Frequency and management of diabetes and hyperglycemia at emergency departments: the GLUCE-URG Study. / Frecuencia y manejo de diabetes mellitus y de hiperglucemia en urgencias: Estudio GLUCE-URG.

INTRODUCTION: Hyperglycemia is a common finding at hospital emergency rooms in diabetic patients, but few data are available on its frequency, management, and subsequent impact based on the assessment made at Emergency rooms. OBJECTIVES: To ascertain the frequency of diabetes mellitus and hyperglycemia in patients admitted from Emergency rooms. Second, to describe management of hyperglycemia at Emergency rooms, and to analyze its potential impact on the course and management of patients during admission. PATIENTS AND METHODS: All patients admitted from the Emergency room for three consecutive weeks were enrolled. Hyperglycemia was defined as two blood glucose measurements ≥ 180mg/dl in the first 48hours after admission. RESULTS: 36.6% of patients admitted from the Emergency room were diabetic, and 58% of these had early, sustained hyperglycemia. On the other hand, 27% of patients admitted from the Emergency room had hyperglycemia (78.3% of diabetic patients and 21.7% with no known diabetes). Diabetic patients with hyperglycemia had higher blood glucose levels than non-diabetic patients (p<.01). Average hospital stay was 8±6.4 days, with no differences between the groups. Hyperglycemia is rarely reported as a diagnosis in the emergency rooms discharge report. In standard hospitalization, this diagnosis appears more commonly in patients with known diabetes (OR 2.5 p<.001). CONCLUSIONS: Prevalence of diabetic patients admitted from emergency rooms is very high. In addition, although hyperglycemia is very common in patients admitted from emergency rooms, there is a trend to underestimate its significance. Based on our results, we think that implementation of measures to give greater visibility to diagnosis of hyperglycemia could help improve application of established protocols.

Humoral immune response of a pneumococcal conjugate vaccine: capsular polysaccharide serotype 14-Lysine modified PspA.

Polysaccharide-protein conjugates are so far the current antigens used for pneumococcal vaccines for children under 2 years of age. In this study, pneumococcal surface protein A (PspA) was used as a carrier protein for pneumococcal capsular polysaccharide serotype 14 as an alternative to broaden the vaccine coverage. PspA was modified by reductive amination with formaldehyde in order to improve the specificity of the reaction between protein and polysaccharide, inhibiting polymerization and the gel formation reaction. In the synthesis process, the currently used activator, 1-[3-(dimethylamine)propyl]-3-ethylcarbodiimide hydrochloride (EDAC) was substituted for 4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium chloride (DMT-MM). BALB/c mice were immunized with either the PS14-mPspA conjugate or the co-administered components in a three dose regimen and sera from the immunized animals were assayed for immunity induced against both antigens: PS14 and mPspA. Modification of more than 70% of lysine residues from PspA (mPspA) did not interfere in the immune response as evaluated by the anti-PspA titer and C3 complement deposition assay. Sera of mice immunized with conjugated PS14-mPspA showed similar IgG titers, avidity and isotype profile as compared to controls immunized with PspA or mPspA alone. The complement deposition was higher in the sera of mice immunized with the conjugate vaccine and the opsonophagocytic activity was similar for both sera. Conjugation improved the immune response against PS14. The anti PS14 IgG titer was higher in sera of mice immunized with the conjugate than with co-administered antigens and presented an increased avidity index, induction of a predominant IgG1 isotype and increased complement deposition on a bacteria with a surface serotype 14. These results strongly support the use of PspA as carrier in a conjugate vaccine where both components act as antigens.

Humoral immune response of a pneumococcal conjugate vaccine Capsular polysaccharide serotype 14-Lysine modified PspA

Polysaccharide-protein conjugates are so far the current antigens used for pneumococcal vaccines for children under 2 years of age. In this study, pneumococcal surface protein A (PspA) was used as a carrier protein for pneumococcal capsular polysaccharide serotype 14 as an alternative to broaden the vaccine coverage. PspA was modified by reductive amination with formaldehyde in order to improve the specificity of the reaction between protein and polysaccharide, inhibiting polymerization and the gel formation reaction. In the synthesis process, the currently used activator, 1-[3-(dimethylamine)propyl]-3-ethylcarbodiimide hydrochloride (EDAC) was substituted for 4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium chloride (DMT-MM). BALB/c mice were immunized with either the PS14-mPspA conjugate or the co-administered components in a three dose regimen and sera from the immunized animals were assayed for immunity induced against both antigens: PS14 and mPspA. Modification of more than 70% of lysine residues from PspA (mPspA) did not interfere in the immune response as evaluated by the anti-PspA titer and C3 complement deposition assay. Sera of mice immunized with conjugated PS14-mPspA showed similar IgG titers, avidity and isotype profile as compared to controls immunized with PspA or mPspA alone. The complement deposition was higher in the sera of mice immunized with the conjugate vaccine and the opsonophagocytic activity was similar for both sera. Conjugation improved the immune response against PS14. The anti PS14 IgG titer was higher in sera of mice immunized with the conjugate than with co-administered antigens and presented an increased avidity index, induction of a predominant IgG1 isotype and increased complement deposition on a bacteria with a surface serotype 14. These results strongly support the use of PspA as carrier in a conjugate vaccine where both components act as antigens.

Desenvolvimento e avaliação da resposta imune humoral de uma vacina anti-pneumocócica conjugada polissacarídeo capsular sorotipo 14 - proteína de superfície pneumocócica A / Development and evaluation of the humoral immune response of na antipneumococcal conjugate vaccine: capsular polysaccharide serotype 14-pneumococcal surface protein A

Streptococcus pneumoniae é uma bactéria encapsulada que coloniza a nasofaringe, sendo uma das principais causas de morte por pneumonia e meningite em crianças e idosos. As vacinas contra S. pneumoniae são compostas por polissacarídeos capsulares (PS) livres ou conjugados à uma proteína. A vantagem do polissacarídeo conjugado em relação ao livre é a resposta timo-dependente. Pelo fato de existirem pelo menos 92 diferentes sorotipos capsulares, a utilização de uma proteína pneumocócica em uma vacina conjugada com apenas alguns sorotipos poderia aumentar a sua cobertura vacinal. Para tal, a utilização da proteína de superfície pneumocócica A (PspA) foi utilizada como carreador protéico covalentemente ligado ao polissacarídeo capsular sorotipo 14. Este trabalho também apresenta uma nova metodologia para a síntese de vacinas conjugadas, que vem demonstrando melhores resultados em nosso laboratório em comparação aos métodos clássicos de conjugação. O conjugado PS14-PspA foi administrado em camundongos BALB/c e o título de IgG anti-PS14 e anti-PspA, o índice de avidez, a deposição de complemento e a distribuição das subclasses de IgG foram avaliados. O título de IgG anti-PS14 conjugado foi significativamente maior do que título de IgG anti-PS14 livre. A avidez e a deposição de complemento do soro anti-PS14 conjugado também foram maiores. A principal subclasse de IgG induzida pelo PS14 livre foi IgG3 enquanto o PS14 conjugado induziu preferencialmente IgG1. No entanto, o índice de avidez, o perfil de distribuição das subclasses de IgG e a medida funcional da atividade opsonofagocítica dos soros anti-PspA livre e conjugada foram os mesmos.

Streptococcus pneumoniae is an encapsulated bacterium that colonizes the nasopharynx, being one of the leading causes of death from pneumonia and meningitis in infants and elderly. Vaccines against S. pneumoniae are constituted by plain capsular polysaccharide (PS) or conjugated to a protein. The advantage of conjugated PS on plain PS vaccine is the thymus dependent immune response. Since there are at least 92 different capsular serotypes, the use of a pneumococcal protein in a conjugate vaccine using only few serotypes might broader its coverage. For this purpose the pneumococcal surface protein A (PspA) was used as protein carrier to bind covalently to the capsular polysaccharide serotype 14. This work also presents a new methodology for the synthesis of conjugate vaccines, which showed better results in our laboratory in comparison to the classic ones. The conjugate PS14-PspA was injected in BALB/c mice and sera were measured for IgG titer against PS14 and PspA. IgG avidity index, complement deposition, and anti-PS14 and anti-PspA IgG subclasses were also evaluated. IgG titer against conjugated PS14 was significantly higher than IgG titer against control PS14. The avidity and the complement deposition of conjugated anti-PS14 serum were also higher. The main IgG subclass induced by free PS14 was IgG3 while conjugated PS14 induced preferably IgG1. Nevertheless, the avidity index, the IgG subclasses distribution profile, and the functional opsonophagocytic measure from free and conjugated anti-PspA sera were the same.