Countrywide spread of OXA-48 carbapenemase in Lebanon: surveillance and genetic characterization of carbapenem-non-susceptible Enterobacteriaceae in 10 hospitals over a one-year period.

OBJECTIVES: To detect, characterize, and assess the genetic clonality of carbapenem-non-susceptible Enterobacteriaceae in 10 Lebanese hospitals in 2012. METHODS: Selected Enterobacteriaceae isolates with reduced susceptibility to carbapenems were subject to phenotypic study including antibiotic susceptibility, cloxacillin effect, modified Hodge test, and activity of efflux pump inhibitor. Carbapenemase genes were detected using PCR; clonal relatedness was studied by pulsed field gel electrophoresis. RESULTS: Out of 8717 Enterobacteriaceae isolated in 2012, 102 (1.2%) showed reduced susceptibility to carbapenems. Thirty-one (70%) of the 44 studied clinical isolates harbored blaOXA-48, including 15 Klebsiella pneumoniae, eight Escherichia coli, four Serratia marcescens, three Enterobacter cloacae, and one Morganella morganii. The majority of OXA-48 producers co-secreted an extended-spectrum beta-lactamase, while one had an acquired AmpC of the ACC type. In the non-OXA-48 producers, carbapenem resistance was attributed to the production of acquired AmpC cephalosporinases of MOX or CIT type, outer membrane impermeability, and/or efflux pump overproduction. DNA fingerprints revealed that OXA-48 producers were different, except for clonal relatedness among four K. pneumoniae, two E. coli, two E. cloacae, and three S. marcescens. CONCLUSIONS: Nosocomial carbapenem-non-susceptible Enterobacteriaceae are moderately spread in Lebanon and the predominant mechanism is OXA-48 production.

Effects of shift schedules on fatigue and physiological functions among firefighters during night duty.

To examine the effects of shift schedules on fatigue and physiological functions among firefighters a 17-day field study at a fire station was carried out. Eleven firefighters, who were engaged in firefighting emergency services, participated in this study. At the fire station, night duty (22:00-07:00) was divided into 5 periods (P1: 22:00-00:00; P2: 23:45-01:45; P3: 01:30-03:30; P4: 03:15-05:15; P5: 05:00-07:00). The participants were assigned to one of these 5 periods and awakened to answer calls from the city's central information centre. They took naps in individual rooms during night duty, except when on night shift or when called out on an emergency. Subjective complaints of fatigue, critical flicker fusion frequencies, 3-choice reaction times, and oral temperature were measured before and after work and following breaks during their 24 working hours. Heart rate variability was also recorded to evaluate autonomic nerve activity. The results show that during P3 and P4, participants who had to wake up at midnight took shorter naps. The rates of subjective complaints regarding P3 and P4 tended to be higher than those for P1, P2, and P5. The ratios of the low frequency component of heart rate variability to the high frequency component during P4 were significantly lower than those during P5. It is assumed that such an irregular sleeping pattern causes many complaints of subjective fatigue, and adversely affects physiological functions. A night-duty shift schedule ensuring undisturbed naps should be considered.

Studies on constituents from Chamaecyparis pisifera and antibacterial activity of diterpenes.

In the course of our research for biologically active constituents from coniferous plants, a chromone derivative (1) and an abietane derivative (2) were isolated along with several diterpenes from Chamaecyparis pisifera. Structures of the new compounds were determined to be 5,7-dihydroxy-2-(1-acetyl-2-methoxycarbonylethyl)-chromone and rel-(8R,10R,20S)-8,10,20-trihydroxy-9(10-->20)-abeo-abieta-9,13-dien-12-one by means of spectral methods including two-dimensional NMR experiments. Some of these abietane-type compounds isolated from this plants showed antibacterial activitv against the gram-positive bacteria Staphylococcus aureus and Bacillus subtilis.

Budd-Chiari syndrome and extrahepatic portal obstruction associated with congenital antithrombin III deficiency.

We report a patient with Budd-Chiari syndrome (BCS) and extrahepatic portal obstruction (EHO) associated with congenital antithrombin (AT) III deficiency. A 35-year-old man was admitted to Nishi Kobe Medical Center for evaluation of abnormal intrahepatic veins. By various imaging modalities, BCS and EHO were diagnosed. Laboratory data revealed parallel decreases in activity and antigen concentration of AT III despite normal liver function. Taken together, the etiology of both BCS and EHO was considered to be thrombosis, associated with congenital AT III deficiency. Two years after beginning warfarin therapy, the patient has no symptoms and his liver function remains normal. Anticoagulant therapy is considered useful for preventing progression of the disease.

A case of localized primary sclerosing cholangitis mimicking intrahepatic bile duct cancer.

A 75-year-old woman with chronic hepatitis was regularly followed-up in our hospital. A computed tomography (CT) scan revealed an obviously enlarged intrahepatic bile duct in the posterior branch of the left lateral segment. Percutaneous cholangiography revealed an enlarged posterior branch of the left lateral segment and a narrow stenotic region at the root of this branch. We diagnosed her as having intrahepatic bile duct cancer, and a left lateral segmentectomy of the liver was performed. However, microscopic examination of the resected specimens revealed peribiliary fibrosis in the stenotic bile duct and other areas of the intrahepatic bile duct with no malignant cells. Thus, the final diagnosis was made to be primary sclerosing cholangitis. We must consider primary sclerosing cholangitis in the differential diagnosis of localized stenosis of the intrahepatic bile duct.

Vascularity of advanced gastric carcinoma: evaluation by using power Doppler imaging.

BACKGROUND: We investigated the vascularity of advanced gastric adenocarcinomas by using percutaneous power Doppler imaging. METHODS: Seventeen patients with gastric cancer and 10 without a gastric tumor, but with a slightly thick gastric wall in the B-mode ultrasound, were investigated with the use of power Doppler imaging. The color signals of the gastric lesion were graded as follows: 1, no color signals or the same as the surroundings; 2, color signals were slightly increasing; and 3, color signals were obviously increasing. RESULTS: The color signals of three patients were graded 1, those of eight patients were graded 2 and those of six patients were graded 3 in the gastric cancer group. The color signals of all 10 patients without a gastric tumor were grade 1. This difference was statistically significant (P = 0.0002). CONCLUSIONS: Power Doppler imaging showed vascularity of gastric cancer increasing in the majority of patients (14 of 17: 82%). Thus, power Doppler imaging might be a good screening examination method for gastric cancer.

Antihypertensive effect of ACE inhibitory oligopeptides from chicken egg yolks.

Oligopeptides of 1 KDa or less were obtained by hydrolysis of chicken egg yolks with a crude enzyme, and by dialysis with a semipermeable membrane filter. Since the extracted peptides had an inhibitory action on the activity of angiotensin I-converting enzyme (ACE) in vitro, they were orally administered at 20, 100 and 500 mg/kg body weight to spontaneously hypertensive rats (SHR) for 12 weeks to analyze the physiological role on cardiovascular functions. The administered oligopeptides suppressed the development of hypertension at all dosages. After 12 weeks at 500 mg/kg body weight, the values for systolic, mean, and diastolic blood pressure were approximately 10% less in SHRs administered than controls. Furthermore, serum ACE activity of the peptide-administered groups was significantly lower than that of the control group in a dose-related manner. Our results imply that oligopeptides extracted from hen's egg yolks could potentially suppress the development of hypertension in SHR, and this effect might be induced by the inhibition of ACE activity.

Endoscopic resection of small inflammatory fibroid polyp of the colon.

Inflammatory fibroid polyp (IFP) is a solitary intestinal lesion of unknown etiology. Although IFP is benign, laparotomy for the resection of colonic IFP is performed in most cases because the polyp is usually large. We report a successful endoscopic resection of cecal IFP. It is considered that colonic IFP should be resected endoscopically if the polyp is small and is located submucosally.

Portal venous volume flow: in vivo measurement by time-domain color-velocity imaging.

The portal venous velocity and flow volume in 39 patients (16 with liver cirrhosis, 11 with chronic hepatitis, 12 without liver disease) were measured using both color velocity imaging quantification (CVI-Q) and conventional Doppler flowmetry. The average portal venous velocity and flow volume values obtained using the two methods were similar. The correlation coefficients for the paired measurements show positive correlations (velocity: 0.73, p < 0.0001; volume: 0.50, p = 0.001). However, the coefficients of variation between the two methods were not good (velocity: 14.9%, volume: 26.4%). In conventional Doppler flowmetry, the mean velocity to maximum velocity ratio (Vmean:Vmax) is assumed to be constant (Vmean:Vmax = 0.57 in this study). However, the Vmean:Vmax ratios calculated from the flow profile in CVI-Q were 0.67 +/- 0.13 in the patients with liver cirrhosis, 0.58 +/- 0.13 in the patients with chronic hepatitis, and 0.53 +/- 0.08 in the patients without liver disease. Therefore, a measurement method that takes the blood flow profile into account, such as CVI-Q, might be useful for the quantitative measurement of the portal venous velocity and volume.

Relationship between asthma and gastro-oesophageal reflux: significance of endoscopic grade of reflux oesophagitis in adult asthmatics.

BACKGROUND: The association between asthma and gastro-oesophageal reflux disease (GERD) is well known. The aim of this study was to elucidate the causal relationship between reflux oesophagitis (RE) and asthma. METHODS: Seventy-two adult asthmatics were examined regarding their GERD symptoms, and each underwent an endoscopic examination. According to the Los Angeles classification, we divided the patients into three groups: group 1 (n= 52), no mucosal break; group 2 (n= 15), RE corresponding to grades A or B; group 3 (n = 5), RE corresponding to grades C or D. The asthmatics in groups 2 and 3 received anti-reflux treatment for their GERD for 8 weeks. Their morning and evening peak expiratory flow rates (PEFR), daily variability of the PEFR and daily use of an inhalation bronchodilator were compared before and after this treatment. RESULTS: The percentage of severe asthma and postprandial exacerbation of asthma in group 3 were significantly higher than those in the other two groups. In contrast, the number of eosinophiles and the serum level of immunoglobulin E in group 3 were significantly lower than those in the other two groups. After the antireflux treatment, significant improvements of both PEFR and daily use of the inhalation bronchodilator were observed only in group 3. CONCLUSIONS: The endoscopic severity of RE is associated with the characteristics of adult asthmatics and the treatment of severe RE improved the asthmatics' condition.

Colonic ulceration caused by administration of loxoprofen sodium.

A 54-year-old female with chronic headache was admitted to our hospital because of hematochezia. She had routinely taken loxoprofen sodium because of severe headache. Emergent colonoscopic examination revealed ulceration of the cecum. After administration of loxoprofen sodium was discontinued and administration of sulfasalazine was initiated, her intestinal bleeding subsided. Two months after discontinuation of loxoprofen sodium, the colonoscopic examination revealed scar formation at the site of cecal ulceration. In this case, it was conceivable that the administration of loxoprofen sodium might have induced colonic ulceration.

Power Doppler imaging of hepatic tumours: differential diagnosis between hepatocellular carcinoma and metastatic adenocarcinoma.

We evaluated the usefulness of power Doppler imaging in the differential diagnosis between hepatocellular carcinoma and metastatic adenocarcinoma. Forty-seven patients with hepatocellular carcinoma and 18 patients with metastatic adenocarcinoma were evaluated using power Doppler imaging. The colour signals of hepatic tumours were graded as follows: 1, colour signals only in the marginal area; 2, small dot or dotted line colour signals within the tumours; 3, continuous solid line colour signals within the tumours. The grade 3 colour signals were classified in the following three patterns; winding line pattern, stretched line pattern and mixed pattern. The colour signals of hepatocellular carcinoma were grade 1 in seven patients, grade 2 in 11 and grade 3 in 29. The colour signals of metastatic adenocarcinoma were grade 1 in three patients and grade 3 in 15. Of the 29 hepatocellular carcinoma patients with a grade 3 signal, 26 patients had winding line patterns and three had mixed patterns. Of the 15 metastatic adenocarcinoma patients with a grade 3 signal, 12 patients had stretched line patterns and three had mixed patterns. In conclusion, power Doppler imaging is useful in the differential diagnosis between hepatocellular carcinoma and metastatic adenocarcinoma to evaluate the colour signal pattern within the tumour.

[The effects of fluid ingestion and its composition on uric acid metabolism during high intensity long term exercise].

The purpose of this study was to analyze the effects of fluid ingestion and its composition on uric acid metabolism after exercise. Six healthy males volunteered for the study which was comprised of three different experiments; Exp. 1, Exp. 2, and Exp. 3. In all the experiments, subjects performed treadmill exercise (70%VO2max) for 70 minutes respectively. For seven hours after exercise, subjects ingested mineral water at 10 degrees C ad-lib in Exp. 1, 1.5 times the volume of mineral water consumed in the first experiment in Exp. 2, and the same volume of sports drink as in the first experiment in Exp. 3. No significant differences were observed in oxygen uptake and heart rate during exercise among the three experiments, so it was considered that the produced serum uric acid (SUA) levels in the three experiments were about the same level. However, the decrease in SUA, urinary uric acid excretion (UUA), clearance of uric acid (CUA) and fractional excretion of uric acid (FEUA) in Exp. 3, in which the sports drink was consumed instead of mineral water were higher than in Exp. 1 and Exp. 2. On the other hand, no significant differences were found in Exp. 2 and Exp. 3. A significant relationship between UUA and FEUA was found among the three experiments, while there was no corrleation between UUA and urine volume. These results show that; 1) the sports drink ingestion can increase the efficiency of recovery from high serum uric acid after exercise, 2) the increase in uric volume due to high mineral water intake does not elevate UUA, and 3) the increase in UUA due to sports drink ingestion was associated with the increase of FEUA.

Urinary 1-hydroxypyrene levels of garbage collectors with low-level exposure to polycyclic aromatic hydrocarbons.

Because garbage collectors work in the street, they are exposed to polycyclic aromatic hydrocarbons (PAHs) in motor vehicle exhaust gas as they work. Urinary 1-hydroxypyrene (1-OH-pyrene) began to be used as a biological monitoring index for human exposure to high concentrations of PAHs. The objective of this study was to examine the applicability of urinary 1-OH-pyrene as a biological monitoring index for human low-level PAH exposure, such as the PAH exposure experienced while working in the street. The subjects were fifteen male garbage collectors. We measured individual exposure to PAHs, urinary 1-OH-pyrene concentrations and urinary cotinine concentrations. Individual air samplers were attached to the collar of the clothing of five workers to capture PAHs. Urine samples were collected before work, around noon and after finishing the day's work. In all, five PAH samples and 45 urine samples were collected. As control data, we analyzed the urinary 1-OH-pyrene and urinary cotinine levels of six smoking and four non-smoking control subjects who were not occupationally exposed to PAHs. The benzo[a]pyrene level in the air sampled for 5-6 h was 2.5-10.5 ng/m3, and the pyrene level as 10.3-70.3 ng/m3. These levels were similar to those in the vicinity of streets in Japan. A positive correlation between total PAH levels and the pyrene levels was observed. The average urinary 1-OH-pyrene level of the smokers was 0.21 +/- 0.13 mumol/mol creatinine, vs. 0.15 +/- 0.11 mumol/mol creatinine in the non-smokers. The urinary 1-OH-pyrene level obtained in this study was slightly higher than in the control group. No correlation was found between pyrene exposure and the urinary 1-OH-pyrene level of the five workers who wore the personal samplers. A significant positive correlation was observed between the urinary 1-OH-pyrene level and urinary cotinine level of the smokers. A significant positive correlation was also observed between the urinary 1-OH-pyrene and urinary cotinine levels of the control group smokers. In conclusion, urinary 1-OH-pyrene is not applicable for biological monitoring of extremely low levels of exposure to PAHs, as in the case of working in the street. Caution is required to exclude the effects of smoking when evaluating PAH exposure.

Is family history an independent risk factor for stroke?

OBJECTIVE: To estimate the influence of family history on the occurrence of stroke. METHODS: A case-control study was carried out from August 1992 to January 1994. The study population comprised 502 patients with a first stroke, aged between 20 and 70 years, who were treated at 48 affiliated hospitals. The same number of age and sex matched controls were selected from outpatients. Diagnoses were based on CT findings and clinical signs. There were 155 case-control pairs for subarachnoid haemorrhage, 158 for intracerebral haematoma, and 159 for cerebral infarction. Information about the patients and their families was obtained from a questionnaire which included the family histories of each subtype of stroke and other potential risk factors for stroke. The data were analysed focusing on the role of the family histories in the occurrence of stroke. RESULTS: In univariate analysis, the family histories of subarachnoid haemorrhage and intracerebral haematoma were positively associated with each of the subtypes of stroke (odds ratios 11.24 for subarachnoid haemorrhage, 2.39 for intracerebral haematoma), whereas family history of cerebral infarction was not a significant risk factor for its occurrence (odds ratio 1.41). Family history of intracerebral haematoma was correlated with a personal history of hypertension and habitual alcohol consumption. After adjustment for potential risk factors (hypertension, diabetes, hyperlipidaemia, obesity, alcohol consumption, and regular smoking), family history of subarachnoid haemorrhage still remained the most powerful risk factor for subarachnoid haemorrhage, whereas family history of intracerebral haematoma no longer showed a significant association with haematoma. CONCLUSION: Genetic factors play a major part in the pathogenesis of subarachnoid haemorrhage, and family history of subarachnoid haemorrhage is the strongest independent risk factor for the disease. On the other hand, family history of intracerebral haematoma was not an independent risk factor for haematoma, but it might be a good predictor, which indirectly influences the pathogenesis of intracerebral haematoma via certain hereditary components such as hypertension, and even lifestyle factors such as alcohol consumption. In cerebral infarction, genetic factors play a minor part in its pathogenesis.

[Reversal of portal-systemic encephalopathy by shunt-preserving disconnection of portal and systemic circulation].

Obliteration of portal-systemic shunts surgically or by interventional radiological techniques is fairly effective in reversing intractable portal-systemic encephalopathy (PSE), but is often associated with ascites accumulation and/or formation of esophageal varices. This study reports four patients with incapacitating PSE who were treated by interventional radiological techniques via percutaneous transhepatic route. One case had the shunt embolized directly. In the other three the blockage was placed on the proximal part of the splenic vein, whereby disconnecting the mesenteric-portal blood flow from the systemic circulation while preserving the shunt. The patient of shunt closure showed transient correction of encephalopathy, but developed massive ascites and esophageal varices, encephalopathy recurred, resulting in death from hepatic failure two months after the procedure. In the cases of shunt-preserving disconnection of portal and systemic circulation (SPDPS) immediate and permanent clearing of encephalopathy was achieved without manifestation of ascites or esophageal varices during the follow-up period of 10 to 31 months. The difference of portal pressure between before and after the procedure was 18 mmHg in the shunt-closed patient and 3 mmHg in SPDPS group. We conclude from this limited experience that SPDPS can be an effective and safe method in treating PSE in adequately selected patients.