Increased Incidence of Central Venous Catheter-Related Infection in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intra-Peritoneal Chemotherapy.

Background: Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) is a complex surgical intervention with associated risks. Central venous catheter (CVC) line sepsis is one of a number of potential morbidities. The aim of this study was to calculate the incidence of catheter-related infection (CRI) in a CRS and HIPEC patient population and to assess its influence on length of hospital stay. Methods: Data were collected on consecutive patients who underwent CRS HIPEC between August 2013 and October 2017. Data included patient demographics, timing of CVC insertion/removal, time spent in critical care, and CVC tip/blood culture results. Charts were reviewed for patients with both positive CVC culture and positive blood cultures to assess for evidence of catheter related infection and systemic inflammatory response syndrome (SIRS). Results: Data on 100 consecutive CRS HIPEC operations performed between August 2013 and October 2017 was analyzed. There were 11 CRIs in 100 CVCs, resulting in a CRI rate of 16.2 per 1,000 CVC days. Patients within the CRI group had a longer high-dependency unit (HDU) stay compared with the non-septic group (6 days vs. 4.07 days, p < 0.05). The CVC duration for the CRI and non-CRI group was 8.4 and 7.6 days, respectively (p = 0.12). The CRI group also had an increased total hospital length of stay (LOS; 20.8 days vs. 15.4 days, p < 0.05). On average, CRIs occurred eight days post-operative and four days post-HDU discharge. There was no association identified with longer CVC duration (p = 0.34). There has been an annual decline in CRI rates in CRS and HIPEC patients over the duration of the study period from 19.1 per 1,000 CVC days in 2016 to 8.2 per 1,000 CVC days in 2017. Conclusion: This is the first study to report on CRI rates in patients undergoing CRS and HIPEC. The CRI rate of 16.2 per 1,000 CVC days is higher than the overall national figure of 5.2 per 1,000 for CVC lines inserted in the operating room. Patients who developed line sepsis had longer HDU and longer overall hospital stay. Catheter-related infection was noted post-HDU discharge in all cases. Implementation of a CVC care bundle in the later years of the study period coincided with a reduction in CRI rates.

Antibiotic resistant Escherichia coli in southeastern Australian pig herds and implications for surveillance.

To investigate public health implications of antibiotics to control post-weaning scours, we surveyed 22 commercial pig herds in southeastern Australia. Fifty faecal samples per herd were collected from pre- and post-weaned piglets. Presumptive Escherichia coli isolates were confirmed by MALDI-TOF MS. Isolates (n = 325) were screened for susceptibility to 19 veterinary antibiotics using MIC broth microdilution. All 325 E. coli isolates underwent further testing against 27 antibiotics used in human medicine and were screened for ETEC adhesin and enterotoxin genes (F4 (K88), F5 (K99), F6 (987P), F18, F41, STa, STb, Stx2e and LT) by multiplex PCR. Isolates identified as phenotypically resistant to third-generation cephalosporin (3GC) and aminoglycoside antibiotics were screened by multiplex PCR/reverse line blot to detect common ß-lactam and aminoglycosides resistance genes, confirmed by sequencing. Twenty (6.1%) of the E. coli isolates were resistant to 3GC antibiotics and 24 (7.4%) to the aminoglycoside antibiotic gentamicin. Genetic analysis revealed six different extended spectrum ß-lactamase (ESBL) genes (blaCTX-M-1, -14, -15, -27, blaSHV-12 and blaCMY-2-like genes), four of which have not been previously reported in Australian pigs. Critically, the prevalence of 3GC resistance was higher in non-pathogenic (non-ETEC) isolates and those from clinically normal (non-diarrhoeal) samples. This highlights the importance of non-ETECE. coli as reservoirs of antimicrobial resistance genes in piglet pens. Antimicrobial resistance surveillance in pig production focused on diagnostic specimens from clinically-affected animals might be potentially misleading. We recommend that surveillance for emerging antimicrobial resistance such as to 3GC antibiotics should include clinically healthy pigs.

Clinical characteristics of juvenile idiopathic arthritis in an area of central Italy: a population-based study.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children and an important cause of short and long-term disability. In a recent systematic review of population based studies, the epidemiology of JIA is variable worldwide with incidence rates ranging between 1.6 and 23.0/100,000, and prevalence rates between 3.8 and 400.0/100,000. We investigate the incidence and describe the characteristics of juvenile idiopathic arthritis in the pediatric population of the central Italy, in the period 2000-2009. METHODS: A retrospective study was conducted in the Marche region to identify patients with a diagnosis of juvenile idiopathic arthritis according to ILAR criteria, between January 1, 2000 and December 31, 2009. JIA was classified according to the ILAR criteria, that is, arthritis of unknown etiology that persisted for > 6 weeks with onset before the age of 16 years. The pooled global ascertainment of cases was estimated by capture-recapture methods and two independent information sources of ascertainment of new cases of JIA were considered. RESULTS: We studied 151 patients (56 males, 37.1% and 95 females, 62.9%) meeting the ILAR criteria of juvenile idiopathic arthritis. Mean age at presentation was 6.8 ± 3.7 years for males and 6.0 ± 4.0 years for females (p=0.22). The overall incidence rate was 6.34 per 100,000/year (C.I. 6.26-7.35) and the total incidence rate increase from 2000-2009 was 8.16%. Oligoarthritis was the most common onset type (n=98, 65.0%) with 62.5% of ANA-positive patients in at least two determinations. CONCLUSIONS: Our results indicate that juvenile idiopathic arthritis incidence rates in Italy are comparable to previous data from southern Europe, with a higher frequency of oligoarthritis. To the best of our knowledge, this is the first population-based epidemiological study carried out in Italy focusing on the incidence of juvenile idiopathic arthritis.

Intra-Pelvic Migration of Sliding Hip Screw During Osteosynthesis of Hip Fracture: A Rare Avoidable Intraoperative Complication.

INTRODUCTION: Hip fractures, which are common among old patients, are classified into two groups: intracapsular and extracapsular fractures. Extracapsular fractures can be treated with extramedullary implants [e.g. dynamic hip screw (DHS)] or intramedullary nails. Dynamic hip screw is the treatment of choice in stable pertrochanteric fractures. Intrapelvic migration of the sliding screw is a very rare complication. CASE REPORT: We report a case of a 90-year old Caucasian woman who had an unusual intraoperative complication during osteosynthesis procedure for extracapsular hip fracture fixation. In fact, the sliding hip screw went deep into the pelvis during surgery. This mishap required an abdominal surgical approach by the general surgeon to remove the screw. CONCLUSION: Taking into consideration the poor quality of the bone in very old patients, we emphasize the importance of following every single step of the surgical procedure, in order to minimize the risk of this complication.

Leishmaniasis and autoimmune diseases in pediatric age.

Leishmaniasis is a group of diseases caused by the protozoa Leishmania, endemic in the Mediterranean countries. Clinical manifestations can be divided into three different forms: cutaneous leishmaniasis, mucosal leishmaniasis and the visceral leishmaniasis, the most severe form which is potentially lethal if untreated. Immunology and pathogenesis are complex: many different aspects of immune response, resistance and susceptibility to Leishmania have been studied but many others remain to be clarified. The gold standard in diagnosis of visceral Leishmaniasis is the presence of amastigotes in bone marrow or tissue sections. Patients can be initially misdiagnosed as having an autoimmune disease because it may mimic diseases like systemic lupus erythematosus, autoimmune hepatitis, dermatomyositis or others disorders. As in pediatric age the risk of life-threatening complications is very high, leishmaniasis, must be kept in mind to the clinician, in order to avoid wrong diagnosis and an inappropriate immunosuppressive therapy.

A longitudinal study of the prevalence and super-shedding of Escherichia coli O157 in dairy heifers.

The fecal shedding and super-shedding of the human pathogen Escherichia coli O157 by cattle has been the focus of many previous studies with varied results observed. The heterogeneity of shedding is becoming more accepted, both in the numbers of animals shedding and the levels at which animals shed. To clarify patterns in shedding and super-shedding we undertook a longitudinal study to investigate shedding within a cohort of replacement dairy heifers. The cohort of 52 heifers was sampled 18 times at approximately weekly intervals with no significant changes in management during the sampling period. An overall prevalence of 44.3% (412/930 samples) was detected with prevalence ranging from 9.6 to 94.3% at individual sampling points. Each of the 52 heifers yielded at least one sample which was detected positive for E. coli O157. Super-shedding was detected at a sample level of 3.6% (32/893) and ranged between 0 and 9.6% at each sampling point. Of the 52 heifers, 24 (46.2%) were detected to be super-shedding at some point during the study, 19 of which were detected as super-shedding at only one point. From our findings we conclude that super-shedding is not associated with a small subset of animals that shed at high levels continually as had been proposed by earlier studies. We propose that the term 'super-shedding event' as opposed to 'super-shedding animal' better describes the nature of shedding.

Relative sensitivity of Escherichia coli O157 detection from bovine feces and rectoanal mucosal swabs.

The need to quantify the potential human health risk posed by the bovine reservoir of Escherichia coli O157 has led to a wealth of prevalence studies and improvements in detection methods over the last two decades. Rectoanal mucosal swabs have been used for the detection of E. coli O157 fecal shedding, colonized animals, and those predisposed to super shedding. We conducted a longitudinal study to compare the detection of E. coli O157 from feces and rectoanal mucosal swabs (RAMS) from a cohort of dairy heifers. We collected 820 samples that were tested by immunomagnetic separation of both feces and RAMS. Of these, 132 were detected as positive for E. coli O157 from both samples, 66 were detected as positive from RAMS only, and 117 were detected as positive from feces only. The difference in results between the two sample types was statistically significant (P < 0.001). The relative sensitivities of detection by immunomagnetic separation were 53% (confidence interval, 46.6 to 59.3) from RAMS and 67% (confidence interval, 59.6 to 73.1) from fecal samples. No association between long-term shedding (P = 0.685) or super shedding (P = 0.526) and detection by RAMS only was observed.

Relationship between inflammatory markers, oxidant-antioxidant status and intima-media thickness in prepubertal children with juvenile idiopathic arthritis.

OBJECTIVE: To investigate the presence of possible early atherosclerotic changes in a group of prepubertal children with juvenile idiopathic arthritis (JIA) and to establish the potential beneficial effects of 1-year treatment. MATERIALS AND METHODS: Inflammatory markers (C-reactive protein, erythrocyte sedimentation rate), proinflammatory cytokines (IL-1ß, IL-6, IFN-γ, TNF-α), lipid profile and oxidant-antioxidant status (urinary isoprostanes [PGF-2α]) were assessed in 38 JIA children (12M/26F, mean age 7.05 ± 2.39 years) and compared with 40 controls (18M/22F, mean age 6.34 ± 2.25 years). Carotid intima-media wall thickness (cIMT) was obtained and blood pressure was measured. All parameters were reassessed in JIA children after 1 year of therapy. RESULTS: At baseline JIA children presented compared to controls higher levels of inflammatory markers, proinflammatory cytokines, total cholesterol, LDL cholesterol, and PGF-2α (all p ≤ 0.01). Furthermore, blood pressure and cIMT were significantly increased (both p ≤ 0.01). After a 1-year treatment with non-steroid anti-inflammatory (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs), a significant reduction of all parameters was detected (all p ≤ 0.01). This was associated with a significant reduction in blood pressure and cIMT (both p ≤ 0.01). Within the JIA group, patients requiring etanercept presented worse laboratory values and cIMT measurements at baseline. Nevertheless, the same improvement of all parameters was obtained after a 1-year treatment. In stepwise multiple regression, LDL cholesterol and IL-1ß were mainly related to cIMT. CONCLUSION: Chronic and systemic inflammation seems to lead to early atherosclerotic abnormalities even in pre-pubertal JIA children. Substantial improvement can be obtained with 1-year of appropriate therapy.

TNF-α Polymorphisms in Juvenile Idiopathic Arthritis: Which Potential Clinical Implications?

Whether tumor necrosis factor alpha (TNF-α) gene polymorphisms (SNPs) influence disease susceptibility and treatment of patients with juvenile idiopathic arthritis (JIA) is presently uncertain. TNF-α is one of the most important cytokine involved in JIA pathogenesis. Several single nucleotide polymorphisms (SNPs) have been identified within the region of the TNF-α gene but only a very small minority have proven functional consequences and have been associated with susceptibility to JIA. An association between some TNF-α SNPs and adult rheumatoid arthritis (RA) susceptibility, severity and clinical response to anti-TNF-α treatment has been reported. The most frenquetly studied TNF-α SNP is located at -308 position, where a substitution of the G allele with the rare A allele has been found. The presence of the allele -308A is associated to JIA and to a poor prognosis. Besides, the -308G genotype has been associated with a better response to anti-TNF-α therapy in JIA patients, confirming adult data. Psoriatic and oligoarticular arthritis are significantly associated to the -238 SNP only in some works. Studies considering other SNPs are conflicting and inconclusive. Large scale studies are required to define the contribution of TNF-α gene products to disease pathogenesis and anti-TNF-α therapeutic efficacy in JIA.

A diagnostic score for molecular analysis of hereditary autoinflammatory syndromes with periodic fever in children.

OBJECTIVE: To identify a set of clinical parameters that can predict the probability of carrying mutations in one of the genes associated with hereditary autoinflammatory syndromes. METHODS: A total of 228 consecutive patients with a clinical history of periodic fever were screened for mutations in the MVK, TNFRSF1A, and MEFV genes, and detailed clinical information was collected. A diagnostic score was formulated based on univariate and multivariate analyses in genetically positive and negative patients (training set). The diagnostic score was validated in an independent set of 77 patients (validation set). RESULTS: Young age at onset (odds ratio [OR] 0.94, P = 0.003), positive family history of periodic fever (OR 4.1, P = 0.039), thoracic pain (OR 4.6, P = 0.05), abdominal pain (OR 33.1, P < 0.001), diarrhea (OR 3.3, P = 0.028), and oral aphthosis (OR 0.2, P = 0.007) were found to be independently correlated with a positive genetic test result. These variables were combined in a linear score whose ability to predict a positive result on genetic testing was validated in an independent data set. In this latter set, the diagnostic score revealed high sensitivity (82%) and specificity (72%) for discriminating patients who were genetically positive from those who were negative. In patients with a high probability of having a positive result on genetic testing, a regression tree analysis provided the most reasonable order in which the genes should be screened. CONCLUSION: The proposed approach in patients with periodic fever will increase the probability of obtaining positive results on genetic testing, with good specificity and sensitivity. Our results further help to optimize the molecular analysis by suggesting the order in which the genes should be screened.

Macrophage activation syndrome in juvenile systemic lupus erythematosus: an under-recognized complication?

Macrophage activation syndrome (MAS) is a life-threatening complication of rheumatic diseases that is thought to be caused by the activation and uncontrolled proliferation of T lymphocytes and macrophages, leading to widespread haemophagocytosis and cytokine overproduction. It is seen most commonly in systemic juvenile idiopathic arthritis, but is increasingly recognized also in juvenile systemic lupus erythematosus (J-SLE). Recognition of MAS in patients with J-SLE is often challenging because it may mimic the clinical features of the underlying disease or be confused with an infectious complication. This review summarizes the characteristics of patients with J-SLE-associated MAS reported in the literature or seen by the authors and analyses the distinctive clinical, diagnostic and therapeutic issues that the occurrence of MAS may raise in patients with J-SLE.

Relationship between damage accrual, disease flares and cumulative drug therapies in juvenile-onset systemic lupus erythematosus.

Our objective was to investigate the pattern of damage accumulation in patients with juvenile-onset systemic lupus erythematosus (JSLE) and the relationship between damage accrual, disease flares and cumulative drug therapies. All patients with SLE followed prospectively in three tertiary care centres were identified. Only patients who presented within 12 months of diagnosis and were followed for at least three years were included. Damage was measures based on chart review using the SLICC/ACR damage index (SDI), which was modified (M-SDI) by adding the item growth failure. Mild-moderate and severe disease flares were defined by the increase in SLEDAI-2K. The cumulative duration of drug therapies was calculated in each patient. Fifty-seven patients were included. The mean M-SDI score for the whole patient group increased over time, from 0.1 at one year to 0.8 at three years to 1.5 at five years. Ocular and renal damage and growth failure were observed most frequently. Compared to patients with stable damage, patients who accrued new damage had a significantly greater frequency of severe disease flare in the first three years of follow-up. No significant difference was observed in any cumulative drug therapy between patients who accrued damage and those who did not. Damage accrual was associated with severe disease flares, suggesting that judicious use of immunosuppressive agents to achieve prompt control of severe exacerbation of disease activity is important in minimizing damage in patients with JSLE.