A retrospective audit of adult and paediatric anaphylaxis management from two Australian metropolitan mixed emergency departments.

BACKGROUND: Anaphylaxis is a potentially life-threatening allergic reaction, with presentations to emergency departments (EDs) increasing across Australia. Understanding the features of those presenting with anaphylaxis and aspects related to its optimal clinical management across the admission, treatment and discharge settings is needed to minimise its impact. We aimed to evaluate the nature and management of presentations related to anaphylaxis across two Australian EDs. METHODS: Retrospective audit of paediatric and adult patients presenting to a community or tertiary level ED with anaphylaxis from 1 May 2018 to 30 April 2019. Data extracted from medical records included demographic characteristics, causative agents, clinical features, treatments administered across community, ambulance or ED settings, as well as post-discharge care arrangements including provision of Adrenaline Auto-Injector (AAI) and Allergy/Anaphylaxis Action Plan (AAP). RESULTS: A total of 369 (107 paediatric and 262 adult) ED presentations were identified. A total of 94 (36%) adult and 46 (43%) paediatric patients received pre-hospital adrenaline, with a further 91 (35%) adult and 29 (27%) paediatric patients receiving a dose of adrenaline in the ED. The most commonly administered treatment in ED were corticosteroids, given to 157 (60%) adult and 55 (51%) paediatric patients. Among those requiring an AAI for discharge, 123/210 (59%) adult and 57/91 (63%) of paediatric patients left hospital with an AAI. In contrast, among those requiring an allergy/anaphylaxis action plan (AAP) on discharge, 61/206 (30%) adult and 30/90 (33%) of paediatric patients left hospital with one. Factors associated with an increased likelihood of receiving AAI on discharge in paediatric and adult patients included receipt of any adrenaline, receipt of two or more doses of adrenaline, and longer duration of hospital stay. Adults presenting within business hours were more likely to be discharged with AAI, but no such difference was observed for paediatric patients. Similar findings were evident for provision of AAP on discharge. CONCLUSION: These findings demonstrate the need to improve assessment and treatment in the ED. In particular, the observed large variability in provision of AAI and AAP on discharge presents opportunities to explore strategies to improve awareness and provision of these critical components of post-discharge care.

Wilson ratio of fermi gases in one dimension.

We calculate the Wilson ratio of the one-dimensional Fermi gas with spin imbalance. The Wilson ratio of attractively interacting fermions is solely determined by the density stiffness and sound velocity of pairs and of excess fermions for the two-component Tomonaga-Luttinger liquid phase. The ratio exhibits anomalous enhancement at the two critical points due to the sudden change in the density of states. Despite a breakdown of the quasiparticle description in one dimension, two important features of the Fermi liquid are retained; namely, the specific heat is linearly proportional to temperature, whereas the susceptibility is independent of temperature. In contrast to the phenomenological Tomonaga-Luttinger liquid parameter, the Wilson ratio provides a powerful parameter for testing universal quantum liquids of interacting fermions in one, two, and three dimensions.

Analytic thermodynamics and thermometry of Gaudin-Yang Fermi gases.

We study the thermodynamics of a one-dimensional attractive Fermi gas (the Gaudin-Yang model) with spin imbalance. The exact solution has been known from the thermodynamic Bethe ansatz for decades, but it involves an infinite number of coupled nonlinear integral equations whose physics is difficult to extract. Here the solution is analytically reduced to a simple, powerful set of four algebraic equations. The simplified equations become universal and exact in the experimental regime of strong interaction and relatively low temperature. Using the new formulation, we discuss the qualitative features of finite-temperature crossover and make quantitative predictions on the density profiles in traps. We propose a practical two-stage scheme to achieve accurate thermometry for a trapped spin-imbalanced Fermi gas.

Crystal structure of human prion protein bound to a therapeutic antibody.

Prion infection is characterized by the conversion of host cellular prion protein (PrP(C)) into disease-related conformers (PrP(Sc)) and can be arrested in vivo by passive immunization with anti-PrP monoclonal antibodies. Here, we show that the ability of an antibody to cure prion-infected cells correlates with its binding affinity for PrP(C) rather than PrP(Sc). We have visualized this interaction at the molecular level by determining the crystal structure of human PrP bound to the Fab fragment of monoclonal antibody ICSM 18, which has the highest affinity for PrP(C) and the highest therapeutic potency in vitro and in vivo. In this crystal structure, human PrP is observed in its native PrP(C) conformation. Interactions between neighboring PrP molecules in the crystal structure are mediated by close homotypic contacts between residues at position 129 that lead to the formation of a 4-strand intermolecular beta-sheet. The importance of this residue in mediating protein-protein contact could explain the genetic susceptibility and prion strain selection determined by polymorphic residue 129 in human prion disease, one of the strongest common susceptibility polymorphisms known in any human disease.

Magnetic phase transitions in one-dimensional strongly attractive three-component ultracold fermions.

We investigate the nature of trions, pairing, and quantum phase transitions in one-dimensional strongly attractive three-component ultracold fermions in external fields. Exact results for the ground-state energy, critical fields, magnetization and phase diagrams are obtained analytically from the Bethe ansatz solutions. Driven by Zeeman splitting, the system shows exotic phases of trions, bound pairs, a normal Fermi liquid, and four mixtures of these states. Particularly, a smooth phase transition from a trionic phase into a pairing phase occurs as the highest hyperfine level separates from the two lower energy levels. In contrast, there is a smooth phase transition from the trionic phase into a normal Fermi liquid as the lowest level separates from the two higher levels.

Characterisation of CTX-M and AmpC genes in human isolates of Escherichia coli identified between 1995 and 2003 in England and Wales.

CTX-M and AmpC genes in human isolates of Escherichia coli, their genetic environment and their host plasmids were examined. Isolates (n=103) were selected based on resistance (minimum inhibitory concentration (MIC)> or =1 microg/mL) to ceftriaxone and cefotaxime. Polymerase chain reaction (PCR) and sequencing identified 29 isolates containing bla(CTX-M-15), 1 each of bla(CTX-M-2) (a strain originating from Israel) and bla(CTX-M-40), 20 isolates containing bla(CMY-7), 4 bla(CMY-2) and 1 bla(CMY-21). This is the first study of plasmid-mediated AmpC genes in E. coli in the UK. Eleven cefoxitin-resistant, AmpC PCR-negative isolates had ampC promoter region mutations. All bla(CTX-M-15) and 24 of 25 bla(CMY) genes were associated with an ISEcp1-like element. The bla(CTX-M-2) was located in an orf513-bearing class 1 integron. Plasmid restriction digests suggest transfer of genes between different plasmid backbones.

One-dimensional interacting anyon gas: low-energy properties and Haldane exclusion statistics.

The low-energy properties of the one-dimensional anyon gas with a delta-function interaction are discussed in the context of its Bethe ansatz solution. It is found that the anyonic statistical parameter and the dynamical coupling constant induce Haldane exclusion statistics interpolating between bosons and fermions. Moreover, the anyonic parameter may trigger statistics beyond Fermi statistics for which the exclusion parameter alpha is greater than one. The Tonks-Girardeau and the weak coupling limits are discussed in detail. The results support the universal role of alpha in the dispersion relations.

Longitudinal farm study of extended-spectrum beta-lactamase-mediated resistance.

Extended-spectrum beta-lactamase (ESBL)-mediated resistance is of considerable importance in human medicine. Recently, such enzymes have been reported in bacteria from animals. We describe a longitudinal study of a dairy farm suffering calf scour with high mortality rates. In November 2004, two Escherichia coli isolates with resistance to a wide range of beta-lactams (including amoxicillin-clavulanate and cefotaxime) were isolated from scouring calves. Testing by PCR and sequence analysis confirmed the isolates as being both bla(CTX-M14/17) and bla(TEM-35) ((IRT-4)) positive. They had indistinguishable plasmid and pulsed-field gel electrophoresis (PFGE) profiles. Transferability studies demonstrated that bla(CTX-M) was located on a conjugative 65-MDa IncK plasmid. Following a farm visit in December 2004, 31/48 calves and 2/60 cows were positive for E. coli with bla(CTX-M). Also, 5/48 calf and 28/60 cow samples yielded bla(CTX)- and bla(TEM)-negative E. coli isolates that were resistant to cefotaxime, and sequence analysis confirmed that these presented mutations in the promoter region of the chromosomal ampC gene. Fingerprinting showed 11 different PFGE types (seven in bla(CTX-M)-positive isolates). Six different PFGE clones conjugated the same bla(CTX-M)-positive IncK plasmid. One clone carried a different-sized, bla(CTX-M)-positive, transformable plasmid. This is the first report of bla(CTX-M) from livestock in the United Kingdom, and this report demonstrates the complexity of ESBL epidemiology. Results indicate that horizontal plasmid transfer between strains as well as horizontal gene transfer between plasmids have contributed to the spread of resistance. We have also shown that some clones can persist for months, suggesting that clonal spread also contributes to the perpetuation of resistance.

Resistance to oxyiminocephalosporins mediated by blaTEM-52 genes in Salmonella typhimurium from humans in England and Wales.

The emergence of antimicrobial resistance among Salmonella is a matter of great public health concern, more so in the case of extended-spectrum cephalosporins, since these antimicrobials are normally regarded as the drugs of choice for complicated cases of infection. This study was designed to determine the occurrence of resistance mediated by the presence of extended-spectrum beta-lactamases (ESBL) enzymes belonging to the TEM family. Only two isolates were detected after analysis of the 278,308 Salmonella isolates from the last 10 years. In both cases, the gene involved was a bla (TEM-52)-like, and infections were linked with foreign travel. ESBL-TEM enzymes remain very rare in Salmonella in England and Wales, and no domestic cases have been detected to date.

Characterization of AmpC-mediated resistance in clinical Salmonella isolates recovered from humans during the period 1992 to 2003 in England and Wales.

The increase in AmpC-mediated resistance in salmonellae constitutes a serious public health concern, since these enzymes confer resistance to a wide range of beta-lactams. One hundred six isolates were selected from 278,308 Salmonella isolates based on resistance to ampicillin and cephalosporins and were subjected to further characterization. Nine isolates had a cefoxitin inhibition diameter < or = 17 mm and were proven to be AmpC positive by multiplex PCR. Sequence analysis revealed the presence of bla(DHA-1), bla(CMY-2), and bla(CMY-4) genes. All nine isolates presented different pulsed-field gel electrophoresis restriction profiles. The AmpC genetic determinants were present in transferable plasmids of around 11, 42, 70, 98, and 99 MDa. A combination of size and restriction fragment length polymorphism (RFLP) analysis showed that all the bla(CMY) plasmids investigated in our study were different, which suggests that bla(CMY) may be located in different plasmid environments. Some United Kingdom isolates linked to foreign travel showed RFLP plasmid patterns consistent with plasmids previously seen in the United States, which suggests that bla(CMY-2) has also been disseminated through plasmid transfer. The fact that two of the domestically acquired United Kingdom isolates presented previously unseen RFLP plasmid patterns could indicate that these strains have followed routes different from those prevalent in North America or other parts of the world. This study represents the first report of bla(CMY) genes in Salmonella isolates in the United Kingdom and the first report of CMY-4 in Salmonella enterica serotype Senftenberg worldwide.

Detection of multiple cephalosporin-resistant Escherichia coli from a cattle fecal sample in Great Britain.

We describe the isolation of multiple cephalosporin-resistant Escherichia coli from cattle feces collected from animals at slaughter in Great Britain. Six E. coli strains were isolated with distinct XbaI pulsed-field gel electrophoresis (PFGE) profiles and different mechanisms of cephalosporin resistance from a single fecal sample. Two of these strains were found to contain conjugative plasmids conferring resistance to extended-spectrum cephalosporins that were indistinguishable from each other by restriction endonuclease digestion. Sequence analysis of the plasmid-encoded ampC showed that they were identical to bla(CMY-2), previously described in multiple-drug-resistant Salmonella and E. coli from animals in other parts of the world. DNA sequence analysis of the chromosomal ampC promoter regions for three cephalosporin-resistant strains lacking CMY-2 was determined. Several mutations were detected in the isolates tested including changes at positions -42 and -32, which are known to increase promoter strength. This report represents the first isolation of E. coli containing bla(CMY-2) from cattle in Great Britain, and, also to our knowledge, the first demonstration of multiple cephalosporin-resistant strains in a single animal.

bla(CTX-M) genes in clinical Salmonella isolates recovered from humans in England and Wales from 1992 to 2003.

Cefotaximases (CTX-M) are a rapidly growing class A beta-lactamase family that has been found among a wide range of clinical bacteria. One hundred and six isolates were selected from 278,308 Salmonella isolates based on resistance to ampicillin and cephalosporins and subjected to further characterization. Fourteen isolates were bla(CTX-M) PCR positive, and cefotaxime MICs for these isolates were > or = 16 mg/liter. Furthermore, sequence analysis revealed the presence of type CTX-M9, -15, or -17 to -18. All 14 isolates presented different PFGE restriction profiles, although six Salmonella enterica serotype Virchow isolates formed a tight cluster. The bla(CTX-M) genetic determinants were present in transferable plasmids of approximately 63, 105, and >148 kb. Plasmid restriction analysis showed that both horizontal transfer of similar plasmids among different clones and transfer of genes between different plasmids were likely mechanisms involved in the spread of bla(CTX-M) genes. We have found that CTX-M enzymes have emerged in community-acquired infections both linked to foreign travel and domestically acquired. This is the first report of a CTX-M enzyme in Salmonella in the United Kingdom. Also, it represents the first report of a bla(CTX-M) gene in Salmonella enterica serotype Stanley and a bla(CTX-M-15) gene in Salmonella enterica serotypes Anatum, Enteritidis, and Typhimurium.

Random walks on finite lattice tubes.

Exact results are obtained for random walks on finite lattice tubes with a single source and absorbing lattice sites at the ends. Explicit formulas are derived for the absorption probabilities at the ends and for the expectations that a random walk will visit a particular lattice site before being absorbed. Results are obtained for lattice tubes of arbitrary size and each of the regular lattice types: square, triangular, and honeycomb. The results include an adjustable parameter to model the effects of strain, such as surface curvature, on the surface diffusion. Results for the triangular lattice tubes and the honeycomb lattice tubes model diffusion of adatoms on single walled zig-zag carbon nanotubes with open ends.

Structural basis for recognition of the translocated intimin receptor (Tir) by intimin from enteropathogenic Escherichia coli.

Intimin is a bacterial adhesion molecule involved in intimate attachment of enteropathogenic and enterohaemorrhagic Escherichia coli to mammalian host cells. Intimin targets the translocated intimin receptor (Tir), which is exported by the bacteria and integrated into the host cell plasma membrane. In this study we localized the Tir-binding region of intimin to the C-terminal 190 amino acids (Int190). We have also determined the region's high-resolution solution structure, which comprises an immunoglobulin domain that is intimately coupled to a novel C-type lectin domain. This fragment, which is necessary and sufficient for Tir interaction, defines a new super domain in intimin that exhibits striking structural similarity to the integrin-binding domain of the Yersinia invasin and C-type lectin families. The extracellular portion of intimin comprises an articulated rod of immunoglobulin domains extending from the bacterium surface, conveying a highly accessible 'adhesive tip' to the target cell. The interpretation of NMR-titration and mutagenesis data has enabled us to identify, for the first time, the binding site for Tir, which is located at the extremity of the Int190 moiety.

Antibody response of patients infected with verocytotoxin-producing Escherichia coli to protein antigens encoded on the LEE locus.

Sera from patients infected with verocytotoxin-producing Escherichia coli (VTEC) O157, from patients with antibodies to E. coli O157 lipopolysaccharide (LPS) and from healthy controls were examined for antibodies to proteins involved in expressing the attaching and effacing phenotype. After SDS-PAGE, purified recombinant intimin, EspA-filament structural protein, translocated protein EspB and three separate domains of the translocated intimin receptor (Tir) were tested for reaction with patients' sera by immunoblotting. An ELISA was also used to detect antibodies to intimin in sera from E. coli O157 LPS antibody-positive individuals. Seven of nine culture-positive patients and one control patient had antibodies to EspA. Five of these patients and two controls had serum antibodies to the intimin-binding region of Tir, whereas none of the sera contained antibodies binding to either of the intracellular domains of Tir. By immunoblotting, 10 of 14 culture-positive patients had antibodies to the conserved region of intimin, eight of whom were infected with E. coli O157 phage type 2. Thirty-six of 60 sera from culture-negative but E. coli O157 LPS antibody-positive patients had antibodies to intimin as determined by ELISA. The secreted proteins are expressed in vivo during infection and are considered as pathogenic markers. Antibodies to these proteins may form the basis of a serodiagnostic test for the detection of patients infected with VTEC which carry the locus for the enterocyte effacement pathogenicity island and provide an adjunct test to the established serological tests based on VTEC LPS.

Human colostrum and serum contain antibodies reactive to the intimin-binding region of the enteropathogenic Escherichia coli translocated intimin receptor.

BACKGROUND: In Brazil, enteropathogenic Escherichia coli (EPEC) diarrhoea is endemic in young infants. A characteristic feature of EPEC adhesion to host cells is intimate attachment leading to the formation of distinctive "attaching and effacing" (A/E) lesions on mammalian cells. Two genes directly involved in intimate adhesion, eae and tir, encode the adhesion molecule intimin and its translocated receptor Tir, respectively. The intimin-binding domain of Tir was recently mapped to the middle part of the polypeptide (Tir-M), and the amino (Tir-N) and carboxy (Tir-C) termini were found to be located within infected host cells. Recently, it was shown that colostrum samples from mothers living in Sao Paulo contain IgA-class antibodies reactive with a number of proteins associated with EPEC virulence. It has also been shown that patients infected with verocytotoxin-producing E. coli O157 can produce antibodies to Tir. In the current study antibody responses to the different Tir domains were analyzed in sera and colostrum samples collected in an EPEC-endemic area of Brazil. METHODS: Recombinant Tir, Tir-N, Tir-M, and Tir-C were expressed as His-tagged protein in E. coli BL21a and purified on nickel columns. Western blot analysis was used to investigate colostrum IgA- and serum IgG-class antibodies reactive with the Tir fragments. RESULTS: Anti-Tir IgG antibodies were detected in the serum of children, with (63%) or without (50%) diarrhoea. Anti-Tir IgA-class antibodies were detected in all the colostrum pools tested. With the use of both serum IgG- and colostrum IgA-class antibodies, an immunodominant domain of the Tir-polypeptide, Tir M, was identified. CONCLUSION: The intimin-binding region of Tir (Tir-M) is the immunodominant region of the polypeptide in humans. Both serum IgG-class and colostrum IgA-class antibodies reacted predominantly with the Tir-M domain.

4-Pyridin-5-yl-2-(3,4,5-trimethoxyphenylamino)pyrimidines: potent and selective inhibitors of ZAP 70.

Activation of the tyrosine kinase ZAP 70 has been shown to be crucial to the transduction of the T-cell receptor signalling pathway, which leads ultimately to proliferation, cytokine gene expression and T-cell effector functions. A series of 2-phenylaminopyrimidines have been identified as potent and selective inhibitors of ZAP 70.

Development of a universal intimin antiserum and PCR primers.

Enteropathogenic Escherichia coli (EPEC) and enterohemorrhagic E. coli (EHEC) constitute a significant risk to human health worldwide. A hallmark of both pathogens is their ability to produce characteristic attaching-and-effacing (A/E) lesions in intestinal epithelial cells. Genes encoding A/E lesion formation map to a chromosomal pathogenicity island termed the locus of enterocyte effacement (LEE). Intimin, an LEE-encoded bacterial adhesion molecule, mediates the intimate bacterium-host cell interaction characteristic of A/E lesions. On the basis of characterization of the C-terminal 280-amino-acid cell binding domain of intimin (Int280(661-939)), four distinct Int280 types (types alpha, beta, gamma, and delta) have been identified. Importantly, Int280alpha and Int280beta antisera specifically recognized their respective intimin types. Using a conserved region of the intimin molecule (Int(388-667)) and primers synthesized to generate the recombinant Int(388-667), we have now generated universal intimin antiserum and PCR primers that are reactive with the different intimin types expressed by both human and animal A/E lesion-forming strains. Use of immunogold electron microscopy to visualize intimin on the surfaces of EPEC and EHEC strains revealed, in general, a uniform distribution on the bacterial cell surface. However, a filamentous staining pattern was observed with a few strains expressing intimin gamma. Cloning of the intimin eae gene from one such strain (strain ICC57) into strain CVD206, an EPEC strain which harbors a null deletion in eae, produced a uniform intimin staining pattern indicating that, if the filamentous staining pattern defines a filamentous form of intimin gamma, it is dependent upon the genetic background of the strain and is not a feature of the intimin molecule.