Clinical and economic burden of community-onset multidrug-resistant infections requiring hospitalization.

OBJECTIVES: To analyze the clinical and economic burden of community-acquired (CA) or community-onset healthcare-associated (COHCA) multidrug-resistant (MDR) infections requiring hospitalization. METHODS: Case-control study. Adults admitted with CA or COHCA MDR infections were considered cases, while those admitted in the same period with non-MDR infections were controls. The matching criteria were source of infection and/or microorganism. Primary outcome was 30-day clinical failure. Secondary outcomes were 90-day and 1-year mortality, hospitalization costs and resource consumption. RESULTS: 194 patients (97 cases and 97 controls) were included. Multivariate analysis identified age (odds ratio [OR], 1.07, 95% confidence interval [CI], 1.01-1.14) and SOFA score (OR, 1.45, CI95%, 1.15-1.84) as independent predictors of 30-day clinical failure. Age (hazard ratio [HR] 1.09, 95%CI, 1.03-1.16) was the only factor associated with 90-day mortality, whereas age (HR 1.06, 95%CI, 1.03-1.09) and Charlson Index (HR 1.2, 95%CI, 1.07-1.34) were associated with 1-year mortality. MDR group showed longer hospitalization (p<0.001) and MDR hospitalization costs almost doubled those in the non-MDR group. MDR infections were associated with higher antimicrobial costs. CONCLUSIONS: Worse economic outcomes were identified with community-onset MDR infections. MDR was associated with worse clinical outcomes but mainly due to higher comorbidity of patients in MDR group, rather than multidrug resistance.

Weighting the impact of virulence on the outcome of Pseudomonas aeruginosa bloodstream infections.

OBJECTIVES: We assessed the association between the lethality of Pseudomonas aeruginosa in a Caenorhabditis elegans model and outcomes of P. aeruginosa bloodstream infections. METHODS: A total of 593 P. aeruginosa bloodstream isolates recovered from a prospective Spanish multicentre study were analysed. Clinical variables, susceptibility profiles and Type III Secretion System (TTSS) genotypes (exoU/exoS genes) were available from previous studies. A C. elegans virulence score (CEVS) was used, classifying the isolates into high (CEVS 4-5), intermediate (CEVS 3) and low (CEVS 1-2) virulence. The main outcome analysed was 30-day mortality. RESULTS: Up to 75% (446/593) of the isolates showed a high-virulence phenotype, and 17% (101/593) a low-virulence one. No association between virulence phenotype and the main outcome variable (30-day mortality) was found (29/101 (28.7%) versus 127/446 (28.5%), p 1). However, an inverse association between C. elegans virulence and multidrug-resistant and extensively drug-resistant profiles was documented (OR 0.655 (95% CI 0.571-0.751) and OR 0.523 (95% CI 0.436-0.627), p <0.001, respectively), whereas the exoU genotype was significantly more frequent among isolates showing high virulence (10/101 (9.9%) versus 112/446 (25.1%), p <0.001). Moreover, although significance was not reached, strains showing a high-virulence phenotype tended to be associated with community-acquired infections (1/101 (1%) versus 25/446 (5.6%), p 0.065), whereas low-virulence phenotypes tended to be associated with a higher illness severity (such as higher median Pitt score: 2 (1-4) versus 1 (0-3), p 0.036, or initial multiorgan dysfunction: 17/101 (16.8%) versus 41/446 (9.2%), p 0.024), with some underlying conditions (such as chronic renal failure 24/101 (23.8%) versus 59/446 (13.2%), p 0.013), and with the respiratory source of infections (17/101 (16.8%) versus 45/446 (10.1%), p 0.058). CONCLUSIONS: Our results indicate that the P. aeruginosa virulence phenotype in a C. elegans model correlates with virulence genotype (TTSS) and resistance profile, but it is a poor prognostic marker of mortality in bloodstream infections.

Skeletal muscle metastasis from the most common carcinomas orthopedic surgeons deal with. A systematic review of the literature.

INTRODUCTION: There is scarce information in the literature dealing with the clinical presentation, management and oncologic outcomes of skeletal muscle metastases (SMM). We sought to perform a systematic review of the literature to investigate: (1) tumor characteristics of SMM, (2) therapeutic approach, and (3) oncological outcomes. METHODS: A systematic review of the literature was performed using PubMed and EMBASE search engines. A total of 3231 references were reviewed and 49 studies were included. Demographic data, presentation characteristics, and oncological outcomes were recorded. Statistical analysis was performed using SPSS 22.0 software (IBM; Armonk, New York) and Comprehensive Meta-Analysis software version 3 (Biostat, Inc.), with p < 0.05 as statistically significant. RESULTS: A total of 231 patients were included. These tumors presented more commonly on males 58.4% (135/231), with a mean age of 60.08 ± 10.6 years, and in the axial area 39.6% (88/222). The most common carcinoma type was lung 41.1% (95/231). Resection of a single metastases did not change survival significantly (p = 0.992). LRR was higher within the group of patients that underwent WLE compared with non-WLE [31.3% (23/74) vs. 8.7% (2/23), p ≤ 0.001]. Kaplan-Meier survival analysis for the entire cohort showed an estimate of 15.3 months [95% confidence interval (CI) 11.6-19; standard error (SE) 0.432], with lung carcinoma carrying the worst prognosis 6.7 months (95% CI 5.4-8.07; SE 0.68). Patients with a single SMM showed a worse estimate mean survival time compared to patients with multiple metastases limited to muscles [8.6 months (95% CI 4.7-12.5; SE 2.0) vs 25.4 months (95% CI 19.8-31.05; SE 2.8; p ≤ 0.001)]. CONCLUSIONS: Overall survival is poor and is driven mainly by the type of carcinoma. An Increased LRR might be present due to the systemic nature of the condition, and degree of control of the primary carcinoma.

Supracondylar humeral fractures in children: current concepts for management and prognosis.

Supracondylar humeral fractures are the most common elbow fractures in children and represent 3 % of all paediatric fractures. The most common cause is a fall onto an outstretched hand with the elbow in extension, resulting in an extension-type fracture (97-99 % of cases). Currently, the Gartland classification is used, which has treatment implications. Diagnosis is based on plain radiographs, but accurate imaging could be limited due to patient pain. Based on fracture type, the definitive treatment could be either non-operative (type I) or operative (type III/IV); however, when handling type II fractures controversy remains. Neither pin configuration have shown higher efficacy over the other. Complications are ~1 %, the most common being pin migration, with compartment syndrome as the most devastating. Overall, functional outcomes are good, and physical therapy does not appear to be necessary.

Impact of multidrug resistance on Pseudomonas aeruginosa ventilator-associated pneumonia outcome: predictors of early and crude mortality.

The prevalence of multidrug-resistant (MDR) Pseudomonas aeruginosa has increased over the past decade and a significant rise in these isolates in ventilator-associated pneumonia (VAP) has been observed. However, the impact of MDR on VAP outcome has not been analysed in depth. We investigated the risk factors for early and crude mortality in a retrospective study of microbiologically and clinically documented VAP. Ninety-one VAP episodes in 83 patients were included, 31 caused by susceptible P. aeruginosa and 60 by MDR strains, of which 42 (70 %) were extensively drug-resistant (XDR) P. aeruginosa. Thirteen episodes concomitantly presented P. aeruginosa bacteraemia, in seven of which the origin was the respiratory tract. Whereas susceptible P. aeruginosa episodes were more likely than MDR episodes to receive adequate empirical (68 % vs. 30 %; p < 0.001) and definitive antimicrobial therapy (96 % vs. 50 %; p < 0.001), susceptible P. aeruginosa VAP presented a trend towards early mortality (29 % vs. 15 %; p = 0.06). A logistic regression model with early mortality as the dependent variable identified multiorgan dysfunction syndrome (MODS) [odds ratio (OR) 10.4; 95 % confidence interval (CI) 1.7-63.5; p = 0.01] and inadequate antibiotic therapy (OR 4.27; 95 % CI 0.98-18.4; p = 0.052) as independent risk factors for early mortality. A similar analysis identified MODS (OR 4.31; 95 % CI 1.14-16.2; p = 0.03) as the only independent predictor of crude mortality. The severity of acute illness clinical presentation was the main predictor of mortality. Despite adequate antibiotic therapy, susceptible P. aeruginosa seems to cause major early mortality. Although adequate therapy is essential to treat VAP, the severity of acute illness is a more important factor than drug resistance.

Extensively drug-resistant Pseudomonas aeruginosa: risk of bloodstream infection in hospitalized patients.

Several studies have suggested that resistance determinants usually reduce virulence. However, their contribution to decrease bloodstream infections is unclear. Our aim was to identify risk factors of extensively drug-resistant (XDR) Pseudomonas aeruginosa (PA) bacteremia and to assess the prevalence of XDR-PA bacteremia. A retrospective study of PA bloodstream infections in our patient population with at least one clinical sample isolate due to PA (2006-2007) was carried out. A total of 2,131 patients with PA clinical samples were detected. Among 1,657 patients with susceptible-PA isolates, 95 developed PA-susceptible bacteremia. Concomitantly, among 474 patients with multidrug-resistant (MDR)-PA isolates, 265 with XDR-PA, and 209 with non-XDR MDR-PA, 43 developed XDR-PA bacteremia and 13 non-XDR MDR-PA bacteremia, respectively. Pulsed-field gel electrophoresis (PFGE) revealed the clonal nature of the two predominant XDR-PA phenotypes and genetic heterogeneity in non-XDR MDR-PA phenotypes. The proportion of XDR-PA bacteremia was higher than the proportion of bacteremia in the susceptible-PA population (16 % vs. 6 %; p < 0.001). A logistic regression model identified prior exposure to fluoroquinolones [odds ratio (OR) 2.80; 95 % confidence interval (CI) 1.02 to 7.70] as the independent variable associated with XDR-PA bacteremia. Our study suggests that XDR-PA strains have a greater ability to develop bacteremia. It remains unclear as to whether this invasive capacity depends on clonal traits or on other virulence determinants.

Calcium Uptake during Immersion of Strawberries in CaCl2 Solutions.

The present study studied calcium uptake in strawberries during immersion in CaCl(2) solutions by analyzing total calcium and cell-wall calcium contents and the relationships between cell-wall calcium content, pectin content, and the degree of pectin esterification, considering different temperatures and concentrations of the immersion solution. In addition, calcium uptake at different zones of the strawberries was studied. Calcium uptake increased significantly when the concentration of the immersion solution increased from 1% to 10% (v/v), and calcium uptake was higher at 38 degrees C at some immersion times, but there were no significant differences between 1 and 24 degrees C. Most of the calcium incorporated by the strawberries was retained in the alcohol insoluble solids and it may be related to calcium bounded to the cell wall. Calcium content did not change during immersion in CaCl(2) solution in the internal or in the central zones; however, it increased significantly in the external zone.

Molecular basis for group-specific activation of the virulence regulator PlcR by PapR heptapeptides.

The transcriptional regulator PlcR and its cognate cell-cell signalling peptide PapR form a quorum-sensing system that controls the expression of extra-cellular virulence factors in various species of the Bacillus cereus group. PlcR and PapR alleles are clustered into four groups defining four pherotypes. However, the molecular basis for group specificity remains elusive, largely because the biologically relevant PapR form is not known. Here, we show that the in vivo active form of PapR is the C-terminal heptapeptide of the precursor, and not the pentapeptide, as previously suggested. Combining genetic complementation, anisotropy assays and structural analysis we provide a detailed functional and structural explanation for the group specificity of the PlcR-PapR quorum-sensing system. We further show that the C-terminal helix of the PlcR regulatory domain, specifically the 278 residue, in conjunction with the N-terminal residues of the PapR heptapeptide determines this system specificity. Variability in the specificity-encoding regions of plcR and papR genes suggests that selection and evolution of quorum-sensing systems play a major role in adaptation and ecology of Bacilli.

Influence of immersion freezing in NaCl solutions and of frozen storage on the viscoelastic behavior of mozzarella cheese.

The freezing of Mozzarella cheese by immersion in NaCl solutions may be an innovative procedure for the dairy industry because it combines conveniently salting and freezing processes. In this work, the influence of this type of freezing method and of the frozen storage of samples on the viscoelastic behavior of Mozzarella cheese was studied. Slabs (2 x 10 x 10 cm(3)) were immersed in 23% w/w NaCl solutions (control samples: 4 degrees C, 90 min; frozen samples: -15 degrees C, 180 min). Half of the frozen samples were immediately thawed at 4 degrees C . The other half was stored at -20 degrees C for 2 mo and then was thawed at 4 degrees C (frozen-stored samples). Samples were stored at 4 degrees C and assayed at 1, 7, 14, 20, 27, 34, and 41 d. Rheological tests were carried out in oscillatory mode (parallel-plate geometry, diameter: 20 mm, gap: 1 mm, frequency: 1 Hz). Strain sweeps were run (0.001

Magnesium-induced linear self-association of the FtsZ bacterial cell division protein monomer. The primary steps for FtsZ assembly.

The bacterial cell division protein FtsZ from Escherichia coli has been purified with a new calcium precipitation method. The protein contains one GDP and one Mg(2+) bound, it shows GTPase activity, and requires GTP and Mg(2+) to polymerize into long thin filaments at pH 6.5. FtsZ, with moderate ionic strength and low Mg(2+) concentrations, at pH 7.5, is a compact and globular monomer. Mg(2+) induces FtsZ self-association into oligomers, which has been studied by sedimentation equilibrium over a wide range of Mg(2+) and FtsZ concentrations. The oligomer formation mechanism is best described as an indefinite self-association, with binding of an additional Mg(2+) for each FtsZ monomer added to the growing oligomer, and a slight gradual decrease of the affinity of addition of a protomer with increasing oligomer size. The sedimentation velocity of FtsZ oligomer populations is compatible with a linear single-stranded arrangement of FtsZ monomers and a spacing of 4 nm. It is proposed that these FtsZ oligomers and the polymers formed under assembly conditions share a similar axial interaction between monomers (like in the case of tubulin, the eukaryotic homolog of FtsZ). Similar mechanisms may apply to FtsZ assembly in vivo, but additional factors, such as macromolecular crowding, nucleoid occlusion, or specific interactions with other cellular components active in septation have to be invoked to explain FtsZ assembly into a division ring.