Buffalo VA Medical Center

New molecular, cellular, and immunologic techniques used to study host–pathogen interactions have led to a reexamination of the role of infection in chronic obstructive pulmonary disease (COPD). There is now considerable evidence that infection plays a major role in the pathogenesis and clinical course of COPD. A vicious circle of infection and inflammation is thought to lead to exacerbations of the disease.

A new hypervirulent (hypermucoviscous) variant of Klebsiella pneumoniae has emerged. First described in the Asian Pacific Rim, it now increasingly recognized in Western countries. Defining clinical features are the ability to cause serious, life-threatening community-acquired infection in younger healthy hosts, including liver abscess, pneumonia, meningitis and endophthalmitis and the ability to metastatically spread, an unusual feature for enteric Gram-negative bacilli in the non-immunocompromised. Despite infecting a healthier population, significant morbidity and mortality occurs. Although epidemiologic features are still being defined, colonization, particularly intestinal colonization, appears to be a critical step leading to infection. However the route of entry remains unclear. The majority of cases described to date are in Asians, raising the issue of a genetic predisposition vs. geospecific strain acquisition. The traits that enhance its virulence when compared with "classical" K. pneumoniae are the ability to more efficiently acquire iron and perhaps an increase in capsule production, which confers the hypermucoviscous phenotype. An objective diagnostic test suitable for routine use in the clinical microbiology laboratory is needed. If/when these strains become increasingly resistant to antimicrobials, we will be faced with a frightening clinical scenario.

Biofilm is complex and consists of bacterial colonies that reside in an exopolysaccharide matrix that attaches to foreign surfaces in a living organism. Biofilm frequently leads to nosocomial, chronic infections in clinical settings. Since the bacteria in the biofilm have developed antibiotic resistance, using antibiotics alone to treat infections brought on by biofilm is ineffective. This review provides a succinct summary of the theories behind the composition of, formation of, and drug-resistant infections attributed to biofilm and cutting-edge curative approaches to counteract and treat biofilm. The high frequency of medical device-induced infections due to biofilm warrants the application of innovative technologies to manage the complexities presented by biofilm.

BACKGROUND: Guideline developers can: (1) adopt existing recommendations from others; (2) adapt existing recommendations to their own context; or (3) create recommendations de novo. Monetary and nonmonetary resources, credibility, maximization of uptake, as well as logical arguments should guide the choice of the approach and processes. OBJECTIVES: To describe a potentially efficient model for guideline production based on adoption, adaptation, and/or de novo development of recommendations utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) frameworks. STUDY DESIGN AND SETTING: We applied the model in a new national guideline program producing 22 practice guidelines. We searched for relevant evidence that informs the direction and strength of a recommendation. We then produced GRADE EtDs for guideline panels to develop recommendations. RESULTS: We produced a total of 80 EtD frameworks in approximately 4 months and 146 EtDs in approximately 6 months in two waves. Use of the EtD frameworks allowed panel members understand judgments of others about the criteria that bear on guideline recommendations and then make their own judgments about those criteria in a systematic approach. CONCLUSION: The "GRADE-ADOLOPMENT" approach to guideline production combines adoption, adaptation, and, as needed, de novo development of recommendations. If developers of guidelines follow EtD criteria more widely and make their work publically available, this approach should prove even more useful.

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States. The precise role of bacterial infection in the course and pathogenesis of COPD has been a source of controversy for decades. Chronic bacterial colonization of the lower airways contributes to airway inflammation; more research is needed to test the hypothesis that this bacterial colonization accelerates the progressive decline in lung function seen in COPD (the vicious circle hypothesis). The course of COPD is characterized by intermittent exacerbations of the disease. Studies of samples obtained by bronchoscopy with the protected specimen brush, analysis of the human immune response with appropriate immunoassays, and antibiotic trials reveal that approximately half of exacerbations are caused by bacteria. Nontypeable Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae are the most common causes of exacerbations, while Chlamydia pneumoniae causes a small proportion. The role of Haemophilus parainfluenzae and gram-negative bacilli remains to be established. Recent progress in studies of the molecular mechanisms of pathogenesis of infection in the human respiratory tract and in vaccine development guided by such studies promises to lead to novel ways to treat and prevent bacterial infections in COPD.

Tinnitus is a common but poorly understood disorder that has a strong association with aging. This review explains how to differentiate subjective from objective tinnitus. Although tinnitus is often associated with hearing loss, in many cases the origin may be central. Multiple treatment options may help in the management of this chronic condition.

It has become increasingly recognized that skeletal muscle dysfunction is common in patients with chronic obstructive pulmonary disease (COPD). Muscle strength and endurance are decreased, whereas muscle fatigability is increased. There is a reduced proportion of type I fibers and an increase in type II fibers. Muscle atrophy occurs with a reduction in fiber cross-sectional area. Oxidative enzyme activity is decreased, and measurement of muscle bioenergetics during exercise reveals a reduced aerobic capacity. Deconditioning is probably very important mechanistically. Other mechanisms that may be of varying importance in individual patients include chronic hypercapnia and/or hypoxia, nutritional depletion, steroid usage, and oxidative stress. Potential therapies include exercise training, oxygen supplementation, nutritional repletion, and administration of anabolic hormones.

OBJECTIVE: To assess the prevalence of oral colonization by respiratory pathogens in a group of ICU patients, with specific attention to dental plaque and the oral mucosa. DESIGN: Prospective, nonrandomized study with age-matched controls. SETTINGS: Medical ICU in a tertiary-care Veterans Affairs Medical Center and a dental school outpatient preventive dentistry clinic. PATIENTS: Nonconsecutive, unselected patients admitted to the medical ICU during a 2-month period; controls were age-matched patients seen for the first time in the preventive dentistry clinic. INTERVENTIONS: None. MEASUREMENTS: Oral hygienic status was assessed in both groups using a semiquantitative system. Quantitative cultures of dental plaque and buccal mucosa were done within 12 hrs of medical ICU admission and every third day thereafter until discharge/death from the medical ICU. In controls, cultures of plaque and buccal mucosa were done on the initial visit only. Severity of illness of medical ICU patients was quantitated using the Acute Physiology and Chronic Health Evaluation (APACHE II) system and McCabe-Jackson criteria. MAIN RESULTS: Oral hygiene of medical ICU patients was poor. These patients had a mean plaque score (1.9 +/- 0.2) that was significantly greater than that same score seen in outpatients of the preventive dentistry clinic (1.4 +/- 0.1; p less than .005). Plaque and/or oral mucosa of 22 (65%) of 34 medical ICU patients were colonized by respiratory pathogens, in contrast to only four (16%) of 25 preventive dentistry clinic patients (p less than .005). The potential respiratory pathogens cultured from medical ICU patients included methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, and ten genera of Gram-negative bacilli. Colonization by respiratory pathogens was statistically associated with concomitant antibiotic therapy within the medical ICU group of patients, but not with severity of illness. Although medical ICU patients tended to have more dental plaque than preventive dentistry clinic patients, there was no statistically significant association noted between the presence of dental plaque and respiratory pathogen colonization. CONCLUSIONS: These findings suggest that bacteria commonly causing nosocomial pneumonia colonize the dental plaque and oral mucosa of intensive care patients. In many cases, this colonization occurs by large numbers of bacteria. Dental plaque may be an important reservoir of these pathogens in medical ICU patients. Efforts to improve oral hygiene in medical ICU patients could reduce plaque load and possibly reduce oropharyngeal colonization.

Precipitating antibodies occurring in 26 "pure" polymyositis (PM) patients and 22 "pure" dermatomyositis (DM) patients were studied by double immunodiffusion using calf thymus nuclear extract and whole calf thymus extract. Seventeen of 26 (65%) PM sera and 13 of 22 (59%) DM sera showed positive reactions, and 18, 10, and 2 sera exhibited 1, 2, and 3 precipitin lines, respectively. Common specificities were established by immunodiffusion for the 11 PM and 6 DM sera with strong precipitin lines. These were classed into three groups of shared specificity and six reactions specific for individual sera. These 9 calf thymus antigens were shown to be different from the known soluble tissue antigens Sm, nuclear RNP, Ro, and La. A 600-fold purification of the most frequently appearing system designated Jo-1 was achieved and its clinical specificity for patients with PM syndromes was established.

BACKGROUND: Gastric emptying scintigraphy (GES) using a radio-labelled meal is used to measure gastric emptying. A nondigestible capsule, SmartPill, records luminal pH, temperature, and pressure during gastrointestinal transit providing a measure of gastric emptying time (GET). AIMS: To compare gastric emptying time and GES by assessing their correlation, and to compare GET and GES for discriminating healthy subjects from gastroparetics. METHODS: Eighty-seven healthy subjects and 61 gastroparetics enrolled with simultaneous SmartPill and GES. Fasted subjects were ingested capsule and [(99m)Tc]-SC radio-labelled meal. Images were obtained every 30 min for 6 h. Gastric emptying time and percentage of meal remaining at 2/4 h were determined for each subject. The sensitivity/specificity and receiver operating characteristic analysis of each measure were determined for each subject. RESULTS: Correlation between GET and GES-4 h was 0.73 and GES-2 h was 0.63. The diagnostic accuracy from the receiver operating characteristic curve between gastroparetics and healthy subjects was GET = 0.83, GES-4 h = 0.82 and GES-2 h = 0.79. The 300-min cut-off time for GET gives sensitivity of 0.65 and specificity of 0.87 for diagnosis of gastroparesis. The corresponding sensitivity/specificity for 2 and 4 h standard GES measures were 0.34/0.93 and 0.44/0.93, respectively. CONCLUSION: SmartPill GET correlates with GES and discriminates between healthy and gastroparetic subjects offering a nonradioactive, standardized, ambulatory alternative to scintigraphy.

Specific bacterial species are implicated in the pathogenesis of exacerbations of chronic obstructive pulmonary disease (COPD). However, recent studies of clinically stable COPD patients have demonstrated a greater diversity of airway microbiota, whose role in acute exacerbations is unclear. In this study, temporal changes in the airway microbiome before, at the onset of, and after an acute exacerbation were examined in 60 sputum samples collected from subjects enrolled in a longitudinal study of bacterial infection in COPD. Microbiome composition and predicted functions were examined using 16S rRNA-based culture-independent profiling methods. Shifts in the abundance (≥ 2-fold, P < 0.05) of many taxa at exacerbation and after treatment were observed. Microbiota members that were increased at exacerbation were primarily of the Proteobacteria phylum, including nontypical COPD pathogens. Changes in the bacterial composition after treatment for an exacerbation differed significantly among the therapy regimens clinically prescribed (antibiotics only, oral corticosteroids only, or both). Treatment with antibiotics alone primarily decreased the abundance of Proteobacteria, with the prolonged suppression of some microbiota members being observed. In contrast, treatment with corticosteroids alone led to enrichment for Proteobacteria and members of other phyla. Predicted metagenomes of particular microbiota members involved in these compositional shifts indicated exacerbation-associated loss of functions involved in the synthesis of antimicrobial and anti-inflammatory products, alongside enrichment in functions related to pathogen-elicited inflammation. These trends reversed upon clinical recovery. Further larger studies will be necessary to determine whether specific compositional or functional changes detected in the airway microbiome could be useful indicators of exacerbation development or outcome.

Serological studies were performed on sera from 66 patients with the clinical picture of systemic lupus erythematosus (SLE). These sera failed to give a positive antinuclear antibody test when tested on cryostat sections of mouse liver and thus these patients' sera appear to be ANA negative. Precipitating antibodies to the cytoplasmic antigen Ro were found in 41 cases and of the remaining 25 sera, 18 were found to have antibodies to single stranded DNA detectable by radioimmunoassay. Thus, 50 of the 66 patients exhibited serological findings which are commonly found in ANA positive SLE patients. Studies with KB cells as immunofluorescent substrate revealed that 66% of these sera were positive for nuclear staining demonstrating that at least part of the failure of these sera to stain mouse liver is due to antigenic deficiency of this substrate. The clinical picture of these patients was dominated by a severe photosensitive dermatitis but more than half of the patients had widespread multisystem disease. As a group these patients had a low frequency of nephritis and neuropsychiatric disease. Detection of these antibodies relates these patients serologically to other SLE patients and suggests that they are best perceived as part of the clinical spectrum of SLE.

CONNECTIVE tissue imparts cohesion, strength, and form to the organs that it invests. It is comprised of several discrete cellular and noncellular components. The fibroblast and its more specialized derivatives (such as chondrocytes and osteocytes) elaborate and release several important molecules such as fibrous proteins (collagen), attachment proteins (fibronectin), glycoproteins, and ground substance. In this article we review the now abundant evidence that fibroblasts and their products are important mediators of some peripheral expressions of thyroid disease, including myxedema, pretibial dermopathy, thyroid acropachy, and ophthalmopathy of Graves' disease. Our review concentrates predominantly on the glycosaminoglycans that comprise ground substance. The fibrous proteins are given less attention. The early prejudice that the ground substance and connective tissue in general were rather unimportant becomes apparent in a quote attributed to Von Haller (1), who in 1757 wrote that “it is evident that a considerable part of the human body consists of matter which for so many centuries has been regarded as rubbish.” Yet it is widely appreciated in contemporary biology that ground substance and the connective tissues play a crucial role in defining the microenvironment for specialized cells to function. They are important in cell attachment and cell-to-cell communication, and they influence the manner in which cells negotiate the extracellular milieu. A brief review of the physicochemical properties of the glycosaminoglycans that compose ground substance precedes the more detailed analysis of the impact that thyroid dysfunction can have on its synthesis and disposal.

Gastric emptying of digestible solids occurs after trituration of food particles. Non-digestible solids are thought to empty with phase III of the migrating motor complex (MMC). The aim of this study was to determine if a non-digestible capsule given with a meal empties from the stomach with return of the fasting phase III MMC or during the fed pattern with the solid meal. Fifteen normal subjects underwent antroduodenal manometry and ingestion of a radiolabelled meal and SmartPill wireless pH and pressure capsule. In five subjects, emptying of the SmartPill was studied in the fasting period by ingesting the SmartPill with radiolabelled water. The SmartPill emptied from the stomach within 6 h in 14 of 15 subjects. SmartPill pressure recordings showed high amplitude phasic contractions prior to emptying. SmartPill gastric residence time (261 +/- 22 min) correlated strongly with time to the first phase III MMC (239 +/- 23 min; r = 0.813; P < 0.01) and correlated moderately with solid-phase gastric emptying (r = 0.606 with T-50% and r = 0.565 with T-90%). Nine of 14 subjects emptied the capsule with a phase III MMC. In five subjects, the SmartPill emptied with isolated distal antral contractions. In five subjects ingesting only water, SmartPill gastric residence time (92 +/- 44 min) correlated with the time to the first phase III MMC (87 +/- 30 min; r = 0.979; P < 0.01). The non-digestible SmartPill given with a meal primarily empties from the stomach with the return of phase III MMCs occurring after emptying the solid-phase meal. However, in some subjects, the SmartPill emptied with isolated antral contractions, an unappreciated mechanism for emptying of a non-digestible solid.

OBJECTIVE: The authors' goal was to determine whether cognitive behavioral treatment of residual symptoms of depression might have a significant effect on relapse rate. METHOD: A 6-year follow-up assessment was conducted of 40 patients with primary major depressive disorder who had been successfully treated with antidepressants and were randomly assigned to either cognitive behavioral treatment of residual symptoms or standard clinical management. RESULTS: Ten of the patients (50%) in the cognitive behavioral treatment group and 15 (75%) in the standard clinical management group relapsed. The difference did not attain statistical significance. When multiple relapses were considered, patients in the cognitive behavioral treatment group had a significantly lower number of depressive episodes than those in the standard clinical management group. Patients responded to the same antidepressant drug used in the index episode; in two cases (4%), resistance occurred. CONCLUSIONS: The protective effects of cognitive behavioral treatment that were evident at 4-year follow-up faded afterward. Cognitive behavioral treatment of residual symptoms, however, improved the long-term outcome of major depression in terms of total number of episodes during the follow-up period.

BACKGROUND: Although global ischemia induces troponin I (TnI) degradation, regional ischemia does not. We hypothesized that this disparity is related to preload-induced proteolysis, which varies as a function of the amount of myocardium at risk of ischemia. METHODS AND RESULTS: Isolated rat hearts were buffer-perfused at controlled levels of preload. Increasing preload to 25 mm Hg in the absence of ischemia produced pronounced TnI degradation (27 kDa versus 31 kDa bands: 16.4 +/- 3.6% versus 4.7 +/- 1.9% in immediately excised controls, P<0.05). TnI degradation could be blocked by preventing the activation of endogenous calpains with 25 micromol/L calpeptin (4.3 +/- 0.6%). This improved function, with left ventricular systolic pressure increasing from 103 +/- 4 mm Hg to 137 +/- 7 mm Hg (P<0.05). Eliminating elevations in preload after global ischemia-induced stunning also prevented TnI degradation. CONCLUSIONS: Calpain-mediated TnI proteolysis can be dissociated from stunning and arises from elevations in preload rather than ischemia. This raises the possibility that ongoing preload-induced TnI degradation could impair myocardial function long-term.

RATIONALE: Pseudomonas aeruginosa is isolated from adults with chronic obstructive pulmonary disease (COPD) in cross-sectional studies. However, patterns of carriage and the role of P. aeruginosa in COPD are unknown. OBJECTIVES: To elucidate carriage patterns, phenotypes of strains, clinical manifestations, and the antibody response to P. aeruginosa in COPD. METHODS: A prospective study of adults with COPD was conducted. Isolates of P. aeruginosa were subjected to genotypic and phenotypic analysis. Sputum samples were studied for P. aeruginosa DNA, and immune responses were assayed. MEASUREMENTS AND MAIN RESULTS: We analyzed longitudinal clinical data, sputum cultures, pulsed-field gel electrophoresis of bacterial DNA, polymerase chain reaction of sputum, and immunoblot assays of serum. Fifty-seven episodes of acquisition of strains of P. aeruginosa were observed in 39 of 126 patients over 10 years. Acquisition of a new strain was associated with exacerbation. Thirty-one episodes of carriage were followed by clearance of the strain; 16 were of short (<1 mo) duration. Thirteen strains demonstrated persistence, and 13 strains were of indeterminate duration. Six strains were mucoid and were more likely to persist than nonmucoid strains (P = 0.005). Antibody responses developed in 53.8% of persistent carriage and in only 9.7% of short-term carriage episodes (P = 0.003). Antibiotics did not account for clearance. CONCLUSIONS: Two distinct patterns of carriage by P. aeruginosa were observed: (1) short-term colonization followed by clearance and (2) long-term persistence. Mucoid strains showed persistence. Acquisition of P. aeruginosa is associated with the occurrence of an exacerbation. Serum antibody responses do not mediate clearance of P. aeruginosa.

CytochalasinB was found to be a competitive inhibitor of the glucose carrier activity of human erythrocyte membrane preparations (K, = 2.6 to 4.0 x lo-' M).Among seven other cytochalasins tested, only cytochalasin A was effective (K, = 1 to 4 x lo-" M), indicating a stringent specificity of this inhibition.With cytochalasin B concentrations up to lo-" M, the range where the inhibition develops to practical saturation, both saturable and linear binding of cytochalasin B to the membranes were observed.Three major subpopulations were distinguished in the saturable binding; Site I (K (apparent dissociation constant) of 3 to 5 x lo-' M and B (total number of sites per mg of dry membranes) of approximately 200 pmol); Site II (K of 1.0 to 1.25 x 10m7 M and B of approximately 60 pmol); and Site III (K of 2 to 4 x lo-" M and B of approximately 40 pmol).All of these saturable bindings were reversible and readily exchanged with cytochalasin B in medium.Cytochalasins which did not inhibit the glucose carrier activity (cytochalasins C, D, and E, 2,3dihydrocytochalasin B, cytochalasin B-4,13-diacetate, and y-lactone derivative of cytochalasin B) readily displaced the ligand at Site II, but did not affect cytochalasin B binding at Site I. Cytochalasin A, a less potent carrier inhibitor, displaced cytochalasin B at all the three sites; the displacement at Site I, however, was much less effective, although that at Site II or III was as effective as cytochalasin B. o-Glucose and other carrier substrates competitively and stoichiometrically displaced cytochalasin B at Site I with the affinity constants similar to the K,,, as carrier substrates, but did not by itself displace the ligand at Sites II and III.Glucose carrier inhibitors such as phloretin and diethylstilbestrol again competitively displaced cytochalasin B at Site I only, and the affinity constants for this displacement were identical with those for the carrier inhibition.These observations strongly indicate that only Site I of three major cytochalasin B bonding sites of human erythrocyte membranes is directly associated with the glucose transport carrier. CytochalasinB inhibits the carrier-mediated glucose transport in human erythrocytes with a potency (K, = 3 to 5 x lo-'

We evaluated whether contractile fatigue of the quadriceps occurs after cycling exercise in patients with chronic obstructive pulmonary disease (COPD) and whether it could contribute to exercise limitation. Eighteen COPD patients performed two constant work-rate cycling exercises up to exhaustion. These tests were preceded by nebulization of placebo or 500 microg of ipratropium bromide. Muscle fatigue was defined as a postexercise reduction in quadriceps twitch force of more than 15% of the resting value. There was an increase in endurance time postipratropium compared with placebo nebulization (440 +/- 244 seconds vs. 322 +/- 188 seconds, p = 0.06). Nine patients developed contractile fatigue after placebo exercise. In these patients, ipratropium did not increase the endurance time (394 +/- 220 seconds with placebo vs. 400 +/- 119 seconds with ipratropium) despite an 11% improvement in FEV1. In the nine patients who did not fatigue after placebo exercise, endurance time increased from 249 +/- 124 seconds with placebo to 479 +/- 298 seconds with ipratropium (p < 0.05). There was a significant correlation between the improvement in endurance time with ipratropium and quadriceps twitch force at 10 minutes after placebo exercise (r = 0.59, p = 0.01). The occurrence of contractile fatigue during exercise may explain why bronchodilation fails to improve exercise tolerance in some COPD patients.

UNLABELLED: Streptococcus pneumoniae is a common human nasopharyngeal commensal colonizing 10% to 40% of healthy individuals, depending on age. Despite a low invasive disease rate, widespread carriage ensures that infection occurs often enough to make S. pneumoniae a leading bacterial cause of respiratory disease worldwide. However, the mechanisms behind transition from asymptomatic colonization to dissemination and disease in otherwise sterile sites remain poorly understood but are epidemiologically strongly linked to infection with respiratory viruses. In this report, we show that infection with influenza A virus and treatment with the resulting host signals (febrile-range temperatures, norepinephrine, extracytoplasmic ATP, and increased nutrient availability) induce the release of bacteria from biofilms in a newly developed biofilm model on live epithelial cells both in vitro and during in vivo colonization. These dispersed bacteria have distinct phenotypic properties different from those of both biofilm and broth-grown, planktonic bacteria, with the dispersed population showing differential virulence gene expression characteristics resulting in a significantly increased ability to disseminate and cause infection of otherwise sterile sites, such as the middle ear, lungs, and bloodstream. The results offer novel and important insights into the role of interkingdom signaling between microbe and host during biofilm dispersion and transition to acute disease. IMPORTANCE: This report addresses the mechanisms involved in transition from pneumococcal asymptomatic colonization to disease. In this study, we determined that changes in the nasopharyngeal environment result in the release of bacteria from colonizing biofilms with a gene expression and virulence phenotype different not only from that of colonizing biofilm bacteria but also from that of the broth-grown planktonic bacteria commonly used for pathogenesis studies. The work importantly also identifies specific host factors responsible for the release of bacteria and their changed phenotype. We show that these interkingdom signals are recognized by bacteria and are induced by influenza virus infection, which is epidemiologically strongly associated with transition to secondary pneumococcal disease. As virus infection is a common inducer of transition to disease among species occupying the nasopharynx, the results of this study may provide a basis for better understanding of the signals involved in the transition from colonization to disease in the human nasopharynx.