Transoral versus transfacial surgical approach to maxillary tumors: evaluation of outcomes and perspectives.

Neoplasms of the maxilla have multiple different origins and histology, and often extend towards the infratemporal fossa, orbit, or skull base. Extensive resection may be required, often leading to poor esthetic and functional results. Usually, these lesions are removed via a transfacial approach. The aim of this study was to compare the outcomes of the transoral versus transfacial approach for maxillary tumors. A single-institution retrospective study was conducted on patients with maxillary-midface tumors, treated between January 2009 and December 2019. The patients were divided into two groups according to the surgical approach, transfacial or transoral, and the following outcomes were assessed: extent of the resection based on Brown's classification; postoperative pathology margin assessment; reconstruction technique; esthetic/functional results. A total of 178 patients were included. A satisfactory resection was obtained in both groups, with the transoral cohort achieving a higher rate of clear oncological margins (positive margins: transoral group 3.7% versus transfacial group 6.8%, P = 0.389) and a significantly higher University of Washington Quality of Life score (mean 72.2 versus 67.8, P < 0.001). Even large and invasive tumors can be treated successfully with the transoral approach, avoiding unesthetic facial scars while still providing complete resection of the tumor.

Social inequalities in the metropolitan area of Rome. A multidisciplinary analysis of the urban segregation of the "formerly-Bastogi" compound.

BACKGROUND: This study tries to evaluate, through a multidisciplinary approach, the relationship between urban structure, isolation and distribution of social determinants of health, in the so-called "formerly-Bastogi, a compound, with more than 1,500 inhabitants, located in north-western Rome, Italy. METHODS: The architectural-urban analysis, conducted through site visits and evaluations of urban situation, showed how strongly the compound is isolated from the neighbourhoods, and structurally degraded. The socio-demographic analysis, based on the National Census data, showed significant differences in the distribution of the social determinants of health between "formerly-Bastogi" and the surrounding areas. RESULTS: The area under study appears to be isolated from the surrounding urban space, both because of social and architectural factors. This situation could have some association with inhabitants' health. CONCLUSIONS: If our preliminary investigation was useful for a diagnosis of the situation, a more complete - qualitative and quantitative - investigation of the context will be needed to plan appropriate multidisciplinary health-promoting interventions.

Genetic diversity of Coxiella burnetii in domestic ruminants in central Italy.

BACKGROUND: As the epidemiology of human Q Fever generally reflects the spread of Coxiella burnetii in ruminant livestock, molecular characterization of strains is essential to prevent human outbreaks. In this study we report the genetic diversity of C. burnetii in central Italy accomplished by MST and MLVA-6 on biological samples from 20 goat, sheep and cow farms. RESULTS: Five MST and ten MLVA profiles emerged from the analysis establishing a part of C. burnetii strain world atlas. In particular, ST32 occurred on 12 farms (60%), prevalently in goat specimens, while ST12 (25%) was detected on 4 sheep and 1 goat samples. ST8 and a variant of this genotype were described on 2 different sheep farms, whereas ST55 was observed on a goat farm. Five complete MLVA profiles different from any other published genotypes were described in this study in addition to 15 MLVA incomplete panels. Despite this, polymorphic markers Ms23, Ms24 and Ms33 enabled the identification of samples sharing the same MST profile. CONCLUSIONS: Integration of such data in international databases can be of further help in the attempt of building a global phylogeny and epidemiology of Q fever in animals, with a "One Health" perspective.

Proteome Analysis of Urticating Setae From Thaumetopoea pityocampa (Lepidoptera: Notodontidae).

Thaumetopoea pityocampa (Denis & Schiffermüller) (Lepidoptera: Notodontidae) is harmful to conifer trees because of defoliation and to public health because of the release of urticating setae from the caterpillars. Contact with setae by humans and domestic animals induces dermatitis, usually localized to the exposed areas. Recent studies demonstrated the presence of a complex urticating mechanism where proteins present in the setae may play a role as activators of immune responses. Yet, limited information is available at present about the proteins occurring in the setae of T. pityocampa. Using a refined method for protein extraction from the setae, and a combination of liquid chromatography tandem-mass spectrometry (LC-MS/MS), de novo assembly of transcriptomic data, and sequence similarity searches, an extensive data set of 353 proteins was obtained. These were further categorized by molecular function, biological process, and cellular location. All the 353 proteins identified were found to match through BLAST search with at least one Lepidoptera sequence available in databases. We found the previously known allergens Tha p 1 and Tha p 2 described from T. pityocampa, as well as enzymes involved in chitin biosynthesis, one of the principal components of the setae, and serine proteases that were responsible for inflammatory and allergic reactions in other urticating Lepidoptera. This new proteomic database may allow for a better understanding of the complexity of allergenic reactions due to T. pityocampa and to other Lepidoptera sharing similar defense systems.

Prevalence and characterization of methicillin-resistant Staphylococcus aureus carrying mecA or mecC and methicillin-susceptible Staphylococcus aureus in dairy sheep farms in central Italy.

Between January and May 2012, a total of 286 bulk tank milk samples from dairy sheep farms located in central Italy were tested for the presence of Staphylococcus aureus. One hundred fifty-three samples were positive for S. aureus (53.5%), with an average count of 2.53 log cfu/mL. A total of 679 S. aureus colonies were screened for methicillin resistance by the cefoxitin disk diffusion test, and 104 selected cefoxitin-susceptible isolates were also tested for their susceptibility to other antimicrobials representative of the most relevant classes active against Staphylococcus spp. by using the Kirby-Bauer disk diffusion method. Two methicillin-resistant Staphylococcus aureus (MRSA) isolates, carrying respectively the mecA and the mecC genes, were detected in 2 samples from 2 different farms (prevalence 0.7%). The mecA-positive MRSA isolate was blaZ positive, belonged to spa type t127, sequence type (ST)1, clonal complex (CC)1, carried a staphylococcal cassette chromosome mec (SCCmec) type IVa, and was phenotypically resistant to all the ß-lactams tested and to erythromycin, streptomycin, kanamycin, and tetracycline. The mecC-positive MRSA isolate was negative for the chromosomally or plasmid-associated blaZ gene but positive for the blaZ allotype associated with SCCmec XI (blaZ-SCCmecXI), belonged to spa type 843, ST(CC)130, carried a SCCmec type XI, and was resistant only to ß-lactams. Both MRSA were negative for the presence of specific immune-evasion and virulence genes such as those coding for the Panton-Valentine leucocidin, the toxic shock syndrome toxin 1, and the immune evasion cluster genes. Regarding the presence of the major S. aureus enterotoxin genes, the mecC-positive MRSA tested negative, whereas the ST (CC)1 mecA-positive MRSA harbored the seh gene. Among the 104 methicillin-susceptible S. aureus isolates examined for antimicrobial susceptibility, 63 (60.58%) were susceptible to all the antimicrobials tested, and 41 (39.42%) were resistant to at least 1 antimicrobial. In particular, 23 isolates (22.12%) were resistant to tetracycline, 16 (15.38%) to sulfonomides, 14 (13.46%) to trimethoprim and sulfamethoxazole, and 9 (8.65%) to ampicillin, whereas only 1 isolate was resistant to both fluoroquinolones and aminoglycosides. The high prevalence of S. aureus found in bulk tank milk samples and the isolation of MRSA, although at a low prevalence, underlines the importance of adopting control measures against S. aureus in dairy sheep farms to minimize the risks for animal and public health. Moreover, this study represents the first report of mecC-positive MRSA isolation in Italy and would confirm that, among livestock animals, sheep might act as a mecC-MRSA reservoir. Although this lineage seems to be rare in dairy sheep (0.35% of farms tested), because mecC-positive MRSA are difficult to detect by diagnostic routine methods employed for mecA-positive livestock-associated MRSA, diagnostic laboratories should be aware of the importance of searching for the mecC gene in all the mecA-negative S. aureus isolates displaying resistance to oxacillin, cefoxitin, or both.

Hepatitis B reactivation characterized by HBsAg negativity and anti-HbsAg antibodies persistence in haematopoietic stem cell transplanted patient after lamivudine withdrawal.

BACKGROUND: HBV reactivation is associated with high mortality rates in hematopoietic stem cell transplantation (HSCT) and prophylactic lamivudine (LMV) treatment is suggested to prevent this phenomenon. However, the duration of LMV treatment in HSCT patients is not fully defined and the time of immune recovery is considered the best parameter for a drug to be safely interrupted. In patients undergoing allogeneic HSCT, the time of immune recovery is not easy to define and may take years after transplantation and prolonged LMV treatments, which can lead to drug-resistant viral strains. CASE PRESENTATION: An anti-HBc-positive hematological patient who was undergoing prolonged immunosuppression and who experienced HBV reactivation 3 months after the suspension of a prolonged LMV prophylaxis is described. HBV-DNA matching an atypical serological profile characterized by HbsAg negativity and anti-HBs positivity was detected in the patient. The genotypic analysis of the HBV strain identified T127P, F170FL and S204R mutations of HbsAg, which can hinder HBsAg recognition in a diagnostic assay. CONCLUSIONS: HBV reactivation in the HSCT host can be sustained by HBsAg viral variants with characteristics of altered immunogenicity that cannot be detected by usual laboratory tests. This clinical case description suggests the importance of screening for serum HBV-DNA levels in the diagnosis of HBV reactivation and monitoring HBV-DNA after prophylaxis suspension, particularly in HSCT subjects who have undergone prolonged periods of LMV treatment.

Compositional analysis of endogenous porphyrins from Helicobacter pylori.

Bacteria able to accumulate porphyrins can be inactivated by visible light irradiation thanks to the photosensitizing properties of this class of aromatic pigments (photodynamic therapy, PDT). Since the bacterial resistance to antibiotic is growing, PDT is becoming a valid alternative. In this context, the pathogen Helicobacter pylori (Hp) is a suitable target for PDT since it spontaneously produces and accumulates porphyrins. It is then important to understand the spectroscopic behavior of these endogenous species to exploit them as photosensitizers, thus improving the results given by the application of PDT in the treatment of Hp infections. In this work we extracted porphyrins from both a laboratory-adapted and a virulent strain of Hp, and we performed spectroscopic and chromatographic experiments to collect information about the composition and the spectrophotometric features of the extracts. The main components of the porphyrin mixtures were identified and their relative contribution to the global red fluorescence was examined.

Hue-based quantification of mechanochromism towards a cost-effective detection of mechanical strain in polymer systems.

HSV is a digital colour space easily accessible by the transformation of RGB images. In this work, the hue parameter H was used to assess mechanically induced colour changes of the aggregation-sensitive fluorescent dye 4,4'-bis-(2-benzoxazolyl)stilbene (BBS), thus implementing a cheap and reliable method for the detection of mechanical deformation in a polymer matrix.

Persistent Atrial Fibrillation And Atrial Flutter Complicated By Tachycardiomyopathy Because Of Intermittent Conduction Through Accessory Pathway.

The term tachycardiomyopathy refers to a specific form of tachycardia-related cardiomyopathy caused by supraventricular or ventricular tachyarrhytmias that are both associated with ventricular rates higher than 120 bpm. The arrhythmias which are most frequently associated with these forms of heart disease are atrial fibrillation and atrial flutter, particularly found in the elderly population. The most frequent clinical manifestation is heart failure. In this case we are reporting a clinical case of a patient that came to our attention because of an episode of heart failure associated with atrial fibrillation and atrial flutter. The patient had also prolonged and repetitive strips of rapid conduction with wide QRS morphology. We don't know if the cause is pre excitation or ectopia. We showed that those strips of tachycardia with wide QRS, particularly when they were associated with atrial flutter, were so fast and consistent to determine the left ventricular contractile dysfunction; we showed also that those strips of wide complex tachycardia were caused by pre-excitation through an accessory right posteroseptal pathway and supported by the reentry circuit of common atrial flutter. The block of conduction through the accessory pathway and the elimination of atrial arrhythmia allowed the regression of left ventricular contractile dysfunction. We believe that this case is interesting because it shows that there is a strict continuity between sophisticated electrophysiological mechanisms and clinical manifestation.

Persistent risk of HBV reactivation despite extensive lamivudine prophylaxis in haematopoietic stem cell transplant recipients who are anti-HBc-positive or HBV-negative recipients with an anti-HBc-positive donor.

The overall rate of hepatitis B virus (HBV) reactivation was evaluated in a population of 373 haematological stem cell transplant (HSCT) patients treated with lamivudine (LMV) if they were anti-HBc-positive/HBV-DNA-negative recipients or if they were HBV-negative recipients with an anti-HBc-positive donor. The incidence of HBV reactivation was calculated in two groups of autologous (auto) or allogeneic (allo) HSCT patients who were stratified according to their HBV serostatus. The former group included 57 cases: 10 auto-HSCT and 27 allo-HSCT anti-HBc-positive recipients, two auto-HSCT and three allo-HSCT inactive carriers, and 15 allo-HSCT recipients with an anti-HBc-positive donor. Forty-seven (82.4%) patients in this group received LMV prophylaxis (the median (interquartile range, IQR) of LMV treatment was 30 (20-38) months). The second group consisted of 320 anti-HBc-negative auto-HSCT and allo-HSCT recipients with anti-HBc-negative donors. None of these patients received any prophylaxis. Two patients in the first group and two in the second group experienced reactivation of HBV infection, with an incidence of 3.5% (95% CI 0.4-12.1%) and 0.6% (95% CI 0.1-2.2%), respectively. Only one out of four reactivated patients was LMV-treated. The cumulative probability of HBV reactivation at 6 years from HSCT was 15.8% (95% CI 15.2-16.4%). Three of four viral isolates obtained from the HBV-reactivated patients harboured mutations in the immune-active HBsAg-region. In a HSCT population carefully evaluated for HBV prophylaxis, a risk of HBV reactivation persisted in the group of patients who were not LMV-treated. Only one LMV-treated patient experienced reactivation of HBV with a resistant HBV isolate.

Prevalence of Staphylococcus aureus and of methicillin-resistant S. aureus clonal complexes in bulk tank milk from dairy cattle herds in Lombardy Region (Northern Italy).

Staphylococcus aureus is the most important causative agent of subclinical mastitis in cattle resulting in reduced milk production and quality. Methicillin-resistant S. aureus (MRSA) strains has a clear zoonotic relevance, especially in the case of occupational exposure. The aim of the study was to evaluate the prevalence of S. aureus and MRSA in bulk tank milk (BTM) from dairy cattle herds in the Lombardy Region (Northern Italy) and to identify the main MRSA circulating genotypes. MRSA strains were characterized by susceptibility testing, multi-locus sequence typing (MLST), spa typing and SCCmec typing. A total 844 BTM samples were analysed and S. aureus and MRSA were detected in 47·2% and 3·8% of dairy herds, respectively. MLST showed that the majority (28/32) of isolates belonged to the typical livestock-associated lineages: ST398, ST97 and ST1. Interestingly, in this study we report for the first time the new ST3211, a single locus variant of ST(CC)22, with the newly described 462 aroE allele. Our study indicates high diffusion of S. aureus mastitis and low, but not negligible, prevalence of MRSA in the considered area, suggesting the need for planning specific control programmes for bovine mastitis caused by S. aureus, especially when MRSA is implicated.

Methicillin-resistant and methicillin-susceptible Staphylococcus aureus in dairy sheep and in-contact humans: An intra-farm study.

Staphylococcus aureus is involved in a wide variety of diseases in humans and animals, and it is considered one of the most significant etiological agents of intramammary infection in dairy ruminants, causing both clinical and subclinical infections. In this study, the intra-farm prevalence and circulation of methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) were investigated on an Italian dairy sheep farm previously identified as MRSA-positive by testing bulk tank milk (first isolation in 2012). Human samples (nasal swabs, hand skin samples, and oropharyngeal swabs) from 3 persons working in close contact with the animals were also collected, and the genetic characteristics and relatedness of the MRSA isolates from human and animal sources within the farm were investigated. After 2yr from the first isolation, we confirmed the presence of the same multidrug-resistant strain of MRSA sequence type (ST)1, clonal complex (CC)1, spa type t127, staphylococcal cassette chromosome mec (SCCmec) type IVa, showing identical pulsed field gel electrophoresis (PFGE) and resistance profiles at the farm level in bulk tank milk. Methicillin-resistant S. aureus isolates were detected in 2 out of 556 (0.34%) individual milk samples, whereas MSSA isolates were detected in 10 samples (1.8%). The MRSA were further isolated from udder skin samples from the 2 animals that were MRSA-positive in milk and in 2 of the 3 examined farm personnel. All MRSA isolates from both ovine and human samples belonged to ST(CC)1, spa type t127, SCCmec type IVa, with some isolates from animals harboring genes considered markers of human adaptation. In contrast, all MSSA isolates belonged to ruminant-associated CC130, ST700, spa type t528. Analysis by PFGE performed on selected MRSA isolates of human and animal origin identified 2 closely related (96.3% similarity) pulsotypes, displaying only minimal differences in gene profiles (e.g., presence of the immune evasion cluster genes). Although we observed low MRSA intra-farm prevalence, our findings highlight the importance of considering the possible zoonotic potential of CC1 livestock-associated MRSA, in view of the ability to persist over years at the farm level. Biosecurity measures and good hygiene practices could be useful to prevent MRSA spread at the farm level and to minimize exposure in the community and in categories related to farm animal industry (e.g., veterinarians, farmers, and farm workers).

A recent epidemiological cluster of acute hepatitis B genotype F1b infection in a restricted geographical area of Italy.

In this study, by phylogenetic analysis, we identified an epidemiological cluster involving eight individuals diagnosed with acute hepatitis B virus (HBV) infection related to unprotected sexual intercourse in a restricted area of central Italy (time period: 2011-2014). Notably, these patients (six of eight Italians) were infected by subgenotype F1b, which is not commonly found in western countries. Ultra-deep pyrosequencing confirmed a superimposable composition of HBV quasi-species in these patients. Despite the availability of effective vaccination, this study highlights the importance of not underestimating the risk of HBV infection, of continuing to set up surveillance programmes for HBV infection, and of investigating the pathogenetic potential of these atypical genotypes.

Short communication: Prevalence of Staphylococcus aureus and methicillin-resistant S. aureus in bulk tank milk from dairy goat farms in Northern Italy.

Staphylococcus aureus is regarded as a leading cause of mastitis in goats. However, few data are available on the presence of methicillin-resistant S. aureus (MRSA) in this species. The aim of this study was to assess the prevalence of S. aureus and MRSA in bulk tank milk samples from dairy goat farms in Northern Italy. Eighty-five out of 197 samples (43.1%) tested positive for S. aureus with counts ranging from 10 to more than 1.5 × 10(4) cfu/mL. The MRSA was screened by both direct plating followed by a disk diffusion test to evaluate methicillin resistance and a selective enrichment method. Methicillin-resistance was confirmed by mecA-specific PCR. Methicillin-resistant S. aureus was identified in 4 samples (2.0%) and multilocus sequence typing (MLST) showed the presence of livestock-associated MRSA belonging to lineages ST398 (n = 3) and ST1 (n = 1). In one case we demonstrated that the same MRSA strain was able to persist over time on the farm, being isolated from both bulk tank milk and the udder of 3 goats 1 yr after the first isolation. The high prevalence of S. aureus-positive herds detected in this study and the presence of MRSA strains belonging to livestock-associated genotypes is of concern, and represents a novel finding in the Italian dairy goat production system. The application of stringent measures for the control of S. aureus mastitis at the farm level seems appropriate to reduce the economic losses, and to minimize the risk of foodborne illness and the transmission of MRSA to humans by occupational exposure.

Chest wall reconstruction with latissimus dorsi and an autologous thoracolumbar fascia graft in a dog.

A new technique for autogenous chest wall reconstruction using a latissimus dorsi muscle flap and a free graft of thoracolumbar fascia was utilised in a two-year-old Dobermann after resection of a high-grade osteosarcoma from the left thoracic wall. En bloc excision of the chest wall mass, including six ribs, was performed. The resulting chest wall defect was too large to be reconstructed with only a pedicled muscle flap and was reconstructed with a latissimus dorsi muscle flap cranially and a free graft of thoracolumbar fascia caudally. The graft was harvested easily, and there was no donor site morbidity or postoperative complications. A free graft of thoracolumbar fascia can be considered as an option to supplement autogenous reconstruction of the chest wall.

High prevalence of chitotriosidase deficiency in Peruvian Amerindians exposed to chitin-bearing food and enteroparasites.

The human genome encodes a gene for an enzymatically active chitinase (CHIT1) located in a single copy on Chromosome 1, which is highly expressed by activated macrophages and in other cells of the innate immune response. Several dysfunctional mutations are known in CHIT1, including a 24-bp duplication in Exon 10 causing catalytic deficiency. This duplication is a common variant conserved in many human populations, except in West and South Africans. Thus it has been proposed that human migration out of Africa and the consequent reduction of exposure to chitin from environmental factors may have enabled the conservation of dysfunctional mutations in human chitinases. Our data obtained from 85 indigenous Amerindians from Peru, representative of populations characterized by high prevalence of chitin-bearing enteroparasites and intense entomophagy, reveal a very high frequency of the 24-bp duplication (47.06%), and of other single nucleotide polymorphisms which are known to partially affect enzymatic activity (G102S: 42.7% and A442G/V: 25.5%). Our finding is in line with a founder effect, but appears to confute our previous hypothesis of a protective role against parasite infection and sustains the discussion on the redundancy of chitinolytic function.

Use of negative contrast computed tomography for diagnosis of a colonic duplication in a dog.

A 24-week-old dog was presented with recurrent rectal prolapse because of colonic duplication. Colonic duplication is an extremely uncommon congenital abnormality, with only six cases reported in veterinary medicine, one diagnosed at necropsy and five after barium enema, colonoscopy, abdominal ultrasound, exploratory laparotomy either alone or in combination. In this case, these techniques failed to identify the abnormality and diagnosis was ultimately achieved via negative contrast computed tomography. The evaluation generated by the computed tomography images allowed a refined surgical approach. To the authors' knowledge, negative contrast computed tomography has not yet been reported in the veterinary literature to diagnose gastrointestinal pathologies. Colonic duplication in this case was treated by removal of the intercolonic septum via colotomy.

Public health impact and antimicrobial selection of meticillin-resistant staphylococci in animals.

Whilst meticillin-resistant Staphylococcus aureus (MRSA) infections reported sporadically in companion animals and cattle in the 1970s were probably of human origin, the recently emerged livestock-associated MRSA (LA-MRSA) and meticillin-resistant Staphylococcus pseudintermedius (MRSP) strains clearly have animal origins and their isolation from humans is usually associated with exposure to livestock and companion animals, respectively. LA-MRSA is primarily an occupational health risk to farm workers and veterinarians. The risk that this zoonotic agent may spread in the community is particularly acute in countries with high livestock production and low MRSA prevalence in the human population. MRSP is primarily a threat to animal health, and cases of human infection are rare but may be overlooked in diagnostic laboratories. There is no conclusive evidence of antimicrobial selection associated with the sudden emergence of LA-MRSA and MRSP. However, the rapid global spread of these bacteria has presumably been favoured by antimicrobial selective pressure. Tetracyclines, zinc and extended-spectrum cephalosporins (including extra-label use) are the most likely selective drivers implicated in the spread of LA-MRSA, whilst increased use of broad-spectrum ß-lactams and fluoroquinolones, partly enhanced by extra-label use and the introduction of cheap generics, may have played an important role in the rapid dissemination of MRSP. Control of LA-MRSA and MRSP requires a dual approach aimed at reducing antimicrobial consumption and preventing transmission between animals and from animals to humans or vice versa. Restricted use of fluoroquinolones and cephalosporins in livestock, and national practice guidelines for rational antimicrobial use both in food and companion animals are warranted.

Environmental methicillin-resistant Staphylococcus aureus contamination in pig herds in relation to the productive phase and application of cleaning and disinfection.

The aim of the study is to better understand MRSA environmental contamination in pig holdings in relation to the productive phase and the application of environmental cleaning and disinfection practices (C&D). This study was carried out on six herds. Dust samples from farrowing crates, weaning boxes, growing and finishing pens were collected from each herd environment prior to and after C&D and cultured for MRSA. Ten samples were collected at the end of each productive phase with the animals present and 10 additional samples were collected after C&D, prior to introduction of a new stock. The proportion of positive samples prior to C&D was lower in fattening than in other phases. The proportion of positive samples prior to and after C&D was 121/240 (50%) and 46/240 (19%) respectively. In the mixed effects logistic regression analysis it was shown not only that both productive phase and C&D were associated with the probability of having a positive sample but also that the C&D effect was different in the different productive phases. In particular the effect of C&D was stronger in farrowing crates than in the other productive phases. The results of this study show that, although current practices of cleaning and disinfection reduce MRSA environmental contamination, they are likely to be inadequate to the elimination of the microorganism. However, a strict application of hygienic protocols can lead to a marked reduction of MRSA environmental contamination.