The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting

STUDY OBJECTIVE

To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission.

DESIGN

Prospective cohort study.

SETTING

A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital.

PATIENTS

Between July 1997 and July 1999, 492 patients were prospectively evaluated.

INTERVENTION

Prospective patient surveillance and data collection.

RESULTS

One hundred forty-seven patients (29.9%) received inadequate antimicrobial treatment for their bloodstream infections. The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment (61.9%) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment (28.4%; relative risk, 2. 18; 95% confidence interval [CI], 1.77 to 2.69; p < 0.001). Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality (adjusted odds ratio [AOR], 6.86; 95% CI, 5.09 to 9.24; p < 0.001). The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n = 17; 100%), Candida species (n = 41; 95.1%), oxacillin-resistant Staphylococcus aureus (n = 46; 32.6%), coagulase-negative staphylococci (n = 96; 21.9%), and Pseudomonas aeruginosa (n = 22; 10.0%). A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality (Spearman correlation coefficient = 0.8287; p = 0.006). Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to Candida species (AOR, 51.86; 95% CI, 24.57 to 109.49; p < 0.001), prior administration of antibiotics during the same hospitalization (AOR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008), decreasing serum albumin concentrations (1-g/dL decrements) (AOR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014), and increasing central catheter duration (1-day increments) (AOR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008) were independently associated with the administration of inadequate antimicrobial treatment.

CONCLUSIONS

The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections. These data suggest that clinical efforts should be aimed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections, especially individuals infected with antibiotic-resistant bacteria and Candida species.

Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients

STUDY OBJECTIVE

To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission.

DESIGN

Prospective cohort study.

SETTING

Barnes-Jewish Hospital, a university-affiliated urban teaching hospital.

PATIENTS

Two thousand consecutive patients requiring admission to the medical or surgical ICU.

INTERVENTIONS

Prospective patient surveillance and data collection.

MEASUREMENTS AND RESULTS

One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission.

CONCLUSIONS

Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.

Identification of the tuberous sclerosis gene TSC1 on chromosome 9q34

Tuberous sclerosis complex (TSC) is an autosomal dominant disorder characterized by the widespread development of distinctive tumors termed hamartomas. TSC-determining loci have been mapped to chromosomes 9q34 (TSC1) and 16p13 (TSC2). The TSC1 gene was identified from a 900-kilobase region containing at least 30 genes. The 8.6-kilobase TSC1 transcript is widely expressed and encodes a protein of 130 kilodaltons (hamartin) that has homology to a putative yeast protein of unknown function. Thirty-two distinct mutations were identified in TSC1, 30 of which were truncating, and a single mutation (2105delAAAG) was seen in six apparently unrelated patients. In one of these six, a somatic mutation in the wild-type allele was found in a TSC-associated renal carcinoma, which suggests that hamartin acts as a tumor suppressor.

Electron microscopical reconstruction of the anterior sensory anatomy of the nematode Caenorhabditis elegans.?2UU

The complete structure of the anterior sensory nervous system of the small nematode C. elegans has been determined by reconstruction from serial section electronmicrographs. There are 58 neurons in the tip of the head. Fifty-two of these are arranged in sensilla. These include six inner labial sensilla, six outer labial sensilla, four cephalic sensilla and two amphids. Each sensillum consists of ciliated sensory neurons ending in a channel enclosed by two non-neuronal cells, the sheath and socket cells. The amphidial channel opens to the outside as does that of the inner labial sensilla so that these probably contain chemoreceptive neurons. The endings of the other sensilla are embedded in the cuticle and may be mechanoreceptive. The cell bodies of all the neurons lie near the nerve ring and their axons project into the ring or into ventral ganglia. One of the ciliated sensory neurons in each of the six inner labial sensilla makes direct chemical synapses onto a muscle making these sensory-motor neurons. The anatomy of four isogenic animals was compared in detail and found to be largely invariant. The anatomy of juveniles is nearly identical to that of the adult, but males have four additional neuron processes.

A global profile of germline gene expression in C. elegans

We used DNA microarrays to profile gene expression patterns in the C. elegans germline and identified 1416 germline-enriched transcripts that define three groups. The sperm-enriched group contains an unusually large number of protein kinases and phosphatases. The oocyte-enriched group includes potentially new components of embryonic signaling pathways. The germline-intrinsic group, defined as genes expressed similarly in germlines making only sperm or only oocytes, contains a family of piwi-related genes that may be important for stem cell proliferation. Finally, examination of the chromosomal location of germline transcripts revealed that sperm-enriched and germline-intrinsic genes are nearly absent from the X chromosome, but oocyte-enriched genes are not.

Chemotaxis by the nematode Caenorhabditis elegans: identification of attractants and analysis of the response by use of mutants

The nematode Caenorhabditis elegans is attracted by at least four classes of attractants: by cyclic nucleotides, cAMP and cGMP; by anions, Cl(-), Br(-), I(-); by cations, Na(+), Li(+), K(+), Mg(+); and by alkaline pH values. The nematode's behavioral response to gradients of these attractants involves orientation and movement up the gradient, accumulation, and then habitutation. Comparison of the tracks of wild-type and mutant animals responding to gradients of attractants indicates that sensory receptors in the head alone mediate the orientation response and that the direction of orientation is determined by the lateral motion of the head. Therefore, the orientation response is a klinotaxis.

Experience with a clinical guideline for the treatment of ventilator-associated pneumonia

OBJECTIVE

To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia.

DESIGN

Prospective before-and-after study design.

SETTING

A medical intensive care unit from a university-affiliated, urban teaching hospital.

PATIENTS

Between April 1999 and January 2000, 102 patients were prospectively evaluated.

INTERVENTIONS

Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia.

MEASUREMENTS AND MAIN RESULTS

The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 +/- 5.7 vs. 25.4 +/- 8.1, p =.798) and the clinical pulmonary infection scores (6.6 +/- 1.0 vs. 6.9 +/- 1.2, p =.105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p <.001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 +/- 5.1 days vs. 14.8 +/- 8.1 days, p <.001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p =.030).

CONCLUSIONS

The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.

The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia

STUDY OBJECTIVE

To determine the influence of mini-BAL culture results on subsequent changes in antibiotic therapy and patient outcomes.

DESIGN

Prospective, single-center, cohort study.

SETTING

Medical ICU of Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital.

PATIENTS

One hundred thirty mechanically ventilated patients undergoing mini-BAL for suspected ventilator-associated pneumonia (VAP).

INTERVENTIONS

Mini-BAL, prospective patient surveillance, and data collection.

MEASUREMENTS AND RESULTS

Sixty (46.2%) patients had mini-BAL cultures that yielded at least one pathogen potentially accounting for the clinically suspected episode of VAP (64 bacterial, 3 viral, 2 fungal). Among the 60 patients with microbiologically positive mini-BAL cultures, 44 (73.3%) were classified as receiving inadequate antibiotic therapy (ie, identification of a microorganism resistant to the prescribed antibiotic regimen). Prior antibiotic administration or its absence remained unchanged in 51 (39.2%) patients based on the mini-BAL culture results, while in another 51 (39.2%) patients, antibiotic therapy was either begun (n=7) or the existing antibiotic regimen was changed (n=44), and in the remaining 28 (21.6%) patients, antibiotic therapy was discontinued altogether. The hospital mortality rates of these three groups were statistically different: 33.3%, 60.8%, and 14.3%, respectively (p<0.001). The most common pattern of antibiotic resistance resulting in an antibiotic change following mini-BAL was the identification of a Gram-negative bacteria resistant to a prescribed third-generation cephalosporin in 23 of 44 (52.3%) patients. Twenty-one of these 23 patients (91.3%) received prior therapy with a cephalosporin class antibiotic during the same hospitalization. Having an immunocompromised state (adjusted odds ratio [OR]=2.45; 95% confidence interval, 1.56 to 3.85; p=0.047) and the presence of a pathogen in the mini-BAL culture resistant to the empirically prescribed antibiotic regimen (adjusted OR=3.28; 95% confidence interval, 2.12 to 5.06; p=0.006) were identified as risk factors independently associated with hospital mortality by logistic regression analysis.

CONCLUSIONS

These data suggest that antibiotic selection prior to obtaining the results of lower airway cultures is an important determinant of outcome for patients with suspected VAP. A delay in initiating adequate antibiotic therapy was associated with a greater mortality. Therefore, the initial selection of antibiotics for the empiric treatment of VAP should be broad enough to cover all likely pathogens, including antibiotic-resistant bacteria. This appears to be especially important in patients having received prior antibiotics.

Genome-wide germline-enriched and sex-biased expression profiles in Caenorhabditis elegans

We performed a genome-wide analysis of gene expression in C. elegans to identify germline- and sex-regulated genes. Using mutants that cause defects in germ cell proliferation or gametogenesis, we identified sets of genes with germline-enriched expression in either hermaphrodites or males, or in both sexes. Additionally, we compared gene expression profiles between males and hermaphrodites lacking germline tissue to define genes with sex-biased expression in terminally differentiated somatic tissues. Cross-referencing hermaphrodite germline and somatic gene sets with in situ hybridization data demonstrates that the vast majority of these genes have appropriate spatial expression patterns. Additionally, we examined gene expression at multiple times during wild-type germline development to define temporal expression profiles for these genes. Sex- and germline-regulated genes have a non-random distribution in the genome, with especially strong biases for and against the X chromosome. Comparison with data from large-scale RNAi screens demonstrates that genes expressed in the oogenic germline display visible phenotypes more frequently than expected.

A systematic review and economic evaluation of statins for the prevention of coronary events

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of statins for the primary and secondary prevention of cardiovascular events in adults with, or at risk of, coronary heart disease (CHD).

DATA SOURCES

Electronic databases were searched between November 2003 and April 2004.

REVIEW METHODS

A review was undertaken to identify and evaluate all literature relating to the clinical and cost effectiveness of statins in the primary and secondary prevention of CHD and cardiovascular disease (CVD) in the UK. A Markov model was developed to explore the costs and health outcomes associated with a lifetime of statin treatment using a UK NHS perspective.

RESULTS

Thirty-one randomised studies were identified that compared a statin with placebo or with another statin, and reported clinical outcomes. Meta-analysis of the available data from the placebo-controlled studies indicates that, in patients with, or at risk of, CVD, statin therapy is associated with a reduced relative risk of all cause mortality, cardiovascular mortality, CHD mortality and fatal myocardial infarction (MI), but not of fatal stroke. It is also associated with a reduced relative risk of morbidity [non-fatal stroke, non-fatal MI, transient ischaemic attack (TIA), unstable angina] and of coronary revascularisation. It is hardly possible, on the evidence available from the placebo-controlled trials, to differentiate between the clinical efficacy of atorvastatin, fluvastatin, pravastatin and simvastatin. However, there is some evidence from direct comparisons between statins to suggest that atorvastatin may be more effective than pravastatin in patients with symptomatic CHD. There is limited evidence for the effectiveness of statins in different subgroups. Statins are generally considered to be well tolerated and to have a good safety profile. This view is generally supported both by the evidence of the trials included in this review and by postmarketing surveillance data. Increases in creatine kinase and myopathy have been reported, but rhabdomyolysis and hepatotoxicity are rare. However, some patients may receive lipid-lowering therapy for as long as 50 years, and long-term safety over such a timespan remains unknown. In secondary prevention of CHD, the incremental cost-effectiveness ratios (ICERs) increase with age varying between pound 10,000 and pound 17,000 per quality adjusted life year (QALY) for ages 45 and 85 respectively. Sensitivity analyses show these results are robust. In primary prevention of CHD there is substantial variation in ICERs by age and risk. The average ICERs weighted by risk range from pound 20,000 to pound 27,500 for men and from pound 21,000 to pound 57,000 for women. The results are sensitive to the cost of statins, discount rates and the modelling time frame. In the CVD analyses, which take into account the benefits of statins on reductions in stroke and TIA events, the average ICER weighted by risk level remains below pound 20,000 at CHD risk levels down to 0.5%. Limitations of the analyses include the requirement to extrapolate well beyond the timeframe of the trial period, and to extrapolate effectiveness results from higher risk primary prevention populations to the treatment of populations at much lower risk. Consequently, the results for the lower age bands and lower risks are subject to greater uncertainty and need to be treated with caution.

CONCLUSIONS

There is evidence to suggest that statin therapy is associated with a statistically significant reduction in the risk of primary and secondary cardiovascular events. As the confidence intervals for each outcome in each prevention category overlap, it is not possible to differentiate, in terms of relative risk, between the effectiveness of statins in primary and secondary prevention. However, the absolute risk of CHD death/non-fatal MI is higher, and the number needed to treat to avoid such an event is consequently lower, in secondary than in primary prevention. The generalisability of these results is limited by the exclusion, in some studies, of patients who were hypersensitive to, intolerant of, or known to be unresponsive to, statins, or who were not adequately compliant with study medication during a placebo run-in phase. Consequently, the treatment effect may be reduced when statins are used in an unselected population. The results of the economic modelling show that statin therapy in secondary prevention is likely to be considered cost-effective. In primary prevention, the cost-effectiveness ratios are dependent on the level of CHD risk and age, but the results for the CVD analyses offer support for the more aggressive treatment recommendation issued by recent guidelines in UK. Evidence on clinical endpoints for rosuvastatin is awaited from on-going trials. The potential targeting of statins at low-risk populations is however associated with major uncertainties, particularly the likely uptake and long-term compliance to lifelong medication by asymptomatic younger patients. The targeting, assessment and monitoring of low-risk patients in primary care would be a major resource implication for the NHS. These areas require further research.

Randomised controlled trial of non-invasive ventilation (NIV) for nocturnal hypoventilation in neuromuscular and chest wall disease patients with daytime normocapnia

BACKGROUND

Long term non-invasive ventilation (NIV) reduces morbidity and mortality in patients with neuromuscular and chest wall disease with hypercapnic ventilatory failure, but preventive use has not produced benefit in normocapnic patients with Duchenne muscular dystrophy. Individuals with nocturnal hypercapnia but daytime normocapnia were randomised to a control group or nocturnal NIV to examine whether nocturnal hypoventilation is a valid indication for NIV.

METHODS

Forty eight patients with congenital neuromuscular or chest wall disease aged 7-51 years and vital capacity<50% predicted underwent overnight respiratory monitoring. Twenty six with daytime normocapnia and nocturnal hypercapnia were randomised to either nocturnal NIV or to a control group without ventilatory support. NIV was started in the control group if patients fulfilled preset safety criteria.

RESULTS

Peak nocturnal transcutaneous carbon dioxide tension (Tcco2) did not differ between the groups, but the mean (SD) percentage of the night during which Tcco2 was >6.5 kPa decreased in the NIV group (-57.7 (26.1)%) but not in controls (-11.75 (46.1)%; p=0.049, 95% CI -91.5 to -0.35). Mean (SD) arterial oxygen saturation increased in the NIV group (+2.97 (2.57)%) but not in controls (-1.12 (2.02)%; p=0.024, 95% CI 0.69 to 7.5). Nine of the 10 controls failed non-intervention by fulfilling criteria to initiate NIV after a mean (SD) of 8.3 (7.3) months.

CONCLUSION

Patients with neuromuscular disease with nocturnal hypoventilation are likely to deteriorate with the development of daytime hypercapnia and/or progressive symptoms within 2 years and may benefit from the introduction of nocturnal NIV before daytime hypercapnia ensues.

Blockade of kit signaling induces transdifferentiation of interstitial cells of cajal to a smooth muscle phenotype

BACKGROUND & AIMS

Interstitial cells of Cajal (ICC) serve as pacemaker cells and mediators of neurotransmission from the enteric nervous system to gastrointestinal muscles. ICC develop from mesenchymal cells that express c-Kit, and signaling via Kit receptors is necessary for normal development of ICC. We studied the fate of functionally developed ICC after blockade of Kit receptors to determine whether ICC undergo cell death or whether the phenotype of the cells is modified. The fate of undeveloped ICC was also investigated.

METHODS

Neutralizing, anti-Kit monoclonal antibody (ACK2) was administered to mice for 8 days after birth. ICC in the small intestine were examined by immunohistochemistry and electron microscopy. Occurrence of apoptosis was also assayed.

RESULTS

When Kit receptors were blocked, ICC nearly disappeared from the small intestine. Apoptosis was not detected in regions where ICC are normally distributed. Remaining Kit-immunopositive cells in the pacemaker region of the small intestine developed ultrastructural features similar to smooth muscle cells, including prominent filament bundles and expression of the muscle-specific intermediate filament protein, desmin, and smooth muscle myosin. ICC of the deep muscular plexus normally develop after birth in the mouse. Precursors of these cells remained in an undifferentiated state when Kit was blocked.

CONCLUSIONS

These data, along with previous studies showing that ICC in the pacemaker region of the small intestine and longitudinal muscle cells develop from the same Kit-immunopositive precursor cells, suggest inherent plasticity between the ICC and smooth muscle cells that is regulated by Kit-dependent cell signaling.

Genetic and environmental conditions that increase longevity in Caenorhabditis elegans decrease metabolic rate

Mutations that increase the longevity of the soil nematode Caenorhabditis elegans could define genes involved in a process specific for aging. Alternatively, these mutations could reduce animal metabolic rate and increase longevity as a consequence. In ectotherms, longevity is often negatively correlated with metabolic rate. Consistent with these observations, environmental conditions that reduce the metabolic rate of C. elegans also extend longevity. We found that the metabolic rate of long-lived C. elegans mutants is reduced compared with that of wild-type worms and that a genetic suppressor that restored normal longevity to long-lived mutants restored normal metabolic rate. Thus, the increased longevity of some long-lived C. elegans mutants may be a consequence of a reduction in their metabolic rate, rather than an alteration of a genetic pathway that leads to enhanced longevity while maintaining normal physiology. The actual mechanism responsible for the inverse correlation between metabolic rate and longevity remains unknown.

Asthma Control Questionnaire in children: validation, measurement properties, interpretation

The Asthma Control Questionnaire (ACQ) has been validated in adults to measure the primary goal of management (minimisation of symptoms, activity limitations, short-acting β₂-agonist use and airway narrowing). The present study evaluated the validity, measurement properties and interpretability of the ACQ in children aged 6-16 yrs. 35 children attended clinic on three occasions (0, 1 and 4 weeks) and completed the ACQ, Mini Paediatric Asthma Quality of Life Questionnaire and the Royal College of Physicians' "Three Questions". Parents completed the Paediatric Asthma Caregiver's Quality of Life Questionnaire. Between visits, children completed the Asthma Control Diary and measured peak expiratory flow. At weeks 1 and 4, clinicians and parents completed Global Rating of Change Questionnaires. All patients completed the study. 19 children were stable between two assessments and provided evidence of good test-retest reliability (intraclass correlation coefficient 0.79). The ACQ was responsive to change in asthma control (p = 0.026) and the mean ± sd Minimal Important Difference was 0.52 ± 0.45. Both cross-sectional and longitudinal correlations between the ACQ and the other outcomes were close to predicted and provided evidence that the ACQ measures asthma control in children. The ACQ has strong measurement properties and is valid for use in children aged 6-16 yrs. In children aged 6-10 yrs, it must be administered by a trained interviewer.

Larger sperm outcompete smaller sperm in the nematode Caenorhabditis elegans

Sperm competition is generally thought to drive the evolution of sperm miniaturization. Males gain advantage by transferring more sperm, which they produce by dividing limited resources into ever smaller cells. Here, we describe the opposite effect of size on the competitiveness of amoeboid sperm in the hermaphroditic nematode Caenorhabditis elegans. Larger sperm crawled faster and displaced smaller sperm, taking precedence at fertilization. Larger sperm took longer to produce, however, and so were more costly than smaller sperm. Our results provide evidence of a mechanism to support recent theoretical and comparative studies that suggest sperm competition can favour not small, but large sperm.

A comparative analysis of patients with early-onset vs late-onset nosocomial pneumonia in the ICU setting

STUDY OBJECTIVE

To compare the clinical outcomes of critically ill patients developing early-onset nosocomial pneumonia (NP; ie, within 96 h of ICU admission) and late-onset NP (ie, occurring after 96 h of ICU admission).

DESIGN

Prospective cohort study.

SETTING

A medical ICU and a surgical ICU from a university-affiliated urban teaching hospital.

PATIENTS

Between July 1997 and November 1998, 3, 668 patients were prospectively evaluated.

INTERVENTION

Prospective patient surveillance and data collection.

RESULTS

Four hundred twenty patients (11.5%) developed NP. Early-onset NP was observed in 235 patients (56.0%), whereas 185 patients (44.0%) developed late-onset NP. Among patients with early onset NP, 114 patients (48. 5%) spent at least 24 h in the hospital prior to ICU admission, compared to 57 patients (30.8%) with late-onset NP (p = 0.001). One hundred eighty-three patients (77.9%) with early-onset NP received antibiotics prior to the development of NP, as compared to 162 patients (87.6%) with late-onset NP (p = 0.010). The most common pathogens associated with early-onset NP were Pseudomonas aeruginosa (25.1%), oxacillin-sensitive Staphylococcus aureus (OSSA; 17.9%), oxacillin-resistant S aureus (ORSA; 17.9%), and Enterobacter species (10.2%). P aeruginosa (38.4%), ORSA (21.1%), Stenotrophomonas maltophilia (11.4%), OSSA (10.8%), and Enterobacter species (10.3%) were the most common pathogens associated with late-onset NP. The ICU length of stay was significantly longer for patients with early-onset NP (10.3 +/- 8.3 days; p < 0.001) and late-onset NP (21. 0 +/- 13.7 days; p < 0.001), as compared to patients without NP (3.5 +/- 3.2 days). Hospital mortality was significantly greater for patients with early-onset NP (37.9%; p = 0.001) and late-onset NP (41.1%; p = 0.001) compared to patients without NP (13.1%).

CONCLUSIONS

Both early-onset and late-onset NP are associated with increased hospital mortality rates and prolonged lengths of stay. The pathogens associated with NP were similar for both groups. This may be due, in part, to the prior hospitalization and use of antibiotics in many patients developing early-onset NP. These data suggest that P aeruginosa and ORSA can be important pathogens associated with early-onset NP in the ICU setting. Additionally, clinicians should be aware of the common microorganisms associated with both early-onset NP and late-onset NP in their hospitals in order to avoid the administration of inadequate antimicrobial treatment.

Sperm morphogenesis in wild-type and fertilization-defective mutants of Caenorhabditis elegans

Taking advantage of conditions that allow spermatogenesis in vitro, the timing and sequence of morphological changes leading from the primary spermatocyte to the spermatozoon is described by light and electron microscopy. Together with previous studies, this allows a detailed description of the nuclear, cytoplasmic, and membrane changes occurring during spermatozoan morphogenesis. By comparison with wild type, abnormalities in spermatogenesis leading to aberrant infertile spermatozoa are found in six fertilization-defective (fer) mutants. In fer-1 mutant males, spermatids appear normal, but during spermiogenesis membranous organelles (MO) fail to fuse with the sperm plasma membrane and a short, though motile. pseudopod is formed. In fer-2, fer-3, and fer-4 mutants, spermatids accumulate 48-nm tubules around their nuclei where the centriole and an RNA containing perinuclear halo would normally be. In all three mutants, spermatids still activate to spermatozoa with normal fusion of their MOs, but the pseudopods formed are aberrant in most fer-2 and fer-4 spermatozoa and in some fer-3 spermatozoa. In fer-5 mutant males, spermatozoa do not form. Instead, defective spermatids with crystalline inclusions and abnormal internal laminar membranes accumulate. In fer-6 mutant males, only a few spermatozoa form and these have defective pseudopods. These spermatozoa retain their fibrous bodies, a structure which normally disassembles in the spermatid. The time of appearance of developmental abnormalities in all of these mutants correlates with the temperature-sensitive periods for development of infertility. The observation that each of these mutants has a different and discreet set of morphological defects, a structure which normally disassembles in the spermatid. The time of appearance of developmental abnormalities in all of these mutants correlates with the temperature-sensitive periods for development of infertility. The observation that each of these mutants has a different and discreet set of morphological defects, a structure which normally disassembles in the spermatid. The time of appearance of developmental abnormalities in all of these mutants correlates with the temperature-sensitive periods for development of infertility. The observation that each of these mutants has a different and discreet set of morphological defects shows that the strict sequence of morphogenetic events that occurs during wild-type spermatogenesis cannot arise because each event is dependent on previous events. Instead, spermatozoa, like bacteriophages, must be formed by multiple independent pathways of morphogenesis.

Exhaled ethane, a marker of lipid peroxidation, is elevated in chronic obstructive pulmonary disease

Ethane is a product of lipid peroxidation and can be measured in the exhaled air as an index of oxidative stress. Oxidant/antioxidant imbalance is important in the pathogenesis of chronic obstructive pulmonary disease (COPD). Therefore, we measured exhaled ethane in 22 patients with COPD (mean age +/- SEM, 59 +/- 8 yr; 19 male) and compared it with other noninvasive markers of oxidative stress and inflammation such as carbon monoxide (CO), measured electrochemically, and nitric oxide (NO), measured by chemiluminescence. Exhaled ethane was collected during a flow and pressure-controlled exhalation into a reservoir, discarding dead space air contaminated with ambient air. A sample of the collected expired air was analyzed by chromatography. Compared with normal subjects (n = 14; eight men; age, 33 +/- 2.8 yr), patients with COPD not on steroid treatment (n = 12; FEV(1), 58 +/- 6%) had elevated levels of exhaled ethane (2.77 +/- 0.25 and 0.88 +/- 0.09 ppb, respectively, p < 0.05), CO (5.96 +/- 0.50 and 2.8 +/- 0.25 ppm, p < 0.05) and NO (11.86 +/- 0.53 and 6.77 +/- 0.50 ppb, p < 0.05) levels. Ethane was correlated to FEV(1) (r = -0.67, p < 0.05). Patients receiving steroid treatment (n = 10; FEV(1), 56 +/- 2%) had lower levels of ethane (0.48 +/- 0.05 ppb) than did steroid-treated patients, whereas CO (5.99 +/- 0.63 ppm) and NO (9.11 +/- 0.53 ppb) levels were similar in the two treatment groups. Exhaled ethane is elevated, correlates with FEV(1), and is significantly lower in patients treated with steroids, so it may be complementary to the use of NO and CO in assessing and monitoring oxidative stress in COPD.

Respiratory bronchiolitis, respiratory bronchiolitis-associated interstitial lung disease, and desquamative interstitial pneumonia: different entities or part of the spectrum of the same disease process?

OBJECTIVE

Our objective was to assess high-resolution CT findings of respiratory bronchiolitis, respiratory bronchiolitis-associated interstitial lung disease, and desquamative interstitial pneumonia and to determine whether these three entities could be reliably differentiated by radiologic criteria.

MATERIALS AND METHODS

CT scans (1- to 3-mm collimation) were reviewed in 40 patients with pathologically proven respiratory bronchiolitis (n = 16), respiratory bronchiolitis-associated interstitial lung disease (n = 8), or desquamative interstitial pneumonia (n = 16). All patients with respiratory bronchiolitis and respiratory bronchiolitis-associated interstitial lung disease were cigarette smokers, and 85% of the patients with desquamative interstitial pneumonia had a history of smoking. CT scans were independently reviewed by two radiologists who assessed the pattern and distribution of abnormalities.

RESULTS

The predominant abnormalities in respiratory bronchiolitis were centrilobular nodules (12 [75%] of 16 patients) and ground-glass attenuation (six [38%] of 16). No single abnormality predominated in the respiratory bronchiolitis-associated interstitial lung disease group; findings included ground-glass attenuation (four [50%] of eight), centrilobular nodules (three [38%] of eight), and mild fibrosis (two [25%] of eight). All patients with desquamative interstitial pneumonia showed ground-glass attenuation, and 10 (63%) of the 16 showed evidence of fibrosis.

CONCLUSION

The significant overlap between the CT findings of respiratory bronchiolitis, respiratory bronchiolitis-associated interstitial lung disease, and desquamative interstitial pneumonia is consistent with the concept that they represent different degrees of severity of small airway and parenchymal reaction to cigarette smoke.

ENCORE: the effect of nutrient enrichment on coral reefs. Synthesis of results and conclusions

Coral reef degradation resulting from nutrient enrichment of coastal waters is of increasing global concern. Although effects of nutrients on coral reef organisms have been demonstrated in the laboratory, there is little direct evidence of nutrient effects on coral reef biota in situ. The ENCORE experiment investigated responses of coral reef organisms and processes to controlled additions of dissolved inorganic nitrogen (N) and/or phosphorus (P) on an offshore reef (One Tree Island) at the southern end of the Great Barrier Reef, Australia. A multi-disciplinary team assessed a variety of factors focusing on nutrient dynamics and biotic responses. A controlled and replicated experiment was conducted over two years using twelve small patch reefs ponded at low tide by a coral rim. Treatments included three control reefs (no nutrient addition) and three + N reefs (NH4Cl added), three + P reefs (KH2PO4 added), and three + N + P reefs. Nutrients were added as pulses at each low tide (ca twice per day) by remotely operated units. There were two phases of nutrient additions. During the initial, low-loading phase of the experiment nutrient pulses (mean dose = 11.5 microM NH4+; 2.3 microM PO4(-3)) rapidly declined, reaching near-background levels (mean = 0.9 microM NH4+; 0.5 microM PO4(-3)) within 2-3 h. A variety of biotic processes, assessed over a year during this initial nutrient loading phase, were not significantly affected, with the exception of coral reproduction, which was affected in all nutrient treatments. In Acropora longicyathus and A. aspera, fewer successfully developed embryos were formed, and in A. longicyathus fertilization rates and lipid levels decreased. In the second, high-loading, phase of ENCORE an increased nutrient dosage (mean dose = 36.2 microM NH4+; 5.1 microM PO4(-3)) declining to means of 11.3 microM NH4+ and 2.4 microM PO4(-3) at the end of low tide) was used for a further year, and a variety of significant biotic responses occurred. Encrusting algae incorporated virtually none of the added nutrients. Organisms containing endosymbiotic zooxanthellae (corals and giant clams) assimilated dissolved nutrients rapidly and were responsive to added nutrients. Coral mortality, not detected during the initial low-loading phase, became evident with increased nutrient dosage, particularly in Pocillopora damicornis. Nitrogen additions stunted coral growth, and phosphorus additions had a variable effect. Coral calcification rate and linear extension increased in the presence of added phosphorus but skeletal density was reduced, making corals more susceptible to breakage. Settlement of all coral larvae was reduced in nitrogen treatments, yet settlement of larvae from brooded species was enhanced in phosphorus treatments. Recruitment of stomatopods, benthic crustaceans living in coral rubble, was reduced in nitrogen and nitrogen plus phosphorus treatments. Grazing rates and reproductive effort of various fish species were not affected by the nutrient treatments. Microbial nitrogen transformations in sediments were responsive to nutrient loading with nitrogen fixation significantly increased in phosphorus treatments and denitrification increased in all treatments to which nitrogen had been added. Rates of bioerosion and grazing showed no significant effects of added nutrients. ENCORE has shown that reef organisms and processes investigated in situ were impacted by elevated nutrients. Impacts were dependent on dose level, whether nitrogen and/or phosphorus were elevated and were often species-specific. The impacts were generally sub-lethal and subtle and the treated reefs at the end of the experiment were visually similar to control reefs. Rapid nutrient uptake indicates that nutrient concentrations alone are not adequate to assess nutrient condition of reefs. Sensitive and quantifiable biological indicators need to be developed for coral reef ecosystems. The potential bioindicators identified in ENCORE should be tested in future research on coral reef/nutrient interactions. Synergistic and cumulative effects of elevated nutrients and other environmental parameters, comparative studies of intact vs. disturbed reefs, offshore vs. inshore reefs, or the ability of a nutrient-stressed reef to respond to natural disturbances require elucidation. An expanded understanding of coral reef responses to anthropogenic impacts is necessary, particularly regarding the subtle, sub-lethal effects detected in the ENCORE studies.

Molecular characterization of the surface layer proteins from Clostridium difficile

Many bacteria express a surface-exposed proteinaceous layer, termed the S-layer, which forms a regular two-dimensional array visible by electron microscopy. Clostridium difficile is unusual in expressing two S-layer proteins (SLPs), which are of varying size in a number of strains. In an approach combining molecular biology with mass spectrometric sequencing strategies, we have identified the structural gene (slpA) for the S-layer from three strains of C. difficile. Both proteins are derived from a common precursor, and processing involves the removal of a signal peptide and a second cleavage to release the two mature SLPs. To our knowledge, this is the first example in which two SLPs have been shown to derive from a single gene product through post-translational processing, rather than from the expression of separate genes. The higher molecular weight (MW) SLP is highly conserved among the three strains, whereas the lower MW SLP shows considerable sequence diversity, reflecting the results from Western blotting. The high-MW SLP shows weak homology to N-acetyl muramoyl-L-alanine amidase from Bacillus subtilis, and both the native SLP from C. difficile and a recombinant protein expressed in Escherichia coli were found to display amidase activity by zymography. The high-MW SLPs showed evidence of glycosylation, whereas the lower MW proteins did not. A family of genes with sequence homology to the amidase domain of the high-MW SLP was identified in the C. difficile strain 630 genome, some of which are located in the same region of the genome as slpA and were shown by reverse transcription-polymerase chain reaction (RT-PCR) analysis to be transcribed.

Developmental genetics of chromosome I spermatogenesis-defective mutants in the nematode Caenorhabditis elegans

Mutations affecting Caenorhabditis elegans spermatogenesis can be used to dissect the processes of meiosis and spermatozoan morphological maturation. We have obtained 23 new chromosome I mutations that affect spermatogenesis (spe mutations). These mutations, together with six previously described mutations, identify 11 complementation groups, of which six are defined by multiple alleles. These spe mutations are all recessive and cause normally self-fertile hermaphrodites to produce unfertilized oocytes that can be fertilized by wild-type male sperm. Five chromosome I mutation/deficiency heterozygotes have similar phenotypes to the homozygote showing that the probable null phenotype of these genes is defective sperm. Spermatogenesis is disrupted at different steps by mutations in these genes. The maturation of 1 degree spermatocytes is disrupted by mutations in spe-4 and spe-5. Spermatids from spe-8 and spe-12 mutants develop into normal spermatozoa in males, but not in hermaphrodites. fer-6 spermatids are abnormal, and fer-1 spermatids look normal but subsequently become abnormal spermatozoa. Mutations in five genes (fer-7, spe-9, spe-11, spe-13 and spe-15) allow formation of normal looking motile spermatozoa that appear to be defective in either sperm-spermathecal or sperm-oocyte interactions.

Equatorius: a new hominoid genus from the Middle Miocene of Kenya

A partial hominoid skeleton just older than 15 million years from sediments in the Tugen Hills of north central Kenya mandates a revision of the hominoid genus Kenyapithecus, a possible early member of the great ape-human clade. The Tugen Hills specimen represents a new genus, which also incorporates all material previously referable to Kenyapithecus africanus. The new taxon is derived with respect to earlier Miocene hominoids but is primitive with respect to the younger species Kenyapithecus wickeri and therefore is a late member of the stem hominoid radiation in the East African Miocene.

Why do worms need cholesterol?

Cholesterol is a structural component of animal membranes that influences fluidity, permeability and formation of lipid microdomains. It is also a precursor to signalling molecules, including mammalian steroid hormones and insect ecdysones. The nematode Caenorhabditis elegans requires too little cholesterol for it to have a major role in membrane structure. Instead, its most probable signalling functions are to control molting and induce a specialized non-feeding larval stage, although no cholesterol-derived signalling molecule has yet been identified for these or any other functions.