Molecular diversity and genetic organization of antibiotic resistance in Klebsiella species

Klebsiella spp. are opportunistic pathogens that cause hospital and community acquired infections such as pneumonia, urinary tract infection, septicaemia, soft tissue infections, liver abscess, and meningitis. Multidrug-resistant strains possessing extended-spectrum β-lactamases (ESBLs) has become an increasing problem worldwide. The over use and, in some cases, misuse of antibiotics in humans and in animal husbandry has been cited as a responsible factor in the development of drug resistance in all bacterial species. The advancing age; female gender, hospital crossinfection, the food chain trade and human migrations have contributed to increase the risk for community-acquired ESBL. A total of 223 isolates collected in 2006 and 2007 at Royal Infirmary of Edinburgh, Scotland, 219 K. pneumoniae, 2 K. oxytoca, 1 Enterobacter cloacae, and one isolate Salmonella enterica were identified by API 20E and confirmed genotypically with gyrA PCR-RFLP method. The antimicrobial susceptibility results showed that 34 (15.2%), 36 (16.1%), 35 (15.7%), 45 (20.2%), 30 (13.5%) and 55 (24.7%) of these strains were found to be resistant to cefotaxime, ceftazidime, ceftriaxone, naladixic acid, ciprofloxacin and cefoxitin. None of the isolates were found resistant to meropenem keeping carbapenems the drug of choice for the treatment of multiresistant isolates. The overall frequency of ESBL producers observed in this study was 35 (15.7%) most of them 32/35 (91.4%) were from K. pneumoniae. The genetic analysis showed that SHV β-lactamases were detected in 32, whereas TEM and CTX-M were detected in 24 and 16 respectively. From the ESBL-producing isolates, molecular methods identified nine strains possessing ESBL-SHV genes (1 strain blaSHV-5, 1 strain blaSHV-80 and 8 strains blaSHV-12), whereas the remaining were from the “non-ESBL” producing strains. Conjugation methods demonstrated that 29/32 isolates harboured transferable blaSHV genes. The large SHV transposon-borne promoters were amplified from only one non-transferable blaSHV-11, 15 isolates produced the small SHV transposon-borne promoters. Furthermore, the IS26 was found 73bp upstream of the blaSHV gene in all small SHV transposon-borne promoters. A new blaLEN gene was identified from K. pneumoniae (KpII) phylogenetic group but remained susceptible to all cephalosporins. Sixteen (7.3%) of K. pneumoniae isolates were found to be producers of the CTX-M- 15 ESBL, of which two isolates (12.5%) were reported to be from communityacquired infections. The insertion sequence ISEcp1 was detected by sequencing 48 nucleotides upstream of blaCTX-M-15 in all isolates but one. Five different clones of CTX-M-15-producing isolates were identified by PFGE. The findings indicated a higher prevalence of qnr genes than in previous studies but still low in general. By PCR, 18 (8%) (11 qnrB1, 2 qnrB6 and 5 qnrA1) genes were identified from K. pneumoniae isolates. Also, the findings indicated the frequent coexpression of fluoroquinolones and ESBLs resistance in the same isolate. Two K. oxytoca strains were isolated from urine and blood specimens of hospitalized patients. Both strains were positive for the blaOXY-2 gene. One strain showed resistance to pencillins, monbactams, cephalosporins including cefotaxime and ceftazidime but was not inhibited by clavulanic acid. It differed by an amino acid substitution Ala237→Thr, which enhances the binding of cefotaxime. S1-nuclease plasmid profiles were obtained for some isolates. A total of one to two plasmids, ranging in size from approximately 40 to 210 kb, were observed per strain. The plasmids from 24 ESBL K. pneumoniae strains were assigned to be IncN or IncFII replicons. Analysis of phylogenetic groups showed that the majority of K. pneumoniae isolates were belonged to KpI-type. Both K. oxytoca strains were assigned to be KoII phylogenetic group based on rpoB and gyrA sequencing. Integrons are capable of capturing and mobilizing genes called gene cassettes which play an important role in the dissemination of antimicrobial resistance through horizontal transmission. In fact, the present study indicated a high frequency of occurrence of class 1 integrons among ESBL-positive K pneumoniae. Three isolates positive for class 1 integrons were found positive for class 2 integrons as well. Class 1 integrons including dfr, aadA and ereA2 gene cassettes have been identified by sequencing, which confer resistance to trimethoprim, streptomycin/spectinomycin and erythromycin respectively. In conclusion, the results from this thesis report the emergence of hospital and community-acquired highly resistant CTX-15 β-lactamase in the Edinburgh, Scotland. The prevalence of ESBL-producing isolates in Scotland is still much lower than in many other European countries. The dissemination of SHV- and TEM- β- lactamase types in this study is more predominate than CTX-M-15

Association of soluble E-selectin and morning blood pressure surge in patients with essential hypertension

BACKGROUND: Elevated soluble E-selectin which reflects a state of endothelial activation with subsequent vasoconstriction may elevate morning blood pressure (BP) surge. This study aimed to analyze soluble E-selectin serum concentrations in patients with essential hypertension against normotensive healthy individuals and to find a role of such molecule in the phenomenon of morning BP surge. MATERIAL AND METHODS: In this case-control study, a 24-hour ambulatory blood pressure monitoring with recording of morning BP surge and serum soluble E-selectin levels were measured for a total of 90 patients (60 patients with essential hypertension and 30 normotensive subjects as a control). RESULTS: Hypertensive patients had higher body mass index in comparison to control subjects (30.7 ± 2.3 kg/m² vs. 27 ± 3.2 kg/m², p < 0.001). Serum uric acid levels were higher in hypertensive patients than control subjects (7.26 ± 2.60 mg/dL vs. 5.92 ± 1.15 mg/dL, p = 0.028). Hypertensive patients had higher left ventricular mass index (LVMI) (110.5 ± 19.2 g/m2 vs. 99.8 ± 9.5 g/m², p = 0.001). Patients with essential hypertension have higher level of soluble E-selectin than normotensive participants (180.6 ± 96.1 vs. 75.9 ± 31.5 ng/mL, p < 0.001). Soluble E-selectin was positively correlated with morning BP surge (r = 0.696, p ≤ 0.001). CONCLUSION: Patients with essential hypertension have higher level of soluble E-selectin than normotensive. Soluble E-selectin was positively correlated with morning BP surge

A room‐based diagnostic imaging system for measurement of patient setup

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135081/1/mp8461.pd

Antidepressant-Like Effect of Selected Egyptian Cultivars of Flaxseed Oil on a Rodent Model of Postpartum Depression

Flaxseed (Linum usitatissimum L.) is a multipurpose crop with health promoting potential. This study was undertaken to investigate the fatty acid profile and yield of fixed oil of six Egyptian flaxseed cultivars. The selected cultivars with the highest content of polyunsaturated fatty acids (PUFAs) (G9 and G10) were assessed for their antidepressant-like effect in rat model of postpartum depression (PPD) induced by hormone-simulated pregnancy followed by hormone withdrawal and compared to fluoxetine. As compared to control group, administration of G9 and G10 (270 mg/kg/day, p.o) for two weeks during the postpartum period can alleviate anxiety and depressive-like behaviors and biochemical changes in PPD-induced rats. This was confirmed by evaluation of anxiety-like behaviors (elevated plus maze, open field test, and forced swim test tests), in addition to biochemical analysis (brain monoamine oxidase-A, corticosterone level, proinflammatory cytokines, and hippocampal redox state). In conclusion, flaxseed oil of Egyptian cultivars G9 and G10 exhibited significant antidepressant-like effect in rat model of PPD without affecting locomotor activity. At the treatment doses, the antidepressant-like activity of Giza 9 oil is comparable to fluoxetine

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

Planning target volume margins for prostate radiotherapy using daily electronic portal imaging and implanted fiducial markers

<p>Abstract</p> <p>Background</p> <p>Fiducial markers and daily electronic portal imaging (EPI) can reduce the risk of geographic miss in prostate cancer radiotherapy. The purpose of this study was to estimate CTV to PTV margin requirements, without and with the use of this image guidance strategy.</p> <p>Methods</p> <p>46 patients underwent placement of 3 radio-opaque fiducial markers prior to prostate RT. Daily pre-treatment EPIs were taken, and isocenter placement errors were corrected if they were ≥ 3 mm along the left-right or superior-inferior axes, and/or ≥ 2 mm along the anterior-posterior axis. During-treatment EPIs were then obtained to estimate intra-fraction motion.</p> <p>Results</p> <p>Without image guidance, margins of 0.57 cm, 0.79 cm and 0.77 cm, along the left-right, superior-inferior and anterior-posterior axes respectively, are required to give 95% probability of complete CTV coverage each day. With the above image guidance strategy, these margins can be reduced to 0.36 cm, 0.37 cm and 0.37 cm respectively. Correction of all isocenter placement errors, regardless of size, would permit minimal additional reduction in margins.</p> <p>Conclusions</p> <p>Image guidance, using implanted fiducial markers and daily EPI, permits the use of narrower PTV margins without compromising coverage of the target, in the radiotherapy of prostate cancer.</p

Early centralized isolation strategy for all confirmed cases of COVID-19 remains a core intervention to disrupt the pandemic spreading significantly

Background: In response to the spread of the coronavirus disease 2019 (COVID-19), plenty of control measures were proposed. To assess the impact of current control measures on the number of new case indices 14 countries with the highest confirmed cases, highest mortality rate, and having a close relationship with the outbreak’s origin; were selected and analyzed.Methods: In the study, we analyzed the impact of five control measures, including centralized isolation of all confirmed cases, closure of schools, closure of public areas, closure of cities, and closure of borders of the 14 targeted countries according to their timing; by comparing its absolute effect average, its absolute effect cumulative, and its relative effect average.Results: Our analysis determined that early centralized isolation of all confirmed cases was represented as a core intervention in significantly disrupting the pandemic’s spread. This strategy helped in successfully controlling the early stage of the outbreak when the total number of cases were under 100, without the requirement of the closure of cities and public areas, which would impose a negative impact on the society and its economy. However, when the number of cases increased with the apparition of new clusters, coordination between centralized isolation and non-pharmaceutical interventions facilitated control of the crisis efficiently.Conclusion: Early centralized isolation of all confirmed cases should be implemented at the time of the first detected infectious case

A randomized study of the effect of patient positioning on setup reproducibility and dose distribution to organs at risk in radiotherapy of rectal cancer patients

BACKGROUND: The patient positioning in pelvic radiotherapy (RT) should be decided based on both reproducibility and on which position that yields the lowest radiation dose to the organs at risk (OAR), and thereby less side effects to patients. The present randomized study aimed to evaluate the influence of patient positioning on setup reproducibility and dose distribution to OAR in rectal cancer patients. METHODS: Ninety-one patients were randomized into receiving RT in either supine or prone position. The recruitment period was from 2005 to 2008. Position deviations were derived from electronic portal image registrations, and setup errors were defined as deviations between the expected and the actual position of bony landmarks. Setup deviations were expressed into three table shift values (∆x, ∆y, ∆z) from which the deviation vector [Formula: see text] were calculated. The estimated lengths of [Formula: see text] defined the main outcome and were compared between prone and supine positions using linear mixed model statistics. The mean volume of each 5 Gy increments between 5 and 45 Gy was calculated for the small bowel and the total bowel, and the dose volumes were compared between prone and supine position. RESULTS AND CONCLUSION: Data from 83 patients was evaluable. The mean [Formula: see text] was 5.8 mm in supine position and 7.1 mm in prone position (p = 0.024), hence the reproducibility was significantly superior in supine position. However, the difference was marginal and may have borderline clinical importance. The irradiated volumes of the small bowel and the total bowel were largest in the supine position for all dose levels, but none of those were significantly different. The patient positioning in RT of rectal cancer patients may therefore be decided based on other factors such as the most comfortable position for the patients