Attributable clinical and economic burden of carbapenem-non-susceptible Gram-negative infections in patients hospitalized with complicated urinary tract infections

BACKGROUND

Gram-negative complicated urinary tract infections (cUTIs) can have serious consequences for patients and hospitals.

AIM

To examine the clinical and economic burden attributable to Gram-negative carbapenem-non-susceptible (C-NS; resistant/intermediate) infections compared with carbapenem-susceptible (C-S) infections in 78 US hospitals.

METHODS

All non-duplicate C-NS and C-S urine source isolates were analysed. A subset had principal diagnosis ICD-9-CM codes denoting cUTI. Collection time (<3 vs ≥3 days after admission) determined isolate classification as community or hospital onset. Mortality, 30-day re-admissions, length of stay (LOS), hospital cost and net gain/loss in US dollars were determined for C-NS and C-S cases, with the C-NS-attributable burden estimated through propensity score matching. Three subgroups with adequate patient numbers were analysed: cUTI principal diagnosis, community onset; other principal diagnosis, community onset; and other principal diagnosis, hospital onset.

FINDINGS

The C-NS-attributable mortality risk was significantly higher (58%) for the other principal diagnosis, hospital-onset subgroup alone (odds ratio 1.58, 95% confidence interval 1.14-2.20; P < 0.01). The C-NS-attributable risk for 30-day re-admission ranged from 29% to 55% (all P < 0.05). The average attributable economic impact of C-NS was 1.1-3.9 additional days LOS (all P < 0.05), US$1512-10,403 additional total cost (all P < 0.001) and US$1582-11,848 net loss (all P < 0.01); overall burden and C-NS-attributable burden were greatest in the other principal diagnosis, hospital-onset subgroup.

CONCLUSION

Greater clinical and economic burden was observed in propensity-score-matched patients with C-NS infections compared with C-S infections, regardless of whether cUTI was the principal diagnosis, and this burden was most severe in hospital-onset infections.

Scedosporium apiospermum, an emerging pathogen in India: Case series and review of literature

Scedosporium apiospermum is a rare cause of infection but is increasingly being reported among immunocompromised individuals around the world. We report two cases of S. apiospermum, one of keratitis and the other of nasal polyp both from immunocompetent patients. The two cases were successfully treated with voriconazole. It is important to diagnose such infections as their antifungal susceptibility to amphotericin B is variable.

Association of ITGAM, TNFSF4, TNFAIP3 and STAT4 gene polymorphisms with risk of systemic lupus erythematosus in a North Indian population

Several susceptibility genes have been associated with systemic lupus erythematosus (SLE) across different populations worldwide. However, data on association between genetic polymorphisms and SLE from Indian population is scarce. We aimed to replicate the association of single nucleotide polymorphisms (SNPs) in ITGAM, TNFSF4, TNFAIP3 and STAT4 genes with susceptibility to SLE in a North Indian population. Three hundred and ninety-four SLE patients and 583 unrelated healthy controls of the same ethnic background were enrolled. All samples were genotyped for SNPs in ITGAM (rs1143679), TNFSF4 (rs2205960), TNFAIP3 (rs5029939) and STAT4 (rs7574865) using TaqMan genotyping assay. At allele level, significant association with susceptibility to SLE was detected with polymorphisms in ITGAM (A vs. G, odds ratio (OR) = 1.73, 95% confidence interval (CI) = 1.30–2.30, p < 0.001), TNFSF4 (T vs. G, OR = 1.33, 95% CI = 1.08–1.64, p < 0.01), TNFAIP3 (G vs. C, OR = 1.91, 95% CI = 1.27–2.85, p < 0.01) and STAT4 (T vs. G, OR = 1.38, 95% CI = 1.13–1.69, p < 0.01). All four SNPs were associated with SLE under a dominant model with an OR of 1.47 (95% CI = 1.07–2.04, p < 0.05) for ITGAM, 1.30 (95% CI = 1.01–1.69, p < 0.05) for TNFSF4, 1.90 (95% CI = 1.25–2.90, p < 0.01) for TNFAIP3 and 1.38 (95% CI = 1.06–1.78, p < 0.05) for STAT4. Under a recessive model, significant association was found with ITGAM (OR = 4.87, 95% CI = 2.17–10.91, p < 0.001), TNFSF4 (OR = 1.84, 95% CI = 1.13–3.00, p < 0.05) and STAT4 (OR = 1.82, 95% CI = 1.19–2.77, p < 0.01). In conclusion, single nucleotide polymorphisms in ITGAM, TNFSF4, TNFAIP3 and STAT4 genes are associated with susceptibility to SLE in a North Indian population.

Estrogen receptor alpha mediates mandibular condylar cartilage growth in male mice

OBJECTIVES

In the appendicular skeleton, estrogen via ERα signalling has been shown to mediate endochondral growth plate fusion in both males and females. However, the role of ERα in mediating growth of the mandibular condylar cartilage is unknown. Thus, this study focuses on the characterization of the mandibular condylar cartilage phenotype in young and adult male ERαKO mice.

SETTING

Columbia University Medical Center.

MATERIAL AND METHODS

WT and ERαKO C57BL/6 male mice were sacrificed at 49 days or 9 months for phenotypic analysis. Changes to MCC thickness, cell number and cell density were measured using histomorphometric methods. Cartilage-specific gene expression and OARSI scores were investigated for 49-day and 9-month-old male ERαKO and WT mice.

RESULTS

In young mice, a significant increase in the number of mandibular condylar cartilage cells and a significant decrease in the expression of Col10, Runx2 and DMP1 were observed in the male ERαKO mice compared to WT. In 9-month-old mice, we found a similar increase in the number of cells but no change in osteoarthritic histological scoring in ERαKO mice compared to WT mice.

CONCLUSION

In summary, estrogen plays a role in mediating mandibular condylar maturation in young male mice. However, according to this study, it does not play a role in mediating long-term growth or age-related mandibular condylar cartilage degeneration in males.

Chronic nonbacterial osteomyelitis from a tertiary care referral center

Chronic nonbacterial osteomyelitis (CNO) is a little known autoinflammatory bone disorder primarily affecting children and sometimes young adults. Diagnosis is often delayed due to its varied and nonspecific initial symptoms. Very few cases are reported from India. The aim of this report is to increase the awareness of this disease among physicians, orthopedic surgeons, and rheumatologists. Four male patients were diagnosed with CNO in the past 3 years. The age at onset varied from 9 to 23 years with a median diagnostic delay of 3.5 years. All patients presented with recurrent bony pain with or without localized swelling over the affected bones. Two patients had previously undergone open surgical procedures with bone biopsies and three patients had received at least one course of antibiotics. Two patients responded well to nonsteroidal anti-inflammatory drugs alone, one patient required a short course of glucocorticoids, and another patient required methotrexate to control disease activity. This case series includes males, onset at a relatively later age in most, and a longer diagnostic delay. Thus, in addition to children and adolescents, CNO should be suspected in young adults presenting with recurrent bony pain with or without localized swelling.

Rapid visual isothermal nucleic acid-based detection assay of Brucella species by polymerase spiral reaction

AIM

The aim of this study was to develop polymerase spiral reaction (PSR) for rapid, sensitive and specific detection of Brucella sp.

METHODS AND RESULTS

Polymerase spiral reaction assay was developed using specifically designed primers targeting the conserved multicopy IS711 gene of Brucella sp. The assay could be performed within 60 min at an isothermal temperature of 64°C. The lower limit of detection of PSR was 11·8 fg and conventional PCR was 1·18 pg of Brucella abortus genomic DNA. Thus, PSR was found to be 100-fold more sensitive than conventional PCR and was comparable to real-time PCR. The specificity of PSR was tested with other non-Brucella bacteria and also with some bacterial and viral pathogens causing abortions. The assay was found to be specific as it did not detect any putative pathogens other than Brucella sp. Fifty-six clinical samples suspected for brucellosis (aborted fetal stomach content) were screened with PSR to validate the applicability of the test to detect Brucella DNA. The same samples were also screened with conventional PCR and real-time PCR. Of 56 samples, 25 samples were found to be positive with both PSR as well as real-time PCR, whereas only 20 samples were found positive with conventional PCR.

CONCLUSIONS

The results of this study indicated that the PSR assay is a simple, rapid, sensitive and specific method for the detection of Brucella sp. that may improve diagnostic potential in clinical laboratories or can be used at diagnostic laboratories with minimal infrastructure.

SIGNIFICANCE AND IMPACT OF THE STUDY

The PSR assay, because of its simplicity and low cost, can be preferred to other molecular methods in the diagnosis of infectious diseases.

Practical consensus recommendatons for Paget's disease in breast cancer

Paget's disease of the breast is a rare type of cancer of the nipple-areola complex and that is often associated with an underlying in situ or invasive carcinoma. Diagnosis and treatment of Paget's disease is controversial. Expert oncologists discuss on the update on the approaches of Paget's disease diagnosis and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Randomized Assessment of the Safety and Efficacy of Intra-Arterial Infusion of Autologous Stem Cells in Subacute Ischemic Stroke

BACKGROUND AND PURPOSE

Stroke is a debilitating illness for which treatment window is limited. Most patients present to the healthcare facility beyond that window. Autologous stem cells have shown some promise for this group of patients. This study was performed to evaluate the safety and the efficacy of intra-arterial infusion of bone marrow-derived mononuclear cells in patients with middle cerebral artery ischemic stroke.

MATERIALS AND METHODS

A prospective, randomized, open-label, blinded-end point study was performed from July 2015 to June 2016. Of 229 patients with acute stroke who presented to the hospital during this period, 20 patients who satisfied the inclusion/exclusion criteria were included and randomized into the control and intervention groups. Intra-arterial stem cell infusion into the ipsilateral MCA was performed in the patients in the intervention group at 8-15 days post-stroke ictus. Final analysis at 6 months was performed for primary (safety) and secondary outcomes (efficacy).

RESULTS

When we compared the primary end point of the study, no procedure-related mortality, complication, new infarct, or symptomatic intracranial hemorrhage was seen in the intervention group. When we compared the secondary end point of good clinical outcome, 8 (80%) patients in the intervention group showed good clinical outcome (modified Rankin Scale score < 2) with 4 (40%) patients in the control group achieving this (95% confidence interval for good outcome in patients with stem cell infusion, 49.03-94.3, and without stem cell infusion, 16.82-68.73; P = .068).

CONCLUSIONS

Intra-arterial infusion of stem cells can be carried out safely in the subacute stage of ischemic stroke. Improved clinical outcomes were observed with intra-arterial stem cell therapy; however, studies with larger cohorts are needed to validate the results.

Perfect transmission of 3D massive Kane fermions in HgCdTe Veselago lenses

The transmission properties of three-dimensional (3D) massive Kane fermions in HgCdTe (MCT) heterojunctions have been studied using the simplified Kane-Melé model. Based on our theoretical calculations, we propose the design of an electronic device, called a mass inverter, which consists of the junction of a narrow-gap semiconductor and semimetal. Such a device can be used in electron optics applications, since it operates as a Veselago lens and presents Klein tunneling (KT) of 3D massive Kane fermions under normal incidence. We found that KT and Veselago lensing can also be observed for general MCT heterojunctions with a specific value of doping level. We show that non-resonant perfect transmission of massive Kane fermions persists in a potential barrier for heterojunctions formed by a semimetal between two standard semiconductors. This effect is quite robust when the ideal conditions of a possible experimental test are deviated. Our findings may have important implications in the development of nano-electronic devices using 3D massive Kane fermions, where transmission features of massless particles are recovered.

Narrowing of the Anterior Chamber Angle during Valsalva Maneuver: A Possible Mechanism for Angle Closure

Purpose

To evaluate changes at the anterior chamber angle during Valsalva maneuver in eyes suspected to have a primary adult glaucoma.

Methods

Seventy-six consecutive patients underwent recording of applanation tonometry, measurement of the anterior chamber angle recess, angle opening distance, angle recess area, scleral spur-iris root distance, iris thickness, iridociliary angle, ciliary body thickness, anterior chamber depth, and pupil size on ultrasound biomicroscopy before and during the Valsalva maneuver. The Valsalva maneuver was standardized to a pressure of 40 mmHg for 15 seconds, using a manometer.

Results

The mean baseline intraocular pressure changed from 19.5±4.1 mmHg to 29.5±4.8 mmHg during Valsalva (p<0.0001). The anterior chamber angle recess narrowed from 17.9±9.5 to 7.8±9.2 degrees (p=0.0001). The angle recess area diminished from 0.15±0.14 mm2 to 0.14±0.12 mm2 (p=0.03) and the scleral spur to iris distance decreased from 0.19±0.2 mm to 0.16±0.18 mm (p=0.0001). The iridociliary angle narrowed from 72.6±33.5 degrees to 62.5±32.8 degrees (p=0.04). There was a significant increase in the thickness of the ciliary body, from 0.99±0.19 mm to 1.12±0.16 mm (p=0.001) and in iris thickness from 0.47±0.07 mm to 0.55±0.09 mm (p=0.0001). There was no significant change in the angle opening distance, anterior chamber depth, or pupillary diameter. A significant narrowing of the angle to less than 5 degrees was seen in 37 eyes, with iridocorneal apposition present in 28 eyes. After multivariate regression analysis it was found that the baseline ciliary body thickness and angle recess were significant predictors of narrowing of the angle (R2=96.1%).

Conclusions

Significant elevation of the intraocular pressure, narrowing of the anterior chamber angle recess, thickening of the ciliary body, and increase in the iris thickness is seen during the Valsalva maneuver. The Valsalva maneuver may lead to angle closure in eyes anatomically predisposed to primary angle closure glaucoma.