Weekend diagnosis of Escherichia coli urinary tract infection does not predict poor outcome.

It has been suggested that mortality is higher in patients admitted to hospitals during the weekend. The objective of this study was to compare outcomes in patients with E. coli urinary tract infection (UTI) depending on the hospital admission day. For this purpose, a secondary analysis of data from a prospective cohort of patients with E. coli UTI was conducted. Weekend diagnosis of UTI was not associated with higher mortality. However, mortality was associated with sepsis, sepsis-induced hypotension and intensive care unit (ICU) admission. Sepsis-induced hypotension and ICU admission were independent determinants of mortality. The results indicate that indicators of severity of illness are associated with higher mortality in patients with UTI rather than the time of diagnosis.

Vancomycin resistance has no influence on outcomes of enterococcal bacteriuria.

BACKGROUND: Infections with vancomycin-resistant enterococci (VRE) are a growing concern in hospitals. The impact of vancomycin resistance in enterococcal urinary tract infection is not well-defined. AIM: To describe the epidemiology of enterococcal bacteriuria in a hospital and compare the clinical picture and patient outcomes depending on vancomycin resistance. METHODS: This was a 6-month prospective cohort study of hospital patients who were admitted with or who developed enterococcal bacteriuria in a 1250-bed tertiary care hospital. We examined clinical presentation, diagnostic work-up, management, and outcomes. FINDINGS: We included 254 patients with enterococcal bacteriuria; 160 (63%) were female and median age was 65 years (range: 17-96). A total of 116 (46%) bacteriurias were hospital-acquired and 145 (57%) catheter-associated. Most patients presented with asymptomatic bacteriuria (ASB) (119; 47%) or pyelonephritis (64; 25%); 51 (20%) had unclassifiable bacteriuria and 20 (8%) had cystitis. Secondary bloodstream infection was detected in 8 (3%) patients. Seventy of 119 (59%) with ASB received antibiotics (mostly vancomycin). There were 74 (29%) VRE bacteriurias. VRE and vancomycin-susceptible enterococci (VSE) produced similar rates of pyelonephritis [19 (25%) vs 45 (25%); P = 0.2], cystitis, and ASB. Outcomes such as ICU transfer [10 (14%) VRE vs 17 (9%) VSE; P = 0.3], hospital length of stay (6.8 vs 5.0 days; P = 0.08), and mortality [10 (14%) vs 13 (7%); P = 0.1] did not vary with vancomycin susceptibility. CONCLUSIONS: Vancomycin resistance did not affect the clinical presentation nor did it impact patient outcomes in this cohort of inpatients with enterococcal bacteriuria. Almost half of our cohort had enterococcal ASB; more than 50% of these asymptomatic patients received unnecessary antibiotics. Antimicrobial stewardship efforts should address overtreatment of enterococcal bacteriurias.

Suicide - a statistical analysis by age, sex and method.

A total of 115 suicide cases dealt with by St. Pancras Coroner's Court, London, UK were studied in order to determine what patterns exist regarding the age and gender of the victims and chosen method of suicide. The results were compared with those of a 1998 study of suicides in England and Wales commissioned by the UK Home Office. It was found that suicides in the male population are approximately twice as common as female victims of suicide. In terms of gross number of cases, the peak age group for both males and females resorting to suicide was found to be the 15-44 age group. When the results were standardised according to 2001 census data, however, the most vulnerable age group per head of population for both sexes was 75 and over. Good agreement was found between the results of this study and those of the Home Office Study.

Patterns of non-firearm homicide.

Sixty-two recent non-firearm homicides dealt with by an inner London public mortuary were studied. The majority of homicides involved stabbing--usually multiple wounds to the trunk. These were followed by blunt instrument homicides--nearly all involved multiple blows to the head, and asphyxiation--usually consisting of strangulation with a ligature being employed in the majority of cases. Homicides tended to occur during the evening and night in spring and early summer. Most victims were found to be in the 20-39 age group, with male victims outnumbering females in a 2:1 ratio. A marked difference in homicide pattern existed between the male and female victims. Males tended to fall victim to strangers encountered while socialising in and around bars and clubs. Females were most often killed by close acquaintances in domestic disputes at home.

Antecedent use of fluoroquinolones is associated with resistance to moxifloxacin in Clostridium difficile.

OBJECTIVE: Moxifloxacin is characterized by high activity against Gram-positive cocci and some Gram-positive and -negative anaerobes, including Clostridium difficile. This study investigates the role of prior quinolone use in relation to patterns of susceptibility of C. difficile to moxifloxacin. METHODS: Sixty-three clinical isolates of C. difficile were investigated for toxigenicity, susceptibility to moxifloxacin, and mutations in the DNA gyrase gene. The medical histories for 50 of these patients were available and used to identify previous fluoroquinolone use. RESULTS: Thirty-three (52.4%) strains showed resistance to moxifloxacin (MICs > or = 16 mg/L). All moxifloxacin-resistant strains harbored a mutation at amino acid codon Ser-83 of gyrA. Forty-five isolates (71.4%) were toxigenic; all moxifloxacin-resistant strains were in this group. Resistance to moxifloxacin was associated with prior use of fluoroquinolones (P-value 0.009, chi-square). CONCLUSIONS: Although the use of moxifloxacin to treat C. difficile-associated diarrhea is not likely to be common, these data show a relationship between antecedent fluoroquinolone use and resistance to moxifloxacin in C. difficile isolates, and raise questions regarding selection pressure for resistance placed on colonizing bacteria exposed to fluoroquinolones. Mutations in gyrA are involved in moxifloxacin resistance.

The use of DNA statistics in criminal trials.

In a number of recent cases in the UK, convictions have been quashed by the Court of Appeal on the grounds that the jury had been misdirected as to the factual significance of random occurrence statistics. The mathematical basis on which those statistics are calculated was reviewed and recent appeal cases involving DNA evidence in the UK and the US were examined. It was found that a widespread misconception exists regarding the random occurrence ratio and its relationship with probability of guilt. It is in fact impossible to relate the two with any degree of accuracy without consideration of social and demographic factors particular to a case as well as any non-DNA evidence obtained.

One-step cloning and expression of Clostridium difficile toxin B gene (tcdB).

The toxin genes of Clostridium difficile have been previously cloned by reconstructing the entire gene in a series of steps in sequence using several cloned fragments. Amplification of a 7.9 kb fragment corresponding to the toxin B gene (tcdB) was obtained with EXPAND Long Template PCR system. The amplified fragment was inserted into the E. coli expression vector pBAD and cloned into competent E. coli TOP 10 cells. tcdB gene sequences representing the complete toxin gene were detected in 3/120 (2.5%) clones analyzed. Culture filtrates of 2/3 clones were found to have cytotoxic activity in human lung fibroblasts. The recombinant protein expressed in E. coli was identified as toxin B by Western immunoblot analysis using C. sordellii antitoxin. This rapid cloning method may be useful in determining the role that individual genes in the pathogenicity locus (PaLoc) play in the virulence of C. difficile. Our results also suggest that the activity of toxin B is independent of other genes in the PaLoc.

Electroporation of DNA sequences from the pathogenicity locus (PaLoc) of toxigenic Clostridium difficile into a non-toxigenic strain.

Toxigenic Clostridium difficile is the etiologic agent of C. difficile-associated diarrhoea (CDAD), the most common cause of hospital-acquired infectious diarrhoea. The genes tcdA and tcdB, which encode for the toxin A and B proteins, are part of the pathogenicity locus (PaLoc) of toxigenic C. difficile. Genetic and virulence studies at the molecular level in C. difficile have been hindered by the lack of techniques for DNA manipulation in this species. We describe the electroporation of DNA fragments from a toxigenic isolate into a non-toxigenic strain of C. difficile. Using previously described methods of electroporation into Clostridium spp., the complete toxin B gene and polymerase chain reaction (PCR) fragments of the PaLoc were cloned and electroporated into a non-toxigenic strain of C. difficile. The resulting transformed clones were screened for the introduced gene fragments by PCR, which confirmed their presence. This is the first description of introduction of DNA into C. difficile by electroporation.

Neutrophils employ the myeloperoxidase system to generate antimicrobial brominating and chlorinating oxidants during sepsis.

The myeloperoxidase system of neutrophils uses hydrogen peroxide and chloride to generate hypochlorous acid, a potent bactericidal oxidant in vitro. In a mouse model of polymicrobial sepsis, we observed that mice deficient in myeloperoxidase were more likely than wild-type mice to die from infection. Mass spectrometric analysis of peritoneal inflammatory fluid from septic wild-type mice detected elevated concentrations of 3-chlorotyrosine, a characteristic end product of the myeloperoxidase system. Levels of 3-chlorotyrosine did not rise in the septic myeloperoxidase-deficient mice. Thus, myeloperoxidase seems to protect against sepsis in vivo by producing halogenating species. Surprisingly, levels of 3-bromotyrosine also were elevated in peritoneal fluid from septic wild-type mice and were markedly reduced in peritoneal fluid from septic myeloperoxidase-deficient mice. Furthermore, physiologic concentrations of bromide modulated the bactericidal effects of myeloperoxidase in vitro. It seems, therefore, that myeloperoxidase can use bromide as well as chloride to produce oxidants in vivo, even though the extracellular concentration of bromide is at least 1,000-fold lower than that of chloride. Thus, myeloperoxidase plays an important role in host defense against bacterial pathogens, and bromide might be a previously unsuspected component of this system.

The eosinophil peroxidase-hydrogen peroxide-bromide system of human eosinophils generates 5-bromouracil, a mutagenic thymine analogue.

Eosinophils use eosinophil peroxidase, hydrogen peroxide (H(2)O(2)), and bromide ion (Br(-)) to generate hypobromous acid (HOBr), a brominating intermediate. This potent oxidant may play a role in host defenses against invading parasites and eosinophil-mediated tissue damage. In this study, we explore the possibility that HOBr generated by eosinophil peroxidase might oxidize nucleic acids. When we exposed uracil, uridine, or deoxyuridine to reagent HOBr, each reaction mixture yielded a single major oxidation product that comigrated on reversed-phase HPLC with the corresponding authentic brominated pyrimidine. The eosinophil peroxidase-H(2)O(2)-Br(-) system also converted uracil into a single major oxidation product, and the yield was near-quantitative. Mass spectrometry, HPLC, UV--visible spectroscopy, and NMR spectroscopy identified the product as 5-bromouracil. Eosinophil peroxidase required H(2)O(2) and Br(-) to produce 5-bromouracil, implicating HOBr as an intermediate in the reaction. Primary and secondary bromamines also brominated uracil, suggesting that long-lived bromamines also might be physiologically relevant brominating intermediates. Human eosinophils used the eosinophil peroxidase-H(2)O(2)-Br(-) system to oxidize uracil. The product was identified as 5-bromouracil by mass spectrometry, HPLC, and UV--visible spectroscopy. Collectively, these results indicate that HOBr generated by eosinophil peroxidase oxidizes uracil to 5-bromouracil. Thymidine phosphorylase, a pyrimidine salvage enzyme, transforms 5-bromouracil to 5-bromodeoxyridine, a mutagenic analogue of thymidine. These findings raise the possibility that halogenated nucleobases generated by eosinophil peroxidase exert cytotoxic and mutagenic effects at eosinophil-rich sites of inflammation.

Bromination of deoxycytidine by eosinophil peroxidase: a mechanism for mutagenesis by oxidative damage of nucleotide precursors.

Oxidants generated by eosinophils during chronic inflammation may lead to mutagenesis in adjacent epithelial cells. Eosinophil peroxidase, a heme enzyme released by eosinophils, generates hypobromous acid that damages tissue in inflammatory conditions. We show that human eosinophils use eosinophil peroxidase to produce 5-bromodeoxycytidine. Flow cytometric, immunohistochemical, and mass spectrometric analyses all demonstrated that 5-bromodeoxycytidine generated by eosinophil peroxidase was taken up by cultured cells and incorporated into genomic DNA as 5-bromodeoxyuridine. Although previous studies have focused on oxidation of chromosomal DNA, our observations suggest another mechanism for oxidative damage of DNA. In this scenario, peroxidase-catalyzed halogenation of nucleotide precursors yields products that subsequently can be incorporated into DNA. Because the thymine analog 5-BrUra mispairs with guanine in DNA, generation of brominated pyrimidines by eosinophils might constitute a mechanism for cytotoxicity and mutagenesis at sites of inflammation.

Production of brominating intermediates by myeloperoxidase. A transhalogenation pathway for generating mutagenic nucleobases during inflammation.

The existence of interhalogen compounds was proposed more than a century ago, but no biological roles have been attributed to these highly oxidizing intermediates. In this study, we determined whether the peroxidases of white blood cells can generate the interhalogen gas bromine chloride (BrCl). Myeloperoxidase, the heme enzyme secreted by activated neutrophils and monocytes, uses H2O2 and Cl(-) to produce HOCl, a chlorinating intermediate. In contrast, eosinophil peroxidase preferentially converts Br(-) to HOBr. Remarkably, both myeloperoxidase and eosinophil peroxidase were able to brominate deoxycytidine, a nucleoside, and uracil, a nucleobase, at plasma concentrations of Br(-) (100 microM) and Cl(-) (100 mM). The two enzymes used different reaction pathways, however. When HOCl brominated deoxycytidine, the reaction required Br(-) and was inhibited by taurine. In contrast, bromination by HOBr was independent of Br(-) and unaffected by taurine. Moreover, taurine inhibited 5-bromodeoxycytidine production by the myeloperoxidase-H2O2-Cl(-)- Br(-) system but not by the eosinophil peroxidase-H2O2-Cl(-)-Br(-) system, indicating that bromination by myeloperoxidase involves the initial production of HOCl. Both HOCl-Br(-) and the myeloperoxidase-H2O2-Cl(-)-Br(-) system generated a gas that converted cyclohexene into 1-bromo-2-chlorocyclohexane, implicating BrCl in the reaction. Moreover, human neutrophils used myeloperoxidase, H2O2, and Br(-) to brominate deoxycytidine by a taurine-sensitive pathway, suggesting that transhalogenation reactions may be physiologically relevant. 5-Bromouracil incorporated into nuclear DNA is a well known mutagen. Our observations therefore raise the possibility that transhalogenation reactions initiated by phagocytes provide one pathway for mutagenesis and cytotoxicity at sites of inflammation.

Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy.

Twenty-five athletes (26 shoulders) who underwent an inferior capsular shift procedure for multidirectional glenohumeral instability based on isolated capsular and ligamentous redundancy were evaluated at a median of 54 months (range, 25 to 113) after the operation. Twenty-one athletes (84%) returned to their preinjury activity level at a median of 5 months after surgery. Of 21 athletes involved in sports using overhead motions, 16 (76%) returned to their previous sport after the operation, and 12 (57%) were still active in this sport at the preinjury level at follow-up. According to the Rowe score, 23 shoulders (88%) were excellent or good. The University of California at Los Angeles score for 24 shoulders (92%) was excellent or good. The operations on two shoulders (8%) failed. One patient had a spontaneous redislocation, and one had recurrent subluxations. Nine contralateral shoulders had a history of significant instability; four of these had undergone Bankart repair. We concluded that athletes who have multidirectional instability based on isolated capsular and ligamentous redundancy can be successfully treated by an inferior capsular shift preserving the subscapularis tendon insertion. We found a high rate of return to demanding upper extremity sports in our patients, range of motion was restored in the majority of shoulders, and the failure rate after a median of 54 months was acceptable.

Molecular chlorine generated by the myeloperoxidase-hydrogen peroxide-chloride system of phagocytes produces 5-chlorocytosine in bacterial RNA.

Myeloperoxidase, a heme enzyme secreted by activated phagocytes, uses H(2)O(2) and Cl(-) to generate the chlorinating intermediate hypochlorous acid (HOCl). This potent cytotoxic oxidant plays a critical role in host defenses against invading pathogens. In this study, we explore the possibility that myeloperoxidase-derived HOCl might oxidize nucleic acids. When we exposed 2'-deoxycytidine to the myeloperoxidase-H(2)O(2)-Cl(-) system, we obtained a single major product that was identified as 5-chloro-2'-deoxycytidine using mass spectrometry, high performance liquid chromatography, UV-visible spectroscopy, and NMR spectroscopy. 5-Chloro-2'-deoxycytidine production by myeloperoxidase required H(2)O(2) and Cl(-), suggesting that HOCl is an intermediate in the reaction. However, reagent HOCl failed to generate 5-chloro-2'-deoxycytidine in the absence of Cl(-). Moreover, chlorination of 2'-deoxycytidine was optimal under acidic conditions in the presence of Cl(-). These results implicate molecular chlorine (Cl(2)), which is in equilibrium with HOCl through a reaction requiring Cl(-) and H(+), in the generation of 5-chloro-2'-deoxycytidine. Activated human neutrophils were able to generate 5-chloro-2'-deoxycytidine. Cellular chlorination was blocked by catalase and heme poisons, consistent with a myeloperoxidase-catalyzed reaction. The myeloperoxidase-H(2)O(2)-Cl(-) system generated similar levels of 5-chlorocytosine in RNA and DNA in vitro. In striking contrast, only cell-associated RNA acquired detectable levels of 5-chlorocytosine when intact Escherichia coli was exposed to the myeloperoxidase system. This observation suggests that oxidizing intermediates generated by myeloperoxidase selectively target intracellular RNA for chlorination. Collectively, these results indicate that Cl(2) derived from HOCl generates 5-chloro-2'-deoxycytidine during the myeloperoxidase-catalyzed oxidation of 2'-deoxycytidine. Phagocytic generation of Cl(2) therefore may constitute one mechanism for oxidizing nucleic acids at sites of inflammation.

8-Nitro-2'-deoxyguanosine, a specific marker of oxidation by reactive nitrogen species, is generated by the myeloperoxidase-hydrogen peroxide-nitrite system of activated human phagocytes.

Reactive intermediates generated by phagocytes damage DNA and may contribute to the link between chronic inflammation and cancer. Myeloperoxidase, a heme protein secreted by activated phagocytes, is a potential catalyst for such reactions. Recent studies demonstrate that this enzyme uses hydrogen peroxide (H2O2) and nitrite (NO2-) to generate reactive nitrogen species which convert tyrosine to 3-nitrotyrosine. We now report that activated human neutrophils use myeloperoxidase, H2O2, and NO2- to nitrate 2'-deoxyguanosine, one of the nucleosides of DNA. Through HPLC, UV/vis spectroscopy, and mass spectrometry, the two major products of this reaction were identified as 8-nitroguanine and 8-nitro-2'-deoxyguanosine. Nitration required each component of the complete enzymatic system and was inhibited by catalase and heme poisons. However, it was independent of chloride ion and little affected by scavengers of hypochlorous acid, suggesting that the reactive agent is a nitrogen dioxide-like species that results from the one-electron oxidation of NO2- by myeloperoxidase. Alternatively, 2'-deoxyguanosine might be oxidized directly by the enzyme to yield a radical species which subsequently reacts with NO2- or NO2* to generate the observed products. Human neutrophils stimulated with phorbol ester also generated 8-nitroguanine and 8-nitro-2'-deoxyguanosine. The reaction required NO2- and was inhibited by catalase and heme poisons, implicating myeloperoxidase in the cell-mediated pathway. These results indicate that human neutrophils use the myeloperoxidase-H2O2-NO2- system to generate reactive species that can nitrate the C-8 position of 2'-deoxyguanosine. Our observations raise the possibility that reactive nitrogen species generated by myeloperoxidase and other peroxidases contribute to nucleobase oxidation and tissue injury at sites of inflammation.

Nasal polyps in a cat.

Ethmoturbinate polyps are described in a one-year-old cat with a four month history of stertorous respiration and frequent sneezing. Remission of clinical signs occurred after rhinotomy and polypectomy. This appears to be the first known case of nasal polyps reported from outside Italy and the USA.

Anaemia and low viability in piglets infected with Eperythrozoon suis.

Eperythrozoon suis infection was identified in a pig herd during an investigation into anaemia and low viability in newborn piglets and severe regenerative macrocytic anaemia in older piglets. The organisms were identified in the erythrocytes of piglets a few days old. Extensive investigations failed to detect other causes of the anaemia and low viability. There was no response to parenteral iron administration alone but the piglets' viability and anaemia responded to the administration of tetracyclines. This is the first report of E suis infection in Northern Ireland.