The design, characteristics and predictors of mortality in the North of England Cellulitis Treatment Assessment (NECTA)

AIMS

Cellulitis is a common cause of acute medical admissions in UK hospitals. The factors that determine susceptibility to an acute admission or to mortality following hospital admission are poorly defined.

METHODS

We studied a retrospective cohort of 568 patients with a diagnosis of cellulitis between 1 January 2001 and 31 December 2003 in the north-east of England to see whether we could determine these factors. We collected data on the factors that were associated with acute hospital admissions and survival. We used a primary end-point of deaths within 1 year of admission for cellulitis.

RESULTS

The characteristics that identified patients at high risk of mortality were present in 39.9% of the cohort studied. The four most common of these characteristics were lower limb oedema 30.1% (95% CI: -26.0 to 34.1), ulceration 24% (95% CI: -20.2 to 27.8), previous myocardial infarction (MI) 19.9% (95% CI: -16.3 to 23.4) and blunt injury 18.7% (95% CI: -15.3 to 22.2). Significant predictors of mortality were: patient's age (p < 0.001), presence of penetrating injury (p < 0.001), previous MI (p < 0.001), presence of liver disease (p = 0.003), presence of lower limb oedema (p = 0.01) and long-term use of drugs that caused sodium and water retention (p < 0.001). Treatment with i.v. flucloxacillin was found to be a significant predictor of survival (odds ratio = 3.43, z =3.42. p < 0.001) at 360 days.

CONCLUSION

Our results show that cellulitis as a cause of an acute medical admission may present with a variety of clinical features. Some of these clinical features can be used to predict mortality within 360 days of an acute hospital admission.

The effect of the major components of Salvia Miltiorrhiza Bunge on bone marrow cells

Salvia Miltiorrhiza Bunge (SMB), a traditional Chinese medicinal herb, has been alleged to support bone healing. However, the effects of the isolated major components of SMB on osseous cells and their corresponding effective doses are still unclear. In the present study, the effects of three components of SMB, including tanshinone IIA (Ts), salvianolic acid B (salB) and protocatechuic aldehyde (Pca), on mesenchymal bone marrow cells with the potential for osteoblastic differentiation were investigated. Various concentrations of Ts, salB and Pca were added to a rat bone marrow cell culture. The total metabolic activity and differentiation of bone marrow cells were evaluated by a metabolic assay and alkaline phosphatase (ALP) activity, respectively. The morphology and number of cells was observed by phase contrast microscopy and fluorescent microscopy after propidium iodide staining, respectively. Ts suppressed the growth and differentiation of bone precursor cells. SalB exhibited a biphasic effect: the high concentration of 160 microg/mL significantly depressed the population of bone marrow cells, however, lower concentrations (3-80 microg/mL) enhanced the total metabolic activity and their ALP expression. Pca suppressed the bone marrow cell population in a dose-dependent manner. Therefore, SalB has the potential to ameliorate bone healing by stimulating both the total metabolic activity and ALP activity of osteoblastic cells. Aqueous extracts, which preferably contain salB over Pca and are free of Ts therefore are recommended for bone formation.

Prospective prediction of spontaneous but not recurrent autoimmune diabetes in the non-obese diabetic mouse

AIMS/HYPOTHESIS

Type 1 diabetes is a T cell-mediated autoimmune disease with a clinically silent prodrome, during which prediction and treatment of disease are theoretically possible. Using retrospective analysis, spontaneous disease in the non-obese diabetic (NOD) mouse has been correlated with islet-specific glucose-6-phosphatase catalytic subunit-related protein (IGRP)-reactive CD8+ T cells in the peripheral blood. In this study, we determined prospectively whether IGRP-reactive T cells in peripheral blood could predict disease occurrence. Since recurrent autoimmunity is an important contributor to transplant failure, we also determined whether failure of islet grafts (syngeneic and allogeneic) could be predicted by the presence of circulating autoreactive T cells.

MATERIALS AND METHODS

Peripheral blood samples were taken weekly from female NOD mice between the ages of 8 and 30 weeks and from NOD mice transplanted with NODscid islets. Peripheral blood cells and islet grafts were analysed for the presence of IGRP-reactive CD8+ T cells by flow cytometry.

RESULTS

Prospective analysis of peripheral blood IGRP-reactive T cells in the prediabetic period predicted disease development with a sensitivity of 100% and a specificity of 60%, resulting in positive and negative predictive values of 85 and 100%, respectively. Significant proportions of IGRP-reactive T cells were found in the grafts, but not in peripheral blood of NOD mice undergoing syngeneic and allogeneic rejection.

CONCLUSIONS/INTERPRETATION

The occurrence of spontaneous diabetes can be predicted prospectively by measuring peripheral blood autoreactive T cells. Rejection of syngeneic or allogeneic islets is associated with large populations of autoreactive CD8+ T cells within islets, suggesting that immunodominant autoreactive T cells during the prediabetic period are also responsible for autoimmune graft rejection.

A non-invasive system for assessment of aortic stiffness in clinical practice

Previously aortic stiffness is frequently assessed through pulse pressure and pulse wave velocity (PWV) measurements. However, these methods need aortic pressure obtained by catheterization. A new model has been developed to rapidly determine the aortic pressure profile and simultaneously calculate aortic stiffness. Comparison between the aortic pressure result obtained from this and catheterization data demonstrates good agreement, while this method is non-invasive. This totally non-invasive method should be useful in assessing arteriosclerotic disease in clinical setting.

Establishment and comprehensive analysis of a new human transformed follicular lymphoma B cell line, Tat-1

A spontaneously EBV transformed follicular lymphoma (FL) cell line, Tat-1, was established from the lymph node biopsy specimen of a patient with B cell FL, grade 1 in transformation to high grade disease. Tat-1 cells expressed lymphoid markers and developed tumor masses in immunodeficient mice. Bcl-2, Bcl-X(L), Bax and p53 protein expression was revealed by Western blotting. Flow cytometric analysis confirmed P-gp expression. Cytogenetically, the Tat-1 cell line showed identical chromosomal alterations to that of the initial biopsy specimen, among which the most notable were the t(14;18) typical of FL and additional abnormalities involving chromosomes 1, 8 and 13. Multicolor FISH analysis delineated all abnormalities, including a t(1p;8q), a der(8)(8q24::14q32::18q21) and a der(13)(13q32::8q24::14q32::18q21). Further FISH investigations using a locus-specific probe cocktail containing c-myc, IgH and bcl-2 revealed fusion of these three loci on the derivatives 8 and 13, in addition to the derivative 14 IgH/bcl-2 fusion and an extra copy of c-myc on derivative chromosome 1. These results demonstrate an additional example of the deregulation of bcl-2 and c-myc expression through recombination with a single IgH enhancer region. The unusual molecular features of the Tat-1 cell line render it a unique tool for studies focused on cytogenetic alterations, expression of multidrug resistance phenotype and expression of anti-apoptotic proteins in FL.

Detection of dengue viral RNA in Aedes aegypti (Diptera: Culicidae) exposed to sticky lures using reverse-transcriptase polymerase chain reaction

Active surveillance for dengue (DEN) virus infected mosquitoes can be an effective way to predict the risk of dengue infection in a given area. However, doing so may pose logistical problems if mosquitoes must be kept alive or frozen fresh to detect DEN virus. In an attempt to simplify mosquito processing, we evaluated the usefulness of a sticky lure and a seminested reverse-transcriptase polymerase chain reaction assay (RT-PCR) for detecting DEN virus RNA under laboratory conditions using experimentally infected Aedes aegypti (L.) mosquitoes. In the first experiment, 40 male mosquitoes were inoculated with 0.13 microl of a 10(4) pfu/ml DEN-2 stock solution. After a 7-d incubation period, the mosquitoes were applied to the sticky lure and kept at room temperatures of 23-30 degrees C. Following 7, 10, 14, and 28 d application, 10 mosquitoes each were removed from the lure, pooled, and assayed for virus. DEN virus nucleic acid was clearly detectable in all pools up to 28 d after death. A second study evaluated sensitivity and specificity using one, two, and five DEN-infected mosquitoes removed after 7,10, 14, 21, and 30 d application and tested by RT-PCR. All four DEN serotypes were individually inoculated in mosquitoes and evaluated using the same procedures as experiment 1. The four serotypes were detectable in as few as one mosquito 30 d after applications to the lure with no evidence of cross-reactivity. The combination of sticky lures and RT-PCR show promise for mosquito and dengue virus surveillance and warrant further evaluation.

Expansion of the antigenic repertoire of a single T cell receptor upon T cell activation

Activated T cells and their naive precursors display different functional avidities for peptide/MHC, but are thought to have identical antigenic repertoires. We show that, following activation with a cognate mimotope (NRP), diabetogenic CD8(+) T cells expressing a single TCR (8.3) respond vigorously to numerous peptide analogs of NRP that were unable to elicit any responses from naive 8.3-CD8(+) T cells, even at high concentrations. The NRP-reactive, in vivo activated CD8(+) cells arising in pancreatic islets of nonobese diabetic mice are similarly promiscuous for peptide/MHC, and paradoxically this promiscuity expands as the aviditiy of the T cell population for NRP/MHC increases with age. Thus, activation and avidity maturation of T lymphocyte populations can lead to dramatic expansions in the range of peptides that elicit functional T cell responses.

Synthesis of phakellistatin 11: a micronesia (Chuuk) marine sponge cyclooctapeptide

The cyclic octapeptide phakellistatin 11 (1), a constituent of The Federated States of Micronesia (Chuuk) marine sponge Phakellia sp., was synthesized using solid-phase techniques. An initial solution-phase synthesis proved to be inadequate owing to spontaneous deprotection of the Fmoc group at the heptapeptide stage. Using the PAL resin attachment and proceeding from Fmoc-Glu-alpha-allyl ester, linear elongation of the octapeptide was performed until the final unit Pro was added. The allyl ester was removed using Pd(0)[P(C(6)H(5))(3)](4). Cleavage of the final Fmoc group and cyclization with PyAOP provided phakellistatin 11 (1) in 17% overall yield. The synthetic specimen of phakellistatin 11 (1) was found to be chemically but not biologically (cancer cell lines) identical to the natural product. The result suggested a conformational difference or more likely the presence of a trace amount of a highly active antineoplastic agent that binds noncovalently to the natural cyclic octapeptide 1.

Cardiovascular effects of hydrocortisone in preterm infants with pressor-resistant hypotension

OBJECTIVE

To study the cardiovascular effects of hydrocortisone in preterm infants with hypotension unresponsive to volume and pressor administration.

STUDY DESIGN

Retrospective review of the cardiovascular response to 23 courses of hydrocortisone administration during the first day of treatment in 21 preterm infants (gestational age: 26.9 +/- 3.9 weeks; postnatal age: 11.3 +/- 13.1 days). Hydrocortisone (2 mg/kg/d in 16 patients and 3-6 mg/kg/d in 5 patients) was administered when dopamine (22.2 +/- 11 microg/kg/min, range: 8-60) alone (n = 16) or in combination with dobutamine (8.4 +/- 4.9 microg/kg/min, range: 5-20, n = 7) and/or epinephrine (0.38 +/- 0.56 microg/kg/min, range: 0.01-1.2, n = 4) failed to normalize blood pressure.

RESULTS

Mean blood pressure increased from 29.3 +/- 4.1 to 34.1 +/- 5.2, 38.0 +/- 8.0, and 41.8 +/- 6.6 mm Hg by 2, 4, and 6 hours of hydrocortisone administration, respectively, and remained stable thereafter. Urine output increased despite a decrease in fluid administration during the first day of hydrocortisone treatment. The dose of dopamine and the number of patients receiving dobutamine and/or epinephrine also decreased during the same period. Eighteen of the 21 patients survived.

CONCLUSIONS

Preterm infants with volume- and pressor-resistant hypotension respond to hydrocortisone with rapid normalization of the cardiovascular status and sustained decreases in volume and pressor requirement.

Utilization of herpes simplex PCR assays for cerebrospinal fluid in a pediatric health care setting

An assessment was made of the utilization and impact of a diagnostic polymerase chain reaction (PCR) assay for the diagnosis of herpes simplex viruses (HSV) 1 and 2 in cerebrospinal fluid of children who attended a Canadian pediatric referral centre. One hundred and three assays were performed on specimens from 103 patients during the period August 1997 to September 1998. Patient ages ranged from newborn to 16 years. Indications for HSV PCR included seizures with or without fever (56.3%), aseptic meningitis (16.5%), and encephalopathy with or without fever (10.7%). Only 2 of 103 (1.9%) assays were positive, including one each for HSV1 and HSV2. Control specimens that were seeded with virus indicated inhibition for 24.3, 8.8, and 6.8% of assays for HSV1, HSV2, and both HSV1 and HSV2, respectively. The mean turn-around time for HSV PCR was 2.5 days, and 90.3% were completed in less than 5 days. Acyclovir was administered to 78.6% of the patients overall; the results of the HSV PCR impacted on the treatment courses for 36 individuals. Nevertheless, 16.5% of patients continued to receive extended courses of antiviral therapy despite negative HSV PCR assays. Although it is desirable to decrease the frequency of PCR inhibitions and to further decrease the interval to assay completion, HSV PCR does have a significant impact on antiviral use in this setting.

Lymphocytic vasculitis in X-linked lymphoproliferative disease

Systemic vasculitis is an uncommon manifestation of X-linked lymphoproliferative disease (XLP), a disorder in which there is a selective immune deficiency to Epstein-Barr virus (EBV). The molecular basis for XLP has recently been ascribed to mutations within SLAM-associated protein (SAP), an SH2 domain-containing protein expressed primarily in T cells. The authors describe a patient who died as a result of chronic systemic vasculitis and fulfilled clinical criteria for the diagnosis of XLP. Sequencing of this patient's SAP gene uncovered a novel point mutation affecting the SH2 domain. The patient presented with virus-associated hemophagocytic syndrome (VAHS) and later had chorioretinitis, bronchiectasis, and hypogammaglobulinemia develop. He further developed mononeuritis and fatal respiratory failure. Evidence of widespread small and medium vessel vasculitis was noted at autopsy with involvement of retinal, cerebral, and coronary arteries as well as the segmental vessels of the kidneys, testes, and pancreas. Immunohistochemical analysis using antibodies to CD20, CD45RO, and CD8 revealed that the vessel wall infiltrates consisted primarily of CD8(+) T cells, implying a cytotoxic T-lymphocyte response to antigen. EBV DNA was detected by polymerase chain reaction (PCR) in arterial wall tissue microdissected from infiltrated vessels further suggesting that the CD8(+) T cells were targeting EBV antigens within the endothelium. The authors propose that functional inactivation of the SAP protein can impair the immunologic response to EBV, resulting in systemic vasculitis.

Preparation and evaluation of insulin-loaded polylactide microspheres using factorial design

The aim of this work was to study the influence of the concentration and molecular weight of poly(DL-lactide) (PLA) on the characteristics and in vivo biological activity of protein-loaded microspheres. At the same time, an attempt was made to achieve further optimization of the formulation. In the study, insulin was chosen as a model of protein drugs. Nine formulations of injectable insulin-loaded PLA microspheres were prepared using an emulsification and solvent evaporation process according to a factorial design. The trapping efficiency, drug loading, and the drop percentages of blood glucose levels at 24 hr and 72 hr in mice were used to evaluate the formulations. The results showed that PLA molecular weight and, especially, PLA concentration exerted influences on the characteristics and in vivo biological activity of insulin-loaded microspheres. The drug-trapping efficiency increased with the increase of the polymer concentration. The drug loading decreased with the increase of the polymer concentration and was not obviously affected by PLA molecular weight. The drop percentage of blood glucose level at 24 hr increased with the increase of polymer concentration and molecular weight. At 72 hr, the drop percentages of blood glucose levels were slightly increased with the increase of PLA concentration and then significantly decreased after the PLA concentration was above 150 mg/ml. An optimized formulation was prepared with PLA-10k at a concentration of 200 mg/ml. The experimental values of the response variables were close to the predicted values. The results suggest that the in vivo release behavior should be taken into consideration in the design of protein-loaded PLA microspheres.

Defective NK cell activation in X-linked lymphoproliferative disease

X-linked lymphoproliferative disease (XLP) is characterized by a selective immune deficiency to EBV. The molecular basis of XLP has been attributed to mutations of signaling lymphocytic activation molecule-associated protein, an intracellular molecule known to associate with the lymphocyte-activating surface receptors SLAM and 2B4. We have identified a single nucleotide mutation in SLAM-associated protein that affects the NK cell function of males carrying the mutated gene. In contrast to normal controls, both NK and lymphokine-activated killer cell cytotoxicity was significantly reduced in two XLP patients. In addition to decreased baseline cytotoxicity, ligation of 2B4 significantly augmented NK lytic function in normal controls but failed to enhance the cytotoxicity of NK cells from XLP patients. These findings suggest that association of SAP with 2B4 is necessary for optimal NK/lymphokine-activated killer cytotoxicity and imply that alterations in SAP/2B4 signaling contribute to the immune dysfunction observed in XLP.