Search

Cerebrospinal fluid (CSF) analysis is often deferred in patients with cryptococcal disease, particularly in the absence of neurologic manifestations. We sought to determine whether a subset of solid organ transplant (SOT) recipients with high likelihood of central nervous system (CNS) disease could be identified in whom CSF analysis must be performed.

Objective.To compare the effects of different skin preparation solutions on surgical-site infection rates.Design.Three skin preparations were compared by means of a sequential implementation Design. Each agent was adopted as the preferred modality for a 6-month period for all general surgery cases. Period 1 used a povidone-iodine scrub-paint combination (Betadine) with an isopropyl alcohol application between these steps, period 2 used 2% Chlorhexidine and 70% isopropyl alcohol (ChloraPrep), and period 3 used iodine povacrylex in isopropyl alcohol (DuraPrep). Surgical-site infections were tracked for 30 days as part of ongoing data collection for the National Surgical Quality Improvement Project initiative. The primary outcome was the overall rate of surgical-site infection by 6-month period performed in an intent-to-treat manner.Setting.Single large academic medical center.Patients.All adult general surgery patients.Results.The study comprised 3,209 operations. The lowest infection rate was seen in period 3, with iodine povacrylex in isopropyl alcohol as the preferred preparation method (3.9%, compared with 6.4% for period 1 and 7.1% for period 2; P= .002). In subgroup analysis, no difference in outcomes was seen between patients prepared with povidone-iodine scrub-paint and those prepared with iodine povacrylex in isopropyl alcohol, but patients in both these groups had significantly lower surgical-site infection rates, compared with rates for patients prepared with 2% Chlorhexidine and 70% isopropyl alcohol (4.8% vs 8.2%; P= .001).Conclusions.Skin preparation solution is an important factor in the prevention of surgical-site infections. Iodophor-based compounds may be superior to Chlorhexidine for this purpose in general surgery patients.

Cell transplantation to restore liver function as an alternative to whole liver transplantation has thus far not been successful in humans.

Education is critical in decision making and the informed consent process in prospective living donors. Little has been written about how and what living donors should be taught. This article describes a multidisciplinary program for living donor education at the University of Virginia. The goals of the program are to impart information needed for prospective donors to make an informed decision and to independently evaluate donors' medical and psychosocial suitability. A partnership between the transplant department and an independent donor advocacy team establishes an environment conducive to education. By embracing independence, transparency, partnership, and advocacy, our program permits bidirectional education. This partnership facilitates unbiased understanding and appreciation of this education and considers each individual's unique circumstances when making informed decisions. Likewise, prospective donors educate the team about their circumstances, which helps the team safeguard the prospective donor and may enhance the safety of prospective donors and the perceived integrity of living organ donation.

ABSTRACTSynergistic interactions were observed between CIs and antifungal agents against 53 (90%) of 59 Cryptococcus neoformansisolates from solid organ transplant recipients with cryptococcosis and may account for better outcomes in patients with cryptococcosis receiving these immunosuppressive agents.

In Candida albicans, calcineurin mediates tolerance to azole antifungal drugs, survival in serum, and virulence. In this study, we examined 24 Candida isolates from liver transplant recipients receiving a calcineurin inhibitor as a component of their immunosuppressive therapy. We were unable to detect a difference in susceptibility to calcineurin inhibitors in combination with fluconazole, serum, or calcium in these isolates.

ABSTRACTIn Candida albicans, calcineurin mediates tolerance to azole antifungal drugs, survival in serum, and virulence. In this study, we examined 24 Candidaisolates from liver transplant recipients receiving a calcineurin inhibitor as a component of their immunosuppressive therapy. We were unable to detect a difference in susceptibility to calcineurin inhibitors in combination with fluconazole, serum, or calcium in these isolates.

The second envelope protein at hypervariable region 1 (HVR1) has been implicated in contributing to hepatitis C virus (HCV)-host cell interactions and CD81 (a multifunctional protein) has been demonstrated to act as a cell surface receptor for HCV and may interact directly with HVR1. The purpose of the current study was to determine if certain HVR1 quasispecies variants more effectively associate with and infect allografts after liver transplantation than other HVR1 variants and whether CD81 receptor expression changes after transplantation. Blood and allograft samples were obtained from the peritransplant period in seven patients. Clones of RT-PCR product were directly sequenced to identify HVR1 quasispecies variants. Explanted liver and serial allograft biopsies in recipients with HCV were examined by immunohistochemistry (IHC) for CD81 expression. Examination of HVR1 sequences demonstrated that only a fraction of the quasispecies variants recovered from each patient's blood sampled immediately prior to transplantation associated with and infected the allografts. Genetic diversity at HVR1 decreased with reperfusion but did not significantly decrease with infection. Expression of CD81 varied during the immediate post-transplant period. In conclusion, HVR1 quasispecies variants differentially associate with, and infect allografts, after liver transplantation. Additionally, allografts express variable amounts of CD81 after transplantation.

In studying potential immunotherapeutics for sepsis, we used a lipopolysaccharide (LPS)-stimulated whole blood model to test the immunomodulating capacity of cytosine-phospho-guanine oligodeoxynucleotides (CpG ODNs). We hypothesized that CpG ODNs would have considerable counterinflammatory effects on LPS-induced cytokine production.

Abstract Several laboratories have resorted to flow‐cytometric crossmatch (FCXM) in an effort to prevent hyperacute and accelerated renal allograft rejections. The currently employed FCXM has problems with both false‐positive and ‐negative reactions, largely as a result of irrelevant IgG binding to Fc IgG receptors. In 1980, we circumvented this problem by digesting Fc IgG receptors with pronase, and demonstrated that, with immunofluorescnce microscopy (IF), detection of IgG anti‐HLA antibodies was highly sensitive and specific. In 1995, we introduced the pronase technique to FCXM and showed that this enzyme did not decrease HLA expression. We present herein a prospective study at our institution to determine whether FCXM using pronase‐digested (PD) lymphocytes is as sensitive and more specific than FCXM with undigested (UD) lymphocytes when compared with the highly sensitive and specific IF assay. In analyzing the 186 donor‐specific prerenal‐transplant crossmatches, we found that PD FCXM was as sensitive and specific as IF and was able to detect weak IgG anti‐HLA antibodies that bound to B cells. Fourteen of these patients would have been denied transplants if one were to have relied on UD FCXM. The data clearly indicate that PD FCXM can reliably be used to detect weak IgG anti‐HLA antibodies before renal transplantation.

Background: It is well documented that tertiary peritonitis is associated with different microbiological flora and worse outcomes than secondary peritonitis. It is unknown, however, if these differences can be explained simply by the nosocomial nature of tertiary peritonitis and underlying severity of illness.Methods: We reviewed all episodes of intraabdominal infection on the inpatient surgical services at a university hospital over a 46-month period. Univariate analysis and logistic regression were used to compare 91 episodes of secondary peritonitis that progressed to tertiary peritonitis (recurrent diffuse or localized intraabdominal infection) to all episodes of secondary peritonitis (n = 453) to identify predictors for developing tertiary peritonitis. Logistic regression was also used to identify predictors of mortality among patients with secondary (n = 473) or tertiary peritonitis (n = 129).Results: Of 602 episodes of intraabdominal infection identified, there were 473 episodes of secondary peritonitis, including 20 patients who died within seven days of diagnosis. A total of 129 episodes of tertiary peritonitis were identified, of which 91 were preceded by a single episode of secondary peritonitis, and 38 were preceded by an episode of secondary peritonitis and at least one prior episode of tertiary peritonitis. Tertiary peritonitis was associated with a high APACHE II score (14.9 ± 0.7), pancreatic or small bowel source, drainage only at initial intervention, gram-positive and fungal pathogens, and a high mortality rate (19%). Increasing APACHE II score (OR 1.07, 95% CI 1.03-1.16, p = 0.0009) independently predicted progression from secondary to tertiary peritonitis while increasing age (OR 0.98, 95% CI 0.97-0.99, p = 0.01) and appendiceal source (OR 0.12, 95% CI 0.02-0.68, p = 0.02) predicted non-progression to tertiary peritonitis. Independent predictors of mortality in this population included increasing age (OR 1.06, 95% CI 1.03-1.1, p < 0.001), increasing APACHE II score (OR 1.18, 95% CI 1.11-1.3, p < 0.001), and four comorbidities: cerebrovascular disease (OR 4.3, 95% CI 1.4-13.1, p = 0.01), malignant disease (OR 2.9, 95% CI 1.3-6.5, p = 0.01), hemodialysis dependency (OR 3.8, 95% CI 1.3-11.2, p = 0.02), and liver disease (OR 4.2, 95% CI 1.6-15.1, p = 0.03). Tertiary peritonitis was not an independent predictor of mortality.Conclusions: We were unable to demonstrate, when compared to secondary peritonitis, that tertiary peritonitis is a significant independent predictor of mortality when other variables are taken into account. This suggests that the high mortality associated with tertiary peritonitis is more a function of the patient population in which it occurs than the severity of the pathologic process itself.

The presence of fever and leukocytosis have traditionally been utilized as important diagnostic markers of infection despite some who question their reliability. To examine this point, the role of fever and leukocytosis as diagnostic and prognostic indicators for surgical infections was evaluated. A prospective observational study was performed on all patients with suspected infection in 1997 on the general surgical services at a university hospital. Fever was defined as maximum temperature (Tmax) = 38.5°C, and leukocytosis was defined as a white blood cell (WBC) count = 11,000/µl. Among all infections, patients presenting with a Tmax = 38.5°C were younger (51.3 ± 1.1 vs. 53.8 ± 0.9 years, p= 0.005) and had a higher APACHE II score (15.1 ± 0.5 vs. 11.4 ± 0.4; p< 0.001). By logistic regression analysis chronic renal insufficiency was associated with a Tmax < 38.5°C [odds ratio (OR) 0.371, 95% confidence interval (CI) 0.195–0.704], and chronic steroid therapy was associated with a WBC count < 11,000/µl (OR 0.556, 95% CI 0.335–0.921). In addition, infected transplant patients were more likely to present with a Tmax < 38.5°C and a WBC count < 11,000/µl (OR 0.195, 95% CI 0.075–0.502). Mortality rates for infected patients with a Tmax < 38.5°C or > 38.5°C were 11.6% and 12.9%, respectively (p< 0.7), and the lengths of stay were 14 ± 1 and 18 ± 1 days, respectively (p< 0.03). Mortality rates for patients with a WBC count < 11,000/µl or > 11,000/µl were 4.7% and 18.6%, respectively (p< 0.001), and the lengths of stay were 14 ± 1 and 19 ± 1 days, respectively (p< 0.001). In the setting of infection, chronic renal insufficiency and chronic steroid therapy are associated with suppression of fever and leukocytosis, respectively. Transplantation is an independent predictor of infection in patients presenting without fever or leukocytosis. Leukocytosis, but not fever, may be predictive of hospital mortality in infected surgical patients.

The purpose of our study is to assess the extent of racial differences in the access to simultaneous pancreas-kidney (SPK) transplantation and evaluate the potential influence of socioeconomic factors on access to transplantation. We performed a retrospective analysis of the US Renal Data System and United Network for Organ Sharing data on all patients with end-stage renal disease (ESRD) due to diabetes mellitus from 1988 to 1996 (n = 562,814), including all dialysis, wait list, and transplant patients. Racial differences in incidence, prevalence, insurance coverage, employment status, and transplantation rates were calculated. Caucasians had the highest prevalence of ESRD caused by type 1 diabetes (73%), followed by blacks (22%), Hispanics (3%), Native Americans (2%), and others (<1%). Both blacks and Native Americans increased their annual incidence of ESRD caused by insulin-dependent diabetes mellitus by 10% compared with only a 3.5% increase in Caucasians, whereas incidence rates increased annually by almost 8% for both blacks and Native Americans compared with a 3% increase for Caucasians. However, Caucasians received 92% of all SPK transplants, whereas all other racial groups combined received a disproportionate minority of the remaining transplants. Lack of private insurance and unemployment status were associated with annual changes in both incidence of ESRD caused by type 1 diabetes and SPK transplant rates. In conclusion, we observed striking racial disparities for access to SPK transplantation in the United States today, which may be related to employment status, access to private insurance, and subsequent health care. Our preliminary data support current efforts to encourage Medicare and Medicaid coverage for all patients requiring SPK transplantation regardless of racial or financial status.

ABSTRACTAlpha-hemolysin (Hly) is a common exotoxin produced byEscherichia colithat enhances virulence in a number of clinical infections. The addition of hemolysin production to laboratory bacterial strains is known to increase the lethality of E. coliperitonitis. However, the mechanisms involved have not been determined and the contribution of hemolysin to the alterations in the host intraperitoneal environment and the leukocyte response is not known. Utilizing a rat peritonitis model, we show that wild-type hemolytic E. colistrains have a significant competitive advantage over nonhemolytic strains within the peritoneum. To examine the specific contribution of Hly to E. coli-induced virulence and alterations within the peritoneum, a mixed peritonitis model of E. coli, Bacteroides fragilis, and sterile fecal adjuvant was used. Three transformed E. colistrains were utilized: one strongly secretes active hemolysin (WAF 270), a second secretes active hemolysin but a reduced amount (WAF 260), and the third does not produce hemolysin (WAF 108). After an equal inoculum of each of the three strains, WAF 270 produced a markedly increased lethality and an increased recovery of both E. coliand B. fragilisfrom the host relative to the other strains. Changes in the intraperitoneal pH, degree of erythrocyte lysis, and recruitment and viability of leukocytes within the peritoneum following the induction of peritonitis differed significantly between the strongly hemolytic and nonhemolytic strains. Induction of peritonitis with WAF 270 caused a pronounced decrease in intraperitoneal pH, lysis of most of the intraperitoneal erythrocytes, and a marked decrease in recoverable viable leukocytes compared to WAF 108. Thus, hemolysin production by E. coliwithin the peritoneum may alter not only the host's ability to control the hemolytic strain itself but also other organisms.

Pancreatic transplantation is able to produce euglycemia in patients with Type I diabetes mellitus. Current surgical techniques utilize revascularization of the graft through the recipient iliac vessels and drainage of the exocrine pancreatic secretions through a duodenal conduit into the bladder. We describe a technique utilized in 3 patients whereby venous pancreatic drainage is into the portal venous circulation via the proximal splenic vein. The exocrine pancreatic secretions are drained into the proximal jejunum via a side‐to‐side donor duodenum to proximal small bowel anastomosis. Results and complications of this technique are presented. Potential short‐term and long‐term advantages and disadvantages of this technique are discussed. Our early experience suggests that paratopic pancreatic transplantation with venous drainage into the portal vein and exocrine drainage into the proximal jejunum is both feasible and desirable.

Liver transplantation is an accepted treatment for end‐stage liver disease due to hepatitis C (HCV), but remains controversial for patients with hepatitis B (HBV). Recently, the use of aggressive hepatitis B immunoglobulin (HBIg) to maintain hepatitis B surface antibody (anti‐HBs) titers greater than 500 IU/L has been reported to improve outcome of transplantation for hepatitis B. The aim of this study was to compare the quality of life of patients transplanted for HBV using this regimen of HBIg immunoprophylaxis (group 1) to patients transplanted for HCV (group 2). The State‐Trait Anxiety Inventory (STAI), Sickness Impact Profile (SIP), and a work survey were administered to two groups of patients. The STAI measured anxiety while the SIP evaluated physical and psychosocial function. Lower scores indicated less anxiety and dysfunction. Questions regarding hours worked prior to illness and hours worked after transplantation were administered to both groups. Group 1 included a majority of patients who were hepatitis B e antigen (HBeAg) positive prior to transplantation. Survey response was 13: 16 (81%) for group 1; and 17: 24 (72%) for group 2. Group 1 revealed significantly lower scores than group 2 on the STAI and the overall SIP score. Group 1 reported working similar hours after transplantation as prior to illness while group 2 did not. Thus, patients transplanted for HBV and treated with aggressive HBIg immunoprophylaxis attained a higher quality of life than patients transplanted for HCV.

Over a 26‐month period we assessed the ability of APACHE II, scored on admission to the surgical intensive care unit (SICU), to predict the in‐hospital mortality of liver and kidney transplant recipients either post‐operatively or after subsequent complications, and compared these results to non‐transplant SICU admissions. There were 866 SICU admissions, of which 128 were liver transplant recipients, 112 were renal transplant recipients, 211 were trauma admissions and 415 were non‐transplant/non‐trauma admissions. In hospital mortalities among all liver transplant admissions were 0%, 10%, 38%, and 82% for APACHE II ranges of 0‐10, 11‐20, 21‐30 and >30, respectively, with differences between the second and third, and third and fourth ranges significant (p≤0.05 by chisquare analysis). These differences were also seen when examining scores following the primary transplantation alone. Mortalities in corresponding APACHE II ranges for trauma and nontransplant/nontrauma admissions were similar. APACHE II scoring was not useful for renal transplant recipients, as it consistently overpredicted mortality. We conclude that APACHE II scoring may be useful in predicting outcome in post‐operative liver transplant recipients, but is not useful in stratifying risk in renal transplant recipients due to the inherently low mortality involved.

Aggressive administration of hepatitis B immune globulin (HBIg) has been shown to prevent hepatitis B viral (HBV) infection of the allograft; however, the clinical sequela of such therapy has not been previously described. We reviewed our experience with high dose, intravenous infusion of an intramuscular HBIg preparation to assess the effectiveness and complications of such therapy. Thirty three orthotopic liver transplants (OLTx) were performed in 32 patients with chronic HBV cirrhosis at the University of Virginia between March 1990 and June 1995. Twenty‐nine of 32 (91%) patients remain free of HBV recurrence (defined by undetectable serum HBsAg and HBV‐DNA) after a mean of 21 months (2–54 months), with one patient requiring retransplantation. Three (10%) patients died of non‐HBV causes (two vascular events, one infectious event). Twenty episodes of acute cellular rejection were treated in 18 patients (two had two episodes). Sixteen rejections occurred within 18 d of transplant, 19 by day 120, and one late rejection occurred at 18 months owing to medication non‐compliance. Eighteen patients had at least one documented infection. Six patients were treated for CMV infection (five empirically). Eight patients were treated for HSV infections (seven) mild herpetic labialis and one herpetic keratitis). Four patients had documented fungal infection (one mucormycosis pneumonia and three minor superficial mucosal infections). With the exception of one necrotizing pneumonia, 11 bacterial infections were successfully treated with conventional antimicrobial agents. No patient developed post‐transplant lymphoproliferative disorder. Symptoms associated with HBIg infusion were intermittent but frequent and consisted of myalgias, predominantly back pain (90%), headache (20%) and flushing (5%). No patient experienced anaphylaxis, fever, rash, arthritis or hypotension. Despite the potential for mercury toxicity and HCV transmission in the HBIg formulations currently available in the United States, serum mercury levels remained below standards for industrial exposure (60 μg/ml), and only one individual developed post‐transplant HCV infection after receiving multiple units of unscreened blood prior to 1991. Summary: High‐dose HBIg prevented HBV infection of the allograft in 29 of 32 patients transplanted for HBV cirrhosis with three non‐HBV associated deaths. The intravenous infusion of HBIg was frequently associated with minor side effects that were safely tolerated by patients. The risk of HCV transmission and mercury toxicity are minimal, but support the need for a new intravenous formulation of HBIg. HBIg therapy successfully decreases post‐OLTX HBV recurrence with no clinical events associated with immunosuppression. Patients did not experience allergic or infusion‐related complications that altered or terminated therapy. Manufacturing modifications of HBIg may allow for improved patient tolerance and decreased risks.

Since endogenous 1:25 vitamin D (1:25VD) is principally involved with involution of secondary hyperparathyroidism post‐renal transplant we correlated 1:25VD levels with intact PTH in 82 random patients with a serum creatinine of <2 mg/dl and with normal hepatic function. All patients studied were normocalcemic with normal phosphorus and received azathioprine, cyclosporin A and prednisone. Of considerable interest, of the 42 patients studied after 2 years post‐transplant, there were 8 (19%) patients with intact PTH of more than twice the upper limit of normal (normal 10‐65 pg/ml) and other 15 (36%) with PTH levels above normal. Secondly, in no patient did we see 1:25VD above normal (normal 15‐60 pg/ml) despite levels of PTH of >200 pg/ml. Of concern, 20% of 73 patients had 1:25VD deficiency (<15 pg/ml). This may not have been previously appreciated because of the number of patients studied. Like previous investigators, we failed to understand why 1:25VD levels were relatively low. There was no correlation between 1:25VD and serum creatinine. Of 25 patients with a serum creatinine of 1.4 or less, there were 10 patients (40%) with 1:25VD of less than 20 pg/ml. Since persistently high PTH can contribute to bone demineralization, which is not uncommon post‐transplant, we treated 8 patients with small doses of oral 1:25VD (rocaltrol). In less than 6 months PTH levels returned to normal in 7 of the 8 patients. The current studies clearly indicate that asymptomatic hyperparathyroidism is common even after 2 years post‐renal transplant. Monitoring for PTH and 1:25VD will help prevent bone disease posttransplant now that rocaltrol is available.

• The systemic tumor necrosis factor (TNF) response has been extensively studied during infection. In addition, antibiotics that cause cell-wall lysis have been associated with endotoxinemia and, therefore, could trigger TNF release. We studied the effects of pretreatment with cefoxitin and/or anti-TNF antibody on mortality and early (90 minutes) and delayed (6 hours) serum TNF levels in a murine model of mixed Escherichia coli/Bacteroides fragilis peritonitis. At low and intermediate inocula levels, cefoxitin, but not anti-TNF antibody, prevented death, and low serum TNF levels were noted in all groups. At the highest inoculum level, mortality was uniform in control, cefoxitin, and anti-TNF antibody groups, and a significant elevation in serum TNF levels was seen only at the 6-hour point in animals receiving cefoxitin. The addition of anti-TNF antibody to cefoxitin at this inoculum level abrogated the 6-hour rise in serum TNF levels and reduced mortality to 40%. These results emphasize that the cytokine response in disease is dependent on both the nature of the insult and other forms of therapeutic interventions.(Arch Surg. 1993;128:73-78)

• Transient nosocomial infections, such as line sepsis and pneumonia, are common in today's critical care patient population. Although generally well treated, the effect of these transient antigen exposures on the immune system is unclear. We have previously shown that prior intraperitoneal inoculation with live bacteria leads to increased numbers of intraperitoneal abscesses. Data presented here demonstrate in a murine model that two immunizations with live Escherichia coli, Bacteroides fragilis, or both, administered systemically via intracardiac injection or at a focal distant site in subcutaneous tissue, significantly increased the number of mixed E coli/B fragilis intraperitoneal abscesses when induced 1 week later. Further, immunization with E coli, either alone or in combination with B fragilis, increased the total number of anaerobes recovered per mouse. Transient or focal sublethal infections can significantly alter an animal's immune response to later infectious insults, particularly the formation of intraperitoneal abscesses.(Arch Surg. 1991;126:164-168)

The hepatic artery and the portal vein blood vary in flow, oxygenation, and hormonal content. It was uncertain which blood supply has a greater effect on the recuperative process of the hepatocytes in the ischemic liver during the initial reperfusion. The ability of the liver cells to restore its energy phosphates is related to the viability of the liver. This study was designed to determine the differences of the high energy phosphate in the liver predicated upon whether reflow was first provided by either the hepatic artery or the portal vein followed by subsequent reperfusion from both vessels. The recovery of ATP upon 10 min of only hepatic arterial reperfusion after 15 min of total ischemia was much slower compared to the portal venous reperfusion only. It may be undesirable, therefore, to reperfuse the liver with hepatic arterial blood first immediately after warm liver ischemia.

The reported incidence of sphincter of Oddi dysfunction following orthotopic liver transplantation has ranged from 3% to 7%. If sphincteric dysfunction is unrecognized, therapy may be inappropriate; when recognized, extensive surgery may be required. To prospectively identify patients with sphincteric dysfunction, we performed sphincter of Oddi motility studies through the t-tube tract three months after transplantation. Baseline sphincter motility and response to intravenous cholecystokinin were evaluated. The results of 10 subjects are reported; nine had normal basal sphincter pressure (16±5.8 mm Hg), and all had normal frequency (3.6±1/min), amplitude (86±31 mm Hg), and duration (4.5±1 sec) of phasic contractions. One subject had an elevated basal pressure (47 mm Hg). All, including the subject with elevated basal pressure, demonstrated a normal response to intravenous cholecystokinin with significant inhibition of phasic contraction frequency and amplitude. We demonstrate that simultaneous studies of the sphincter and duodenum can be obtained via the t-tube tract, providing the opportunity for prospective evaluation of sphincteric function. We conclude that sphincter of Oddi function usually remains normal following liver transplantation with choledochocholedochostomy.

• A greater proportion of Escherichia coli strains isolated from clinical extraintestinal infections produce α-hemolysin than do strains isolated from normal fecal flora. Proposed mechanisms to explain this observation have stressed the fact that hemolysis liberates hemoglobin, which may provide a nutritional boost for E coli growth. Alternatively, a cytolytic effect of hemolysin upon host neutrophils has been postulated. Our previous studies have suggested a third possibility: Human neutrophils incubated in the supernatant of an α-hemolysin—producing E coli strain produced a selective inhibition of chemotaxis toward C5a. Bacteria-free supernatants from 14 clinical strains of E coli were therefore evaluated for an ability to lyse sheep erythrocytes, alter human polymorphonuclear neutrophil (PMN) chemotaxin receptors, and affect release of PMN enzymes. Supernatants possessing hemolytic activity decreased the C5a receptor activity of human PMNs and increased the number of peptide receptors. A stimulation of secondary granule release, as evidenced by the release of PMN lysozyme, may account for the increased expression of peptide receptors. Perturbation of host defenses through a loss of neutrophil migratory function and secondary granule contents may allow for enhanced survival of E coli, which produce α-hemolysin.(Arch Surg 1985;120:212-216)

• The ability of Bacteroides fragilis and Escherichia coli to produce synergistic mortality when mixed into intraperitoneal (IP) fibrin clots was tested in rats. The addition of B fragilis (2×109 colony-forming units/clot) to E coli (2 ×108 colonyforming units/clot) in the clot significantly enhanced both early and late mortality rates when compared to either E coli or B fragilis alone. Multiple washings of B fragilis prior to mixing with E coli in the clot delayed the enhancement of lethality from 24 to 48 hours. By seven days, washed B fragilis was as synergistic with E coli as unwashed B fragilis plus E coli. Furthermore, unwashed killed B fragilis was as synergistic when mixed with E coli in the fibrin clot as unwashed living B fragilis. However, washed dead B fragilis plus E coli produced no greater mortality than E coli alone. The lethality of an IP clot containing E coli was significantly increased when B fragilis was mixed with it in the same clot, injected free IP, and or implanted into a separate IP clot. intraperitoneal E coli—fibrin clot lethality was not increased by subcutaneous B fragilis and was only slightly enhanced by intravenous B fragilis inoculation. The strain of B fragilis used in these studies did not produce fibrinolysins at any concentration. The data support the idea that synergistic mortality between E coli and B fragilis in this model is caused by a heat-stable surface factor produced by B fragilis, which acts to increase the lethal effects of E coli.(Arch Surg 1985;120:146-151)

• We previously demonstrated that Bacteroides species elaborate a factor that impairs polymorphonuclear leukocyte (PMN) migration. This factor, active at a pH of 5.5 but not at 7.4, had similar inhibitory characteristics as the Bacteroides metabolite succinic acid. We examined the kinetics of production of this inhibitory factor and correlated its presence with succinic acid concentrations in the culture filtrate. In the four to six hours after Bacteroides fragilis 9032 reached the stationary phase of growth, there was a large increase in succinic acid production with an accompanying reduction in culture pH. This correlated well with the generation of a leukocyte-inhibitory factor. Pure succinic acid in sterile culture medium at concentrations similar to those detected in the 18-hour culture filtrate (20 mmol/L) produced comparable reduction in PMN migration. Following gel filtration chromatography of B fragilis culture filtrate, the fractions containing succinic acid labeled with carbon 14 inhibited PMN migration.(Arch Surg 1987;122:93-98)

• Experimental intra-abdominal abscesses were initiated by surgical implantation of a fibrin clot contaminated with either Bacteroides fragilis, Bacteroides thetaiotaomicron, or B fragilis—Escherichia coli. Seven days after surgery the numbers of bacteroides (per gram) in B fragilis and B thetaiotaomicron abscesses were typically log10 8.4 ± 0.5 (n = 6) and log10 6.4 ± 0.6 (n=4), respectively; B fragilis—E coli abscesses typically contained log10 8.9 ± 0.5 B fragilis and l og10 7.6 ± 0.6 E coli (n = 5). Of 38 B fragilis abscesses, 14 B fragilis—E coli abscesses, and nine B thetaiotaomicron abscesses, additional intestinal bacteria were recovered from 21 (55%), 13 (93%), and seven (89%) abscesses, respectively. The additional organisms, in decreasing order of frequency, were enterococci, E coli, staphylococci, α-streptococci, lactobacilli, and Proteus species in numbers ranging from 2.5 log10 to 7.9 log10 per gram of abscess. Histologic sections of contaminated abscesses adherent to the intestine, liver, or spleen revealed normal tissue histology and no breakdown of the abscess wall. Thus, intestinal bacteria translocated into intra-abdominal abscesses by a mechanism that did not appear to be surgical soilage.(Arch Surg 1986;121:102-107)

• We have previously demonstrated that Bacteroides fragilis enhanced Escherichia coli–induced lethality in the rat fibrin—clot peritonitis model. As a possible mechanism for this phenomenon, it was hypothesized that B fragilis inhibited host defense mechanisms, allowing the E coli to flourish and kill the animal. Culture filtrates of three Bacteroides species were tested in vitro for their effect on human polymorphonuclear leukocyte (PMN) chemotaxis and random migration. Two of these, B fragilis and Bacteroides distasonis, impaired PMN migration. The other, Bacteroides thetaiotaomicron, caused variable inhibition of neutrophil chemotaxis. The ability of the culture filtrates to inhibit neutrophil function appeared to depend on two factors: (1) adequate growth of the Bacteroides culture, permitting production of the leukotoxic factor, and (2) reduction of the culture pH to a level at which the putative toxin could exert its effect. Further studies revealed that the factor was heat stable, had a molecular weight less than 500, and that its effect on PMNs was only partially reversed by multiple washings. This supports the concept that Bacteroides species may contribute to the pathogenicity of mixed infections by producing a factor that inhibits host neutrophil function.(Arch Surg 1986;121:82-88)

ABSTRACTMany pathogenic Escherichia coliproduce the toxin alpha-hemolysin (Hly), and lipopolysaccharide (LPS), interleukin-1 (IL-1), and tumor necrosis factor (TNF) have all been recognized as important effector molecules during infections by gram-negative organisms. Despite the characterization of many in vitro effects of hemolysin, no direct relationship has been established between hemolysin, LPS, proinflammatory cytokine production, and E. coli-induced mortality. Previously, we have shown in vivo that hemolysin elicits a distinct IL-1α spike by 4 h into a lethal hemolytic E. coliinfection. Using three transformedE. colistrains, WAF108, WAF270, and WAH540 (which produce no Hly [Hlynull], acylated Hly [Hlyactive], or nonacylated Hly [Hlyinactive], respectively), we sought to determine the specific roles of hemolysin acylation, LPS, IL-1, and TNF in mediating the lethality of E. coliinfection in mice. WAF270 was 100% lethal in BALB/c, C3H/HeJ, and C57BL/6 mice; in mice pretreated with antibody to the type 1 IL-1 receptor; in type 1 IL-1 receptor-deficient mice; and in dual (type 1 IL-1 receptor-type 1 TNF receptor)-deficient mice at doses which were nonlethal (0%) with both WAF108 and WAH540. At lethal doses, WAF270 killed by 6 ± 2.3 h while WAF108 and WAH540 killed at 36 ± 9.4 and 36 ± 13.8 h, respectively. These differences in mortality were not due to IL-1 or TNF release, and the enhanced expression of LPS, which corresponded to Hly expression, was not likely the primary factor causing mortality. We demonstrate that bacterial fatty acid acylation of hemolysin is required in order for it to elicit IL-1 release by monocytes and to confer its virulence on E. coli.

Recent reports indicate a higher incidence of both acute and chronic liver allograft rejection when, at the time of transplantation, the recipients serum contains donor-specific anti-HLA antibodies. From 9/89 to 5/91, 133 liver allografts were performed at our institution. Thirteen liver recipients had donor-specific IgG anti-HLA antibodies (complement-fixing) at the time of transplantation. In eleven patients, antibodies reacted to donor class I antigens while in 1 patient the donor-specific antibody had class II reactivity. Twelve patients have been followed for a minimum of 12 months (median 18 months, range 28–12 months). No hyperacute rejection was seen in any of the cases and four patients had acute rejections. Thus far only one of the twelve patients has biopsy evidence suggestive of chronic liver injury. The remaining have normal liver enzymes and bilirubin. Three of these twelve patients died (one from a myocardial infarction and the others from sepsis) accounting for a one-year graft survival of 75. There was no significant statistical difference in the one-year graft survival in those recipients without donor-specific antibodies (i.e., 80.5).

Fever patterns were studied prospectively in 200 consecutive patients referred for infectious disease consultation and retrospectively in 204 patients with selected infectious or noninfectious diseases. Most patients had remittent or intermittent fever, which, when due to infection, usually followed diurnal variation. Hectic fever occurred less commonly but was observed in patients with all categories of infectious or noninfectious diseases. Although hectic fevers were seen more frequently in patients who had documented bacteremia, there were many nonbacteremic subjects who had this pattern and others without this pattern who had bacteremia. Sustained fever nearly always occurred in patients with Gram-negative pneumonia or CNS damage, although some patients with these diseases had other patterns as well. Our data suggest that, with the possible exception of sustained fever in Gram-negative pneumonia or CNS damage, the fever pattern is not likely to be helpful diagnostically.(Arch Intern Med 139:1225-1228, 1979)

The current prospective investigation was conducted to determine whether development of IgG donor-specific lymphocytotoxins detected at the onset of acute rejections was predictive of a poor-prognosis acute rejection. Between January 1990 and August 1993, 206 kidney transplants were performed. Cadaver kidney recipients were managed with antilymphocyte globulin as induction therapy and all recipients (i.e., cadaver and living related donor kidneys) received triple immunosuppressive therapy, i.e., CsA, AZA, and prednisone. Rejections were treated with intravenous Solu-Medrol and OKT3. Presence of donor-specific IgG lymphocytotoxin was detected by using dithiothreitol-pretreated sera (obtained at onset of rejection) and frozen donor cells. In addition, percentage of panel reactive antibody was determined on this dithiothreitol-pretreated sera.

Percutaneous catheter drainage is an effective treatment for abscesses arising in a variety of sites. The most experience has been gained in the treatment of intra-abdominal abscesses, which has led to the recognition of the efficacy of catheter drainage as the sole decompressive procedure of simple bacterial abscesses. Additionally, catheter drainage has been effective for the palliation of complex intraabdominal infections, allowing for a planned operative intervention after symptomatic improvement. The fully defined role of catheter drainage in the management of surgical infections, however, is still evolving.

Circulating microRNAs (miRNAs) can be biomarkers for diagnosis and progression of several pathophysiological conditions. In a cohort undergoing total pancreatectomy with islet autotransplantation (TPIAT) from the multicenter Prospective Observational Study of TPIAT (POST), we investigated associations between a panel of circulating miRNAs (hsa-miR-375, hsa-miR-29b-3p, hsa-miR-148a-3p, hsa-miR-216a-5p, hsa-miR-320d, hsa-miR-200c, hsa-miR-125b, hsa-miR-7-5p, hsa-miR-221-3p, hsa-miR-122-5p) and patient, disease and islet-isolation characteristics. Plasma samples (n= 139) were collected before TPIAT and miRNA levels were measured by RTPCR. Disease duration, prior surgery, and pre-surgical diabetes were not associated with circulating miRNAs. Levels of hsa-miR-29b-3p (P= 0.03), hsa-miR-148a-3p (P= 0.04) and hsa-miR-221-3p (P= 0.01) were lower in those with genetic risk factors. Levels of hsa-miR-148a-3p (P= 0.04) and hsa-miR-7-5p (P= 0.04) were elevated in toxic/metabolic disease. Participants with exocrine insufficiency had lower hsa-miR-29b-3p, hsa-miR-148a-3p, hsa-miR-320d, hsa-miR-221-3p (P< 0.01) and hsa-miR-375, hsa-miR-200c-3p, and hsa-miR-125b-5p (P< 0.05). Four miRNAs were associated with fasting C-peptide before TPIAT (hsa-miR-29b-3p, r= 0.18; hsa-miR-148a-3p, r= 0.21; hsa-miR-320d, r= 0.19; and hsa-miR-221-3p, r= 0.21; all P< 0.05), while hsa-miR-29b-3p was inversely associated with post-isolation islet equivalents/kg and islet number/kg (r= −0.20, P= 0.02). Also, hsa-miR-200c (r= 0.18, P= 0.03) and hsa-miR-221-3p (r= 0.19, P= 0.03) were associated with islet graft tissue volume. Further investigation is needed to determine the predictive potential of these miRNAs for assessing islet autotransplant outcomes.

Human induced pluripotent stem cells (h‐iPSCs) represent a potentially unlimited source for the generation of human hepatocyte‐like cells (h‐iHLCs) for the establishment of platforms to study drug‐induced hepatotoxicity, liver disease modeling, and ultimately the application of h‐iHLCs in treatment of patients with end‐stage liver disease. To understand the impact of donor‐specific factors on the generation of h‐iHLCs, the model for the direct comparison of h‐iHLCs and primary human hepatocytes (PHHs) from the same human donor is needed. This study proposes a step‐by‐step protocol for plating, expansion, and characterization of primary human hepatic non‐parenchymal cells (h‐NPCs) isolated from the human liver, the reprogramming of generated h‐NPCs into h‐iPSCs and subsequent differentiation of reprogrammed h‐iPSCs into h‐iHLCs. The ultimate goal is to compare the gene expression involved in hepatocyte metabolism between h‐iHLCs and PHHs from the same human donor thus eliminating interdonor variability. This newly developed protocol of h‐NPC culture, expansion, and reprogramming into h‐iPSCs allows: (1) utilization of a single organ source (i.e., liver) for isolation of PHHs and h‐NPCs and (2) the in‐depth study of donor factors involved in the generation of h‐iHLCs with direct comparison to PHHs from the same donor. © 2020 Wiley Periodicals LLC. Basic Protocol 1: Plating and expansion of human hepatic NPCs in culture Basic Protocol 2: Reprogramming of h‐NPCs to h‐NPC‐derived induced pluripotent stem cells (h‐iPSCs) Basic Protocol 3: Culture, passaging, and freezing of h‐iPSCs Support Protocol 1: Confirmation of h‐NPC ability to uptake Sendai virus: GFP‐Sendai infection Support Protocol 2: Characterization of h‐NPCs amenable to transduction with Sendai particles Support Protocol 3: Characterization of h‐iPSCs: Clearance of viral reprogramming vectors Support Protocol 4: Preparation of Matrigel‐coated plates

This study describes the association of allograft loss and immune reconstitution syndrome (IRS) in the course of Cryptococcosis neoformansinfection in renal transplant recipients. Patients comprised 54 renal allograft recipients with cryptococcosis in a prospective, multicenter study. IRS developed in 5.5% (3/54) of the renal transplant recipient with C. neoformansinfection. The renal allograft was lost to chronic rejection in 66% (2/3) of the patients with cryptococcosis who developed IRS compared to 5.9% (3/51) of those who did not (P0.012). Kaplan-Meier survival analysis showed that subsequent to cryptococcal infection the probability of allograft survival was significantly lower in patients who developed IRS compared to those who did not develop IRS (P0.0004). Temporal association of graft loss with IRS suggests a common pathophysiologic basis for these entities with implications relevant for the optimal management of renal transplant recipients with cryptococcosis.