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The state of somatic energy stores in metazoans is communicated to the brain, which regulates key aspects of behaviour, growth, nutrient partitioning and development1. The central melanocortin system acts through melanocortin 4 receptor (MC4R) to control appetite, food intake and energy expenditure2. Here we present evidence that MC3R regulates the timing of sexual maturation, the rate of linear growth and the accrual of lean mass, which are all energy-sensitive processes. We found that humans who carry loss-of-function mutations in MC3R, including a rare homozygote individual, have a later onset of puberty. Consistent with previous findings in mice, they also had reduced linear growth, lean mass and circulating levels of IGF1. Mice lacking Mc3r had delayed sexual maturation and an insensitivity of reproductive cycle length to nutritional perturbation. The expression of Mc3r is enriched in hypothalamic neurons that control reproduction and growth, and expression increases during postnatal development in a manner that is consistent with a role in the regulation of sexual maturation. These findings suggest a bifurcating model of nutrient sensing by the central melanocortin pathway with signalling through MC4R controlling the acquisition and retention of calories, whereas signalling through MC3R primarily regulates the disposition of calories into growth, lean mass and the timing of sexual maturation.

Quantifying the effect of public health actions on population health is essential when justifying sustained public health investment. Using modeling, we conservatively estimated that rapid response to a multistate foodborne outbreak of Salmonella Typhimurium in the United States in 2018 potentially averted 94 reported cases and $633,181 in medical costs and productivity losses.

Background Earlier puberty is widely linked with future obesity and cardiometabolic disease. We examined whether age at puberty onset likely influences adiposity and cardiometabolic traits independent of childhood adiposity. Methods and findings One-sample Mendelian randomisation (MR) analyses were conducted on up to 3,611 white-European female and male offspring from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort recruited at birth via mothers between 1 April 1991 and 31 December 1992. Time-sensitive exposures were age at menarche and age at voice breaking. Outcomes measured at age 18 y were body mass index (BMI), dual-energy X-ray absorptiometry ±based fat and lean mass indices, blood pressure, and 230 cardiometabolic traits derived from targeted metabolomics (150 concentrations plus 80 ratios from nuclear magnetic resonance [NMR] spectroscopy covering lipoprotein subclasses of cholesterol and triglycerides, amino acids, inflammatory glycoproteins, and others). Adjustment was made for pre-pubertal BMI measured at age 8 y. For negative control MR analyses, BMI and cardiometabolic trait measures taken at age 8 y (before puberty, and which therefore cannot be an outcome of puberty itself) were used. For replication analyses, 2-sample MR was conducted using summary genome-wide association study data on up to 322,154 adults for post-pubertal BMI, 24,925 adults for post-pubertal NMR cardiometabolic traits, and 13,848 children for pre-pubertal obesity (negative control). Like observational estimates, 1-sample MR estimates in ALSPAC using 351 polymorphisms for age at menarche (explaining 10.6% of variance) among 2,053 females suggested that later age at menarche (per year) was associated with −1.38 kg/m2 of BMI at age 18 y (or −0.34 SD units, 95% CI −0.46, −0.23; P = 9.77 × 10−09). This coefficient attenuated 10-fold upon adjustment for BMI at age 8 y, to −0.12 kg/m2 (or −0.03 SDs, 95% CI −0.13, 0.07; P = 0.55). Associations with blood pressure were similar, but associations across other traits were small and inconsistent. In negative control MR analyses, later age at menarche was associated with −0.77 kg/m2 of pre-pubertal BMI measured at age 8 y (or −0.39 SDs, 95% CI −0.50, −0.29; P = 6.28 × 10−13), indicating that variants influencing menarche also influence BMI before menarche. Cardiometabolic trait associations were weaker and less consistent among males and both sexes combined. Higher BMI at age 8 y (per 1 kg/m2 using 95 polymorphisms for BMI explaining 3.4% of variance) was associated with earlier menarche among 2,648 females (by −0.26 y, 95% CI −0.37, −0.16; P = 1.16 × 10−06), likewise among males and both sexes combined. In 2-sample MR analyses using 234 polymorphisms and inverse variance weighted (IVW) regression, each year later age at menarche was associated with −0.81 kg/m2 of adult BMI (or −0.17 SD units, 95% CI −0.21, −0.12; P = 4.00 × 10−15). Associations were weaker with cardiometabolic traits. Using 202 polymorphisms, later menarche was associated with lower odds of childhood obesity (IVW-based odds ratio = 0.52 per year later, 95% CI 0.48, 0.57; P = 6.64 × 10−15). Study limitations include modest sample sizes for 1-sample MR, lack of inference to non-white-European populations, potential selection bias through modest completion rates of puberty questionnaires, and likely disproportionate measurement error of exposures by sex. The cardiometabolic traits examined were heavily lipid-focused and did not include hormone-related traits such as insulin and insulin-like growth factors. Conclusions Our results suggest that puberty timing has a small influence on adiposity and cardiometabolic traits and that preventive interventions should instead focus on reducing childhood adiposity.

Therapeutic strategies that target disease-associated transcripts are being developed for a variety of neurodegenerative syndromes. Protein levels change as a function of their half-life, a property that critically influences the timing and application of therapeutics. In addition, both protein kinetics and concentration may play important roles in neurodegeneration; therefore, it is essential to understand in vivo protein kinetics, including half-life. Here, we applied a stable isotope-labeling technique in combination with mass spectrometric detection and determined the in vivo kinetics of superoxide dismutase 1 (SOD1), mutation of which causes amyotrophic lateral sclerosis. Application of this method to human SOD1-expressing rats demonstrated that SOD1 is a long-lived protein, with a similar half-life in both the cerebral spinal fluid (CSF) and the CNS. Additionally, in these animals, the half-life of SOD1 was longest in the CNS when compared with other tissues. Evaluation of this method in human subjects demonstrated successful incorporation of the isotope label in the CSF and confirmed that SOD1 is a long-lived protein in the CSF of healthy individuals. Together, the results of this study provide important insight into SOD1 kinetics and support application of this technique to the design and implementation of clinical trials that target long-lived CNS proteins.

Importance The causal direction and magnitude of the association between telomere length and incidence of cancer and non-neoplastic diseases is uncertain owing to the susceptibility of observational studies to confounding and reverse causation. Objective To conduct a Mendelian randomization study, using germline genetic variants as instrumental variables, to appraise the causal relevance of telomere length for risk of cancer and non-neoplastic diseases. Data Sources Genomewide association studies (GWAS) published up to January 15, 2015. Study Selection GWAS of noncommunicable diseases that assayed germline genetic variation and did not select cohort or control participants on the basis of preexisting diseases. Of 163 GWAS of noncommunicable diseases identified, summary data from 103 were available. Data Extraction and Synthesis Summary association statistics for single nucleotide polymorphisms (SNPs) that are strongly associated with telomere length in the general population. Main Outcomes and Measures Odds ratios (ORs) and 95%confidence intervals (CIs) for disease per standard deviation (SD) higher telomere length due to germline genetic variation. Results Summary data were available for 35 cancers and 48 non-neoplastic diseases, corresponding to 420 081 cases (median cases, 2526 per disease) and 1 093 105 controls (median, 6789 per disease). Increased telomere length due to germline genetic variation was generally associated with increased risk for site-specific cancers. The strongest associations (ORs [95%CIs] per 1-SD change in genetically increased telomere length) were observed for glioma, 5.27 (3.15-8.81); serous low-malignant-potential ovarian cancer, 4.35 (2.39-7.94); lung adenocarcinoma, 3.19 (2.40-4.22); neuroblastoma, 2.98 (1.92-4.62); bladder cancer, 2.19 (1.32-3.66); melanoma, 1.87 (1.55-2.26); testicular cancer, 1.76 (1.02-3.04); kidney cancer, 1.55 (1.08-2.23); and endometrial cancer, 1.31 (1.07-1.61). Associations were stronger for rarer cancers and at tissue sites with lower rates of stem cell division. There was generally little evidence of association between genetically increased telomere length and risk of psychiatric, autoimmune, inflammatory, diabetic, and other non-neoplastic diseases, except for coronary heart disease (OR, 0.78 [95%CI, 0.67-0.90]), abdominal aortic aneurysm (OR, 0.63 [95%CI, 0.49-0.81]), celiac disease (OR, 0.42 [95%CI, 0.28-0.61]) and interstitial lung disease (OR, 0.09 [95%CI, 0.05-0.15]). Conclusions and Relevance It is likely that longer telomeres increase risk for several cancers but reduce risk for some non-neoplastic diseases, including cardiovascular diseases.

ImportanceUnderstanding the natural history of familial amyotrophic lateral sclerosis (ALS) caused by SOD1 mutations (ALSSOD1) will provide key information for optimising clinical trials in this patient population.ObjectiveTo establish an updated natural history of ALSSOD1.Design, setting and participantsRetrospective cohort study from 15 medical centres in North America evaluated records from 175 patients with ALS with genetically confirmed SOD1 mutations, cared for after the year 2000.Main outcomes and measuresAge of onset, survival, ALS Functional Rating Scale (ALS-FRS) scores and respiratory function were analysed. Patients with the A4V (Ala-Val) SOD1 mutation (SOD1A4V), the largest mutation population in North America with an aggressive disease progression, were distinguished from other SOD1 mutation patients (SOD1non-A4V) for analysis.ResultsMean age of disease onset was 49.7±12.3 years (mean±SD) for all SOD1 patients, with no statistical significance between SOD1A4V and SOD1non-A4V (p=0.72, Kruskal-Wallis). Total SOD1 patient median survival was 2.7 years. Mean disease duration for all SOD1 was 4.6±6.0 and 1.4±0.7 years for SOD1A4V. SOD1A4V survival probability (median survival 1.2 years) was significantly decreased compared with SOD1non-A4V (median survival 6.8 years; p

Objective.To determine whether multidrug-resistant (MDR) gram-negative organisms are present in Afghanistan or Iraq soil samples, contaminate standard deployed hospital or modular operating rooms (ORs), or aerosolize during surgical procedures.Design.Active surveillance.Setting.US military hospitals in the United States, Afghanistan, and Iraq.Methods.Soil samples were collected from sites throughout Afghanistan and Iraq and analyzed for presence of MDR bacteria. Environmental sampling of selected newly established modular and deployed OR high-touch surfaces and equipment was performed to determine the presence of bacterial contamination. Gram-negative bacteria aerosolization during OR surgical procedures was determined by microbiological analysis of settle plate growth.Results.Subsurface soil sample isolates recovered in Afghanistan and Iraq included various pansusceptible members of Enterobacteriaceae,Vibriospecies,Pseudomonasspecies,Acinetobacter Iwojfii, and coagulase-negativeStaphylococcus(CNS). OR contamination studies in Afghanistan revealed 1 surface with aMicrococcus luteus. Newly established US-based modular ORs and the colocated fixed-facility ORs revealed no gram-negative bacterial contamination prior to the opening of the modular OR and 5 weeks later. Bacterial aerosolization during surgery in a deployed fixed hospital revealed a mean gram-negative bacteria colony count of 12.8 colony-forming units (CFU)/dm2/h (standard deviation [SD], 17.0) during surgeries and 6.5 CFU/dm2/h (SD, 7.5;P= .14) when the OR was not in use.Conclusion.This study demonstrates no significant gram-negative bacilli colonization of modular and fixed-facility ORs or dirt and no significant aerosolization of these bacilli during surgical procedures. These results lend additional support to the role of nosocomial transmission of MDR pathogens or the colonization of the patient themselves prior to injury.

The increased incidence of sexually transmitted infections has historically been associated with military personnel at war. The incidence of gonorrhea and Chlamydia in personnel deployed in the current wars in Iraq and Afghanistan has not been reported. An electronic records' review of testing done from January 2004 to September 2009 revealed higher rates of Chlamydia than gonorrhea, especially among females who deploy to Iraq. Additionally, increasing Chlamydia rates were noted over the study. Overall, the rates of gonorrhea and Chlamydia were the same or lower than age- and year-matched U.S. rates reported by the Center for Disease Control and Prevention. Ongoing education with emphasis on prevention and treatment are needed, as are development of specific projects to define the risk factors and timing of acquisition of sexually transmitted infections in combat zones.

Methicillin-resistant Staphylococcus aureus (MRSA) in health-care settings results in life-threatening infections. We examined the incidence of MRSA at the combat support hospital located at the Ibn Sina Hospital in Baghdad, Iraq. We compiled isolate data from 2005 to 2009 characterizing antibiotic susceptibilities, annual trends, patient populations, infection sites, and hospital locations. Approximately 46.1% of S. aureus were MRSA, with increase in numbers of yearly isolates. MRSA was isolated in higher numbers from U.S. military personnel. Non-U.S. patient isolates displayed higher antibiotic susceptibility compared to U.S. military personnel isolates. Outpatient clinic, forward operating bases, and intermediate care ward 1 isolated the most MRSA. Common isolation sites were wound and skin cultures. Community-acquired MRSA was likely present in 291 out of 303 isolates based on antibiotic susceptibility. Our data suggests that most MRSA were community-acquired with limited nosocomial spread. We recommend increases in combat support hospital molecular lab capability to rapidly identify both MRSA categories.

Staphylococcus aureus infections complicate care of combat-related injuries and can independently result in skin and soft-tissue infections during deployments or training. Community-associated methicillin-resistant S. aureus (CA-MRSA) strains seem to produce severe disease but retain susceptibility to many oral antimicrobials. This study characterizes 84 MRSA isolates recovered from wound cultures at a combat support hospital in Iraq.MRSA strains recovered from December 2007 through March 2009 were analyzed. Antimicrobial resistance testing was determined by broth microdilution and the BD Phoenix Automated Microbiology System. The genotypic pattern was analyzed by pulsed-field gel electrophoresis and polymerase chain reaction identification of resistance and virulence genes.No MRSA isolates from wound cultures were resistant to vancomycin. The most active oral antistaphylococcal agents were tetracycline (95% susceptibility), trimethoprim-sulfamethoxazole (94%), and clindamycin (94%). Of agents not typically recommended as monotherapy, 98% of isolates were susceptible to rifampin, 91% to moxifloxacin, and 60% to levofloxacin. The most common pulsed-field type (PFT) was USA300 (79%). The typical staphylococcal cassette chromosome mec IV elements carrying the CA-MRSA resistance genes were present in 88% of the isolates. Panton-Valentine leukocidin virulence genes were identified in 88% of isolates, including 100% of PFT USA300. The virulence gene associated with an arginine catabolic mobile element was present in 75% of isolates, including 94% of PFT USA300.This study is the first genotypic and phenotypic characterization of CA-MRSA recovered from wound cultures in a deployed combat hospital. The pattern noted was similar to that seen in soldiers stationed in the United States.

Background.Multidrug-resistant (MDR)Acinetobacter baumanniiandPseudomonas aeruginosahave emerged as the causes of nosocomial infections in critically ill patients.Objective.To characterize the incidence of these MDR bacteria over time in the military healthcare system, comparing isolates recovered from overseas combat casualties with isolates recovered from local military and civilian patients.Methods.Retrospective electronic records review of culture and/or susceptibility testing results of patients admitted to a military level I trauma center in San Antonio, Texas, during the period from January 2001 through December 2008. Multidrug resistance was defined as the first isolated organism resistant to 3 or more classes of antimicrobial agents.Results.Over time, the percentage of MDRA. baumanniiisolates increased from 4% to 55%, whereas the percentage of MDRP. aeruginosaisolates increased from 2% to 8%. Respiratory tract specimens had a higher percentage of MDRA. baumanniiisolates (49%), compared with specimens obtained from blood (30%), wound sites (24%), or urine (19%). No difference in the percentages of MDRP. aeruginosaisolates was observed with regard to source of specimen. The percentage of MDRA. baumanniiisolates recovered was higher among patients who had been deployed overseas (52%) than among local patients (20%). When isolates recovered from patients in the burn intensive care unit (53% of MDRA. baumanniiisolates) were removed from analysis, the percentage of MDRA. baumanniiisolates decreased from 38% to 30% while the percentage of MDRP. aeruginosaisolates remained unaffected.Conclusion.The percentage of MDRA. baumanniiisolates increased in this facility among combat casualties and among local patients, which indicates nosocomial transmission; however, there was no significant increase in the percentage of MDRP. aeruginosaisolates. Isolated changes in the MDR pathogens within a facility can occur. Possible interventions to limit the spread of these organisms could include implementing aggressive infection control practices, controlling antibiotic use, and using active culture surveillance.

Study design Retrospective cohort. Objective The purpose of this study is to determine the fusion rates of a consecutive series of anterior cervical decompressions and fusions with allograft patella using both static and dynamic plates. Summary of background data Anterior cervical diskectomy and fusion (ACDF) has been shown to improve symptoms of radiculopathy and myelopathy. The gold standard for obtaining fusion is using autogenous iliac crest bone graft (ICBG). The complication rate of using ICBG can be as high as 20%. To minimize this morbidity, various forms of allograft are presently used. We have used patellar allograft that we hypothesize exhibits a good combination of strength and sufficient porosity to facilitate fusion. Methods A consecutive series of 179 levels in 136 patients who underwent single and multilevel ACDF with allograft patella were retrospectively investigated. Final follow-up lateral cervical spine radiographs were evaluated for evidence of bony fusion. Fusions were graded independently by 2 of the investigators according to an interbody fusion classification proposed by Bridwell and colleagues, Spine, 1995. Fusion rates were compared with historical controls for single-level ACDF with autogenous ICBG and plating. Multivariate analysis was used to evaluate plate type, smoking, revision rate, and Odom's criteria compared with fusion. Results Ninety-one consecutive single and 81 multilevel anterior cervical decompression and fusions with allograft patella were reviewed. Demographics were similar (average age 47.75 y). Average follow-up was 19.3 months. Fusion rates were 86% (159/179). Our revision rate was 8%. Eighty-one percent (85/98) union rate was noted in the single-level group, and 85% (69/81 levels) or 74% (28/38 patients) in the multilevel group. Conclusions Fusion rates were 86%. Plate design (static vs. dynamic) did not seem to affect fusion rates or clinical outcomes. There was a higher nonunion rate at the most inferior level of the multilevel fusions. Nonunions in the dynamic group were more commonly revised and had more kyphosis at final follow-up.

U.S. combat casualties from Iraq and Afghanistan continue to develop infections with multidrug-resistant (MDR) bacteria. This study assesses the infection control database and clinical microbiology antibiograms at a single site from 2005 to 2007, a period when all Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) casualties admitted to the facility underwent initial isolation and screening for MDR pathogens. During this 3-year period, there were 2,242 OIF/OEF admissions: 560 in 2005, 724 in 2006, and 958 in 2007. The most commonly recovered pathogens from OIF/OEF admission screening cultures were methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae and Acinetobacter. The yearly nosocomial infection rate of these three pathogens among OIF/OEF admissions ranged between 2 and 4%. There were remarkable changes in resistance profiles for Acinetobacter, K. pneumoniae, and S. aureus over time. Despite aggressive infection control procedures, there is continued nosocomial transmission within the facility and increasing antimicrobial resistance in some pathogens. Novel techniques are needed to control the impact of MDR bacteria in medical facilities.

The performance of a real-time polymerase chain reaction (PCR) assay using the Smart Cycler instrument and a minor groove binding MGB Eclipse probe (Epoch Biosciences, Bothell, WA) for identification of Mycobacterium tuberculosis complex in acid-fast bacillus smear-positive and smear-negative clinical specimens was assessed by comparing results to the Amplified M. tuberculosis Direct Test (MTD) and mycobacterial culture plus clinical diagnosis. After initial testing, the overall sensitivity, specificity, and positive and negative predictive values of PCR for the 172 specimens submitted for mycobacterial culture were 86.3%, 100%, 100%, and 94.5%, respectively. These same values for MTD were 98.0%, 99.2%, 98.0%, and 99.2%. For 83 additional specimens, only MTD and PCR were performed; 5 specimens were positive and 78 were negative by both tests. The sensitivity of the PCR assay was improved by using different primers and probes. The time to a result for real-time PCR, starting with a decontaminated sample, was less than 3 h compared with 5-6 h for the MTD.

The telomere repeat amplification protocol (TRAP) was recently developed to detect telomerase activity in cellular protein extracts. Teleomerase synthesizes a specific repeating nucleotide sequence onto the ends of telomeres, which stabilize eukaryotic chromosomes. Telomeric repeats are identified in the TRAP method by polymerase chain reaction amplification and incorporation of radionucleotides detected by autoradiography. Several drawbacks to this method have been recognized, including the time required to complete the assay, the resolution of the results, and the hazards of radioactive material. We have developed a new fluorescent method of detecting telomerase to alleviate these problems. Telomeric repeats are identified in the fluorescent TRAP (F-TRAP) assay by incorporation of fluorescein-labeled primers during amplification and subsequent detection with an automated DNA sequencer. This new method appears to be as sensitive as the standard TRAP assay and offers advantages in speed, resolution, cost, and safety.

Organisms that produce extended-spectrum beta-lactamase (ESBL) are significant causes of infection among deployed service members. These specific organisms have increased resistance to several antibiotics, limiting the choice of therapy for the provider. Currently, the deployed microbiology lab uses, by default, the Siemens NBPC30 panel to identify and measure antibiotic susceptibility of gram-negative organisms. However, when an ESBL is suspected, additional confirmatory testing is performed, during which time the health care provider is forced to use broad spectrum antibiotics to protect the patient from infection. In this study, we evaluated the NBPC30 and NBC41 panels for their ability to rapidly and accurately detect ESBL-producing organisms.Identification and antimicrobial susceptibility testing of 79 strains of Enterobacteriaceae isolated from patients treated at Ibn Sina tertiary hospital (Baghdad) were performed using the NBPC30 and NBC41 panels. These results were confirmed using a Kirby-Bauer disk diffusion reference method described by the Clinical Laboratory Standards Institute. Sensitivities and specificities of the panels were determined in relation to this reference method.Sensitivity and specificity of the NBC41 were 96.7% and 89%, while they were 86.7% and 72% for the NBPC30 panel. False positive and false negative rates were higher for the NBPC30 panel.Our data shows that the NBC41 panel is superior to the NBPC30 panel in rapidly identifying ESBL-producing organisms. Use of the NBPC41 panel decreases the turnaround time by 24 hours, allowing the provider to more accurately apply appropriate antibiotic therapy. Additionally, the NBPC41 panel provides more useful antibiotic susceptibility results compared to the NBPC30. We recommend use of this panel as a primary identification and susceptibility panel for gram-negative organisms.

Biopsy reports from 150 periradicular tissue specimens obtained from teeth refractory to nonsurgical endodontic therapy were reviewed. The specimens were submitted by postdoctoral dental students in the Department of Endodontics, and the biopsy reports were prepared by oral pathologists at the University of Texas Health Science Center at San Antonio. The study found that 59.3% of the periradicular lesions were granulomas, 22% cysts, 12% scars, and 6.7% other pathoses. The majority (56%) of endodontically treated cases which failed to heal were recognized within 2 yr after the completion of therapy. The most common location for surgical retreatment was the anterior maxilla, followed by the posterior maxilla, the posterior mandible, and the anterior mandible. The periapical granuloma was the predominant pathosis at each location.

Quality assurance (QA) in the clinical laboratory is a process that ensures accurate and high-quality results. Successful QA programs avoid mistakes, provide consistent test results and data integrity, and are cost effective. In traditional hospitals, QA is an integral part of the laboratory with dedicated staff and published guidelines and regulations. The Department of Defense provides little direction for a QA program in the deployed environment. AR 40-3 and ARTEP 8-705-MTP implement the Tri-Service Clinical Laboratory Improvement Program (CLIP) regulations/standards for the clinical laboratory in medical treatment facilities (MTFs) and combat support hospitals. 1,2 Deployed units are not regulated by CLIP, but must meet minimal requirements. These include training verifi cation and competency, updating test standard operating procedures (SOPs), maintaining document quality control, quality assurance, and equipment maintenance programs, validation of all procedures, and participating in continuing education. 3 The Army Medical Department Center and School (AMEDDC&S) publishes and updates a fi eld laboratory information program (FLIP) disk, providing the latest SOPs and forms. However, the FLIP disk does not publish guidelines on QA. This editorial discusses the need to establish a set of guidelines to be used during deployment. Current Status in Theater In the Iraq theater of operations (ITO), military hospitals have varying capabilities, instrumentation, and laboratory test menus. Several universal issues affect the fl ow of operations of each MTF. These problems include: laboratory information system (LIS) interoperability, instrument maintenance, specimen shipping, personnel availability, reagent acquisition, and kit duplication.

Infections caused by multidrug-resistant (MDR) pathogens are associated with significant morbidity and mortality in patients with burn injuries. We performed a 6-year antibiotic susceptibility records review from January 2003 to December 2008 to assess the prevalence of MDR isolates by pathogen at the US Army Institute of Surgical Research Burn Center. During the study period Acinetobacter baumannii (780 isolates [22%]) was the most prevalent organism recovered, followed by Pseudomonas aeruginosa (703 isolates [20%]), Klebsiella pneumoniae (695 isolates [20%]), and Staphylococcus aureus (469 isolates [13%]). MDR prevalence rates among these isolates were A. baumannii 53%, methicillin-resistant S. aureus (MRSA) 34%, K. pneumoniae 17% and P. aeruginosa 15%. Two isolates, 1 A. baumannii and 1 P. aeruginosa, were identified as resistant to all 4 classes of antibiotics tested plus colistin. A. baumannii isolates recovered from patients with burns greater than 30% of total body surface area (TBSA) were more likely to be MDR (61%) with no significant difference for P. aeruginosa and K. pneumoniae. A higher proportion of MDR P. aeruginosa isolates were recovered from respiratory specimens compared to blood specimens (24% vs. 9%) while the opposite was true for MRSA (35% vs. 54%). A comparison of A. baumannii recovered during hospitalization days 1-5 and 15-30 revealed higher MDR levels as length of stay increased (48% vs. 75%) while no significant trends were observed for P. aeruginosa and K. pneumoniae. A similar pattern was observed for MDR A. baumannii levels for the facility between 2003 and 2005 and 2006-2008 (39% vs. 70%), with no significant increase in MDR P. aeruginosa and MDR K. pneumoniae. Increasing antibiotic resistance patterns of the most prevalent isolates recovered during extended hospitalization, impact of % TBSA and other clinical parameters may affect empirical antimicrobial therapy and patient management decisions during treatment.

Considerable advancements in shock resuscitation and wound management have extended the survival of burned patients, increasing the risk of serious infection. We performed a 6-year review of bacteria identification and antibiotic susceptibility records at the US Army Institute of Surgical Research Burn Center between January 2003 and December 2008. The primary goal was to identify the bacteria recovered from patients with severe burns and determine how the bacteriology changes during extended hospitalization as influenced by population and burn severity. A total of 460 patients were admitted to the burn ICU with 3507 bacteria recovered from 13,727 bacteriology cultures performed. The most prevalent organisms recovered were Acinetobacter baumannii (780), Pseudomonas aeruginosa (703), Klebsiella pneumoniae (695) and Staphylococcus aureus (469). A. baumannii was most often recovered from combat-injured (58%) and S. aureus the most frequent isolate from local (46%) burn patients. Culture recovery rate of A. baumannii and S. aureus was highest during the first 15 hospital days (73% and 71%); while a majority of P. aeruginosa and K. pneumoniae were recovered after day 15 (63% and 53%). All 4 pathogens were recovered throughout the course of hospitalization. A. baumannii was the most prevalent pathogen recovered from patients with total body surface area (TBSA) burns less than 30% (203) and 30-60% (338) while P. aeruginosa was most prevalent in patients with burns greater than 60% TBSA (292). Shifting epidemiology of bacteria recovered during extended hospitalization, bacteriology differences between combat-injured and local burn patients, and impact of % TBSA may affect patient management decisions during the course of therapy.

Background: Enteroviruses are a leading cause of aseptic meningitis in adult and pediatric populations. We describe the development of a real-time RT-PCR assay that amplifies a small target in the 5′ nontranslated region upstream of the classical Rotbart enterovirus amplicon. The assay includes an RNA internal control and incorporates modified nucleotide chemistry.Methods: We evaluated the performance characteristics of this design and performed blinded parallel testing on clinical samples, comparing the results with a commercially available RT-PCR assay (Pan-Enterovirus OligoDetect kit) that uses an enzyme immunoassay–like plate end detection.Results: We tested 778 samples and found 14 discrepant samples between the 2 assays. Of these, the real-time assay detected 6 samples that were negative by the OligoDetect kit, 5 of which were confirmed as positive by sequence analysis using an alternative primer set. Eight discrepant samples were positive by the OligoDetect kit and real-time negative, with 6 confirmed by sequencing. Overall, detection rates of 97% and 96% were obtained for the OligoDetect kit and real-time assays, respectively. Sequence analysis revealed the presence of a number of single nucleotide polymorphisms in the targeted region. The comparative sensitivities of the 2 assays were equivalent, with the limit of detection for the real-time assay determined to be approximately 430 copies per milliliter in cerebrospinal fluid.Conclusions: This novel real-time enterovirus assay is a sensitive and suitable assay for routine clinical testing. The presence of single nucleotide polymorphisms can affect real-time PCR assays.

Explant analysis for bone ingrowth of retrieved cervical disc prosthesis in chimpanzees and humans.To assess the bone ingrowth into retrieved Bryan Cervical Discs.Bone ingrowth in cervical disc prosthesis has not been documented in the literature.Chimpanzee: Two chimpanzees underwent placement of the Bryan disc at C3-C4 and 3 months later had explantation and interbody fusion. Human: Two patients had removal of their Bryan disc and interbody fusion for failure to resolve symptoms at 8 and 10 months. The explants were analyzed for bone ingrowth.Chimpanzee: Histologic analysis showed bony ingrowth through the interstices of the porous coating and apposition ranging from 10% to 50% of toluidine blue-stained sections. New ingrowth, rather than bony impaction, was confirmed with fluorochrome-labeled sections Human: Bone ingrowth was a mean of 30.1% (12% SD). No difference was observed between peripheral, intermediate, or central locations.Adequate bony apposition was found in all primate device-to-vertebral body interfaces. Human retrievals also demonstrated significant ingrowth in all four surfaces. This compares with hip and knee arthroplasty percent ingrowth rates of 10% to 30%. All implants had stable fixation judged by radiographs and at the time of implant removal.

Six methods of extracting Mycobacterium tuberculosis DNA from sputum for testing by quantitative PCR were compared: Tris-EDTA (TE) buffer, PrepMan Ultra, 2% sodium dodecyl sulfate (SDS)-10% Triton X with and without sonication, Infectio Diagnostics, Inc. (IDI) lysing tubes, and QIAGEN QIAamp DNA mini kit; all included a 15-min boiling step. Pooled digested and decontaminated sputum was spiked with M. tuberculosis ATCC 27294. Each extraction method was repeated eight times. Quantitative PCR was performed on the Smart Cycler and Rotor-Gene 3000 using primers targeting an 83-bp fragment of IS 6110 . An minor grove binding Eclipse probe with a fluorescent label was used for detection. An internal control was included to detect amplification inhibition. The limit of detection of M. tuberculosis DNA was 0.5 fg with both instruments. Calculated DNA concentrations (picograms) extracted using IDI, PrepMan, QIAGEN, and TE were 42.8, 30.4, 28.2, and 7.4, respectively, when run on the Smart Cycler, and 51.7, 20.1, 14.9, and 8.6, respectively, when run on Rotor-Gene. All extractions using SDS/Triton X with or without sonication were inhibited. Of the extraction methods evaluated, IDI lysis tubes provided the greatest yield of mycobacterial DNA, and the procedure can be completed in less than 1 h versus 2.5−3 h for the QIAGEN extraction.

Laboratory evidence for tuberculous meningitis is difficult to acquire due to the low numbers of organisms present in cerebrospinal fluid (CSF) and the presence of nucleic acid amplification inhibitors. The Amplified Mycobacterium tuberculosis Direct Test (MTD) is sensitive and specific for the direct detection of M. tuberculosis complex in respiratory samples but has not been approved for CSF. We evaluated a modified version of the current MTD, optimized for use with CSF samples. Samples were prepared by spiking CSF with various numbers of M. tuberculosis complex organisms. The modified MTD performance was compared with results obtained using a purified RNA sample extracted using the Qiagen RNeasy Protect Bacteria Mini Kit. By use of CSF artificially spiked with M. tuberculosis complex, the sensitivity of the modified MTD was 100% (six of six) for CSF samples containing approximately 600 CFU/ml, 78% (seven of nine) for approximately 60 CFU/ml, 50% (three of six) for 6 CFU/ml, and 17% (one of six) for samples with

Background: Rapid diagnostic methods for respiratory syncytial virus are useful tools available for the clinician. Objectives: The Thermo Electron™ RSV OIA® (optical immunoassay kit) was prospectively compared with direct immunofluorescent assay and viral culture at Primary Children's Medical Center, Salt Lake City, Utah. Study design: Specimens from three hundred and thirty patients exhibiting respiratory symptoms were collected for testing by the three methods above. Several specimens were positive by both OIA and DFA with a negative culture result. These culture results were verified by RT-PCR analysis. Results: Overall, 107 specimens were positive for RSV by the reference tests (culture or RT-PCR). DFA analysis identified an additional 40 patient specimens positive for other respiratory viruses. Compared to the reference tests the sensitivity, specificity, positive, and negative predictive values of the OIA for detection of RSV were 87.9%, 99.6%, 98.9% and 94.5%, respectively. Conclusions: The rapid OIA assay format proved to be cost effective, and simple to use in comparison to DFA and viral culture. Negative rapid test results should still be confirmed with a secondary test.

The Binax NOW immunochromatographic assay for respiratory syncytial virus was prospectively compared with direct fluorescent assay and viral culture at Primary Children's Medical Center, Salt Lake City, Utah during February 2003. Three hundred ten patient specimens were collected for testing, of which 102 specimens were positive for respiratory syncytial virus by the reference tests, direct immunofluorescence assay (DFA), and culture or molecular analysis. DFA analysis identified an additional 40 patient specimens positive for other respiratory viruses. Compared to the reference tests, the sensitivity, specificity, and positive and negative predictive values of the rapid immunochromatographic assay for detection of respiratory syncytial virus were 89.2%, 100.0%, 100.0%, and 94.9%, respectively. This rapid assay format proved to be cost-effective and simple to use in comparison to DFA and viral culture. Negative rapid test results should still be confirmed with a secondary test.

A 32-year-old male patient with severe factor VIII (FVIII) deficiency had developed a high-titer FVIII inhibitor at age 13. Recurrent hemarthroses caused bony destruction in both knees, significantly impairing his ability to walk. Knee examination revealed 20 degrees of varus, destruction of the medial joint line, and flexion contracture. Total knee arthroplasty was performed using recombinant factor VIIa (rFVIIa, NovoSeven) for hemostatic control. rFVIIa (85 microg/kg given intravenously over 3-5 minutes) was given just prior to surgery. The dose was repeated every 2 hours during and for the first 48 hours after surgery. When the tourniquet was removed, rFVIIa had not been infused for 1.5 hours, and significant hemorrhage was noted. The hemorrhage responded promptly to rFVIIa infusion. The infusion interval was extended to every 4 hours for an additional 48 hours, and subsequent doses were given every 6 hours until the patient returned to the clinic 2 days postdischarge. Hemoglobin levels dropped from 16.9 gm/dL on admission to 9.1 gm/dL at discharge. After 2 months, the patient returned to work. We recommend that tourniquet release be performed immediately after rFVIIa administration and that aggressive physical therapy be considered in the early postoperative period when rFVIIa infusions are frequent.

BACKGROUND: A proposed etiology of tumor activation involves p53 mutations while telomerase may serve as a key enzyme for maintenance of tumor cell proliferation. METHODS: Telomerase activity levels were measured in colorectal adenocarcinomas and corresponding normal tissue using a modified telomeric repeat amplification protocol, and p53 mutations were identified using immunohistochemical staining. Results were compared with staging data using regression analysis. RESULTS: Telomerase activity was present in 23 of 23 (100%) of the tumors and only 2 (9%) of. normal specimens (P

Human recombinant interferon (IFN)-alpha (alpha)-2b was given to a 57-year-old man with hypereosinophilia syndrome refractory to prednisone and hydroxyurea. One year later, he developed progressive renal failure and nephrotic-range proteinuria. Percutaneous kidney biopsy showed focal and segmental glomerular and mesangial sclerosis, chronic interstitial nephritis, and focal tubular necrosis. Discontinuation of cytokine therapy led to marked improvement in renal function and significant reduction in proteinuria. The potential role of IFN-alpha as the cause of renal failure and nephrotic-range proteinuria is discussed. The spectrum of renal disease attributed to IFN-alpha and the proposed pathogenic mechanisms are reviewed.

Computer visualization techniques were used to map and to quantitatively reconstruct the entire locus coeruleus, including the nucleus subcoeruleus, to compare the topographic patterns of cell loss in postmortem brains from patients with Parkinson's disease, Alzheimer's disease, and Down syndrome. There was comparable cell loss in all three diseases (approximately 60%) compared with aged normal subjects, and there was a significant loss of nucleus subcoeruleus cells specifically in patients with Parkinson's disease (63%). There was a significant positive correlation between the magnitude of locus coeruleus cell loss and the duration of Alzheimer's disease, but no such correlation was found for Parkinson's disease. In patients with Parkinson's disease, there was comparable cell loss throughout the rostral-caudal extent of the nucleus; however, in patients with Alzheimer's disease and Down syndrome, the greatest cell loss always occurred within the rostral portion of the nucleus, with a relative sparing of caudal cells. These data are consistent with the hypothesis that cell loss in Parkinson's disease is the result of a pathological process that attacks the catecholaminergic cells of the locus coeruleus and the subcoeruleus in general; in Alzheimer's disease and Down syndrome, however, the pathological process only affects the rostral, cortical-projecting locus coeruleus cells and spares the caudal, noncortical-projecting cells.

The development of the microprocessor has enabled biomedical researchers to use powerful computers as single user workstations. Many such systems are now in use—some developed for use within individual laboratories, and others purchased commercially. These systems typically mix computer graphics and image processing capabilities. No standard exists that allows users of these workstations to exchange anatomical data in graphical or image form. This paper considers issues involved in designing a flexible format for exchanging digital anatomical data between laboratories.

Serum leukoagglutinating activity against the leukocytes of four patients with neutropenia was demonstrated using a modified microcapillary agglutination test. Cells from a panel of donors proved useful in attempting to define the identity of the antigens involved. In one instance anti-HLA-A9 activity could be demonstrated in a patient possessing HLA-A9. In the other three individuals no definite antigen assessment to HLA Series A and B antigens or the Lalezari series of neutrophil antigens could be made. Two of the patients' sera showed cross-reactivity and may be reactive with the same antigen or antigenic group. The microcapillary agglutination test appears to be useful in the evaluation of possible cases of autoimmune neutropenia.

Computer visualization techniques were used to map the distribution of dopaminergic neurons within midbrain tissue sections from 5 parkinsonian patients and 3 age-matched control subjects. The Parkinsonian brains had over 50% fewer dopaminergic neurons within the midbrain than age-matched normal brains. The cell loss occurred within the combined substantia nigra (dopaminergic nucleus A9) and retrorubral (dopaminergic nucleus A8) areas (greater than 61%) and the ventral tegmental area (dopaminergic nucleus A10) (greater than 42%). The cell loss was greatest within the ventral portion of the substantia nigra zona compacta. The specific pattern of cell loss is very similar to the pattern of cells that project to the striatum (as opposed to cortical and limbic sites) in animal neuroanatomical tracing experiments. These data suggest that Parkinson's disease preferentially destroys midbrain dopaminergic neurons in nuclei A8, A9, and A10, which project to the striatum.

Quantitative neuroanatomical techniques were developed to map the distribution of norepinephrine-containing locus coeruleus (LC) neurons in the adult human brain. These neurons reside in the dorsolateral pontine tegmentum and are identifiable by their neuromelanin pigment content. Five brains, ranging in age from 60 to 104 years, were examined. Outlines of coronal or sagittal sections containing the LC were entered into a computer along with the location of each cell, certain neuroanatomical landmarks, and cell size. Sections were aligned with specific neuroanatomical landmarks so that the computer-generated distribution of cells was representative of the in situ distribution of cells. Analysis of (1) the number of cells in sections throughout the rostrocaudal extent of the nucleus, (2) cell size, (3) 3-dimensional reconstructions of the distribution of cells within the brain stem, and (4) 2-dimensional cell-frequency maps, make it possible to quantitatively characterize the distribution of cells within this large nucleus. The total estimated number of LC cells on both sides of the brain ranged from 45,562 to 18,940 (youngest to oldest), and mean soma area ranged from 835 to 718 micron 2 (youngest to oldest). The nucleus is “tube-like” in shape, has a rostrocaudal extent of approximately 16 mm, and is bilaterally symmetrical. Two-dimensional cell-frequency maps were developed to illustrate the regional distribution of cell frequencies at any rostrocaudal/mediolateral point on the horizontal plane; the total unilateral area of the LC ranged from 32.8 to 17.2 mm2 (youngest to oldest). The techniques developed to characterize the 2- and 3-dimensional distributions of LC neurons can be used in future studies to quantitatively examine the effects of aging and disease on this and other brain nuclei.

Trying to remember something now typically improves your ability to remember it later. However, after watching a video of a simulated bank robbery, participants who verbally described the robber were 25% worse at identifying the robber in a lineup than were participants who instead listed U.S. states and capitals—this has been termed the “verbal overshadowing” effect (Schooler & Engstler-Schooler, 1990). More recent studies suggested that this effect might be substantially smaller than first reported. Given uncertainty about the effect size, the influence of this finding in the memory literature, and its practical importance for police procedures, we conducted two collections of preregistered direct replications (RRR1 and RRR2) that differed only in the order of the description task and a filler task. In RRR1, when the description task immediately followed the robbery, participants who provided a description were 4% less likely to select the robber than were those in the control condition. In RRR2, when the description was delayed by 20 min, they were 16% less likely to select the robber. These findings reveal a robust verbal overshadowing effect that is strongly influenced by the relative timing of the tasks. The discussion considers further implications of these replications for our understanding of verbal overshadowing.