Conjugative transfer of plasmid p_8N_qac(MN687830.1) carrying qacA gene from Staphylococcus aureus to Escherichia coli C600: potential mechanism for spreading chlorhexidine resistance.

The methicillin resistant Staphylococcus aureus (MRSA) is recognized by its ability to acquire and transferring resistance genes through interspecies conjugative plasmids. However, transference of plasmids from Gram-positive cocci to Gram-negative bacilli is not well characterized. In this report, we describe the transfer of a conjugative plasmid carrying qacA from MRSA to Escherichia coli C600. We performed a conjugation experiment using a chlorhexidine resistant MRSA isolate (ST-105/SCCmec type III) carrying the gene qacA and qacC as the donor and a chlorhexidine susceptible E. coli C600 isolate as the receptor. Transconjugants were selected using MacConkey agar plates containing chlorhexidine in concentrations ranging from 0.25 to 16 g.L-1. To genotypically confirm the transfer of the resistance gene, the transconjugants were screened by Polymerase Chain Reaction (PCR) and submitted to Sanger's sequencing. MRSA isolates successfully transferred the chlorhexidine resistance gene (qacA) to the recipient E. coli strain C600. The E. coli transconjugant exhibited an important reduction of chlorhexidine susceptibility, with MICs increasing from ≤ 0.25 to ≥ 16 g.L-1 after conjugation. The qacA gene was detected by PCR as well as in the Sanger's sequencing analysis of DNA from transconjugant plasmids. To the best of our knowledge, this is the first report of the plasmid p_8N_qac(MN687830.1) carrying qacA and its transfer by conjugation from a MRSA to an E. coli. These findings increase concerns on the emergence of resistance dissemination across the genus and emphasizes the importance of continuous antiseptic stewardship.

Susceptibility to chlorhexidine and mupirocin among methicillin-resistant Staphylococcus aureus clinical isolates from a teaching hospital.

Despite the widespread use of chlorhexidine (CHX) to prevent infection, data regarding the in vitro action of CHX against methicillin-resistant Staphylococcus aureus (MRSA) are limited. Clinical isolates from Hospital das Clinicas, Sao Paulo, Brazil, identified during 2002/2003 and 2012/2013 were studied to describe the susceptibility to CHX and mupirocin, molecular characteristics, and virulence profile of MRSA. Susceptibility test to Mupirocin was performed by the disk diffusion method and to CHX by the agar dilution technique. PCR for virulence genes, mecA gene and Staphylococcal Cassette Chromosome mec (SCCmec) types were investigated as well. Mupirocin- and CHX-resistant isolates were sequenced using the IlluminaTM plataform. Two hundred and sixteen MRSA clinical isolates were evaluated: 154 from infected and 62 from colonized patients. Resistance to mupirocin was observed in four isolates assigned as SCCmec type III and STs (ST05; ST239 and ST105) carrying mupA and blaZ, two of them co-harboring the ileS gene. Only one isolate assigned as SCCmec type III was resistant to CHX (MIC of 8.0 µg.mL-1) and harbored the qacA gene. Resistance to chlorhexidine and mupirocin were found in isolates carrying qacA and mupA in our hospital. Since these genes are plasmid-mediated, this finding draws attention to the potential spread of resistance to mupirocin in our hospital.

Deriving a parsimonious cardiac endpoint for use in epidemiological studies of Chagas disease: results from the Retrovirus Epidemiology Donor Study-II (REDS-II) cohort.

Chagas cardiomyopathy (ChCM) is a severe consequence of Trypanosoma cruzi infection and has a range of electrocardiographic (ECG) and echocardiographic (ECHO) manifestations. There is a need for a standard and parsimonious research cardiac end point that does not rely on expert panel adjudication, and it is not intended to change the ChCM definition. We use data from the REDS-II cohort to propose a simplified cardiac endpoint. A total of 499 T. cruzi-seropositive blood donors were included. All participants underwent a 12-lead ECG, echocardiogram and clinical examination, and those with abnormal findings were reviewed by a panel of cardiologists who classified cases as having Chagas cardiomyopathy or not. We created an exhaustive set of ECG and ECHO finding combinations and compared these with the panel's classification. We selected the simplest combination that most accurately reproduced the panel's results. Individual ECG and ECHO variables had low sensitivity for panel-defined cardiomyopathy. The best performing combination was right bundle branch block and/or ECHO evidence of left ventricular hypocontractility. This combination had 98% specificity and 85% sensitivity for panel-defined ChCM. It was not possible to improve the overall accuracy by addition of any other ECG or ECHO variable. Substituting right bundle branch block for the more inclusive finding of QRS interval > 120 ms produced similar results. The combination of prolonged QRS interval and/or left ventricular hypocontractility closely reproduced the REDS-II expert panel classification of Chagas ChCM. In conclusion, the simple and reproducible research endpoint proposed here captures most of the spectrum of cardiac abnormalities in Chagas disease.

Prevalence of methicillin-resistant Staphylococcus aureus colonization in individuals from the community in the city of Sao Paulo, Brazil.

Staphylococcus aureus (SA) is a commensal habitant of nasal cavities and skin. Colonization by community-acquired methicillin-resistant SA (CA-MRSA) is associated with infections in patients who have not been recently hospitalized. The aim of this study is to determine the prevalence of MRSA colonization in an outpatient population, currently unknown in Brazil. Three-hundred patients or caregivers from two teaching hospitals were included. A questionnaire was applied and nasal swabs were obtained from patients. Swabs were inoculated in brain heart infusion (BHI) with 2.5% NaCl and seeded in mannitol. Suspicious colonies were subjected to MALDI-TOF MS Microflex™ identification. Antimicrobial susceptibility test for oxacillin was performed for SA-positive samples by microdilution. Polymerase chain-reactions for detection of mecA and coA genes were performed for resistant samples. Data about MRSA carriers were compared with non-carriers. There were 127 S. aureus isolates, confirmed by MALDI-TOF. Only seven (2.3%) were MRSA and positive for mecA and coA genes. Factors associated with MRSA carriage were African ethnicity, skin diseases or antibiotic use. The majority of them were from Dermatology clinics. Prevalence of MRSA colonization in individuals from the community was low in our study (2.3%). This finding raises the hypothesis of inter-household transmission of SA, although we did not find any association between MRSA-colonization and the shared use of personal objects. Given the low prevalence of MRSA carriers observed, empirical antimicrobial coverage for MRSA in community-acquired infections should be not necessary.

Tuberculose exclusivamente colônica em paciente com HIV / Colonic tuberculosis in patient with HIV

A coinfecção pelo vírus da imunodeficiência humana (HIV) e pelo Mycobacterium tuberculosis pode elevar em 25 vezes o risco de desenvolver a tuberculose-doença. Mesmo assim, o comprometimento do cólon pela tuberculose é extremamente incomum. Relatamos um caso de paciente HIV positivo com tuberculose colônica.

Co-infection with the human immunodeficiency virus (HIV) and Mycobacterium tuberculosis may increase by 25-fold the risk of developing tuberculosis. Nevertheless, commitment of the colon by tuberculosis is extremely unusual. Here we report the case of a HIV-positive patient with colon tuberculosis.

Actinomicose ovariana em paciente não usuária de dispositivo intrauterino / Ovarian Actinomycosis in a non-IUD user

Neste relato é descrito caso de Actinomicose ovariana, estendendo-se ao epíploon, em mulher de 49 anos não usuária de DIU, com dor abdominal, febre, diarreia, massa abdominal palpável e irritação peritoneal, que foi submetida à laparotomia exploradora, seguida de ooferectomia unilateral, devido a abscesso tubo ovariano esquerdo.

Here we report the case of ovarian Actinomycosis extending to the omentum, in a non-IUD user, a 49-year-old woman with abdominal pain, fever, diarrhea, palpable abdominal mass and peritoneal irritation, who underwent laparotomy followed by unilateral oophorectomy due to left tube ovarian abscess.

Tuberculose cutânea em paciente sem infecção pelo HIV / Cutaneous tuberculosis in patients without HIV infection

Trata-se de um caso de tuberculose cutânea escrofulodérmica, secundária a foco tuberculoso pulmonar. Paciente de 40 anos, masculino, que apresentava duas fístulas externas em região perineal direita. O exame anátomo-patológico de biópsia da lesão demonstrou granulomas tuberculoides cutâneos com necrose caseosa, com pesquisa para bacilos álcool-ácido-resistentes positiva. Baciloscopia direta do escarro e raio X de tórax mostraram o pulmão como sítio primário. Tratamento específico para tuberculose determinou regressão completa das lesões cutâneas.

A case of scrofulodermal tuberculosis secondary to a pulmonary tuberculosis focus. Forty-year-old male patient who had two external fi stulas in the right perineal area. The pathological examination of biopsy showed cutaneous tuberculoid granulomas with caseous necrosis, which tested positive for acid-fast bacilli. Direct sputum smear microscopy and chest X-ray showed the lung as the primary site. Specifi c treatment for tuberculosis determined complete regression of skin lesions.

Intratesticular and intraovarian epidermoid inclusion cysts: report of two cases / Cistos de inclusão epidérmica intratesticular e intraovariano: relato de dois casos

Two rare cases of intragonadal epidermoid inclusion cysts are described. Their etiology remains controversial and a possible hypothesis is monodermal abortive teratomas, with no mesodermal and endodermal components. As the ultrasound test results were inconclusive, it became difficult to rule out the possibility of neoplasm. Therefore, patients were submitted to radical therapy. The definitive diagnosis for both cases was provided by the anatomopathological examination.

Trata-se de dois casos raros de cistos de inclusão epidérmica intragonadais, cuja etiologia permanece controversa, sendo uma hipótese a de teratomas monodérmicos abortivos, sem componentes mesodérmicos e endodérmicos. Devido a resultados inespecíficos dos exames ultrassonográficos, torna-se difícil afastar a possibilidade de neoplasia e o tratamento padrão permanece sendo, portanto, a terapia radical. O diagnóstico definitivo, em ambos os casos, foi firmado pelo exame anatomopatológico.

Relação da violência intrafamiliar e o uso abusivo de álcool ou entorpecentes na cidade de Pelotas, RS / Relation of intrafamiliar violence and abuse of alcohol or narcotics in the city of Pelotas, RS

Introdução: A violência intrafamiliar se entende por toda agressão cometida dentro e fora de casa por qualquer integrante da família que esteja em relação de poder com a pessoa agredida e pode resultar da influência do uso imoderado de álcool e entorpecentes. O presente estudo busca explicitar a realidade vivida por algumas famílias que lidam com a violência intra-familiar na cidade de Pelotas, RS. Métodos: Estudo transversal realizado através de questionário autoaplicável preenchido pelas vítimas de violência intrafamiliar que realizaram exame de corpo delito no Posto Regional Médico Legal (PRML) do município de Pelotas, RS, no período de julho a dezembro de 2011, totalizando uma amostra de 166 pessoas. Resultados: Foi constatado que, em Pelotas, RS, a predominância das vítimas de violência intrafamiliar são do sexo feminino (89%), cor branca (73%) e o agressor costuma ser o(a) companheiro(a) (86,6%). Em 67,3% dos casos a agressão ocorreu pela primeira vez e 82,5% das vítimas não pretendem seguir convivendo com o agressor. De acordo com o estudo, em 27,7% dos casos o agressor ingeriu somente álcool, 10,2% ingeriu álcool e usou outra droga, 7,8% apenas usou outra droga, e 54,2% dos casos o agressor não havia usado nenhuma substância. Conclusão: O desequilíbrio familiar em virtude do uso de álcool ou demais drogas, associado a pressões socioeconômicas, pode gerar conflitos e agressões domésticas, havendo necessidade de medidas urgentes na prevenção e interseção da violência intra familiar.

Introduction:Domestic violence is understood as any aggression committed inside and outside the home by any family member who has a power relationship over the aggressed person and may result from the influence of immoderate use of alcohol and narcotics. This study seeks to explain the reality experienced by some families dealing with domestic violence in the city of Pelotas/RS. Methods: Cross-sectional study using self-administered questionnaire completedby victims of domestic violence who conducted the examination of body offense in the local forensic post (PRML) of Pelotas/RS, from July to December 2011, with a final sample of 166 people. Results: It was found that in Pelotas/RS, the predominance of victims of domestic violence are female (89%), white (73%) and usually the aggressor is the partner (86,6%). In 67.3% of cases, the attack occurred for the first time, and 82.5% of the victims did not wish to live with the abuser anymore. According to the study, in 27.7% of cases the perpetrator drank alcohol only, 10.2% drank alcohol and used other drugs, 7.8% used another drug only, and in 54.2% of cases the perpetrator had not used any substance. Conclusion: The family imbalance arising from abuse of alcohol or other drugs, combined with socioeconomic pressures, can generate conflict and domestic violence, with the need for urgent action to prevent and stop domestic violence.

Cuspal dehiscence at a post and along the stent cloth in a bovine pericardium heart valve implanted for seven years.

A failing mitral valve prosthesis made from bovine pericardium was explanted from a 50-year-old patient. Preoperative transthoracic-echocardiography had confirmed severe mitral regurgitation due to structural failure of this HP Bio bovine pericardium heart valve prosthesis. The explanted device was examined macroscopically, by scanning electron microscopy (SEM), by light microscopy, and by transmission electron microscopy (TEM). Samples of unassembled patches of bovine pericardium were used as a pre-implantation control to better understand the changes that occurred in the structure of the pericardium following the 7 years of implantation. Examination confirmed complete dehiscence of a cusp along a valve post and the stent: This detached cusp was observed floating in the bloodstream at echocardiography. The fibrous pannus overgrowth was well developed along the stent and extended to the bottom of the cusps both on the inflow and the outflow sides. The fibrous panni were found to be poorly adhesive to the pericardium cusps and had become stiff, thus impairing the opening and closure of the valve. The structure of the pericardium cusps was severely deteriorated compared to the control bovine pericardium tissue samples. The collagen bundles were frequently broken and more stretched in the explanted device, lacking the wavy histological pattern of normal collagen fibers. However, the tissues were devoid of any calcification. In conclusion, the failure mode of this valve was the dehiscence of a cusp from a valve post and along the stent cloth in the absence calcification.

Can marine mammals be a reliable source for the manufacture of prosthetic heart valves for percutaneous surgery?

Marine mammals experience unique physiological conditions when diving. Myocardial function is sustained despite a 90% reduction of the blood flow in the coronaries. Therefore, their heart valves and pericardium could serve as a unique source of tissue for the manufacture of prosthetic heart valves. The pericardium of a stillborn pup sea lion was investigated to determine its morphology using gross observation, scanning electron microscopy (SEM), light microscopy, and transmission electron microscopy (TEM). Depending upon the site of sampling, the structure of the pericardium varied significantly. The atrial sample was well structured with wavy bundles of collagen fibers. The thickness in the atrial sample was regular with a smooth serous surface. The fibrous side of the pericardium of the auricular sample was irregular and incorporated microcapillaries. Both the sternoperitoneal ligament and the phrenoperitoneal ligament section were irregular and incorporated various amounts of adipocytes. Because of the increased amount of adipocytes, the fibrils of the collagen fibers were also observed to be occasionally agglutinated. Practically, the harvesting of pericardium would have to be restricted to the atrial surface. The presence of adipocytes in the pericardium wall makes the selection of this tissue a poor choice compared to alternative existing tissue sources.