COPD phenotypes by computed tomography and ventilatory response to exercise

INTRODUCTION

Computed tomographic (CT) phenotypic patterns of chronic obstructive pulmonary disease (COPD) identify different clinical features of disease. The impact of these variables on the physiological response to exercise has been the focus of a great deal of research as it allows more individualized clinical approaches. The aim of our study was to evaluate the relationships between CT phenotyping of subjects with COPD and the ventilatory response during cardiopulmonary exercise testing (CPET).

METHODS

Subjects with COPD were classified into four phenotypes based on CT metrics of emphysema (low attenuation area less than a threshold of -950 Hounsfield [%LAA-950]) and airwall thickness (bronchial wall area percentage [%WA]).

RESULTS

Eighty COPD patients (78.8% males, median age 65±11.3 years) were enrolled in the study. Based on CT phenotype, 25 (31.3%) patients were classified as normal, 27 (33.8%) air dominant, 17 (21.3%) emphysema dominant and 11 (13.8%) mixed type. The emphysema and mixed phenotypes showed the highest ventilatory equivalent for carbon dioxide (VE/VCO2) and VE/VCO2 slope (p<0,05). In all phenotypes, %LAA was positive correlated with VE/VCO2 and VE/VCO2 slope (r = 0.437, p = 0.006 and r = 0.503, p<0.001, respectively). %WA also showed a positive correlation with VE/VCO2 and VE/VCO2 slope (r = 0.541, p<0.001 and r = 0.299, p = 0.033, respectively). In multivariate regression models, after adjustment for age, BMI, sex and FEV1, %LAA was the only independent predictor of VE/VCO2 and VE/VCO2 slope (β 0.343, SE 0.147, 95% CI 0.009/0.610, p = 0.044 and β 0.496, SE 0.081, 95% CI 0.130/0.455, p = 0.001, respectively).

CONCLUSION

Emphysema (%LAA) and airways metrics (%WA) had strong relationships with the different characteristics of ventilatory response to exercise in subjects with mild to moderate COPD. In particular, %LAA seemed to play an important role as an independent predictor of VE/VCO2 and VE/VCO2 slope. These results suggested that CT phenotyping may help predicting ventilatory response to exercise in subjects with COPD.

Spatial accumulation of flood-driven riverside litter in two Northern Atlantic Rivers

The escalation of litter accumulation in aquatic environments is recognized as an emerging global concern. Although rivers represent the main conduits for land-based waste into the oceans, the spatial dynamics of litter accumulation in these systems remain poorly investigated, especially after hydro-climatic extreme events. Floods have been identified as major drivers of litter mobilization, including macroplastics, within rivers. However, predicting flood-induced litter accumulation along riverbanks is complex due to the cumulative interplay of multiple environmental (geomorphological and riparian) and anthropogenic factors. Using empirical data collected from 14 stream reaches in two Northern Atlantic rivers in Portugal, our study evaluates which factors, among geomorphological, riparian, and anthropogenic descriptors, best drive riverside litter accumulation after floods. Taking into account the longitudinal gradient and the spatial heterogeneity of the studied reaches, our study enhances how the accumulation and characteristics (type, size) of riverside litter vary across a rural-urban continuum. Our model reveals that the combination of the human population density and the stream slope at river reach showed the highest explanatory power for the accumulation of riverside litter. Our findings indicate that litter tends to be retained close to the source, even under flood conditions. We also found that the structure of riparian vegetation showed low explanatory power for litter accumulation. However, riparian trapping could be influenced by litter input (density and type) which varies with anthropogenic activities. This work highlights the importance of gathering field data to identify critical areas of riverside litter accumulation within river basins. Our findings can further support environmental managers in designing and implementing effective cleanup campaigns and implementing plastic recovery strategies at specific areas. Nevertheless, it is crucial to enhance coordinated efforts across the entire value chain to reduce plastic pollution, promote innovative approaches for plastic litter valorization, and establish effective prevention pathways.

Life cycle assessment of pharmaceutical packaging addressing end-of-life alternatives

Pharmaceutical packaging waste has increased due to a higher global demand for pharmaceutical products, leading to more waste generation and associated environmental impacts. The main goal of this article is to present a cradle-to-grave life cycle assessment of pharmaceutical packaging, evaluating end-of-life (EoL) alternatives, aiming to identify hotspots and opportunities for improvement. A life cycle model was implemented for three types of pharmaceutical packaging (blisters, sachets, bottles; 23 packaging). The functional unit is the storage and delivery of medicines containing the same active pharmaceutical ingredient, dosage, and amount of medicines. Two EoL analyses were performed: 1) compare take-back (recycling and incineration) with domestic waste collection (landfill or incineration); and 2) assess different EoL situations of pharmaceutical packaging in Europe. A life cycle impact assessment was performed for 13 categories. Analysis 1 shows that take-back presents lower environmental impacts than domestic waste collection for seven out of 13 categories due to paper and glass recycling benefits. Analysis 2 shows that in the take-back, higher amounts of packaging are recycled or incinerated, which leads to lower EoL impacts. A sensitivity analysis was performed to evaluate the influence of parameters and assumptions in packaging EoL impacts. Packaging production contributes significantly to life cycle impacts, followed by transportation, EoL, and packing process. Ecodesign initiatives are recommended, such as packaging with less material and volume, using materials with lower impacts to significantly reduce the impacts of pharmaceutical packaging.

Insights on trends in the management of metrological analysis of devices in blood and transfusion medicine services: Verification based on their fitness for purpose and suitability for their respective applications

In the field of blood and transfusion medicine, European Directorate for the Quality of Medicines & HealthCare recommends practices for metrological devices. Monitoring and measurement resources, as well as their permitted metrological limits, must be considered in this regard. We must understand variables such as metrological domains, the International System of Units, metrological traceability, and metrological requirements and controls in the field of transfusions in order to understand these metrological devices. An approach to metrological analysis and subsequent actions was constructed using flowcharts. As part of this methodology, a metrological device was selected, along with regulatory and normative requirements. A calibration and a test were conducted to demonstrate the application of the figure based on current recommendations. Current recommendations are consistent with the suggested ROC approach. The metrological devices must be verified based on their suitability for their respective applications (fitness-for-purpose).

Medication literacy and its social contextuality

This article aims to contribute to the discussion about medication literacy, by focussing on the social contextuality of the information mobilised in the use of medicines. We aim to explore the social construction processes of medication literacy, as an essential dimension for a more layperson-centred approach in the promotion of literacy in this field. This approach is justified by the growing social and cultural dissemination of medication use, the diversification of its uses beyond health and illness, and the increasing degree of lay autonomy in managing its use. The article is organised in two main sections. In the first section, we review the social history of medication literacy, including a discussion of the social contextuality of literacy phenomena. In the second section, the analysis of social contextuality is operationalised with a focus on information, covering: (i) ways of relating to institutional information and sources of information about medication; (ii) contexts of sociability in which information is shared and validated. This analysis is empirically supported by selected results from two research projects, conducted in Portugal, on the consumption of medicines and dietary supplements for performance purposes - that is, for the management and/or improvement of cognitive, bodily or relational performance.

Antibiotics in Catalan Primary Care: Prescription, Use and Remedies for a Crisis of Care

Antimicrobial resistance is one of the twenty-first century's major health challenges. Linked to the extensive use of antibiotics and other antimicrobials, resistance occurs when microbes stop responding to medications. Rates of antibiotic consumption in Spain are among the highest in Europe. Drawing on research conducted in Catalonia, in this article we present findings from ethnographic fieldwork and semi-structured interviews with general practitioners, residents of Barcelona, and professionals who have worked in antibiotic stewardship. We argue that the circulation of antibiotics should be understood in relation to broader historical processes and the deficient systems of health and social care provision they have produced.

Implementation of a Patient Specific QA Protocol for a Novel Dedicated Stereotactic Radiosurgery Linear Accelerator

PURPOSE/OBJECTIVE(S)

To describe the patient specific QA (Quality Assurance) protocol implemented for plan integrity verification, in stereotactic radiosurgery (SRS) and radiotherapy (SRT) treatments performed on a novel dedicated frameless image guided radiosurgery system using conical collimator, and a combination of yoked gimbals to cover near2pi solid angle. Startup and commissioning results obtained for planned vs measured dose distributions with several detectors are presented.

MATERIALS/METHODS

The patient specific QA protocol includes: A) Review of the approved plan based on AAPM TG 275 report recommendations B) 1D verification using small volume ionization chambers inside an anthropomorphic head phantom C) 2D dose verification of a coronal and sagittal dose plan performed with high resolution 2D Array and respective phantom apparatus D) In-house independent MU (Monitor Unit) calculation using the same formalism of the vendor TPS (Treatment Planning Systems) RayTracing dose-calculation algorithm E) Monte Carlo based secondary dose check & plan QA. A retrospective analysis of the results of the first 15 patients treated is presented, focusing on plan complexity vs QA results.

RESULTS

The 1D results obtained for the 15 SRS plans were within ±5% for all reported cases, with a mean percent difference of -1,25%, confirming an overall good agreement and, as expected, a partial volume effect in plans with smaller collimators. For the 2D dose verifications, with a 10% dose threshold, gamma passing rates of 97,5% (coronal) and 96,78 (sagittal) with 3% 1mm criteria, 95,1% (coronal) and 94,3% (sagittal) for 2% 1 mm criteria and 90,7% (coronal) and 90,0% (sagittal) for 1% 1mm criteria were obtained. Moreover, the results showed a correlation between lesion volume or number of collimators used with gamma passing rates. All MU verification results were within ±0,3% and provides an efficient risk mitigation approach for this new delivery technique.

CONCLUSION

The verification results of the first 15 treated SRS plans confirmed point dose and planar measurements in agreement with TPS calculations, with superior results for planes with smaller lesions and fewer collimators. This also represents an integral validation of the image-based alignment system and fine treatment couch movements, as treatments are intrinsically multi-isocentric.

Phages against Noncapsulated Klebsiella pneumoniae: Broader Host range, Slower Resistance

Klebsiella pneumoniae (Kp), a human gut colonizer and opportunistic pathogen, is a major contributor to the global burden of antimicrobial resistance. Virulent bacteriophages represent promising agents for decolonization and therapy. However, the majority of anti-Kp phages that have been isolated thus far are highly specific to unique capsular types (anti-K phages), which is a major limitation to phage therapy prospects due to the highly polymorphic capsule of Kp. Here, we report on an original anti-Kp phage isolation strategy, using capsule-deficient Kp mutants as hosts (anti-Kd phages). We show that anti-Kd phages have a broad host range, as the majority are able to infect noncapsulated mutants of multiple genetic sublineages and O-types. Additionally, anti-Kd phages induce a lower rate of resistance emergence in vitro and provide increased killing efficiency when in combination with anti-K phages. In vivo, anti-Kd phages are able to replicate in mouse guts colonized with a capsulated Kp strain, suggesting the presence of noncapsulated Kp subpopulations. The original strategy proposed here represents a promising avenue that circumvents the Kp capsule host restriction barrier, offering promise for therapeutic development. IMPORTANCE Klebsiella pneumoniae (Kp) is an ecologically generalist bacterium as well as an opportunistic pathogen that is responsible for hospital-acquired infections and a major contributor to the global burden of antimicrobial resistance. In the last decades, limited advances have been made in the use of virulent phages as alternatives or complements to antibiotics that are used to treat Kp infections. This work demonstrates the potential value of an anti-Klebsiella phage isolation strategy that addresses the issue of the narrow host range of anti-K phages. Anti-Kd phages may be active in infection sites in which capsule expression is intermittent or repressed or in combination with anti-K phages, which often induce the loss of capsule in escape mutants.

Genomic features of Klebsiella isolates from artisanal ready-to-eat food production facilities

Increasing reports on K. pneumoniae strains with antimicrobial resistance and virulence traits from food and farm animals are raising concerns about the potential role of Klebsiella spp. as a foodborne pathogen. This study aimed to report and characterize Klebsiella spp. isolates from two artisanal ready-to-eat food (soft cheese and salami) producing facilities, and to track similar genotypes in different ecological niches. Over 1170 samples were collected during the whole production chain of different food batches. The overall Klebsiella prevalence was 6%. Strains were classified into the three Klebsiella species complexes: K. pneumoniae (KpSC, n = 17), K. oxytoca (KoSC, n = 38) and K. planticola (KplaSC, n = 18). Despite high genetic diversity we found in terms of known and new sequence types (STs), core genome phylogeny revealed clonal strains persisting in the same processing setting for over 14 months, isolated from the environment, raw materials and end-products. Strains showed a natural antimicrobial resistance phenotype-genotype. K. pneumoniae strains showed the highest virulence potential, with sequence types ST4242 and ST107 strains carrying yersiniabactin ybt16 and aerobactin iuc3. The latter was detected in all K. pneumoniae from salami and was located on a large conjugative plasmid highly similar (97% identity) to iuc3+ plasmids from human and pig strains circulating in nearby regions of Italy. While identical genotypes may persist along the whole food production process, different genotypes from distinct sources in the same facility shared an iuc3-plasmid. Surveillance in the food chain will be crucial to obtain a more comprehensive picture of the circulation of Klebsiella strains with pathogenic potential.

Phylogenomics of Globally Spread Clonal Groups 14 and 15 of Klebsiella pneumoniae

Klebsiella pneumoniae sequence type 14 (ST14) and ST15 caused outbreaks of CTX-M-15 and/or carbapenemase producers worldwide, but their phylogeny and global dynamics remain unclear. We clarified the evolution of K. pneumoniae clonal group 14 (CG14) and CG15 by analyzing the capsular locus (KL), resistome, virulome, and plasmidome of public genomes (n = 481) and de novo sequences (n = 9) representing main sublineages circulating in Portugal. CG14 and CG15 evolved independently within 6 main subclades defined according to the KL and the accessory genome. The CG14 (n = 65) clade was structured in two large monophyletic subclades, CG14-I (KL2, 86%) and CG14-II (KL16, 14%), whose emergences were dated to 1932 and 1911, respectively. Genes encoding extended-spectrum β-lactamase (ESBL), AmpC, and/or carbapenemases were mostly observed in CG14-I (71% versus 22%). CG15 clade (n = 170) was segregated into subclades CG15-IA (KL19/KL106, 9%), CG15-IB (variable KL types, 6%), CG15-IIA (KL24, 43%) and CG15-IIB (KL112, 37%). Most CG15 genomes carried specific GyrA and ParC mutations and emerged from a common ancestor in 1989. CTX-M-15 was especially prevalent in CG15 (68% CG15 versus 38% CG14) and in CG15-IIB (92%). Plasmidome analysis revealed 27 predominant plasmid groups (PG), including particularly pervasive and recombinant F-type (n = 10), Col (n = 10), and new plasmid types. While blaCTX-M-15 was acquired multiple times by a high diversity of F-type mosaic plasmids, other antibiotic resistance genes (ARGs) were dispersed by IncL (blaOXA-48) or IncC (blaCMY/TEM-24) plasmids. We first demonstrate an independent evolutionary trajectory for CG15 and CG14 and how the acquisition of specific KL, quinolone-resistance determining region (QRDR) mutations (CG15), and ARGs in highly recombinant plasmids could have shaped the expansion and diversification of particular subclades (CG14-I and CG15-IIA/IIB). IMPORTANCE Klebsiella pneumoniae represents a major threat in the burden of antibiotic resistance (ABR). Available studies to explain the origin, the diversity, and the evolution of certain ABR K. pneumoniae populations have mainly been focused on a few clonal groups (CGs) using phylogenetic analysis of the core genome, the accessory genome being overlooked. Here, we provide unique insights into the phylogenetic evolution of CG14 and CG15, two poorly characterized CGs which have contributed to the global dissemination of genes responsible for resistance to first-line antibiotics such as β-lactams. Our results point out an independent evolution of these two CGs and highlight the existence of different subclades structured by the capsular type and the accessory genome. Moreover, the contribution of a turbulent flux of plasmids (especially multireplicon F type and Col) and adaptive traits (antibiotic resistance and metal tolerance genes) to the pangenome reflect the exposure and adaptation of K. pneumoniae under different selective pressures.

Tafamidis polyneuropathy amelioration requires modest increases in transthyretin stability even though increases in plasma native TTR and decreases in non-native TTR do not predict response

BACKGROUND

TTR aggregation causes hereditary transthyretin (TTR) polyneuropathy (ATTRv-PN) in individuals with destabilised TTR variants. ATTRv-PN can be treated with ligands that bind TTR and prevent aggregation. One such ligand, tafamidis, is widely approved to treat ATTRv-PN. We explore how TTR stabilisation markers relate to clinical efficacy in 210 ATTRv-PN patients taking tafamidis.

METHODS

TTR concentration in patient plasma was measured before and after tafamidis treatment using assays for native or combined native + non-native TTR. TTR tetramer dissociation kinetics, which are slowed by tafamidis binding, were also measured.

RESULTS

Native TTR levels increased by 56.8% while combined native + non-native TTR levels increased by 3.1% after 24 months of tafamidis treatment, implying that non-native TTR decreased. Accordingly, the fraction of native TTR increased from 0.54 to 0.71 with tafamidis administration. Changes in native and non-native TTR levels were uncorrelated with clinical response to tafamidis. TTR tetramer dissociation generally slowed to an extent consistent with ∼40% of TTR being tafamidis-bound. Male non-responders had a lower extent of binding.

CONCLUSIONS

Native and non-native TTR concentration changes cannot be used as surrogate measures for therapeutic efficacy. Also, successful tafamidis therapy requires only moderate TTR stabilisation. Male patients may benefit from higher tafamidis doses.

Silver Nanostar-Based SERS for the Discrimination of Clinically Relevant Acinetobacter baumannii and Klebsiella pneumoniae Species and Clones

The development of rapid, reliable, and low-cost methods that enable discrimination among clinically relevant bacteria is crucial, with emphasis on those listed as WHO Global Priority 1 Critical Pathogens, such as carbapenem-resistant Acinetobacter baumannii and carbapenem-resistant or ESBL-producing Klebsiella pneumoniae. To address this problem, we developed and validated a protocol of surface-enhanced Raman spectroscopy (SERS) with silver nanostars for the discrimination of A. baumannii and K. pneumoniae species, and their globally disseminated and clinically relevant antibiotic resistant clones. Isolates were characterized by mixing bacterial colonies with silver nanostars, followed by deposition on filter paper for SERS spectrum acquisition. Spectral data were processed with unsupervised and supervised multivariate data analysis methods, including principal component analysis (PCA) and partial least-squares discriminant analysis (PLSDA), respectively. Our proposed SERS procedure using silver nanostars adsorbed to the bacteria, followed by multivariate data analysis, enabled differentiation between and within species. This pilot study demonstrates the potential of SERS for the rapid discrimination of clinically relevant A. baumannii and K. pneumoniae species and clones, displaying several advantages such as the ease of silver nanostars synthesis and the possible use of a handheld spectrometer, which makes this approach ideal for point-of-care applications.

Macrophage Resistance to Ionizing Radiation Exposure Is Accompanied by Decreased Cathepsin D and Increased Transferrin Receptor 1 Expression

PURPOSE

To identify a molecular signature of macrophages exposed to clinically relevant ionizing radiation (IR) doses, mirroring radiotherapy sessions.

METHODS

Human monocyte-derived macrophages were exposed to 2 Gy/ fraction/ day for 5 days, mimicking one week of cancer patient's radiotherapy. Protein expression profile by proteomics was performed.

RESULTS

A gene ontology analysis revealed that radiation-induced protein changes are associated with metabolic alterations, which were further supported by a reduction of both cellular ATP levels and glucose uptake. Most of the radiation-induced deregulated targets exhibited a decreased expression, as was the case of cathepsin D, a lysosomal protease associated with cell death, which was validated by Western blot. We also found that irradiated macrophages exhibited an increased expression of the transferrin receptor 1 (TfR1), which is responsible for the uptake of transferrin-bound iron. TfR1 upregulation was also found in tumor-associated mouse macrophages upon tumor irradiation. In vitro irradiated macrophages also presented a trend for increased divalent metal transporter 1 (DMT1), which transports iron from the endosome to the cytosol, and a significant increase in iron release.

CONCLUSIONS

Irradiated macrophages present lower ATP levels and glucose uptake, and exhibit decreased cathepsin D expression, while increasing TfR1 expression and altering iron metabolism.

Limited Transmission of Klebsiella pneumoniae among Humans, Animals, and the Environment in a Caribbean Island, Guadeloupe (French West Indies)

Guadeloupe (French West Indies), a Caribbean island, is an ideal place to study the reservoirs of the Klebsiella pneumoniae species complex (KpSC) and identify the routes of transmission between human and nonhuman sources due to its insularity, small population size, and small area. Here, we report an analysis of 590 biological samples, 546 KpSC isolates, and 331 genome sequences collected between January 2018 and May 2019. The KpSC appears to be common whatever the source. Extended-spectrum-β-lactamase (ESBL)-producing isolates (21.4%) belonged to K. pneumoniae sensu stricto (phylogroup Kp1), and all but one were recovered from the hospital setting. The distribution of species and phylogroups across the different niches was clearly nonrandom, with a distinct separation of Kp1 and Klebsiella variicola (Kp3). The most frequent sequence types (STs) (≥5 isolates) were previously recognized as high-risk multidrug-resistant (MDR) clones, namely, ST17, ST307, ST11, ST147, ST152, and ST45. Only 8 out of the 63 STs (12.7%) associated with human isolates were also found in nonhuman sources. A total of 22 KpSC isolates were defined as hypervirulent: 15 associated with human infections (9.8% of all human isolates), 4 (8.9%) associated with dogs, and 3 (15%) associated with pigs. Most of the human isolates (33.3%) belonged to the globally successful sublineage CG23-I. ST86 was the only clone shared by a human and a nonhuman (dog) source. Our work shows the limited transmission of KpSC isolates between human and nonhuman sources and points to the hospital setting as a cornerstone of the spread of MDR clones and antibiotic resistance genes. IMPORTANCE In this study, we characterized the presence and genomic features of isolates of the Klebsiella pneumoniae species complex (KpSC) from human and nonhuman sources in Guadeloupe (French West Indies) in order to identify the reservoirs and routes of transmission. This is the first study in an island environment, an ideal setting that limits the contribution of external imports. Our data showed the limited transmission of KpSC isolates between the different compartments. In contrast, we identified the hospital setting as the epicenter of antibiotic resistance due to the nosocomial spread of successful multidrug-resistant (MDR) K. pneumoniae clones and antibiotic resistance genes. Ecological barriers and/or limited exposure may restrict spread from the hospital setting to other reservoirs and vice versa. These results highlight the need for control strategies focused on health care centers, using genomic surveillance to limit the spread, particularly of high-risk clones, of this important group of MDR pathogens.

Exclusive breastfeeding during the COVID-19 pandemic in 17 WHO European Region countries

Background

Maternal experience of labour and delivery is multidimensional and is influenced by a variety of factors.

Aim

to report maternal childbirth experience as described by the women themselves during the COVID-19 pandemic in Sweden using a WHO Standards-based tool adapted for an online survey (Quality of maternal and newborn care-QMNC).

Methods

Women ≥ 18 years of age who gave birth from March 1, 2020 to June 30, 2021 were asked to give voluntary consent to participate in an online survey. The survey included 40 questions on four key domains: provision of care, experience of care, availability of human and physical resources and organisational changes due to COVID-19.

Results

5003 women were included in the analysis. Among those who underwent labour (n = 4528), 46.7% perceived a reduction in QMNC due to the COVID-19 pandemic, 50.7% were not allowed a companion of choice, 62.5% reported that health workers were not always using protective personal equipment and 36.5% rated the number of health workers as “insufficient”. Fundal pressure was applied in 22.2% of instrumental vaginal births and 36.8% received inadequate breastfeeding support. In addition, 18.4% of women did not feel treated with dignity and 6.9% reported some form of abuse. In general, findings were significantly worse among women who did not undergo labour (n = 475).

Conclusions

Swedish mothers’ satisfaction of care provided during childbirth was strongly influenced by many variables. Actions to promote high-quality, evidence-based, patient-centered respectful care for all mothers and newborns are urgently needed.

Chronic obstructive pulmonary disease exacerbations' management in Portuguese hospitals - EvaluateCOPDpt, a multicentre, observational, prospective study

INTRODUCTION AND OBJECTIVES

In order to improve the quality of chronic obstructive pulmonary disease (COPD) patients' care, better knowledge of clinical practice and the factors associated with patient outcomes are needed. This study aimed to evaluate the relation between clinical practice and the outcomes of patients admitted for COPD exacerbations in Portuguese hospitals.

MATERIALS AND METHODS

Observational, multicentre, prospective study with a 60-days follow-up period, in 11 hospitals, including patients aged ≥ 30 years, admitted to hospital for at least 24 hours due to an acute exacerbation of COPD. Demographic and clinical data were collected, including sex, age, smoking habits, hospitalisations, pulmonary function, comorbidities, COPD symptoms, and treatment. Sixty days after discharge, COPD exacerbations management, outcome measures, and readmission data were evaluated through a structured phone follow-up interview.

RESULTS

196 patients were included (85.7% male, mean age 71.2 years), the majority admitted through the emergency service. Ex-smokers and current smokers accounted for 51% and 36%, respectively. On admission, 72.4% were on LAMA, 54.6% on LABA, and 45.5% were on LABA/LAMA. Inhaled corticosteroids (ICS) were used in 37.3% and systemic steroids (SCS) in 10.3%. 35.7 % had had at least one exacerbation, with hospitalisation, in the previous year. There was no spirometry data for 23.2%. On hospitalisation, 98.5% of patients were treated with oxygen and 38.3% with non-invasive ventilation. Additionally, 93.4% used SCS and 60.2% ICS. Antibiotics were administered to 85.2%. 95.4% of patients were discharged; 9 died, 5 of whom had a COPD-related death. The median length of stay was 12 days for discharged patients and 33 days for patients who died. At discharge, 79.1% were prescribed with LAMA, 63.6% SCS, 61.5% LABA and 55.6% LAMA+LABA. 26,2% were prescribed with ICS+LABA+LAMA. At follow-up, 44.4% had a scheduled medical appointment within the 60 days after being discharged, and 28.3% were later readmitted due to exacerbation, of whom 52.8% were hospitalised.

CONCLUSIONS

The severity of COPD, particularly in exacerbations, is directly related to impaired lung function and quality of life, mortality, and significant health system costs. Knowledge about COPD exacerbations' management in acute hospital admissions in Portugal may help stimulate a national discussion and review of existing data to engage clinicians, policymakers, managers, and patients, raising awareness and promoting action on COPD.

Glaucoma and Psychotropics

Introduction

Glaucoma is a heterogeneous group of conditions which result in optic neuropathy and visual defects, majorly linked with the increase of intra-ocular pressure (IOP). It is known that psychotropic drugs have been implicated in drug induced angle-closure glaucoma, mostly through its anti-cholinergic effect.

Objectives

Systematize the drugs most and least implicated in its appearance and worsening and understand the care needed on prescribing.

Methods

A search on Pubmed database was made having in consideration the Mesh Terms Glaucoma and Psychotropic Drugs and its different classes. Specific searches were made when appropriate on different platforms.

Results

Implications on the appearance and worsening of glaucoma are clear for tricyclic antidepressants. The evidence is not clear for SSRIs, SNRIs and mirtazapine, but they might be related with increased IOP. Other classes of antidepressants seem to be of lower risk. Antipsychotics do not seem to be greatly associated with angle closure, although there are some case reports. There are descriptions of the potencial use of haloperidol, anti-convulsive mood stabilizers, with exception of topiramate, melatonin and anti-dementia drugs on the treatment of this condition. In practice, benzodiazepines do not seem to precipate angle-closure. Methamphetamines are contraindicated. Eletroconvulsive therapy its an option.

Conclusions

Although not prevalent, angle-closure glaucoma can have serious implications and culminate in irreversible blindness. In patients with known risk-factors its important to have it on consideration at the time of the prescription and warn on seeking immediate help if having acute ocular pain, redness and/ or cloudy vision.

Disclosure

No significant relationships.

Management of antipsychotic-related sexual dysfunction

Introduction

Sexual dysfunction (SD) can often be a side-effect of treatment with antipsychotics (APS). It often jeopardizes long-term adherence to treatment, while deeply affecting the patient’s quality of life. The pathogenic mechanisms may be associated with postsynaptic dopamine antagonism, a1-antagonism and prolactin elevation. APS-induced hyperprolactinemia has been linked to the occurrence of galactorrhea, gynecomastia, amenorrhea and SD.

Objectives

To synthesize the available evidence on the management of APS-related sexual dysfunction, with a main focus on the second-generation antipsychotics.

Methods

A search for randomized controlled trials (RCT) published between 2021 and 2011 on PubMed was made using the keywords “sexual”; “dysfunction”; “antipsychotic” and “treatment”, from which resulted sixteen articles. Only six of those were considered relevant for the study’s objectives.

Results

Three studies focused on the comparison between different APS and prolactin levels and SD occurrence, showing that treatment with aripiprazole is mostly related to prolactin levels with the normal range and a lower incidence of sexual dysfunction. Addition of aripiprazole to previous APS may be associated with normalization of sexual function and pose as a possible management option. Adjunctive treatment with tadalafil showed no significant effect on its primary outcome.

Conclusions

There seems to be a general consensus that patients treated with first-generation antipsychotics (FGA), along with risperidone, paliperidone and amissulpride show higher prolactin levels and incidence of SD. Whether there is a causal relationship between these two variables still remains a question. Larger and more prolonged trials are still needed to evaluate APS-related sexual dysfunction and its management.

Disclosure

No significant relationships.

A curated collection of Klebsiella metabolic models reveals variable substrate usage and gene essentiality

The Klebsiella pneumoniae species complex (KpSC) is a set of seven Klebsiella taxa that are found in a variety of niches and are an important cause of opportunistic health care-associated infections in humans. Because of increasing rates of multi-drug resistance within the KpSC, there is a growing interest in better understanding the biology and metabolism of these organisms to inform novel control strategies. We collated 37 sequenced KpSC isolates isolated from a variety of niches, representing all seven taxa. We generated strain-specific genome-scale metabolic models (GEMs) for all 37 isolates and simulated growth phenotypes on 511 distinct carbon, nitrogen, sulfur, and phosphorus substrates. Models were curated and their accuracy was assessed using matched phenotypic growth data for 94 substrates (median accuracy of 96%). We explored species-specific growth capabilities and examined the impact of all possible single gene deletions using growth simulations in 145 core carbon substrates. These analyses revealed multiple strain-specific differences, within and between species, and highlight the importance of selecting a diverse range of strains when exploring KpSC metabolism. This diverse set of highly accurate GEMs could be used to inform novel drug design, enhance genomic analyses, and identify novel virulence and resistance determinants. We envisage that these 37 curated strain-specific GEMs, covering all seven taxa of the KpSC, provide a valuable resource to the Klebsiella research community.

Ecodesign approach for pharmaceutical packaging based on Life Cycle Assessment

Packaging ecodesign can contribute to improve the environmental performance of pharmaceutical products. The main goal of this article is to present an ecodesign approach based on Life Cycle Assessment (LCA) for pharmaceutical packaging, assessing opportunities to improve the packaging environmental performance, and providing ecodesign recommendations to the pharmaceutical sector. The proposed ecodesign approach consists of five phases. I) The most representative packaging of medicines in the market (blister, bottle, and sachet), with different sizes, materials and weights, were investigated. II) Three ecodesign strategies were selected to analyze with LCA: i) weight and/or volume reduction, ii) alternative types of packaging, and iii) transportation with less environmental impact. III-IV) A cradle-to-gate life cycle model has been implemented, including transport to pharmacies. Alternative transportation modes (truck, train, airplane, and ship) and different packaging production locations have been considered. Thirteen environmental categories have been analyzed. V) Ecodesign recommendations for improving the environmental performance of pharmaceutical packaging are presented in two stages: i) specific recommendations based on LCA, illustrated in sheets with examples of ecodesign, quantifying the environmental impact reduction of an ecodesign solution compared to the original; and ii) generic recommendations for different packaging life cycle phases. Ecodesign recommendations highlight the use of smaller-size packaging, avoiding superfluous elements and empty spaces, which reduces material and production costs, and transportation impacts; the selection of modes of transportation with less environmental impact, considering the packaging production location; and the use of electric vehicles for pharmacy distribution. This ecodesign approach based on LCA allows quantifying environmental impacts robustly to support the incorporation of environmental information from the design, material selection, and packaging production to distribution till the final consumer. This article emphasizes the importance of developing specific packaging ecodesign based on LCA to improve environmental performance and provide more informed recommendations to stakeholders.

Comparative phylogenomics of ESBL-, AmpC- and carbapenemase-producing Klebsiella pneumoniae originating from companion animals and humans

Background

WHO considers ESBL- and carbapenemase-producing Klebsiella pneumoniae a major global concern. In animals, ESBL- and carbapenemase-producing K. pneumoniae of human-related ST11, ST15 and ST307 have been reported, but not in the context of large WGS-based One Health investigations.

Objectives

To perform comparative phylogenomics on a large collection of multidrug-resistant (MDR) K. pneumoniae recovered from diseased companion animals and humans.

Methods

MDR K. pneumoniae (n = 105) recovered from companion animals in France during 2010–18 were phenotypically characterized. All isolates were whole-genome sequenced using the NovaSeq technology and phylogenomic analysis across animal and human K. pneumoniae was performed using appropriate pipelines.

Results

bla_CTX-M-15, bla_DHA-1 and bla_OXA-48 were strongly associated with IncFIIk, IncR and IncL plasmids, respectively. When compared with human K. pneumoniae genomes, four groups of closely related French human and animal isolates belonging to ST11, ST15 and ST307 were detected, suggesting the circulation of clones between the human and animal sectors at country level. A large cluster of 31 ST11-KL105 animal isolates from France and Switzerland suggested it corresponds to a sub-lineage that is particularly well-adapted to the animal host.

Conclusions

This study demonstrates the spread of bla_CTX-M-15-carrying ST15 and ST307, and bla_DHA-1-carrying ST11 K. pneumoniae clones in animal populations. ST11 was the main vector of bla_OXA-48/IncL, despite the absence of carbapenem use in French animals. Comparative phylogenomics suggests cross-transmission of K. pneumoniae sub-lineages more prone than others to colonize/infect the animal host. Our data also evidenced the emergence of convergent hypervirulent and MDR K. pneumoniae in animals.

High Prevalence of Klebsiella pneumoniae in European Food Products: a Multicentric Study Comparing Culture and Molecular Detection Methods

The Klebsiella pneumoniae species complex (KpSC) is a leading cause of multidrug-resistant human infections. To better understand the potential contribution of food as a vehicle of KpSC, we conducted a multicentric study to define an optimal culture method for its recovery from food matrices and to characterize food isolates phenotypically and genotypically. Chicken meat (n = 160) and salad (n = 145) samples were collected in five European countries and screened for the presence of KpSC using culture-based and zur-khe intergenic region (ZKIR) quantitative PCR (qPCR) methods. Enrichment using buffered peptone water followed by streaking on Simmons citrate agar with inositol (44°C for 48 h) was defined as the most suitable selective culture method for KpSC recovery. A high prevalence of KpSC was found in chicken meat (60% and 52% by ZKIR qPCR and the culture approach, respectively) and salad (30% and 21%, respectively) samples. Genomic analyses revealed high genetic diversity with the dominance of phylogroups Kp1 (91%) and Kp3 (6%). A total of 82% of isolates presented a natural antimicrobial susceptibility phenotype and genotype, with only four CTX-M-15-producing isolates detected. Notably, identical genotypes were found across samples-same food type and same country (15 cases), different food types and same country (1), and same food type and two countries (1)-suggesting high rates of transmission of KpSC within the food sector. Our study provides a novel isolation strategy for KpSC from food matrices and reinforces the view of food as a potential source of KpSC colonization in humans. IMPORTANCE Bacteria of the Klebsiella pneumoniae species complex (KpSC) are ubiquitous, and K. pneumoniae is a leading cause of antibiotic-resistant infections in humans. Despite the urgent public health threat represented by K. pneumoniae, there is a lack of knowledge of the contribution of food sources to colonization and subsequent infection in humans. This is partly due to the absence of standardized methods for characterizing the presence of KpSC in food matrices. Our multicentric study provides and implements a novel isolation strategy for KpSC from food matrices and shows that KpSC members are highly prevalent in salads and chicken meat, reinforcing the view of food as a potential source of KpSC colonization in humans. Despite the large genetic diversity and the low levels of resistance detected, the occurrence of identical genotypes across samples suggests high rates of transmission of KpSC within the food sector, which need to be further explored to define possible control strategies.

Genomic evolution of the globally disseminated multidrug-resistant Klebsiella pneumoniae clonal group 147

The rapid emergence of multidrug-resistant Klebsiella pneumoniae is being driven largely by the spread of specific clonal groups (CGs). Of these, CG147 includes 7-gene multilocus sequence typing (MLST) sequence types (STs) ST147, ST273 and ST392. CG147 has caused nosocomial outbreaks across the world, but its global population dynamics remain unknown. Here, we report a pandrug-resistant ST147 clinical isolate from India (strain DJ) and define the evolution and global emergence of CG147. Antimicrobial-susceptibility testing following European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines and genome sequencing (Illumina and Oxford Nanopore Technologies, Unicycler assembly) were performed on strain DJ. Additionally, we collated 217 publicly available CG147 genomes [National Center for Biotechnology Information (NCBI), May 2019]. CG147 evolution was inferred within a temporal phylogenetic framework (beast) based on a recombination-free sequence alignment (Roary/Gubbins). Comparative genomic analyses focused on resistance and virulence genes and other genetic elements (BIGSdb, Kleborate, PlasmidFinder, phaster, ICEfinder and CRISPRCasFinder). Strain DJ had a pandrug-resistance phenotype. Its genome comprised the chromosome, seven plasmids and one linear phage-plasmid. Four carbapenemase genes were detected: bla_NDM-5 and two copies of bla_OXA-181 in the chromosome, and a second copy of bla_NDM-5 on an 84 kb IncFII plasmid. CG147 genomes carried a mean of 13 acquired resistance genes or mutations; 63 % carried a carbapenemase gene and 83 % harboured bla_CTX-M. All CG147 genomes presented GyrA and ParC mutations and a common subtype I-E CRISPR-Cas system. ST392 and ST273 emerged in 2005 and 1995, respectively. ST147, the most represented phylogenetic branch, was itself divided into two main clades with distinct capsular loci: KL64 (74 %, DJ included, emerged in 1994 and disseminated worldwide, with carbapenemases varying among world regions) and KL10 (20 %, emerged in 2002, predominantly found in Asian countries, associated with carbapenemases NDM and OXA-48-like). Furthermore, subclades within ST147-KL64 differed at the yersiniabactin locus, OmpK35/K36 mutations, plasmid replicons and prophages. The absence of IncF plasmids in some subclades was associated with a possible activity of a CRISPR-Cas system. K. pneumoniae CG147 comprises pandrug-resistant or extensively resistant isolates, and carries multiple and diverse resistance genes and mobile genetic elements, including chromosomal bla_NDM-5. Its emergence is being driven by the spread of several phylogenetic clades marked by their own genomic features and specific temporo–spatial dynamics. These findings highlight the need for precision surveillance strategies to limit the spread of particularly concerning CG147 subsets.

A large-scale genomic snapshot of Klebsiella spp. isolates in Northern Italy reveals limited transmission between clinical and non-clinical settings

The Klebsiella group, found in humans, livestock, plants, soil, water and wild animals, is genetically and ecologically diverse. Many species are opportunistic pathogens and can harbour diverse classes of antimicrobial resistance genes. Healthcare-associated Klebsiella pneumoniae clones that are non-susceptible to carbapenems can spread rapidly, representing a high public health burden. Here we report an analysis of 3,482 genome sequences representing 15 Klebsiella species sampled over a 17-month period from a wide range of clinical, community, animal and environmental settings in and around the Italian city of Pavia. Northern Italy is a hotspot for hospital-acquired carbapenem non-susceptible Klebsiella and thus a pertinent setting to examine the overlap between isolates in clinical and non-clinical settings. We found no genotypic or phenotypic evidence for non-susceptibility to carbapenems outside the clinical environment. Although we noted occasional transmission between clinical and non-clinical settings, our data point to a limited role of animal and environmental reservoirs in the human acquisition of Klebsiella spp. We also provide a detailed genus-wide view of genomic diversity and population structure, including the identification of new groups.

[Digital home-based multidisciplinary cardiac rehabilitation: How to counteract physical inactivity during the COVID-19 pandemic]

Introduction and Objectives

Center-based cardiac rehabilitation (CR) programs have been forced to close due to COVID-19. Alternative delivery models to maintain access to CR programs and to avoid physical inactivity should be considered. The aim of this study was to assess physical activity (PA) levels after completing a home-based digital CR program.

Methods

A total of 116 cardiovascular disease (CVD) patients (62.6±8.9 years, 95 male) who had been attending a face-to-face CR program were recruited and assessed (baseline and at three months) on the following parameters: PA, sedentary behavior, adherence, cardiovascular and non-cardiovascular symptoms, feelings toward the pandemic, dietary habits, risk factor control, safety and adverse events. The intervention consisted of a multidisciplinary digital CR program, including regular patient assessment, and exercise, educational and psychological group sessions.

Results

Ninety-eight CVD patients successfully completed all the online assessments (15.5% drop-out rate). A favorable main effect of time was an increase in moderate to vigorous PA and a decrease in sedentary time at three months. Almost half of the participants completed at least one online exercise training session per week and attended at least one of the online educational sessions. No major adverse events were reported and only one minor event occurred.

Conclusion

During the pandemic, levels of moderate to vigorous PA improved after three months of home-based CR in CVD patients with previous experience in a face-to-face CR model. Diversified CR programs with a greater variety of content tailored to individual preferences are needed to meet the motivational and clinical requirements of CVD patients.

Virulence and antibiotic resistance of Klebsiella pneumoniae strains isolated from wastewater

Background

Multidrug-resistant Klebsiella pneumoniae (Kp) strains are considered a global public health threat. The aim of the present study was to assess the occurrence of resistant and virulent Kp in Italian environmental wastewater, in order to evaluate the contribution of wastewater as reservoir of virulent and multidrug-resistant bacteria.

Methods

Forty samples of wastewater were collected in six sampling sessions from June to November 2018 in Central Italy and processed to detect Kp. All the presumptive Kp colonies isolated were identified by MALDI-TOF MS (Bruker Daltonics, Germany), then the genome sequences of all the confirmed Kp were obtained using Illumina Sequencing. Finally, characterization of virulence and resistance genes was performed in silico using the BIGSdb-Kp database provided by the Institut Pasteur (http://bigsdb.web.pasteur.fr).

Results

Kp was detected in 32 out of 40 samples (80%) and all strains were confirmed as Kp by MALDI-TOF MS. Genotyping analysis showed that besides the native bla-SHV, bla-LEN, bla-OKP genes linked to β-lactams resistance, gyr and par genes, involved in quinolone resistance, and no other resistance genes were detected. Regarding virulence, all strains carried the fimbriae encoding gene mrk, associated with adhesion and biofilm formation. The ferric aerobactin receptor iutA was harbored by 3 strains (9.4%). The siderophore Yersiniabactin locus (ybtS, ybtX, ybtQ, ybtP, ybtA, irp2 irp1, ybtU, ybtT, ybtE, fyuA), essential for iron scavenging, is carried by 7 out of 32 strains (21.9%).

Conclusions

Our results showed a high prevalence of Kp in wastewater that also harbored several resistance and virulence genes. These results make interesting to investigate more about wastewater as hot spots of enrichment, recombination, genetic exchange and selection of antibiotic resistant “super-bugs” that persisting and surviving in the environment could be a health risk for humans and animals.

Key messages

Wastewater could play a role as Klebsiella pneumoniae reservoir of virulence and resistance genes that can disseminate into wildlife and reach humans. It’s necessary a “one health” approach to deeply investigate about the presence of superbugs bacteria in the environment and the possible risks for human health.

Klebsiella pneumoniae in vegetable products: antimicrobial resistance and consumer health risk

Background

Klebsiella pneumoniae (Kp) is considered one of the major causes of human hospital infections. Moreover, Kp is often present in several food products and it could be a potential health hazard for the consumers through the increase of Kp antimicrobial resistance (AMR) to the main routinely used antibiotics classes. The aim of this study was to evaluate the AMR profile of Kp strains isolated from vegetable food products.

Methods

The whole genome sequences of 10 Kp strains, previously isolated from carrots (n. 4), salads (n. 3), tomatoes (n. 2) and pumpkin (n. 1) samples, were obtained by next generation sequencing technique, using Illumina platform. Phenotypic and genotypic AMR profiles, with particular attention to β-lactams, quinolones and aminoglycosides resistances, were acquired by both agar diffusion and micro-dilution susceptibility testing and uploading the Kp sequences to Institut Pasteur platform (https://bigsdb.pasteur.fr/), respectively.

Results

Most of Kp strains (9 of 10) resulted susceptible to the main antibiotics tested and few AMR genes were detected in silico besides the native blaSHV, blaOKP and blaLEN. Only one Kp harboured blaAMPC and blaCMY, showing resistance to 5 β-lactams (amoxicillin/clavulanate, cefoxitin, cefpodoxime, cefpodoxime/clavulanate, ceftobiprole). Regarding the quinolone resistances, all the Kp strains carried gyr and par genes. No aminoglycoside resistance genes were highlighted in the 10 Kp strains studied.

Conclusions

These preliminary results showed the presence, in vegetable foods, mainly in ready to eat raw products, of Kp strains, harbouring no or few AMR genes. Good hygiene practices should be properly applied during the entire food processing chain, to avoid hazardous implications for the consumer. Further studies are needed in order to: analyse more vegetable samples, deeply evaluate the phenotypic and genotypic AMR profile of the Kp strains and their possible transmission from food products to consumer.

Key messages

Klebsiella pneumoniae is often isolated in food, as ready to eat vegetables, and it could be a potential public health risk due to the antimicrobial resistance increase to main antibiotics. The presence of Klebsiella pneumoniae in food implies the correct application of good hygiene practices in the entire food processing chain, in order to avoid dangerous effects for consumers.

On- vs off-hours primary percutaneous coronary intervention: a single-centre experience

Introduction

In ST-segment elevation myocardial infarction (STEMI) patients, emergency medical system delays importantly affect outcomes. The effect of admission time in STEMI patients is dubious when percutaneous coronary intervention (PCI) is the preferred reperfusion strategy.

Aims

The authors aimed to retrospectively describe the association between admission time and STEMI patient's care standards and outcomes.

Methods

Characteristics and outcomes of 1222 consecutive STEMI patients treated in a PCI-centre were collected. On-hours were defined as admission on non-national-holidays from Monday to Friday from 8 AM to 6 PM. Time delays, in-hospital and one-year all-cause mortality were assessed.

Results

A total of 439 patients (36%) were admitted on-hours and 783 patients (64%) were admitted off-hours. Baseline characteristics were well-balanced between groups, including the percentage of patients admitted in cardiogenic shock (on-hours: 4.6% vs off-hours 4%; p=0.62).

Median emergency system dependent time to reperfusion (i.e. first-medical contact to reperfusion) did not differ between the two groups (on-hours: 120 min vs. off-hours 123 min, p=0.54). The authors observed no association between admission time and in-hospital mortality (on-hours: 5% vs. off-hours 4.9%, p=0.90) or 1-year mortality (on-hours: 10% vs. off-hours 10%, p=0.97).

In patients admitted directly in the PCI-centre, median time from first-medical contact to reperfusion (on-hours: 87 min vs off-hours: 88 min, p=0.54), in-hospital mortality (on-hours: 4% vs off-hours: 7%, p=0.30) and 1 year mortality (on-hours: 9% vs off-hours: 13%, p=0.27) did not differ between the two groups.

Survival analysis showed no survival benefit of on-hours PCI over off-hours PCI (HR 1.01; 95% CI [0.77–1.46], p=0.95).

Conclusion

In a contemporary well-organized emergency network, STEMI patients admission time in the PCI-centre was not associated with reperfusion delays or increased mortality.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier curve

The success of particular Acinetobacter baumannii clones: accumulating resistance and virulence inside a sugary shield

BACKGROUND

In Portugal, carbapenem-resistant Acinetobacter baumannii (CRAB) has been associated with ST98, ST103 and ST208 (Oxford Scheme, Oxf) and a clone has usually been associated with a particular period of time. These clonal shifts were primarily explained by an increased antimicrobial resistance profile. Here we explore genomic and biochemical differences among these and more recent clones, which could further explain the diversity and evolution of this species.

METHODS

A total of 116 CRAB isolates (2010-15), together with representatives of a previously described CRAB collection (4 isolates, 2001-06) were characterized by attenuated total reflection Fourier transform infrared spectroscopy (FTIR-ATR) and MLST. Representatives of different FTIR-ATR/MLST clusters were selected for WGS (n = 13), which allowed the in silico extraction of resistance and virulence genes, capsule locus and SNP analysis.

RESULTS

A. baumannii clonal shifts of OXA-58-producing ST103Oxf (2001-04), OXA-40-producing ST98Oxf (2002-06), OXA-23-producing ST208Oxf (2006-10) and OXA-23-producing ST218Oxf (2010-15) were accompanied by an increase in AMR genes and virulence factors. FTIR-ATR clustering was congruent with sugar composition predicted from the capsular locus: a fucosamine cluster comprising ST98Oxf, ST103Oxf and a single ST218Oxf isolate; a pseudaminic acid cluster of ST208Oxf and ST1557Oxf isolates; and legionaminic acid, resembling the sialic acid from mammalian cells, in a cluster comprising ST218Oxf isolates. The whole-genome phylogenetic tree was congruent with MLST, with isolates presenting 5-28 938 SNPs. ST208Oxf and ST218Oxf presented ∼1900 SNPs while ST103Oxf and ST1557Oxf showed a greater number of SNPs (∼28 000).

CONCLUSIONS

Clonal shifts of CRAB were promoted, in our country, by consecutive virulence and AMR gene pool enlargement, together with features increasing pathogen-host adaptation. Worldwide dominance of ST218Oxf is supported by the combination of high AMR and virulence levels.

The need for European harmonization of Nutrivigilance in a public health perspective: a comprehensive review

According to the European Union regulation, some countries have established a pre-market notification system for food supplements while others have not. As this regulation is unfulfilled, a notified and marketed food supplement ingredient in one country may be forbidden in another. Even though food supplements shall not be placed on the market if unsafe, some products may still expose the consumers to risks. The risk is increased by easier access due to worldwide dissemination fostered by the internet and free movement of goods in the European Union. The Rapid Alert System for Food and Feed and the Emerging Risks Exchange Network are described. To date, the European Union legislation does not include a provision to establish a dedicated vigilance system for food supplements (Nutrivigilance). Six European Union countries have nevertheless set up national systems, which are presented. The present lack of European Union data collection harmonization, does not allow easy cooperation between countries. This article advocates for creating a coordinated European Nutrivigilance System to detect and scrutinize adverse effects of food supplements. This, to help in directing science-based risk assessments and reinforce the science-based decision of policy makers to improve public health safety.

Klebsiella MALDI TypeR: a web-based tool for Klebsiella identification based on MALDI-TOF mass spectrometry

Klebsiella pathogens affect human and animal health and are widely distributed in the environment. Among these, the Klebsiella pneumoniae species complex, which includes seven phylogroups, is an important cause of community and hospital infections. The Klebsiella oxytoca species complex also causes hospital infections and antibiotic-associated haemorrhagic colitis. The unsuitability of currently used clinical microbiology methods to distinguish species within each of these species complexes leads to high rates of misidentifications that are masking the true clinical significance and potential epidemiological specificities of individual species. We developed a web-based tool, Klebsiella MALDI TypeR, a platform-independent and user-friendly application that enables uploading MALDI-TOF mass spectrometry data in order to identify Klebsiella isolates at the species complex and phylogroup levels. The tool, available at https://maldityper.pasteur.fr/, leverages a database of previously identified biomarkers that are specific for species complexes, individual phylogroups, or related phylogroups. We obtained 84%-100% identification accuracy depending on phylogroup. Identification results are obtained in a few seconds from batches of uploaded spectral data. Klebsiella MALDI TypeR enables fast and reliable identification of Klebsiella strains that are often misidentified with standard microbiological methods. This web-based identification tool may be extended in the future to other human bacterial pathogens.

Body composition, lipid profile and mediterranean diet adherence in cardiovascular disease patients attending a long-term exercise-based cardiac rehabilitation program during COVID-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Cardiovascular disease (CVD) is recognized as a major public health issue and remains the leading cause of mortality worldwide. There is a clear association between adiposity, blood lipid profile, and adherence to the Mediterranean diet (MD) with the risk of CVD. However, the assessment of body composition parameters, dietary patterns and nutritional intervention in CVD patients undergoing a cardiovascular rehabilitation (CR) program remains insufficient. 

Purpose

 to characterize body composition, lipid profile and MD adherence in patients with CVD who were attending an exercise-based CR program during COVID-19 era. 

Methods

 The study was developed between October 2020 and January 2021 in a phase III centre-based CR program. Body composition was assessed by dual energy x-ray absorptiometry Hologic Explorer-W. Adherence to the MD was assessed by the 14-item MD questionnaire. Fasting blood sample was taken for measurement of lipid profile. 

Results

 A sample of 41 patients (mean age 64.4 ± 7.9 years, 87.8% male) was evaluated. The most prevalent CVD were coronary artery disease (89.5%) and heart failure (21.1%). The main CVD risk factors at admission in the CR program were dyslipidaemia (71.1%), hypertension (68.4%), physical inactivity (26.3%) and diabetes mellitus (21.0%). In our sample the mean body mass index was 28 ± 3.8 kg/m2, being most patients overweight (75.6%), and having a substantially increased risk of metabolic complications (85.3%) accordingly to waist-hip ratio. Body composition assessment showed that 14.6% of the patients had a body fat mass index above 90th percentile. Although only 9.8% of the patients had reduced fat free mass, 17.1% showed appendicular lean mass below the reference value. In addition, less than one third of the patients (31.7%) revealed a high adherence to the MD pattern. A sub-analysis on blood lipids (n = 26) showed that most patients had levels of LDL cholesterol (76.9%) and non-HDL cholesterol (65.4%) above the therapeutic target and 15.4% had triglycerides higher than 150 mg/dl. 

Conclusion

 Body composition, lipid profile and dietary patterns, play a major role in CVD secondary prevention. Our findings showed that a substantial number of CVD patients, in COVID-19 era, did not have optimal body composition, were above lipid profile targets, and had a low/medium adherence to the MD. Thus, this study highlights the relevance of nutrition on cardiometabolic status and demonstrates the crucial role of nutritional intervention as an integrated part of a long-term phase III CR program. Moreover, further research about nutritional intervention in patients undergoing CR is warranted.

Left ventricular remodeling: is there a real impact of cardiac rehabilitation?

Funding Acknowledgements

Type of funding sources: None.

Introduction

A number of randomized controlled trials have examined the effect of exercise training on left ventricle (LV) remodeling in individuals with cardiovascular disease. However, the results of these trials have been inconclusive. 

Purpose

Evaluation of the impact of a cardiac rehabilitation program (CRP) on left ventricle remodelling evaluated by echocardiogram. 

Methods

Observational single centre study including consecutive patients, undergoing structured CRP since June 2016 until February 2020. Phase II CRP included 3 months of exercise training, aerobic and strength exercise, individually prescribed, 3 times a week, 60 minutes sessions. All patients were submitted to a clinical evaluation, echocardiogram, and cardiopulmonary exercise test before and after the CRP.

Results

205 patients (62.6 ± 11 years, 83.4% men, 82.3% ischemic disease) were included in a phase II CRP. Most patients had ischemic disease (82.3%) and 23.5% of patients had left ventricular ejection fraction (LVEF) &lt;40%. Of the cardiovascular risk factors, hypertension was the most prevalent (76%), followed by dyslipidaemia (67.4%), active smoking (45.9%) and diabetes (26.9%). 

After the CRP, there was a significant improvement of LVEF (from 48.3 ± 13 to 52 ± 11.6 %, p = 0.001) and a significant reduction of LV volumes (LV end-diastolic volume, LVEDV , decreased from 140 ± 81 to 121 ± 57, p = 0.002; LV end-systolic volume , LVESV , reduced from 80 ± 75 to 64 ± 48, p = 0.004). Considering only the patients with LVEF &lt; 40% (n = 38), the improvement was even greater: LVEF increased from 30 ± 8 to 39 ± 13 (p = 0.002); LVEDV reduced from 206 ± 107 to 159 ± 81 (p = 0.001) and LVESV reduced from 142 ± 99 to 101 ± 66 (p = 0.002). 63.6%(n = 14) of these patients improved at least 10% of LVEF and only 1 of them had a cardiac resynchronization therapy device. 

Conclusions

A phase II CR program was associated with significant improvements in left ventricular reverse remodelling irrespective of baseline EF classification. Those with reduced baseline EF derived an even greater improvement, highlighting the great importance of CR in this subgroup of patients.

Female sexual function and quality of life after pelvic floor surgery: a prospective observational study

INTRODUCTION AND HYPOTHESIS

Knowledge about the impact of pelvic floor surgery on sexual function is limited and inconsistent. A prospective study assessed the impact of surgery for prolapse (POP) or stress urinary incontinence (SUI) on sexual function and determined the biopsychosocial predictors for changes in sexual function after surgery.

MATERIALS AND METHODS

Sexually active women scheduled for correction of POP and/or SUI were recruited over a 6-month period. Consenting participants were asked to complete the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to evaluate sexual function. The King's Health Questionnaire and Prolapse Quality-of-Life Questionnaire were used to assess UI and POP symptoms and their impact on quality of life (QoL), respectively. Women were reviewed over a period of 1 year post-surgery.

RESULTS

Ninety-one patients were followed up over 1 year. After stratification into only or both SUI and POP surgery, global sexual function improved significantly in each group (p < 0.001). The improvement in the overall QoL score after pelvic surgery showed a significant correlation with the improvement in global sexual function (SUI group: r = - 0.38, p < 0.01; POP group: r = - 0.44, p < 0.05). For women undergoing SUI surgery, only educational level and prior hysterectomy had a significant association with improved sexual function. For women undergoing POP surgery with or without SUI surgical repair, no sociodemographic characteristics were preditive of improvement of sexual function.

CONCLUSIONS

Significantly improved sexual function was observed 1 year after pelvic floor surgery, and the improvement was predicted by other social and physical factors in addition to normal functional anatomy.

Population genomics and antimicrobial resistance in Corynebacterium diphtheriae

Background

Corynebacterium diphtheriae, the agent of diphtheria, is a genetically diverse bacterial species. Although antimicrobial resistance has emerged against several drugs including first-line penicillin, the genomic determinants and population dynamics of resistance are largely unknown for this neglected human pathogen.

Methods

Here, we analyzed the associations of antimicrobial susceptibility phenotypes, diphtheria toxin production, and genomic features in C. diphtheriae. We used 247 strains collected over several decades in multiple world regions, including the 163 clinical isolates collected prospectively from 2008 to 2017 in France mainland and overseas territories.

Results

Phylogenetic analysis revealed multiple deep-branching sublineages, grouped into a Mitis lineage strongly associated with diphtheria toxin production and a largely toxin gene-negative Gravis lineage with few toxin-producing isolates including the 1990s ex-Soviet Union outbreak strain. The distribution of susceptibility phenotypes allowed proposing ecological cutoffs for most of the 19 agents tested, thereby defining acquired antimicrobial resistance. Penicillin resistance was found in 17.2% of prospective isolates. Seventeen (10.4%) prospective isolates were multidrug-resistant (≥ 3 antimicrobial categories), including four isolates resistant to penicillin and macrolides. Homologous recombination was frequent (r/m = 5), and horizontal gene transfer contributed to the emergence of antimicrobial resistance in multiple sublineages. Genome-wide association mapping uncovered genetic factors of resistance, including an accessory penicillin-binding protein (PBP2m) located in diverse genomic contexts. Gene pbp2m is widespread in other Corynebacterium species, and its expression in C. glutamicum demonstrated its effect against several beta-lactams. A novel 73-kb C. diphtheriae multiresistance plasmid was discovered.

Conclusions

This work uncovers the dynamics of antimicrobial resistance in C. diphtheriae in the context of phylogenetic structure, biovar, and diphtheria toxin production and provides a blueprint to analyze re-emerging diphtheria.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s13073-020-00805-7.

Carbohydrates as targeting compounds to produce infusions resembling espresso coffee brews using quality by design approach

All coffee brews are prepared with roasted coffee and water, giving origin to espresso, instant, or filtered coffee, exhibiting distinct physicochemical properties, depending on the extraction conditions. The different relative content of compounds in the brews modulates coffee body, aroma, and colour. In this study it was hypothesized that a coffee infusion allows to obtain extracts that resemble espresso coffee (EC) physicochemical properties. Carbohydrates (content and composition) were the target compounds as they are organoleptically important for EC due to their association to foam stability and viscosity. The freeze-drying of the extracts allowed better dissolution properties than spray-drying. Instant coffee powders were obtained with chemical overall composition resembling espresso, although with lower lipids content. The extracts were able to produce the characteristic foam through CO₂ injection or salts addition. Their redissolution at espresso concentration allowed a viscosity, foamability and volatile profile representative of an espresso coffee, opening new exploitation possibilities.

Immune Modulation and CMV Reactivation In Sepsis-Induced Immunosuppression

Introduction/Objective

Sepsis is a global health priority and is often accompanied by a transient immune paralysis, associated with impairment in innate and adaptive immunity leading to progressive immunosuppression and higher susceptibility to secondary infections. Reactivation of Cytomegalovirus (CMV) occurs frequently and has been associated with adverse outcomes even in immunocompetent patients, with sepsis. Study objective was to evaluate the association between incidence of CMV reactivation and immune alteration in sepsis-induced immunosuppression in patients with prolonged sepsis.

Methods

Prospective observational study, which included consecutive patients admitted to hospital ICU, with severe sepsis and length of stay &gt; 48 hours. Patients with other causes of immune-suppression and anti-CMV treatment were excluded. Blood samples were collected on enrolment and further weekly until 21 days or death/discharge.

Quantification of CMV viremia was done using RT-PCR (qPCR). Markers used to evaluate immune suppression using Flow Cytometry were i) lymphocyte subsets (CD3+,CD19+,CD16+CD56+,CD4+,CD8+ and regulatory T cells - CD25+ CD127-), ii) surface receptor expression of HLA-DR on monocytes, and Programmed Death marker expression (PD-1) on T lymphocyte, iii) Measurement of pro-inflammatory(IL-6,TNF-a,IFN-g) and anti-inflammatory cytokines(IL-4,IL-10) by Cytometric Bead Array (CBA) assay.

Results

A total of 25 CMV IgG positive patients and 11 healthy controls were analyzed. CMV reactivation occurred in 20 patients. Median time for reactivation was 7 days. Patients with CMV reactivation had significant T-cell lymphopenia (p&lt;0.01). PD-1 expression on both CD4+ and CD8+ T cells in these patients was markedly elevated as compared to non-reactive group. HLA-DR expression was significantly low on monocytes in all sepsis patients (p&lt;0.01) vs healthy controls; however it did not show any significant correlation. Levels of IL-6 showed marked elevation from day 7 while, IL-10 was observed to be significantly higher from day 0 in CMV reactivated group as compared to the CMV non-reactive group of patients.

Conclusion

Our study evidence suggests that monitoring lymphocyte subsets, PD-1expression on T lymphocyte, and levels of IL-6/IL-10 using flow cytometry, may serve as indicators for reactivation of CMV. Individualized immune therapy such as PD-1 receptor blockade drugs can be used to optimize treatment of patients with severe sepsis.

Klebsiella pneumoniae carriage in low-income countries: antimicrobial resistance, genomic diversity and risk factors

Background Klebsiella pneumoniae (hereafter, Kp) is a major public health threat responsible for high levels of multidrug resistant (MDR) human infections. Besides, Kp also causes severe infections in the community, especially in Asia and Africa. Although most Kp infections are caused by endogenous intestinal carriage, little is known about the prevalence and microbiological characteristics of Kp in asymptomatic human carriage, and attached risk factors including environmental sources exposure. Methods Here, 911 pregnant women from communities in Madagascar, Cambodia, and Senegal were screened for gut colonization by Kp. Characteristics of Kp strains (antimicrobial susceptibility, genomic diversity, virulence, and resistance genes) were defined, and associated risk factors were investigated. Results Kp carriage rate was 55.9%, and Kp populations were highly heterogeneous (6 phylogroups, 325 sequence types, Simpson index 99.6%). One third of Kp isolates had acquired antimicrobial resistance genes. MDR-Kp (11.7% to 39.7%) and extended spectrum beta-lactamase (ESBL)-producing Kp (0.7% to 14.7%) varied among countries. Isolates with virulence genes were detected (14.5%). Environmental exposure factors including food, animal contacts, or hospitalization of household members were associated with carriage of Kp, antimicrobial resistance and hypervirulence. However, risk factors were country-specific and Kp subpopulation-specific. Conclusion This large-scale multicenter study uncovers the huge diversity of Kp in human gut carriage, demonstrates that antimicrobial resistance is widespread in communities of three low-income countries, and underlines the challenges posed by Kp colonization to the control of antimicrobial resistance.

Individual preparedness for natural disasters: a cross-sectional study from Portugal

Background

Individual preparedness is critical in mitigating the adverse effect of natural disasters (ND). Factors influencing preparedness are complex and multifaceted, with certain groups having different needs and vulnerabilities. We aimed to explore the factors associated with individual ND preparedness in residents from Vila Nova Gaia (VNG), Portugal.

Methods

A cross-sectional study was conducted in VNG, Portugal, in January 2020 (N = 192; ≥18 years). Data on sociodemographic characteristics, risk perception, and preparedness were collected using a structured questionnaire, in parishes randomly selected. Crude and adjusted odds ratio (OR) and respective 95% confidence intervals (CI) were estimated using logistic regression models.

Results

About 33% of participants aged ≥65 years and 66% had low education. Results show that 20% had a survival kit. In univariate comparisons, older (11% vs. 24%, p=.029) and lower educated participants (≤12th grade: 13% vs. &gt;12th grade: 32%, p=.002) were less likely to have a survival kit; only education remained associated after adjustment for age (OR = 2.61, 95%CI:1.22-5.58). About 21% had a family plan for disaster and only education level is associated (≤12th grade: 17% vs. &gt;12th grade: 29%, p=.040). Almost 35% had a family member with basic life support training; older age, lower education and higher risk perception were negatively associated and these remained after adjustment (≥65 vs. &lt;65 years OR = 0.36, 95%CI:0.16-0.77; ≤12th vs. &gt;12th grade OR = 0.40, 95%CI:0.21-0.78; risk perception OR = 0.66, 95%CI:0.45-0.95). Only 22% participated in community drills; older people (6% vs. 31%, p&lt;.001) and less educated (14% vs. 39%, p&lt;.001) were less likely to have ever participated, which persisted in multivariate model.

Conclusions

Our findings revealed a low-level of ND preparedness, and older and less educated people seem to present worse preparedness. This highlights the need to design specific public health interventions among these groups.

Key messages

We found a low-level of individual preparedness for natural disasters in VNG, Portugal. Community-based public health interventions are needed to improve individual preparedness for natural disasters. Specific interventions targeting older and less educated people should be designed to decrease their vulnerability facing a natural disaster.

Differences for managing mother’s own milk for very preterm infants across 11 European countries

Background

There is an ongoing debate about the best practices to handle mother's own milk (MOM) for infants born very preterm (VPT, ≤32 weeks of gestation), specifically to prevent the human cytomegalovirus (HCMV) transmission and bacterial contamination of expressed MOM. Thus, we aimed to compare practices for managing MOM for VPT infants in European neonatal intensive care units (NICUs).

Methods

Data were collected as part of the EPICE (Effective Perinatal Intensive Care in Europe) study which explored the use of evidence-based practices for the care of VPT infants in 11 European countries. Structured questionnaires were sent to the head of all participating NICUs with at least 10 VPT admissions. Of the eligible 135 NICUs, 134 replied.

Results

A written protocol for breastfeeding/human milk use was available in 91% of the NICUs. Overall, 34% used human bank milk for all VPT infants whose mothers did not express and 56% reported using fresh MOM without restrictions regarding minimum gestational age, birth weight or risk of HCMV transmission (country range: 0-100%). In 22% of units all VPT infants received MOM pasteurized (country range: 0-73%). HCMV serology on all mothers who express their milk was not required in 71% of units (country range: 7-100%). Among NICUs that performed HCMV serology, 3% provided untreated fresh MOM and 23.5% formula in the case of positive mothers. Systematic bacteriological analyses of MOM were not performed in 76% NICUs (country range: 29-100%) while less than 10% did it for the first milk feeding, 7% every week and 8% with another frequency.

Conclusions

There are large variations in managing MOM across countries, which could reflect differences in regulations or guidelines, and among the same country NICUs, revealing that different options can operate locally. This variability suggests substantial differences in attitudes about what constitutes best practices among European neonatologists.

Key messages

We found significant differences across and within European countries for managing MOM for VPT infants suggesting lack of strong recommendations at the international and national level. There is wide variation in what European neonatologists consider best practices. To guide practice and not jeopardise VPT infants from MOM we need strong evidence-based data.

Community-acquired infection caused by the uncommon hypervirulent Klebsiella pneumoniae ST66-K2 lineage

Klebsiella pneumoniae (Kp) reference strain Kp52.145 is widely used in experimental Klebsiella pathophysiology. Since 1935, only one other strain of the same sublineage (sequence type ST66, capsular serotype K2) was isolated (AJ210, Australia). Here, we describe a community-acquired invasive infection caused by a ST66-K2 Kp strain in France. Four hypermucoviscous Kp isolates responsible for acute otitis media, meningitis, bacteraemia and bacteriuria, respectively, were obtained from a patient with a history of chronic alcoholism and diabetes mellitus, and infected with HIV. The isolates were characterized by phenotypic and genomic methods. The four genetically identical ST66-K2 isolates presented a full antimicrobial susceptibility profile, including to ampicillin, corresponding to a single strain (SB5881), which was more closely related to AJ210 (135 SNPs) than to Kp52.145 (388 SNPs). Colibactin and yersiniabactin gene clusters were present on the integrative and conjugative element ICEKp10 in the chromosome. The two plasmids from Kp52.145 were detected in SB5881. In addition to carrying genes for virulence factors RmpA, aerobactin and salmochelin, plasmid II has acquired in SB5881, the conjugation machinery gene cluster from plasmid I. We report the first case of community-acquired infection caused by a hypervirulent ST66-K2 Kp strain in Europe. This demonstrates the long-term persistence of the high-virulence and laboratory model ST66-K2 sublineage. The combination of a conjugative apparatus and major virulence genes on a single plasmid may contribute to the co-occurrence of hypervirulence and multidrug resistance in single Kp strains.