A CLEAR CASE OF MRSA SEPSIS, OF AN UNEXPECTED ORIGIN.

A 56-year-old man with a history of uncontrolled type 2 diabetes mellitus, benign prostatic hypertrophy and history of recent knee and elbow abscess presented to the emergency department with nausea, vomiting, and fevers. Two days prior, he presented to the ER and was diagnosed with acute presumed prostatitis and urinary retention. He was discharged on ciprofloxacin and an indwelling Foley catheter with urology follow-up. After being unable to tolerate oral medications, he presented again to the emergency department, at which time, he was febrile and tachycardic. Physical exam was benign except for a boggy and tender prostate and bilateral CVA tenderness. Labs demonstrated leukocytosis, elevated HbA1C, and pyuria on urinalysis. Urine cultures collected at the patient's earlier emergency department visit demonstrated no growth. Computed tomography indicated an enlarged prostate with patchy areas of low density. He was admitted with sepsis secondary to prostatitis. Blood cultures on day one showed gram-positive cocci , methicillin resistant staph aureus (MRSA isolate) and persistent bacteremia for three days despite therapy with vancomycin. After adequate dosing of vancomycin, sterilization of the blood was achieved, yet urine culture demonstrated growth of MRSA. Transthoracic rchocardiogram (TTE) showed no signs of endocarditis with good visualization of valves. He was successfully treated with 14 days of vancomycin.

Identification of a Dau c PRPlike protein (Dau c 1.03) as a new allergenic isoform in carrots (cultivar Rodelika).

BACKGROUND: Up to 25% of food allergic subjects in central Europe suffer from carrot allergy. Until now, two isoforms of the major carrot (Daucus carota) allergen Dau c 1 have been described: Dau c 1.01, comprising five variants (Dau c 1.0101-Dau c 1.0105) and Dau c 1.02. OBJECTIVE: To investigate potential allergenic properties of a Dau c PRPlike protein, a novel isoform of the PR-10 protein family in carrot. METHODS: Dau c PRPlike cDNA from carrot roots (cv Rodelika) was cloned after RT-PCR and 5'RACE. Dau c PRPlike protein was expressed in E. coli, purified under native conditions by Ni-NTA chromatography and analysed by CD spectroscopy. Immuno-reactivity of the rDau c PRPlike protein was compared with rDau c 1.0104 and rDau c 1.0201 in terms of IgE binding (immunoblotting, ImmunoCAP), IgE cross-reactivity (ELISA inhibition) and in vitro mediator release with sera from carrot allergic patients. mRNA expression of Dau c PRPlike protein in wild-type and transgenic carrot roots was analysed by qRT-PCR. RESULTS: The Dau c PRPlike protein was identified as a new allergenic isoform, Dau c 1.03, in carrot roots. 68% of carrot allergic patients were sensitized to rDau c 1.03. The IgE-reactivity of rDau c 1.03 strongly correlated with reactivity to rDau c 1.0104, but not to rDau c 1.0201. The extent of IgE cross-reactivity and allergenic potency of Dau c 1 isoforms varied between the individual sera tested. Dau c 1.03 mRNA transcripts were up-regulated in Dau c 1.01 and Dau c 1.02 gene-silenced carrot roots. CONCLUSION AND CLINICAL RELEVANCE: Dau c 1 isoforms display distinct IgE epitope heterogeneity. Dau c 1.03 appears to contribute to the allergenicity of carrots and the manifestation of carrot allergy. The epitope diversity of different Dau c 1 isoforms should be considered for component-resolved diagnosis and gene silencing of carrot allergens.

Cloning, expression and immunological characterization of full-length timothy grass pollen allergen Phl p 4, a berberine bridge enzyme-like protein with homology to celery allergen Api g 5.

BACKGROUND: Timothy grass pollen is a common cause of respiratory allergy in the temperate regions. The major group 4 allergen, Phl p 4, has previously been purified and studied biochemically and immunologically, but has so far not been produced and characterized as a recombinant protein. OBJECTIVE: To clone and characterize timothy grass pollen allergen Phl p 4. METHODS: Full-length Phl p 4 cDNA was cloned using a PCR-based strategy including 3'-and 5'-RACE. Recombinant Phl p 4 was expressed in Escherichia coli and purified by immobilized metal ion affinity chromatography. Its immunological activity was investigated using experimental ImmunoCAP tests, sera from Phl p 4 sensitized individuals and Phl p 4 reactive polyclonal and monoclonal animal antibodies. RESULTS: Five full-length Phl p 4 cDNA clones were analysed. Sequence deviations between the clones were present at nine amino acid positions, and the consensus sequence comprised an open reading frame of 525 amino acids, including a predicted 25-residue signal peptide. The calculated molecular weight of the deduced mature protein was 55.6 kDa and the isoelectric point 9.9, both consistent with previously observed properties of purified nPhl p 4. Close sequence similarity was found to genomic clones from several other Pooideae grass species and to Bermuda grass pollen allergen BG60. Further, similarity was found to members of the berberine bridge enzyme (BBE) family, including celery allergen Api g 5. Recombinant Phl p 4 bound specific immunoglobulin (Ig)E from 31 of 32 nPhl p 4-reactive sera, and the IgE binding to rPhl p 4 could be inhibited by nPhl p 4 in a dose-dependent manner. CONCLUSIONS: Full-length Phl p 4 cDNA was cloned and showed sequence similarity to members of the BBE family. Recombinant Phl p 4 was produced and shared epitopes with natural Phl p 4.

Molecular and immunological characterization of a novel timothy grass (Phleum pratense) pollen allergen, Phl p 11.

BACKGROUND: Allergy to grass pollen is typically associated with serum IgE antibodies to group 1 and/or group 5 allergens, and additionally often to one or several less prominent allergens. Most of the grass pollen allergens identified to date have been characterized in detail by molecular, biochemical and immunological methods, timothy grass being one of the most thoroughly studied species. However, a 20-kDa allergen frequently recognized by IgE antibodies from grass pollen allergics has so far escaped cloning and molecular characterization. OBJECTIVE: To clone and characterize the 20 kDa timothy grass pollen allergen Phl p 11. METHODS: Phl p 11 cDNA was cloned by PCR techniques, utilizing N-terminal amino acid sequence obtained from the natural allergen. Phl p 11 was expressed as a soluble fusion protein in Escherichia coli, purified to homogeneity and used for serological analysis and to study Phl p 11 specific induction of histamine release from basophils and skin reactivity in sensitized and control subjects. RESULTS: Phl p 11 cDNA defined an acidic polypeptide of 15.8 kDa with homology to pollen proteins from a variety of plant species and to soybean trypsin inhibitor. The sequence contained one potential site for N-linked glycosylation. Serological analysis revealed that recombinant Phl p 11 shared epitopes for human IgE antibodies with the natural protein and bound serum IgE from 32% of grass pollen-sensitized subjects (n = 184). Purified recombinant Phl p 11 elicited skin reactions and dose-dependent histamine release from basophils of sensitized subjects, but not in non-allergic controls. CONCLUSION: As the first representative of group 11 grass pollen allergens, Phl p 11 has been cloned and produced as a recombinant protein showing allergenic activity. One-third of grass pollen-sensitized subjects showed specific IgE reactivity to recombinant Phl p 11, corresponding in magnitude to a significant proportion of specific IgE to grass pollen extract.

Quantitative analysis of the EGF receptor autocrine system reveals cryptic regulation of cell response by ligand capture.

Autocrine signaling is important in normal tissue physiology as well as pathological conditions. It is difficult to analyze these systems, however, because they are both self-contained and recursive. To understand how parameters such as ligand production and receptor expression influence autocrine activity, we investigated a human epidermal growth factor/epidermal growth factor receptor (EGF/EGFR) loop engineered into mouse B82 fibroblasts. We varied the level of ligand production using the tet-off expression system and used metalloprotease inhibitors to modulate ligand release. Receptor expression was varied using antagonistic blocking antibodies. We compared autocrine ligand release with receptor activation using a microphysiometer-based assay and analyzed our data using a quantitative model of ligand release and receptor dynamics. We found that the activity of our autocrine system could be described in terms of a simple ratio between the rate of ligand production (V(LT)) and the rate of receptor production (V(R)). At a V(LT)/V(R) ratio of <0.3, essentially no ligand was found in the extracellular medium, but a significant number of cell receptors (30-40%) were occupied. As the V(LT)/V(R) ratio increased from 0.3 towards unity, receptor occupancy increased and significant amounts of ligand appeared in the medium. Above a V(LT)/V(R) ratio of 1.0, receptor occupancy approached saturation and most of the released ligand was lost into the medium. Analysis of human mammary epithelial cells showed that a V(LT)/V(R) ratio of < 5 x 10(-4)was sufficient to evoke >20% of a maximal proliferative response. This demonstrates that natural autocrine systems can be active even when no ligand appears in the extracellular medium.

A survey of psychiatrists' attitudes toward electroconvulsive therapy.

Sixty-seven psychiatrists who were employed in state hospitals in Texas were surveyed about their attitudes toward use of electroconvulsive therapy (ECT) and the laws and regulations associated with its use. The majority of respondents agreed with accepted professional guidelines on ECT usage and had a positive attitude toward ECT treatment. However, the number of referrals for ECT by these psychiatrists was low, perhaps due to the view that Texas laws and policies about ECT are restrictive and limiting to patient care. The majority of respondents indicated that more professional education about laws and policies related to ECT is needed.

Double or bifid zygomaticus major muscle: anatomy, incidence, and clinical correlation.

The anatomy of the double or bifid zygomaticus major muscle is investigated in a series of 50 hemifacial cadaver dissections. The double zygomaticus major muscle represents an anatomical variation of this muscle of facial expression. This bifid muscle originates as a single structure from the zygomatic bone. As it travels anteriorly, it then divides at the sub-zygomatic hollow into superior and inferior muscle bundles. The superior bundle inserts at the usual position above the comer of the mouth. The inferior bundle inserts into the modiolus below the corner of the mouth. The incidence of the double zygomaticus major muscle was 34% in the present study, as it was found to be present in 17 of 50 cadaver dissections. This study shows that variation in the individual morphology of the mimetic muscles can be a common finding. Clinically, the double or bifid zygomaticus major muscle may explain the formation of cheek "dimples." The inferior bundle was observed in several specimens to have a dermal attachment along its mid-portion, which tethers the overlying skin. When an individual with this anatomy smiles, traction on the skin may create a dimple due to this dermal tethering effect.

Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging.

The contribution of maxillary retrusion to the formation of the nasolabial fold is evaluated in the present study. Clinical observation of patients from the craniofacial unit with concomitant maxillary retrusion revealed prominent signs of midfacial aging: specifically these individuals displayed a prominent nasolabial fold at an early age. This observation led to the hypothesis that relative maxillary retrusion occurs as a normal feature of the aging process. Retrusion of the lower facial skeleton below the soft tissue of the nasolabial fold causes the nasolabial fold to appear more prominent. To test this hypothesis, computed tomographic data were assembled retrospectively and included both males and females, young and old. The age range of the males (n = 14) was 18 to 24 years (young) and 43 to 57 years (old); the age range of the females (n = 14) was 15 to 30 years (young) and 43 to 57 years (old). All individuals had complete upper dentition and had no bony facial injury. Computed tomographic data were reconstructed into three-dimensional images, and a technique was developed to create a standardized lateral view which eliminated rotational variance. Analysis of anterior-posterior changes showed that there is a tendency for the lower maxillary skeleton at pyriform to become retrusive with age relative to the upper face in individuals with complete dentition. Findings were very significant for both males and females (p = 0.0001 and p = 0.002, respectively). In both groups, a slight increase in vertical maxillary dimension was noted, consistent with previous studies. It is suggested that relative maxillary retrusion is a factor in the development of the nasolabial fold. The skeletal features of normal midfacial aging can be combined with the soft-tissue features such as ptosis and atrophy into an integrated model of midfacial aging. A model such as this has significance regarding both the timing and choice of procedure used to restore the aging midface.

A computer program for quality control in the blood gas laboratory.

In blood gas laboratory quality-assurance programs, which are routinely included with materials sold for quality control, raw data are sent to a data processing center for reduction to statistics meaningful to the laboratory's quality-control effort. This data reduction service usually requires a turn-around time of 2 weeks or more. I describe a computer program for the more timely, in-house computation of a laboratory's mean, standard deviation, and coefficient of variation. We have also found this program useful in calculating values for a new lot number of controls during the period between receipt of the controls and receipt of the first set of statistics from the data processing center. Comparing these values to the assayed values in the manufacturer's insert provides timely feedback and augments the manufacturer's professional data reduction service.