Is water delivery a good idea to prevent obstetric anal sphincter injuries in low risk primiparae? An exploratory study in a Swiss public teaching hospital.

OBJECTIVE: Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries. STUDY DESIGN: In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor. RESULTS: 1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance. CONCLUSIONS: In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries.

Adding insulin glargine vs. NPH insulin to metformin results in a more efficient postprandial beta-cell protection in individuals with type 2 diabetes.

AIM: Postprandial release of intact proinsulin (IP) is an independent marker for beta-cell dysfunction in patients with type 2 diabetes. This open-label, parallel-group, two-arm, pilot study compared the beta-cell protective effect of adding insulin glargine (GLA) vs. NPH insulin to ongoing metformin. MATERIAL AND METHODS: Overall, 28 insulin-naive type 2 diabetes subjects (mean +/- SD age, 61.5 +/- 6.7 years; diabetes duration, 9.8 +/- 6.5 years; HbA1c, 7.1 +/- 0.5%; BMI, 30.7 +/- 4.3 kg/m(2)) treated with metformin and sulfonylurea were randomized to add once-daily GLA or NPH at bedtime. At baseline and after 3 months, subjects received a standardized breakfast, lunch and dinner, with pre- and postprandial blood sampling to measure plasma IP, total insulin and blood glucose (BG). RESULTS: Insulin dose after 3 months was comparable in both groups (GLA vs. NPH: 23.6 +/- 13.4 vs. 23.3 +/- 12.7; p = NS ). Both treatments significantly reduced fasting BG levels (GLA: 158 +/- 19 to 121 +/- 23 mg/dl; NPH: 156 +/- 34 to 119 +/- 29 mg/dl; both p < 0.01 vs. baseline). Fasting and postprandial BG levels did not differ between groups. IP levels decreased in both groups (p < 0.05 at all timepoints). Although IP release after breakfast did not differ between treatments, GLA induced a greater reduction in IP release after lunch (p = 0.08) and dinner (p = 0.04). Total plasma insulin levels did not differ between groups. CONCLUSIONS: Adding basal insulin to metformin reduces postprandial beta-cell load. While GLA and NPH had comparable effects at breakfast, GLA reduces beta-cell stress more effectively at dinner, and with a trend at lunch, most probably because of its longer lasting pharmacodynamic profile.

[Freiburg Cardiac Arrest Receiving Team (CART) : Interdisciplinary solution for the acute management of non-traumatic out-of-hospital cardiac arrest]. / Freiburger Cardiac Arrest Receiving Team (CART) : Konzept zur Strukturierung des Behandlungsablaufs nach nichttraumatischem außerklinischem Herz­Kreislauf-Stillstand in einem interdisziplinären Team.

Standard procedures and guidelines provide specific instructions for basic and advanced cardiac life support. Recommendations for the admission of patients from preclinical into clinical structures after successful cardiopulmonary resuscitation (CPR) are available, but only a few are detailed. In the presence of ST-elevation myocardial infarction after return of spontaneous circulation (ROSC), coronary angiography must be performed as soon as possible. However, acute management and consecutive diagnostic procedures after hospital admission are up to the doctor on duty, who can rely on standard internal hospital procedures at best. Despite the enormous progress and new findings in intensive care and emergency medicine, intra-hospital mortality, as well as long-term survival, after CPR remains low and depends on a wide variety of influencing factors. To optimize in-hospital acute care of successfully resuscitated patients, an interdisciplinary admission team, a so-called cardiac arrest receiving team (CART), has been implemented at the University Hospital of Freiburg, Germany. The aim of the CART is to provide primary care to resuscitated patients as quickly and in as standardized a manner as possible with predefined diagnostic and therapeutic pathways by a team with special expertise in the field of CPR and post-resuscitation management. Accordingly, clear criteria for procedures and the location of primary care (e.g. emergency room vs. cardiac catheter laboratory), the composition of the CART and concrete treatment measures were defined.

Activation of bacterial porin gene expression by a chimeric signal transducer in response to aspartate.

The Tar chemoreceptor of Escherichia coli is a membrane-bound sensory protein that facilitates bacterial chemotaxis in response to aspartate. The EnvZ molecule has a membrane topology similar to Tar and is a putative osmosensor that is required for osmoregulation of the genes for the major outer membrane porin proteins, OmpF and OmpC. The cytoplasmic signaling domain of Tar was replaced with the carboxyl portion of EnvZ, and the resulting chimeric receptor activated transcription of the ompC gene in response to aspartate. The activation of ompC by the chimeric receptor was absolutely dependent on OmpR, a transcriptional activator for ompF and ompC.

Xenorhabdus antibiotics: a comparative analysis and potential utility for controlling mastitis caused by bacteria.

AIMS: The role of antibiotics produced by bacterial symbionts of entomopathogenic nematodes is to suppress growth of microbes in the soil environment. These antibiotics are active against Gram-positive and Gram-negative bacteria, and were tested against mastitis isolates from dairy cows. METHODS AND RESULTS: Two bioassays were adapted for Xenorhabdus antibiotics; an overlay method on agar plates, and serially diluted, cell-free, Xenorhabdus cultures. The antimicrobial activities of the liquid cultures of 13 strains from five Xenorhabdus species were further evaluated. Antimicrobial activities of the type strains of X. nematophila, X. budapestensis and X. szentirmaii were tested on mastitis isolates of Staphylococcus aureus, Escherichia coli and Klebsiella pneumoniae with both bioassays. A previously reported antibiotic from X. nematophila, nematophin, was synthesized in three steps from tryptamine and 4-methyl-2-oxovaleric acid sodium salt. CONCLUSIONS: The antibiotics of all three Xenorhabdus strains were powerful in either bioassay, but the sensitivity of the isolates differed from each other. While Kl. pneumoniae was the least susceptible, Staph. aureus had the highest sensitivity to each Xenorhabdus strain. Xenorhabdus szentirmaii and X. budapestensis were more potent antibiotic producers than X. nematophila, and raceme nematophin was ineffective against all mastitis isolates. SIGNIFICANCE AND IMPACT OF THE STUDY: These results indicate that Xenorhabdus antibiotics are effective against mastitis isolates and should be further evaluated for their potential in mastitis control or prevention.

Relation between binding and the action of phospholipases A2 on Escherichia coli exposed to the bactericidal/permeability-increasing protein of neutrophils.

Exposure of Escherichia coli to the bactericidal/permeability-increasing protein (BPI) of neutrophils renders the bacterial phospholipids susceptible to hydrolysis by only a few of numerous phospholipases A2 tested. To explore further the determinants of hydrolysis we measured the binding of 125I-labeled phospholipase A2 to E. coli in the presence and absence of BPI. Phospholipases A2 from Aqkistrodon piscivorus piscivorus venom and pig pancreas neither degraded nor bound to BPI-treated E. coli. In contrast, the phospholipases A2 from Aqkistrodon halys blomhoffii and Aqkistrodon halys palas venoms actively hydrolyzed the phospholipids of BPI-treated E. coli: they also bound to E. coli in the presence but not in the absence of BPI. Carbamylation of lysines of the A.h. blomhoffii phospholipase A2 progressively reduced binding in parallel with reduced phospholipid hydrolysis. Both binding and hydrolysis increased with increasing BPI dose. However, maximal binding occurred at 25% of the BPI dose that produced optimal hydrolysis. Thus, binding may be necessary but is not sufficient for maximal BPI-mediated phospholipid hydrolysis. Comparison of the NH2-terminal amino sequences of the active and inactive phospholipase A2 suggests that this portion of the phospholipase A2 molecule plays a role in BPI-independent binding and hydrolysis.

MicF: an antisense RNA gene involved in response of Escherichia coli to global stress factors.

The micF gene is a stress response gene found in Escherichia coli and related bacteria that post-transcriptionally controls expression of the outer membrane porin gene ompF. The micF gene encodes a non-translated 93 nt antisense RNA that binds its target ompF mRNA and regulates ompF expression by inhibiting translation and inducing degradation of the message. In addition, other factors, such as the RNA chaperone protein StpA also play a role in this regulatory system. Expression of micF is controlled by both environmental and internal stress factors. Four transcriptional regulators are known to bind the micF promoter region and activate micF expression. The crystal structure of one these transcriptional activators, Rob, complexed with the micF promoter has been reported. Here, we review new developments in the micF regulatory network.

Molecular analysis of OmpR binding sequences involved in the regulation of ompF in Escherichia coli.

OmpR, the transcriptional regulatory protein of ompF, had not been previously shown to specifically bind to the -70 to -60-bp region of ompF. We show that the -102 to -76-bp sequence of ompF has a high affinity binding site for OmpR and produced a single OmpR/ompF complex (complex b). Extension of this DNA fragment to include an inverted repeat sequence located between the -71 and -64-bp region resulted in the formation of a second, slower migrating complex (complex a). A -102 to -58-bp fragment containing a substitution of the -70 CG bp was able to form complex b, but not complex a. A mutant OmpR protein derived from a strain that can not repress ompF was unable to form complex a, while complex b was formed normally. Deletion of the -70 CG bp resulted in incomplete repression of OmpF. These results suggest that OmpR binds to the -71 to -64-bp region and that this sequence plays a role in the regulation of ompF in Escherichia coli.

Effects of occupied and unoccupied bed making on myocardial work in healthy subjects.

Strict bed rest prescribed after acute myocardial infarction provides rest for the heart in an effort to lessen myocardial work. However, bed rest has been implicated as a threat to physical and psychosocial well-being. Nurses must question whether activities associated with bed rest, such as bed making by hospital personnel while the patient is occupying the bed, actually require less myocardial work than out-of-bed activities. In this study we examined cardiovascular function of 22 healthy individuals, 10 (45.5%) men and 12 (54.5%) women ranging in age from 34 to 69 years (mean 48 years), during occupied (side to side method) and unoccupied (patient up to chair) bed making. Cardiac output, heart rate, stroke volume, systolic blood pressure, diastolic blood pressure, mean arterial pressure, total peripheral resistance, and the ratio of preejection period to left ventricular ejection time were measured by using an impedance cardiograph and vital signs monitor. Although differences between these measurements during the two bed making procedures were statistically significant (p less than 0.001), they were not deemed clinically significant for healthy subjects because they represent transient reflexive responses to posturally induced changes in venous return rather than substantial increases in myocardial work. When the goal is minimal myocardial energy expenditure, making the bed when it is unoccupied may offer a sound alternative to making an occupied bed.

The potential for beach sand to serve as a reservoir for Escherichia coli and the physical influences on cell die-off.

AIMS: The Escherichia coli burden at a Great Lakes urban beach was evaluated during the summer months to determine if sand served as a reservoir for E. coli, and if there was evidence of cell replication in situ. Field and laboratory studies investigated the effects of moisture, temperature and UV on E. coli densities in the sand. METHODS AND RESULTS: Sand samples (n = 481) were collected across three distinct transects of the beach, the top, a middle streamline, and the berm, over 15 sample days. The highest levels were found in the middle streamline, which was affected by stormwater discharge from nearby outfalls and roosting gulls; daily geometric mean levels of these seven sites ranged from 6700 to 40,900 CFU per 100 g of sand. Escherichia coli levels were greatest in samples with moisture levels between 15% and 19%, and were significantly higher than 0-4 and 20-24% ranges (P < 0.05). Pre- and post-rain samples at the beach demonstrated an increase in E. coli levels nearly 100-fold within 30 min, suggesting sand washout as a major mechanism for loading of E. coli into the beach waters. Rep PCR analysis of 160 isolates obtained from eight sites demonstrated that 21% of the isolates fell into one of the six clonal patterns, suggesting that bacteria may be able to replicate and possibly colonize beach sand. Sand field plots inoculated with E. coli cells containing pGFPuv that expresses GFP (green fluorescent protein) as a marker showed an initial two- to 100-fold increase at 24 h, depending on the temperature condition. The sand appeared to provide considerable protection from UV exposure as no significant difference was seen in cell densities within the first 2-4 cm of sand between exposed and unexposed plots (P < 0.05). CONCLUSIONS: Beach sand may act as a reservoir for E. coli. Replication of cells appears to be one possible contributing factor to the persistently high levels, as indicated by both field studies and laboratory studies, and warrants further investigation. Moisture content of sand may also be a determinant of cell persistence in the sand environment. SIGNIFICANCE AND IMPACT OF THE STUDY: Escherichia coli is used as an indicator organism for faecal pollution at most Great Lakes coastal beaches; therefore, a better understanding of how E. coli might survive, or possibly replicate, in the environment would improve interpretation of beach monitoring results.

Analysis of the PixA inclusion body protein of Xenorhabdus nematophila.

The symbiotic pathogenic bacterium Xenorhabdus nematophila produces two distinct intracellular inclusion bodies. The pixA gene, which encodes the 185-residue methionine-rich PixA inclusion body protein, was analyzed in the present study. The pixA gene was optimally expressed under stationary-phase conditions but its expression did not require RpoS. Analysis of a pixA mutant strain showed that PixA was not required for virulence towards the insect host or for colonization of or survival within the nematode host, and was not essential for nematode reproduction. The pixA gene was not present in the genome of Xenorhabdus bovienii, which also produces proteinaceous inclusions, indicating that PixA is specifically produced in X. nematophila.

Performance of the continuous glucose monitoring system (CGMS) during development of ketosis in patients on insulin pump therapy.

AIMS: Ketoacidosis is one of the most severe complications of Type 1 diabetes. Development of ketosis leads to substantial shifts in electrolyte and ion concentrations in the different fluid compartments of the body. This study was performed to investigate the performance of the continuous glucose monitoring device (CGMS) during ketoacidosis. METHODS: Twelve patients with Type 1 diabetes using continuous subcutaneous insulin infusion (CSII) participated in this trial [10 women, two men; age (mean +/- sd) 34 +/- 9 years; disease duration 17 +/- 10 years; HbA(1c) 7.1 +/- 1.0%]. In the morning, patients ate breakfast and the insulin pump was stopped at 11.00 h and restarted after 8 h. Observation parameters during this experiment were: blood glucose (laboratory reference and CGMS), 3-hydroxy-butyrate (3-OHB), pH, Na, pCO(2), pO(2), free fatty acids, osmolarity, standard bicarbonate, and lactate. RESULTS: Blood glucose increased and reached a plateau within 2 h after pump stop (from 6.2 +/- 2.56 to 16.7 +/- 4.44 mmol/l, P < 0.001). A constant increase in 3-OHB (from 0.0 to 0.8 +/- 0.5 mmol/l, P < 0.001) and decrease in pH (from 7.43 +/- 0.02 to 7.40 +/- 0.03, P < 0.05) indicated ketosis development. Na decreased from 141 +/- 1.4 to 138 +/- 2.8 mmol/l, P < 0.001). Free fatty acids increased from 0.577 +/- 0.330 to 1.330 +/- 0.462 mmol/l (P < 0.001). The CGMS values showed excellent agreement with the capillary blood laboratory method during the entire experiment, and a modified error grid analysis revealed that 99.5% of the values were in the clinically acceptable zones A and B. CONCLUSION: The CGMS device was confirmed to be reliable and accurate during the development of hyperglycaemia and ketotic conditions.

Identification of a conserved N-terminal sequence involved in transmembrane signal transduction in EnvZ.

To determine whether N-terminal sequences are involved in the transmembrane signaling mechanism of EnvZ, the nucleotide sequences of envZ genes from several enteric bacteria were determined. Comparative analysis revealed that the amino acid sequence between Pro41 and Glu53 was highly conserved. To further analyze the role of the conserved sequence, envZ of Escherichia coli was subjected to random PCR mutagenesis and mutant alleles that produced a high-osmolarity phenotype, in which ompF was repressed, were isolated. The mutations identified clustered within, as well as adjacent to, the Pro41-to-Glu53 sequence. These findings suggest that the conserved Pro41-to-Glu53 sequence is involved in the signal transduction mechanism of EnvZ.

Molecular analysis of the two-component genes, ompR and envZ, in the symbiotic bacterium Xenorhabdus nematophilus.

In Escherichia coli the histidine kinase sensor protein, EnvZ, undergoes autophosphorylation and subsequently phosphorylates the regulatory protein, OmpR. Modulation of the levels of OmpR-phosphate controls the differential expression of ompF and ompC. While the phosphotransfer reaction between EnvZ and OmpR has been extensively studied, the domains involved in the sensing function of EnvZ are not well understood. We have used a comparative approach to study the sensing function of EnvZ. During our search of numerous bacteria we found that the symbiotic/pathogenic bacterium Xenorhabdus nematophilus contained the operon encoding both ompR and envZ. Nucleotide sequence analysis revealed that EnvZ of X. nematophilus (EnvZX.n.) is composed of 342 amino acid residues, which is 108 residues shorter than EnvZ of E. coli (EnvZE.c.). Amino acid sequence comparison showed that the cytoplasmic domains of the EnvZ molecules shared 57% sequence identity. In contrast, the large hydrophilic periplasmic domain of EnvZE.c. was absent in EnvZX.n., and was replaced by a shorter hydrophobic region. Although the periplasmic domains had diverged extensively, envZX.n. was able to complement a delta envZ strain of E. coli. OmpF and OmpC were differentially produced in response to changes in medium osmolarity in this strain. Further genetic analysis established that heterologous phosphorylation between EnvZX.n. and OmpR of E. coli (OmpRE.c.) accounted for the complementation of the delta envZ strain. In addition we show that the OmpR molecules of X. nematophilus and E. coli share 78% amino acid sequence identity. These results indicate that the EnvZ protein of X. nematophilus was able to sense these changes in the osmolarity of the growth environment and properly regulate the levels of OmpR-phosphate in E. coli.

Molecular analysis of the signaling pathway between EnvZ and OmpR in Escherichia coli.

OmpR is a DNA-binding protein that regulates transcription of ompF and ompC. The activity of OmpR is controlled by the inner membrane osmosensor, EnvZ. In order to study the signaling process between EnvZ and OmpR, we analyzed two different envZ strains: the envZ473 strain, in which OmpC is constitutively produced and OmpF is fully repressed, and the envZ3 strain, in which the production of OmpC is greatly reduced and OmpF is not fully repressed by high-osmolarity growth conditions. Using direct sequencing of DNA derived from the polymerase chain reaction amplification method, we identified the mutation in the envZ473 strain as a Val-241-to-Gly substitution and the mutation in the envZ3 as an Ala-219-to-Val substitution. The relative DNA-binding affinity of OmpR derived from the envZ473 strain was dramatically increased for the upstream sequence of both ompF and ompC. In contrast, OmpR derived from the envZ3 strain was not converted to the high-affinity form. The intracellular levels of OmpR-phosphate, as analyzed by the in vivo phosphorylation approach, significantly increased in the envZ473 strain, while in the envZ3 strain the levels were considerably reduced, relative to those found in the parent strain. The intracellular level of OmpR protein in the envZ473 strain was also found to be markedly elevated relative to that of the parent strain. These results are discussed in relation to the role of phosphorylation and relative DNA-binding affinity of OmpR in the expression of ompF and ompC.

Role of the histidine kinase, EnvZ, in the production of outer membrane proteins in the symbiotic-pathogenic bacterium Xenorhabdus nematophilus.

We show that inactivation of envZ, the gene encoding the histidine kinase sensor protein, EnvZ, of Xenorhabdus nematophilus, affected the production of several outer membrane proteins (Opns). X. nematophilus produced five major Opns during exponential growth. Insertional inactivation of envZ led to a decrease in the production of OpnP, the OmpF-like pore-forming protein which constitutes approximately 50% of the total outer membrane protein in X. nematophilus. OpnA production was also reduced, while the remaining Opns were produced normally. During the transition to stationary phase, three new outer membrane proteins, OpnB, OpnS, and OpnX, were induced in the wild-type strain. The envZ-minus strain, ANT1, did not produce OpnB and OpnX, while OpnS was induced at markedly reduced levels. These results suggest that EnvZ was required for the high-level production of OpnP during exponential growth and may be involved in the production of OpnB, OpnS, and OpnX during stationary-phase growth. We also show that ANT1 was more pathogenic than the wild-type strain when as few as five cells were injected into the hemolymph of the larval stage of the tobacco hornworm (Manduca sexta). The larvae died before significant numbers of bacteria were detectable in the hemolymph. These results are discussed in relation to the role of EnvZ in the life cycle of X. nematophilus.

The role of phospholipase A2 lysines in phospholipolysis of Escherichia coli killed by a membrane-active neutrophil protein.

Purified rabbit bactericidal/permeability-increasing protein at bactericidal concentrations is a membrane-perturbing agent that triggers hydrolysis of envelope phospholipids of a phospholipase A-less Escherichia coli (S17) mutant by a highly basic (pI greater than 10) phospholipase A2, purified from Agkistrodon halys blomhoffii snake venom. Most other purified phospholipases A2 do not degrade the phospholipids of E. coli killed by the bactericidal protein. To study the role of enzyme charge in bactericidal protein-dependent phospholipid hydrolysis, lysines of the Agkistrodon phospholipase A2 were modified, either by carbamylation (decreases net charge), or by reductive methylation (no delta charge). Incorporation of [14C]cyanate or [14C]formaldehyde and amino acid analysis served to monitor modification. Modification appears to be limited to epsilon-NH2 groups. Incorporation of up to 5 mol of cyanate or formaldehyde/mol of enzyme did not affect catalytic activity. In contrast, incorporation of, on average, 1 mol of either reagent/mol of protein reduced by 80% the activity of the enzyme toward E. coli S17 killed by the bactericidal protein. Since this loss is similar with carbamylation and reductive methylation, the role of the epsilon-NH2 group in the bactericidal protein-dependent hydrolysis seems independent of charge. Thus, the lysines in this phospholipase A2 are not essential for catalysis and substrate binding, but are essential for the action of this enzyme on E. coli killed by the bactericidal protein.

Inactivation of a novel gene produces a phenotypic variant cell and affects the symbiotic behavior of Xenorhabdus nematophilus.

Xenorhabdus nematophilus is an insect pathogen that lives in a symbiotic association with a specific entomopathogenic nematode. During prolonged culturing, variant cells arise that are deficient in numerous properties. To understand the genetic mechanism underlying variant cell formation, a transposon mutagenesis approach was taken. Three phenotypically similar variant strains of X. nematophilus, each of which contained a single transposon insertion, were isolated. The insertions occurred at different locations in the chromosome. The variant strain, ANV2, was further characterized. It was deficient in several properties, including the ability to produce antibiotics and the stationary-phase-induced outer membrane protein, OpnB. Unlike wild-type cells, ANV2 produced lecithinase. The emergence of ANV2 from the nematode host was delayed relative to the emergence of the parental strain. The transposon in ANV2 had inserted in a gene designated var1, which encodes a novel protein composed of 121 amino acid residues. Complementation analysis confirmed that the pleiotropic phenotype of the ANV2 strain was produced by inactivation of var1. Other variant strains were not complemented by var1. These results indicate that inactivation of a single gene was sufficient to promote variant cell formation in X. nematophilus and that disruption of genetic loci other than var1 can result in the same pleiotropic phenotype.