A novel characterized multi-drug-resistant Pseudocitrobacter sp. isolated from a patient colonized while admitted to a tertiary teaching hospital.

BACKGROUND: Reports of nosocomial infections typically describe recognised microorganisms. Here, a novel bacterial species was isolated, based on rectal swab screening for carbapenemases post-admission, then phenotypically and genetically characterized. METHODS: Sensititre, Vitek and API kits, MALDI and Illumina MiSeq were employed before profiles and phylogeny were compared with other related species. FINDINGS: Determined to be a possible Enterobacterales, the isolate was found to have 99.7% 16s rRNA identity to Pseudocitrobacter corydidari; an Asian cockroach-associated species. Given the highly conserved/low variability of 16S rRNA genes in Enterobacterales, average nucleotide identity (ANI) analysis compared the new isolate's genome with those of 18 Enterobacteriaceae species, including confirmed species of Pseudocitrobacter and unnamed Pseudocitrobacter species in the SILVA database. Of these, Pseudocitrobactercorydidari had the highest ANI at 0.9562. The published genome of the only known isolate of P.corydidari does not include Antimicrobial Resistance Genes (ARGs), with exception of potential drug efflux transporters. In contrast, our clinical isolate bears recognised antimicrobial resistance genes, including Klebsiella pneumoniae carbapenemase. The associated genome suggests resistance to carbapenems, ß-lactams, sulfonamides, fluoroquinolones, macrolides, aminoglycosides and cephalosporins. Phenotypic antimicrobial resistance was confirmed. CONCLUSION: Evident variations in ARG profiles, human colonization and origin in a clinically relevant niche that is geographically, physically and chemically disparate lend credibility for divergent evolution or, less likely, parallel evolution with P. corydidari. Genome data for this new species have been submitted to GENBANK using the proposed nomenclature Pseudocitrobacter limerickensis. The patient was colonized, rather than infected, and did not require antimicrobial treatment.

Large-scale characterization of hospital wastewater system microbiomes and clinical isolates from infected patients: profiling of multi-drug-resistant microbial species.

BACKGROUND: Hospital-acquired infections (HAIs) and infectious agents exhibiting antimicrobial resistance (AMR) are challenges globally. Environmental patient-facing wastewater apparatus including handwashing sinks, showers and toilets are increasingly identified as sources of infectious agents and AMR genes. AIM: To provide large-scale metagenomics analysis of wastewater systems in a large teaching hospital in the Republic of Ireland experiencing multi-drug-resistant HAI outbreaks. METHODS: Wastewater pipe sections (N=20) were removed immediately prior to refurbishment of a medical ward where HAIs had been endemic. These comprised toilet U-bends, and sink and shower drains. Following DNA extraction, each pipe section underwent metagenomic analysis. FINDINGS: Diverse taxonomic and resistome profiles were observed, with members of phyla Proteobacteria and Actinobacteria dominating (38.23 ± 5.68% and 15.78 ± 3.53%, respectively). Genomes of five clinical isolates were analysed. These AMR bacterial isolates were from patients >48 h post-admission to the ward. Genomic analysis determined that the isolates bore a high number of antimicrobial resistance genes (ARGs). CONCLUSION: Comparison of resistome profiles of isolates and wastewater metagenomes revealed high degrees of similarity, with many identical ARGs shared, suggesting probable acquisition post-admission. The highest numbers of ARGs observed were those encoding resistance to clinically significant and commonly used antibiotic classes. Average nucleotide identity analysis confirmed the presence of highly similar or identical genomes in clinical isolates and wastewater pipes. These unique large-scale analyses reinforce the need for regular cleaning and decontamination of patient-facing hospital wastewater pipes and effective infection control policies to prevent transmission of nosocomial infection and emergence of AMR within potential wastewater reservoirs.

Evaluation of a formative peer assessment in research methods teaching using an online platform: A mixed methods pre-post study.

BACKGROUND: In higher education settings, there are increasing calls to shift away from traditional summative assessment practices, such end of term written tests, to explore methods of assessing learning in alternative ways. Peer assessment has been advocated as a means of formative assessment to enhance student engagement, empowering students to take responsibility for their own learning. While there is accumulating evidence for the value of peer assessment in higher education, one cannot assume peer feedback will translate appropriately to all settings and educational contexts. OBJECTIVES: This study evaluated the implementation of formative online peer assessment in a nursing and midwifery research methods module. We explored students' expectations, experiences, and ultimately the acceptability of this approach. DESIGN: A quantitative descriptive study. SETTING: Ireland. METHODS: An online survey to collate expectations and experiences of engagement in peer assessment. Scales were drawn from previous research and non-parametric tests explored changes in perceptions over time. Qualitative content analysis explored patterns evident in open-text responses. RESULTS: The response rate was 28% (n = 74) at baseline and 31% at follow-up (n = 81). Peer assessment was a new experience for 95% of respondents. Students initially expressed apprehension, perceiving the task as daunting, and doubting their ability to provide feedback to peers. However, through providing instruction and tools to support students in the activity, high levels of satisfaction with the process and the experience were reported. Significant differences in perceptions of peer assessment were evident over time, including an enhanced belief that respondents had the requisite skills to appraise the work of their peers. CONCLUSIONS: In sum, nursing and midwifery students agreed that peer assessment was a valuable learning experience as part of research methods training and critical skills development.

Acinetobacter baumannii biofilm biomass mediates tolerance to cold plasma.

Acinetobacter baumannii is an intrinsically multidrug-resistant pathogen that, when existing as a biofilm, confers increased environmental tolerance to desiccation, nutrient starvation as well as increased tolerance to antimicrobials. Outbreaks of A. baumannii infections within the clinical setting are often associated with the biofilm phenotype. This study investigates the role of biofilm biomass in A. baumannii susceptibility to exposure to a kilohertz-driven, in-house-designed, cold plasma jet, through the examination of cold plasma treatment efficacy in A. baumannii biofilms grown over various times for up to 72 h. For biofilms grown for 24, 48 and 72 h, D values were 19·32 ± 2·71, 29·18 ± 3·15 and 24·70 ± 3·07 s respectively. Monitoring A. baumannii biofilm biomass over these time periods revealed that the greatest biomass was observed at 48 h with the lowest biofilm biomass at 24 h growth. Enumeration of viable biofilm colony counts at each time point was comparable. Scanning electron microscopy images of plasma-treated biofilms revealed extensive surface damage of A. baumannii cells. These results describe the role of biomass in mediating A. baumannii biofilm susceptibility to cold plasma treatment, implicating the biofilm matrix as a protective barrier to the antimicrobial effects of cold plasma. SIGNIFICANCE AND IMPACT OF THE STUDY: Acinetobacter baumannii biofilm formation results in increased environmental and antimicrobial tolerance and resistance compared to the planktonic phenotype. Cold plasma technology is increasingly investigated as a new tool for decontamination of biofilm-contaminated surfaces, especially those found in the clinical setting. This new technology presents a promising approach to the remediation of surfaces contaminated by biofilms. This study identifies the role played by A. baumannii biofilm biomass in mediating tolerance and susceptibility to cold plasma treatment. This work demonstrates that increased biofilm biomass reduces the efficacy of antimicrobial species generated by cold plasma, resulting in greater tolerance to plasma exposure.

ICD-11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire.

OBJECTIVE: Support for ICD-11 post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) is growing; however, few studies include refugees or examine the clinical utility of PTSD/CPTSD classifications. This study sought to provide the first evaluations of (i) the factor structure of ICD-11 PTSD/CPTSD amongst refugees in the Middle East; and (ii) the clinical utility of the International Trauma Questionnaire (ITQ) to identify PTSD/CPTSD in a humanitarian context. METHOD: Participants were 112 treatment-seeking Syrian refugees living in Lebanon. Factorial validity was assessed using confirmatory factor analysis (CFA) based on responses to the ITQ. Clinical utility of the ITQ was assessed through semi-structured interviews with six Lebanese psychotherapists. RESULTS: Complex PTSD (36.1%) was more common than PTSD (25.2%), and no sex or age differences were observed at the prevalence or symptomatic levels. CFA results supported a two-factor higher-order model consistent with ICD-11 PTSD/CPTSD. Qualitative findings indicated that the ITQ is generally positively regarded, with some limitations and suggested modifications noted. CONCLUSION: This is the first study to support the ICD-11 PTSD/CPTSD amongst refugees in the Middle East and the clinical utility of the ITQ in a humanitarian context. Findings support the growing evidence for the cross-cultural applicability of ICD-11 PTSD/CPTSD.

Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable within a treatment-seeking sample of Syrian refugees living in Lebanon?

BACKGROUND: The World Health Organization will publish its 11th revision of the International Classification of Diseases (ICD-11) in 2018. The ICD-11 will include a refined model of posttraumatic stress disorder (PTSD) and a new diagnosis of complex PTSD (CPTSD). Whereas emerging data supports the validity of these proposals, the discriminant validity of PTSD and CPTSD have yet to be tested amongst a sample of refugees. METHODS: Treatment-seeking Syrian refugees (N = 110) living in Lebanon completed an Arabic version of the International Trauma Questionnaire; a measure specifically designed to capture the symptom content of ICD-11 PTSD and CPTSD. RESULTS: In total, 62.6% of the sample met the diagnostic criteria for PTSD or CPTSD. More refugees met the criteria for CPTSD (36.1%) than PTSD (25.2%) and no gender differences were observed. Latent class analysis results identified three distinct groups: (1) a PTSD class, (2) a CPTSD class and (3) a low symptom class. Class membership was significantly predicted by levels of functional impairment. CONCLUSION: Support for the discriminant validity of ICD-11 PTSD and CPTSD was observed for the first time within a sample of refugees. In support of the cross-cultural validity of the ICD-11 proposals, the prevalence of PTSD and CPTSD were similar to those observed in culturally distinct contexts.

Robot-assisted repair of diaphragmatic hernias following ventricular assist device implantation.

Use of ventricular assist devices (VADs) is increasingly common, as is the need for surgeons to be familiar with the management of common complications in this population. Nonetheless, repair of diaphragmatic hernias which commonly develop following VAD implantation remains technically challenging due to intra-abdominal adhesions and the proximity of vital structures. Despite the potential benefits of improved dexterity and visualization, robotic approaches have thus far not been used to address this. We present the first two described cases of robot-assisted repair of diaphragmatic hernias in the setting of prior or current VAD placement.

Microbiological interactions with cold plasma.

There is a diverse range of microbiological challenges facing the food, healthcare and clinical sectors. The increasing and pervasive resistance to broad-spectrum antibiotics and health-related concerns with many biocidal agents drives research for novel and complementary antimicrobial approaches. Biofilms display increased mechanical and antimicrobial stability and are the subject of extensive research. Cold plasmas (CP) have rapidly evolved as a technology for microbial decontamination, wound healing and cancer treatment, owing to the chemical and bio-active radicals generated known collectively as reactive oxygen and nitrogen species. This review outlines the basics of CP technology and discusses the interactions with a range of microbiological targets. Advances in mechanistic insights are presented and applications to food and clinical issues are discussed. The possibility of tailoring CP to control specific microbiological challenges is apparent. This review focuses on microbiological issues in relation to food- and healthcare-associated human infections, the role of CP in their elimination and the current status of plasma mechanisms of action.

Antimicrobial efficacy of an innovative emulsion of medium chain triglycerides against canine and feline periodontopathogens.

OBJECTIVES: To test the in vitro antimicrobial efficacy of a non-toxic emulsion of free fatty acids against clinically relevant canine and feline periodontopathogens METHODS: Antimicrobial kill kinetics were established utilising an alamarBlue(®) viability assay against 10 species of canine and feline periodontopathogens in the biofilm mode of growth at a concentration of 0·125% v/v medium chain triglyceride (ML:8) emulsion. The results were compared with 0·12% v/v chlorhexidine digluconate and a xylitol-containing dental formulation. Mammalian cellular cytotoxicity was also investigated for both the ML:8 emulsion and chlorhexidine digluconate (0·25 to 0·0625% v/v) using in vitro tissue culture techniques. RESULTS: No statistically significant difference was observed in the antimicrobial activity of the ML:8 emulsion and chlorhexidine digluconate; a high percentage kill rate (>70%) was achieved within 5 minutes of exposure and was maintained at subsequent time points. A statistically significant improvement in antibiofilm activity was observed with the ML:8 emulsion compared with the xylitol-containing formulation. The ML:8 emulsion possessed a significantly lower (P < 0·001) toxicity profile compared with the chlorhexidine digluconate in mammalian cellular cytotoxicity assays. CLINICAL SIGNIFICANCE: The ML:8 emulsion exhibited significant potential as a putative effective antimicrobial alternative to chlorhexidine- and xylitol- based products for the reduction of canine and feline periodontopathogens.

Atmospheric pressure, nonthermal plasma inactivation of MS2 bacteriophage: effect of oxygen concentration on virucidal activity.

AIMS: The main aim of this study was to determine the virucidal inactivation efficacy of an in-house-designed atmospheric pressure, nonthermal plasma jet operated at varying helium/oxygen feed gas concentrations against MS2 bacteriophage, widely employed as a convenient surrogate for human norovirus. METHODS AND RESULTS: The effect of variation of percentage oxygen concentration in the helium (He) carrier gas was studied and found to positively correlate with MS2 inactivation rate, indicating a role for reactive oxygen species (ROS) in viral inactivation. The inactivation rate constant increased with increasing oxygen concentrations up to 0·75% O2 . 3 log10 (99·9%) reductions in MS2 viability were achieved after 3 min of exposure to the plasma source operated in a helium/oxygen (99·25% : 0·75%) gas mixture, with >7 log10 reduction after 9 min exposure. CONCLUSIONS: Atmospheric pressure, nonthermal plasmas may have utility in the rapid disinfection of virally contaminated surfaces for infection control applications. SIGNIFICANCE AND IMPACT OF STUDY: The atmospheric pressure, nonthermal plasma jet employed in this study exhibits rapid virucidal activity against a norovirus surrogate virus, the MS2 bacteriophage, which is superior to previously published inactivation rates for chemical disinfectants.

Comparison of the cidal activity of tea tree oil and terpinen-4-ol against clinical bacterial skin isolates and human fibroblast cells.

AIMS: The aim of this study was to compare both the antimicrobial activity of terpinen-4-ol and tea tree oil (TTO) against clinical skin isolates of meticillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (CoNS) and their toxicity against human fibroblast cells. METHODS AND RESULTS: Antimicrobial activity was compared by using broth microdilution and quantitative in vitro time-kill test methods. Terpinen-4-ol exhibited significantly greater bacteriostatic and bactericidal activity, as measured by minimum inhibitory and bactericidal concentrations, respectively, than TTO against both MRSA and CoNS isolates. Although not statistically significant, time-kill studies also clearly showed that terpinen-4-ol exhibited greater antimicrobial activity than TTO. Comparison of the toxicity of terpinen-4-ol and TTO against human fibroblasts revealed that neither agent, at the concentrations tested, were toxic over the 24-h test period. CONCLUSIONS: Terpinen-4-ol is a more potent antibacterial agent against MRSA and CoNS isolates than TTO with neither agent exhibiting toxicity to fibroblast cells at the concentrations tested. SIGNIFICANCE AND IMPACT OF THE STUDY: Terpinen-4-ol should be considered for inclusion as a single agent in products formulated for topical treatment of MRSA infection. However, further work would initially be required to ensure that resistance would not develop with the use of terpinen-4-ol as a single agent.

Peptides containing acylated C-terminal gem diamines: novel irreversible inactivators of the cysteine and serine proteinases.

This study reports on the synthesis of peptides containing C-terminal acylated gem-diamines and their utilization for the preparation of irreversible inactivators of the serine and cysteine proteinases. We have succeeded in obtaining an inhibitor Acetyl-Val-Pro-g-Val-CO-O-C(6)H(4)-NO(2) of neutrophil and pancreatic elastases that functions in a time-dependent manner, indicative of the action of an irreversible inactivator, functioning, most probably, through the formation of a long-lived acyl enzyme intermediate. In addition, we have demonstrated the irreversible inhibition of the cysteine proteinase bovine cathepsin B, by chloroacetyl and bromoacetyl derivatives of a dipeptide gem-diamine, Cbz-Phe-g-Ala-CO-CH(2)Hal (Hal = Br, Cl).

The inactivation of bovine cathepsin B by novel N-chloro-acetyl-dipeptides: application of the Houghten 'tea bag' methodology to inhibitor synthesis.

In this study, a series of N-chloro-acetylated dipeptides were synthesised by the application of Houghten's methodology of multiple analog peptide syntheses (MAPS). The peptides, all of which contain a C-terminal free acid, were tested as inactivators of bovine cathepsin B, in an attempt at exploiting the known and, amongst the cysteine proteinases, unique carboxy dipeptidyl peptidase activity of the protease. We have succeeded in obtaining a number of effective inactivators, the most potent of which-chloroacetyl-Leu-Leu-OH, inactivates the enzyme with an apparent second-order rate constant of 3.8 x 10(4)M(-1)min(-1). In contrast, the esterified analog, chloroacetyl-Leu-Leu-OMe, inactivates the enzyme some three orders of magnitude less efficiently, lending credence to our thesis that a free carboxylic acid moiety is an important determinant for inhibitor effectiveness. This preliminary study has highlighted a number of interesting features about the specificity requirements of the bovine proteinase and we believe that our approach has great potential for the rapid delineation of the subsite specificities of cathepsin B-like proteases from various species.

Serial bedside emergency ultrasound in a case of pediatric blunt abdominal trauma with severe abdominal pain.

We present a case of a teenager with isolated left renal laceration with perirenal hematoma. The patient had presented with severe left upper quadrant (LUQ) pain following blunt abdominal trauma (BAT) sustained during a sledding accident. A screening bedside focused abdominal sonogram for trauma (FAST) rapidly excluded free fluid on two serial examinations, 30 minutes apart. It provided the pediatric emergency physician with a measure of diagnostic confidence that the patient could be safely transported to the CT suite for detailed delineation of his injury. Moreover, narcotic analgesia was liberally administered early in his illness course, without the fear of unmasking potential hypovolemia when it was known that he did not have gross intra-abdominal bleeding on his bedside ultrasound (US). It also provided a working diagnosis of the primary organ of injury. Our hospital, like many pediatric hospitals around the nation, does not have in-house 24-hour radiology support. We suggest that the use of the bedside US be extended to the stable pediatric patient in severe abdominal pain following BAT. It can serve as a valuable, rapid, noninvasive, bedside, easily repeated, fairly accurate triage tool to evaluate pediatric BAT with severe pain.

Determination of systolic blood pressure via pulse oximeter in transported pediatric patients.

OBJECTIVE: To compare pulse oximetry waveform systolic blood pressure measurements (POWSBP) to measurements obtained by noninvasive blood pressure measurement (NIBPM) during the transport of children. DESIGN: A prospective, convenience sample. SETTING AND PARTICIPANTS: All patients transported by a dedicated Pediatric Critical Care Transport Team were eligible for inclusion. Senior transport nurses with over 3 years of transport experience who had been instructed by the principal investigator (PI) in the technique, obtained the measurements and recorded the results. A convenience sample was obtained based on the presence or absence of one of the senior nurses on the transport team. METHODS: Measurements of blood pressure were obtained by POWSBP and NIBPM (PROPAQ@; Protocol Systems, Beaverton, OR) on pediatric patients during transport in moving ambulances or fixed wing aircraft. Measurement of systolic blood pressure by pulse oximetry (POWSBP) was obtained on all patients by observing the return of the plethysmographic waveform of the pulse oximeter as the blood pressure cuff deflated. The patients were divided into two groups; in group A POWSBP measurements were obtained by using the automated BP cuff from the PROPAQ@ and in group B by a manual BP cuff. These measurements were compared to NIBPM readings obtained at the same time. Between 3 and 13 paired readings were obtained for each patient. The actual transport time determined the number of measurements obtained. RESULTS: A total of 24 patients were enrolled in the study. Multiple matched pair readings (both POWSBP and NIBPM) were obtained from each patient for a total of 180 data points. A two variable linear regression model was run which identified a significant correlation between POWSBP and NIBPM. Group A, r = 0.7592 and r = 0.9477 for group B significant at P< 0.000001. Further, a corrective equation was developed for use with an automated BP cuff. CONCLUSIONS: The use of pulse oximetry waveform systolic blood pressure measurement is a quick and easy method with which to obtain systolic blood pressure in children during transport and shows a close correlation to the standard noninvasive blood pressure measurement. If an automated blood pressure cuff is used, then a corrective equation [NIBP-S = 41.686 + 0.7377(POBPS)] is required. Further validation in a larger group of patients is recommended.

Expression of transforming growth factor-beta receptors during hyperoxia-induced lung injury and repair.

Lung injury and repair processes involve many cellular activities, including cell growth, differentiation, and remodeling of extracellular matrix components. Transforming growth factor-beta (TGF-beta) is a major class of signaling peptide growth factors regulating these cellular activities. Type I (T beta RI) and type II (T beta RII) receptors for TGF-beta are transmembrane serine/threonine kinases that are essential for TGF-beta signaling. To gain insight into the possible molecular mechanisms of lung injury and repair, we investigated the expression of T beta RI and T beta RII in an acute hyperoxia-induced model of lung injury and repair. Localization of message expression of T beta RI and T beta RII in oxygen-exposed rat lung tissue was analyzed by using in situ hybridization. T beta RI mRNA expression was found in the interstitium, capillaries, and the alveolar septa of rat lungs exposed for 60 h to 100% oxygen. The distribution of T beta RII mRNA in oxygen-exposed rat lung tissue overlapped the localization of T beta RI mRNA. Temporal changes of T beta RI and T beta RII mRNA expressions in rat lung during hyperoxic exposure and repair were examined by Northern analysis. We found that expression of T beta RI was upregulated in adult rats undergoing prolonged exposure to 100% oxygen, and the increase of T beta RI expression persisted during 2 wk of repair of lung injury. The pattern of T beta RII expression during hyperoxic exposure and repair was distinct from that of T beta RI. The expression of T beta RII increased with a peak at 3 days postexposure and then declined after 7 days of repair. Changes of T beta RI and T beta RII protein expressions in rat lung during hyperoxic exposure and repair were examined further by Western blot analysis, which correlated with the mRNA expression. The results suggest that T beta RI and T beta RII may play important roles during the lung injury and repair by mediating signaling activity of TGF-beta and may regulate interactions between the mesenchyme and the epithelium.

Laparoscopic cholecystectomy in the treatment of acalculus cholecystitis in patients after thermal injury.

Acalculus cholecystitis accounts for 2% to 14% of all cases of acute cholecystitis and is seen with increasing frequency in patients after major trauma and burns. In these already compromised patients, acute acalculus cholecystitis can be difficult to diagnose and more difficult to treat. We present our experience with laparoscopic cholecystectomy in seven patients with this often lethal combination treated over the last 5 years. All the patients who underwent surgery survived and had minimal morbidity from their operations. We discuss the etiology and diagnosis and review the literature of the treatment of acalculus cholecystitis in patients after thermal injury.

Effective temporal lobectomy in childhood without invasive EEG.

Temporal lobectomy abolished complex partial seizures (CPSs) in 14 consecutive children (12 years or younger) whose presurgical evaluation included clinical analysis, scalp EEG, and neuroimaging. Seizures of 13 of 14 patients began with a simple partial component whose symptoms were suggestive of limbic system involvement. EEG recorded clinically typical seizures arising from the ultimately operated on temporal lobe in seven (50%) and never falsely lateralized seizure origin. Most active interictal spikes arose from the epileptogenic temporal lobe in 13 (93%) and never falsely lateralized epileptogenesis. Neuroimaging disclosed epileptogenic lesions in all: magnetic resonance imaging (MRI; 11 patients) and computed tomography (CT; three patients). Children may obtain relief from CPSs by temporal lobectomy without invasive electroencephalography.