Improved Diagnosis and Treatment of Bone and Joint Infections Using an Evidence-based Treatment Guideline.

BACKGROUND: Our institution created a multidisciplinary guideline for treatment of acute hematogenous osteomyelitis (AHO) and septic arthritis (SA) in response to updates in evidence-based literature in the field and existing provider variability in treatment. This guideline aims to improve the care of these patients by standardizing diagnosis and treatment and incorporating up to date evidence-based research into practice. The primary objective of this study is to compare cases before versus after the implementation of the guideline to determine concrete effects the guideline has had in the care of patients with AHO and SA. METHODS: This is an Institutional Review Board-approved retrospective study of pediatric patients age 6 months to 18 years hospitalized between January 2009 and July 2016 with a diagnosis of AHO or SA qualifying for the guideline. Cohorts were categorized: preguideline and postguideline. Exclusion criteria consisted of: symptoms >14 days, multifocal involvement, hemodynamic instability, sepsis, or history of immune deficiency or chronic systemic disease. Cohorts were compared for outcomes that described clinical course. RESULTS: Data were included for 117 cases that qualified for the guideline: 54 preguideline and 63 postguideline. Following the successful implementation of the guideline, we found significant decrease in the length of intravenous antibiotic treatment (P<0.001), decrease in peripherally inserted central catheter use (P<0.001), and an increase in bacterial identification (P=0.040). Bacterial identification allowed for targeted antibiotic therapy. There was no change in length of hospital stay or readmission rate after the implementation of the guideline. CONCLUSION: Utilizing an evidence-based treatment guideline for pediatric acute hematogenous bone and joint infections can lead to improved bacterial diagnosis and decreased burden of treatment through early oral antibiotic use. LEVEL OF EVIDENCE: Level III- retrospective comparative study.

[Time bacterial growth in blood cultures in neonates]. / Tiempo de crecimiento bacteriano en hemocultivos en neonatos.

INTRODUCTION: Sepsis is a major cause of neonatal morbidity and mortality. OBJECTIVES: To detect the time when the bacterial growth curve is evidenced in the blood sample inoculated blood cultures and comparing the times of bacterial growth between Gram negative and Gram positive bacteria, among the types of neonatal sepsis and identifying microorganisms more often isolated from preterm and term. PATIENTS AND METHOD: A descriptive study. 114 positive blood cultures from 1,932 blood cultures taken from 01-May-2010 and 31-May-2014 were evaluated. Data were analyzed with Stata(®) 11.0. RESULTS: 5.9% of blood cultures had bacterial growth. The median and interquartile range of Gram negative times of bacterial growth was 11h (10-13h), for Gram positive coagulase-negative Staphylococcus different (CoNS) 12h (12-18h) and CoNS 42h (36-44h). 95.8% of Gram positive and 96% of Gram negative, were the times of bacterial growth≤24h incubation, whereas the 100% CoNS was positive≤62h of incubation. CONCLUSION: 100% of sepsis by Gram negative and Gram positive no CoNS and 90% of those caused by CoNS are identified in blood cultures in 48h, so we can conclude that to rule out sepsis, an incubation period of 48h in blood cultures is sufficient.

[Seroconversion in response to a reinforced primary hepatitis B vaccination in children with cancer]. / Seroconversión frente a primovacunación reforzada contra hepatitis B en niños con cáncer.

INTRODUCTION: Immune response against vaccine antigens may be impaired in children with cancer. The aim of this study was to evaluate the seroconversion response against hepatitis B vaccination (HBV) at the time of chemotherapy onset and/or remission in children with cancer. PATIENTS AND METHOD: Prospective, two-centre, controlled, non-randomised study conducted on children recently diagnosed with cancer, paired with healthy subjects. Cases received HBV at time 0, 1 and 6 months with DNA recombinant HBV at a dose of 20 and 40 µg if < or > than 10 years of age, respectively, at the time of diagnosis for solids tumours and after the remission in case of haematological tumours. Controls received the same schedule, but at of 10 and 20 µg doses, respectively. HBs antibodies were measured in serum samples obtained at 2, 8 and 12 months post-vaccination. Protective titres were defined as > 10 mIU/ml at 8th month of follow up. RESULTS: A total of 78 children with cancer and 25 healthy controls were analysed at month 8th of follow up. Seroconversion rates in the cancer group reached 26.9%, with no differences by age, gender or type of tumour (P = .13, .29, and .44, respectively). Control group seroconversion was 100% at the 8th month, with P < .0001 compared with the cancer group. At month 12 of follow up, just 31.9% of children with cancer achieved anti-HBs antibodies > 10 mIU/ml. CONCLUSIONS: Vaccination against hepatitis B with three doses of DNA recombinant vaccine at an increased concentration, administrated at the time of onset of chemotherapy and/or remission provided an insufficient immune response in a majority of children with cancer. More immunogenic vaccines should be evaluated in this special population, such as a third generation, with more immunogenic adjuvants, enhanced schedules at 0, 1, 2, 6 month, evaluation of antibody titres at month 8 and 12h to evaluate the need for further booster doses.

Proteomic analysis reveals heat shock protein 70 has a key role in polycythemia Vera.

JAK-STAT signaling through the JAK2V617F mutation is central to the pathogenesis of myeloproliferative neoplasms (MPN). However, other events could precede the JAK2 mutation. The aim of this study is to analyze the phenotypic divergence between polycytemia vera (PV) and essential thrombocytemia (ET) to find novel therapeutics targets by a proteomic and functional approach to identify alternative routes to JAK2 activation. Through 2D-DIGE and mass spectrometry of granulocyte protein from 20 MPN samples, showed differential expression of HSP70 in PV and ET besides other 60 proteins. Immunohistochemistry of 46 MPN bone marrow samples confirmed HSP70 expression. The median of positive granulocytes was 80% in PV (SD 35%) vs. 23% in ET (SD 34.25%). In an ex vivo model KNK437 was used as an inhibition model assay of HSP70, showed dose-dependent inhibition of cell growth and burst formation unit erythroid (BFU-E) in PV and ET, increased apoptosis in the erythroid lineage, and decreased pJAK2 signaling, as well as a specific siRNA for HSP70. These data suggest a key role for HSP70 in proliferation and survival of the erythroid lineage in PV, and may represent a potential therapeutic target in MPN, especially in PV.

Prevalence of Protein-Energy Wasting in Dialysis Patients Using a Practical Online Tool to Compare with Other Nutritional Scores: Results of the Nutrendial Study.

This cross-sectional study aims to explore the prevalence of protein-energy wasting (PEW) in dialysis patients in Catalonia, Spain, using a new and practical online tool which enables rapid calculation and comparison with other nutritional scores. METHODS: A web tool (Nutrendial) was created to introduce different variables and automatically calculate PEW, Malnutrition inflammation Score (MIS) and Subjective Global Assessment (SGA) in 1389 patients (88% in haemodialysis (HD)), 12% in peritoneal dialysis (PD) from different regions of Catalonia. RESULTS: A prevalence of 23.3% (26% HD, 10.2% PD) of PEW was found, with a mean MIS score of 6 and SGA score of C in 7% of the patients. ROC analysis showed MIS as the best nutritional score to diagnose PEW (AUC 0.85). Albumin delivered lower diagnostic precision (AUC 0.77) and sensitivity (66%). A cut off point of 7 (86% sensitivity and 75% specificity) for MIS and 3.7 mg/dL for albumin were found to predict the appearance of PEW in this population. SGA B or C showed an 87% sensitivity and 55% specificity to diagnose PEW. Very low nutritional intervention (14%) was recorded with this tool in patients with PEW. CONCLUSIONS: This new online tool facilitated the calculation of PEW, enabling different professionals-including nephrologists, dieticians and nurses-to efficiently obtain insights into the nutritional status of the Catalonian dialysis population and implement the required nutritional interventions. MIS is the score with more sensitivity to diagnose PEW.

Identification of an Emergent Pathogen, Bartonella vinsonii, Using Next-Generation Sequencing in a Patient With Culture-Negative Endocarditis.

Diagnosis and treatment of culture negative endocarditis remains a challenge. This report describes a rare cause of endocarditis in humans, Bartonella vinsonii, identified through next generation sequencing of plasma microbial cell-free DNA with confirmation of cardiac valve tissue infection through immunohistochemical staining and polymerase chain reaction.

Oral Narrow-Spectrum Antibiotics for the Treatment of Urinary Tract Infection in Infants Younger Than 60 Days.

Data on the outcome of infants younger than 60 days treated with a combination of intravenous and oral antibiotics for urinary tract infection are limited. This study examined susceptibility and successful outcomes of treatment with narrow-spectrum oral antibiotics. In addition, we describe the effects of antimicrobial stewardship education intervention on prescribing practices.

Acute Flaccid Myelitis Among Hospitalized Children in Texas, 2016.

BACKGROUND: Acute flaccid myelitis is characterized by acute-onset flaccid limb weakness with predominantly gray matter lesions in the spinal cord spanning one or more segments. Rates of full recovery are poor, and there is no standard treatment or definitive cause. METHODS: This is a retrospective review of children diagnosed with acute flaccid myelitis in Texas during 2016. Patients were identified through a Texas collaborative of six hospitals in four major metropolitan areas. Data abstraction included health history, illness presentation, medical treatments, laboratory studies, imaging data, recovery, and ability to perform activities of daily living up to approximately two years from illness onset. RESULTS: Among all sites, 21 patients met inclusion criteria. Treatments varied with the most common being intravenous immunoglobulin, high-dose methylprednisolone, and plasmapheresis. No differences were seen in response to medical treatments. A potential etiology was found in 12 (57%) cases, including four with enterovirus D68. Five cases recovered fully. Of the 16 patients without full recovery, abilities ranged from (1) able to perform all activities of daily living for age independently (n = 5), (2) mild deficits (n = 5), and (3) substantial reliance on caregivers for activities of daily living (n = 6). CONCLUSION: Many reports describe symptoms and outcomes of acute flaccid myelitis, but limited data are available on long-term functional outcomes. We were unable to make a strong case for any single cause or treatment modality. Fortunately, the majority of patients (15, 71%) were able to perform activities of daily living with complete independence or only mild deficits.

Epidemiological and clinical variables related with the predominant polarity on bipolar disorder: A systematic review. / Factores asociados a la polaridad predominante en el trastorno bipolar: una revisión sistemática.

INTRODUCTION: Current classification of bipolar disorder (BD) in type i or type ii, however useful, may be insufficient to provide relevant clinical information in some patients. As a result, complementary classifications are being proposed, like the predominant polarity (PP) based, which is defined as a clear tendency in the patient to present relapses in the manic or depressive poles. METHODS: We carried out a search in PubMed and Web of Science databases, following the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses -PRISMA- guidelines, to identify studies about BD reporting PP. The search is updated to June 2016. RESULTS: Initial search revealed 907 articles, of which 16 met inclusion criteria. Manic PP was found to be associated with manic onset, drug consumption prior to onset and a better response to atypical antipsychotics and mood stabilisers. Depressive PP showed an association with depressive onset, more relapses, prolonged acute episodes, a greater suicide risk and a later diagnosis of BD. Depressive PP was also associated with anxiety disorders, mixed symptoms, melancholic symptoms and a wider use of quetiapine and lamotrigine. LIMITATIONS: Few prospective studies. Variability in some results. CONCLUSION: PP may be useful as a supplement to current BD classifications. We have found consistent data on a great number of studies, but there is also contradictory information regarding PP. Further studies are needed, ideally of a prospective design and with a unified methodology.

Decreasing Exposure to Radiation, Surgical Risk, and Costs for Pediatric Complicated Pneumonia: A Guideline Evaluation.

OBJECTIVES: This report describes the creation and successful implementation of a complicated pneumonia care algorithm at our institution. Outcomes are measured for specific goals of the algorithm: to decrease radiation exposure, surgical risk, and patient charges without adversely affecting clinical outcomes. METHODS: We describe steps involved in algorithm creation and implementation at our institution. To depict outcomes of the algorithm, we completed a retrospective cohort study of hospitalized pediatric patients with a diagnosis of complicated pneumonia at a single institution between January 2010 and April 2016 who met criteria for the algorithm. Charts were manually reviewed and data were analyzed via Wilcoxon rank sum, χ2, and Fisher's exact tests. RESULTS: Throughout the algorithm creation process, our institution began to see a change in practice. We saw a statistically significant decrease in the number of patients who underwent a chest computed tomography scan and an increase in patients who underwent a chest ultrasound (P < .001). We also saw an increase in the use of chest tube placement with fibrinolytics and a decrease in the use of video-assisted thoracoscopic surgery as the initial chest procedure (P ≤ .001) after algorithm implementation. These interventions reduced related charges without significantly affecting length of stay, readmission rate, or other variables studied. CONCLUSIONS: The collaborative creation and introduction of an algorithm for the management of complicated pneumonia at our institution, combined with an effort among physicians to incorporate evidence-based clinical care into practice, led to reduced radiation exposure, surgical risk, and cost to patient.

Cytological and biochemical evidence for an early cell dismantling event in surface cultures of Streptomyces antibioticus.

A process of programmed cell death taking place late in the aerial mycelium was previously reported in surface cultures of Streptomyces antibioticus ATCC11891. In this study, we present evidence for the occurrence of a similar process taking place early in the vegetative mycelium of surface cultures of the same strain. Several indicators, such as cell wall and membrane disruption, DNA degradation and release of the cytoplasmic content into the exocellular medium, support the existence of active, highly regulated cell suicide involving specific enzymes. Calcium-dependent proteolytic activation of a precursor of nucleases and the nucleolytic formation of a ladder of chromosomal bands are conspicuous events associated with the initiation of the death process.

Mycelium development in Streptomyces antibioticus ATCC11891 occurs in an orderly pattern which determines multiphase growth curves.

BACKGROUND: The current model for the developmental cycle of Streptomyces confluent cultures on agar surface is based on the assumption that the only differentiation takes place along the transverse axis (bottom-up): a vegetative (substrate) mycelium grows completely live and viable on the surface and inside the agar until it undergoes a death process and differentiates to a reproductive (aerial) mycelium which grows into the air. Hence, this vertical description assumes that the development in the pre-sporulating phases is more or less homogeneous in all zones of the plate surface. RESULTS: The work presents a detailed analysis of the differentiation cycle in Streptomyces antibioticus ATCC11891 considering a different spatial dimension: the longitudinal axes, represented by the plate surface. A previously unsuspected complexity during the substrate mycelial phase was detected. We have demonstrated that the young substrate hyphae suffer an early death round that has not been previously described. Subsequently, the remaining mycelium grows in successive waves which vary according to the density of the spore inoculum. In the presence of dense inocula (1.5 x 10(6) spores per plate), the hyphae develop in regular circles, approximately 0.5 cm in diameter. By contrast, with highly diluted inocula (6 x 10(3) spores per plate), aerial mycelium develops initially in the form of islands measuring 0.9 mm in diameter. Further mycelial development occurs between the circles or islands until the plate surface is totally covered. This pattern persists throughout the entire developmental cycle including the sporulation phases. CONCLUSION: An early death round during the substrate mycelial phase of Streptomyces antibioticus ATCC11891 takes place prior to successive growth periods in surface cultures. These developmental periods in turn, determine the shape of the complex multiphase growth curves observed. As shown here, these results also apply to other Streptomyces strains and species. Understanding these peculiarities of the Streptomyces developmental cycle is essential in order to properly interpret the morphological/biochemical data obtained from solid cultures and will expand the number of potential phenotypes subject to study.

[Plasma homocysteine concentration and its relationship with the development of preeclampsia. Effect of prenatal administration of folic acid]. / Concentraciones de homocisteína plasmática en embarazadas y su relación con el desarrollo de preeclampsia. Efecto de la administración prenatal de ácido fólico.

The increase of plasmatic homocysteine (Hc) in pregnant women, who later develop preeclampsia/eclampsia, the cause of this increment and its pathogenic role in toxemia of pregnancy, are still controversial. The objectives of the present research were to determine the plasmatic He concentrations during the first and second trimesters of pregnancy and the effect of folic acid administration on these values, and in the prevention of preeclampsia. Ninety six pregnant women of low economic background were studied on the first prenatal consultation: 27 women in the first trimester of pregnancy and 59 in the second. After 8 hours of fasting, venous blood was extracted and each patient was provided with 1 mg folic acid tablets and instructed to ingest one tablet daily, and to come back to the laboratory after three months. Plasma homocysteine and serum folic acid were determined for each patient before and after the folic acid treatment, by using the IMX system (Abbott Lab) and radioimmunoassay, respectively. Basal homocysteine concentrations were 4.0 +/- 2.1 micromol/L and 4.8 +/- 2.1 micromol/L in the first and second trimesters respectively, with no significant modifications after three months of folic acid. Although the degree of desertion from the study was high, it was possible to determine the evolution of 65 pregnancies. Ten of them developed preeclampsia (15.4%). No significant differences were found in Hc concentrations, or the frequency of hyperhomocysteinemia in the different stages of pregnancy, between women with normal gestation and those who developed preeclampsia. The small sample size of these groups, preclude any valid conclusion, however the results do not suggest that Hc concentration or folic acid administration influence the development of toxemia of pregnancy.

Aspects of meaning of life in different subcultures in Peru.

The categorization system for perceptions of meaning of life developed by Ebersole, et al. was applied in four different Peruvian subsamples (middle/upper-class university students, lower-class night students, slum dwellers who had emigrated from the South Andes and settled in the capital, and Highland Indians), totaling 168 participants. Analysis showed most answers could be satisfactorily fitted into the eight categories, although slight modifications had to be made and two more categories had to be created. For middle/upper-class students, lower-class night students, and slum dwellers, Growth was the most important category followed by Relationships. In contrast, the major topic within the Indian sample of the South Andes was Relationships, whereas Growth turned out to be irrelevant. More educated subjects described meaning of life in a more abstract way than less educated subjects. The discrepancies between the subsamples suggest that individual concepts of meaning of life contain culture-specific as well as universal elements.

Comprehensive clinical evaluation of a large Spanish family with Anderson-Fabry disease, novel GLA mutation and severe cardiac phenotype.

BACKGROUND AND OBJECTIVE: Fabry disease is an X-linked multisystemic lysosomal-storage condition. We describe a large family with a novel GLA mutation: p.M187R/g7219 T>G. PATIENTS AND METHODS: Anamnesis/physical-exam, blood/urine analysis, α-Gal-A activity and/or genetic study of at-risk individuals and multidisciplinary evaluation in confirmed cases. RESULTS: 4 males and 13 heterozygous-females displayed the mutation. Cardiac/renal/neurological disease was diagnosed at a mean age of 41/29/39 years in males and 51/56/46 years in females. Onset mean age was 20 years versus 42 years. 9/15 had cardiomyopathy. Delta wave suggestive of accessory pathway was identified in 1 male and 2 females. 1 female had cardiac arrest (ventricular fibrillation, 61 years). 2 females and 1 male died suddenly (63, 64 and 57 years). Cardiac-subscore of Mainz Severity-Score-Index was severe for males and females over 40 years. 4/15(26%) developed early renal disease. 2 males needed dialysis. 1 male died at 69 years in spite of kidney-heart transplant. CONCLUSION: We describe the largest genetically confirmed Spanish family using multidisciplinary evaluation and MSSI calculation. The novel mutation p.M187R/g7219 T>G is associated with a particularly malignant cardiac phenotype in males and females over 40 years. Severity was higher than that of the largest Spanish FOS-cohort. Short-PR with delta is being reported for the first time.

Proteomics identifies ubiquitin-proteasome targets and new roles for chromatin-remodeling in the Arabidopsis response to phosphate starvation.

In order to identify new regulators of the phosphate (Pi) starvation signaling pathway in plants, we analyzed variation in the abundance of nuclear-enriched proteins isolated from Arabidopsis roots that depends on Pi supply. We used 2-D fluorescence difference gel electrophoresis and MALDI-TOF/TOF techniques for proteome separation, visualization and relative protein abundance quantification and identification. Pi-controlled proteins identified in our analysis included components of the chromatin remodeling, DNA replication, and mRNA splicing machineries. In addition, by combining Pi starvation conditions with proteasome inhibitor treatments, we characterized the role of the ubiquitin-proteasome system, a major mechanism for targeted protein degradation in eukaryotes, in the control of the stability of Pi-responsive proteins. Among Pi-responsive proteins, the histone chaperone NAP1;2 was selected for further characterization, and was shown to display differential nucleo-cytoplasmic accumulation in response to Pi deprivation. We also found that mutants affecting three members of the NAP1 family accumulate lower Pi levels and display reduced expression of Pi starvation-inducible genes, reflecting a potential regulatory role for these chromatin-remodeling proteins in Pi homeostasis. BIOLOGICAL SIGNIFICANCE: In this study, we explore the feasibility of nuclear proteomics to identify regulatory proteins and ubiquitin-proteasome targets within a specific stress signaling pathway in plants, in our case phosphate starvation signaling in Arabidopsis. It will be of interest for researchers involved in the dissection of any signaling pathway in plants, in particular those with an interest in the ubiquitin-proteasome functions, and for the plant nutrition community.

Biochemical Characterization of Hypothetical Proteins from Helicobacter pylori.

The functional characterization of Open Reading Frames (ORFs) from sequenced genomes remains a bottleneck in our effort to understand microbial biology. In particular, the functional characterization of proteins with only remote sequence homology to known proteins can be challenging, as there may be few clues to guide initial experiments. Affinity enrichment of proteins from cell lysates, and a global perspective of protein function as provided by COMBREX, affords an approach to this problem. We present here the biochemical analysis of six proteins from Helicobacter pylori ATCC 26695, a focus organism in COMBREX. Initial hypotheses were based upon affinity capture of proteins from total cellular lysate using derivatized nano-particles, and subsequent identification by mass spectrometry. Candidate genes encoding these proteins were cloned and expressed in Escherichia coli, and the recombinant proteins were purified and characterized biochemically and their biochemical parameters compared with the native ones. These proteins include a guanosine triphosphate (GTP) cyclohydrolase (HP0959), an ATPase (HP1079), an adenosine deaminase (HP0267), a phosphodiesterase (HP1042), an aminopeptidase (HP1037), and new substrates were characterized for a peptidoglycan deacetylase (HP0310). Generally, characterized enzymes were active at acidic to neutral pH (4.0-7.5) with temperature optima ranging from 35 to 55°C, although some exhibited outstanding characteristics.