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Cardiac regeneration is a natural phenomenon that occurs in many species outside of humans. The goldfish (Carassius auratus) is an understudied model of cardiac wound response, despite its ubiquity as pets as well as its relationship to the better-studied zebrafish. In this study, we examined the response of the goldfish heart to a resection injury. We found that by 70 days post-injury, goldfish scarlessly heal cardiac wounds under a certain size, with local cardiomyocyte proliferation driving the restoration of the myocardial layer. We also found the upregulation of extracellular matrix components related to cardiac regeneration in the injury site. This upregulation correlated with the level of cardiomyocyte proliferation occurring in the injury site, indicating an association between the two that warrants further exploration., (© 2024 American Association for Anatomy.)

Following the discovery of heart regeneration in zebrafish, several more species within the Cyprinidae family have been found to have the same capability, suggesting heart regeneration may be conserved within this family. Although gonad regeneration has been observed in grass carp (Ctenopharyngodon idella), one of the largest cyprinid fish, the species' response to cardiac injury has not been characterized. Surprisingly, we found cardiomyocytes do not repopulate the injured region following cryoinjury to the ventricle, instead exhibiting unresolved fibrosis and decreased cardiac function that persists for the 8-week duration of this study. Additionally, fibroblasts are likely depleted following injury, a phenomenon not previously described in any cardiac model. The data collected in this study indicate that heart regeneration is unlikely in grass carp (C. idella). It is possible that not all members of the Cyprinidae family possesses regenerative capability observed in zebrafish. Further study of these phenomenon may reveal the underlying differences between regeneration versus unresolved fibrosis in heart disease., (© 2021 American Association for Anatomy.)

Hepatocellular carcinoma (HCC) represents a leading cause of cancer-related death, but it remains difficult to treat. Intratumor genetic and phenotypic heterogeneity are inherent properties of breast, skin, lung, prostate, and brain tumors, and intratumor heterogeneity (ITH) helps define prognosis and therapeutic response in these cancers. Several recent studies estimate that ITH is inherent to HCC and attribute the clinical intractability of HCC to this heterogeneity. In this review, we examine the evidence for genomic, phenotypic, and tumor microenvironment ITH in HCC, with a focus on two of the top molecular drivers of HCC: β-catenin (CTNNB1) and Telomerase reverse transcriptase (TERT). We discuss the influence of ITH on HCC diagnosis, prognosis, and therapy, while highlighting the gaps in knowledge and possible future directions.

Xist is the master regulator of X-Chromosome Inactivation (XCI), the mammalian dosage compensation mechanism that silences one of the two X chromosomes in a female cell. XCI is established during early embryonic development. Xist transgene (Tg) integrated into an autosome can induce transcriptional silencing of flanking genes; however, the effect and mechanism of Xist RNA on autosomal sequence silencing remain elusive. In this study, we investigate an autosomal integration of Xist Tg that is compatible with mouse viability but causes male sterility in homozygous transgenic mice. We observed ectopic Xist expression in the transgenic male cells along with a transcriptional reduction of genes clustered in four segments on the mouse chromosome 1 (Chr 1). RNA/DNA Fluorescent in situ Hybridization (FISH) and chromosome painting confirmed that Xist Tg is associated with chromosome 1. To determine the spreading mechanism of autosomal silencing induced by Xist Tg on Chr 1, we analyzed the positions of the transcriptionally repressed chromosomal sequences relative to the Xist Tg location inside the cell nucleus. Our results show that the transcriptionally repressed chromosomal segments are closely proximal to Xist Tg in the three-dimensional nucleus space. Our findings therefore support a model that Xist directs and maintains long-range transcriptional silencing facilitated by the three-dimensional chromosome organization., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Naciri, Lin, Webb, Jiang, Carmona, Liu, Mortazavi and Sun.)

Long noncoding RNAs (lncRNAs) have been identified in all eukaryotes and are most abundant in the human genome. However, the functional importance and mechanisms of action for human lncRNAs are largely unknown. Using comparative sequence, structural, and functional analyses, we characterize the evolution and molecular function of human lncRNA JPX. We find that human JPX and its mouse homolog, lncRNA Jpx, have deep divergence in their nucleotide sequences and RNA secondary structures. Despite such differences, both lncRNAs demonstrate robust binding to CTCF, a protein that is central to Jpx's role in X chromosome inactivation. In addition, our functional rescue experiment using Jpx-deletion mutant cells shows that human JPX can functionally complement the loss of Jpx in mouse embryonic stem cells. Our findings support a model for functional conservation of lncRNAs independent from sequence and structural divergence. This study provides mechanistic insight into the evolution of lncRNA function., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

X-chromosome inactivation (XCI) is the mammalian dosage compensation strategy for balancing sex chromosome content between females and males. While works exist on initiation of symmetric breaking, the underlying allelic choice mechanisms and dynamic regulation responsible for the asymmetric fate determination of XCI remain elusive. Here we combine mathematical modeling and experimental data to examine the mechanism of XCI fate decision by analyzing the signaling regulatory circuit associated with long noncoding RNAs (lncRNAs) involved in XCI. We describe three plausible gene network models that incorporate features of lncRNAs in their localized actions and rapid transcriptional turnovers. In particular, we show experimentally that Jpx (a lncRNA) is transcribed biallelically, escapes XCI, and is asymmetrically dispersed between two X's. Subjecting Jpx to our test of model predictions against previous experimental observations, we identify that a self-enhanced transport feedback mechanism is critical to XCI fate decision. In addition, the analysis indicates that an ultrasensitive response of Jpx signal on CTCF is important in this mechanism. Overall, our combined modeling and experimental data suggest that the self-enhanced transport regulation based on allele-specific nature of lncRNAs and their temporal dynamics provides a robust and novel mechanism for bi-directional fate decisions in critical developmental processes.

Self-cleaving ribozymes fold into intricate structures, which orient active site groups into catalytically competent conformations. Most ribozyme families have distinct catalytic cores stabilized by tertiary interactions between domains peripheral to those cores. We show that large hepatitis delta virus (HDV)-like ribozymes are activated by peripheral domains that bring two helical segments, P1 and P2, into proximity - a "pinch" that results in rate acceleration by almost three orders of magnitude. Kinetic analysis of ribozymes with systematically altered length and stability of the peripheral domain revealed that about one third of its free energy of formation is used to lower an activation energy barrier, likely related to a rate-limiting conformational change leading to the pre-catalytic state. These findings provide a quantitative view of enzyme regulation by peripheral domains and may shed light on the energetics of allosteric regulation.

Characterizing Epstein-Barr virus (EBV) dynamics in asymptomatic immunocompetent persons provides a baseline for defining quantitative thresholds associated with EBV disease. Studying latent membrane protein (LMP)-1 sequence variation over time could establish the rates of reactivation and superinfection, and also trace transmission. Twelve asymptomatic adult subjects were evaluated prospectively nine times over 6 months. EBV serum antibodies were measured by enzyme immunoassay. EBV DNA in oral and whole-blood samples was quantitated by real-time (TaqMan) PCR and analyzed for LMP-1 sequence variability. All 11 antibody positive subjects had EBV DNA detected in their oral compartment at least once during the 6-month study. The quantities ranged from 1.70 to 4.91 log10 copies EBV per ml of oral cell pellet. One subject was continuously viremic for 79 days. Overall, EBV DNA was detected in 63 (24%) of 260 samples from 11 antibody-positive subjects and in 0/27 samples from an antibody-negative subject. The quantities in positive samples ranged from 1.7 to 4.9 log10 copies EBV per ml. EBV LMP-1 gene sequence variations in subjects were constant over time regardless of the compartment sampled. Subjects 18-30 years old had EBV DNA detected more frequently than subjects >30 years old (38/108 positive samples versus 25/152; P<0.001). In conclusion, EBV DNA shedding is common in asymptomatic adults. The younger adults shed more frequently, which may reflect a shorter time from their primary EBV infection to sampling. The LMP-1 sequence analysis method employed here could be used to trace person-to-person transmission because patterns remained almost identical over time.

Splicing components play an essential role in mediating accurate and efficient splicing. The complexity of the spliceosome and its regulatory networks increase the difficulty of studying the splicing reaction in detail. Nuclear extracts derived from HeLa cells provide all of the obligatory components to carry out intron removal in vitro. This chapter describes the large-scale preparation of nuclear extract from HeLa cells.

HDV ribozymes catalyze their own scission from the transcript during rolling circle replication of the hepatitis delta virus. In vitro selection of self-cleaving ribozymes from a human genomic library revealed an HDV-like ribozyme in the second intron of the human CPEB3 gene and recent results suggest that this RNA affects episodic memory performance. Bioinformatic searches based on the secondary structure of the HDV/CPEB3 fold yielded numerous functional ribozymes in a wide variety of organisms. Genomic mapping of these RNAs suggested several biological roles, one of which is the 5' processing of non-LTR retrotransposons. The family of HDV-like ribozymes thus continues to grow in numbers and biological importance.

Summary Objective: To evaluate the feasibility of conducting a definitive study to assess the impact of introducing a rapid PCR-based test for candidemia on antifungal drug prescribing., Method: Prospective, single centre, interrupted time series study consisting of three periods of six months' duration. The assay was available during the second period, during which the PCR assay was available for routine use by physicians Monday-Friday with guaranteed 24-h turnaround time. For each period total antifungal drug use, expressed as treatment-days, was recorded and an adjustment was made to exclude estimated use for proven candidemia. Also, during the intervention period, antifungal prescribing decisions for up to 72 h after each PCR result became available were recorded as either concordant or discordant with that result., Results: While overall antifungal use remained relatively stable throughout, after adjustment for candidemia, there was a 38% reduction in use following introduction of the PCR test; however, this was nonsignificant at the 95% level. During the intervention period overall concordance between the PCR result and prescribing decisions was 84%., Conclusions: The PCR assay for candidemia was requested, prescribing decisions were generally concordant with the results produced and there was an apparent decrease in antifungal prescription, although this was sustained even after withdrawal of the intervention; these findings should be more thoroughly evaluated in a larger trial., (Copyright (c) 2010 The British Infection Society. Published by Elsevier Ltd. All rights reserved.)

Hepatitis delta virus (HDV) and cytoplasmic polyadenylation element-binding protein 3 (CPEB3) ribozymes form a family of self-cleaving RNAs characterized by a conserved nested double-pseudoknot and minimal sequence conservation. Secondary structure-based searches were used to identify sequences capable of forming this fold, and their self-cleavage activity was confirmed in vitro. Active sequences were uncovered in several marine organisms, two nematodes, an arthropod, a bacterium, and an insect virus, often in multiple sequence families and copies. Sequence searches based on identified ribozymes showed that plants, fungi, and a unicellular eukaryote also harbor the ribozymes. In Anopheles gambiae, the ribozymes were found differentially expressed and self-cleaved at basic developmental stages. Our results indicate that HDV-like ribozymes are abundant in nature and suggest that self-cleaving RNAs may play a variety of biological roles.

In contrast to the multitude of studies on fungal PCR assay methods, little work has been reported evaluating Candida PCR performance when using whole blood compared with serum in candidaemic patients. Here, a comparison of the performance of whole-blood and serum specimens using a set of real-time PCR Candida species assays is described. Specimens were collected prospectively from non-neutropenic adults who were recruited to a diagnostic clinical trial, the primary purpose of which was to verify the performance of the assays using serum; in all, 104 participants also had whole-blood specimens submitted for analysis in addition to the serum specimen. Of these participants, 10 had laboratory-confirmed candidaemia and 94 were categorized as being 'unlikely' to have invasive Candida infection. PCR results from the whole-blood specimens are presented here and compared with the results from serum specimens in this subgroup among whom both specimen types were obtained contemporaneously. All participants with candidaemia were PCR-positive from serum samples; however, only seven were PCR-positive from whole blood. All specimens from patients in the 'unlikely' category were PCR-negative in both types of specimen. Moreover, DNA extraction from serum required 1 h; extraction from whole blood required approximately 3 h. These data tentatively suggest that, overall, serum is an appropriate specimen for Candida PCR for detection of candidaemia in non-neutropenic adults.

Background: Invasive Candida infection among nonneutropenic, critically ill adults is a clinical problem that has received increasing attention in recent years. Poor performance of extant diagnostic modalities has promoted risk-based, preemptive prescribing in view of the poor outcomes associated with inadequate or delayed antifungal therapy; this risks unnecessary overtreatment. A rapid, reliable diagnostic test could have a substantial impact on therapeutic practice in this patient population., Methods: Three TaqMan-based real-time polymerase chain reaction assays were developed that are capable of detecting the main medically important Candida species, categorized according to the likelihood of fluconazole susceptibility. Assay 1 detected Candida albicans, Candida parapsilosis, Candida tropicalis, and Candida dubliniensis. Assays 2 and 3 detected Candida glabrata and Candida krusei, respectively. The clinical performance of these assays, applied to serum, was evaluated in a prospective trial of nonneutropenic adults in a single intensive care unit., Results: In all, 527 specimens were obtained from 157 participants. All 3 assays were run in parallel for each specimen; they could be completed within 1 working day. Of these, 23 specimens were obtained from 23 participants categorized as having proven Candida infection at the time of sampling. If a single episode of Candida famata candidemia was excluded, the estimated clinical sensitivity, specificity, and positive and negative predictive values of the assays in this trial were 90.9%, 100%, 100% and 99.8%, respectively., Conclusions: These data suggest that the described assays perform well in this population for enhancing the diagnosis of candidemia. The extent to which they may affect clinical outcomes, prescribing practice, and cost-effectiveness of care remains to be ascertained.

The limitations of classical diagnostic methods for invasive Candida infections have led to the development of molecular techniques such as real-time PCR to improve diagnosis. However, the detection of low titres of Candida DNA in blood from patients with candidaemia requires the use of extraction methods that efficiently lyse yeast cells and recover small amounts of DNA suitable for amplification. In this study, a Candida-specific real-time PCR assay was used to detect Candida albicans DNA in inoculated whole blood specimens extracted using seven different extraction protocols. The yield and quality of total nucleic acids were estimated using UV absorbance, and specific recovery of C. albicans genomic DNA was estimated quantitatively in comparison with a reference (Qiagen kit/lyticase) method currently in use in our laboratory. The extraction protocols were also compared with respect to sensitivity, cost and time required for completion. The TaqMan PCR assay used to amplify the DNA extracts achieved high levels of specificity, sensitivity and reproducibility. Of the seven extraction protocols evaluated, only the MasterPure yeast DNA extraction reagent kit gave significantly higher total nucleic acid yields than the reference method, although nucleic acid purity was highest using either the reference or YeaStar genomic DNA kit methods. More importantly, the YeaStar method enabled C. albicans DNA to be detected with highest sensitivity over the entire range of copy numbers evaluated, and appears to be an optimal method for extracting Candida DNA from whole blood.

Objectives: To describe the species distribution and antifungal susceptibility trends for documented episodes of candidemia at the Royal Hospitals, Belfast, 2001-2006., Methods: Laboratory-based retrospective observational study of all episodes of candidemia., Results: There were 151 episodes of candidemia. The species recovered were: 96 C. albicans; 26 C. glabrata; 18 C. parapsilosis; five C. tropicalis; four C. guilliermondii; one C. famata and one C. dubliniensis. We separated the data into two periods 2001-2003 and 2004-2006; contrary to the findings of other investigators, there was a notable trends toward increasing frequency of C. albicans and decreasing frequency of non-albicans species over time. Although the proportion of C. albicans, C. parapsilosis and C. tropicalis isolates susceptible to fluconazole was unchanged over time, a trend of decreased susceptibility of C. glabrata to fluconazole was noted over the six-year period. Overall, 73% and 7.7% of C. glabrata isolates had susceptible-dose-dependent and resistant phenotypes, respectively. The percentage of C. glabrata isolates susceptible to fluconazole (MIC <8 microg/ml) decreased from 36% in 2001-2003 to 0% in 2004-2006. Flucytosine resistance was detected in only 4 (2.7%) isolates. None of the isolates had an amphotericin B MIC <1 microg/ml., Conclusion: A shift towards increasing dominance of C. albicans contrasts both with reports from other countries and previous data from Northern Ireland. Upwards fluconazole MIC drift among C. glabrata has important implications for empirical therapeutic decisions.

In view of both the delay in obtaining identification by conventional methods following blood-culture positivity in patients with candidaemia and the close relationship between species and fluconazole (FLC) susceptibility, early speciation of positive blood cultures has the potential to influence therapeutic decisions. The aim was to develop a rapid test to differentiate FLC-resistant from FLC-sensitive Candida species. Three TaqMan-based real-time PCR assays were developed to identify up to six Candida species directly from BacT/Alert blood-culture bottles that showed yeast cells on Gram staining at the time of initial positivity. Target sequences in the rRNA gene complex were amplified, using a consensus two-step PCR protocol, to identify Candida albicans, Candida parapsilosis, Candida tropicalis, Candida dubliniensis, Candida glabrata and Candida krusei; these are the most commonly encountered Candida species in blood cultures. The first four of these (the characteristically FLC-sensitive group) were identified in a single reaction tube using one fluorescent TaqMan probe targeting 18S rRNA sequences conserved in the four species. The FLC-resistant species C. krusei and C. glabrata were detected in two further reactions, each with species-specific probes. This method was validated with clinical specimens (blood cultures) positive for yeast (n=33 sets) and the results were 100 % concordant with those of phenotypic identification carried out concomitantly. The reported assay significantly reduces the time required to identify the presence of C. glabrata and C. krusei in comparison with a conventional phenotypic method, from approximately 72 to <3 h, and consequently allows optimization of the antifungal regimen at an earlier stage.

Background: Characterizing virus-host interactions during self-limited infectious mononucleosis could explain how Epstein-Barr virus (EBV) replication is normally controlled and provide insight into why certain immunocompromised patients fail to contain it., Methods: University students had an average of 7 clinical and virologic evaluations during acute infectious mononucleosis. EBV was quantified in 697 samples of oral wash fluid, whole blood, peripheral blood mononuclear cells (PBMCs), and plasma by a real-time (TaqMan) polymerase chain reaction (qEBV) assay developed in our laboratory., Results: Twenty of 25 subjects had serologically confirmed primary EBV infection. EBV was cleared from whole blood by a first-order process with a median half-life of 3 days, and its quantity was associated with severity of illness (r2=0.82). Oral shedding persisted at a median of >or=1x104 copies/mL for 32 weeks and was unrelated to severity of illness. Subjects with nonprimary EBV infection shed virus intermittently, and median quantities for all samples became undetectable within 4 weeks., Conclusions: Using a novel qEBV assay, we demonstrated that young adults with primary EBV infection rapidly cleared virus from blood but not from the oropharynx. High oral concentrations of EBV in asymptomatic persons who have resumed normal activities support the concept that infectious mononucleosis is most likely acquired by kissing.

The C terminus of the human immunodeficiency virus type 1 (HIV-1) accessory protein vpr acts in viral cell cycle arrest, nuclear localization, and apoptosis. Polymorphisms in this region are described in series of long-term nonprogression cases. We determined vpr sequences of archived baseline specimens from 96 participants in a historical trial of single- versus double-nucleoside reverse-transcriptase inhibitors. These sequences were then analyzed by study-entry and -outcome characteristics such as baseline absolute CD4(+) T cell count, prior treatment, CD4(+) T cell response, and clinical endpoints. Frequency of C-terminal mutations did not correlate to any measures of disease intensity. Changes in that portion of vpr did not attenuate disease.

A 6-year-old boy presented with endocarditis of the tricuspid valve caused by penicillin resistant pneumococcus. He had no history of congenital cardiac disease. The likely portal of entry for the organism was the middle ear.

Objective: To determine the relationship between, and antibiotic resistance of, endotracheal tube (ET) biofilm and pulmonary pathogens in ventilator-associated pneumonia (VAP)., Setting: General intensive care units in two university teaching hospitals., Design: The microbiology of ET biofilm and tracheal samples from patients with and without VAP were compared. For individual patients, matching pairs of pathogens were confirmed as identical and characterised for antibiotic susceptibility., Patients: 40 intensive care unit patients - 20 with VAP, 20 without VAP as control. The duration of intubation (median and range) was 6.5 days (3-17) and 5 days (2-10), respectively., Measurements and Results: Samples of tracheal secretions were taken during ventilation for bacteriological culture. Following extubation, ETs were examined for the presence of biofilm. Isolates of high pathogenic potential included Staphylococcus aureus, enterococci, Enterobacteriaceae, pseudomonads and Candida spp. Where the same microorganism was found on tracheal and ET samples by phenotyping, these were confirmed as identical by genotyping and characterised for antibiotic susceptibility in both the free floating and biofilm forms. Seventy per cent of patients with VAP had identical pathogens isolated from both ET biofilm and tracheal secretions. No pairing of pathogens was observed in control patients (p < 0.005). Susceptibility data for these pairs show that the ET acts as a reservoir for infecting microorganisms which exhibit significantly greater antibiotic resistance than their tracheal counterparts., Conclusion: This investigation provides further evidence for the role of ET biofilm in VAP. The difficulty in eradicating an established microbial biofilm using antibiotics implies that increased attention must be directed towards modification of the ET to prevent or substantially reduce biofilm formation.

Closed tracheal suction catheters offer a number of microbiological advantages over the conventional single-use suction catheters. Intensive care staff, however, have experienced difficulties such as pooling of the catheter irrigation saline within the connectors, and hand contamination from condensate which escapes via the irrigation port. Using a descriptive survey design we quantified how frequently these problems occurred. Over an eight-week period, staff completed 923 survey forms. Hand contamination from condensate was reported in 61% of responses. Rinsing the catheter after use was ineffective in 39% of responses, and 70% reported pooling of the saline in the swivel and ventilator connectors. Forty-five percent of responses reported ineffective secretion removal. The infection implications for clinical practice are discussed.

The use of closed multi-use tracheal suction systems in ventilated patients is increasingly popular as it offers a number of potential physiological and microbiological advantages. As the use of these systems has been associated with an increased prevalence of tracheal colonization, effective self-cleaning mechanisms employed in these catheters are necessary. Using an in-vitro model we assessed the degree of catheter colonization in two multi-use catheter systems; Stericath and Trach-Care. Fifty of each catheter type were tested for colonization with five challenge organisms: Staphylococcus aureus (NCTC 6571); Pseudomonas aeruginosa (NCTC 10662); Haemophilus influenzae type b; S. epidermidis (slime producer); and S. epidermidis (slime non-producer). All five challenge strains had colonized both catheter types after 24 h and all 100 catheter tips were colonized. The extent and density of colonization was variable and interspecies variation in the pattern of catheter colonization was observed. The mean colonized lengths of Stericath catheters was 10.9 +/- 1.4 cm and of Trach-Care 2.7 +/- 1.3 cm (P < 0.0001).

From July to September 1993 in the intensive care unit of the Royal Victoria Hospital there were 10 cases of pneumonia associated with sputum culture of Pseudomonas aeruginosa. The isolates had an identical biotype and pyocine typing profile. The same strain of P. aeruginosa was recovered from the sink plug-hole in two rooms, and the tap handles and ventilator tubing in a third room. All strains were retrospectively typed by the random amplification of polymorphic DNA (RAPD) method using a 26-mer oligonucleotide primer, and were identical in profile. Recommendations to medical and nursing staff included secretion isolation precautions, terminal disinfection after patient discharge, use of disposable vinyl gloves by hospital staff for all body substance contacts, thorough handwashing with 4% chlorhexidine gluconate before and after dealing with all patient contacts, and prompt, appropriate antibiotic treatment for P. aeruginosa pneumonia. RAPD is a simple and effective method to determine the relatedness of P. aeruginosa isolates, and typing results are available within a single working day; thus dramatically increasing its clinical relevance over existing molecular methods.

Objective: To determine the use of new drugs in one United Kingdom region., Design: Examination of data on prescribing of angiotensin converting enzyme inhibitors, new broad spectrum antibiotics, and H2 receptor antagonists. Calculation of number of defined daily doses prescribed each month., Setting: All general practices in Northern Ireland., Main Outcome Measures: Drug use index and market share of each drug., Results: During 1988-91 prescribing of angiotensin converting enzyme inhibitors increased by 126%, of H2 receptor antagonists by 46%, and of new antibiotics by 207%. The first drug on the market usually retained the largest market share. Use of oral antibiotics increased threefold irrespective of the reporting policy of the general practitioners' local laboratory., Conclusions: The increase in prescribing of these drugs seems to be greater than can be accounted for by an increase in patients with specific indications for these drugs. This suggests that the profession has not instituted effective checks to ensure that the legitimate promotion of new products does not lead to inappropriate and wasteful use.

The purpose of selective decontamination of the digestive tract (SDD) is to eradicate potentially disease-producing micro-organisms from the oropharynx and gastro-intestinal tract of intensive care unit (ICU) patients, thereby reducing the incidence of nosocomial sepsis, particularly pneumonia. Microbial biofilms form on endotracheal (ET) tubes even when SDD is being administered and may represent a persistent focus for infection. The aim of this investigation was to determine the susceptibilities of organisms adherent to ET tubes to SDD antibiotics (amphotericin B, tobramycin and polymyxin) and to measure the concentrations of these agents in the tracheal aspirates of 11 patients who were being mechanically ventilated. Following extubation, a section was cut from the tip of each ET tube and any adherent microorganisms subsequently isolated were identified and their MICs determined. Samples of tracheal aspirate were obtained three hours after administration of the SDD regimen and the concentrations of the constituent antimicrobials were measured. Enterobacteriaceae were not recovered from any of the tubes but six strains of Staphylococcus aureus, three Pseudomonas spp., three enterococci and four yeasts were isolated. Wide variations in the concentrations of all antibiotics were observed and in many cases they were below the MICs for the organisms isolated. In particular, tobramycin concentrations were uniformly less than the median MIC for the S. aureus isolates and this may account for the predominance of Gram-positive bacteria adherent to the ET tubes. Microbial biofilms attached to these tubes may have a role in the pathogenesis of nosocomial pneumonia in ICU patients.

Prehospital emergency services personnel often are exposed to high levels of occupational stress. Besides chronic stress, they can be involved in critical incidents, which cause a well-recognized set of overwhelming emotional reactions. If these reactions are not addressed promptly, emergency responders and their families can suffer further emotional trauma, and this can impair the ability of responders to care for patients in the field. A critical incident stress management team has been established through cooperation between the Charleston Division of the West Virginia University Health Sciences Center and emergency personnel in Charleston, as well as the rural countries in southern West Virginia. This team provides preincident education and postincident interventions for firefighters, police, emergency medical services, and on occasion, hospital emergency department personnel. This team can serve as a model for other such teams to organize to deal with this growing problem in the health care delivery field.

A cluster of five cases of pseudobacteraemia due to the organism Alcaligenes denitrificans occurred in three hospital medical wards over a four week period. The same organism was isolated from four of twelve commercially prepared bottles for erythrocyte sedimentation tests. The most likely explanation for the outbreak is that the ESR bottles were filled prior to inoculation of blood culture bottles. The outbreak was brought to an end by advising on correct procedure.

In addition to the routine pressures associated with their demanding roles, prehospital emergency responders can suffer severe stress as a result of exposure to a critical incident. Such an event overwhelms the individual's ability to emotionally adjust, and can lead to symptoms which cause suffering in emergency personnel, their families and their patients. A Critical Incident Stress Management (CISM) Team has been established in southern West Virginia to address this occupational hazard. This group was formed as a cooperative arrangement between the Charleston Division of the West Virginia University Health Sciences Center and emergency personnel in the Greater Kanawaha Valley. This article offers an explanation of the team's functioning and specific information regarding its activation.

Selective decontamination of the digestive tract (SDD) aims to reduce the rate of nosocomial infections in critical care patients. Pseudomonas spp. are common nosocomial pathogens and in this study isolates collected from patients and the environment during an SDD trial were examined. The study enrolled 161 SDD cases and 170 controls. Pseudomonads were isolated from 27% of SDD patients and 30% of controls. SDD partially suppressed colonization in the 'gastro-respiratory' mucosae but not in the rectum. A total of 108 isolates of pseudomonads were recovered from the environment. Resistance in rectal isolates was minimal but isolates from 'gastro-respiratory' sites showed increasing aminoglycoside resistance. Eighty-six per cent of aminoglycoside-resistant isolates from both patient groups and environment were pyocine type 1x. Episodes of infection were reduced in the SDD patients (6) compared with the controls (16), aminoglycoside-resistant strains being associated with zero episodes in SDD patients but with five in the control group.

Infection following prosthetic joint implant jeopardizes the prosthesis and may lead to long-term locomotor disability. Interoperative antimicrobial prophylaxis can reduce the incidence of infectious complications. The comparative safety and efficacy of single-dose teicoplanin and four doses of cephamandole over a 24-hour period is currently being assessed in a single-blind, randomized concurrent study of patients who undergo first time hip or knee arthroplasty. Of 660 evaluated patients, 352 have received cephamandole and 308 teicoplanin. Two patients in each group had a surgical wound infection at 1 week after surgery. Reassessment 30 days postoperatively showed resolution of the infection in both of the teicoplanin patients and in one of the cephamandole patients. Proven or suspected infection involving other body systems occurred in 30 teicoplanin and 38 cephamandole patients at 1 week postoperatively and in 5 teicoplanin and 3 cephamandole patients 1 month after surgery. Adverse events occurred in 20 (5.1%) teicoplanin patients and 29 (7.1%) cephamandole patients. These preliminary results suggest that single-dose teicoplanin is a safe and effective prophylactic agent in prosthetic joint implant surgery.

We report a case of Haemophilus aphrophilus endocarditis involving mitral and tricupsid valves in a boy with congenital heart disease. He had received dental treatment without antibiotic cover. Prolonged high-dose ampicillin with gentamicin was necessary for cure. Short courses of ampicillin alone may not successfully treat H. aphrophilus.

Serum erythromycin concentrations were estimated following administration of 100 mg erythromycin ethyl succinate intramuscularly and 500 mg erythromycin stearate orally. The subjects (30 healthy students) were randomly divided into two groups and each subject received a single dose of the alternate form of the drug after a 4-week interval. Blood samples were obtained at 0.5, 1, 1.5, 2, 3 and 4 h after administration by separate venepuncture. All 30 subjects recorded serum levels above 0.2 microgram/ml following administration of the intramuscular form of the drug. Following administration of the oral form of the drug, five subjects failed to record serum levels above 0.2 microgram/ml by the 2-h sampling time and three failed to do so by the 4th hour. It is concluded from the results that, despite the high serum levels recorded with the oral form when taken with food, the intramuscular route gives a greater assurance of consistent absorption into the blood stream. This result suggests that the use of the oral form of the drug as a prophylactic antibiotic in patients receiving dental treatment remains in doubt.

The auscultatory or indirect technique of measuring blood pressure has been proved reliable in multiple clinical settings and has received wide application. In clinical studies, special efforts are used to train observers in the measurement of blood pressure and to ensure properly functioning equipment. Similar diligence in providing quality control is necessary in everyday practice to guard against potential errors. With proper care it is possible to obtain readings that classify the pressure to the nearest 5 mm Hg. Table 1 lists some of the sources of error that are possible with the indirect technique and the magnitude of these errors. It should be emphasized that many factors affect blood pressure variation and that any single reading is of limited value. A number of specific sources of information are useful to the practicing physician and his staff for maintaining equipment and for standardizing technique and procedure. Application of these principles to primary care practice should improve the accuracy of health maintenance and allow proper clinical application of the results of the many clinical studies of mild hypertension that are presently being conducted around the world.