concentrating on the virus in a microbicide formulation. Candida albicans Chronic vulvovaginal candidiasis severely impacts the quality of life for hundreds of thousands of ladies on the earth and is frequently refractory to antifungal remedies (Sobel, 2003). Monoclonal antibodies focusing on 1,3-glucan, a serious cell wall part, inhibited hyphal progress and adherence to human epithelial cells in vitro and conferred significant safety in opposition to Can. Yeast killer toxin anti-idiotypic monoclonal (mAb K10) and scFv (scFv-H6) antibodies were able to exert a direct candidacidal activity in vitro and in the rat vaginitis mannequin (Magliani et al. Furthermore, engineered Streptococcus gordonii strains producing scFv-H6 colonize the mucosal surfaces when inoculated intravaginally in rats and exert a therapeutic effect on Can. It is hoped that advances in genomics and proteomics will end in improved data relating to the molecular mechanisms of pathogenicity. The chance of generating absolutely human antibodies from transgenic, humanized mice, and perhaps within the near future transgenic humanized cows, as nicely as new developments in phage library expertise will speed up the event of antibody manufacturing.

Syndromes

• Sweating
• Blood clots in the legs that may travel to the lungs
• Nerve conduction studies
• Paralysis
• Amount swallowed
• Scoliosis

There can be no evidence that any of the various antioxidative factors produced by N arteria entupida 70 cheap 50 mg tenormin with amex. It is attention-grabbing to observe that full piliation resulting from the action of a metalloprotease also protects N heart attack acoustic 100 mg tenormin generic with visa. Hormonal Factors As mentioned arterial blood tenormin 100 mg generic online, gonococcal genital tract infections in women are often inapparent arrhythmia ppt generic tenormin 50 mg amex, with rates of inapparent cervical infections ranging between 19% and 80% (McCormack et al. Repeat infections are common and might happen with the same PorB serovar (Brooks et al. However, as a result of the humoral immune response to infection is transient and the titer of particular antibody in serum and genital secretions is undetectable or not outstanding (Hedges et al. The lack of an adaptive response to gonococcal mucosal an infection has also been investigated utilizing the mouse an infection model. Estradiol-treated mice develop a transient and insignificant humoral response to N. These reviews are the primary in vivo demonstrations that safety against gonococcal infection and induction of a memory response can be obtained by strategically manipulating the host response. Several mechanisms have been described that lead to immunosuppression of Th1-/Th2-mediated specific immune responses. Gonorrhea Vaccine Development Progress within the improvement of a gonorrhea vaccine has been slow. Difficulties in growing a vaccine in opposition to gonorrhea embrace the shortage of known correlates of protection against gonorrhea and the excessive number of antigenically or phase variable N. Early studies in chimpanzees showed promising outcomes with outer membrane vesicle-based vaccines, however only two vaccines, a killed complete cell vaccine and a purified pilin vaccine, have been tested in medical trials, neither of which was effective (reviewed in Zhu et al. The transferrin receptor is a promising target on the basis of its floor publicity, restricted antigenic variability, and significance for experimental urethritis of male topics (Cornelissen et al. The antisera are bactericidal and block Gc development on media containing solely human transferrin as an iron supply (Price et al. PorB is an attractive vaccine target due to its stable expression, abundance in the outer membrane, and roles in pathogenesis. Immunization of mice with recombinant PorB devoid of Rmp (reduction-modifiable protein) was not protecting, though lowered colonization occurred in mice that developed a Th1 response after footpad immunizations with viral replicon particles expressing recombinant PorB (Zhu et al. The PorB monomer has eight surfaceexposed loops, most of which have antigenic heterogeneity because of immune stress. The sequence heterogeneity of many of the surface-exposed PorB loops may be circumvented by the use of cyclic PorB loop peptides that mimic conformational epitopes. Cyclic PorB loop peptides can elicit antibodies that crossreact with gonococcal strains of different porB variable region sorts; some elicit antibodies which are crossreactive for strains of the PorB1a and PorB1b serotypes (Garvin et al. Further improvement of broadly reactive PorB peptide antigens will require the introduction of Th cell epitopes or conjugation to larger antigens. Many antigens have been unsuccessfully tested in the mouse model (Jerse, unpublished observation). The common lack of success in figuring out a protecting antigen in this model suggests the necessity for a larger understanding of the mechanisms by which N. The number of contaminated people will increase with age, and extra ladies are contaminated than men (Xu et al. The lowest charges are in West Europe, the place the prevalence is approximately 18% for ladies and 13% for males. When current, the symptoms encompass localized painful genital lesions and swollen regional lymph nodes. The lesions are mucocutaneous and the end result of direct infection and the cytopathic impact of the virus, resulting in mobile lysis and focal necrosis of the genital epithelium. The lesions, when present, may be very painful and a supply of significant morbidity for the affected person. Viral reactivation could additionally be asymptomatic or may be associated with prodrome (tingling or burning) or be manifested as genital ulcers. Reactivation could be caused by numerous components, together with stress, hormonal changes, and immunosuppression. Although the incidence of mother-to-child transmission is low in North America, ranging between 4 and 31 per one hundred,000 reside births, neonatal an infection may be very severe; 80% of infants with disseminated herpes illness die, and those who survive regularly have mind harm. According to one study, 4 of nine infants born to ladies who acquired infection shortly before labor developed neonatal an infection, of which one died (Brown et al. In addition, major infection resembles that seen in people, with the development of genital lesions adopted by full restoration. Primary an infection in rats is related to the unfold of the virus to different organs, such because the liver, and after recovery from major an infection, rats develop spontaneous medical recurrences that mimic human disease and an infection (Yim et al. It has also been used broadly for inspecting protecting immune responses generated in response to major an infection and after immunization with vaccine formulations. The main operate of innate responses is to lower the viral replication, thus Animal Models and Vaccine Development Chapter 107 2077 limiting the native injury and viral burden, and to initiate adaptive immune responses. These molecules usually act on surrounding cells, through their cognate receptors, to initiate an antiviral state by which antiviral molecules, similar to protein kinase R, are upregulated to both block or scale back viral infection (Akira and Takeda, 2004). IgA can also be present, however in decrease quantities, and is produced primarily within the upper genital tract (11). T Cells, Treg, and Th17 Cells T cells expressing receptors are present in ample numbers in pores and skin and mucosal websites, together with intestines, uterus, and vagina, in the type of intraepithelial lymphocytes in mice (Hayday and Tigelaar, 2003). These results recommend that the native microenvironment within the feminine genital tract regulates antiviral immune responses after immunization. Randomized, blinded, placebo-controlled trials on subunit vaccines continued from this time, and some of the earliest research performed within the mid-1980s to the early 1990s have been led by researchers who focused on developing vaccines consisting of a mix of envelope glycoproteins. More recently, studies have evaluated the effectiveness of a truncated recombinant gD2 (at 20 g) subunit vaccine, formulated with an adjuvant consisting of a mix of aluminum hydroxide and 3-deacylated monophosphoryl lipid A. Two doses of one hundred g of gD2 with aluminum hydroxide have been administered 2 months apart in a blinded, placebo-controlled trial (Straus et al. A statistically vital discount in the number of genital herpes recurrences was detected during the 12-month remark period and neutralizing antibody and lymphoproliferative responses had been increased in vaccinees. However, no correlations were famous between immune responses and vaccine efficacy among the treated group. A few Phase I medical trials have been conducted to evaluate the protection and immunogenic potency of monovalent (Koelle et al. In comparability to subunit and peptide vaccines, reside attenuated virus-based vaccines have the benefit of inducing long-lasting and broad immunity. Their disadvantages are security issues, including the risk of reversion again to a wild-type phenotype. The vaccine was related to a decreased number of self-reported genital herpes recurrences in contrast with placebo (Casanova et al. However, high vaccine doses (3000 g) had been needed to elicit an immune response in most vaccinees (Cattamanchi et al. Women carry a disproportionately larger burden of these infections and their illness sequelae. These models have contributed Animal Models and Vaccine Development Chapter 107 2083 considerably toward the progress over the past three many years that has increased our understanding of the underlying mechanisms of pathogenesis of, and immune responses against, these brokers. We have also summarized the progress towards vaccine development for every of these infections. Mucosal and peripheral immune responses to chlamydial heat shock proteins in ladies contaminated with Chlamydia trachomatis. Partial protection against chlamydial reproductive tract an infection by a recombinant major outer membrane protein/CpG/cholera toxin intranasal vaccine within the guinea pig Chlamydia caviae mannequin. In-vivo modulation of macrophage capabilities by herpes simplex virus type 2 in resistant and delicate inbred mouse strains. Humoral immune response to herpes simplex virus sort 2 glycoproteins in sufferers receiving a glycoprotein subunit vaccine. The pilus-induced Ca2+ flux triggers lysosome exocytosis and will increase the amount of Lamp1 accessible to Neisseria IgA1 protease. Constitutively Opa-expressing and Opadeficient Neisseria gonorrhoeae strains differentially stimulate and survive exposure to human neutrophils. Role of neutrophils in controlling early levels of a Chlamydia trachomatis infection.