Adopting prospective antimicrobial stewardship (AMS) practice in high-risk immunosuppressed groups: an urgent call to action in the era of antimicrobial resistance (AMR).

Life-saving immunosuppressive treatments including intensive chemotherapy and bone marrow transplantation expose patients to a considerable risk of death from infection globally. With evolving AMR and transmission, this could spell disaster for patients across the world and society at large. Antimicrobial stewardship (AMS) and prompt appropriate management of potentially fatal, emergent infections are essential. It is now apparent that antibacterial prophylaxis in patients with haematological cancer may not provide survival benefit while simultaneously increasing risks for AMR carriage. With evolving AMR and increasing immunosuppressed populations across the world, we must institute robust AMS practices. Significant resources are used to combat the impact of AMR on immunosuppressed patients. For lower-middle income countries (LMICs) these resources may not be available and as such the impact caused by AMR is greater. By considering the patient journey holistically we consider risk of infection presented to patients temporally and geographically. A short-term and easy to implement approach of multi-disciplinary team (MDT)-style advance care planning for infection is advocated. Antimicrobials, when used appropriately, enable healthcare procedures to occur and exist. Indeed, the very future of clinical medicine will rely on this yet to be realized value of enablement. Proactive effort and change must occur across all sectors with holism; hence our impetus for convening a joint industry and clinical working group. With at-risk immunosuppressed groups being a sentinel for change, awareness and implementation of patient-centric actions for infection are essential and our recommendations serve as an urgent call to action.

Vascular effects on ciliary tissue from endoscopic versus trans-scleral cyclophotocoagulation.

AIM: To determine the acute and chronic vascular effects of endoscopic cyclophotocoagulation (ECP) versus trans-scleral cyclophotocoagulation (TCP) in a rabbit model. METHODS: 20 rabbits underwent ECP in one eye and another 20 rabbits had unilateral TCP. Five treated eyes from each group underwent endoscopic fluorescein angiography (EFA) of the treated ciliary processes at each of the following time points: immediate, 1 day, 1 week, and 1 month. Five untreated rabbits were used as controls. The NIH Image software program was used to trace ciliary processes in order to determine their mean intensity, as a measure of their perfusion. Histopathology was also performed on eyes from each time point. RESULTS: Immediately and 1 day after laser, both TCP and ECP eyes demonstrated severely reduced or non-existent blood flow in the areas of treatment. TCP treated processes essentially remained non-perfused at the 1 week and 1 month time points. ECP treated processes showed some reperfusion at 1 week and greater reperfusion by 1 month. Histopathology confirmed the overall greater vascular occlusion seen with TCP. CONCLUSIONS: Chronic poor perfusion of the ciliary body after TCP may account, in part, for its efficacy, as well as the significant complications including hypotony and phthisis. Late reperfusion of this region after ECP may provide some insight into the differences in efficacy and complication rates compared to TCP.

OCEANOGRAPHY. Contrasting futures for ocean and society from different anthropogenic CO2 emissions scenarios.

The ocean moderates anthropogenic climate change at the cost of profound alterations of its physics, chemistry, ecology, and services. Here, we evaluate and compare the risks of impacts on marine and coastal ecosystems­and the goods and services they provide­for growing cumulative carbon emissions under two contrasting emissions scenarios. The current emissions trajectory would rapidly and significantly alter many ecosystems and the associated services on which humans heavily depend. A reduced emissions scenario­consistent with the Copenhagen Accord's goal of a global temperature increase of less than 2°C­is much more favorable to the ocean but still substantially alters important marine ecosystems and associated goods and services. The management options to address ocean impacts narrow as the ocean warms and acidifies. Consequently, any new climate regime that fails to minimize ocean impacts would be incomplete and inadequate.

Relationship between lipofuscin granules and polyunsaturated fatty acids in the housefly, Musca domestica.

The fractional volume occupied by lipofuscin granules in epithelial cells of the midgut or oenocytes of abdominal fat body of 3-day-old and 13-day-old male houseflies was determined in two groups of flies by electron microscopic morphometry. One group had developed from larvae reared on diets containing no added polyunsaturated fatty acids and the second from larvae reared on diets containing added linoleic acid. No polyunsaturated fatty acids could be detected in the lipids of the first group of flies using a method which would have detected their presence in amounts greater than 0.1% of the total esterified fatty acids. The second group contained at least two hundred times more than this minimal level. The volume of lipofuscin granules increased significantly (p less than 0.01) (about threefold for the fat body and twofold in midgut cells) between 3 days and 13 days of age but no statistically significant difference was seen between the two groups of flies at the same age. The results show that if lipofuscin formation depends on the oxidation of polyunsaturated fatty acids in the housefly, then extremely small amounts of the acids are involved which lie below the detection limit of the methods employed. The age-associated small increase of extractable fluorescence seen previously in the linoleic acid group of flies is not associated with an increase in the lipofuscin granules.

Molecular characterisation of adenosylhomocysteinase from Trichomonas vaginalis.

The enzyme S-adenosylhomocysteine hydrolase (SAHH) has been identified as a potential target for chemotherapy in protozoan parasites including Trichomonas vaginalis. To investigate this area of trichomonad metabolism in more detail, we have isolated and characterised a gene which encodes this activity from the WAA38 strain of this parasite. The gene was isolated by probing a Bg/II genomic mini-library with a fragment of the gene generated by thermal cycling using degenerate oligonucleotide primers. A 5.9-kb Bg/II clone was isolated and has been partially sequenced to reveal a 1458-bp open reading frame which encodes a 486-residue polypeptide (computed molecular mass of 53.4 kDa). The deduced amino acid sequence showed a high degree of sequence similarity to the hydrolases from other species, but was most similar to the enzyme from photosynthetic organisms. The trichomonal sahh gene also contains two "insertion sequences', one of which appears to be unique to this parasite while the second has previously been found only in photosynthetic organisms and in Plasmodium falciparum. Characterisation of the sahh mRNA from T. vaginalis confirmed that both of these insertion sequences (encoding 9 and 37 amino acid residues, respectively) are expressed in the protein product. The sahh mRNA is similar to those characterised from other protozoa in having a short, 12-bp untranslated 5'-leader sequence but the leader sequence does not conform well with the consensus sequence of the other mRNAs. Finally, Southern blots and sequence differences between genomic and cDNA clones indicate that there are multiple copies of the sahh gene in T. vaginalis.

Aqueous immune complexes in immunogenic uveitis.

A primary immunogenic uveitis was produced in rabbits by the intravitreal injection of bovine plasma albumin or ovalbumin. A secondary or recurrent uveitis was induced by intravenous injection of the specific soluble antigen several months after the cessation of primary inflammation. Aqueous antigen-antibody complexes were studied at times of maximal clinical response in both primary and recurrent forms during resolution of primary immunogenic uveitis, and in a nonspecific protein extravasation induced by aqueous paracentesis. Immune complexes could be demonstrated only during times of clinically evident inflammation in immunogenic uveitis. The results indicate the importance of antigen-antibody complex formation in the pathogenesis of this form of experimental ocular inflammatory disease.

Quantitation of acute experimental ocular inflammation with 111indium-leukocytes.

The cellular component of an acute ocular inflammation in rabbits was measured with autologous leukocytes exogenously labeled with 111Indium tropolonate. Inflammation was induced by intravitreal bacterial lipopolysaccharide (LPS). After 16 hr blood was removed, leukocytes separated, labeled with 111Indium tropolonate and reinjected. Three cell fractions were examined: a leukocyte rich fraction which had been prepared with Dextran; and polymorphonuclear and mononuclear leukocyte fractions which had been prepared using a discontinuous Percoll gradient. Two hours after labeled leukocytes were injected, measurements of 111Indium were made in blood, plasma, the whole eye and in ocular compartments. From these data the numbers of each leukocyte population present were estimated and compared directly to histopathologic changes. Both polymorphonuclear and mononuclear leukocytes entered ocular tissues during the 2 hr period beginning 20 hr after LPS injection. Altered ocular vascular permeability was successfully measured with 125Iodine-albumin in some of these same rabbits. Both the number and type of inflammatory cell entering ocular tissues during a set period of time of the inflammatory response could thus be measured. This technique provides an opportunity to define the relationship of leukocyte infiltration and altered ocular vascular permeability in ocular tissues during the inflammatory response.

Hyaluronan in the human trabecular meshwork.

PURPOSE: Hyaluronan (HA) is a high-molecular weight glycosaminoglycan that can affect water and solute fluxes in the extracellular matrix. The distribution of HA in the human trabecular meshwork of nonglaucomatous eyes was examined to help understand the potential role of HA in the regulation of aqueous outflow resistance. METHODS: Histolocalization of HA was established in situ in the trabecular meshwork of human eyes with no known diseases of the anterior segment. A specific biotinylated HA-binding peptide was used as a probe for this study, with enhanced sensitivity of HA detection achieved by modifications of the fixation and staining procedures. RESULTS: Evaluation of HA staining in the aqueous outflow pathway in comparison to that in other ocular structures (e.g., the vitreous) showed pronounced staining in the trabecular meshwork. The staining intensity was similar between various layers of the meshwork. Both the filtering and the anterior nonfiltering portions of the trabecular meshwork showed pronounced HA staining. The staining was localized primarily to the trabecular meshwork endothelial cells. CONCLUSIONS: Pronounced HA staining observed in the various layers of the trabecular meshwork suggests that substantial amount of HA is present in the nonglaucomatous outflow pathway. The staining pattern suggests that HA is associated with the endothelial cells lining the trabecular beams. This finding supports potential roles for this glycosaminoglycan in the regulation of the physiological aqueous outflow resistance or in the maintenance of the outflow channels or both. Histochemical localization of HA in the various layers of the non-glaucomatous meshwork provides a useful basis for future comparative studies of HA distribution and relative amounts in the trabecular meshworks of eyes affected by various types of glaucoma.

Mononuclear cells in the corneal response to endotoxin.

A severe keratitis can be produced after the direct injection of bacterial endotoxin, or lipopolysaccharide (LPS), in rabbits. Corneal inflammation can progress to scarring and vascularization within a 2 to 3 week period. Pretreatment with systemic adrenal corticosteroids (triamcinolone) prevents this response. Limbal cellular and vascular events were studied during the first 20 hr after injection of LPS in treated and nontreated rabbits. Perivascular limbal inflammatory cells were counted and limbal vascular permeability was assessed by extravasation of 131I-albumin and 125I-fibrinogen in the cornea. Corticosteroids decreased but did not prevent the early protein extravasation and profoundly altered the inflammatory cell population around blood vessels at the limbus. Mononuclear cells, particularly mononuclear phagocytes, were sharply reduced. It is proposed that these cell types play an important role in the perpetuation and amplification of the inflammatory response in this reaction.

Characterization of endotoxin-induced C5-derived chemotactic activity in aqueous humor.

Although a cellular exudate characterizes acute anterior uveitis, few studies have sought to identify the chemoattractant(s) contributing to this phenomenon. As a model of acute ocular inflammation, the authors have injected rabbits intravenously with endotoxin (Salmonella typhimurium LPS, 2.5 micrograms/kg). In a Boyden chamber assay, aqueous humor drawn 3 hr after LPS (post-LPS aqueous) exhibited chemotactic activity for purified rabbit granulocytes (PMN). "Checkerboard" analysis indicated that chemotaxis, rather than protein-induced chemokinesis, primarily accounted for PMN migration. Aqueous from normal rabbits demonstrated no chemotactic activity. Chemotactic activity was maximal at 3 hr post-LPS (versus 1 or 5 hr). PMN migration exhibited a direct correlation with the concentration of aqueous tested (0.5-5%). Several observations indicated that this chemotactic activity is complement (C5)-derived. It is inhibited by antibodies to C5 but not affected by antibodies to C3. Similar to rabbit C5a, chemotactic activity in post-LPS aqueous was heat stable at 56 degrees C X 30 min, attracted both human and rabbit PMN at similar concentrations and induced release of beta glucuronidase from PMN. In addition, prior incubation of rabbit PMN with partially purified C5a (densensitization) specifically inhibited chemotactic responses to both C5a and post-LPS aqueous without inhibiting responses to another chemoattractant, n-formyl-methionyl-leucyl-phenylalanine. Finally, chemotactic activity from post-LPS aqueous could be recovered from a Sephadex G75 column and eluted similarly to chemotactic activity in zymosan activated rabbit serum or 13,700 D molecular weight marker. The presence of complement-derived chemotactic activity in this model should not be construed as evidence that this activity contributes to the pathogenesis of endotoxin-induced inflammation.(ABSTRACT TRUNCATED AT 250 WORDS)

Histopathology of delayed hypersensitivity reacitons in the guinea pig uveal tract.

Two distinct patterns of delayed-onset, cell-mediated hypersensitivity have been induced in the guinea pig eye with the same soluble protein antigen and two different methods of immunization. The predominant histologic feature of these reactions was the large number of eosinophils which infiltrated the uveal tract and the limbus. Skin test reactions in the same animals contained very few eosinophils and were typical of cutaneous basophil hypersensitivity or classic delayed hypersensitivity of the tuberculin type. It is suggested that local factors play a role in determining the character of immune expression in different tissues.

Retinoblastoma: tissue culture lines and monoclonal antibody studies.

Retinoblastoma patients have cellular and humoral reactivity towards antigens expressed on retinoblastoma cells. We report the ultrastructural, cytogenetic, and immunologic features of four new retinoblastoma derived tissue culture cell lines. Studies with hybridoma produced monoclonal antibodies demonstrate that these lines share antigens with a previously described long-term allogeneic retinoblastoma derived tissue culture cell line, as well as with antigens on fresh retinoblastoma.

Cellular and vascular responses in acute experimental ocular inflammation.

PURPOSE: To measure simultaneously blood volume, altered vascular permeability, and leukocyte extravasation in ocular inflammation in rabbits at various times and in different anatomic locations after intravitreal endotoxin (lipopolysaccharide [LPS]). METHODS: Nuclides of different emission and decay were used for labeling and then injected intravenously. Ocular blood volumes were measured with technetium 99m, altered vascular permeability with I-125 albumin, and polymorphonuclear leukocyte or mononuclear cell extravasation after labeling with Indium 111. Eyes were divided into anterior eye section, iris-ciliary body, aqueous, and vitreous and posterior eye sections, and measurements were made at 3, 6, 9, 18, and 24 hours after intravitreal LPS injection. Blood volume measurements made it possible to estimate the amount of extravascular protein and the number of extravascular leukocytes. RESULTS: Blood volumes were consistently elevated at all times, usually by approximately 50% and predominantly in the anterior segment. Altered vascular permeability was present at 3 hours, increased at 6 hours, decreased at 9 hours, and was elevated at 18 to 24 hours, predominantly in the anterior eye. Leukocytes in iris-ciliary body appeared in small numbers at 6 hours, increased at 9 hours, and continued to extravasate at 18 and 24 hours. Mononuclear cells were as numerous as polymorphonuclear leukocytes at each time measured. CONCLUSIONS: The quantitation of multiple parameters of ocular inflammation in this experimental model has been helpful in defining when and in what tissue changes occur. Leukocytes are primarily within tissues, particularly in the iris-ciliary body region. Mononuclear leukocytes are a prominent feature at all times and add further support to the concept that the mononuclear phagocyte plays a pivotal role in reactions to LPS.

Transgenic mice expressing IFN-gamma in the retina develop inflammation of the eye and photoreceptor loss.

PURPOSE: Inflammatory mediators such as interferon-gamma (IFN-gamma) are thought to play a role in ocular disease. Although IFN-gamma was found in the vitreous of mice with experimentally induced autoimmune uveitis, intracameral injection of this cytokine did not induce intraocular inflammation in mice. Therefore, the authors created a transgenic mouse line using the rhodopsin promoter to direct the expression of IFN-gamma in the photoreceptor cells of the retina. These mice, designated rho gamma, enabled them to model intraocular inflammatory disease. METHODS: The authors fused a 2.1 kb 5' Hind III fragment from the murine rhodopsin gene to the IFN-gamma gene and introduced the DNA construct into fertilized zygotes. These were implanted into pseudopregnant C57BL/6 mice, and the resulting progeny were crossed back to balb/c mice. The transgene was identified by Southern blot hybridization. Eyes from the rho gamma mice were either fixed in zinc formalin and stained with hematoxylin and eosin or were frozen in OCT compound and processed for immunostaining using the indirect immunoperoxidase method with DAB as a chromogen. RESULTS: The rho gamma transgenic mice developed intraocular disease, manifested as intraocular cellular infiltration, loss of photoreceptors, corneal clouding, cataract formation, and epithelial and microglial proliferation. Additionally, rho gamma mice exhibited antigenic changes, comprising GFAP expression on Müller cells, accumulation of neurofilament on photoreceptors, and expression of MHC class I and class II molecules on retinal cells. CONCLUSIONS: IFN-gamma alters the antigenic properties of intraocular tissue and induces intraocular inflammation in mice. The results suggest a key position of IFN-gamma in the development of pathologic conditions related to intraocular inflammation and provide a useful animal model for the further study of inflammatory disorders, including autoimmune diseases.

Localization of tumor necrosis factor receptor messenger RNA in normal and herpes simplex virus-infected mouse eyes.

PURPOSE: To investigate the distribution of p75 and p55 tumor necrosis factor receptor (TNFR) mRNA in normal mouse eyes and in mouse eyes acutely infected with McKrae strain herpes simplex virus (HSV). METHODS: In situ hybridization with antisense 35S-labeled riboprobes for p55 and p75 TNFR subtypes was used in uninfected and HSV-infected mouse eyes. Controls included the use of sense riboprobes and corneas inoculated with vehicle alone. RESULTS: In uninfected and infected mouse eyes, in situ hybridization produced an autoradiographic signal for mRNA, encoding both p75 and p55 over the corneal endothelium, iris, ciliary body, choroid, and arachnoid layers of the optic nerve sheath. In addition, the signal was observed over scattered cells at the vitreoretinal interface. Signal for p75, but not p55, was observed over cells in the retinal ganglion cell layer. Acute HSV infection was accompanied by an intense leukocytic infiltrate in the conjunctiva, the corneal subepithelium and stroma, the anterior and posterior chambers, the iris root and ciliary body, and the vitreous cavity. In this setting, increased p75 and p55 mRNA signal was correlated closely with the number and location of receptor-bearing white blood cells. Signal over control sections hybridized with sense p75 and p55 TNFR cRNA probes was comparable to background. Signal over control eyes inoculated with sterile vehicle showed slight increased signal in the immediate vicinity of the traumatic keratitis, but otherwise it was comparable to that observed in uninfected animals. CONCLUSIONS: The observed distribution of p75 and p55 TNFR mRNA in normal and acutely infected mouse eyes, and particularly over the heavily vascularized uveal tract and over cells at the vitreoretinal interface, supports a role for TNF as a mediator of intraocular inflammation, perhaps as a key regulator of the blood-ocular barrier.

The structural basis of altered vascular permeability following intraocular inflammation.

An immunogenic uveitis was produced in rabbits by the intravitreal injection of bovine gamma-globulin. Four to six months later, an alteration in vascular permeability was determined by greater accumulation of iodinated I 125 serum albumin in the previously inflamed eye than in the normal eye. An altered vascular permeability was found only in eyes with profound structural changes. Possible sites of extravascular protein leakage were: (1) proliferated blood vessels in the posterior chamber and vitreous; and (2) leakage through the disrupted and scarred ciliary epithelium. In eyes without evidence of altered vascular permeability, a persistent chronic inflammation was observed, and gliosis and chorioretinal scarring was prominent.

Lipopolysaccharide tolerance inhibits eye inflammation. II. Preliminary studies on the mechanism.

The effect of endotoxin tolerance on ocular inflammation was studied in rabbits. Compared with a control group, a passive Arthus reaction in tolerant rabbits was characterized by a sharp decline in the expected increase in vascular permeability and slightly reduced leukocyte extravasation. Aqueous humor withdrawal (paracentesis) and intravitreal injection of prostaglandin E2 were also examined in lipopolysaccharide (LPS)-tolerant rabbits; in both circumstances, ocular protein exudation was decreased. These studies suggest that the prostaglandin system is particularly affected in the ocular responses of LPS-tolerant rabbits, and raise the possibility that other phenomena described in LPS tolerance may have a similar basis.

Circulating immune complexes. Effects on ocular vascular permeability in the rabbit.

Sudden transient, alteration in vascular permeability is producible in rabbit eyes by intravenous injection of large quantities of antigen, bovine gamma-globulin (BGG), into immunized animals or by intravenous injection of large amounts of antigen-antibody complexes (BGG-antiBGG) prepared in antigen excess (20 to 25times) in normal rabbits. Change is measured by ocular accumulation of iodinated I125 serum albumin, relative to that in heart blood, in intact eyes and separate anatomical compartments, in aqueous, in the anterior eye including (lens plus vitreous), and in the posterior segment. Primarily affected are vessels in the iridial portion of ciliary processess; edema is the primary finding. The same vessels are affected by intravenous injection of bacterial endotoxin, but compared with endotoxin, altered vascular permeability is short-lived and is not associated with formation of platelet plugs and intravenous fibrin strands.

Ocular pathology of infantile Niemann-Pick disease. Study of fetus of 23 weeks' gestation.

A fetus of 23 weeks' gestation was aborted following the demonstration of sphingomyelinase deficiency (infantile form of Niemann-Pick disease) in cultured amniotic fluid cells that were obtained by amniocentesis. Histopathologic study of the eyes disclosed normal findings for the fetal age, except for fine lipid droplets in the inner plexiform layer of the retina. By electron microscopy, membranous cytoplasmic bodies (MCB) characteristic of lipid storage diseases were identified in many ocular tissues, including corneal epithelium and keratocytes, lens epithelial cells and fibroblasts of choroid and sclera, and in extraocular muscle. Selective accumulation of MCB in ganglion cells in the primitive macular region was not apparent. An extremely fine membranous component (30 to 40 Angstroms) was seen in some inclusions, suggesting a relatively pure phospholipid content.

Combined nevi of the conjunctiva.

OBJECTIVE: To report the clinical and histologic features of combined nevi of the conjunctiva, a type of nevus that is not uncommon in the skin but rarely has been reported in the conjunctiva. METHODS: Conjunctival nevi and melanomas in the files of the University of California at San Francisco Eye Pathology Laboratory from 1984 to 1999 were reviewed for the presence of features of both standard nevocytic nevi and blue nevi. Clinical histories and, when available, clinical photographs were obtained. RESULTS: Thirty combined nevi were discovered between 1984 and 1999. One case before 1984 had been incorrectly diagnosed as a junctional nevus. The dendritic and spindle-shaped blue nevus cells had been overlooked because they were not recognized as distinct from the standard nevocytic nevus cells. The recognition of blue as well as a brown color, a deep as well as a superficial component in the lesion, or a history of pigmentation since birth may help to establish the correct clinical diagnosis and prevent an unnecessarily deep surgical resection. Although growth of the lesion or "satellites" in some may favor a clinical diagnosis of melanoma, no lesions in this series were malignant. CONCLUSION: Despite a paucity of reports of combined nevi of the conjunctiva in the medical literature, this type of nevus, a combination of a nevocytic and a blue nevus, is common and has been overlooked in the past.