Vancomycin-resistant enterococcus bacteraemia in an endemic region: clinical features and genomic analysis: a 12-year cohort.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are important nosocomial pathogens with increasing prevalence worldwide. Hospitals in Jerusalem, Israel are known to have high rates of VRE carriage. However, the clonicity of this pathogen in endemic areas remains unclear. METHODS: The medical files of patients with VRE bacteraemia (N=182) hospitalized in the three major hospitals in Jerusalem between 2009 and 2020 were reviewed. These were compared with 100 patients with vancomycin-susceptible enterococcus (VSE) bacteraemia during the same period, and their clinical and demographic characters were analysed. Whole-genome sequencing (WGS) of the VRE isolates was performed, and the results were analysed considering the demographic, epidemiologic and clinical outcome data. RESULTS: Patients with VRE bacteraemia had higher rates of central line use, haematologic malignancy and immunosuppression compared with patients with VSE bacteraemia (63% vs 27%, P<0.001; 25% vs 13%, P=0.02; 24% vs 13%, P=0.04, respectively). Patients with VRE bacteraemia had significantly higher 7- and 30-day in-hospital mortality rates (31% vs 18%, P= 0.02; 57% vs 34%, P<0.001, respectively) and a longer mean hospital stay (39 vs 24 days, P=0.005) than patients with VSE bacteraemia. The WGS results of VRE isolates showed diversity rather than endemicity of a single clone. No clones were associated with specific ethnicity, geographical distribution or worse prognosis. CONCLUSIONS: WGS revealed the occurrence of small unrelated outbreaks rather than the expansion of large clusters in Jerusalem. VRE bacteraemia was found in sicker patients, and was associated with higher mortality and longer hospitalization compared with VSE bacteraemia.

Familial haplotyping and embryo analysis for Preimplantation genetic diagnosis (PGD) using DNA microarrays: a proof of principle study.

PURPOSE: Development of PGD assays for molecular disorders is based on analysis of a familial mutation together with linked polymorphic STR markers; a process which is lengthy and requires the identification of multiple informative markers prior to PGD analysis. On the other hand, whole genome amplification (WGA), in conjunction with microarray platforms, allows the use of a universal assay for the analysis of a very large number of SNP markers at once. The aim of this study was to test high throughput pre-PGD familial haplotyping for in-case blastomere analysis in order to eliminate time-consuming pre-case preparations for each family. METHODS: A PGD cycle was performed for a couple with paternal Charcot Marie Tooth 1A (CMT1A) using a classic multiplex nested PCR approach. Mutant embryos from the case were blindly reanalyzed, as single or multi-cell biopsies, using a multiple displacement amplification-based WGA protocol and microarray SNP analysis. In parallel, relevant genomic DNA samples from the family were also analyzed by SNP microarray. RESULTS: After applying a 'unique informative allele' selection algorithm to the data, this array-based assay reconfirmed the initial diagnosis in all samples. CONCLUSIONS: We describe a PGD method that is both accurate and feasible during the time-frame required for embryo transfer. This strategy greatly reduces the time for pre-case haplotype preparation.

Twin gestations and prophylactic hospitalization.

The study evaluates the benefit of elective hospitalization in preventing premature deliveries of twin gestations. Three groups of women with twin gestations, having no other complications of pregnancy which could cause premature delivery, were evaluated. The study group was comprised of 43 women who were electively hospitalized between 30-32 and 36 weeks of gestation. Control group 1 was comprised of 55 women who were not hospitalized but were instructed to rest at home. Control group 2 was comprised of 53 women who were not hospitalized and were not instructed to rest at home. Our results showed that elective hospitalization did not significantly affect the gestational duration or the prematurity rate. However the mean birthweight difference between the study group and the two control groups were 143 +/- 83 g and 205 +/- 84 g, respectively. This result was more significant in multiparous women. The slight increase in birthweight of the hospitalized women compared to the controls, does not seem to justify the cost of hospitalization.

Vaginal delivery following one previous cesarean birth: nation wide survey.

The present state of vaginal delivery following a previous cesarean section (CS) was evaluated through a nation wide survey, including 22,815 deliveries. The overall cesarean rate was 9.6%. Of all the parturients with one previous cesarean section 55.1% delivered vaginally. A previous CS and labor arrest were the major indications for a repeated CS in 28.7% and 26.4%, respectively. Rupture of the uterus following vaginal delivery was found more often in the group with a previous CS than in those with no uterine scar (1.2% and 0.03%, respectively), (P less than 0.0001). None of the uterine ruptures was fatal neither to the mother nor to the fetus. Post partum fever appeared more often among vaginal deliveries following a CS than among those with no uterine scar. However, CS is followed by fever 10.8 times more than vaginal delivery. Intrapartum and neonatal death rates following vaginal delivery were similar for those with or without a previous CS (3.42% and 3.38%, respectively). An average of 3 hospitalization days were saved for each vaginal birth replacing a repeated CS. It is concluded that vaginal delivery, following CS, does not cause substantial morbidity, nor mortality either to the mother or the neonate, and may be practiced with a reasonable margin of safety in well selected cases.

In vitro fertilization. Correlation of vaginal cytology and hormonal profile with success rates.

Cytologic parameters of the vaginal epithelium in 59 women undergoing in vitro fertilization-embryo transfer (ET) were correlated with plasma levels of 17-beta estradiol and progesterone on the oocyte pickup (OPU) and ET days. On the OPU day a late proliferative/late proliferative-early secretory pattern was observed in 84.6% of the 13 women who conceived (group 1) but in only 52% of the 46 who failed to conceive (group 2) (P less than .04). On the ET day a secretory phase appeared in 100% and 61% of group 1 and 2 patients, respectively (P less than .01). Between the OPU and ET days the mean karyopyknotic index dropped by 60% and 13% in group 1 and 2 patients, respectively (P less than .001). It seems that a high estrogenic effect followed by an advanced progestational environment, on the OPU and ET days, respectively, can provide a favorable milieu for implantation.

Serum lactic dehydrogenase and primary carcinoma of the ovary.

Serum lactic dehydrogenase (LDH) was evaluated in 51 patients with primary carcinoma of the ovary. An increased activity of this enzyme was found in 69% of the patients. The mean +/- SD activity of LDH correlated significantly with stage of disease: 200 +/- 73 U/l in stages 1 and 2, 295 +/- 107 U/l in stages 3A and 3B, and 362 +/- 91 U/l in stages 3C and 4. Moreover, LDH activity correlated significantly with the histological type of the tumor: 170 +/- 57 U/l in mucinous, 300 +/- 107 U/l in serous, 330 +/- 106 U/l in endometroid, and 352 +/- 98 U/l in undifferentiated carcinoma. Normal activity of LDH was observed in 86% of patients in stages 1 and 2, but in only 21% of patients in stages 3 and 4. Serum LDH activity was not found to be a good predictor of late prognosis of the disease, and it did not correlate with the surgical findings on second-look laparotomy. In addition, LDH activity did not correlate with the surgical debulking effort. However, after completion of cytoreductive surgery and adjuvant therapy, LDH did correlate with the course of the disease. It is concluded that LDH may have a role in the evaluation of a patient with carcinoma of the ovary or with a pelvic mass.

Antepartum fetal heart rate characteristics in cases of premature rupture of membranes.

The present retrospective study investigates the effect of premature rupture of membranes on fetal neurocardiac maturation as reflected by the fetal heart rate (FHR) pattern. The FHR tracings of 41 cases involving premature rupture of membranes of at least 48 hours' duration at 24 to 37 weeks' of gestation were studied. Fifty-two cases of normal pregnancy who were matched for gestational age served as controls. The results demonstrate similar baseline FHR and variability in the study and control group. The incidence of FHR accelerations of 15 beats/min was significantly greater in cases of premature rupture of membranes, and their onset was detected at an earlier gestational age. In addition, the mean amplitude of FHR accelerations was significantly greater in the study group compared with the control group. As a result, patients with premature rupture of membranes have a reactive nonstress test at an earlier gestational age than do control patients. These findings support the concept that premature rupture of membranes causes accelerated neurocardiac fetal maturation, as reflected by FHR pattern, possibly by inducing a stressful intrauterine environment.

Advanced ultrasonic placental maturation in twin pregnancies.

The mean length of twin pregnancies is shorter than that of singleton pregnancies. The possibility that the shorter gestation of twins is associated with advanced fetal maturational changes was studied in relation to placental maturation. For this purpose, the sonographically determined placental gradings of 158 twin pregnancies and 474 singleton pregnancies were compared at different gestational ages. The percent distributions of placental grades, from I to III, were significantly different throughout the third trimester, with a preponderance of Grade III placentas in the twin group (p less than 0.001). Considering the reported association of Grade III placentas with advanced gestation as well as fetal lung maturity, the present study suggests earlier maturational changes in twin fetuses compared with singleton fetuses.

A lupus-like syndrome due to lbuprofen hypersensitivity.

A patient with degenerative joint disease with an unusual hypersensitivity reaction to ibuprofen is described. The patient developed transient fever, myalgia polyarthritis and rash following each of 4 exposures to the drug. These manifestations were associated with positive Coombs' and FANA tests.