Hospital outbreak caused by a carbapenem-resistant strain of Acinetobacter baumannii: patient prognosis and risk-factors for colonisation and infection

Between October 2001 and August 2002, 30 hospital patients became infected or colonised by a multiresistant (including to carbapenems) epidemic strain of Acinetobacter baumannii (AbMR) in a hospital outbreak. This study analysed the risk-factors associated with acquisition of this epidemic strain and investigated the prognosis of patients infected by AbMR, with the aim of elucidating factors which lead to mortality. A case-control study of the acquisition of AbMR in patients infected or colonised in the hospital outbreak was performed. Independent risk-factors leading to death were studied by logistic regression analysis. Multivariate analysis of the risk-factors for colonisation/infection with AbMR revealed an independent association with the presence of an arterial catheter (OR, 1.13; 95% CI, 1.03-1.25) and administration of imipenem as monotherapy (OR, 11.12; 95% CI, 2.33-53.09). Multivariate analysis of the prognostic features leading to mortality revealed a significant association with hypotension or shock (OR, 24.63; 95% CI, 1.56-387.56) at the time of bacterial isolation.     

Osteochondritis dissecans of the patella: 12 cases followed for 4 years

Osteochondritis dissecans of the patella in 9 patients (6 men, 3 women; mean age 19 years) was located in the median ridge and paramedial areas and was bilateral in 3 patients. All patients were initially treated conservatively with complete relief of symptoms in 5. In 7 patients fragments were excised and the crater was curetted and drilled. At follow-up after 4 (2-8) years, the patients had no restriction of activities and they had no pain.     

Consanguinity-associated kidney diseases in Lebanon: an epidemiological study

Consanguineous marriages are common in many countries of the Middle East including Lebanon. Their impact on the repartition of kidney diseases and on the risk for familial nephritis is not known. We surveyed all of the dialysis centers in Lebanon. Nine hundred and twenty-five (925) patients and their private physicians were asked to answer a questionnaire. More than half of the hemodialysis (HD) patients had an unknown etiology of their kidney disease. Diabetes, polycystic kidney disease (PKD), chronic pyelonephritis and nephrosclerosis (NS) were the most commonly documented diagnoses. Consanguinity was present in 26% of the total HD population. More consanguineous patients with unknown renal etiology were diagnosed with their kidney diseases and initiated on dialysis before the age of 30 when compared with their non-consanguineous counter-parts (45% versus 33%, P<0.02 and 42% versus 27%, P<0.01), respectively. Similarly, consanguineous polycystic patients were diagnosed and started earlier on dialysis when compared with the non-consanguineous population (34% versus 12%, P<0.05 and 28% versus 8%, P<0.05), respectively suggesting a different disease pattern. Furthermore, the risk for family history of kidney disease was noticeable in the non-consanguineous population and significantly higher among the consanguineous patients (12% versus 18%, P<0.04). Consanguinity-associated kidney diseases affected all religious communities, in particular the Muslim and the Druze (36 and 39%), respectively versus 17% of the Christian community. Certain geographical areas were more involved than others such as the North, South and the Bekaa with the highest percentage (40%) in the latter. Socio-economical level was not a contributing factor. We conclude that the documentation of the underlying etiology in end-stage renal diseases (ESRD) seems to be deficient. Furthermore, consanguinity is prevalent in the Lebanese dialysis patients population, in particular the Muslim and the Druze communities. Consanguinity-associated kidney diseases pattern seems to differ from that of the general HD population by disease diagnosis and initiation at a younger age and a significantly higher risk for familial renal disease. It is a cultural phenomenon prevalent predominantly in the rural areas. We recommend a multi-approach including educational, informative and probably legislative strategy in order to limit and hopefully discourage consanguineous marriages.     

Three families with high expression of a fragile site at Xq27.3, lack of anomalies at the FMR-1 CpG island, and no clear phenotypic association.

We report on 3 families where the presence and segregation at high frequency of a fragile Xq27.3 site is not associated with the mutations and methylation anomalies typically seen in the fragile X [Fra(X)] syndrome. In one family, a folate insensitive fragile site was associated with Robin sequence in the propositus. In a second family a fra(X) negative mother has two fra(X) positive sons (one mentally retarded and the other newborn). The third family presents very high expression of a folate sensitive site, unlinked to mental retardation, and was described previously by Voelckel et al. [1989]. The fragile sites in these or similar families recently described must be different from the one associated with the fra(X) syndrome. Their association with a clinical phenotype or with mental retardation is certainly not consistent, and may represent an ascertainment bias. However, the relatively high frequency with which they have been found among previously diagnosed fra(X) families suggests that, at least in some cases, the association with mental impairment may be significant. In two families reported up to now, a male with high expression of such variant fra(X) site failed to transmit it to his daughter, which may reflect an imprinting effect. Previously diagnosed families should be reinvestigated before direct DNA analysis is used for prenatal or carrier diagnosis of the fra(X) syndrome.     

‘Hybrid’ Bariatric Surgery: Bilio-pancreatic Diversion and Duodenal Switch - Preliminary Experience

Background: Hybrid, combined or mixed bariatric surgery is the combination of a degree of ‘malabsorption’ (as achieved by the intestinal bypass) with a ‘rrestriction’ (as achieved by gastric bypass or gastroplasty), thereby simultaneously reducing the absorption of fats in the small bowel and decreasing the intake of food. Methods: A modification of the bilio-pancreatic diversion (BPD) with a duodenal switch procedure, vertical lineal gastrectomy and preservation of the pylorus, has been used in 23 patients. The antropyloric pump and 4 cm of the duodenum are left intact to preserve physiologic gastric emptying and to prevent anastomotic ulcer. The use of staplers and continuous running sutures reduces surgical risks and operative time. Results: One patient, converted from a vertical gastroplasty, had an intrathoracic esophageal perforation and died of multisystemic organ failure, a mortality rate of 4.5%. One patient had a partial dehiscence of the laparotomy wound. Three patients developed subcutaneous seromas. Mean weight losses during the first 4 months were 13, 11, 6 and 5 kg, with a loss of 70% of excess weight in patients approaching 1 year. No patient needs treatment for diarrhea. No serious secondary side-effects have been detected. Conclusion: This operation appears to result in very satisfactory weight loss, improved quality of life, and a low incidence of complications.     

Serotonin levels are abnormally elevated in the fetus of the monoamine oxidase-A-deficient transgenic mouse

Developmental changes in levels of serotonin, L-tryptophan and 5-hydroxyindol acetic acid (5-HIAA) were measured by high pressure liquid chromatography (HPLC) in the forebrain, brainstem and cervical cord of fetal, neonatal and adult mice from the wild strain C3H and the transgenic strain Tg8, created from the C3H line by the disruption of the gene encoding monoamine oxidase A. The results indicated that the absence of monoamine oxidase A activity in Tg8 mice results in abnormally high 5-hydroxytryptamine (5-HT) levels in all the central nervous structures and at all the studied developmental ages. Since serotonin levels were 4-5 times larger in Tg8 than in C3H mice at gestational day 20, comparing the central network function at birth of C3H and Tg8 neonates should shed some light on the role of serotonin in prenatal network maturation.     

Effectiveness of an informative report on the prevention of nosocomial bloodstream infections in a neonatal intensive care unit]

OBJECTIVE: Few studies have evaluated the impact of an information and prevention process specifically aimed at neonatalogists and nurses working in a neonatal intensive care unit (NICU) towards the prophylaxis of nosocomial bloodstream infections. Our objective was first to analyze nosocomial infections within our unit, and secondly to evaluate the impact of a monthly report providing information related to the number and characteristics of such infections. PARTICIPANTS AND METHODS: A prospective study was performed in the NICU of Angers University Hospital during 2 six-month periods. All cases of nosocomial bloodstream infections and their characteristics were analyzed. We then published a nosocomial infections report every month during the second period, in order to inform the medical staff and nurses of the results. The impact of the information and prevention process was evaluated by comparing the results between the 2 periods. We also assessed the staff's interest by questionnaire. RESULTS: Two hundred and fifty-four (first period) and 240 (second period) patients were included. A decrease in the specific incidence rate and density of catheter related bloodstream infections was observed between the 2 periods, especially for preterms with a birth weight<1000 g and gestational age<28 SA (P<0.01). Coagulase negative Staphylococcus was identified in 82.3% and 62.5% of cases respectively. 54% of the members of staff expressed their concerns related to the findings and were very interested to read about the observations made during the study. CONCLUSION: This original process seems to be both effective and inexpensive, and can be easily reproduced to decrease the frequency of bloodstream infections in NICU. However, its long-term impact still needs to be evaluated.     

Use of complement monoclonal antibody eculizumab in Shiga toxin producing Escherichia coli associated hemolytic uremic syndrome: A review of current evidence

Complement activation plays an important role in the pathogenesis of atypical hemolytic uremic syndrome. Eculizumab is a monoclonal antibody that blocks complement activity and has been approved for use in the treatment of atypical hemolytic uremic syndrome (HUS). Less well appreciated is the role of complement in Shiga toxin‐induced HUS (Shiga toxin producing Escherichia coli [STEC]‐HUS). To a limited extent, eculizumab has been used off label in patients with severe STEC‐HUS with neurological involvement. Through a systematic search of available databases, we identified 16 reports describing the use of eculizumab in STEC‐HUS (eight case reports/series, seven retrospective studies, and one prospective cohort study). All studies described its use in severe STEC‐HUS with neurological or multiorgan dysfunction; none were randomized or blinded. Four studies used the control groups. Although the overall quality of evidence is low, some published studies showed positive clinical improvement after treatment with eculizumab in severe STEC‐HUS with progressive neurological involvement.