Outbreak Caused by an Ertapenem-Resistant,CTX-M-15-Producing Klebsiella pneumoniae Sequence Type 101 Clone Carrying an OmpK36 Porin Variant

Although numerous studies have documented outbreaks of carbapenem-resistant Klebsiella pneumoniae (CRKP) possessing various carbapenemases, reports on outbreaks due to CRKP possessing extended-spectrum β-lactamases (ESBLs) and/or AmpCs with porin lesions have been limited. Here, we describe an outbreak caused by an ertapenem-resistant, CTX-M-15-producing clonal K. pneumoniae strain expressing an OmpK36 porin variant. From May 2012 to November 2012, 37 ertapenem-resistant K. pneumoniae isolates phenotypically negative for carbapenemase production were recovered from 19 patients hospitalized in the intensive care unit of a Greek hospital. The isolates were either susceptible or intermediate to other carbapenems and resistant to all remaining β-lactams but cefotetan. Phenotypic and molecular analysis revealed the presence in all isolates of the bla_CTX-M-15 gene on a conjugative 100-kb plasmid, disruption in the expression of the ompK35 gene, and the production of an Ompk36 porin variant. The index case was a patient admitted from another hospital. Active surveillance upon admission and on a weekly basis was immediately initiated; environmental samples were also periodically tested. Molecular typing showed that all clinical isolates as well as two ertapenem-resistant environmental K. pneumoniae isolates belonged to the same clonal type and were assigned to multilocus sequence typing (MLST) sequence type 101 (ST101). As all colonized/infected patients were hospitalized during overlapping periods, cross-infection was considered the main route for the dissemination of the outbreak strain. Despite reinforcement of infection control measures and active surveillance, the outbreak lasted approximately 7 months. Identification of hidden carriers upon admission and by screening on a weekly basis was found valuable for early recognition and subsequent successful management of the outbreak.     

Vertical Banded Gastroplasty Versus Standard or Distal Roux-en-Y Gastric Bypass Based on Specific Selection Criteria in the Morbidly Obese: Preliminary Results

Background: Predicting successful outcomes after bariatric surgical procedures has been difficult, and the establishment of specific selection criteria has been a subject of ongoing research. In an effort to choose the most appropriate surgical procedure for each patient, we have established a specific set of selection criteria for each procedure based on degree of obesity, preoperative dietary habits, eating behavior, and various metabolic features. Methods: From June 1994 to December 1998, 90 bariatric surgical procedures were performed at the authors' institution by a single surgeon (F.K.) based on specific selection criteria. Vertical banded gastroplasty (VBG) was performed in 35 patients, standard Roux-en-Y gastric bypass (RYGB) in 38 patients, and distal RYGB in 17 patients. All patients were monitored postoperatively 1, 3, 6, and 12 months and once per year thereafter, with an additional visit at 18 months in distal RYGB patients. Results: Early postoperative morbidity (<30 days) did not differ significantly between the three groups and averaged 9% of total patients. Long-term postoperative morbidity (>30 days) included 9 incisional hernias (2 in the VBG group, 5 after RYGB, and 2 in the distal RYGB group). There were 6 cases of staple-line disruption, 4 after VBG and 2 after standard RYGB, 1 of which resulted in stomal ulcer. Early postoperative mortality was 0%, and long-term mortality was 1.1%, which was due to pulmonary embolism in 1 standard RYGB patient on the 65th postoperative day. Average percentage of excess weight loss (%EWL) was 62% the first year, 61% the second year, and 50% the third year in VBG patients, and 63.6%, 65%, and 63.3%, respectively, in standard RYGB patients. In distal RYGB patients, where the patient number was significantly smaller, the %EWL at 1 and 2 years, respectively, was 51% and 53%. The most significant metabolic/nutritional complication was the appearance of hypoproteinemia (hypoalbuminemia) in 1 distal RYGB patient 20 months after surgery, which was corrected by total parenteral nutrition and subsequent increase in dietary protein intake. Significant improvement or resolution of pre-existing comorbid conditions was observed in all patient groups. The postoperative quality of eating, as evaluated by variety of food intake and frequency of vomiting, was significantly better in RYGB patients. Conclusions: These results show that selection of the bariatric surgical procedure to be performed in each patient based on specific criteria leads to acceptable weight loss, improvement in preexisting comorbid conditions, and a high degree of patient satisfaction in most patients. On the basis of our own observations as well as those of others, our selection criteria have become more strict over time and our selection of VBG as the operation of choice increasingly infrequent.     

Symptomatology of the initial prodromal phase in schizophrenia

The initial prodromal symptoms in schizophrenia were studied in 100 DSM-diagnosed patients and 100 controls. The median number of symptoms in the patients and the controls was 8 (range 2-13) and 0 (range 0-5), respectively. Patients developed symptoms indicating social, occupational, and affective dysfunction, whereas the controls' symptoms included magical content and disturbance in mood. There were significant differences in the frequency of several symptoms appearing in the subtypes. Initial prodromal symptoms were classified into negative, positive-prepsychotic, and positive-disorganization categories. Patients with the disorganized subtype were more likely to have had negative symptoms in the prodromal state, and patients with the paranoid subtype were more likely to have had positive symptoms in the prodromal state. Observation of the course of symptoms from the prodromal to the psychotic state revealed that 58 percent of the symptoms showed increased intensity, 21 percent remained unchanged, 5 percent decreased, 3 percent evolved into other affective difficulties, 9 percent progressed into delusions, 1 percent progressed into hallucinations, and 3 percent disappeared. The Global Assessment of Functioning Scale showed that functioning is differentially affected among the subtypes even in the prodromal phase. These findings provide a better understanding of the initial prodromal state of schizophrenia, the signs and symptoms that best define it, and their prognostic significance.     

Developing and testing an instrument for identifying performance incentives in the Greek health care sector

Background  

In the era of cost containment, managers are constantly pursuing increased organizational performance and productivity by aiming at the obvious target, i.e. the workforce. The health care sector, in which production processes are more complicated compared to other industries, is not an exception. In light of recent legislation in Greece in which efficiency improvement and achievement of specific performance targets are identified as undisputable health system goals, the purpose of this study was to develop a reliable and valid instrument for investigating the attitudes of Greek physicians, nurses and administrative personnel towards job-related aspects, and the extent to which these motivate them to improve performance and increase productivity.     

Impact of body mass index on fasting blood glucose concentration among Helicobater pylori carriers

BACKGROUND/AIMS: Despite the fact that Helicobacter pylori (Hp) is regarded as a major gastroduodenal pathogen, it has recently been suggested to be an important factor for non-gastroenterologic conditions such as diabetes mellitus. Accordingly, it seems that Hp infection may have implications in glycemic control and in fasting plasma glucose concentrations. As overnutrition and obesity are directly related to impaired glucose tolerance, the aim of the present study was to determine whether Hp infection leads to alterations in fasting plasma glucose concentrations of Hp carriers and especially in relation to their body mass index. METHODS: Serum was obtained from 224 young, male navy recruits. An enzyme-linked immunosorbent assay to detect Hp-specific IgG serum antibodies as well as gastroscopy along with biopsy was used to identify the infected individuals. Serum levels of glucose, urea, creatinine and uric acid were also determined. Non-fasting subjects and persons with abnormal oral glucose tolerance curve test were excluded. RESULTS: Among Hp-positive individuals, obese persons presented with a significantly lower mean blood glucose level than non-obese persons. Obese Hp-contaminated participants had significantly lower mean fasting blood glucose concentrations as well as a significantly smaller percentage of participants with abnormal elevated blood glucose levels than obese participants negative to Hp infection. CONCLUSIONS: Our data suggest that obesity in combination with Hp infection may induce an enhanced response to insulin leading to reduced fasting blood glucose levels, among Hp-positive obese persons in comparison to Hp-positive lean persons.     

Evaluation of spiral computed tomography versus ventilation/perfusion scanning in patients clinically suspected of pulmonary embolism

OBJECTIVE: To prospectively evaluate the diagnostic accuracy of spiral computed tomography (CT) versus ventilation/perfusion (V/Q) scanning in the examination of patients clinically suspected of having pulmonary embolism (PE). PATIENTS AND METHODS: Sixty-three patients, presenting to the emergency department and departments of radiology and nuclear medicine of a large hospital, highly suspected of having PE, underwent sequential imaging testing with V/Q scanning and contrast-enhanced spiral CT, in addition to other clinical and laboratory tests. RESULTS: PE was diagnosed in 42 (66.7%) of the 63 patients. Thirty-nine of these 42 patients had positive findings in their CT scans, while 18 of the remaining 21 patients without PE had negative findings in their spiral CT [sensitivity, 92.9%, specificity, 85.7% Positive Predictive Value (PPV), 92.9%, Negative Predictive Value (NPV), 85.7%]. V/Q scans showed high-probability of PE in 24 of the 42 patients with PE and were negative in 9 of the remaining 21 patients without PE (sensitivity, 571%, specificity, 42.9%, PPV, 66.7%, NPV, 33.3%). There were statistically significant differences in specificity and sensitivity favoring spiral CT among men and women patients or patients > 50 years old. Fifty-four patients (85.7%) rated their satisfaction towards spiral CT as 'good' or 'very good', whereas the respective rate for V/Q scanning was only 14.3%. CONCLUSION: Spiral CT has an excellent sensitivity, specificity, PPV and NPV for the diagnosis of PE and it could be used as the first-line imaging modality in patients suspected of PE.     

The effect of alcohol and gemfibrozil co-administration in Wistar rats

INTRODUCTION: The ingestion of alcohol (Alc) as well as gemfibrozil (Gem), a fibrate drug used to treat hypertriglyceridaemia, may occur on a long-term basis in humans. Since both Alc and Gem can disturb liver function, we assessed the effects of administering Alc together with Gem in Wistar rats. MATERIALS AND METHODS: Male Wistar rats were randomized and divided into 4 groups of 10 each. They were fed (once a day) via a stomach tube with: i) 2 ml of polyethylene glycol (Peg); group Peg, ii) 2 ml of Peg + 2 ml of 25% v/v pure Alc in water; group Alc + Peg, iii) 2 ml of Gem solution in Peg (3.4 mg/100 g body weight); group Gem +Peg, iv) 2 ml of Gem solution in Peg 2 + 2 ml of Alc; group Gem +Alc +Peg. Another 13 male Wistar rats were only fed a standard laboratory diet (control group). After 8 weeks, blood samples were drawn and the livers removed. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (AP), total cholesterol (TC) and triglycerides (TG) were measured. Liver histopathology was also assessed. RESULTS: All tube-fed groups had higher body mass index compared to controls (p<0.001). The control group had lower AP compared to Gem+Peg and Gem +Alc+Peg groups (p=0.005 and p=0.018, respectively). The Peg group had lower AP compared to G+Peg (p=0.041). All tube-fed groups had lower ALT compared to controls (p<0.001). The TC levels were lower in tube-fed groups with Gem (Gem +Peg and Gem+Alc +Peg) compared to controls (p=0.002 and p=0.039, respectively). Among the tube-fed groups, the TC level was lower in Gem +Peg compared to Peg and Alc+Peg groups (p=0.047 and p=0.01, respectively). No differences were found among tube-fed groups and control rats in blood AST and TG. Liver histopathology was similar in all groups and within the normal range. CONCLUSION: A moderate amount of Alc daily together with Gem is safe in rats. Peg administration in Wistar rats protects from the Alc-induced TG and AST rises.     

Computer‐Based Malnutrition Risk Calculation May Enhance the Ability to Identify Pediatric Patients at Malnutrition‐Related Risk for Unfavorable Outcome

Background: The study aimed to test the hypothesis that computer‐based calculation of malnutrition risk may enhance the ability to identify pediatric patients at malnutrition‐related risk for an unfavorable outcome. The Pediatric Digital Scaled MAlnutrition Risk screening Tool (PeDiSMART), incorporating the World Health Organization (WHO) growth reference data and malnutrition‐related parameters, was used. Materials and Methods: This was a prospective cohort study of 500 pediatric patients aged 1 month to 17 years. Upon admission, the PeDiSMART score was calculated and anthropometry was performed. Pediatric Yorkhill Malnutrition Score (PYMS), Screening Tool Risk on Nutritional Status and Growth (STRONGkids), and Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) malnutrition screening tools were also applied. PeDiSMART's association with the clinical outcome measures (weight loss/nutrition support and hospitalization duration) was assessed and compared with the other screening tools. Results: The PeDiSMART score was inversely correlated with anthropometry and bioelectrical impedance phase angle (BIA PhA). The score's grading scale was based on BIA Pha quartiles. Weight loss/nutrition support during hospitalization was significantly independently associated with the malnutrition risk group allocation on admission, after controlling for anthropometric parameters and age. Receiver operating characteristic curve analysis showed a sensitivity of 87% and a specificity of 75% and a significant area under the curve, which differed significantly from that of STRONGkids and STAMP. In the subgroups of patients with PeDiSMART‐based risk allocation different from that based on the other tools, PeDiSMART allocation was more closely related to outcome measures. Conclusion: PeDiSMART, applicable to the full age range of patients hospitalized in pediatric departments, graded according to BIA PhA, and embeddable in medical electronic records, enhances efficacy and reproducibility in identifying pediatric patients at malnutrition‐related risk for an unfavorable outcome. Patient allocation according to the PeDiSMART score on admission is associated with clinical outcome measures.     

Altered long chain fatty acids composition in Duchenne muscular dystrophy erythrocytes

BACKGROUND: Biochemical abnormalities, increased efflux of soluble enzymes and muscle proteins, and altered permeability of muscle membranes imply the presence of a disorganized erythrocyte membrane in Duchenne muscular dystrophy (DMD). The purpose of the present study was to investigate this hypothesis of a generalized membrane defect. MATERIALS AND METHODS: Twenty-five patients with the disease were analyzed for their erythrocyte lipid composition and for alterations in their fatty acid content compared to twenty-five healthy subjects. RESULTS: DMD patients showed a decreased concentration of total phospholipids compared to healthy volunteers, with striking fluctuations in concentrations of erythrocyte long chain fatty acids. Specifically, the unsaturated fatty acids such as oleic, linoleic and arachidonic acids were significantly decreased in the disease, whereas the saturated fatty acid, palmitic acid was increased in DMD patients compared to healthy controls. CONCLUSION: Our findings suggest an abnormal fatty acid composition and disorganization of erythrocyte membrane in patients with DMD associated with possible functional alterations.     

Experimental and investigational phosphodiesterase inhibitors in development for asthma

Introduction: Severe, inadequately-controlled asthma remains a clinical challenge. For this reason, clinical trials and preclinical experimental studies on novel agents as an add-on therapies continue emerge. Phosphodiesterases (PDEs) are enzymes that regulate the function of immune cells by hydrolyzing cyclic guanosine monophosphate/cGMP and cyclic adenosine monophosphate/cAMP. PDEs are divided into subfamilies [PDE3, PDE4, PDE5 and PDE7] which are mainly found in the respiratory tract. Inhibitors of PDEs have already been approved for COPD and pulmonary hypertension.

Areas covered: The role of PDE inhibitors in asthma treatment and the possible mechanism of action via their anti-inflammatory and/or bronchodilating effect are discussed.

Expert opinion: Novel PDE inhibitors exhibiting fewer adverse events may have a role as add-on therapies in asthma treatment in the future. More clinical trials are necessary to prove their efficacy and evaluate their safety profile before approval by regulatory bodies is granted.