High prevalence of chronic kidney disease among patients with diabetic foot: A cross-sectional study at a tertiary hospital in China.

OBJECTIVE: Chronic kidney disease (CKD) is a severe complication of diabetes mellitus (DM). However, the prevalence of CKD among DM patients with diabetic foot (DF) is unknown. Accordingly, we conducted a cross-sectional study at a tertiary hospital to explore the prevalence of CKD among DF patients. METHODS: A total of 42 132 inpatients with DM were enrolled from May 2015 to October 2018. Four hundred and forty-seven DF patients were selected, and 116 patients with incomplete data were excluded. CKD was defined as an estimated glomerular filtration rate < 60 mL/min per 1.73 m2 or presence of proteinuria (urine protein ≥1). We compared the CKD prevalence of DF patients with non-DF patients and general CKD patients hospitalized in China. Multivariable regression analysis was performed to explore the relationship between different variables in DF patients and CKD. RESULTS: A total of 361 DF patients aged 67.9 ± 12.2 years were analyzed. Of these patients, 63.7% of were males. The prevalence of CKD was 49.0% (n = 177), which was higher than that observed for the general inpatients (4.5%, n = 871 742). However, 59.9% of CKD patients were not diagnosed during their hospitalizations. In the multivariable logistic regression analysis, after adjusting for potential confounders, the following variables were correlated with CKD: uric acid (odds ratio (OR) = 1.49, 95% confidence interval (CI) = 1.22-1.82), homocysteine (OR = 1.05, 95% CI = 1.00-1.10), and HBA1C (OR = 1.23, 95% CI = 1.04-1.47). CONCLUSION: This study revealed that the prevalence of CKD among DF patients was high, and special attention should be paid to these patients.

Glycine Potentiates AMPA Receptor Function through Metabotropic Activation of GluN2A-Containing NMDA Receptors.

NMDA receptors are Ca2+-permeable ion channels. The activation of NMDA receptors requires agonist glutamate and co-agonist glycine. Recent evidence indicates that NMDA receptor also has metabotropic function. Here we report that in cultured mouse hippocampal neurons, glycine increases AMPA receptor-mediated currents independent of the channel activity of NMDA receptors and the activation of glycine receptors. The potentiation of AMPA receptor function by glycine is antagonized by the inhibition of ERK1/2. In the hippocampal neurons and in the HEK293 cells transfected with different combinations of NMDA receptors, glycine preferentially acts on GluN2A-containing NMDA receptors (GluN2ARs), but not GluN2B-containing NMDA receptors (GluN2BRs), to enhance ERK1/2 phosphorylation independent of the channel activity of GluN2ARs. Without requiring the channel activity of GluN2ARs, glycine increases AMPA receptor-mediated currents through GluN2ARs. Thus, these results reveal a metabotropic function of GluN2ARs in mediating glycine-induced potentiation of AMPA receptor function via ERK1/2 activation.

Bacterial Etiology and Risk Factors Associated with Cellulitis and Purulent Skin Abscesses in Military Trainees.

Military trainees are at high risk for skin and soft-tissue infections (SSTIs). Although Staphylococcus aureus is associated with purulent SSTI, it is unclear to what degree this pathogen causes nonpurulent cellulitis. To inform effective prevention strategies and to provide novel insights into SSTI pathogenesis, we aimed to determine the etiology of SSTI in this population. We conducted a prospective observational study in US Army Infantry trainees with SSTI (cutaneous abscesses and cellulitis) from July 2012 through December 2014. We used standard microbiology, serology, and high-throughput sequencing to determine the etiology of SSTI. Furthermore, we compared purported risk factors as well as anatomic site colonization for S. aureus. Among 201 SSTI cases evaluated for SSTI risk factors, cellulitis was associated with lower extremity blisters (P = 0.01) and abscess was associated with methicillin-resistant S. aureus (MRSA) colonization (P<0.001). Among the 22 tested cellulitis cases that were part of the microbiome analysis, only 1 leading edge aspirate was culturable (Coagulase-negative Staphylococcus). Microbiome evaluation of aspirate specimens demonstrated that Rhodanobacter terrae was the most abundant species (66.8% average abundance), while abscesses were dominated by S. aureus (92.9% average abundance). Although abscesses and cellulitis share the spectrum of clinical SSTI, the bacterial etiologies as determined by current technology appear distinct. Furthermore, the presence of atypical bacteria within cellulitis aspirates may indicate novel mechanisms of cellulitis pathogenesis. CLINICAL TRIALS REGISTRATION: NCT01105767.

Frequent use of chlorhexidine-based body wash associated with a reduction in methicillin-resistant Staphylococcus aureus nasal colonization among military trainees.

In a field-based trial among military trainees, personal hygiene measures, including chlorhexidine (CHG) body wash, did not prevent overall and methicillin-resistant Staphylococcus aureus (MRSA) skin and soft-tissue infections (SSTI). We conducted a secondary analysis of anterior nares cultures obtained during the trial to evaluate the impact of hygiene measures on Staphylococcus aureus colonization. A cluster-randomized trial for SSTI prevention was conducted among U.S. Army infantry trainees from May 2010 to January 2012. There were three study groups with incrementally increasing education- and hygiene-based components: standard (S), enhanced standard (ES), and CHG. Anterior nares cultures were obtained from participants to determine the prevalence of S. aureus colonization. A total of 1,706 participants (469 S, 597 ES, and 640 CHG) without SSTI were included in the colonization analysis. Of those randomized to the CHG group, 360 (56.3%) reported frequent use of body wash. Frequent use of body wash had no effect on overall S. aureus colonization (53.3% versus 56.8% among infrequent/nonusers; P=0.25). MRSA colonization prevalence was marginally lower among frequent users (2.5% versus 4.7%; P=0.07). In multivariable analysis, the odds of MRSA colonization were lower among frequent users (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.16 to 0.77). This CHG-associated reduction was not observed when comparing colonization with USA300 to that with non-USA300 types (OR, 0.59; 95% CI, 0.06 to 5.76). Frequent use of CHG body wash was associated with a reduction in MRSA nasal colonization among high-risk military trainees. Topical chlorhexidine may contribute to MRSA SSTI prevention by reducing colonization. However, further studies evaluating the pathogenesis of SSTI are needed. (This study has been registered at ClinicalTrials.gov under registration no. NCT01105767).

Correlation between nasal microbiome composition and remote purulent skin and soft tissue infections.

The incidence of skin and soft tissue infections (SSTIs) has increased dramatically over the past decade, resulting in significant morbidity in millions of otherwise healthy individuals worldwide. Certain groups, like military personnel, are at increased risk for SSTI development. Although nasal colonization with Staphylococcus aureus is an important risk factor for the development of SSTIs, it is not clear why some colonized individuals develop disease while others do not. Recent studies have revealed the importance of microbial diversity in human health. Therefore, we hypothesized that the nasal microbiome may provide valuable insight into SSTI development. To examine this hypothesis, we obtained anterior-naris samples from military trainees with cutaneous abscesses and from asymptomatic (non-SSTI) participants. We also obtained samples from within abscess cavities. Specimens were analyzed by culture, and the microbial community within each sample was characterized using a 16S sequencing-based approach. We collected specimens from 46 non-SSTI participants and from 40 participants with abscesses. We observed a significantly higher abundance of Proteobacteria in the anterior nares in non-SSTI participants (P < 0.0001) than in participants with abscesses. Additionally, we noted a significant inverse correlation between Corynebacterium spp. and S. aureus (P = 0.0001). The sensitivity of standard microbiological culture for abscesses was 71.4%. These data expand our knowledge of the complexity of the nasal and abscess microbiomes and potentially pave the way for novel therapeutic and prophylactic countermeasures against SSTI.

Prevalence of nasal colonization and strain concordance in patients with community-associated Staphylococcus aureus skin and soft-tissue infections.

OBJECTIVE: Determine the prevalence and relatedness of Staphylococcus aureus anterior nares colonization in individuals with community-associated staphylococcal skin and soft-tissue infection (SSTI). DESIGN: Observational cohort. SETTING: US Army soldiers undergoing infantry training. PARTICIPANTS: Trainees who developed SSTI from May 2010 to January 2012. METHODS: Participants underwent anterior nares culture at the time of presentation for purulent SSTI. We determined the prevalence of S. aureus nasal colonization and strain relatedness between colonizing and clinical isolates with pulsed-field gel electrophoresis (PFGE). RESULTS: We enrolled 1,203 SSTI participants, of whom 508 had culture-confirmed S. aureus SSTI. Overall, 70% (357/508) were colonized with S. aureus. Phenotypically, concordant colonization was more common with methicillin-susceptible S. aureus (MSSA; 56%; 122/218) than methicillin-resistant S. aureus (MRSA) SSTI (41%; 118/290; P < .01). With PFGE, 48% (121 of 254) of clinical-colonizing pairs were indistinguishable, and concordant colonization was more common with MRSA (53%; 92/173) than MSSA SSTI (36%; 29/81; P < .01). Restricting analysis to concomitant MRSA-MRSA or MSSA-MSSA pairs, 92% (92/100) of MRSA SSTI were indistinguishable, and 40% (29/72) MSSA SSTI were indistinguishable (P < .01). All 92 MRSA pairs were USA300. CONCLUSIONS: On the phenotypic level, concordant anterior nares colonization with incident staphylococcal SSTI is more common in MSSA than MRSA; however, the opposite is observed when accounting for molecular typing, and MRSA SSTI displays greater concordance. USA300 was responsible for strain concordance with MRSA SSTI. Studies are needed to examine the roles of nasal and extra-nasal carriage, colonization preceding infection, and increased virulence in the pathogenesis of MRSA SSTI. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01105767.

Prevalence of chlorhexidine-resistant methicillin-resistant Staphylococcus aureus following prolonged exposure.

Chlorhexidine has been increasingly utilized in outpatient settings to control methicillin-resistant Staphylococcus aureus (MRSA) outbreaks and as a component of programs for MRSA decolonization and prevention of skin and soft-tissue infections (SSTIs). The objective of this study was to determine the prevalence of chlorhexidine resistance in clinical and colonizing MRSA isolates obtained in the context of a community-based cluster-randomized controlled trial for SSTI prevention, during which 10,030 soldiers were issued chlorhexidine for body washing. We obtained epidemiological data on study participants and performed molecular analysis of MRSA isolates, including PCR assays for determinants of chlorhexidine resistance and high-level mupirocin resistance and pulsed-field gel electrophoresis (PFGE). During the study period, May 2010 to January 2012, we identified 720 MRSA isolates, of which 615 (85.4%) were available for molecular analysis, i.e., 341 clinical and 274 colonizing isolates. Overall, only 10 (1.6%) of 615 isolates were chlorhexidine resistant, including three from the chlorhexidine group and seven from nonchlorhexidine groups (P > 0.99). Five (1.5%) of the 341 clinical isolates and five (1.8%) of the 274 colonizing isolates harbored chlorhexidine resistance genes, and four (40%) of the 10 possessed genetic determinants for mupirocin resistance. All chlorhexidine-resistant isolates were USA300. The overall prevalence of chlorhexidine resistance in MRSA isolates obtained from our study participants was low. We found no association between extended chlorhexidine use and the prevalence of chlorhexidine-resistant MRSA isolates; however, continued surveillance is warranted, as this agent continues to be utilized for infection control and prevention efforts.

Regulation of nuclear TDP-43 by NR2A-containing NMDA receptors and PTEN.

The dysfunction of TAR DNA-binding protein-43 (TDP-43) is implicated in neurodegenerative diseases. However, the function of TDP-43 is not fully elucidated. Here we show that the protein level of endogenous TDP-43 in the nucleus is increased in mouse cortical neurons in the early stages, but return to basal level in the later stages after glutamate accumulation-induced injury. The elevation of TDP-43 results from a downregulation of phosphatase and tensin homolog (PTEN). We further demonstrate that activation of NR2A-containing NMDA receptors (NR2ARs) leads to PTEN downregulation and subsequent reduction of PTEN import from the cytoplasm to the nucleus after glutamate accumulation. The decrease of PTEN in the nucleus contributes to its reduced association with TDP-43, and thereby mediates the elevation of nuclear TDP-43. We provide evidence that the elevation of nuclear TDP-43, mediated by NR2AR activation and PTEN downregulation, confers protection against cortical neuronal death in the late stages after glutamate accumulation. Thus, this study reveals a NR2AR-PTEN-TDP-43 signaling pathway by which nuclear TDP-43 promotes neuronal survival. These results suggest that upregulation of nuclear TDP-43 represents a self-protection mechanism to delay neurodegeneration in the early stages after glutamate accumulation and that prolonging the upregulation process of nuclear TDP-43 might have therapeutic significance.

Regulation of PINK1 by NR2B-containing NMDA receptors in ischemic neuronal injury.

Dysfunction of PTEN-induced kinase-1 (PINK1) is implicated in neurodegeneration. We report here that oxygen-glucose deprivation (OGD), an in vitro insult mimicking ischemic neuron injury, resulted in a significant reduction of PINK1 protein expression in cultured cortical neurons. The decrease of PINK1 expression was blocked by the antagonists of NMDA receptors. We revealed that the overactivation of NR2B-containing NMDA receptors (NR2BRs) was responsible for the OGD-induced PINK1 reduction. The overactivated NR2BRs also inhibited the phosphorylation, but not the protein expression, of the cell survival-promoting kinase Akt after OGD insult, indicating that OGD-induced reduction of PINK1 protein is specific in the injury paradigm. We further showed that enhancing the protein expression of PINK1 antagonized OGD-induced reduction of Akt phosphorylation, suggesting that Akt may be a downstream target of PINK1 in ischemic neuron injury. Importantly, we provided evidence that both NR2BR antagonist and PINK1 over-expression protected against OGD-induced neuronal death. These results suggest that the overactivation of NR2BRs may contribute to ischemic neuron death through suppressing PINK1-dependent survival signaling. Thus, selectively antagonizing NR2BR signal pathway-induced neurotoxicity may be a potential neuroprotection strategy.