Staphylococcus aureus isolates from blood and anterior nares induce similar innate immune responses in endothelial cells

To evaluate the possibility to distinguish virulent from non-virulent isolates, gene expression in human umbilical vein endothelial cells (HUVEC) induced by invasive and colonizing isolates of Staphylococcus aureus was compared. Gene expression in HUVEC was analyzed by microarray analysis after 4 h of infection with Staphylococcus aureus, isolated from healthy nasal carriers (n = 5) and from blood of septic patients (n = 5), to explore possible differences between the groups of bacteria in interaction with HUVEC. All isolates were spa-typed to disclose strain relatedness. Moreover, the isolates were characterized with DNA microarray to determine the presence of virulence genes and to investigate the potential genes of importance in HUVEC interaction. The expression of 41 genes was up-regulated, and four were down-regulated in HUVEC by all isolates. Most of the up-regulated genes encode cytokines, chemokines, interferon-induced proteins, proteins regulating apoptosis and cell proliferation. There was no difference in the gene expression pattern between HUVEC infected with invasive or colonizing isolates. Furthermore, there was no difference in the presence of bacterial virulence genes between the two groups. In conclusion, our data indicate that S. aureus isolates induce comparable expression patterns in HUVEC, irrespective of invasiveness or presence of virulence genes.

The Presence of a Specific Genotype of Legionella pneumophila Serogroup 1 in a Hospital and Municipal Water Distribution System over a 12-year Period

The genotypic distribution of Legionella pneumophila serogroup 1 was investigated in the water distribution system of a 450-bed Swedish hospital and the surrounding community. A single genotype identified by amplified fragment length polymorphism (AFLP) analysis, was found in all 34 hospital isolates and in 18 out of 20 community isolates over a 12-y surveillance period. All isolates were either monoclonal antibody subtypes Benidorm or Bellingham. In a geographical comparison, the hospital genotype was also identified in 2 out of 6 Swedish hospitals, both located within 100 km of the studied community. In all, 70 isolates originating from 7 Swedish communities clustered in 4 groups, each also containing 1 AFLP type as defined by the European Working Group on Legionella Infections (EWGLI). It was concluded that a single Legionella pneumophila serogroup 1 genotype may colonize a large water distribution system over a long period of time, and that certain clones seem to be widely spread in the environment. Results from molecular typing of isolates originating from a limited geographical area must, therefore, be interpreted cautiously in epidemiological investigations of Legionnaires' disease.

Decreased expression of the chemokine CCL21 in human colorectal adenocarcinomas

Recent studies have revealed participation of chemokines in cancer by regulating leukocyte movement to modify local immunoresponse. The chemokine CCL21 has been identified to play a pivotal role in homing and localization of immune cells to lymphoid tissue and into organ of non-lymphoid origin. In the cancer biology CCL21 seems to have multifaceted roles. CCL21 attracts CCR7 bearing cells especially T and dendritic cells but also various cancer cells. Besides the antitumour role as leukocyte recruiting, CCL21 has been shown to facilitate dendritic cell functions and to exert an angiostatic effect. To gain insight into the possible influence of CCL21 on colorectal cancer (CRC) we determined whether the CCL21 is altered in CRC tissue. Collectively, by using ELISA we noted a significant lower CCL21 level in cancer tissue compared with paired normal tissue. Patients with a tumour localized in the rectum revealed significantly lower level of CCL21 than patients with a tumour localized in the colon both compared with paired normal tissue. We used immunohistochemistry and found heterogeneous immunoreactivity predominantly within areas of stromal cells mainly in macrophages. We also used a TaqMan system to investigate two single-nucleotide polymorphisms rs 11574915 and rs 2812377 with supposed effect on CRC. No significant difference was observed between CRC and control subjects regarding genotype and allelic distributions or associations to clinical characteristics or CCL21 tissue levels. Our study implied that lower level of CCL21 in CRC tissue supports the idea that cancer is related to immunodeficiency probably depending on regulatory factors produced by tumour cells and that the different levels of CCL21 in rectum and colon may reflect divergent mechanisms in colorectal carcinogenesis. Further studies are needed to clarify whether the CCL21 level has an impact on CRC progression and survival rate.

Cytokines in urine in elderly subjects with acute cystitis and asymptomatic bacteriuria

OBJECTIVE

Searching for useful diagnostic tools to discriminate between asymptomatic bacteriuria (ASB) and acute cystitis, this study compared urinary levels of cytokines/chemokines and leukocyte esterase in three groups of elderly subjects; those with acute cystitis, those with ASB, and those without bacteriuria.

DESIGN

Comparative laboratory.

SETTING

Primary care.

SUBJECTS

A total of 16 patients with acute cystitis, 24 subjects with ASB, and 20 controls without bacteriuria, all of whom were aged 80 or over.

MAIN OUTCOME MEASURES

Urinary levels of IL-1 beta, TNF-alpha, IL-12, IL-18, CXCL1 (GRO-alpha), CXCL8 (IL-8), CCL2 (MCP-1), IL-6, IL-10, and leukocyte esterase.

RESULTS

Urinary levels of CXCL1, CXCL8, and IL-6 were significantly higher in acute cystitis patients than in the ASB group. The sensitivities and specificities for CXCL8, IL-6, and leukocyte esterase to discriminate between acute cystitis and ASB were 63% (95% CI 36-84) and 96% (95% CI 77-100) (cut-off > 285 pg/mg creatinine), 81% (95% CI 54-95) and 96% (95% CI 77-100) (cut-off > 30 pg/mg creatinine), and 88% (95% CI 60-98) and 79% (95% CI 57-92) (cut-off > 2, on a scale of 0-4), respectively.

CONCLUSIONS

The results indicate that measurement of urinary cytokines, and also leukocyte esterase, when using a cut-off value > 2, could be useful in clinical practice to discriminate between symptomatic and asymptomatic urinary tract infections in the elderly. A combination of IL-6 and leukocyte esterase could be even more useful. This needs to be evaluated in prospective studies on the diagnosis and treatment of urinary tract infections in an elderly population.

Asymptomatic bacteriuria in the elderly: high prevalence and high turnover of strains

Asymptomatic bacteriuria (ASB) was followed in repeated prevalence surveys in a cohort of non-institutionalized residents (n=330), aged>or=80 y. Urine samples were collected at baseline, and at 6, and at 18 months. Phenotyping (PhenePlate) was performed on isolates of Escherichia coli to evaluate strain relatedness. ASB occurred in 19.0, 19.4, and 19.9% in women, and in 9.4, 9.6 and 7.9% in men, at baseline and at the 6- and 18-months follow-up, respectively, and ASB was found at least once in 37% of women and in 20% of men. Of those with ASB at baseline, 60% also had ASB in the 2 subsequent surveys. Among those with persisting E. coli bacteriuria, 76% and 40%, respectively, carried the same strain at the 6- and 18-months follow-ups. In women, we found that the risk of developing a symptomatic urinary tract infection within 24 months was higher among those with ASB at baseline than in those without bacteriuria (p=0.019). ASB is common and often persistent, but we found a high turnover of strains, indicating a high rate of recolonization.

Polymorphism in MHC class II transactivator gene is not associated with susceptibility to colorectal cancer in Swedish patients

BACKGROUND

Reduced expression of major histocompatibility complex class II (MHC-II) genes in colorectal cancer (CRC) has been reported. MHC-II transactivator (CIITA), encoded by the MHC2TA gene, is considered to be the master regulator for MHC-II gene expression. A functional single nucleotide polymorphism (SNP) -168A-->G in the promoter region of the MHC2TA gene is suggested to have an influence on different autoimmune diseases.

PATIENTS AND METHODS

Our study was performed to evaluate the association between the -168A-->G MHC2TA gene variant in patients with CRC versus a control group. Using the TaqMan system, this SNP was screened in 248 CRC patients and 256 controls.

RESULTS

No significant difference in genotype distribution or in allelic frequencies was found between the two groups, nor any association with clinical characteristics.

CONCLUSION

The results of this study suggest that -168A-->G polymorphism of the MHC2TA gene is not associated with susceptibility to CRC.

Quantification of the chemokines CCL17 and CCL22 in human colorectal adenocarcinomas

Chemokines are believed to play a crucial role in local immunoresponse by regulating leukocyte movement in various tissues, including the intestinal mucosa. It has been suggested that they are key players in cancer biology, and several studies have identified leukocyte infiltration as a hallmark of most cancers. The chemokines CCL17 and CCL22 attract CCR4-bearing cells, which are especially polarised to Th2-type cells and regulatory T cells (Treg). Recent studies have revealed the participation of the CCL17 and CCL22 proteins in diseases such as atopic dermatitis and lymphoma. The purpose of this study was to assess the role of CCL17 and CCL22 protein expression in colorectal cancer (CRC) and to ascertain whether an association exists between promoter -431C>T CCL17 and -961G>A CCL22 gene polymorphisms in CRC versus non-CRC subjects. Using the ELISA assay, we noted a significantly higher expression of CCL22 in tumour tissue with a 2.3-fold up-regulation (tumour vs. paired normal tissue, n=78) but no significant difference in CCL17 protein expression. Immunohistochemistry revealed protein expression of CCL22 and CCL17 in the epithelial compartment of cancer tissue, in epithelial cells at the resection border that reflects normal tissue, and in some stromal cells such as lymphocytes, macrophages, and fibroblasts. Using a TaqMan system we screened for -431C>T CCL17 and -961G>A CCL22 gene variants in 245 CRC patients and 256 controls, but could not find any significant difference in genotype distribution or in allelic frequencies between the two groups. The genotype and allelic distributions of CRC patients were not related to tissue levels of CCL17 and CCL22 protein, and none of the variables were associated with plasma levels or clinical characteristics. To ascertain whether the tissue expression of CCL17 and CCL22 exerts an influence on the pathogenesis of CRC, a forthcoming study on the 5-year survival rate of CRC patients will be conducted.

Identification of unique gene expression patterns within different lesional sites of keloids

Keloid disease is a significant clinical problem, especially in black populations, with an estimated incidence of 4-16%. Keloids are fibroproliferative dermal tumors developing as a result of deregulated wound healing. The dynamic nature of keloids is illustrated by clinical regression in the center, while the margin remains active growing into the surrounding healthy skin. Therefore, the gene expression profiles of fibroblasts from different sites of the keloids were characterized using Affymetrix microarrays covering the whole human genome. This study revealed 105 genes that were differentially regulated (79 genes were up-regulated and 26 down-regulated) in a unique gene expression profile in different sites of keloids where progression or regression of the process was in progress. The apoptosis inhibitor AVEN was found to be up-regulated at the active margin of keloids, while apoptosis-inducing genes such as ADAM12 and genes inducing extracellular matrix (ECM) degradation such as matrix metalloproteinase-19 were up-regulated in the regressing keloid center. We identified genes previously not described in the development of keloids. Activating proapoptotic genes or inhibiting ECM-inducing genes as INHBA or monocyte chemoattractant protein-1 might be possible target genes for new treatment strategies for keloid disease.

Polymorphisms of Fractalkine receptor CX3CR1 and plasma levels of its ligand CX3CL1 in colorectal cancer patients

BACKGROUND AND AIMS

The chemokine Fractalkine/CX3CL1, which is expressed by epithelial cells within normal colorectal mucosa and in colorectal cancer (CRC), is thought to have a crucial role in colorectal mucosal immunity by recruiting leucocytes via the receptor CX3CR1. The purpose of this study was to investigate two single-nucleotide polymorphisms of the Fractalkine receptor/CX3CR1 gene, V249I and T280M, in CRC to find out whether they occur more often in patients with CRC than in non-CRC individuals. In the search for tumour markers, we also intended to determine whether plasma levels of Fractalkine were correlated with parameters such as Dukes' stage, tumour localisation, gender and age in CRC patients.

MATERIALS AND METHODS

Genomic deoxyribonucleic acid from 223 CRC patients and 229 controls was amplified by polymerase chain reaction, and the polymorphisms were detected by the restriction fragment length polymorphism analysis. Fractalkine/CX3CL1 was analysed in plasma from 62 CRC patients and 78 controls using enzyme-linked immunosorbent assay.

RESULTS

The variant V249I was significantly different in genotype and allelic distribution between CRC patients and control subjects, P = 0.028 and P = 0.048, respectively. We also found that individuals with the I249 allele in homozygote state were less frequent in the CRC group (3.1%) compared with controls (9.2%; P = 0.008). No significant difference was observed regarding Fractalkine/CX3CL1 levels in plasma between patients and the control group.

CONCLUSION

Our results suggest that the lack of the allele I249 of the CX3CR1 gene may play a partial or minor role in CRC and that plasma Fractalkine/CX3CL1 does not seem to be a useful tumour marker that reflects the disease outcome of CRC.

Analysis of single nucleotide polymorphism in the promoter and protein expression of the chemokine eotaxin-1 in colorectal cancer patients

BACKGROUND

Previous studies suggest that chemokines (chemotactic cytokines) promote and regulate neoplastic progression including metastasis and angiogenesis. The chemokine eotaxin-1 is a powerful eosinophil attractant but also exerts chemotaxis of other leukocytes. Eotaxin-1 has been implicated in gastrointestinal disorders and may play an important role in colorectal mucosal immunity.

PATIENTS AND METHODS

The objective of this study was to assess the role of eotaxin-1 in colorectal cancer (CRC). Levels of eotaxin-1 protein in CRC tissues (n = 86) and paired normal mucosa were compared after determination by ELISA. Plasma eotaxin-1 levels from CRC patients (n = 67) were also compared with controls (n = 103) using the same method. Moreover, a TaqMan system was used to evaluate the -384A>G eotaxin-1 gene variant in CRC patients (n = 241) and in a control group (n = 253).

RESULTS

Eotaxin-1 protein levels in colorectal tumours were significantly (P < 0.0001) higher than in normal tissue. Immunohistochemistry revealed eotaxin-1 expression in stromal cells such as fibroblasts and leukocytes of the CRC tissue. The plasma eotaxin-1 level in CRC patients was lower compared with controls (P < 0.0001). Patients with tumours classified as Dukes' stage B and C had lower levels than patients with tumours in Dukes' stage A. We found no difference in genotype distribution but noted a difference regarding allele distribution (P = 0.036) and a dominance of allele G in rectal cancer patients.

CONCLUSION

The up-regulated eotaxin-1 protein expression in cancer tissue may reflect an eotaxin-1 mediated angiogenesis and/or a recruitment of leukocytes with potential antitumourigenic role. We noticed a dominance of the G allele in rectal cancer patients compared with colon cancer patients that was independent of eotaxin-1 expression.

Expression and gene polymorphisms of the chemokine CXCL5 in colorectal cancer patients

Several studies indicate that chemokines play important roles in colorectal mucosal immunity by recruiting leukocytes into and out of the lamina propria adjacent to the epithelium. The chemokine CXCL5 which is expressed by epithelial cells within colorectal mucosa is a chemoattractant for neutrophils and has been implicated in Crohn's disease and ulcerative colitis. In addition, CXCL5 is one chemokine which promote angiogenesis related to cancer. The objective of this study was to determine by ELISA assay whether CXCL5 protein level is altered in colorectal cancer (CRC) tissues (n=80) compared with paired normal mucosa. Furthermore, the plasma CXCL5 levels from CRC patients (n=62) compared with controls (n=71) were also examined. Using a TaqMan system we screened for -156G--> C and +398G-->A CXCL5 gene variants in CRC patients (n=228) and a control group (n=231) to assess the role of CXCL5 genotype in CRC. The analyses showed that CXCL5 protein level in colorectal tumours was significantly (P<0.0001) higher than in normal tissue and was lower in plasma in CRC patients compared with controls (P=0.026). Immunohistochemistry revealed CXCL5 immunoreactivity mainly in epithelial cells of the colorectal carcinoma and in normal epithelial cells. Furthermore, patients who were -156C carriers had higher CXCL5 protein concentration compared with -156G carriers in normal tissue (P=0.027) and CXCL5 protein levels in cancerous tissue tended to be higher for the patient -156C carriers (P=0.059). To our knowledge this is the first report on the influence of CXCL5 gene variants and their relation to expression of CXCL5 protein in human CRC.

No Immune Risk Profile among individuals who reach 100 years of age: findings from the Swedish NONA immune longitudinal study

In the present NONA immune longitudinal study, we investigate the previously identified Immune Risk Profile (IRP), defined by an inverted CD4/CD8 ratio and associated with persistent cytomegalovirus infection and increased numbers of CD8+CD28- cells, relative 6-year survival and age in NONA individuals. These subjects have now reached age 92, 96, and for the first time in this study, 100 years at follow-up. A 55 year old middle-aged group was used for comparison. Immunological monitoring included the analysis of numbers of lymphocytes and neutrophils, the T-cell subsets CD3+CD4+, CD3+CD8+, CD8+CD28+, CD8+CD28-, and the CD4/CD8 ratio. Longitudinal data were analysed by multivariate analyses of variance (MANOVA) from four measurement occasions at 2-year inter-intervals. One-way ANOVA was used for cross-sectional comparisons at baseline and the 6-year follow-up. The results confirmed the importance of the IRP as a major predictor of mortality in this population of very old. Moreover, the results suggested that survival to the age of 100 years is associated with selection of individuals with an "inverted" IRP that was stable across time, i.e., maintenance of a high CD4/CD8 ratio and low numbers of CD8+CD28- cells. The results underlines the importance of a longitudinal study design in dissecting immune parameters predictive of survival and show for the first time that centenarian status is associated with avoidance of the IRP over at least the previous 6 years and probably throughout life.

Transmission of Staphylococcus aureus from maternity unit staff members to newborns disclosed through spa typing

BACKGROUND

We observed previously that newborn infants are colonized with Staphylococcus aureus, even if their mothers do not carry S aureus. This observation indicated a cross colonization, and, thus, a risk for nosocomial infection, although the infants are roomed in with their mothers.

METHODS

The S aureus colonization of infants, their parents, and staff members was measured at 3 maternity units. Possible transmission routes were determined using spa typing of S aureus isolates.

RESULTS

Infants had the highest S aureus carriage (45%) compared with fathers (39%), mothers (27%), and staff members (27%). In 13 out of 44 colonized infants, transmission from staff members was indicated. This transmission was more frequent than was transmission from their own parents (11 cases), and occurred even in cases when parents were colonized with S aureus of other spa types.

CONCLUSIONS

We confirm a high level of transmission of S aureus from staff members to infants, indicating a risk for patient safety, which necessitates continuing work with implementing scientific evidence for infection control. The spa typing is a rapid and valuable epidemiological tool, and it can be used in improving hospital hygiene control programs.

Polymorphism and circulating levels of the chemokine CXCL12 in colorectal cancer patients

The chemokine CXCL12, also known as stromal cell-derived factor-1 (SDF-1), is a small protein that regulates leukocyte trafficking and is variably expressed in a number of normal and cancer tissues. CXCL12 as ligand and its receptor CXCR4 have been implicated in colorectal cancer (CRC) progression including angiogenesis and metastasis. A CXCL12 gene variant CXCL12-A (CXCL12-G801A, a single nucleotide polymorphism in the 3' untranslated region) is associated with increased susceptibility to breast cancer. Based on the suggested role of CXCL12 in the pathogenesis of cancer we examined the association of the gene variant CXCL12-A with CRC. The polymorphism was analysed with PCR and RFLP methods. Furthermore, the plasma CXCL12 levels from patients with CRC were also examined. There was no significant difference in genotype distribution and allelic frequencies between CRC patients (n=151) and controls (n=141). On the other hand, we found that the carrying rate of allele CXCL12-A was higher in colon cancer patients compared with rectal cancer patients (P=0.017). Analyses by ELISA showed that CRC patients (n=63) had a lower CXCL12 plasma level compared with controls (P<0.0001). Moreover, patients with tumours classified as Dukes' stage B and C revealed lower levels than patients with tumours in Dukes' stage A. Further studies with larger samples of patients are necessary to determine whether the CXCL12 polymorphism and plasma level reflect the clinical outcome of CRC and have an impact on CRC progression.

Antinuclear antibodies in the oldest-old women and men

The aim of this study was to compare the prevalence of antinuclear antibodies (ANA) in very old individuals (>or=86 years of age) with healthy younger (18-68 years) blood donors (n=200) regarding gender, health status, ratio of circulating CD4/CD8 cells and cytomegalovirus (CMV) serology. Frozen plasma was used for ANA detection in two study groups, i.e. 'OCTO' (97 persons aged 86-92 years, 65% women) and 'NONA' (136 persons aged 86-95 years, 70% women). OCTO participants were recruited on the basis that they were healthy or moderately healthy according to a selection protocol. No exclusion criteria regarding health status were applied in the NONA sample. The prevalence of ANA was significantly higher in the oldest-old samples compared to blood donors. There was no association between health status and the presence of ANA in the oldest-old. The difference across age was most pronounced in men, with low levels at younger age, whereas the prevalence among the oldest-old men reached similar levels as in women. There were no associations between the presence of ANA and CD4/CD8 ratio or with CMV status in the oldest-old. Our findings confirm an increased prevalence of ANA in the oldest-old, and emphasize the importance of taking gender and age into consideration when evaluating ANA.

Expression of interleukin-17 in human colorectal cancer

The proinflammatory cytokine IL-17 plays a potential role in T-cell mediated angiogenesis and promotes tumourigenicity of human cervical cancer. The objective of this study was to determine whether IL-17 protein level is altered in colorectal tumours (n=74) compared with paired normal mucosa and in plasma from patients (n=61) with colorectal cancer (CRC) compared with a healthy group (n=78). Analyses by ELISA showed that IL-17 protein was undetectable in 48.6% of the patients with cancer, as well as corresponding normal tissue which may in part reflect an individual difference. No significant difference was observed regarding IL-17 protein levels between cancer and matched normal tissue or in plasma between patients and the healthy group. Immunohistochemistry (n=20) revealed heterogenous immunoreactivity in 65% of the cases. The results of this study suggest that IL-17 plays a minor or partial role in CRC.

Effects of simvastatin on human T cells in vivo

OBJECTIVE

The use of statins has shown several anti-inflammatory actions, including modulatory effects on T cells in vitro. Since the effects on human T cells in vivo are less clarified, our aim was to investigate the effects of simvastatin on human T cells in vivo and ex vivo.

METHODS AND RESULTS

A randomized, double-blind, placebo-controlled study design was applied. Eighty volunteers with mild to moderate hypercholesterolemia received either simvastatin 40 mg or placebo for 6 weeks. The serum levels of C-reactive protein (CRP) were significantly reduced by simvastatin. The proportions of CD4+ and CD8+ T cell subsets expressing early (CD25) or late (HLA-DR) activation markers, as assessed by flow cytometry, were not changed by simvastatin. However, simvastatin tended to increase the density of HLA-DR and L-selectin per CD8+ T cell. The T helper(h)1/Th2 response was evaluated by stimulatory assays followed by intra-cellular staining of interferon-gamma and interleukin-4. Simvastatin treatment did not affect the Th1 response but the results indicated a potential to suppress Th2.

CONCLUSION

Simvastatin treatment resulted in a few discrete changes as regards peripheral T cells. However, the findings do not provide evidence that simvastatin-induced anti-inflammatory actions are related to any significant modulatory effects on human T cells in clinically healthy men with hypercholesterolemia.

The immune risk phenotype is associated with IL-6 in the terminal decline stage: findings from the Swedish NONA immune longitudinal study of very late life functioning

In the present NONA immune longitudinal study, we further examine the previously identified T cell immune risk phenotype (IRP), relative inflammatory activity, morbidity and 2-year mortality in very old individuals >90 years. T-cell subsets as well as the inflammatory markers IL-6, IL-10, C-reactive protein, transthyretin and albumin were evaluated. IRP and low-grade inflammation predicted 57% of observed deaths and 97% of survival over 2 years, and was not significantly affected by individuals' health status, suggesting that the physiological ageing processes of T-cell immunosenescence and low-grade inflammation are of primary importance in late life survival. IRP non-survivors showed only a minor inflammatory activity at baseline, but had in contrast to survivors developed increased activity at follow-up. The results suggest a sequence of stages for IRP individuals that begin with acquisition of CMV infection in earlier life, followed by generation of CD8+CD28- cells to control persistent CMV infection and eventually the development of an IRP. Intriguingly, we also found that rare individuals moved out of the IRP category by a process of immune suppression, including increases in IL-6 and IL-10 and decreases in the number of CD3+CD8+CD28- cells. The further characterisation of these exceptional individuals may allow insight into remedial approaches for those who remain in the IRP category until death.

An immune risk phenotype, cognitive impairment, and survival in very late life: impact of allostatic load in Swedish octogenarian and nonagenarian humans

In the previous OCTO longitudinal study, we identified an immune risk phenotype (IRP) of high CD8 and low CD4 numbers and poor proliferative response. We also demonstrated that cognitive impairment constitutes a major predictor of nonsurvival. In the present NONA longitudinal study, we simultaneously examine in a model of allostatic load IRP and compromised cognition in 4-year survival in a population-based sample (n = 138, 86-94 years). Immune system measurements consisted of determinations of T-cell subsets, plasma interleukin 6 and cytomegalovirus and Epstein-Barr virus serology. Interleukin 2 responsiveness to concanavalin A, using data from the previous OCTO (octogenarians) immune study, hereafter OCTO immune, was also examined. Cognitive status was rated using a battery of neuropsychological tests. Logistic regression indicated that the IRP and cognitive impairment together predicted 58% of observed deaths. IRP was associated with late differentiated CD8+CD28-CD27- cells (p < .001), decreased interleukin 2 responsiveness (p < .05) and persistent viral infection (p < .01). Cognitive impairment was associated with increased plasma interleukin 6 (p < .001). IRP individuals with cognitive impairment were all deceased at the follow-up, indicating an allostatic overload.

Infection of Human Endothelial Cells with Staphylococcus aureus Induces Transcription of Genes Encoding an Innate Immunity Response

Staphylococcus aureus is a gram-positive bacterium frequently isolated from patients with bloodstream infections. Endothelial cells (EC) play an important role in host defence against bacteria, and recent reports have shown that infection of EC with S. aureus induces expression of cytokines and cell surface receptors involved in activating the innate immune response. The ability of S. aureus to invade nonphagocytic cells, including EC, has been documented. However, the knowledge of the role of EC in pathogenesis of S. aureus infection is still limited. In this study, we investigate the gene-expression program in human EC initiated by internalized S. aureus, using microarray analysis. We found 156 genes that were differentially regulated at least threefold, using arrays representing 14,239 genes. Many of the upregulated genes code for proteins involved in innate immunity, such as cytokines, chemokines and cell adhesion proteins. Other upregulated genes encode proteins involved in antigen presentation, cell signalling and metabolism. Furthermore, intracellular bacteria survived for days without inducing EC death.

Metabolism of human cytochrome P450 marker substrates in mouse: a strain and gender comparison

The aim was to characterize mouse gender and strain differences in the metabolism of commonly used human cytochrome (CYP) P450 probe substrates. Thirteen human CYP probe substrates (phenacetin, coumarin, 7-ethoxy-4-trifluoromethyl coumarin, amiodarone, paclitaxel, diclofenac, S-mephenytoin, bufuralol, dextromethorphan, chlorzoxazone, p-nitrophenol, testosterone and lauric acid) were used in activity measurements. The metabolism of the probe substrates was compared in liver microsomes from male and female NMRI, CBA, C57bl/6, 129/SvJ and CD1 strains. The expression of proteins identified on Western blots with commonly available antibodies selective for specific human and rat CYP enzymes were compared in the different mouse strains. Males had higher metabolism than corresponding females for phenacetin O-deethylation (human marker for CYP1A2 activity), and a high correlation was found between phenacetin activity and immunoreactivity in Western blots produced with rat CYP1A2 antibodies. Protein detected by antibodies cross-reacting with human CYP2B6 and rat CYP2B1/2 antibodies was female specific except for the 129/SvJ strain, where it was absent in both genders. Females generally had a higher metabolism of bufuralol 1'-hydroxylation and dextromethorphan O-demethylation (human markers for CYP2D activity). Bufuralol 1'-hydroxylation correlated with a female-dominant mouse CYP, which was detected with antibodies against rat CYP2D4. p-Nitrophenol 2-hydroxylation correlated better than chlorzoxazone 6-hydroxylation with the protein detected with antibodies against rat CYP2E1, indicating that p-nitrophenol is a more specific substrate for mouse CYP2E1.

Clinical Isolates of Staphylococcus aureus Vary in Ability to Stimulate Cytokine Expression in Human Endothelial Cells

Human umbilical vein endothelial cells (HUVEC) were infected for 24 h with 18 well-characterized Staphylococcus aureus isolates, and the supernatants from infected HUVEC were analysed for interleukin (IL)-1beta, tumour necrosis factor-alpha, IL-6, IL-8, IL-10, IL-12p70, growth-related oncogene (GRO)-alpha, granulocyte macrophage colony-stimulating factor (GM-CSF) and regulated upon activation, normal T cell expressed and secreted (RANTES) by immunoassay. All staphylococcal isolates induced the expression of IL-6, IL-8, GRO-alpha, GM-CSF and RANTES. The magnitude of cytokine expression varied between isolates. Staphylococcus aureus inducing high expression of one of these cytokines also showed simultaneous high expression of the other four, indicating a common mechanism for the ability of individual S. aureus to induce expression of these cytokines. No direct correlation between cytokine expression and adhesion of S. aureus to HUVEC was observed, indicating that bacterial properties besides adhesion contribute to the activation of HUVEC.

Legionella pneumophila serogroup 1 antibody kinetics in patients with Legionnaires' disease: implications for serological diagnosis

To evaluate current serological criteria for Legionella pneumophila serogroup 1 (Lp1), the antibody response was prospectively studied in all patients hospitalized for Legionnaires' disease in a Swedish county during 11 y (n = 62). A 4-fold or greater rise in antibody titre to > or = 128 (the minimum convalescent antibody level for diagnosis, as recommended by the Centers for Disease Control and Prevention), using the indirect immunofluorescence antibody test, was found in 21/52 (40%) of tested patients. By referring to the titre levels in healthy residents from the local population (World Health Organization criteria), 45/52 (87%) cases were confirmed serologically. In 21 patients followed longitudinally for 10 y, the median antibody titre fell from 256 (range 32-1024) to 16 (range 2-128) in 3 y. No booster reactions were observed in any patient. After 10 y, the geometric mean titre of this clinical cohort had reached the same level as observed in the background population 5 y earlier. Titre levels in subjects exposed to Legionella from a municipal water system indicate that only 1 out of 10 of all infections are identified clinically. Indirect immunofluorescent antibody testing with local reference sera is a sensitive method for laboratory confirmation of Lp1 in an unselected pneumonia population.

Morbidity does not influence the T-cell immune risk phenotype in the elderly: findings in the Swedish NONA Immune Study using sample selection protocols

A critical issue in our understanding of ageing and the immune system refers to the health status of the population from which inferences are drawn. The commonly used SENIEUR protocol, selecting individuals representing 'normal ageing' has recently been under debate because a substantial amount of individuals with various health problems are excluded. The aim of the present study was to investigate the influence of morbidity on immune parameters and to evaluate the associations with the T-cell immune risk phenotype (IRP), related to cytomegalovirus (CMV) seropositivity by applying the SENIEUR protocol and the OCTO-Immune protocol in the unselected population based sample (n=138) of oldest-olds, participating in the Swedish NONA Immune Study. The SENIEUR protocol excluded over 90% of the sample whereas the OCTO-Immune protocol excluded almost 65% of the sample. Three independent groups, very healthy (SENIEUR), moderately healthy (OCTO-Immune) and frail (non-SENIEUR/non-OCTO-Immune) were created. Flow cytometry studies on lymphocyte sub-populations revealed no significant difference in CD4/CD8 ratio, CD3+CD4-CD8+, CD3+CD4+CD8-, CD8+CD57+CD28-, CD8+CD56+CD57- or CD8+CD56+CD57+ between the very healthy, moderately healthy and the frail subsamples. Our findings indicate that morbidity does not significantly influence the T-cell immune risk profile in the elderly, and we suggest the inclusion of broader samples in future immunogerontological studies.

Toxicity of ultraviolet radiation exposure to the lens expressed by maximum tolerable dose

The maximum tolerable dose (MTD2.3:16) for avoidance of cataract on exposure to ultraviolet radiation (UVR)-300 nm in the rat was here estimated at 3.65 kJ/m2. Sprague-Dawley rats were unilaterally exposed to UVR in the 300 nm wavelength region. One week after the exposure, the intensity of forward light scattering was measured. Toxicity for continuous response events can be estimated with MTD. Current safety standards for avoidance of cataract after exposure to UVR are based on a binary response event. It has, however, recently been shown that UVR-induced cataract is a continuous dose-dependent event. MTD provides a statistically well-defined criterion of toxicity for continuous response events.

Control of nosocomial Legionnaires' disease by keeping the circulating hot water temperature above 55 degrees C: experience from a 10-year surveillance programme in a district general hospital

After a nosocomial outbreak of Legionnaires' disease in a 450-bed district general hospital in 1991, the circulating hot water temperature was kept above 55 degrees C as the sole control measure. From 1991 to 2000, all cases of nosocomial pneumonia were clinically monitored and tested for Legionella pneumophila serogroup 1 by serology or urinary antigen detection. Water samples from peripheral tap sites were cultured for Legionella spp. twice a year. An infection with L. pneumophila serogroup 1 was diagnosed in four out of 366 (1.1%) patients treated for nosocomial pneumonia, representing one case per 26,000 admissions. All patients were cured without complications. L. pneumophila serogroup 1 was isolated in 30 of 251 (12%) cultured hospital water samples during the monitoring period. We conclude that control of nosocomial Legionnaires' disease in a primary referral hospital is possible by keeping the circulating hospital hot water temperature above 55 degrees C, together with careful clinical surveillance. Complete eradication of Legionella spp. from the hot water system does not seem necessary.

Variations among clinical isolates of Staphylococcus aureus to induce expression of E-selectin and ICAM-1 in human endothelial cells

Eighteen clinical isolates of Staphylococcus aureus, nine methicillin-sensitive and nine methicillin-resistant, were investigated for their ability to induce expression of E-selectin and ICAM-1 in human endothelial cells. Upregulation of adhesion molecules varied between isolates; 17 isolates induced expression of E-selectin and 13 of ICAM-1. Some isolates induced a significant expression of E-selectin without stimulation of ICAM-1, whereas the opposite was not found. Bacterial viability was required for induction of the adhesion molecules. The kinetics of ICAM-1 expression in S. aureus-infected cells differed from those stimulated with interleukin-1beta (IL-1beta). On the other hand, expression of E-selectin was very similar in S. aureus-infected and IL-1beta-stimulated cells. There was no correlation between ability of S. aureus to induce expression of cell adhesion molecules, methicillin susceptibility, pulse field gel electrophoresis patterns, biochemical characteristics, phage typing and toxin production.

Community spread of Legionella pneumophila serogroup 1 in temporal relation to a nosocomial outbreak

To clarify whether a nosocomial outbreak of legionnaires' disease in the Värnamo hospital in Sweden was part of a wider outbreak in the Värnamo community a number of investigations were performed. First, the proportion of cases of legionnaires' disease in a group with nosocomially acquired pneumonia (11%) was compared to the proportion within a group with community-acquired pneumonia (14%) and the difference was found not to be significant (p > 0.05). Second, the proportion of the nursing staff at the Värnamo hospital with an elevated antibody titre (> or = 16) to Legionella pneumophila serogroup (sg) 1 (33%, 84/258) was compared to the proportion in a group of local residents of Värnamo community (26%, 25/96) and found not to be significant; in contrast, comparison with the proportion in a group from the assistant nursing staff at another hospital 60 km away (5%, 4/80) was highly significant (p < 0.001). Furthermore, Legionella species were cultured from samples drawn from the hospital water supply as well from the water supply from municipal buildings. In 1996 a follow-up study was conducted, which showed that < 1% of the assistant nurses and local residents had an elevated titre to L. pneumophila sg 1. These results indicate that there was a temporary spread of L. pneumophila sg 1 in the Värnamo community at the beginning of 1991, both in the local hospital and the surrounding community. This implies that physicians should be aware of community-acquired cases of legionnaires' disease when a nosocomial outbreak is detected.

Expansions of peripheral blood CD8 T-lymphocyte subpopulations and an association with cytomegalovirus seropositivity in the elderly: the Swedish NONA immune study

Results from a previous longitudinal study, the Swedish OCTO-Immune study, indicated that the combination of higher CD8 peripheral blood lymphocytes (PBLs), decreased CD4 PBLs, and poor proliferative response to mitogenic stimulation in very old humans were associated with an increased 2 year mortality. In follow up studies this combination of immune parameters was significantly associated with a CD4/CD8 ratio less than one and positive IgG serologic titers to cytomegalovirus (CMV). The present study, the Swedish NONA-Immune study, was an extension of that study, using a new sample of the very old. The results of this study confirmed the results of the previous study and extended the surface marker profile of the PBLs, indicating that the CD4/CD8 ratio change is associated with increased CD8 cells, decreased CD4 cells, and lymphocyte activation. The predominant phenotypes of the CD3+CD8+ cells were CD27-, CD28-, CD56+, and CD57+, CD45RA+, and double marked CD45RA+RO+. As in the OCTO study, the NONA-Immune data indicated that the changes are associated significantly with seropositive responses to CMV.

Lens lactate dehydrogenase inactivation after UV-B irradiation: an in vivo measure of UVR-B penetration

PURPOSE

To elucidate the spatial distribution of inactivation of lactate dehydrogenase (LDH) in ultraviolet-B radiation (UVR-B)-exposed eyes. To determine the in vivo penetration depth of UVR-B in the lens.

METHODS

LDH activity in cornea and lens was investigated with an enzyme histochemical technique. Thirty rats were exposed in vivo to UVR-B of approximately 300 nm, and the eyes were enucleated and frozen at 0, 2, and 6 hours after exposure. LDH activity in frozen sections was determined quantitatively in the corneal epithelium and four different regions in the lens. UVR-B penetration depth was estimated by using a calculated Lambertian absorption coefficient.

RESULTS

The LDH activity was decreased in the cornea and the outer anterior lens cortex at all three time points. The average decrease in enzyme activity in the time range was 35% in the cornea and 20% in the outer anterior lens cortex. UVR-B inhibition of LDH was immediate and not dependent on an inflammatory reaction within the eye. Penetration depth, corresponding to 1/e(2) ( approximately 14%) residual UVR-B intensity, was 0.45 mm.

CONCLUSIONS

UVR-B does not exhibit any significant effect on LDH activity in the major part of the lens, and this is attributed to the shallow penetration (0.45 mm) of UVR-B into the anterior parts of the lens.

Environmental effects of one thousand years of copper production at Falun, central Sweden

Copper production in Falun, central Sweden, has emitted sulfur dioxide (SO2) and metals to the air during at least 1000 years. Emissions peaked in the 17th century when Falun produced 2/3 of the world's copper supply. This area offers unique opportunities to study long-term effects of acid deposition and metal pollution, including recovery following the three centuries of decreasing SO2 and metal deposition. Here we present a 1000-yr perspective on local emissions of SO2, estimated air concentrations and dry deposition of SO2, as well as results on acidification and metal pollution of soils and lakes. Despite a long period when deposition of SO2 exceeded the critical load, soil acidification is limited to the most heavily polluted area 12 km NW and SE from the mine. According to diatom analyses of take sediments, only 8 of 14 lakes have become acidified (0.4-0.8 pH units). None of these lakes show recovery from acidification, probably due to large amounts of sulfate still accumulated in the soils and changes in land use.

Age-related change in peripheral blood T-lymphocyte subpopulations and cytomegalovirus infection in the very old: the Swedish longitudinal OCTO immune study

Results from the previous times (Times 1-3) of the Swedish longitudinal OCTO immune study indicated that a combination of high CD8 and low CD4 percentages and poor T-cell proliferation in PBL was associated with a higher 2-year mortality in a sample of very old Swedish individuals. The combination of immune parameters was closely related to an inverted CD4/CD8 ratio. In the present study at Time 4 (T4) results are reported from the final follow-up of this longitudinal study, 8 years after it was initiated in 1989. An additional goal at this time point was to examine the immune system alterations in the very old in relation to evidence of lymphocyte activation and cytomegalovirus antibody status. In the present study immune system changes were identified that suggest a loss of T-cell homeostasis, as reflected by a decrease in the number of CD4 cells and a very significant increase in the number of CD8 cells in individuals with an inverted CD4/CD8 ratio. When considered over the duration of the OCTO study the inversion occurred in a high percentage (32%) of the individuals included in the original sample and was associated with non-survival. At T4 the changes were apparent in a number of the T-cell subsets, but particularly in the CD8+CD28-and CD57+ subsets. T-cell activation was significantly associated with the inversion of the CD4/CD8 ratio. In this very old sample the subset alterations were associated with evidence of cytomegalovirus (CMV) infection.

An action spectrum for UV-B radiation and the rat lens

PURPOSE

To determine an action spectrum for UV-B radiation and the rat lens and to show the effect of the atmosphere and the cornea on the action spectrum.

METHODS

One eye of young female rats was exposed to 5-nm bandwidths of UV-B radiation (290, 295, 300, 305, 310, and 315 nm). Light scattering of exposed and nonexposed lenses was measured 1 week after irradiation. A quadratic polynomial was fit to the dose-response curve for each wave band. The dose at each wave band that produced a level of light scattering greater than 95% of the nonexposed lenses was defined as the maximum acceptable dose (MAD). Transmittance of the rat cornea was measured with a fiberoptic spectrophotometer. The times to be exposed to the MAD in Stockholm (59.3 degrees N) and La Palma (28 degrees N) were compared.

RESULTS

Significant light scattering was detected after UV-B at 295, 300, 305, 310, and 315 nm. The lens was most sensitive to UV-B at 300 nm. Correcting for corneal transmittance showed that the rat lens is at least as sensitive to UV radiation at 295 nm as at 300 nm. The times to be exposed to the MAD at each wave band were greater in Stockholm than in La Palma, and in both locations the theoretical time to be exposed to the MAD was least at 305 nm.

CONCLUSIONS

After correcting for corneal transmittance, the biological sensitivity of the rat lens to UV-B is at least as great at 295 nm as at 300 nm. After correcting for transmittance by the atmosphere, UV-B at 305 nm is the most likely wave band to injure the rat lens in both Stockholm and La Palma.

Repair in the rat lens after threshold ultraviolet radiation injury

PURPOSE

To investigate the development and recovery of lens damage after in vivo close-to-threshold exposure to ultraviolet B radiation.

METHODS

One eye of young, female Sprague-Dawley rats was exposed to 5 kJ/m2 narrowband ultraviolet radiation (UVR) (lambda(max) = 302 nm) for 15 minutes. Groups of rats were killed 1, 7, and 56 days after exposure. The structure of the exposed and nonexposed lenses was examined with light microscopy, scanning electron microscopy, transmission electron microscopy, freeze-fracture, fluorescent membrane staining, and Fourier transform analysis.

RESULTS

One day after UVR exposure the lens surface had flakelike opacities. Seven days after exposure, the lens surface appeared opaque and corrugated, and the equatorial cortex had small opacities. At 56 days postexposure, the surface and equator appeared clear, but the cortex had a subtle shell-shaped opacity. At 1 day postexposure, apoptotic cell death occurred in the lens epithelium, but the cortical fibers were normal. At 7 days postexposure, the epithelium and the fibers between the 10th and 40th growth shell below the capsule contained extracellular spaces of different sizes. After 56 days, the epithelial layer appeared normal, and the extracellular spaces had disappeared; but abnormal fibers were found between the 60th and 100th growth shell below the capsule. Fibers above and below the damaged growth shells appeared fully normal.

CONCLUSIONS

A close-to-threshold dose of UVR causes cataract, which is largely reversible. The UVR exposure leads to apoptosis in the lens epithelium, and after a latency period of several days, lens fibers are abnormal. Extracellular spaces develop in the epithelium and fibers. Within several weeks after exposure, the epithelium fully recovers and new fibers develop normally. The originally affected fibers are repaired. However, this repair is incomplete, leaving a small zone of enhanced light scattering in the equatorial cortex.

Lens opacities after repeated exposure to ultraviolet radiation

PURPOSE

To investigate the effect of the interval between two, near-threshold exposures to ultraviolet radiation (UVR) on cataract development.

METHODS

One eye of Sprague-Dawley rats was exposed twice to 4 kJ/m2 narrow band UVR (lambdaMAX=300 nm) for 15 min each. The interval between exposures was 0, 6, 24 or 48 h. One week after the first exposure both lenses were removed for photography and measurement of the intensity of forward light scattering to quantify lens opacities.

RESULTS

All exposed lenses developed cataract. Forward light scattering was the same after double exposure with no interval or a 6 h interval. Forward light scattering after a 24 or 48 h interval was nearly twofold greater than that following no interval or a 6 h interval. The exposed lenses in all groups had mild anterior surface opacities and intense equatorial opacities as judged with a stereomicroscope.

CONCLUSION

Two, near-threshold UVR exposures at 0 or a 6 h interval produce the same degree of lens opacification. When the second exposure follows 24 or 48 h after the first, lenticular damage increases. Repair processes between 24 and 48 h after exposure appear to be sensitive to UVR, and an additional exposure during this time may aggravate cataract development.

Histochemical determination of lactate dehydrogenase activity in rat lens; influence of different parameters

PURPOSE

1. To optimize a histochemical technique for the determination of lactate dehydrogenase activity in rat lens. 2. To determine the distribution of lactate dehydrogenase activity within the lens. 3. To analyse different components of variation in the method.

METHODS

A total of 24 six-week-old Sprague-Dawley rats were used. Cryosections of whole eyes were incubated with different media. The influence of incubation time, pH, the concentration of dye, lactate, nicotinamide dinucleotide, phenazine methosulfate, sodium azide, hydrazine and polyvinyl alcohol on the enzyme histochemical reaction was investigated. The staining reactant was nitrobluetetrazolium and the staining density was measured with a microscope-based photometer.

RESULTS

The lactate dehydrogenase activity was highest in the epithelium, followed by the nucleus, the anterior cortex, and the posterior cortex. The three largest components of variation in the analyses were rats, sections (including variation in section thickness) and density measurements (including variation within the different regions).

CONCLUSION

The composition of the final incubation medium for the detection of lactate dehydrogenase activity in rat lens are similar to that shown for other tissues. Lactate dehydrogenase activity varies in different regions of the lens.

Rat lens glycolysis after in vivo exposure to narrow band UV or blue light radiation

UV radiation and short wavelength visible light are known to damage various tissues in the eye. This paper investigates the effect on rat lens glycolysis after in vivo exposure with 90 kJ m-2 narrow band UV radiation (UVB, 300 nm) and 90 kJ m-2 blue light (435 nm) radiation. After exposure, all lenses were incubated in Medium 199. Samples of culture medium were withdrawn after 2, 4, 6 h and 5, 10, 20 h in two UVB studies and after 5, 10 and 20 h in a blue light study. Lactate is the major end product of lens glycolysis. Lactate was determined with a modified enzymatic-photometric method. Intralenticular lactate was determined in one UVB experiment. In the UVB experiments we found a lower lactate production in the exposed lenses 2-6 h after exposure. There was an accumulation of lactate inside UVB-exposed lenses after 6 h incubation compared with their contralateral lenses. No significant effect on lactate production was observed in the blue light experiment. CONCLUSIONS. UVB induced a reversible inhibition of glycolysis. UVB also induced an accumulation of lactate inside the lens. Blue light tended to increase glycolysis.

Antibody prevalence and immunoglobulin IgG subclass pattern to Norwalk virus in Sweden

The antibody prevalence in Sweden to Norwalk virus (NV) was investigated using a baculovirus expressed capsid antigen. One hundred thirty-two serum samples were examined for IgA, total IgG and IgG subclass antibodies to Norwalk virus. In young children, NV IgG antibody prevalence was higher than the IgA prevalence, whereas no difference was found in individuals older than 21 years. The IgG antibody prevalence was 50% in children below 5 years of age and increased to > 80% in individuals older than 10 years of age. To examine the IgG antibody response in more detail, IgG subclass patterns were characterized. IgG 1 predominated in all age groups. IgG 4, usually detected after repeated exposure to antigen, was the second most prevalent subclass, but was only found in individuals older than 21 years of age. IgG 3 subclass antibodies were found in 13% and IgG 2 in 3% of the sera examined. IgG 3 subclass antibodies have been recognized as a marker for recent or ongoing viral infections.

Legionella urinary antigen in early disease

The results of Legionella urinary antigen testing were correlated to the interval between onset of disease and sampling of urine in 134 patients in connection with a large outbreak of Legionnaires' disease at a Swedish hospital. In 17 patients with the disease, 5/7 sampled during the first 5 days of illness proved negative in the urinary antigen test. The risk of obtaining negative results during the first days of the disease is emphasized.

An outbreak of Legionnaires' disease in a Swedish hospital

We report a nosocomial outbreak of Legionella pneumophila serogroup (sg) 1 infection at the general hospital, Värnamo, Sweden. From December 1990 to February 1991, 28 patients and 3 staff fell ill with pneumonia and 3 died. L. pneumophila sg 1 together with several other Legionellae were isolated from the hot water supply to 17 of 20 hospital wards, probably being spread by aerosolization via shower nozzles. Raising the hospital's hot water temperature from 45 degrees C to 65 degrees C, together with heat disinfection of the shower equipment, arrested the outbreak within a week. Keeping the hot water temperature > or = 60 degrees C without chlorination eliminated L. pneumophila from > 75% of the wards. During a period of 2 years after the outbreak we have diagnosed only 1 case of nosocomial legionellosis at the hospital despite an active surveillance program.