Evaluation of immunogenicity of enterobactin conjugate vaccine for the control of Escherichia coli mastitis in dairy cows

Mastitis is the most common disease of dairy cows that incurs severe economic losses to the dairy industry. Currently, environmental mastitis pathogens are a major problem for most dairy farms. A current commercially available Escherichia coli vaccine does not prevent clinical mastitis and production losses, likely due to antibody accessibility and antigenic variation issues. Therefore, a novel vaccine that prevents clinical disease and production losses is critically needed. Recently a nutritional immunity approach, which restricts bacterial iron uptake by immunologically sequestering conserved iron-binding enterobactin (Ent), has been developed. The objective of this study was to evaluate the immunogenicity of the keyhole limpet hemocyanin-enterobactin (KLH-Ent) conjugate vaccine in dairy cows. Twelve pregnant Holstein dairy cows in their first through third lactations were randomized to the control or vaccine group, with 6 cows per group. The vaccine group received 3 subcutaneous vaccinations of KLH-Ent with adjuvants at drying off (D0), 20 (D21), and 40 (D42) days after drying off. The control group was injected with phosphate-buffered saline (pH 7.4) mixed with the same adjuvants at the same time points. Vaccination effects were assessed over the study period until the end of the first month of lactation. The KLH-Ent vaccine did not cause any systemic adverse reactions or reduction in milk production. Compared with the control group, the vaccine elicited significantly higher levels of serum Ent-specific IgG at calving (C0) and 30 d postcalving (C30), mainly its IgG2 fraction, which was significantly higher at D42, C0, C14, and C30 d, with no significant change in IgG1 levels. Milk Ent-specific IgG and IgG2 levels in the vaccine group were significantly higher on C30. Fecal microbial community structures were similar for both control and vaccine groups on the same day and shifted directionally along the sampling days. In conclusion, the KLH-Ent vaccine successfully triggered strong Ent-specific immune responses in dairy cows without significantly affecting the gut microbiota diversity and health. The results show that Ent conjugate vaccine is a promising nutritional immunity approach in control of E. coli mastitis in dairy cows.

A National Registry for People With All Stages of Kidney Disease: The National Kidney Foundation (NKF) Patient Network

RATIONALE & OBJECTIVE

The National Kidney Foundation (NKF) launched the first national US kidney disease patient registry, the NKF Patient Network, that is open to patients throughout the continuum of chronic kidney disease (CKD). The Network provides individualized education and will facilitate patient-centered research, clinical care, and health policy decisions. Here, we present the overall design and the results of a feasibility study that was conducted July through December 2020.

STUDY DESIGN

Longitudinal observational cohort study of patient-entered data with or without electronic health care record (EHR) linkage in collaboration with health systems.

SETTING & PARTICIPANTS

People with CKD, age≥18 years, are invited through their provider, NKF communications, or national outreach campaign. People self-enroll and share their data through a secure portal that offers individualized education and support. The first health system partner is Geisinger.

EXPOSURE

Any cause and stage of CKD, including dialysis and kidney transplant recipients.

OUTCOME

Feasibility of the EHR data transfer, participants' characteristics, and their perspectives on usability and content.

ANALYTICAL APPROACH

Data were collected and analyzed through the registry portal powered by the Pulse Infoframe healthie 2.0 platform.

RESULTS

During the feasibility study, 80 participants completed their profile, and 42 completed a satisfaction survey. Mean age was 57.5 years, 51% were women, 83% were White, and 89% were non-Hispanic or Latino. Of the participants, 60% were not aware of their level of estimated glomerular filtration rate and 91% of their urinary albumin-creatinine ratio.

LIMITATIONS

Challenges for the Network are lack of awareness of kidney disease for many with CKD, difficulty in recruiting vulnerable populations or those with low digital readiness, and loss to follow-up, all leading to selection bias.

CONCLUSIONS

The Network is positioned to become a national and international platform for real-world data that can inform the development of patient-centered research, care, and treatments.

Isolation and characterization of Escherichia albertii originated from the broiler farms in Mississippi and Alabama

Escherichia albertii is an emerging foodborne enteropathogen with increasing outbreaks worldwide, particularly in Japan recently. However, major features of this zoonotic pathogen, such as prevalence, virulence, and antibiotic resistance (AR), still remain under characterized. In a recent pilot study, we reported isolation of E. albertii from a chicken farm in Tennessee, suggesting chicken is an important reservoir for E. albertii. In this large-scale study, we examined prevalence of E. albertii in 9 farms in Mississippi and Alabama. Of a total of 270 cloacal swabs (30 per farm), 43 were PCR positive and 12 E. albertii strains were isolated with different isolation rates in individual farms ranging from 0 to 23.3 %. Both PFGE and whole genome analysis showed the E. albertii from different farms were phylogenetically distant, but those from the same farm displayed clonal relationships. Consistently, the antibiogram, AR gene profiles, and plasmid replicon types were similar across the strains in the same farm. Notably, 9 of the 12 E. albertii strains displayed multidrug resistance; one strain was even resistant to imipenem, a clinically important carbapenem antibiotic. In addition, comparative genomics analysis showed that two chicken E. albertii clusters displayed very close evolutionary relationships and similar virulence gene profiles to human E. albertii strains. In vitro growth assay demonstrated that the anti-enterobactin antibodies could dramatically inhibit the growth of two representative chicken E. albertii, supporting the feasibility of the novel enterobactin-based immune intervention for controlling this emerging pathogen. Taken together, the findings from this study further indicated chickens as an important reservoir for E. albertii in the U.S., highlighting the need to prevent and control E. albertii in poultry production.

Chronic Kidney Disease Testing Among At-Risk Adults in the U.S. Remains Low: Real-World Evidence From a National Laboratory Database

OBJECTIVE

An estimated 37 million Americans have chronic kidney disease (CKD). Nearly 90% do not know about their condition because of low awareness about the importance of CKD testing and diagnosis among practitioners and people at risk for CKD. This study uses data from a national clinical laboratory to identify guideline-recommended CKD testing rates across the U.S.

RESEARCH DESIGN AND METHODS

Patients with Laboratory Corporation of America Holdings (Labcorp) testing between 2013 and 2019 were defined as at risk for CKD if they had any testing ordered with diagnosis codes for diabetes and/or hypertension. Guideline-concordant CKD assessment was defined by estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (uACR) testing within the study year.

RESULTS

We identified 28,295,982 at-risk patients (mean age 60.6 ± 14.8 years; 53.6% women): 16.2% had diabetes, 63.8% had hypertension, and 20.1% had both comorbidities. Of these, 80.3% did not receive guideline-concordant assessment during the study period. Furthermore, only 21.0% had uACR testing versus 89.6% with eGFR. CKD assessment occurred at least once in 28.7% of patients with diabetes, 10.5% of patients with hypertension, and 41.4% of patients with both conditions. In a state-by-state comparison, annual testing rates ranged from 5 to 30%. The nationwide rate increased modestly each year between 2013 and 2018 (from 10.7% to 15.2%).

CONCLUSIONS

Despite guideline recommendations, testing for CKD with uACR and eGFR in U.S. adults with diabetes and hypertension is low in routine clinical care. These data highlight the need for strategies to improve routine CKD assessment nationwide.

Understanding and Overcoming the Challenges Related to Cardiovascular Trials Involving Patients with Kidney Disease

Cardiovascular disease is a prevalent and prognostically important comorbidity among patients with kidney disease, and individuals with kidney disease make up a sizeable proportion (30%-60%) of patients with cardiovascular disease. However, several systematic reviews of cardiovascular trials have observed that patients with kidney disease, particularly those with advanced kidney disease, are often excluded from trial participation. Thus, currently available trial data for cardiovascular interventions in patients with kidney disease may be insufficient to make recommendations on the optimal approach for many therapies. The Kidney Health Initiative, a public-private partnership between the American Society of Nephrology and the US Food and Drug Administration, convened a multidisciplinary, international work group and hosted a stakeholder workshop intended to understand and develop strategies for overcoming the challenges with involving patients with kidney disease in cardiovascular clinical trials, with a particular focus on those with advanced disease. These efforts considered perspectives from stakeholders, including academia, industry, contract research organizations, regulatory agencies, patients, and care partners. This article outlines the key challenges and potential solutions discussed during the workshop centered on the following areas for improvement: building the business case, re-examining study design and implementation, and changing the clinical trial culture in nephrology. Regulatory and financial incentives could serve to mitigate financial concerns with involving patients with kidney disease in cardiovascular trials. Concerns that their inclusion could affect efficacy or safety results could be addressed through thoughtful approaches to study design and risk mitigation strategies. Finally, there is a need for closer collaboration between nephrologists and cardiologists and systemic change within the nephrology community such that participation of patients with kidney disease in clinical trials is prioritized. Ultimately, greater participation of patients with kidney disease in cardiovascular trials will help build the evidence base to guide optimal management of cardiovascular disease for this population.

Isolation and characterization of Escherichia albertii in poultry at the pre-harvest level

Escherichia albertii, often misidentified as Escherichia coli, has become an emerging foodborne human enteric pathogen. However, the prevalence and major animal reservoirs of this significant pathogen are still not clear. Here, we performed comprehensive microbiological, molecular, comparative genomics and animal studies to understand the status and features of E. albertii in the US domestic and food animals. Although no E. albertii was identified in a total of 1,022 diverse E. coli strains isolated from pets and food animals in a retrospective screening, in a pilot study, E. albertii was successfully isolated from a broiler farm (6 out of 20 chickens). The chicken E. albertii isolates showed clonal relationship as indicated by both pulsed-field gel electrophoresis (PFGE) and whole-genome sequence analysis. The isolated chicken E. albertii displayed multidrug resistance; all the resistance determinants including the extended-spectrum beta-lactamase gene, carried by plasmids, could be conjugatively transferred to E. coli, which was further confirmed by S1-PFGE and Southern hybridization. Whole-genome sequence-based phylogenetic analysis showed the chicken E. albertii strains were phylogenetically close to those of human origins. Challenge experiment demonstrated that the E. albertii strains isolated from human and wild bird could successfully colonize in the chicken intestine. Together, this study, for the first time, reported the isolation of E. albertii in poultry at the pre-hrvest level. The findings from multi-tier characterization of the chicken E. albertii strains indicated the importance of chickens as a reservoir for E. albertii. A large scale of E. albertii survey in poultry production at the pre-harvest level is highly warranted in the future.

Genome-wide association study identifies loci associated with milk leukocyte phenotypes following experimental challenge with Streptococcus uberis

Mastitis is a detrimental disease in the dairy industry that decreases milk quality and costs upwards of $2 billion annually. Often, mastitis results from bacteria entering the gland through the teat opening. Streptococcus uberis is responsible for a high percentage of subclinical and clinical mastitis. Following an intramammary experimental challenge with S. uberis on Holstein cows (n = 40), milk samples were collected and somatic cell counts (SCC) were determined by the Dairy Herd Improvement Association Laboratory. Traditional genome-wide association studies (GWAS) have utilized test day SCC or SCC lactation averages to identify loci of interest. Our approach utilizes SCC collected following a S. uberis experimental challenge to generate three novel phenotypes: (1) area under the curve (AUC) of SCC for 0-7 days and (2) 0-28 days post-challenge; and (3) when SCC returned to below 200,000 cells/mL post-challenge (< 21 days, 21-28 days, or > 28 days). Polymorphisms were identified using Illumina's BovineSNP50 v2 DNA BeadChip. Associations were tested using Plink software and identified 16 significant (p < 1.0 × 10^-4) single-nucleotide polymorphisms (SNPs) across the phenotypes. Most significant SNPs were in genes linked to cell signaling, migration, and apoptosis. Several have been recognized in relation to infectious processes (ATF7, SGK1, and PACRG), but others less so (TRIO, GLRA1, CELSR2, TIAM2, CPE). Further investigation of these genes and their roles in inflammation (e.g., SCC) can provide potential targets that influence resolution of mammary gland infection. Likewise, further investigation of the identified SNP with mastitis and other disease phenotypes can provide greater insight to the potential of these SNP as genetic markers.

Important Role of a Putative Lytic Transglycosylase Cj0843c in β-Lactam Resistance in Campylobacter jejuni

Beta-lactam antibiotics are an important class of antibiotics for treating bacterial infections. Despite prevalent β-lactam resistance in Campylobacter jejuni, the leading bacterial cause of human diarrhea in developed countries, molecular mechanism of β-lactam resistance in C. jejuni is still largely unknown. In this study, C. jejuni 81–176 was used for random transposon mutagenesis. Screening of a 2,800-mutant library identified 22 mutants with increased susceptibility to ampicillin. Of these mutants, two mutants contains mutations in Cj0843c (a putative lytic transglycosylase gene) and in its upstream gene Cj0844c, respectively. Complementation experiment demonstrated that the Cj0843 contributes to β-lactam resistance. The Cj0843c insertional mutation was subsequently introduced to diverse C. jejuni clinical strains for MIC test, showing that Cj0843c contributes to both intrinsic and acquired β-lactam resistance of C. jejuni. Consistent with this finding, inactivation of Cj0843c also dramatically reduced β-lactamase activity. Genomic examination and PCR analysis showed Cj0843c is widely distributed in C. jejuni. High purity recombinant Cj0843c was produced for generation of specific antiserum. The Cj0843 was localized in the periplasm, as demonstrated by immunoblotting using specific antibodies. Turbidimetric assay further demonstrated the capability of the purified Cj0843c to hydrolyze cell walls. Inactivation of Cj0843c also significantly reduced C. jejuni colonization in the intestine. Together, this study identifies a mechanism of β-lactam resistance in C. jejuni and provides insights into the role of cell wall metabolism in regulating β-lactamase activity.

Effect of Renal Function on the Pharmacokinetics of Palifermin

Palifermin (deltaN23KGF) decreases the incidence, severity, and duration of oral mucositis. The objectives of this open-label study were to evaluate the pharmacokinetics of single-dose palifermin in subjects with varying degrees of renal function. A single 90-mcg/kg intravenous dose of palifermin was administered to 31 subjects with varying levels of renal function (normal to requiring hemodialysis). Pharmacokinetic analyses were conducted using serum palifermin concentrations. There was considerable overlap in mean palifermin serum clearance among the groups, ranging from 318 to 495 mL/h/kg, indicating that the level of renal function did not affect clearance in humans; thus, no dose adjustment of palifermin is indicated for patients with renal dysfunction.

Bayesian estimation of the diagnostic accuracy of a multiplex real-time PCR assay and bacteriological culture for 4 common bovine intramammary pathogens

Bacteriological culture (BC) is the traditional method for intramammary infection diagnosis but lacks sensitivity and is time consuming. Multiplex real-time PCR (mr-PCR) enables testing the presence of several bacteria and reduces diagnosis time. Our objective was to estimate bacterial species-specific sensitivity (Se) and specificity of both BC and mr-PCR tests for detecting bacteria in milk samples from clinical mastitis cases and from apparently normal quarters, using a Bayesian latent class model. Milk samples from 1,014 clinical mastitis cases and 1,495 samples from apparently normal quarters were analyzed by BC and mr-PCR. Two positive culture definitions were used: ≥1 cfu/0.01 mL and ≥10 cfu/0.01 mL of the specified bacteria. The mr-PCR was designed to simultaneously detect Staphylococcus aureus, Streptococcus uberis, Escherichia coli, and Streptococcus agalactiae. The priors used in our Bayesian model were weakly informative, with BC priors using the best available error data. Results were compared with those obtained using uniform priors for mr-PCR to test robustness. Weak and uniform priors gave about the same posterior distributions except for Strep. uberis from normal quarters and Strep. agalactiae. Multiplex real-time PCR Se on milk from clinical mastitis were lower than mr-PCR Se on milk from normal quarters. Multiplex real-time PCR Se was higher than BC on milk from normal quarters. Multiplex real-time PCR Se was generally lower than BC on milk from clinical mastitis and it varied by clinical severity. The estimate specificities of detection for all pathogens were ≥99%, regardless of sample type. The effect of milk sample preservation before testing was evaluated and may have been a factor that affected our observed results. A significant association was observed between sample age and mr-PCR results leading to reduced detection of E. coli and Strep. agalactiae in nonclinical samples. Differences in sample age between conduct of BC and of mr-PCR did not concur with any apparent differences between Se estimates of the 2 tests. Further work should be done to extend these results to other PCR-based tests for detecting bacterial species in milk samples, for which presented results could be used as prior parameter distributions. Limits of sample handling and storage and the potential existence of substances in clinical case samples that may interfere with PCR reactions also are worth further investigation.

Human exposure from dioxins in soil

Dioxins are a family of chemical compounds that has received considerable attention, both historically and currently. This article reviews scientific field studies that examine the relationship between living on soil contaminated with dioxins and the level of dioxins in people's serum, with an emphasis on the University of Michigan Dioxin Exposure Study (UMDES), the largest and most comprehensive study of its kind. These studies conclude that the levels of dioxins in serum are most strongly correlated with age, gender, body mass index, weight loss, breast feeding, and smoking. Levels of dioxins in soil are not significant predictors for dioxin concentrations in serum. The increase in serum dioxin levels that is seen with age results from historic exposure and does not represent ongoing exposure. Based on the scientific field studies conducted to date, it appears that, in the absence of the consumption of contaminated animal products, there is little evidence of ongoing exposure from contaminated soil.

Statistical comparison of residential soil concentrations of PCDDs, PCDFs, and PCBs from two communities in Michigan

The University of Michigan dioxin exposure study was undertaken to address concerns that the industrial discharge of dioxin-like compounds in the Midland, MI area had resulted in contamination of soils in the Tittabawassee River floodplain and downwind of the incinerator. The study was designed in a rigorously statistical manner comprising soil measurements of 29 polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), and polychlorinated biphenyls (PCBs) from 766 residential properties, selected probabilistically, in the Midland area and in Jackson and Calhoun Counties (Michigan) as a background comparison. A statistical comparison determined that the geometric mean toxic equivalent (TEQ) levels in samples from the target populations were statistically significantly above background. In addition, the probabilities of being above the 75th and 95th percentiles of background were also greater. Congener contributions to the TEQ were dominated by 2,3,4,7,8-PeCDF and 2,3,7,8-TCDF in the floodplain and by 2,3,7,8-TCDD in the incinerator plume. However, PCB 126 was the top congener contributing to the background TEQ. On the basis of statistical inference to the total population, it was estimated that about 36% of the properties in the floodplain and incinerator plume have at least one soil sample over the Michigan Department of Environmental Quality's soil direct contact criterion of 90 pg/g TEQ.

Association of intradialytic blood pressure changes with hospitalization and mortality rates in prevalent ESRD patients

The relationship between blood pressure (BP) and clinical outcomes among hemodialysis patients is complex and incompletely understood. This study sought to assess the relationship between blood pressure changes with hemodialysis and clinical outcomes during a 6-month period. This study is a secondary analysis of the Crit-Line Intradialytic Monitoring Benefit Study, a randomized trial of 443 hemodialysis subjects, designed to determine whether blood volume monitoring reduced hospitalization. Logistic regression was used to estimate the association between BP changes with hemodialysis (Deltasystolic blood pressure=postdialysis-predialysis systoic BP (SBP) and the primary outcome of non-access-related hospitalization and death. Subjects whose systolic blood pressure fell with dialysis were younger, took fewer blood pressure medications, had higher serum creatinine, and higher dry weights. After controlling for baseline characteristics, lab variables, and treatment group, subjects whose SBP remained unchanged with hemodialysis (N=150, DeltaSBP -10 to 10 mm Hg) or whose SBP rose with hemodialysis (N=58, DeltaSBP > or =10 mm Hg) had a higher odds of hospitalization or death compared to subjects whose SBP fell with hemodialysis (N=230, DeltaSBP < or =-10 mm Hg) (odds ratio: 1.85, confidence interval: 1.15-2.98; and odds ratio: 2.17, confidence interval: 1.13-4.15). Subjects whose systolic blood pressure fell with hemodialysis had a significantly decreased risk of hospitalization or death at 6 months, suggesting that hemodynamic responses to dialysis are associated with short-term outcomes among a group of prevalent hemodialysis subjects. Further research should attempt to elucidate the mechanisms behind these findings.

Designing clinical trials on energy healing: ancient art encounters medical science

Demand for energy healing is growing rapidly in the United States. Until recently, however, few clinical trials have been conducted to investigate its clinical efficacy, risks, and cost-effectiveness. This article discusses principles underlying the research design of clinical trials on energy healing, based on the experience of an interdisciplinary team conducting a large-sample clinical study on qigong funded by the National Institutes of Health. The first part overviews the background and contemporary practice of qigong therapy. The second addresses some difficulties and unique issues to be considered in designing a clinical trial on energy healing. These issues include research emphasis on outcome versus mechanism, randomization, control, expectations/placebo effects, staff and practitioner bias/conflict of interest, patients' belief, selection bias, intent-to-treat analysis, ethics, informed consent, sample size, and outcome report. The ultimate goal is to promote more scholarly and clinical discussion on the evaluation of energy healing.

Urinary tract infection among women aged 40 to 65: behavioral and sexual risk factors

We conducted a case-control study to explore the role of health behavior and sexual and medical history on urinary tract infection (UTI) risk among otherwise healthy women aged 40-65. Cases and controls were recruited from nine practices and clinics in Michigan and a single clinic in Israel. In both countries, several factors were reported significantly more frequently among UTI cases than controls: a previous UTI within 12 months, incontinence symptoms, a recent episode of 30-plus minutes of cold hands, feet, back or buttocks, and recent antibiotic use. Cases were less likely than controls to report recent estrogen use, but the results were only statistically significant in Michigan. Sexual activity during the previous 2 weeks and having ceased menses were modestly, but not statistically significantly, protective at both study sites. Risk factors for UTI among women 40-65 differ from those for younger women and these differences cannot be attributed solely to changes in menopausal status.

Oxygen desaturation on the six-minute walk test and mortality in untreated primary pulmonary hypertension

There are no reliable predictors of mortality in primary pulmonary hypertension (PPH). This study assessed whether exercise oxygen desaturation and distance achieved during a six-minute walk are associated with mortality in moderately symptomatic patients with PPH. Thirty-four patients with PPH underwent a pretreatment six-minute walk test, and an invasive haemodynamic assessment of pulmonary vasodilator reserve, to select the best treatment option (epoprostenol in 27 and nifedipine in 7). Median follow-up was 26 months (12 months for the nonsurvivors was 26%), and median survival, >46 months by Kaplan-Maier estimate. The mean+/-SD distance walked was 275+/-155 m and reduction in arterial oxygen saturation (Sa,O2) at maximal distance (deltaSa,O2) was 8.4+/-4.5%). A distance < or =300 m increased mortality risk by 2.4, and a deltaSa,O2 of > or = 10% increased mortality risk by 2.9. Only Sa,O2 at peak distance, deltaSa,O2 and pulmonary vascular resistance (PVR) were related to mortality. After adjusting for PVR, there remained a 27% increase in risk of death for each per cent decrease in Sa,O2. The six-minute walk distance and exercise oxygen saturation may be helpful in selecting patients with primary pulmonary hypertension for whom transplant listing is appropriate.

Diagnostic value of resting tricuspid regurgitation velocity and right ventricular ejection flow parameters for the detection of exercise induced pulmonary arterial hypertension

Our objectives were to evaluate resting tricuspid regurgitation velocity (TRV) and right ventricular outflow tract velocity curve (RVOTvc) profiles as markers for development of exercise induced pulmonary arterial hypertension (ExPHT). ExPHT is an elusive cause of dyspnea and fatigue. When present, Doppler echocardiography can detect and quantify elevated pulmonary pressure. However, the characteristics and diagnostic value of resting TRV and RVOTvc indices in patients with ExPHT have not been fully addressed. The study population consisted of 52 subjects (mean age 40.5 +/- 10.9, range 22-68 years) and was divided into three subsets as follows: 1. Patients (n = 22) with overt pulmonary hypertension (PHT), 2. Patients (n = 8) with ExPHT, 3. Healthy, asymptomatic volunteers (n = 22). RVOTvc indices included: Mean and peak velocity, systolic velocity time integral (VTI); velocity time integral at peak velocity (VTImax), acceleration time; ejection time. TRV was used as an index of pulmonary artery systolic pressure. There were significant differences between normals and ExPHT for TRV, acceleration time, VTI(Vmax). TRV and VTImax were predictive of EXPHT in a logistic regression model.

CONCLUSION

(1) Patients with ExPHT have distinct Doppler velocity patterns suggesting the presence of a compromised pulmonary vascular bed even with normal pulmonary pressure at rest. (2) TRV and RVOTvc indices have potential diagnostic value in the early detection of ExPHT.

Respiratory symptoms in mothers of young children

OBJECTIVES

Children receiving child care outside the home are at greater risk of upper respiratory infection, but whether parents of those children are also at increased risk is undocumented. We describe the incidence of 2 or more respiratory symptoms in the previous 2 weeks among 185 mothers of children 3 years of age or younger by child care use.

METHODS

Mothers in Michigan and Nebraska were interviewed by phone regarding respiratory symptoms, use of outside child care (for an index child), sleeping habits, and demographic information.

RESULTS

Nearly one half (46.5%) reported 2 or more symptoms during the past 2 weeks; 15.1% had contacted a health care provider and 13.0% spent 1 or more days in bed because of their symptoms, which lasted an average of 5.5 days. Prevalence of symptoms was invariant to sociodemographic characteristics. Mothers using outside child care (74.6%) were twice as likely as those without outside care to have been ill in the past 2 weeks (odds ratio: 2.26; 95% confidence interval [CI]: 1.12,4.54). Most mothers (69.2%) reported having their sleep interrupted by their children at least once in the last 2 weeks or sharing a bed with a child part or all of the night (61.1%); 25.4% slept 6 hours or less nightly. Women reporting that they rarely or never felt rested (26. 5%) were 2.65 times more likely to be ill (95% CI: 1.26,5.55), compared with those reporting that they frequently or always felt rested (46.5%), after adjusting for any outside child care.

CONCLUSIONS

Future studies should focus on risk factors that can be modified to reduce illness among both children and their parents.

Urinary tract infection: self-reported incidence and associated costs

PURPOSE

To estimate the annual incidence, cumulative probability of presumed urinary tract infection (UTI) by age, and the social costs.

METHODS

Analysis of a random digit dialing survey of 2000 women in the United States.

RESULTS

10.8 percent (95% CI: 9.4, 12.1%) of women aged 18 and older reported at least one presumed UTI during the past 12 months, with the majority of the cases occurring among women with a history of two or more UTI episodes in their life. We estimate that by age 24, one-third of women will have at least one physician-diagnosed UTI that was treated with prescription medication. Overall, an estimated 11.3 million women in the United States had at least one presumed UTI treated with antibiotics in 1995. We estimate the annual cost of UTI cases with prescriptions to be $1.6 billion in 1995. If the costs occurring after 1995 are discounted at 5% annually, the total cost over 20 years has a present value of $25.5 billion.

CONCLUSION

If a vaccine were developed that would prevent either initial or recurrent UTI the net benefits to society would be substantial, even at a developmental cost of one billion dollars.

Improved sealant retention with bonding agents: a clinical study of two-bottle and single-bottle systems

Recent in vitro work and a short clinical study suggest that adding a bonding agent layer between sealant and saliva-contaminated enamel allows for adequate bond strength and retention of resin sealants and may improve success of all sealant applications. This five-year clinical study scored 617 occlusal and 441 buccal/lingual molar sealants, with use of a split-mouth design, with half receiving sealant alone and half bonding agent plus sealant. Treatment effects and potential risk factors for sealant failure were tested by means of a Cox regression model. Three bonding agent groups were analyzed for treatment effect: Tenure primer, Scotchbond Multi-Purpose, and 3 single-bottle dentin bonding agents as a third group. The single-bottle group was successful in reducing risk of sealant failure, with a hazard ratio (HR) of 0.53 (p = 0.014) for occlusal and 0.35 (p = 0.006) for buccal/lingual sealants. Scotchbond was detrimental to occlusal sealant success, with a HR of 2.96 (p = 0.0003). Tenure primer was neutral, showing HRs close to 1.0. Variables that affected success differed between occlusal and buccal/lingual sealants, suggesting that failures on these two surfaces may be dependent upon differing factors. Early eruption stage was a significant risk factor for both surfaces (HR = 2.91, p = 0.00001, occlusal; and HR = 1.52, p = 0.015, buccal/lingual). Behavior (HR = 1.96, p = 0.0007), salivary problems (HR = 1.73, p = 0.002), and visually apparent variations in enamel (HR = 1.51, p = 0.018) were significant risk factors for occlusal sealants only. In addition to completing detailed analyses of risk factors for sealant survival, this study shows that single-bottle bonding agents protect sealant survival, yielding half the usual risk of failure for occlusal sealants and one-third the risk of failure for buccal/lingual sealants.

Nonglassy kinetics in the folding of a simple single-domain protein

Theory suggests that the otherwise rapid folding of simple heteropolymer models becomes "glassy"-dominated by multiple kinetically trapped misfolded states-at low temperatures or when the overall bias toward the native state is reduced relative to the depth of local minima. Experimental observations of nonsingle-exponential protein-folding kinetics have been taken as evidence that the protein-folding free energy landscape is similarly rough. No equivalent analysis, however, has been reported for a simple single-domain protein lacking prolines, disulfide bonds, prosthetic groups, or other gross structural features that might complicate folding. In an effort to characterize the glassiness of a folding free energy landscape in the absence of these potentially complicating factors, we have monitored the folding of a kinetically simple protein, peptostreptococcal protein L (protein L). We observe no statistically significant deviation from homogeneous single-exponential relaxation kinetics across temperatures ranging from near the protein's melting temperature to as low as -15 degrees C. On the basis of these observations, we estimate that, if there is a glass transition in the folding of protein L, it occurs at least 45 degrees C and possibly more than 145 degrees C below the freezing point of water. Apparently the folding free energy landscape of protein L is extremely smooth, which may be indicative of a rate-limiting step in folding that is, effectively, a nonglassy process.

Risk factors for second urinary tract infection among college women

To better understand the etiology of recurrent urinary tract infection (UTI), the authors followed a cohort of 285 female college students with first UTI for 6 months or until second UTI. A first UTI due to Escherichia coli was followed by a second UTI three times more often than was a non-E. coli first UTI (24 vs. 8%; p = 0.02). In a logistic regression analysis limited to the 224 women from the University of Michigan Health Service and the University of Texas at Austin Health Service from September 1992 to December 1994, with a first UTI due to E. coli, vaginal intercourse increased the risk of a second UTI with both a different (odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.19, 2.15) and the same (OR = 1.37, 95% CI: 0.91, 2.07) uropathogen, as did using a diaphragm, cervical cap, and/or spermicide (same uropathogen: OR = 1.53, 95% CI: 0.95, 2.47; different uropathogen: OR = 1.77, 95% CI: 1.22, 2.58). Condom use decreased the risk of a second UTI caused by a different uropathogen (OR = 0.68, 95% CI: 0.48, 0.99) but had no effect on a second UTI caused by the same E. coli (OR = 0.99; 95% CI: 0.66, 1.50). Type or duration of treatment was not associated with a second UTI. Although the risk of second UTI is strongly influenced by sexual behavior, women with a first UTI caused by E. coli are more likely than are those with a non-E. coli first UTI to have a second UTI within 6 months.

Birth weight references for twins

OBJECTIVE

We sought to formulate fetal and birth weight references for twins from longitudinal data.

STUDY DESIGN

This historic cohort study was based on 1831 pregnancies of twins born alive at >/=28 weeks' gestation from Baltimore, Maryland; Miami, Florida; Charleston, South Carolina; and Ann Arbor, Michigan.

RESULTS

When we compared singletons and twins, the percentiles of twins fell substantially below the 10th percentile of singletons by 28 weeks' gestation, below the 50th percentile by 30 weeks' gestation, and below the 90th percentile by 34 weeks' gestation. The difference at the 50th percentile was 147 g (10%) at 30 weeks' gestation, 242 g (14%) at 32 weeks' gestation, 347 g (17%) at 34 weeks' gestation, 450 g (19%) at 36 weeks' gestation, 579 g (22%) at 38 weeks' gestation, and 772 g (27%) at 40 weeks' gestation.

CONCLUSION

This new reference demonstrates that, although the overall pattern of fetal growth is slower for twins versus singletons from about 30 weeks' gestation, well-grown twins and singletons do not differ as much as previously believed.

Candida vaginitis: self-reported incidence and associated costs

BACKGROUND AND OBJECTIVES

Incidence of Candida vaginitis by age and racial or ethnic group is poorly described.

GOAL

Estimate incidence, cumulative probability of presumed C vaginitis by age, racial or ethnic group, and associated costs.

STUDY DESIGN

Random digit-dialing survey of 2000 US women.

RESULTS

A total of 6.5 percent (95% CI, 5.4-7.5%) of women older than 18 years reported a least one episode of presumed C vaginitis during the previous 2 months. Women reporting a 1-year period with four or more episodes comprised 8.0% of the sample but accounted for 37.2% of women reporting episodes. Black women reported approximately three times more yeast infections in the previous 2 months (17.4%; 95% CI, 11.2-23.5%) than white women (5.8%; 95% CI, 4.7-6.9%).

CONCLUSION

The high incidence and the propensity for recurrence underscore the need for a better understanding of the epidemiology and pathogenesis, and stress the need for the development of more accurate, rapid diagnostics and effective treatments.

The energetics of T4 lysozyme reveal a hierarchy of conformations

We have used native state exchange to examine the energy landscape of the well-characterized protein T4 lysozyme. Although the protein exhibits two-state behavior by traditional probes, the energy landscape determined here is much more complex. The average stability of the C-terminal subdomain is significantly higher than that for the N-terminus suggesting at least two regions of unfolding. At a more detailed level, there appears to be a broad continuum of stabilities throughout each region. The overall subdomain hierarchy of energies does not mirror data on the folding pathway for this protein, challenging the relationship between energy landscapes and folding trajectories.

FDA evaluations using in vitro metabolism to predict and interpret in vivo metabolic drug-drug interactions: impact on labeling

Recent advances in in vitro metabolism methods have led to an improved ability to predict clinically relevant metabolic drug-drug interactions. To address the relationships of in vitro metabolism data and in vivo metabolism outcomes, the Office of Clinical Pharmacology and Biopharmaceutics in the Center for Drug Evaluation and Research, Food and Drug Administration, evaluated a number of recently approved new drug applications. The goal of these evaluations was to determine the contribution of in vitro metabolism data in (1) predicting in vivo drug-drug interactions, (2) determining the need to conduct an in vivo drug-drug interaction study, and (3) incorporating findings into drug product labeling. Ten cases are presented in this article. They fall into two major groups: (1) in vitro data were predictive of in vivo results, and (2) in vitro data were not predictive of in vivo results. Discussion of these cases highlights factors limiting predictability of in vivo metabolic interactions from in vitro metabolism data. The integration of these findings into drug product labeling is also discussed.

Regulation of phosphatase activity in bacterial chemotaxis

Bacterial chemotaxis is the most studied model system for signaling by the widely spread family of two-component regulatory systems. It is controlled by changes in the phosphorylation level of the chemotactic response regulator, CheY, mediated by a histidine kinase (CheA) and a specific phosphatase (CheZ). While it is known that CheA activity is regulated, via the receptors, by chemotactic stimuli, the input that may regulate CheY dephosphorylation by CheZ has not been found. We measured, by using stopped-flow fluorometry, the kinetics of CheZ-mediated dephosphorylation of CheY. The onset of dephosphorylation was delayed by approximately 50 ms after mixing phosphorylated CheY (CheY approximately P) with CheZ, and a distinct overshoot was observed in the approach to the new steady state of CheY approximately P. The delay and overshoot were not observed in a hyperactive mutant CheZ protein (CheZ54RC) that does not support chemotaxis in vivo and appears to be constitutively active. CheZ activity was cooperative with respect to CheY approximately P, with a Hill-coefficient of 2.5. The observed delayed modulation of CheZ activity and its cooperativity suggest that the phosphatase activity is regulated at the level of CheY approximately P-CheZ interaction. This novel kind of interplay between a response regulator and its phosphatase may be involved in signal tuning and in adaptation to chemotactic signals.

The importance of early weight gain in the intrauterine growth and birth weight of twins

OBJECTIVE

It was our objective to evaluate the association between early maternal weight gain (before 20 weeks), midpregnancy weight gain (20-28 weeks), and late pregnancy weight gain (28 weeks to birth) with fetal growth and birth weight in twins.

STUDY DESIGN

This historic cohort study was based on 1564 births of live twins >/=28 weeks' gestation from Baltimore, Maryland, Miami, Florida, Charleston, South Carolina, and Ann Arbor, Michigan.

RESULTS

Early fetal growth was affected only by smoking and chorionicity. Factors in models of both mid and late fetal growth included maternal age, pregravid weight, parity, rates of early pregnancy and midpregnancy maternal weight gain, smoking, and pre-eclampsia. Increased midpregnancy fetal growth was associated with early maternal weight gain (10.91 g/wk per pound per week) and midpregnancy maternal weight gain (15.89 g/wk per pound per week). Increased late fetal growth was associated with early maternal weight gain (16.86 g/wk per pound per week) and midpregnancy maternal weight gain (23.88 g/wk per pound per week). Increased birth weight was associated with early (283.02 g per pound per week), mid (163.58 g per pound per week), and late (69.76 g per pound per week) maternal weight gains.

CONCLUSIONS

These findings confirm the importance of early maternal weight gain in twin fetal growth and birth weight.

Frequency and response to vaginal symptoms among white and African American women: results of a random digit dialing survey

The prevalence of vaginal symptoms and response to those symptoms in a nonclinic setting has not been previously described. Two thousand women living throughout the United States identified by random digit dialing completed a computer-assisted telephone interview about history of vaginal symptoms and use of healthcare services in response to these symptoms. The analysis was limited to 1698 white (WA) and 144 African American (AA) women (n = 1842). An episode of vaginal symptoms of any severity during 1995 was reported by 7.5% of WA women and 18.1% of AA women. Fifty-five percent of WA women and 83% of AA women with symptoms consulted a healthcare professional about their most recent episode. The racial difference in prevalence and consultation was not explained by marital status, education, employment, or lifetime number of sex partners. Most women purchased an over-the-counter antifungal preparation to treat their symptoms, whether or not a physician was consulted. The racial differences in prevalence and use of health services in response to vaginal symptoms observed here should be confirmed, and the potential causes should be explored.

A model for the number of cores per prostate biopsy based on patient age and prostate gland volume

PURPOSE

The systematic sextant biopsy is currently the gold standard for the tissue diagnosis of prostate cancer. However, it is unknown whether this 6 core approach provides optimal sampling of all prostate glands in men of all ages. The goal of the current study was to determine the appropriate number of cores per prostate biopsy based on patient age and prostate gland volume.

MATERIALS AND METHODS

Patient age and tumor volume doubling time were used to calculate life threatening, clinically significant tumor volumes at diagnosis for 5-year intervals of patient age. A mathematical model was created to determine the minimum number of cores necessary to identify these life threatening tumor volumes in prostate glands 10 to 80 cm.3 without detecting clinically insignificant cancers.

RESULTS

Younger men and men with larger prostate glands require more than 6 cores to ensure the diagnosis of life threatening prostate cancer. These prostates are currently under sampled by sextant biopsy. In a select group of older men who require fewer than 6 cores sextant biopsy may over sample these prostates and lead to over treatment.

CONCLUSIONS

The standard sextant biopsy provides optimal sampling of only a minority of prostate glands. An approach to prostate biopsy based on patient age and prostate gland volume maximizes the detection of clinically significant prostate cancer.

Critical periods of maternal weight gain: effect on twin birth weight

OBJECTIVE

Our purpose was to evaluate the association between maternal weight gain and twin birth weight.

STUDY DESIGN

This historic cohort study was based on 646 live-born twin births of > or = 28 weeks from Baltimore, Maryland, Miami, Florida, and Ann Arbor, Michigan. The sum of twin-pair birth weight was modeled as a function of either net maternal weight at delivery or rates of maternal weight gain with use of multiple regression.

RESULTS

Birth weight was significantly associated with weight gain before 20 weeks in underweight women, before 20 weeks and after 28 weeks in overweight women, and during all three gestational periods in normal-weight women. Weight gain before 20 weeks had the largest effect on infants of underweight women, less of an effect on infants of normal-weight women, and half as much effect on infants of overweight women. Weight gain after 28 weeks significantly affected the infant birth weights of normal-weight and overweight women, but the effect was half as great among infants of the latter group.

CONCLUSIONS

These findings suggest that weight gain during critical periods of gestation significantly influences twin birth weight; these critical periods vary by maternal pregravid weight status.

Condom use and first-time urinary tract infection

We evaluated the effects of condom use, lubricated condom use, and spermicide use on risk of acquiring first urinary tract infection in a case-control study of sexually active college women ages 18-39 years. Cases (N = 144) were women with first urinary tract infection that was confirmed by culture recruited at the student health service; controls (N = 286) were women without a history of urinary tract infection who were randomly sampled from all women enrolled at the university. Participants completed a self-administered questionnaire regarding type and frequency of condom use during the previous 2 weeks. Condoms and spermicides usually were used in combination with each other or oral contraceptives. After adjusting for frequency of vaginal intercourse, using unlubricated condoms compared with using no birth control method strongly increased the risk of first urinary tract infection (odds ratio = 29.1; 95% confidence interval = 3.1-1,335). Using a lubricated condom (with or without spermicide in the lubricant) or a spermicidal cream or gel with an unlubricated condom was associated with two- to eightfold risk of first urinary tract infection. Unlubricated condom use was strongly associated with risk of first urinary tract infection, but this effect was largely neutralized by using a spermicidal cream or gel with the unlubricated condom or by using a lubricated condom.

Virulence characteristics of Escherichia coli causing first urinary tract infection predict risk of second infection

Escherichia coli causes most urinary tract infections (UTIs) in ambulatory populations. Several bacterial virulence factors occur more frequently among urinary E. coli isolates than among fecal isolates, but none have been reported to predict risk of second UTIs. DNA hybridization was used to characterize the bacterial virulence profiles of urinary E. coli isolates from 174 women with first UTI and compared for risk of second UTI. Of the women, 28 (16%) had a culture-confirmed second UTI within 6 months of a negative test-of-cure. Three virulence factors were associated with a significantly lower risk of second UTI: cytotoxic necrotizing factor (relative risk [RR] = 0.0; 95% confidence interval [CI], 0.0, 0.42); hemolysin (RR, 0.10; 95% CI, 0.01, 0.69), and S fimbrial adhesin (RR, 0.25; 95% CI, 0.06, 1.00). Dr binding was associated with a 2-fold increased risk of second UTI (RR, 2.30; 95% CI, 1.23, 4.29). Half of all paired first and second UTI isolates from the same subject were apparently the same.