Do intraoperative pyloric interventions predict the need for postoperative endoscopic interventions after minimally invasive esophagectomy?

Intraoperative pyloric procedures are often performed during esophagectomies to reduce the rates of gastric conduit dysfunction. They include pyloroplasty (PP), pyloromyotomy (PM), and pylorus botulinum toxin type-A injections (BI). Despite these procedures, patients frequently warrant further endoscopic interventions. The aim of this study is to compare intraoperative pyloric procedures and the rates of postoperative endoscopic interventions following minimally invasive esophagectomy (MIE). We identified patients who underwent MIE for esophageal carcinoma and grouped them as 'None' (no intervention), 'PP', 'PM', or 'BI' based on intraoperative pyloric procedure type. The rates of endoscopic interventions for the first six postoperative months were compared. To adjust for variability due to MIE type, the rates of >1 interventions were compared using a zero-inflated Poisson regression analysis. Significance was established at P < 0.05. There were 146 patients who underwent an MIE for esophageal cancer from 2008 to 2015; 77.4% were three-hole MIE, and 22.6% were Ivor- Lewis MIE. BI was most frequent in Ivor-Lewis patients (63.5%), while PP was most frequent (46.9%) in three-hole patients. Postoperative endoscopic interventions occurred in 38 patients (26.0%). The BI group had the highest percentage of patients requiring a postoperative intervention (n = 13, 31.7%). After adjusting for higher rates of interventions in three-hole MIE patients, the BI and None groups had the lowest rates of >1 postoperative interventions. Our data did not show superiority of any pyloric intervention in preventing endoscopic interventions. The patients who received BI to the pylorus demonstrated a trend toward a greater likelihood of having a postoperative intervention. However when adjusted for type of MIE, the BI and None groups had lower rates of subsequent multiple interventions. Further research is needed to determine if the choice of intraoperative pyloric procedure type significantly affects quality of life, morbidity, and overall prognosis in these patients.

Mobilization of vancomycin resistance by transposon-mediated fusion of a VanA plasmid with an Enterococcus faecium sex pheromone-response plasmid.

A striking feature of recent outbreaks of vancomycin-resistant (VmR) enterococci is the apparent horizontal dissemination of resistance determinants. The plasmids pHKK702 and pHKK703 from Enterococcus faecium clinical isolate R7 have been implicated in the conjugal transfer of VmR. pHKK702 is a 41-kb plasmid that contains an element indistinguishable from the glycopeptide-resistance transposon Tn1546. pHKK703 is an approx. 55-kb putative sex pheromone-response plasmid that is required for conjugative mobilization of pHKK702. During experiments in which strain R7 was used as a donor, a highly conjugative VmR transconjugant was isolated that formed constitutive cellular aggregates. Restriction analyses and DNA hybridizations revealed that the transconjugant harbored a single plasmid of approx. 92 kb and this plasmid (pHKK701) was composed of DNA from both pHKK702 and pHKK703. Results from DNA sequence analyses showed that a 39-kb composite transposon (Tn5506) from pHKK702 had inserted into pHKK703. The left end of Tn5506 contained a single insertion sequence (IS) element, IS1216V2, whereas the right end was composed of a tandem IS structure consisting of the novel 1065-bp IS1252 nested within an IS1216V1 element. Transposition of Tn5506 from pHKK702 to pHKK703 created an 8-bp target sequence duplication at the site of insertion and interrupted an ORF (ORFX) that was 91% identical to that of prgX, a gene proposed to negatively regulate sex pheromone response of the E.faecalis plasmid, pCF10. We propose that the interruption of ORFX by Tn5506 led to the constitutive cellular aggregation phenotype and thereby enhanced the efficiency with which VmR was transferred. Similar IS1216V-mediated transposition events may contribute to the horizontal spread of glycopeptide resistance among enterococci in nature.

American Society of Microbiology 101st General Meeting. 20-24 May 2001, Orlando, FL, USA.

The application of sophisticated molecular biology, genetics and genomics has made possible the advanced analyses of microbial genes, the topology of DNA and chromosomes, and insight into the regulation of gene expression during all stages of the life cycle of microbes, both in vitro and in vivo. The struggle to control contagious pathogens continues world wide amidst resistance emergence to many classes of antimicrobial agents. Many hospital, research and community labs are applying themselves to a more thorough understanding of the molecular basis of this resistance. New drugs which improve on predecessor agents were presented. The following classes of antimicrobial agents were represented: quinolones, cephems, macrolides and natural products. New target opportunities against both lethal (essential) gene targets and virulence targets were presented throughout the conference. In addition, increasing attention to the involvement of microbial life forms in immune function and dysfunction were described in numerous presentations.

Insertional inactivation of a gene which controls expression of vancomycin resistance on plasmid pHKK100.

Expression of inducible high level vancomycin resistance (Vmr) in enterococci appears to require other plasmid-encoded genes in addition to the previously described structural genes vanA and vanH. Tn917 mutagenesis was used to identify such a region in the Vmr plasmid pHKK100. Insertional inactivation of a 693-bp open reading frame upstream from vanH resulted in complete loss of Vmr. This putative 26,642-Da protein has been designated VanR.

American Society of Microbiology - 101st General Meeting. 20-24 May 2001, Orlando, FL, USA.

Sessions on prokaryotic genomics, bioinformatics, antibiotic resistance, intrinsic antibacterial resistance, and the identification of novel targets were the main highlights of this year's American Society Microbiology (ASM) meeting. In addition, updates on the status of antimicrobial developmental candidates and recently approved agents, were also discussed.

American Society of Microbiology - 100th General Meeting.

Symposium sessions on genomics, surveillance, and pharmaceutical intervention opportunities were highlights of this annual ASM meeting. Two-component signal transduction was highlighted by both academic and industrial representatives, as was prokaryotic genomics. Recurring themes throughout the meeting were the contribution of efflux mechanisms to worldwide resistance, target modifications responsible for fluoroquinolone resistance, and the role of structural biology in the discovery and exploitation of bacterial targets.

Detergent-resistant Streptococcus faecium derivatives that display conditional penicillin lysis.

Three spontaneous derivatives of Streptococcus faecium ATCC 9790, originally isolated as conditionally Triton X-100 detergent-resistant at 25 degrees C, displayed normal penicillin-induced rates of lysis at 37 degrees C but substantially reduced rates of lysis and killing at 25 degrees C. The addition of exogenous unsaturated fatty acids at 25 degrees C restored wild-type penicillin lysis rates.

Cloned gtfA gene of Streptococcus mutans LM7 alters glucan synthesis in Streptococcus sanguis.

Streptococcus mutans LM7 (Bratthall serotype e) chromosomal DNA was partially digested with EcoRI and ligated into the positive-selection plasmid vector pOP203(A2+). The ligation mixture was transformed into Escherichia coli, and transformants were selected for tetracycline resistance. Recombinant-bearing clones were screened for their ability to ferment raffinose, using the procedure of Robeson et al. (J. Bacteriol. 153:211-221, 1983). One raffinose-fermenting clone was isolated and found to contain a plasmid with an insert consisting of four EcoRI fragments totalling approximately 10.3 kilobases (kb). This strain was capable of growth on defined medium plus raffinose or sucrose and generated reducing sugars from a sucrose substrate. Southern hybridization analysis of the four EcoRI fragments revealed homology not only to S. mutans LM7 chromosomal DNA but also to S. mutans serotypes b, c, and f. Subcloning of this fragment array into a streptococcal E. coli shuttle vector indicated that a 2.4-kb EcoRI fragment was essential for sucrase activity. E. coli minicell experiments revealed a gene product of 55 kilodaltons. These data along with restriction endonuclease analysis and Southern hybridizations suggested that the cloned S. mutans LM7 gene was closely related to the gtfA gene cloned by Robeson et al. from S. mutans PS13 (Bratthall serotype c). The shuttle plasmid containing the 2.4-kb fragment was transformed into Streptococcus sanguis, which subsequently displayed increased sucrase activity in both intracellular and extracellular fractions. Elevated levels of synthesis of alcohol-insoluble and water-insoluble glucans were observed with crude extracellular fractions of the S. sanguis strain bearing the 2.4-kb fragment. An isolate cured of the shuttle plasmid plus the 2.4-kb fragment displayed wild-type S. sanguis glucan synthesis. In S. sanguis, this gtfA allele may play a role in glucan synthesis by interacting with extant high-molecular-weight glucosyltransferases.

Penicillin-binding proteins are regulated by rpoS during transitions in growth states of Escherichia coli.

Attention has been recently focused on the role of the rpoS (formerly katF) gene product as a regulator during the transition from the exponential growth phase to the stationary phase as well as during nutritional starvation. It has been demonstrated that RpoS is an alternate sigma factor which would bind to promoters of genes induced at these times. It was previously noted that rpoS mutants do not undergo a transition to short rods during entry into the stationary phase. Because of their well-established role in morphogenesis, we investigated the status of the penicillin-binding proteins (PBPs) in Escherichia coli wild-type and isogenic rpoS mutants. Samples from cultures of E. coli ZK126 and ZK1000 (rpoS::kan) were taken in the midlogarithmic, early stationary, and late (24 h) stationary phases. The increase in PBP 6 seen upon entry of the wild-type strain into the stationary phase was not observed with the rpoS::kan cells, even after 24 h. There was also a marked decrease of PBP 3 in wild-type stationary-phase cells; PBP 3 has a known influence on morphogenesis. This decrease in PBP 3 was found to be markedly affected by the disruption of rpoS. Similar observations were made after prolonged starvation of the two strains for either glucose or a required amino acid. Inasmuch as PBPs are involved in peptidoglycan synthesis, we also examined two properties of peptidoglycan, autolysis and cross-linkage, that might be altered by the PBP differences. However, neither of these properties, which are known to undergo changes in the stationary phase, appeared to be influenced by the status of RpoS.

Molecular organization and expression of the gtfA gene of Streptococcus mutans LM7.

The Streptococcus mutans LM7 gene gtfA was cloned in Escherichia coli along with flanking regions of the chromosome as a fragment representing 10.3 kilobases (kb) of streptococcal DNA. Restriction endonuclease mapping revealed that the cloned DNA consisted of four EcoRI fragments with gtfA sucrase activity localized to one fragment, EcoRI-B (2.4 kb). Subsequent analysis with E. coli minicells indicated that three polypeptides were encoded on the 10.3-kb insert (55 [GtfA], 45, and 35 kilodaltons). Neither the 45- nor 35-kilodalton polypeptide exhibited any detectable sucrase activity. The approximate positions and directions of transcription of the two larger proteins were determined from minicell protein profiles displaying truncated versions of these polypeptides. The restriction endonuclease data for the cloned gtfA gene were used to develop a strategy for insertional inactivation of this locus in vivo. An internal HincII fragment of the gtfA gene was removed and replaced with a DNA fragment containing a tetracycline resistance determinant. This new recombinant plasmid was linearized and then transformed into S. mutans GS5 and S. mutans V403 where it was incapable of replication. It was predicted that Tcr colonies would result from double-crossover recombinational events involving homologous regions flanking the gtfA gene. This was verified by Southern DNA hybridization analyses. The inactivation of the gtfA gene in both S. mutans GS5 and S. mutans V403 resulted in a decrease of water-soluble exopolysaccharide but no detectable changes in the amounts of water-insoluble polymers.

Intergeneric and intrageneric conjugal transfer of plasmid-encoded antibiotic resistance determinants in Leuconostoc spp.

Transfer of the broad-host-range resistance plasmids pIP501 and pAM beta 1 from Streptococcus faecalis to Leuconostoc dextranicum and Leuconostoc cremoris occurred between cells that were immobilized on nitrocellulose filters in the presence of DNase. Transfer of pIP501 to Leuconostoc spp. also occurred when Streptococcus sanguis and Streptococcus lactis were used as donors. In addition, transfer of pIP501 and pAM beta 1 was observed from L. cremoris and L. dextranicum transconjugants to S. sanguis and S. faecalis. Expression of the pAM beta 1 erythromycin and pIP501 erythromycin and chloramphenicol resistance determinants was essentially equivalent in donors and transconjugants. Frequencies of transfer generally ranged from 10(-4) to 10(-7) transconjugants per input donor cell. Intrageneric transfer of pIP501 and pAM beta 1 occurred between L. cremoris and L. dextranicum strains in the same approximate range. These data further extend the host range of pIP501 and pAM beta 1 and demonstrate another example of gene transfer in the genus Leuconostoc.

The Escherichia coli mutant requiring D-glutamic acid is the result of mutations in two distinct genetic loci.

D-Glutamic acid is an essential component of bacterial cell wall peptidoglycan in both gram-positive and gram-negative bacteria. Very little is known concerning the genetics and biochemistry of D-glutamate production in most bacteria, including Escherichia coli. Evidence is presented in this report for the roles of two distinct genes in E. coli WM335, a strain which is auxotrophic for D-glutamate. The first gene, which restores D-glutamate independence in WM335, was mapped, cloned, and sequenced. This gene, designated dga, is a previously reported open reading frame, located at 89.8 min on the E. coli map. The second gene, gltS, is located at 82 min. gltS encodes a protein that is involved in the transport of D- and L-glutamic acid into E. coli, and the gltS gene of WM335 was found to contain two missense mutations. To construct D-glutamate auxotrophs, it is necessary to transfer sequentially the mutated gltS locus, and then the mutated dga locus into the recipient. The sequences of the mutant forms of both dga and gltS are also presented.

Human serum antibody response against Streptococcus mutans antigens.

Antigens from Streptococcus mutans were examined to identify specific polypeptides that may have stimulated antibody responses and possibly play some role in caries immunity. A group of 10 adult human subjects was screened for serum antibodies reactive with antigens from S. mutans. Extracellular and cellular protein preparations from S. mutans LM7 (Bratthall serotype e) and V403 (biotype c) were subjected to sodium dodecyl sulfate-polyacrylamide gel electrophoresis followed by Western electrophoretic transfer and immunoblotting analysis. Antibodies reactive with polypeptides ranging from 34 to 400 kilodaltons in apparent molecular mass were detected by these means. Radioimmunoassay competition experiments revealed that the cellular and extracellular antigens did not compete with each other for serum antibodies. Preabsorption of sera with extracellular proteins from other oral streptococcal species prior to immunoblotting indicated that the antigens unique to S. mutans have molecular masses greater than 100 kilodaltons, and each individual produced antibodies against different antigens of high molecular mass. Examination of sera from young children also indicated heterogeneous responses against S. mutans LM7 antigens.

Vancomycin resistance is encoded on a pheromone response plasmid in Enterococcus faecium 228.

In Enterococcus faecium 228, vancomycin resistance is encoded on a 55-kilobase conjugative plasmid, pHKK100. This plasmid was transferred with high frequency into susceptible strains of Enterococcus faecalis and conferred responses to pheromones produced by E. faecalis and Streptococcus sanguis. pHKK100 is the first plasmid described that mediates both vancomycin resistance and pheromone response.

Cloning and identification of the Escherichia coli murB DNA sequence, which encodes UDP-N-acetylenolpyruvoylglucosamine reductase.

The murB gene, which complemented the UDP-N-acetylenolpyruvoylglucosamine reductase (EC 1.1.1.158) mutation in Escherichia coli ST5, was cloned from an E. coli chromosomal library. murB was subcloned on a 2.8-kb PvuII fragment into pUC19 and sequenced. A 1,029-bp open reading frame encoded a 342-amino-acid polypeptide of 37,859 Da. A DNA sequence homology search revealed that murB had almost 100% homology with a previously reported unidentified open reading frame, ORFII, at 89.9 min. Physical and genetic mapping results were consistent with this map position, and minicell analyses of murB subclones showed a plasmid-encoded protein of approximately 37,000 Da, which closely matched the calculated size of the murB protein.

Why are there no new antibiotics?

Renewed efforts are underway in the pharmaceutical industry to address the growing problem of antibiotic resistant pathogens. With this rededication to novel antibiotic discovery, new tools and technologies are being deployed to understand critical therapeutic intervention points in bacterial metabolism.