Description of novel resistance islands harbouring blaCTX-M-2 in IncC type 2 plasmids.

OBJECTIVES: We sequenced two IncA/C plasmids harbouring blaCTX-M-2 in Klebsiella pneumoniae clinical isolates and compared their antibiotic resistance islands. METHODS: Transconjugants were obtained from two clinical K. pneumoniae isolates harbouring blaCTX-M-2. Plasmid DNA from transconjugants underwent short-read whole-genome sequencing, reads were assembled, and gaps were closed by PCR and sequencing. Determination of plasmid replicons, antibiotic resistance genes, identification and characterisation of insertion sequence (IS) elements, and comparison with publicly available plasmid sequences were performed. RESULTS: blaCTX-M-2 was located in a complex class 1 integron In35::ISCR1::blaCTX-M-2, inserted in two different transposons designated Tn7057 and Tn7058, that reside in the resistance islands of plasmids pUR-KP0923 and pUR-KP1025, respectively. The general modules of both transposons were In35::ISCR1::blaCTX-M-2-Tn1000-like-Tn2*-ISKpn11-12-13 variable module-ΔTn21. In Tn7057 there was ΔIS10R-catA2 associated with an additional ISKpn13. Both plasmids belonged to IncC type 2 and ST3. pUR-KP0923 was 167 138 bp in length and had a 37 926-bp resistance island at position 4 (RI-4). Plasmid pUR-KP1025 was 168 128 bp with a RI-4 of 36 222 bp. CONCLUSION: This report describes the molecular nature of two transposons (Tn7057 and Tn7058) harbouring blaCTX-M-2 that reside in IncC type 2 ST3 plasmids. These transposons mediate resistance to oxyimino-cephalosporins, gentamicin and, in the case of Tn7057, chloramphenicol. CTX-M-2 is an important extended-spectrum ß-lactamase (ESBL) to South American epidemiology. It is remarkable that despite being only two plasmid sequences, the information revealed here could contribute to a better understanding of the resistance islands from IncC type 2 plasmids.

Wearable, Fiber-less, Multi-Channel System for Continuous Wave Functional Near Infrared Spectroscopy Based on Silicon Photomultipliers Detectors and Lock-In Amplification.

Development and in-vivo validation of a Continuous Wave (CW) functional Near Infrared Spectroscopy (fNIRS) system is presented. The system is wearable, fiber-less, multi-channel (16×16, 256 channels) and expandable and it relies on silicon photomultipliers (SiPMs) for light detection. SiPMs are inexpensive, low voltage and resilient semiconductor light detectors, whose performances are analogous to photomultiplier tubes (PMTs). The advantage of SiPMs with respect to PMTs is that they allow direct contact with the scalp and avoidance of optical fibers. In fact, the coupling of SiPMs and light emitting diodes (LEDs) allows the transfer of the analog signals to and from the scalp through thin electric cables that greatly increase the system flexibility. Moreover, the optical probes, mechanically resembling electroencephalographic electrodes, are robust against motion artifacts. In order to increase the signal-to-noise-ratio (SNR) of the fNIRS acquisition and to decrease ambient noise contamination, a digital lock-in technique was implemented through LEDs modulation and SiPMs signal processing chain. In-vivo validation proved the system capabilities of detecting functional brain activity in the sensorimotor cortices. When compared to other state-of-the-art wearable fNIRS systems, the single photon sensitivity and dynamic range of SiPMs can exploit the long and variable interoptode distances needed for estimation of brain functional hemodynamics using CW-fNIRS.

Estimation of screening sensitivity and sojourn time from an organized screening program.

Regular screening with mammography is widely recommended to reduce breast cancer mortality. However, whether breast screening does more harm than good has long been debated. Since a full evaluation of the effect on mortality could take 10-15 years in order to provide a reliable estimate of the eventual benefits and harms, it is unrealistic to expect each new modification of a screening technique to be evaluated in this way. Therefore, one needs to rapidly estimate suitable measures of the screening effect. In this paper, two measures of interest, the length of the pre-clinical state and the screening false negative rate, are discussed. A procedure is proposed to model the pre-clinical disease state duration, the false negative rate of the screening exam, and the underlying incidence rate in the screened population. We applied the model to data from the Ontario Breast Screening Program in Canada. Our results suggest that the mean preclinical duration is longer than 2 years. We also find only small marginal gains by screening every two instead of three years. The most important objective of a screening program should be to encourage first-time screening attendance.

Response to oyster mushroom (Pleurotus ostreatus) extract by sensitized and nonsensitized guinea pig trachea.

Occupational exposure to oyster mushroom (Pleurotus ostreatus) has been associated with obstructive lung disease. Previously, we studied an extract of oyster mushroom (OME) and determined that it causes dose-dependent contractions of nonsensitized guinea pig trachea (GPT). We extend these studies to the investigation of sensitized tissue. In the present study 24 animals were sensitized using ovalbumin (OA) and subsequently challenged with an aerosol of 2.5% OA. A control group of 12 nonsensitized GPs was also studied. Tracheas were removed and were divided into rings in which the epithelium was retained (EP+) or removed (EP-). Dose-related contractions of sensitized and nonsensitized GPTs were elicited with OME. In nonsensitized animals the EP+ GPTs demonstrated a significantly greater response to OME (100-1000 µl) than did the EP- GPTs (p < 0.01). By contrast, in sensitized GPTs with and without epithelium there was no difference to challenge with OME. Finally, sensitized GPTs with and without epithelium and nonsensitized GPTs with epithelium responded similarly to challenge with OME. These findings suggest that in nonsensitized animals there is an enhancement of contractile response to OME which is in part mediated by the GPT epithelium. In sensitized animals with or without epithelium, the level of bronchoconstrictor response is similar to that of the nonsensitized animals with epithelium, suggesting an enhanced constrictor response independent of epithelium in the sensitized animals.

Respiratory function in wind instrument players.

BACKGROUND: The playing of wind instruments has been associated with changes in respiratory function. STUDY OBJECTIVES: To investigate the effect of playing wind instruments on lung function and respiratory symptoms. METHODS: The present study included 99 wind instrument players and a group of 41 string instrument players as a control from 3 major orchestras in Zagreb, Croatia. Data on chronic respiratory symptoms were recorded in all studied subjects. Lung function was measured in wind instrument players by recording maximum expiratory flow-volume curves. RESULTS: Wind instrument players demonstrated significantly higher prevalences of sinusitis, nasal catarrh and hoarseness compared to control musicians. One wind instrument player developed asthma associated with his work. Odds ratios for wind instrument players were significant for chronic cough, chronic phlegm and chronic bronchitis by smoking habit (p<0.05 or p<0.01) but not for length of employment. Ventilatory capacity data indicate that wind instrument players had significantly greater FEV1 (smokers and nonsmokers) as well as FEF50 (nonsmokers) (p<0.05) compared to predicted values. Regression analysis of pulmonary function tests in wind instrument players demonstrate a significant link between FEV1 and FEF50 and length of employment. Those wind instrument players with longer employment had the greatest increases in lung function. CONCLUSIONS: Our data suggest that musicians playing wind instruments may be susceptible to chronic upper airway symptoms. Interestingly wind instrument playing may be associated with higher than expected lung function parameters.

Respiratory findings in art and medical students. Effects of the art environment.

BACKGROUND: Art students are exposed to many noxious agents during their training, in contrast to medical students, who are not exposed to known environmental pollutants. OBJECTIVES: In order to investigate the potential effects of toxic agents in the art students' environment, we studied respiratory findings in a cohort of 117 art students and 128 medical students, matched for age, sex and smoking. METHODS: Acute and chronic respiratory symptoms were evaluated by modifying the British Medical Research Council questionnaire. Lung function studies were performed with a spirometer (Jaeger, Germany) measuring maximum expiratory flow-volume (MEFV) curves. On these curves we calculated the forced vital capacity (FVC), one second forced expiratory volume (FEV1) and the maximal expiratory flow at 50% and the last 25% of the FVC (FEF50, FEF25). RESULTS: Significantly higher prevalences of most of the chronic respiratory symptoms were recorded in art students compared to medical students (p < 0.05). Art students who were smokers had significantly higher prevalences of many of the chronic respiratory symptoms than nonsmoking art students. Among medical students these differences were not statistically significant (NS). High prevalences of acute symptoms related to the study environment were recorded for art students. Odds ratios in male and female art students were significant for chronic cough, chronic phlegm and chronic bronchitis for the risk factor of smoking. Significantly decreased lung function values compared to predicted values were recorded mostly for FEF50 and FEF25 in male and female art students. Smoking and non-smoking art students had similar reductions of lung function. Lung function data in medical students were within predicted values. CONCLUSIONS: Our data indicate that art students may be at risk of developing chronic respiratory symptoms and lung function changes as a result of their environmental exposure and their smoking habits.

Pharmacological study of oyster mushroom (Pleurotus ostreatus) extract on isolated guinea pig trachea smooth muscle.

Mushroom farm workers suffer from respiratory symptoms during the farming of mushrooms. The objective of this study was to analyze the effects of oyster mushroom (Pleurotus ostreatus) extract (OME) on isolated guinea pig tracheal smooth muscle in vitro. Isolated guinea pig tracheal tissue from 27 nonsensitized guinea pigs were studied. The OME was obtained from indoor mushroom growing fields and prepared as a 1:10 w/v aqueous solution. Dose-related contractions of nonsensitized guinea pig trachea were demonstrated using these extracts. The OME contained significant quantities of bacterial components (eg., endotoxin: 43,072.92 EU/mg). Parallel, pharmacological studies were performed by pre-treating the tissues with mediator-modifying agents including atropine, indomethacin, pyrilamine, BPB, acivicin, NDGA, captopril, TMB8 and capsaicin. Atropine consistently and strikingly reduced the contractile effects of this extract. These observations suggest an interaction of the OME with parasympathetic nerves or more directly with muscarinic receptors. Pretreatment with TMB8 (inhibitor of intracellular calcium mobilization) also significantly blocked the constrictor effect of OME, indicating a role of calcium mobilization in the constricting effect of OME. Inhibition of contraction by blocking of other mediators was less effective and varied depending on the drug. We conclude that OME causes a dose-related airway smooth muscle constriction by nonimmunological mechanisms involving a variety of airway mediators and possibly cholinergic receptors. This effect is not dependent on pre-sensitization of the guinea pigs.

The plastic surgeon and Graves disease.

Thyroid-associated ophthalmopathy is a disease caused by autoimmune processes that also affects the thyroid gland and the lower limbs; at orbital level, it involves the muscle and adipose tissue. When medical treatment fails to achieve appreciable results, surgery aims to decompress the orbital cavity. In recent years, the treatment has been considerably improved by the introduction of transpalpebral lipectomy, which has produced valid results especially in cases when extrinsic muscle hypertrophy is limited; if it is severe, however, lipectomy can be combined with expansion of the orbital cavity, thus enabling the latter to be restricted to one or two walls instead of three. Studying 52 patients who underwent orbital decompression involving lipectomy and/or orbital expansion, affecting a total of 96 orbits, enabled an assessment of the pros and cons of the single techniques in an attempt to identify a rational approach to this pathology. It emerged that lipectomy alone may suffice and obtain valid results in cases of mild-to-moderate proptosis (up to 24 mm) with limited extrinsic muscle hypertrophy, whereas orbital expansion--with or without lipectomy--is likely to be necessary in moderate-to-severe cases (proptosis greater than 24 mm). Additional procedures to correct the elevator and retractor muscles of the eyelids were almost always necessary.

Donor and organ suitability: risk due to donor social behavior.

For many patients experiencing organ failure, transplantation may be the only opportunity to improve their quality of life and to extend life expectancy. Organ shortage is an important problem for Italian and international procurement organizations. A review of donor and organ suitability is necessary to expand the donor pool. The suitability of donors at risk for HIV infection, as well as other marginal individuals, must be carefully evaluated before rejecting them. For donors with a social history considered to be at risk for HIV infection, laboratory testing is necessary to establish the actual HIV infection risk. It is important to consider every organ available for transplantation, even those considered to be marginal or coming from marginal donors. The only condition that we must always consider is that the organs be of acceptable quality and, above all, not expose patients to unacceptable risks.

Breast screening outcomes in women with and without a family history of breast and/or ovarian cancer.

OBJECTIVES: To compare breast screening outcomes between women with a moderate or strong family history of breast and/or ovarian cancer with those without such a history. SETTING: The Ontario Breast Screening Programme (OBSP) is a population-based programme offering mammography and clinical breast examination to Ontario women of 50 and older. METHODS: Data from a cohort of 143,574 women screened by the OBSP from 1996 to 1997 were included. Referral rates, cancer detection rates, positive predictive values and the histological features of screen-detected cancers were examined within family history groups, age groups and screening modalities. Logistic regression analysis of cancer detection was conducted to adjust for potential confounding variables; subgroup analysis by hormone replacement therapy (HRT) use was also undertaken. RESULTS: Compared with women with no family history, women with a moderate or strong family history of breast and/or ovarian cancer were more likely to have their cancer detected (odds ratio [OR]=1.44, 95% confidence interval [CI] 1.20-1.74 and OR=1.42, 95% CI 1.10-1.83, respectively). Among women using HRT, however, there was no association observed between family history and cancer detection (moderate: OR=0.98, 95% CI 0.65-1.48; strong: OR=1.17, 95% CI 0.68-2.02) with history. The histological features of invasive tumours were similar among family history groups. CONCLUSIONS: Greater cancer detection rates and high proportions of invasive tumours with good prognosis indicate that women aged 50 and over with a family history may have the potential to benefit from regular breast cancer screening. Further studies are required to identify optimal screening guidelines and to examine whether HRT reduces the ability to detect cancer in these women.

Socioeconomic status & returning for a second screen in the Ontario breast screening program.

In a retrospective cohort study involving 57902 women initially screened between January 1, 1995 and December 31 1997 by the Ontario Breast Screening Program (OBSP), we examined the relationship between geographically derived socioeconomic status (SES) and returning for a second screen. We controlled for age, rurality, preferred language, initial mammography results, previous mammography history, and referral by a health professional. Although SES was related to returning, rurality was an effect modifier of this relationship, a finding not previously reported. Compared to women in the highest ('richest') quintile, urban women in the first and second quintile were less likely to return; this relationship was not found in rural women. Low SES women, particularly in urban areas, should be specifically targeted to increase their likelihood of re-attendance for breast cancer screening within an organized program.

False-positive result and reattendance in the Ontario Breast Screening Program.

OBJECTIVE: To determine the association between initial screen result and returning for a second screen in an organised breast screening programme for women with a biennial screening recommendation. SETTING: Women who attended the Ontario Breast Screening Program (OBSP). METHODS: A retrospective cohort study was conducted of 140723 Ontario women aged 50 years and older who had an initial screen at the OBSP between 1 July 1990 and 31 December 1995 and were followed until 30 June 1998. Rescreening rates at 36 months and risk ratio estimates were calculated using survival methods. Age of women, year of screen, region (within Ontario) and initial screen result were compared. For initial screen results, returning for a second screen was examined by integration of screening centre with an assessment programme and by modality of referral. RESULTS: Women with a false-positive result were less likely to return for a second screen as were women aged 70 and older and those living in regions of Ontario with fewer OBSP screening centres. However, there were minimal differences in reattendance behaviour by initial screen result for women screened at the OBSP centre with an assessment programme. CONCLUSIONS: Integration of breast screening and assessment services improved reattendance of women with false-positive screen results within an organised screening programme.

Contribution of clinical breast examination to mammography screening in the early detection of breast cancer.

OBJECTIVES: As the benefit of clinical breast examination (CBE) over that of screening mammography alone in reducing breast cancer mortality is uncertain, it is informative to monitor its contribution to interim measures of effectiveness of a screening programme. Here, the contribution of CBE to screening mammography in the early detection of breast cancer was evaluated. SETTING: Four Canadian organised breast cancer screening programmes. METHODS: Women aged 50-69 receiving dual screening (CBE and mammography) (n = 300,303) between 1996 and 1998 were followed up between screen and diagnosis. Outcomes assessed by mode of detection (CBE alone, mammography alone, or both CBE and mammography) included referral rate, positive predictive value, pathological features of tumours (size, nodal status, morphology), and cancer detection rates overall and for small cancers (< or = 10 mm or node-negative). Heterogeneity in findings across programmes was also assessed. RESULTS: On first versus subsequent screen, CBE alone resulted in 28.5-36.7% of referrals, and 4.6-5.9% of cancers compared with 52.6-60.1% of referrals and 60.0-64.3% of cancers for mammography alone. Among cancers detected by CBE, 83.6-88.6% were also detected by mammography, whereas for mammographically detected cancers only 31.7-37.2% were also detected by CBE. On average, CBE increased the rate of detection of small invasive cancers by 2-6% over rates if mammography was the sole detection method. Without CBE, programmes would be missing three cancers for every 10,000 screens and 3-10 small invasive cancers in every 100,000 screens. CONCLUSIONS: Inclusion of CBE in an organised programme contributes minimally to early detection.

Reconstruction of the inner canthus region with a forehead muscle flap: a report on three cases.

We report our experience of using a forehead flap to repair the defect left by the excision of skin tumours in the medial canthal region involving both eyelids in three patients. Both eyelids and the inner canthus were reconstructed using a myofascial flap taken from the forehead, combined with septal chondro-mucosal grafts, oral mucosa and skin grafts. After a careful anatomical study of the vascularisation of the frontal region, we used only the frontal myofascial portion, a part of the forehead muscle vascularised by the deep branch of the supraorbital artery and by the supratroclear artery; the skin left behind is adequately nourished by the fine mesh of anastomoses in the area between the two supratroclear arteries, the supraorbital artery and the terminal vessels of the superficial temporal artery. The particularly thin, elastic and resistant features of this flap enabled us to repair a loss of substance in a difficult area with a successful outcome in terms of morphology, function and cosmetic appearance.

Pregnancy outcomes in females after treatment for childhood cancer.

This Ontario province-wide cohort study was conducted to compare the risk of adverse pregnancy outcomes in female childhood cancer survivors who received abdominal-pelvic radiation and/or chemotherapy with alkylating agents with the risk among those who were treated by non-sterilizing alkylating agents with the risk among those who were treated by non-sterilizing surgery only. Females in Ontario, Canada, diagnosed in 1964-1988 before age 20 with a histologically confirmed malignancy and who had survived for at least 5 years, attained age 18, and were alive at the time of study, were identified through the Ontario Cancer Registry. We ascertained pregnancy outcomes by a telephone-administered questionnaire. Treatment data were abstracted from medical records for 830 subjects 18-49 years of age, the analysis comprised 340 survivors who had one or more pregnancies after treatment. There was no evidence of an increased risk of having a spontaneous abortion or an infant with a birth defect. Survivors receiving abdominal-pelvic radiation were more likely to have a low birth weight infant (odds ratio estimate [OR] = 3.64; 95% confidence interval [CI] = 1.33-9.96), a premature low birth weight infant (OR = 3.29; 95% CI = 0.97-11.1), or an infant who died in the perinatal period (OR = 2.41; 95% CI = 0.50-11.5), compared with those receiving surgery. Risks of perinatal death and having a low birth weight infant increased with dose of radiotherapy directed to the abdomen.

Early menopause and infertility in females after treatment for childhood cancer diagnosed in 1964-1988 in Ontario, Canada.

This study was conducted to determine the risk of menopause and infertility in female childhood cancer survivors who received abdominal-pelvic radiation and/or chemotherapy with alkylating agents in comparison with those who were treated by nonsterilizing surgery only. Females who were diagnosed in 1964-1988 before age 20 years with a histologically confirmed malignancy and who had survived for at least 5 years, had attained age 18, and were alive at time of study were identified through the Ontario Cancer Registry. Reproductive outcomes were ascertained by a telephone-administered questionnaire, and treatment data were abstracted from medical records for 830 subjects aged 18-49 years; 719 survivors who were nonmenopausal at the end of treatment were included in the analyses. Survivors who received both alkylating agents and abdominal-pelvic radiation were more likely to be postmenopausal than were those who underwent surgery (risk ratio = 2.58; 95% confidence interval: 1.14, 5.80). Women treated with abdominal-pelvic radiation alone had a fertility deficit of 23% compared with those in the surgery group; the deficit was restricted to women diagnosed postpuberty. Risks of menopause and infertility increased with increasing dose of abdominal-pelvic radiation and amount of alkylating agent.

[Total enteral nutrition versus mixed enteral and parenteral nutrition in patients at an intensive care unit]. / La nutrizione enterale totale verso la nutrizione mista enterale e parenterale in pazienti ricoverati in una terapia intensiva polivalente.

OBJECTIVE: To compare metabolic, nutritional and epidemiological data in two groups of patients, one receiving total enteral nutrition, via nasoenteric tube, and one receiving both enteral and parenteral nutrition. DESIGN: A prospective, randomized study. SETTING: A general ICU, with both medical and surgical patients, in a big regional University and National Health Service hospital. PATIENTS: 24 patients requiring Intensive Care after major surgery or because suffering from severe head injury or major neurological impairment. INTERVENTIONS: All patients initially received total parenteral nutrition: after 4 days 12 patients were "weaned" to total enteral nutrition and 12 stayed on mixed parenteral and enteral nutrition. LABORATORY INVESTIGATIONS AND OBSERVATIONAL DATA: Blood levels of albumin, prealbumin, transferrin, ALT, AST, bilirubin, blood urea, blood glucose, total linfocite count, and nutritional and epidemiological data such as nitrogen balance, calorie intake, diarrhea incidence, blood and sputum cultures and radiologic evidence of pneumonia are analysed. RESULTS: At T1, NET patients were able to reduce their nitrogen losses (0.27.1 g/kg +/-0.12 vs 0.35 +/- 0.13 at TO; p < 0.05) and improve nitrogen balance (-9 +/- 7 vs -2 +/- 6 at T0; p < 0.05); they also had a better total linfocite count (2034 +/- 304 vs. 1413 +/- 360 of the MISTA group; p < 0.05), and a lower incidence of pneumonia as documented by sputum cultures and radiograms. CONCLUSIONS: Patients fed with both parenteral and enteral nutrition did no better than those on total enteral nutrition as far as nutritional and metabolic indices were concerned; they also seemed more prone to infections than those on total enteral nutrition, indicating that mixed nutrition may result in more stable feeding, but this does not seem to have any beneficial nutritional, immunological and metabolic effect.

[Hemodynamic stability in thoracic-abdominal trauma with multiple intrahepatic abscesses. A clinical case]. / Stabilità emodinamica in trauma toraco-addominale con ascessi multipli intraepatici. Un caso clinico.

A case of multiple injury is reported in a young 35-year-old man affecting three different areas of the body which showed a septic-type development. Complete recovery was largely determined by the accuracy of the preoperative diagnosis and the correct maintenance of hemodynamic parameters.

Surgical repair of an anterior tibialis muscle hernia with Mersilene mesh.

The most frequent muscle hernia of the lower extremities is the anterior tibialis muscle hernia. A number of surgical procedures are available for the treatment of symptomatic anterior tibialis muscle hernias. However, in case of a large fascial defect, their use may be unfeasible or inconvenient. Moreover, current surgical procedures are prone to the risk of an anterior tibial compartment syndrome. The use of a synthetic patch could provide an alternative, particularly for large defects. In this paper we report the repair of a large, symptomatic, long-standing anterior tibialis muscle hernia with polyester mesh (Mersilene) fixed to the edges of the defect (muscular fascia and tibial periosteum). This simple procedure provided excellent functional results and a good cosmetic appearance without complications and sequelae.