Program-specific transplant rate ratios: Association with allocation priority at listing and posttransplant outcomes.

The Scientific Registry of Transplant Recipients (SRTR) is considering more prominent reporting of program-specific adjusted transplant rate ratios (TRRs). To enable more useful reporting of TRRs, SRTR updated the transplant rate models to adjust explicitly for components of allocation priority. We evaluated potential associations between TRRs and components of allocation priority that could indicate programs' ability to manipulate TRRs by denying or delaying access to low-priority candidates. Despite a strong association with unadjusted TRRs, we found no candidate-level association between the components of allocation priority and adjusted TRRs. We found a strong program-level association between median laboratory Model for End-stage Liver Disease (MELD) score at listing and program-specific adjusted TRRs (r = .37; P < .001). The program-level association was likely confounded by regional differences in donor supply/demand and listing practices. In kidney transplantation, higher program-specific adjusted TRRs were weakly associated with better adjusted posttransplant outcomes (r = -.14; P = .035) and lower adjusted waitlist mortality rate ratios (r = -.15; P = .022), but these associations were absent in liver, lung, and heart transplantation. Program-specific adjusted TRRs were unlikely to be improved by listing candidates with high allocation priority and can provide useful information for transplant candidates and programs.

Potential Implications of Recent and Proposed Changes in the Regulatory Oversight of Solid Organ Transplantation in the United States.

Every 6 months, the Scientific Registry of Transplant Recipients (SRTR) publishes evaluations of every solid organ transplant program in the United States, including evaluations of 1-year patient and graft survival. The Centers for Medicare & Medicaid Services (CMS) and the Organ Procurement and Transplantation Network (OPTN) Membership and Professional Standards Committee (MPSC) use SRTR's 1-year evaluations for regulatory review of transplant programs. Concern has been growing that the regulatory scrutiny of transplant programs with lower-than-expected outcomes is harmful, causing programs to undertake fewer high-risk transplants and leading to unnecessary organ discards. As a result, CMS raised its threshold for a "Condition-Level Deficiency" designation of observed relative to expected 1-year graft or patient survival from 1.50 to 1.85. Exceeding this threshold in the current SRTR outcomes report and in one of the four previous reports leads to scrutiny that may result in loss of Medicare funding. For its part, OPTN is reviewing a proposal from the MPSC to also change its performance criteria thresholds for program review, to review programs with "substantive clinical differences." We review the details and implications of these changes in transplant program oversight.

Effects of High-Risk Kidneys on Scientific Registry of Transplant Recipients Program Quality Reports.

There is a perception that transplanting high-risk kidneys causes programs to be identified as underperforming, thereby increasing the frequency of discards and diminishing access to transplant. Thus, the Organ Procurement and Transplantation Network (OPTN) has considered excluding transplants using kidneys from donors with high Kidney Donor Profile Index (KDPI) scores (≥0.85) when assessing program performance. We examined whether accepting high-risk kidneys (KDPI ≥0.85) for transplant yields worse outcome evaluations. Despite a clear relationship between KDPI and graft failure and mortality, there was no relationship between a program's use of high-KDPI kidneys and poor performance evaluations after risk adjustment. Excluding high-KDPI donor transplants from the June 2015 evaluations did not alter the programs identified as underperforming, because in every case underperforming programs also had worse-than-expected outcomes among lower-risk donor transplants. Finally, we found that hypothetically accepting and transplanting additional kidneys with KDPI similar to that of kidneys currently discarded would not adversely affect program evaluations. Based on the study findings, there is no evidence that programs that accept higher-KDPI kidneys are at greater risk for low performance evaluations, and risk aversion may limit access to transplant for candidates while providing no measurable benefit to program evaluations.

Anisotropic nutrient transport in three-dimensional single species bacterial biofilms.

The ability for a biofilm to grow and function is critically dependent on the nutrient availability, and this in turn is dependent on the structure of the biofilm. This relationship is therefore an important factor influencing biofilm maturation. Nutrient transport in bacterial biofilms is complex; however, mathematical models that describe the transport of particles within biofilms have made three simplifying assumptions: the effective diffusion coefficient (EDC) is constant, the EDC is that of water, and/or the EDC is isotropic. Using a Monte Carlo simulation, we determined the EDC, both parallel to and perpendicular to the substratum, within 131 real, single species, three-dimensional biofilms that were constructed from confocal laser scanning microscopy images. Our study showed that diffusion within bacterial biofilms was anisotropic and depth dependent. The heterogeneous distribution of bacteria varied between and within species, reducing the rate of diffusion of particles via steric hindrance. In biofilms with low porosity, the EDCs for nutrient transport perpendicular to the substratum were significantly lower than the EDCs for nutrient transport parallel to the substratum. Here, we propose a reaction-diffusion model to describe the nutrient concentration within a bacterial biofilm that accounts for the depth dependence of the EDC.

Head-column field-amplified sample stacking in presence of siphoning. Application to capillary electrophoresis-electrospray ionization mass spectrometry of opioids in urine.

Capillary electrophoresis (CE) with head-column field-amplified sample stacking (FASS) in presence of a water plug inserted at the capillary tip is a robust approach providing a more than 1000-fold sensitivity enhancement when applied to low-conductivity samples that are analyzed in an integrated instrument. Employing modular systems comprising a small hydrodynamic buffer flow (siphoning) towards the capillary end and featuring UV absorption or electrospray ionization mass spectrometric (MS) detection, insertion of a water plug is demonstrated to deteriorate the performance of head-column FASS or making it unfunctional. Electroinjection in the absence of the water plug can be employed instead and is shown to provide a ng/ml sensitivity when applied to low conductivity samples. With some suction of sample into the capillary during electroinjection, contamination of the sample vial with buffer is thereby largely avoided. Electroinjection applied to the CE-ion trap MS-MS and MS-MS-MS analysis of twofold diluted urines, urinary solid-phase extracts and urinary liquid-liquid extracts is shown to provide much improved sensitivity compared to hydrodynamic injection of these samples. With electroinjection from diluted urine and urinary solid-phase extracts, the presence of free opioids and their glucuronic acid conjugates can be unambiguously confirmed in urines that were collected after single-dose administration of small amounts of opioids (tested with about 7 mg codeine and 25 mg dihydrocodeine, respectively). Thus, CE-multiple MS with direct electroinjection of opioids from untreated urines could prove to become a rapid and simple approach for unambiguous urinary testing of drug abuse. Procedures leading to the reduction of siphoning in modular CE setups are briefly discussed as well.

Capillary electrophoresis-electrospray ionization ion trap mass spectrometry for analysis and confirmation testing of morphine and related compounds in urine.

Using an aqueous background electrolyte containing 25 mM ammonium acetate and NH3 (pH 9), CE-tandem MS and CE-triple MS with atmospheric pressure electrospray ionization in the positive ion mode are shown to represent attractive approaches for analysis and confirmation testing of morphine (MOR) and related opioids in human urine. Injection of plain or diluted urine permits monitoring of solutes at concentrations above 2-5 microg/ml. For the recognition of lower concentrations, solute extraction and concentration is required. Liquid-liquid extraction at alkaline pH is shown to be suitable for analysis of free opioids only whereas solid-phase extraction using a mixed-mode polymer phase is demonstrated to permit analysis of both free and glucuronidated opioids. The former sample preparation approach, however, requires about half of the time only. Commencing with 2 ml of urine, reconstitution to provide a sample volume of 0.2 ml and hydrodynamic sample injection, detection limits for free opioids are shown to be on the 100-200 ng/ml drug level. Much improved (ppb) sensitivity is obtained by infusing the extract directly into the source of the MS system. However, solutes that produce equal fragments (such as the two glucuronides of MOR) can thereby not be distinguished. CE-tandem MS and CE-triple MS are demonstrated to be suitable to confirm the presence of MOR, MOR-3-glucuronide, 6-monoacetylmorphine, codeine, codeine-6-glucuronide, dihydrocodeine, methadone and 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine in a toxicological quality control urine. The same is shown for selected metabolites of codeine and dihydrocodeine in urines collected after administration of pharmaceutical preparations.

Analysis of codeine, dihydrocodeine and their glucuronides in human urine by electrokinetic capillary immunoassays and capillary electrophoresis-ion trap mass spectrometry.

Screening for and confirmation of illicit, abused and banned drugs in human urine is a timely topic in which capillary separation techniques play a key role. Capillary electrophoresis (CE) represents the newest technology employed in this field of analysis. Two rapid competitive binding, electrokinetic capillary-based immunoassays are shown to be capable of recognizing the presence, but not the identity, of urinary opioids, namely codeine (COD), codeine-6-glucuronide, dihydrocodeine (DHC), dihydrocodeine-6-glucuronide, morphine (MOR), morphine-3-glucuronide and ethylmorphine (EMOR). In these approaches, aliquots of urine and immunoreagents of a commercial, broadly cross-reacting fluorescence polarization immunoassay for opiates were combined and analyzed by capillary zone electrophoresis or micellar electrokinetic capillary chromatography with laser induced fluorescence detection. With the fluorescent tracer solution employed, the former method is shown to provide simple electropherograms which are characterized by an opioid concentration dependent magnitude of the free tracer peak. In presence of dodecyl sulfate micelles, however, two tracer peaks with equal opioid concentration sensitivity are monitored. These data suggest the presence of two fluorescent tracers which react competitively with the urinary opioids for the binding sites of the antibody. Assay sensitivities for COD and MOR are comparable (10 ng/ml), whereas those for DHC and EMOR are about four-fold lower. Furthermore, glucuronides are shown to react like the corresponding free opioids. Analysis of urines that were collected after administration of 7 mg COD and 25 mg DHC tested positively in both assay formats. The presence of the free and conjugated codeinoids in these urines and their identification was accomplished by capillary electrophoresis-ion trap mass spectrometry (CE-MS). This confirmatory assay is based upon solid-phase extraction using a mixed-mode polymer cartridge followed by CE hyphenated to the LCQ mass spectrometer with electrospray ionization in the positive ion mode. With this technology, MS2 is employed for proper identification of COD (m/z 300.4) and DHC (m/z 302.4) whereas MS3 provides unambiguous identification of the glucuronides of COD (m/z 476.5) and DHC (m/z 478.5) via their fragmentation to COD and DHC, respectively. MSn (n > or = 2) is shown to be capable of properly identifying the urinary codeinoids on the 100-200 ng/ml concentration level.

Head-column field-amplified sample stacking in binary system capillary electrophoresis. Preparation of extracts for determination of opioids in microliter amounts of body fluids.

Head-column field-amplified sample stacking (head-column FASS) is an efficient, on-line sample concentration technique that can easily provide a sensitivity enhancement of three orders of magnitude. Application of head-column FASS to the capillary electrophoretic analysis of opioid extracts prepared from 20 to 100 microliters of human plasma, serum or urine is reported. In the described approach, efficient concentration of cationic opiates from low conductivity extracts of body fluids is effected across a water plug, with separation taking place in a binary buffer comprising 60% (v/v) ethylene glycol, 75 mM Na2HPO4 and 25 mM NaH2PO4 (pH 7.9), and detection is effected at 210 nm. Sample extracts are prepared in 55% (v/v) ethylene glycol containing 100 microM H3PO4. Application of mixed-mode polymer solid-phase resins is shown to provide extracts that are either too salty or contain quite a large number of endogenous substances that could interfere with certain opioids. Liquid-liquid extraction with hexane, dichloromethane, ethyl acetate and dichloromethane-isopropanol is shown to provide extracts that are sufficiently clean. At a given pH, however, only closely related opioids can be extracted. Using ethyl acetate at alkaline pH, dihydrocodeine and nordihydrocodeine can reproducibly be recovered from 20-100 microliters of plasma, serum and urine. Application of head-column FASS and UV absorption detection thereby leads to the determination of ppb concentrations (> or = 1 ng/ml) of these compounds, an approach that only requires microliter amounts of sample and organic solvents.

Identification of new oxycodone metabolites in human urine by capillary electrophoresis-multiple-stage ion-trap mass spectrometry.

Capillary electrophoresis-electrospray ionization multiple-stage ion-trap mass spectrometry (CE-MSn) and computer simulation of fragmentation are demonstrated to be effective tools to detect and identify phase I and phase II metabolites of oxycodone (OCOD) in human urine. OCOD is a strong analgesic used for the management of moderate to severe mainly postoperative or cancer-related pain whose metabolism in man is largely unknown. Using an aqueous pH 9 ammonium acetate buffer and CE-MSn (n < or = 5), OCOD and its phase I metabolites produced by O-demethylation, N-demethylation, 6-ketoreduction and N-oxidation (such as oxymorphone, noroxycodone, noroxymorphone, 6-oxycodol, nor-6-oxycodol, oxycodone-N-oxide and 6-oxycodol-N-oxide) and phase II conjugates with glucuronic acid of several of these compounds could be detected in alkaline solid-phase extracts of a patient urine that was collected during a pharmacotherapy episode with daily ingestion of 240-320 mg of OCOD chloride. The data for three known OCOD metabolites for which the standards had to be synthesized in-house, 6-oxycodol, nor-6-oxycodol and oxycodone-N-oxide, were employed to identify two new metabolites, the N-oxidized derivative of 6-oxycodol and an O-glucuronide of this compound. CE-MSn and computer simulation of fragmentation also led to the identification of the N-glucuronide of noroxymorphone, another novel OCOD metabolite for which no standard compound or mass spectra library data were available.

Monoculture parameters successfully predict coculture growth kinetics of Bacteroides thetaiotaomicron and two Bifidobacterium strains.

Microorganisms rarely live in isolation but are most often found in a consortium. This provides the potential for cross-feeding and nutrient competition among the microbial species, which make it challenging to predict the growth kinetics in coculture. In this paper we developed a mathematical model to describe substrate consumption and subsequent microbial growth and metabolite production for bacteria grown in monoculture. The model characterized substrate utilization kinetics of 18 Bifidobacterium strains. Some bifidobacterial strains demonstrated preferential degradation of oligofructose in that sugars with low degree of polymerization (DP) (DP≤3 or 4) were metabolized before sugars of higher DP, or vice versa. Thus, we expanded the model to describe the preferential degradation of oligofructose. In addition, we adapted the model to describe the competition between human colonic bacteria Bacteroides thetaiotaomicron LMG 11262 and Bifidobacterium longum LMG 11047 or Bifidobacterium breve Yakult for inulin as well as cross-feeding of breakdown products from the extracellular hydrolysis of inulin by B. thetaiotaomicron LMG 11262. We found that the coculture growth kinetics could be predicted based on the respective monoculture growth kinetics. Using growth kinetics from monoculture experiments to predict coculture dynamics will reduce the number of in vitro experiments required to parameterize multi-culture models.

Bartonella endocarditis: a pathology shared by animal reservoirs and patients.

Bartonellae were first recognized to cause endocarditis in humans in 1993 when cases caused by Bartonella quintana, B. elizabethae, and B. henselae were reported. Since the first isolation of Bartonella vinsonii subspecies berkhoffii from a dog with endocarditis, this organism has emerged as an important pathogen in dogs and an emerging pathogen in people. Subsequently, four types of B. vinsonii subsp. berkhoffii have been described, all of which have been associated with endocarditis in dogs. A limited number of dog endocarditis cases have also been associated with B. clarridgeiae, B. washoensis, B. quintana, and B. rochalimae. The second canine B. clarridgeiae endocarditis case is presented. The clinical and pathological characteristics of Bartonella endocarditis in dogs are similar to disease observed in humans, more often affecting the aortic valve, presenting with highly vegetative lesions with accompanying calcification, and in most instances high antibody titers. Pathological features in dogs include a combination of fibrosis, mineralization, endothelial proliferation, and neovascularization with variable inflammation. Endocarditis has also been described in animal species, which are the natural reservoir of specific Bartonella species, once thought to be solely healthy carriers of these pathogens. A few Bartonella endocarditis cases, including B. henselae, have been reported in cats in the USA and Australia. The second case of B. henselae type Houston I identified in the USA is presented. Furthermore, two cases of B. bovis endocarditis were recently described in adult cows from France. Finally, on-going investigation of valvular endocarditis in free-ranging Alaskan sea otters suggests the involvement of Bartonella species.

Capillary electrophoresis in clinical and forensic analysis: recent advances and breakthrough to routine applications.

This paper is a comprehensive review article on capillary electrophoresis (CE) in clinical and forensic analysis. It is based upon the literature of 1997 and 1998, presents CE examples in major fields of application, and provides an overview of the key achievements encountered, including those associated with the analysis of drugs, serum proteins, hemoglobin variants, and nucleic acids. For CE in clinical and forensic analysis, the past two years witnessed a breakthrough to routine applications. As most coauthors of this review are associated with diagnostic or forensic laboratories now using CE on a routine basis, this review also contains data from routine applications in drug, protein, and DNA analysis. With the first-hand experience of providing analytical service under stringent quality control conditions, aspects of quality assurance, assay specifications for clinical and forensic CE and the pros and cons of this maturing, cost-and pollution-controlled age technology are also discussed.

The encephalomyocarditis virus 3C protease is a substrate for the ubiquitin-mediated proteolytic system.

The encephalomyocarditis virus 3C protease has been shown to be rapidly degraded in infected cells and in vitro in rabbit reticulocyte lysate. The in vitro degradation, at least, is accomplished by a virus-independent, ATP-dependent proteolytic system. Here we identify this proteolytic system as the ubiquitin-mediated system. Incubation of the 3C protease in rabbit reticulocyte or cultured mouse cell lysate preparations, alone or in the presence of added ubiquitin or methylated ubiquitin, resulted in the generation of new higher molecular weight species. These new products were shown to be 3C protease-ubiquitin conjugates by their ability to bind antibodies against both the 3C protease and ubiquitin. Supplemental ubiquitin also stimulated the degradation of the 3C protease in these preparations. Large 3C protease-polyubiquitin conjugates were observed to accumulate in reticulocyte lysate in the presence of adenosine 5'-O-(3-thiotriphosphate), an inhibitor of the 26 S multicatalytic protease. This, combined with the fact that the proteolytic activity could be removed from the lysate by sedimentation, implicates the multicatalytic protease in the degradation of the 3C protease-ubiquitin conjugates. It was also found that the slow rate of degradation of a model polyprotein, which resembles the stable viral 3CD diprotein produced in vivo, is likely due to the fact that the polyprotein is a poor substrate for the ubiquitin-conjugating system.

Aortic valve endocarditis in a dog due to Bartonella clarridgeiae.

We report the first documented case of endocarditis associated with Bartonella clarridgeiae in any species. B. clarridgeiae was identified as a possible etiological agent of human cat scratch disease. Infective vegetative valvular aortic endocarditis was diagnosed in a 2.5-year-old male neutered boxer. Historically, the dog had been diagnosed with a systolic murmur at 16 months of age and underwent balloon valvuloplasty for severe valvular aortic stenosis. Six months later, the dog was brought to a veterinary hospital with an acute third-degree atrioventricular block and was diagnosed with infective endocarditis. The dog died of cardiopulmonary arrest prior to pacemaker implantation. Necropsy confirmed severe aortic vegetative endocarditis. Blood culture grew a fastidious, gram-negative organism 8 days after being plated. Phenotypic and genotypic characterization of the isolate, including partial sequencing of the citrate synthase (gltA) and 16S rRNA genes indicated that this organism was B. clarridgeiae. DNA extraction from the deformed aortic valve and the healthy pulmonic valve revealed the presence of B. clarridgeiae DNA only from the diseased valve. No Borrelia burgdorferi or Ehrlichia sp. DNA could be identified. Using indirect immunofluorescence tests, the dog was seropositive for B. clarridgeiae and had antibodies against Ehrlichia phagocytophila but not against Ehrlichia canis, Ehrlichia ewingii, B. burgdorferi, or Coxiella burnetii.