Polyclonal Spread of Fosfomycin Resistance among Carbapenemase-Producing Members of the Enterobacterales in the Czech Republic.

Fosfomycin (FOS) has been recently reintroduced into clinical practice, but its effectiveness against multidrug-resistant (MDR) Enterobacterales is reduced due to the emergence of FOS resistance. The copresence of carbapenemases and FOS resistance could drastically limit antibiotic treatment. The aims of this study were (i) to investigate fosfomycin susceptibility profiles among carbapenem-resistant Enterobacterales (CRE) in the Czech Republic, (ii) to characterize the genetic environment of fosA genes among the collection, and (iii) to evaluate the presence of amino acid mutations in proteins involved in FOS resistance mechanisms. During the period from December 2018 to February 2022, 293 CRE isolates were collected from different hospitals in the Czech Republic. FOS MICs were assessed by the agar dilution method (ADM), FosA and FosC2 production was detected by the sodium phosphonoformate (PPF) test, and the presence of fosA-like genes was confirmed by PCR. Whole-genome sequencing was conducted with an Illumina NovaSeq 6000 system on selected strains, and the effect of point mutations in the FOS pathway was predicted using PROVEAN. Of these strains, 29% showed low susceptibility to fosfomycin (MIC, ≥16 µg/mL) by ADM. An NDM-producing Escherichia coli sequence type 648 (ST648) strain harbored a fosA10 gene on an IncK plasmid, while a VIM-producing Citrobacter freundii ST673 strain harbored a new fosA7 variant, designated fosA7.9. Analysis of mutations in the FOS pathway revealed several deleterious mutations occurring in GlpT, UhpT, UhpC, CyaA, and GlpR. Results regarding single substitutions in amino acid sequences highlighted a relationship between ST and specific mutations and an enhanced predisposition for certain STs to develop resistance. This study highlights the occurrence of several FOS resistance mechanisms in different clones spreading in the Czech Republic. IMPORTANCE Antimicrobial resistance (AMR) currently represents a concern for human health, and the reintroduction of antibiotics such as fosfomycin into clinical practice can provide further option in treatment of multidrug-resistant (MDR) bacterial infections. However, there is a global increase of fosfomycin-resistant bacteria, reducing its effectiveness. Considering this increase, it is crucial to monitor the spread of fosfomycin resistance in MDR bacteria in clinical settings and to investigate the resistance mechanism at the molecular level. Our study reports a large variety of fosfomycin resistance mechanisms among carbapenemase-producing Enterobacterales (CRE) in the Czech Republic. Our study summarizes the main achievements of our research on the use of molecular technologies, such as next-generation sequencing (NGS), to describe the heterogeneous mechanisms that reduce fosfomycin effectiveness in CRE. The results suggest that a program for widespread monitoring of fosfomycin resistance and epidemiology fosfomycin-resistant organisms can aide timely implementation of countermeasures to maintain the effectiveness of fosfomycin.

Intercondylar distal humerus fractures--surgical treatment and results.

INTRODUCTION: Controversy persists concerning the preferred treatment for intercondylar distal humerus fractures. The present study was undertaken to evaluate the clinical results after the surgical treatment of 40 intercondylar distal humerus fractures with an average follow-up of 3.9 years. METHODS: The fractures were classified following the AO/ASIF comprehensive classification. Eight patients presented multiplane fractures. Skeletal traction was used temporarily in two cases. The stabilization method was selected according to the fracture pattern, bone quality and associated lesions. Bone graft was used in seven cases. Fibrin-glue was used in two cases. Unilateral hinged external fixators were used in addition in four cases. Functional assessment was done according to the scoring system of the Orthopedic Trauma Association and additional parameters taken from the system of Jupiter. RESULTS: Final global results were excellent in 13 patients, good in 21, fair in four and poor in two. Complications included three non-unions, two heterotopic ossifications, two internal fixation failures and two lateral condyle resorptions (avascular necrosis). DISCUSSION: Final results are related to the severity of the initial trauma, time elapsed between the accident and definitive surgery, associated lesions, bone quality, precise reconstruction of a smooth and congruent joint surface, surgical technique, implants used, stability obtained and patient cooperation. The type, number and location of the osteosynthesis material must be selected according to the fracture pattern, bone quality and associated lesions.

Resultados de la incorporacion de aloinjerto oseo libre crioconservado no histocompatible vs. aloinjerto oseo fresco libre no histocompatible: cirugia experimental / Results of non-histocompatible free frozen bone allograft vs. non-histocompatible free fresh bone allograft: experimental surgery

Desarrollamos un estudio experimental cuyo proposito principal fue comparar y ayudar a esclarecer el proceso de incorporacion del aloinjerto oseo, teniendo en cuenta su habitual forma de utilizacion, aloinjerto oseo crioconservado libre no histocompatible (AOC), y su forma menos experimentada, como aloinjerto cortical fresco libre no histocompatible (AOF). Se intervinieron quirurgicamente 40 conejos neozelandeses, no consanguineos, divididos en 2 grupos experimentales controles, grupo A y grupo B. Se creo un defecto oseo en diafisis femoral y se coloco AOC intercalar en el grupo A, y AOF intercalar en el grupo B. Los resultados fueron evaluados a los 6 meses del trasplante mediante la interrelacion de dos variables independientes, clase de injerto y tiempo de estudio, con variables dependientes analizadas por radiologia y histologia. La incorporacion radiologica e histologica del grupo A arrojo mejores resultados porcentuales que aquellos animales tratados con AOF. El porcentaje de complicaciones fue menor en el grupo A. Probablemente, la no consanguinidad entre donante y receptor, el mayor potencial inmunogenico del AOF y la respuesta inmunologica del receptor, atenuada por los efectos de la crioconservacion, hayan sido los factores que condicionaron una mejor incorporacion porcentual del AOC, sin embargo, la incorporacion del AOF fue aceptable y con un porcentaje de complicaciones que no se aleja de los valores publicados. Estadisticamente, el valor p arrojo resultados no significativos

Resultados de la incorporacion de aloinjerto oseo libre crioconservado no histocompatible vs. aloinjerto oseo fresco libre no histocompatible: cirugia experimental / Results of non-histocompatible free frozen bone allograft vs. non-histocompatible free fresh bone allograft: experimental surgery

Desarrollamos un estudio experimental cuyo proposito principal fue comparar y ayudar a esclarecer el proceso de incorporacion del aloinjerto oseo, teniendo en cuenta su habitual forma de utilizacion, aloinjerto oseo crioconservado libre no histocompatible (AOC), y su forma menos experimentada, como aloinjerto cortical fresco libre no histocompatible (AOF). Se intervinieron quirurgicamente 40 conejos neozelandeses, no consanguineos, divididos en 2 grupos experimentales controles, grupo A y grupo B. Se creo un defecto oseo en diafisis femoral y se coloco AOC intercalar en el grupo A, y AOF intercalar en el grupo B. Los resultados fueron evaluados a los 6 meses del trasplante mediante la interrelacion de dos variables independientes, clase de injerto y tiempo de estudio, con variables dependientes analizadas por radiologia y histologia. La incorporacion radiologica e histologica del grupo A arrojo mejores resultados porcentuales que aquellos animales tratados con AOF. El porcentaje de complicaciones fue menor en el grupo A. Probablemente, la no consanguinidad entre donante y receptor, el mayor potencial inmunogenico del AOF y la respuesta inmunologica del receptor, atenuada por los efectos de la crioconservacion, hayan sido los factores que condicionaron una mejor incorporacion porcentual del AOC, sin embargo, la incorporacion del AOF fue aceptable y con un porcentaje de complicaciones que no se aleja de los valores publicados. Estadisticamente, el valor p arrojo resultados no significativos

High incidence of renal artery stenosis in patients with coronary artery disease.

The incidence of renal artery stenosis (RAS) in patients with coronary artery disease (CAD) has not been well documented. Over a 9-month period, 196 patients who underwent coronary angiography because of clinically suspected CAD had routine nonselective renal cine or digital subtraction angiography. There were 68 females and 128 males with a mean age of 63 years (range 35-85). Angiographically significant CAD was present in 152 patients (78%). Of the total patient cohort, 29 patients (15%) had mild RAS (< 50%), and 36 patients (18%) had significant RAS (> or = 50%). In patients with normal coronary arteries, only three patients (7%) had RAS. Thirty-three patients (92%) with severe RAS also had CAD. Of these 33 patients, 45% had hypertension, 30% had hyperlipidemia, 24% had diabetes mellitus, 24% had renal insufficiency (creatinine > or = 1.5), and 51% were smokers. In addition, it was noted that 20 of these patients (61%) had two or more of the above-listed clinical parameters. However, univariate analysis using the chi-square test revealed that only CAD (22% P < 0.03) and renal insufficiency (29% P < 0.15) were reliable clinical predictors of RAS. In conclusion, RAS is a frequent finding in patients with CAD, particularly when renal insufficiency is also present.

Ablation of left free-wall accessory pathways using radiofrequency energy at the atrial insertion site: transseptal versus transaortic approach.

INTRODUCTION: Transcatheter ablation of the left free-wall atrioventricular accessory pathways (AP) by delivery of radiofrequency current at the ventricular insertion site has been shown to be effective. The efficacy of such a technique targeting the atrial insertion site of the AP was evaluated. METHODS AND RESULTS: One hundred consecutive patients with left free-wall APs and symptomatic supraventricular tachyarrhythmias were included. APs were manifest in 55 patients and concealed in 45. There were 55 men and 45 women with a mean age of 35 years. A total of 107 left free-wall APs were identified in these patients. In these 100 patients, successful ablation was accomplished in all by using a transseptal (45 patients) or transaortic (54 patients) technique. In one patient, ablation was accomplished from within the coronary sinus. Seven patients required a repeat ablative procedure, which was performed successfully. During 107 ablative procedures, six were associated with nonfatal complications including pericardial effusion (hemopericardium) in two patients, mild mitral regurgitation in two patients, swelling of the left arm in one patient, and staphylococcal bacteremia in one patient. Eighty-two (82%) patients underwent a repeat electrophysiologic study 6 to 8 weeks after successful ablation and were found to have no functioning AP or inducible supraventricular tachycardia. During a mean follow-up of 20 +/- 8 months, none of the 100 patients had a recurrence of tachyarrhythmias. CONCLUSION: These data indicate that the atrial insertion site of the AP can be successfully ablated in the majority of patients with left free-wall APs by using either a transseptal or transaortic approach. Furthermore, both techniques are associated with minimal morbidity and no mortality.

[Intestinal intussusceptions in adults. Apropos of a case of spontaneous colo-colonic intussusception]. / Les invaginations intestinales de l'adulte. A propos d'un cas d'invagination colo-colique spontanée.

A case of idiopathic colonic intussusception in a 39-year old woman is reported. The main features of the disease are reviewed: the clinical presentation may be subacute or chronic, diagnosis is based on ultrasonography and water-soluble contrast media enema. Because of the frequency of malignancy primary resection in the treatment of choice.

Management of Brucella endocarditis with aortic root abscess.

Three cases of Brucella endocarditis with aortic root abscess are reported. Two patients were successfully managed by a combination of medical therapy and surgery. The third patient died suddenly 36 hours after admission to hospital.

Beta-adrenergic receptor blockade in the management of pregnant women with mitral stenosis.

Twenty-five pregnant women with symptomatic mitral valve stenosis (mean valve area, 1.1 +/- 0.25 cm2) were managed by initiation or modification of beta-adrenergic receptor blockade with the use of either propranolol or atenolol. Significant improvement of symptoms occurred in 23 patients (92%) (p less than 0.01); the mean maternal heart rate was reduced significantly from 86 +/- 4 to 78 +/- 5 beats/min (p less than 0.0001). The overall fetal heart rate ranged between 130 to 150 beats/min during treatment. Only two patients required urgent closed mitral valvotomy, after pulmonary edema developed as a result of poor compliance to beta-blockade. All patients were safely delivered of infants at term. Fetal heart rates ranged between 120 to 140 beats/min at delivery. There was no maternal or fetal death. Pregnant woman with symptomatic mitral valve stenosis can be safely managed with beta-blockade, giving significant reduction in the incidence of pulmonary edema with no unwanted neonatal side effect.