Sepsis Program Activities in Acute Care Hospitals - National Healthcare Safety Network, United States, 2022

Sepsis, life-threatening organ dysfunction secondary to infection, contributes to at least 1.7 million adult hospitalizations and at least 350,000 deaths annually in the United States. Sepsis care is complex, requiring the coordination of multiple hospital departments and disciplines. Sepsis programs can coordinate these efforts to optimize patient outcomes. The 2022 National Healthcare Safety Network (NHSN) annual survey evaluated the prevalence and characteristics of sepsis programs in acute care hospitals. Among 5,221 hospitals, 3,787 (73%) reported having a committee that monitors and reviews sepsis care. Prevalence of these committees varied by hospital size, ranging from 53% among hospitals with 0-25 beds to 95% among hospitals with >500 beds. Fifty-five percent of all hospitals provided dedicated time (including assigned protected time or job description requirements) for leaders of these committees to manage a program and conduct daily activities, and 55% of committees reported involvement with antibiotic stewardship programs. These data highlight opportunities, particularly in smaller hospitals, to improve the care and outcomes of patients with sepsis in the United States by ensuring that all hospitals have sepsis programs with protected time for program leaders, engagement of medical specialists, and integration with antimicrobial stewardship programs. CDC's Hospital Sepsis Program Core Elements provides a guide to assist hospitals in developing and implementing effective sepsis programs that complement and facilitate the implementation of existing clinical guidelines and improve patient care. Future NHSN annual surveys will monitor uptake of these sepsis core elements.

Intravenous Antimicrobial Starts among Hemodialysis Patients in the National Healthcare Safety Network Dialysis Component, 2016-2020

NHSN total IV antimicrobial start rates for patients on hemodialysis decreased from 2016 to 2020, but rates unsupported by NHSN surveillance documentation did not. There were 80% of reporting hemodialysis facilities that had ≥1 unsupported IV antimicrobial start, and the fraction of facilities with unsupported starts increased yearly. Accurate reporting and timely review of antimicrobial data is critical to understanding prescribing trends and practices in hemodialysis facilities.

Severe acute respiratory coronavirus virus 2 (SARS-CoV-2) outbreaks in nursing homes involving residents who had completed a primary coronavirus disease 2019 (COVID-19) vaccine series-13 US jurisdictions, July-November 2021

Among nursing home outbreaks of coronavirus disease 2019 (COVID-19) with ≥3 breakthrough infections when the predominant severe acute respiratory coronavirus virus 2 (SARS-CoV-2) variant circulating was the SARS-CoV-2 δ (delta) variant, fully vaccinated residents were 28% less likely to be infected than were unvaccinated residents. Once infected, they had approximately half the risk for all-cause hospitalization and all-cause death compared with unvaccinated infected residents.

Outbreaks of SARS-CoV-2 Infections in Nursing Homes during Periods of Delta and Omicron Predominance, United States, July 2021-March 2022

SARS-CoV-2 infections among vaccinated nursing home residents increased after the Omicron variant emerged. Data on booster dose effectiveness in this population are limited. During July 2021-March 2022, nursing home outbreaks in 11 US jurisdictions involving >3 infections within 14 days among residents who had received at least the primary COVID-19 vaccine(s) were monitored. Among 2,188 nursing homes, 1,247 outbreaks were reported in the periods of Delta (n = 356, 29%), mixed Delta/Omicron (n = 354, 28%), and Omicron (n = 536, 43%) predominance. During the Omicron-predominant period, the risk for infection within 14 days of an outbreak start was lower among boosted residents than among residents who had received the primary vaccine series alone (risk ratio [RR] 0.25, 95% CI 0.19-0.33). Once infected, boosted residents were at lower risk for all-cause hospitalization (RR 0.48, 95% CI 0.40-0.49) and death (RR 0.45, 95% CI 0.34-0.59) than primary vaccine-only residents.

Transmission of Mycobacterium tuberculosis to healthcare personnel resulting from contaminated bone graft material, United States, June 2021- August 2022

A nationwide tuberculosis outbreak linked to a viable bone allograft product contaminated with Mycobacterium tuberculosis was identified in June 2021. Our subsequent investigation identified 73 healthcare personnel with new latent tuberculosis infection following exposure to the contaminated product, product recipients, surgical instruments, or medical waste.

Nationwide tuberculosis outbreak in the USA linked to a bone graft product: an outbreak report

BACKGROUND

Mycobacterium tuberculosis transmission through solid organ transplantation has been well described, but transmission through transplanted tissues is rare. We investigated a tuberculosis outbreak in the USA linked to a bone graft product containing live cells derived from a single deceased donor.

METHODS

In this outbreak report, we describe the management and severity of the outbreak and identify opportunities to improve tissue transplant safety in the USA. During early June, 2021, the US Centers for Disease Control and Prevention (CDC) worked with state and local health departments and health-care facilities to locate and sequester unused units from the recalled lot and notify, evaluate, and treat all identified product recipients. Investigators from CDC and the US Food and Drug Administration (FDA) reviewed donor screening and tissue processing. Unused product units from the recalled and other donor lots were tested for the presence of M tuberculosis using real-time PCR (rt PCR) assays and culture. M tuberculosis isolates from unused product and recipients were compared using phylogenetic analysis.

FINDINGS

The tissue donor (a man aged 80 years) had unrecognised risk factors, symptoms, and signs consistent with tuberculosis. Bone was procured from the deceased donor and processed into 154 units of bone allograft product containing live cells, which were distributed to 37 hospitals and ambulatory surgical centres in 20 US states between March 1 and April 2, 2021. From March 3 to June 1, 2021, 136 (88%) units were implanted into 113 recipients aged 24-87 years in 18 states (some individuals received multiple units). The remaining 18 units (12%) were located and sequestered. 87 (77%) of 113 identified product recipients had microbiological or imaging evidence of tuberculosis disease. Eight product recipients died 8-99 days after product implantation (three deaths were attributed to tuberculosis after recognition of the outbreak). All 105 living recipients started treatment for tuberculosis disease at a median of 69 days (IQR 56-81) after product implantation. M tuberculosis was detected in all eight sequestered unused units tested from the recalled donor lot, but not in lots from other donors. M tuberculosis isolates from unused product and recipients were more than 99·99% genetically identical.

INTERPRETATION

Donor-derived transmission of M tuberculosis via bone allograft resulted in substantial morbidity and mortality. All prospective tissue and organ donors should be routinely assessed for tuberculosis risk factors and clinical findings. When these are present, laboratory testing for M tuberculosis should be strongly considered.

FUNDING

None.

Multistate Outbreak of Melioidosis Associated with Imported Aromatherapy Spray

Melioidosis, caused by the bacterium Burkholderia pseudomallei, is an uncommon infection that is typically associated with exposure to soil and water in tropical and subtropical environments. It is rarely diagnosed in the continental United States. Patients with melioidosis in the United States commonly report travel to regions where melioidosis is endemic. We report a cluster of four non-travel-associated cases of melioidosis in Georgia, Kansas, Minnesota, and Texas. These cases were caused by the same strain of B. pseudomallei that was linked to an aromatherapy spray product imported from a melioidosis-endemic area.

Association Between Acute Exposure to Crime and Individual Systolic Blood Pressure

INTRODUCTION

Hypertension is associated with adverse cardiovascular outcomes and is geographically concentrated in urban underserved neighborhoods. This study examines the temporal-spatial association between individual exposure to violent crime and blood pressure.

METHODS

A retrospective observational cohort study analyzed 39,211 patients with 227,595 blood pressure measurements from 2014 to 2016 at 3 outpatient clinics at an academic medical center in Chicago. Patients were included in the study if they had documentation of blood pressure in the medical record and resided in census tracts with >1,000 observations. Geocoded violent crime events were obtained from the Chicago Police Department. Individual-level exposure was defined on the basis of spatial and temporal buffers around each patient's home. Spatial buffers included 100-, 250-, 500-, and 1,000-meter disc radii, and temporal buffers included 7, 30, and 60 days preceding each outpatient appointment. Systolic blood pressure measurements (mmHg) were abstracted from the electronic health record. Analysis was performed in 2019-2020.

RESULTS

For each violent crime event within 100 meters from home, systolic blood pressure increased by 0.14 mmHg within 7 days of exposure compared with 0.08 mmHg at 30 days of exposure. In analyses stratified by neighborhood cluster, systolic blood pressure increased by 0.37 mmHg among patients in the suburban affluent cluster relative to that among those in an extreme poverty cluster for the same spatial and temporal buffer.

CONCLUSIONS

Exposure to a violent crime event was associated with increased blood pressure, with gradient effects by both distance and time from exposure.

393. Characteristics of SARS-CoV-2 RNA Viral Loads among Nursing Home Residents and Staff with Repeat Positive Tests ≥ 90 Days After Initial Infection: 5 US Jurisdictions, July 2020–March 2021

Background

Background. Understanding the viral load and potential infectivity of individuals in nursing homes (NH) with repeat positive SARS-CoV-2 tests ≥ 90 days after initial infection has important implications for safety related to transmission in this high-risk setting.

Methods

Methods. We collected epidemiologic data by reviewing records of a convenience sample of NH residents and staff with respiratory specimens who had positive SARS-CoV-2 rRT-PCR test results from July 2020 through March 2021 and had a SARS-CoV-2 infection diagnosed ≥ 90 days prior. No fully vaccinated individuals were included. Each contributed one repeat positive specimen ≥ 90 days after initial, which was sent to CDC and retested using rRT-PCR. Specimens were assessed for replication-competent virus in cell culture if Cycle threshold (Ct) < 34 and sequenced if Ct < 30. Using Ct values as a proxy for viral RNA load, specimens were categorized as high (Ct < 30) or low (if Ct ≥ 30 or rRT-PCR negative at retesting). Continuous variables were compared using Wilcoxon signed-rank tests. Proportions were compared using Chi-squared or Fisher’s exact tests.

Results

Results. Of 64 unvaccinated individuals with specimens from 61 unique NHs, 14 (22%) were sent for culture and sequencing. Ten of 64 (16%) had a high viral RNA load, of which four (6%) were culture positive and none were known variants of interest or concern (Figure 1). Median days to repeat positive test result were 122 (Interquartile range (IQR): 103–229) and 201 (IQR: 139–254), respectively, for high versus low viral load specimens (p=0.13). More individuals with high viral loads (5/10, 50%) reported COVID-19 symptoms than with a low viral load (1/27, 4%, p=0.003). Most individuals (46/58, 79%) were tested following known or suspected exposures, with no significant differences between high and low viral load (p=0.18).

Conclusion

In this study, nearly 1 in 6 NH residents and staff with repeat positive tests after 90 days demonstrated high viral RNA loads and viable virus, indicating possible infectivity. While individuals with high RNA viral load may be more likely to be symptomatic, distinguishing asymptomatic individuals who have high viral loads may be difficult with timing since initial infection, other test results, or exposure history alone.

Disclosures

John A. Jernigan, MD, MS, Nothing to disclose.

Multisystem Inflammatory Syndrome in Adults after SARS-CoV-2 infection and COVID-19 vaccination

Background

Multisystem inflammatory syndrome in adults (MIS-A) was reported in association with the coronavirus disease 2019 (COVID-19) pandemic. MIS-A was included in the list of adverse events to be monitored as part of the emergency use authorizations issued for COVID-19 vaccines.

Methods

Reports of MIS-A patients received by the Centers for Disease Control and Prevention (CDC) after COVID-19 vaccines became available were assessed. Data collected on the patients included clinical and demographic characteristics and their vaccine status. The Vaccine Adverse Events Reporting System (VAERS) was also reviewed for possible cases of MIS-A.

Results

From 14 December 2020 to 30 April 2021, 20 patients who met the case definition for MIS-A were reported to CDC. Their median age was 35 years (range, 21–66 years), and 13 (65%) were male. Overall, 16 (80%) patients had a preceding COVID-19-like illness a median of 26 days (range 11–78 days) before MIS-A onset. All 20 patients had laboratory evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Seven MIS-A patients (35%) received COVID-19 vaccine a median of 10 days (range, 6–45 days) before MIS-A onset; 3 patients received a second dose of COVID-19 vaccine 4, 17, and 22 days before MIS-A onset. Patients with MIS-A predominantly had gastrointestinal and cardiac manifestations and hypotension or shock.

Conclusions

Although 7 patients were reported to have received COVID-19 vaccine, all had evidence of prior SARS-CoV-2 infection. Given the widespread use of COVID-19 vaccines, the lack of reporting of MIS-A associated with vaccination alone, without evidence of underlying SARS-CoV-2 infection, is reassuring.

Absence of SARS-CoV-2 infections among patients with end-stage renal disease following facility-wide testing in four outpatient hemodialysis facilities

Facility-wide testing performed at 4 outpatient hemodialysis facilities in the absence of an outbreak or escalating community incidence did not identify new SARS-CoV-2 infections and illustrated key logistical considerations essential to successful implementation of SARS-CoV-2 screening. Facilities could consider prioritizing facility-wide SARS-CoV-2 testing during suspicion of an outbreak in the facility or escalating community spread without robust infection control strategies in place. Being prepared to address operational considerations will enhance implementation of facility-wide testing in the outpatient dialysis setting.

Developmental exposure to the organochlorine insecticide endosulfan alters expression of proteins associated with neurotransmission in the frontal cortex

Exposure to environmental contaminants, such as organochlorine insecticides during critical periods of neurodevelopment has been shown to be a major contributor to several neuropsychological deficits seen in children, adolescence, and adults. Although the neurobehavioral outcomes resulting from exposure to these compounds are known the neurotransmitter circuitry and molecular targets that mediate these endpoints have not been identified. Given the importance of the frontal cortex in facilitating numerous neuropsychological processes, our current study sought to investigate the effects of developmental exposure to the organochlorine insecticide, endosulfan, on the expression of specific proteins associated with neurotransmission in the frontal cortex. Utilizing in vitro models we were able to show endosulfan reduces cell viability in IMR-32 neuroblastoma cells in addition to reducing synaptic puncta and neurite outgrowth in primary cultured neurons isolated from the frontal cortex of mice. Elaborating these findings to an in vivo model we found that developmental exposure of female mice to endosulfan during gestation and lactation elicited significant alterations to the GABAergic (GAT1, vGAT, GABAA receptor), glutamatergic (vGlut and GluN2B receptor), and dopaminergic (DAT, TH, VMAT2, and D2 receptor) neurotransmitter systems in the frontal cortex of male offspring. These findings identify damage to critical neurotransmitter circuits and proteins in the frontal cortex, which may underlie the neurobehavioral deficits observed following developmental exposure to endosulfan and other organochlorine insecticides.

Exposure to the polybrominated diphenyl ether mixture DE-71 damages the nigrostriatal dopamine system: role of dopamine handling in neurotoxicity

In the last several decades polybrominated diphenyl ethers (PBDEs) have replaced the previously banned polychlorinated biphenyls (PCBs) in multiple flame retardant utilities. As epidemiological and laboratory studies have suggested PCBs as a risk factor for Parkinson's disease (PD), the similarities between PBDEs and PCBs suggest that PBDEs have the potential to be neurotoxic to the dopamine system. The purpose of this study was to evaluate the neurotoxic effects of the PBDE mixture, DE-71, on the nigrostriatal dopamine system and address the role of altered dopamine handling in mediating this neurotoxicity. Using an in vitro model system we found DE-71 effectively caused cell death in a dopaminergic cell line as well as reducing the number of TH+ neurons isolated from VMAT2 WT and LO animals. Assessment of DE-71 neurotoxicity in vivo demonstrated significant deposition of PBDE congeners in the brains of mice, leading to reductions in striatal dopamine and dopamine handling, as well as reductions in the striatal dopamine transporter (DAT) and VMAT2. Additionally, DE-71 elicited a significant locomotor deficit in the VMAT2 WT and LO mice. However, no change was seen in TH expression in dopamine terminal or in the number of dopamine neurons in the substantia nigra pars compacta (SNpc). To date, these are the first data to demonstrate that exposure to PBDEs disrupts the nigrostriatal dopamine system. Given their similarities to PCBs, additional laboratory and epidemiological research should be considered to assess PBDEs as a potential risk factor for PD and other neurological disorders.

Reorganization of receptive fields following hearing loss in inferior colliculus neurons

We explored frequency and intensity encoding in the inferior colliculus (IC) of the C57 mouse model of sensorineural hearing loss. Consistent with plasticity reported in the IC of other models of hearing loss, frequency response areas (FRAs) in hearing-impaired (HI) mice were broader with fewer high-frequency units than normal-hearing (NH) mice. The broad FRAs recorded from HI mice had lower cutoffs on the low frequency edge of the FRA. Characteristic frequency (CF) and sharpness of tuning (Q10) calculated from the FRA were used to divide the sample into four categories: low-CF sharp-FRA, low-CF broad-FRA, high-CF sharp-FRA, and high-CF broad-FRA units. Rate-intensity functions (RIFs) for CF tones and noise were used to determine the minimum and maximum response counts as well as the sound pressure levels resulting in 10%, 50%, and 90% of the maximum spike count. Tone RIFs of broad FRA units were shifted to the right of tone RIFs of sharp FRA units in both NH and HI mouse IC, regardless of the unit CF. The main effects of hearing loss were seen in the noise RIFs. The low-CF broad-FRA units in HI mice had elevated responses to noise, and the high-CF sharp-FRA units in HI mice had lower maximum rates, as compared with the units recorded from NH mice. These results suggest that, as the IC responds to peripheral hearing loss with changes in the representation of frequency, an altered balance between inhibitory and excitatory inputs to the neurons recorded from the HI mice alters aspects of the units' intensity encoding. This altered balance likely occurs, at least in part, outside of the IC.

Predicting protein crystallization from a dilute solution property

A dilute solution parameter obtained from static light-scattering measurements is proposed as a predictor for protein crystallization experiments. The osmotic second virial coefficients, B(22), have been measured for a variety of proteins in solvents that are known to promote crystallization and the values for B(22) were found to lie within a fairly narrow range which we refer to as a crystallization slot. Solution conditions which were known not to favor crystallization of the proteins resulted in B(22) values well outside the crystallization slot.

A computational sensorimotor model of bat echolocation

A computational sensorimotor model of target capture behavior by the echolocating bat, Eptesicus fuscus, was developed to understand the detection, localization, tracking, and interception of insect prey in a biological sonar system. This model incorporated acoustics, target localization processes, flight aerodynamics, and target capture planning to produce model trajectories replicating those observed in behavioral insect capture trials. Estimates of target range were based on echo delay, azimuth on the relative intensity of the echo at the two ears, and elevation on the spectral pattern of the sonar return in a match/mismatch process. Flapping flight aerodynamics was used to produce realistic model trajectories. Localization in all three spatial dimensions proved necessary to control target tracking and interception for an adequate model of insect capture behavior by echolocating bats. Target capture using maneuvering flight was generally successful when the model's path was controlled by a planning process that made use of an anticipatory internal simulation, while simple homing was successful only for targets directly ahead of the model bat.

Polynitrogen chemistry. Synthesis, characterization, and crystal structure of surprisingly stable fluoroantimonate salts of N5+

The new N5+ salt, N5+ SbF(6)(-), was prepared from N(2)F(+)SbF(6)(-) and HN(3) in anhydrous HF solution. The white solid is surprisingly stable, decomposing only at 70 degrees C, and is relatively insensitive to impact. Its vibrational spectrum exhibits all nine fundamentals with frequencies that are in excellent agreement with the theoretical calculations for a five-atomic V-shaped ion of C(2)(v)symmetry. The N5+ Sb(2)F(11)(-) salt was also prepared, and its crystal structure was determined. The geometry previously predicted for free gaseous N5+ from theoretical calculations was confirmed within experimental error. The Sb(2)F(11)(-) anions exhibit an unusual geometry with eclipsed SbF(4) groups due to interionic bridging with the N5+ cations. The N5+ cation is a powerful one-electron oxidizer. It readily oxidizes NO, NO(2), and Br(2) but fails to oxidize Cl(2), Xe, or O(2).

Status of methods for assessing bacterial cell surface charge properties based on zeta potential measurements

Surface interfacial physiology is particularly important to unicellular organisms with regard to maintenance of optimal cell function. Bacterial cell surfaces possess net negative electrostatic charge by virtue of ionized phosphoryl and carboxylate substituents on outer cell envelope macromolecules which are exposed to the extracellular environment. The degree of peripheral electronegativity influences overall cell surface polarity and can be assessed on the basis of zeta potential which is most often determined by estimating the electrophoretic mobility of cells in an electric field. The purpose of this review is to provide bacteriologists with assistance as they seek to better understand available instrumentation and fundamental principles concerning the estimation of zeta potential as it relates to bacterial surface physiology.

Background noise differentially effects temporal coding by tonic units in the mouse inferior colliculus

In natural environments, temporally complex signals often occur in a background of noise. The neural mechanisms underlying the preservation of temporal sensitivity in background noise are poorly understood. In the present study, we examined the ability of inferior colliculus (IC) units with primary-like and sustained response patterns ('tonic units') to encode silent gaps in quiet and in background noise. Minimum gap thresholds (MGTs), the shortest silent gap in a noise burst evoking a neural response, were measured in quiet and background noise for 34 IC units. Units were classified as background noise resistant (BNR; MGT did not change in background noise) or background noise sensitive (BNS; MGTs became elevated in background noise). In quiet, the MGTs of BNR and BNS units were comparable and both types of units encoded the gap by a cessation of activity during the gap. The addition of background noise had little effect on the response rate of BNR units either during or after the gap stimulus. In contrast, for BNS units, background noise reduced the response rate during the gap stimulus while increasing the response rate after the gap stimulus. Background noise also altered the first spike latency of BNS units. For BNS units, the mean first spike latency was no longer inversely related to BF, but this relationship was maintained in BNR units. These results suggest that the response of BNS units to background noise obliterates their response to the gap stimulus.

Heteronuclear NMR studies of cobalt corrinoids. 20. 31P chemical shift anisotropy of aquacobalamin and its complex with a haptocorrin from chicken serum

Static light scattering measurements have been used to determine the molecular mass (65.3 kDa) and second virial coefficient (3.66 x 10(-4) mol mL g-2) for the complex between chicken serum haptocorrin (HC) and aquacobalamin (H2OCbl). Dynamic light scattering measurements have also been used to determine the translational diffusion coefficient of the H2OCbl-HC complex as a function of concentration. From the diffusion coefficient at infinite dilution (4.71 x 10(-7) cm2 s-1), the hydrodynamic radius (45.5 A) and rotational correlation time (85.4 ns) have been calculated. Using the latter, and measured values of the 31P NMR linewidths of the H2OCbl-HC complex at several field strengths, a detailed analysis of the 31P nuclear relaxation is possible. The chemical shift anisotropy term from the transverse relaxation equation is determined to be 95.7 ppm, and the average phosphorus-proton internuclear distance is 2.05 A. For comparison to protein-free H2OCbl, the chemical shift anisotropy of the phosphorus atom was studied by solid state NMR spectroscopy and the 31P relaxation by solution T1 measurements. These studies give values of 110.3 ppm for the chemical shift anisotropy term and 2.45 A for the average phosphorus-proton internuclear distance. The results are consistent with a significant change in the conformation of the H2OCbl phosphodiester upon binding to haptocorrin which could be due to a shortening of the axial Co-N bond.

Auditory motion induces directionally dependent receptive field shifts in inferior colliculus neurons

This research focused on the response of neurons in the inferior colliculus of the unanesthetized mustached bat, Pteronotus parnelli, to apparent auditory motion. We produced the apparent motion stimulus by broadcasting pure-tone bursts sequentially from an array of loudspeakers along horizontal, vertical, or oblique trajectories in the frontal hemifield. Motion direction had an effect on the response of 65% of the units sampled. In these cells, motion in opposite directions produced shifts in receptive field locations, differences in response magnitude, or a combination of the two effects. Receptive fields typically were shifted opposite the direction of motion (i.e., units showed a greater response to moving sounds entering the receptive field than exiting) and shifts were obtained to horizontal, vertical, and oblique motion orientations. Response latency also shifted as a function of motion direction, and stimulus locations eliciting greater spike counts also exhibited the shortest neural latency. Motion crossing the receptive field boundaries appeared to be both necessary and sufficient to produce receptive field shifts. Decreasing the silent interval between successive stimuli in the apparent motion sequence increased both the probability of obtaining a directional effect and the magnitude of receptive field shifts. We suggest that the observed directional effects might be explained by "spatial masking," where the response of auditory neurons after stimulation from particularly effective locations in space would be diminished. The shift in auditory receptive fields would be expected to shift the perceived location of a moving sound and may explain shifts in localization of moving sources observed in psychophysical studies. Shifts in perceived target location caused by auditory motion might be exploited by auditory predators such as Pteronotus in a predictive tracking strategy to capture moving insect prey.

Regenerable biosensor platform: a total internal reflection fluorescence cell with electrochemical control

A new biosensor platform that provides simultaneous fluorescence detection and electrochemical control of biospecific binding has been developed and investigated using antibody-antigen and streptavidin-biotin interactions. Specifically, biotin was covalently bound to a transparent indium-tin oxide (ITO) working electrode, which also served as an integral part of a total internal reflection fluorescence (TIRF) flow cell. TIRF was used to monitor biospecific interactions, while electrochemical polarization was employed to control interactions between biotin and streptavidin or between biotin and anti-biotin antibodies. Both streptavidin and polyclonal anti-biotin antibodies bound kinetically irreversibly to the biotinylated surface. In the absence of electrochemical control, the assay exhibited an extremely slow release of the bound analytes, causing poor regeneration ability of the biosensor surface. However, electrochemical polarization was found to stimulate dissociation of kinetically irreversibly bound biotin-streptavidin and antibody-antigen complexes. A "square wave" polarization function stimulated dissociation more effectively than a "saw tooth" function over the same voltage range. Application of the square wave polarization resulted in regeneration of an active biotinylated surface. Electrochemical polarization also modified affinity and kinetics of protein adsorption, which could likely be used to promote biospecific interactions and/or to suppress nonspecific adsorption.

Interfacial Aggregation of Bovine Serum Albumin Related to Crystallization Conditions Studied by Total Internal Reflection Fluorescence

Total internal reflection fluorescence (TIRF) was used to examine adsorption and interfacial aggregation of bovine serum albumin (BSA) from solvent conditions that are known to promote BSA crystallization. In the absence of a crystallizing agent (thermodynamically good solvent conditions), adsorption from a 0.1 mg/mL BSA solution in 50 mM phosphate buffer, pH 6.2, 25&deg;C, results in formation of not more than monolayer protein films on both hydrophilic and hydrophobic surfaces. However, in the presence of ammonium sulfate, which is used as an agent to crystallize BSA, adsorption yields a relatively thick multilayer protein film. The interfacial aggregation is sensitive to hydrophobicity of the substrate as well as to the prehistory of adsorption. A hydrophilic substrate promotes formation of thicker protein films than a hydrophobic one. For example, in the presence of 2.13 M ammonium sulfate, BSA adsorption during approximately 10 h yields approximately a 20-monolayer film on the quartz surface, in contrast to a 6-7 monolayer film on the hydrophobic surface. Rates of multilayer adsorption and desorption and the ultimate thickness of the multilayer protein film critically depend on the concentration of crystallizing agent. The rates correlate with the osmotic second virial coefficient, B22, which has been shown to be a predictor for protein crystallization. In the range of B22 values known as a "crystallization slot," the multilayer adsorption demonstrates a uniform rate of film growth. Noncrystallizing solvents do not exhibit this feature. The TIRF technique can be used to investigate molecular mechanisms of crystal growth and growth cessation as well as epitaxial and pseudoepitaxial growth using protein crystals grown at or attached to the surface. TIRF provides a sensitive and powerful tool to probe in situ and in real time the interactions of dissolved protein with a growing protein solid phase. Copyright 1997 Academic Press. Copyright 1997Academic Press

Technology assessment in healthcare: a review and description of a "best practice" technology assessment process

BACKGROUND

Technology assessment has become a rapidly growing component of the healthcare system. It has assumed a functional role in operational settings and is rapidly impacting decisions involving purchasing, coverage, and reimbursement. This review is intended to assist the healthcare decision maker in considering the application of technology assessment in healthcare, so as to maximize the efficiency of future purchasing decisions.

METHODS

This "best practice" was synthesized after identifying key institutions performing technology assessment in healthcare and analyzing their working processes, including literature review, consensus panel discussions, and expert opinion.

RESULTS

We describe this best practice on a reiterative loop that consists of five processes: awareness, strategic appropriateness, analysis versus need, acquisition and implementation, and reassessment. Typical barriers to adoption of technology assessment are also identified and discussed.

CONCLUSIONS

This review suggests a common terminology for the core processes involved in technology assessment, thereby facilitating a more uniform understanding among the different components of the healthcare system (i.e., payer, provider, and society) while recognizing their different perspectives.

Heteroenergetics of Bovine Serum Albumin Adsorption from Good Solvents Related to Crystallization Conditions

Total internal reflection fluorescence (TIRF) was applied to study adsorption of bovine serum albumin (BSA) from a thermodynamically good solvent commonly used as a buffer for BSA crystallization. BSA adsorption is shown to exhibit heteroenergetics, which is possibly a general property of protein interfacial behavior. For example, BSA adsorption on quartz, SnO2 , and alkyl-modified surfaces demonstrates broad continuous distributions of energies of adsorption activation and protein-surface binding. For heteroenergetic adsorption, the type of the isotherm and kinetics depends on the type of the energy distribution functions and the type of correlation between the energies. In the case of BSA adsorption on quartz and SnO2 surfaces, protein interfacial behavior is consistent with a model suggesting rectangular distributions both of activation energies of adsorption and energies of protein-surface binding. In the case of an alkyl-modified surface, BSA adsorption kinetics is interpreted in terms of a heteroenergetic model suggesting initial adsorption at selected adsorption sites with maximum rate constants. The model also suggests that lateral diffusion quickly redistributes the molecules from the initial adsorption sites to the sites with higher binding energies. The combination of TIRF spectroscopy with an electrochemical system was used to study the effect of surface charge on protein adsorption on a transparent SnO2 electrode. BSA behavior on the SnO2 electrode was found to correlate with surface hydrophobicity and indifferent to charges both of the surface and the protein. Hydrophobic interactions seem to be the principal driving force in determining the behavior of BSA at the solid-liquid interface and likely plays an important role in protein crystallogenesis.

Effect of polymyxin B nonapeptide on daptomycin permeability and cell surface properties in Pseudomonas aeruginosa, Escherichia coli, and Pasteurella multocida

The present study was carried out to determine if sensitization of Gram-negative bacteria to the polyanionic antibiotic daptomycin by cationic molecules can be explained on the basis of decreased cell surface charge in order to better understand intrinsic resistance. Turbidimetric assessments of batch cultural growth kinetics revealed the outer membrane permeabilizer polymyxin B nonapeptide sensitized Pseudomonas aeruginosa and Escherichia coli to the hydrophobic probe novobiocin, whereas little or no sensitization was observed for two surface hydrophobicity variants of Pasteurella multocida. Polymyxin B nonapeptide and daptomycin synergistically inhibited growth of P. aeruginosa only. A hydrocarbon adherence assay revealed permeabilizing concentrations of polymyxin B nonapeptide increased cell surface hydrophobicity of P. aeruginosa and the hydrophobic P. multocida variant, while E. coli and the hydrophilic P. multocida variant remained unaffected. Measurement of cellular electrophoretic mobility showed polymyxin B nonapeptide permeabilization of P. aeruginosa to daptomycin occurred concomitantly with a significant decrease in cell surface charge, while no such sensitization occurred in organisms which failed to undergo polymyxin B nonapeptide-induced surface charge decreases. These data suggest that sensitization of Gram-negative bacteria to polyanionic lipopeptides by growth in the presence of polycationic outer membrane permeabilizers such as polymyxin B nonapeptide is dependent on diminution of overall cell surface charge and polarity, thereby allowing outer cell envelope permeation.

Creation of ultra-rare restriction sites in intact eucaryotic chromosomes mediated by bacterial methylases: an approach to sequencing and analyzing tumor and normal genomes

The limited restriction of eucaryotic chromosomes would facilitate our understanding of the aberrant genomes of genetic diseases and cancer. We have described methods for methylating eucaryotic chromosomes embedded in agarose plugs. We now describe how Cla I methylase can be utilized in a methylation-dependent restriction cleavage with Dpn I to restrict eucaryotic genomes into a limited number of fragments. We have restricted the genomes of Saccharomyces cerevisiae at four sites and cleaved the three chromosomes of Schizosaccharomyces pombe into eleven fragments. Unlike the recently published methodologies using DNA sequences inserted into procaryotic and eucaryotic genomes, the methodologies described here use unaltered eucaryotic genomes for highly limited restriction. This methodology has applications in speeding, simplifying, and reducing the cost of sequencing the human genome.

Methylation of intact chromosomes by bacterial methylases in agarose plugs suitable for pulsed-field electrophoresis. Methylation of intact chromosomes in agarose by methylases

Conditions were determined for the methylation of intact yeast chromosomes by EcoRI, HhaI, and MspI bacterial methylases using an endonuclease protection assay while the chromosomes were embedded in agarose plugs suitable for transverse-field electrophoresis. Parameters were also established for the methylation of human chromosomes by EcoRI methylase. Methylation of embedded chromosomes by EcoRI methylase required prewashes with EDTA. EcoRI, HhaI, and MspI methylases showed optimal activity when nonacetylated bovine serum albumin, high levels of S-adenosylmethionine, and high levels of methylase were used. The use of bacterial methylases for methylation of embedded chromosomes will allow investigators to normalize variations in cellular DNA methylation prior to restriction and create new and rare endonuclease recognition sites which will facilitate the detection of chromosomal alterations and deletions.

Acute myocardial infarction associated with single vessel coronary artery disease: an analysis of clinical outcome and the prognostic importance of vessel patency and residual ischemic myocardium

The long-term outcome and the significance of residual ischemic myocardium, as assessed by predischarge exercise thallium scintigraphy and vessel patency, were studied in 97 patients with single vessel coronary artery disease by angiography 12 +/- 4 days after uncomplicated myocardial infarction. During a mean follow-up period of 39 +/- 17 months, no patients died, 6 (6%) had a recurrent nonfatal infarction and 25 (26%) experienced rapidly progressive angina requiring hospitalization. Although neither exercise-induced angina nor ST segment depression was predictive of a recurrent cardiac event, the mean number of infarct zone scan segments showing thallium redistribution (1.0 +/- 1.0 versus 0.5 +/- 0.8, p = 0.01) and the percent of patients with infarct zone redistribution (61 versus 39%, p = 0.05) were greater in those patients who experienced a late ischemic event. Kaplan-Meier analysis demonstrated a lower event-free survival rate in patients with redistribution (n = 45) than in those without redistribution (n = 52) (p = 0.019). Although no patient received immediate thrombolytic therapy, the infarct-related vessel was angiographically patent in 40 patients (41%). Vessel patency did not influence event-free survival, although a patent vessel, as compared with an occluded vessel, was associated with a greater prevalence of non-Q wave infarction (58 versus 21%, p less than 0.001), fewer persistent infarct zone thallium defects (1.2 +/- 1.1 versus 2.0 +/- 1.2, p = 0.001), more reversible infarct zone thallium defects (1.0 +/- 1.0 versus 0.5 +/- 0.9, p = 0.02) and a trend toward a higher left ventricular ejection fraction (53 +/- 10% versus 49 +/- 12%, p = 0.07). In summary, uncomplicated myocardial infarction in patients with single vessel coronary artery disease is associated with a very low incidence of subsequent death and reinfarction. The presence of infarct zone thallium redistribution, compared with its absence, is predictive of a higher cardiac event rate. These data should be considered when recommending prophylactic percutaneous transluminal angioplasty after uncomplicated myocardial infarction in asymptomatic patients with single vessel coronary disease. On the basis of these results, future randomized trials designed to evaluate the therapeutic efficacy of revascularization in asymptomatic postinfarction patients with single vessel disease should limit enrollment to those patients with residual ischemia located within the infarct zone.

Purification and characterization of phospholamban from canine cardiac sarcoplasmic reticulum

Phospholamban, the putative protein regulator of the Ca2+ pump of cardiac sarcoplasmic reticulum, was purified to apparent homogeneity from canine cardiac sarcoplasmic reticulum vesicles by selective extraction with sodium cholate, followed by adsorption to calcium oxalate, solubilization in Zwittergent 3-14, and specific elution from p-hydroxymercuribenzoate-agarose. Phospholamban, isolated in the dephosphorylated state, was purified 80-fold in 15% yield (approximately 2 mg of phospholamban/g of sarcoplasmic reticulum protein). Nondissociated phospholamban exhibited an apparent Mr = 25,000 in sodium dodecyl sulfate-polyacrylamide gels. Partially dissociated phospholamban, induced by boiling in sodium dodecyl sulfate, exhibited five distinct mobility forms in sodium dodecyl sulfate-polyacrylamide gels, of apparent molecular weights between 5,000-6,000 and 25,000. Phospholamban was phosphorylated to a level of 190 nmol of Pi/mg of protein by cAMP-dependent protein kinase, consistent by minimum stoichiometry with a subunit molecular weight of approximately 5,000. Phospholamban prepared by the present method was different in several respects from the proteins that have been isolated in other laboratories. Pure phospholamban was cysteine rich, containing 6 residues/100 amino acid residues. Dephosphorylated phospholamban was strongly basic with a pI = 10; phosphorylation decreased the pI to approximately 6.7. Pure phospholamban (and phospholamban present in sarcoplasmic reticulum vesicles) was not readily extracted into acidified chloroform/methanol, suggesting that the protein does not behave as an acidic proteolipid. The purified protein was highly antigenic. Phospholamban was localized by immunochemical methods to cardiac membranes enriched in sarcoplasmic reticulum, but was absent from sarcoplasmic reticulum membranes prepared from fast skeletal muscle. The method described for isolation of cardiac phospholamban is highly reproducible and relatively simple, and should be useful for further detailed studies designed to probe the molecular structure of the protein.

Revision operations after primary gastric surgery

A single surgeon working in a district general hospital gives his experience over 31 years of 179 reoperations after a primary gastric operation has failed to relieve symptoms of duodenal ulcer.

Potential identification of chemical carcinogens in a viral transformation system

Chemical carcinogens from several diverse chemical classes i.e.; aromatic amines, polycyclic hydrocarbons, nitrosamines, hormonal derivatives, metals and direct alkylating agents cause a 6.2-60.5-fold increase in the frequency of murine sarcoma virus (MSV)-induced transformation in a normal rat kidney (NRK) cell system. Exogenous metabolic activation with a rat liver S-9 homogenate is required for expression of this activity by procarcinogens. Non-carcinogenic analogs of these compounds fail to cause significant increases in the transformation frequency either with or without prior metabolic activation. Iododeoxyuridine, a mutagen also does not cause enhancement of transformation. This system may serve as the basis for a rapid and quantifiable means of identifying chemical carcinogens while introducing a new model for the understanding of the interactions between oncornaviruses and chemical carcinogens.

Radical versus modified radical mastectomy for breast cancer

A prospective randomised trial (534 patients, 1969-75) was designed to determine whether radical mastectomy conferred advantages over modified radical mastectomy for breast cancer in terms of total survival, local recurrence, distant metastasis, and disease-free interval. The results showed no significant difference in outcome as regards these variables between the two treatments.

Porcine superoxide dismutase. Isolation and characterization of a relatively basic cuprozinc enzyme

A cuprozinc superoxide dismutase has been isolated from pig liver. The enzyme is similar to previously described cuprozinc superoxide dismutases in that it is a dimer of about 32 000 molecular weight consisting of approximately two equally sized subunits, and 2 atoms of copper and two atoms of zinc per molecule. It differs, however, from previously described cuprozinc superoxide dismutases because of its higher isoelectric point; pI 6.8 vs 4.9 for bovine enzyme. The diffusion coefficient for the porcine enzyme was determined to be 7.53 x 10(-7) cm2 s-1, while the equivalent spherical hydrodynamic radius was computed as 28.5 A. The enzyme was observed to undergo self-association with time. Sulfhydryl interaction is postulated to be involved.

Melanoma

Melanoma most often occurs on the leg in women and on the head or neck in men. The appearance of the lesion should suggest the diagnosis, but pathologic examination and classification based on depth of skin penetration are essential for optimal therapy. Wide surgical excision should be followed by lymph node dissection, chemotherapy and/or immunotherapy depending on classification.

Specific muscle protein-sparing postoperative dextrose-free amino acid infusions

The protein-sparing and ketogenic effect of postoperative infusion of maintenance solutions containing either 3.5% amino acids or 5% dextrose in 0.33 normal (N) saline was compared by nitrogen balance and urinary acetone determination in 31 patients. A specific muscle protein sparing effect was determined by quantitation of excretion of 3-methylhistidine in seven patients of the amino acid group and eight patients in the dextrose group. In addition, an extensive hormone and substrate profile was determined. It was found that amino acid infusions not only produce a less negative nitrogen balance but also significantly reduce excretion of 3-methylhistidine indicating specific preservation of the muscle compartment.

Pregelation aggregation of sickle cell hemoglobin

Quasi-elastic light scattering was used to detect the initial stage of aggregation of hemoglobin S solutions. Aggregation of a hemolysate upon deoxygenation was found to occur at concentrations above 11 g/dl, but purified hemoglobin S solutions showed evidence of aggregation only for concentrations greater than 14 g/dl. A transition from a nonaggregated to an aggregated state was observed when the oxygen pressure in solution was reduced below a critical value. The total intensity of the scattered light during the early stages of aggregation was found to increase linearly with time. This result is consistent with a linear association process in which any size aggregate can combine with any other size aggregate.