The cultivation of Anabaena variabilis in a bubble column operating under bubbly and slug flows

In a bubble column reactor with an inner diameter of 6cm and a height of 63cm for the culture of cyanobacteria two different shapes of bubbles can be generated, resulting in bubbly flow or slug flow. Growth of Anabaena variabilis under slug flow (1.9g/l/day) was 1.73 times higher than that under bubbly flow (1.1g/l/day) when the specific irradiation rate was maintained above 10μmol/s/g dry cell. Although a stepwise increase in superficial gas velocity enhanced the average cell growth rate under bubbly flow by 1.57 times, the average cell growth rate during the deceleration phase under bubbly flow (1.98g/l/day) was 0.61 times smaller than that under slug flow (3.22g/l/day). These results demonstrate that the bubble shape in the slug flow was advantageous in regards to the radial circulation of cells.

Apoptosis-mediated in vivo toxicity of hydroxylated fullerene nanoparticles in soil nematode Caenorhabditis elegans

Although a number of manufactured nanoparticles are applied for the medical and clinical purposes, the understanding of interaction between nanomaterials and biological systems are still insufficient. Using nematode Caenorhabditis elegans model organism, we here investigated the in vivo toxicity or safety of hydroxylated fullerene nanoparticles known to detoxify anti-cancer drug-induced oxidative damages in mammals. The survival ratio of C. elegans rapidly decreased by the uptake of nanoparticles from their L4 larval stage with resulting in shortened lifespan (20 d). Both reproduction rate and body size of C. elegans were also reduced after exposure to 100 μg mL(-1) of fullerol. We found ectopic cell corpses caused by apoptotic cell death in the adult worms grown with fullerol nanoparticles. By the mutation of core pro-apoptotic regulator genes, ced-3 and ced-4, these nanoparticle-induced cell death were significantly suppressed, and the viability of animals consequently increased despite of nanoparticle uptake. The apoptosis-mediated toxicity of nanoparticles particularly led to the disorder of digestion system in the animals containing a large number of undigested foods in their intestine. These results demonstrated that the water-soluble fullerol nanoparticles widely used in medicinal applications have a potential for inducing apoptotic cell death in multicellular organisms despite of their antioxidative detoxifying property.

Synovial chondromatosis in the temporomandibular joint: a case with typical imaging features and pathological findings

Synovial chondromatosis of the temporomandibular joint is a rare benign joint disorder that has been reported in only a few studies. However, we recently encountered a pathologically proven case of this disorder. This case also showed the typical imaging findings on panoramic radiographs and on CT and MR images. Therefore, we report this case and the imaging and pathological findings.

High glucose diets shorten lifespan of Caenorhabditis elegans via ectopic apoptosis induction

Diets based on carbohydrates increase rapidly the blood glucose level due to the fast conversion of carbohydrates to glucose. High glucose diets have been known to induce many lifestyle diseases. Here, we demonstrated that high glucose diet shortened the lifespan of Caenorhabditis elegans through apoptosis induction. Control adult groups without glucose diet lived for 30 days, whereas animals fed 10 mg/L of D-glucose lived only for 20 days. The reduction of lifespan by glucose diet showed a dose-dependent profile in the concentration range of glucose from 1 to 20 mg/L. Aging effect of high glucose diet was examined by measurement of response time for locomotion after stimulating movement of the animals by touching. Glucose diet decreased the locomotion capacity of the animals during mid-adulthood. High glucose diets also induced ectopic apoptosis in the body of C. elegans, which is a potent mechanism that can explain the shortened lifespan and aging. Apoptotic cell corpses stained with SYTO 12 were found in the worms fed 10 mg/L of glucose. Mutation of core apoptotic regulatory genes, CED-3 and CED-4, inhibited the reduction of viability induced by high glucose diet, which indicates that these regulators were required for glucose-induced apoptosis or lifespan shortening. Thus, we conclude that high glucose diets have potential for inducing ectopic apoptosis in the body, resulting in a shortened lifespan accompanied with loss of locomotion capacity.

Outer retinal abnormalities associated with inner retinal pathology in nonglaucomatous and glaucomatous optic neuropathies

Inner and outer retinal morphology were quantified in vivo for 6 nonglaucomatous and 10 glaucomatous optic neuropathy patients. Custom, ultrahigh-resolution imaging modalities were used to evaluate segmented retinal layer thickness in 3D volumes (Fourier-domain optical coherence tomography), cone photoreceptor density (adaptive optics fundus camera), and the length of inner and outer segments of cone photoreceptors (adaptive optics-optical coherence tomography). Quantitative comparisons were made with age-matched controls, or by comparing affected and nonaffected retinal areas defined by changes in visual fields. The integrity of outer retinal layers on optical coherence tomography B-scans and density of cone photoreceptors were correlated with visual field sensitivity at corresponding retinal locations following reductions in inner retinal thickness. The photoreceptor outer segments were shorter and exhibited greater variability in retinal areas associated with visual field losses compared with normal or less affected areas of the same patient's visual field. These results demonstrate that nonglaucomatous and glaucomatous optic neuropathies are associated with outer retinal changes following long-term inner retinal pathology.

Detection and characterization of enterovirus associated with herpangina and hand, foot, and mouth disease in Seoul, Korea

BACKGROUND

Human enteroviruses (HEVs) are a major cause of herpangina, HFMD (hand, foot, and mouth disease), and other neurological diseases in Seoul, Korea.

METHODS

A total of 56 specimens from hospitalized patients collected from February to December 2009 (37 females and 19 males) in Seoul were tested for HEV from stool, throat swab, and vesicle swab samples taken from patients with herpangina or HFMD using cell culture and RT-PCR in 2009. By the 1D gene, encoding the VP1 capsid protein, seven different HEV genotypes were detected with Coxsackievirus A2, A4, A5, A9, A16 (CA), Coxsackievirus B1 (CB), and Enterovirus 71 (EV71). The most prevalent genotype was CA16 (6, 10.7%), followed by CA2 (4, 7.1%), CA5 (4, 7.1%), EV71 (2, 3.6%), CA4 (1, 1.8%), CA9 (1, 1.8%), and CB1 (1, 1.8%). The 1D gene sequences of two EV71 strains were closely related with one another (98.5% nucleotide similarity) and belonged to the C4 genotype.

CONCLUSIONS

It is important to continuously survey the genetic characteristics of EV71 and CA16 from patients, which will provide useful data that aids in our understanding of HFMD infections in Seoul, Korea and may contribute to future control.

Viral agents associated with acute gastroenteritis in Seoul, Korea

BACKGROUND

The present study was carried out to describe the epidemiologic characteristics of viral gastroenteritis and determine the phylogenetic composition of norovirus strains detected in hospitalized children with acute gastroenteritis in Seoul, Korea.

METHODS AND RESULTS

In total, 10,603 stool samples were collected from 2004 to 2008 and tested by RT-PCR or ELISA. In 4,170 (39.3%) samples at least one viral pathogen was present. Rotavirus (RoV) (1,864, 17.5%) was found to be the causative agent followed by norovirus (NoV) (1,845, 17.4%), human adenovirus (HAdV) (266, 2.5%), human astrovirus (HAstV) (194, 1.8%), and sapovirus (SV) (1, 0.009%). Five GI genotypes (GI-1, GI-3, GI-4, GI-8, and GI-9) and eight GII genotypes (GII-2, GII-3, GII-4, GII-6, GII-7, GII-12, GII-16, and GII-17) of NoV were identified in acute gastroenteritis patients in 2008.

CONCLUSIONS

The genetic characteristics of norovirus and the epidemiologic patterns of a viral pathogen from acute gastroenteritis patients may give potentially effective data for epidemiological studies in Seoul, Korea.

Diffusion MR imaging of hypoglycemic encephalopathy

BACKGROUND AND PURPOSE

MR imaging features of HE have not been fully established. The purpose of this study was to determine the topographic distribution and DWI findings of HE.

MATERIALS AND METHODS

We retrospectively evaluated HE MR imaging (n = 11). The topographic distribution of the lesions was evaluated on routine MR imaging, and DWI SI and ADC values were assessed. The ADC value of involved lesions was compared with the noninvolved subcortical WM area by use of the paired t test.

RESULTS

MR images demonstrated bilateral diffusion-restrictive lesions in the posterior limb of the IC (n = 6), cerebral cortex (n = 8), CR (n = 7), CS (n = 9), hippocampus (n = 4), and BG (n = 1). The mean ADC value of lesions was 448.82 +/- 92.34 x 10(-6) mm(2)/s compared with the mean ADC value of noninvolved lesions (837.72 +/- 62.14 x 10(-6) mm(2)/s); this difference was statistically significant (P < .000). The lesions showed complete resolution on follow-up DWI for 6 patients. Three patients with cortical involvement of > or = 2 lobes showed partial recovery or death, but most of the other patients with WM involvement or cortical involvement in only 1 lobe experienced complete recovery.

CONCLUSIONS

The topographic localization of the lesions was the posterior limb of the IC, cerebral cortex, CR, CS, hippocampus, and BG. Most HE lesions probably correspond to areas of reversible cytotoxic edema as seen on DWI, which can predict the prognosis of HE according to the degree of lesion extent.

Investigation of structural transition of dsDNA on various substrates studied by atomic force microscopy

Structural transition of single dsDNA molecule which is immobilized on 3-aminopropyltriethoxysilane (APTES) treated substrate (APTES/substrate) or alkylthiol treated substrate (alkylthiol/substrate) has been investigated by atomic force microscopy (AFM). The obtained force versus distance (F-D) curves are used to dissect the transition from B-form to S-form, the melting from double stranded (ds) to single stranded (ss) DNA, and its Young's modulus as well as persistence length. The melt from dsDNA to ssDNA is evidenced by fitting with freely jointed chain (FJC) model. FJC fit and Young's modulus or persistence length values when the molecules are fixed on alkylthiol/substrate are more agreeable with other studies than those on APTES. We have clarified the different results of those experiments by analyzing the binding force between DNA molecules and APTES or alkylthiol linkers on the substrate. The DNA binding to APTES linker is much stronger than that on alkylthiol/substrate.

The hedgehog pathway regulates remodelling responses to biliary obstruction in rats

BACKGROUND

Chronic biliary obstruction provokes fibrosis and accumulation of immature ductular cells. This fibroductular reaction resolves following biliary decompression, suggesting that it may also be involved in the repair of biliary damage. The hedgehog (Hh) pathway becomes activated in liver after bile duct ligation (BDL), and might modulate hepatic remodelling because Hh ligands are potent morphogens.

OBJECTIVE

To study the induction of the Hh pathway during progression and resolution of biliary fibrosis, and to clarify whether Hh signalling regulates accumulation of bile duct progenitor cells.

DESIGN AND MAIN OUTCOME MEASURES

Livers from rats with BDL were examined by quantitative real-time polymerase chain reaction analysis and immunohistochemistry to identify factors that might stimulate Hh signalling. BDL rats were subjected to Roux-en-Y hepaticojejunostomy (R-Y) to relieve biliary obstruction in order to determine whether these factors and Hh signalling declined as ductular populations and concomitant fibrosis regressed. Cultures of immature ductular cells were treated with putative Hh inducers and Hh ligands to confirm their functional relevance.

RESULTS

BDL increased expression of platelet-derived growth factor-BB (PDGF-BB) and sonic hedgehog (Shh), downregulated hedgehog-interacting protein (Hip), activated Hh signalling, and expanded populations of Hh-responsive ductular cells that expressed pancyotkeratin, a liver progenitor cell marker. After R-Y, Hip remained suppressed, expression of PDGF-BB and Shh gradually declined, and populations of hedgehog-responsive ductular cells regressed. In cultured ductular cells, PDGF-BB treatment induced Shh expression, and incubation with Shh inhibited apoptotic activity.

CONCLUSIONS

These results identify a mechanism for activation of the Hh pathway during cholestasis and suggest that Hh signalling regulates ductular cell accumulation after biliary injury.

Complicated giant diverticulum of the transverse colon accompanied by right inguinal hernia of the greater omentum

Giant colonic diverticulum is a very rare entity in colonic diverticular disease and is characterized by a high rate of complications such as perforation, abscess formation and even carcinoma. We report a case of a complicated giant diverticulum of the transverse colon accompanied by a right inguinal hernia of the greater omentum in a 52-year-old man, as demonstrated on CT.

Dual reporter genes enabling cell tracing with viable and reliable selection of various cell types

Dual reporter genes driven by either a ubiquitous cytomegalovirus (CMV) or a neuro-specific tubulin alpha1 promoter (Talpha1) were constructed. The new genes, CMV (pCMV-GL) or Talpha1 promoter-driven GFP-LacZ (pTalpha1-GL), robustly expressed the fused GFP-LacZ protein reporting constitutive expressions in various cell types including CHO cells, loach and chicken embryos, and neuro-specific expression in differentiating mouse embryonic stem cells, respectively. The dual reporter genes thus provide a versatile tool for the studies of gene expression, cell lineage within the embryo and possibly the fate of stem cells in transplantation experiment, thus facilitating different analyses depending on the experimental purposes.

Effects of Lactobacillus strains on cancer cell proliferation and oxidative stress in vitro

AIMS

The objective of this study was to assess in vitro, whether heat-killed (HK) lactic acid bacteria cells and fractionations of HK cells could suppress the viability of human cancer cells and inhibit the cytotoxicity associated with oxidative stress.

METHODS AND RESULTS

Among the strains, the HK cells of Lactobacillus acidophilus 606 and Lactobacillus casei ATCC 393 exhibited the most profound inhibitory activity in all of the tested cell lines. HK cells of L. acidophilus 606 were determined to be less toxic to healthy human embryo fibroblasts (hEF cells) than were HK cells of L. casei ATCC 393. The soluble polysaccharides from L. acidophilus 606 evidenced the most effective anticancer activity, but inhibited hEF cell growth by only 20%. The soluble polysaccharides from L. acidophilus 606 were partly observed to induce apoptosis in the HT-29 cells by DNA fragmentation and propidium iodine staining. Both the HK cells of L. acidophilus 606 and the soluble polysaccharide components of this strain also exhibited potent antioxidative activity.

CONCLUSIONS

Our findings suggest that the soluble polysaccharide fraction from L. acidophilus 606 may constitute a novel anticancer agent, which manifests a high degree of selectivity for human cancer cells and antioxidative agent in the food industry.

SIGNIFICANCE AND IMPACT OF THE STUDY

These soluble polysaccharide components from Lactobacillus may be applied to various foods, and used as adjuncts for cancer therapy and prevention.

Comparison between high and low molecular weight hyaluronates in knee osteoarthritis patients: open-label, randomized, multicentre clinical trial

Efficacy and safety of high and low molecular weight hyaluronates in knee osteoarthritis patients were compared in a randomized, open-label trial. Patients in the high molecular weight hyaluronate group were treated once weekly for 3 weeks and in the low molecular weight group once weekly for 5 weeks. We evaluated weight-bearing pain, degree of flexion, swelling and knee tenderness; frequency and amount of rescue medication; patient and investigator global assessment of pain, and safety over 12 weeks after final injection of study medication. Significant improvements in pain and WOMAC-Likert scores were observed in both groups, but not between groups. Knee joint pain improvement was noted in both groups by patients and investigators during follow-up. Close correlation was observed between patient- and investigator-reported data. There was no significant difference in side-effects between the groups. In conclusion, the efficacy and safety of high and low molecular weight hyaluronate are similar.

Enhancement of recombinant protein production in Chinese hamster ovary cells through anti-apoptosis engineering using30Kc6 gene

It was previously reported that silkworm hemolymph (SH) inhibits apoptosis and increases the production of recombinant human erythropoietin (EPO) in Chinese hamster ovary (CHO) cells. The apoptosis-inhibiting component in SH is a member of 30K protein family. In this study, the CHO cell line producing EPO was manipulated genetically to express the 30Kc6 gene encoding a 30K protein in the hemolymph of the silkworm, Bombyx mori. The transient expression of 30Kc6 significantly suppressed the cell death induced by serum deprivation. A stable cell line expressing 30Kc6 with an anti-apoptotic property was established. The stable expression of 30Kc6 inhibited serum-deprivation-induced apoptosis and increased the cell density and EPO titer by 5- and 10-fold, respectively. The positive effects of the 30Kc6 expression on cell viability and productivity were due to the stable maintenance of the mitochondrial activity. The 30Kc6 expression efficiently suppressed the depolarization of the mitochondrial membrane and subsequently balanced the generation/consumption of ATP. The use of the 30Kc6 gene is expected to provide a new method of host cell engineering for improving the productivity of the recombinant protein.

Beneficial effect of silkworm hemolymph on a CHO cell system: Inhibition of apoptosis and increase of EPO production

To produce erythropoietin (EPO), Chinese hamster ovary (CHO) cells were first cultured in a medium containing FBS (growth medium) and then in a serum-free medium containing sodium butyrate (production medium). Sodium butyrate increases recombinant protein production, but also induces apoptosis, which reduces cell viability and productivity. In a previous study, we found that silkworm hemolymph (SH), an insect serum, inhibits the apoptosis of insect and mammalian cells. To overcome sodium butyrate-induced apoptosis, we added SH to growth medium. This pretreatment with SH inhibited the sodium butyrate-induced apoptosis of CHO cells and consequently increased their longevity and their ability to produce EPO. As a result, the volumetric productivity of EPO was increased five-fold. SH was found to inhibit cytochrome c release from mitochondria into the cytosol, and prevented the activation of caspase-3 and other subsequent caspase reactions.

Coronary artery spasm induced by carotid sinus stimulation during neck surgery

We observed four transient episodes of marked ST-segment elevation in a 58-yr-old man with no history of coronary artery disease undergoing resection of a metastatic neck mass under general anaesthesia. Elevations of the ST segment were abrupt, with no change in arterial pressure or heart rate, and resolved spontaneously. When the carotid sinus was compressed directly, ST-segment elevation was noted 1 min after the onset of stimulation. After surgery, coronary angiography showed diffuse, slight narrowing of the distal bed of the posterolateral branch of the right coronary artery. Ergonovine caused total occlusion of the posterolateral branch of the right coronary artery with chest pain and ST-segment elevation, confirming the diagnosis of variant angina. The coronary artery spasm seems to have been provoked by vagal activation from carotid sinus stimulation during general anaesthesia.

Fenofibrate lowers abdominal and skeletal adiposity and improves insulin sensitivity in OLETF rats

The effect of peroxisome proliferator-activated receptor (PPAR)-alpha activators on the liver is well established, but the other effects on muscle and adipose tissue about lipid metabolism and insulin sensitivity are not clear. We investigated whether PPAR-alpha activation affects adiposity of skeletal muscle as well as adipose tissue and improves insulin sensitivity in spontaneous type 2 diabetes model, Otsuka Long-Evans Tokushima Fatty (OLETF) rats. Thirty-three weeks of aged, 20 male OLETF rats were divided into two groups. Control group (n=10) was fed with chow and treatment group (n=10) with chow contained fenofibrate for 7 weeks. At the age of 40 weeks, all rats were examined with MRI, intravenous glucose tolerance test, and then sacrificed for measurement of fat mass and RNA analyses. The total fat (the sum of subcutaneous, mesenteric, epididymal, and retroperitoneal fat pads) measured by dissection was significantly reduced in treatment group. The signal intensity of muscular adiposity was significantly decreased in treatment group. The mRNA levels of FAT/CD36 and mitochondrial carnitine palmitoyltransferase I (M-CPT I) in liver were remarkably increased. Fasting plasma insulin and leptin levels, insulin response after intravenous glucose loading and homeostasis model assessment insulin resistance (HOMA(IR)) index were lowered in treatment group. Fenofibrate increase mitochondrial fatty acid beta-oxidation in liver but not in skeletal muscle and lower the plasma levels of triglyceride and free fatty acid. It might result in reduction of adiposity of truncal adipose tissue and skeletal muscle. We suggest that reduction of adiposity in trunk and skeletal muscle might improve insulin sensitivity.

Inhibition of human cell apoptosis by silkworm hemolymph

Many studies on preventing apoptosis have been carried out from the viewpoint of anti-apoptotic cloned-gene expressions inside cells, whereas in this study, we investigated the inhibition of apoptosis by the addition of silkworm hemolymph, a natural compound, from outside of the cells. In a previous study, we reported the inhibition effect of silkworm hemolymph on the baculovirus-induced insect cell apoptosis. Using the vaccinia virus-HeLa cell system as a model system in this study, we found that silkworm hemolymph, the insect serum, inhibits apoptosis not only in the insect cell system but also in the human cell system. The vaccinia virus-induced HeLa cell apoptosis was analyzed using DNA electrophoresis, TUNEL, and flow cytometry, and the resulting data confirmed that silkworm hemolymph inhibits human cell apoptosis. The inhibition of apoptosis due to silkworm hemolymph was not caused by an inhibition of virus binding and internalization steps, nor did silkworm hemolymph interfere with the virus production. The inhibition of apoptosis by silkworm hemolymph decreased the cell detachment from an adhering surface. With these characteristics, silkworm hemolymph can be effectively used to minimize cell death in commercial animal cell culture.

Antinociceptive profiles of aspirin and acetaminophen in formalin, substance P and glutamate pain models

Aspirin (ASA) is widely used oral analgesics and acts as an inhibitor of cyclo-oxygenase. Also, acetaminophen (APAP) is effective analgesics and may selectively inhibit brain prostaglandin synthetase. However, their mechanisms of action in CNS are poorly defined, although several authors have shown that the antinociceptive effects of ASA and APAP have different underlying mechanisms and play some possible roles on spinal nociceptive processing, such as inhibition of prostaglandin synthesis. To define and characterize antinociceptive profiles of ASA and APAP on various pain models, we performed intraplantar formalin injection test, intrathecal (i.t.) substance P (0.7 microg)-induced nociceptive response test, and i.t. glutamate (20 microg)-induced nociceptive response test after ASA or APAP (from 10 to 300 mg/kg) administered orally to the mouse. In the formalin test, ASA produced an antinociceptive effect during only the 2nd phase (20-40 min), but not the 1st phase (0-5 min), in a dose-dependent manner. However, APAP showed a dose-dependent antinociceptive effect during both phases of the formalin test. In addition, both ASA and APAP reduced nociceptive behavior induced by glutamate administered i.t. in a dose-dependent manner. In substance P-induced nociceptive response, APAP, but not ASA, showed antinociceptive effect in a dose-dependent manner. Our results suggest that ASA and APAP administered orally may be mediated by different nociceptive processing at the spinal cord level.

Short term surgical outcomes of modified deep sclerectomy with catgut implant

We compared the effectiveness of and complications resulting from modified deep sclerectomy with catgut implant (modified-DSCI) with those of standard deep sclerectomy with collagen implant (DSCI) in the short term following surgery. In this retrospective study, standard-DSCI was performed on thirteen patients (17 eyes), and modified-DSCI was performed on seven patients (11 eyes). After dissection of a 5x5 mm sized superficial scleral flap, a 3x4 mm sized rectangular deep scleral flap was constructed in DSCI and a 2x3 mm sized triangular deep scleral flap in modified DSCI. A collagen implant was placed on the scleral bed in DSCI and # 0 CHROMIC Catgut Absorbable Suture was used in modified DSCI. The mean follow up was 11.0+/-6.1 months in DSCI and 9.3+/-4.7 months in modified DSCI. The mean preoperative intraocular pressure (IOP) was 38.6+/-10.9 mmHg in DSCI and 34.8+/-8.6 mmHg in modified DSCI. In the DSCI group, the IOP was 13.4+/-3.0 mmHg at final follow up, and was 11.4+/-3.2 mmHg in the modified DSCI group. The number of Nd:YAG goniopuncture was 3 cases (25%) in the modified DSCI group, and 3 cases (21.4%) in the DSCI group. The number of intraoperative microperforations was 3 in the DSCI group and 2 in the modified DSCI group. Temporary hypotony was encountered in 8 eyes (57.1%) of the DSCI group and 4 eyes (50%) of the modified DSCI group. There was no significant difference observed between the two groups in regards to the effectiveness or rate of complications seen during short term follow up.

Enhanced urinalysis improves identification of febrile infants ages 60 days and younger at low risk for serious bacterial illness

OBJECTIVE

Investigators have sought to establish "low-risk" criteria to identify febrile young infants who can be observed safely without antibiotics. Previous studies have used criteria for standard urinalysis to identify suspected urinary tract infection; however, cases of urinary tract infection have been missed. Enhanced urinalysis, using hemocytometer cell count and Gram stain performed on uncentrifuged urine, has been shown to have greater sensitivity and negative predictive value than standard urinalysis. The objective of this study was to evaluate the ability of criteria that incorporate enhanced urinalysis to identify febrile young infants who are at low risk for serious bacterial illness (SBI).

METHODS

Institutional guidelines were established in 1999 to evaluate in a retrospective cohort study infants who were </=60 days of age with temperature >/=38.0 degrees C. "Low-risk" criteria included 1) well appearance without focal infection (excluding otitis media); 2) no history of prematurity, illness, or previous antibiotics; 3) peripheral white blood cell count (WBC) between 5 and 15 000/mm(3); 4) absolute band count </=1500/mm(3); 5) cerebrospinal fluid WBC </=5/mm(3) with a negative Gram stain; 6) enhanced urinalysis with WBC </=9/mm(3) with a negative Gram stain; 7) stool WBC <5/high power field in infants with diarrhea; and 8) chest radiograph without lobar infiltrate(s) in infants with respiratory signs or symptoms. SBI was defined as a lobar infiltrate on chest radiograph or presence of a bacterial pathogen in blood, urine, cerebrospinal fluid, stool, or culture obtained from the soft tissue. The hospital records of all infants who presented to the emergency department for evaluation of fever after January 1999, including those who did not meet low-risk criteria, were reviewed; data were collected regarding history, physical examination, laboratory test results, treatment, and clinical course.

RESULTS

During the study period, 434 infants presented to the emergency department for evaluation of fever. Thirty patients were excluded from additional analysis because of incomplete data; 60 patients were identified immediately as "not low risk" on the basis of history or physical examination. Of the 344 remaining infants, 127 were identified as "low risk" on the basis of laboratory criteria; 83 (65.4%) were observed without antibiotics. None of the "low-risk" infants had an SBI. A total of 217 well-appearing infants were classified as "not low risk" on the basis of laboratory criteria; 28 (12.9%) had an SBI. The overall incidence of SBI in infants with complete data was 10.1%, whereas the incidence of SBI in all "not low-risk" infants was 14.8%. The negative predictive value for the "Pittsburgh" criteria was 100% (95% confidence interval: 96.7%-100%); the sensitivity was 100% (95% confidence interval: 89.7%-100%).

CONCLUSIONS

. The application of low-risk criteria using enhanced urinalysis improves identification of infants who are at low risk for SBI.