Pragmatic, open-label, single-center, randomized, phase II clinical trial to evaluate the efficacy and safety of methylprednisolone pulses and tacrolimus in patients with severe pneumonia secondary to COVID-19: The TACROVID trial protocol.

INTRODUCTION: Some COVID-19 patients evolve to severe lung injury and systemic hyperinflammatory syndrome triggered by both the coronavirus infection and the subsequent host-immune response. Accordingly, the use of immunomodulatory agents has been suggested but still remains controversial. Our working hypothesis is that methylprednisolone pulses and tacrolimus may be an effective and safety drug combination for treating severe COVID-19 patients. METHODS: and analysis: TACROVID is a randomized, open-label, single-center, phase II trial to evaluate the efficacy and safety of methylprednisolone pulses and tacrolimus plus standard of care (SoC) versus SoC alone, in patients at advanced stage of COVID-19 disease with lung injury and systemic hyperinflammatory response. Patients are randomly assigned (1:1) to one of two arms (42 patients in each group). The primary aim is to assess the time to clinical stability after initiating randomization. Clinical stability is defined as body temperature ≤37.5 °C, and PaO2/FiO2 > 400 and/or SatO2/FiO2 > 300, and respiratory rate ≤24 rpm; for 48 consecutive hours. DISCUSSION: Methylprednisolone and tacrolimus might be beneficial to treat those COVID-19 patients progressing into severe pulmonary failure and systemic hyperinflammatory syndrome. The rationale for its use is the fast effect of methylprednisolone pulses and the ability of tacrolimus to inhibit both the CoV-2 replication and the secondary cytokine storm. Interestingly, both drugs are low-cost and can be manufactured on a large scale; thus, if effective and safe, a large number of patients could be treated in developed and developing countries. TRIAL REGISTRATION NUMBER: NCT04341038 / EudraCT: 2020-001445-39.

Efficacy of extended infusion of ß-lactam antibiotics for the treatment of febrile neutropenia in haematologic patients: protocol for a randomised, multicentre, open-label, superiority clinical trial (BEATLE).

BACKGROUND: Febrile neutropaenia (FN) is a very common complication in patients with haematological malignancies and is associated with considerable morbidity and mortality. Broad-spectrum antipseudomonal ß-lactam antibiotics (BLA) are routinely used for the treatment of cancer patients with FN. However, the clinical efficacy of BLA may be diminished in these patients because they present with pathophysiological variations that compromise the pharmacokinetic (PK) parameters of these antibiotics. Optimised administration of BLA in prolonged infusions has demonstrated better clinical outcomes in critically ill patients. However, there is a paucity of data on the usefulness of this strategy in patients with FN. The aim of this study is to test the hypothesis that the administration of BLA would be clinically more effective by extended infusion (EI) than by intermittent infusion (II) in haematological patients with FN. METHODS: A randomised, multicentre, open-label, superiority clinical trial will be performed. Patients with haematological malignancies undergoing chemotherapy or haematopoietic stem-cell transplant and who have FN and receive empirical antibiotic therapy with cefepime, piperacillin-tazobactam or meropenem will be randomised (1:1) to receive the antibiotic by EI (during half the time of the dosing interval) in the study group, or by II (30 min) in the control group. The primary endpoint will be clinical efficacy, defined as defervescence without modifying the antibiotic treatment administered within the first 5 days of therapy. The primary endpoint will be analysed in the intention-to-treat population. The secondary endpoints will be pharmacokinetic/pharmacodynamic (PK/PD) target achievement, bacteraemia clearance, decrease in C-reactive protein, overall (30-day) case-fatality rate, adverse events and development of a population PK model of the BLA studied. DISCUSSION: Data on the usefulness of BLA administration in patients with FN are scant. Only three clinical studies addressing this issue have been published thus far, with contradictory results. Moreover, these studies had some methodological flaws that limit the interpretation of their findings. If this randomised, multicentre, phase IV, open-label, superiority clinical trial validates the hypothesis that the administration of BLA is clinically more effective by EI than by II in haematological patients with FN, then the daily routine management of these high-risk patients could be changed to improve their outcomes. TRIAL REGISTRATION: European Clinical Trials Database: EudraCT 2018-001476-37. ClinicalTrials.gov, ID: NCT04233996.

Genetic and Biochemical Characterization of OXA-535, a Distantly Related OXA-48-Like ß-Lactamase.

OXA-535 is a chromosome-encoded carbapenemase of Shewanella bicestrii JAB-1 that shares only 91.3% amino acid sequence identity with OXA-48. Catalytic efficiencies are similar to those of OXA-48 for most ß-lactams, except for ertapenem, where a 2,000-fold-higher efficiency was observed with OXA-535. OXA-535 and OXA-436, a plasmid-encoded variant of OXA-535 differing by three amino acids, form a novel cluster of distantly related OXA-48-like carbapenemases. Comparison of blaOXA-535 and blaOXA-436 genetic environments suggests that an ISCR1 may be responsible for blaOXA-436 gene mobilization from the chromosome of Shewanella spp. to plasmids.

GES-11-producing Acinetobacter baumannii clinical isolates from Tunisian hospitals: Long-term dissemination of GES-type carbapenemases in North Africa.

Acinetobacter baumannii is an emerging threat in healthcare facilities owing to its ability to be multidrug-resistant (MDR) and to be involved in outbreaks. GES-type extended-spectrum ß-lactamases (ESBLs) have been increasingly identified in A. baumannii. In this study, clinical A. baumannii isolates were characterised using standard biochemical methods and antibiotic susceptibility testing. Antibiotic resistance genes were sought by PCR and sequencing. Genetic support was characterised using S1 nuclease pulsed-field gel electrophoresis (PFGE) mapping, conjugation and electroporation assays. The genetic environment was investigated by PCR, and genetic relatedness was investigated by PFGE. Two MDR A. baumannii clinical isolates susceptible only to colistin and rifampicin were isolated from a tracheal aspirate of a 49-year-old woman hospitalised in 2006 at the Military Hospital of Tunis, Tunisia, and from a tracheal aspirate of a 53-year-old man hospitalised in 2010 at the Institut Orthopédique Mohamed El Kassab of Tunis, Tunisia. PCR revealed that the two isolates harboured the acquired carbapenemase blaOXA-23 and ESBL blaGES-11 genes along with chromosomally-encoded blaOXA-51 and blaADC-like genes. PFGE revealed that these A. baumannii isolates were unrelated; nevertheless, plasmid analysis revealed a similar sized plasmid following electrophoresis of the isolates. In addition, A. baumannii CIP70.10 transformants displayed similar resistance patterns. blaGES-11 was integron-borne and the ISAbaI element was identified upstream of blaOXA-23 and blaADC-like. Here we described two unrelated clinical A. baumannii isolates producing GES-11 ESBL and OXA-23 carbapenemase from two Tunisian hospitals. This work further illustrates the emergence of GES-type ß-lactamases in A. baumannii in North Africa as early as 2006.

Outbreak of NDM-1-producing Acinetobacter baumannii in France, January to May 2013.

We report the first outbreak of carbapenem-resistant NDM-1-producing Acinetobacter baumannii in Europe, in a French intensive-care unit in January to May 2013. The index patient was transferred from Algeria and led to the infection/colonisation of five additional patients. Concurrently, another imported case from Algeria was identified. The seven isolates were genetically indistinguishable, belonging to ST85. The bla(NDM-1) carbapenemase gene was part of the chromosomally located composite transposon Tn125. This report underscores the growing concern about the spread of NDM-1-producing A. baumannii in Europe.

Dissemination of New Delhi metallo-ß-lactamase-1-producing Acinetobacter baumannii in Europe.

Multidrug-resistant and New Delhi metallo-ß-lactamase 1 (NDM-1) -producing Acinetobacter baumannii are increasingly reported. A collection of five NDM-1-positive A. baumannii isolates recovered in four European countries were analysed. Genotyping was performed by pulsed-field gel electrophoresis, multiplex PCR sequence typing, Diversilab and multilocus sequence typing. Three distinct sequence types were identified. All isolates harboured a chromosomally located bla(NDM-1) gene within a Tn125-like transposon. One isolate co-expressed another unrelated carbapenemase OXA-23. This report constitutes the first epidemiological study of NDM-1-producing A. baumannii from four countries.

NDM-2 carbapenemase-producing Acinetobacter baumannii in the United Arab Emirates.

Screening 155 carbapenem non-susceptible Acinetobacter baumannii strains recovered in Abu Dhabi hospitals identified two metallo-ß-lactamase bla(NDM) gene-carrying isolates. They were isolated 4 months apart from the urine of a cancer patient previously treated in Egypt, Lebanon and in the United Arab Emirates. They were clonally related and carried the bla(NDM-2) gene recently identified in A. baumannii in Egypt and Israel. Sequences surrounding the bla(NDM-2) gene showed significant similarities with those associated with bla(NDM-1) in Enterobacteriaceae and A. baumannii. Repeated isolation of bla(NDM-2)-positive A. baumannii in the Middle East raises the possibility of the local emergence and spread of a unique clone.

Identification of the naturally occurring genes encoding carbapenem-hydrolysing oxacillinases from Acinetobacter haemolyticus, Acinetobacter johnsonii, and Acinetobacter calcoaceticus.

Carbapenem resistance is increasingly being reported among Acinetobacter species, and results mostly from the expression of acquired carbapenem-hydrolysing oxacillinases (CHDLs). Several Acinetobacter species intrinsically possess chromosomal CHDL genes: Acinetobacter baumannii (bla(OXA-51) ), Acinetobacter radioresistens (bla(OXA-23) ), and Acinetobacter lwoffii (bla(OXA-134) ). We aimed to identify the progenitors of novel CHDL-encoding genes for identification of potential reservoirs. We performed PCR screening using degenerated internal primers designed from a sequence alignment of the known CHDLs (OXA-23, OXA-40, OXA-51, OXA-58, OXA-134, and OXA-143) applied to a collection of 50 Acinetobacter strains belonging to 23 different species. Two strains of Acinetobacter johnsonii, one strain of Acinetobacter calcoaceticus and two strains of Acinetobacter haemolyticus were found to harbour, respectively, the totally novel bla(OXA-211) -like, bla(OXA-213) -like and bla(OXA-214) -like genes. In addition, the complete genomes of those three species available in GenBank, i.e. one A. johnsonii genome, four A. calcoaceticus genomes, and one A. haemolyticus genome, were analysed and found to be positive for the presence of bla(OXA211) -like, bla(OXA-213) -like and bla(OXA-214) -like genes, respectively. The ß-lactamases OXA-211, OXA-213 and OXA-214 are diverse, with amino acid identities ranging from 53% to 76%, as compared with the naturally occurring OXA-51-like CHDL from A. baumannii. These ß-lactamases showed a peculiar hydrolysis profile, including mostly penicillins and carbapenems. Regarding bla(OXA-23) in A. radioresistens and bla(OXA-134) in A. lwoffii, these genes were not expressed (or expressed at a non-significant level) in their host. Detection of these ß-lactamase genes might be used as a useful tool for accurate identification of these Acinetobacter species.

Genetic diversity of carbapenem-hydrolysing ß-lactamases in Acinetobacter baumannii from Romanian hospitals.

Thirteen carbapenem-resistant Acinetobacter baumannii isolates, collected in Romania during 2009-2010, were investigated to identify the mechanism(s) responsible for carbapenem resistance. Genotyping was performed by pulsed-field gel electrophoresis, multiplex PCR sequence typing and multilocus sequence typing. Eleven non-clonally related isolates harboured the bla(OXA-23) gene on their chromosome within a Tn2008 transposon structure. The two remaining isolates harboured a bla(OXA-58) gene that was either plasmid or chromosome borne. Two isolates co-expressed OXA-23 together with the extended-spectrum ß-lactamase PER-1. This study constitutes the first report of OXA-58 and OXA-23-producing A. baumannii isolates in Romania.

Accuracy of emergency department bedside ultrasonography.

OBJECTIVES: To determine which focused ultrasound examinations can be interpreted accurately by emergency physicians who have limited training and experience. To determine whether image quality and/or the operator's level of confidence in the findings correlates with accurate scan interpretation. METHODS: A prospective sample of consenting adult emergency department patients with the conditions was selected for study. Scans were performed by emergency physicians who had attended a 3-day focused ultrasound examinations instruction course. All scans were videotaped and subsequently reviewed by a radiologist. Accuracy was determined by comparing the emergency physicians scan interpretation with preselected gold standards. Chi-squared tests were employed to determine if the individual performing the scan, the type of scan, patient's body habitus, image quality and/or operator confidence were reliable predictors of accuracy. RESULTS: Between September 1997 and January 1999, 221 scans were studied. Accuracy varied widely depending on the type of scan performed: aortic scans were 100% accurate whereas renal scans had 68% accuracy. On bivariate analyses, there was little variation in the various operators' levels of proficiency and accuracy of interpretation was not associated with patient body habitus, image quality or operator confidence. CONCLUSIONS: Neophytes can accurately perform and interpret aortic scans; additional training and/or experience appear to be necessary to achieve proficiency in conducting most of the other scans studied. Inexperienced operators are unable to discern whether their scan interpretations will prove accurate.

Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous.

STUDY OBJECTIVE: This study was conducted to determine whether emergency physicians with relatively limited training and experience can accurately identify the presence or absence of abdominal aortic aneurysms (AAAs) by performing bedside ultrasound scanning, and to assess the potential impact of ultrasound scanning on clinical management. METHODS: Patients in whom AAAs were suspected, including those patients older than 50 years presenting with abdominal/back pain of unclear origin or presumed renal colic, were eligible for study entry. Consenting adults had ultrasound scanning by an emergency physician who was not responsible for their primary care. Treating physicians remained blinded to the results unless an unexpected AAAs was discovered. Scan accuracy was ascertained by comparing our ultrasound results with preselected gold standards. The clinical impact of the ultrasound studies was determined by comparing the preultrasound and postultrasound assessment sheets that detailed the presumed diagnosis, proposed investigations and therapies, and patient disposition. RESULTS: Our convenience sample includes 68 scans for AAAs; findings of 26 scans were positive, 40 scans yielded negative findings, and 2 scans were indeterminate. Scan interpretations were 100% accurate. The ultrasound results would have improved the care of 46 patients without adverse sequelae. Ultrasound scanning served primarily to exclude AAA in patients who proved not to have aneurysms; however, scans also provided significant benefits for those with AAAs and improved patient management plans. CONCLUSION: Relative neophytes can perform aortic ultrasound scans accurately. These scans appear useful as a screening measure in high-risk emergency department patients; they may also aid in rapidly verifying the diagnosis in patients who require immediate surgical intervention.

Salivary testosterone in postmenopausal women with rheumatoid arthritis.

OBJECTIVE: To study changes in testosterone concentrations in saliva and total testosterone, free testosterone, and sex hormone binding globulin (SHBG) concentrations in serum in 2 groups of postmenopausal women with rheumatoid arthritis (RA), one group with glucocorticoid treatment and the other without it. METHODS: The above mentioned hormonal levels were measured in 20 postmenopausal women with RA undergoing glucocorticoid treatment, in 24 postmenopausal women with RA without treatment, and in 36 postmenopausal women without RA. RESULTS: We observed significantly lower levels of total testosterone in serum, SHBG in serum, testosterone in saliva, and the free testosterone index in the group of patients with RA undergoing glucocorticoid treatment compared to the group without treatment. We did not observe changes in free testosterone concentrations in serum of the groups studied, which is believed due to its lower specificity. CONCLUSION: Testosterone in saliva is a useful indicator for monitoring androgenic status in women with RA.

Analytical evaluation of an improved procedure for measuring thyrotropin.

The analytical characteristics of the AxSYM Ultrasensitive hTSH-II (Abbott Laboratories) procedure for quantitation of serum thyrotropin (TSH) concentration were evaluated. Within- and between-run imprecisions, functional sensitivity, analytical interval and relative inaccuracy with respect to the Enzymum-Test TSH (Boehringer Mannheim) were studied. In all cases, the within-run and between-run of coefficients variation were lower than 6.69% and 8.12% respectively. The measurement range was tested with serial dilutions of a serum with a high thyrotropin concentration, and the procedure was found to be linear up to at least 87.0 mIU/l. The functional sensitivity was 0.018 mIU/l. The relative inaccuracy study (Passing-Bablok non-parametric linear regression) produced the following linear equation: (AxSYM) = 1.02. (ES-700)-0.03 mIU/l, with 95% confidence intervals of a (-0.05; -0.01); b (0.98; 1.06).

The association of dehydroepiandrosterone sulphate levels with bone mineral density in systemic lupus erythematosus.

OBJECTIVES: To evaluate, in premenopausal systemic lupus erythematosus (SLE) patients, the possible protective role of androgens on bone mass. METHODS: Bone mineral density (BMD) was measured in the lumbar spine and femoral neck in 37 women with SLE (mean age 31.1 years) without disturbances or therapy that could interfere with bone metabolism except glucocorticoid therapy. We measured serum intact parathyroid hormone (iPTH): 2.5 +/- 1.3 pmol/L, serum testosterone: 1.6 +/- 1.1 nmol/L, salivary testosterone: 0.09 +/- 0.1 nmol/L, and serum dehydroepiandrosterone sulphate (DHEAS): 2.2 +/- 2.2 umol/L. RESULTS: BMD in the spine (L2-L4) was 0.94 +/- 0.1 g/cm2 and in the femoral neck 0.77 +/- 0.1 g/cm2. Four patients (10.8%) had osteoporosis. We found a significant positive relationship between DHEAS and BMD, a negative relationship between DHEAS and the glucocorticoid dose at the time of study, and a negative correlation between iPTH and DHEAS. CONCLUSIONS: Bone loss in corticosteroid-treated premenopausal patients with SLE may be modulated through down-regulation of the endogenous production of DHEAS.

Bone mineral density and hormonal status in men with systemic lupus erythematosus.

A loss in bone mass was reported in premenopausal systemic lupus erythematosus (SLE) women, but this problem has not been studied in SLE males. We evaluated bone mineral density (BMD) in SLE males and the relationship between prolactin (PRL) and testosterone with BMD. We also studied the controversial effect of steroid therapy on BMD in these patients. We measured BMD in the lumbar spine and at the hip in 20 SLE men (mean age 37 y) and in the controls (n = 40). We measured PRL and testosterone in serum and saliva. The mean dose of prednisone at the time of study was 11.6 mg; and cumulative dose was 17.6 g. No significative decrease in BMD was detected in SLE males vs controls; either in the lumbar spine (1.00 +/- 0.1 vs 1.05 +/- 0.1 g/cm2) or in the femoral neck (0.84 +/- 0.1 vs 0.87 +/- 0.1 g/cm2). No patient or control had osteoporosis or fractures. We did not find any relationship between BMD and cumulative dose and baseline dose of corticosteroids. The mean values of PRL and testosterone (serum and salivary) were in the normal range. We did not find any correlation between BMD, PRL and androgens. This study did not show a loss in bone mass in SLE men on corticosteroid therapy.

[Bone mineral density in female patients with systemic lupus erythematosus treated with high glucocorticoid doses]. / Densidad mineral ósea en enfermas con lupus eritematoso sistémico tratadas con dosis altas de glucocorticoides.

OBJECTIVE: To study the bone mineral density (BMD) in premenopausal women with systemic lupus erythematosus receiving glucocorticoids (GL) and at 6 months, when the dose of GL was decreased to a level below half of the initial dose. METHODS: Twelve premenopausal women with SLE were prospectively studied after initiating prednisone therapy at a dose > or = 0.5 mg/kg/day. A densitometric study was performed (Hologic 1000 QDR) of the lumbar spine and femoral neck. Levels of osteocalcine (BGP), catacalcine (PDN-21), testosterone in plasma and saliva, and dehydroepiandrosterone sulphate (DHEAS) were measured. Measurements were repeated after 6 months. RESULTS: The initial mean dose of prednisone was 40 +/- 10.2 mg/day (0.66 mg/kg/day) with an accumulated dose of 27.6 +/- 23 g. Lumbar and femoral BMD were 1 +/- 0.13 and 0.831 +/- 0.07 g/cm2, respectively. A significant increase was observed in BGP an adrogen levels studied after a 6 months when the dose of GL was decreased to a mean dose of 13.9 +/- 7.5 mg/day (0.23 mg/kg/day), whereas no differences were found in BMD values. In none of the two phases of the study were osteoporosis, correlations between BMD and BGP, between PDN-21 and androgens or with the accumulated or punctual doses of GL documented. CONCLUSIONS: No decrease in BMD was observed after 6 months of therapy with high doses of GL. In contrast, an increase in BGP and androgenic status was observed when the GL dose was decreased.

[The value of the parathyrin-related protein (PTH-RP) in the diagnosis of cancer-associated hypercalcemia]. / Valor de la proteína relacionada con la paratirina (PTH-RP) en el diagnóstico de la hipercalcemia asociada al cáncer.

BACKGROUND: The parathyrine related protein (PTH-RP) is very similar, both in structure and in function, to the PTH and is considered as a mediator in humoral hypercalcemia in cancer. The aim of this study was to know the clinical value of PTH-RP measurement. METHODS: Serum PTH-RP concentrations were studied in 22 healthy subjects, 13 patients with primary hyperparathyroidism, 9 patients with solid neoplasms and normocalcemia, 26 patients with solid neoplasms and hypercalcemia and 4 patients with hematologic neoplasms and hypercalcemia. The PTH-RP was quantified by a competitive radioimmunoassay technique using a specific antibody of the PTH-RP 1-40 fragment. Intact parathyrine (i-PTH) was quantified by an IRMA method using 2 polyclonal antibodies (INCSTAR). RESULTS: Fifteen (68%) of the healthy controls presented undetectable serum PTH-RP concentrations. The serum PTH-RP concentration was normal in all those patients with hyperparathyroidism. Elevated serum PTH-RP values were not found in patients with solid neoplasms and normocalcemia or in those with hematologic neoplasms and hypercalcemia. High values of PTH-RP were observed in 8 out of 9 (88%) of the patients with solid neoplasms and hypercalcemia with bone metastasis and in 7 out of 11 (63%) of the patients with bone involvement. CONCLUSIONS: Serum parathyrine-related protein was found to be high in a large proportion of patients with solid neoplasms and hypercalcemia. Serum PTH-RP determination is useful in the clinical investigation of patients with hypercalcemia. Even in patients with bone metastasis, hypercalcemia may have a humoral background.