Trends in the use of laboratory tests for the diagnosis of Clostridium difficile infection and association with incidence rates in Quebec, Canada, 2010-2014.

BACKGROUND: Several Clostridium difficile infection (CDI) surveillance programs do not specify laboratory strategies to use. We investigated the evolution in testing strategies used across Quebec, Canada, and its association with incidence rates. METHODS: Cross-sectional study of 95 hospitals by surveys conducted in 2010 and in 2013-2014. The association between testing strategies and institutional CDI incidence rates was analyzed via multivariate Poisson regressions. RESULTS: The most common assays in 2014 were toxin A/B enzyme immunoassays (EIAs) (61 institutions, 64%), glutamate dehydrogenase (GDH) EIAs (51 institutions, 53.7%), and nucleic acid amplification tests (NAATs) (34 institutions, 35.8%). The most frequent algorithm was a single-step NAAT (20 institutions, 21%). Between 2010 and 2014, 35 institutions (37%) modified their algorithm. Institutions detecting toxigenic C difficile instead of C difficile toxin increased from 14 to 37 (P < .001). Institutions detecting toxigenic C difficile had higher CDI rates (7.9 vs 6.6 per 10,000 patient days; P = .01). Institutions using single-step NAATs, GDH plus toxigenic cultures, and GDH plus cytotoxicity assays had higher CDI rates than those using an EIA-based algorithm (P < .05). CONCLUSIONS: Laboratory detection of CDI has changed since 2010. There is an association between diagnostic algorithms and CDI incidence. Mitigation strategies are warranted.

Using Clinical Signs and Symptoms for Medical Management of Radiation Casualties - 2015 NATO Exercise.

The utility of early-phase (≤5 days) radiation-induced clinical signs and symptoms (e.g., vomiting, diarrhea, erythema and changes in blood cell counts) was examined for the prediction of later occurring acute radiation syndrome (ARS) severity and the development of medical management strategies. Medical treatment protocols for radiation accident victims (METREPOL) was used to grade ARS severities, which were assigned response categories (RCs). Data on individuals (n = 191) with mild (RC1, n = 45), moderate (RC2, n = 19), severe (RC3, n = 20) and fatal (RC4, n = 18) ARS, as well as nonexposed individuals (RC0, n = 89) were generated using either METREPOL (n = 167) or the system for evaluation and archiving of radiation accidents based on case histories (SEARCH) database (n = 24), the latter comprised of real-case descriptions. These data were converted into tables reflecting clinical signs and symptoms, and submitted to eight teams representing five participating countries. The teams were comprised of medical doctors, biologists and pharmacists with subject matter expertise. The tables comprised cumulated clinical data from day 1-3 and day 1-5 postirradiation. While it would have reflected a more realistic scenario to provide the data to the teams over the course of a 3- or 5-day period, the logistics of doing so proved too challenging. In addition, the team members participating in this exercise chose to receive the cumulated reports of day 1-3 and 1-5. The teams were tasked with predicting ARS incidence, ARS severity and the requirement for hospitalization for multiple cases, as well as providing the certainty of their diagnosis. Five of the teams also performed dose estimates. The teams did not employ harmonized methodologies, and the expertise among the members varied, as did the tools used and the means of analyzing the clinical data. The earliest report time was 3 h after the tables were sent to the team members. The majority of cases developing ARS (89.6% ± 3.3 SD) and requiring hospitalization (88.8% ± 4.6 SD) were correctly identified by all teams. Determination of ARS severity was particularly challenging for RC2-3, which was systematically overestimated. However, RC4 was correctly predicted at 94-100% by all teams. RC0 and RC1 ARS severities were more difficult to discriminate. When reported RCs (0-1 and 3-4) were merged, on average 89.6% (±3.3 SD) of all cases could be correctly classified. Comparisons on frequency distributions revealed no statistically significant differences among the following: 1. reported ARS from different teams (P > 0.2); 2. cases generated based on METREPOL or SEARCH (P > 0.5); or 3. results reported at day 3 and 5 postirradiation (P > 0.1). Dose estimates of all teams increased significantly along with ARS severity (P < 0.0001) as well as with dose estimates generated from dicentric chromosomal-aberration measurements available for SEARCH cases (P < 0.0001). In summary, early-phase radiation-induced clinical signs and symptoms proved to be useful for rapid and accurate assessment, with minor limitations, toward predicting life-threatening ARS severity and developing treatment management strategies.

Enzymatic Assays for Studying Intramembrane Proteolysis.

Proteolysis within the membrane is catalyzed by a diverse family of proteases immersed within the hydrophobic environment of cellular membranes. These ubiquitous intramembrane-cleaving proteases (I-CLiPs) hydrolyze the transmembrane domains of a large variety of membrane-embedded proteins to facilitate signaling events essential to normal biological functions found in all forms of life. The importance of this unique class of enzyme is highlighted by its central involvement in a variety of human pathologies, including Alzheimer's disease (AD), Parkinson's disease, cancer, and the virulence of a number of viral, bacterial, and fungal pathogens. I-CLiPs therefore represent promising targets for the therapeutic treatment of numerous diseases. The key to understanding the normal biological function of I-CLiPs and capitalizing on their therapeutic potential is through a thorough understanding of the complex catalytic mechanisms that govern this unusual class of enzyme. This is an intrinsically difficult endeavor, given that these enzymes and their substrates reside within lipid membranes, making any in vitro assay technically challenging to design and execute. Here, we describe several in vitro enzymatic assays for the study of the AD-associated γ-secretase protease, which have aided the development of potent γ-secretase-targeting compounds as candidate therapeutics. These assays have also been applied in various forms for the study of other I-CLiPs, providing valuable mechanistic insights into some of the functional similarities and differences between several members of this fascinating family of proteases.

Ellagic acid protects against arsenic toxicity in isolated rat mitochondria possibly through the maintaining of complex II.

Chronic arsenic exposure has been linked to many health problems including diabetes and cancer. In the present study, we assessed the protective effect of ellagic acid (EA) against toxicity induced by arsenic in isolated rat liver mitochondria. Reactive oxygen species (ROS) and mitochondrial membrane potential decline were assayed using dichlorofluorescein diacetate and rhodamine 123, respectively, and dehydrogenase activity obtained by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide conversion assay. Arsenic increased ROS levels and mitochondrial dysfunction, which led to a reduction in mitochondrial total dehydrogenase activity. Mitochondria pretreated with EA exposed to arsenic at various concentrations led to a reversal of ROS production and mitochondrial damage. Our results showed that mitochondria were significantly affected when exposed to arsenic, which resulted in excessive ROS production and mitochondrial membrane disruption. Pretreatment with EA, reduced ROS amounts, mitochondrial damage, and restored total dehydrogenase activity specifically associated with mitochondrial complex II. EA protective characteristics may be accomplished particularly throughout the mitochondrial maintenance either directly by its antioxidant property or indirectly through its maintaining of complex II. These findings also suggest a potential role for EA in treating or preventing mitochondria associated disorders.

Clindamycin and quinolone therapy for Bacillus anthracis Sterne infection in 60Co-gamma-photon-irradiated and sham-irradiated mice.

OBJECTIVES: Sublethal ionizing doses of radiation increase the susceptibility of mice to Bacillus anthracis Sterne infection. In this study, we investigated the efficacy of clindamycin in 60Co-gamma-photon-irradiated and sham-irradiated mice after intratracheal challenge with B. anthracis Sterne spores. Clindamycin has in vitro activity against B. anthracis and inhibits the production of toxin from other species, although no direct evidence exists that production of B. anthracis toxin is inhibited. METHODS: Ten-week-old B6D2F1/J female mice were either sham-irradiated or given a sublethal 7 Gy dose of 60Co-gamma-photon radiation 4 days prior to an intratracheal challenge with toxigenic B. anthracis Sterne spores. Mice were treated twice daily with 200 mg/kg clindamycin (subcutaneous or oral), 100 mg/kg moxifloxacin (oral), 50 mg/kg ciprofloxacin (subcutaneous) or a combination therapy (clindamycin + ciprofloxacin). Bacteria were isolated and identified from lung, liver and heart blood at five timed intervals after irradiation. Survival was recorded twice daily following intratracheal challenge. RESULTS: The use of clindamycin increased survival in gamma-irradiated and sham-irradiated animals challenged with B. anthracis Sterne in comparison with control mice (P < 0.001). Ciprofloxacin-treated animals had higher survival compared with clindamycin-treated animals in two experiments, and less survival in a third experiment, although differences were not statistically significant. Moxifloxacin was just as effective as clindamycin. Combination therapy did not improve survival of sham-irradiated animals and significantly decreased survival among gamma-irradiated animals (P = 0.01) in comparison with clindamycin-treated animals. B. anthracis Sterne was isolated from lung, liver and heart blood, irrespective of the antimicrobial treatment. CONCLUSIONS: Treatment with clindamycin, ciprofloxacin or moxifloxacin increased survival in sham-irradiated and gamma-irradiated animals challenged intratracheally with B. anthracis Sterne spores. However, the combination of clindamycin and ciprofloxacin increased mortality associated with B. anthracis Sterne infection, particularly in gamma-irradiated animals.

Functional role of alpha-calcitonin gene-related peptide in the regulation of the cardiovascular system.

It remains unknown whether the extent of vasoactive response to exogenous calcitonin gene-related peptide (CGRP) varies among different regional vascular beds. It is also unclear whether endogenous CGRP plays a functional role in regulating basal vascular activity. To address these two issues, experiments were conducted in 27 anesthetized rats instrumented with a carotid flow probe and catheters in a jugular vein, left ventricle (LV), and femoral artery, and in 6 conscious dogs, chronically instrumented with LV pressure gauge, aortic and atrial catheters, and ascending aortic, coronary, carotid, and renal flow probes. In both species, administration of human alpha-CGRP (0.1-0.5 microg/kg, i.v.) induced a dose-dependent peripheral vasodilation that was completely abolished by pretreatment with alpha-CGRP[8-37] (30 microg/kg/min, i.v.), a competitive antagonist of CGRP receptors. Regional blood flow measured by the radioactive microsphere technique in rats showed that the alpha-CGRP (0.3 microg/kg, i.v.)-induced increase in blood flow was greater (p < 0.05) in the heart (+53 +/- 16%) than in the brain (+14 +/- 6%). In the presence of beta-adrenergic receptor blockade with propranolol, however, the increases in blood flow in these two vascular beds were identical. In conscious dogs, alpha-CGRP (0.3 microg/kg, i.v.) produced similar increases in coronary (+24 +/- 6%), carotid (+26 +/- 3%), and renal (+26 +/- 6%) blood flow, which were different from the patterns induced by other vasodilators; at an equivalent level of reduction in mean arterial pressure and total peripheral resistance, alpha-CGRP increased coronary and carotid blood flow significantly less (p < 0.05) than adenosine or nitroprusside. Unlike alpha-CGRP, adenosine and nitroprusside, as expected, induced pronounced differential blood flow changes in these vascular beds. Neither systemic hemodynamics nor regional blood flow distribution was altered by the administration of a pharmacological blocking dose of alpha-CGRP[8-37] in the two species. Thus, we conclude that endogenous alpha-CGRP does not play an important role in cardiovascular regulation under normal, resting conditions, although exogenous alpha-CGRP induces a marked, comparable vasorelaxation in different regional vascular beds.

An electronic simulator for testing infant apnoea monitors that uses actual physiologic data.

An electronic simulator of physiologic signals used in infant monitoring has been designed, constructed and applied in the Collaborative Home Infant Monitor Evaluation (CHIME). A unique feature of the simulator is that it contains actual physiologic waveforms recorded from infants rather than artificial, idealized signals. The simulator stores breathing waveforms that can be used to test transthoracic-impedance- and inductance-plethysmography-based monitors, and heart rate channels are tested by playing a neonatal QRS complex at preset fixed rates or a variable rate as determined from infant recordings. The transfer characteristics of the simulator are constant over frequencies ranging from 0.5 to 8 Hz for the respiration channels. Data stored in memory are divided into 60 second epochs that can be presented to the monitor being tested in a programmable sequence. A group of 66 CHIME monitors was tested using a simulator programmed with 17 apnoea and bradycardia waveforms. The agreement between monitors as to the duration of detected apnoea decreases as the amount of artefact in the signal increases. Discrepancies between monitors in detecting apnoea duration were found to be similar to inconsistencies between CHIME investigators manually scoring similar waveforms.

A single dose of an effective whole cell pertussis vaccine does not significantly increase protection in children primed with a less effective vaccine.

We evaluated if a single dose of a protective whole cell pertussis vaccine given before school entry to children primed with a less effective vaccine would increase their protection. A school cohort including 3876 students and a family cohort including 162 children were assessed. Although there was a trend toward increased protection. the better vaccine did not provide a significant improvement. These results suggest that a single dose of an effective vaccine given to children primed with a less effective one does not raise the protection to at level similar to that provided by three doses of the better vaccine.

Proteolytic profile of recombinant pro-opiomelanocortin in embryonal carcinoma P19 cells: conversion to beta-lipotropin and secretion are inhibited following incubation with canavanine.

A variety of proteins and peptides are produced through limited proteolysis of precursors at paired basic residues. This proteolytic bioactivation is carried out by subtilisin-like proteases, called convertases. The mRNAs of several convertases are expressed during prenatal life as well as in P19 embryonal carcinoma cells, which are a model of the totipotent cells of the embryo before and at the time of implantation. To determine whether converting activities accompany convertase mRNA expression in the early embryo, we transferred the gene of pro-opiomelanocortin (POMC) into P19 cells, by lipofection, and searched for the presence of mature peptides by high-performance liquid chromatography and radioimmunoassay techniques. In P19 cells, POMC, a precursor of several endocrine peptides, is mainly processed to beta-lipotropin rather than to beta-endorphin, both peptides having been identified by their immunoreactivity, polarity, and molecular size. These results indicate that converting capacities appear early in the embryo and that they are more similar to the activity of furin and of convertase PC1 than that of convertase PC2 in their cleavage selectivity of POMC sites. Efficiency of POMC processing can reach 50%, suggesting that convertases, with other proteases, can have an important role in ontogenesis. As for other peptide precursors in endocrine cells, the conversion of POMC in P19 cells was inhibited by the biosynthetic replacement of its arginine residues by the analog canavanine. However, the incorporation of canavanine into P19 cells also inhibited peptide secretion, suggesting that inhibition of conversion in these cells as well as in endocrine cells could indirectly result from the impairment of intracellular traffic and not only from a direct inhibition of the converting activity.

The choice of medical providers in rural Bénin: a comparison of discrete choice models.

In this paper we estimate three different discrete choice models of provider choice using data from the rural District of Ouidah in Bénin. These three model are: Multinomial Logit (ML); (2) Independent Multinomial Probit (IMP); (3) Multinomial Probit (MP). A comparison of IMP and MP allows us to reject the independence assumption between providers. Furthermore, the cross-price elasticities computed from the restrictive specifications (ML and IMP) are dramatically different from those computed from the more general one (MP). These results cast some doubt on the validity of the previous findings and policy recommendations that are typically based on the ML specification.

Evidence for the involvement of the thromboxane synthase pathway in human natural cytotoxic cell activity.

We and other investigators have recently shown that inhibitors of lipoxygenase reversibly inhibit natural cytotoxic (NC) or natural killer (NK) cell activity, whereas some inhibitors of cyclooxygenase enhance these functions. In addition, exogenous LTB4 augments NC and NK activity, whereas PGE2 depresses it. In the present studies, we sought to investigate the possible role of the TxA2 synthase pathway in NC function. Inhibition of this pathway by OKY-1581 or dazoxiben significantly inhibited NC activity against HSV-infected cells as well as NK function against K562 target cells. The inhibition was dose dependent, reversible, and not due to direct toxicity. NC activity was also significantly inhibited by the addition of PGE2 or PGI2 to the 4-hr assay, whereas addition of 6-keto-PGF1 alpha had no effect. Addition of PGH2, which could be converted to TxA2 or other PG, had no significant effect, but concomitant use of OKY-1581 produced a greater inhibition of NC function than by using OKY-1581 alone. U44069, a TxA2 analog, was inhibitory by itself and could not alter the inhibition caused by OKY-1581 or dazoxiben. In contrast, the TxA2 receptor blocker 13-APA significantly enhanced NC activity and even reversed the inhibitory effect of U44069 at equimolar (10(-7)M) concentrations. Taken together, these data suggest that most of the inhibitory effect of the TxA2 synthase inhibitors on NC and NK cell function derives from their ability to reorient cyclic endoperoxide metabolism toward more inhibitory compounds. In addition, TxA2 itself could exert a negative feedback on NC function through its receptor, as evidenced by the use of a TxA2 analog and a TxA2 blocker.

The effects of vasoactive intestinal peptide on human natural killer cell function.

Vasoactive intestinal peptide (VIP) can be found at nerve endings in various tissues and has recently been shown to interact with human lymphocytes through an adenylate cyclase-linked receptor. Because various neuroendocrine factors are thought to influence immune responsiveness, we studied the effect of VIP on natural killer (NK) effector function. Human lymphocytes were incubated with 51Cr-labeled K562 target cells in a 4-hr cytotoxicity assay in the absence or presence of increasing concentrations of VIP. As expected from its activation of adenylate cyclase, VIP was inhibitory at 10(-6) to 10(-10) M. Interestingly, however, when lymphocytes were preincubated with VIP for 30 or 60 min, then washed and added to target cells, a significant augmentation of NK activity ensued. Binding studies revealed that preincubation with VIP resulted in increased numbers of effector-target conjugates, whereas cytotoxic activity in agarose was not affected at the single cell level. Studies with synthetic analogs of VIP revealed that the integrity of the 14-28 C-terminal amino acid sequence was essential for its activity in cytotoxicity. These data strongly suggest a functional role for VIP in modulating immune responses during neuroendocrine interactions with the immune system.

Induction of cytotoxic cell activity by peptide fragments of beta 2-microglobulin.

A heptapeptide fragment of beta 2-microglobulin has been described by Abiko in hemodialysates of uremic patients and found to inhibit E-rosette formation by human T cells. In order to study the possible immunoregulatory effects of this heptapeptide, we investigated its effect on human cytotoxic cell activity. Low concentrations (10(-8) to 10(-7)M) of the heptapeptide enhanced cytotoxic activity of human lymphocytes against herpes simplex virus-infected cells by 50-60% whereas higher concentrations (10(-4)M) depressed cytotoxicity. When lymphocytes were incubated with the heptapeptide during an in vitro sensitization assay, an even stronger enhancement was observed. In an attempt to define possible structure-activity correlations, synthetic peptide fragments were also tested for their effect on cytotoxic cell activity. Thus, the corresponding desHis-hexapeptide (2-7) had little enhancing effect on fresh lymphocyte cytotoxicity but significantly enhanced cytotoxic activity following presensitization. In contrast, further amino acid deletions resulting in 3-7, 4-7, 5-7 or 6-7 fragments had no significant activity. Alternatively, C-terminal deletions resulting in 1-6, 1-5 or 1-4 fragments also failed to exert any effect on lymphocyte-mediated cytotoxicity. We suggest that the heptapeptide and its 2-7 hexapeptide fragment may play a role in regulating host cytotoxic responses to viruses in health and disease.

Cellular immune function in uremia: altered cytotoxic and suppressor cell responses to an immunomodulating heptapeptide.

Hemodialysates of uremic patients have been shown by T. Abiko, M. Kumikawa, and H. Sekimo (Biochem. Biophys. Res. Commun. 86, 945, 1979) to contain a heptapeptide which inhibits E-rosette formation by human T cells. This heptapeptide also corresponds to a fragment of beta 2-microglobulin and may play an immunoregulatory role in uremia. We investigated the potential for induction of cytotoxic and suppressor cells by the synthetic heptapeptide (HP) in blood lymphocytes of normal donors and uremic patients. Cytotoxic activity of normal lymphocytes was significantly enhanced by low concentrations of HP while high concentrations depressed it. Two patterns of responsiveness were observed among uremic patients: a high responder group reacted similarly to normals, whereas a low responder group showed little reactivity to HP. Removal of the NH2-terminal histidine of the heptapeptide strongly diminished its enhancing activity on normal cytotoxic cells while maintaining activity on uremic lymphocytes. When HP and des-His-HP were studied as possible inducers of suppressor cell activity, only the latter was found to be active on normal cells. Lymphocytes from uremic patients failed to respond to either HP or des-His-HP in suppressor cell generation. It is suggested that continuous interaction between lymphocytes and high concentrations of HP or des-His-HP in uremia may have altered their sensitivity to the immunomodulatory effects of the peptides and may be instrumental in the immune deficiency associated with renal failure.