Challenges of Francisella classification exemplified by an atypical clinical isolate.

The accumulation of sequenced Francisella strains has made it increasingly apparent that the 16S rRNA gene alone is not enough to stratify the Francisella genus into precise and clinically useful classifications. Continued whole-genome sequencing of isolates will provide a larger base of knowledge for targeted approaches with broad applicability. Additionally, examination of genomic information on a case-by-case basis will help resolve outstanding questions regarding strain stratification. We report the complete genome sequence of a clinical isolate, designated here as F. novicida-like strain TCH2015, acquired from the lymph node of a 6-year-old male. Two features were atypical for F. novicida: exhibition of functional oxidase activity and additional gene content, including proposed virulence determinants. These differences, which could potentially impact virulence and clinical diagnosis, emphasize the need for more comprehensive methods to profile Francisella isolates. This study highlights the value of whole-genome sequencing, which will lead to a more robust database of environmental and clinical genomes and inform strategies to improve detection and classification of Francisella strains.

Parental smoking and allergic sensitization in offspring defined by skin prick testing.

Investigations of parental smoking during childhood and allergic sensitization have produced contradictory results, but this may be because of variations in the definition of allergy and other influences. We investigated associations of parental smoking with an objective measure of allergy, skin prick testing (SPT), and considered associations with maternal and paternal smoking, independently of each other. A stratified random sample, aged 22-74 yr, of 720 Swedish FinEsS-study members were skin prick tested for 15 allergens. Subjects with at least one positive SPT were defined as atopic. Data on childhood exposures, including parental smoking, were collected by structured interview. Logistic regression used atopy as the dependent variable. After adjustment, paternal smoking was statistically significantly associated with an increased risk and maternal smoking a non-statistically significant decreased risk in offspring, with odds ratios (and 95% confidence intervals) of 1.48 (1.04-2.10) and 0.73 (0.48-1.12), respectively. Analysis of families with a non-smoking mother produced an odds ratio for paternal smoking of 1.61 (1.09-2.37). The negative association between maternal smoking and atopy may not operate through passive smoke exposure and could conceal a significant increased risk associated with passive exposure to tobacco smoke in childhood.

Electrospray ionization with ambient pressure ion mobility separation and mass analysis by orthogonal time-of-flight mass spectrometry.

Rapid screening and identification of drug and other mixtures are possible using a novel ambient pressure high-resolution ion mobility (APIMS) orthogonal reflector time-of-flight mass spectrometer (TOFMS). Departing ions from the APIMS drift tube traversed a pressure interface between the APIMS and TOFMS where they were subjected to numerous gas collisions that could produce selective fragmentation. By increasing the accelerating field in the pressure interface region, the ions generated using water-cooled electrospray ionization (ESI) underwent collision-induced dissociation (CID). Mixtures of ESI ions were separated by APIMS based on their respective size-to-charge (s/z) ratios while CID and analysis of mass-to-charge (m/z) ratios occurred in the pressure interface and TOFMS. Product ions that were formed in this pressure interface region could be readily assigned to precursor ions by matching the mobility drift times. This process was demonstrated by the examination of a mixture of amphetamines and the resulting fragmentation patterns of the mobility-separated precursor ion species [M + H](+).

Electrospray ionization high-resolution ion mobility spectrometry for the detection of organic compounds, 1. Amino acids.

Our aim in this investigation was to demonstrate the potential of the high-resolution electrospray ionization ion mobility spectrometry (ESI-IMS) technique as an analytical separation tool in analyzing biomolecular mixtures to pursue astrobiological objectives of searching for the chemical signatures of life during an in-situ exploration of solar system bodies. Because amino acids represent the basic building blocks of life, we used common amino acids to conduct the first part of our investigation, which is being reported here, to demonstrate the feasibility of using the ESI-IMS technique for detection of the chemical signatures of life. The ion mobilities of common amino acids were determined by electrospray ionization ion mobility spectrometry using three different drift gases (N2, Ar, and CO2). We demonstrated that the selectivity can be vastly improved in ion mobility spectroscopy (IMS) in detecting organic molecules by using different drift gases. When a judicial choice of drift gas is made, a vastly improved separation of two different amino acid ions resulted. It was found that each of the studied amino acids could be uniquely identified from the others, with the exception of alanine and glycine, which were never separable by more then 0.1 ms. This unique identification is a result of the different polarizabilities of the various drift gases. In addition, a better separation was achieved by changing the drift voltage in successive experimental runs without significantly degrading the resolution. We also report the result of our analysis of liquid samples containing mixtures of amino acids.

Evaluation of opiate separation by high-resolution electrospray ionization-ion mobility spectrometry/mass spectrometry.

The separation of opiates and the primary metabolites was evaluated with ESI-IMS/MS. Seven opiate molecules were analyzed, and spectra were shown for each compound. The IMS separation of two isomers (morphine and norcodeine) was shown with baseline separation. Differences in the mobilities were found for the nonacetylated, monoacetylated, and biacetylated compounds. In this study, two primary findings are reported. First, IMS can easily separate metabolic isomers, and second, the two-dimensional separation capability of IMS/MS can be employed to confidently identify and separate both the opiates and metabolites. Although previous IMS studies have shown the separation of isomers, this is the first example to show the capability of IMS to separate metabolic isomers (within 70 s), a significant advantage in high-throughput screening for pharmacokinetic studies. Second, the monoacetylated and biacetylated compounds were found to form more compact ions for the sodium adducts in comparison to the protonated molecular ions. On the basis of the mobilities, information on structures and conformation can be deduced when sodium and protonated ions are compared.

Evaluation of suspected interferents for TNT detection by ion mobility spectrometry.

The use of ion mobility spectrometry systems to detect explosives in high security situations creates a need to determine compounds that interfere and may compromise accurate detection. This is the first study to identify possible interfering air contaminants common in airport settings by IMS. Seventeen suspected contaminants from four major sources were investigated. Due to the ionization selectivity gained by employing chloride reactant ion chemistry, only 7 of the 17 compounds showed an IMS response. Of those seven compounds, only 4,6-dinitro-o-cresol (4,6DNOC) was found to have a similar mobility to 2,4,6-trinitrotoluene (TNT) with K(o) values of 1.55 and 1.50 cm(2) V(-1) s(-1), respectively. Although baseline resolution between TNT and 4,6DNOC was not achieved, the drift time for TNT was still easily identified. Alkyl-nitrated phenols, due to acidic fog, responded the strongest in the IMS. The effect of contamination on TNT sensitivity was investigated. Charge competition between TNT and 2,4-dinitrophenol (2,4DNP) was found to occur and to effect TNT sensitivity.

High prevalence of osteoporosis in cardiac transplant recipients and discordance between biochemical turnover markers and bone histomorphometry.

OBJECTIVE: All patients attending the cardiac transplantation clinic at the Royal Perth Hospital were investigated to determine the prevalence of osteoporosis and to assess changes in bone metabolism and histomorphometry in a cohort of cardiac transplant recipients. DESIGN: Retrospective cross-sectional study. PATIENTS: Thirty-two patients (27 male; 5 female) who had received a cardiac transplant during the past 10 years and who were receiving immunosuppressive therapy with cyclosporin, azathioprine and prednisolone were studied. MEASUREMENTS: All patients had bone densitometry by DEXA of the lumbar spine and femoral neck and X-rays of the thoracolumbar spine. Fasting serum ionized calcium, intact PTH, creatinine, 25 hydroxy-vitamin D, alkaline phosphatase, osteocalcin, testosterone and free thyroxine and urine calcium, creatinine, hydroxyproline and deoxypyridinoline were measured. Six osteoporotic patients consented to transiliac bone biopsy following double tetracycline labelling. RESULTS: Osteoporosis was present at the lumbar spine in eight patients, femoral neck in seven patients and was present at one or more sites in 13 patients (41%). Seven patients (22%) had vertebral fractures which were asymptomatic in five patients. Secondary hyperparathyroidism was present in 16 patients (53%) but significant renal failure (creatinine clearance < 70 ml/min) was only found in 8 (50%). Levels of biochemical markers of bone turnover were increased in 23 patients (72%). Serum osteocalcin (P = 0.02) and alkaline phosphatase (P = 0.04) were significantly higher in osteoporotic patients than in nonosteoporotic patients. Histomorphometric findings varied markedly between patients. Microscopic features of hyperparathyroidism were not observed. CONCLUSIONS: Osteoporosis and asymptomatic vertebral fractures are common following cardiac transplantation. Biochemical markers of bone turnover were increased in the majority of patients. Many had biochemical evidence of secondary hyperparathyroidism but this could be attributable to significant renal failure in only 50% of cases. Osteocalcin and alkaline phosphatase correlated inversely with bone density. Histomorphometric findings did not correlate with these biochemical changes in most cases. These results suggest that multiple factors are responsible for osteoporosis in cardiac transplant recipients. Osteocalcin and alkaline phosphatase may be useful biochemical markers, predicting patients at highest risk of fracture.

Fat necrosis in surveillance biopsies of heart transplants.

Fat necrosis was observed in surveillance biopsies of five patients following heart transplant. This reaction is poorly documented in the literature, but in personal communication, some pathologists working in the field have had experience with it. Four of the cases developed two to six days after transplantation, but in the fifth case, fat necrosis developed ten months after transplantation. Autopsy study of one case showed extensive severe fat necrosis involving both donor and recipient tissues. The cause is not known, and the changes are independent of rejection. However, the fat necrosis can be found within the interstitial tissues of the myocardium and subendocardium and may be mistaken for rejection if lymphocytes and polymorphs are part of the inflammatory response. The only clinical finding thought to be related to the fat necrosis was the development of transient complete heart block in a patient in whom the International Society for Heart and Lung Transplantation (ISHLT) standardised rejection grading was never greater than IA.

Collecting duct carcinoma of the kidney: a report of three cases and review of the literature.

Collecting duct carcinoma (CDC) of the kidney is a rare neoplasm arising from the medullary collecting ducts. The clinicopathological features of three cases are here presented to add to the 42 cases reported so far in the English language literature. Hematuria is the most common presenting symptom, although 10% of patients present with metastatic disease, often in neck lymph nodes. The tumor mass is typically centred on the medulla of the kidney and extends into the cortex. Radiological diagnosis may be difficult because the radiological features of CDC are poorly described. The histological appearances have been described as tubulo-papillary, tubular, solid and sarcomatoid. Intracytoplasmic mucin may be present. The typical immunohistochemical profile is positive staining with antibodies for low and high molecular weight keratin and epithelial membrane antigen (EMA) and positive staining with the lectin Ulex europaeus agglutinin. Literature reports of cytogenetic characterisation show loss of chromosomes resulting in monosomies. Prognosis is poor as more than half of the reported cases have developed metastases or died within two years of presentation.

Patient outcomes measure home health care accomplishments.

Professional, governmental, and economic stakeholders are calling for more explicit accountability for consistent quality from home health-care agencies. A system oriented toward outcomes for the patient rather than toward service design and distribution is more likely to improve the quality of care and satisfy everyone involved.

Flexible sigmoidoscopy screening in an industrial setting.

Little is known about the yield of colorectal cancer screening programs in an industrial setting. We therefore established a flexible sigmoidoscopy screening program at a chemical manufacturing plant and offered testing to all employees over the age of 40. After a Fleet enema preparation had been administered, a digital rectal examination and sigmoidoscopy were performed on each volunteer worker in the medical office of the plant. The plant had an average census of about 650 workers; 202 were screened during a 2-yr period. The mean (+/- SEM) age of participants was 52 +/- 0.4. Sixty-four employees had polyps (31.7%); data on follow-up colonoscopy were available in 69%. Colonoscopy revealed adenomatous polyps in 23 workers (53.5%), hyperplastic polyps in 10 (23%), and no evidence of neoplasia in 10 (23%). Seven workers did not arrange for follow-up colonoscopy and 12 individuals could not be contacted. No cancers were detected. In the 40- to 50-yr age group, polyps were detected in 19.5% of employees (25% adenomatous). Incidental findings were common, and included prostatic nodules, hemorrhoids, diverticulosis, and proctitis, among others. We conclude that screening sigmoidoscopy can be conveniently and economically performed at the workplace, with a high yield and good worker acceptance. The high yield suggests a possible association between polyp formation and work in a chemical plant. The finding of adenomatous polyps in the younger patients suggests that the threshold for flexible sigmoidoscopy at age 50 needs to be reassessed.

Abdominal aortic dissection due to idiopathic medial aortopathy in a 32-year-old Caucasian man.

A case of dissection of the abdominal aorta in a 32-year-old Caucasian man associated with a histological diagnosis of granulomatous aortitis and a clinical diagnosis of idiopathic medial aortopathy is described. The relationship between giant cell "temporal" arteritis, Takayasu's disease and idiopathic medial aortopathy is discussed.

Esophageal malignancies: is preoperative radiotherapy the way to go?

During the period 1969 to 1988, 68 patients with esophageal malignancy were subjected to preoperative radiotherapy consisting of 30 Gy over 3 weeks followed by esophagectomy after a wait of 2 weeks. Sixty-two of 68 patients (91%) were followed up retrospectively (5-year survival rate, 17.2%; 10-year survival rate, 4.8%). Radiosensitivity of the tumor was graded by a radiation effect scoring method devised by us, and this was found to correlate with long-term prognosis (p = 0.05). Radiotherapy "sterilized" malignant involvement of adventitia and draining lymph nodes in 8 patients and thereby converted "palliative" into potentially "curative" resections with a mean survival of 57.2 months in this group of patients. Preoperative radiotherapy was found to increase the survival, decrease the incidence of residual tumor at the resected stump, reduce the incidence of local recurrence, and increase the resectability rate.