Adherence to a strict medication protocol can reduce length of stay in hospitalized patients with Parkinson's Disease.

BACKGROUND: Patients with Parkinson's Disease (PD) are at higher risk of complications when admitted to the hospital. Delays in PD medications and use of contraindicated medications contribute to the increased risk and prolong their lengths of stay (LOS). Using a hospital-wide PD protocol, we aimed to ensure PD medications were placed with "custom" timing to resemble the home schedules, and also to avoid ordering or administering contraindicated medications. MATERIAL AND METHODS: 569 patients admitted in 2017 and 2018, were reviewed retrospectively. Mean age was 76.5 (SD 10.6), 332 were males and 237 were females. Charts were reviewed to assess if A) PD medications were ordered with custom timing, B) if not, were the orders changed to custom timed C) if contraindicated medications were ordered, and D) if they were administered. We also assessed the actual/expected length of stay during this time period. Chi Square and post hoc analyses were done to compare time points. Poisson regression analysis was done to assess relative improvement of variables. RESULTS: There was a 2.7 fold increase in orders placed with custom timing in 2018 compared to 2017 (RR = 2.651, 95%CI: 1.860-3.780, p < 0.0001), and a 3.2 fold increase in correction of non-custom orders in the same time period (RR = 3.246, 95%CI: 1.875-1.619, p < 0.0001). We also observed a decrease in the actual/expected LOS ratio from 1.54  to 1.32  (p < 0.05). CONCLUSION: By utilizing an established platform for quality improvement, we were able to improve adherence to the home medication regimen timing in admitted PD patients. Our findings also suggests that adherence to a strict medication regimen protocol may decrease LOS for this patient population.

Systemic inflammatory response after extremity or truncal fracture operations.

BACKGROUND: The purpose of this study was to assess proinflammatory markers in blunt trauma patients regarding the relationship of these and blood loss and duration of surgery in different fracture locations. DESIGN: Prospective, multicenter, nonrandomized cohort study. SETTING: Three level I trauma centers. PATIENTS: Sixty-eight blunt trauma patients, who did not require emergency operations and had sustained truncal or extremity fractures, were included. In two index patient groups, patients with spinal fractures (group SF, n = 24) and pelvic and acetabular fractures (group PAF, n = 21) underwent fixation of their fractures and were compared with a group of patients with isolated fractures (group FF, n = 28). Ten healthy volunteers served as controls. INTERVENTION: Internal fixation of pelvic, acetabular and spinal fractures, intramedullary nailing of femoral fractures, measurement of proinflammatory cytokines. MAIN OUTCOME MEASURES: From serially sampled central venous blood, the perioperative concentrations of interleukin-6 (IL-6) and IL-8 were evaluated during a 24-hour period and set into relation with the duration of surgery and the degree of blood loss. RESULTS: Intramedullary instrumentation for isolated PAF caused a significant perioperative increase in the concentrations of IL-6 (preoperative: 16 pg/mL +/- 12 pg/mL, 7 hours: 89 pg/mL +/- 15 pg/mL, and 24 hours: 107 pg/mL +/- 27 pg/mL, p < 0.05). This increase was comparable with the isolated femoral fracture (group FF: IL-6 preoperative, 52 pg/mL +/- 12 pg/mL; 7 hours, 78 pg/mL +/- 14 pg/mL; and 24 hours, 120 pg/mL +/- 23 pg/mL, p = 0.02). The changes observed after spinal fracture fixations (group SF) were considerably lower (IL-6 preoperative: 11 pg/mL +/- 6 pg/mL, 7 hours: 16 pg/mL +/- 11 pg/mL, and 24 hours: 56 pg/mL +/- 19 pg/mL). The percent change of baseline IL-6 and IL-8 concentrations, and the blood loss in group PAF at 24 hours were positively correlated (IL-6 r = 0.72, p < 0.03, IL-8 0.67, p = 004) after insertion. No correlation with the duration of surgery was found. CONCLUSIONS: The release of proinflammatory cytokines was higher in patients when their pelvic fractures were operated than in patients with spine fracture fixations, and was associated with the degree of blood loss. A higher increase in cytokine levels occurred when they were performed early (day 1-2) across all patient groups. The level of the released markers seems to be related to the magnitude of surgery, rather than to the duration of the procedure. This study supports the value of immunologic markers in determining subclinical changes during and after orthopedic surgical procedures.

Forces and torques during fracture reduction: Intraoperative measurements in the femur.

Reduction is a crucial step in fracture treatment. We determined intraoperative peak forces and torques during fracture reduction in seven patients with eight fractures of the femoral shaft. All fractures were temporarily stabilized by external fixation. Force and torque measurements were performed during the subsequent intramedullary nailing procedure. A three-dimensional load cell was attached to the distal femur fragment using two Schanz screws. All forces and torques were registered on-line during the reduction process. The maximum resulting force was 411 N, the maximum resulting torque 74 N x m. The highest force was observed along the shaft axis with 396 N for distraction. The maximum torque value was measured around the frontal axis, being 74 N x m for antecurvature. These results may assist the development of new reduction techniques and devices.

Severe pneumonia due to Parachlamydia acanthamoebae following intranasal inoculation: a mice model.

Parachlamydia acanthamoebae is an obligate intracellular bacterium naturally infecting free-living amoebae. The role of this bacterium as an agent of pneumonia is suggested by sero-epidemiological studies and molecular surveys. Furthermore, P. acanthamoebae may escape macrophages microbicidal effectors. Recently, we demonstrated that intratracheal inoculation of P. acanthamoebae induced pneumonia in 100% of infected mice. However, the intratracheal route of infection is not the natural way of infection and we therefore developed an intranasal murine model. Mice inoculated with P. acanthamoebae by intranasal inoculation lost 18% of their weight up to 8 days post-inoculation. All mice presented histological signs of pneumonia at day 2, 4, 7, and 10 post-inoculation, whereas no control mice harboured signs of pneumonia. A 5-fold increase in bacterial load was observed from day 0 to day 4 post-inoculation. Lungs of inoculated mice were positive by Parachlamydia-specific immunohistochemistry 4 days post-inoculation, and P. acanthamoebae were localized within macrophages. Thus, we demonstrated that P. acanthamoebae induce a severe pneumonia in mice. This animal model (i) further supports the role of P. acanthamoebae as an agent of pneumonia, confirming the third Koch postulate, and (ii) identified alveolar macrophages as one of the initial cells where P. acanthamoebae is localized following infection.

Temperature and host cell-dependent changes in virulence of Chlamydia pneumoniae CWL029 in an optimized mouse infection model.

The obligate intracellular bacterium Chlamydia (C.) pneumoniae causes respiratory infections and is associated with vascular diseases. To elucidate how temperature and host cells used for propagation alter chlamydial virulence, C. pneumoniae CWL0129 (Cpn) was cultured at 35 or 37°C in two different cell lines and then applied to mice. These mice infected with differentially propagated chlamydiae showed differences in clinical score, body weight and inflammatory cytokines in the lung. Our study demonstrates that Cpn cultured at 37°C in hamster fibroblast BHK-21 are able to colonize the mouse lung faster and better, and induce stronger symptoms and cytokine induction than bacteria cultured at 35°C. The temperature-triggered virulence alteration could not be observed for Cpn propagated in HeLa cells and was independent of host cell protein synthesis. Transcriptome analysis did not reveal temperature-induced effects on chlamydial gene expression, suggesting that the observed virulence changes are regulated on a different, so far unknown level. Preculture close to the central body temperature of its warm-blooded human or murine host might 'prepare' Cpn for subsequent in vivo infection. Our identification of culture-dependent virulence alteration helps to establish an optimized mouse lung infection model for Cpn and provides the basis to further unravel the molecular mechanisms underlying chlamydial pathogenicity.

A new role of the complement system: C3 provides protection in a mouse model of lung infection with intracellular Chlamydia psittaci.

The complement system modulates the intensity of innate and specific immunity. While it protects against infections by extracellular bacteria its role in infection with obligate intracellular bacteria, such as the avian and human pathogen Chlamydia (C.) psittaci, is still unknown. In the present study, knockout mice lacking C3 and thus all main complement effector functions were intranasally infected with C. psittaci strain DC15. Clinical parameters, lung histology, and cytokine levels were determined. A subset of infections was additionally performed with mice lacking C5 or C5a receptors. Complement activation occurred before symptoms of pneumonia appeared. Mice lacking C3 were ∼100 times more susceptible to the intracellular bacteria compared to wild-type mice, with all C3(-/-) mice succumbing to infection after day 9. At a low infective dose, C3(-/-) mice became severely ill after an even longer delay, the kinetics suggesting a so far unknown link of complement to the adaptive, protective immune response against chlamydiae. The lethal phenotype of C3(-/-) mice is not based on differences in the anti-chlamydial IgG response (which is slightly delayed) as demonstrated by serum transfer experiments. In addition, during the first week of infection, the absence of C3 was associated with partial protection characterized by reduced weight loss, better clinical score and lower bacterial burden, which might be explained by a different mechanism. Lack of complement functions downstream of C5 had little effect. This study demonstrates for the first time a strong and complex influence of complement effector functions, downstream of C3 and upstream of C5, on the outcome of an infection with intracellular bacteria, such as C. psittaci.

Actin re-organization induced by Chlamydia trachomatis serovar D--evidence for a critical role of the effector protein CT166 targeting Rac.

The intracellular bacterium Chlamydia trachomatis causes infections of urogenital tract, eyes or lungs. Alignment reveals homology of CT166, a putative effector protein of urogenital C. trachomatis serovars, with the N-terminal glucosyltransferase domain of clostridial glucosylating toxins (CGTs). CGTs contain an essential DXD-motif and mono-glucosylate GTP-binding proteins of the Rho/Ras families, the master regulators of the actin cytoskeleton. CT166 is preformed in elementary bodies of C. trachomatis D and is detected in the host-cell shortly after infection. Infection with high MOI of C. trachomatis serovar D containing the CT166 ORF induces actin re-organization resulting in cell rounding and a decreased cell diameter. A comparable phenotype was observed in HeLa cells treated with the Rho-GTPase-glucosylating Toxin B from Clostridium difficile (TcdB) or HeLa cells ectopically expressing CT166. CT166 with a mutated DXD-motif (CT166-mut) exhibited almost unchanged actin dynamics, suggesting that CT166-induced actin re-organization depends on the glucosyltransferase motif of CT166. The cytotoxic necrotizing factor 1 (CNF1) from E. coli deamidates and thereby activates Rho-GTPases and transiently protects them against TcdB-induced glucosylation. CNF1-treated cells were found to be protected from TcdB- and CT166-induced actin re-organization. CNF1 treatment as well as ectopic expression of non-glucosylable Rac1-G12V, but not RhoA-G14A, reverted CT166-induced actin re-organization, suggesting that CT166-induced actin re-organization depends on the glucosylation of Rac1. In accordance, over-expression of CT166-mut diminished TcdB induced cell rounding, suggesting shared substrates. Cell rounding induced by high MOI infection with C. trachomatis D was reduced in cells expressing CT166-mut or Rac1-G12V, and in CNF1 treated cells. These observations indicate that the cytopathic effect of C. trachomatis D is mediated by CT166 induced Rac1 glucosylation. Finally, chlamydial uptake was impaired in CT166 over-expressing cells. Our data strongly suggest CT166's participation as an effector protein during host-cell entry, ensuring a balanced uptake into host-cells by interfering with Rac-dependent cytoskeletal changes.

Identification of high- and low-virulent strains of Chlamydia pneumoniae by their characterization in a mouse pneumonia model.

Contradicting reports exist about the pathogenicity of Chlamydia pneumoniae and the severity of the respiratory disease they cause. This study aimed to clarify, in mice, our hypothesis that marked differences in virulence of well-defined C. pneumoniae strains might exist for lung infections. C57BL/6J mice were intranasally infected with equal amounts of five different, identically prepared laboratory strains of C. pneumoniae. Based on the clinical score, weight, histopathological score, the granulocyte marker-enzyme myeloperoxidase, and the amount of Chlamydiae in the lung tissue, the C. pneumoniae isolates exhibited clear differences in overall growth characteristics or clearance, and pathological potential. Thus, we could identify chlamydial strains (Kajaani-K6 and CWL-029), where mice became seriously ill, as well as a relatively low-virulent isolate (TWAR-183). Cytokine profiles also varied drastically between the five strains in extent and kinetic. Our results indicate that C. pneumoniae isolates differ markedly with regard to their interaction with the host and their pathological potential. This might also be true for the infection in humans. Because the genomic diversity of C. pneumoniae is rather small, more subtle genomic deviations account most likely for the apparent functional differences. Our results will be useful to identify additional virulence factors in the future.

The current injury situation of bicyclists--a medical and technical crash analysis.

BACKGROUND: The purpose of the study was to analyze the actual injury situation of bicyclists in Germany to create a basis for effective preventive measures. METHODS: Technical and medical data were prospectively collected shortly after the crash at the crash scenes. RESULTS: Included were 4,264 injured bicyclists from 1985 to 2003. Fifty-five percent of the bicyclists were male and 45% were women. The mean age of bicyclists was 52.0 years. The crashes took place in urban areas in 95.2% of the cases, and in rural areas in 4.8% of the cases. Collision opponents were cars in 65.8%, trucks in 7.2%, bicyclists in 7.4%, standing objects in 8.8%, multiple opponents or objects in 4.3%, and others in 6.5%. The mean collision speed was 21.3 km/h. The helmet use rate was 1.7%. Fifty-five percent of bicyclists used bicycle traffic lanes before the crash. The mean Maximum Abbreviated Injury Scale/Injury Severity Score (ISS) was 1.45 of 3.9. The incidence of multiple injuries (ISS>16)/death was 2.0%/1.5%. The ISS/Maximum Abbreviated Injury Scale score was higher in bicyclists without a helmet than in bicyclists with a helmet, and in bicyclists who had not used bicycle traffic lanes than in bicyclists who had used bicycle traffic lanes (t test, p<0.05). CONCLUSION: In bicyclists, head and extremities are at high risk for injuries. The helmet use rate is unsatisfactorily low. Remarkably, two-thirds of the head injuries could have been prevented by helmets. More consequent helmet use and an extension of bicycle traffic lanes for a better separation of bicyclists and motorized vehicles would be simple but very effective preventive measures.

Function of the N-terminal cap of the PAS domain in signaling by the aerotaxis receptor Aer.

Aer, the Escherichia coli receptor for behavioral responses to oxygen (aerotaxis), energy, and redox potential, contains a PAS sensory-input domain. Within the PAS superfamily, the N-terminal segment (N-cap) is poorly conserved and its role is not well understood. We investigated the role of the N-cap (residues 1 to 19) in the Aer PAS domain by missense and truncation mutagenesis. Aer-PAS N-cap truncations and an Aer-M21P substitution resulted in low cellular levels of the mutant proteins, suggesting that the N-terminal region was important for stabilizing the structure of the PAS domain. The junction of the N-cap and PAS core was critical for signaling in Aer. Mutations and truncations in the sequence encoding residues 15 to 21 introduced a range of phenotypes, including defects in FAD binding, constant tumbling motility, and an inverse response in which E. coli cells migrated away from oxygen concentrations to which they are normally attracted. The proximity of two N-cap regions in an Aer dimer was assessed in vivo by oxidatively cross-linking serial cysteine substitutions. Cross-linking of several cysteine replacements at 23 degrees C was attenuated at 10 degrees C, indicating contact was not at a stable dimer interface but required lateral mobility. We observed large multimers of Aer when we combined cross-linking of N-cap residues with a cysteine replacement that cross-links exclusively at the Aer dimer interface. This suggests that the PAS N-cap faces outwards in a dimer and that PAS-PAS contacts can occur between adjacent dimers.