The filamentous type III secretion translocon of enteropathogenic Escherichia coli.

Enteropathogenic Escherichia coli (EPEC) uses a type III secretion system (TTSS) to inject effector proteins into the plasma membrane and cytosol of infected cells. To translocate proteins, EPEC, like Salmonella and Shigella, is believed to assemble a macromolecular complex (type III secreton) that spans both bacterial membranes and has a short needle-like projection. However, there is a special interest in studying the EPEC TTSS owing to the fact that one of the secreted proteins, EspA, is assembled into a unique filamentous structure also required for protein translocation. In this report we present electron micrographs of EspA filaments which reveal a regular segmented substructure. Recently we have shown that deletion of the putative structural needle protein, EscF, abolished protein secretion and formation of EspA filaments. Moreover, we demonstrated that EspA can bind directly to EscF, suggesting that EspA filaments are physically linked to the EPEC needle complex. In this paper we provide direct evidence for the association between an EPEC bacterial membrane needle complex and EspA filaments, defining a new class of filamentous TTSS.

Role of EscF, a putative needle complex protein, in the type III protein translocation system of enteropathogenic Escherichia coli.

Type III secretion systems, designed to deliver effector proteins across the bacterial cell envelope and the plasma membrane of the target eukaryotic cell, are involved in subversion of eukaryotic cell functions in a variety of human, animal and plant pathogens. In enteropathogenic Escherichia coli (EPEC), several protein substrates for the secretion apparatus were identified, including EspA, EspB and EspD. EspA is a structural protein and the major component of a large transiently expressed filamentous surface organelle that forms a direct link between the bacterium and the host cell, whereas EspD and EspB seem to form the mature translocation pore. Recent studies of the type III secretion systems of Shigella and Salmonella pathogenicity island (SPI)-1 revealed the existence of a macromolecular complex that spans both bacterial membranes and consists of a basal structure with two upper and two lower rings and a needle-like projection that extends outwards from the bacterial surface. MxiH (Shigella) and PrgI (Salmonella) are the main components of the needle of the type III secretion complex. A needle-like complex has not yet been reported in EPEC. In this study, we investigated EscF, a protein sharing sequence similarity with MxiH and PrgI. We report that EscF is required for type III protein secretion and EspA filament assembly. Moreover, we show that EscF binds EspA, suggesting that EspA filaments are an extension of the type III secretion needle complexes in EPEC.

Stroke in surgery of the thoracic aorta: incidence, impact, etiology, and prevention.

OBJECTIVES: To determine the incidence, impact, etiology, and methods for prevention of stroke after surgery of the thoracic aorta. METHODS: A total of 317 thoracic aortic operations on 303 patients (194 male, 109 female) aged 13 to 87 years (mean 61 years) were reviewed. There were 218 procedures on the ascending aorta and arch and 99 on the descending aorta. Of the 218 procedures on the ascending aorta and arch, 86 involved cardiopulmonary bypass, 122 involved deep hypothermic circulatory arrest, 2 involved antegrade cerebral perfusion, and 8 involved "clamp and sew" or left heart bypass. Of the 99 procedures on the descending aorta, 20 involved "clamp and sew," 69 involved left heart or full bypass, and 10 involved deep hypothermic circulatory arrest. A total of 206 cases were elective and 97 were emergency operations. RESULTS: Twenty-three (7.3%) of 317 patients had a stroke. Fifteen strokes occurred in operations on the ascending aorta and 8 in operations on the descending aorta (6.9% vs 8.1%; P =.703). Stroke occurred in 16 (16.5%) of 97 emergency operations and 7 (3.4%) of 206 elective operations (P =.001). In the 300 patients surviving the operation, stroke was a significant predictor of postoperative death (9/23 [39.1%] vs 23/277 [8.3%]; P =.001). Analysis of operative reports, brain images, and neurologic consultations revealed 15 of the 23 strokes were embolic, 3 were ischemic, 3 hemorrhagic, and 2 indeterminate. Patients with stroke had longer intensive care unit stays (18.4 vs 6.8 days; P =.0001), longer times to extubation (12.7 vs 3.8 days; P <.0012), longer postoperative stays (31.4 vs 14.3 days; P =.001), and decreased age-adjusted survival (relative risk 2.775; P =.0013). After implementation of a rigorous antiembolic regimen, both strokes and mortality trended downward. CONCLUSIONS: (1) Stroke complicates surgery of both the ascending and descending thoracic aorta and warrants consideration in decision making. (2) Strokes are largely embolic. (3) Antiembolic measures for particles and air are essential, including gentle aortic manipulation, thorough debridement, transesophageal echocardiography to identify aortic atheromas, carbon dioxide flooding of the field, and (in descending cases) proximal clamp application before initiating femoral perfusion.

Coiled-coil domain of enteropathogenic Escherichia coli type III secreted protein EspD is involved in EspA filament-mediated cell attachment and hemolysis.

Many animal and plant pathogens use type III secretion systems to secrete key virulence factors, some directly into the host cell cytosol. However, the basis for such protein translocation has yet to be fully elucidated for any type III secretion system. We have previously shown that in enteropathogenic and enterohemorrhagic Escherichia coli the type III secreted protein EspA is assembled into a filamentous organelle that attaches the bacterium to the plasma membrane of the host cell. Formation of EspA filaments is dependent on expression of another type III secreted protein, EspD. The carboxy terminus of EspD, a protein involved in formation of the translocation pore in the host cell membrane, is predicted to adopt a coiled-coil conformation with 99% probability. Here, we demonstrate EspD-EspD protein interaction using the yeast two-hybrid system and column overlays. Nonconservative triple amino acid substitutions of specific EspD carboxy-terminal residues generated an enteropathogenic E. coli mutant that was attenuated in its ability to induce attaching and effacing lesions on HEp-2 cells. Although the mutation had no effect on EspA filament biosynthesis, it also resulted in reduced binding to and reduced hemolysis of red blood cells. These results segregate, for the first time, functional domains of EspD that control EspA filament length from EspD-mediated cell attachment and pore formation.

EspA filament-mediated protein translocation into red blood cells.

Type III secretion allows bacteria to inject effector proteins into host cells. In enteropathogenic Escherichia coli (EPEC), three type III secreted proteins, EspA, EspB and EspD, have been shown to be required for translocation of the Tir effector protein into host cells. EspB and EspD have been proposed to form a pore in the host cell membrane, whereas EspA, which forms a large filamentous structure bridging bacterial and host cell surfaces, is thought to provide a conduit for translocation of effector proteins between pores in the bacterial and host cell membranes. Type III secretion has been correlated with an ability to cause contact-dependent haemolysis of red blood cells (RBCs) in vitro. As EspA filaments link bacteria and the host cell, we predicted that intimate bacteria-RBC contact would not be required for EPEC-induced haemolysis and, therefore, in this study we investigated the interaction of EPEC with monolayers of RBCs attached to polylysine-coated cell culture dishes. EPEC caused total RBC haemolysis in the absence of centrifugation and osmoprotection studies were consistent with the insertion of a hydrophilic pore into the RBC membrane. Cell attachment and haemolysis involved interaction between EspA filaments and the RBC membrane and was dependent upon a functional type III secretion system and on EspD, whereas EPEC lacking EspB still caused some haemolysis. Following haemolysis, only EspD was consistently detected in the RBC membrane. This study shows that intimate bacteria-RBC membrane contact is not a requirement for EPEC-induced haemolysis; it also provides further evidence that EspA filaments are a conduit for protein translocation and that EspD may be the major component of a translocation pore in the host cell membrane.

The type III protein translocation system of enteropathogenic Escherichia coli involves EspA-EspB protein interactions.

Enteropathogenic Escherichia coli (EPEC), like many bacterial pathogens, use a type III secretion system to deliver effector proteins across the bacterial cell wall. In EPEC, four proteins, EspA, EspB, EspD and Tir are known to be exported by a type III secretion system and to be essential for 'attaching and effacing' (A/E) lesion formation, the hallmark of EPEC pathogenicity. EspA was recently shown to be a structural protein and a major component of a large, transiently expressed, filamentous surface organelle which forms a direct link between the bacterium and the host cell. In contrast, EspB is translocated into the host cell where it is localized to both membrane and cytosolic cell fractions. EspA and EspB are required for translocation of Tir to the host cell membrane suggesting that they may both be components of the translocation apparatus. In this study, we show that EspB co-immunoprecipitates with the EspA filaments and that, during EPEC infection of HEp-2 cells, EspB localizes closely with EspA. Using a number of binding assays, we also show that EspB can bind and be copurified with EspA. Nevertheless, binding of EspA filaments to the host cell membranes occurred even in the absence of EspB. These results suggest that following initial attachment of the EspA filaments to the target cells, EspB is delivered into the host cell membrane and that the interaction between EspA and EspB may be important for protein translocation.

The coiled-coil domain of EspA is essential for the assembly of the type III secretion translocon on the surface of enteropathogenic Escherichia coli.

Enteropathogenic E. coli (EPEC) utilize a type III secretion system to deliver virulence-associated effector proteins to the host cell. Four proteins, EspA, EspB, EspD, and Tir, which are integral to the formation of characteristic "attaching and effacing" (A/E) intestinal lesions, are known to be exported via the EPEC type III secretion system. Recent work demonstrated that EspA is a major component of a filamentous structure, elaborated on the surface of EPEC, which is required for translocation of EspB and Tir. The carboxyl terminus of EspA is predicted to comprise an alpha-helical region, which demonstrates heptad periodicity whereby positions a and d in the heptad repeat unit abcdefg are occupied by hydrophobic residues, indicating a propensity for coiled-coil interactions. Here we demonstrate multimeric EspA isoforms in EPEC culture supernatants and EspA:EspA interaction on solid phase. Non-conservative amino acid substitution of specific EspA heptad residues generated EPEC mutants defective in filament assembly but which retained the ability to induce A/E lesions; additional mutation totally abolished EspA filament assembly and A/E lesion formation. These results demonstrate a similarity to flagellar biosynthesis and indicate that the coiled-coil domain of EspA is required for assembly of the EspA filament-associated type III secretion translocon.

The type IV bundle-forming pilus of enteropathogenic Escherichia coli undergoes dramatic alterations in structure associated with bacterial adherence, aggregation and dispersal.

BFP, a plasmid-encoded type IV bundle-forming pilus produced by enteropathogenic Escherichia coli (EPEC), has recently been shown to be associated with the aggregation of bacteria and dispersal of bacteria from bacterial microcolonies. In standard 3 h HEp-2 cell assays, EPEC adhere in localized microcolonies; after 6 h, bacterial microcolonies are no longer present, indicating that bacterial aggregation and dispersal occurs in vitro during EPEC adhesion to cultured epithelial cells. To examine the role of BFP in EPEC aggregation and dispersal, we examined HEp-2 cell adhesion of strain E2348/69 and defined E2348/69 mutants by immunofluorescence and immunoelectron microscopy. BFP was expressed initially as approximately 40 nm diameter pilus bundles that promoted bacteria-bacteria interaction and microcolony formation. BFP subsequently underwent a striking alteration in structural organization with the formation of much longer and thicker ( approximately 100 nm diameter) pilus bundles, which frequently aggregated laterally to form even thicker bundles often arranged in a loose three-dimensional network; EPEC dispersal from bacterial microcolonies was associated with this transformation of BFP from thin to thick bundles. Bacterial dispersal and transformation of BFP from thin to thick bundles did not occur with a bfpF mutant of strain E2348/69. It is concluded that BFP promotes both the formation and the dispersal of EPEC microcolonies, that the dispersal phase requires BfpF and that dispersal is associated with dramatic alterations in the structure of BFP bundles.

Free radial artery grafts: surgical technique and results.

In the search for alternative conduits, the use of radial artery (RA) grafts has found renewed interest. This study sought to evaluate prospectively the perioperative morbidity, including the postoperative complications in the donor forearm, and mortality in the routine use of RA grafts in coronary artery bypass surgery. Data were obtained prospectively on 200 consecutive patients who underwent coronary revascularization using at least one RA graft from January 1995 to April 1997. The mean age of the patents was 61.9+/-10.5 years (mean+/-standard deviation [SD]). The RA was obtained from one forearm in 197 patients and both forearms in 3 patients. Two patients (1%) required exploration for donor site hematomas, 4 patients (2%) had temporary perioperative dysesthesias in the region of the lateral cutaneous nerve of the forearm, and none had donor site wound infection. Two patients (1%) had a myocardial infarction with electrocardiographic changes in the areas grafted by the RA in the immediate postoperative period, indicating graft failure. The two deaths in the series were due to comorbid factors. Our data suggest that the RA is a safe and suitable conduit for coronary revascularization, and it provides good clinical results. Long-term follow-up of these patients is necessary to confirm the patency of RA conduits. Free RA grafts have the potential for use in other areas of surgery where a conduit is necessary for revascularization procedures.

Should angiographically disease-free saphenous vein grafts be replaced at the time of redo coronary artery bypass grafting?

BACKGROUND: Controversy exists regarding the management of angiographically disease-free saphenous vein grafts at the time of redo coronary artery bypass grafting (CABG). Some authorities favor replacement of these disease-free grafts, arguing that occlusion is likely in the near future. Others believe that these grafts are "biologically privileged" and should not be replaced. METHODS: One hundred thirty-two consecutive patients (113 men, 19 women, aged 46 to 88 years, mean 67 years) underwent redo revascularization with one or more angiographically disease-free saphenous vein grafts at the time of redo CABG. Thirty-six patients had the disease-free grafts replaced (R) and 96 did not (NR). The mean interval from the first CABG was 9.25 years. RESULTS: Surgical mortality was comparable in the NR and R groups (5 of 96 or 5.2% versus 3 of 36 or 8.3%, respectively; p < 0.5). Survival at 1 and 3 years was higher in the NR group than the R group (98% versus 80%, and 95% vs. 66% respectively; p < 0.0001). Late myocardial infarction was less common in the NR group than in the R group (12 of 91 or 12.9% versus 12 of 33 or 36.4%; p < 0.003). Recurrent angina was less common in the NR than in the R group (21 of 91 or 23.1% versus 15 of 33 or 45.5%; p < 0.015). Cardiac hospitalization was required less commonly in the NR than in the R group (11 of 91 or 12.1% versus 12 of 33 or 36.4%; p < 0.002). In nondiseased grafts undergoing angiographic evaluation late after redo CABG, rate of new stenosis was lower in NR grafts than in R grafts (2 of 12 or 16.7% versus 2 of 3 or 66.7%; p < 0.05). CONCLUSIONS: With a conservative approach that does not replace nondiseased saphenous vein grafts at redo CABG (1) there is no increase in operative mortality, (2) good late survival is obtained, (3) clinical ischemia related to the NR saphenous vein grafts is uncommon, and (4) NR grafts continue to be patent. We conclude that disease-free vein grafts may not require routine replacement at redo CABG. A randomized study is required for definitive resolution.

Ability of enteroaggregative Escherichia coli strains to adhere in vitro to human intestinal mucosa.

A collection of 44 enteroaggregative Escherichia coli (EAggEC) strains isolated from infants with diarrhea in India and the United Kingdom were examined for their ability to adhere in vitro to human intestinal mucosa and by electron microscopy for production of putative adherence factors. None of the strains adhered to human duodenal mucosa, and six strains tested did not adhere to ileal mucosa; all 44 strains, however, adhered to human colonic mucosa in localized aggregates. Electron microscopy of infected colonic mucosa indicated fimbrially mediated adhesion of the EAggEC strains. Four morphologically distinct kinds of fimbriae, including a new morphological type of E. coli fimbriae consisting of bundles of fine filaments, were identified among the EAggEC strains; this new type of fimbria was observed in 43 of the 44 EAggEC strains. Forty-three of the 44 EAggEC strains were positive with a DNA probe developed to identify EAggEC, and most of the strains belonged to serotypes unrelated to the other major classes of diarrheic E. coli. These results suggest that EAggEC may be a large-bowel pathogen and colonize the colon by a fimbrially mediated adhesion mechanism.

Electrophysiological evaluation of phrenic nerve function in candidates for diaphragm pacing.

The electrophyisological status of phrenic nerve function has been determined by an assessment of the conduction time and diaphragm muscle action potential in patients who were being evaluated as candidates for diaphragm pacing, or who were being studied for suspected phrenic nerve injury or disease. The conduction time and muscle action potential were evoked by transcutaneous phrenic nerve stimulation or by stimulation with a permanently implanted diaphragm pacemaker. In normal volunteers the conduction time was found to be 8.40 msec +/- 0.78 msec (SD). Transcutaenous phrenic nerve stimulation was successful in predicting phrenic nerve viability in 116 of 120 nerves studied. The four false negatives were due to technical difficulty in locating the nerves in obese or uncooperative subjects. In patients who were selected for implantation of a diaphragm pacemaker, a conduction time that was prolonged (10 to 14 msec) preoperatively did not preclude successful diaphragm pacing. Postoperatively, a prolonged (> 10 msec) conduction time was associated with severe systemic disease or local nerve injury caused by trauma or infection. The elucidation of phrenic nerve function by such electrophysiological studies serves as a valuable adjunct to the selection and management of patients undergoing diaphragm pacing.

Air entrapment as a cause of transient cardiac pacemaker malfunction.

Air within a pacemaker pocket may cause transient malfunction of a replacement unipolar cardiac pacemaker. This was noted in a patient in whom entrapped air prevented tissue contact of the anode, resulting in complete cessation of myocardial stimulation and absence of an electrocardiographic pacemaker artifact. Methods for avoiding this complication are proposed.

Ventriculopleural shunting in the management of hydrocephalus.

6 cases of ventriculopleural shunting for control of hydrocephalus are presented. In the other child and adult, drainage of cerebrospinal fluid into the pleural cavity seems to be well tolerated in exceptional circumstances where other shunt procedures, including intracranial shunts, are contraindicated. In the infant and young child, accumulation of fluid in the pleural space is enchanced by a poorly understood immune-related mechanism and may lead to significant pulmonary dysfunction. On the basis of our experience, this procedure appears contraindicated in this age-group.