Identification of plasmids in avian-associated Escherichia coli using nanopore and illumina sequencing.

BACKGROUND: Avian pathogenic Escherichia coli (APEC) are the causative agents of colibacillosis in chickens, a disease which has significant economic impact on the poultry industry. Large plasmids detected in APEC are known to contribute to strain diversity for pathogenicity and antimicrobial resistance, but there could be other plasmids that are missed in standard analysis. In this study, we determined the impact of sequencing and assembly factors for the detection of plasmids in an E. coli whole genome sequencing project. RESULTS: Hybrid assembly (Illumina and Nanopore) combined with plasmid DNA extractions allowed for detection of the greatest number of plasmids in E. coli, as detected by MOB-suite software. In total, 79 plasmids were identified in 19 E. coli isolates. Hybrid assemblies were robust and consistent in quality regardless of sequencing kit used or if long reads were filtered or not. In contrast, long read only assemblies were more variable and influenced by sequencing and assembly parameters. Plasmid DNA extractions allowed for the detection of physically smaller plasmids, but when averaged over 19 isolates did not significantly change the overall number of plasmids detected. CONCLUSIONS: Hybrid assembly can be reliably used to detect plasmids in E. coli, especially if researchers are focused on large plasmids containing antimicrobial resistance genes and virulence factors. If the goal is comprehensive detection of all plasmids, particularly if smaller sized vectors are desired for biotechnology applications, the addition of plasmid DNA extractions to hybrid assemblies is prudent. Long read sequencing is sufficient to detect many plasmids in E. coli, however, it is more prone to errors when expanded to analyze a large number of isolates.

Computational Modeling and Design of New Inhibitors of Carbapenemases: A Discussion from the EPIC Alliance Network.

The EPIC consortium brings together experts from a wide range of fields that include clinical, molecular and basic microbiology, infectious diseases, computational biology and chemistry, drug discovery and design, bioinformatics, biochemistry, biophysics, pharmacology, toxicology, veterinary sciences, environmental sciences, and epidemiology. The main question to be answered by the EPIC alliance is the following: "What is the best approach for data mining on carbapenemase inhibitors and how to translate this data into experiments?" From this forum, we propose that the scientific community think up new strategies to be followed for the discovery of new carbapenemase inhibitors, so that this process is efficient and capable of providing results in the shortest possible time and within acceptable time and economic costs.

Writing for Wikipedia: An Exercise in Microbiology, Writing, Research, Communication, and Public Service.

The COVID-19 pandemic has had a tremendous impact on how postsecondary education was and is delivered. Educators were forced to rapidly move their instruction online and find new and innovative ways to convey content, stimulate student engagement, and satisfy curricular requirements. The purpose of this article is to describe the use of a Wikipedia writing assignment in Veterinary Bacteriology and Mycology, a second-year course in the Doctor of Veterinary Medicine (DVM) curriculum at the University of Saskatchewan. Students had the opportunity to write and edit incomplete articles on topics related to course content. In addition to deep exploration of a topic, this fostered in students the development of research and communication skills, which have been articulated as core competencies in veterinary programs.

A review of antimicrobial resistance in imported foods.

Antimicrobial resistance is one of the most serious threats to medical science. Food supply is recognized as a potential source of resistant bacteria, leading to the development of surveillance programs targeting primarily poultry, pork, and beef. These programs are limited in scope, not only in the commodities tested, but also in the organisms targeted (Escherichia coli, Salmonella, and Campylobacter); consequently, neither the breadth of food products available nor the organisms that may harbour clinically relevant and (or) mobile resistance genes are identified. Furthermore, there is an inadequate understanding of how international trade in food products contributes to the global dissemination of resistance. This is despite the recognized role of international travel in disseminating antimicrobial-resistant organisms, notably New Delhi metallo-beta-lactamase. An increasing number of studies describing antimicrobial-resistant organisms in a variety of imported foods are summarized in this review.

Evaluation of selective media in antimicrobial surveillance programs capturing broad-spectrum ß-lactamase producing Escherichia coli from chickens at slaughter.

Antimicrobial resistance surveillance targeting agricultural animals is practiced in many countries but does not often include media selective for cephalosporin resistance. Here, we compared the frequency of recovery of resistant Escherichia coli using selective and non-selective media from the cecal contents of 116 chickens collected by the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS). Third generation cephalosporin resistance was detected in 24 samples including 12, 10, and 2 on selective, non-selective, and both media, respectively. Isolates producing the CTX-M-1 ESBL were grown from 11 samples, 10 on selective medium only. Our results suggest that current surveillance approaches underestimate the true prevalence of resistance to critically important antimicrobials.

Évaluation de milieux sélectifs dans des programmes de surveillance antimicrobienne isolant Escherichia coli produisant des ß-lactamases à large spectre provenant de poulets à l'abattage. La surveillance de la résistance aux antimicrobiens ciblant les animaux d'élevage est pratiquée dans de nombreux pays mais n'inclut pas souvent les milieux sélectifs pour la résistance aux céphalosporines. Ici, nous avons comparé la fréquence d'isolement d'Escherichia coli résistants à l'aide de milieux sélectifs et non sélectifs à partir du contenu caecal de 116 poulets collectés dans le cadre du Programme intégré canadien de surveillance de la résistance aux antimicrobiens (PICRA). Une résistance aux céphalosporines de troisième génération a été détectée dans 24 échantillons dont 12, 10 et 2 sur des milieux sélectifs, non sélectifs et les deux, respectivement. Les isolats produisant les BLSE CTX-M-1 ont été cultivés à partir de 11 échantillons, 10 sur un milieu sélectif uniquement. Nos résultats suggèrent que les approches de surveillance actuelles sous-estiment la prévalence réelle de la résistance aux antimicrobiens d'importance critique.(Traduit par Dr Serge Messier).

Epidemiological and genomic characterization of community-acquired Clostridium difficile infections.

BACKGROUND: Clostridium difficile infection (CDI) is a major cause of morbidity and mortality in North America and Europe. The aim of this study was to identify epidemiologically-confirmed cases of community-acquired (CA)-CDI in a large North American urban center and analyze isolates using multiple genetic and phenotypic methods. METHODS: Seventy-eight patients testing positive for C. difficile from outpatient clinics were further investigated by telephone questionnaire. CA-CDI isolates were characterized by antibiotic susceptibility, pulsed-field gel electrophoresis and whole genome sequencing. CA-CDI was defined as testing positive greater than 12 weeks following discharge or no previous hospital admission in conjunction with positive toxin stool testing. RESULTS: 51.3% (40/78) of the patients in this study were found to have bona fide CA-CDI. The majority of patients were female (71.8% vs. 28.2%) with 50-59 years of age being most common (21.8%). Common co-morbidities included ulcerative colitis (1/40; 2.5%), Crohn's disease (3/40; 7.5%), celiac disease (2/40; 5.0%) and irritable bowel syndrome (8/40; 20.0%). However, of 40 patients with CA-CDI, 9 (29.0%) had been hospitalized between 3 and 6 months prior and 31 (77.5%) between 6 and 12 months prior. The hypervirulent North American Pulostype (NAP) 1-like (9/40; 22.5%) strain was the most commonly identified pulsotype. Whole genome sequencing of CA-CDI isolates confirmed that NAP 1-like pulsotypes are commonplace in CA-CDI. From a therapeutic perspective, there was universal susceptibility to metronidazole and vancomycin. CONCLUSIONS: All CA-CDI cases had some history of hospitalization if the definition were modified to health care facility exposure in the last 12 months and is supported by the genomic analysis. This raises the possibility that even CA-CDI may have nosocomial origins.

Antimicrobial resistance and beta-lactamase production of Escherichia coli causing canine urinary tract infections: Passive surveillance of laboratory isolates in Saskatoon, Canada, 2014.

The antimicrobial susceptibility of canine urinary Escherichia coli (n = 113) isolated by a regional diagnostic laboratory over a 1-year period was determined. Antimicrobial minimum inhibitory concentrations were determined, and those isolates resistant to beta-lactams were screened for broad-spectrum beta-lactamases. Isolates were unexpectedly susceptible, 79.6% were susceptible to all drugs tested and no extended-spectrum beta-lactamases were identified. Our findings indicate that empiric treatment of canine urinary tract infections with first line drugs such as amoxicillin or trimethoprim + sulfamethoxazole is likely to be successful.

Résistance antimicrobienne et production de bêta-lactamase parEscherichia colicausant des infections des voies urinaires canines : surveillance passive des isolats de laboratoire à Saskatoon, au Canada, en 2014. La susceptibilité antimicrobienne de la bactérie Escherichia coli (n = 113) d'origine urinaire canine isolée par un laboratoire de diagnostique régional pendant une période de 1 an a été déterminée. Les concentrations inhibitrices minimales d'antimicrobiens ont été déterminées et les isolats résistants aux bêta-lactamines ont été vérifiés pour la production de bêta-lactamases à large spectre. Fait inattendu, les isolats étaient sensibles et 79,6 % étaient sensibles à tous les médicaments testés et aucune bêta-lactamase à large spectre prolongé n'a été identifiée. Nos résultats indiquent que le traitement empirique des infections des voies urinaires canines avec des médicaments de première ligne, comme amoxicilline ou triméthoprime + sulfaméthoxazole, se traduira probablement par un succès du traitement.(Traduit par Isabelle Vallières).

Antimicrobial susceptibility of Staphylococcus pseudintermedius colonizing healthy dogs in Saskatoon, Canada.

This study reports antimicrobial susceptibility of Staphylococcus pseudintermedius carried by healthy dogs in Saskatoon, and describes changes in antimicrobial resistance since a 2008 study. One hundred healthy dogs presenting to the wellness service at the Western College of Veterinary Medicine were screened for S. pseudintermedius by culturing rectal and pharyngeal swabs. Staphylococcus pseudintermedius was identified biochemically and antimicrobial minimum inhibitory concentrations were determined by broth microdilution. Methicillin resistance was confirmed by polymerase chain reaction (PCR) and sequencing of the mecA gene. Of 221 S. pseudintermedius isolates from 78 dogs, 7 were methicillin resistant. No resistance to the fluoroquinolones, nitrofurantoin, tigecycline, vancomycin, quinupristin-dalfopristin, linezolid, or daptomycin was identified. Of the 78 positive dogs, isolates resistant to penicillin were found in 78%, to ampicillin in 61% and to tetracycline in 26%; resistance to oxacillin, erythromycin, clindamycin, trimethoprim + sulfamethoxazole, chloramphenicol, and gentamicin was found in < 10% of dogs. Compared to the 2008 study, the frequency of resistance to all drugs increased, and the frequency of colonization with pan-susceptible isolates decreased from 46% to 30%.

Susceptibilité antimicrobienne deStaphylococcus pseudintermediuscolonisant des chiens en santé à Saskatoon, au Canada. Cette étude présente un rapport sur la susceptibilité de Staphylococcus pseudintermedius chez des chiens porteurs en santé à Saskatoon et décrit les changements de la résistance antimicrobienne depuis une étude réalisée en 2008. On a réalisé un dépistage auprès de 100 chiens en santé présentés au service de bien-être du Western College of Veterinary Medicine pour S. pseudintermedius en réalisant une culture d'écouvillons rectaux et pharyngés. Staphylococcus pseudintermedius a été identifié par des tests biochimiques et les concentrations minimales inhibitrices d'antimicrobiens ont été déterminées par microdilution en bouillon. La résistance à la méthicilline a été confirmée par ACP et le séquençage du gène mecA. Parmi les 221 isolats de S. pseudintermedius provenant de 78 chiens, 7 étaient résistants à la méthicilline. Aucune résistance aux fluoroquinolones, à la nitrofurantoine, à la tigecycline, à la vancomycine, à la quinupristine-dalfopristine, au linézolide ou à la daptomycine n'a été identifiée. Parmi les 78 chiens positifs, des isolats résistants à la pénicilline ont été trouvés chez 78 %, à l'ampicilline chez 61 % et à la tétracycline chez 26 %; la résistance à l'oxacilline, à l'érythromycine, à la clindamycine, au triméthoprime + sulfaméthoxazole, au chloramphenicol et à la gentamicine a été trouvée chez < 10 % des chiens. Comparativement à l'étude de 2008, la fréquence de la résistance à tous les médicaments a augmenté et la fréquence de la colonisation par des isolats sensibles a chuté de 46 % à 30 %.(Traduit par Isabelle Vallières).

Travel-related carbapenemase-producing Gram-negative bacteria in Alberta, Canada: the first 3 years.

We describe here the characteristics of Alberta, Canada, patients with infections or colonizations with carbapenemase-producing Gram-negative bacteria during 2010 to 2013 that were linked to recent travel outside Canada. Antimicrobial susceptibility was determined by broth microdilution, and isolates were characterized using PCR, sequencing, and multilocus sequencing typing. A broth mating study was used to assess the transferability of resistance plasmids, which were subsequently characterized. All the patients (n=12) included in our study had contact with a health care system while abroad. Most of the patients presented with urinary tract infections (UTIs) and were admitted to hospitals within weeks after their return to Alberta. Secondary spread occurred in 1 case, resulting in the death of another patient. The carbapenemase-producing bacteria (n=17) consisted of Escherichia coli (sequence type 101 [ST101], ST365, ST405, and ST410) with NDM-1, Klebsiella pneumoniae (ST15, ST16, ST147, ST258, ST340, ST512, and ST972) with NDM-1, OXA-181, KPC-2, and KPC-3, Acinetobacter baumannii with OXA-23, Providencia rettgeri with NDM-1, Enterobacter cloacae with KPC-2, and Citrobacter freundii with NDM-1. The blaNDM-1 gene was associated with various narrow- (i.e., IncF) and broad- (i.e., IncA/C and IncL/M) host-range plasmids with different addiction factors. Our results show that NDM-producing K. pneumoniae, belonging to a variety of sequence types with different plasmid scaffolds, are regularly imported from India into Alberta. Clinical microbiology laboratories should remain vigilant in detecting bacteria with carbapenemases.

Confirmation that "Brachyspira hampsonii" clade I (Canadian strain 30599) causes mucohemorrhagic diarrhea and colitis in experimentally infected pigs.

BACKGROUND: "Brachyspira hampsonii", discovered in North America in 2010 associated with dysentery-like illness, is an economically relevant swine pathogen resulting in decreased feed efficiency and increased morbidity, mortality and medication usage. "B. hampsonii" clade II strain 30446 has been shown to be causally associated with mucohemorrhagic diarrhea and colitis. Our objectives were to determine if "Brachyspira hampsonii" clade I strain 30599 is pathogenic to pigs, and to evaluate the relative diagnostic performance of three ante mortem sampling methodologies (direct PCR on feces, PCR on rectal GenoTube Livestock swabs, Brachyspira culture from rectal swabs). Five-week old pigs were intragastrically inoculated thrice with 108 genomic equivalents "B. hampsonii" (n = 12), or served as sham controls (n = 6). Feces were sampled and consistency assessed daily. Necropsies were performed 24 h after peak clinical signs. RESULTS: One pig died due to unrelated illness. Nine of 11 inoculated pigs, but no controls, developed mucoid or mucohemorrhagic diarrhea (MHD). Characteristic lesions of swine dysentery were observed in large intestine. "B. hampsonii" strain 30599 DNA was detected by qPCR in feces of all inoculated pigs for up to 6 days prior to the onset of MHD. The organism was isolated from the feces and colons of pigs demonstrating MHD, but not from controls. B. intermedia was isolated from inoculated pigs without MHD, and from 5 of 6 controls. CONCLUSIONS: We conclude that "Brachyspira hampsonii" clade I strain 30599 is pathogenic and causes mucohemorrhagic diarrhea and colitis in susceptible pigs. Moreover, the three sampling methodologies performed similarly. GenoTube Livestock, a forensic swab designed to preserve DNA during shipping is a useful tool especially in settings where timely transport of diagnostic samples is challenging.

Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial.

BACKGROUND: This study sought to describe the results of a single-arm multicenter clinical trial using image-guided percutaneous cryoablation for the palliation of painful metastatic tumors involving bone. METHODS: Over a 44-month period, 61 adult patients with 1 or 2 painful bone metastases with a score of 4 or more on a scale of 0 to 10 (≥4/10) worst pain in a 24-hour period who had failed or refused conventional treatment were treated with percutaneous image-guided cryoablation. Patient pain and quality of life was measured using the Brief Pain Inventory prior to treatment, 1 and 4 days after the procedure, weekly for 4 weeks, and every 2 weeks thereafter for a total of 6 months. Patient analgesic use was also recorded at these same follow-up intervals. Complications were monitored. Analysis of the primary endpoint was undertaken via paired comparison procedures. RESULTS: A total of 69 treated tumors ranged in size from 1 to 11 cm. Prior to cryoablation, the mean score for worst pain in a 24-hour period was 7.1/10 with a range of 4/10 to 10/10. At 1, 4, 8, and 24 weeks after treatment, the mean score for worst pain in a 24-hour period decreased to 5.1/10 (P < .0001), 4.0/10 (P < .0001), 3.6/10 (P < .0001), and 1.4/10 (P < .0001), respectively. One of 61 (2%) patients had a major complication with osteomyelitis at the site of ablation. CONCLUSIONS: Percutaneous cryoablation is a safe, effective, and durable method for palliation of pain due to metastatic disease involving bone.

Isolation and characterization of Brachyspira spp. including "Brachyspira hampsonii" from lesser snow geese (Chen caerulescens caerulescens) in the Canadian Arctic.

Brachyspira is associated with diarrhea and colitis in pigs, and control of these pathogens is complicated by their complex ecology. Identification of wildlife reservoirs of Brachyspira requires the discrimination of colonized animals and those simply contaminated through environmental exposure. Lesser snow geese (Chen caerulescens caerulescens) were sampled in the Canadian arctic during the summer of 2011, and cloacal swabs were cultured on selective media. Brachyspira isolates were obtained from 15/170 (8.8 %) samples, and 12/15 isolates were similar to isolates previously recovered from pigs, including "Brachyspira hampsonii", a recently characterized species associated with dysentery-like disease in pigs in North America. A pilot inoculation study with one strongly ß-hemolytic B. hampsonii isolate resulted in fecal shedding of the isolate by inoculated pigs for up to 14 days post-inoculation, but no severe clinical disease. Results of this study indicate that lesser snow geese can be colonized by Brachyspira strains that can also colonize pigs. Millions of lesser snow geese (C. caerulescens caerulescens) travel through the major pork-producing areas of Canada and the USA during their annual migration, making them a potential factor in the continental distribution of these bacteria.

Fecal shedding of Brachyspira spp. on a farrow-to-finish swine farm with a clinical history of "Brachyspira hampsonii"-associated colitis.

BACKGROUND: Brachyspira associated diarrhea is a re-emerging concern for Canadian swine producers. To identify critical control points for reducing the impact of Brachyspira on production, improved diagnostic tools and a better understanding of the on-farm epidemiology of these pathogens are required. A cross-sectional study was conducted for the detection of Brachyspira on a commercial, two-site, farrow-to-finish pork production unit in Saskatchewan, Canada with a clinical history of mucohaemorrhagic colitis associated with "B. hampsonii". RESULTS: Rectal swabs from pigs at all production stages were collected over 13 weeks (n=866). Two swabs were collected per pig for culture and Gram stain, and for PCR. Ninety-one culture positive samples were detected, with the highest prevalence of Brachyspira shedding in grower pigs (21%). No Brachyspira were detected in pre-weaned piglets. PCR and Gram stain of rectal swabs detected fewer positive samples than culture. The most prevalent species detected was B. murdochii; other species detected included B. pilosicoli, B. innocens, and "Brachyspira hampsonii". Phylogenetic analysis revealed that several of the isolates, including some strongly beta-haemolytic isolates, might represent novel taxa. CONCLUSIONS: Our results indicate that apparently healthy pigs can be colonized with diverse Brachyspira species, including some potential pathogens, and that frequency of shedding peaks in the grower stage. Difference in the detection rates of Brachyspira amongst culture, Gram stain or PCR on rectal swabs have implications for choice of detection methods and surveillance approaches that may be most effective in Brachyspira control strategies.

Antimicrobial susceptibility of western Canadian Brachyspira isolates: Development and standardization of an agar dilution susceptibility test method.

The re-emergence of Brachyspira-associated disease in pigs since the late 2000s has illuminated some of the diagnostic challenges associated with this genus; notably, the lack of standardized antimicrobial susceptibility testing (AST) methods and interpretive criteria. Consequently, laboratories have relied heavily on highly variable in-house developed methods. There are currently no published investigations describing the antimicrobial susceptibility of Brachyspira isolates collected from pigs in Canada. The first objective of this study was therefore to develop a standardized protocol for conducting agar dilution susceptibility testing of Brachyspira spp., including determining the optimal standardized inoculum density, a key test variable that impacts test performance. The second objective was to determine the susceptibility of a collection of western Canadian Brachyspira isolates using the standardized methodology. After assessing multiple media, an agar dilution test was standardized in terms of starting inoculum (1-2 × 108 CFU/ml), incubation temperature and time, and assessed for repeatability. The antimicrobial susceptibility of a collection of clinical porcine Brachyspira isolates (n = 87) collected between 2009-2016 was then determined. This method was highly reproducible; repeat susceptibility testing yielded identical results 92% of the time. Although most of the isolates had very low MICs to the commonly used antimicrobials to treat Brachyspira-associated infections, several isolates with elevated MICs (>32 µg/ml) for tiamulin, valnemulin, tylosin, tylvalosin, and lincomycin were identified. Overall, this study underscores the importance of establishing CLSI approved clinical breakpoints for Brachyspira to facilitate the interpretation of test results and support the evidence-based selection of antimicrobials in swine industry.

Hybrid Genome Assemblies of 245 Avian and Broiler Barn Environment-Associated Escherichia coli Strains Isolated from Saskatchewan Broiler Farms.

Escherichia coli infections in poultry cause significant morbidity and economic losses for producers each year. In a 3-year period, we collected and sequenced the whole genomes of E. coli disease isolates (n = 91), isolates from presumed healthy birds (n = 61), and isolates from 8 barn sites (n = 93) on broiler farms in Saskatchewan.

Perceptual Barriers to Becoming a Plastic Surgeon among Underrepresented Medical Students.

Background: The field of plastic surgery has experienced difficulty increasing diversity among trainees, despite significant efforts. Barriers to recruitment of underrepresented in medicine (URM) students are poorly understood. This study assesses URM students' exposure to plastic surgery, access to mentors and research opportunities, and the importance of diversity in the field. Methods: A survey was designed and distributed to members of the Student National Medical Association over 3 months. Survey data were collected using Qualtrics and descriptive statistics, and logistical regressions were performed using SAS. Results: Of the 136 respondents, 75.0% identified as Black (n = 102/136), and 57.4% (n = 66/115) reported a plastic surgery program at their home institution. Of the total respondents, 97.7% (n = 127/130) were concerned about racial representation in plastic surgery, and 44.9% (n = 53/114) would be more likely to apply if there were better URM representation. Most respondents disagreed that there was local (73.4%, n = 58/79) or national (79.2%, n = 57/72) interest in URM recruitment. Students whose plastic surgery programs had outreach initiatives were more likely to have attending (OR 11.7, P < 0.05) or resident mentors (OR 3.0 P < 0.05) and access to research opportunities (OR 4.3, P < 0.05). Conclusions: URM students feel there is an evident lack of interest in recruiting URM applicants in plastic surgery. Programs with outreach initiatives are more likely to provide URM students access to mentorship and research opportunities, allowing students to make informed decisions about pursuing plastic surgery.

Hepatic artery embolization for neuroendocrine tumors: postprocedural management and complications.

BACKGROUND: There is scant evidence to guide the management of patients after hepatic artery embolization (HAE). We examined length of stay (LOS), laboratory patterns, medication usage, morbidity, and mortality of patients hospitalized after HAE for metastatic neuroendocrine tumors. METHODS: Data were abstracted retrospectively from electronic medical records on LOS, liver function tests (LFTs), i.v. antibiotics, analgesia, peak temperature, bacteremia, hepatic abscess formation, carcinoid crisis, and metastatic burden on cross-sectional imaging. RESULTS: In 2005-2009, 72 patients underwent 174 HAEs for carcinoid and islet cell tumors. The median LOS was 4 days (range, 1-8 days). There was no correlation between peak LFTs and tumor burden. Declines in LFTs were not uniform before hospital discharge; 25%, 37%, 30%, 53%, and 67% of patients were discharged before their respective aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total and direct bilirubin levels began to decline, with no readmissions for acute hepatic failure. The median i.v. analgesia dose was 60 mg oral morphine equivalents (range, 3-1,961 mg). Pre-HAE i.v. antibiotics were administered in 99% of cases; post-HAE fever occurred in 37% of patients, with no documented bacteremia. One patient developed a hepatic abscess after HAE. There were two carcinoid crises. The single in-hospital death was associated with air in the portal veins. CONCLUSIONS: The duration and intensity of in-hospital care following HAE should be managed on an individual basis. A downward trend in LFTs is not required before discharge. Modest use of i.v. analgesia suggests that many patients could exclusively receive oral analgesics. Given the rarity of serious complications, hospital stays could be shortened, thereby reducing costs and nosocomial risks.

An international, multicenter phase II trial of bortezomib in patients with hepatocellular carcinoma.

BACKGROUND AND RATIONALE: Bortezomib (PS-341, VELCADE®) is a selective inhibitor of the 26S proteasome, an integral component of the ubiquitin-proteasome pathway. This phase II study evaluated the activity and tolerability of bortezomib in unresectable hepatocellular carcinoma (HCC) patients. METHODS: The primary endpoint was confirmed tumor response rate (RR) with secondary endpoints including duration of response, time to disease progression, survival and toxicity. Treatment consisted of bortezomib, 1.3 mg/m2 IV bolus on days 1, 4, 8, and 11 of each 21-day treatment cycle. Eligibility included: no prior systemic chemotherapy, ECOG PS 0-2, Child-Pugh A or B, preserved hematologic, hepatic and neurologic function; prior liver-directed therapy was permitted. RESULTS: Thirty-five patients enrolled and received a median of 2 cycles of treatment (range 1-12). Overall, 24 and 4 patients had a maximum severity of grade 3 and 4 adverse events (AEs), respectively. No treatment related deaths occurred. Only thrombocytopenia (11%) was seen in greater than 10% of patients. One patient achieved a partial response, lasting 13 weeks during treatment and progressed 11.6 months later; two patients received treatment for greater than 6 months. Median time-to-progression was 1.6 months and median survival was 6.0 months. CONCLUSIONS: This international, multicenter trial evaluated bortezomib as monotherapy in unresectable HCC patients. And, despite the lack of significant activity, this report serves as a baseline clinical experience for the development of future dual biologic approaches including bortezomib.