SOX7 deficiency causes ventricular septal defects through its effects on endocardial-to-mesenchymal transition and the expression of Wnt4 and Bmp2

SOX7 is a transcription factor-encoding gene located in a region on chromosome 8p23.1 that is recurrently deleted in individuals with ventricular septal defects (VSDs). We have previously shown that Sox7-/- embryos die of heart failure around E11.5. Here, we demonstrate that these embryos have hypocellular endocardial cushions with severely reduced numbers of mesenchymal cells. Ablation of Sox7 in the endocardium also resulted in hypocellular endocardial cushions, and we observed VSDs in rare E15.5 Sox7flox/-;Tie2-Cre and Sox7flox/flox;Tie2-Cre embryos that survived to E15.5. In atrioventricular explant studies, we showed that SOX7 deficiency leads to a severe reduction in endocardial-to-mesenchymal transition (EndMT). RNA-seq studies performed on E9.5 Sox7-/- heart tubes revealed severely reduced Wnt4 transcript levels. Wnt4 is expressed in the endocardium and promotes EndMT by acting in a paracrine manner to increase the expression of Bmp2 in the myocardium. Both WNT4 and BMP2 have been previously implicated in the development of VSDs in individuals with 46,XX sex reversal with dysgenesis of kidney, adrenals and lungs (SERKAL) syndrome and in individuals with short stature, facial dysmorphism and skeletal anomalies with or without cardiac anomalies 1 (SSFSC1) syndrome, respectively. We now show that Sox7 and Wnt4 interact genetically in the development of VSDs through their additive effects on endocardial cushion development with Sox7+/-;Wnt4+/- double heterozygous embryos having hypocellular endocardial cushions and perimembranous and muscular VSDs not seen in their Sox7+/- and Wnt4+/- littermates. These results provide additional evidence that SOX7, WNT4 and BMP2 function in the same pathway during mammalian septal development and that their deficiency can contribute to the development of VSDs in humans.

Identifying phenotypic expansions for congenital diaphragmatic hernia plus (CDH+) using DECIPHER data

Congenital diaphragmatic hernia (CDH) can occur in isolation or in conjunction with other birth defects (CDH+). A molecular etiology can only be identified in a subset of CDH cases. This is due, in part, to an incomplete understanding of the genes that contribute to diaphragm development. Here, we used clinical and molecular data from 36 individuals with CDH+ who are cataloged in the DECIPHER database to identify genes that may play a role in diaphragm development and to discover new phenotypic expansions. Among this group, we identified individuals who carried putatively deleterious sequence or copy number variants affecting CREBBP, SMARCA4, UBA2, and USP9X. The role of these genes in diaphragm development was supported by their expression in the developing mouse diaphragm, their similarity to known CDH genes using data from a previously published and validated machine learning algorithm, and/or the presence of CDH in other individuals with their associated genetic disorders. Our results demonstrate how data from DECIPHER, and other public databases, can be used to identify new phenotypic expansions and suggest that CREBBP, SMARCA4, UBA2, and USP9X play a role in diaphragm development.

Delineation of a novel neurodevelopmental syndrome associated with PAX5 haploinsufficiency

PAX5 is a transcription factor associated with abnormal posterior midbrain and cerebellum development in mice. PAX5 is highly loss-of-function intolerant and missense constrained, and has been identified as a candidate gene for autism spectrum disorder (ASD). We describe 16 individuals from 12 families who carry deletions involving PAX5 and surrounding genes, de novo frameshift variants that are likely to trigger nonsense-mediated mRNA decay, a rare stop-gain variant, or missense variants that affect conserved amino acid residues. Four of these individuals were published previously but without detailed clinical descriptions. All these individuals have been diagnosed with one or more neurodevelopmental phenotypes including delayed developmental milestones (DD), intellectual disability (ID), and/or ASD. Seizures were documented in four individuals. No recurrent patterns of brain magnetic resonance imaging (MRI) findings, structural birth defects, or dysmorphic features were observed. Our findings suggest that PAX5 haploinsufficiency causes a neurodevelopmental disorder whose cardinal features include DD, variable ID, and/or ASD.

Underlying genetic etiologies of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is often detectable prenatally. Advances in genetic testing have made it possible to obtain a molecular diagnosis in many fetuses with CDH. Here, we review the aneuploidies, copy number variants (CNVs), and single genes that have been clearly associated with CDH. We suggest that array-based CNV analysis, with or without a chromosome analysis, is the optimal test for identifying chromosomal abnormalities and CNVs in fetuses with CDH. To identify causative sequence variants, whole exome sequencing (WES) is the most comprehensive strategy currently available. Whole genome sequencing (WGS) with CNV analysis has the potential to become the most efficient and effective means of identifying an underlying diagnosis but is not yet routinely available for prenatal diagnosis. We describe how to overcome and address the diagnostic and clinical uncertainty that may remain after genetic testing, and review how a molecular diagnosis may impact recurrence risk estimations, mortality rates, and the availability and outcomes of fetal therapy. We conclude that after the prenatal detection of CDH, patients should be counseled about the possible genetic causes of the CDH, and the genetic testing modalities available to them, in accordance with generally accepted guidelines for pretest counseling in the prenatal setting.

A comparison of Listerine® and sodium bicarbonate oral cleansing solutions on dental plaque colonisation and incidence of ventilator associated pneumonia in mechanically ventilated patients: a randomised control trial

BACKGROUND

Effective oral hygiene has been proposed as a key factor in the reduction of dental plaque colonisation and subsequent development of ventilator associated pneumonia (VAP). Listerine(®) oral rinse, while used extensively in dental practice has rarely been tested in mechanically ventilated patients. Sodium bicarbonate as an oral rinse has been more commonly utilised in oral hygiene regimens in intensive care patients.

AIM

To test the efficacies of the essential oil mouth rinse, Listerine(®) (Pfizer) and sodium bicarbonate in the reduction of dental plaque colonisation with respiratory pathogens and the subsequent development of VAP.

METHODS

The study design was a prospective, single blind randomised comparative study of adult patients mechanically ventilated for at least 4 days. Patients were randomised to Listerine(®) (Pfizer) oral rinse twice daily, sodium bicarbonate oral rinse 2/24 or sterile water 2/24 (control group). All groups received tooth brushing 3 times a day. Dental plaque colonisation (primary outcome) and incidence of ventilator associated pneumonia (secondary outcome) were studied.

RESULTS

Three hundred and ninety-eight patients were randomised to either the Listerine group (127), sodium bicarbonate group (133) or the control group (138). Baseline characteristics were similar for all groups. There were no significant differences between the control and study groups in colonisation of dental plaque at Day 4 (p=0.243). Ventilator associated pneumonia was diagnosed in 18 patients. The incidence was, Listerine(®) group 4.7%, sodium bicarbonate group 4.5% and control 4.3% [OR, 0.99; 95% CI, 0.31 to 3.16; p=0.92].

CONCLUSIONS

Compared to the control group, Listerine(®) or sodium bicarbonate oral rinses were not more effective in the reduction of colonisation of dental plaque or the incidence of VAP. Given the low incidence of VAP, the common factor of a small, soft toothbrush as part of an oral hygiene regimen suggests possible benefit in mechanically ventilated patients.

Novel hypothesis for unexplained sudden unexpected death in infancy (SUDI)

OBJECTIVE

Two recent retrospective studies independently reported typically pathogenic bacteria in normally sterile sites of infants succumbing to sudden unexpected death in infancy (SUDI). These findings suggested a proportion of unexplained SUDI might be triggered by bacteraemia. The objective was to assess these observations in the context of the pathology and epidemiology of sudden infant death syndrome (SIDS) in relation to the role of infection and inflammation as triggers of these deaths.

DESIGN

A review of the literature to identify potential risk factors for unexplained infant deaths and proposal of a theoretical model for SUDI.

RESULTS

Pathologic and epidemiological evidence suggests a hypothesis based on three factors: bacterial translocation, pathogen pattern recognition insufficiency and prenatal exposure to infection.

CONCLUSION

We propose that sterile site infections in which common toxigenic bacteria are identified indicate a brief bacteraemic episode prior to death. This might reflect an ineffective innate response to invasive pathogens that results in reduced clearance of the bacteria. Thymomegaly observed consistently among infants diagnosed under the category of SIDS might have its origins in prenatal life, perhaps generated via in utero infection or exposure to microbial antigens which results in thymocyte priming. There is consistent evidence for an infectious aetiology in many unexplained SUDI. Future directions for research are suggested.

Truncated hemoglobins in actinorhizal nodules of Datisca glomerata

Three types of hemoglobins exist in higher plants, symbiotic, non-symbiotic, and truncated hemoglobins. Symbiotic (class II) hemoglobins play a role in oxygen supply to intracellular nitrogen-fixing symbionts in legume root nodules, and in one case ( Parasponia Sp.), a non-symbiotic (class I) hemoglobin has been recruited for this function. Here we report the induction of a host gene, dgtrHB1, encoding a truncated hemoglobin in Frankia-induced nodules of the actinorhizal plant Datisca glomerata. Induction takes place specifically in cells infected by the microsymbiont, prior to the onset of bacterial nitrogen fixation. A bacterial gene (Frankia trHBO) encoding a truncated hemoglobin with O (2)-binding kinetics suitable for the facilitation of O (2) diffusion ( ) is also expressed in symbiosis. Nodule oximetry confirms the presence of a molecule that binds oxygen reversibly in D. glomerata nodules, but indicates a low overall hemoglobin concentration suggesting a local function. Frankia trHbO is likely to be responsible for this activity. The function of the D. glomerata truncated hemoglobin is unknown; a possible role in nitric oxide detoxification is suggested.

Hopanoid lipids in Frankia: identification of squalene-hopene cyclase gene sequences

In Frankia, the microsymbiont in actinorhizal root nodules, nitrogen fixation takes place in specialized structures called vesicles. The lipidic vesicle envelope forms a barrier to oxygen diffusion, an essential part of the nitrogenase oxygen protection system. We have shown previously that the vesicle envelope is composed primarily of two species of hopanoid lipids, sterol-like molecules that are synthesized in a wide range of bacteria, including Frankia, several cyanobacteria, and rhizobia. The levels of hopanoid found in Frankia are among the highest of any organism known to date. Here we report that short (328-bp) DNA sequences from several strains of Frankia spp. have been identified that are homologous to a portion of the coding region of squalene-hopene cyclase (shc) genes. The fragments and corresponding polymerase chain reaction (PCR) primers can be used in phylogenetic comparisons of Frankia, both within Frankiaceae and among bacteria that synthesize hopanoids.

Genetic characterization of vanG, a novel vancomycin resistance locus of Enterococcus faecalis

Enterococcus faecalis strain WCH9 displays a moderate level of resistance to vancomycin (MIC = 16 microgram/ml) and full susceptibility to teicoplanin but is negative by PCR analysis using primers specific for all known enterococcal vancomycin resistance genotypes (vanA, vanB, vanC, vanD, and vanE). We have isolated and sequenced a novel putative vancomycin resistance locus (designated vanG), which contains seven open reading frames, from this strain. These are organized differently from those of all the other enterococcal van loci, and, furthermore, the individual vanG gene products exhibit less than 50% amino acid sequence identity to other van gene products.

Dg93, a nodule-abundant mRNA of Datisca glomerata with homology to a soybean early nodulin gene

We have isolated a 590-bp full-length cDNA clone designated Dg93, an mRNA that is highly expressed in symbiotic root nodules of the actinorhizal host Datisca glomerata. Dg93 mRNA encodes a deduced polypeptide of 105 amino acids with significant identity (74%) to the soybean (Glycine max) early nodulin (ENOD) gene GmENOD93 (Kouchi and Hata, 1993). Dg93 mRNA is abundant in nodules at 4 weeks post inoculation, the earliest time assayed, and steady-state mRNA levels remain elevated 11 weeks after inoculation. Spatial patterns of Dg93 mRNA expression are complex, with transcript accumulation in the nodule lobe meristem, early infection zone, periderm, and cells of the vascular cylinder, but not in the surrounding uninfected cortical cells. Dg93 is encoded by a small gene family in D. glomerata. To our knowledge, this is the first report of a gene from an actinorhizal host that is expressed in the nodule meristem and that shares sequence homology with an early nodulin gene from a legume.

Molecular analysis of putative pneumococcal virulence proteins

Although the polysaccharide capsule has been recognized as a sine qua non of virulence, recent attention has focused on the role of pneumococcal proteins in pathogenesis, particularly in view of their potential as vaccine antigens. The contribution of pneumolysin, two distinct neuraminidases, autolysin, hyaluronidase, and the 37 kDa pneumococcal surface adhesin A has been examined by specifically mutagenizing the respective genes in the pneumococcal chromosome and examining the impact on virulence in animal models. The vaccine potential of these proteins has also been assessed by immunization of mice with purified antigens, followed by challenge with virulent pneumococci.

Additive attenuation of virulence of Streptococcus pneumoniae by mutation of the genes encoding pneumolysin and other putative pneumococcal virulence proteins

Although the polysaccharide capsule of Streptococcus pneumoniae has been recognized as a sine qua non of virulence, much recent attention has focused on the role of pneumococcal proteins in pathogenesis, particularly in view of their potential as vaccine antigens. The individual contributions of pneumolysin (Ply), the major neuraminidase (NanA), autolysin (LytA), hyaluronidase (Hyl), pneumococcal surface protein A (PspA), and choline-binding protein A (CbpA) have been examined by specifically mutagenizing the respective genes in the pneumococcal chromosome and comparing the impact on virulence in a mouse intraperitoneal challenge model. Mutagenesis of either the ply, lytA, or pspA gene in S. pneumoniae D39 significantly reduced virulence, relative to that of the wild-type strain, indicating that the respective gene products contribute to pathogenesis. On the other hand, mutations in nanA, hyl, or cbpA had no significant impact. The virulence of D39 derivatives carrying a ply deletion mutation as well as an insertion-duplication mutation in one of the other genes was also examined. Mutagenesis of either nanA or lytA did not result in an additional attenuation of virulence in the ply deletion background. However, significant additive attenuation in virulence was observed for the strains with ply-hyl, ply-pspA, and ply-cbpA double mutations.

Symbiotic root nodules of the actinorhizal plant Datisca glomerata express Rubisco activase mRNA

N2-fixing symbiotic root nodules of the actinorhizal host Datisca glomerata express Dgrca (D. glomerata Rubisco activase) mRNA, a transcript usually associated with photosynthetic organs or tissues. In northern blots a mature, 1700-nucleotide Dgrca mRNA was detected in green plant organs (leaves, flowers, and developing fruits) and in nodules but was not detected in roots. A second message of 3000 nucleotides was observed only in nodules. Both size classes of transcripts were polyadenylated. The larger transcript was 2- to 5-fold more abundant than the mature mRNA; it was hybridized to an intronic probe, indicating that a stable, incompletely spliced transcript was accumulating. Treatment with light on excised nodules did not alter the relative abundance of the two species. In in situ hybridizations the Dgrca message was expressed intensely in the nuclei of infected cells. The Dgrca transcripts also accumulated at lower levels in uninfected cortical cells adjacent to the periderm and the vascular cylinder. mRNA encoding the large subunit of Rubisco (DgrbcL) was abundant in mature infected cells and in the amyloplast-rich sheath of uninfected cortical cells lying between the infected cells and nodule periderm. The proteins Rubisco activase, Rubisco, and the 33-kD O2-evolving complex subunit did not accumulate to detectable levels, indicating that a functional photosynthetic apparatus was not prevalent in nodule tissue. Signals or factors required for the transcription of Dgrca appeared to be present in nodules, but efficient splicing and translation of the message were not observed in Frankia-infected tissue where transcript accumulation was highest.

Comparative virulence of Streptococcus pneumoniae strains with insertion-duplication, point, and deletion mutations in the pneumolysin gene

Pneumolysin is a 471-amino-acid toxin produced by Streptococcus pneumoniae which has both cytolytic and complement activation properties. We have constructed a derivative of the type 2 S. pneumoniae strain D39 in which the portion of the pneumolysin gene encoding amino acids 55 to 437 has been deleted in-frame. The virulence of this strain (DeltaPly) was compared with those of wild-type D39, a pneumolysin insertion-duplication mutant (PLN-A), and a derivative (PdT) carrying a toxin gene with three point mutations known to abolish both cytolytic activity and complement activation. PdT was intermediate in virulence between D39 and either PLN-A or DeltaPly in a mouse intraperitoneal challenge model. This provides unequivocal evidence that pneumolysin has an additional property that is not abolished by point mutations which reduce cytotoxicity and complement activation to virtually undetectable levels.

The crystal structure of pneumococcal surface antigen PsaA reveals a metal-binding site and a novel structure for a putative ABC-type binding protein

BACKGROUND

. The surface protein PsaA of the pathogenic bacterium Streptococcus pneumoniae plays an essential role in its virulence. PsaA is a putative ATP-binding cassette-type (ABC-type) binding protein involved in the uptake of Mn2+ and possibly Zn2+ and is considered to be both a potential drug target and and a candidate vaccine component.

RESULTS

. The structure of PsaA has been determined to 2.0 A resolution using X-ray crystallography and is the first structure obtained for an ABC-type binding protein from a Gram-positive organism. The protein consists of two (beta/alpha)4 domains linked together by a single helix. A metal-binding site is formed in the domain interface by the sidechains of His67, His139, Glu205 and Asp280 and is occupied in the structure.

CONCLUSIONS

. The structural topology of PsaA is fundamentally different from that of other ABC-type binding proteins determined thus far in that PsaA lacks the characteristic 'hinge peptides' involved in conformational change upon solute uptake and release. In our structure, the metal-binding site is probably occupied by Zn2+. The site seems to be well conserved amongst related receptors from both Gram-positive and Gram-negative bacteria.

Pneumolysin in pneumococcal adherence and colonization

The universal and highly conserved production of pneumolysin, the major pneumococcal cytolysin, among clinical isolates of Streptococcus pneumoniae and the previously reported association of pneumolysin production with increased pneumococcal adherence to respiratory epithelium in organ cultures suggest that this toxin might be important for nasopharyngeal colonization. We confirmed that pneumolysin-deficient mutant pneumococcal strains had decreased adherence to respiratory epithelial cells in vitro compared with their isogeneic wild-type strains. However, neither early nor sustained colonization by type 14 S. pneumoniae in an established murine model was dependent on bacterial production of pneumolysin. We conclude that pneumolysin production is not a major determinant of successful nasopharyngeal colonization by pneumococci.

Expression, purification and preliminary X-ray crystallographic analysis of PsaA, a putative metal-transporter protein of Streptococcus pneumoniae

The putative metal-transporter protein PsaA of Streptococcus pneumoniae is of potential interest both as a vaccine and also as a drug target. The overexpression of the protein in E. coli, and its subsequent purification and crystallization are described. The crystals are rectangular rods and diffract to beyond 2.7 A resolution. The crystal space group is P212121 with unit-cell dimensions a = 59.9, b = 66.5 and c = 69.9 A.

The laryngeal mask airway in emergency medicine, neonatal resuscitation, and intensive care medicine

In assessing the potential role of the LMA outside the operating room, the risks of a less secure airway must be balanced against the benefits of ease of training, success and speed of insertion, no need for direct visualization of laryngeal structures, and lesser need for ancillary equipment. The LMA has a role as an alternative to FMV in CPR when personnel skilled in tracheal intubation are not available. When skilled intubators are present, it has an important role as an alternative airway when intubation has been impossible. These roles extend to the prehospital setting, with an additional specific indication for its use when access to a patient is limited making tracheal intubation impossible. The LMA is incorporated into advanced life support training and as such should be regarded as a device providing temporary airway support, rather than a replacement for a tracheal tube. The LMA, and possibly also the ILM, should be standard equipment carried by prehospital trauma teams and by all those attending victims in the field.

A comparison of the laryngeal mask airway and cuffed oropharyngeal airway in anesthetized adult patients

We compared the cuffed oropharyngeal airway (COPA) with the laryngeal mask airway (LMA) in 120 anesthetized adult patients. We compared 1) placement success rates, 2) airway interventional requirements, 3) airway stability in different head/neck positions, 4) cardiorespiratory tolerance, and 5) intra- and postoperative adverse events/symptoms. A standardized anesthesia protocol was followed by four anesthesiologists experienced with both devices. Observational data were validated by independent analysis of continuous video recordings. Postoperative interviews were double-blind to the device used. The LMA had a more frequent success rate than COPA (97% vs 55%, P < 0.00001), an overall higher success rate (100% vs 83%; P = 0.001), a shorter time to achieve an effective airway (49 vs 188 s; P < 0.00001), a higher oropharyngeal leak pressure (21 vs 16 cm H2O; P = 0.003), and a fewer number of chin lift airway interventions required (0.1% vs 42%; P < 0.00001). When comparing mean tidal volumes in different head/neck positions to assess airway stability, the quality of airway was unchanged in 98% patients with the LMA and 54% with the COPA (P < 0.00001). The incidences of intraoperative adverse events were similar. On removal, blood was detected more often on the COPA (3% vs 14%; P = 0.04). In the late postoperative period, more patients complained of adverse symptoms with the COPA than with the LMA (26% vs 57%; P = 0.001). Late postoperative symptoms occurred more frequently with the COPA (0.87 vs 0.34; P = 0.003). There was more late postoperative sore throat (14% vs 36%; P = 0.0003) and more jaw/neck pain (12% vs 26%; P = 0.0008) in patients managed with the COPA. This study demonstrates that the LMA offers advantages over the COPA in most technical aspects of airway management and in terms of postoperative morbidity.

IMPLICATIONS

In this randomized, prospective study, we compared the laryngeal mask airway and the cuffed oropharyngeal airway in anesthetized patients. The laryngeal mask airway offers advantages in most technical aspects of airway management and in terms of postoperative morbidity.

An evaluation of the factors influencing selection of the optimal size of laryngeal mask airway in normal adults

The purpose of this randomised single blinded study was to determine the optimal size of laryngeal mask airway in the normal adult population, to test the validity of the current selection criteria and to determine if any externally measured anatomical variable correlated with optimal size. In each of 30 apnoeic anaesthetised adults weighting less than 100 kg, size 3, 4 and 5 laryngeal mask airways were inserted in random order by a skilled user and the cuff inflated to a standard pressure (60 cm H2O). Optimal size was based on four criteria in order of priority: number of attempts at placement, oropharyngeal leak pressure, fiberoptic score and percentage of vocal cords seen. The size 5 laryngeal mask airway was optimal in 19/30 and the size 4 in 11/30. In no patient was the size 3 the optimal fit. Oropharyngeal leak pressure was significantly higher for each progressively large size and the fiberoptic view was significantly better for the size 4 and size 5. There was no significant predictive value in any externally measured anatomical variable, but height was the most useful. The best current selection strategy was to choose a size 5 for males and size 4 for females. Potentially useful new strategies may be to use the size 5 in all adults, or a size 5 > or = 165 cm in height and size 4 for < 165 cm. We conclude that predicting the optimal size of laryngeal mask airway for individual adult patients is complex. The best size selection strategies involve use of the size 4 and 5 laryngeal mask airways in adults.

Amino acid changes affecting the activity of pneumolysin alter the behaviour of pneumococci in pneumonia

Pneumolysin is a multi-functional toxin produced by Streptococcus pneumoniae. The toxin has distinct cytotoxic activity and complement-activating activity mediated by different parts of the toxin molecule. Mice challenged intranasally with a type 2 pneumococcal strain contract bronchopneumonia and bacteremia [1]. Mice were infected intranasally with isogenic mutants of this strain in which the chromosomal pneumolysin gene carried point mutations affecting either or both properties of pneumolysin. Reduction in either cytotoxic activity or complement activation by pneumolysin decreased the virulence of the mutant pneumococci. However, it was the ability to activate complement that most affected the behaviour of pneumococci in the lungs and associated bacteremia in the first 24 h following infection.

Cricoid pressure

PURPOSE

Although cricoid pressure (CP) is a superficially simple and appropriate mechanical method to protect the patient from regurgitation and gastric insufflation, in practice it is a complex manoeuvre which is difficult to perform optimally. The purpose of this review is to examine and evaluate studies on the application of (CP). It deals with anatomical and physiological considerations, techniques employed, safety and efficacy issues and the impact of CP on airway management with special mention of the laryngeal mask airway. SOURCE OF MATERIAL: Three medical databases (48 Hours, Medline, and Reference Manager Update) were searched for citations containing key words, subject headings and text entries on CP to October 1996.

PRINCIPLE FINDINGS

There have been no studies proving that CP is beneficial, yet there is evidence that it is often ineffective and that it may increase the risk of failed intubation and regurgitation. After evaluation of all available data, potential guidelines are suggested for optimal use of CP in routine and complex situations.

CONCLUSIONS

If CP is to remain standard practice during induction of anaesthesia, it must be shown to be safe and effective. Meanwhile, further understanding of its advantages and limitations, improved training in its use, and guidelines on optimal force and method of application should lead to better patient care.

Sequence heterogeneity of PsaA, a 37-kilodalton putative adhesin essential for virulence of Streptococcus pneumoniae

psaA encodes a 37-kDa putative pneumococcal surface adhesin. Although its complete nucleotide sequence has been determined, its contribution to the pathogenicity of Streptococcus pneumoniae has not previously been assessed. In this study, we used a PCR-amplified internal fragment of the psaA gene from S. pneumoniae type 2 strain D39 cloned in pVA891, to direct the construction of D39 derivatives in which the psaA gene had been specifically interrupted, by insertion-duplication mutagenesis. Two independent D39 psaA mutants (PsaA-(1) and PsaA-(2)) were significantly less virulent (as judged by intranasal or intraperitoneal challenge of mice) than either the wild-type D39 strain or a derivative of PsaA-(1) in which the psaA gene had been reconstituted by back-transformation with an intact copy of the cloned gene. pVA891-directed mutagenesis of an open reading frame (designated ORF3) immediately 3' to psaA or insertion of pVA891 between psaA and ORF3 had no impact on intranasal virulence. However, a small but significant difference in virulence was observed between these two derivatives and the parental D39 strain in a low-dose intraperitoneal challenge model, suggesting that the ORF3 product may also contribute to pathogenesis. Adherence of PsaA-(1) to A549 cells (type II pneumocytes) was only 9% of that for D39, while the ORF3-negative strain exhibited intermediate adherence (23%). This is the first functional evidence that PsaA is an adhesin. Sequence analysis of the psaA gene from D39 indicated significant deviation from that previously published for the homolog from S. pneumoniae R36A. The deduced amino acid sequences of mature PsaA from the two strains had only 81% homology, with the bulk of the variation occurring in the amino-terminal portion.

Sequence variation in the Streptococcus pneumoniae pneumolysin gene affecting haemolytic activity and electrophoretic mobility of the toxin

When 30 clinical isolates of Streptococcus pneumoniae, representing 16 capsular serotypes, were analysed by Western blot for production of the haemolytic toxin pneumolysin (Ply), all strains produced an immunoreactive band of similar intensity. However, six isolates of serotype 8 and two of type 7F expressed Ply whose mobility on SDS-PAGE was anomalously slow. Culture lysates from these strains also had low haemolytic activities compared with those for clinical isolates of other serotypes, suggesting the possibility of mutations affecting specific activity. Genes encoding Ply from one type 8 isolate and one type 7F isolate were cloned into Escherichia coli and sequenced. Compared with the published sequence for Ply, the deduced amino acid sequence for the type 8 Ply variant contained three amino acid substitutions, and the type 7F variant four amino acid substitutions. Both variants also had Val270 and Lys271 deleted. The variant Ply proteins were purified from recombinant E. coli expressing the cloned genes, and shown to have substantially reduced specific haemolytic activities [6.8 x 10(4) haemolytic units (HU)/mg and 2.3 x 10(4) HU/mg for type 8 Ply and type 7F Ply respectively] compared with Ply itself (1.2 x 10(6) HU/mg). Studies with chimeric toxin gene constructs indicated that both the reduced haemolytic specific activity and the anomalous electrophoretic mobility of the variant Plys were attributable to a single amino acid substitution (Thr172-->Ile).

Cloning and characterization of nanB, a second Streptococcus pneumoniae neuraminidase gene, and purification of the NanB enzyme from recombinant Escherichia coli

Streptococcus pneumoniae is believed to produce more than one form of neuraminidase, but there has been uncertainty as to whether this is due to posttranslational modification of a single gene product or the existence of more than one neuraminidase-encoding gene. Only one stable pneumococcal neuraminidase gene (designated nanA) has been described. In the present study, we isolated and characterized a second neuraminidase gene (designated nanB), which is located close to nanA on the pneumococcal chromosome (approximately 4.5kb downstream). nanB was located on an operon separate from that of nanA, which includes at least five other open reading frames. NanB has a predicted size of 74.5 kDa after cleavage of a 29-amino-acid signal peptide. There was negligible amino acid homology between NanA and NanB, but NanB did exhibit limited homology with the sialidase of Clostridium septicum. NanB was purified from recombinant Escherichia coli and found to have a pH optimum of 4.5, compared with 6.5 to 7.0 for NanA. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis suggested that NanB has a molecular size of approximately 65 kDa. The discrepancy between this estimate and the size predicted from the nucleotide sequence is most likely a consequence of C-terminal processing or anomalous electrophoretic behavior.

Distinct roles for pneumolysin's cytotoxic and complement activities in the pathogenesis of pneumococcal pneumonia

Pneumolysin, the major Streptococcus pneumoniae cytotoxin, contributes to the early pathogenesis of invasive pneumococcal pneumonia by facilitating intrapulmonary bacterial growth and invasion into the blood. Pneumolysin is a multifunctional toxin, with distinct cytolytic ("hemolytic") and complement-activation ("complement") activities that have been mapped to several regions of the molecule. To characterize the specific contributions of pneumolysin's hemolytic and complement properties to the pathogenesis of pneumococcal pneumonia, we compared the in vivo effects of type 2 S. pneumoniae mutant strains, which produce pneumolysins deficient in these activities. The absence of either pneumolysin's hemolytic or complement activities rendered mutant strains less virulent than the wild-type strain during pulmonary infection. Pneumolysin's hemolytic activity correlated with acute lung injury and bacterial growth at 3 and 6 h after endotracheal instillation. In contrast, pneumolysin's complement activity correlated with bacterial growth and bacteremia at 24 h after pulmonary infection. Pneumolysin's complement activity was not associated with the degree of alveolar-capillary injury or recruitment of leukocytes during initial pulmonary infection. However, pneumolysin's complement activity inhibited killing of mutant bacteria in an in vitro complement-dependent neutrophil killing assay. Thus, both pneumolysin's hemolytic and complement activities made specific contributions to the early pathogenesis of pneumococcal pneumonia at different stages of infection and by different mechanisms.

Effect of defined point mutations in the pneumolysin gene on the virulence of Streptococcus pneumoniae

The thiol-activated toxin pneumolysin is a known pneumococcal virulence factor, with both cytotoxic (hemolytic) and complement activation properties. Copies of the pneumolysin gene carrying defined point mutations affecting either or both of these properties were introduced into the chromosome of Streptococcus pneumoniae D39 by insertion-duplication mutagenesis. The virulences of these otherwise isogenic strains were then compared. There was no significant difference in either the median survival time or overall survival rate between mice challenged with D39 derivatives producing the wild-type toxin and those expressing a pneumolysin gene with an Asp-385-->Asn mutation, which abolishes the complement activation property. However, mice challenged with strains carrying either His-367-->Arg or Trp-433-->Phe plus Cys-428-->Gly mutations, which reduce hemolytic activity to approximately 0.02 and 0.0001% of the wild-type level, respectively, had significantly greater median survival times and overall survival rates than mice challenged with D39 derivatives expressing a wild-type pneumolysin gene. No additional reduction in virulence was observed when mice were challenged with a D39 derivative carrying Trp-433-->Phe, Cys-428-->Gly, and Asp-385-->Asn, rather than Trp-433-->Phe and Cys-428-->Gly, mutations in the pneumolysin gene. Thus, it appears that in the intraperitoneal challenge model, the contribution of pneumolysin to virulence is largely attributable to its hemolytic (cytotoxic) properties rather than to its capacity to activate complement. Interestingly, however, the amount of pneumolysin required for full virulence may be very small, as D39 derivatives carrying the Trp-433-->Phe mutation (which reduces hemolytic activity to 0.1% of the wild-type level) had intermediate virulence.

Use of the laryngeal mask airway in otolaryngology

The laryngeal mask airway (LMA) provides a third type of airway for consideration in otolaryngology that offers some of the benefits of intubation and avoids many of the associated hazards. It can be inserted without the use of a laryngoscope or muscle relaxant, and is designed to produce an airtight seal around the laryngeal inlet. The LMA provides a secure airway suitable for spontaneous or controlled ventilation, acts as an airtight throat pack, and is well tolerated during recovery. The reinforced LMA (RLMA), specifically designed for otolaryngology anaesthesia, has recently become available. The purpose of this article to is provide a brief overview of the LMA with special emphasis on its use in otolaryngology--head and neck surgery.

Cloning and nucleotide sequence of the Streptococcus pneumoniae hyaluronidase gene and purification of the enzyme from recombinant Escherichia coli

A gene bank of Sau3A1-generated Streptococcus pneumoniae type 23 DNA fragments was constructed in Escherichia coli K-12 with the low-copy-number cosmid vector pOU61cos. Clone lysates were screened by immunoblotting using a mouse antiserum raised against a crude pneumococcal hyaluronidase preparation. One immunoreactive clone was isolated, and it produced high level of hyaluronidase activity. This clone contained a recombinant cosmid (designated pJCP800) with an approximately 35-kb DNA insert, and the putative hyaluronidase coding sequence was subcloned into pBluescript SK as a 3.8-kb PstI-ClaI fragment (designated pJCP802). The complete nucleotide sequence of this insert was determined. The region included an open reading frame sufficient to encode a polypeptide with an M(r) of 107,751. An active hyaluronidase with an M(r) of approximately 89,000 was purified to homogeneity from E. coli DH5 alpha(pJCP802). N-terminal amino acid sequence analysis of the purified protein suggested that translation initiation was occurring primarily at a TTG codon within the major open reading frame. However, immunoblot analysis using antiserum raised against the purified 89-kDa hyaluronidase indicated that E. coli DH5 alpha(pJCP802) also expressed the 107-kDa form of the enzyme. This antiserum labelled a 107-kDa protein in partially purified hyaluronidase preparations from S. pneumoniae. The hyaluronidase activity in this pneumococcal extract was also neutralized by the antiserum.

Hopanoid lipids compose the Frankia vesicle envelope, presumptive barrier of oxygen diffusion to nitrogenase

Biological nitrogen fixation in aerobic organisms requires a mechanism for excluding oxygen from the site of nitrogenase activity. Oxygen exclusion in Frankia spp., members of an actinomycetal genus that forms nitrogen-fixing root-nodule symbioses in a wide range of woody Angiosperms, is accomplished within specialized structures termed vesicles, where nitrogen fixation is localized. The lipidic vesicle envelope is apparently a functional analogue of the cyanobacterial heterocyst envelope, forming an external gas-diffusion barrier around the nitrogen-fixing cells. We report here that purified vesicle envelopes consist primarily of two hopanoid lipids, rather than of glycolipids, as is the case in cyanobacteria. One envelope hopanoid, bacteriohopanetetrol phenylacetate monoester, is vesicle-specific. The Frankia vesicle envelope thus represents a layer specific to the locus of nitrogen fixation that is biosynthetically uniquely derived.

Topical anaesthesia for extracorporeal shock wave lithotripsy

We have investigated 60 patients in a prospective double-blind, placebo-controlled study to assess the efficacy of EMLA (Eutectic Mixture of Local Anaesthetics) cream to provide analgesia during extracorporeal shock wave lithotripsy (ESWL) with a second generation lithotriptor. Before operation, EMLA or placebo cream was applied to the patient's back at the anticipated shock head-skin interface. During the procedure increments of fentanyl 0.5 micrograms kg-1 were given i.v. on patient demand. There was no significant difference (P = 0.83) in the dose of fentanyl given to each group. We cannot recommend, therefore, the use of EMLA cream as an analgesic during ESWL with a second generation lithotriptor.

Effect of insertional inactivation of the genes encoding pneumolysin and autolysin on the virulence of Streptococcus pneumoniae type 3

Derivatives of Streptococcus pneumoniae type 3 deficient in production of either pneumolysin or autolysin were constructed. This was achieved by transformation of type 3 pneumococci with DNA from derivatives of a rough strain (Rx1), in which the respective genes had been interrupted by insertion-duplication mutagenesis using internal fragments of the cloned genes in the vector pVA891. Southern blot analysis confirmed that the pneumolysin or autolysin genes in the respective transformants had been interrupted by insertion of the plasmid-derived sequences. Both the pneumolysin-negative and the autolysin-negative strains had significantly reduced (P less than 0.0001) virulence in mice, as judged by survival time after intraperitoneal challenge. The median survival time of mice challenged with type 3 pneumococci in which either pneumolysin or autolysin production had been reconstituted by back-transformation of the mutants with an intact copy of the respective cloned gene (with concomitant elimination of plasmid-derived sequences), was indistinguishable from that of mice challenged with the wild-type strain. These results establish the importance of both pneumolysin and autolysin to the virulence of type 3 pneumococci.

Purification and immunogenicity of genetically obtained pneumolysin toxoids and their conjugation to Streptococcus pneumoniae type 19F polysaccharide

As part of an ongoing study concerned with improving human vaccines against Streptococcus pneumoniae, the genes for two defined pneumolysin (PL) toxoids (pneumolysoids), Pd-A (PL with a Cys----Gly substitution at amino acid 428) and Pd-B (PL with a Trp----Phe substitution at position 433), were inserted into the high-expression vector pKK233-2 in Escherichia coli and the pneumolysoids were purified. Groups of mice which had been immunized with either Pd-A, Pd-B, or native PL purified from S. pneumoniae were then challenged either intranasally or intraperitoneally with virulent pneumococci. Mice in all immunized groups survived significantly longer than sham-immunized controls. Both pneumolysoids were more effective than PL as protective immunogens. Pneumolysoid Pd-B was conjugated covalently with pneumococcal type 19F capsular polysaccharide (19F PS), and the immunogenicities of both the protein and the PS moieties of the conjugate in mice were determined. Significant anti-PL titers were obtained, and the immunogenicity of the 19F PS moiety was markedly enhanced compared with that of unconjugated PS. Conjugation also appears to have converted the 19F PS into an antigen capable of inducing a booster effect. These results support the notion that the efficacy of human, PS-based antipneumococcal vaccines might be improved by supplementation with pneumolysoid in the form of a covalent pneumolysoid-PS conjugate.

Bacteriohopanetetrol: abundant lipid in frankia cells and in nitrogen-fixing nodule tissue

An unusual class of lipid with amphiphilic properties has been detected in nodule tissue of Alnus and Ceanothus. High levels of the same lipid (20-50% of total cell lipids) were detected in solvent extracts of Frankia spp. cells. However, the lipid was absent in host roots. The lipid was purified and quantified by high-performance liquid chromatography/flame ionization detector. Phenol-sulfuric acid determinations and proton nuclear magnetic resonance indicated that the purified lipid is not a glycolipid. Mass spectra of the predominant species are consistent with published spectra for bacteriohopanetetrol (C(35)H(62)O(4)), a pentacyclic triterpenoid, or hopanoid.

Presence of a small plasmid in clinical isolates of Streptococcus pneumoniae

We have detected the presence of a small (2.95 kb) plasmid in a clinical isolate of Streptococcus pneumoniae. A restriction map was constructed for this plasmid and for pDP1 (the only previously reported pneumococcal plasmid); no apparent differences were observed and the two plasmids hybridized strongly to each other. Portions of pDP1 were then cloned into Escherichia coli K-12, using the vector pUC19, and the pneumococcal DNA insert was used as a probe to screen 500 clinical isolates of S. pneumoniae for pDP1 sequences. The plasmid was detected in a total of 8 isolates. These were of various serotypes and no correlation could be found between the presence of the plasmid and the geographical location from which it came, the type of infection, or with resistance to antibacterial drugs. Although no function has yet been assigned to pDP1, it may form the basis of a useful vector for cloning in S. pneumoniae, as it contains at least seven unique restriction sites.

Contribution of autolysin to virulence of Streptococcus pneumoniae

Insertion-duplication mutagenesis was used to construct an autolysin-negative derivative of Streptococcus pneumoniae. This derivative was obtained by first transforming the nonencapsulated strain Rx1 with a derivative of the vector pVA891 carrying a 375-base-pair TaqI DNA fragment from the middle of the autolysin structural gene. DNA was extracted from the resultant erythromycin-resistant, autolysin-negative rough pneumococcus and used to transform S. pneumoniae D39, a virulent type 2 strain. Several erythromycin-resistant transformants were obtained from two independent experiments, and none of these transformants produced autolysin. Southern blot analysis confirmed that the autolysin gene in these transformants had been interrupted by the plasmid-derived sequences. The autolysin-negative mutants showed markedly reduced virulence for mice compared with that of strain D39; intranasal and intraperitoneal 50% lethal doses were increased 10(2)- and 10(5)-fold, respectively. Autolysin production was reinstated in one of the mutants by back-transformation with the cloned autolysin gene, with the concomitant loss of erythromycin resistance; the virulence of this isolate for mice was indistinguishable from that of D39. The importance of autolysin in pathogenesis was confirmed by immunization-challenge studies. Mice immunized with purified autolysin survived significantly longer than did control mice after intranasal challenge with strain D39. This study provides direct evidence that the pneumococcal autolysin contributes to virulence and identifies it as a potential vaccine antigen.

Reduced virulence of a defined pneumolysin-negative mutant of Streptococcus pneumoniae

Insertion-duplication mutagenesis was used to construct a pneumolysin-negative derivative of Streptococcus pneumoniae. This was achieved by first transforming the nonencapsulated strain Rx1 with a derivative of the vector pVA891 carrying a 690-base-pair DNA fragment from the middle of the pneumolysin structural gene. DNA was extracted from the resultant erythromycin-resistant, pneumolysin-negative rough pneumococcus and used to transform S. pneumoniae D39, a virulent type 2 strain. Several erythromycin-resistant transformants were obtained from two independent experiments, and none of these produced pneumolysin. Southern blot analysis confirmed that the pneumolysin gene in these transformants had been interrupted by the plasmid-derived sequences. The pneumolysin-negative mutants showed reduced virulence for mice compared with D39, as judged by survival time after intranasal challenge, intraperitoneal 50% lethal dose, and blood clearance studies. Pneumolysin production was reinstated in one of the mutants by transformation with the cloned pneumolysin gene, with the concomitant loss of erythromycin resistance; the virulence in mice of this isolate was indistinguishable from that of D39. These results confirm the involvement of pneumolysin in pneumococcal pathogenesis.

Epidemiological patterns of scurvy among Ethiopian refugees

In the Horn of Africa, scurvy is a serious public health problem for refugees who are dependent on standard relief food (cereals, legumes, and oil). To assess the risk factors and to quantify the potential magnitude of scurvy among these displaced communities, we reviewed data collected from 1985 to 1987 by relief programmes in five refugee camps in Somalia and one in the Sudan. Outbreaks of clinical scurvy occurred among refugees in all the camps from 3 to 4 months after their arrival. The incidence of scurvy in two camps was, respectively, 14% over a period of 4 months and 19.8% over a period of 18 months. Prevalences of scurvy estimated from random population samples in the six study camps ranged from 13.6% to 44%. The risk of developing scurvy increased significantly with the length of time that refugees had been in the camps and was also significantly higher among those who were older and among females, particularly those of childbearing age. The prevalence of scurvy among refugees was similar, irrespective of whether or not they had attended supplementary feeding programmes. The control measures that were implemented had a moderate and slow impact on the disease. In both Somalia and the Sudan the relief food distributed to the refugees was almost completely deficient in vitamin C, while the environment where the camps were located precluded an adequate supply of fresh food. To avoid scurvy among refugee communities in this area of Africa it is therefore recommended that vitamin C supplements be added to the relief food at an early stage of a crisis.

Cloning and expression of the pneumococcal neuraminidase gene in Escherichia coli

A gene bank of Sau3AI-generated Streptococcus pneumoniae DNA fragments was constructed in Escherichia coli K-12 by cloning into the BamHI site of the cosmid vector pHC79. One clone capable of cleaving the fluorogenic neuraminidase substrate 2'-(4-methylumbelliferyl)-alpha-D-N-acetyl-neuraminic acid was isolated. This activity was inhibited by treatment with a mouse antiserum raised against purified pneumococcal neuraminidase. The recombinant plasmid purified from this clone (designated pJCP301) contained approximately 3.0 kb of pneumococcal DNA. Western-blot analysis indicated that E. coli K-12[pJCP301] produced a 98-kDa polypeptide which reacted with antineuraminidase serum.

Limitations of anthropometry during acute food shortages: high mortality can mask refugees' deteriorating nutritional status

Longitudinal comparison of anthropometric data from cross-sectional surveys is commonly used to assess nutritional status in relief operations. In a refugee camp in Sudan, assessment indicated a high level of childhood malnutrition, but nutritional status appeared relatively unchanged between cluster sample surveys in January (26.3% below 80% of median weight-for-height) and March 1985 (28.4% below 80% of median weight-for-height). However, in this interval, which was marked by irregular food supplies and relatively low energy (calorie) intake as well as by a high incidence of diarrhoeal disease and measles, nearly 13% of all children in the camp died. This deceptive appearance of stability in nutritional status in the face of high mortality may be explained by ongoing nutritional deterioration ("replacement malnutrition") among surviving children. These findings demonstrate that collection and analysis of mortality data are essential for the correct interpretation of anthropometric results during periods of uncertain food supply.

Cytokinin Secretion by Frankia sp. HFP ArI3 in Defined Medium

Frankia sp. HFP ArI3 (host plant Alnus rubra Bong.) was grown in defined medium and the culture solution was analyzed for the presence of various cytokinins and related compounds. N(6)- (Delta(2)-isopentenyl) adenosine was the only cytokinin detected by both high performance liquid chromatography and gas chromatography-mass spectrometry, at levels of approximately 1 ng/ml culture medium.

Epidemiological assessment of the health and nutrition of Ethiopian refugees in emergency camps in Sudan, 1985

The findings from epidemiological data that were collected from emergency camps for Ethiopian refugees during a mass influx of refugees into Eastern Sudan in 1985 are presented. An overall mortality of 8.9 per 10,000 a day was recorded during February 1985, and in children under 5 years of age the rate was 22 per 10,000 a day. The estimated prevalence of malnutrition (calculated as less than 80% of the reference weight for height) ranged from 32% to 52% among children of preschool age. The principal causes of morbidity and mortality were measles, diarrhoea and dysentery, respiratory infections, and malaria. The findings suggest that malnutrition and disease increased in these refugees after they arrived in the camps. Epidemiological assessment is essential to help to maintain the health and nutrition of refugees in emergency camps.

Cloning and expression in Escherichia coli of the Streptococcus pneumoniae gene encoding pneumolysin

A gene bank of Sau3A1-generated Streptococcus pneumoniae DNA fragments was constructed in Escherichia coli K-12 by cloning into the BamHI site of the cosmid vector pHC79. Clones expressing the pneumolysin determinant were selected by testing for hemolytic activity which could be inhibited by antibody to purified pneumolysin and by cholesterol. Restriction analysis of pneumolysin-positive recombinant cosmid DNA indicated that the coding sequence for the toxin was located within a 2.9-kilobase-pair (kbp) ClaI DNA fragment. This fragment, which included 0.35 kbp of vector pHC79 DNA, was subcloned into the plasmid pBR322. E. coli cells harboring this recombinant plasmid (designated pJCP20) produced approximately one-third of the amount of pneumolysin found in the donor S. pneumoniae strain. Plasmid pJCP20 was stably maintained in E. coli and resulted in the accumulation of active pneumolysin in the cytoplasm. Western blot analysis showed that E. coli harboring pJCP20 produced two forms of the toxin with molecular weights of 54,000 and 52,000. The lower-molecular-weight form was indistinguishable from native pneumolysin. Subcloning the 2.9-kbp DNA fragment into the expression vector pEV31 allowed the determination of the direction of transcription of the pneumolysin gene. The pneumolysin-coding sequence (approximately 1.5 kbp) has been localized to within a 1.75-kbp segment of pneumococcal DNA.