Diagnostic Value of Different 3-D Shear Wave Elastography Sections in the Diagnosis of Thyroid Nodules

The aim of the study was to explore the value of 3-D shear wave elastography (SWE) in differentiating malignant from benign thyroid nodules. A total of 188 patients with 216 nodules who underwent conventional ultrasound, 2-D SWE and 3-D SWE were included in this study. All patients underwent surgical excision, and the pathological results were the gold standard. Receiver operating characteristic (ROC) curves of the American College of Radiology's Thyroid Imaging Reporting and Data System (ACR TI-RADS), 2-D SWE and 3-D SWE were plotted, and the areas under the curves (AUCs) were compared using a Z-test. There were 62 benign thyroid nodules and 154 malignant thyroid nodules in this study. Young's modulus (E_min, E_mean, E_max, E_sd) values of thyroid malignant nodules in different sections of 2-D SWE and 3-D SWE were significantly higher than those of thyroid benign nodules (p < 0.001). The AUC of E_max in 2-D SWE transverse sections was significantly lower than that in 3-D SWE transverse sections and 3-D SWE sagittal sections (0.768 vs. 0.831 and 0.844, p < 0.05). The AUC of 3-D S-E_max combined with ACR TI-RADS was 0.859; the specificity increased from 54.84% to 85.71%, and the diagnostic accuracy increased from 74.54% to 85.19%, compared with ACR TI-RADS. The difference was statistically significant (p < 0.05). Three-dimensional SWE combined with ACR TI-RADS for the diagnosis of thyroid nodules significantly improved the diagnostic ability of ACR TI-RADS, and was significantly better than 2-D SWE combined with ACR TI-RADS.     

Microbiological analysis of patients with first and recurrent episodes of acute cholangitis in a middle-sized hospital: A single-center retrospective study in rural North Kyoto,Japan

BackgroundKnowledge of the bacterial spectrum involved in acute cholangitis is essential for adequate empiric antibiotic treatment. There is a lack of published data comparative data between patients with first and recurrent episodes of acute cholangitis. This study aimed to analyze the microbial spectrum in patients with first and second episodes of acute cholangitis.MethodsWe retrospectively assessed 251 patients with first episodes of acute cholangitis between January 2014 to September 2020.ResultsAt the first episode of acute cholangitis, the predominant strains belonged to Escherichia coli (17.9%), followed by Klebsiella spp. (15.5%), Enterobacter spp. (6.4%), and Enterococcus spp. (5.6%). During follow-up, acute cholangitis recurred in 109 patients; at the second episode, the predominant strains belonged to Enterococcus spp. (35.8%), followed by Klebsiella spp. (27.5%), Enterobacter spp. (22.9%), and Escherichia coli (15.6%). Enterococcus spp. were the most common pathogen in patients with second episode of acute cholangitis, regardless of whether the cholangitis was caused by a malignant tumor or a benign disease.ConclusionsUnlike in patients with a first episode of acute cholangitis, clinicians should consider empirical treatment with anti-enterococcal antibiotics in patients with recurrent episodes of acute cholangitis.     

实时剪切波弹性成像对甲状腺结节良恶性的诊断及影响因素分析

目的 探讨剪切波弹性成像(SWE)各参数对甲状腺结节良恶性鉴别诊断的临床价值。方法 应用SWE对拟接受手术或活检的221例甲状腺结节患者(265个结节)进行检查,测量结节的绝对弹性值。以病理结果为金标准,绘制ROC曲线,得到最优的诊断界点,并以此进行良恶性诊断。根据ROC曲线下面积评价各个SWE参数的诊断价值。同时,分析可能存在的影响因素。结果 265个甲状腺结节中,良性177个,恶性88个。恶性结节的杨氏模量均高于良性结节,差异有统计学意义(P均<0.05)。5个SWE参数(SWE_whole_mean、SWE_whole_min、SWE_mean、SWE_min、SWE_max)诊断结节良恶性的ROC曲线下面积分别为0.793、0.656、0.801、0.796和0.791。SWE_mean的ROC曲线下面积(AUC)面积最大,以最优的诊断界点为39.2 kPa进行良恶性诊断,诊断的敏感度和特异度分别为67.05% 和83.62%。各可能的影响因素中,结节内钙化会使测量到的杨氏模量值增加。SWE与常规超声联合应用的诊断敏感度为86.36%。结论 SWE有助于甲状腺结节良恶性的鉴别诊断。     

Evaluation of the dosimetric influence of interfractional 6D setup error in hypofractionated prostate cancer treated with IMRT and VMAT using daily kV-CBCT

IntroductionProstate cancer is one of the most common malignant tumors in men and is usually treated with advanced intensity modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT). Significant uncorrected interfractional 6-Dimensional setup errors could impact the delivered dose. The aim of this study was to assess the dosimetric impact of 6D interfractional setup errors in hypofractionated prostate cancer using daily kilovoltage cone-beam computed tomography (kV-CBCT).MethodsThis retrospective study comprised twenty prostate cancer patients treated with hypofractionated IMRT (8) and VMAT (12) with daily kV-CBCT image guidance. Interfraction 6D setup errors along lateral, longitudinal, vertical, pitch, roll, and yaw axes were evaluated for 400 CBCTs. For targets and organs at risk (OARs), the dosimetric impact of rotational error (R_Error), translational error (T_Error), and translational plus rotational error (T+R_Error) were evaluated on kV-CBCT images.ResultsThe single fraction maximum T_Error ranged from 12–20 mm, and the R_Error ranged from 2.8⁰–3.0⁰. The maximum mean absolute dose variation ΔD in D_98% (dose to 98% volume) of CTV-55 and PTV-55 was -0.66±0.82 and -5.94±3.8 Gy, respectively, in the T+R_Error. The maximum ΔD (%) for D_98% and D_0.035cc in CTV-55 was -4.29% and 2.49%, respectively, while in PTV-55 it was -24.9% and 2.36%. The mean dose reduction for D_98% in CTV-55 and D_98% and D_95% in PTV-55 was statistically significant (p<0.05) for T_Error and T+R_Error. The mean dose variation for D_mean and D_50% in the rectum was statistically significant (p<0.05) for T_Error and T+R_Error.ConclusionThe uncorrected interfractional 6D setup error results in significant target underdosing and OAR overdosing in prostate cancer. This emphasizes the need to correct interfractional 6D setup errors daily in IMRT and VMAT.     

Continuous Renal Replacement Therapy Liberation and Outcomes of Critically Ill Patients With Acute Kidney Injury

ObjectiveTo examine the association between continuous renal replacement therapy (CRRT) liberation and clinical outcomes among patients with acute kidney injury (AKI) requiring CRRT.MethodsThis single-center, retrospective cohort study included adult patients admitted to intensive care units with AKI and treated with CRRT from January 1, 2007, to May 4, 2018. Based on the survival and renal replacement therapy (RRT) status at 72 hours after the first CRRT liberation, we classified patients into liberated, reinstituted, and those who died. We observed patients for 90 days after CRRT initiation to compare the major adverse kidney events (MAKE₉₀).ResultsOf 1135 patients with AKI, 228 (20%), 437 (39%), and 470 (41%) were assigned to liberated, reinstituted, and nonsurvival groups, respectively. The MAKE₉₀, mortality, and RRT independence rates of the cohort were 62% (707 cases), 59% (674 cases), and 40% (453 cases), respectively. Compared with reinstituted patients, the liberated group had a lower MAKE₉₀ (29% vs 39%; P=.009) and higher RRT independence rate (73% vs 65%; P=.04) on day 90, but without significant difference in 90-day mortality (26% vs 33%; P=.05). After adjustments for confounders, successful CRRT liberation was not associated with lower MAKE₉₀ (odds ratio, 0.71; 95% CI, 0.48 to 1.04; P=.08) but was independently associated with improved kidney recovery at 90-day follow-up (hazard ratio, 1.81; 95% CI, 1.41 to 2.32; P<.001).ConclusionOur study demonstrated a high occurrence of CRRT liberation failure and poor 90-day outcomes in a cohort of AKI patients treated with CRRT.     

Prediction of presence of fastidious bacteria by the Fully Automated Urine Particle Analyzer UF-1000i in the case of ineffective antimicrobial therapy for urinary tract infection

IntroductionRecent studies have reported associations between fastidious bacteria that are difficult to grow and isolate in conventional urine culture conditions and urinary tract infections (UTIs). Because the Fully Automated Urine Particle Analyzer UF-1000i (hereinafter referred to as “UF-1000i”) detects fastidious bacteria without being affected by culture conditions, owing to its flow cytometry-based principle, we evaluated the robustness of UF-1000i detection using clinical urine samples from patients with UTIs following ineffective antimicrobial therapy.MethodsA total of 150 patients diagnosed with UTIs were enrolled, and their laboratory findings were analyzed, focusing on the discrepancy in bacterial numbers between UF-1000i and conventional culture at each antimicrobial therapy effectiveness classification. In addition, gene identification was conducted by molecular analysis using 16S ribosomal RNA gene sequencing and next-generation sequencing (NGS) to elucidate the reason for the presence of fastidious bacteria in these samples.ResultsThe ineffective therapy cases showed more than 100-fold discrepancy in bacterial counts, with a higher proportion (30.8%) than effective therapy cases without secondary administration (5.7%) between the bacterial counts in UF-1000i and conventional culture methods. The presence rates of fastidious bacteria were 100% and 66.7% in discrepant cases of ineffective and effective without secondary administrations, respectively.ConclusionThis study suggests that discrepancies in bacterial numbers between the conventional culture method and UF-1000i measurement at the primary visit can predict the presence of fastidious bacteria, especially in cases of ineffective antimicrobial therapy.     

Antidiabetic Effects of the Senolytic Agent Dasatinib

ObjectiveTo evaluate the antidiabetic effects of the senolytic agent dasatinib in older patients with type 2 diabetes mellitus.MethodsThis retrospective cohort study included enterprise-wide Mayo Clinic patients using Informatics for Integrating Biology at the Bedside from January 1994 through December 2019. The antidiabetic outcomes (change in hemoglobin A_1c value, serum glucose concentration, and diabetic medications) after 1 year of a strongly senolytic tyrosine kinase inhibitor, dasatinib (n=16), was compared with a weakly senolytic tyrosine kinase inhibitor, imatinib (n=32).ResultsRelative to imatinib, patients treated with dasatinib had a mean reduction of 43.7 mg/dL (P=.005) in serum glucose concentration (to convert glucose values to mmol/L, multiply by 0.0555) and required 28.8 fewer total daily insulin units (P=.08) in the setting of a 4.8-kg relative weight loss (5.3% of total body weight; P=.045). Linear regression analysis suggests that the relative difference in weight accounts for 8.4 mg/dL of the 43.7 mg/dL blood glucose value decrease, or 19.2%. Relative to imatinib, patients treated with dasatinib had a mean 0.80 absolute point (P=.05) reduction in hemoglobin A_1c and required 18.2 fewer total daily insulin units (P=.16) in the setting of a 5.9-kg relative weight loss (6.3% of total body weight; P=.06).ConclusionDasatinib may have antidiabetic effects comparable to contemporary diabetic treatments and may be considered for use as a novel diabetic therapy. Future studies are needed to determine whether these results are translatable to patients with type 2 diabetes mellitus without underlying malignant diseases and to determine whether the antidiabetic effects of dasatinib are due to its senolytic properties.     

Renal Neoplasia in Tuberous Sclerosis: A Study of 41 Patients

ObjectiveTo study the clinical features and identify unique renal neoplasia subtypes and their prognostic implications in individuals with tuberous sclerosis complex (TSC).Patients and MethodsThe Mayo Clinic nephrectomy registry included 37 patients with TSC diagnosed between 1970 and 2018. Four additional patients were identified from the pathology consultation and autopsy files. All available renal tumors were further characterized using immunohistochemistry and fluorescence in situ hybridization. Clinicopathologic features and follow-up were obtained from the medical record. The American Association for Cancer Research Project GENIE registry was accessed using cBioPortal for molecular profiling of angiomyolipoma (AML).ResultsA total of 276 renal tumors from 41 patients were analyzed. Renal tumors were classified into 9 distinct morphological subtypes, with AML predominating (238 [86%]). Interestingly, all these tumors acted in a benign fashion except one renal cell carcinoma with clear cells and fibromyomatous stroma and one epithelioid AML that metastasized. Molecular profiling studies revealed that epithelioid AMLs were enriched for alterations of TP53, RB1, and ATRX. Eight patients died of direct complications of TSC, including 3 of end-stage renal disease. To date, none have died of a renal epithelial neoplasm.ConclusionThe identification of unique renal neoplasia subtypes may provide important clues to establish a diagnosis of TSC, and in the somatic setting, this finding has important implications for accurate prognostication. These tumors tend to be indolent, and only 2 of 276 tumors in our study exhibited metastatic behavior. Our results support multidisciplinary management with a focus on preservation of renal function.     

Dissecting the clonality of I1 plasmids using ORF-based binarized structure network analysis of plasmids (OSNAp)

ObjectivesWe aimed to elucidate the relationship among bla_CTX-M-carrying plasmids and their transmission between humans and domestic animals.MethodsPhylogenetic relationship of 90 I1 plasmids harboring bla_CTX-M genes encoding extended-spectrum β-lactamase (ESBL) was analyzed using the ORF-based binarized structure network analysis of plasmids (OSNAp).ResultsThe majority of plasmids carrying bla_CTX-M-1 or bla_CTX-M-8 belonged to a single lineage, respectively, and were primarily associated with domestic animals especially chickens. On the other hand, plasmids carrying bla_CTX-M-14 or bla_CTX-M-15, identified from both humans and domestic animals, were distributed in two or more lineages.ConclusionOSNAp has revealed the phylogenetic relationships and diversity of plasmids carrying bla_CTX-M more distinctly than pMLST. The findings suggest that circulation of I1 plasmids between humans and animals may contribute to their diversity.     

First description of a clinical glutamine-dependent Escherichia coli with a missense mutation in the glnA

IntroductionSmall-colony variants (SCVs) of bacteria are subpopulations with a small colony size, low growth rate, and atypical colony morphology. The purpose of this study was to comprehensively elucidate the characteristics and underlying mechanism of the development of a glutamine-dependent SCV of E. coli, GU-92_SCV, isolated from the blood of a patient with pyelonephritis.MethodsThe GU-92_SCV strain was tested for auxotrophy testing for glutamine. DNA mutations in genes related to glutamine synthesis were analysed by sequencing. The isolate's proliferation and antimicrobial susceptibility in Mueller-Hinton II medium supplemented with glutamine were examined.ResultsThe colony of the GU-92_SCV strain did not grow on Mueller-Hinton II agar, but growth around the filter paper containing l-glutamine was enhanced on Mueller-Hinton II agar. The GU-92_SCV strain had a single nucleotide substitution in glnA, c.193G>A, corresponding to p.Asp65Asn. Changing c.193G>A to the wild-type sequence in glnA restored these phenotypes. Because GU-92_SCV did not grow in Mueller-Hinton II broth, antimicrobial susceptibility test results were not obtained; however, in the presence of 10 mg mL^?1 l-glutamine, the results were consistent with those of the revertant strain GU-92_REV.ConclusionTo the best of our knowledge, this is the first clinical isolation of a glutamine-dependent E. coli SCV from a patient blood culture. Our data showed that glnA was important for the growth of E. coli in Mueller-Hinton II medium, which also required the presence of glutamine when performing antimicrobial susceptibility testing for glutamine-dependent SCV strains.     

The Buteyko breathing technique in children with asthma: a randomized controlled pilot study

BackgroundEvidence supports the Buteyko breathing technique (BBT) as reducing medication and improving control and quality of life in adults with asthma, but having minimal impact on spirometry. For children with asthma, evidence addressing the utility of BBT is sparse. We evaluated the effectiveness of BBT in managing various aspects of asthma in children.MethodsThirty-two children with partly controlled asthma (age 6-15 years, 66% male) were randomized to either Treatment as Usual (TAU) or TAU combined with Buteyko training (Buteyko group, BG). Children in the BG received an intensive five-day training followed by three months of home practice. Primary outcome was bronchodilator reduction. Secondary outcomes were changes in physiological parameters FEV1_AR (at rest), FEV1_ER (after ergometry), FEV1_BR (after bronchospasmolysis), corticosteroid use, FeNO, SpO2, breath-hold test and questionnaire data [Asthma Control Questionnaire and Pediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ)]. All measures were collected at Baseline and a three-month follow-up.ResultsFor the primary outcome, no significant between-group difference was found. Regarding the secondary outcomes, children receiving treatment augmented with BBT revealed significantly greater improvement at the follow-up than those receiving TAU for FEV1_AR (p = .04, d=-0.50), FEV1_ER (p = .02, d=-0.52), and the emotional function subscale of the PACQLQ (p < .01, d = 1.03). No between-group differences were found for the remaining secondary measures of outcome.ConclusionsOur preliminary findings suggest that the addition of BBT to treatment as usual for children with asthma enhances outcomes with respect to spirometry and parental emotional function but does not lead to reductions in medication, at least over the short term.     

Alcohol Consumption Levels as Compared With Drinking Habits in Predicting All-Cause Mortality and Cause-Specific Mortality in Current Drinkers

ObjectiveTo investigate the joint associations of amounts of alcohol consumed and drinking habits with the risks of all-cause mortality and cause-specific mortality.Patients and MethodsA total of 316,627 healthy current drinkers, with baseline measurements between March 13, 2006, and October 1, 2010, were included in this study. We newly created a drinking habit score (DHS) according to regular drinking (frequency of alcohol intake ≥3 times/wk) and whether consuming alcohol with meals (yes).ResultsDuring a median follow-up of 8.9 years, we documented 8652 incident cases of all-cause death, including 1702 cases of cardiovascular disease death, 4960 cases of cancer death, and 1990 cases of other-cause death. After adjustment confounders and amount of alcohol consumed, higher DHS was significantly associated with a lower risk of all-cause mortality, cardiovascular disease mortality, cancer mortality, or other-cause mortality (P_trend<.001, P_trend=.03, P_trend<.001, and P_trend<.001, respectively). We observed that the amount of alcohol consumed have different relationships with the risks of all-cause mortality and cause-specific mortality among participants with distinct drinking habits, grouped by DHS. For example, in the joint analyses, a J-shaped association between the amount of alcohol consumed and all-cause mortality was observed in participants with unfavorable DHS (P_{quadratic trend}=.02) while the association appeared to be U-shaped in participants with favorable DHS (P_{quadratic trend}=.003), with lower risks in those consuming greater than or equal to 50 g/wk and less than 300 g/wk.ConclusionOur results indicate that alcohol consumption levels have different relationships with the risk of mortality among current drinkers, depending on their drinking habits.     

Newer P2Y12 Inhibitors vs Clopidogrel in Acute Myocardial Infarction With Cardiac Arrest or Cardiogenic Shock: A Systematic Review and Meta-analysis

ObjectiveTo evaluate the outcomes, safety, and efficacy of dual antiplatelet therapy (DAPT) with newer P2Y₁₂ inhibitors compared with clopidogrel in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) or cardiogenic shock (CS).Patients and MethodsMEDLINE, EMBASE, and the Cochrane Library were queried systematically from inception to January 2021 for comparative studies of adults (≥18 years) with AMI-CA/CS receiving DAPT with newer P2Y₁₂ inhibitors as opposed to clopidogrel. We compared outcomes (30-day or in-hospital and 1-year all-cause mortality, major bleeding, and definite stent thrombosis) of newer P2Y₁₂ inhibitors and clopidogrel in patients with AMI-CA/CS.ResultsEight studies (1 randomized trial and 7 cohort studies) comprising 1100 patients (695 [63.2%] receiving clopidogrel and 405 [36.8%] receiving ticagrelor or prasugrel) were included. The population was mostly male (68.5%-86.7%). Risk of bias was low for these studies, with between-study heterogeneity and subgroup differences not statistically significant. Compared with the clopidogrel cohort, the newer P2Y₁₂ cohort had lower rates of early mortality (odds ratio [OR], 0.60; 95% CI, 0.45 to 0.81; P=.001) (7 studies) and 1-year mortality (OR, 0.51; 95% CI, 0.36 to 0.71; P<.001) (3 studies). We did not find a significant difference in major bleeding (OR, 1.21; 95% CI, 0.71 to 2.06; P=.48) (6 studies) or definite stent thrombosis (OR, 2.01; 95% CI, 0.63 to 6.45; P=.24) (7 studies).ConclusionIn patients with AMI-CA/CS receiving DAPT, compared with clopidogrel, newer P2Y₁₂ inhibitors were associated with lower rates of early and 1-year mortality. Data on major bleeding and stent thrombosis were inconclusive.     

Effects of Bilateral Transcutaneous Tibial Nerve Stimulation on Neurogenic Detrusor Overactivity in Spinal Cord Injury: A Urodynamic Study

ObjectiveTo study the short-term effect of bilateral transcutaneous tibial nerve stimulation (TTNS) on urodynamic study (UDM) parameters in spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO).DesignSingle-blinded sham-controlled study.SettingRehabilitation center.ParticipantsSCI patients with NDO (N=17) were recruited. Fifteen patients (mean age, 40±18y) completed the study. Most of the patients had chronic incomplete SCI.InterventionsUDM was performed 3 times. The first UDM was performed after taking anticholinergics for 1 hour to assess the effects of medication. After stopping anticholinergics for a 5 half-lives, the second UDM was performed immediately after a 20-minute sham TTNS (switch on for 30s at the beginning, switch off for 20min, and switch on for 30s before stopping). The third UDM was performed immediately after a 20-minute bilateral TTNS.Main Outcome MeasuresReflex volume (mL), cystometric capacity (mL), maximum pressure detrusor (mmH₂O), and bladder compliance (mL/mmH₂O).ResultsUDM tracings were interpreted by 2 blinded assessors. This study used per-protocol analysis and repeated measures Analysis of variance with Bonferroni post hoc analysis. When compared with sham stimulation, bilateral TTNS and anticholinergics produced greater increases in reflex volume (136.1±99.88, 212.2±112.82, and 226.3±111.52 mL; P<.001), cystometric capacity (218.3±137.66, 319.1±143.74, and 350.7±163.43 mL; P<.001), and compliance (5.8±6.81, 7.9±6.74, 9.7±8.12 mL/cmH₂O; P=.02). No significant differences were found in reflex volume, cystometric capacity, or compliance between bilateral TTNS and anticholinergics (P>.05). The maximum pressure detrusor was not significantly different between groups (P>.05).ConclusionBilateral TTNS may be an effective short-term intervention to improve UDM parameters in SCI with NDO. Further study is necessary to determine the long-term effects and benefits of combined bilateral TTNS with anticholinergics.     

Implementation of an All-Day Artificial Intelligence–Based Triage System to Accelerate Door-to-Balloon Times

ObjectiveTo implement an all-day artificial intelligence (AI)–based system to facilitate chest pain triage in the emergency department.MethodsThe AI-based triage system encompasses an AI model combining a convolutional neural network and long short-term memory to detect ST-elevation myocardial infarction (STEMI) on electrocardiography (ECG) and a clinical risk score (ASAP) to prioritize patients for ECG examination. The AI model was developed on 2907 twelve-lead ECGs: 882 STEMI and 2025 non-STEMI ECGs.ResultsBetween November 1, 2019, and October 31, 2020, we enrolled 154 consecutive patients with STEMI: 68 during the AI-based triage period and 86 during the conventional triage period. The mean ± SD door-to-balloon (D2B) time was significantly shortened from 64.5±35.3 minutes to 53.2±12.7 minutes (P=.007), with 98.5% vs 87.2% (P=.009) of D2B times being less than 90 minutes in the AI group vs the conventional group. Among patients with an ASAP score of 3 or higher, the median door-to-ECG time decreased from 30 minutes (interquartile range [IQR], 7?59 minutes) to 6 minutes (IQR, 4?30 minutes) (P<.001). The overall performances of the AI model in identifying STEMI from 21,035 ECGs assessed by accuracy, precision, recall, area under the receiver operating characteristic curve, F1 score, and specificity were 0.997, 0.802, 0.977, 0.999, 0.881, and 0.998, respectively.ConclusionImplementation of an all-day AI-based triage system significantly reduced the D2B time, with a corresponding increase in the percentage of D2B times less than 90 minutes in the emergency department. This system may help minimize preventable delays in D2B times for patients with STEMI undergoing primary percutaneous coronary intervention.     

Isolation of three distinct carbapenemase-producing Gram-negative bacteria from a Vietnamese medical tourist

Carbapenem-resistant Klebsiella pneumoniae and Escherichia coli, multidrug-resistant Pseudomonas aeruginosa and vancomycin-resistant Enterococcus faecium were isolated from a single patient. The patient came to Japan for advanced medical treatment after having undergone laparoscopic cholecystectomy and hospitalization in Vietnam. Whole-genome sequence analysis revealed that K. pneumoniae harbored bla_OXA-48 that was found on a Col156 -type small plasmid, E. coli harbored bla_NDM-5 and P. aeruginosa harbored both bla_NDM-1 and 16S rRNA methyltransferase (rmtB). To the best of our knowledge, this is the first report of detection of K. pneumoniae harboring bla_OXA-48 on a Col156-type small plasmid in the world and P. aeruginosa coharboring genes encoding NDM-1 and RmtB in Japan.     

Unilateral Strength Training of the Less Affected Hand Improves Cortical Excitability and Clinical Outcomes in Patients With Subacute Stroke: A Randomized Controlled Trial

ObjectivesTo investigate whether unilateral strength training helps improve cortical excitability and clinical outcomes after stroke.DesignRandomized controlled trial.SettingRehabilitation sciences research center.ParticipantsPatients with subacute stroke (N=26) were randomly assigned to a control group (n=13) or the experimental group (n=13).InterventionsParticipants in both groups received conventional physiotherapy. The experimental group also received unilateral strength training of the less affected wrist extensors. Interventions were applied for 4 weeks (12 sessions, 3 d/wk).Main Outcome MeasuresCortical excitability in both the ipsilesional hemisphere (ipsiH) and contralesional hemisphere (contraH) was assessed by measuring resting motor threshold (RMT), active motor threshold (AMT), motor evoked potential (MEP), and cortical silent period (CSP) at baseline and after the 4-week intervention period. Clinical outcomes were obtained by evaluating wrist extension strength in both the more affected and less affected hands, upper extremity motor function, activities of daily living (ADL), and spasticity.ResultsThe experimental group showed greater MEP amplitude (P=.001) in the ipsiH and shorter CSP duration in both the ipsiH (P=.042) and contraH (P=.038) compared with the control group. However, the reductions in RMT and AMT in both hemispheres were not significantly different between groups. Improvements in wrist extension strength in the more affected (P=.029) and less affected (P=.001) hand, upper extremity motor function (P=.04), and spasticity (P=.014) were greater in the experimental group. No significant difference in ADLs was detected between groups.ConclusionsA combination of unilateral strength training and conventional physiotherapy appears to be a beneficial therapeutic modality for improving cortical excitability and some clinical outcomes in patients with stroke.     

The Functional Independence of Patients With Stroke Sequelae: How Important Is the Speed,Oxygen Consumption,and Energy Cost of Walking?

ObjectiveTo evaluate the association between self-selected walking speed (S_free), oxygen consumption at S_free (Vo_2free), the oxygen cost of walking (Cw) at S_free, and mobility independence and independence for activities of daily living in individuals poststroke.DesignCross-sectional study.SettingHospital.ParticipantsIndividuals with stroke who were able to walk without human assistance were included. We included 90 individuals (N=90; mean age, 63.5±14.0y).InterventionsNot applicable.Main Outcome MeasuresCw was captured during walking from measurements of S_free and Vo_2free. We assessed mobility independence based on the modified Functional Ambulation Classification (mFAC) and independence in activities of daily living by the Barthel Index (BI). Multiple linear regression analyses were performed to evaluate the independence of Cw, Vo_2free, and S_free from the determination of BI and mFAC among the various characteristics of the population (age, stroke delay, body mass index, motor function, spasticity).ResultsWe reported Cw=0.36 mL/kg/m (interquartile range [IQR]=0.28 mL/kg/m), S_free=0.60±0.32 m/s, Vo_2free=11.2 mL/kg/min (IQR=1.8 mL/kg/min). The multiple linear regression analyses showed that Cw and S_free were independently associated with the BI (P<.01) and the mFAC (P<.01) scores. Vo_2free was not found to be an explanatory variable of functional independence (P>.05).ConclusionsCw was independently associated with functional independence. This association appears to be primarily determined by S_free and not Vo_2free, underscoring the importance of evaluating and acting on S_free to improve the functional independence of individuals with stroke.     

The Association of Sleep Apnea and Cardiorespiratory Fitness With Long-Term Major Cardiovascular Events

ObjectiveTo determine the risk of long-term major adverse cardiovascular events (MACE) when sleep-disordered breathing (SDB) and decreased cardiorespiratory fitness (CRF) co-occur.MethodsWe included consecutive patients who underwent symptom-limited cardiopulmonary exercise tests between January 1, 2005, and January 1, 2010, followed by first-time diagnostic polysomnography within 6 months. Patients were stratified based on the presence of moderate-to-severe SDB (apnea/hypopnea index ≥15 per hour) and decreased CRF defined as <70% predicted peak oxygen consumption (VO₂). Long-term MACE was a composite outcome of myocardial infarction (MI), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), stroke or transient ischemic attack (TIA), and death, assessed until May 21, 2018. Cox-proportional hazard models were adjusted for factors known to influence CRF and MACE.ResultsOf 498 included patients (60±13 years, 28.1% female), 175 (35%) had MACE (MI=17, PCI=14, CABG=13, stroke=20, TIA=12, deaths=99) at a median follow-up of 8.7 years (interquartile range=6.5 to 10.3 years). After adjusting for age, sex, beta blockers, systemic hypertension, diabetes mellitus, coronary artery disease, cardiac arrhythmia, chronic obstructive pulmonary disease, smoking, and use of positive airway pressure (PAP), decreased CRF alone (hazard ratio [HR]=1.91, 95% confidence interval [CI], 1.15 to 3.18; P=.01), but not SDB alone (HR=1.26, 95% CI, 0.75 to 2.13, P=.39) was associated with increased risk of MACE. Those with SDB and decreased CRF had greater risk of MACE compared with patients with decreased CRF alone (HR=1.85; 95% CI, 1.21 to 2.84; P<.005) after accounting for these confounders. The risk of MACE was attenuated in those with reduced CRF alone after additionally adjusting for adequate adherence to PAP (HR=1.59; 95% CI, 0.77 to 3.31; P=.21).ConclusionThe incidence of MACE, especially mortality, was high in this sample. Moderate-to-severe SDB with concurrent decreased CRF was associated with higher risk of MACE than decreased CRF alone. These results highlight the importance of possibly including CRF in the risk assessment of patients with SDB and, conversely, that of screening for SDB in patients with low peak VO₂.