Burkholderia pseudomallei multi-centre study to establish EUCAST MIC and zone diameter distributions and epidemiological cut-off values.

OBJECTIVES: Melioidosis, caused by Burkholderia pseudomallei, requires intensive antimicrobial treatment. However, standardized antimicrobial susceptibility testing (AST) methodology based on modern principles for determining breakpoints and ascertaining performance of methods are lacking for B. pseudomallei. This study aimed to establish MIC and zone diameter distributions on which to set epidemiological cut-off (ECOFF) values for B. pseudomallei using standard EUCAST methodology for non-fastidious organisms. METHODS: Non-consecutive, non-duplicate clinical B. pseudomallei isolates (9-70 per centre) were tested at eight study centres against eight antimicrobials by broth microdilution (BMD) and the EUCAST disc diffusion method. Isolates without and with suspected resistance mechanisms were deliberately selected. The EUCAST Development Laboratory ensured the quality of study materials, and provided guidance on performance of the tests and interpretation of results. Aggregated results were analysed according to EUCAST recommendations to determine ECOFFs. RESULTS: MIC and zone diameter distributions were generated using BMD and disc diffusion results obtained for 361 B. pseudomallei isolates. MIC and zone diameter ECOFFs (mg/L; mm) were determined for amoxicillin-clavulanic acid (8; 22), ceftazidime (8; 22), imipenem (2; 29), meropenem (2; 26), doxycycline (2; none), tetracycline (8; 23), chloramphenicol (8; 22) and trimethoprim-sulfamethoxazole (4; 28). CONCLUSIONS: We have validated the use of standard BMD and disc diffusion methodology for AST of B. pseudomallei. The MIC and zone diameter distributions generated in this study allowed us to establish MIC and zone diameter ECOFFs for the antimicrobials studied. These ECOFFs served as background data for EUCAST to set clinical MIC and zone diameter breakpoints for B. pseudomallei.

A mosaic cell layer in human pregnancy.

We present evidence for a novel histological and embryological relationship at the human materno-fetal interface. Here an epi- endo- thelium forms an integrated unicellular layer lining the intervillus space in between the anchoring villi that attach the placenta to the uterus. This layer appears to be derived from two different germ layers (mesoderm and ectoderm). The data presented here reveals that when a probe for the Y-chromosome is used to test the gender of placental cells following the birth of male or female babies, the cell-sheet is a genetic mosaic derived from two individuals (mother and baby). The endothelium is maternally derived; the epithelium is fetal derived. This new allo- epi- endothelium model is relevant to theories of germ layer separation in development, reproductive immunology and the endocrinology of implantation and placentation. It demonstrates cooperative intercellular interactions that are fundamental to achieving a major goal of human interstitial implantation the establishment of a blood sinus for haematotrophic nutrition. Poor implantation is a fundamental cause of pregnancy pathology and this knowledge will be useful in development of our understanding of pregnancy diseases.

Temporal mating isolation driven by a behavioral gene in Drosophila.

Speciation is the evolutionary process in which new barriers to gene exchange are created. These barriers may be physical, leading to spatial separation of subpopulations and resulting in allopatric speciation, or they may be temporal, giving rise to allochronic speciation, and may include the time of day or the time of year when mating takes place. Drosophila melanogaster and D. pseudoobscura show different temporal patterns of circadian locomotor activity that are determined by the circadian clock gene period (per). Genes that control aspects of behavior that might be relevant to courtship and mating, such as locomotor patterns, become obvious candidates for involvement in the speciation process. However, evidence for the role of individual genes in the mechanism of mate choice has proved elusive. We have used transgenic flies carrying the natural per genes from these two Drosophila species to reveal that per has the potential to provide the permissive conditions for speciation, by affecting mate choice through a mechanism involving the species-specific timing of mating behavior.

Haemophilus influenzae type b conjugate vaccine stability: catalytic depolymerization of PRP in the presence of aluminum hydroxide.

The structural stability of the Haemophilus influenzae type b (Hib) capsular polysaccharide, polyribosylribitolphosphate (PRP) in an aluminum hydroxide adsorbed, polysaccharide-protein conjugate vaccine was monitored using modifications of an HPLC assay developed by Tsai et al. [Tsai C-M, Gu X-X, Byrd RA. Quantification of polysaccharide in Haemophilus influenzae type b conjugate and polysaccharide vaccines by high-performance anion-exchange chromatography with pulsed amperometric detection. Vaccine 1993;12:700-706.]. As applied to products containing PRP conjugated to the outer membrane protein complex (OMPC) from Neisseria meningitidis, this assay allows direct measurement of the total PRP content in very complex samples including commercial vaccine products. In addition, with the use of a high-speed centrifugation step, the assay can be used to directly quantify any PRP that is not conjugated to the OMPC carrier protein. These results provide evidence of what appears to be a catalytic reaction taking place between the phosphodiester bond of PRP and the aluminum hydroxide adjuvant that results in hydrolysis of the PRP polymer into smaller chain lengths and liberation of PRP oligomers from the conjugate particle. The reaction approaches an asymptotic limit after approximately two years at 2-8 degrees C. Clinical studies which span this time period confirm that the modest decrease in conjugated PRP content over time does not impact the overall clinical effectiveness of PRP-OMPC-containing vaccines.

Molecular coevolution within a Drosophila clock gene.

The period (per) gene in Drosophila melanogaster provides an integral component of biological rhythmicity and encodes a protein that includes a repetitive threonine-glycine (Thr-Gly) tract. Similar repeats are found in the frq and wc2 clock genes of Neurospora crassa and in the mammalian per homologues, but their circadian functions are unknown. In Drosophilids, the length of the Thr-Gly repeat varies widely between species, and sequence comparisons have suggested that the repeat length coevolves with the immediately flanking amino acids. A functional test of the coevolution hypothesis was performed by generating several hybrid per transgenes between Drosophila pseudoobscura and D. melanogaster, whose repetitive regions differ in length by about 150 amino acids. The positions of the chimeric junctions were slightly altered in each transgene. Transformants carrying per constructs in which the repeat of one species was juxtaposed next to the flanking region of the other were almost arrhythmic or showed a striking temperature sensitivity of the circadian period. In contrast, transgenes in which the repeat and flanking regions were conspecific gave wild-type levels of circadian rescue. These results support the coevolutionary interpretation of the interspecific sequence changes in this region of the PER molecule and reveal a functional dimension to this process related to the clock's temperature compensation.

Natural variation in a Drosophila clock gene and temperature compensation.

The threonine-glycine (Thr-Gly) encoding repeat within the clock gene period of Drosophila melanogaster is polymorphic in length. The two major variants (Thr-Gly)17 and (Thr-Gly)20 are distributed as a highly significant latitudinal cline in Europe and North Africa. Thr-Gly length variation from both wild-caught and transgenic individuals is related to the flies' ability to maintain a circadian period at different temperatures. This phenomenon provides a selective explanation for the geographical distribution of Thr-Gly lengths and gives a rare glimpse of the interplay between molecular polymorphism, behavior, population biology, and natural selection.

Psychosocial benefits of postmastectomy lymphedema therapy.

The effect of a comprehensive lymphedema management program was assessed in 25 patients in whom moderate to severe lymphedema had developed after surgery and/or radiotherapy for carcinoma of the breast. Intensive treatment (4 weeks) involved massage, compression bandaging, and sequential pneumatic compression, with an adjunct program of education to provide skills in exercise, massage, bandage, and containment garment use. The intensive treatment phase was followed by a self-management phase based on the skills that had been acquired. A significant reduction in limb circumference and volume, with continuing improvement over 12 months of self-management, was observed. There was a decrease in need for physical assistance. Quality of life generally remained high and stable throughout the 12 months. Quality of life specific to lymphedema, however, declined during the intensive phase of treatment, but recovered and surpassed pretreatment levels during the self-management phase of treatment. Perceived comfort and strength in the lymphedematous limb improved, and perceived size decreased. The study confirmed that the combination of multimodal physical therapy and education for self-management reduces lymphedema and its adverse subjective consequences and maintains the improvement thus achieved.

Post-mastectomy lymphoedema treatment and measurement.

OBJECTIVE: To evaluate multimodal treatment (massage, pneumatic compression, bandaging and education) of post-mastectomy lymphoedema and to review methods of measurement of lymphoedema. DESIGN: Prospective cohort study with 12 months' follow-up. PATIENTS: Twenty-five consecutive women referred for lymphoedema examination after mastectomy to a private day-patient clinic attached to a tertiary referral hospital. INTERVENTION: Patients received multimodal therapy, including education on self-management techniques, for four weeks. MAIN OUTCOME MEASURES: Changes in body weight, limb circumference and volume, and patient reports of self-management (exercise, massage, bandaging and sleeve wearing). RESULTS: Excess limb volume decreased by approximately 40% immediately after treatment and by over 50% at 6 months' follow-up, remaining stable to 12 months' follow-up. Self-management that required assistance (massage and bandage wearing) declined more after treatment than did exercise or compression sleeve wearing. Correlations between body mass and limb volume and self-management and limb volume reduction were non-significant. CONCLUSION: Multimodal therapy reduced lymphoedematous limb volume by at least half in 18 of 25 patients. Patients can maintain these reductions independently through exercise and sleeve wearing and without further treatment. We used a replicable method of measuring lymphoedema, which we recommend for adoption by researchers in this field.

Microprocessors: from desktops to supercomputers.

Continuing improvements in integrated circuit technology and computer architecture have driven microprocessors to performance levels that rival those of supercomputers-at a fraction of the price. The use of sophisticated memory hierarchies enables microprocessor-based machines to have very large memories built from commodity dynamic random access memory while retaining the high bandwidth and low access time needed in a high-performance machine. Parallel processors composed of these high-performance microprocessors are becoming the supercomputing technology of choice for scientific and engineering applications. The challenges for these new supercomputers have been in developing multiprocessor architectures that are easy to program and that deliver high performance without extraordinary programming efforts by users. Recent progress in multiprocessor architecture has led to ways to meet these challenges.

Carbon dioxide retention and oxygen desaturation during gastrointestinal endoscopy.

BACKGROUND: Pulse oximetry measures arterial oxygen saturation (SpO2), not hypoventilation, which is directly reflected by increases in carbon dioxide tension. METHODS: In the present study, transcutaneous carbon dioxide tension (PtcCO2) and SpO2 were measured during 101 endoscopic procedures selected for long duration or comorbid illnesses, and relationships between hypercapnia and hypoxemia were evaluated. Nasal oxygen was administered only for sustained desaturation (SpO2 < 90%). RESULTS: Mean peak increase in PtcCO2 was significantly higher in patients requiring oxygen for sustained desaturation (16.3 mm Hg; range, 4-52) than in patients breathing room air who had transient or no desaturation (10.2 mm Hg [range, 3-19] and 5.1 mm Hg [range, 0-15]). If nasal oxygen corrected desaturation, even transient recurrence of desaturation indicated worsening CO2 retention, which preceded respiratory arrest in one patient. Independent predictors of hypercapnia were fentanyl and midazolam doses, oxygen requirement, and dementia. CONCLUSIONS: Severe hypoventilation may occur during endoscopy, undetected by clinical observation or pulse oximetry, but only in sedated patients who require supplemental oxygen to maintain SpO2 above 90%. After oxygen supplementation corrects desaturation, recurrence of desaturation implies severe hypoventilation and warrants limitation of further sedation.

Serotype distribution of Campylobacter jejuni and Campylobacter coli isolated from hospitalized patients with diarrhea in central Australia.

Campylobacter jejuni and/or Campylobacter coli was cultured from 218 of 1,078 patients of all age groups admitted to Alice Springs Hospital, Alice Springs, central Australia, between July 1988 and June 1989 for treatment of diarrhea. One hundred sixty-six Campylobacter colonies from 127 patients were subjected to O serotyping by using the Penner typing scheme. All except 29 colonies could be serotyped. A total of 46 serotypes were identified, and the predominant serotypes were O:8, 17, O:22, O:1,44, and O:19. A large proportion of colonies reacted with more than one antiserum, and nine serotypes had antigenic compositions not observed previously. Several patients had multiple infections with more than one serotype, and some patients were shown for the first time to be infected with up to three different serotypes. Repeated reinfections with different serotypes were seen in some patients. In some patients, provided it was not due to reinfection with the same serotype, long-term excretion of the same serotype was seen, and for the first time, one patient showed evidence of excretion of the same serotype for up to 73 days.

Evaluation of a simplified procedure for serotyping Campylobacter jejuni and Campylobacter coli which is based on the O antigen.

A simplified procedure for serotyping Campylobacter jejuni and Campylobacter coli on the basis of thermostable antigens was developed and tested for its applicability as a routine typing method. The assay involves the sensitization of erythrocytes with an antigenic extract and performance of a slide agglutination assay with specific antisera. In order to simplify the typing system to a greater extent, the standard typing antisera were pooled into nine groups for C. jejuni and four groups for C. coli. The five antiserum samples allocated to each pool were selected so that pairs or groups of cross-reacting antisera were included in the same pool. When this system was tested with the serotype reference strains, it was found that, in most cases, a strain reacted in only one pool. The specific serotype of that strain could then be further defined by typing in each of the antisera belonging to that pool. To evaluate the specificity of the simplified method, 246 clinical isolates of C. jejuni and 57 clinical isolates of C. coli were typed at the same time by the standard passive hemagglutination assay and by the rapid slide agglutination system. Although both schemes effectively differentiated isolates and results from both schemes were generally very similar, differences were noted for a few isolates. On the basis of these findings, the simplified procedure may be recommended as an alternative means for serotyping these species for epidemiological purposes.

Antigenic shifts in serotype determinants of Campylobacter coli are accompanied by changes in the chromosomal DNA restriction endonuclease digestion pattern.

Changes in somatic (O) lipopolysaccharide (LPS) antigenic specificities of Campylobacter coli serostrains were observed after continuous laboratory subculture. Two serostrains (C. coli O34 and C. coli O48) lost O specificity and did not react with homologous or any of the available heterologous antisera. The C. coli serostrain for serogroup O5, after subculture, yielded a variant that had acquired a new specificity which was detectable with a heterologous antiserum. In a repeat experiment with the original isolate of the O5 strain, a second variant was obtained which had not only acquired the same new determinant but had, unlike the first variant, lost reactivity with the homologous antiserum. Immunoblot experiments with homologous and heterologous antisera indicated that changes in antigenic specificity were associated with the O side chains of the LPS molecules. Results of restriction endonuclease analysis of chromosomal DNA of the variants and their parents revealed minor differences in restriction patterns which suggested that C. coli is capable of undergoing genomic re-arrangements that lead to changes in LPS specificity and structure.

Marfanoid children. Etiologic heterogeneity and cardiac findings.

The clinical, cardiac, and echocardiographic test results of 20 children with marfanoid features are reviewed. Fifteen were diagnosed as having Marfan syndrome, two had "possible" Marfan syndrome, and three had other diagnoses. On first evaluation, eight patients with Marfan syndrome (53%) had mitral regurgitation and none had aortic regurgitation. Echocardiography showed aortic root enlargement in 12 (80%) of 15 patients and mitral valve prolapse in 12 (80%) of 15. None had a normal echocardiogram. At follow-up examination, one patient had developed aortic root enlargement, and one patient, mitral valve prolapse. Thus, although aortic root enlargement is usually present in early childhood in patients with Marfan syndrome, it is not considered specific because in this study it also occurred in one child with Alport's syndrome and in one with marfanoid features. Four patients with aortic root enlargement were treated with propranolol and their echocardiograms showed no further increase in the aortic root diameter for several years. We recommend echocardiography in the diagnosis and routine management of children in whom Marfan syndrome is suspected.