A US-based national surveillance study for the susceptibility and epidemiology of Clostridioides difficile isolates with special reference to ridinilazole: 2020-2021.

We have previously reported on the susceptibility and epidemiology of Clostridioides difficile isolates from six geographically dispersed medical centers in the United States. This current survey was conducted with isolates collected in 2020-2021 from six geographically dispersed medical centers in the United States, with specific attention to susceptibility to ridinilazole as well as nine comparators. C. difficile isolates or stools from patients with C. difficile antibiotic-associated diarrhea were collected and referred to a central laboratory. After species confirmation of 300 isolates at the central laboratory, antibiotic susceptibilities were determined by the agar dilution method [M11-A9, Clinical and Laboratory Standards Institute (CLSI)] against the 10 agents. Ribotyping was performed by PCR capillary gel electrophoresis on all isolates. Ridinilazole had a minimum inhibitory concentration (MIC) 90 of 0.25 mcg/mL, and no isolate had an MIC greater than 0.5 mcg/mL. In comparison, fidaxomicin had an MIC 90 of 0.5 mcg/mL. The vancomycin MIC 90 was 2 mcg/mL with a 0.7% resistance rate [both CLSI and European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria]. The metronidazole MIC 90 was 1 mcg/mL, with none resistant by CLSI criteria, and a 0.3% resistance rate by EUCAST criteria. Among the 50 different ribotypes isolated in the survey, the most common ribotype was 014-020 (14.0%) followed by 106 (10.3%), 027 (10%), 002 (8%), and 078-126 (4.3%). Ridinilazole maintained activity against all ribotypes and all strains resistant to any other agent tested. Ridinilazole showed excellent in vitro activity against C. difficile isolates collected between 2020 and 2021 in the United States, independent of ribotype.

Epidemiologic trends in Clostridioides difficile isolate ribotypes in United States from 2011 to 2016.

BACKGROUND: Geographic and temporal trends in the distribution of PCR ribotypes for Clostridioides difficile associated diarrheal isolates obtained in the United States (US) are changing. As part of a US national surveillance program of C. difficile susceptibility to fidaxomicin, we quantified the distribution of PCR ribotypes of stool isolates collected from 2011 to 2016. METHODS: C. difficile isolates or C. difficile toxin + stools from patients with C. difficile infection (CDI) were submitted for testing to Tufts Medical Center from 6 geographically distinct medical centers. Following isolation and confirmation as C. difficile, approximately 35% of the isolates were randomly sampled, stratified by center, for PCR ribotyping by capillary gel electrophoresis. Toxin gene profiling was performed on all isolates. RESULTS: 939 isolates from a total of 2814 (33.4%) isolated over the 6 years were analyzed. Seventy unique ribotypes were observed, including 19 ribotypes observed 10 or more times. Sixteen ribotypes were not previously observed in our data base. Ribotype 027 declined by more than 60% over the 6 years of the survey from 35.3% to 13.1% (p < 0.001). Ribotype 106 was the most common in 2016, followed by 027 and 014-020. There were strong correlations between 027 and binary toxin with the 18 base pair deletion of tcdC and ribotype 078-126 had 100% concordance with the previously described tcdC 39 base pair deletion. CONCLUSIONS: The frequency of ribotypes in the US has changed with a marked decline in 027. Each of the geographical areas had variations which differed from each other, but collectively, these results suggest that the changing epidemiology of C. difficile in the US is consistent with what is being seen in Europe. Continued surveillance and monitoring of changes in ribotype distributions of C. difficile are warranted.

U.S.-Based National Surveillance for Fidaxomicin Susceptibility of Clostridioides difficile-Associated Diarrheal Isolates from 2013 to 2016.

In 2011, we initiated a sentinel surveillance network to assess changes in Clostridioides (formerly Clostridium) difficile antimicrobial susceptibility to fidaxomicin from 6 geographically dispersed medical centers in the United States. This report summarizes data from 2013 to 2016. C. difficile isolates or toxin-positive stools from patients were referred to a central laboratory. Antimicrobial susceptibility was determined by agar dilution. CLSI, EUCAST, or FDA breakpoints were used, where applicable. Toxin gene profiles were characterized by multiplex PCR on each isolate. A random sample of approximately 40% of isolates, stratified by institution and year, was typed by restriction endonuclease analysis (REA). Among 1,889 isolates from 2013 to 2016, the fidaxomicin MIC90 was 0.5 µg/ml; all isolates were inhibited at ≤1 µg/ml. There were decreases in metronidazole and vancomycin MICs over time. Clindamycin resistance remained unchanged (27.3%). An increase in imipenem resistance was observed. By 2015 to 2016, moxifloxacin resistance decreased in all centers. The proportion of BI isolates decreased from 25.5% in 2011 to 2012 to 12.8% in 2015 to 2016 (P < 0.001). The BI REA group correlated with moxifloxacin resistance (BI 84% resistant versus non-BI 12.5% resistant). Fidaxomicin MICs have not changed among C. difficile isolates of U.S. origin over 5 years post licensure. There has been an overall decrease in MICs for vancomycin, metronidazole, moxifloxacin, and rifampin and an increase in isolates resistant to imipenem. Moxifloxacin resistance remained high among the BI REA group, but the proportion of BI isolates has decreased. Continued geographic variations in REA groups and antimicrobial resistance persist.

Distance and direction, but not light cues, support response reversal learning.

Across three experiments, we examined the cuing properties of metric (distance and direction) and nonmetric (lighting) cues in different tasks. In Experiment 1, rats were trained on a response problem in a T-maze, followed by four reversals. Rats that experienced a change in maze orientation (Direction group) or a change in the length of the start arm (Distance group) across reversals showed facilitation of reversal learning relative to a group that experienced changes in room lighting across reversals. In Experiment 2, rats learned a discrimination task more readily when distance or direction cues were used than when light cues were used as the discriminative stimuli. In Experiment 3, performance on a go/no-go task was equivalent using both direction and lighting cues. The successful use of both metric and nonmetric cues in the go/no-go task indicates that rats are sensitive to both types of cues and that the usefulness of different cues is dependent on the nature of the task.

Selective method for identification and quantification of Bifidobacterium animalis subspecies lactis BB-12 (BB-12) from the gastrointestinal tract of healthy volunteers ingesting a combination probiotic of BB-12 and Lactobacillus rhamnosus GG.

AIM: To develop a novel validated method for the isolation of Bifidobacterium animalis ssp. lactis BB-12 (BB-12) from faecal specimens and apply it to studies of BB-12 and Lactobacillus rhamnosus GG (LGG) recovered from the healthy human gastrointestinal (GI) tract. METHODS AND RESULTS: A novel method for isolating and enumerating BB-12 was developed based on its morphologic features of growth on tetracycline-containing agar. The method identified BB-12 correctly from spiked stool close to 100% of the time as validated by PCR confirmation of identity, and resulted in 97-104% recovery of BB-12. The method was then applied in a study of the recovery of BB-12 and LGG from the GI tract of healthy humans consuming ProNutrients® Probiotic powder sachet containing BB-12 and LGG. Viable BB-12 and LGG were recovered from stool after 21 days of probiotic ingestion compared to baseline. In contrast, no organisms were recovered 21 days after baseline in the nonsupplemented control group. CONCLUSIONS: We demonstrated recovery of viable BB-12, using a validated novel method specific for the isolation of BB-12, and LGG from the GI tract of healthy humans who consumed the probiotic supplement. SIGNIFICANCE AND IMPACT OF THE STUDY: This method will enable more detailed and specific studies of BB-12 in probiotic supplements, including when in combination with LGG.

Impaired Morris water task retention following T21 light dark cycle exposure is not due to reduced hippocampal c-FOS expression.

Circadian rhythms influence virtually all aspects of physiology and behavior. This is problematic when circadian rhythms no longer reliably predict time. Circadian rhythm disruption can impair memory, yet we don't know how this fully works at the systems and molecular level. When trying to determine the root of a memory impairment, assessing neuronal activation with c-FOS is useful. This has yet to be assessed in the hippocampi of circadian rhythm disrupted rats in a hippocampal gold standard task. Rats were trained on the Morris water task (MWT), then received 6 days of a 21-h day (T21), 13 days of a normal light dark cycle, probe trial, and tissue extraction an hour later. Despite having impaired memory in the probe trial, compared to controls there were no differences in c-FOS expression in hippocampal sub regions: CA1; CA3; Dentate gyrus. These data confirm others in hamsters demonstrating that arrhythmicity which produces an impairment in spontaneous alternation does not affect c-FOS in the dentate gyrus. The current study indicates that the memory impairment induced by a lighting manipulation is likely not due to attenuated neuronal activation. Determining how the master clock in the brain communicates with the hippocampus is needed to untangle the relationship between circadian rhythms and memory.

Variation in rapid sequence induction techniques: current practice in Wales.

A questionnaire survey examining rapid sequence induction techniques was sent to all anaesthetists in Wales. The questionnaire presented five common clinical scenarios: emergency appendicectomy; elective knee arthroscopy with a symptomatic hiatus hernia; elective knee arthroscopy with an asymptomatic hiatus hernia; elective Caesarean section; and emergency laparotomy for bowel obstruction. Completed surveys were received from 421 anaesthetists, a 68% response rate. Rapid sequence induction was chosen by 398/400 respondents (100%) for bowel obstruction, 392/399 (98%) for Caesarean section, 388/408 (95%) for appendicectomy, 328/395 (83%) for symptomatic hiatus hernia but only 98/399 (25%) for asymptomatic hiatus hernia (p < 0.001). Trainees were more likely to use a rapid sequence induction technique than consultants and staff grades for the appendicectomy (p = 0.025), symptomatic hiatus hernia (p = 0.004) and asymptomatic hiatus hernia (p = 0.001) scenarios and were also more likely to use a thiopental-suxamethonium combination for rapid sequence induction (p < 0.001).

Mineralocorticoid effects due to cortisol inactivation overload explain the beneficial use of hydrocortisone in septic shock.

The role of corticosteroids in septic shock remains controversial despite their use for over 50 years. Large prospective trials of their use continue with the aim of resolving the controversy. These may well remain indecisive if basic endocrine principles are ignored. Review of the available evidence suggests that use of synthetic glucocorticoids is harmful but hydrocortisone beneficial. Consideration of the basic properties of the corticosteroids used and their receptors suggest an explanation for their differing therapeutic effects. The harmful synthetic glucocorticoids have no or reduced mineralocorticoid effects in contrast with the significant mineralocorticoid effects of hydrocortisone at the doses which have been found to be beneficial. The potent synthetic mineralocorticoid fludrocortisone is well recognised to raise peripheral resistance by sensitising the resistance vessels to endogenous or exogenous catecholamines and also causes metabolic alkalosis. We provide evidence to support our hypothesis that at the doses of hydrocortisone used, cortisol inactivation overload is the basis of the beneficial effect. The consequent mineralocorticoid effects result in increased sensitivity of the resistance vessels to endogenous and exogenous catecholamines with an increase in peripheral resistance correcting shock. In addition the metabolic alkalotic component of mineralocorticoid effect would tend to correct the prevailing metabolic acidosis. Hydrocortisone also has an attenuating, as opposed to the suppressing effect of synthetic glucocorticoids on the immune response which is also regarded as beneficial.

Shiga toxins activate translational regulation pathways in intestinal epithelial cells.

Shiga toxins (Stxs) cause irreversible damage to eukaryotic ribosomes, yet cellular intoxication of intestinal epithelial cells (IECs) results in increased synthesis of selected proteins, notably cytokines. How mRNA translation is maintained in this circumstance is unclear. This study was designed to assess whether Stx-induced alterations in host signal transduction machinery permit translation despite protein synthesis inhibition. A key step of translation is recruitment of initiation machinery to the 5' mRNA cap. This event occurs in part via interaction of the 5' cap with the cap binding protein, eIF4E, whose activity is positively regulated by phosphorylation and negatively regulated by binding to the translational repressor 4E-BP1. Following Stx treatment of IECs, eIF4E phosphorylation was detected by Western blotting using phospho-specific antibodies. Treatment with the p38 inhibitor, SB202190, or either of the ERK1/2 inhibitors, PD98059 and U0126, partially blocked Stx1-induced eIF4E phosphorylation. The Mnk1 inhibitor, CGP57380, blocked both basal and Stx-induced eIF4E phosphorylation. Interestingly, pretreatment with CGP57380 did not alter basal protein synthesis, but diminished the ability of cells to maintain translation following Stx1 challenge. Stx1 also induced hyperphosphorylation of 4E-BP1 and phosphorylation of S6Kinase; both effects were blocked by rapamycin. These data are novel observations showing that Stxs regulate multiple signal transduction pathways controlling translation in host cells, and support a role for eIF4E phosphorylation in maintaining host cell translation despite ribosomal intoxication.

Structure refinement of fructose-1,6-bisphosphatase and its fructose 2,6-bisphosphate complex at 2.8 A resolution.

The structures of the native fructose-1,6-bisphosphatase (Fru-1,6-Pase), from pig kidney cortex, and its fructose 2,6-bisphosphate (Fru-2,6-P2) complexes have been refined to 2.8 A resolution to R-factors of 0.194 and 0.188, respectively. The root-mean-square deviations from the standard geometry are 0.021 A and 0.016 A for the bond length, and 4.4 degrees and 3.8 degrees for the bond angle. Four sites for Fru-2,6-P2 binding per tetramer have been identified by difference Fourier techniques. The Fru-2,6-P2 site has the shape of an oval cave about 10 A deep, and with other dimensions about 18 A by 12 A. The two Fru-2,6-P2 binding caves of the dimer in the crystallographically asymmetric unit sit next to one another and open in opposite directions. These two binding sites mutually exchange their Arg243 side-chains, indicating the potential for communication between the two sites. The beta, D-fructose 2,6-bisphosphate has been built into the density and refined well. The oxygen atoms of the 6-phosphate group of Fru-2,6-P2 interact with Arg243 from the adjacent monomer and the residues of Lys274, Asn212, Tyr264, Tyr215 and Tyr244 in the same monomer. The sugar ring primarily contacts with the backbone atoms from Gly246 to Met248, as well as the side-chain atoms, Asp121, Glu280 and Lys274. The 2-phosphate group interacts with the side-chain atoms of Ser124 and Lys274. A negatively charged pocket near the 2-phosphate group includes Asp118, Asp121 and Glu280, as well as Glu97 and Glu98. The 2-phosphate group showed a disordered binding perhaps because of the disturbance from the negatively charged pocket. In addition, Asn125 and Lys269 are located within a 5 A radius of Fru-2,6-P2. We argue that Fru-2,6-P2 binds to the active site of the enzyme on the basis of the following observations: (1) the structure similarity between Fru-2,6-P2 and the substrate; (2) sequence conservation of the residues directly interacting with Fru-2,6-P2 or located at the negatively charged pocket; (3) a divalent metal site next to the 2-phosphate group of Fru-2,6-P2; and (4) identification of some active site residues in our structure, e.g. tyrosine and Lys274, consistent with the results of the ultraviolet spectra and the chemical modification. The structures are described in detail including interactions of interchain surfaces, and the chemically modifiable residues are discussed on the basis of the refined structures.(ABSTRACT TRUNCATED AT 400 WORDS)

A two-platform task reveals a deficit in the ability of rats to return to the start location in the water maze.

The ability of rats to return to the start location was examined with a 4-arm radial water maze. The task required rats to find 2 hidden platforms in sequence. Rats were released from 1 of 3 arms and there was a platform located in the fourth arm. Once a rat found this platform, a 2nd platform was raised in another location, which was either the start location, for 1 group, or another fixed location, for a control group. Across 3 experiments, all rats learned the location of the 1st fixed platform in 80 to 120 trials. However, rats had difficulty finding a 2nd platform if it was at the start location. Control groups revealed that rats could learn 2 platform locations and that the difficulty in learning to return to the start location did not seem to be attributable to its aversive nature. In separate groups, exposure to the start location was increased by starting the rats from an initially stable platform. Rats still did not readily learn to return to the start location. The authors suggest that start location, when varied, cannot readily be used to define the location of a hidden platform.

Spatial problem solving and hippocampal place cell firing in rats: control by an internal sense of direction carried across environments.

Rats learned to find the baited corner of a box surrounded by a curtain, regardless of whether they had a fixed or random point of entry (POE) through the curtain. On probe trials, rats used an internal direction sense carried from outside the curtain to solve the problem, and only used the visual cue inside the curtain if disoriented and denied access to a view of the room en route. Similar disorientation procedures were required to obtain cue control of hippocampal place fields. The results suggest that: (1) POE effects previously found in the water maze may be task-specific; (2) an undisrupted internal sense of direction carried from one environment to another may provide the preferred solution to spatial problems in the second environment, even when this second environment is a familiar one with stable visual cues; and (3) choice behaviour is sometimes, but not always, representative of the hippocampal representation of space.

Case of lipoblastoma with two derivative chromosomes 8 containing homogeneously staining-like regions and a review of the literature: lipoblastoma and chromosome 8.

We report a case of a lipoblastoma in a 10-month-old girl in which the cytogenetic aberration showed a homogeneously staining-like region (hsr) within two derivative chromosomes 8. There was a loss of one normal copy of chromosome 8 and gain of two identical derivative chromosomes 8 with the karyotype designation 47,XX,psu idic(8)(pter-->q12 approximately 13::hsr::q12 approximately 13-->pter),+psu idic (8)(pter-->q12 approximately 13::hsr::q12 approximately 13-->pter). This is the first report of a chromosomal aberration of this type seen in lipoblastoma.

Apparatus for emergency transtracheal ventilation.

Twenty anaesthetists were asked what equipment they would use to ventilate a patient after having performed an emergency cricothyroid puncture. Six systems were described and these were assessed for efficiency in delivery of oxygen through a 14 gauge cannula. Delivery of oxygen depended on the pressure achieved within the system. Apparatus utilizing a Bain circuit achieved volumes of around 200 ml for each double-handed squeeze of the reservoir bag. Use of a system taught on the Advanced Trauma and Life Support (ATLS) course resulted in higher system pressures and consequently greater volumes of oxygen delivered. Use of the oxygen flush with this system provides the highest flow rate and system pressure which results in 628 ml being delivered for a one second compression.

Clinical evidence for delayed chloroform poisoning.

From its introduction in 1847, chloroform proved to be a potent anaesthetic agent and over the next 50 yr its use became widespread. However, in 1912 the Committee on Anaesthesia of the American Medical Association stated that they were concerned with the occurrence of delayed chloroform poisoning in a number of cases. This conclusion was based on case reports and experimental animal data. However, subsequent studies and reported series of chloroform anaesthesia in humans have suggested a lower incidence of clinically significant liver injury. In this article we have investigated this discrepancy by analysing the published clinical data relating chloroform anaesthesia to liver damage.

Arterial oxygen saturation during induction of anaesthesia.

Three groups of 10 ASA 1 patients were studied to determine the incidence of hypoxaemia (oxygen saturation less than or equal to 90%) using pulse oximetry during induction of 'mask' anaesthesia, and whether simple oxygenation techniques could prevent its occurrence. We also surveyed all anaesthetists in three major hospitals to ascertain their techniques for this method of anaesthesia. Anaesthesia was induced in all patients with thiopentone and maintained with nitrous oxide and isoflurane. The first group received 33% oxygen in nitrous oxide as carrier gases, a second group a few normal breaths of 100% oxygen during thiopentone administration followed by 33% oxygen in nitrous oxide, while a third group received 100% oxygen after loss of eyelash reflex until spontaneous breathing was established. No patient received positive pressure ventilation before spontaneous breathing was established. Six of the 10 patients in the first group became hypoxaemic compared to none in the second group, and three patients became hypoxaemic in the third group. Thirty-seven percent of anaesthetists who responded to the survey either did not apply positive pressure ventilation before establishment of spontaneous breathing, or only did so if apnoea was prolonged. Only one anaesthetist fully pre-oxygenated patients lungs. We conclude that to avoid the likely occurrence of hypoxaemia during induction of mask anaesthesia, a minimum of a few breaths pre-oxygenation is necessary.

Vaporization of isoflurane by liquid infusion.

We investigated the vaporization of liquid isoflurane when infused directly into a circuit. Pooling of isoflurane occurred within the circuit tubing at infusion rates used during clinical practice when constant gas flows were used. Despite pooling, the concentration of isoflurane was linearly related to infusion rate. Cyclical gas flow, such as that seen in a circle system, increased vaporization so that pooling occurred only at the higher infusion rates used during the first five minutes of totally closed circuit anaesthesia. There were no major differences in pooling or the maximum concentration of isoflurane reached between 26 gauge needle and droplet administration of isoflurane: however the maximum concentration was reached more quickly by droplet administration. We conclude that direct infusion of liquid isoflurane into an anaesthetic circuit will result in complete vaporization during maintenance anaesthesia.

Air inlets for infusion bottles.

We assessed the resistance to air flow in four commonly used air inlets. The Avon A81 and Codan air inlets provide the least resistance to flow, followed by the Baxter CO413 and lastly the Braun air inlet. The presence of a valve confers an advantage when rapid infusion of fluid is attempted. The valve in the Codan air inlet performed best out of the inlets tested.

Use of aprotinin in knee replacement surgery.

We have studied the effect of aprotinin on blood loss and subsequent blood transfusion in 17 patients undergoing knee replacement surgery. Patients receiving aprotinin (total dose 2,000,000 kallikrein inhibiting units) received fewer units of blood than control patients (P < 0.05), although there was no significant difference in blood loss between the two groups. The study was stopped when one patient in the aprotinin group needed an above-knee amputation because of ischaemia secondary to arteriovenous thrombosis after knee replacement surgery. Although the patient had peripheral vascular disease which could have accounted for the thrombosis, the role of aprotinin under tourniquet conditions is unclear.