Hospital discharge in patients at risk of surgical site infection: antimicrobial stewardship at Ferrara University Hospital, Italy.

INTRODUCTION: The appropriate use of antibiotics is a global priority in order to avoid antibiotic resistance. Up to 50% of antibiotics usage in hospital is inappropriate (e.g. prolonged surgical prophylaxis, "defensive medicine" approach). In 2015, at the Ferrara University Hospital, an antimicrobial stewardship intervention to reduce antimicrobial prescription at the time of hospital discharge in patients at risk of surgical site infection was implemented. This programme included: update meetings for health professionals, focused meetings for critical wards, reviews of some surgical prophylaxis protocols, recommendations to reduce broad-spectrum antimicrobials use, and planning of an audit. The purpose of this study has been to evaluate the effect of this antimicrobial stewardship programme. METHODS: To evaluate the effect of this intervention, a study has been carried out including inpatients in surveillance for surgical site infection who had surgery during the last quarter of 2014 (pre-intervention group; 461 patients) and of 2015 (post-intervention group; 532 patients). RESULTS: The proportion of patients with prescription of at least one antimicrobial at discharge decreased from 33% to 24.4% (p = 0.002). The most prescribed categories of antimicrobials in both groups were the combination of penicillins with beta-lactamase inhibitors (with prescription rate reduced from 21.9% to 18%; p = 0.13) and fluoroquinolones (from 8.2% to 3.2%; p < 0.001). CONCLUSIONS: This statistically significant reduction in antimicrobial prescription after the intervention was registered without a change in surgical site infections rate (from 3.5% to 3.2%; p = 0.08). Therefore, this intervention was effective in reducing the antimicrobial prescription at discharge, without affecting patients' safety.

Estrogen receptor signaling in the ferutinin-induced osteoblastic differentiation of human amniotic fluid stem cells.

AIMS: Ferutinin is a diaucane sesquiterpene with a high estrogenic activity. Since ferutinin is able to enhance osteoblastic differentiation of human amniotic fluid stem cells (hAFSCs), the aim of this study was to evaluate the role of the estrogen receptors α (ERα) and G-protein coupled receptor 30 (GPR30) in ferutinin-mediated osteoblastic differentiation. Moreover, it was investigated if MEK/ERK and PI3K/Akt signaling pathways are involved in ferutinin-induced effects. MAIN METHODS: hAFSCs were cultured in a standard medium or in an osteoblastic medium for 14 or 21days and ferutinin was added at 10-8M. Immunofluorescence techniques and Western-blot 21analysis were used to study estrogen receptors and signaling pathways. KEY FINDINGS: In both undifferentiated and differentiated hAFSCs we identified ERα and GPR30 with a nuclear or cytoplasmatic localization, respectively. The presence of ferutinin in the osteoblastic medium leads to an increase in ERα expression. To dissect the role of estrogen receptors, MPP and G15 were used to selectively block ERα and GPR30, respectively. Notably, ferutinin enhanced osteoblastic differentiation in cells challenged with G15. Ferutinin was able to increase ERK and Akt phosphorylations with a different timing activation. These phosphorylations were antagonized by PD0325901, a MEK inhibitor, and wortmannin, a PI3K inhibitor. Both MPP and G15 inhibited the ferutinin-induced MEK/ERK and PI3K/Akt pathway activations. In the osteoblastic condition, PD0325901, but not wortmannin, reduced the expression of OPN and RUNX-2, whereas ferutinin abrogated the down-modulation triggered by PD0325901. SIGNIFICANCE: PI3K/Akt pathways seems to mediate the enhancement of hAFSCs osteoblastic differentiation triggered by ferutinin through ERα.

Enrichment in c-Kit improved differentiation potential of amniotic membrane progenitor/stem cells.

INTRODUCTION: Human term placenta has attracted increasing attention as an alternative source of stem cells for regenerative medicine since it is accessible without ethical objections. The amniotic membrane (AM) contains at least two stem cell types from different embryological origins: ectodermal amniotic epithelial stem cells, and mesodermal mesenchymal stromal cells. Among the second group we studied the characteristics of amniotic mesenchymal cells (AMC) versus the ones enriched for the commonly used surface marker c-Kit (amniotic progenitor/stem cells-ASC), a stem cell factor receptor with crucial functions in a variety of biological systems and presents in early progenitors of different origin, as been already demonstrated in the enriched chorionic stem cells. METHODS: After isolation, cells from the amniotic membranes (amniotic cells-AC) were selected for c-Kit (ASC) and compared these cells with c-Kit unselected (AMC), evaluating the expression of other stem cell markers (Oct-4, Tra-1-81, SSEA-4), CD271 and Slug. RESULTS: Immunofluorescence analysis showed that ASC cells exhibited greater stem cell marker expression and included more CD271 and Slug positive cells. This was consistent with the interpretation that c-Kit enriched AC show greater stemness capacity compared to c-Kit unselected AMC. DISCUSSION: AMC and ASC can both differentiate into various cell types including adipogenic, osteogenic, chondrogenic, neurogenic and hepatic lineages, but the enrichment in c-Kit improved stemness and differentiation potential of ASC.

Enrichment in c-Kit+ enhances mesodermal and neural differentiation of human chorionic placental cells.

OBJECTIVE: Human term placenta (HTP) has attracted increasing attention as an alternative source of stem cells for regenerative medicine since the amniochorionic membrane harbors stem cells populations that are easily accessible, abundantly available without ethical objections. In the chorionic side of HTP we found a progenitor perivascular "niche" in which rare cells co-express Oct-4 and c-Kit. We investigated the stem cell characteristics and differentiation potential of a chorionic derived population enriched in c-Kit(+) cells and compared this to the unenriched population. STUDY DESIGN: Cells, isolated from the chorion of HTP, were expanded and enriched in c-Kit(+) cells (Chorionic Stem Cells-CSC). Histological staining, immunofluorescence, Western blot and flow cytometry were used to verify the stem cells characteristics of the populations and to compare the differentiation capability towards mesodermal and neural lineages in vitro. RESULTS: The expression of the pluripotent marker Oct-4 was greater in the CSCs compared to the unselected cells (Chorionic Cell-CC) but both Oct-4 and c-Kit expression decreased during passages. After differentiation, CSC displayed stronger chondrogenic and osteogenic potential and a greater adipogenic forming capacity compared to unselected ones. CSC differentiated better into immature oligodendrocytes while CC showed a neuronal progenitor differentiation potential. Moreover, both populations were able to differentiate in hepatogenic lineage. CONCLUSION: CSC display improved Oct-4 expression and a high differentiation potential into mesodermal lineages and oligodendrocytes.

Ferutinin promotes proliferation and osteoblastic differentiation in human amniotic fluid and dental pulp stem cells.

AIMS: The phytoestrogen Ferutinin plays an important role in prevention of osteoporosis caused by ovariectomy-induced estrogen deficiency in rats, but there is no evidence of its effect on osteoblastic differentiation in vitro. In this study we investigated the effect of Ferutinin on proliferation and osteoblastic differentiation of two different human stem cells populations, one derived from the amniotic fluid (AFSCs) and the other from the dental pulp (DPSCs). MAIN METHODS: AFSCs and DPSCs were cultured in a differentiation medium for 14 or 21days with or without the addition of Ferutinin at a concentration ranging from 10(-11) to 10(-4)M. 17ß-Estradiol was used as a positive drug at 10(-8)M. Cell proliferation and expression of specific osteoblast phenotype markers were analyzed. KEY FINDINGS: MTT assay revealed that Ferutinin, at concentrations of 10(-8) and 10(-9)M, enhanced proliferation of both AFSCs and DPSCs after 72h of exposure. Moreover, in both stem cell populations, Ferutinin treatment induced greater expression of the osteoblast phenotype markers osteocalcin (OCN), osteopontin (OPN), collagen I, RUNX-2 and osterix (OSX), increased calcium deposition and osteocalcin secretion in the culture medium compared to controls. These effects were more pronounced after 14days of culture in both populations. SIGNIFICANCE: The enhancing capabilities on proliferation and osteoblastic differentiation displayed by the phytoestrogen Ferutinin make this compound an interesting candidate to promote bone formation in vivo.

[Vancomycin-resistant enterococci: prevalence and factors associated with intestinal colonization in oncology patients from Hospital de Niños de Córdoba]. / Enterococos resistentes a vancomicina: prevalencia y factores asociados a la colonización intestinal en pacientes oncológicos del Hospital de Niños de Córdoba.

Vancomycin-resistant enterococci (VRE) have an important impact on pediatric oncology population. The objectives of this study were: to know the prevalence of VRE intestinal colonization in oncology patients, to identify the risk factors that predispose hospitalized patients to VRE intestinal colonization, and to determine the VRE resistance profile to different antimicrobial agents. We studied all children with oncological disease aged 1 month to 16 years that had joined the protocol and had been hospitalized from October 2006 to April 2007. VRE intestinal colonization was analyzed when the patient was admitted to hospital, 72 hours later, and weekly during hospitalization. A total of 333 samples were taken from 67 patients. From these, VRE were isolated in 12 patients, with a prevalence of 17.9%. Of the 28 isolates studied, taking one per patient, 10 were Enterococcus faecium and 2 Enterococcus faecalis, both with resistance phenotype VanA (CIM90 512 microg/ml to vancomycin and CIM90 256 microg/ml to teicoplanin). The use of vancomycin (p = 0.02), duration of neutropenia greater than 7 days (p = 0.03) and prolonged hospitalization (42.8 days on average) (p = 0.0001) were risk factors significantly related to VRE colonization. We considered it necessary to carry out an epidemiological surveillance and to implement prevention and control measures.

Influence of density, elasticity, and structure on ultrasound transmission through trabecular bone cylinders.

The aim of this in vitro study is to evaluate the potentiality of quantitative ultrasound (QUS) to separate information on density, elasticity, and structure on specimens of trabecular bone. Fifteen cylinders of spongy bone extracted from equine vertebrae were progressively demineralized and subjected to QUS, micro computed tomography (muCT), Dual energy X-ray absorptiometry (DXA) at various mineralization levels. Eventually all cylinders underwent a compression test to calculate the Young's modulus. Correlation analysis shows that speed of sound (SOS) is strictly associated to bone mineral density (BMD), Young's modulus, and all muCT parameters except for degree of anisotropy (DA). Fast wave amplitude (FWA) is directly correlated with bone surface and total volume ratio (BS/TV) and trabecular separation (Tb Sp), and inversely correlated with trabecular number (Tb N). Because muCT parameters were strictly correlated to BMD and Young's modulus data, partial correlation analysis was performed between SOS, FWA, and structural and elastic data in order to eliminate the effect of density. SOS was significantly correlated to bone volume and total volume ratio (BV/TV), BS/TV, and Young's modulus, and FWA was significantly correlated to Tb Sp only. These results show that SOS is strongly influenced by volumetric mineral bone density and elastic modulus of the specimen, and FWA is mainly affected by trabecular separation independently on density. Therefore, SOS and FWA are able to provide different and complementary information, at least on trabecular bone samples.

[Prevalence and antimicrobial susceptibility patterns of microorganisms causing bacteremia and fungemia in pediatric oncology patients]. / Prevalencia de microorganismos causantes de bacteriemias y fungemias en pacientes oncológicos pediátricos. Patrones de sensibilidad a los antimicrobianos.

The purpose of our research was to know the frequency of microorganisms causing bacteremia and/or fungemia in oncology patients from Hospital de Niños de Córdoba, as well as to describe the antimicrobial susceptibility patterns of bacteria isolated from January 2006 to April 2007. A total of 59 bacteremia and fungemia cases in 44 patients were studied. From the total number of isolations, 45.8% were gram-negative bacilli, 35.6% were gram-positive cocci, and 18.6% were yeasts. The global distribution of the most prevalent microorganisms was the following: Klebsiella spp. 15.3%; Staphylococcus aureus and Candida parapsilosis 11.9%; coagulase-negative staphylococci 10.2%; Escherichia coli 8.5%, and Pseudomonas aeruginosa 6.8%. More than 40% (41.2%) of enterobacteria showed an extended-spectrum beta-lactamase phenotype, and 20.0% of non-fermenting gram-negative bacilli were multi-resistant to tested antibiotics, while 38.5% of Staphylococcus spp. were methicillin-resistant. In conclusion, the most prevalent microorganisms were gram-negative bacilli, and within this group, enterobacteria evidenced a higher percentage of resistance to tested antibiotics.

Prevalencia de microorganismos causantes de bacteriemias y fungemias en pacientes oncológicos pediátricos: Patrones de sensibilidad a los antimicrobianos / Prevalence and antimicrobial susceptibility patterns of microorganisms causing bacteremia and fungemia in pediatric oncology patients

El objetivo del presente trabajo fue conocer la distribución y frecuencia de los microorganismos causantes de bacteriemias y fungemias en los pacientes oncológicos internados en el Hospital de Niños de Córdoba, así como describir sus patrones de sensibilidad a los antimicrobianos. Se estudiaron 59 episodios de bacteriemias y fungemias ocurridos entre enero de 2006 y abril de 2007 en 44 pacientes. Del total de los aislamientos recuperados, el 45,8% fueron bacilos gram-negativos, el 35,6% cocos gram-positivos y el 18,6% levaduras. La distribución global de los microorganismos más prevalentes fue: Klebsiella spp. 15,3%; Staphylococcus aureus 11,9%; Candida parapsilosis 11,9%; estafilococos coagulasa negativos 10,2%; Escherichia coli 8,5% y Pseudomonas aeruginosa 6,8%. El 41,2% de las enterobacterias aisladas presentó un fenotipo compatible con la presencia de alguna b-lactamasa de espectro extendido, y el 20,0% de los bacilos gram-negativos no fermentadores presentó multirresistencia a los antibióticos ensayados. En cuanto a los cocos gram-positivos, el 38,5% de los Staphylococcus spp. fue resistente a meticilina. Se puede concluir que los microorganismos más prevalentes en la población estudiada fueron los bacilos gram-negativos; dentro de este grupo las enterobacterias fueron las que presentaron mayor porcentaje de resistencia a los antibióticos ensayados.

The purpose of our research was to know the frequency of microorganisms causing bacteremia and/or fungemia in oncology patients from Hospital de Niños de Córdoba, as well as to describe the antimicrobial susceptibility patterns of bacteria isolated from January 2006 to April 2007. A total of 59 bacteremia and fungemia cases in 44 patients were studied. From the total number of isolations, 45.8% were gram-negative bacilli, 35.6% were gram-positive cocci, and 18.6% were yeasts. The global distribution of the most prevalent microorganisms was the following: Klebsiella spp. 15.3%; Staphylococcus aureus and Candida parapsilosis 11.9%; coagulase-negative staphylococci 10.2%; Escherichia coli 8.5%, and Pseudomonas aeruginosa 6.8%. More than 40% (41.2%) of enterobacteria showed an extended-spectrum b-lactamase phenotype, and 20.0% of non-fermenting gram-negative bacilli were multi-resistant to tested antibiotics, while 38.5% of Staphylococcus spp. were methicillin-resistant. In conclusion, the most prevalent microorganisms were gram-negative bacilli, and within this group, enterobacteria evidenced a higher percentage of resistance to tested antibiotics.

Sympathectomy alters bone architecture in adult growing rats.

Sympathetic nervous system (SNS) fibres and alpha- and beta-receptors are present in bone, indicating that the SNS may participate in bone metabolism. The importance of these observations is controversial because stimulation or inhibition of the SNS has had various effects upon both anabolic and catabolic activity in this tissue. In this study we evaluated the effects of pharmacological sympathectomy, using chronic treatment of maturing male rats with 40 mg of guanethidine/kg i.p., upon various parameters in bone. Double labelling with tetracycline injection was also performed 20 and 2 days before sacrifice. Bone mass, mineral content, density and histomorphometric characteristics in different skeletal regions were determined. Bone metabolic markers included urinary deoxypyridinoline and serum osteocalcin measurements. Guanethidine significantly reduced the accretion of lumbar vertebral bone and of mineral content and density, compared to controls. Femoral bone mineral content and density were also significantly reduced, compared to controls. Histomorphometric analyses indicated these effects were related to a reduction of cortical bone and mineral apposition rate at femoral diaphysials level. Both markers of bone metabolism were reduced in controls as they approached maturity. Guanethidine significantly decreased serum osteocalcin compared to controls, while urinary deoxypyridinoline was unchanged. These data indicate that guanethidine-induced sympathectomy caused a negative balance of bone metabolism, leading to decreased mass by regulating deposition rather than resorption during modeling and remodeling of bone.

Different skeletal regional response to continuous brain infusion of leptin in the rat.

This study was designed to evaluate whether or not continuous intracerebroventricular infusion of leptin (1.5 microg/rat/24 h, for 28 days) produced different regional response on the skeleton of growing rats. Leptin reduce the accretion of total femoral bone mineral content (BMC) and density (BMD). This effect was related to a reduction of metaphyseal femur as no changes were detected in the diaphysis. Despite the reduced accretion in the volumetric of both femur and tibia compared to controls, leptin had no significant effects on the lumbar vertebrae. Urine deoxypyrydinoline and serum osteocalcin remained more elevated in the leptin-treated group as compared to controls. The results demonstrate that long-term central infusion of leptin activates bone remodeling with a negative balance. Leptin induces distinct responses in the different structure of bone and in the axial and appendicular skeleton.

Contact sensitization to disperse dyes in children.

From January 1996 to December 2000, 1098 children, including 667 subjects with suspected allergic contact dermatitis and 431 patients with atopic dermatitis (AD), were patch tested with seven disperse dyes: disperse blue 124 (DB124), disperse blue 106 (DB106), disperse red 1 (DR1), disperse yellow 3 (DY3), disperse orange 3 (DO3), p-aminoazobenzene (PAAB), and p-dimethylaminoazobenzene (PDAAB). Of these, 51 patients (4.6%; 34 girls and 17 boys) proved sensitized to disperse dyes. AD or history of AD was present in 30 patients (59%). The most common sensitizer was DY3 (17 patients), followed by DO3 (15 patients), and DB124 (14 patients). Among dye-positive patients, about 12% were sensitized to disperse dyes alone and only 14% reacted to para-phenylenediamine. In disperse dye-sensitive children not affected by AD, the feet, axillae, and groin appeared to be the most common localizations, whereas in those with AD, involvement of the face and the flexural areas of the limbs was more common. In conclusion, our study showed that in children with suspected contact sensitization, disperse dyes should be regarded as potential triggering allergens.

Frequency and intensity of responses to mite patch tests are lower in nonatopic subjects with respect to patients with atopic dermatitis.

BACKGROUND: So far the issue of patch tests with mite allergens in subjects not affected by atopic dermatitis (AD) has been poorly investigated. The aim of this study was to assess the frequency and intensity of responses to atopy patch tests with Dermatophagoides in non-AD subjects, and to compare them to the ones observed in AD patients. METHODS: Patch tests were performed, employing a mixture of Dermatophagoides pteronyssinus and farinae at two different concentrations (20 and 40% pet.), on 75 non-AD subjects, including 33 patients with allergic rhinitis and 42 healthy volunteers, and on 210 AD patients, as controls. RESULTS: Positive responses to 20% mite patch tests were observed in 17 non-AD subjects (23%) and in 102 AD ones (49%). The former showed a lower intensity of the responses, with a mean score of 1.4 compared with 2.1 in atopics. CONCLUSIONS: Although positive responses to mite patch tests are also observable in subjects without AD, their frequency and intensity are significantly lower compared with AD patients.

Combined skin prick and patch testing enhances identification of peanut-allergic patients with atopic dermatitis.

BACKGROUND: Food atopy patch tests (APTs) are considered a useful tool for the diagnosis of food allergy. Hypersensitivity to peanuts has not been investigated by means of APTs so far. METHODS: APTs and skin prick tests (SPTs) with peanuts were performed in 136 atopic dermatitis (AD) patients. Relevance of positive and negative responses to these tests was assessed by repeated open challenges with peanuts. RESULTS: Nine percent of our AD patients reacted to the challenge. Positive responses to APTs were recorded in 19% of the patients, whereas in 12% positive SPTs were observed. APTs were more frequently positive in subjects with eczematous responses after challenge with respect to those with urticarial reactions. SPT reactivity proved to be higher in patients above 12 years of age, whereas APT positivity was more frequent in children under 6 years. APT sensitivity proved significantly higher than SPT sensitivity, in particular in children under 12 years of age. On the contrary, SPT specificity and positive predictive value were significantly higher with respect to those of APT in the age group of subjects under 6 years of age. CONCLUSIONS: Our data suggest that APTs with peanuts may represent a useful integration to standard testing modalities employed for the diagnosis of peanut allergy in AD patients.

Skin barrier, hydration, and pH of the skin of infants under 2 years of age.

The goal of this study was to instrumentally evaluate the skin of healthy infants and to compare it to adult skin. A total of 70 infants, 45 girls and 25 boys, ages 8-24 months, and 30 healthy women were studied by means of transepidermal water loss (TEWL), capacitance, and pH measurements at two different skin sites, the volar forearm and the buttocks. No significant differences in TEWL were found between infants and adults, either on the buttocks or on the volar forearm. On the contrary, capacitance values were higher in infants. Their skin also appeared less acid than that of adults, with high statistical significance. No TEWL, capacitance, or pH variations were observed in infants according to sex and age. On the basis of the above data, the skin of infants 8-24 months of age shows functional signs of immaturity. This may lead to an increased permeability and a reduced capacity for defense against chemical and microbial aggression.

Thickness and echogenicity of the skin in children as assessed by 20-MHz ultrasound.

BACKGROUND: Skin anatomy and physiology undergo modifications throughout the whole lifespan. In children the skin appears with structural characteristics, as evaluated by histology, which differ from those of adults, especially in the first years of life. OBJECTIVE: The aim of our study was to evaluate skin thickness and echogenicity at different sites in children by 20-MHz ultrasound. METHODS: Eight skin sites of 42 children and 30 young adults were studied with a 20-MHz B scanner. Skin thickness and mean echogenicity were evaluated. The echographic images were processed and segmented by a dedicated program: the 0-30 amplitude interval, which marks the hypoechogenic parts of the tissue, and the 201-255 range, highlighting the hyperreflecting areas, have been selected. RESULTS AND CONCLUSION: Whereas skin thickness shows a gradual increase from birth to adulthood, maturation of the skin leads to variations in the intensity of its echogenicity, depending on the different skin areas. Whereas on the face and the trunk it appears lower in adults with respect to children, a gradual increase can be observed on the limbs with growing age. The distribution of skin reflectivity also greatly varies in different phases of life.

Late onset of CAD gene amplification in unamplified PALA resistant Chinese hamster mutants.

In rodent cells, resistance to PALA (N-phosphonacetyl-L-aspartate) has always been found associated with amplification of the CAD gene (carbamyl-P synthetase, aspartate transcarbamylase, dihydro-orotase). We describe two PALA resistant Chinese hamster mutant cell lines in which amplification of the CAD gene was not present. The PALA resistant phenotype was stable when the cells were grown in non-selective medium. However, after prolonged growth in the presence of the same drug concentration used for selection, cells with increased CAD gene copy number and higher levels of resistance overrode the original population. In these cell populations, a heterogeneous organization of the CAD genes was revealed by fluorescence in situ hybridization on mitotic chromosomes indicating that the additional copies of the gene were generated in several ways, such as non-disjunction and breakage-fusion-bridge cycles. The clastogenic effect of PALA, evidenced as chromosomal aberrations in the cells grown in the presence of the drug, could have favored the late onset of the amplified mutants. It is tempting to speculate that, during the expansion of tumor populations, different drug resistance mechanisms, including gene amplification, could occur in succession and lead to the generation of cells highly resistant to chemotherapeutic agents.