Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement

IMPORTANCE

Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence.

OBJECTIVE

To construct a clinical guideline for pyogenic osteomyelitis management, with a new standard of evidence to resolve the gap between strength of recommendation and quality of evidence, through the use of a novel open access approach utilizing social media tools.

EVIDENCE REVIEW

This consensus statement and systematic review study used a novel approach from the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. In June 2021 and February 2022, authors recruited via social media conducted multiple PubMed literature searches, including all years and languages, regarding osteomyelitis management; criteria for article quality and inclusion were specified in the group's charter. The GRADE system for evaluating evidence was not used based on previously published concerns regarding the potential dissociation between strength of recommendation and quality of evidence. Instead, the charter required that clear recommendations be made only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were drafted to discuss pros and cons of care choices. Both clear recommendations and clinical reviews were planned with the intention to be regularly updated as new data become available.

FINDINGS

Sixty-three participants with diverse expertise from 8 countries developed the group's charter and its first guideline on pyogenic osteomyelitis. These participants included both nonacademic and academic physicians and pharmacists specializing in general internal medicine or hospital medicine, infectious diseases, orthopedic surgery, pharmacology, and medical microbiology. Of the 7 questions addressed in the guideline, 2 clear recommendations were offered for the use of oral antibiotic therapy and the duration of therapy. In addition, 5 clinical reviews were authored addressing diagnosis, approaches to osteomyelitis underlying a pressure ulcer, timing for the administration of empirical therapy, specific antimicrobial options (including empirical regimens, use of antimicrobials targeting resistant pathogens, the role of bone penetration, and the use of rifampin as adjunctive therapy), and the role of biomarkers and imaging to assess responses to therapy.

CONCLUSIONS AND RELEVANCE

The WikiGuidelines approach offers a novel methodology for clinical guideline development that precludes recommendations based on low-quality data or opinion. The primary limitation is the need for more rigorous clinical investigations, enabling additional clear recommendations for clinical questions currently unresolved by high-quality data.

[Vasonatrin peptide attenuates hypoxia-induced increase in [Ca(2+)] (i) of culured rat cardiac fibroblasts]

The purpose of this work was to test the hypothesis that vasonatrin peptide (VNP) can attenuate the growth-promoting effect by hypoxia in cardiac fibroblasts of cultured neonatal rats. Cultured fibroblasts were divided into four groups: control group, hypoxia group, VNP group and VNP+hypoxia group. The growth of cardiac fibroblasts was observed using MTT method and the incorporation of (3)H-TdR, and the effect of VNP on the intracellular level of Ca(2+) was measured by means of interactive laser cytometry. It was found that hypoxia (2% - 3%) increased significantly the MTT optical density (OD) of cardiac fibroblasts (P<0.05 vs control group), but the increase was greatly attenuated in the VNP (10(- 6)mol/L) group and also the incorporation of (3)H-TdR in cardiac fibroblasts (P<0.05 vs hypoxia group). VNP (10(- 6)mol/L) also decreased the intracellular level of Ca(2+) which was increased by hypoxia (P<0.05) as compared with control and hypoxia group. These findings demonstrate that VNP can attenuate the hypoxia-induced growth-promoting effect in cardiac fibroblasts, which may be associated with the elevation of intracellular Ca(2+).

Binding of ATP to the fructose-2,6-bisphosphatase domain of chicken liver 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase leads to activation of its 6-phosphofructo-2-kinase

To understand the mechanism by which the activity of the 6-phosphofructo-2-kinase (6PF-2K) of chicken liver 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase is stimulated by its substrate ATP, we studied two mutants of the enzyme. Mutation of either Arg-279, the penultimate basic residue within the Walker A nucleotide-binding fold in the bisphosphatase domain, or Arg-359 to Ala eliminated the activation of the chicken 6PF-2K by ATP. Binding analysis by fluorescence spectroscopy using 2'(3')-O-(N-methylanthraniloyl)-ATP revealed that the kinase domains of these two mutants, unlike that of the wild type enzyme, showed no cooperativity in ATP binding and that the mutant enzymes possess only the high affinity ATP binding site, suggesting that the ATP binding site on the bisphosphatase domain represents the low affinity site. This conclusion was supported by the result that the affinity of ATP for the isolated bisphosphatase domain is similar to that for the low affinity site in the wild type enzyme. In addition, we found that the 6PF-2K of a chimeric enzyme, in which the last 25 residues of chicken enzyme were replaced with those of the rat enzyme, could not be activated by ATP, despite the fact that the ATP-binding properties of this chimeric enzyme were not different from those of the wild type chicken enzyme. These results demonstrate that activation of the chicken 6PF-2K by ATP may result from allosteric binding of ATP to the bisphosphatase domain where residues Arg-279 and Arg-359 are critically involved and require specific C-terminal sequences.

Multiple RGS proteins alter neural G protein signaling to allow C. elegans to rapidly change behavior when fed

Regulators of G protein signaling (RGS proteins) inhibit heterotrimeric G protein signaling by activating G protein GTPase activity. Many mammalian RGS proteins are expressed in the brain and can act in vitro on the neural G protein G(o), but the biological purpose of this multiplicity of regulators is not clear. We have analyzed all 13 RGS genes in Caenorhabditis elegans and found that three of them influence the aspect of egg-laying behavior controlled by G(o) signaling. A previously studied RGS protein, EGL-10, affects egg laying under all conditions tested. The other two RGS proteins, RGS-1 and RGS-2, act as G(o) GTPase activators in vitro but, unlike EGL-10, they do not strongly affect egg laying when worms are allowed to feed constantly. However, rgs-1; rgs-2 double mutants fail to rapidly induce egg-laying behavior when refed after starvation. Thus EGL-10 sets baseline levels of signaling, while RGS-1 and RGS-2 appear to redundantly alter signaling to cause appropriate behavioral responses to food.

[Comparison of inhibitory effects of three natriuretic peptides on the proliferation of pulmonary artery smooth muscle cells of rats]

The inhibitory effects of atrial natriuretic peptide (ANP), C-type natriuretic peptide (CNP) and vasonatrin peptide (VNP) on the proliferation of pulmonary artery smooth muscle cells (PASMCs) were compared in rats. Total protein and OD value of MTT were detected in cultured rat PASMCs to examine the influence of the three peptides on PASMC proliforation induced by phorbol 12-myristate 13-acetate (PMA). The results show that PMA (10( 9) 10( 7) mol/L) increased and VNP (10( 8) 10( 6) mol/L), ANP and CNP (10( 7) 10( 6) mol/L) decreased the total protein and OD value in a dose-dependent manner (P<0.05). The data above suggest that PMA stimulates the proliferation of PASMCs while the three peptides inhibit the proliferation induced by PMA. Of the three peptides VNP has the strongest inhibitory effect.

[Comparison of sensitivity of mental load assessment indexes]

Objective. To compare the sensitivities of indexes used in the assessment of mental load. Method. Twenty five indexes belonging to primary task performance, additional task performance, subjective rate and psychophysiological measure were recorded during performance of 11 different difficult tasks. Result. It showed that tracking error (ER), reaction time (RT), correct rate (CR), category scale (CS), multistage evaluation scale (MES), multi-dimensional scale (MDS), latency of P3 (LAT), inter beat interval (IBI), inter respiration interval (IRI) and blink rate (BR) were significantly different among the various tasks. CS, MES and MDS were more sensitive to the total load; ER, LAT, IBI and IRI were more sensitive to the load of primary task, while RT and CR to that of additional task and BR to the visual load. Conclusion. It demonstrated that the sensitivities of the various indexes are different and the information are limited. Multi-indexes may be preferred for mental load assessment.

Intrathymic delta selection events in gammadelta cell development

The major pathway of gammadelta cell development is shown to be regulated by in-frame rearrangements at the T cell receptor (TCR) delta locus. Such "delta selection" occurs at or around the same point in thymocyte development as selection for in-frame rearrangements at the TCRbeta locus. However, there are at least two major differences with beta selection: first, delta selection commonly involves selection on the cognate TCR chain, gamma, suggesting that there is no "preTgamma" chain of major biological significance; second, most gammadelta-selected thymocytes differentiate rather than proliferate. Nonetheless, some delta selection events seemingly facilitate thymocyte expansion, similar to alphabeta T cell development. In these cases, TCRgamma selection is less obvious. Furthermore, the capacity of individual gamma chains to facilitate gammadelta selection is shown to vary with developmental age. The results further clarify early T cell development at the beta selection/delta selection stage and place clear constraints on models of cell fate determination.

Expression of chicken liver 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase in Escherichia coli

Chicken liver 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase was expressed in E. coli by using a pET3a T7 RNA polymerase-based expression system and was purified to homogeneity. The kinase and bisphosphatase of the expressed bifunctional enzyme had kinetic properties identical to those of the native chicken liver enzyme. However, the kinase activity of the chicken liver enzyme was 7-fold higher, while the bisphosphatase activity was 50 percent lower than those of the rat liver enzyme. Cys-256 of the rat liver bisphosphatase domain is not conserved in the chicken liver enzyme. A site-directed mutation was engineered at Cys-256 of the rat liver enzyme and the results indicate that the variation of this residue is not responsible for the difference in fructose-2,6-bisphosphatase activity between the rat and chicken liver enzymes. It is postulated that the difference in the kinase/bisphosphatase activity ratios of these two enzymes results from differences in their NH2-terminal regions.