Biomedical subjects
Publications and source records attributed to R B Thomson.
Medical treatment alone is rarely successful in left-sided infective endocarditis caused by Pseudomonas aeruginosa. We report the cure of such a case with high-dose meropenem in combination with tobramycin.
We have previously reported pilot data regarding the safety of saving partially used syringes of a glutaraldehyde cross-linked collagen for use in subsequent treatment sessions with the same individual. That single institution study involved 56 partially used syringes cultured for aerobic bacteria. Only one weakly positive culture was detected among these 56 samples, which prompted us to carry out this expanded study involving multiple centers and different injection techniques. Samples were collected from four centers. Following periurethral injection in an office setting, 166 partially used syringes of glutaraldehyde cross-linked collagen were refrigerated for between 1 and 104 weeks (average 58). Material from all 166 syringes was then cultured qualitatively and quantitatively for both aerobic and anaerobic organisms. Collagen from one syringe grew >100,000 colonies of Escherichia coli. All other cultures were negative. In the pilot study, one culture of 56 syringes was weakly positive for coagulase-negative staphylococcus. When the results from both studies were considered together, only two of 222 partially used syringes (0.9%) were contaminated. The background risk of local infection associated with periurethral collagen injection is approximately 0.29%. Using the statistical equation 'number needed to harm', we found that a clinician would have to reuse 111 syringes at a saving of $34,965 before he or she would cause a single local injection by so doing. Therefore, we feel that it may be cost-effective and safe to reinject material from a partially used syringe of glutaraldehyde cross-linked collagen during a subsequent treatment session on an individual.
A key function of the proximal tubule is retrieval of most of the vast quantities of NaCl and water filtered by the kidney. Physiological studies using brush border vesicles and perfused tubules have indicated that a major fraction of Cl(-) reabsorption across the apical membrane of proximal tubule cells occurs via Cl(-)-formate exchange. The molecular identity of the transporter responsible for renal brush border Cl(-)-formate exchange has yet to be elucidated. As a strategy to identify one or more anion exchangers responsible for mediating Cl(-) reabsorption in the proximal tubule, we screened the expressed sequence tag database for homologs of pendrin, a transporter previously shown to mediate Cl(-)-formate exchange. We now report the cDNA cloning of CFEX, a mouse pendrin homolog with expression in the kidney by Northern analysis. Sequence analysis indicated that CFEX very likely represents the mouse ortholog of human SLC26A6. Immunolocalization studies detected expression of CFEX, but not pendrin, on the brush border membrane of proximal tubule cells. Functional expression studies in Xenopus oocytes demonstrated that CFEX mediates Cl(-)-formate exchange. Taken together, these observations identify CFEX as a prime candidate to mediate Cl(-)-formate exchange in the proximal tubule and thereby to contribute importantly to renal NaCl reabsorption. Given its wide tissue distribution, CFEX also may contribute to transcellular Cl(-) transport in additional epithelia such as the pancreas and contribute to transmembrane Cl(-) transport in nonepithelial tissues such as the heart.
Modern medicine has led to dramatic changes in infectious diseases practice. Vaccination and antibiotic therapy have benefited millions of persons. However, constrained resources now threaten our ability to adequately manage threats of infectious diseases by placing clinical microbiology services and expertise distant from the patient and their infectious diseases physician. Continuing in such a direction threatens quality of laboratory results, timeliness of diagnosis, appropriateness of treatment, effective communication, reduction of health care-associated infections, advances in infectious diseases practice, and training of future practitioners. Microbiology laboratories are the first lines of defense for detection of new antibiotic resistance, outbreaks of foodborne infection, and a possible bioterrorism event. Maintaining high-quality clinical microbiology laboratories on the site of the institution that they serve is the current best approach for managing today's problems of emerging infectious diseases and antimicrobial agent resistance by providing good patient care outcomes that actually save money.
The laboratory diagnosis of CNS infection is essential for optimal therapy. Acute infection requires rapid turn-around testing with high predictive values, that is, the ability of a test to accurately identify those patients who do or do not have disease caused by a specific etiology. The Gram's stain, fungal stains of direct smears, antigen testing for C. neoformans, and culture of bacteria, fungi, mycobacteria, and some viruses are important tests for the diagnosis of acute infection. The laboratory diagnosis of chronic infection necessitates discussion between the clinician and laboratory technician to allow triaging of testing. Antigen tests for bacteria, fungi, and viruses; antibody tests for multiple microorganisms; and PCR testing for bacteria, M. tuberculosis, and many viruses are all important in limited clinical situations. All testing for acute or chronic disease depends on sufficient specimen that is transported to the laboratory in a manner that will not compromise viability or chemical integrity. Sterile containers that maintain moisture content, exclude oxygen for anaerobic requests, and are stored at proper temperatures (22 degrees C room, 4 degrees C refrigeration, or -20 degrees C freezer depending on pathogen and test) are mandatory. Many laboratory issues addressing the diagnosis of CNS infection are changing or evolving. Most important is the recognition that bacterial antigen testing for the diagnosis of acute bacterial meningitis rarely impacts patient management and is not routinely needed, CSF shunt infections differ from usual meningeal infections and require rapid diagnosis, and TB meningitis remains a difficult disease to diagnosis but may be confirmed first by PCR testing of CSF. In addition, Whipple's disease of the CNS can be confirmed using PCR with CSF; CJD has a marker protein, referred to as 14-3-3 antigen, that can be detected in CSF, and the diagnosis of fungal CNS disease requires careful interpretation of direct smears, antigen and antibody testing, and culture. Most difficult to diagnose among the CNS infections are viral meningitis and encephalitis. The appearance of new etiologies, such as West Nile virus, and the common use of PCR for the herpes viruses and enteroviruses represent important advances. Evolving methods for the laboratory diagnosis of CNS infection represent significant improvements over previous testing; however, the array of tests available demands more attention for appropriate selection, is significantly more expensive, and requires new skills for performance and interpretation. The responsibility for proper use of laboratory testing lies both with the clinician and laboratory technician.
To validate the accuracy of rapid tests for identification of Escherichia coli, five laboratories sequentially collected 1,064 fresh, clinically significant strains with core criteria of indole-positive, oxidase-negative, nonspreading organisms on sheep blood agar plates (BAP), having typical gram-negative rod plate morphology, defined as good growth on gram-negative rod-selective media. An algorithm using beta-hemolysis on BAP, lactose reaction on eosin-methylene blue or MacConkey agar, L-pyrrolidonyl-beta-naphthylamide (PYR), and 4-methylumbelliferyl-beta-D-glucuronide (MUG) was evaluated. Identifications using the algorithm were compared to those obtained using commercial kit system identifications. One thousand strains were E. coli and 64 were not E. coli by kit identifications, which were supplemented with conventional biochemical testing of low probability profiles. Of the 1,064 isolates meeting the core criteria, 294 were beta-hemolytic and did not require further testing to be identified as E. coli. None of the 64 non-E. coli strains were hemolytic, although other indole-positive, lactose-negative species were found to be hemolytic when further strains were examined in a follow-up study. Of the remaining strains, 628 were identified as E. coli by a lactose-positive and PYR-negative reaction. For nonhemolytic, lactose-negative E. coli, PYR was not helpful, but a positive MUG reaction identified 65 of 78 isolates as E. coli. The remaining 13 E. coli strains required kit identifications. This scheme for E. coli identification misidentified three non-E. coli strains as E. coli, for an error rate of 0.3%. A total of 13 kit identifications, 657 PYR tests, and 113 MUG tests were needed to identify 1,000 E. coli strains with the algorithm. The use of this rapid system saves laboratory resources, provides timely identifications, and yields rare misidentifications.
PURPOSE: We evaluated the safety of saving partially used syringes of glutaraldehyde cross-linked collagen for subsequent treatment sessions in an individual. MATERIALS AND METHODS: After periurethral injection in an office setting 56 partially used syringes of glutaraldehyde cross-linked collagen were stored in a refrigerator for 1 to 61 weeks (mean 15). Collagen from all 56 syringes was then cultured qualitatively using a broth medium at 35C and semiquantitatively using a chocolate agar plate at 22 to 30C for 5 days each. RESULTS: A qualitative broth culture was positive for coagulase negative staphylococcus but the results of semiquantitative chocolate agar culture of material from the same syringe were negative. All cultures of the other 55 syringes were negative. CONCLUSIONS: The positive culture most likely resulted from contamination during periurethral injection or the culturing process. Minimal contamination from and the great potential cost savings of reusing glutaraldehyde cross-linked collagen for subsequent treatments in an individual indicate the need for an expanded study involving multiple centers.
Our knowledge regarding the pathogenesis of infections relative to the oral cavity is rapidly expanding, similar to our overall understanding of how infectious diseases impact our daily lives. The complexity of the flora within the oral cavity is quite unique and often makes diagnosis difficult; however, it is becoming more apparent that accurate diagnostic testing is important from the standpoint of focusing appropriate therapy on pathogens within this crucial body site, and avoiding overuse of antimicrobial agents in settings of infection where they have no demonstrated benefit. New diagnostic methods are being developed to detect pathogens and rapidly delineate resistance patterns. Many will be based on new genetic assays, but they must be cost effective, sensitive, and specific. Another growing challenge is to provide adequate lab support to outpatient offices and clinics, without compromising the specimen culture or turnaround times. So many patients are being seen away from hospital laboratories that we need ways to diagnose sinusitis, pharyngitis, abscess, and other infections of the oral cavity without killing the anaerobes and other significant facultative bacteria, and without ruining the direct stains by overgrowth or inflammatory cell degradation during specimen transport. These results need to be available quickly enough to give useful information for office diagnosis in order to effect therapy. To optimize both diagnosis and treatment, a key to the future will be better communication between the clinical practitioner and laboratory, with an increasing emphasis on training expertise in medical microbiology and infectious diseases.
The laboratory diagnosis of infections of the respiratory tract is not an exact science, with many clinicians electing to empirically select antimicrobial therapy without the benefit of laboratory testing. With trained laboratory personnel and the proper selection of tests, accurate laboratory diagnosis is available. Progress is occurring most rapidly with molecular methods, such as polymerase chain reaction (PCR) testing. As molecular approaches are technically simplified and become less expensive, advances in the laboratory diagnosis of most respiratory tract infections caused by fastidious pathogens will occur. The diagnosis of non-fastidious bacteria, that require in-vitro antimicrobial testing, will continue to require conventional culture methods. New bronchoscopic methods, quantitative evaluation of cultures, and recognition of intracellular bacteria in stained smears do improve the usefulness of conventional culture and stain in the diagnosis of pneumonia.
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The potential for Ksp-cadherin involvement in either the development or maintenance of the metanephric kidney was assessed by immunocytochemical localization of a monoclonal antibody directed against the rabbit isoform of Ksp-cadherin in both neonatal and adult rabbit kidneys. In the adult kidney Ksp-cadherin expression was detected on the basolateral membrane of all cell types in both the tubular nephron and the collecting system. Immunoelectron microscopy indicated that Ksp-cadherin was expressed at uniform levels along the entire length of both the lateral membranes and the basal infoldings of all tubular epithelial cell types. In the nephrogenic zone of the neonatal rabbit kidney Ksp-cadherin expression was detected exclusively on the basolateral membranes of epithelial cells in the more highly differentiated regions of the expanding ureteric duct. In the highly differentiated corticomedullary and medullary regions of the neonatal kidney, distinct basolateral staining was observed in all segments of the tubular nephron and the collecting system. The relatively late appearance of Ksp-cadherin expression in the developing metanephros indicates that Ksp-cadherin probably does not participate in the direction of renal morphogenesis. However, the high levels of Ksp-cadherin expression observed in all segments of the tubular nephron and the collecting system in the adult kidney suggests that it may play a role in the maintenance of the terminally differentiated tubular epithelial phenotype.
Kidney-specific cadherin (Ksp-cadherin, cadherin 16) is a novel, kidney-specific member of the cadherin superfamily that is expressed exclusively in the basolateral membrane of renal tubular epithelial cells. To characterize the Ksp-cadherin gene promoter, a lambda bacteriophage clone containing 3.7 kb of the proximal 5' flanking region of the mouse Ksp-cadherin gene was isolated. The transcription initiation site was mapped by RNase protection assays and 5' rapid amplification of cDNA ends, and a 709-bp intron was identified within the 5' untranslated region. The proximal 5' flanking region was "TATA-less" but contained other consensus promoter elements including an initiator (Inr), GC boxes, and a CAAT box. Potential binding sites were identified for transcription factors that are involved in tissue-specific gene expression including activator protein-2 (AP-2), hepatocyte nuclear factor-3 (HNF-3), basic helix-loop-helix (bHLH) proteins, CCAAT/enhancer-binding protein (C/EBP), and GATA factors. Transfection of luciferase reporter plasmids containing 2.6 kb of the 5' flanking region markedly increased luciferase activity in renal epithelial cells (MDCK and mIMCD-3) but not in mesenchymal cells (NIH 3T3 and MMR1). Deletion analysis identified an 82-bp region from -31 to -113 that was essential for promoter activity in transfected renal epithelial cells. Electrophoretic mobility-shift assays showed that mIMCD-3 cells contain nuclear proteins that bind to this region of the promoter. Mutational analysis showed that sequences within the HNF-3 consensus site and CAAT box were involved in protein binding and promoter activity. We conclude that the proximal 5' flanking region of the mouse Ksp-cadherin gene contains an orientation-dependent promoter that is kidney epithelial cell specific. The region of the promoter from -113 to -31 is required for transcriptional activity and contains binding sites for nuclear proteins that are specifically expressed in renal epithelial cells.
Kidney-specific cadherin (Ksp-cadherin, cadherin 16) is a tissue-specific member of the cadherin superfamily that is expressed exclusively in the basolateral membrane of tubular epithelial cells in the kidney. To determine the basis for tissue-specific expression of Ksp-cadherin in vivo, we evaluated the activity of the promoter in transgenic mice. Transgenic mice containing 3.3 kb of the mouse Ksp-cadherin promoter and an Escherichia coli lacZ reporter gene were generated by pronuclear microinjection. Assays of beta-galactosidase enzyme activity showed that the transgene was expressed exclusively in the kidney in both adult and developing mice. Within the kidney, the transgene was expressed in a subset of renal tubular epithelial cells that endogenously expressed Ksp-cadherin and that were identified as collecting ducts by colabeling with Dolichos biflorus agglutinin. In the developing metanephros, expression of the transgene in the branching ureteric bud correlated with the developmental expression of Ksp-cadherin. Identical patterns of expression were observed in multiple founder mice, indicating that kidney specificity was independent of transgene integration site. However, heterocellular expression was observed consistent with repeat-induced gene silencing. We conclude that the Ksp-cadherin gene promoter directs kidney-specific expression in vivo. Regulatory elements that are sufficient to recapitulate the tissue- and differentiation-specific expression of Ksp-cadherin in the renal collecting duct are located within 3.3 kb upstream to the transcriptional start site.
Ksp-cadherin is a novel kidney-specific member of the cadherin superfamily of cell adhesion molecules. We have determined the complete cDNA coding sequences of both the human and the mouse isoforms of Ksp-cadherin. The inferred amino acid sequences of the human and mouse isoforms are 79 and 75% identical to the originally described rabbit isoform of Ksp-cadherin (Thomson et al., 1995; J. Biol. Chem. 270, 17594-17601), respectively. The relative locations of cadherin-specific sequence motifs, putative N-glycosylation sites, and characteristic protein domains are entirely conserved in all three isoforms. Multiple organ Northern analyses indicate that, as in the rabbit, both the human and the mouse Ksp-cadherin transcripts appear to have distinct kidney-specific distributions. The human Ksp-cadherin gene (CDH16) maps to chromosome 16q21-proximal 16q22. The mouse Ksp-cadherin gene (Cdh16) was localized to a highly syntenic region of distal Chromosome 8. Both the human and the mouse Ksp-cadherin genes were localized to previously identified clusters of cadherin gene sequences, consistent with the hypothesis that most cadherin family members arose by gene duplication from a single ancestral gene at a relatively early stage in the evolution of the mammalian genome.
The proper use and interpretation of clinical microbiology test results may be complicated but critical to the care of cancer patients. The microbiology laboratory director is often available to offer advice concerning the differential diagnosis, choice of specimens, as well as the optimal stains and cultures to facilitate diagnosis. Additionally, the rapid interpretation of Gram-stained smears provides useful, occasionally lifesaving, information relative to the etiologic diagnosis and empiric antimicrobial therapy. The microbiology laboratory director should also provide further interpretation of culture and antimicrobial testing results that allow the clinical service to focus on the most critical data. Person-to-person or telephone conversations discussing important laboratory information should be followed up by a written summary report placed in the patient's chart so all services involved share the same interpretation (Figure 2). The clinical service has an important responsibility to communicate with the laboratory to optimize care of the patient with cancer. The laboratory compiles data collected from groups of patients that is available and useful to physicians. Review and discussion of test utilization is essential for cost-effective, quality health care. This may include analysis of blood cultures documenting an acceptable level of contamination, appropriate number collected per day, and sufficient blood volume per culture. In addition, information about changing resistance patterns or nosocomial transmission can be provided to the clinician. As patients with malignancies become more complex and their infections increasingly difficult to treat, regular interaction between the laboratory and clinician is likely to improve patient care.
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Cadherins are recognized as the principal mediators of homotypic cellular recognition and play a demonstrated role in the morphogenic direction of tissue development. We report here the identification of a structurally unique, kidney-specific member of the cadherin multigene family (Ksp-cadherin). cDNA cloning and molecular analysis of the 130-kDa protein confirmed that it was novel and indicated that it most closely resembled members of the LI-cadherin/HPT-1 cadherin subgroup. The predicted protein possesses the definitive cadherin-specific sequence motifs LDRE, DXND, and DXD in well conserved sequential arrangement, and the characteristic cysteine residues found in the last ectodomains of almost all known cadherins. Like LI-cadherin and HPT-1, Ksp-cadherin lacks the prosequence and HAV adhesion recognition sequence typical of most classical cadherins, and possesses a truncated cytoplasmic domain (18-22 amino acids). When expressed in a transient Vaccinia/T7 expression system, Ksp-cadherin displayed the classic calcium sensitivity to trypsin proteolysis that is observed in all cadherins. Immunolocalization studies and Northern analysis indicated that expression of Ksp-cadherin was kidney-specific and limited to the basolateral membranes of renal tubular epithelial cells. In summary, we have identified and cloned a novel, kidney-specific member of the cadherin multigene family that we propose be designated Ksp-cadherin.