Association of rheumatic diseases with symptom severity, quality of life, and treatment outcome in patients with fibromyalgia.

OBJECTIVES: To evaluate the frequency of rheumatic diseases and their association with symptom severity, quality of life (QoL), and treatment outcome in patients with fibromyalgia (FM). METHOD: Our study contained 536 FM patients who completed a brief, interdisciplinary fibromyalgia treatment programme (FTP) at our institution, with emphasis on cognitive behavioural therapy (CBT). The Fibromyalgia Impact Questionnaire (FIQ) and the 36-item Short Form Health Status Questionnaire (SF-36) were completed at initial evaluation and at 6 and 12 months after the FTP. The presence of inflammatory rheumatic disease (IRD) was determined by physician diagnoses. A two-sample t-test and multivariate linear regression analyses were performed to compare the rheumatic and non-rheumatic groups. RESULTS: Thirty-six patients (6.7%) had documented IRD. At baseline, the rheumatic group had poorer scores in SF-36 physical functioning (p = 0.02), pain index (p = 0.01), and physical component summary (p = 0.009) than the non-rheumatic group. After treatment, both groups tended to improve; however, the rheumatic group had significantly less improvement on the FIQ subscales in pain (p = 0.01) and missed work days (p = 0.01), as well as in the SF-36 physical functioning (p = 0.01), pain index (p = 0.049), and physical component summary (p = 0.049) compared with the non-rheumatic group. CONCLUSIONS: The frequency of rheumatic diseases in patients with FM seen at FTP was 6.7%. FM patients with rheumatic diseases were found to have worse SF-36-assessed pain and physical health and less improvement in these measures following treatment from FTP than patients without rheumatic diseases. FM patients with rheumatic disease may require additional intervention to address underlying rheumatic disease-related limitations.

Referral and ascertainment bias in patients with synchronous and metachronous endometrial malignancy.

The purpose of this study was to evaluate the frequency in patients with endometrial cancer of other malignancies and the influence of referral and ascertainment biases on these associations. Analysis of 1,028 local and referred patients who had a hysterectomy for endometrial cancer was based on residence at the time of diagnosis. Altogether, 208 patients had a history of another malignancy, most frequently breast, colon, and ovary. At the time of surgery for endometrial cancer, the prevalence of lymphoma and breast and ovarian cancers was greater than expected although the higher prevalence of lymphoma was limited to referred patients. During follow-up after hysterectomy, the incidence of lung cancer was lower than expected, whereas the incidence of lymphoma was higher. Breast, colorectal, and bladder cancers were more common than expected although this finding was limited to local patients. We concluded that results of epidemiologic studies from tertiary care centers may be misleading if they do not account for referral and ascertainment biases.

The effect of online status on the impact factors of general internal medicine journals.

BACKGROUND: We sought to determine the effects of becoming available online on impact factors of general medicine journals. METHODS: Through MEDLI NE with an institutional subscription, the 2004 online status of "Medicine, General and Internal" journals listed in the Institute for Scientific Information (ISI ) Journal Citation Reports (JCR) was classified as full text on the Net (FU TON), abstract only, or no abstract available (NAA)/unavailable in MEDLI NE. Similarly, through use of a home computer without an institutional subscription, the 2004 online status of the same journals was determined. For each journal, impact factors for 1992 to 2003 were obtained. RESULTS: Of the 102 "Medicine, General and Internal" journals listed in the ISI JCR, 71 (70%) existed in both pre-Internet (1992) and Internet (2003) eras. Of these 71 journals, those available as FU TON in 2004 had higher median impact factors than non-FU TON journals in 1992 (p < 0.0001> and 2003 (p < 0.0001). Journals that became available online, at least partially, had significant increases in median impact factors from 1992 to 2003 (p< 0.0001 for journals that became available as FUTON and for journals that provided an abstract only. However, journals that became available as FUTON had a greater increase in median impact from 1992 to 2003 than other journals (p = 0.002). Similar results were obtained using impact factor data according to journal online status through use of a home computer without an institutional subscription and for English-language journals only. CONCLUSION: Becoming available online as FUTON is associated with a significant increase in journal impact factor.

Depression and alcohol withdrawal syndrome: is antidepressant therapy associated with lower rates of hospital readmission?

BACKGROUND: Alcohol withdrawal syndrome (AWS) is a frequent cause of admission to acute care hospitals and many of these patients have a history of depression. AIM: Our objective was to determine if antidepressant use in patients with a history of depression is associated with lower rates of hospital readmission for AWS. METHODS: A retrospective study was performed of patients admitted with AWS between January 1, 2006 and December 31, 2008 to an academic tertiary referral hospital. RESULTS: Three hundred and twenty-two patients were admitted with AWS during the study period. One hundred and sixty-one patients (50 %) had no history of depression, 111 patients (34 %) had a history of depression and antidepressant use, and 50 patients (16 %) had a history of depression and no antidepressant use. There was no significant difference in the number of hospitalizations for AWS between these three groups. Patients with a history of depression on antidepressant medication were more likely to be retired or work disabled compared to the other two groups (p < 0.05). The antidepressant class most commonly used was SSRI (63 %). CONCLUSION: Our study highlights the high frequency of depression and antidepressant use in patients admitted with AWS to an acute care hospital. As alcohol withdrawal is associated with increased morbidity and mortality and depression is common in those with alcohol use disorder, further research is necessary to clarify the optimal treatment of comorbid depression and alcohol use disorder in reducing these revolving door admissions.

Prostate-specific antigen as a pretherapy prognostic factor in patients treated with radiation therapy for clinically localized prostate cancer.

PURPOSE: This study was conducted to determine the value of prostate-specific antigen (PSA) as a pretherapy prognostic factor for localized prostate cancer treated with primary irradiation (RT). PATIENTS AND METHODS: Between March 1987 and December 1990, 254 patients with pretherapy PSA determinations were treated for clinical stage A2 to C prostate adenocarcinoma. In conjunction with other prognostic factors, pretherapy PSA was evaluated to determine whether it had independent predictive value for disease outcome. RESULTS: Pretherapy PSA was highly and directly correlated with clinical stage, tumor grade, and acid phosphatase level. With a median follow-up duration of 24 months, 241 patients (95%) were fully assessable for disease outcome. In these patients, PSA and tumor grade were the sole independent predictive factors for tumor relapse (ie, clinically determined and/or increasing PSA level). The combination of pretherapy PSA and tumor grade information defined groups of patients with distinctly different outcome. For patients in low- (favorable PSA and tumor grade), intermediate- (favorable PSA or tumor grade), and high- (adverse PSA and tumor grade) risk categories, the actuarial rates of survival free of tumor relapse or increasing PSA level were 94%, 77%, and 42% at 3 years, respectively (P < .0001). CONCLUSION: Pretherapy PSA is a strongly independent prognostic factor for disease outcome following primary RT. The combination of adverse pretherapy PSA and unfavorable tumor grade identified a cohort of patients with a high risk of early treatment failure in whom combined modality therapy may be appropriately investigated.

Early evaluation of combined fluorouracil and leucovorin as a radiation enhancer for locally unresectable, residual, or recurrent gastrointestinal carcinoma. The North Central Cancer Treatment Group.

PURPOSE: To develop a tolerable regimen of fluorouracil (5-FU), low-dose leucovorin, and radiation, and to obtain an early estimate of therapeutic effectiveness. PATIENTS AND METHODS: Forty patients with locally unresectable or recurrent gastrointestinal carcinoma were studied (pancreas, n = 22; rectum and sigmoid, n = 10; gastric, n = 6; other, n = 2). Irradiation therapy was administered in 1.8-Gy fractions 5 days per week, with total doses ranging from 45 to 54 Gy. 5-FU 400 mg/m2/d plus leucovorin 20 mg/m2/d, both by rapid intravenous injection, were administered for 3 or 4 days during the first and fifth weeks of radiation. 5-FU 425 mg/m2/d plus leucovorin 20 mg/m2/d were administered for 4 days at 4 weeks following radiation and for 5 days at 9 weeks. RESULTS: Major toxicities with upper abdominal treatment were nausea, vomiting, weight loss, and leukopenia. A tolerable dosage regimen was radiation at 45 Gy with 4 days of 5-FU plus leucovorin during the first week and 3 days during the last week with postradiation chemotherapy. Major toxicities with pelvic radiation were diarrhea and leukopenia. A tolerable regimen was 54 Gy with 4 days of 5-FU plus leucovorin during the first and fifth week followed by the postradiation chemotherapy. Median survival durations for pancreatic and rectal/sigmoid carcinomas are 13 months and 31 months, respectively. Five patients have no evidence of disease from 38 to 50 months after the onset of therapy (rectal, n = 2; stomach, n = 2; pancreas, n = 1). CONCLUSION: We have developed patient-tolerable regimens for combined 5-FU plus leucovorin followed by radiation to the abdomen and to the pelvis. The favorable results observed in locally unresectable disease allow cautious optimism for possible effectiveness in the surgical adjuvant setting, a possibility currently being tested in national trials of rectal and gastric carcinoma.

Intraoperative radiation therapy in gynecologic cancer: update of the experience at a single institution.

PURPOSE: To update the Mayo Clinic experience with intraoperative radiation therapy (IORT) in patients with gynecologic cancer. METHODS AND MATERIALS: Between January 1983 and June 1991, 39 patients with recurrent or locally advanced gynecologic malignancies received intraoperative radiation therapy with electrons. The anatomical area treated was pelvis (side walls or presacrum) or periaortic nodes or a combination of both. In addition to intraoperative radiation therapy, 28 patients received external beam irradiation (median dose, 45 Gy; range, 0.9 to 65.7 Gy), and 13 received chemotherapy preoperatively. At the time of intraoperative radiation therapy and after maximum debulking operation, 23 patients had microscopic residual disease and 16 had gross residual disease up to 5 cm in thickness. Median follow-up for surviving patients was 43.4 months (range, 27.1 to 125.4 months). RESULTS: The 5-year actuarial local control with or without central control was 67.4%, and the control within the IORT field (central control) was 81%. The risk of distant metastases at 5 years was 52% (82% in patients with gross residual disease and 33% in patients with only microscopic disease postoperatively). Actuarial 5-year overall survival and disease-free survival was 31.5 and 40.5%, respectively. Patients with microscopic disease had 5-year disease-free and overall survival of 55 and 50%, respectively. Grade 3 toxicity was directly associated with IORT in six patients (15%). CONCLUSION: Patients with local, regionally recurrent gynecologic cancer may benefit from maximal surgical debulking and IORT with or without external beam irradiation, especially those with microscopic residual disease.

High-dose preoperative external beam and intraoperative irradiation for locally advanced pancreatic cancer.

PURPOSE: To analyze results of high-dose preoperative external beam irradiation followed by surgical exploration and intraoperative radiation therapy in patients with unresectable pancreatic cancer. METHODS AND MATERIALS: From December 1983 through December 1990, 27 patients with primary unresectable but localized pancreatic adenocarcinoma received high-dose (50 to 54 Gy) external beam irradiation with or without concomitant bolus 5-fluorouracil followed by surgical exploration and intraoperative electron beam irradiation (20 Gy) at the Mayo Clinic. RESULTS: Local control was achieved in 21 of 27 (78%) patients. Actuarial local control at 1, 2, and 5 years was 86%, 68%, and 45%, respectively. In 19 (70%) of the 27 patients, distant metastasis developed, and peritoneal or liver progression (or both) was found in 14 (52%). The actuarial distant metastasis rate at 2 and 5 years was 69% and 83%, respectively. Median survival from the date of diagnosis was 14.9 months. Actuarial 2- and 5-year overall survival was 27% and 7%, respectively. These survival rates are higher (p = 0.001) than the 6% and 0% actuarial 2- and 5-year survival observed in 56 patients who underwent intraoperative radiation therapy followed by postoperative high-dose external beam treatment at our institution. CONCLUSION: Administering the full component of external beam irradiation before exploration and intraoperative radiation therapy may be more appropriate because it allows better patient selection. Unfortunately, altered patient selection was not effective in decreasing the relative risk of abdominal failure. Because effective systemic chemotherapy does not currently exist, whole abdominal irradiation alone or in combination with chemotherapy warrants evaluation.

Intraoperative irradiation for locally recurrent colorectal cancer in previously irradiated patients.

PURPOSE: Information in the literature regarding salvage treatment for patients with locally recurrent colorectal cancer who have previously been treated with high or moderate dose external beam irradiation (EBRT) is scarce. A retrospective review was therefore performed in our institution to determine disease control, survival, and tolerance in patients treated aggressively with surgical resection and intraoperative electron irradiation (IOERT) +/- additional EBRT and chemotherapy. METHODS AND MATERIALS: From 1981 through 1994, 51 previously irradiated patients with recurrent locally advanced colorectal cancer without evidence of distant metastatic disease were treated at Mayo Clinic Rochester with surgical resection and IOERT +/- additional EBRT. An attempt was made to achieve a gross total resection before IOERT if it could be safely accomplished. The median IOERT dose was 20 Gy (range, 10--30 Gy). Thirty-seven patients received additional EBRT either pre- or postoperatively with doses ranging from 5 to 50.4 Gy (median 25.2 Gy). Twenty patients received 5-fluorouracil +/- leucovorin during EBRT. Three patients received additional cycles of 5-fluorouracil +/- leucovorin as maintenance chemotherapy. RESULTS: Thirty males and 21 females with a median age of 55 years (range 31--73 years) were treated. Thirty-four patients have died; the median follow-up in surviving patients is 21 months. The median, 2-yr, and 5-yr actuarial overall survivals are 23 months, 48% and 12%, respectively. The 2-yr actuarial central control (within IOERT field) is 72%. Local control at 2 years has been maintained in 60% of patients. There is a trend toward improved local control in patients who received > or =30 Gy EBRT in addition to IOERT as compared to those who received no EBRT or <30 Gy with 2-yr local control rates of 81% vs. 54%. Distant metastatic disease has developed in 25 patients, and the actuarial rate of distant progression at 2 and 4 years is 56% and 76%, respectively. Peripheral neuropathy was the main IOERT-related toxicity; 16 (32%) patients developed neuropathies (7 mild, 5 moderate, 4 severe). Ureteral narrowing or obstruction occurred in seven patients. All but one patient with neuropathy or ureter fibrosis received IOERT doses > or =20 Gy. CONCLUSION: Long-term local control can be obtained in a substantial proportion of patients with aggressive combined modality therapy, but long-term survival is poor due to the high rate of distant metastasis. Re-irradiation with EBRT in addition to IOERT appears to improve local control. Strategies to improve survival in these poor-risk patients may include the more routine use of conventional systemic chemotherapy or the addition of novel systemic therapies.

Patterns of failure in grossly resected pancreatic ductal adenocarcinoma treated with adjuvant irradiation +/- 5 fluorouracil.

PURPOSE: Analyze patterns of failure, survival, and tolerance in patients with totally resected ductal adenocarcinoma of the pancreas treated with adjuvant irradiation alone or combined with chemotherapy. METHODS AND MATERIALS: The records of 29 patients treated with radiotherapy following curative resection of pancreas cancer at the Mayo Clinic were retrospectively reviewed. Twenty-two (76%) patients underwent a subtotal pancreatectomy (Whipple procedure), six (21%) a total pancreatectomy, and one (3.5%) a distal pancreatectomy. Twenty-six (90%) had lesions located in the head of the pancreas and three (10%) were located either in the body or tail. Twelve (41%) of the tumors were histologic Grade 3, 15 (52%) Grade 2, and two Grade 1. Contiguous invasion of adjacent tissues or organs was found in fifteen patients (52%) and seventeen (59%) had lymph node involvement. Greater than 75% of patients received more than 45 Gy, with a median dose of 54 Gy, and twenty-seven (93%) patients received concomitant 5-fluorouracil chemotherapy. RESULTS: The median survival was 22.8 months and the 2-year survival 48%. When survival was compared with that achieved with surgery alone in our institution, data suggested a doubling in both median and long-term survival with the addition of adjuvant treatment. Eighty-three percent of patients experienced tumor relapse with seventeen of 29 (59%) developing either liver metastases or peritoneal spread. In three patients, tumors recurred locally; one of one with microscopic residual disease after resection and two of 28 (7%) with negative margins (one of the two was treated with inadequate radiation portals). Patients tolerated adjuvant treatment with minimal acute toxicity consisting mostly of vomiting or nausea which, were controlled with medication in all patients. Chronic toxicity was acceptable; while 5 of 29 (17%) developed some form of possible treatment related complication, only one patient (3.5%) developed a small bowel obstruction. CONCLUSION: These results corroborate data in previous studies which have shown a survival benefit when adjuvant irradiation plus 5-fluorouracil is used in patients with completely resected ductal adenocarcinoma of the pancreas. The patterns of failure indicate that post-operative adjuvant treatment can effectively control disease locally but that future survival improvements will be achieved only by reducing the incidence of liver and peritoneal metastases.

Clinical features and splenic pathologic changes in patients with autoimmune hemolytic anemia and congenital hemolytic anemia.

We characterized the pathologic changes in 50 spleens from patients with autoimmune hemolytic anemia and in 13 spleens from patients with congenital hemolytic anemia. The major pathologic findings in autoimmune hemolytic anemia were mild to pronounced cord congestion and variable white pulp area, erythrophagocytosis in conjunction with an increased polymorphonuclear neutrophil reaction, and increased deposition of hemosiderin and extramedullary hematopoiesis. In contrast, both the severity and the frequency of polymorphonuclear neutrophil reactions, deposition of hemosiderin, and extramedullary hematopoiesis were less in patients with congenital hemolytic anemia, and prominent cord congestion associated with an empty or collapsed sinus was noted in patients with hereditary spherocytosis. The activity of erythrophagocytosis in the sinus was more distinct in patients with congenital hemolytic anemia, especially those with nonspherocytic congenital hemolytic anemia, than in patients with autoimmune hemolytic anemia. These findings are consistent with the existence of different mechanisms of trapping and destruction of erythrocytes in autoimmune hemolytic anemia and congenital hemolytic anemia.

DNA ploidy in endometrial carcinoma: major objective prognostic factor.

Paraffin-embedded tissue samples from 256 patients who received primary treatment (surgical staging, reduction of tumor size, and adjuvant therapy based on surgical and pathologic risk factors) for endometrial carcinoma at the Mayo Clinic between 1979 and 1983 were analyzed by flow cytometry to determine DNA ploidy characteristics. Diploid patterns constituted 78% of the cases, whereas aneuploid and tetraploid patterns accounted for 17% and 5%, respectively. Only 10% of patients with diploid tumors had a relapse in comparison with 39% of those with nondiploid lesions (34% with aneuploid; 58% with tetraploid). Significant differences (P less than 0.001) were noted in estimated 4-year progression-free survivals--88% for patients with diploid and 57% for those with nondiploid tumors. Stage, grade, depth of myometrial invasion, histologic subtype, peritoneal cytology, and DNA ploidy all demonstrated independent prognostic significance (P less than 0.001) in this study population. When subjected to multivariate analysis, however, grade and depth of myometrial penetration failed to retain prognostic significance (P greater than 0.15) and surgical stage was marginally significant (P = 0.05), whereas histologic subtype and DNA ploidy maintained significant predictive powers (P less than 0.001 and P less than 0.01, respectively). We conclude that DNA ploidy is a major objective prognostic factor and therapeutic determinant for endometrial carcinoma.

Colorectal cancer. Dukes' stage, tumor site, preoperative plasma CEA level, and patient prognosis related to tumor DNA ploidy pattern.

Flow cytometric DNA histograms of colorectal carcinomas from 264 patients were evaluated for the association of tumor site, Dukes' stage, tumor grade, and preoperative carcinoembryonic level with patient survival. The DNA nondiploid carcinomas were significantly more common from the left (descending and sigmoid) colon and the rectum. A poorer prognosis was found for patients with DNA nondiploid cancers than for patients with DNA diploid cancers. This was particularly true for patients with Dukes' stages B2 and C tumors with a small number (one to three) of lymph nodes with metastatic deposits. The DNA nondiploid cancers also had a relatively poorer prognosis in patients with unresectable disease. In a Cox multivariate analysis model, the DNA pattern was an independent prognostic variable for this group of 264 patients with resected colorectal carcinoma.

Irradiation for locally recurrent carcinoma of the prostate following radical prostatectomy.

OBJECTIVES: To evaluate the outcome of patients treated with irradiation (RT) for isolated, clinically apparent local tumor recurrence following prostatectomy for carcinoma of the prostate (CaP). METHODS: Between May 1979 and July 1992, 35 patients received external-beam RT as sole salvage therapy for post-prostatectomy locally recurrent CaP. Patient outcome was evaluated through retrospective medical record review with respect to clinical and prostate-specific antigen-based (that is, biochemical) control rates, as well as disease-free (clinical and biochemical) and overall survival estimates. Chronic RT-induced morbidity was also examined, and pre-RT disease characteristics were evaluated for their association with disease outcome. RESULTS: With median follow-up of 5.2 years (range 1.7 to 12.1) in survivors (30 patients), 19 patients (54%) had clinical (local, 1 patient [3%]; metastatic, 7 patients [20%]) or biochemical only (11 patients [31%]) relapse. The 8-year clinical relapse-free and any relapse-free (clinical or biochemical) rates were 80% and 56%, respectively, whereas the overall survival estimate was 97%. A chronic complication(s) of treatment was noted in 15 patients (43%) but spontaneously resolved in all but 6 (17%); persistent complications were mild and associated with rectal (grade 1 to 2, 14%) and lymphatic (3%) systems. The interval between prostatectomy and local tumor recurrence, the pre-RT prostate-specific antigen serum level, the pathologic stage, and tumor differentiation may be associated with disease outcome. CONCLUSIONS: External-beam RT resulted in excellent local tumor control without serious long-term morbidity in most patients. Although this study could not define an optimal management strategy (for example, symptomatic measures only, RT, or hormonal therapy), these results provided outcome measures, in relationship to pre-RT tumor-related factors, that may be valuable for clinical decision-making.

Correlation of DNA ploidy, histopathology, stage and clinical outcome in gastric carcinoma.

The determination of nuclear DNA ploidy from paraffin-embedded specimens was performed by flow cytophotometry on 277 surgically resected primary gastric carcinomas to assess the relationship of various pathological findings and DNA content with survival. The preparation of samples was performed by a modification of Hedley's technique and the staining method of Vindelov. Eighty-nine (32%) carcinomas were DNA diploid, 69 (25%) were DNA tetraploid, and 119 (43%) were DNA aneuploid. DNA non-diploid patterns were significantly associated with macroscopic ulcerative appearance, location of the tumour in the proximal stomach, histological grade, and advanced stage of tumour. Patients with DNA non-diploid cancers, and specifically DNA aneuploid cancers, exhibited significantly poorer survival than patients with DNA diploid tumours. These data support the prognostic value of tumour DNA content in patients with resected gastric carcinoma.

Chronic idiopathic thrombocytopenic purpura. Splenic pathologic features and their clinical correlation.

We studied 83 patients who had chronic idiopathic thrombocytopenic purpura refractory to steroid therapy and who underwent splenectomy. The positive rates of antiplatelet and antinuclear antibodies were 40% (30/75 patients tested) and 41% (25/61 patients tested), respectively. The morphologic characteristics of splenic pathologic findings included prominent secondary follicles and foamy macrophages, present in 23 (28%) and 56 (67%) of patients, respectively. Extramedullary hematopoiesis was noted in 50 (60%) of the patients. Eight patients (10%) presented with periarterial fibrosis, and three of them had systemic lupus erythematosus. The 23 patients (28%) with prominent secondary follicles were younger than the other patients, were preponderantly female, and had a higher rate of antiplatelet antibody production, and all had an initial response with a greater increase in platelets postoperatively. Eight patients (10%) had neither prominent secondary follicles nor foamy macrophages and lower splenic weights; their initial response compared with that of other patients was significantly poorer. The thrombocytopenia in these patients might have a different mechanism.

Pharmacokinetics of daily versus monthly vitamin D3 supplementation in non-lactating women.

This study compared serum cholecalciferol and 25-hydroxyvitamin D (25(OH)D) concentrations over four weeks in healthy, non-pregnant, non-lactating females aged 18-40 years, who were randomized to oral cholecalciferol 5000 international units (IU) daily for 28 days or a single dose of 150 000 IU. The study was conducted in Rochester, MN in March and April of 2010. We found no difference in mean 25(OH)D between treatment groups on study day 0 or day 28 (P=0.14 and 0.28, respectively). The daily group had 11 more days of detectable serum cholecalciferol than the single-dose group (P<0.001). There was no difference observed in cholecalciferol area under the curve (AUC28) between groups (P=0.49). However, the single-dose group had a significantly greater mean 25(OH)D AUC28 compared with the daily group (P<0.001).

Association of the bla(CMY-10) gene with a novel complex class 1 integron carrying an ISCR1 element in clinical isolates from Korea.

The bla(CMY-10) gene responsible for ß-lactam resistance was located on a new complex class 1 integron within a conjugative plasmid. The sul1-type class 1 integron, containing an aadA2a gene cassette, was identified upstream of bla(CMY-10). A unique gene array (yqgF-yqgE-gshB-orf97--orf105) was identified downstream of bla(CMY-10.).