Histopathology of valves in infective endocarditis, diagnostic criteria and treatment considerations.

BACKGROUND: Infective endocarditis (IE) is a severe disease. Pathogen isolation is fundamental so as to treat effectively and reduce morbidity and mortality. Blood and valve culture and histopathology (HP) are routinely employed for this purpose. Valve HP is the gold standard for diagnosis. OBJECTIVES: To determine the sensitivity and specificity of clinical criteria for IE (the modified Duke and the St Thomas' minor modifications, STH) of blood and valve culture compared to valve HP, and to evaluate antibiotic treatment duration. METHODS: Prospective case series of patients, from 2006 to 2014 with surgically treated IE. Statistical analysis was done by the R software. RESULTS: There were 136 clinically definite episodes of IE in 133 patients. Mean age ± SD was 43 ± 15.6 years and IE was left sided in 81.6 %. HP was definite in 96 valves examined, which were used as gold standard. Sensitivity of blood culture was 61 % (CI 0.51, 0.71) and of valve culture 15 % (CI 0.07, 0.26). The modified Duke criteria were 65 % (CI 0.55, 0.75) sensitive and 33 % specific, while the STH's sensitivity was 72 % (CI 0.61, 0.80) with similar specificity. In multivariate analysis and logistic regression, the only variable with statistical significance was duration of antibiotic therapy postoperatively. CONCLUSIONS: Valve HP had high sensitivity and valve culture low sensitivity in the diagnosis of IE. The STH's criteria were more sensitive than the modified Duke criteria. Valve HP should guide duration of postoperative antibiotic treatment.

Transcriptomic analysis of the stationary phase response regulator SpdR in Caulobacter crescentus.

BACKGROUND: As bacterial cells enter stationary phase, they adjust their growth rate to comply with nutrient restriction and acquire increased resistance to several stresses. These events are regulated by controlling gene expression at this phase, changing the mode of exponential growth into that of growth arrest, and increasing the expression of proteins involved in stress resistance. The two-component system SpdR/SpdS is required for the activation of transcription of the Caulobacter crescentus cspD gene at the onset of stationary phase. RESULTS: In this work, we showed that both SpdR and SpdS are also induced upon entry into stationary phase, and this induction is partly mediated by ppGpp and it is not auto-regulated. Global transcriptional analysis at early stationary phase of a spdR null mutant strain compared to the wild type strain was carried out by DNA microarray. Twenty-three genes showed at least twofold decreased expression in the spdR deletion mutant strain relative to its parental strain, including cspD, while five genes showed increased expression in the mutant. The expression of a set of nine genes was evaluated by quantitative real time PCR, validating the microarray data, and indicating an important role for SpdR at stationary phase. Several of the differentially expressed genes can be involved in modulating gene expression, including four transcriptional regulators, and the RNA regulatory protein Hfq. The ribosomal proteins NusE and NusG, which also have additional regulatory functions in transcription and translation, were also downregulated in the spdR mutant, as well as the ParE1 toxin. The purified SpdR protein was shown to bind to the regulatory region of CC0517 by Electrophoretic Mobility Shift Assay, and the SpdR-regulated gene CC0731 was shown to be expressed at a lower level in the null cspD mutant, suggesting that at least part of the effect of SpdR on the expression of this gene is indirect. CONCLUSIONS: The results indicate that SpdR regulates several genes encoding proteins of regulatory function, which in turn may be required for the expression of other genes important for the transition to stationary phase.

Diagnosis of blood culture-negative endocarditis and clinical comparison between blood culture-negative and blood culture-positive cases.

PURPOSE: To analyze the clinical characteristics of blood culture-negative endocarditis (BCNE) and how it compares to those of blood culture-positive endocarditis (BCPE) cases and show how molecular tools helped establish the etiology in BCNE. METHODS: Adult patients with definite infective endocarditis (IE) and having valve surgery were included. Valves were studied by polymerase chain reaction (PCR). Statistical analysis compared BCNE and BCPE. RESULTS: One hundred and thirty-one patients were included; 53 (40 %) had BCNE. The mean age was 45 ± 16 years; 33 (62 %) were male. BCNE was community-acquired in 41 (79 %). Most patients were referred from other hospitals (38, 73 %). Presentation was subacute in 34 (65 %), with fever in 47/53 (90 %) and a new regurgitant murmur in 34/42 (81 %). Native valves were affected in 74 %, mostly left-sided. All echocardiograms showed major criteria for IE. Antibiotics were used prior to BC collection in 31/42 (74 %). Definite histological diagnosis was established for 35/50 (70 %) valves. PCR showed oralis group streptococci in 21 (54 %), S. aureus in 3 (7.7 %), gallolyticus group streptococci in 2 (5.1 %), Coxiella burnetii in 1 (2.5 %) and Rhizobium sp. in 1 (2.5 %). In-hospital mortality was 9/53 (17 %). Fever (p = 0.06, OR 4.7, CI 0.91-24.38) and embolic complications (p = 0.003, OR 3.3, CI 1.55-6.82) were more frequent in BCPE cases, while new acute regurgitation (p = 0.05, OR 0.3, CI 0.098-0.996) and heart failure (p = 0.02, OR 0.3, CI 0.13-0.79) were less so. CONCLUSIONS: BCNE resulted mostly from prior antibiotics and was associated with severe hemodynamic compromise. Valve histopathology and PCR were useful in confirming the diagnosis and pointing to the etiology of BCNE.

CspC regulates the expression of the glyoxylate cycle genes at stationary phase in Caulobacter.

BACKGROUND: The Cold Shock proteins are RNA binding proteins involved in various cellular processes, including adaptation to low temperature, nutritional stress, cell growth and stationary phase. They may have an impact on gene expression by interfering with RNA stability and acting as transcription antiterminators. Caulobacter crescentus cspC is an essential gene encoding a stationary phase-induced protein of the Cold Shock Protein family and this work had as goal investigating the basis for the requirement of this gene for survival at this phase. In this work we investigate the role of CspC in C. crescentus stationary phase and discuss the molecular mechanisms that could be involved. RESULTS: The expression of cspC increased significantly at stationary phase in complex media and in glucose depletion, indicating a putative role in responding to carbon starvation. Global transcriptional profiling experiments comparing cspC and the wild type strain both at exponential and stationary phases as well as comparing exponential and stationary phase in wild type strain were carried out by DNA microarray analysis. The results showed that the absence of cspC affected the transcription of 11 genes at exponential phase and 60 genes at stationary phase. Among the differentially expressed genes it is worth noting those encoding respiratory enzymes and genes for sulfur metabolism, which were upregulated, and those encoding enzymes of the glyoxylate cycle, which were severely downregulated in the mutant at stationary phase. mRNA decay experiments showed that the aceA mRNA, encoding isocitrate lyase, was less stable in the cspC mutant, indicating that this effect was at least partially due to posttranscriptional regulation. These observations were supported by the observed arrested growth phenotype of the cspC strain when grown in acetate as the sole carbon source, and by the upregulation of genes for assimilatory sulfate reduction and methionine biosynthesis. CONCLUSIONS: The stationary phase-induced RNA binding protein CspC has an important role in gene expression at this phase, and is necessary for maximal expression of the glyoxylate cycle genes. In the case of aceA, its downregulation may be attributed to the shorter half-life of the mRNA in the cspC mutant, indicating that one of the possible regulatory mechanisms is via altering RNA stabilization.

Cold shock genes cspA and cspB from Caulobacter crescentus are posttranscriptionally regulated and important for cold adaptation.

Cold shock proteins (CSPs) are nucleic acid binding chaperones, first described as being induced to solve the problem of mRNA stabilization after temperature downshift. Caulobacter crescentus has four CSPs: CspA and CspB, which are cold induced, and CspC and CspD, which are induced only in stationary phase. In this work we have determined that the synthesis of both CspA and CspB reaches the maximum levels early in the acclimation phase. The deletion of cspA causes a decrease in growth at low temperature, whereas the strain with a deletion of cspB has a very subtle and transient cold-related growth phenotype. The cspA cspB double mutant has a slightly more severe phenotype than that of the cspA mutant, suggesting that although CspA may be more important to cold adaptation than CspB, both proteins have a role in this process. Gene expression analyses were carried out using cspA and cspB regulatory fusions to the lacZ reporter gene and showed that both genes are regulated at the transcriptional and posttranscriptional levels. Deletion mapping of the long 5'-untranslated region (5'-UTR) of each gene identified a common region important for cold induction, probably via translation enhancement. In contrast to what was reported for other bacteria, these cold shock genes have no regulatory regions downstream from ATG that are important for cold induction. This work shows that the importance of CspA and CspB to C. crescentus cold adaptation, mechanisms of regulation, and pattern of expression during the acclimation phase apparently differs in many aspects from what has been described so far for other bacteria.

Treatment for TMD with occlusal splint and electromyographic control: application of the FARC protocol in a Brazilian population.

The purpose of this study was to apply Functional Anatomy Research Center (FARC) Protocol of TMD treatment, which includes the use of a specific type of mandibular occlusal splint, adjusted based on the electromyographic index, in a group of 15 patients with disc displacement, classified according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and then analyzing the results compared with the control group. The clinical evaluations were completed both before and after the treatment. Electromyographic (EMG) data was collected and recorded on the day the splint was inserted (visit 1), after one week (visit 2) and after five weeks of treatment (visit 3). The control group consisted of 15 asymptomatic subjects, according to the same diagnostic criteria (RDC/TMD), who were submitted to the same evaluations with the same interval periods as the treatment group. Immediately after splint adjustment, masseter muscle symmetry and total muscular activity were significantly different with than without the splint (p < 0.05), showing an increased neuromuscular coordination. After treatment, significant variations (p < .05) were found in mouth opening and in pain remission. There were no significant differences among the three sessions, either with or without the splint. There were significant differences between the TMD and control groups for all analyzed indices of muscular symmetry, activity and torque, with the exception of total muscular activity. The use of the splint promoted balance of the EMG activities during its use, relieving symptoms. EMG parameters identified neuromuscular imbalance, and allowed an objective analysis of different phases of TMD treatment, differentiating individuals with TMD from the asymptomatic subjects.

Expression of the vascular endothelial growth factor and angiopoietins in mucoepidermoid carcinoma of salivary gland.

Disrupted coordination of angiogenesis regulating signals, among them the vascular endothelial growth factor (VEGF) and angiopoietins (Angs), has been associated with abnormal angiogenesis and tumor progression. While VEGF induces endothelial cell proliferation, thereby initiating vessel formation, Angs are subsequently required for mural cell attachment, thus influencing remodeling and maturation of this vasculature. In addition to tumor cell, endothelial and mural cells, as well as myofibroblasts may also contribute to the secretion of these factors. In this study, we have analyzed by immunohistochemistry the expression of VEGF, Ang-1, Ang-2 and the Angs receptor Tie2 in both the stroma and tumor cells of mucoepidermoid carcinoma (MEC) of salivary gland. We have demonstrated that when myofibroblasts were detected adjacent to the cancer cells, they were frequently associated with intense positive staining for Ang-1 and Ang-2, and no reactivity to VEGF and Tie2. These myofibroblast-rich Ang-1 and Ang-2-stained areas were more commonly found in high-grade MEC cases than in low-grade ones. As for the malignant cells, they frequently expressed all proteins studied, but Ang-2 and VEGF were detected at higher levels compared to Ang-1 and Tie2. Our results indicate that the MEC environment favors cooperative activity between Angs and VEGF in modulating vascular growth and tumor aggressiveness.

SpdR, a response regulator required for stationary-phase induction of Caulobacter crescentus cspD.

The cold shock protein (CSP) family includes small polypeptides that are induced upon temperature downshift and stationary phase. The genome of the alphaproteobacterium Caulobacter crescentus encodes four CSPs, with two being induced by cold shock and two at the onset of stationary phase. In order to identify the environmental signals and cell factors that are involved in cspD expression at stationary phase, we have analyzed cspD transcription during growth under several nutrient conditions. The results showed that expression of cspD was affected by the medium composition and was inversely proportional to the growth rate. The maximum levels of expression were decreased in a spoT mutant, indicating that ppGpp may be involved in the signalization for carbon starvation induction of cspD. A Tn5 mutant library was screened for mutants with reduced cspD expression, and 10 clones that showed at least a 50% reduction in expression were identified. Among these, a strain with a transposon insertion into a response regulator of a two-component system showed no induction of cspD at stationary phase. This protein (SpdR) was able to acquire a phosphate group from its cognate histidine kinase, and gel mobility shift assay and DNase I footprinting experiments showed that it binds to an inverted repeat sequence of the cspD regulatory region. A mutated SpdR with a substitution of the conserved aspartyl residue that is the probable phosphorylation site is unable to bind to the cspD regulatory region and to complement the spdR mutant phenotype.

CspC and CspD are essential for Caulobacter crescentus stationary phase survival.

The cold shock response in bacteria involves the expression of low-molecular weight cold shock proteins (CSPs) containing a nucleic acid-binding cold shock domain (CSD), which are known to destabilize secondary structures on mRNAs, facilitating translation at low temperatures. Caulobacter crescentus cspA and cspB are induced upon cold shock, while cspC and cspD are induced during stationary phase. In this work, we determined a new coding sequence for the cspC gene, revealing that it encodes a protein containing two CSDs. The phenotypes of C. crescentus csp mutants were analyzed, and we found that cspC is important for cells to maintain viability during extended periods in stationary phase. Also, cspC and cspCD strains presented altered morphology, with frequent non-viable filamentous cells, and cspCD also showed a pronounced cell death at late stationary phase. In contrast, the cspAB mutant presented increased viability in this phase, which is accompanied by an altered expression of both cspC and cspD, but the triple cspABD mutant loses this characteristic. Taken together, our results suggest that there is a hierarchy of importance among the csp genes regarding stationary phase viability, which is probably achieved by a fine tune balance of the levels of these proteins.

Prevalence and risk factors for aminoglycoside nephrotoxicity in intensive care units.

In order to assess the prevalence of and risk factors for aminoglycoside-associated nephrotoxicity in intensive care units (ICUs), we evaluated 360 consecutive patients starting aminoglycoside therapy in an ICU. The patients had a baseline calculated glomerular filtration rate (cGFR) of > or =30 ml/min/1.73 m(2). Among these patients, 209 (58%) developed aminoglycoside-associated nephrotoxicity (the acute kidney injury [AKI] group, which consisted of individuals with a decrease in cGFR of >20% from the baseline cGFR), while 151 did not (non-AKI group). Both groups had similar baseline cGFRs. The AKI group developed a lower cGFR nadir (45 +/- 27 versus 79 +/- 39 ml/min/1.73 m(2) for the non-AKI group; P < 0.001); was older (56 +/- 18 years versus 52 +/- 19 years for the non-AKI group; P = 0.033); had a higher prevalence of diabetes (19.6% versus 9.3% for the non-AKI group; P = 0.007); was more frequently treated with other nephrotoxic drugs (51% versus 38% for the non-AKI group; P = 0.024); used iodinated contrast more frequently (18% versus 8% for the non-AKI group; P = 0.0054); and showed a higher prevalence of hypotension (63% versus 44% for the non-AKI group; P = 0.0003), shock (56% versus 31% for the non-AKI group; P < 0.0001), and jaundice (19% versus 8% for the non-AKI group; P = 0.0036). The mortality rate was 44.5% for the AKI group and 29.1% for the non-AKI group (P = 0.0031). A logistic regression model identified as significant (P < 0.05) the following independent factors that affected aminoglycoside-associated nephrotoxicity: a baseline cGFR of <60 ml/min/1.73 m(2) (odds ratio [OR], 0.42), diabetes (OR, 2.13), treatment with other nephrotoxins (OR, 1.61) or iodinated contrast (OR, 2.13), and hypotension (OR, 1.83). In conclusion, AKI was frequent among ICU patients receiving an aminoglycoside, and it was associated with a high rate of mortality. The presence of diabetes or hypotension and the use of other nephrotoxic drugs and iodinated contrast were independent risk factors for the development of aminoglycoside-associated nephrotoxicity.