The Outer Membrane Cytochrome OmcA Is Essential for Infection of Shewanella oneidensis by a Zebrafish-Associated Bacteriophage.

The microbiota-the mixture of microorganisms in the intestinal tract of animals-plays an important role in host biology. Bacteriophages are a prominent, though often overlooked, component of the microbiota. The mechanisms that phage use to infect susceptible cells associated with animal hosts, and the broader role they could play in determining the substituents of the microbiota, are poorly understood. In this study, we isolated a zebrafish-associated bacteriophage, which we named Shewanella phage FishSpeaker. This phage infects Shewanella oneidensis strain MR-1, which cannot colonize zebrafish, but it is unable to infect Shewanella xiamenensis strain FH-1, a strain isolated from the zebrafish gut. Our data suggest that FishSpeaker uses the outer membrane decaheme cytochrome OmcA, which is an accessory component of the extracellular electron transfer (EET) pathway in S. oneidensis, as well as the flagellum to recognize and infect susceptible cells. In a zebrafish colony that lacks detectable FishSpeaker, we found that most Shewanella spp. are sensitive to infection and that some strains are resistant to infection. Our results suggest that phage could act as a selectivity filter for zebrafish-associated Shewanella and show that the EET machinery can be targeted by phage in the environment. IMPORTANCE Phage exert selective pressure on bacteria that influences and shapes the composition of microbial populations. However, there is a lack of native, experimentally tractable systems for studying how phage influence microbial population dynamics in complex communities. Here, we show that a zebrafish-associated phage requires both the outer membrane-associated extracellular electron transfer protein OmcA and the flagellum to infect Shewanella oneidensis strain MR-1. Our results suggest that the newly discovered phage-FishSpeaker-could exert selective pressure that restricts which Shewanella spp. colonize zebrafish. Moreover, the requirement of OmcA for infection by FishSpeaker suggests that the phage preferentially infects cells that are oxygen limited, a condition required for OmcA expression and an ecological feature of the zebrafish gut.

Use of Laboratory Tests and Their Prognostic Value in Patients with Stable Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is not merely a lung disease as the name indicates. Patients with COPD experience associated complications with systemic inflammation, heart strain, muscle wasting, poor functional performance, and psychological issues. An assessment of these patients based only on lung function tests or functional capacity would be inadequate. Many studies have reported the significance and prognostic value of several laboratory tests. Troponin, C-reactive protein (CRP), hemoglobin, and carbon dioxide are older tests but compared with the newly developed tests, they are relatively inexpensive to measure and widely available. This article will review laboratory tests used for COPD and discuss their prognostic value. The laboratory tests that can identify high-risk patients will be discussed. We will explore the role of these tests in clinical practice.

Isolated Retrodental Epidural Hematoma Without Dens Fracture.

BACKGROUND: Traumatic spinal epidural hematomas (TSEDH) are rare, with the reported incidence being < 1% of all spinal injuries. Causes of TSEDHs include vertebral fractures, obstetrical birth trauma, lumbar punctures, postsurgical bleeding, epidural anesthesia, and missile injuries. The retrodental location has not been reported as a location for spontaneous epidural hematoma. CASE REPORT: A 4-year-old boy was admitted to our Emergency Department after falling down and experiencing head trauma. Glasgow Coma Scale score was 15/15 with no neurologic deficit. Brain computed tomography scan showed isolated hyperdense hematoma in the retrodental area without any fractures in the skull or cervical vertebrae. Brain and cervical magnetic resonance imaging showed a retrodental acute hematoma that was isointense in T1-weighted sequences and hypointense in T2-weighted sequences. The hematoma was in the epidural space with possible odontoid process intracapsular origin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Isolated retrodental epidural hematoma without dens fracture is an extremely rare pathology and finding, and to the best of our knowledge, this is the first case to be reported in the literature. Emergency physicians should consider this pathology for any patients presenting for head trauma with head hematoma.

Delayed Supratentorial Intracerebral Hemorrhage After Posterior Fossa Acoustic Neuroma Surgery.

A 72-year-old female patient was complaining from gradual loss of hearing in the left ear, left facial palsy with gait imbalance. Neuroimaging showed left cerebellopontine angle extra-axial mass and was diagnosed as acoustic neuroma. She was operated with left retromastoid suboccipital and gross total excision of the tumor was achieved. Early postoperative period was uneventful and brain computed tomographic (CT) scan in the postoperative day 1 showed gross total resection of the tumor without complications, and patient was discharged at the postoperative day 4. In the postoperative day 7, the patient showed decrease level of consciousness and brain CT scan showed a small hematoma in the anterior part of the left temporal lobe, which was evolved to large intraparanchymal hemorrhage with midline shift in postoperative day 9.

FLAG/FLAG-IDA regimen for children with relapsed/refractory acute leukemia in the era of targeted novel therapies.

BACKGROUND: Outcomes of relapsed/refractory childhood acute leukemia remain poor. We analyzed the safety/efficacy of fludarabine, cytarabine, and granulocyte colony stimulating factor, with/without idarubicin (FLAG ± IDA) as salvage therapy compared with recent published results of novel therapies. METHODS: This retrospective study included children aged 1 to 15 years with relapsed/refractory acute leukemia who received FLAG ± IDA salvage therapy from January 2000 to December 2014. Patients with infant leukemia, mixed lineage leukemia, Philadelphia-positive acute leukemia, or secondary leukemia were excluded. RESULT: Fifty patients were identified: 25 with acute lymphoblastic leukemia and 25 with acute myeloid leukemia. The median age at initiation of FLAG ± IDA was seven years. Site of relapse was the bone marrow in 29, isolated central nervous system in 11, and combined in 10 patients. FLAG ± IDA was used after first relapse in 68% and after multiple relapses in 32%. Complete remission was achieved in 34 (68%) patients. No variables predictive of complete remission were identified. Grade 3 or greater toxicity was observed in 96% and 6% died from toxicity. Toxicities included hematologic toxicity (96%), infection (52%), and enterocolitis (28%). Twenty-four of 50 (48%) patients achieved a sustained complete remission and survived to bone marrow transplantation. The five-year overall survival was 23.9% ± 6.9%. Patients achieving second complete remission and patients proceeding to bone marrow transplantation following second complete remission demonstrated significantly improved overall survival (p = 0.001). CONCLUSION: Despite a 68% complete remission rate using FLAG ± IDA, only 48% of patients survived to bone marrow transplantation. The regimen was associated with 96% toxicity and only one in four patients was alive at five years. This underscores the need to find more effective lower toxicity salvage regimens.

Challenges in the management of childhood low-grade glioma in a developing country.

BACKGROUND: Treatment modality impacts outcome of childhood low-grade glioma (LGG). Optimizing management in developing countries can be challenging. This study evaluates the clinical characteristics, treatment, and factors influencing outcome of childhood LGG in Saudi Arabia. PATIENTS AND METHODS: This study retrospectively evaluated 59 children consecutively diagnosed with LGG between January 2001 and June 2016. RESULTS: Median age at diagnosis was 6.0 years. Pilocytic astrocytoma represented 64.9% of cases. The anatomic site was cerebellar in 23.7%, cerebral in 18.6%, hypothalamic-optic pathway in 33.9%, and midline in 23.7%. The 5-year overall survival (OS) and progression-free survival (PFS) were 90.6 ± 4.7 and 54.3 ± 8.4%, respectively. Initial treatment was observation in 28.8%, surgery alone in 35.6%, chemotherapy in 13.6%, radiotherapy in 5.1%, and combined in 16.9% of cases. The corresponding 5-year PFS was 56.3 ± 15.6, 53.3 ± 14.0, 22.9 ± 19.7, 33.3 ± 27.2, and 88.9 ± 10.5%, respectively (p = 0.006). Among the 61% who had surgical intervention (either alone or in combination with other therapies), 22% achieved complete resection with 5-year radiation/progression-free survival (RPFS) of 87.5 ± 11.7% compared to 27.6 ± 10.8% for subtotal resection/biopsy and 62.2 ± 17.0% for no surgery (p = 0.013). Adjuvant therapy for residual tumor improved survival with 5-year PFS of 66.7 ± 19.2% for chemotherapy and 100% for radiotherapy compared to 12.5 ± 11.4% for observation (p = 0.033). CONCLUSIONS: We identified variability in the outcomes of LGG. Fewer surgeries with lower rates of total resection were noted, compared to reports from international cooperative groups. The extent of resection was predictive of RPFS. Adjuvant therapy improved the outcome of patients with residual disease, resulting in PFS rates comparable to international data.

Identifying causes of variability in outcomes in children with acute lymphoblastic leukemia treated in a resource-rich developing country.

BACKGROUND: The outcome of children with acute lymphoblastic leukemia (ALL) in developing countries is less favorable than in developed countries, primarily due to resource constraints. However, it is unknown whether the therapeutic results differ. Thus, we hypothesized that outcomes in resource-rich developing countries would be similar to those in industrialized regions. PROCEDURE: We performed a retrospective analysis of 224 consecutive children with ALL, who were treated according to the Children's Cancer Group (CCG) protocols between January 2001 and December 2007. High-risk (HR) and standard-risk (SR) patients were treated with modified CCG-1961 and CCG-1991 protocols, respectively. Modifications included substitution of dexamethasone for prednisone in HR patients and addition of two intrathecal methotrexate treatments for CNS2 patients during induction. All patients received double delayed intensification with two interim maintenance phases. RESULTS: Five-year overall survival (OS), event-free survival (EFS) and disease-free survival (DFS) were 84.7 ± 2.4%, 77.0 ± 2.9%, and 81.4 ± 2.7%, respectively. Remission was achieved in 98.1% of the patients. Induction failure and relapse rates were 1.9% and 15.1%, respectively. Death as the first event occurred in 6.4% of cases, of which 2.7% and 3.7% involved deaths in induction and remission, respectively. Interestingly, a significant reduction in induction deaths was observed over time. CONCLUSIONS: Despite the encouraging results observed in the present study, our patients displayed significantly lower survival outcomes compared to subjects treated in major clinical trials conducted by leading leukemia cooperative groups. Furthermore, this work underscores the need for targeted interventions to reduce death as the first event in developing regions.

Pituitary stalk interruption syndrome: a case report and literature review.

Background: Pituitary stalk interruption syndrome is a rare congenital anomaly of the pituitary gland characterized by growth hormones deficiency (with or without other pituitary hormone deficiencies) along with radiological features of a thin or interrupted pituitary stalk, an ectopic or absent posterior pituitary, or a hypoplastic or absent anterior pituitary. Case presentation: A 10-year-old baby boy came with short stature. The laboratory investigations were done and showed low growth hormones and low thyroid-stimulating hormone. MRI showed an ectopic posterior pituitary, a small hypoplastic anterior pituitary, and an absent pituitary stalk. Conclusion: Pituitary stalk interruption syndrome is a very rare entity. MRI is used to diagnose it. Early detection of this syndrome improve the patient symptoms especially before puberty.

CT-based generation of synthetic-pseudo MR images with different weightings for human knee.

Synthetic MR images are generated for their high soft-tissue contrast avoiding the discomfort by the long acquisition time and placing claustrophobic patients in the MR scanner's confined space. The aim of this study is to generate synthetic pseudo-MR images from a real CT image for the knee region in vivo. 19 healthy subjects were scanned for model training, while 13 other healthy subjects were imaged for testing. The approach used in this work is novel such that the registration was performed between the MR and CT images, and the femur bone, patella, and the surrounding soft tissue were segmented on the CT image. The tissue type was mapped to its corresponding mean and standard deviation values of the CT# of a window moving on each pixel in the reconstructed CT images, which enabled the remapping of the tissue to its MRI intrinsic parameters: T1, T2, and proton density (ρ). To generate the synthetic MR image of a knee slice, a classic spin-echo sequence was simulated using proper intrinsic and contrast parameters. Results showed that the synthetic MR images were comparable to the real images acquired with the same TE and TR values, and the average slope between them (for all knee segments) was 0.98, while the average percentage root mean square difference (PRD) was 25.7%. In conclusion, this study has shown the feasibility and validity of accurately generating synthetic MR images of the knee region in vivo with different weightings from a single real CT image.

Implementation of a multidisciplinary inpatient heart failure service and its association with hospitalized patient outcomes: First experience from the Middle East and North Africa region.

BACKGROUND: Multidisciplinary care models have been associated with improved clinical outcomes and an increase in adherence to guideline-directed medical therapy among patients hospitalized with heart failure (HF). OBJECTIVE: This study aims to evaluate the association between the creation of a multidisciplinary inpatient HF service and patient outcomes at a tertiary care center in the Middle East/ North Africa. METHODS: We used electronic health records to retrospectively identify patients hospitalized for acute HF between June-2015 and June-2018. Patients were categorized by whether they were hospitalized before (n = 71) or after (n = 86) the implementation of a multidisciplinary HF team (HF-MDT), starting on 1/1/2017. The groups were compared for optimal use of guideline-directed medical therapy, hospital length of stay, 30-day hospital readmission, and in-hospital mortality. RESULTS: The creation of the HF-MDT was associated with significantly better adherence to GDMT at discharge (27.5% vs. 55.4%, (OR 3.3, 95% CI [1.65-6.5]), P<0.001), shorter median hospital length of stay (8, IQR [4.8 - 19] vs. 5, IQR [3- 9], P = 0.02) and a reduction in 30-day hospital readmission (26.5% vs. 11%; OR 0.3, 95% CI [0.1-0.8], P = 0.02). However, there was no difference in-hospital mortality (10.5% vs. 3.5%; OR 0.3, 95% CI [0.1-1.2], P = 0.1). CONCLUSIONS: Implementing an HF-MDT in the care of patients hospitalized with HF is associated with better adherence to GDMT on discharge, reduced hospital length of stay, and lower 30-day readmission rates. The current data support the broader adoption of dedicated HF programs in the Middle East to improve outcomes of patients with HF.

LAD-III, a Mild Phenotype Resulting From a Novel Variant of FERMT3 Gene: A Case Report.

Leukocyte adhesion deficiency-III (LAD-III) is a rare recessive autosomal disorder characterized by bleeding syndrome of Glanzmann-type and life-threatening infections. The main etiology of this condition is variations in the FERMT3 gene, which encodes kindlin-3, an integrin-binding protein. This protein is responsible for the activation of fibrinogen receptors and integrin-mediated hematopoietic cell adhesion. So far, only limited cases of LAD-III have been reported. This case report discusses a two-year-old male infant from the Asir region, Saudi Arabia, who was referred to the pediatric hematology service due to recurrent ecchymosis and epistaxis. He was born at full term with a history of transient tachypnea of the newborn and recurrent bronchiolitis. The patient exhibited normal platelet count and coagulation profiles alongside a familial history of bleeding disorders, including a cousin with a similar condition. The patient also presented with hypospadias and café-au-lait spots. Laboratory findings revealed anemia, microcytosis, and hypochromia indicative of iron deficiency anemia. Whole exome sequencing (WES) identified a homozygous variant of uncertain significance in the FERMT3 gene, associated with autosomal recessive LAD-III. The patient was subsequently referred to an immunology subspecialty for further investigation and bone marrow transplant preparation. This case underscores the importance of comprehensive clinical and genetic evaluations in pediatric patients with unexplained bleeding tendencies.

Incarcerated Umbilical Hernia Following Therapeutic Paracentesis in a Cirrhotic Patient.

Umbilical hernia is a relatively common complication developing in patients with liver cirrhosis with recurrent ascites. Abdominal paracentesis is considered the mainstay procedure to manage refractory ascites and to diagnose spontaneous bacterial peritonitis. Incarceration of umbilical hernia is a rare but serious adverse event following therapeutic paracentesis that requires prompt management. We describe a case of an incarcerated umbilical hernia following paracentesis requiring surgical repair in a cirrhotic patient.

Organizing Pneumonia Secondary to Pulmonary Actinomycosis: A Case Report and Literature Review.

Pulmonary actinomycosis is a common clinical infection caused by Actinomyces species. Although its treatment is very effective with Intravenous (IV) antibiotics, its diagnosis is challenging and easily missed. Organizing Pneumonia (OP) can be cryptogenic or secondary to different clinical diseases. Herein, we discuss a case of acute hypoxemic respiratory failure that was found to be due to OP, secondary to pulmonary actinomycosis, with a brief review of the literature. A 64-year-old male presented with acute hypoxemic respiratory failure two days after undergoing elective right total hip arthroplasty. Chest imaging with CT scan showed symmetric bilateral ground-glass opacities most pronounced within the upper lung lobes. The patient was treated initially with IV diuresis, steroids, and broad-spectrum antibiotics. However, his clinical status continued to worsen and his chest imaging showed worsening lung opacities. Video-assisted thoracoscopic lung biopsy (VATS) was done, and pathology results showed features of organizing pneumonia. Tissue culture confirmed Actinomyces species. The patient had clinical improvement after treatment with IV methylprednisolone and IV penicillin G. Pulmonary actinomycosis is very rarely associated with OP but this bacterial infection should always be in the differential diagnosis when OP is confirmed as the treatment is effective with IV antibiotics.

A Case Report of Life-Threatening Hemopneumothorax as a Result of Spinal Manipulation Performed by Chiropractor.

Chiropractic is a very popular alternative medicine practice in the United States. Despite that, this practice has been associated with several complications raising concerns for its safety. We report the case of an otherwise healthy 36-years-old, tall and thin male who presented with sudden onset shortness of breath associated with chest pain two days after chiropractic spinal manipulation. Chest imaging revealed left-sided hemopneumothorax required treatment with left-sided chest tube placement. Patients with a high risk of developing primary or secondary pneumothorax should consider avoiding chiropractic chest or spinal manipulations due to possible complications.

Coronary artery anomalies in patients with zero calcium score: A new evidence supports the 2016-NICE guidance.

BACKGROUND: Currently, guidelines from around the world endorse measurement of coronary artery calcium (CAC) to improve clinical risk prediction in appropriately selected asymptomatic and stable symptomatic individuals. A CAC score of zero may discourage from further testing as coronary computed tomography angiography (CCTA). We investigate the presence of malignant coronary artery anomalies (CAA)s among stable symptomatic patients with zero CAC. METHODS: A total of 281 individuals' information was obtained. These individuals had low to intermediate pre-test probability of coronary artery disease, complained of stable typical or atypical chest pain, were not known to have CAD, and had CAC scan score of zero. After investigating the CCTA, Angelini's classification system for CAA was utilized in adapted form to determine the presence, the class and type of the CAA. RESULTS: The CAAs were detected in 16 (5.7 %) patients on CCTA, 15 (8.1 %) of them were below 45 years. The mean age for patients with CAAs was 31.8. According to Angelini classification system, most of the detected CAAs were malignant such as the origination of the coronary artery from the opposite sinus with arterial course between the aortic and pulmonary trunks and the intramural muscular bridge course. CONCLUSION: It is preferable to perform CCTA in young patients with cardiac symptoms, especially in Asian and Middle Eastern countries even of the CAC score is zero.

Inter-Gender Pelvic Shape Variations as a Cause of DDH Overdiagnosis.

OBJECTIVE: Developmental dysplasia of the hip (DDH) is an abnormal relationship between the acetabulum and the head of the femur. Plain x-ray of both hips at the age of 3 months is still in use in some countries. On plain films, classic lines and angles are evaluated to meet current guidelines for positive DDH. Among these is the acetabular angle (AA), which most did not exceed 30° in normal pelvis regardless of gender. A flat promontory gives the impression of a high AA angle, whereas a sharp promontory gives the impression of a low AA angle. MATERIALS AND METHODS: All anteroposterior (AP) pelvic digital x-ray studies performed to rule out DDH were collected from the PACS systems. A novel angle was measured between a line parallel to the lateral aspect of the region of the inferior iliac spines and a line that extends along the acetabular roof to quantify the roundness of the iliac promontory. We called the former line the Miral line and the formed angle the iliac promontory angle. RESULTS: We show that the promontory shape is significantly different between genders, and therefore it is mistaken to generalize an upper AA limit for males and females. In addition, we show that the current guideline of the upper limit of AA did not predict the incidence of DDH. CONCLUSION: We suggest that the current practice is introducing a high rate of false positive, especially among females, and the current guidelines on AA should be reviewed and assigned separately for males and females. This is more important for countries that did not utilize the ultrasonographic assessment for DDH.

Ankylosing Spondylitis With Bilateral Symmetrical Uptake in the Greater Trochanters on Bone Scan.

Ankylosing spondylitis is a chronic inflammatory bone disease that commonly affects the spine and the sacroiliac joints. Ankylosing spondylitis can also cause enthesitis, or enthesopathy, which is an inflammation at the tendinous or ligamentous insertion sites on the bones. In this study, we present the case of a 37-year-old man with ankylosing spondylitis with a unique Tc-HDP bone scan finding of symmetrical increased uptake bilaterally in the greater trochanters.

Familial and Environmental Risk Predisposition in Tonsillectomy: A Case-Control Study.

BACKGROUND: Tonsillectomy is one of the most commonly performed procedures among children and it is the gold standard management to reduce episodes of tonsillitis and obstructive symptoms. Many studies showed a significantly higher incidence of previous tonsillectomy in the parents and siblings. This study investigated the influence of familial and environmental trends in tonsillectomy. METHODS: Retrospectively, we identified those patients who underwent tonsillectomy (the case group). Also, a control group of participants attending the hospital as visitors who had not undergone tonsillectomy was collected. Both groups are compared using the proper statistical tests. RESULTS: This study included 1,232 participants; 615 underwent tonsillectomy (cases) and 617 did not (controls). It was found that paternal and maternal history of tonsillectomy, childhood asthma, and daycare attendance are independent factors influencing tonsillectomy in the offspring. Of about 85.4% of fathers who underwent tonsillectomy their children will also have tonsillectomy. Also, regarding the maternal history, 72.5% of offspring will have tonsillectomy if the mothers underwent the procedure. CONCLUSION: This study reveals that genetic predisposition factors may have a role for tonsillectomy and its underlying causative indications. Also, it highlights the importance of asthma control in children. Moreover, the role of ethnicity may be minimal due to the similar trend of this study with other studies. Further studies and prospective research are recommended.

Ischio-anal fossa hydatid cyst.

Extrahepatic hydatid disease has been reported in several locations, including the pelvis, and it often poses a diagnostic challenge. There are very few reported cases of primary perineal ischio-anal fossa hydatid cysts. We present a case of a 46-year-old female who had complained of painless left perianal mass for 8 months. The first clinical and radiological diagnosis was a cystic lesion of the perianal region. However, surgical and pathological examination revealed the diagnosis of hydatid disease of ischio-anal fossa. The patient underwent surgical excision. At 1-year follow-up, the patient was disease-free. Hydatid disease of the perianal area, although rare, must be kept in the differential diagnosis of pathologies of any perianal mass or lump.

A snapshot of Ischemic stroke risk factors, sub-types, and its epidemiology: Cohort study.

The burden of stroke can be substantially studied by establishing the functional consequences of stroke and its predictors on the population, economy and to guide rehabilitation efforts. This study aims to determine the subtypes, risk factors, and epidemiology of stroke in Jordan. Methods: A retrospective cohort study design was carried out to determine the risk factors and subtypes of stroke during 2017-2018. The study sample included 176 ischemic stroke patients of the King Abdullah University Hospital. Data was collected through medical records, which was then statistically analysed through frequencies and percentages. Results: Total 176 cases were identified out of which 101 (57.38%) were males and 75 (42.61%) were females and male to female ratio was 1.9:1. Hypertension was the commonest risk factor identified (50.56%), followed by diabetes mellitus (19.88%), hyperlipidaemia (15.34%), coronary artery disease (6.25%), atrial fibrillation (4.54%), and past history of stroke (1.13%). Risk factors such as hypertension (p = 0.007), diabetes (p = 0.000), coronary artery disease (p = 0.000) were significantly associated with subtypes of ischemic strokes. Conclusion: The study concludes that mean age of men was higher as compared to women in small vessel occlusion. The risk of ischemic stroke in patients with dyslipidaemia, diabetes mellitus, and hypertension was higher in middle-aged and old patients.