Increased salivary syndecan-1 level is associated with salivary gland function and inflammation in patients with Sjögren's syndrome.

OBJECTIVE: Syndecan-1 (SDC-1), a transmembrane heparin sulphate proteoglycan predominantly expressed on epithelial cells, also exists in a soluble form through ectodomain shedding. SDC-1 expression and shedding may be modulated in the inflammatory milieu of primary Sjögren's syndrome (SS). We investigated SDC-1 expression in minor salivary glands (MSGs) and analysed the association between salivary or plasma levels of SDC-1 and clinical parameters in SS. METHOD: We measured salivary and plasma SDC-1 levels via an enzyme-linked immunosorbent assay and assessed the salivary flow rates (SFRs) in 70 patients with SS and 35 healthy subjects. Disease activity indices, serological markers, salivary gland scintigraphy, and MSG biopsy were evaluated in patients with SS. RESULTS: SDC-1 expression was upregulated on ductal epithelial cells in inflamed salivary glands. Salivary SDC-1 levels in patients significantly exceeded those in healthy subjects [median (interquartile range) 49.0 (20.7-79.1) vs 3.7 (1.7-6.3) ng/mL, p < 0.001] and inversely correlated with SFRs (r = -0.358, p = 0.032) and ejection fractions of the parotid (r = -0.363, p = 0.027) and submandibular (r = -0.485, p = 0.002) glands in salivary gland scintigraphy. Plasma SDC-1 levels were significantly correlated with the EULAR Sjögren's Syndrome Disease Activity Index (r = 0.507, p < 0.001) and EULAR Sjögren's Syndrome Patient Reported Index (r = 0.267, p = 0.033). Focus scores were correlated with salivary SDC-1 levels (r = 0.551, p = 0.004). CONCLUSIONS: Salivary and plasma SDC-1 levels may constitute potential biomarkers for salivary gland function and disease activity, respectively, in SS.

Incidence and Distribution of the Pathogens Causing Central Nervous System Infections at the University Hospital of Korea.

BACKGROUND: The pathogens involved in central nervous system (CNS) infections are various, such as viruses, bacteria, and fungi, so a syndromic approach can be required. In addition, since their rapid and accurate detection is very crucial, molecular diagnostics using cerebrospinal fluid is becoming the emerging standard method. METHODS: The study was conducted retrospectively to identify the incidence and distribution patterns of the pathogens according to gender, age, season, and month and to analyze their codetection from August 2017 to July 2020. It was also conducted to investigate turn-around times (TATs) according to the detection method. The detection methods were FilmArray® Meningitis/Encephalitis (M/E) method (FilmArray), Cepheid® Xpert EV assay (Xpert), and Multiplex PCR method for five species of bacteria. RESULTS: The overall incidence for at least one pathogen was 13.9% (346/2,496). The highest incidence was shown in age group 4 (3 - 6 years), with 27.4%. The detection rates by FilmArray, Xpert, and Multiplex PCR method were 39.8%, 41.7%, and 0.4%, respectively. Enterovirus (EV) showed the highest incidence rate, which accounted for 37.0%. The distribution of the pathogens according to the age groups were the highest in age group 4, with 47.5% (168/354), followed by 27.4% (97/354) in age group 5. Of the ten cases in which bacteria were detected, S. agalactiae accounted for 60.0% (6/10), most of which occurred in age group 1. E. coli K1, L. monocytogenes, and N. meningitidis were not detected. In the viral distribution, EV accounted for the highest proportion in all age groups. The overall proportion of EV accounted for 87.6% (310/354), followed by human parechovirus with 2.8% (10/354). The most commonly detected season was summer, comprising 75.1%. A total of eight cases of co-detection with two pathogens accounted for 1.6% (8/507) in FilmArray. In FilmArray, all TATs were found to be shorter than Xpert. CONCLUSIONS: The information on the incidence and distribution patterns of the pathogens causing CNS infections and their rapid detection are critically important to clinicians in the management of immunocompromised patients, elderly, and children. The expeditious molecular diagnostics for these pathogens would be valuable in medical decisions by clinicians.

Fluoroquinolone resistance in Haemophilus influenzae from nursing home residents in Taiwan: correlation of MICs and mutations in QRDRs.

AIMS: To study the association between number and positions of mutations with MICs of fluoroquinolone non-susceptible Haemophilus influenzae. METHODS AND RESULTS: More than 40% of 48 H. influenzae isolated from nursing home residents were not susceptible to fluoroquinolone. Amino acid changes in the quinolone resistance determining regions, and correlation with MICs and inhibition zone diameters were analysed. All isolates with reduced susceptibility to fluoroquinolones (MIC ≥0·125 µg ml-1 ) had at least one mutation in gyrA at position 84 and were resistant to nalidixic acid. Compared to isolates with reduced susceptibility, resistant isolates were associated with mutations in gyrA at positions 88 and 134, and in parC at position 88 (P < 0·001). Inhibition zone diameter for nalidixic acid disk ≥23 mm may detect susceptible isolates. CONCLUSIONS: Reduced susceptibility to fluoroquinolones was associated with mutations at position 84 in gyrA. A further increase in fluoroquinolone MIC was associated with mutations in gyrA at positions 88 and 134, and parC at position 88. SIGNIFICANCE AND IMPACT OF THE STUDY: Due to limited resistant H. influenzae strains, prior studies on association between positions of mutations and fluoroquinolone MICs were inconclusive. The comparison of mutations between isolates with susceptibility, reduced susceptibility and high resistance supported the importance of the present study.

Incidence and Distribution of Respiratory Microorganisms Causing Acute Respiratory Infections at the University Hospital of Korea.

BACKGROUND: Acute respiratory infection caused by respiratory microorganisms including various kinds of viruses and bacteria is the most common infectious disease. When managing patients, it is crucial to detect these microorganisms rapidly and monitor their occurrence and tendency. Recently, the methods of detecting them have been implemented by molecular diagnostics. The authors intended to investigate their incidence and distribution and identify the significance of the molecular diagnosis for their detection. METHODS: The retrospective study was conducted to investigate the incidence and distribution of respiratory microorganisms according to the age, gender, month, season, and the detection method and to analyze their co-infections from July 2016 to December 2019. In addition, the four types of turn-around time (TAT) for each detec-tion method were also analyzed. RESULTS: The overall incidence for at least one respiratory microorganism was 23.1% (3,645/15,808). The highest incidence was identified in age group 2 (1 - 3 months), 38.5%. The incidence rates by multiplex PCR using Anyplex and Allplex, FilmArray method, and influenza virus (flu) antigen detection test were 44.2% (718/1,625), 63.1% (1,198/1,899), and 14.1% (1,729/12,284), respectively. The overall incidence between male and female patients showed no statistically significant difference (p = 0.980), except for the flu antigen detection test (p = 0.000). Influenza A viruses (flu A) accounted for the highest percentage (34.9%), followed by rhinovirus/enterovirus (20.5%), RSV (12.8%), flu B (8.3%), and adenovirus (7.6%). These microorganisms showed characteristic distribution patterns according to season and month. Flu A and flu B predominated in winter and accounted for an increasing proportion as age increased according to the age groups. The overall co-infection rate was 22.5% (432/1,916). The average TATs of the FilmArray method were significantly much faster than multiplex PCR using Anyplex and Allplex (p = 0.000). CONCLUSIONS: The information on the incidence and distribution of respiratory microorganisms and their expeditious detection are considered critical to the management of the elderly, immunocompromised patients, and children. The rapid molecular-based diagnosis of respiratory infections would be beneficial in medical decision and prevention of their propagation.

Types and Frequencies of Pre-Analytical Errors in the Clinical Laboratory at the University Hospital of Korea.

BACKGROUND: The results of laboratory tests play a critical role in patient management, so the clinical laboratory is obligated to report accurate results. However, the pre-analytical phase, in which human factors are mainly involved, is clearly a vulnerable part of the laboratory process. This study was conducted to investigate and analyze pre-analytical errors. The author intended to reduce these errors by some measures in order to enhance the credibility of the laboratory. METHODS: A retrospective study was conducted to identify the rates and the types and frequencies of pre-analytical errors in the laboratory and analyze them according to the departments of patients, the sections of the laboratory, and the wards of the hospital. The reasons for these errors were persistently identified and analyzed in order to make efforts to reduce the errors. The activities for quality improvement including education and training programs on the phlebotomy teams were also accomplished to reduce these errors. RESULTS: The overall rate of pre-analytical errors was 0.40%. The rate of these errors significantly decreased from 0.44% in 2017 to 0.36% in 2018. In particular, the proportion of improper volume decreased from 46.1% in 2017 to 36.4% in 2018. The most common pre-analytical error was 'improper volume' (41.5%), followed by 'undue clotting' (32.8%). These errors were overwhelmingly more common in inpatients than in outpatients. The rate of these errors was the highest in stat section (1.95%). CONCLUSIONS: Clinical laboratory should make efforts to reduce pre-analytical errors in order to report accurate and expeditious results. Reduction of these errors can be achieved through analyzing and correcting the reasons for them and education and training on the phlebotomy teams and, as a result, the credibility of the laboratory may also be enhanced.

Nanoporous anodic aluminum oxide internalized with gold nanoparticles for on-chip PCR and direct detection by surface-enhanced Raman scattering.

Nanoporous anodic aluminum oxide internalized with gold nanoparticles was utilized as an integrated platform miniaturized for consecutively performing on-chip PCR and downstream detection of the amplified product of a 183 bp eaeA gene fragment from Escherichia coli O157:H7 using surface-enhanced Raman scattering (SERS).

Empirical combination of a ß-lactam to vancomycin may not improve outcomes of methicillin-susceptible Staphylococcus aureus bacteremia, compared to vancomycin monotherapy.

To evaluate effect of empirical combination of a ß-lactam to vancomycin and vancomycin monotherapy in Staphylococcus aureus bacteremia (MSSA-B), we conducted a retrospective cohort study. Electronic medical records of individuals who were diagnosed with MSSA-B between January 2005 and February 2015 at a tertiary care center were reviewed. Patients were classified into three groups according to empirical antibiotic regimen (BL group, ß-lactam; VAN group, vancomycin; BV group, combination of ß-lactam and vancomycin), and 30-day all-cause mortality of each group was compared. During the study period, 561 patients with MSSA-B were identified. After exclusion of 198 patients (36 with poly-microbial infection, 114 expired within 2 days, and 48 already received parenteral antibiotics) and a matching process, 46 patients for each group were included. Baseline characteristics were similar except for severity and comorbidity scores. The 30-day mortality for all three groups were not significantly different (BL 4.3%, VAN 6.5%, BV 8.7%; P = 0.909). In a multivariate analysis, type of empirical antibiotic regimen was not statistically associated with 30-day all-cause mortality. In comparison with the VAN group, the BV group yielded a HR of 0.579 (95% CI = 0.086-3.890, P = 0.574). Pitt bacteremia score was the only significant factor for mortality. The empirical combination of a ß-lactam to vancomycin was not associated with lower mortality in treating MSSA-B, compared to vancomycin monotherapy.

Clinical characteristics of Raoultella ornithinolytica bacteremia.

PURPOSE: Raoultella ornithinolytica is not well known as a clinical pathogen. We performed a retrospective review of R. ornithinolytica bacteremia to investigate its clinical features, antimicrobial susceptibility, and overall patient outcomes. METHODS: R. ornithinolytica bacteremia cases were collected from an electronic database of all cases of bacteremia over a 10-year period. Medical records were retrospectively reviewed. Demographic data, clinical information, the presence of underlying comorbidities, the results of antimicrobial susceptibility testing, and the antimicrobial regimen administered were investigated. RESULTS: R. ornithinolytica was isolated from blood culture specimens in 16 cases. The majority of these patients had an underlying malignant condition of advanced stage (15 patients, 94 %). Seven of these patients had a solid tumor with lesions or metastases that extended to the bile duct or biliary tract. Neutropenic fever following hematologic stem cell transplantation was found in three cases. No resistance to piperacillin/tazobactam or imipenem was found. Four cases showed resistance to cefoxitin, while one of these cases showed resistance to multiple cephalosporins. In overall outcomes, seven patients (44 %) did not recover from the infection and subsequently expired. CONCLUSIONS: R. ornithinolytica bacteremia occurs mainly in patients with underlying malignancies. The overall outcome was not favorable, despite favorable antimicrobial susceptibility test results. The findings of this study contradict those of other studies that demonstrated that infection from Raoultella species have good prognoses.

Optimization of low-temperature blanching combined with calcium treatment to inactivate Escherichia coli O157:H7 on fresh-cut spinach.

AIMS: To develop a mild blanching method with calcium salts to ensure microbiological safety and quality of fresh-cut spinach. METHODS AND RESULTS: The antimicrobial efficacy of eight calcium salts was evaluated on Escherichia coli O157:H7 at 45-65°C and calcium hydroxide (Ca(OH)2 ) showed the greatest synergistic antimicrobial effect with heat. Combinations of low temperature treatments (45, 55, 65°C), time (20, 40, 60 s) and Ca(OH)2 (0·25, 0·50, 0·75%) were applied for E. coli O157:H7 disinfection on fresh-cut spinach to develop a predictive model using a Box-Behnken experimental design. A suitable quadratic model was produced (R(2) = 0·98, P < 0·001) and the optimum condition (64·9°C with 0·52% Ca(OH)2 for 42·4 s) was drawn by reducing 6·6 log CFU g(-1) of E. coli O157:H7 on fresh-cut spinach. Blanching at 61·9°C with 0·52% Ca(OH)2 for 41·7 s can inactivate E. coli O157:H7 on spinach by 5·4 log CFU g(-1) . The new method was comparable to the CDC recommendation for safe spinach cooking (71·1°C, 15 s; 5·0 log CFU g(-1) reduction) with lower levels of weight loss of the spinach (P < 0·05). CONCLUSIONS: This study suggests an efficient spinach blanching method for E. coli O157:H7 disinfection. SIGNIFICANCE AND IMPACT OF THE STUDY: This blanching method will enhance microbiological safety of fresh-cut produce while minimizing the use of energy and chemicals.

Comparison of diagnostic methods for onychomycosis, and proposal of a diagnostic algorithm.

BACKGROUND: Traditionally, the gold standard for diagnosis of onychomycosis has been the combination of direct microscopy with potassium hydroxide (KOH) staining and fungal culture. However, several studies have suggested that periodic-acid-Schiff (PAS) staining of nail-plate clippings may be a very sensitive method for the diagnosis of onychomycosis. AIM: To compare the sensitivities of direct microscopy with KOH, fungal culture and PAS staining of nail-plate clippings, and to define an efficient, high-yield and cost-effective diagnostic strategy for the diagnosis of onychomycosis in the clinical setting. METHODS: We evaluated a total of 493 patients with clinically suspected onychomycosis. Group A comprised 400 patient samples, evaluated using fungal culture and PAS stain, while group B comprised 93 patient samples evaluated using KOH, fungal culture and PAS. Diagnosis of onychomycosis was defined as clinical morphology plus at least one positive test result. RESULTS: In group A, sensitivities of fungal culture and PAS were 49.5% and 93.1% (P < 0.005), respectively. In group B, the most sensitive single test was PAS (88.2%) followed by KOH (55.9%) and fungal culture (29.4%). The combination of fungal culture and PAS (94.1%) was significantly (P < 0.001) more sensitive than that of KOH and culture (72.1%). CONCLUSION: PAS staining of nail clippings is much more sensitive than KOH and fungal culture for the diagnosis of onychomycosis. Based on our results, we propose a diagnostic algorithm for onychomycosis that takes into consideration the sensitivity, cost-effectiveness and necessary time for each test.

Phase I study of weekly nab-paclitaxel + weekly cetuximab + intensity-modulated radiation therapy (IMRT) in patients with stage III-IVB head and neck squamous cell carcinoma (HNSCC).

BACKGROUND: There is a clinical need to improve the efficacy of standard cetuximab + concurrent intensity-modulated radiation therapy (IMRT) for patients with locally and/or regionally advanced HNSCC. Taxanes have radiosensitizing activity against HNSCC, and nab-paclitaxel may offer therapeutic advantage in comparison with other taxanes. PATIENTS AND METHODS: This was a single-institution phase I study with a modified 3 + 3 design. Four dose levels (DLs) of weekly nab-paclitaxel were explored (30, 45, 60, and 80 mg/m(2)), given with standard weekly cetuximab (450 mg/m(2) loading dose followed by 250 mg/m(2) weekly) and concurrent IMRT (total dose, 70 Gy). RESULTS: Twenty-five eligible patients (20 M, 5 F) enrolled, with median age 58 years (range, 46-84 years). Primary tumor sites were oropharynx, 19 (10 human papillomavirus [HPV] pos, 8 HPV neg, 1 not done); neck node with unknown primary, 2; larynx 2; and oral cavity and maxillary sinus, 1 each. Seven patients had received prior induction chemotherapy. Maximum tolerated dose (MTD) was exceeded at DL4 (nab-paclitaxel, 80 mg/m(2)) with three dose-limiting toxicities (DLTs) (grade 3 neuropathy, grade 3 dehydration, with grade 3 mucositis grade 3 anemia) among five assessable patients. There was only one DLT (grade 3 supraventricular tachycardia) among six patients at DL3 (nab-paclitaxel, 60 mg/m(2)), and this was deemed the MTD. Among 23 assessable patients, the most common ≥ g3 AEs were lymphopenia 100%, functional mucositis 65%, and pain in throat/oral cavity 52%. At a median follow-up of 33 months, 2-year failure-free survival (FFS) is 65% [95% confidence interval (CI) 42% to 81%] and 2-year overall survival (OS) is 91% (95% CI 69-97). CONCLUSION: The recommended phase II dose for nab-paclitaxel is 60 mg/m(2) weekly when given standard weekly cetuximab and concurrent IMRT. This regimen merits further study as a nonplatinum alternative to IMRT + cetuximab alone. CLINICALTRIALSGOV ID: NCT00736619.

Risk factors for cytomegalovirus gastrointestinal diseases in adult patients with cancer.

Cytomegalovirus (CMV) gastrointestinal (GI) disease has been noticed frequently in cancer patients, causing abdominal pain, diarrhea, and GI bleeding. However, little is known about its actual incidence, clinical presentation, and the risk factors for its development among cancer patients. To answer these questions, we analyzed all cases that occurred during an 18-year period at our center. A case-control study was performed to identify risk factors for CMV GI disease. Electronic medical records were reviewed from individuals who were admitted and diagnosed with CMV GI disease during the period of January 1995 through March 2013 at a tertiary care center. Two CMV disease-free cancer patients were matched as controls. A total of 98 episodes of CMV GI disease were included in this study, and the overall incidence rate was 52.5 per 100,000 cancer patients, with an increasing trend throughout the study period. According to multivariate analysis, male sex, low body mass index, lymphopenia, hematological malignancy, and steroid use and red blood cell transfusion within 1 month prior to the CMV disease were identified to be independent risk factors. Among these factors, RBC transfusion showed the highest odds ratio (OR = 5.09). Male sex, low body mass index, lymphopenia, hematological malignancy, steroid use, and red blood cell transfusion within 1 month prior to the CMV disease diagnosis were independent risk factors for the development of CMV GI disease in adult patients with cancer.

Low virulence? Clinical characteristics of Raoultella planticola bacteremia.

PURPOSE: Numerous case reports regarding Raoultella planticola infection have accumulated in the literature; however, its significance as a clinical pathogen remains unknown. We performed a retrospective review of R. planticola bacteremia to characterize its clinical features, antimicrobial susceptibility, and patient outcome. METHODS: Raoultella planticola bacteremia cases were culled from an electronic database of all bacteremia cases occurring over a 4-year-period. Medical records were retrospectively reviewed and demographic data, clinical findings, presence of underlying disease, results of antimicrobial susceptibility testing, and the antibiotic regimens administered during the treatment were evaluated. RESULTS: Raoultella planticola was isolated from blood culture specimens in 20 cases. The majority of these patients had underlying malignant conditions (17 patients, 85%). The most prevalent causes of malignancy were adenocarcinoma involving the gallbladder or bile duct (7 patients) and hematologic malignancies (6 patients). No cases with resistance to carbapenem or third generation cephalosporins were found. All 14 patients with R. planticola as the sole microbial isolate recovered with the use of empirical antibiotics. Of the six patients with polymicrobial infection, three did not recover and subsequently expired. CONCLUSIONS: Raoultella planticola bacteremia seemed to occur mainly in immunocompromised patients, and was also frequently found in patients with lesions involving the gallbladder or bile duct. The overall outcome was favorable when R. planticola was treated with administration of empirical antibiotics. Mixed outcomes were found when blood cultures yielded multiple species of microbes.

The evaluation of combined chemical and physical treatments on the reduction of resident microorganisms and Salmonella Typhimurium attached to chicken skin.

This study was conducted to evaluate the efficacy of sodium hypochlorite (NaOCl, 0-200 mg/kg), thiamine dilauryl sulfate (TDS, 1,000 mg/kg), and ultrasound (37 kHz, 380 W) on reducing Salmonella Typhimurim, mesophilic aerobic bacteria (MAB), and coliforms on chicken skin. Chemical and physical treatments were applied for 5 min either singly or jointly, and Salmonella previously inoculated on chicken skin were quantitatively assessed using brilliant green agar, and the populations of MAB and coliforms in the native flora were enumerated using plate count agar and violet red bile agar, respectively. In the evaluation of bacterial attachment/detachment, chicken skin was quantitatively assessed for loosely, intermediately, and tightly attached bacteria. The treatment effects on bacteria detachment were also visualized using field emission scanning electron microscopy. In addition, color and textural properties of the skin after treatments were evaluated using a color difference meter and texture analyzer. Antimicrobial activity of NaOCl increased as the NaOCl concentration was increased, especially for loosely attached cells. The combination of 200 mg/kg NaOCl and ultrasound (NaOCl/ultrasound) significant reduced loosely, intermediately, and tightly attached bacteria populations by 0.75 to 0.47, 0.43 to 0.41, and 0.83 to 0.54 log cfu/g for MAB, coliforms, and Salmonella Typhimurium, respectively. However, the combination of NaOCl and TDS (NaOCl/TDS) did not sufficiently reduce those cells on chicken skins, except for loosely attached MAB and coliforms. The NaOCl/ultrasound combination produced a higher reduction in numbers of inoculated and native bacteria flora than any single application, with no negative effect on skin color or texture. Generally, the loosely attached bacteria were less resistant to the chemical and physical treatments than the intermediately and tightly attached bacteria in chicken skin, presumably due to their location in deeper skin layer and crevices. Further research is needed to investigate how the intermediately and tightly attached microorganisms can be effectively eliminated from chicken skin.

"Primer shot" fractionation with an early treatment break is theoretically superior to consecutive weekday fractionation schemes for early-stage non-small cell lung cancer.

PURPOSE: Radiotherapy is traditionally given in equally spaced weekday fractions. We hypothesize that heterogeneous interfraction intervals can increase radiosensitivity via reoxygenation. Through modeling, we investigate whether this minimizes local failures and toxicity for early-stage non-small cell lung cancer (NSCLC). METHODS: Previously, a tumor dose-response model based on resource competition and cell-cycle-dependent radiosensitivity accurately predicted local failure rates for early-stage NSCLC cohorts. Here, the model mathematically determined non-uniform inter-fraction intervals minimizing local failures at similar normal tissue toxicity risk, i.e., iso-BED3 (iso-NTCP) for fractionation schemes 18Gyx3, 12Gyx4, 10Gyx5, 7.5Gyx8, 5Gyx12, 4Gyx15. Next, we used these optimized schedules to reduce toxicity risk (BED3) while maintaining stable local failures (TCP). RESULTS: Optimal schedules consistently favored a "primer shot" fraction followed by a 2-week break, allowing tumor reoxygenation. Increasing or decreasing the assumed baseline hypoxia extended or shortened this optimal break by up to one week. Fraction sizes of 7.5 Gy and up required a single primer shot, while smaller fractions needed one or two extra fractions for full reoxygenation. The optimized schedules, versus consecutive weekday fractionation, predicted absolute LF reductions of 4.6%-7.4%, except for the already optimal LF rate seen for 18Gyx3. Primer shot schedules could also reduce BED3 at iso-TCP with the biggest improvements for the shortest schedules (94.6Gy reduction for 18Gyx3). CONCLUSION: A validated simulation model clearly supports non-standard "primer shot" fractionation, reducing the impact of hypoxia-induced radioresistance. A limitation of this study is that primer-shot fractionation is outside prior clinical experience and therefore will require clinical studies for definitive testing.

Bloodstream infections caused by IMP-8-producing Enterobacteriaceae isolates: the need for clinical laboratory detection of metallo-ß-lactamases?

A retrospective study was conducted at a Taiwanese medical center to characterize bloodstream infections caused by IMP-8 metallo-ß-lactamase (MBL)-producing Enterobacteriaceae isolates and to assess the need for laboratory detection of IMP producers. We analyzed 37 patients infected with IMP-8 producers (two Escherichia coli, nine Klebsiella pneumoniae, 25 Enterobacter cloacae, and one Citrobacter freundii) and 107 patients infected with non-IMP-8 producers (eight E. coli, 26 K. pneumoniae, 70 E. cloacae, and three C. freundii) that were interpreted as carbapenem-nonsusceptible based on the updated Clinical and Laboratory Standards Institute (CLSI) 2010 guidelines. Only 18 (48.6 %) of the IMP-8 producers were regarded as potential carbapenemase producers based on the CLSI 2012 guidelines. The production of extended-spectrum ß-lactamases (ESBLs) was more common in the MBL group (73.0 %) than in the non-MBL group (41.1 %). There were no significant differences in carbapenem susceptibilities, clinical characteristics, carbapenem use for empirical and definitive treatment, and mortality rates between the two groups. Eighteen IMP-8 producers could be deemed as resistant to all carbapenems [minimum inhibitory concentration (MIC) of any carbapenem ≥2 µg/mL]; patients with these isolates had a lower, but non-significant, 28-day mortality rate (27.8 %) than patients infected with non-MBL producers having similar carbapenem MICs (39.0 %) (p = 0.41). A multivariate analysis revealed severity of acute illness as the single independent variable associated with both 7-day and 28-day mortality rates (p < 0.01) for infections caused by Enterobacteriaceae with decreased carbapenem susceptibilities. Our findings suggest that the clinical detection of IMP-producing Enterobacteriaceae is not required even when the "old" CLSI criteria are used.

Characteristics of patients with Clostridium difficile infection in Taiwan.

The medical records of 84 patients with stool cultures positive for Clostridium difficile during the period August 2007 to June 2009 were retrospectively reviewed. A case of confirmed (toxigenic)C. difficile infection (CDI) was defined by the presence of symptoms (fever, diarrhoea, abdominal discomfort or distension, ileus) and the presence of toxigenic C. difficile. Patients with compatible clinical symptoms and stool cultures positive for non-toxigenic C. difficile isolates were defined as probable (non-toxigenic) CDI cases. Of these 84 patients, 50 (59.5%) were diagnosed as confirmed CDI and 34 (40.5%) as probable CDI. Thirteen (15.5%) of the 84 patients died during their hospital stay. Usage of proton pump inhibitors was a significant independent risk factor for CDI (OR 3.21, P=0.014). Of the 50 isolates associated with confirmed CDI, seven (8.3%) carried binary toxin genes (cdtAB), and six (7.1%) had a deletion in the tcdC gene. The mortality rate in confirmed CDI patients with isolates exhibiting deletion in the tcdC gene (2/6, 33.3%), those with isolates harbouring binary toxin genes (2/7, 28.6%), and those with isolates containing mutations in gyrA (2/7, 28.6%) and gyrB (1/2, 50%) was higher than the overall mortality rate (10/50, 20%) in patients with confirmed CDI.

An alternative local anaesthesia technique to reduce pain in paediatric patients during needle insertion.

AIM: Pain control, which is necessary during most dental procedures, is administered by injecting a local anaesthetic. Because the injection itself can be painful, the procedure via which pain is reduced warrants continued investigation. Only a few studies regarding the reaction of children to dental needle insertion without the use of topical anaesthetics have been reported. This study was conducted to evaluate the efficacy of the local anaesthetic procedure without topical application as compared to the conventional insertion technique for alleviating pain in children receiving local anaesthesia injections. MATERIALS AND METHODS: For the alternative injection procedure, the dentist quickly and gently pulled or pushed the clean and dried loose tissue at the injection site over the tip of the needle to a depth of 1 to 1.5 mm. When the end of the bevel of the needle tip entered the tissue, a few drops of solution were released, after which the needle was advanced to its proper and intended depth to continue anaesthetic release. RESULTS: There was a significant difference regarding the pain response between the alternative insertion technique (less painful) and the conventional one according to Sound, Eye, and Motor (SEM) scale ratings (P < 0.000). No significant difference was observed in the response between the maxilla and mandible, nor between boys and girls, between the conventional and alternative techniques. CONCLUSION: This alternative technique can reduce discomfort in paediatric dental patients and allow the clinician to administer a superficial local anaesthesia injection before the needle is advanced into deeper tissue. This technique is simple, quick, devoid of additional costs, and potentially more effective than the conventional needle insertion method.

Excretory-secretory products of Giardia lamblia induce interleukin-8 production in human colonic cells via activation of p38, ERK1/2, NF-κB and AP-1.

Giardia lamblia, a pathogen causing diarrhoeal outbreaks, is interesting how it triggers immune response in the human epithelial cells. This study defined the crucial roles of signalling components involved in G. lamblia-induced cytokine production in human epithelial cells. Incubation of the gastrointestinal cell line HT-29 with G. lamblia GS trophozoites triggered production of interleukin (IL)-1ß, IL-8 and tumour necrosis factor (TNF)-α. IL-8 production was not significantly decreased by physically separating the HT-29 cells and G. lamblia GS trophozoites. Indeed, treatment of HT-29 with G. lamblia excretory-secretory products (ESP) induced IL-8 production. Electrophoretic mobility gel shift and transfection assays using mutagenized IL-8 promoter reporter plasmids indicated that IL-8 production by G. lamblia ESP occurs through activation of two transcriptional factors, nuclear factor kappaB (NF-κB) and activator protein 1 (AP-1) in HT-29 cells. In addition, activation of two mitogen-activated protein kinases (MAPKs), p38 and ERK1/2, was also detected in the HT-29 cells stimulated with G. lamblia ESP. Selective inhibition of these MAPKs resulted in decreased production of ESP-induced IL-8. These results indicate that activation of p38, ERK1/2 MAPK, NF-κB and AP-1 comprises the signalling pathway responsible for IL-8 production by G. lamblia ESP.

Characterization of carbapenem-nonsusceptible Klebsiella pneumoniae bloodstream isolates at a Taiwanese hospital: clinical impacts of lowered breakpoints for carbapenems.

This study was conducted in order to characterize carbapenem-nonsusceptible Klebsiella pneumoniae isolates and to evaluate the impacts of recently lowered interpretative breakpoints for carbapenems for Enterobacteriaceae. Among 152 K. pneumoniae bloodstream isolates suspected as AmpC or extended-spectrum ß-lactamase (ESBL) producers, 58 (38.2%) isolates were currently interpreted as nonsusceptible to ertapenem, imipenem, or meropenem, and 42 (72.4%) of them were categorized as carbapenem-susceptible by the previous criteria. The high revision rate was associated with the predominance (79.3%) of DHA-1 among the carbapenem-nonsusceptible isolates due to both polyclonal and clonal spread. ESBLs were common (~57%) in both ertapenem-susceptible and -nonsusceptible isolates; however, 84.8% of the carbapenem-nonsusceptible isolates were also AmpC producers. The IMP-8 metallo-ß-lactamase was detected in three isolates. Polyacrylamide gel electrophoresis suggested decreased OmpK35 expression in all but one ertapenem-nonsusceptible isolate, and genetic disruptions of ompK35 and ompK36 were detected in 30 and six ertapenem-nonsusceptible isolates, respectively. A comparison between patients infected by AmpC- or ESBL-producing ertapenem-susceptible (n=62) isolates and those with isolates revised as ertapenem-nonsusceptible (n=41) revealed more cases of malignancies (36.6% versus 14.5%; p=0.01) and higher Charlson score (p=0.033) among the patients with ertapenem-nonsusceptible isolates; however, the acquisition of an isolate revised as carbapenem-nonsusceptible was not identified as an independent mortality risk factor.