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Biomedical subjects

A J Fox

Publications and source records attributed to A J Fox.

At least 19 recordsLinked to original sources
PubMed1999

Improved recognition of MRSA case clusters by the application of molecular subtyping using pulsed-field gel electrophoresis.

Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly common in hospital and community populations, making the recognition of true nosocomial outbreaks more difficult. We have used pulsed-field gel electrophoresis (PFGE) with Sma I digestion to analyse retrospectively two perceived outbreaks of epidemic methicillin-resistant Staphylococcus aureus 15 (EMRSA 15) colonization. The first cluster of cases in patients and staff on a general ward (ward D) revealed three different antibiograms based on differences in ciprofloxacin and rifampicin sensitivities. All isolates typed using PFGE, which was more discriminatory than phage-typing. One PFGE banding profile labelled type 5 was predominant, but 12 isolates proved to be subtypes of type 5 and two were PFGE type 11. Four staff members carried a strain not found in patients, three carried strains found in patients and transient carriage was highlighted as a problem when screening staff. PFGE enhanced the epidemiological data and proved that the cases on this ward did not comprise one large outbreak but numerous sporadic cases and smaller clusters. In contrast, isolates from a second cluster of cases which occurred on ward F were indistinguishable using antibiograms, phage-typing and PFGE, confirming this was more likely to be a true outbreak of colonization. We conclude that PFGE usefully augments epidemiological information and allows more logical infection control decisions to be made, with better utilization of scarce resources.

Bacterial Typing Techniques↗
PubMed1999

Importance of intracranial atherosclerotic disease in patients with symptomatic stenosis of the internal carotid artery. The North American Symptomatic Carotid Endarterectomy Trail.

BACKGROUND AND PURPOSE: The estimated prevalence of intracranial atherosclerotic disease (IAD) in patients with stenosis of the extracranial internal carotid artery (ICA) varies between 20% and 50%. The benefits of carotid endarterectomy (CE) in patients with both IAD and symptomatic extracranial ICA stenosis are uncertain. METHODS: The association between IAD and other vascular risk factors and with the risk of stroke at 3 years were studied in patients with symptomatic extracranial ICA stenosis who participated in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Since the NASCET protocol excluded severe IAD, only a modest number of patients in this category could be studied. RESULTS: IAD was observed in one third of the patients. In medically treated patients, the relative risk of stroke associated with IAD varied from 1.3 (95% CI, 0.9 to 1.9) with extracranial ICA stenosis of <50% to 1.8 (95% CI, 1.1 to 3.2) with 85% to 99% ICA stenosis. In contrast, IAD did not affect the risk of stroke among surgically treated patients. To prevent 1 stroke ipsilateral to the symptomatic ICA stenosis over 3 years in patients who have also IAD, 12 patients with 50% to 69%, 5 patients with 70% to 84%, and 3 patients with 85% to 99% ICA stenosis have to undergo CE. In patients without IAD these numbers are 26, 7, and 6, respectively. CONCLUSIONS: IAD is an independent risk factor for subsequent stroke in medically treated patients with symptomatic ICA stenosis. CE reduces this risk. The additional risk imposed by IAD in medically treated patients enhances the value of CE in patients with moderate symptomatic extracranial ICA stenosis. Detection of IAD, requiring angiography, is an important prelude to planning CE in symptomatic patients with moderate extracranial ICA stenosis.

Aged↗
PubMed1999

Evaluation of early computed tomographic findings in acute ischemic stroke.

BACKGROUND AND PURPOSE: Detection of large, hypoattenuated brain-tissue volume on hyperacute CT scan has been suggested as an exclusion criterion for early intravenous tissue plasminogen activator (IV-tPA) treatment. This study assessed the reliability of detection for these findings and their relationship to outcome. METHODS: Fifty hyperacute CT scans (<6 hours after ictus) were selected from a randomized trial evaluating IV-tPA (ATLANTIS trial). Three neuroradiologists blinded to all clinical information evaluated scans for degree of MCA territory involvement (<33% or >33%) and the presence of a hyperdense MCA. Evaluations were compared with 24-hour scan results, 30-day infarct volumes, and baseline NIH stroke scale scores (NIHSS). RESULTS: Readers reliably evaluated the degree of MCA territory hypodensity (intraclass correlation=0.53, P<0.001), with all 3 readers agreeing in 36 of 50 cases (72%). They correctly called >33% involvement with a sensitivity of 60% to 85% and a specificity of 86% to 97%. The baseline NIHSS was higher when >33% MCA hypodensity was seen (P=0. 021). Detection of significant hypodensity (>33%) correlated with poorer outcome. When >33% hypodensity was not detected, mean 30-day infarct volumes were 27.0 to 33.0 cm3, versus 84.3 to 123.1 cm3 when >33% hypodensity was present (P=0.002). CONCLUSIONS: Detection of MCA territory hypodensity on hyperacute CT scans is a sensitive, prognostic, and reliable indicator of the amount of MCA territory undergoing infarction.

Acute Disease↗
PubMed1998

Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.

BACKGROUND: Previous studies have shown that carotid endarterectomy in patients with symptomatic severe carotid stenosis (defined as stenosis of 70 to 99 percent of the luminal diameter) is beneficial up to two years after the procedure. In this clinical trial, we assessed the benefit of carotid endarterectomy in patients with symptomatic moderate stenosis, defined as stenosis of less than 70 percent. We also studied the durability of the benefit of endarterectomy in patients with severe stenosis over eight years of follow-up. METHODS: Patients who had moderate carotid stenosis and transient ischemic attacks or nondisabling strokes on the same side as the stenosis (ipsilateral) within 180 days before study entry were stratified according to the degree of stenosis (50 to 69 percent or <50 percent) and randomly assigned either to undergo carotid endarterectomy (1108 patients) or to receive medical care alone (1118 patients). The average follow-up was five years, and complete data on outcome events were available for 99.7 percent of the patients. The primary outcome event was any fatal or nonfatal stroke ipsilateral to the stenosis for which the patient underwent randomization. RESULTS: Among patients with stenosis of 50 to 69 percent, the five-year rate of any ipsilateral stroke (failure rate) was 15.7 percent among patients treated surgically and 22.2 percent among those treated medically (P=0.045); to prevent one ipsilateral stroke during the five-year period, 15 patients would have to be treated with carotid endarterectomy. Among patients with less than 50 percent stenosis, the failure rate was not significantly lower in the group treated with endarterectomy (14.9 percent) than in the medically treated group (18.7 percent, P=0.16). Among the patients with severe stenosis who underwent endarterectomy, the 30-day rate of death or disabling ipsilateral stroke persisting at 90 days was 2.1 percent; this rate increased to only 6.7 percent at 8 years. Benefit was greatest among men, patients with recent stroke as the qualifying event, and patients with hemispheric symptoms. CONCLUSIONS: Endarterectomy in patients with symptomatic moderate carotid stenosis of 50 to 69 percent yielded only a moderate reduction in the risk of stroke. Decisions about treatment for patients in this category must take into account recognized risk factors, and exceptional surgical skill is obligatory if carotid endarterectomy is to be performed. Patients with stenosis of less than 50 percent did not benefit from surgery. Patients with severe stenosis (> or =70 percent) had a durable benefit from endarterectomy at eight years of follow-up.

Aged↗
PubMed1998

False positive diagnosis of meningococcal infection by the IS1106 PCR ELISA.

At a time when optimal case ascertainment for meningococcal infection is a high priority, the need for non-culture case confirmation, in particular by DNA amplification, is seen as being of vital importance to assist contact management and cluster recognition. A solution hybridisation assay with colorimetric microtitre plate detection (polymerase chain reaction-enzyme-linked immunosorbent assay (PCR ELISA)¿ has been developed using the multicopy insertion sequence IS1106 which had reportedly achieved a specificity of 100% and was described as being meningococcal specific. This PCR ELISA assay was evaluated on specimens from over 5000 patients at the national Meningococcal Reference Unit (MRU) between late 1995 and early 1997 and was found to be highly sensitive. Insertion sequences, however, are genetically mobile with the ability to spread between species and even genera. During the evaluation period of the IS1106 PCR ELISA a number of false positives proved to be caused by organisms other than N. meningitidis were recorded resulting in the withdrawal of this assay as a front line screening assay for routine confirmation of meningococcal infection.

Bacteriological Techniques↗
PubMed1998

siaD PCR ELISA for confirmation and identification of serogroup Y and W135 meningococcal infections.

Non-culture diagnosis and serogroup determination of meningococcal infection is important in contact management where vaccination may be possible. A serogroup B and C PCR ELISA assay for the non-culture diagnosis and serogroup determination has proved invaluable for enhanced epidemiological surveillance and contact management. A polymerase chain reaction assay, based on a restriction fragment length polymorphism in the meningococcal serogroup Y and W135 sialyltransferase (siaD) gene, was developed to enhance the range of non-culture diagnosis of meningococcal infection from clinical samples. The PCR assay was adapted to an ELISA format incorporating hybridisation with serogroup-specific Y and W135 oligonucleotide probes. The serogroup-specific W135 and Y PCR ELISA is a useful addition to currently available serogroup B and C assay for non-culture diagnosis of meningococcal infection and outbreak investigation.

Enzyme-Linked Immunosorbent Assay↗
PubMed1998

A reverse transcriptase polymerase chain reaction assay for the detection of thermophilic Campylobacter spp.

A novel method was developed for the detection of thermophilic enteropathogenic campylobacters based on the detection of mRNA using the reverse transcriptase polymerase chain reaction (RT-PCR). The RNA extraction method, DNase treatment and RT-PCR assay were shown to be specific for mRNA. The assay is specific for the thermophilic campylobacters Campylobacter jejuni, Campylobacter coli and Campylobacter upsaliensis and restriction fragment length polymorphism (RFLP) analysis of the 256 bp amplified product with the restriction endonucleases Alu I, Dde I and Dra I revealed distinct species specific patterns. The assay was applied to the detection of C. jejuni cells killed by heating at 72 degreesC for 5 min and mRNA was detected by RT-PCR immediately after heat killing but became undetectable within 4 h when the cells were held at 37 degreesC. The assay therefore can differentiate between viable and dead cells of C. jejuni.

Campylobacter↗
PubMed1998

Epidemiological characterization of methicillin-resistant Staphylococcus aureus isolated in the North West of England by protein A (spa) and coagulase (coa) gene polymorphisms.

In a comparative study, isolates of methicillin-resistant Staphylococcus aureus (MRSA) with known pulsed-field gel electrophoresis (PFGE) and bacteriophage type were analysed by polymerase chain reaction (PCR) and restriction fragment length polymorphisms (RFLP) for additional discriminatory subtyping information. PFGE was previously performed using standardized, commercially available kits and pre-programmed software. Isolates were examined for coagulase (coa) and protein A (spa) gene polymorphisms following PCR amplification of the coa hypervariable and spa repeat regions. Coa gene RFLPs produced a total of 38 distinct combined patterns after digestion with HaeIII and AluI and identified the predominant epidemic (EMRSA) types 15 and 16. A unique HaeIII restriction site was identified by RFLP and sequence analysis in the coa gene for EMRSA 15 but not EMRSA 16. The spa gene PCR yielded a total of 14 different profiles ranging from 3-18 repeats with the 2 predominant EMRSA types falling into 2 distinct groups. PCR detection of coa and spa polymorphisms offer a rapid preliminary strain identification and discriminatory subtyping information for surveillance of MRSA.

Bacteriophage Typing↗
PubMed1998

Amplification of the meningococcal porB gene for non-culture serotype characterization.

Since 1992, the proportion of culture-confirmed meningococcal infections compared with numbers of notified cases of meningococcal disease has decreased in England and Wales. As most meningococcal strain characterization methods depend on a clinical isolate, this has resulted in a loss of epidemiological information. To address this problem, and to aid nonculture diagnosis, a semi-nested PCR protocol for the amplification of the meningococcal porB gene from clinical specimens was developed. This gene encodes the meningococcal serotyping antigen; strain typing data was provided by hybridization of allele-specific oligonucleotide probes to the digoxigenin-labelled porB amplicon in a 'PCR ELISA'. This assay was specific for meningococcal DNA and sensitivities of 0.81 for cerebrospinal fluid (CSF), 0.57 for serum, and 0.62 for whole blood taken from patients with proven meningococcal infection were obtained.

Bacterial Outer Membrane Proteins↗
PubMed1998

Molecular variation of meningococcal serotype 4 antigen genes.

Changes in the frequency of serogroup B non serotypable (B:NT) meningococci isolated in England and Wales were investigated by T-track fingerprint analysis, DNA nucleotide sequence determination, and serotyping by whole cell ELISA and dot blot assay. Seventy-three per cent of the isolates designated as B:NT by the Meningococcal Reference Unit (MRU) dot blot assay during 1993-4, expressed variants of the serotyping antigen, PorB, that were serotype 4 by whole cell ELISA. T-track fingerprint patterns of these and other 'serotype 4' isolates revealed five distinct porB alleles which were shown by nucleotide sequence determination to encode different peptide sequences. Differential binding of the 'serotype 4' mAbs MN14G21 and 5DC4C8G8 in whole cell ELISA and dot blot assays was the result, (i) of differences in the peptide sequence of predicted surface loop I and (ii) an amino acid deletion in predicted loop VI of the PorB protein.

Amino Acid Sequence↗
PubMed1998

Characterisation of 16 Campylobacter jejuni and C. coli typing bacteriophages.

Taxonomic classification of bacteriophages specific for Campylobacter jejuni and C. coli has not been reported previously. A set of 16 virulent phages, distinguishable by their lytic spectra, has been used extensively for epidemiological typing of C. jejuni and C. coli at Preston Public Health Laboratory. These phages were investigated by electron microscopy, pulsed-field gel electrophoresis and restriction endonuclease analysis. All phages had icosahedral heads and long contractile tails. Accordingly, they were classified as members of the Myoviridae family. These phages could be subdivided into three groups according to genome size and head diameter: group I, two phages with head diameters of 140.6 and 143.8 nm and genome sizes of 320 kb; group II, five phages with average head diameters of 99 nm and average genome sizes of 184 kb; and group III, nine phages with average head sizes of 100 nm and average genome sizes of 138 kb. Phages NCTC12676 and NCTC12677 of group I had unusually large genomes of c. 320 kb which are two of the largest phage genomes to be described. Restriction endonuclease analysis demonstrated that DNA from the 16 phages was refractory to digestion by a number of restriction enzymes.

Bacteriophage Typing↗
PubMed1998

Heterogeneity of the PorB protein in serotype 22 Neisseria meningitidis.

The genetic diversity of porB genes from meningococcal isolates characterized as serotype 22 was investigated by gene sequencing. This procedure identified seven distinct porB sequences, demonstrating variation in the PorB protein recognized by the serotype 22 monoclonal antibody. This is consistent with the genetic heterogeneity of serotype 22 meningococci reported previously.

Amino Acid Sequence↗
PubMed1998

Associations between heat-stable (O) and heat-labile (HL) serogroup antigens of Campylobacter jejuni: evidence for interstrain relationships within three O/HL serovars.

A comparative examination of the heat-stable (O) and heat-labile (HL) serogrouping results for 9,024 sporadic human isolates of Campylobacter jejuni revealed conserved associations between specific O and HL antigens (O/HL serovars). Forty-nine percent of the isolates which grouped for both O and HL antigens belonged to one of three serovars: O 4 complex/HL 1 (17.9%), O 1/HL 2 (16.8%), or O 50/HL 7 (14.5%). Other common serovars were O 2/HL 4 (8.3%), O 6/HL 6 (8.1%), O 53/HL 11 (4.5%), O 19/HL 17 (3.3%), O 5/HL 9 (3.3%), O 9/HL 9 (3.2%), and O 23/HL 5 (3.1%). These 10 serovars accounted for 83.1% of the serogroupable isolates. A large number of strains (41.3%) could be typed by only one of the two methods or could not be serogrouped (11%). Strains belonging to three serovars, O 2/HL 4, O 50/HL 7, and O 23/HL 5, were further characterized by combining data from expressed features (O/HL serogroups, phage groups, and biotypes) with restriction fragment length polymorphism genotypes. These polyphasic data demonstrated that within each serovar, individual isolates showed substantial conservation of both genomic and phenotypic characteristics. The essentially clonal nature of the three serovars confirmed the potential of combined O and HL serogrouping as a practical and phylogenetically valid method for investigating the epidemiology of sporadic C. jejuni infection.

Animals↗
PubMed1998

PCR-ELISA for the early diagnosis of invasive pulmonary aspergillus infection in neutropenic patients.

AIM: To evaluate a newly developed aspergillus mitochondrial gene PCR-ELISA assay for the early diagnosis of invasive pulmonary aspergillosis (IPA) in neutropenic patients. METHODS: The aspergillus mitochondrial gene was chosen for the amplification target for use with a solution hybridisation assay with colorimetric end stage detection in microtitre plate format (PCR-ELISA). The study group comprised neutropenic patients undergoing febrile episodes not responding to standard antibacterial antibiotics. Patients underwent computed tomography and bronchoscopy. Bronchoalveolar lavage (BAL) fluids were examined by culture and PCR. RESULTS: The aspergillus mitochondrial gene PCR-ELISA was both sensitive (100%) and specific (100%) for IPA in neutropenic patients. All 12 patients with definite or probable IPA had PCR positive BAL fluids. None of the patients with undiagnosed or confirmed infections of other aetiologies were mitochondrial PCR positive. Speciation based upon amplicon size difference was possible. CONCLUSIONS: Aspergillus mitochondrial DNA PCR-ELISA on BAL fluid is useful in the early diagnosis of IPA in neutropenic patients alone or, potentially, as an indication for thoracic computed tomography.

Adolescent↗
PubMed1998

Molecular characterisation of methicillin resistant Staphylococcus aureus.

Finer discrimination between strains of methicillin resistant Staphylococcus aureus (MRSA) than phage typing can provide is needed to identify and characterise spread of infection in outbreaks. This study compares three molecular methods with each other and with phage typing. Pulsed field gel electrophoresis provides the greatest discrimination, but finer discrimination is obtainable by combining methods.

Bacterial Typing Techniques↗
PubMed1998

Thromboembolic events associated with the treatment of cerebral aneurysms with Guglielmi detachable coils.

BACKGROUND AND PURPOSE: The purpose of this study was to document the prevalence, radiologic appearance, and treatment of thromboembolic events related to GDC embolization of cerebral aneurysms. METHODS: The clinical and radiologic records of all patients undergoing GDC treatment of intracranial aneurysms at our institution were reviewed. All cases in which unexpected complications occurred were selected. Those complications related to presumed thromboembolic events were analyzed. RESULTS: Of 59 patients (60 aneurysms) treated with GDCs, 17 (28%) experienced thromboembolic events. Seven patients had transient ischemic attacks and 10 had strokes. In 10 patients, the deficits occurred during or immediately after the procedure; in the rest, the complications were delayed. In six patients, all radiologic investigations were negative for infarction and in seven patients, CT scans showed new ischemic lesions. In four patients, MR imaging alone showed infarcts, and in four of nine patients who underwent subsequent angiography, acute ischemic findings were demonstrated. Eight patients were treated with volume expansion, eight with full heparinization, and one patient underwent intraarterial thrombolysis. Clinical outcome was excellent or good in 14 of 17 patients, with only three patients (5%) incurring permanent neurologic deficits. CONCLUSION: Thromboembolic events related to GDC treatment may be more common than has been reported in the literature. In our experience, this rate was 28%, with persisting deficits in 5%. These events can occur after uncomplicated procedures and may be unaccompanied by radiologic findings. Clinical outcome is usually favorable.

Adult↗