Molecular characterisation of methicillin-resistant Staphylococcus aureus from chronically colonised cystic fibrosis paediatric patients in Brazil.

Persistent methicillin-resistant Staphylococcus aureus (MRSA) infection in cystic fibrosis (CF) patients has been associated with a more rapid decline in lung function, increased hospitalisation and mortality. The aim of this study was to evaluate the clonal relationships among 116 MRSA isolates from 12 chronically colonised CF pediatric patients over a 6-year period in a Rio de Janeiro CF specialist centre. Isolates were characterised by antimicrobial resistance, SCCmec type, presence of Panton-Valentine Leukocidin (PVL) genes and grouped according to DNA macrorestriction profile by pulsed-field gel electrophoresis (PFGE) and spa gene type. High resistance rates were detected for erythromycin (78%) and ciprofloxacin (50%) and SCCmec IV was the most common type (72.4%). Only 8.6% of isolates were PVL positive. High genetic diversity was evident by PFGE (39 pulsotypes) and of nine that were identified spa types, t002 (53.1%) and t539 (14.8%) were the most prevalent. We conclude that the observed homogeneity of spa types within patients over the study period demonstrates the persistence of such strain lineages throughout the course of chronic lung infection.

Behavioral and genetic color vision evaluation of an albino male capuchin monkey (Sapajus apella).

Albinism is a rare phenotype that affects the pigmentation in eyes, hair, and skin. The effects of albinism in color vision are still unclear. Our study aimed to evaluate the color vision phenotype and genotype of an albino capuchin monkey. An adult albino male capuchin monkey (Sapajus apella) had the L and M opsin gene analyzed, and was trained in a behavioral task of color discrimination. Color discrimination thresholds were determined along 20 chromatic axes around the background chromaticity. A color discrimination ellipse was drawn by interpolation among these thresholds. The albino monkey's behavioral color discrimination ellipse showed poor discrimination along the red-green axis indicating a deutan phenotype. Genetic analysis revealed only the presence of the L gene in the albino monkey. This result did not differ from that obtained with ten previously tested non-albino monkeys. Behavioral and molecular analyses agreed that the albino capuchin monkey had color vision similar to that of non-albino dichromat monkeys, suggesting no influence of albinism on color discrimination.

Species distribution, sequence types and antimicrobial resistance of Acinetobacter spp. from cystic fibrosis patients.

Acinetobacter spp. are important healthcare pathogens, being closely linked to antibiotic resistance and outbreaks worldwide. Although such species are rarely observed in patients with cystic fibrosis (CF), we describe the characteristics of 53 strains of Acinetobacter spp. isolated from the sputum of 39 Brazilian patients with CF. The species distribution was A. baumannii (n = 29), A. pittii (n = 13), A. nosocomialis (n = 8), A. seifertii (n = 1), A. soli (n = 1) and A. variabilis (n = 1) determined by partial rpoB gene sequencing. Sixteen strains (10 A. baumannii, 3 A. pittii and 3 A. nosocomialis) were multidrug-resistant (MDR) by disk diffusion test (30%) and eight MDR carbapenem-resistant A. baumannii strains harboured the bla OXA-23-like oxacillinase gene. Thirty-three sequence types (STs) were identified by multilocus sequence typing of which eight were novel (A. baumannii: 843, 844, 845, 847, 848; A. pitti: 643; A. nosocomialis: 862 and A. seifertii: 846); six STs (2 A. baumannii, 3 A. pittii and 1 A. nosocomialis) were found in more than one patient. Four strains of A. baumannii were assigned to two common clonal complexes (CCs), namely, CC1 (ST1, ST20 and ST160), and CC79 (ST79). This study underlines the extensive species diversity of Acinetobacter spp. strains in CF lung infections which may present difficulties for therapy due to significant antimicrobial resistance.

Splinted and unsplinted overdenture attachment systems: A systematic review and meta-analysis.

Splinted and unsplinted overdenture attachment systems have unique advantages and disadvantages. The aim of the present systematic review was to determine the influence of splinted and unsplinted overdenture attachment systems on the marginal bone loss, prosthetic complications and implant survival rate. PubMed/MEDLINE, Scopus and Cochrane databases were searched for articles published up to October 2017, using the following search terms: "overdenture AND attachment OR overdenture AND bar OR overdenture splinted." The PICO question "Do splinted overdenture attachment systems promote better clinical results in comparison to unsplinted systems?" was evaluated. Eligible studies included randomized controlled clinical trials, prospective studies with at least 10 participants and a minimum follow-up of 6 months, and studies published in English that compared splinted and unsplinted attachment systems within the same study. The 95% confidence interval (CI) was considered for all outcomes analysed. After completion of the different steps in the article selection process, nine articles were included in the qualitative and quantitative analyses. A total of 984 implants were placed in 380 patients (mean age: 62.8 years). The meta-analysis demonstrated no statistically significant differences between splinted and unsplinted attachment systems with regard to marginal bone loss (P = .39; MD: -0.11; 95% CI: -0.37 to 0.14), complications (P = .31; RR: 1.26; CI: 0.80-1.99) and implant survival rate (P = .14; RR: 0.37% CI: 0.10-1.36). In addition, splinted and unsplinted overdenture attachment systems achieved similar results with regard to marginal bone loss, prosthetic complications and implant survival rate.

Patterns of virulence factor expression and antimicrobial resistance in Achromobacter xylosoxidans and Achromobacter ruhlandii isolates from patients with cystic fibrosis.

Achromobacter spp. are opportunistic pathogens increasingly recovered from adult patients with cystic fibrosis (CF). We report the characterization of 122 Achromobacter spp. isolates recovered from 39 CF patients by multilocus sequence typing, virulence traits, and susceptibility to antimicrobials. Two species, A. xylosoxidans (77%) and A. ruhlandii (23%) were identified. All isolates showed a similar biofilm formation ability, and a positive swimming phenotype. By contrast, 4·3% and 44·4% of A. xylosoxidans and A. ruhlandii, respectively, exhibited a negative swarming phenotype, making the swimming and swarming abilities of A. xylosoxidans significantly higher than those of A. ruhlandii. A. xylosoxidans isolates from an outbreak clone also exhibited significantly higher motility. Both species were generally susceptible to ceftazidime, ciprofloxacin, imipenem and trimethoprim/sulphamethoxazole and there was no significant difference in susceptibility between isolates from chronic or sporadic infection. However, A. xylosoxidans isolates from chronic and sporadic cases were significantly more resistant to imipenem and ceftazidime than isolates of the outbreak clone.

Prevalence, risk factors, and epidemiology of methicillin-resistant Staphylococcus aureus carried by adults over 60 years of age.

The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in the community in Portugal is not completely understood. To evaluate S. aureus and MRSA carriage among the elderly, we conducted a large cross-sectional study between April 2010 and December 2012. A total of 3,361 adults over 60 years of age were screened for S. aureus nasopharyngeal and oropharyngeal carriage. MRSA were characterized by staphylococcal cassette chromosome mec (SCCmec) typing, spa typing, multilocus sequence typing (MLST), and tested for the presence of Panton-Valentine leukocidin (PVL). Risk factors for MRSA carriage were identified by multiple logistic regression analysis. The prevalence of S. aureus and MRSA carriage among the elderly was 20.1 % and 1.8 %, respectively. The risk of being an MRSA carrier was higher among the elderly living in retirement homes [odds ratio (OR) = 2.90, 95 % confidence interval (CI): 1.48-5.48] and those that had been hospitalized in the previous year (OR = 2.64, 95 % CI: 1.47-4.58). Among the 62 MRSA isolates, 64.5 % were multidrug-resistant and none carried PVL. Most MRSA (82.3 %) were related to three hospital-associated (HA-MRSA) clones disseminated in Portugal: ST105-II (New York/Japan clone; 43.5 %), ST5-IVc (Pediatric clone; 19.4 %), and ST22-IVh (EMRSA-15 clone; 19.4 %). The New York/Japan and Pediatric clones were significantly associated with carriers living in retirement homes, while the EMRSA-15 clone was associated with carriers that had been hospitalized. We conclude that the elderly population in Portugal is essentially free of MRSA. Given the current European societal challenges for a healthy active aging, these results are of importance to healthcare professionals and public authorities to decide on strategies to promote health in this age group.

Characteristics of Haemophilus influenzae invasive isolates from Portugal following routine childhood vaccination against H. influenzae serotype b (2002-2010).

We aimed to characterize Haemophilus influenzae invasive isolates recovered in Portugal over a 9-year period (2002-2010) following the inclusion of H. influenzae serotype b (Hib) conjugate vaccination in the National Immunization Program (NIP) in the year 2000 and compare the results with those obtained in a similar study from the pre-vaccination era (1989-2001) previously described by us. As part of a laboratory-based passive surveillance system, 144 invasive isolates obtained in 28 Portuguese hospitals were received at the National Reference Laboratory for Bacterial Respiratory Infections and were characterized. Capsular types and antibiotic susceptibility patterns were determined. The ftsI gene encoding PBP3 was sequenced for ß-lactamase-negative ampicillin-resistant (BLNAR) isolates. Genetic relatedness among isolates was examined by multilocus sequencing typing (MLST). Most isolates (77.1%) were non-capsulated, a significant increase compared to the pre-vaccination era (19.0%, p < 0.001). Serotype b strains decreased significantly (from 81.0 to 13.2%, p < 0.001) and serotype f increased significantly (from 0.8 to 6.9%, p = 0.03). Ten percent of the isolates were ß-lactamase producers, a value lower than that previously observed (26.9%, p = 0.005). Eight percent of all isolates were BLNAR. A high genetic diversity among non-capsulated isolates was found. By contrast, capsulated isolates were clonal. The implementation of Hib vaccination has resulted in a significant decline in the proportion of serotype b H. influenzae invasive disease isolates. Most episodes of invasive disease occurring in Portugal are now due to fully susceptible, highly diverse, non-capsulated strains. Given the evolving dynamics of this pathogen and the increase in non-type b capsulated isolates, continuous surveillance is needed.

Genomic insights into the expansion of carbapenem-resistant Klebsiella pneumoniae within Portuguese hospitals.

Carbapenem-resistant Klebsiella pneumoniae (CR-KP) are a public health concern, causing infections with a high mortality rate, limited therapeutic options and challenging infection control strategies. In Portugal, the CR-KP rate has increased sharply, but the factors associated with this increase are poorly explored. In order to address this question, phylogenetic and resistome analysis were used to compare the draft genomes of 200 CR-KP isolates collected in 2017-2019 from five hospitals in the Lisbon region, Portugal. Most CR-KP belonged to sequence type (ST) 13 (29%), ST17 (15%), ST348 (13%), ST231 (12%) and ST147 (7%). Carbapenem resistance was conferred mostly by the presence of KPC-3 (74%) or OXA-181 (18%), which were associated with IncF/IncN and IncX plasmids, respectively. Almost all isolates were multi-drug resistant, harbouring resistance determinants to aminoglycosides, beta-lactams, trimethoprim, fosfomycin, quinolones and sulphonamides. In addition, 11% of isolates were resistant to colistin. Colonizing and infecting isolates were highly related, and most colonized patients (89%) reported a previous hospitalization. Moreover, among the 171 events of cross-dissemination identified by core genome multi-locus sequence typing data analysis (fewer than five allelic differences), 41 occurred between different hospitals and 130 occurred within the same hospital. The results suggest that CR-KP dissemination in the Lisbon region results from acquisition of carbapenemases in mobile genetic elements, influx of CR-KP into the hospitals by colonized ambulatory patients, and transmission of CR-KP within and between hospitals. Prudent use of carbapenems, patient screening at hospital entry, and improvement of infection control are needed to decrease the burden of CR-KP infection in Portugal.

Overview of molecular typing methods for outbreak detection and epidemiological surveillance.

Typing methods for discriminating different bacterial isolates of the same species are essential epidemiological tools in infection prevention and control. Traditional typing systems based on phenotypes, such as serotype, biotype, phage-type, or antibiogram, have been used for many years. However, more recent methods that examine the relatedness of isolates at a molecular level have revolutionised our ability to differentiate among bacterial types and subtypes. Importantly, the development of molecular methods has provided new tools for enhanced surveillance and outbreak detection. This has resulted in better implementation of rational infection control programmes and efficient allocation of resources across Europe. The emergence of benchtop sequencers using next generation sequencing technology makes bacterial whole genome sequencing (WGS) feasible even in small research and clinical laboratories. WGS has already been used for the characterisation of bacterial isolates in several large outbreaks in Europe and, in the near future, is likely to replace currently used typing methodologies due to its ultimate resolution. However, WGS is still too laborious and time-consuming to obtain useful data in routine surveillance. Also, a largely unresolved question is how genome sequences must be examined for epidemiological characterisation. In the coming years, the lessons learnt from currently used molecular methods will allow us to condense the WGS data into epidemiologically useful information. On this basis, we have reviewed current and new molecular typing methods for outbreak detection and epidemiological surveillance of bacterial pathogens in clinical practice, aiming to give an overview of their specific advantages and disadvantages.

Serotypes and Clonal Composition of Streptococcus pneumoniae Isolates Causing IPD in Children and Adults in Catalonia before 2013 to 2015 and after 2017 to 2019 Systematic Introduction of PCV13.

The goal of this study was to investigate the distribution of serotypes and clonal composition of Streptococcus pneumoniae isolates causing invasive pneumococcal disease (IPD) in Catalonia, before and after systematic introduction of PCV13. Pneumococcal strains isolated from normally sterile sites obtained from patients of all ages with IPD received between 2013 and 2019 from 25 health centers of Catalonia were included. Two study periods were defined: presystematic vaccination period (2013 and 2015) and systematic vaccination period (SVP) (2017 to 2019). A total of 2,303 isolates were analyzed. In the SVP, there was a significant decrease in the incidence of IPD cases in children 5 to 17 years old (relative risk [RR] 0.61; 95% confidence interval [CI] 0.38 to 0.99), while there was a significant increase in the incidence of IPD cases in 18- to 64-year-old adults (RR 1.33; 95% CI 1.16 to 1.52) and adults over 65 years old (RR 1.23; 95% CI 1.09 to 1.38). Serotype 8 was the major emerging serotype in all age groups except in 5- to 17-year-old children. In children younger than 5 years old, the main serotypes in SVP were 24F, 15A, and 3, while in adults older than 65 years they were serotypes 3, 8, and 12F. A significant decrease in the proportions of clonal complexes CC156, CC191, and ST306 and an increase in those of CC180, CC53, and CC404 were observed. A steady decrease in the incidence of IPD caused by PCV13 serotypes indicates the importance and impact of systematic vaccination. The increase of non-PCV13 serotypes highlights the need to expand serotype coverage in future vaccines and rethink vaccination programs for older adults. IMPORTANCE We found that with the incorporation of the PCV13 vaccine, the numbers of IPD cases caused by serotypes included in this vaccine decreased in all of the age groups. Still, there was an unforeseen increase of the serotypes not included in this vaccine causing IPD, especially in the >65-year-old group. Moreover, a significant increase of serotype 3 included in the vaccine has been observed; this event has been reported by other researchers. These facts call for the incorporation of more serotypes in future vaccines and a more thorough surveillance of the dynamics of this microorganism.

Sexual dysfunction in uraemic patients undergoing haemodialysis: predisposing and related conditions.

Chronic kidney disease and sexual dysfunction are common entities in clinical practice in haemodialysis (HD) units. This article is a review of some articles that focus on sexual dysfunction in patients undergoing HD and its possible relationship in multiple ways.

Effect of Bleaching Gel Concentration on Tooth Color and Sensitivity: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to evaluate a high concentration of hydrogen peroxide (35%) regarding tooth sensitivity and color change in tooth bleaching in comparison to low concentrations (6% to 20%). METHODS AND MATERIALS: This review was conducted using the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and is registered on the Prospective Register of Systematic Reviews (CRD42017064493). The PICO question was "Does a concentration of hydrogen peroxide ≥35% using in-office bleaching procedure contribute to greater tooth sensitivity?" A search was made in PubMed/MEDLINE, Scopus, and the Cochrane Library. RESULTS: Fourteen studies were selected for the qualitative analysis and seven for quantitative analysis. A total of 649 patients were evaluated (mean age: 36.32 years; range: 13.9 to 31 years), and the follow-up period ranged from one week to 12 months. The meta-analysis demonstrated that tooth sensitivity was higher in the patients submitted to treatment involving a high concentration of hydrogen peroxide (0.67; 95% confidence interval [CI]: 0.44 to 1.03; p=0.04; I 2 : 56%), and a significant difference was found regarding objective color ΔE (1.53; 95% CI: 2.99 to 0.08; p<0.0001; I 2 : 82%) but no significant difference was found regarding subjective color ΔSGU (0.24; CI: 0.75 to 1.23; p<0.00001; I 2 : 89%). CONCLUSIONS: This study indicated that a lower concentration of hydrogen peroxide causes less tooth sensitivity and better effectiveness in objective color change (ΔE); however, there is no difference between them related to subjective color (ΔSGU).

Partial orchiectomy: The Princess Margaret cancer centre experience.

INTRODUCTION: Radical orchiectomy (RO) is the standard treatment for a testis cancer. Organ sparing surgery can be considered in the setting of a solitary functioning testis or bilateral tumors. It has also been suggested as an alternative to RO for small lesions. In this study we report our partial orchiectomy (PO) experience. METHODS: We performed a retrospective review using our prospectively maintained database analyzing PO. RESULTS: Between 1983 and 2018, 77 patients underwent PO. Mean age was 31.3 years (range 17-56). A lesion was palpable in 70 (90.9%) and median lesion size 14.1 mm (range 3-35 mm). Reasons for PO included ``small lesion" in 39 (50.6%); solitary functioning testis in 30 (39%); bilateral lesions in 6 (7.8%); or assumed benign lesion in 1 (1.3%). Median follow-up was 43.5 months (range 1-258). Lesion histology was benign in 25 (32.5%). A positive surgical margin was noted in 6 (7.8%) with none developing local or distant recurrence. Sixteen (20.8%) patients underwent salvage ipsilateral RO at a median of 3 months (range 0-46). Reasons for salvage RO included a radiologically detected lesion in 7, palpable lesion in 4, positive surgical margin in 3 and adverse pathology in 2 patients. Malignant histology was present in 12 (75%) of the salvage RO specimens. There were no reported Clavien-Dindo Grade 3 to 5 complications. CONCLUSION: Organ sparing surgery is a safe and feasible approach to small testis lesions. For the third with benign disease, and even those with malignant histology, a RO can be avoided in carefully selected patients.

Effects of Hyperosmolality on Hypothalamic Astrocytic Area, mRNA Expression and Glutamate Balance In Vitro.

During prolonged dehydration, body fluid homeostasis is challenged by extracellular fluid (ECF) hyperosmolality, which induce important functional changes in the hypothalamus, in parallel with other effector responses, such as the activation of the local renin-angiotensin system (RAS). Therefore, in the present study we investigated the role of sodium-driven ECF hyperosmolality on glial fibrillary acid protein (GFAP) immunoreactivity and protein expression, membrane capacitance, mRNA expression of RAS components and glutamate balance in cultured hypothalamic astrocytes. Our data show that hypothalamic astrocytes respond to increased hyperosmolality with a similar decrease in GFAP expression and membrane capacitance, indicative of reduced cellular area. Hyperosmolality also downregulates the transcript levels of angiotensinogen and both angiotensin-converting enzymes, whereas upregulates type 1a angiotensin II receptor mRNA. Incubation with hypertonic solution also decreases the immunoreactivity to the membrane glutamate/aspartate transporter (GLAST) as well as tritiated-aspartate uptake by astrocytes. This latter effect is completely restored to basal levels when astrocytes previously exposed to hypertonicity are incubated under isotonic conditions. Together with a direct effect on two important local signaling systems (glutamate and RAS), these synaptic rearrangements driven by astrocytes may accomplish for a coordinated increase in the excitatory drive onto the hypothalamic neurosecretory system, ultimately culminating with increased AVP release in response to hyperosmolality.

Zinner's syndrome: an up-to-date review of the literature based on a clinical case.

The authors made an up-to-date review of the literature concerning the management of Zinner's syndrome and evaluated a young patient with Zinner's syndrome who had presented with urinary and ejaculatory complaints. Physical examination and transrectal ultra-sonography showed a 7.0 cm right seminal vesicle cyst. Magnetic resonance imaging (MRI) confirmed the diagnosis of Zinner's syndrome. Oligoasthenoteratozoospermia was present at the two seminal analyses. Symptomatic improvement was achieved with conservative measures. Actually, the patient is still on a follow-up programme. The diagnosis is usually established at the age of increased sexual activity. Patients may be asymptomatic or present pain, irritative urinary or ejaculatory symptoms and infertility. MRI has proved to be the best imaging examination. Treatment should be adapted to symptoms, surveillance being the best option in the absence of clinical manifestations. Surgical approach may be adequate when conservative measures prove ineffective. Zinner's syndrome should be suspected if a male young patient presents with unilateral renal agenesis and pelvic complaints and has a supraprostatic mass on digital rectal examination. The initial approach should be medical, but invasive procedures may be the only way to solve the patient's complaints. Nowadays, laparoscopic and robotic techniques must replace the open surgical approach.

Emergence of a serotype 1 Streptococcus pneumoniae lineage colonising healthy children in Portugal in the seven-valent conjugate vaccination era.

Serotype 1 pneumococci are rarely isolated from carriers, but are an important cause of pneumococcal invasive disease in many regions of the world. This report describes the emergence and expansion of a single serotype 1 lineage (characterised by multilocus sequence type 306) among healthy carriers attending day-care centres in Portugal. The prevalence of serotype 1 strains among all pneumococci increased from 0% in 2001 and 2002, to 0.4% in 2003, and 3.1% in 2006. These observations paralleled the introduction and increased use of the seven-valent pneumococcal conjugate vaccine in the study group, suggesting a direct relationship between these events.

Determinants of left ventricular diastolic dysfunction in hypertensive patients.

INTRODUCTION: The progression of hypertensive heart disease leads to the left ventricular diastolic dysfunction (LVDD), which is associated with increased cardiovascular morbidity and mortality. The purpose of this analysis is to explore the determinants for LVDD in patients with hypertension. METHODS: This is a secondary analysis of data of Impedance Cardiography in the Evaluation of Left Ventricular Diastolic Dysfunction in Patients with Arterial Hypertension (IMPEDDANS) Study. Mann-Whitney and Chi-square tests were used for univariable analysis. Multiple logistic regression was used to model for LVDD occurrence and discriminative capacity of the model assessed by the value of the area under the curve given by the receiver-operating characteristic curve. RESULTS: Older age (65 vs. 58 years, p<0.001), longer duration of hypertension (160 vs. 48 months, p<0.001), uncontrolled hypertension (59.8 vs. 15.9%, p<0.001), tobacco smoking (17.8 vs. 3.8%, p=0.016), higher systolic blood pressure (133 vs. 124mmHg, p=0.001) and slower heart rate (62 vs. 66bpm, p=0.023) were associated with LVDD. Multivariate model identified uncontrolled hypertension (AdjOR 36.90; 95% CI 7.94-171.58; p<0.001), smoking (AdjOR 6.66; 95% CI 1.63-27.26; p=0.008), eccentric hypertrophy (AdjOR 3.59; 95% CI 0.89-14.39; p=0.072), duration of hypertension (AdjOR 1.03; 95% CI 1.02-1.05; p<0.001) and concentric remodeling (AdjOR 0.19; 95% CI 0.04-0.93; p=0.041) as the more determinant for occurrence of LVDD. The discriminative capacity of the model was AUC=0.95 (95% CI 0.91-0.98). CONCLUSION: The occurrence of LVDD in hypertensive patients was strongly associated to long-lasting, uncontrolled hypertension, tobacco smoking, concentric remodeling and eccentric hypertrophy.

Enterobacter cloacae harbouring blaKPC-2 and qnrB-1 isolated from a cystic fibrosis patient: a case report.

We describe the first detection of a KPC-2- and QnrB-producing Enterobacter cloacae from a patient with cystic fibrosis. The blaKPC-2 and qnrB-1 genes were located in a 79.8-kb plasmid. The presence of blaKPC-2 and qnrB-1 genes was determined by PCR and sequencing. Mobilization of plasmid containing blaKPC2 gene was assayed by conjugation.