Whole-genome sequencing reveals two prolonged simultaneous outbreaks involving Pseudomonas aeruginosa high-risk strains ST111 and ST235 with resistance to quaternary ammonium compounds.

OBJECTIVE: Water-bearing systems are known as frequent Pseudomonas aeruginosa (PA) outbreak sources. However, many older buildings continue to have sanitary facilities in high-risk departments such as the ICU. We present two simultaneous prolonged multi-drug-resistant (MDR) PA outbreaks detected at the ICU of a pulmonology hospital, which were resolved by whole-genome sequencing (WGS). METHODS: Outbreak management and investigations were initiated in August 2019 after detecting two patients with nosocomial VIM-2-positive MDR PA. The investigations involved weekly patient screenings for four months and extensive environmental sampling for 15 months. All patient and environmental isolates were collected and analysed by WGS. RESULTS: From April to September 2019, we identified 10 patients with nosocomial MDR PA, including five VIM-2-positive strains. VIM-2-positive strains were also detected in nine sink drains, two toilets, and a cleaning bucket. WGS revealed that of 16 VIM-2-positive isolates, 14 were ST111 that carried qacE, or qacEΔ1 genes, whereas 13 isolates clustered (difference of ≤11 alleles by cgMLST). OXA-2 (two toilets), and OXA-2, OXA-74, PER-1 (two patients, three toilets) qacEΔ1-positive ST235 isolates dominated among VIM-2-negative isolates. The remaining seven PA strains were ST17, ST233, ST273, ST309 and ST446. Outbreak containment was achieved by replacing U-bends, and cleaning buckets, and switching from quaternary ammonium compounds (QUATs) to oxygen-releasing disinfectant products. CONCLUSION: Comprehension and management of two simultaneous MDR PA outbreaks involving the high-risk strains ST111 and ST235 were facilitated by precise control due to identification of different outbreak sources per strain, and by the in-silico detection of high-level QUATs resistance in all isolates.

[Pneumocystis jirovecii pneumonia in patients with autoimmune diseases]. / Pneumocystis-jirovecii-Pneumonie bei Patienten mit Autoimmunerkrankungen.

Pneumocystis jirovecii pneumonia plays an increasing role in patients with autoimmune disorders, due to more intensive immunosuppressive therapy. Humans seem to be the most important pathogen reservoir. Diseases are probably caused by airborne new infections. Cough, subfebrile temperature and dyspnea on exertion are the leading symptoms. In addition to imaging, in particular high-resolution computed tomography, pathogen detection by staining methods or molecular genetic methods plays the decisive role. Trimethoprim and sulfamethoxazole (TMP-SMX) is the most important medication for treatment. Adjuvant corticosteroid treatment is sometimes recommended, but evidence for benefits in patients with rheumatological disorders is not well documented. For patients on high-dose systemic corticosteroid treatment or intensive combined immunosuppression, primary prophylaxis is recommended by many experts. TMP-SMX remains the first-choice preventive treatment in these patients.

Cognitive functions and glycemic control in children and adolescents with type 1 diabetes.

BACKGROUND: The relationship between metabolic control and cognitive function in adolescents with type 1 diabetes (DM type 1) is not clear. We compared the quality of glycemic control (GC) and cognitive measures in adolescents with DM type 1 to find out if the quality of diabetes management is related to cognitive impairment. METHOD: We assessed executive functions (EFs) and other neuropsychological and psychosocial variables in 70 adolescent patients with DM type 1 and 20 age-matched controls. Patients were divided into two groups according to their last hemoglobin A1c (HbA1c): acceptable (HbA1c 5.9-8.0%, mean 6.9%, 36 patients, mean age 14 years) and non-optimal (HbA1c 8.2-11.6%, mean 9.3%, 34 patients, mean age 15.6 years). RESULTS: We found impaired EFs, mainly problems of concept formation (p=0.038), cognitive flexibility (p=0.011) and anticipation (p=0.000), in the patients with DM type 1. Both groups did not differ in intelligence, most assessed EFs and adjustment to chronic illness (Youth Self-Report; YSR). Younger patients (<15 years) were cognitively less flexible. GC was worse in older patients and in patients with longer duration of the disease. We also found significant differences between patients with diabetes and controls concerning somatic complaints, internalizing problems (Child Behavior Checklist; CBCL) and social activity (CBCL and YSR). CONCLUSIONS: DM type 1 is associated with cognitive deficits in adolescents independent of the quality of metabolic control and the duration of the disease. These deficits are probably related to the disease, especially in patients with early-onset diabetes.

CpG-oligodeoxynucleotides stimulate immunoglobulin A secretion in intestinal mucosal B cells.

Bacterial DNA motifs (such as CpG-oligodeoxynucleotides: CpG-ODN) induce innate immune responses via binding to Toll-like-receptor-9 (TLR-9). In murine intestinal mucosa treatment with CpG-ODN worsens chronic intestinal inflammation, whereas it prevents or ameliorates colitis when given in a prophylactic setting. In tonsils B cells have been reported to express TLR-9, especially after activation. Whether B cells in the human intestinal mucosa also express TLR-9 and whether their function can be influenced by CpG-ODN is, so far, unknown. Mucosal B cells were isolated according to a new protocol from surgical specimens of patients with inflammatory bowel disease and from controls by collagenase digestion followed by magnetic cell sorting using anti-CD19 antibody armed magnetic beads. TLR-9 mRNA and protein expression were quantified by real-time polymerase chain reaction (PCR) and Western blot, respectively. Immunoglobulin A (IgA) secretion was measured by enzyme-linked immunosorbent assay after stimulation of isolated B cells with CpG-ODN, control GpC-ODN or lipopolysaccharide (LPS). Flow cytometric analysis of the isolated lamina propria mononuclear cells showed a purification of 73% (+/-22%) CD19(+) cells. By quantitative reverse transcription-PCR and by Western blot TLR-9 expression in this cell population was evident. IgA secretion was increased significantly by CpG-ODN incubation compared with GpC-ODN and LPS. Compared with unstimulated controls, CpG-ODN up-regulated IgA secretion to 139% (+/-21%). These data demonstrate that CD19(+) mucosal B cells express TLR-9 and secrete increased levels of IgA upon stimulation with CpG-ODN, indicating an additional link between adaptive and innate intestinal immune responses.

Self-injurious behavior in adolescent girls. Association with psychopathology and neuropsychological functions.

BACKGROUND: Self-injurious behavior (SIB) is increasingly popular in psychically ill adolescents, especially in girls with posttraumatic stress (PTSD) and personality disorders. Adolescents with SIB frequently exhibit neurofunctional and psychopathological deficits. We speculated that specific neuropsychological deficits and temperamental factors could predispose patients to SIB and prospectively explored adolescent psychiatric patients with and without SIB in order to find out differences in psychopathology, and neuropsychological or temperamental factors. SAMPLING AND METHODS: Ninety-nine psychically ill adolescent girls with SIB, aged 12-19 years and treated at our clinic, were prospectively recruited during a period of 5.5 years (1999-2005). The clinical (ICD-10) diagnoses were mainly substance abuse, eating disorders, depression, PTSD and personality disorders. The control group was also prospectively recruited during the same period and consisted of 77 girls with similar diagnoses and ages but no SIB. All patients were subjected to the same selection of clinical and neuropsychological tests, mainly self-rating questionnaires and tests evaluating executive functions. RESULTS: Adolescent girls with psychiatric disease and SIB were more severely traumatized and depressed. They reported severe emotional and behavioral problems and deficits of self-regulation. In addition, their parents more frequently had psychiatric problems. Temperament, intelligence, investigated executive functions and presence of dissociative symptoms were not different in patients with and without SIB. CONCLUSIONS: We could not verify our primary hypothesis that SIB is related to specific neuropsychological deficits or temperamental factors. SIB was associated with traumatic experience, depression, problems of self-regulation and parental psychiatric disease. The prevention of SIB should therefore focus on improving affect regulation, the management of emotional distress and problem-solving strategies.

High proportion of large genomic deletions and a genotype phenotype update in 80 unrelated families with juvenile polyposis syndrome.

BACKGROUND: In patients with juvenile polyposis syndrome (JPS) the frequency of large genomic deletions in the SMAD4 and BMPR1A genes was unknown. METHODS: Mutation and phenotype analysis was used in 80 unrelated patients of whom 65 met the clinical criteria for JPS (typical JPS) and 15 were suspected to have JPS. RESULTS: By direct sequencing of the two genes, point mutations were identified in 30 patients (46% of typical JPS). Using MLPA, large genomic deletions were found in 14% of all patients with typical JPS (six deletions in SMAD4 and three deletions in BMPR1A). Mutation analysis of the PTEN gene in the remaining 41 mutation negative cases uncovered a point mutation in two patients (5%). SMAD4 mutation carriers had a significantly higher frequency of gastric polyposis (73%) than did patients with BMPR1A mutations (8%) (p<0.001); all seven cases of gastric cancer occurred in families with SMAD4 mutations. SMAD4 mutation carriers with gastric polyps were significantly older at gastroscopy than those without (p<0.001). In 22% of the 23 unrelated SMAD4 mutation carriers, hereditary hemorrhagic telangiectasia (HHT) was also diagnosed clinically. The documented histologic findings encompassed a wide distribution of different polyp types, comparable with that described in hereditary mixed polyposis syndromes (HMPS). CONCLUSIONS: Screening for large deletions raised the mutation detection rate to 60% in the 65 patients with typical JPS. A strong genotype-phenotype correlation for gastric polyposis, gastric cancer, and HHT was identified, which should have implications for counselling and surveillance. Histopathological results in hamartomatous polyposis syndromes must be critically interpreted.

[Chronic anaemia in a patient with hereditary haemorrhagic telangiectasia and juvenile gastric polyposis]. / Chronische Anämie bei hereditärer hämorrhagischer Teleangiektasie und juveniler Polyposis des Magens.

HISTORY: A 52-year-old woman with chronic anaemia presented with recurrent epistaxis, telangiectasias and haemangiomas, suggesting the presence of hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber disease). Moreover, previous investigations had also shown multiple polyps of the stomach. INVESTIGATIONS: A severe microcytic iron deficiency anaemia in combination with hepatic haemangiomas and duodenal angio-dysplasia were detected. Gastrointestinal endoscopy revealed multiple juvenile polyps in the gastric fundus and body, indicating the diagnosis of hereditary haemorrhagic telangiectasia in combination with juvenile polyposis. THERAPY AND COURSE: A gastrectomy was performed because of recurrent gastrointestinal bleeding and the malignant potential of juvenile gastric polyposis. Histopathology confirmed the diagnosis and did not reveal any malignancy. CONCLUSION: The association of hereditary haemorrhagic telangiectasia and juvenile polyposis, as seen in this patient, has been reported repeatedly. A diagnosis of one of the described entities should initiate the screening for evidence of the other one to prevent (life-threatening) complications.

[Effects of contemporaneous control of DRG-relevant coding by physicians]. / Effekte des ärztlichen Controllings auf die DRG-gerechte Diagnosenverschlüsselung.

OBJECTIVE: In a prospective study we analysed the quality of ICD-coding in clinical everyday life of a department for internal medicine. METHODS: A skilled intern--the so-called DRG assistant--was temporarily released from clinical work. Over nine weeks he had to control all diagnoses contemporaneously that were ICD-coded by his colleagues on admission and discharge of their patients. The DRG-assistant had to ask for missing or correct implausible diagnoses, or inappropriate ICD-coding and with it also train his colleagues in appropriate coding. The effects of the DRG-assistant's correction of coding, on DRG-consistent grouping and on the potential financial loss or benefit generated by his work were recorded. After stoppage of this control in a subsequent phase of the study the effect of the absence of the DRG-assistant, the absence of reminders and coding control and the changes of the clinic's revenue were determined. RESULTS: Corrections of ICD-coding by the DRG-assistant alone caused a remarkable increase in case-mix-index (CMI). CMI's mean value increased from 1.76 to 1.84 and the clinic's revenue increased by 180 Euro per patient (a total of about 80,000 Euro in nine weeks). After the end of the control, the case-mix-index dropped within three weeks down to 1.14, corresponding with a potential loss of 1200 Euro per patient (assuming that patients' morbidity was the same over the time of the study). Coding corrections could not improve CMI in this situation. CONCLUSION: Contemporaneous control of ICD-coding by physicians seems to be essential in DRG based accounting.

Pericarditis as primary manifestation of Mycobacterium bovis SSP. caprae infection.

A 76-year-old white male presented with progressive malaise, weight loss and dyspnea at rest. Echocardiography revealed a circular pericardial effusion and global hypokinesia. Pericardiocentesis showed a purulent exudate and microbiologic examination revealed Mycobacterium bovis fully sensitive to isoniazid, streptomycin, ethambutol, rifampin, and pyrazinamide. By spoligotyping the isolate could be further differentiated to M. bovis ssp. caprae. Antimycobacterial therapy was initiated but 3 weeks later the patient's circulation and renal function deteriorated and he died with clinical signs of sepsis despite intensive care treatment. Pericarditis is a rare manifestation of tuberculosis and can be fatal even when diagnosed and treated appropriately. In low incidence countries diagnosis is often delayed and even overlooked.

Screening cDNA expression libraries in lambda gt11 with a T cell hybridoma.

A T cell hybridoma specific for a protein of Plasmodium chabaudi chabaudi has been used to test a system for direct T cell screening of a cDNA library of P. chabaudi in the phage lambda gt11. The technique is based upon the rapid separation of the recombinant beta-galactosidase fusion protein from the bacterial mixtures using polystyrene beads coated with anti-beta-galactosidase antibodies. These coated beads are cultured with antigen-presenting cells and the T cell hybridoma. The technique is sufficiently sensitive to pick up the products of one recombinant phage in a pool of 1000-10,000 other phages. Individual plaques or clones of recombinant phage can be selected after testing of sequential dilutions of pools containing positive recombinant phages. This technique will be generally applicable and should be useful for the identification of important T cell peptides in infectious diseases.