Estimating the association between antibiotic exposure and colonization with extended-spectrum ß-lactamase-producing Gram-negative bacteria using machine learning methods: a multicentre, prospective cohort study.

OBJECTIVES: The aim of the study was to measure the impact of antibiotic exposure on the acquisition of colonization with extended-spectrum ß-lactamase-producing Gram-negative bacteria (ESBL-GNB) accounting for individual- and group-level confounding using machine-learning methods. METHODS: Patients hospitalized between September 2010 and June 2013 at six medical and six surgical wards in Italy, Serbia and Romania were screened for ESBL-GNB at hospital admission, discharge, antibiotic start, and after 3, 7, 15 and 30 days. Primary outcomes were the incidence rate and predictive factors of new ESBL-GNB colonization. Random forest algorithm was used to rank antibiotics according to the risk of selection of ESBL-GNB colonization in patients not colonized before starting antibiotics. RESULTS: We screened 10 034 patients collecting 28 322 rectal swab samples. New ESBL-GNB colonization incidence with and without antibiotic treatment was 22/1000 and 9/1000 exposure-days, respectively. In the adjusted regression analyses, antibiotic exposure (hazard ratio (HR) 2.38; 95% CI 1.29-4.40), age 60-69 years (HR 1.19; 95% CI 1.05-1.34), and spring season (HR 1.25; 95% CI 1.14-1.38) were independently associated with new colonization. Monotherapy ranked higher als combination therapy in promoting ESBL-GNB colonization. Among monotherapy, cephalosporins ranked first followed by tetracycline (second), macrolide (fourth) and cotrimoxazole (seventh). Overall the ranking of cephalosporins was lower when used in combination. Among combinations not including cephalosporins, quinolones plus carbapenems ranked highest (eighth). Among sequential therapies, quinolones ranked highest (tenth) when prescribed within 30 days of therapy with cephalosporins. CONCLUSIONS: Impact of antibiotics on selecting ESBL-GNB at intestinal level varies if used in monotherapy or combination and according to previous antibiotic exposure. These finding should be explored in future clinical trials on antibiotic stewardship interventions. CLINICAL TRIAL REGISTRATION: NCT01208519.

Results of primary repair of distal triceps tendon ruptures in a general population: a multicentre study.

Aims: The aim of the study was to analyze the results of primary tendon reinsertion in acute and chronic distal triceps tendon ruptures (DTTRs) in the general population. Patients and Methods: A total of 28 patients were operated on for primary DTTR reinsertions, including 21 male patients and seven female patients with a mean age of 45 years (14 to 76). Of these patients, 23 sustained an acute DTTR and five had a chronic injury. One patient had a non-simultaneous bilateral DTTR. Seven patients had DTTR-associated ipsilateral fracture or dislocation. Comorbidities were present in four patients. Surgical treatment included transosseous and suture-anchors reinsertion in 22 and seven DTTRs, respectively. The clinical evaluation was performed using Mayo Elbow Performance Score (MEPS), the modified American Shoulder and Elbow Surgeons Score (m-ASES), the Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), and the Medical Research Council (MRC) Scale. Results: A total of 27 patients (28 DTTRs) were available for review at a mean of 47.5 months (12 to 204). The mean MEPS, QuickDASH, and m-ASES scores were 94 (60 to 100), 10 (0 to 52), and 94 (58 to 100), respectively. Satisfactory results were observed in 26 cases (93%). Muscle strength was 5/5 and 4/5 in 18 and ten DTTRs, respectively. One patient with chronic renal failure experienced a traumatic rerupture of distal triceps. One patient (1 DTTR) experienced mild elbow stiffness. Conclusion: Primary repair of acute and chronic DTTRs in a general population yields satisfactory results in the majority of patients with a low rerupture rate. Cite this article: Bone Joint J 2018;100-B:610-16.

Predictors of outcome in ICU patients with septic shock caused by Klebsiella pneumoniae carbapenemase-producing K. pneumoniae.

The aim of this study was to identify factors associated with mortality in intensive care unit patients with Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp) septic shock. A retrospective analysis of intensive care unit patients with KPC-Kp infection and septic shock observed in a large teaching hospital from November 2010 to December 2014 was performed. A total of 111 patients were included in the study. The most frequent source of infection was unknown-focus bacteraemia in 53 patients (47.7%). The rate of resistance to colistin was 51.3%; 30-day mortality was reported for 44 patients (39.6%). Surviving patients were more frequently treated with an initial therapy (within 24 hours) including two or more antibiotics displaying in vitro activity against the isolated KPC-Kp strain (41.8 vs. 18.1%, p 0.01) and were also more likely to receive a definitive therapy including two or more in vitro active antibiotics (85.1 vs. 15.9%, p <0.001). Cox regression analysis revealed that a colistin-containing antibiotic regimen (hazard ratio (HR) 0.21, confidence interval (CI) 95% 0.05-0.72, p <0.001), use of two or more in vitro active antibiotics as definite therapy (HR 0.08, CI 95% 0.02-0.21, p <0.001) and control of removable source of infection (HR 0.14, CI 95% 0.04-0.25, p <0.001) were associated with favourable outcome; colistin resistance (HR 8.09, CI 95% 3.14-11.23, p 0.001) and intra-abdominal source of infection (HR 2.92, CI 95% 2.11-4.12, p 0.002) were associated with death. In conclusion, use of a definitive therapy with at least two antibiotics displaying in vitro activity against the KPC-Kp isolates was the most important determinant of favourable outcome, whilst isolation of colistin-resistant strains was associated with death in septic patients with KPC-Kp infection.

Necesidades protésicas de la población de Rio Chico Edo. Miranda: agosto-noviembre 2010 / Prosthetic needs in population of Río Chico Edo. Miranda agust-november 2010

La pérdida parcial o total de la dentición natural es el resultado más frecuente de caries dental o enfermedad periodontal. Estos, ocasionan la extracción temprana de las piezas dentarias permanentes trayendo como consecuencia la necesidad de rehabilitación al individuo afectado. Determinar las necesidades protésicas de los pacientes de la población de Río Chico-Edo. Miranda. Estudio descriptivo y transversal. El instrumento de recolección de datos fue la Historia Clínica empleada por ambos centros, se estudiaron 701 pacientes entre masculinos y femeninos que acudieron a solicitar tratamiento odontológico al ambulatorio urbano tipo III Centro de Especiales Médico Odontológicas (C.E.M.O.) y el ambulatorio urbano tipo II Asociación Damas Salesianas (ADS) durante el período agosto-noviembre 2010. Se elaboró una matriz de datos en el programa Excel para la organización de los datos. 72% de la muestra eran mujeres y 28% eran hombres. La edad más afectada fue entre 21 y 30 años (28%). De acuerdo a las necesidades protésicas el 71% requiere una o más prótesis fija, 26% requerían prótesis parciales removibles tanto dento-soportadas como dento-muco-soportadas y 3% requería de prótesis totales. Se ratifica la importancia de este estudio para proveer información a las entidades del Estado encargados de brindar los recursos para rehabilitar a nivel bucal a esta población.

The partial or complete loss of the natural dentition is the most frequent result of dental caries or periodontal disease. There from the early extraction of teeth permanent bringing as a result the need for rehabilitation tothose affected individual. To determine the population of Río Chico- Miranda State, Venezuela, patients prosthetic needs. descriptive and transversal study. The data collection instrument was the clinical history, used by bothenters, 701 patients of both sexes who came to seek dental treatment to urban ambulatory type III special medical dental (C.E.M.O.) Centre and urban ambulatory type II partnership Damas Salesianas (ADS) during the period August-November 2010. Developed an array of data inthe Excel program for the Organization of the data 72% 28% to the masculine and feminine gender. The most affected age was between 21 and 30 years (28%). Needs prosthetic : 71% requires one or more fixed prosthesis, 26% require removable dento-supported both dento-muco-supported partial dentures and dentures requires 3%. Confirms the importance of this study to provide information to State entities responsible for providing resources to rehabilitate oral level to this population.

Toll-like receptor 4 (TLR4) gene polymorphisms in giant cell arteritis.

OBJECTIVE: To investigate potential associations between toll-like receptor 4 (TLR4) gene polymorphisms and susceptibility to, and clinical features of giant cell arteritis (GCA). METHODS: A total of 155 patients with biopsy-proven GCA who were residents of Reggio Emilia, Italy, and 210 population-based controls from the same geographical area were genotyped for two coding single nucleotide polymorphisms of TLR4 (Asp299Gly and Thr399Ile) by molecular methods. The patients were subgrouped according to the presence or absence of polymyalgia rheumatica and severe ischemic complications (visual loss and/or cerebrovascular accidents). RESULTS: The distribution of allele and genotype frequencies did not differ significantly between GCA patients and healthy controls. Carriers of the -299 G allele (G/A+ G/G) [odds ratio (OR) 1.78, 95% confidence intervals (CI) 0.90-3.50)] were more frequent among GCA patients than among the controls, but the difference was not statistically significant. No significant associations were found when GCA patients with and without PMR or with and without severe ischemic complications were compared. CONCLUSION: Our data suggest that the TLR4 gene polymorphisms are not associated with susceptibility to, and clinical expression of, GCA in Italian patients.

Risk factors for severe cranial ischaemic events in an Italian population-based cohort of patients with giant cell arteritis.

OBJECTIVE: To evaluate the impact of traditional cardiovascular risk factors, carotid atherosclerosis and the effect of anti-platelet/anti-coagulant therapy on the occurrence of severe cranial ischaemic events (CIEs) in GCA. METHODS: We identified 180 Reggio Emilia (Italy) residents with biopsy-proven GCA diagnosed between 1986 and 2005. We evaluated data on demographics, clinical features, laboratory investigations, cardiovascular risk factors, anti-platelet/anti-coagulant use and carotid atherosclerosis. RESULTS: Systemic signs/symptoms were significantly less frequent (P = 0.004) and ESR and C-reactive protein (CRP) values at diagnosis were significantly lower (P = 0.03 and P = 0.04, respectively) in patients with CIEs. The prevalence of hypertension and ischaemic heart disease was significantly higher in patients with CIEs than in those without (P = 0.01 and P = 0.006, respectively). Patients treated with anti-platelet/anti-coagulant therapy were significantly more likely to suffer CIEs than those without (P = 0.03), while CIEs were significantly associated with ischaemic heart disease in this subset of patients (P = 0.02). By multivariate logistic regression, we found that the best predictors for the development of severe CIEs included the absence of high (>5.38 mg/dl) CRP levels at diagnosis (OR = 0.31, 95% CI 0.08, 1.20), the absence of systemic manifestations (OR = 0.30, 95% CI 0.08, 1.08), the presence of hypertension (OR = 7.77, 95% CI 0.83, 72.76), and a past history of ischaemic heart disease (OR = 8.65, 95% CI 0.92, 80.95). CONCLUSIONS: In GCA, hypertension, a past history of ischaemic heart disease and a low inflammatory response are associated with a higher risk of developing severe CIEs.

-463 G/A myeloperoxidase promoter polymorphism in giant cell arteritis.

OBJECTIVE: To investigate potential associations between-463 G/A myeloperoxidase (MPO) promoter polymorphism and susceptibility to, and clinical features of giant cell arteritis (GCA). METHODS: A total of 156 patients with biopsy-proven GCA who were residents of Reggio Emilia, Italy, and 235 population-based controls from the same geographic area were genotyped for-463 G/A promoter polymorphism of the MPO gene by molecular methods. The patients were subgrouped according to the presence or absence of polymyalgia rheumatica and severe ischaemic complications (visual loss and/or cerebrovascular accidents). RESULTS: The distribution of the MPO-G/A genotype differed significantly between patients with GCA and the controls (p(corr) = 0.003). Allele G was significantly more frequent in patients with GCA than in the controls (p(corr) = 0.0002, OR 2.0, 95% CI 1.4 to 2.9). Homozygosity for the G allele was significantly more frequent in patients with GCA than in controls (p(corr) = 0.0002, OR 2.2, 95% CI 1.4 to 3.4). No significant associations were found when patients with GCA with and without polymyalgia rheumatica or with and without severe ischaemic complications were compared. CONCLUSIONS: Our findings show that the-463 G/A promoter polymorphism of the MPO gene is associated with GCA susceptibility and support a role for MPO in the pathophysiology of GCA.

Clinical manifestations of Behçet's disease in 137 Italian patients: results of a multicenter study.

OBJECTIVE: To determine the type and frequency of clinical features of Behçet's disease in a population of Italian patients. METHODS: We retrospectively studied 137 Italian patients (76 males and 61 females, age at onset 29.6 +/- 12.2 [mean +/- SD] years) seen consecutively in nine different referral centers. The duration of follow-up at study entry was 10.9 +/- 8.2 years. Virtually all patients fulfilled the classification criteria developed by the International Study Group for Behçet's disease. The clinical manifestations of the patients were recorded by the attending physicians using specifically designed forms. RESULTS: The most frequent manifestations at disease onset were oral (78.3%) and genital aphthae (29.2%) followed by inflammatory ocular involvement (20%) and arthritis (14.2%). The commonest (>50% of cases) manifestations observed throughout the disease course were oral aphthae (99.3%), genital aphthae (62.8%), various cutaneous lesions including erythema nodosum (81.8%), and inflammatory ocular disease (60.6%). Panuveitis and posterior uveitis/retinitis occurred more frequently in males compared with females (28.9% versus 11.5% and 57.9% versus 36.1%, respectively; p < 0.05). 61.6% of our patients were HLA-B51 positive. CONCLUSION: Behçet's disease in Italian patients is characterized by a variety of clinical manifestations in agreement with the medical literature. Panuveitis and posterior uveitis/retinitis occur more frequently in male patients.

Lp(a) levels and reduced risk of vascular atheromatosis in patients with alcoholic liver disease.

In a group of 80 patients (50 male and 30 female) aged between 44 and 65, affected by alcoholic liver disease (46 with steatosis and 34 with liver cirrhosis) the Authors examined the relationship between the plasma lipid, in particular of Lp(a), and the incidence of vascular atherosclerotic plaques. The results were compared with those found in the controls (50 subjects of similar age, social and working status to that of the above patients but nondrinkers without liver or other metabolic disease). In the patients with steatosis we found a moderate increase in plasma lipid fractions including total, HDL and LDL cholesterol, but low levels of Lp(a), with an incidence of arterial plaques of 10.86%. In those with liver cirrhosis the findings were characterized by low levels of lipids and in particular of Lp(a), with an incidence of arterial plaques of 8.82%, decidedly less marked than in the controls (16%). In both cases the low incidence of vascular involvement appears to be in some way linked with low levels of Lp(a) and the severity of liver disease and not with the behaviour of HDL cholesterol.

[Alcohol and idiopathic dilatated cardiomyopathy: a pathogenetic hypothesis]. / Alcool e cardiomiopatia dilatativa idiopatica: una ipotesi patogenetica.

In a group of 120 chronic alcoholics, we observed two cases of severe dilated cardiomyopathy, fatal within a year, similar to the so called "idiopathic" form, among cases of cardiovascular involvement related to alcohol abuse (63.5%) but susceptible of improvement following abstention. On the basis of their observation we believe that alcohol itself, as has already been demonstrated for certain viruses, in the presence of particular genetic factors can cause the onset of an immune reaction able to impart an autonomous course which cannot be checked even after abstention from alcohol.

[Possibility of early diagnosis of hepatic fibrosis in chronic alcoholics determining the N-terminal peptide of type-III procollagen]. / Possibilità di diagnosi precoce di fibrosi epatica negli alcoolisti cronici mediante dosaggio del peptide N-terminale del procollagene tipo III.

The authors examined the behaviour of sP-III-P and other parameters in 40 patients affected by alcoholic liver disease (20 of whom with steatosis, 10 with steatofibrosis, 10 with liver cirrhosis) and at the same time in a group of non drinking controls. The levels of sP-III-P appeared significantly increased in the patients with steato-fibrosis and even more so in those with liver cirrhosis, while in those with steatosis the increase was insignificant. The gamma-globulins showed similar behaviour while serum albumin appeared proportionally reduced in the cases in which sP-III-P and gamma-globulins showed a greater increase. The authors believe that the study of sP-III-P is valuable in the follow-up of patients with alcoholic liver disease and in particular in chronic alcoholism to reveal the presence of an increased fibrogenesis.

[Plasma fibronectin and alcoholic liver disease]. / Fibronectina plasmatica ed epatopatia alcoolica.

The authors examined, in 58 chronic alcoholics, the behaviour of plasma fibronectin, SGPT and seric albumin. Among the patients, ten were without liver damage while the others were affected with alcoholic liver disease at different stages, such as steatosis (12), steatofibrosis (14), evolutive chronic hepatitis (10), cirrhosis (12). The levels of plasma fibronectin appeared significantly increased in the cases with steatofibrosis, evolutive chronic hepatitis and cirrhosis; unimportant changes were noted in the cases with steatosis. SGPT always resulted increased, showing the existence of cytolysis related with plasma fibronectin levels, while seric albumin was constantly reduced with negative ratio to fibronectin levels, except in cases of decompensated cirrhosis. The authors believe that the monitoring of plasma fibronectin in chronic alcoholics may be a suitable means to reveal an increased liver fibrosis.

In vivo and in vitro study of antigens and allergens in pollen extracts of Graminaceae.

The standardization of the diagnostic and immunotherapeutic products plays an even more definite role in allergology. The investigations performed in the last few years allowed to attain the purification and characterization of the allergenic extracts, both from the allergenic and antigenic viewpoint, implementing the most sophisticated techniques. The identification of the allergens in the extracts is of primary importance in the standardization and purification of the allergens themselves. The allergenic activity may be determined both in vitro and in vivo and the combination of the two techniques allows reaching a higher reliability in the assay. The Authors thought it very timely to verify the reliability of the in vivo and in vitro assays by employing four allergenic extracts of Graminaceae pollens, due to their importance in the allergological field. Phleum, Lolium, Cynodon, Anthoxanthum, were selected for the investigations. The extracts were also characterized by immunoprecipitation techniques. The results allowed to state that good results may be obtained by the in vivo assay (prick test) of allergenic extracts, with a precision comparable to that obtainable with the RAST inhibition, even using a restricted sample of allergic patients. It was ascertained that it is possible to express the allergenic activity versus a reference extract (Phleum). The three extracts (Anthoxanthum, Cynodon, Lolium), for which good antisera were obtained, were antigenically characterized, by means of CRIE and CIE, and the major allergens were identified.

Dupuytren's contracture: clinical and therapeutic aspects.

The writers first describe the main features of the pathological anatomy and clinical characteristics of Dupuytren's contracture. They classify the lesions by Tubiana's method, which is eminently objective and practical. This classification divides the lesions, according to their severity, in five stages: 0, 1, 2, 3, 4. The surgical technique of total aponeurectomy used by the authors is described. The total case material is thirty patients, with thirty-three hands operated on. By comparing the state of the hand before and after operation, the degree of improvement was calculated as a percentage derived from Tubiana's method of classification. A careful evaluation of the results confirms the validity of the therapeutic approach adopted. The indications and prognosis depend on the severity of the initial lesions. In general the chances of cure are good up to stage 3; but once this stage has been passed, and especially if hyperextension of the terminal phalanx is present, there is a high probability of recurrence and failure. In these cases they advise against corrective surgery and consider arthrodesis or amputation a more suitable alternative.