CXC chemokine receptor CXCR2 is essential for protective innate host response in murine Pseudomonas aeruginosa pneumonia

Pulmonary infection due to Pseudomonas aeruginosa has emerged as a leading cause of mortality. A vigorous host response is required to effectively clear the organisms from the lungs. This host defense is dependent on the recruitment and activation of neutrophils and macrophages. A family of chemotactic cytokines (chemokines) has been shown to participate in this protective response. In this study, we assessed the role of the ELR(+) (glutamic acid-leucine-arginine motif positive) CXC chemokines and their CXC chemokine receptor (CXCR2) in lung antibacterial host defense. The intratracheal administration of Pseudomonas to mice resulted in the time-dependent influx of neutrophils to the lung, peaking at 12 to 24 h after inoculation. The influx of neutrophils was associated with a similar time-dependent expression of the ELR(+) CXC chemokines, KC, macrophage inflammatory protein 2 (MIP-2), and lipopolysaccharide-induced CXC chemokine (LIX). Selective neutralization of MIP-2 or KC resulted in modest changes in neutrophil influx but no change in bacterial clearance or survival. However, neutralization of CXCR2 resulted in a striking increase in mortality, which was associated with a marked decrease in neutrophil recruitment and bacterial clearance. Conversely, the site-specific transgenic expression of KC resulted in enhanced clearance of bacteria after Pseudomonas challenge. This study indicates that ELR(+) CXC chemokines are critical mediators of neutrophil-mediated host defense in Pseudomonas pneumonia.

Effect of atrial fibrillation on pulmonary venous flow patterns assessed by Doppler transesophageal echocardiography

STUDY OBJECTIVES

To investigate the effect of atrial fibrillation (AF) on pulmonary venous flow (PVF) patterns in a cohort with nonrheumatic AF.

DESIGN AND SETTINGS

A prospective and controlled study undertaken at a tertiary referral medical center.

PATIENTS AND MEASUREMENTS

The echocardiographic parameters of left superior PVF as assessed by Doppler transesophageal echocardiography in 40 patients with chronic AF (group 1) were compared to those of 33 volunteers with sinus rhythm (group 2) and well-matched baseline characteristics.

RESULTS

: All group 1 patients presented with single systolic forward flow (SFF) patterns. In contrast, single and double SFF patterns were found equally in group 2. With regard to reverse flow (RF), most group 1 patients (33 of 40) had an early systolic RF and none had atrial RF; however, most group 2 subjects (29 of 33) had an atrial RF. Some of the group 1 patients (17%) had a late systolic RF in the absence of significant mitral regurgitation. In group 1, the SFF appeared later and disappeared earlier than in group 2. The mean systolic peak velocity and time-velocity integral (TVI) of the SFF were significantly lower in group 1 compared to group 2. The diastolic peak velocity and TVI were not significantly different between groups.

CONCLUSIONS

: Our data indicate that AF independently and significantly affects the PVF and leads to characteristic flow patterns different from sinus rhythm. The presence of AF reduces SFF in addition to the absence of atrial RF. These changes in the flow patterns should be taken into account while interpreting the implications of PVF in the presence of AF.

Characterization of the inhibition of DNA synthesis in proliferating mink lung epithelial cells by insulin-like growth factor binding protein-3

Insulin-like growth factor binding protein-3 (IGFBP-3) can inhibit cell growth by directly interacting with cells, as well as by forming complexes with IGF-I and IGF-II that prevent their growth-promoting activity. The present study examines the mechanism of inhibition of DNA synthesis by IGFBP-3 in CCL64 mink lung epithelial cells. DNA synthesis was measured by the incorporation of 5-bromo-2'-deoxyuridine, using an immunocolorimetric assay. Recombinant human IGFBP-3 (rh[N109D,N172D]IGFBP-3) inhibited DNA synthesis in proliferating and quiescent CCL64 cells. Inhibition was abolished by co-incubation of IGFBP-3 with a 20% molar excess of Leu(60)-IGF-I, a biologically inactive IGF-I analogue that binds to IGFBP-3 but not to IGF-I receptors. DNA synthesis was not inhibited by incubation with a preformed 1:1 molar complex of Leu(60)-IGF-I and IGFBP-3, indicating that only free IGFBP-3 inhibits CCL64 DNA synthesis. Inhibition by IGFBP-3 is not due to the formation of biologically inactive complexes with free IGF, since endogenous IGFs could not be detected in CCL64 conditioned media; any IGFs that might have been present could only have existed in inactive complexes, since endogenous IGFBPs were present in excess; and biologically active IGFs were not displaced from endogenous IGFBP complexes by Leu(60)-IGF-I. After incubation with CCL64 cells, (125)I-IGFBP-3 was covalently cross-linked to a major thick similar400-kDa complex. This complex co-migrated with a complex formed after incubation with (125)I-labeled transforming growth factor-beta (TGF-beta) that has been designated the type V TGF-beta receptor. (125)I-IGFBP-3 binding to the thick similar400-kDa receptor was inhibited by co-incubation with unlabeled IGF-I or Leu(60)-IGF-I. The ability of Leu(60)-IGF-I to decrease both the inhibition of DNA synthesis by IGFBP-3 and IGFBP-3 binding to the thick similar400-kDa receptor is consistent with the hypothesis that the thick similar400-kDa IGFBP-3 receptor mediates the inhibition of CCL64 DNA synthesis by IGFBP-3.

Cytokines as targets of immunotherapy in bacterial pneumonia

The generation of a vigorous inflammatory response is essential for the rapid clearance of microbes from the alveolar space. The magnitude of the inflammatory response is tightly controlled by host-derived cytokines, which mediate lung inflammation by serving as leukocyte chemoattractants, leukocyte activating factors, or afferent signals in the induction or regulation of other effector molecules. In this article the role of specific cytokines in lung innate immunity will be reviewed. Future directions regarding the use of specific forms of immunotherapy, including compartmentalized cytokine delivery with gene therapy as adjuvant therapy in the treatment of pneumonia, will be explored.

G-33A mutation in the promoter region of thrombomodulin gene and its association with coronary artery disease and plasma soluble thrombomodulin levels

Thrombomodulin is an endothelial glycoprotein that decreases thrombin activity and activates protein C. A recent study has shown that G-33A promoter mutation of the thrombomodulin gene occurs particularly in Asians. In this study, we analyzed the distribution of G-33A mutation in the promoter region of the thrombomodulin gene in the Chinese population and determined whether the mutation might be a risk for coronary artery disease (CAD). In addition, the influence of this mutation on plasma soluble thrombomodulin levels in patients with CAD was also examined. We studied 320 consecutive patients (mean age 63 years; 73% men) with CAD and 200 age- and sex-matched control subjects. Screening for thrombomodulin G-33A promoter mutation was conducted using polymerase chain reaction, single-strand conformation polymorphism, and direct deoxyribonucleic acid sequencing. The frequency of the G-33A mutation (GA+AA genotypes) was significantly higher in the CAD group (23.8% vs 15.5%, odds ratio [OR] 1.70, p = 0.031). Multiple logistic regression analysis showed that the mutation was an independent risk factor (OR 1.81, p = 0.016) for CAD, as was hypertension (OR 1.44, p = 0.040), diabetes mellitus (OR 2.50, p <0.001), and smoking (OR 2.15, p <0.001). In CAD patients with GG genotype, the soluble thrombomodulin level increased with the extent of CAD (36 +/- 15 vs 47 +/- 18 vs 55 +/- 36 ng/ml in 1-, 2-, or 3-vessel CAD, p <0.001). However, in CAD patients with G-33A mutation, there was no difference between the levels of soluble thrombomodulin (39 +/- 17 vs 37 +/- 15 vs 42 +/- 18 ng/ml, p = NS) in 1-, 2-, or 3-vessel CAD. Our observations suggest that there is a significant association of the G-33A mutation in thrombomodulin gene with CAD, and this mutation may influence the soluble thrombomodulin levels in patients with CAD.

Correlation of homocytsteine levels with the extent of coronary atherosclerosis in patients with low cardiovascular risk profiles

Elevation of homocysteine is now known as an independent risk factor for vascular diseases. However, influences of homocysteine to the extent of coronary atherosclerosis in patients with different coronary risk profiles have not been studied. In this study, we used angiographic "diffuse score" and "clinical vessel score" to evaluate the extent of coronary atherosclerosis, and examined the correlation between levels of serum total homocysteine and angiographic scores among patients with high- and low-risk profiles. Seventy consecutive patients (58 men and 12 women, mean age 50 years) undergoing selective coronary angiography for the first time were recruited for this study. Patients were divided into high-risk (risk factor > or =3, n = 35) and low-risk (risk factor <3, n = 35) groups. Linear regression analysis revealed that levels of serum homocysteine were only significantly correlated with diffuse (r = 0.217, p = 0.007) and clinical vessel (r = 0.078, p = 0.037) scores in low-risk patients. These correlations could not be observed in diffuse (r = 0.070, p = 0.319) and clinical vessel (r = -0.001, p = 0.970) scores in the high-risk group. In conclusion, levels of homocysteine correlated with the extent of coronary atherosclerosis only among patients with low cardiovascular risk profiles.

CXC chemokine receptor-2 ligands are necessary components of neutrophil-mediated host defense in invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis is a devastating complication of immunosuppression, which occurs in association with neutrophil dysfunction or deficiency. ELR+ CXC chemokines are a subfamily of chemokines that play a critical role in neutrophil chemotaxis and activation both in vitro and in vivo. We hypothesized that interaction of these ligands with CXC chemokine receptor-2 (CXCR2), their sole murine receptor, is a major component of neutrophil-dependent pulmonary host defense against Aspergillus fumigatus. In immunocompetent animals, neutrophils were recruited to the lung in response to intratracheally administered A. fumigatus conidia. In a model of transient in vivo depletion of neutrophils, animals developed invasive pulmonary aspergillosis, associated with delayed influx of neutrophils into the lung. In both normal and neutrophil-depleted animals, the ELR+ CXC chemokines MIP-2 and KC were induced in response to intratracheal administration of conidia. Ab-mediated neutralization of the common ELR+ CXC chemokine receptor, CXCR2, resulted in development of invasive disease indistinguishable from the disease in neutrophil-depleted animals, while control animals were highly resistant to the development of infection. CXCR2 neutralization was associated with reduced lung neutrophil influx and resulted in a marked increase in mortality compared with controls. In contrast, animals with constitutive lung-specific transgenic expression of KC were resistant to the organism, with reduced mortality and lower lung burden of fungus. We conclude that CXCR2 ligands are essential mediators of host defense against A. fumigatus, and may be important targets in devising future therapeutic strategies in this disease.

The mechanical properties of the heel pad in unilateral plantar heel pain syndrome

Plantar heel pain syndrome has been attributed to entrapment neuropathy, plantar fasciitis, calcaneal spurs, and stress fractures of the calcaneus. Although deteriorated mechanical properties of the heel pads may play an important role in the pathogenesis of heel pain syndrome, this has received little notice. In this study, a specially designed compression relaxation device with a push-pull scale and a 10-MHz linear array transducer was used to determine thickness of the heel pad under different loading conditions. Twenty consecutive patients aged 29 to 77 years with unilateral plantar heel pain syndrome were enrolled. Thickness of heel pad bilaterally was measured when the heel pad was compressed by serial increments of 0.5 kg to a maximum of 3 kg and then relaxed sequentially. The load-displacement curve during a loading-unloading cycle was plotted, and the compressibility index and energy dissipation ratio of the heel pad were calculated accordingly. Phase I displacement of the heel pad (from 0 to 1 kg load) on the painless side was greater than that on the painful side (P < 0.01), but there was no statistically significant difference between painless and painful sides in thickness of unloaded heel pads, compressibility index, or energy dissipation ratio (P > 0.05). In conclusion, the affected heel pad in plantar heel pain syndrome was stiffer under light pressure than the heel pad on the painless side. The changed nature of chambered adipose tissue in a painful heel pad may be responsible for its increased stiffness under light pressure.

HLA-DMA and HLA-DMB genotyping in patients with systemic lupus erythematosus

OBJECTIVE. To investigate the relation of HLA-DMA and DMB alleles to the development of systemic lupus erythematosus (SLE).

METHODS

We studied HLA-DMA and DMB alleles in 108 patients with SLE and 138 healthy controls using the amplification created restriction site method.

RESULTS

The phenotypic frequency of HLA-DMA*0104 was significantly higher in patients with SLE than in healthy controls. The HLA-DMA and DMB alleles were not related to clinical manifestations and various laboratory tests in patients with SLE.

CONCLUSION

HLA-DMA*0104 may be associated with the susceptibility of SLE.

Pulmonary artery leiomyosarcoma

Pulmonary artery leiomyosarcoma is a rare but highly lethal disease, and can be mistaken for pulmonary thromboembolism. We report a case of pulmonary artery leiomyosarcoma managed with surgical resection, chemotherapy, and radiotherapy. A 57-year-old woman was admitted with complaints of aggravated dyspnea. She was initially treated with oxygen therapy and heparinization for a suspected pulmonary embolism. Echocardiography revealed a dilated right atrium and ventricle and severe tricuspid regurgitation, with an estimated systolic right ventricular pressure of 95 mm Hg; a shadow of a mass in the main pulmonary artery was also noted. Right ventriculography revealed a filling defect, and to-and-fro motion of the mass in the main pulmonary artery. The left pulmonary artery was almost totally occluded by the mass. The patient's condition improved dramatically after palliative excision of the mass and patch reconstruction of the outflow tract of the right ventricle with a bicuspid xenograft. Pathologic examination of the mass revealed leiomyosarcoma. Chemotherapy and radiotherapy were subsequently administered and follow-up imaging studies 3 months postoperatively revealed no recurrence of the tumor. The patient remains well, more than 1 year after treatment. This report emphasises that pulmonary artery sarcoma should be considered in the differential diagnosis in cases of suspected pulmonary thromboembolism.

Prognostic determinants of infective endocarditis in the 1990s

The clinical profiles of infective endocarditis (IE) might have changed in recent years, owing to the advent of transesophageal echocardiography, the introduction of new diagnostic criteria, and the increased frequency of intravenous drug abuse. In this retrospective study, we sought to identify factors affecting the in-hospital outcome of IE patients in a single tertiary referral center in the 1990s (1990-1997). Eighty-eight episodes of IE in 80 consecutive patients admitted from January 1990 through June 1997 were evaluated. Clinical variables that were significantly associated with in-hospital mortality in univariate analyses were entered into a multiple logistic regression model. A total of 22 patients (25%) died. Fatal episodes were significantly more likely than non-fatal episodes to involve older patients (> or = 50 years), use of coumadin, short interval between symptom onset and hospitalization (< 15 days), noncardiac shock, and complications of the heart, central nervous system, and kidneys. White blood cell counts and C-reactive protein concentrations were also significantly higher in fatal than in non-fatal episodes of IE. Multivariate analysis showed that in-hospital mortality was associated with noncardiac shock, neurological complications, cardiac complications, and older age (> or = 50 years). Compared with previous reports, our findings suggest that the clinical profiles of IE have undergone some changes in the 1990s. The most important prognostic predictors of in-hospital mortality in patients with IE were noncardiac shock and neurologic complications.

HLA-DMA and HLA-DMB genotyping in patients with rheumatic diseases

To investigate the correlation of HLA-DMA and DMB alleles to some rheumatic diseases, HLA-DMA and DMB genes were detected in 11 patients with juvenile rheumatoid arthritis (JRA), 22 patients with psoriatic arthritis, 26 patients with Behcet's disease, 62 patients with ankylosing spondylitis (AS), and 138 unrelated healthy controls. There was no significant difference in phenotypic frequencies of HLA-DMA and DMB alleles between controls and patients with these rheumatic diseases. HLA-DMA and DMB genes are not related to the susceptibility of JRA, psoriatic arthritis, Behcet's disease, and AS.

Prognostic significance of elevated hemostatic markers in patients with acute myocardial infarction

OBJECTIVES

The purpose of this study was to determine whether the elevated levels of hemostatic markers in the early phase of myocardial infarction may serve as risk factors for subsequent cardiac mortality.

BACKGROUND

Increased plasma hemostatic markers were noted in acute myocardial infarction, indicating that the blood coagulation system is highly activated in those patients. However, there are few clinical data concerning the association between the elevated hemostatic markers and survival in patients with myocardial infarction.

METHODS

Blood samples were obtained from 64 patients (mean age 67 +/- 11 years; 49 male) with acute myocardial infarction within 12 h after the onset of symptoms and before the initiation of any antithrombotic treatment. We measured plasma concentrations of fibrinopeptide A (FPA), prothrombin fragment 1+2 (F1+2) and thrombin-antithrombin complex (TAT) using the enzyme-linked immunosorbent assay method, and examined the associations between the level of these markers and survival with Cox proportional hazards models.

RESULTS

The follow-up time was 27 +/- 17 months, and 19 patients died of cardiac causes during the follow-up. Univariate survival analysis identified Killip class IV (hazard ratio 4.86; 95% confidence interval [CI] 1.55-15.19), left ventricular ejection fraction (hazard ratio 0.94; 95% CI 0.90-0.99), FPA (hazard ratio 1.54; 95% CI 1.13-2.10), F1+2 (hazard ratio 2.03; 95% CI 1.17-3.53) and TAT (hazard ratio 1.88; 95% CI 1.27-2.79) as significant factors associated with cardiac mortality. In multivariate analyses, only FPA level (hazard ratio 1.84; 95% CI 1.03-3.30) and left ventricular ejection fraction (hazard ratio 0.93; 95% CI 0.88-0.98) were independent predictors of cardiac mortality.

CONCLUSIONS

Elevated FPA in the early phase of myocardial infarction identifies patients with increased risk for subsequent cardiac death. This association appears to be independent of residual left ventricular function after infarction.

Prognostic value of Doppler-derived mitral deceleration time in postinfarction patients with left ventricular ejection fractions of 35% or more

Short Doppler-derived mitral deceleration time of early filling has been proved to be an independent predictor of poor prognosis in patients with left ventricular dysfunction. However, the prognostic value of Doppler-derived mitral deceleration time in postinfarction patients without overt left ventricular dysfunction is poorly understood. A total of 27 survivors of acute myocardial infarction with left ventricular ejection fractions of 35% or more, as determined by radionuclide ventriculography, were prospectively studied. Doppler study was performed 5 to 7 days after the index infarction. The patients were divided into two groups. Group A included 10 patients whose mitral deceleration time was 125 msec or less and group B consisted of 17 patients whose mitral deceleration time was 125 msec or more. The two groups were similar in terms of age and gender distribution and there were no statistically significant differences in coronary risk factors, peak creatine kinase concentration, location of infarction, Killip classification, thrombolytic therapy, left ventricular ejection fraction, or medications. After a mean follow-up period of 30 months, the rate of congestive heart failure (New York Heart Association, NYHA, class II or above) was significantly higher in group A (5/10) than in group B (1/17) (p < 0.01). These results suggest that a short mitral deceleration time could be a useful early predictor of the potential development of future congestive heart failure in postinfarction patients with left ventricular ejection fractions of 35% or more.

Identification of Enterobacteriaceae bacteria by direct matrix-assisted laser desorptiom/ionization mass spectrometric analysis of whole cells

Several members of Enterobacteriaceas were analyzed by matrix-assisted laser desorption ionization (MALDI) time-of-flight mass spectrometry (TOFMS). Characteristic mass spectral peaks and patterns were observed in the mass range of 2 to 20 kDa. The mass peaks reported to be reproducibly observed by previous researchers, which were claimed to serve as species/strain-specific biomarkers, are consistently observed in our current study. Despite the high degree of similarity found in the MALDI mass spectra within the enteric bacteria, minor yet notable differences existed to allow their differentiation. Five spectral peaks at m/z 4364, 5380, 6384, 6856, and 9540, generated reproducibly for each genus studied here, are assigned as family-specific biomarkers for the Family Enterobacteriaceae. The mass peaks at m/z 7324, 7724, 9136, and 9253 are assigned as genus-specific biomarkers for Salmonella. Some unique biomarkers characterizing the species and strains of E. coli are also presented.

Decreased left atrial appendage function is an important predictor of elevated left ventricular filling pressure in patients with congestive heart failure

OBJECTIVE

The aim of this study was to investigate whether left atrial (LA) appendage function, as indicated by LA appendage blood flow velocities and its ejection fraction, could identify elevated left ventricular filling pressure in patients with chronic congestive heart failure.

METHODS

Using transesophageal echocardiography, adequate pulsed Doppler LA appendage active emptying and filling velocities could be recorded in 25 consecutive patients (16 men and 9 women, aged 57+/-10 years) with chronic congestive heart failure (symptom duration > or =1 year). LA appendage ejection fraction calculated as (LA appendage maximal area)-(LA appendage minimal area)/(LA appendage maximal area) x 100 was also determined in these patients. Left ventricular end-diastolic pressure was recorded during cardiac catheterization performed within 24 h of echocardiographic study.

RESULTS

Left ventricular end-diastolic pressure was 2 to 47 mm Hg. There were close negative correlations of LA appendage emptying velocity (r=-0.508; P<0.01), filling velocity (r=-0.429; P<0.05) and LA appendage ejection fraction (r=-0.523; P<0.005) with left ventricular end-diastolic pressure. LA appendage active emptying velocity <30 cm/s predicted left ventricular end-diastolic pressure >25 mm Hg with a sensitivity of 72.7%, a specificity of 92.9% and a positive and negative predictive value of 88.9 and 81.3%.

CONCLUSIONS

The findings suggest that measurement of LA appendage blood flow velocities and contractile function by transesophageal echocardiography can be used to predict elevated left ventricular filling pressure in patients with congestive heart failure.

Liquid ventilation in an infant with pulmonary alveolar proteinosis

Partial liquid ventilation (PLV) has been applied in various pulmonary diseases. We describe the use of partial liquid ventilation as a lavage method following normal saline (NS) lavage in an infant with pulmonary alveolar proteinosis (PAP) and severe hypoxemia. A 6 weeks old 3.4 kg former 36 weeks gestation boy on supplemental oxygen was transferred to our NICU with persistent tachypnea, dry cough, and increasing oxygen requirements. A lingular open lung biopsy revealed PAP. He developed progressive respiratory failure requiring ventilatory support, necessitating conventional NS lavage, followed by lung lavage with perflubron (LiquiVent; Alliance Pharmaceutical Corp. and Hoechst Marion Roussel) while on venovenous extracorporeal life support (ECLS). Lung lavage with NS and perflubron yielded minimal cloudy effluent. Gas exchange and pulmonary function deteriorated following NS lavage and attempts to discontinue ECLS were poorly tolerated. In contrast, tidal volume, PaO2, and pulmonary compliance increased after PLV, while the (A-a) D(O2) decreased to a point where ECLS was no longer required. Once perflubron was added repeatedly to the ventilator circuit to correct for evaporation over the 4 days of PLV. Cardiovascular status remained stable for several days; however, eventually he required reinitiation of ECLS and more mechanical ventilatory support with each trial off ECLS. He was maintained on high pressures and FiO2 without any possibility to wean him from mechanical ventilation. Life support was withdrawn 1 month after admission. The survival from PAP in infants remains dismal, even with total lung NS lavage. While both NS and perflubron lavage in this patient were not effective in removing the proteinaceous alveolar debris, PLV following NS lavage was associated with an improvement in gas exchange and lung compliance.

Genetic analysis of interleukin-10 promoter region in patients with systemic lupus erythematosus in Taiwan

Overproduction of interleukin-10 (IL-10) may play an important role in the development of systemic lupus erythematosus (SLE) or lupus nephritis. There is also a polymorphic dinucleotide repeat in the human IL-10 promoter region (IL-10PR). Our aim was to study whether or not the IL-10PR alleles contributed to the susceptibility to SLE or lupus nephritis. One hundred SLE patients and 103 healthy controls were studied for IL-10PR by PCR and electrophoretic analysis. The distribution of IL-10PR alleles, genotypes and the sum of both alleles (SBA) from different groups or subgroups were analyzed. SLE patients showed no difference in the distribution of IL-10PR alleles, genotypes and SBA, as compared to healthy controls. Lupus nephritis patients (N = 49) also showed no difference in IL-10PR alleles, genotypes and SBA, as compared to SLE patients without nephritis (N = 51). Of 49 lupus nephritis patients, ten developed end-stage renal disease (ESRD) and four of them were found to suffer from rapid progressive renal failure (RPRF). Patients with RPRF presented much smaller SBA than other ESRD patients (p = 0.005). Lupus nephritis patients carrying small SBA (< 18) suffered from a higher prevalence of RPRF than lupus nephritis patients without small SBA (50% V.S. 0%, p < 0.001, relative risk 82). Our data provide the first evidence of a strong association between IL-10PR and severe progression of lupus nephritis in human patients. In the future, a prospective genetic analysis of IL-10PR for patients with lupus nephritis is recommended. It might be helpful for physicians to identify the lupus nephritis subgroup with a high risk of developing RPRF early, because this might lead to a better therapy and prognosis for these patients.

Use of fluorescein labelled antibody and fluorescence activated cell sorter for rapid identification of Mycobacterium species

A fluorescein labelled antibody (Ab)/Fluorescence Activated Cell Sorter (FACS)-based assay was developed for detection of a wide range of mycobacterial species directly from bacterial culture and sputum specimens. The whole process could be completed within 3 hours and had a high specificity and sensitivity for cultured bacteria. The method was also shown to be applicable for direct identification from clinical specimens. This study showed that pretesting of clinical specimens for mycobacteria to the genus level with an antibody to Mycobacterium species offers the routine clinical laboratory a single convenient test for the detection of tuberculous and nontuberculous mycobacteria. Depending on the availability of species-specific antibody, the identification of Mycobacterium to the species level can be achieved.

Treatment of emotionalism with fluoxetine during rehabilitation

Emotionalism (emotional lability) is a common but distressing phenomenon that occurs frequently in individuals suffering cerebral vascular accidents and other brain diseases. Patients with emotionalism sometimes embarrass their families and themselves, becoming socially disabled despite normal physical function. At its worst, emotionalism interferes with rehabilitation programs, delays progress and sometimes makes these programs impossible. This paper reports the effect of fluoxetine in treating three patients with persistent emotionalism (2 cases following cerebrovascular accidents, 1 case following encephalitis). All 3 patients demonstrated dramatic improvement in emotionalism within 6 days of treatment. The severity, frequency and duration of each episode were reduced greatly. The treatment improved the effectiveness of the rehabilitation program, relieved patient and family embarrassment, and enabled patients to resume rapidly their previous lifestyle patterns. All patients reached the functional goals planned prior to the onset of rehabilitation. We conclude that fluoxetine is highly effective in treating the symptoms of emotionalism in all patients, and allows for recovery of both physical and social function.

Comparison of the mechanical properties of the heel pad between young and elderly adults

OBJECTIVE

To compare the mechanical properties of the human heel pad between young and aged adults.

DESIGN

A 7.5-MHz linear-array ultrasound transducer was incorporated into a specially designed device to measure the thickness of the heel pad under different loads. The heel pad was compressed with serial increments of 0.5kg to a maximum of 3kg and then relaxed sequentially. Then the load-displacement curve of the heel pad during a loading-unloading cycle was plotted.

PARTICIPANTS

Convenience sample of 33 volunteers without heel problems, aged 18 to 78 years, were divided into young (less than 40 years) and elderly (older than 60 years) groups.

MAIN OUTCOME MEASURES

Unloaded heel-pad thickness, compressibility index, stiffness, and energy dissipation ratio were calculated from the load-displacement curves. Student's t-test was used to compare the mechanical properties of the heel between these two groups.

RESULTS

The average unloaded heel-pad thickness was 1.76+/-.20cm in the young group and 2.01+/-.24cm in the elderly group (p < .001). The average compressibility index was 53.3%+/-7.7% in the young group and 61.3%+/-5.5% in the elderly group (p < .001). Energy dissipation ratio representing shock absorbency of the heel pad, was 23.7%+/-6.9% in the young group and 35.3%+/-10% in the elderly group (p < .001).

CONCLUSION

Unloaded heel-pad thickness, compressibility index, and energy dissipation ratio of the heel pad were significantly increased in the elderly group, indicating loss of the elasticity of the heel pad. The loss of elasticity may be responsible for the higher incidence of heel injury in elderly individuals.

Successful delayed thrombolytic therapy in a patient with massive pulmonary embolism

Pulmonary embolism can be a catastrophic event leading to early death or serious hemodynamic instability. Thrombolytic therapy, in addition to heparin therapy, may improve the clinical condition and reduce the chance of recurrent pulmonary embolism in some cases. However, the acceptable "time window" for thrombolytic therapy is not well documented, though it has been used successfully as late as 14 days after pulmonary embolism. Successful delayed thrombolytic therapy beyond this "time window" in patients with massive pulmonary embolism has not been reported. We report a case of massive pulmonary embolism in which thrombolytic therapy was delayed more than 1 month after symptom onset. A 56-year-old woman was taken to National Cheng Kung University Hospital because of an episode of recurrent syncope, followed by progressive shortness of breath of 1 month's duration. Hypoxemia and hemodynamic instability were noted on admission. Echocardiography and a lung perfusion scan provided strong evidence of pulmonary embolism. Subsequent pulmonary angiography confirmed the diagnosis of multiple pulmonary emboli. The patient received a standard dose of intravenous tissue plasminogen activator 7 days after admission because of persistent symptoms and hypoxemia. Her clinical condition dramatically improved after treatment. Follow-up imaging studies showed resolution of the emboli. She was discharged in good condition. This case suggests that delayed thrombolytic therapy in patients with massive pulmonary embolism can still be beneficial in selected cases, even if given more than 2 weeks after symptom onset.

Lung-specific transgenic expression of KC enhances resistance to Klebsiella pneumoniae in mice

A vigorous host response is required to effectively clear pathogenic bacteria from the lungs and is dependent upon the recruitment and activation of neutrophils and macrophages. A family of chemotactic cytokines, referred to as chemokines, have been shown to participate in this complex protective response. In this study, we assessed the role of the C-X-C chemokine KC in lung antibacterial host defense using wild-type (wt) B6D2 mice or transgenic mice that had been bred on a B6D2 background expressing KC under the control of a Clara cell-specific promoter within the lung. The administration of Klebsiella pneumoniae to both wt and KC-transgenic mice resulted in a time-dependent expression of KC protein within the lung that peaked at 24 to 48 h postinoculation. When infected with K. pneumoniae, the KC-transgenic mice showed a striking improvement in survival compared with wt control mice. This improved survival was due to an increase in bacterial clearance, which occurred in association with a vigorous recruitment of neutrophils in the KC-transgenic mice compared with their wt control counterparts. No differences in the lung levels of the specific cytokines TNF-alpha, IFN-gamma, IL-12, and IL-10 were noted. However, inducible macrophage inflammatory protein-2 levels were significantly decreased in the KC-transgenic mice compared with the wt mice. This study indicates that the compartmentalized overexpression of KC in vivo results in increased lung bacterial clearance and improved survival, which occurs in association with enhanced polymorphonuclear leukocyte influx to the lung.

[Septicemic melioidosis in Southern Taiwan: a case report]

The patient was a 56 year-old man, a resident of Hen-Tsueng Township in Ping-Tung County. He worked as a ranger at Ken-Ting Farm in southern Taiwan, and had been to Thailand for sight-seeing 5 years ago. He came to our outpatient department about one month prior to hospitalization for intermittent fever of one week duration. At that time, complete blood count was within normal limits and a chest roentgenogram was unremarkable. He was given erythromycin without showing any clinical improvement. Two days prior to admission, he noted pain in the left hip. The next day, severe dyspnea developed suddenly and chest x-ray film revealed bilateral nodular lesions. Physical examination on hospitalization revealed an acutely ill and jaundiced male with a temperature of 37.4 degrees C, blood pressure: 110/47 mmHg, pulse rate: 137/min, and respiratory rate: 26/min. There were rales in both lungs, but no lymphadenopathy or organ enlargement. Laboratory study showed WBC: 1,470/mm(3), platelet count: 47,000/mm(3), blood sugar: 226 mg/dL, mildly elevated transaminases and bilirubin, and BUN: 69 mg/dL, Cr: 4.3 mg/dL. Arterial blood gas analysis indicated an acute metabolic acidosis with PaO2 of 32 mmHg. Despite the initial impression of melioidosis and administration of ceftazidime plus gentamicin, his condition rapidly deteriorated and expired 18 hours after admission. Two sets of blood cultures grew Burkholderia pseudomallei. Melioidosis has been called a great imitator of diseases and culture results are frequently misinterpreted. The mortality is high even with suggested therapy with ceftazidime, cotrimoxazole, amoxicillin-clavulanate, chloramphenicol, and/or tetracycline. There has been a total of 10 cases reported in southern Taiwan and 2 of them were clearly indigenous. Melioidosis should be included in the reportable diseases, and its prevalence in Taiwan also should be investigated.

T cell receptor gene V alpha and V beta usage in patients with rheumatoid arthritis in Taiwan

To investigate the correlation of T cell receptor (TCR) genes to rheumatoid arthritis (RA) in Taiwan, synovial fluid and peripheral blood were examined simultaneously in 14 patients with RA, and peripheral blood only was examined in 15 healthy controls. RNA was extracted from T cell in synovial fluid and peripheral blood, and cDNA was synthesized using the reverse transcription method. Then, TCR-V alpha and V beta gene families were determined using the polymerase chain reaction and slot blot methods. The numbers of TCR-V alpha and V beta families, especially V beta, were decreased in rheumatoid synovial fluid compared with numbers found in the peripheral blood of the same RA patients. TCR-V beta 7 and V beta 8 could be found in the synovial fluid of all patients with positive HLA-DR4. However, there was no significant difference in the numbers of TCR-V alpha and V beta families in peripheral blood of RA patients and the peripheral blood of healthy controls. In conclusion, restricted heterogeneity of TCR-V gene, especially V beta, can be found in synovial fluid of patients with RA. TCR-V beta 7 and V beta 8 may be related to the pathogenesis of HLA-DR4 positive RA patients in Taiwan.

Ethanol feeding impairs innate immunity and alters the expression of Th1- and Th2-phenotype cytokines in murine Klebsiella pneumonia

The prolonged and excessive consumption of alcohol has been shown to predispose the host to a variety of infectious complications, which may be due, in part, to the inability to produce important activating cytokines. In this study, we assessed the effect of chronic alcohol ingestion on bacterial clearance, survival, and cytokine mRNA and protein expression in mice with Klebsiella pneumonia. Two-week ethanol feeding resulted in substantial impairment in the clearance of K. pneumoniae and decreased survival, compared with CD-1 mice receiving an isocaloric diet without ethanol. No differences were noted between control and ethanol groups in the total numbers or percent of bronchoalveolar lavage fluid neutrophils or macrophages at 24 and 48 hr post-intratracheal K. pneumoniae. Importantly, the lungs of alcohol-fed mice with Klebsiella pneumonia displayed a decrease or delay in the expression of interleukin (IL)-12 p35 and p40 mRNA and interferon-gamma mRNA, respectively, as well as reduced IL-12 and interferon-gamma protein levels, compared with controls. Conversely, a time-dependent increase in lung IL-10 mRNAand protein was noted in ethanol-fed animals, compared with control animals challenged with K. pneumoniae. In summary, our studies indicate that ethanol ingestion results in a profound suppression of lung bacterial clearance and decreased survival in Klebsiella pneumonia, which occurs in association with a shift in the balance of lung cytokine mRNA and protein expression favoring Th2- rather than Th1-phenotype cytokines.

Amebic liver abscess complicated with cardiac tamponade and mediastinal abscess

Amebic pericarditis is an extremely rare complication of liver abscess and an uncommon etiology of sterile pericardial effusion with cardiac tamponade. The association of mediastinal abscess in this clinical setting has not been reported in the literature. Herein, we describe a case of amebic liver abscess complicated with mediastinal abscess and amebic pericarditis with cardiac tamponade. A 44-year-old man was admitted to our hospital because of shortness of breath for the previous 2 days. Cardiac tamponade was diagnosed and emergency pericardiectomy was performed. Chocolate-like pus was found in the pericardial sac and mediastinal space during surgery. Abdominal computed tomography revealed an ill-defined hypodense lesion over the left lobe of the liver, suggesting a liver abscess. Amebic liver abscess and pericarditis were diagnosed on the basis of a high serum titer of amebic antibodies on hemagglutination test. The patient was treated with metronidazole for 2 weeks and discharged in good condition. This case should alert clinicians to the possibility of amebic pericarditis in patients with cardiac tamponade associated with chocolate-like sterile pus in the pericardium and mediastinum. To establish the diagnosis of amebic pericarditis, one should investigate the presence of a liver abscess, a high serum titer of amebic hemagglutination antibodies, and the presence of Entamoeba histolytica trophozoites in the pericardium or pericardial aspirate.

Venous access thrombosis detected by transcutaneous vascular ultrasound in patients with single-polyurethane-lead permanent pacemaker

In order to assess the incidence of significant venous thrombosis after transvenous permanent pacemaker implantation, transcutaneous ultrasound studies were performed in 109 consecutive patients with single-polyurethane-lead pacemakers. Ultrasonic evaluation was found to be a good noninvasive method in assessing the veins. Six patients (5.5%) were found to have significant venous obstruction in the subclavian vein. However, none of them were symptomatic. No difference in the incidence of venous obstruction was found, based on the age, duration of implantation, operative technique, potentially thrombogenic factors including atrial fibrillation, diabeties mellitus, hypertension, heart failure and end-stage renal disease.

Expression of arthritis-causing HLA-B27 on Hela cells promotes induction of c-fos in response to in vitro invasion by Salmonella typhimurium

HLA-B27 confers a very strong genetic predisposition to development of a reactive arthritis after infection by bacteria such as Salmonella typhimurium. This study examines the role of HLA-B27 in the initiation of the earliest host activities after exposure to Salmonella, namely activation of the immediate early genes in the epithelial cells. Our major finding is that in Hela cells, the expression of c-fos was induced by Salmonella invasion only when the cells expressed the transfected HLA-B27 gene, but not the HLA-A1 gene or a truncated HLA-B27 gene lacking the exons encoding the cytoplasmic domain. C-fos is potentially capable of complexing with members of the c-jun family to become the AP-1 transcription complex. Parallel to c-fos expression, we found that only with the HLA-B27 transfectant was there expression of AP-1. AP-1 potentially controls the expression of a large number of genes. On screening a panel of proinflammatory molecules, we found that Salmonella invasion induced expression of monocyte chemoattractant protein-1 in the HLA-B27 cells. Since each of these separate positive findings belong to the same cascade of events after cell activation, together they reinforce the hypothesis that HLA-B27 plays a modulatory role in the early signal transduction events induced by Salmonella invasion. This hypothesis adds another item to the list of allele-specific activities carried out by HLA class I molecules. If similar activation also occurs in the joints, it may play a major role in arthritis.

[Identification of Staphylococcus epidermidis by desferrioxamine susceptibility and trehalose fermentation tests]

The importance of coagulase-negative staphylococci, especially Staphylococcus epidermidis in clinical and nosocomial infection are recognized increasingly in recent years. A rapid and accurate identification of S. epidermidis is therefore important and necessary. A new test, susceptibility to desferrioxamine, coupled with trehalose fermentation has been recommended for the identification of this organism. However, the medium and method used are different from what has been recommended by the NCCLS. To investigate the feasibility of using the desferrioxamine susceptibility test in conjunction with the routinely used disc agar diffusion test, we employed 111 staphylococcal strains (including 51 S. epidermidis isolates, 15 S. hominis and 45 other coagulase-negative staphylococci) as test organisms, and followed the procedures recommended by the NCCLS in which Mueller-Hinton agar and standard inoculum were used. Results indicated that all strains of S. epidermidis and S. hominis were susceptible to 1 mg desferrioxamine (the diameter of the inhibition zone were 28-37 mm). The minimum inhibitory concentrations of desferrioxamine to S. epidermidis and S. hominis isolates were determined to be 125 micrograms/ml. Further differentiation of S. hominis and S. epidermidis can be made by their ability to ferment trehalose, the former could while the latter could not. We conclude that the desferrioxamine susceptibility test of coagulase-negative staphylococci can be used in conjunction with the routine disc agar diffusion method. S. epidermidis can be identified rapidly and accurately by its susceptibility to 1 mg desferrioxamine and inability to ferment trehalose.

Anti-interleukin-12 therapy protects mice in lethal endotoxemia but impairs bacterial clearance in murine Escherichia coli peritoneal sepsis

The overzealous production of proinflammatory cytokines in sepsis can result in shock, multiorgan dysfunction, and even death. In this study we assessed the role of endogenously produced interleukin (IL)-12 in murine models of endotoxemia and Gram-negative peritoneal sepsis. Initial studies indicated that intraperitoneal lipopolysaccharide (LPS) administration to mice induced a significant time-dependent increase in plasma, lung, and liver IL-12 levels. Passive immunization with anti-IL-12 serum intraperitoneally before LPS resulted in a marked reduction in plasma levels of tumor necrosis factor and interferon-gamma. Furthermore, we observed an increase in endotoxin-induced mortality in mice transiently overexpressing murine IL-12 using a recombinant adenoviral vector (Ad5 mIL-12) administered intraperitoneally. Neutralization of tumor necrosis factor or interferon-gamma in animals overexpressing IL-12 resulted in significant reductions in LPS-induced mortality, suggesting that the mechanism whereby IL-12 increases LPS-induced mortality is primarily mediated by the enhancement of these cytokines. In contrast, we observed no survival benefit in animals passively immunized with anti-IL-12 serum before the intraperitoneal administration of 2 x 10(8) live Escherichia coli. Interestingly, there was an approximately 70-fold increase in peritoneal fluid E. coli colony-forming units and the early onset of bacteremia in animals treated with anti-IL-12 serum, as compared with control animals. These results indicate that IL-12 is produced in response to LPS exposure, and the neutralization of this cytokine improves survival in endotoxin-challenged animals. However, IL-12 represents an essential component of antibacterial host defense, as anti-IL-12 therapy results in significant impairment in the host's ability to clear Gram-negative bacterial infection.

Elevation of soluble adhesion molecules is associated with the severity of myocardial damage in acute myocardial infarction

In 20 patients with acute myocardial infarction, blood samples were taken to study the serial changes in the soluble intercellular adhesion molecule-1 (ICAM-1), vascular cellular adhesion molecule-1 (VCAM-1) and E-selectin. Results indicated that soluble ICAM-1 increased significantly and persisted throughout the study period; however, soluble E-selectin was significantly elevated only transiently and decreased rapidly thereafter, and the VCAM-1 did not increase during entire study period. There was a significant correlation between the levels of ICAM-1, E-selectin 6 hours after admission, and peak creatine kinase level; the levels of ICAM-1 and E-selectin were also positively correlated with total leukocyte count at admission.

MCP-1 protects mice in lethal endotoxemia

The overzealous production of proinflammatory cytokines in sepsis can result in shock, multiorgan dysfunction, and even death. In this study, we assessed the role of monocyte chemoattractant protein-1 (MCP-1) as a mediator of sepsis in endotoxin-challenged mice. Intraperitoneal administration of LPS to CD-1 mice induced a substantial time-dependent increase in MCP-1 in plasma, lung, and liver. The passive immunization of mice with rabbit antimurine MCP-1 antiserum 2 h before endotoxin administration resulted in a striking increase in LPS-induced mortality from 10% in control animals to 65% in anti-MCP-1-treated animals. Importantly, the administration of anti-MCP-1 antibodies to endotoxin-challenged mice resulted in increases in peak TNF-alpha and IL-12 levels, and also in a trend toward decreased serum levels of IL-10. Conversely, the administration of recombinant murine MCP-1 intraperitoneally significantly protected mice from endotoxin-induced lethality, and resulted in an increase in IL-10 levels, a decrease in IL-12 levels, and a trend toward decreased levels of TNF. In conclusion, our findings indicate that MCP-1 is a protective cytokine expressed in murine endotoxemia, and does so by shifting the balance in favor of antiinflammatory cytokine expression in endotoxin-challenged animals.

Nitric oxide is required for effective innate immunity against Klebsiella pneumoniae

Nitric oxide (NO) has been associated with protection against various parasitic and viral infections and may play a similar role in bacterial infections. We studied the role of NO in host defense against Klebsiella pneumoniae infection in the lung. Initial studies demonstrated a time-dependent increase in NO production of the lungs of CBA/J mice following the intratracheal administration of K. pneumoniae (7 x 10(2) CFU). To assess the role of NO in Klebsiella pneumonia, mice were treated intraperitoneally with either L-NAME (N-omega-nitro-L-arginine methylester), a competitive inhibitor of NO synthesis, or D-NAME, an inert enantiomer. The treatment of Klebsiella-infected mice with L-NAME resulted in a 10- and 46-fold increase in K. pneumoniae CFU in lungs and blood, respectively, at 48 h post-K. pneumoniae inoculation compared to treatment of mice with D-NAME. In addition, a greater-than-twofold increase in mortality was evident in L-NAME-treated mice compared to the mortality in control animals. No significant difference in bronchoalveolar lavage inflammatory cell profiles was noted between L-NAME- and D-NAME-treated mice with Klebsiella pneumonia. Interestingly, increased levels of tumor necrosis factor, gamma interferon, macrophage inflammatory protein 1alpha (MIP-1alpha), and MIP-2 mRNA and protein were noted in infected mice treated with L-NAME compared to the levels in mice treated with D-NAME. Importantly, the in vitro incubation of murine alveolar macrophages with L-NAME, but not with D-NAME, resulted in a significant impairment in both the phagocytosis and killing of K. pneumoniae. In total, these results suggest that NO plays a critical role in antibacterial host defense against K. pneumoniae, in part by regulating macrophage phagocytic and microbicidal activity.

HLA-DMA and DMB genotyping in patients with rheumatoid arthritis

OBJECTIVE

To investigate the relation of HLA-DMA and DMB alleles to the development of rheumatoid arthritis (RA).

METHODS

We studied HLA-DMA and DMB alleles in 153 patients with RA and 138 healthy controls using the amplification created restriction site method and digestion with restriction enzymes.

RESULTS

There was no significant difference in frequencies of HLA-DMA and DMB alleles between patients with RA and controls. The HLA-DMA and DMB alleles were not related to extraarticular involvement, seropositivity for rheumatoid factor, or bone erosion. There was also no significant difference in frequencies of HLA-DMA and DMB alleles among DR4-positive and DR4-negative patients and controls.

CONCLUSION

HLA-DMA and DMB do not appear to be associated with the pathogenesis of RA.

Combined use of astemizole and ketoconazole resulting in torsade de pointes

Torsade de pointes is a serious ventricular arrhythmia which is usually associated with a long QT interval. It is important to recognize the possible predisposing factors for the management of this arrhythmia. Prolongation of the QT interval and torsade de pointes has been reported in patients with an overdose of astemizole. We report on a 63-year-old woman presenting with torsade de pointes and a long QT interval caused by the combined use of astemizole (at recommended dosage), and ketoconazole. After discontinuation of these drugs and treatment with a temporary pacemaker, magnesium sulfate and lidocaine, the arrhythmia was no longer observed and she was discharged in good condition with a normal electrocardiogram. This case should alert clinicians to the possibility of torsade de pointes with the combined use of astemizole and ketoconazole.

[Identification of Candida albicans by specific primers of polymerase chain reaction and DNA probes]

Candida albicans is a pathogenic yeast. Two sets of universal primers were used for specific identification of Candida albicans with PCR-amplified ribosomal DNA internal transcribed spacers (ITS). Among the species of Candida, the amplified ITSI and ITSII of DNA fragments were similar in size. The PCR product was purified and labeled with digoxigenin and used as DNA probe in the detection with target DNA of Candida albicans by hybridization. Two sets of specific primers (CA1 and CA2 to amplify ITSI, CA3 and CA4 to amplify ITSII) were designed by alignment of ribosomal ITS sequence of pathogenic Candida albicans with other species to detect C. albicans by PCR. The sensitivity of PCR using the specific primers to detect pure culture of C. albicans was 0.1 ng (about 10(3)-10(4) cells). If the yeast cells were mixed with two other strains, there was a 10-fold decrease in sensitivity (1 ng or 10(4)-10(5) cells) under the same PCR conditions.

The TNF2 allele does not contribute towards susceptibility to systemic lupus erythematosus

The uncommon allele (TNF2) of a polymorphism in the promoter region of the tumor necrosis factor-alpha (TNF-alpha) gene has been reported to be increased in Caucasian systemic lupus erythematosus (SLE) patients (associated with HLA-DR3). To investigate whether TNF2 contributes towards susceptibility to Chinese SLE patients (not associated with HLA-DR3), 100 patients with SLE and 107 controls were studied. The frequency of TNF2 allele in controls was 0.140. There was a strong association between TNF2 allele and HLA-DR3 (P < 10(-8)) in controls. The frequency of TNF2 allele in SLE patients was 0.15. There was no difference in frequencies of TNF2 allele between patients and controls. This finding strongly suggests that TNF2 does not play a direct role in the susceptibility of SLE.

Decreased bone mineral density in premenopausal patients with systemic lupus erythematosus

To study bone mineral density (BMD) in premenopausal adult female patients with systemic lupus erythematosus (SLE) and its relation with clinical parameters, 56 SLE patients (mean age 31 years, mean disease duration 6.3 years) and 15 normal controls were studied. BMD at the lumbar vertebrae (L2-L4) was measured by dual energy X-ray absorptiometry (DEXA). Classification of BMD was made according to the WHO criteria in 1994. Correlation between BMD and clinical parameters was calculated. It was found BMD in the SLE patients (0.942 +/- 0.136 g/cm2) was lower than in the control group (1.055 +/- 0.080 g/cm2) (P < 0.01). According to the WHO criteria, 17 patients (30%) had normal BMD, 22 patients (40%) had osteopenia and 17 patients (30%) had osteoporosis. BMD was inversely correlated with disease duration in SLE patients (p < 0.005). The minimal disease duration for a female SLE patient to develop osteopenia was 3.5 years. In conclusion, SLE patients have lower lumbar BMD than normal controls. SLE patients with longer disease duration have lower BMD. In order to achieve early prevention of osteoporosis, we suggest that female SLE patients with disease duration for more than 3.5 years should take a BMD examination.

[Dystrophin abnormality in a patient with polymyositis associated with primary biliary cirrhosis and myocardial injury]

We have reported a 58-year-old Japanese female with polymyositis, primary biliary cirrhosis (PBC) and arrhythmia. In contrast to the previously reported 13 cases of polymyositis associated with PBC, symptoms and laboratory data abnormalities responded to oral administration of predonisolone. Interestingly, immunohistochemical and immunoblot analyses of biopsied skeletal muscle revealed diminished expression of dystrophin carboxyl-terminal domain in the sarcolemma, suggesting that, in analogy to Duchenne muscular dystrophy, secondary abnormality of the link between the basal lamina and cytoskeleton via the dystrophinglycoprotein complex may have played a role in the molecular pathogenesis of muscle fiber degeneration in this patient.

Microbiologic assay for detection of antimicrobial agents in urine

Antimicrobial therapy can be a confounding factor in the diagnosis of urinary tract infection and is not always reported to laboratories by physicians. We developed a microbiologic assay for screening urine specimens for antimicrobial agents. Bacillus stearothermophilus was used as the indicator bacteria. A total of 1,921 urine specimens from three hospitals in Taiwan were screened using this assay. Of the samples assayed, 1,293 were positive for antimicrobial agents. Agreement between information provided by physicians and laboratory findings was 68.5% (419/612). In the presence of antimicrobial agents in the urine samples, the isolation of yeasts and Pseudomonas aeruginosa increased dramatically, from 4.5 to 19.5% and 4.2 to 13.2%, respectively. Additionally, Escherichia coli was more resistant to gentamicin (75.3% vs 48.7%, p < 0.0001), norfloxacin (85.2% vs 64.6%, p = 0.0006) and co-trimoxazole (58.5% vs 35.5%, p = 0.0018). In view of the high rate of occurrence of antimicrobial agents in urine specimens and the lack of information provided by most physicians to laboratories, a screening method to detect the presence (or absence) of antimicrobials in urine specimens may be a useful tool particularly in areas such as Taiwan where antimicrobial agents are commonly abused.

Afebrile spontaneous pneumopyopericardium

A 77-year-old woman had spontaneous pneumopyopericardium caused by Klebsiella pneumoniae. Chest X-ray revealed a horizontal air-fluid level in the cardiac shadow. Echocardiogram showed characteristic spontaneous contrast echoes in the pericardial effusion. She received pericardiectomy and remained in good condition postoperatively.

A patient-derived cytotoxic T-lymphocyte clone and two peptide-dependent monoclonal antibodies recognize HLA-B27-peptide complexes with low stringency for peptide sequences

HLA-B27 molecules expressed on the T2 mutant cell line do not have peptides. Such empty HLA-B27 molecules were not recognized by an HLA-B27-restricted cytotoxic T-lymphocyte (CTL) clone (auto-1) derived from synovial fluid. To test for peptide dependency of the clone, B27-T2 cells were incubated with a panel of 48 different peptides. This lack of stringency was compared with that of a peptide-dependent monoclonal antibody, B27.M2. Positive B27.M2 reactivity resulted when the B27-T2 cells were incubated with two peptides: RRKAMFEDI and RRMGPPVGHR, derived from Chlamydia HSP60 and human ribonucleoprotein, respectively. Because of the limited availability of CTL versus monoclonal antibody, the specificity of B27.M2 was studied in greater detail. The importance of the HLA-B27 heavy chain in antibody recognition of class I-peptide complexes was demonstrated by site-directed mutagenesis. The stringency of the peptide residues was tested by making analogs of each of the nine residues in RRKAMFEDI, creating a panel of 180 analogs. Although stringency was highest for the sixth position, as many as six different amino acids provided positive reactivity. These results indicate that immune recognition of HLA-B27-peptide complexes might have rather low stringency for the peptide sequences. In theory, then, pathogen-derived peptides which induce autoimmunity by generating autoreactive CTL might not share much sequence similarity with the responsible self peptides.

Clinical microbiology quality assurance program: a Taiwan experience

Quality assurance programs have been established during the last two decades in developed countries to promote high quality performance in clinical laboratories. In Taiwan, such a program for clinical microbiology laboratories has been in place since July 1987. It has been supported by the Department of Health, Executive Yuan, R.O.C. and was set up by the authors. The manpower status, facilities and equipment, and performance of clinical laboratories were investigated during the first year and standards of laboratory quality were recommended. Since then, under a continuing education program, we have conducted seminars, symposia, workshops, short-courses or panel discussions approximately 4 times a year. There have been about 150 participants per session and they have come from local hospitals (primary care hospitals), regional hospitals (secondary care hospitals) and medical centers (tertiary care hospitals). Proficiency test specimens or external unknown specimens were sent to all the laboratories twice a year and approximately 3 specimens were used each time for the evaluation of each laboratory's diagnostic capability and quality of service. Results indicated that there were tremendous improvements in the quality of laboratory performance. At the same time, several laboratory manuals describing the methods of quality control of clinical specimens, test procedures, media and reagents, personnel management and a compilation of reports etc. were published as guidelines of basic requirements for each level of the laboratories. For local hospital laboratories in remote areas, several regional hospitals or medical centers with high quality laboratories were selected to serve as back-ups. Our evaluation has shown that the performance and quality of service provided by most clinical microbiology laboratories in Taiwan have now reached nearly the level of those found in the so-called "developed countries".

Light-emitting aeromonas and plesiomonas generated by transconjugating luxAB from Escherichia coli

The transposon derivative has been placed on a transposition suicide vector to yield pDB30 in Escherichia coli WA803. A simple method, using a Tn5 derivative Tn5-Lux, has been successfully devised for the introduction and stable expression of the bioluminescence property in Pseudomonas sp., Agrobacterium sp., and Rhizobium sp. In this study, there was also successful mating between Escherichia coli WA803(pDB30) and strains of Acromonas hydrophila and Plesiomonas shigelloides. These bacteria emitted bioluminescence after they gained pDB30 by transconjugation.

[Assessment of a new four-hour diagnostic kit--RapID onE system for the identification of enteric bacteria]

RapID onE System is a newly developed four-hour rapid diagnostic kit for the identification of enteric bacteria. To know the effectiveness of this system, we used 125 strains of oxidase-negative, gram-negative bacilli for this evaluation. Except for Acinetobacter calcoaceticus, all the bacilli belong to family Enterobacteriaceae. The bacterial strains of this assessment belong to 12 genera and 20 species. Among them, 84 strains were freshly isolated from clinical specimens and 41 strains were frozen (-70 degrees C) stock clinical isolates. The results show that 115 (92.0%) strains were correctly identifed to the species level. It yielded 92.9% and 90.2% of correct identification of fresh isolates and frozen stocks, respectively. In this paper, the reading criteria of RapID onE System would also be discussed.