Prevalence and characterization of extended-spectrum beta-lactamases producing Enterobacteriaceae in healthy children and associated risk factors.

BACKGROUND: Community acquired infections due to extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) had been increased. The fecal flora of children in the community represents a huge potential reservoir for ESBLs which are located on highly transmissible plasmids. This study examined the prevalence of ESBL-PE fecal carriage, antimicrobial susceptibility pattern, possible risk factors, and characterized the genes encoding these ESBL enzymes in Lebanese children community. METHODS: A total of 125 rectal swabs were taken from healthy children aged from 1 to 5 years. Detection of ESBLs was carried out using combination-disc method test and multiplex PCR. A questionnaire concerning child's lifestyle and risk factors for ESBL carriage was illustrated. RESULTS: Thirty-one of 125 participants (24.8 %) carried ESBL-PE. Regular consumption of meat, and chicken were significantly associated with high carriage rate of ESBL-PE, while dairy products (milk, yogurt, cheese) association was non-significant. Intimate hygiene habits were found also affecting the carriage rate. Multiple bla genes were the most common, 48.4 % (15/31) of ESBL-PE carried both bla CTX-M and bla TEM, and 22.6 % (7/31) carried bla CTX-M, bla SHV, and bla TEM, 29 % (9) carried bla CTX-M only. Concerning CTX-M-types, CTX-M-9 was the most predominant (24/31) and mostly in combination with CTX-M-15 type. CONCLUSION: High rate of colonization in healthy children with ESBL-PE was observed, regular consumption of dietary products from animal source (meat or chicken) were associated with this colonization in the community in non-hospitalized children. To our best knowledge it is the first study about regular consumption of dairy product as a risk factor for ESBL-PE community carriage, the first data about the carriage rate of ESBL-PE in community children in Lebanon and Middle East, and for the wide dissemination of CTX-M-9 type in this population.

Pelvic lymph node dissection for nodal oligometastatic prostate cancer detected by 68Ga-PSMA-positron emission tomography/computerized tomography.

BACKGROUND: The first evaluation of pelvic extended lymph node dissection (pLND) in oligometastatic prostate cancer (PCa) detected by (68)Ga-PSMA PET/CT. METHODS: Retrospective analysis of 35 PCa patients underwent (68)Ga-PSMA PET/CT affected by biochemical recurrence (BCR) after curative treatment (n = 23) or before primary therapy of high-risk PCa (n = 12). We performed pLND associated with pathologic imaging in 17 men with nodal oligometastatic PCa. RESULTS: Indicative lesions for PCa in PET/CT were detected in 91.4% (32 of 35) of patients. Nodal, bone, visceral (pulmonary), and within the prostate suspected disease were detected in 72% (23 of 32), 16% (5 of 32), 6% (2 of 32), and 47% (15 of 32) of patients, respectively. Median serum PSA in patients with pathological radiotracer uptake in recurrent and high-risk PCa patients was 2.9 ng/ml (range 0.18-30) and 19.5 ng/ml (range 6-90), respectively. The median number of removed lymph nodes with pLND in recurrent and high-risk PCa was 10 (range 4-17) and 12 (range 8-29) per patient and the median number of positive lymph nodes was 1 (range 1-2) and 3 (2-3) per patient, respectively. In total, two false positive and one false-negative lymph node were found. Diagnostic accuracies per nodal lesion in total of 213 removed nodes: sensitivity, 94%; specificity, 99%; positive predictive value (PPV), 89%, and negative predictive value (NPV), 99.5%. After pLND, 53% (9 of 17) of patients received androgen deprivation therapy and/or radiation therapy and hormonal therapy, while 47% (8 of 17) of patients remained free of any post-surgery therapy. Follow-up PSA remained less than 0.2 ng/ml in 82% (14 of 17) of patients. After pLND, immediate BCR (PSA never measured less than 0.2 ng/ml) in 18% (3 of 17) of patients was recorded. CONCLUSIONS: This represents the first study of pLND in the setting of nodal oligometastatic PCa detected by (68)Ga-PSMA PET/CT. The use of (68)Ga-PSMA PET/CT could be to improve the accuracy for the detection of nodal micrometastases. These promising findings need validation in larger studies.

Seat belt syndrome, a new pattern of injury in developing countries. Case report and review of literature*.

BACKGROUND: Classically, seat belt syndrome appears with seat belt marks on the body, bowel perforations, and lumbar spine fractures. However the symptoms are not limited to those previously mentioned, and organ damage can vary greatly. CASE REPORT: A 34-year-old female passenger, was admitted to our hospital after a motor vehicle crash. The physical examination revealed an ecchymosis across the chest, a transverse abdominal abrasion, and fractures of the left humerus, the left femur, and the right tibia. The laparotomy revealed multiple jejunal perforations, such as a seromuscular tear of the hepatic and splenic flexure of the colon and a defect of the abdominal wall. The primary suture of jejunum, resection with end to end anastomosis of jejunum, suture of a seromuscular tear of the colon, and primary repair of the abdominal wall defect procedures were performed. On the fifth day, the patient underwent osteosynthesis. CONCLUSION: The abdominal pain in the polytraumatized patients with seat belt syndrome may be dominated by the pain caused by extra-abdominal injuries. The presence of a seat belt mark across the abdomen increases suspicion of abdominal injuries.

Adaptation of the school health index to assess the healthy school environment in Jordan.

When the Jordan Ministry of Education planned workshops to raise teachers' awareness of the health environment in schools in underdeveloped governorates, a pre-post intervention study assessed the impact of these workshops in changing teachers' perceptions. A total of 193 teachers completed the self-administered Centers for Disease Control and Prevention school health index (SHI) for elementary schools, adapted for this setting using 6 of the 8 original modules. After the workshops, teachers' mean scores on all modules improved significantly, from 49.5% to 55.9% for health and safety/environment policies; 44.2% to 56.5% for health education; 40.3% to 52.9% for physical education; 51.3% to 59.2% for nutrition services; 62.5% to 73.8% for health services; and 55.2% to 68.3% for family/community involvement. The SHI model is implementable in a developing country

Staphylococcus aureus nasal carriage rate and associated risk factors in individuals in the community.

The increasing prevalence of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) strains together with their disease impact on hospital patients and individuals in the community has posed a major challenge to healthcare workers. This study examined the prevalence of S. aureus nasal carriage, antimicrobial susceptibility patterns, and possible risk factors in the community. Of 500 studied subjects (aged from 6 to 65 years) in Lebanon, the overall S. aureus nasal carriage rate was 38.4%, the highest (57.1%) being in children aged 6-10 years. Only eight individuals (1.6%) were carriers of MRSA. Risk factors for S. aureus nasal colonization were male gender, young age, contact with healthcare workers, use of needle injections, and having asthma. A significant decrease in colonization rate was associated with nasal wash with water, use of nasal sprays, and the presence of acne. These findings may assist in better understanding of control measures to decrease nasal colonization with S. aureus in Lebanon and elsewhere.

Alterations in androgen deprivation enhanced prostate-specific membrane antigen (PSMA) expression in prostate cancer cells as a target for diagnostics and therapy.

BACKGROUND: Prostate-specific membrane antigen (PSMA) is a promising target for diagnostics and therapy of prostate carcinoma (PCa). Based on the hypothesis that PSMA expression can be modulated by variations in androgen deprivation therapy (ADT), we investigated the binding of a PSMA-directed radiopharmaceutical in vitro in order to get an insight of the interactions between altered premedication and PSMA expression before repetitive PSMA-directed PET/CT for therapy response and targeted therapy implementation. METHODS: The human castration-resistant PCa cell line VCaP (CRPC) was treated with either 1 nmol/L testosterone (T) over 20 passages yielding the androgen-sensitive cell line (revCRPC) or with 5 µmol/L abiraterone acetate (AA) generating the abiraterone-tolerant subtype CRPCAA. In these cell lines, T and AA were varied by either supply or withdrawal of T and AA. PSMA expression of the three cell culture models was detected by Western blot and immunohistochemical staining. For quantitative measurement of tracer uptake, 0.3 nmol/L (68)Ga-labelled PSMA-HBED-CC peptide (100-300 kBq/ml) was added to different treated parallel cultures (n = 9 each). Time-dependent uptake per 10(6) cells of each culture was calculated and evaluated. PSMA mRNA expression was investigated by qPCR. RESULTS: PSMA expression increased dependently on intensified ADT in all three basic cell lines. (68)Ga-PSMA-HBED-CC uptake almost doubled during 3 h in all cell lines (p < 0.01). Compared to the basic cells, pre-incubation with abiraterone for 48 h resulted in a significant increased uptake in CRPC (p < 0.001). In revCRPC, 48-h AA pre-incubation resulted in an eightfold higher uptake after 3 h (p < 0.001). Additional withdrawal of external testosterone increased the uptake up to tenfold (p < 0.01). The increase of PSMA expression upon ADT and AA treatments was confirmed by qPCR and Western blot data. Furthermore, in CRPCAA, 48-h AA withdrawal increased the uptake up to fivefold (p < 0.01). CONCLUSIONS: The investigated three PCa cell culture subtypes represent a serial preclinical model of androgen deprivation therapy as a proxy for clinical situations with differing basal PSMA expression. The uptake of PSMA-binding tracers could be stimulated by therapeutic effective short-term variation in premedication in all stages of ADT response. These complex interactions have to be considered in the interpretation of diagnostic imaging using PSMA ligands as well as in the optimal timing of PSMA-based therapies.

Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V.

Three hundred six children with probable Group A beta-hemolytic streptococcal pharyngitis were enrolled in a randomized double blind trial to compare the effects of immediate vs. delayed treatment with oral penicillin V. Among the 229 culture-positive patients, 111 were randomly assigned to receive penicillin V immediately and 118 to receive a placebo for 48 to 52 hours followed by penicillin V. Patients were evaluated clinically for 48 to 52 hours following initiation of treatment. The Streptozyme test was used to measure acute to convalescent antibody titer. Both regimens resulted in a greater than 92% cure rate. Early treatment was associated with significantly fewer and milder signs and symptoms on Day 3 and a significantly lower rise in the antibody titer. On the other hand we found 8 (7%) relapses and 18 (16%) early and 14 (13%) late recurrences in this group; all were significantly higher than the corresponding numbers of 2 (2%), 6 (5%) and 4 (3%), respectively, in the late treatment group. This study shows the beneficial effect of early treatment with penicillin V on the clinical course of Group A beta-hemolytic streptococcal pharyngitis. This study also shows that delayed penicillin treatment may be associated with a lower incidence of subsequent Group A beta-hemolytic streptococcal pharyngitis.

Mortality pattern of infants and young children in rural Amman.

PIP: A cross-sectional study describing the clinical; anthropometric; hematological; morbidity; and mortality pattern of 3734 Jordanian infants and young children in rural Ammen was conducted. Waterlow's public health classification was used. Children of the main sample were grouped into A (well nourished) and B (malnourished). Total number of pregnancies the mothers in this study had was 23,545; total number of abortions and stillbirths the mothers had was 2711, and total number of live births was 20,834. Total number of siblings who died in different age groups was 1981. Calculated neonatal mortality rate per 1000 liveborn was 26; postneonatal was 52; infant mortality rate was 78; 1 to 4 years was 11.5 and for age 4 years, the rate was 5/1000 livebirths. No significant differences were observed between Groups A and B except at the 1-4 year age group, which has a mortality rate twice as high in Group B as in Group A, a significant difference at the 1% level. Half of the deaths in the 1st year occurred in the 1st month of life. The socioeconomic and health status of Jordan is reflected in its mortality pattern. The infant mortality rate in this study, 78/1000 is 4.4 times as great as it is in advanced countries. Cook mentioned 3 factors which contribute to the vulnerability of infants to death: 1) relatively high nutritional requirements; 2) transition from breastfeeding to normal family diet; and 3) lack of their own antibodies to infectious organisms. Comparison of mortality rates with other countries were presented.^ieng

Cryptosporidium. A cause of gastroenteritis in preschool children in Jordan.

In this case-control study, we investigated the role of Cryptosporidium in gastroenteritis in children < 6 years old. Six hundred fresh stool specimens were examined for various pathogenic parasites, bacteria, and rotaviruses. Wet-mount preparations, formaline-ether concentrations, and Sheather's floatation techniques were used to recover the parasite oocysts. Permanent stained slides using acid-fast stain and trichrome stains were prepared. Of 300 children with gastroenteritis symptoms, 20 (6.7%) had Cryptosporidium oocysts; seven of the 20 had concomitant infections so they were excluded from the counts. This infection rate is significantly different (Z = 2; p < 0.05) from that found in the control group (1.7%) of children who reported no symptoms. The most frequent symptoms reported beside diarrhea were abdominal pain, cramps, anorexia, nausea, vomiting, and fatigue. Contaminated drinking water is suspected to be the source of infection; other possible factors are discussed.

Rotavirus-associated diarrhoea in children in a refugee camp in Jordan.

Studies on the rotavirus-associated acute diarrhoeal illness in Jordanian children are non-existent. The present case-control study was conducted to investigate the prevalence of rotavirus diarrhoea among children aged less than 5 years, attending the United Nations Refugee World Aid Clinic in northern Jordan. The potential environmental and behavioural risk factors contributing to the infection were also studied. Using the ELISA technique rotavirus antigens were detected in the stool samples of 35% of the 220 cases of gastroenteritis and in 3% of the control group. The control subjects were matched for age and sex with the cases. The overall prevalence was significantly higher (62%) in children aged less than 24 months [OR = 2.4, 95% CI (1.1-5.1)] than those in the older age groups. Severe cases of diarrhoea were rare. Diarrhoea due to rotavirus was more prevalent during the summer months (June-August). Risk factors for acute diarrhoea in these children are related to the infant feeding practices of using unboiled tap water to prepare the formula milk, and the low educational level of the mothers.

Growth patterns of jordanian children: a national study.

This study examined the growth patterns of Jordanian children below three years of age in comparison with the NCHS reference population. Weight and length measurements of 1224 boys, and 1120 girls were obtained from a national multipurpose study of Jordanian preschool children carried out in 1984. The study results showed that children of both sexes grew at Gentiles that were close and parallel to the NCHS in the first quarter of the first year. However, both weight and length Gentiles departed from the NCHS counterparts later on with length showing marked differences from the reference. The differences observed between the local and the NCHS reference population suggest that the NCHS should be used as a target for planning and evaluation of' intervention programs at a national level while the need for the local standards to assess individual cases remains a necessity.

Distribution of adult lactase phenotypes in Bedouins and in urban and agricultural populations of Jordan.

Lactose tolerance tests with breath hydrogen determination identified 39 lactose malabsorbers among 162 Jordanian Bedouins (24%), and 111 lactose malabsorbers among 148 subjects from the urban/agricultural zone of western Jordan and Palestine (75%). This highly significant difference supports the hypothesis that milk dependence in nomadic desert populations resulted in selective pressures in favour of the lactase persistence gene. Within the urban/agricultural zone which extends from the desert border in Jordan to the Mediterranean shore, a significant increase in the frequency of lactose malabsorbers (and hypolactasia gene frequencies) from east to west was observed. The suggested genetic cline is problably due to migration from the desert populations to the agricultural zone.

Serum ferritin in evaluation of iron status in children.

The value of serum ferritin in assessing iron status was studied in 192 preschool age children between the ages of 3 and 60 months. Children were considered to have iron deficiency if the transferrin saturation was less than 16% and the peripheral smear revealed microcytosis and hypochromia. Anemia was present when hemoglobin level was 10.5 g/dl. According to this criteria, 46% of children screened had either iron deficiency (11.5%) or iron deficiency anemia (34.4%). Mean serum ferritin for the iron deficiency anemia group was 39.1 ng/mg as compared to 41.7 ng/ml for the iron deficiency group and 84.7 ng/ml for the normal group. Even though the serum ferritin level was lower in the iron deficiency group, the difference in the means did not reach statistical significance. Furthermore, only 30% of children who had either iron deficiency or iron deficiency anemia had serum ferritin level of less than 12 ng/ml, the level considered diagnostic for iron deficiency. It can be concluded that serum ferritin cannot be used alone for iron status determination. Multiple parameters will make the assessment more reliable.

The duration for which exclusive breast-feeding is adequate. A study in Jordan.

The object of this study was to determine the length of time for which exclusive breast-feeding supported adequate growth in a cohort of infants from families in and around Amman, Jordan. The infants were described as "faltering" if their incremental growth over 4 weeks fell below -2 standard deviations of the increments reported by Fomon in the USA. The infants were examined every 2 weeks until they faltered, or, without faltering, were started on supplementary foods. In general, up to the time of faltering, growth was satisfactory by international standards. The median time of faltering was 6 months. The results support the view that, at least in this relatively well-nourished community, exclusive breast-feeding is satisfactory for 4-6 months. However, further examination is needed of the risk factors that lead to early faltering in some breast-fed children.

Effectiveness of iron therapy on breath-holding spells.

OBJECTIVE: The objective of this study is to investigate the effect of iron therapy on breath-holding spells (BHS). METHODOLOGY: Sixty-seven children with BHS were enrolled in a clinical trial to evaluate the effect of iron therapy on BHS. At the beginning of therapy, the clinical, laboratory, and demographic characteristics of the patients in the treatment group (n = 33) and placebo group (n = 34) were comparable. Patients were assessed weekly for the first 8 weeks and then every 2 weeks for the next 8 weeks. Response to therapy was assessed by the change in the frequency of BHS. RESULTS: Children treated with iron showed significant reduction in the frequency of BHS (88%) compared with the frequency (6%) in the placebo group. As expected, the treated group showed a significant improvement of a number of blood indexes compared with the placebo group. Baseline mean levels of hemoglobin and total iron binding capacity were predictive of a favorable response to iron treatment. CONCLUSION: Results of this study indicate that iron therapy is effective in the treatment of BHS and that iron-deficient children seem to be more likely to benefit from such therapy. Response to iron therapy was strongly correlated with improvement in blood indexes.