Clinical outcomes of adults hospitalized for laboratory confirmed respiratory syncytial virus or influenza virus infection.

OBJECTIVES: Respiratory syncytial virus (RSV) can cause severe disease in adults, but far less is known than for influenza. The aim of our study was to compare the disease course of RSV infections with influenza infections among hospitalized adults. METHODS: We retrieved clinical data from an ongoing surveillance of adults hospitalized with RSV or influenza virus infection in two acute care hospitals in North-Eastern Switzerland during the winter seasons 2017/2018 and 2018/2019. Our main analysis compared the odds between RSV and influenza patients for admission to an intensive care unit (ICU) or in-hospital death within 7 days after admission. RESULTS: There were 548 patients, of whom 79 (14.4%) had an RSV and 469 (85.6%) an influenza virus infection. Both groups were similar with respect to age, sex, smoking status, nutritional state, and comorbidities. More RSV patients had an infiltrate on chest radiograph on admission (46.4% vs 29.9%, p = .007). The proportion of patients with RSV who died or were admitted to ICU within seven days after admission was 19.0% compared to 10.2% in influenza patients (p = .024). In multivariable analysis, a higher leukocyte count (adjusted OR 1.07, 95% CI 1.02-1.13, p = .013) and the presence of a pneumonic infiltrate (aOR 3.41, 95% CI 1.93-6.02) significantly increased the risk for experiencing the adverse primary outcome while the effect of the underlying viral pathogen became attenuated (aOR 1.18, 95% CI 0.58-2.41, p = .0.655). CONCLUSIONS: Our results suggest that RSV is responsible for clinical courses at least as severe as influenza in adults. This supports the need for better guidance on diagnostic strategies as well as on preventive and therapeutic measures for hospitalized adults with RSV infection.

The Toxin-Producing Pathobiont Klebsiella oxytoca Is Not Associated with Flares of Inflammatory Bowel Diseases.

BACKGROUND: Alterations in the intestinal microbiota are thought to be involved in the pathogenesis of inflammatory bowel diseases (IBD). Klebsiella oxytoca is an intestinal pathobiont that can produce a cytotoxin (tillivaline). AIM: We aimed to elucidate the pathogenetic relevance of toxin-producing K. oxytoca in patients with IBD flares and investigated the clonal relationship of K. oxytoca isolates from IBD patients using multilocus sequence typing (MLST). METHODS: Fecal samples of 235 adult IBD patients were collected from January 2008 to May 2009 and were tested for K. oxytoca, C. difficile toxin, and other pathogens by standard microbiological methods. Clinical data and disease activity scores were collected. K. oxytoca isolates were tested for toxin production using cell culture assays. A total of 45 K. oxytoca isolates from IBD patients, healthy, asymptomatic carriers and from patients with antibiotic-associated hemorrhagic colitis in part from our strain collection were tested for their clonal relationship using MLST. RESULTS: The prevalence of K. oxytoca in IBD overall was 4.7%. Eleven K. oxytoca isolates were detected. Two of 11 isolates were tested positive for toxin production. There was no significant difference in the distribution of K. oxytoca isolates between the groups (active vs. remission in UC and CD). MLST yielded 33 sequence types. K. oxytoca isolates from IBD did not cluster separately from isolates from asymptomatic carriers. CONCLUSIONS: Our data demonstrate that toxin (tilivalline)-producing K. oxytoca is not associated with IBD flares.

Enterotoxicity of a nonribosomal peptide causes antibiotic-associated colitis.

Antibiotic therapy disrupts the human intestinal microbiota. In some patients rapid overgrowth of the enteric bacterium Klebsiella oxytoca results in antibiotic-associated hemorrhagic colitis (AAHC). We isolated and identified a toxin produced by K. oxytoca as the pyrrolobenzodiazepine tilivalline and demonstrated its causative action in the pathogenesis of colitis in an animal model. Tilivalline induced apoptosis in cultured human cells in vitro and disrupted epithelial barrier function, consistent with the mucosal damage associated with colitis observed in human AAHC and the corresponding animal model. Our findings reveal the presence of pyrrolobenzodiazepines in the intestinal microbiota and provide a mechanism for colitis caused by a resident pathobiont. The data link pyrrolobenzodiazepines to human disease and identify tilivalline as a target for diagnosis and neutralizing strategies in prevention and treatment of colitis.

Genotypes of Klebsiella oxytoca isolates from patients with nosocomial pneumonia are distinct from those of isolates from patients with antibiotic-associated hemorrhagic colitis.

Klebsiella oxytoca acts as a pathobiont in the dysbiotic human intestinal microbiota, causing antibiotic-associated hemorrhagic colitis (AAHC), but it also infects other organs, resulting in pneumonia and urinary tract and skin infections. The virulence of K. oxytoca is still poorly understood. The production of a specific cytotoxin has been linked to AAHC pathogenesis. To investigate the clonal relationships of K. oxytoca with regard to clinical origin and virulence attributes, we established a multilocus sequence typing (MLST) method and analyzed 74 clinical K. oxytoca isolates from asymptomatic carriers and patients with AAHC, respiratory infections, and other infections. The isolates were phenotypically characterized, typed, and compared phylogenetically based on the sequences of seven housekeeping genes. MLST analysis yielded 60 sequence types, 12 of which were represented by more than one isolate. The phylogenetic tree distinguished clusters of K. oxytoca isolates between patients with AAHC and those with respiratory infections. Toxin-positive and -negative strains were observed within one sequence type. Our findings indicate that AAHC isolates share a genetic background. Interestingly, K. oxytoca isolates from nosocomial pneumonia showed a different genetic clustering, suggesting that these strains do not originate from the intestines or that they are specialized for respiratory tract colonization. Our results further indicate a polyphyletic origin and possible horizontal transfer of the genes involved in K. oxytoca cytotoxin production. This work provides evidence that K. oxytoca isolates colonizing the two main clinically relevant habitats (lower gastrointestinal [GI] tract and respiratory tract) of the human host are genetically distinct. Applications of this MLST analysis should help clarify the sources of nosocomial infections.

The effect of metritis on luteal function in dairy cows.

BACKGROUND: Disturbed uterine involution impairs ovarian function in the first weeks after calving. This study analyzed the long-term effect of metritis on luteal function of 47 lactating Holstein-Friesian cows during the first four postpartum estrous cycles. Cows with abnormal uterine enlargement and malodorous lochia were classified as having metritis (group M, n = 18), and all others were considered healthy (group H, n = 29). Luteal size was measured once between days 9 and 13 of the first (group H, n = 11; group M, n = 12), second (group H, n = 23; group M, n = 18) and fourth (group H, n = 11; group M, n = 7) postpartum luteal phases. Serum progesterone concentration was measured at the same time. Sixteen cows (group H, n = 9; group M, n = 7) underwent transvaginal luteal biopsy for gene expression analysis of steroidogenic regulatory proteins during the second and fourth cycles. Cows with persistence of the corpus luteum (CL) underwent determination of luteal size, luteal biopsy and serum progesterone measurement once between days 29 and 33, followed by prostaglandin treatment to induce luteolysis. The same procedures were repeated once between days 9 and 13 of the induced cycle. RESULTS: The cows in group M had smaller first-cycle CLs than the cows in group H (p = 0.04), but progesterone concentrations did not differ between groups. Luteal size, progesterone concentration and gene expression did not differ between the two groups during the second and fourth cycles. Compared with healthy cows (10%), there was a trend (p = 0.07) toward a higher prevalence of persistent CLs in cows with metritis (33%). Persistent CLs were limited to the first cycle. Persistent CLs and the induced cyclic CLs did not differ with regard to the variables investigated. CONCLUSIONS: An effect of metritis on luteal activity was apparent in the first postpartum estrous cycle. However, after the first postpartum cycle, no differences occurred in analyzed parameters between metritis and control cows. Therefore, a metritis is able to impair luteal activity transiently, but does not seem to have a long-term effect on luteal function.

Bovine luteal blood flow: basic mechanism and clinical relevance.

The introduction of transrectal colour Doppler sonography (CDS) has allowed the evaluation of luteal blood flow (LBF) in cows. Because appropriate angiogenesis plays a decisive role in the functioning of the corpus luteum (CL), studies on LBF may provide valuable information about the physiology and pathophysiology of the CL. Studies on cyclic cows have shown that progesterone concentrations in blood plasma can be more reliably predicted by LBF than by luteal size (LS), especially during the regression phase of the CL. In contrast with non-pregnant cows, a significant increase in LBF is seen in pregnant cows during the third week after insemination. However, because there are high interindividual variations in LBF between animals, LBF is not useful for the early diagnosis of pregnancy. Determination of LBF is more sensitive than LS for detecting the effects of acute systemic inflammation and exogenous hormones on the CL. Cows with low progesterone levels have smaller CL during the mid-luteal phase, but LBF related to LS did not differ between cows with low and high progesterone levels. In conclusion, LBF determined by CDS provides additional information about luteal function compared with LS and plasma progesterone concentrations, but its role concerning fertility in the cow is yet to be clarified.

Gene expressions in the persistent corpus luteum of postpartum dairy cows: distinct profiles from the corpora lutea of the estrous cycle and pregnancy.

Persistence of the corpus luteum (CL) in cattle usually occurs during the puerperium and is associated with interference of prostaglandin (PG) F(2α) release from the uterus. The objective of the present study was to determine for the first time the gene expressions in the persistent CL compared with the CL of pregnancy and cyclic CL. Three types of CL biopsy samples were collected from 32 lactating Holstein cows: (1) CL persisting for 29 to 33 days after the first ovulation postpartum (persistent CL, n=9), (2) CL between days 29 and 33 of early pregnancy (CL of pregnancy, n=8) and (3) CL between days 10 and 13 of the estrous cycle (cyclic CL, n=27). mRNA expression of 2',5'-oligoadenylate synthetase-1 was upregulated only in the CL of pregnancy, confirming exposure to interferon-τ (IFNT) produced by trophoblasts in pregnant cows. mRNA expressions of immune tolerance-related factors (PGES and forkhead/winged helix transcription factor 3) were upregulated in the CL of pregnancy but not in the persistent CL, suggesting that IFNT controls upregulation of these genes. mRNA expression relating to some of the major systems such as lymphangiogenesis, inflammation and apoptosis were similarly upregulated in the persistent CL and the CL of pregnancy but not in the cyclic CL. The results suggest that the persistent CL may survive for a long period without changes in local immune tolerance but develops several major systems required for CL maintenance similar to the CL of pregnancy.

Ultrasound image analysis offers the opportunity to predict plasma progesterone concentrations in the estrous cycle in cows: a feasibility study.

In recent years, several attempts have been made to evaluate the activity of a corpus luteum by determining its sonographic echo texture. In all of these studies the values of the echo texture parameters depended on the type and settings of the ultrasound machine. Therefore, the aim of the study was to investigate if a quantitative analysis of ultrasound (US) images of the corpus luteum (CL) after calibration of the ultrasound machine enables the assessment of the peripheral plasma progesterone (P4) level. Ten Holstein Friesian cows were examined daily at Days 4 to 8, 10 to 16, and -5 to -1 (Day 1=ovulation) of the estrous cycle. B-mode sonography of the corpora lutea was performed and blood samples were taken for plasma P4 analysis. US images were calibrated and analyzed using a software package (CAUS) developed by the authors. In addition to the area of the CL (Total Area, TotA; Tissue Area interactive, TisAi; Tissue Area Automatic, TisAa), the following US parameters were calculated from the gray level histogram and from the size of the speckles: Mean, Standard Deviation (SD) and Signal-to-Noise Ratio (SNR=Mean/SD) of echo levels, Residual Attenuation (ResAtt), Axial and Lateral speckle size (Ax and Lat, respectively). The inter-individual variability of the P4 level was expressed by the coefficient of variability (CV), averaged over all days. It appeared that the CV of the absolute P4 was high (0.65) and the P4 relative to that at Day 4 and at Day 16 was of comparable magnitude. Correlations of US parameters with P4 were highest for the P4 relative to Day 16 (P4_rel_D16). This relative P4 measure was then used for further analysis. The correlations of P4_rel_D16 with TotA, TisAa (CL area after automatic segmentation of tissue) and ResAtt were found the highest (R=0.68, 0.74, and -0.42, respectively). Multiple linear regression analysis, incorporating all US parameters revealed the formula: P4_rel_D16(pred)=-0.315+0.225TisAa-0.023ResAtt, and a goodness of fit: R(2)=0.59 (p<0.001). This formula was then used to "predict" for each image the P4_rel_D16 from the estimated US parameters. A high correlation of the predicted with the measured P4_rel_D16 was found: R=0.77. Classification of images using the predicted P4_rel_D16 to be in the range >0.80 (corresponding to 0.95 times the average_P4_rel_D16 measured during the "static" phase of the luteal cycle) by ROC analysis was correctly made in 88% of cases. In conclusion the quantitative analysis of calibrated ultrasound images may yield a good prediction of cyclic changes of P4 levels and has potential for predicting the phase in the estrous cycle of a cow.

Vascular changes in the corpus luteum during early pregnancy in the cow.

The present study determined vascular changes in the bovine corpus luteum (CL) at Day 16 (early maternal recognition period) and Day 40 in early pregnancy and compared them to the CL from Day 12 and Day 16 of the estrous cycle. The CLs were analyzed in the central and peripheral regions, where site-depending features of vessels and angiogenic factors are evident. The same protein level of the endothelial cell marker von Willebrand factor was retained in the CL from Day 16 of the estrous cycle to Day 40 of early pregnancy. The protein level of pericytes and smooth muscle cells was determined using smooth muscle alpha-actin; the level decreased at Day 40 of early pregnancy in both regions of the CL. No significant change in the expressions of vascular endothelial growth factors VEGF(164) and VEGF(120) mRNA occurred from Day 16 of the estrous cycle until Day 40 of early pregnancy. Angiopoietin (ANGPT)-2 / ANGPT-1 mRNA ratio (an index of instability of vasculature) increased in the periphery at Day 16 of the estrous cycle and then decreased until Day 40 of early pregnancy. The results suggest that there is no difference in vascular structure between non-pregnant and pregnant luteal tissue during the early maternal recognition period (Day 16). Also, luteal rescue by early pregnancy may be not associated with further blood vessel formation but rather may be related to the decrease of blood vessels per unit of area and blood vessel stabilization in the bovine CL.

Genital blood flow and endometrial gene expression during the preovulatory period after Prostaglandin F(2alpha)-induced luteolysis in different luteal phases in cows.

The aim of this study was to examine the hypothesis that follicular and uterine perfusion as well as endometrial gene expression during the ovulatory period differs after induction of luteolysis during the 1(st) follicular wave compared with the 2(nd) wave or in intact cycle. Nine healthy non-lactating Holstein-Friesian cows were examined during three estrous cycles. A prostaglandin F(2alpha) analogue (PGF) was administered randomly either on Day 7 (1(st) wave cycle) or Day 11 (2(nd) wave cycle) after detection of ovulation (=Day 1). No hormonal treatment was used in the intact cycle with spontaneous ovulation. Transrectal Doppler sonography was conducted daily after PGF injection and in the intact cycle beginning on Day 18 of the estrous cycle until ovulation. Follicular blood flow (FBF) was determined by measuring the maximum area of colour pixels on digitalized images of the follicles. Uterine blood flow was quantified by the time-averaged maximum velocity (UTAMV) and pulsatility index (PI) in both uterine arteries. Blood flow measurements were carried out on Days -1 and 0. Endometrial biopsy specimens were taken on Day 1 and analyzed for the gene expressions of estrogen, progesterone, oxytocin and VEGF receptors and eNOS and iNOS using RT-PCR. The interval from PGF injection to ovulation was shorter (P<0.05) in 1(st) wave cycles than in 2(nd) wave cycles. On Days 0 and -1, FBF was greater (P<0.05) in 1(st) wave cycles than in intact and 2(nd) wave cycles. On Day -1, UTAMV was greater (P<0.05) in 1(st) wave cycles than in intact and 2(nd) wave cycles. There were no differences (P>0.05) in FBF and UTAMV values between 2(nd) wave and intact cycles. No differences (P>0.05) were detected in the gene expressions of endometrial receptors and enzymes between intact, 1(st) and 2(nd) wave cycles. The results show that follicular and uterine perfusion during the ovulatory phase are higher after induction of luteolysis during the 1(st) follicular wave compared with the 2(nd) wave or intact cycle. There were no effects on endometrial gene expression.

Computer-aided B-mode ultrasound diagnosis of hepatic steatosis: a feasibility study.

Fatty liver (steatosis) occurs in obese patients, among others, and is related to the development of diabetes type-2. Timely diagnosis of steatosis is therefore of great importance. Steatosis is also the most common liver disease of high-yielding dairy cattle during early lactation. This makes it a suitable animal model for studying liver steatosis. Furthermore, reference of derived ultrasound parameters against a "gold standard" is possible in cattle by taking a liver biopsy for the assessment of fat concentration. The authors undertook this pilot study to investigate the hypothesis that quantitative, computer-aided B-mode ultrasound enables the noninvasive detection of hepatic steatosis. Echographic images were obtained postpartum from dairy cows (n = 12) in transcutaneous and direct (intraoperative) applications using a convex array transducer at 4.2 MHz. During surgery, a biopsy was taken from the caudate lobe to assess the liver fat content (fat score). A custom-designed software package for computer-aided ultrasound diagnosis (CAUS) was developed. After linearizing the post-processing look-up-table (LUT), the image gray levels were transferred into echo levels in decibels relative to the mean echo level in a tissue-mimicking phantom. The quantitative comparison of transcutaneous and intraoperative images enabled the correction for the attenuation effect of skin and subcutaneous fat layer on the mean echo level in the liver, as well as for the effects of the beam formation and attenuation of liver tissue on the echo level vs. depth. The residual attenuation coefficient (dB/cm) in fatty liver vs. normal liver was estimated and compensated for. Finally, echo level was estimated relative to the phantom used for calibration, and echo texture was characterized by the mean axial and lateral speckle size within the regions of interest. In the no fat/low fat group (n = 5) skin plus fat layer attenuation was 3.4 dB/cm. A correlation of skin layer thickness vs. fat score of r = 0.48 was found. The mean transcutaneous liver tissue echo level correlated well with fat score: r = 0.80. A residual liver attenuation coefficient of 0.76 dB/cm and 1.19 dB/cm was found in medium and high fat liver, respectively. In transcutaneous images, correlation of residual attenuation coefficient with fat score was r = 0.69. Axial and lateral speckle sizes were on the order of 0.2 and 1.0 cm, respectively, and no correlation was found with liver fat content. Results for transcutaneous and intraoperative images were similar. The authors conclude that this pilot study shows the feasibility of calibrated, computer-aided ultrasound for noninvasively diagnosing, possibly even screening, steatosis of the liver.

[Sonographic evaluation of the uterus in Holstein-Friesian cows without and with disturbances of the puerperium during the first 14 days postpartum]. / Sonographische Beurteilung des Uterus bei Holstein-friesian Kühen ohne und mit Puerperalstörungen in den ersten 14 Tagen post partum.

The aim of this study was to investigate if, compared with transrectal manual palpation, B-mode sonography provides additional information about the uterine structures and contents of Holstein-Friesian cows without and with disturbances during the early puerperal phase, that lead to a more precise diagnosis. The examinations were carried out once per cow either during the first four days p. p. (contraction phase, KPH) or on days 5 to 10 (desquamation phase, DPH) or on days 11 to 14 (regeneration phase, RPH) in 57 cows with undisturbed (UP) and 69 with disturbed puerperal phases (GP). The mean size of the uterus measured by transrectal palpation was 0.94 to 1.51 points (on a 6-point scale, p < 0.05) larger throughout the examination period and the fluctuation was 1.29 and 0.92 points (on a 4-point scale, p < 0.05) higher in GP cows compared with UP cows during the KPH and RPH, respectively. During the KPH, contractility of the uterus was 0.56 points (on a 3-point scale, p < 0.05) lower in GP cows compared with UP cows. Sonographically the cross sectional area of the most caudally located caruncle was 0.47 to 3.53 cm2 bigger (p < 0.05) in GP cows than in UP cows. The GP cows showed in the KPH a 0.21 cm thinner (p < 0.05) endometrium compared with the UP cows. In the DPH and RPH, the echogenicity was 1.63 and 1.04 points (on a 4-point scale, p < 0.05) higher and the intraluminal diameter of the uterine body was 0.49 to 0.67 cm greater (p < 0.05) in GP cows compared with UP cows, respectively. By means of dicriminant analysis 96.7% and 91.7% of the animals of the GP and UP group, respectively, where classified correctly during the DPH, whereas in the other two phases these proportions were between 70.0% and 87.5%. The results show that B-mode sonography is an additional valuable method for a more accurate differentiation of uterine involutionary processes between cows without and with disturbances of the puerperal phase.

Examination of cyclic changes in bovine luteal echotexture using computer-assisted statistical pattern recognition techniques.

B-mode sonography is a well-established diagnostic tool for determination of cycle stage in gynaecology. The aim of this study was to determine whether computer-assisted texture analysis of B- mode sonographic images of bovine luteal glands provides further information about the animal's plasma progesterone concentration and cycle stage. Four Simmenthal cows were examined during two consecutive estrous cycles with an ultrasound device equipped with a 7.5MHz microconvex probe. During each examination three B-mode images of the corpus luteum (CL) were digitized and analyzed off-line using a computer-assisted texture analysis program. Size, echogeneity, and echotexture of the CL were characterized by the following texture parameters: area of cross-sectional planes of the CL (A), mean gray level (MGL), correlation (CORR), run percentage (RPERC), and long-run emphasis (LREM). Plasma progesterone levels (P4) were also determined. All parameters showed characteristic changes during the estrous cycle (P<0.05). Variance component estimates for the effect of Day of estrous cycle on A, MGL, CORR, RPERC, and LREM were 56.6%, 64.6%, 77.6%, 89.9%, and 86.0%, respectively, and 20.6%, 24.5%, 7.2%, 0.0%, and 14.0% for the influence of the individual cow. The factor estrous cycle within cows was responsible for 22.8%, 10.9%, 15.2%, 10.1%, and 0.0% of the variability of A, MGL, CORR, RPERC and LREM values, respectively. Cyclic changes were similar in A and P4. In contrast to P4, which decreased already between Days -5 and -3 (Day 0=ovulation), A stayed at constant high values until Day -3. Mean MGL values were higher (P<0.05) on Days 7, 9, and 13 compared to Days 3 and -3. Mean CORR values were constantly high (P>0.05) during the first days after ovulation and decreased continuously (P<0.05) between Days 5 and 13. Thereafter, mean CORR values remained low (P<0.05) until the next ovulation, except on Day -3 (P<0.05). Mean RPERC rose between Days 1 and 9 from low to high values (P<0.0001) remained at these high values (P>0.05) between Days 9 and 15, and decreased (P<0.05) afterwards to baseline values on Day -1. Mean LREM inclined steeply (P<0.0001) from minimum to maximum between Days 1 and 5. From Days 7 to -3, mean LREM remained (P>0.05) at a constant level close below the maximum value, and decreased to baseline values on Day -1. The results of this study show that statistical pattern recognition techniques provide new information about the luteal glands, thus facilitating a more accurate differentiation between different cycle stages in cows.

Diagnostic procedures and surgical treatment of craniodorsal coxofemoral luxation in calves.

OBJECTIVE: To report use of ultrasonographic examination of the coxofemoral joint, a surgical technique for repair of craniodorsal coxofemoral dislocation, and outcome. STUDY DESIGN: Clinical case reports. ANIMALS: Calves (n=4) with coxofemoral luxation. METHODS: Craniodorsal coxofemoral luxation was diagnosed by physical examination, radiographic, and ultrasonographic findings. Open surgical reduction of the femoral head was performed using a modified caudal approach. RESULTS: Craniodorsal luxation of the femoral head and the presence of an intact femoral neck were confirmed by ultrasonography. All luxations were successfully reduced and reluxation did not occur. At follow-up, 1 heifer had calved and 1 was 5 months pregnant. One calf died of bronchopneumonia 6 days after surgery. One calf had severe coxofemoral degenerative joint disease diagnosed (ultrasonography, radiography, and arthrocentesis) 3 months after surgery and confirmed by necropsy. CONCLUSION: Ultrasonography proved to be a simple and effective non-invasive technique for diagnosis of coxofemoral luxation. Immediate surgical intervention in hip dislocation in calves is necessary to avoid unnecessary trauma to subchondral structures. In calves, open instead of closed surgical reduction appears preferable because it allows access to the acetabular cavity for removal of debris. CLINICAL RELEVANCE: Ultrasonography should be considered a supplementary but not an alternative to radiographic examination for diagnosis of coxofemoral luxation and for follow-up examinations after reduction.