The impact of obesity on the outcome of severe SARS-CoV-2 ARDS in a high volume ECMO centre: ECMO and corticosteroids support the obesity paradox.

PURPOSE: The aim was to verify the impact of obesity on the long-term outcome of patients with severe SARS-CoV-2 ARDS. MATERIALS AND METHODS: The retrospective study included patients admitted to the high-volume ECMO centre between March 2020 and March 2022. The impact of body mass index (BMI), co-morbidities and therapeutic measures on the short and 90-day outcomes was analysed. RESULTS: 292 patients were included, of whom 119(40.8%) were treated with veno-venous ECMO cannulated mostly (73%) in a local hospital. 58.5% were obese (64.7% on ECMO), the ECMO was most frequent in BMI > 40(49%). The ICU mortality (36.8% for obese vs 33.9% for the non-obese, p = 0.58) was related to ECMO only for the non-obese (p = 0.04). The 90-day mortalities (48.5% obese vs 45.5% non-obese, p = 0.603) of the ECMO and non-ECMO patients were not significantly influenced by BMI (p = 0.47, p = 0.771, respectively). The obesity associated risk factors for adverse outcome were age <50 (RR 2.14) and history of chronic immunosuppressive therapy (RR 2.11, p = 0.009). The higher dosage of steroids (RR 0.57, p = 0.05) associated with a better outcome. CONCLUSIONS: The high incidence of obesity was not associated with worse short and long-term outcomes. ECMO in obese patients together with the use of steroids in the later stage of ARDS may improve survival.

Burden of antimicrobial resistance in European hospitals: excess mortality and length of hospital stay associated with bloodstream infections due to Escherichia coli resistant to third-generation cephalosporins.

OBJECTIVES: This study determined excess mortality and length of hospital stay (LOS) attributable to bloodstream infection (BSI) caused by third-generation-cephalosporin-resistant Escherichia coli in Europe. METHODS: A prospective parallel matched cohort design was used. Cohort I consisted of patients with third-generation-cephalosporin-resistant E. coli BSI (REC) and cohort II consisted of patients with third-generation-cephalosporin-susceptible E. coli BSI (SEC). Patients in both cohorts were matched for LOS before infection with patients free of the respective BSI. Thirteen European tertiary care centres participated between July 2007 and June 2008. RESULTS: Cohort I consisted of 111 REC patients and 204 controls and cohort II consisted of 1110 SEC patients and 2084 controls. REC patients had a higher mortality at 30 days (adjusted odds ratio = 4.6) and a higher hospital mortality (adjusted hazard ratio = 5.7) than their controls. LOS was increased by 8 days. For SEC patients, these figures were adjusted odds ratio = 1.9, adjusted hazard ratio = 2.0 and excess LOS = 3 days. A 2.5 times [95% confidence interval (95% CI) 0.9-6.8] increase in all-cause mortality at 30 days and a 2.9 times (95% CI 1.2-6.9) increase in mortality during entire hospital stay as well as an excess LOS of 5 days (95% CI 0.4-10.2) could be attributed to resistance to third-generation cephalosporins in E. coli BSI. CONCLUSIONS: Morbidity and mortality attributable to third-generation-cephalosporin-resistant E. coli BSI is significant. If prevailing resistance trends continue, high societal and economic costs can be expected. Better management of infections caused by resistant E. coli is becoming essential.

A case of OXA-48 carbapenemase-producing Klebsiella pneumoniae in a patient transferred to Slovenia from Libya, November 2011.

We report the first documented case of OXA-48-producing Klebsiella pneumoniae in Slovenia isolated from rectal surveillance cultures from a patient transferred from Libya. The patient was colonised with both ESBL-producing Escherichia coli and ESBL- and OXA-48-producing K. pneumoniae. Three further patients were colonised with ESBL-producing E. coli. This underscores the importance of an early warning system on European level and screening upon admission of patients transferred across borders and between healthcare systems.

Characterisation of invasive Haemophilus influenzae isolates in Slovenia, 1993-2008.

The objectives of our study were to describe the epidemiology of invasive Haemophilus influenzae disease from 1993 to 2008 in Slovenia, a country with routine H. influenzae serotype b (Hib) conjugate vaccination since the year 2000. A total of 292 isolates of H. influenzae, recovered from a normally sterile site, were collected in the study period. The isolates were serotyped by slide agglutination and antibiotic susceptibility was determined. One hundred and eight isolates received after the year 2000 were serotyped by slide agglutination and by polymerase chain reaction (PCR) capsule typing, and both methods were compared. After the introduction of the routine Hib vaccination, the incidence of H. influenzae disease in children under the age of 5 years has decreased by 87.6% and type b was replaced by non-typeable H. influenzae as the predominant serotype. The proportion of serotype b decreased from 85.3% in the pre-vaccination period to 13.0% in the vaccination period and the proportion of non-capsulated isolates increased from 12.0 to 85.2%. The study of genetic relatedness by pulsed-field gel electrophoresis (PFGE) demonstrated that the isolates of serotypes b and f were genetically homogeneous within the serotype. The results of our national surveillance showed that the vaccine has been very efficient in preventing Hib invasive disease in Slovenia. Nevertheless, we see a need for further monitoring of invasive H. influenzae infections at a national level.

Genetic dissection of a mammalian replicator in the human beta-globin locus.

The timing and localization of DNA replication initiation in mammalian cells are heritable traits, but it is not known whether initiation requires specific DNA sequences. A site-specific recombination strategy was used to show that DNA sequences previously identified as replication initiation sites could initiate replication when transferred to new chromosomal locations. An 8-kilobase DNA sequence encompassing the origin of DNA replication in the human beta-globin locus initiated replication in the simian genome. Specific deletions within the globin origin did not initiate replication in these chromosomal sites. These data suggest that initiation of DNA replication in mammalian cells requires specific sequence information and extend the replicon hypothesis to higher eukaryotes.

Ethics and methods in surgical trials.

This paper focuses on invasive therapeutic procedures, defined as procedures requiring the introduction of hands, instruments, or devices into the body via incisions or punctures of the skin or mucous membranes performed with the intent of changing the natural history of a human disease or condition for the better. Ethical and methodological concerns have been expressed about studies designed to evaluate the effects of invasive therapeutic procedures. Can such studies meet the same standards demanded of those, for example, evaluating pharmaceutical agents? This paper describes a research project aimed at examining the interplay and sometimes apparent conflict between ethical standards for human research and standards for methodological rigor in trials of invasive procedures. The paper discusses how the authors plan to develop a set of consensus standards that, if met, would result in substantial and much-needed improvements in the methodological and ethical quality of such trials.

[Osteosynthesis of intracapsular femoral neck fractures by dynamic hip screw (DHS) fixation]. / Osteosyntéza intrakapsulárních zlomenin krcku stehenní kosti metodou DHS.

PURPOSE OF THE STUDY: The treatment of femoral neck fractures shows a relatively high number of poor outcomes, usually due to late complications, such as avascular necrosis of the femoral head or pseudoarthrosis. The latter may develop when the osteosynthesis of osteoporotic bone fails. The aim of this retrospective study was to evaluate a group of patients treated by osteo- synthesis for intra-capsular femoral neck fractures at our department, and to verify indication criteria and identify the therapeutic procedures that are best suited to our conditions. MATERIAL: In the 1997-2001 period, a total of 81 patients with intra-capsular femoral neck fractures were operated on. Of these, 64 treated by dynamic hip screw (DHS) fixation were followed up for at least 5 years. There were 33 women and 31 men; the average age was 21.5 years (range, 21 to 74 years). METHODS: The Garden classification was used to evaluate the displacement of femoral neck fractures. Preferably, osteosynthesis was carried out by closed reduction; only exceptionally was an extension device for the operating table used. A 135-degree sliding hip screw, with a short thread, directed to the head centre and a two-hole side plate were used most often.The average follow-up was 6.9 years. Evaluated were: the occurrence of late complications in relation to the length of time between injury and surgery, quality of fracture reduction, use of an anti-rotation screw and necessity of repeat surgery. RESULTS: Garden I or II fractures were diagnosed in 13 patients, 51 had Garden III or Garden IV fractures. Bone union without complications was achieved in 73.4 % of the patients within 12 months of surgery. Late complications were found in 26.6 %; of these, only one had Garden I fracture and the rest were Garden III and IV fractures. An anti-rotation screw was used in 39 patients (60.9 %) and its use had no effect on the development of late complications. Of the seven patients who developed pseudoarthrosis, the screw was used in four (57.1%); out of the nine patients with avascular necrosis, it was used in six (66.7 %). In the whole group, an unsatisfactory outcome of post-operative reduction was recorded in 29.7 %. In the patients with late complications this was found in 52.9 %, which was a statistically significant difference. Of the 17 patients with poor outcomes, 14 underwent total hip arthroplasty; in the patients with necrosis, arthroplasty was carried out at an average of 26 months post-operatively, in those with pseudoarthrosis it was at 7 months post-operatively. DISCUSSION: For the treatment of intra-capsular fractures of the femoral neck, surgery is the most frequent approach, but there are controversial views on various relevant issues. An important factor affecting the treatment outcome is the patient's bone quality. CONCLUSIONS: Our results show a direct relationship between the extent of fracture displacement and late complications, i.e., avascular necrosis and non-union. The quality of fracture reduction had a greater effect on fracture non-union than on the development of femoral head necrosis. The length of time between injury and surgery played a lesser role than it is believed. The use of an anti-rotation screw was not significantly related to the occurrence of late complications. The DHS method is economical and available, and provided sufficient results whose comparisons with the literature data show that this therapeutic approach is correct.

Role of alpha9 nicotinic ACh receptor subunits in the development and function of cochlear efferent innervation.

Cochlear outer hair cells (OHCs) express alpha9 nACh receptors and are contacted by descending, predominately cholinergic, efferent fibers originating in the CNS. Mice carrying a null mutation for the nACh alpha9 gene were produced to investigate its role(s) in auditory processing and development of hair cell innervation. In alpha9 knockout mice, most OHCs were innervated by one large terminal instead of multiple smaller terminals as in wild types, suggesting a role for the nACh alpha9 subunit in development of mature synaptic connections. Alpha9 knockout mice also failed to show suppression of cochlear responses (compound action potentials, distortion product otoacoustic emissions) during efferent fiber activation, demonstrating the key role alpha9 receptors play in mediating the only known effects of the olivocochlear system.

Localization of a bidirectional DNA replication origin in the native locus and in episomally amplified murine adenosine deaminase loci.

Gene amplification is frequently mediated by the initial production of acentric, autonomously replicating extrachromosomal elements. The 4,000 extrachromosomal copies of the mouse adenosine deaminase (ADA) amplicon in B-1/50 cells initiate their replication remarkably synchronously in early S phase and at approximately the same time as the single-copy chromosomal locus from which they were derived. The abundance of ADA sequences and favorable replication timing characteristics in this system led us to determine whether DNA replication initiates in ADA episomes within a preferred region and whether this region is the same as that used at the corresponding chromosomal locus prior to amplification. This study reports the detection and localization of a discrete set of DNA fragments in the ADA amplicon which label soon after release of synchronized B-1/50 cells into S phase. A switch in template strand complementarity of Okazaki fragments, indicative of the initiation of bidirectional DNA replication, was found to lie within the same region. This putative replication origin is located approximately 28.5 kbp upstream of the 5' end of the ADA gene. The same region initiated DNA replication in the single-copy ADA locus of the parental cells. These analyses provide the first evidence that the replication of episomal intermediates involved in gene amplification initiates within a preferred region and that the same region is used to initiate DNA synthesis within the native locus.

Prolonged remission of Epstein-Barr virus associated lymphoma secondary to T cell-depleted bone marrow transplantation.

High grade non-Hodgkin's lymphoma developed 42 days after allogeneic T cell-depleted bone marrow transplantation (BMT) for idiopathic aplastic anaemia. DNA hybridization studies confirmed clonality and incorporation of Epstein-Barr virus (EBV) genome. Prolonged remission followed low dose chemotherapy, local radiotherapy and early withdrawal of cyclosporin.

Activity of telithromycin and seven other agents against 1034 pediatric Streptococcus pneumoniae isolates from ten central and eastern European centers.

OBJECTIVE: To test the activity of telithromycin against 1034 Streptococcus pneumoniae isolates from pediatric patients in ten centers from ten central and eastern European countries during 2000-2001, and to compare it with the activities of erythromycin A, azithromycin, clarithromycin, clindamycin, and quinupristin-dalfopristin. METHODS: The minimum inhibitory concentrations (MICs) of telithromycin, erythromycin A, azithromycin, clarithromycin, clindamycin, levofloxacin, quinupristin-dalfopristin and penicillin G were tested by the agar dilution method with incubation in air, and mechanisms of resistance to macrolides and quinolones were investigated. RESULTS: Strains were isolated from sputum, tracheal aspirates, ear, eye, blood, and cerebrospinal fluid. Among S. pneumoniae strains tested, 36% had raised penicillin G MICs (>/= 0.12 mg/L). Susceptibilities were as follows: telithromycin, quinupristin-dalfopristin and levofloxacin, >/= 99%; clindamycin, 83%; and erythromycin A, azithromycin and clarithromycin, 78%. Of 230 (22.3%) erythromycin A-resistant S. pneumoniae strains, 176 (79.6%) had erm(B), 38 (16.1%) had mef(A), and 10 (4.3%) had mutations in 23S ribosomal RNA or in ribosomal protein L4. The rates of drug-resistant S. pneumoniae are high in all centers except Kaunas, Riga, and Prague. CONCLUSION: Telithromycin had low MICs against all strains, irrespective of macrolide, azalide or clindamycin resistance. Ribosomal methylation was the most prevalent resistance mechanism among all resistant strains, except in Sofia, where the prevalence of the efflux mechanism was higher.

Activity of telithromycin compared with seven other agents against 1039 Streptococcus pyogenes pediatric isolates from ten centers in central and eastern Europe.

In total, 1039 pediatric Streptococcus pyogenes isolates from Bulgaria, Croatia, the Czech Republic, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia and Slovenia were studied. All strains were susceptible to penicillin G, levofloxacin, and quinupristin-dalfopristin, 91-100% to telithromycin, and 82-100% to erythromycin, azithromycin, and clarithromycin, and 90-100% to clindamycin. Macrolide resistance occurred mainly in Slovakia (25%), the Czech Republic (17.3%), and Croatia (15.8%). Overall, 9.7% of S. pyogenes isolates were erythromycin resistant due to erm(B)- or erm(A)-encoded methylases (72.3%) or to a mef(A)-encoded efflux pump (25.7%). One strain had alterations of both 23S rRNA (A2058G Escherichia coli numbering) and ribosomal protein L22 (G95D).

Serologic examination of human population in South Moravia (Czechoslovakia) on the presence of antibodies to arboviruses of the Alfavirus, Flavivirus, Turlock groups and Bunyamwera supergroup.

A statistically representative group of human population from the South Moravian region (CSSR) was examined on the presence of antibodies against the following arboviruses: Lednice, Sindbis, tick-borne encephalitis, West Nile, Tahyna and Calovo. The ascertained absence of antibodies to the Lednice virus is an evidence that at present this virus is of no epidemiological importance in the region studied. No antibodies to Sindbis, West Nile and Calovo viruses were demonstrated. 17.8 to 42.0% of antibodies to Tahyna virus were detected in all age groups examined. The total infection rate was 26.0%. Antibodies to the tick-borne encephalitis virus occurred primarily in persons over 40 years. The total infection rate was 5.5%.

Serologic examination of birds from the area of southern Moravia for the presence of antibodies against arboviruses of the groups Alfa, Flavo, Uukuniemi, Turlock and Bunyamwera supergroup. II. Wild living birds.

280 specimens of 29 species of wild living birds from 11 families captured in the endemic area of the virus Lednice in Southern Moravia (CSSR) were investigated by haemagglutination-inhibition test (HIT) on presence of antibodies against 12 arbovirus antigens of the groups Alfa-virus (Western and Eastern Equine Encephalomyelitis, Semliki, Sindbis, Chikungunya), Flavovirus (Tick-Borne Encephalitis, Dengue, West Nile), the Uukuniemi group (Poteplí), the Turlock group (Lednice) and the Bunyamwera supergroup (Tahyna, Calovo). Antibodies were found only against the virus Lednice, merely in water birds--i.e. in Mallard (Anas platyrhynchos)--31.9%, in Grey Lag-Goose (Anser anser)--17.2%, and in one of three Mute Swans (Cygnus olor). In relation to these findings the question of ornithophilia of mosquitoes of Culex modestus species, which are the only probable vectors of Lednice virus as yet, is discussed.

Integration of Emergency Medical Services and Special Weapons and Tactics (SWAT) Teams: The Emergence of the Tactically Trained Medic.

The emphasis of training for paramedics that function in the civilian sector in the United States has focused on the management of blunt trauma. The personal risks they face generally are the result of accidents or public health threats. The management of penetrating trauma under the threat of intentional personal harm is a different matter.Law enforcement agencies have responded to the threat of apprehending heavily armed felons by forming special units highly trained in military-style, small-unit tactics. To provide care in this special environment, and support a special weapons and tactics (SWAT) team in fulfilling its mission, there is a requirment for a unique body of knowledge and special skills. (Prehospital care providers with at least emergency medical technician [EMT] skills and SWAT training will be referred to as tactical medics.).

Radial haemolysis in gel for detection of antibodies to bunyavirus Lednice (Turlock group).

The method of radial haemolysis in gel (RHG) was used for detection of antibodies to Lednice virus. Repeated and comparative experiments proved that the method gave reliable and sufficiently specific standard results. No cross-reactions were detected with sera to other arboviruses. Comparison of antibody titres achieved in RHG with those of haemagglutination inhibition (HIT) and indirect immunofluorescence (IF) tests showed a satisfactory sensitivity, as the antibody titres in RHG and HIT were practically of the same range.

Isolation of Tettnang coronavirus from man?

A virus, identified as Tettnang virus, was isolated from the cerebrospinal fluid (CSF) of an 18 months old child with pharyngitis accompanied by an encephalitic reaction. The isolation of virus was followed by seroconversion. The aetiological role of the virus in the given disease is discussed.

[Maisonneuve fracture.]. / Maisonneuveova zlomenina.

Nineteen patients with acute Maisonneuve fracture of ankle were treated at the Orthopaedic Clinic IPVZ FN Bulovka in 1993-1997. This number represets 5 % of all patients treated acutely for fracturedislocation of ankle. Another 5 patients were managed for poor results of the management of this fracture treated at other Clinic. In all patients surgical therapy was indicated: 14 times - the method of insertion of two parallel transfixation (positioning) screws, 5 times - the method of insertion of 1 screw combined with plaster cast fixation. In patients with the resulting poor outcomes after the fracture, reconstruction was performed in 1 case and in case of ankle fusion 4 times. The follow-up covered 10 patients after acute operation, of which in 7 patients the result was exellent, in 1 patient good and 2 patients evaluate the condition as satifactory. On this basis it may be concluded that surgical therapy in the shortest possible interval after the trauma with the use of 2 transfixation (positioning) screws and fixation of medial melleolus or by suture of deltoid ligament is fully indicated. In case of contrasindication of surgical treatment a high cast has to be applied extending above the knee in the internal rotation of the lower limb. Key words: Maisonneuve fracture, fracture-dislocation of ankle, therapy, diagnosis.

[Chronic tibialis anterior syndrome.]. / Chronický tibialis anterior syndrom.

Chronic tibialis anterior syndrome affects most frequently adolescent sportsmen. It is manifested by pain on the anterior side of the leg and sometimes also by claudications after burdening. The cause is hypertrophy of the m. tibialis anterior which leads to increased subfascial pressure and thus development of the syndrome. The diagnosis is frequently incorrect and the condition is treated as periostitis or enthesopathy. As the cause is increased subfascial pressure after burdening, causal treatment is fasciotomy of the anterior compartment of the leg. The authors present a case of bilateral syndrome in a female canoeist operated at the age of 19 years. Key words: chronic tibialis anterior syndrome, chronic compartment syndrome, compartment syndrome.

[Total endoprosthesis replacement after hip joint arthrodesis]. / Totální endoprotéza po artrodéze kycelního kloubu.

PURPOSE OF THE STUDY: To evaluate mid-term results of conversion of arthrodesis to total hip replacement in terms of X-ray findings and benefits for the patient. MATERIAL: Ten patients who had undergone hip joint arthrodesis were clinically examined and X-rayed and the findings evaluated. The most common indications for arthrodesis were posttraumatic lesions or the sequelae of a dysplastic hip joint, Perthes disease and inflammatory hip arthritis. The average age was 24.6 years (range, 15-37) at the first operation (arthrodesis) and 42.5 years (range, 30-61) at the second operation (hip arthroplasty). The average follow-up was 9.3 years (range, 1-16). Patients with true ankylosis of the hip joint were not included. METHODS: The patients were clinically examined for the range of motion, which was evaluated by Harris hip scores and X-ray findings. RESULTS: All eight patients who underwent total hip replacement due to persistent pain in the lumbosacral region experienced pain relief or its absence. This also applied to the patients whose X-ray films showed signs of spondylarthritis. The Harris hip scores showed that six patients were able to walk to longer distances without any support. No radiographic evidence of acetabular component loosening was found. One patient had to undergo reimplantation of the femoral component because of aseptic loosening. In the early postoperative period, one dislocation of the prosthesis and one sciatic nerve injury resulting in transient paresis of the peroneal nerve were recorded. None of the complications required repeat surgery. All patients reported that they would undergo the procedure again despite an increased risk associated with this procedure. DISCUSSION: Our results are in agreement with similar findings in this field. We did not find an increase in failed hip arthroplasty in older patients. The X-ray findings were very satisfactory, particularly those concerning the acetabular component. Patients who had true ankylosis of the hip joint were not included in the study. The average range of motion achieved in our patients corresponds to that reported in the literature. CONCLUSIONS: Conversion of hip arthrodesis to total hip replacement is not a frequent surgical procedure. It is associated with a higher degree of risk because of changed anatomy due to previous surgical interventions in that region. Motion restoration in the hip joint results in reducing low back pain and, consequently, improving the quality of life. All evaluated patients would be willing to undergo the operation again.