Clinical effectiveness of cefiderocol for the treatment of bloodstream infections due to carbapenem-resistant Acinetobacter baumannii during the COVID-19 era: a single center, observational study

BACKGROUND

We assessed the clinical effectiveness of cefiderocol (CFDC) in comparison with colistin (COL) for the treatment of carbapenem-resistant Acinetobacter baumannii (CRAB) bloodstream infections (BSI).

MATERIALS/METHODS

Retrospective cohort study including adults with CRAB-BSI. Outcomes were mortality, clinical cure and adverse events during therapy. The average treatment effect of CFDC compared to COL was weighted with the inverse-probability treatment weight (IPTW).

RESULTS

Overall, 104 patients were included (50 CFDC, 54 COL), median age 66.5 years, median Charlson Comorbidity Index 5, septic shock in 33.6% of patients. Primary BSI accounted for 43.3% of cases, followed by ventilator-associated pneumonia (VAP) (26%), catheter-related BSI (20.2%) and hospital-acquired pneumonia (HAP) (9.6%). Although not significantly, mortality at all time points was lower for CFDC than COL, while clinical cure was higher in CFDC than COL (66% vs. 44.4%, p = 0.027). Adverse events were more frequent in COL than CFDC-group (38.8% vs. 10%, p < 0.0001), primarily attributed to acute kidney injury (AKI) in the COL group. Patients with bacteremic HAP/VAP treated with CFDC had a significant lower 30-d mortality and higher clinical cure than COL (p = 0.008 and p = 0.0008, respectively). Increment of CCI (p = 0.005), ICU (p = 0.025), SARS-CoV2 (p = 0.006) and ECMO (p < 0.0001) were independently associated with 30-d mortality, while receiving CFDC was not associated with survival.

CONCLUSIONS

CFDC could represent an effective and safe treatment option for CRAB BSI, especially in patients with bacteremic HAP/VAP and frail patients where the risk of acute renal failure during therapy should be avoided.

Ceftazidime/avibactam-resistant meropenem-susceptible KPC-producing Klebsiella pneumoniae: analysis of cases and evaluation of in-vitro activity of fosfomycin-containing combinations

BACKGROUND

Little is known regarding outcomes and optimal therapeutic regimens of infections caused by KPC-producing Klebsiella pneumoniae (KPC-Kp) resistant to ceftazidime/avibactam (CZA) and susceptible to meropenem (MEM). Although in-vitro susceptible to MEM, the possibility of developing MEM resistance overtime is a concern. We described the clinical characteristics of patients with colonization/infection due to KPC-variant with a focus on the in-vitro activity of fosfomycin (FOS)-containing combinations.

MATERIALS/METHODS

Patients with colonization/infection due to KPC-variant were included. FOS susceptibility was performed by agar dilution method. Synergistic activity of FOS-based combinations was evaluated by gradient strip-agar diffusion method. The emergence of in-vitro MEM resistance was also tested.

RESULTS

Eleven patients were included, 8 with infection [4 ventilator-associated pneumonia, 4 bloodstream infections], 3 with colonization. A previous therapy with CZA was administered to all the patients (mean cumulative duration 23 days). All subjects with infection received meropenem, in monotherapy (n=4) or with amikacin (n=2) or fosfomycin (n=2) and achieved clinical cure. A new CZA-susceptible and MEM-resistant KPC-Kp strain was subsequently isolated in 3 patients (27.3%). Meropenem/vaborbactam (MVB) showed high in-vitro activity, while FOS+MEM combination was synergistic in 40% of cases. In-vitro resistance to MEM was observed, with maintenance of CZA resistance.

DISCUSSION

Detection of KPC-variant may occur within the same patient, especially if CZA has been previously administered. Although clinical success has been obtained with carbapenems, the emergence of MEM resistance is a concern. Fosfomycin plus meropenem is synergistic and may represent a valuable combination option for KPC-variant, while MVB may be considered in monotherapy.

IMPORTANCE

The detection of KPC-variants in an endemic setting for KPC-Kp represents a worryingly emerging condition. The optimal therapeutic approach is still unknown and the development of meropenem resistance is a concern, which may finally lead to a therapeutic failure in the clinical practice. In these cases, the addition of fosfomycin to meropenem or a more potent antibiotic such as meropenem/vaborbactam may represent valuable therapeutic options.

Presence of cagPAI genes and characterization of vacA s, i and m regions in Helicobacter pylori isolated from Alaskans and their association with clinical pathologies

Introduction. Gastric cancer is a health disparity in the Alaska Native people. The incidence of Helicobacter pylori infection, a risk factor for non-cardia gastric adenocarcinoma, is also high. Gastric cancer is partially associated with the virulence of the infecting strain.Aim. To genotype the vacA s, m and i and cag pathogenicity island (cagPAI) genes in H. pylori from Alaskans and investigate associations with gastropathy.Methodology. We enrolled patients with gastritis, peptic ulcer disease (PUD) and intestinal metaplasia (IM) in 1998-2005 and patients with gastric cancer in 2011-2013. Gastric biopsies were collected and cultured and PCR was performed to detect the presence of the right and left ends of the cagPAI, the cagA, cagE, cagT and virD4 genes and to genotype the vacA s, m and i regions.Results. We recruited 263 people; 22 (8 %) had no/mild gastritis, 121 (46 %) had moderate gastritis, 40 (15%) had severe gastritis, 38 (14 %) had PUD, 30 (11 %) had IM and 12 (5 %) had gastric cancer. H. pylori isolates from 150 (57%) people had an intact cagPAI; those were associated with a more severe gastropathy (P≤0.02 for all comparisons). H. pylori isolates from 77 % of people had either the vacA s1/i1/m1 (40 %; 94/234) or s2/i2/m2 (37 %; 86/234) genotype. vacA s1/i1/m1 was associated with a more severe gastropathy (P≤0.03 for all comparisons).Conclusions. In this population with high rates of gastric cancer, we found that just over half of the H. pylori contained an intact cagPAI and 40 % had the vacA s1/i1/m1 genotype. Infection with these strains was associated with a more severe gastropathy.

High Prevalence of Adenomatous Polyps in Alaska Native People Aged 40-49 years

BACKGROUND

Although colorectal cancer occurs earlier in life and at twice the frequency in Alaska Native (AN) people compared with the general population, the colorectal polyp burden in this group has not been quantified. In addition, an appropriate age for initial screening in ANs has not been defined.

MATERIALS AND METHODS

A retrospective chart review of 766 AN people who had screening colonoscopy from 2015 to 2016 was performed. The polyp burden in patients aged 40-49 y was compared with that in those aged 50-59 y in both the AN and the general US populations.

RESULTS

In total, 345 adenomas were removed: 121 (35%) from 40- to 49-year-olds and 224 (65%) from 50- to 59-year-olds. Twenty-six percent of AN people aged 40 y to 49 y and 40% of AN people aged 50 to 59 y had at least one adenoma. Low- and high-risk adenomas were significantly less frequent in the younger group (22% versus 29%, P = 0.048; 9.2% versus 15%, P = 0.035; respectively). Advanced adenomas were also less frequent in the younger group, although not statistically significant. Polyp histology, size, location, and morphology did not differ significantly between groups.

CONCLUSIONS

The adenoma and advanced adenoma prevalence in 40- to 49-year-old AN people is high, suggesting colorectal cancer screening should begin at age 40 y in ANs.

Disseminated fungal infection due to Saprochaete clavata in a kidney transplant recipient

Saprochaete clavata and Saprochaete capitata are closely related fungal species (family Dipodascaceae, order Saccharomycetales) that are rarely involved in the etiology of systemic infections in humans. In recent years, these yeasts are emerging as cause of life-threatening infections in patients with severe neutropenia and haematological malignancies. Infections by these fungi have been reported mostly from Mediterranean countries. To the best of our knowledge, only 2 cases of infection due to S. capitata have been reported in solid organ transplant recipients and none due to S. clavata. Herein we report a fatal case of S. clavata disseminated infection occurring in a patient with recent kidney transplantation and severe neutropenia. Patient was receiving antifungal echinocandin prophylaxis and the yeast was isolated from the blood and multiple non contiguous sites. Saprochaete spp. should be considered in the differential diagnosis of invasive mycoses in transplant recipients, especially if they are neutropenic and living or travelling in Mediterranean countries.

H. pylori-associated pathologic findings among Alaska native patients

Helicobacter pylori infection is common among Alaska native (AN) people, however scant gastric histopathologic data is available for this population. This study aimed to characterise gastric histopathology and H. pylori infection among AN people. We enrolled AN adults undergoing upper endoscopy. Gastric biopsy samples were evaluated for pathologic changes, the presence of H. pylori, and the presence of cag pathogenicity island-positive bacteria. Of 432 persons; two persons were diagnosed with gastric adenocarcinoma, two with MALT lymphoma, 40 (10%) with ulcers, and 51 (12%) with intestinal metaplasia. Fifty-five per cent of H. pylori-positive persons had cag pathogenicity island positive bacteria. The gastric antrum had the highest prevalence of acute and chronic moderate-severe gastritis. H. pylori-positive persons were 16 and four times more likely to have moderate-severe acute gastritis and chronic gastritis (p < 0.01), respectively. An intact cag pathogenicity island positive was correlated with moderate-severe acute antral gastritis (53% vs. 31%, p = 0.0003). H. pylori-positive persons were more likely to have moderate-severe acute and chronic gastritis compared to H. pylori-negative persons. Gastritis and intestinal metaplasia were most frequently found in the gastric antrum. Intact cag pathogenicity island positive was correlated with acute antral gastritis and intestinal metaplasia.

Platelet Activation in Patients with Benign and Malignant Ovarian Diseases

Plasma concentration of beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4) were measured by radioimmunoassay in 45 patients with benign and malignant ovarian diseases. All patients with ovarian carcinoma showed increased beta-TG and PF4 levels. Among benign ovarian diseases the patients with serous cystadenoma more frequently showed signs of platelet activation, whereas those with endometriotic cyst and mucinous cystadenoma generally had normal beta-TG and PF4 values. These results indicate that an increased platelet activation is consistently associated with malignant tumors of the ovary, whereas benign tumors show a different capacity to induce platelet activation.

A prospective evaluation of 200 upper endoscopies performed in Alaska Native persons

OBJECTIVES

To characterize the nature and prevalence of disease in Alaska Native patients referred for evaluation of upper gastrointestinal signs and symptoms.

STUDY DESIGN

Cross-sectional.

METHODS

Two hundred consecutive Alaska Native patients referred to a statewide tertiary center were prospectively evaluated. A standardized data collection form documenting EGD findings was utilized. Routine biopsies of the antrum and fundus were taken on all patients. Additional tissue was obtained from any areas of clinical concern.

RESULTS

Among 200 patients who underwent EGD during the study period, 130 (65%) tested H. pylori-positive on histology. Among 173 patients with histologic evidence of gastritis, 114 (66%) tested H. pylori-positive on histology. Chronic gastritis (87%), gastric ulcer (GU 12%), duodenal ulcer (DU 3%) and gastric cancer (2%) were the predominant findings. The GU:DU ratio was 4:1, the inverse of that reported in the general U.S. population.

CONCLUSIONS

Alaska Native patients referred for upper endoscopy have a high rate of H. pylori infection with predominantly gastric manifestations of disease and a GU:DU ratio, which is the inverse of what is typically seen in the U.S. and other developed countries. The high prevalence of H. pylori in Alaska Native patients resembles prevalence patterns reported from developing countries and may be linked to a rate of gastric cancer that is over three times that found in the U.S. population at large.

Virulence Characterization and Identification of Maize Lines Resistant to Puccinia sorghi Schwein. Present in the Argentine Corn Belt Region

Puccinia sorghi Schwein., the causal agent of maize common rust, is an endemic disease in the Argentine Corn Belt region. Virulence surveys of the pathogen population within the region have not been performed; thus, the understanding of the pathogen population is low and it is difficult to deploy resistance genes that could be effective at controlling the disease. In total, 58 single-uredinial isolates derived from infected maize leaves collected in different locations throughout the Argentine Corn Belt region during 2010 to 2012 were tested on a set of 25 maize lines carrying different Rp genes. Maize lines Rp3-A and PIO19802 showed the lowest virulence frequencies (3.4 and 1.7%, respectively) for all tested isolates. Moreover, the combination in a single genotype of the resistance genes carried by lines Rp3-A and PIO19802 or either of these lines combined with the resistance genes from PIO12345 would confer resistance to all isolates tested. Virulent isolates on maize lines Rp-G, Rp1-K, and Rp-GI were most frequent in 2012. Twenty-four virulence phenotypes were identified, with phenotypes TCCG (17.2%), TTBB (15.5%), and TCFG (10.3%) being the most common throughout the region. Adult plant resistance associated with hypersensitive response was identified at vegetative stage 6 in maize lines PIO68752, PIO28427, and PIO36420.

Muscular forearm activation in hand-grip tasks with superimposition of mechanical vibrations

The purpose of this paper is to evaluate the muscular activation of the forearm, with or without vibration stimuli at different frequencies while performing a grip tasks of 45s at various level of exerted force. In 16 individuals, 9 females and 7 males, the surface electromyogram (EMG) of extensor carpi radialis longus and the flexor carpi ulnari muscles were assessed. At a short latency from onset EMG, RMS and the level of MU synchronization were assessed to evaluate the muscular adaptations. Whilst a trend of decay of EMG Median frequency (MDFd) was employed as an index of muscular fatigue. Muscular tasks consists of the grip of an instrumented handle at a force level of 20%, 30%, 40%, 60% of the maximum voluntary force. Vibration was supplied by a shaker to the hand in mono-frequential waves at 20, 30, 33 and 40Hz. In relation to EMG, RMS and MU synchronization, the muscular activation does not seem to change with the superimposition of the mechanical vibrations, on the contrary a lower MDFd was observed at 33Hz than in absence of vibration. This suggests an early muscular fatigue induced by vibration due to the fact that 33Hz is a resonance frequency for the hand-arm system.

A Process Evaluation of the Alaska Native Colorectal Cancer Family Outreach Program

This article presents the results of a process evaluation of the Alaska Native (AN) Colorectal Cancer (CRC) Family Outreach Program, which encourages CRC screening among AN first-degree relatives (i.e., parents, siblings, adult children; hereafter referred to as relatives) of CRC patients. Among AN people incidence and death rates from CRC are the highest of any ethnic/racial group in the United States. Relatives of CRC patients are at increased risk; however, CRC can be prevented and detected early through screening. The evaluation included key informant interviews (August to November 2012) with AN and non-AN stakeholders and program document review. Five key process evaluation components were identified: program formation, evolution, outreach responses, strengths, and barriers and challenges. Key themes included an incremental approach that led to a fully formed program and the need for dedicated, culturally competent patient navigation. Challenges included differing relatives' responses to screening outreach, health system data access and coordination, and the program impact of reliance on grant funding. This program evaluation indicated a need for more research into motivating patient screening behaviors, electronic medical records systems quality improvement projects, improved data-sharing protocols, and program sustainability planning to continue the dedicated efforts to promote screening in this increased risk population.

Helmet use among Alaskan children involved in off-road motorized vehicle crashes

BACKGROUND

Off-road motorized vehicle crashes are a common source of trauma among Alaska children. Injury morbidity is worse in Alaska Native children than non-Native children, but the reasons are unclear.

OBJECTIVE

To evaluate the differences in helmet use between the Native and the non-Native children, and to assess the impact of helmet use on injury patterns and outcomes.

DESIGN

This retrospective cohort study identified patients aged 17 or younger admitted after all-terrain vehicle, snowmobile or motorbike injury between 2001 and 2011 from the Alaska Trauma Registry. Helmeted and non-helmeted patients were compared with respect to demographics, central nervous system (CNS) injury and the overall risk of death or permanent disability. Logistic regression was used to evaluate predictors of helmet use and the effects of ethnicity and helmet use on outcomes.

RESULTS

Of the 921 injured children, 51% were Alaska Native and 49% were non-Native. Helmet use was lower among Native versus non-Native patients on unadjusted comparison (24% vs. 71%) and multivariable logistic regression (OR 0.17, 95% CI 0.11-0.27, p<0.0001). Prevalence of CNS injury was higher among Native children (39.7% vs. 30.4%, p=0.016). However, on logistic regression with adjustment for helmet use, Native ethnicity was not a significant predictor of CNS injury (OR 1.07, 95% CI 0.68-1.68, p=0.78), whereas helmet use was strongly protective against CNS injury (OR 0.28, 95% CI 0.18-0.44, p<0.0001) as well as death or permanent disability (OR 0.26, 95% CI 0.10-0.67, p=0.006).

CONCLUSIONS

Helmet use is lower among Alaska Native children involved in off-road motorized vehicle crashes. These ethnic disparities in helmet use contribute to higher rates of CNS injury among Native children. Helmet use significantly improves overall outcome. Helmet promotion efforts should be expanded, especially in Native communities.

Paediatric trauma on the Last Frontier: an 11-year review of injury mechanisms, high-risk injury patterns and outcomes in Alaskan children

Background

Paediatric trauma system development in Alaska is complicated by a vast geographic coverage area, wide regional variations in environment and culture, and a lack of available published data.

Objective

To provide a detailed description of paediatric trauma mechanisms, high-risk injury patterns and outcomes in Alaska.

Design

This retrospective study included all children aged 17 years or younger in the State of Alaska Trauma Registry database admitted with traumatic injury between 2001 and 2011. Each injury record was reviewed individually and assigned a mechanism based on Centers for Disease Control E-codes. Geographic definitions were based on existing Emergency Medical Services regions. Mechanisms were compared by geographic region, patient demographics, injury characteristics and outcome. Subgroup analysis of fatal injuries was performed to identify causes of death.

Results

Of 5,547 patients meeting inclusion criteria, the most common mechanisms of injury were falls (39%), motor vehicle collisions (10%) and all-terrain vehicle (ATV) accidents (9%). The overall case fatality rate was 2%. Mechanisms with the greatest risk of death were gunshot wounds (21%), pedestrians struck by motorized vehicles (9%) and motor vehicle collisions (5%). These 3 mechanisms accounted for 15% of injuries but 60% of deaths in the overall cohort. Injury patterns involving combined central nervous system (CNS) and torso injuries were unusual but especially lethal, occurring in 3% of patients but carrying a case fatality rate of 18%. Although the distribution of mechanisms was generally similar for each geographic region, ATV and snowmobile injuries were significantly more common in remote areas (23% remote vs. 7% non-remote, p < 0.0001).

Conclusions

Mechanisms of paediatric trauma in Alaska have widely varying impacts on outcome and show some variation by region. Highest-risk mechanisms include gunshot wounds and motorized vehicle-related accidents. Prevention efforts should give special attention to CNS injury prevention, ATV and snowmobile safety in remote areas, and optimization of management of multisystem trauma. Further studies should investigate predictors of outcome in greater detail.

Fine mapping of LrSV2, a race-specific adult plant leaf rust resistance gene on wheat chromosome 3BS

Fine mapping permits the precise positioning of genes within chromosomes, prerequisite for positional cloning that will allow its rational use and the study of the underlying molecular action mechanism. Three leaf rust resistance genes were identified in the durable leaf rust resistant Argentinean wheat variety Sinvalocho MA: the seedling resistance gene Lr3 on distal 6BL and two adult plant resistance genes, LrSV1 and LrSV2, on chromosomes 2DS and 3BS, respectively. To develop a high-resolution genetic map for LrSV2, 10 markers were genotyped on 343 F2 individuals from a cross between Sinvalocho MA and Gama6. The closest co-dominant markers on both sides of the gene (3 microsatellites and 2 STMs) were analyzed on 965 additional F2s from the same cross. Microsatellite marker cfb5010 cosegregated with LrSV2 whereas flanking markers were found at 1 cM distal and at 0.3 cM proximal to the gene. SSR markers designed from the sequences of cv Chinese Spring BAC clones spanning the LrSV2 genetic interval were tested on the recombinants, allowing the identification of microsatellite swm13 at 0.15 cM distal to LrSV2. This delimited an interval of 0.45 cM around the gene flanked by the SSR markers swm13 and gwm533 at the subtelomeric end of chromosome 3BS.

Comparison of fecal occult blood tests for colorectal cancer screening in an Alaska Native population with high prevalence of Helicobacter pylori infection, 2008-2012

Introduction

Alaska Native colorectal cancer (CRC) incidence and mortality rates are the highest of any ethnic/racial group in the United States. CRC screening using guaiac-based fecal occult blood tests (gFOBT) are not recommended for Alaska Native people because of false-positive results associated with a high prevalence of Helicobacter pylori-associated hemorrhagic gastritis. This study evaluated whether the newer immunochemical FOBT (iFOBT) resulted in a lower false-positive rate and higher specificity for detecting advanced colorectal neoplasia than gFOBT in a population with elevated prevalence of H. pylori infection.

Methods

We used a population-based sample of 304 asymptomatic Alaska Native adults aged 40 years or older undergoing screening or surveillance colonoscopy (April 2008–January 2012).

Results

Specificity differed significantly (P < .001) between gFOBT (76%; 95% CI, 71%–81%) and iFOBT (92%; 95% CI, 89%–96%). Among H. pylori-positive participants (54%), specificity of iFOBT was even higher (93% vs 69%). Overall, sensitivity did not differ significantly (P = .73) between gFOBT (29%) and iFOBT (36%). Positive predictive value was 11% for gFOBT and 32% for iFOBT.

Conclusion

The iFOBT had a significantly higher specificity than gFOBT, especially in participants with current H. pylori infection. The iFOBT represents a potential strategy for expanding CRC screening among Alaska Native and other populations with elevated prevalence of H. pylori, especially where access to screening endoscopy is limited.

The effect of Helicobacter pylori infection on iron stores and iron deficiency in urban Alaska Native adults

BACKGROUND

Helicobacter pylori (H. pylori) infection has been correlated with low serum ferritin and iron deficiency. As a secondary analysis of a study of H. pylori reinfection, we investigated the association of H. pylori infection and the effect of its eradication on serum ferritin and iron deficiency.

METHODS

Alaska Native adults undergoing esophagogastroduodenoscopy had sera collected and a (13) C urea breath test (UBT) was performed. Those H. pylori positive were treated with an antibiotic regimen; those who tested negative 2 months after treatment were evaluated at 4, 6, 12, and 24 months by UBT and serum ferritin with an immunoradiometric assay. We excluded persons from further analysis if they were prescribed iron by their provider.

RESULTS

We measured serum ferritin for 241 persons; 121/241 were H. pylori positive. The geometric mean ferritin (GMF) for persons with and without H. pylori infection was 37 μg/L and 50 μg/L, respectively (p = .04). At enrollment, 19/121 H. pylori-positive persons had iron deficiency compared with 8/120 H. pylori negative (p = .02). Among 66 persons tested at 24 months, the GMF was higher at 24 months (49.6 μg/L) versus enrollment (36.5 μg/L; p = .02). Six of 11 persons with iron deficiency at enrollment no longer had iron deficiency and had a higher GMF (p = .02) 24 months after treatment.

CONCLUSIONS

H. pylori infection was correlated with lower serum ferritin and iron deficiency. After H. pylori eradication, serum ferritin increased and approximately half of persons resolved their iron deficiency. Testing for H. pylori infection and subsequent treatment of those positive could be considered in persons with unexplained iron deficiency.

Colorectal cancer in alaska native people, 2005-2009

BACKGROUND

Colorectal cancer (CRC) is the most frequently diagnosed cancer among Alaska Native (AN) people, and the second leading cause of cancer death. The incidence rate for the combined years 1999 through 2003 was 30% higher than the rate among U.S. whites (USWs) for the same period. Current incidence rates may serve to monitor the impact of screening programs in reducing CRC in the AN population.

METHODS

Incidence data are from the Alaska Native Tumor Registry and the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program. We compared AN CRC incidence, survival rates, and stage at diagnosis with rates in USWs for cases diagnosed from 2005 through 2009. Relative survival calculations were produced in SEER*Stat by the actuarial method.

RESULTS

The CRC age-adjusted incidence rate among AN men and women combined was higher than those in USW men and women (84 vs. 43/100,000; P < .05; AN:USW rate ratio [RR] = 2.0). The greatest differences between rates in AN people and USWs were for tumors in the hepatic flexure (RR = 3.1) and in the transverse (RR = 2.9) and sigmoid (RR = 2.5) regions of the colon. Rectal cancer rates among AN people were significantly higher than rates in USWs (21 vs.12/100,000). Five-year relative survival proportions by stage at diagnosis indicate that the CRC 5-year relative survival was similar in AN people and USWs for the period 2004 through 2009.

CONCLUSIONS

The high rate of CRC in AN people emphasizes the need for screening programs and interventions to reduce known modifiable risks. Research in methods to promote healthy behaviors among AN people is greatly needed.

First isolation and characterization of genomic SSR markers for the giant red shrimp Aristaeomorpha foliacea (Risso, 1827)

Fourteen microsatellite markers were isolated from the giant red shrimp Aristaeomorpha foliacea (Risso, 1827) using the FIASCO protocol (fast isolation by AFLP of sequences containing repeats). Polymorphism was assessed in 30 individuals from two localities of the western Mediterranean basin (N = 20 from Sardinia and N = 10 from Sicily); nine loci showed polymorphism with 2 to 19 alleles per locus (average: 8.9). Polymorphic information content ranged from 0.36 to 0.91, and the observed and expected heterozygosities ranged from 0.50 to 0.97 and from 0.47 to 0.93, respectively. Two loci showed significant deviation from Hardy-Weinberg equilibrium, and evidence of linkage disequilibrium was found for only one locus pair. These loci are the first to be characterized in A. foliacea and could be effective tools for the investigation of genetic diversity, population structure, and demographic connectivity, useful information for the management of this important commercial resource.

Genetic analysis of leaf rust resistance genes and associated markers in the durable resistant wheat cultivar Sinvalocho MA

In the cross of the durable leaf rust resistant wheat Sinvalocho MA and the susceptible line Gama6, four specific genes were identified: the seedling resistance gene Lr3, the adult plant resistance (APR) genes LrSV1 and LrSV2 coming from Sinvalocho MA, and the seedling resistance gene LrG6 coming from Gama6. Lr3 was previously mapped on 6BL in the same cross. LrSV1 was mapped on chromosome 2DS where resistance genes Lr22a and Lr22b have been reported. Results from rust reaction have shown that LrSV1 from Sinvalocho is not the same allele as Lr22b and an allelism test with Lr22a showed that they could be alleles or closely linked genes. LrSV1 was mapped in an 8.5-cM interval delimited by markers gwm296 distal and gwm261 proximal. Adult gene LrSV2 was mapped on chromosome 3BS, cosegregating with gwm533 in a 7.2-cM interval encompassed by markers gwm389 and gwm493, where other disease resistance genes are located, such as seedling gene Lr27 for leaf rust, Sr2 for stem rust, QTL Qfhs.ndsu-3BS for resistance to Fusarium gramineum and wheat powdery mildew resistance. The gene LrG6 was mapped on chromosome 2BL, with the closest marker gwm382 at 0.6 cM. Lines carrying LrSV1, LrSV2 and LrG6 tested under field natural infection conditions, showed low disease infection type and severity, suggesting that this kind of resistance can be explained by additive effects of APR and seedling resistance genes. The identification of new sources of resistance from South American land races and old varieties, supported by modern DNA technology, contributes to sustainability of agriculture through plant breeding.

Diagnostic accuracy of tests for Helicobacter pylori in an Alaska Native population

AIM: To evaluate the accuracy of two non-invasive tests in a population of Alaska Native persons. High rates of Helicobacter pylori (H. pylori) infection, H. pylori treatment failure, and gastric cancer in this population necessitate documentation of infection status at multiple time points over a patient’s life.

METHODS: In 280 patients undergoing endoscopy, H. pylori was diagnosed by culture, histology, rapid urease test, ¹³C urea breath test (UBT), and immunoglobulin G antibodies to H. pylori in serum. The performances of ¹³C-UBT and antibody test were compared to a gold standard defined by a positive H. pylori test by culture or, in case of a negative culture result, by positive histology and a positive rapid urease test.

RESULTS: The sensitivity and specificity of the ¹³C-UBT were 93% and 88%, respectively, relative to the gold standard. The antibody test had an equivalent sensitivity of 93% with a reduced specificity of 68%. The false positive results for the antibody test were associated with previous treatment for an H. pylori infection [relative risk (RR) = 2.8]. High levels of antibodies to H. pylori were associated with chronic gastritis and male gender, while high scores in the ¹³C-UBT test were associated with older age and with the H. pylori bacteria load on histological examination (RR = 4.4).

CONCLUSION: The ¹³C-UBT outperformed the antibody test for H. pylori and could be used when a non-invasive test is clinically necessary to document treatment outcome or when monitoring for reinfection.

Efficacy of four different moxifloxacin-based triple therapies for first-line H. pylori treatment

Moxifloxacin has been used in the first-line treatment of Helicobacter pylori infection. The optimal dosage and duration have not been assessed.

AIM

To evaluate the effectiveness of moxifloxacin, amoxicillin and esomeprazole in four regimens, in previously untreated patients infected by H. pylori.

METHODS AND PATIENTS

Patients were randomly assigned to: esomeprazole 20 mg b.i.d., amoxicillin 1g b.i.d., and one of each of the four following dosages of moxifloxacin: moxifloxacin 400 mg b.i.d. for 10 days (EAM800x10), moxifloxacin 400 mg b.i.d. for 7 days (EAM800x7), moxifloxacin 400 mg b.i.d. for 5 days (EAM800x5), moxifloxacin 400 mg o.i.d. for 10 days (EAM400x10). Eradication was assessed by the Urea Breath Test (UBT) 2 months following the end of therapy.

RESULTS

Ninety-four, 102, 92 and 105 patients were recruited in EAM800x10, EAM800x7, EAM800x5, and EAM400x10 respectively. The eradication rate was for Intention-To-Treat (ITT) and Per Protocol (PP) analyses: EAM800x10 group ITT: 90.4%, PP: 94.4%; EAM800x7 group ITT: 80.3%, PP: 86.3%; EAM800x5 group ITT: 71.4%, PP: 75.2%; EAM400x10 group ITT: 80.0%, PP 84.8%. A statistically significant difference was reached between EAM800x10 vs. EAM800x7 (ITT and PP: P<0.05), and between EAM800x10 vs. EAM800x5 (ITT and PP: P<0.01) and vs. EAM400x10 (ITT: P<0.05; PP: P<0.04). Thirty patients treated unsuccessfully with EAM800x5 and EAM400x10 were re-treated with EAM800x10 with an eradication rate of 86.7% (ITT) and 92.2% (PP). Nineteen patients with positive UBT after EAM800x10 and EAM800x7 underwent a second-line rifabutin-based therapy with an eradication rate of 84.2% (ITT and PP).

CONCLUSION

A triple therapy with 800 mg of moxifloxacin a day for 10 days is more effective than the same treatment for 5 or 7 days and a treatment with 400mg of moxifloxacin a day for 10 days for the first-line eradication of H. pylori infection. The high cost of moxifloxacin-based treatment however, may limit its wide use as first-line treatment of H. pylori infection.

[Sildenafil and nitric oxide inhalation in neonatal pulmonary hypertension. Three case reports]

INTRODUCTION

Neonatal persistent pulmonary hypertension (NPPH) is characterised by persistently high pulmonary vascular resistance (PVR). Sildenafil has recently been suggested as an alternative to or an associative therapy with inhaled nitric oxide (iNO) to reduce mortality (10-40%) and morbidity (major neurologic disabilities among surviving newborns remains approximately 15-60%). The objective is to report three cases of NPPH treated with sildenafil in association of iNO.

CASE REPORTS

Echocardiography examination of three newborn babies with respiratory distress syndrome and a gestational age between 33 and 39 weeks revealed pulmonary hypertension following early onset sepsis. Synchronized intermittent mandatory ventilation (SIMV) and surfactant therapy had no effect on oxygen saturation (SatO2) and oxygen alveolar-arterial difference (AaDO2). High frequency oscillatory ventilation (HFOV) and iNO therapy proved to be equally ineffective. Oral sildenafil was administered at 2 mg/Kg/6 hs. A gradual but significant improvement in oxygenation was achieved and a reduction in AaDO2 along with oxygenation index (OI) and pulmonary arterial pressure (PAP) was observed in the first 6-10 hrs after administration of sildenafil. The therapy was maintained for 36-48 hrs with total success.

CONCLUSIONS

A beneficial pulmonary vasodilator effect was obtained in treating NPPH with sildenafil where conventional methods had failed. Sildenafil used in association with iNO reduces the duration of treatment, the quantity of iNO normally required and the associated toxic effects. A multicentric, randomized trial could be useful in demonstrating the safety, efficacy, doses and forms of administration of sildenafil.

Alaska sentinel surveillance for antimicrobial resistance in Helicobacter pylori isolates from Alaska native persons, 1999-2003

BACKGROUND

Previous studies in Alaska have demonstrated elevated proportions of antimicrobial resistance among Helicobacter pylori isolates.

MATERIALS AND METHODS

We analyzed H. pylori data from the Centers for Disease Control and Prevention (CDC)'s sentinel surveillance in Alaska from July 1999 to June 2003 to determine the proportion of culture-positive biopsies from Alaska Native persons undergoing routine upper-endoscopy, and the susceptibility of H. pylori isolates to metronidazole [minimum inhibitory concentration (MIC) of > 8 g metronidazole/mL), clarithromycin (MIC > or = 1), tetracycline (MIC > or = 2) and amoxicillin (MIC > or = 1)] using agar dilution.

RESULTS

Nine-hundred sixty-four biopsy specimens were obtained from 687 participants; 352 (51%) patients tested culture positive. Mean age of both culture-positive and culture-negative patients was 51 years. Metronidazole resistance was demonstrated in isolates from 155 (44%) persons, clarithromycin resistance from 108 (31%) persons, amoxicillin resistance from 8 (2%) persons, and 0 for tetracycline resistance. Metronidazole and clarithromycin resistance varied by geographic region. Female patients were more likely than male subjects to show metronidazole resistance (p < .01) and clarithromycin resistance (p = .05).

CONCLUSIONS

Resistance to metronidazole and clarithromycin is more common among H. pylori isolates from Alaska Native persons when compared with those from elsewhere in the USA.

Dynamics of Helicobacter pylori-specific immunoglobulin G for 2 years after successful eradication of Helicobacter pylori infection in an American Indian and Alaska Native population

Helicobacter pylori antibodies were measured over 24 months in American Indian and Alaska Native persons who cleared their infections. Two months after treatment, 82% of H. pylori-negative persons remained seropositive. While there were declines in H. pylori antibodies for 12 months, after 24 months 71% of persons remained seropositive.

Reinfection after successful eradication of Helicobacter pylori: a 2-year prospective study in Alaska Natives

BACKGROUND

Limited information exists regarding risk factors for reinfection after cure of Helicobacter pylori infection.

AIM

To determine the 2-year reinfection rate of H. pylori in a cohort of urban Alaska Natives.

METHODS

Participants over 18 years of age undergoing oesophagogastroduodenoscopy had (13)C urea breath test, culture, CLOtest and histology performed. Those diagnosed with H. pylori who tested urea breath test-negative at 8 weeks after treatment were followed prospectively at 4 months, 6 months, 1 year and 2 years. Subjects experiencing H. pylori reinfection as defined by a positive urea breath test were compared with those who did not become reinfected using univariable and multivariable analysis. Risk of reinfection over time was estimated by the Kaplan-Meier method.

RESULTS

Helicobacter pylori reinfection occurred in 14 of 98 subjects successfully treated. The cumulative reinfection rate was 5.1% (95% CI: 0.7%-9.5%) at 4 months, 7.2% (2.0-12.3%) at 6 months, 10.3% (4.2-16.3%) at 1-year and 14.5% (7.5-21.6%) at 2 years. In multivariable analysis, a history of previous peptic ulcer disease or presence of ulcer at time of study oesophagogastroduodenoscopy were the only risk factors associated with reinfection (P = 0.01).

CONCLUSIONS

Based on the findings from our study, subjects with a history of or current peptic ulcer disease should be followed, after successful treatment for H. pylori, with periodic urea breath test to detect reinfection, as reinfection would put them at high risk for ulcer recurrence.

Occurrence of esophageal and gastric cancer in Alaska Natives, 1969-2003

BACKGROUND

Early reports of esophageal and gastric cancer in American Indians/Alaska Natives documented high rates.

METHODS

Esophageal and gastric cancers in Alaska Natives were reviewed for 1969-2003 using the Alaska Native Tumor Registry database. Alaska Native incidence rates were age-adjusted and compared to rates of several US populations.

RESULTS

The incidence of esophageal and gastric cancer has remained relatively stable during the 35-year period. Gastric cancer is higher than that seen in US Whites, Blacks and American Indians of New Mexico and similar US Asian/Pacific Islanders. Esophageal cancer incidence is higher than US Whites, Asian/Pacific Islanders and American Indians of New Mexico but similar to US Blacks.

CONCLUSION

The rates of esophageal and gastric cancer in the Alaska Native population have remained high over 35 years. While the rate of gastric cancer has declined among US Whites, a similar decline has not been seen in Alaska Natives.

Physical and genetic mapping of amplified fragment length polymorphisms and the leaf rust resistance Lr3 gene on chromosome 6BL of wheat

The Argentinian wheat cultivar Sinvalocho MA carries the Lr3 gene for leaf rust resistance on distal chromosome 6BL. In this cultivar, 33 spontaneous susceptible lines were isolated and cytogenetically characterized by C-banding. The analysis revealed deletions on chromosome 6BL in most lines. One line was nulli-6B, two lines were ditelo 6BS, two, three, and ten lines had long terminal deletions of 40, 30, and 20%, respectively, three lines showed very small terminal deletions, and one line had an intercalary deletion of 11%. Physical mapping of 55 amplified fragment length polymorphism (AFLP) markers detected differences between deletions and led to the division of 6BL into seven bins delimited by deletion breakpoints. The most distal bin, with a length smaller than 5% of 6BL, contained 22 AFLP markers and the Lr3 gene. Polymorphism for nine AFLPs between Sinvalocho MA and the rust leaf susceptible cultivar Gamma 6 was used to construct a linkage map of Lr3. This gene is at a genetic distance of 0.9 cM from a group of seven closely linked AFLPs. The location of the gene in a high recombinogenic region indicated a physical distance of approximately 1 Mb to the markers.

Guidelines for the management of head injuries in remote and rural Alaska

Numerous recommendations on the initial evaluation and treatment of the head injured patient have been proposed over the last several years. Most assume there is readily available access to computed tomography and neurosurgical specialists. Many clinicians in Alaska must evaluate and begin treatment of head injured patients in circumstances quite different from this. Vast distances, severe weather and limited medical evacuation capability are factors that come into play while caring for these patients. The current medicolegal climate also contributes to clinician anxiety over missing rare but potentially serious injuries. These guidelines developed by Alaska clinicians from multiple specialties are meant to assist clinicians dealing with this very common problem and represent a reasonable approach to these patients in remote and rural Alaska.

The relationship among previous antimicrobial use, antimicrobial resistance, and treatment outcomes for Helicobacter pylori infections

BACKGROUND

The relationship between previous antimicrobial treatments and infection with drug-resistant Helicobacter pylori is unknown.

OBJECTIVES

To determine whether previous use of antimicrobial agents predicts subsequent antibiotic resistance of H. pylori and whether resistance affects treatment outcome.

DESIGN

Retrospective cohort analysis of adults recruited sequentially from a clinical practice.

SETTING

A referral hospital in Anchorage, Alaska.

PATIENTS

125 adults infected with H. pylori.

MEASUREMENTS

Medical records were reviewed for antimicrobial agents prescribed in the 10 years before diagnosis with H. pylori infection. Antimicrobial susceptibility of H. pylori isolates obtained from endoscopic gastric biopsy was determined by using agar dilution. Cure was determined by using the urea breath test 2 months after antimicrobial treatment.

RESULTS

Among the 125 patients, 37 (30%) were found to have H. pylori isolates resistant to clarithromycin and 83 (66%) were found to have H. pylori isolates resistant to metronidazole. Resistance to clarithromycin was associated with previous use of any macrolide antibiotic (P < 0.001), and resistance to metronidazole was associated with previous use of metronidazole (P < 0.001). The odds of isolates being resistant to clarithromycin increased in relation to the number of courses of macrolides received (P < 0.001). Among 53 persons treated with clarithromycin-based regimens, treatment failed in 77% of those carrying clarithromycin-resistant H. pylori (10 of 13) and 13% of those with clarithromycin-susceptible strains (5 of 40) (relative risk, 6.2 [95% CI, 1.9 to 37.1]; P < 0.001).

CONCLUSIONS

Previous use of macrolides and metronidazole is associated with H. pylori resistant to these antimicrobial agents. Clarithromycin resistance is associated with a greater risk for failure with clarithromycin-based treatments.

Cloning and mapping of genes involved in wheat-leaf rust interaction through gene-expression analysis using chromosome-deleted near-isogenic wheat lines

Molecular markers on wheat chromosome 6BL were isolated using mRNA differential display. Two wheat isolines inoculated with Puccinia recondita were analysed: Sinvalocho MA line carrying the Lr3 gene for leaf rust resistance on distal chromosome 6BL, and a rust-susceptible derivative of the Sinvalocho MA line with a deletion at the distal end of chromosome 6BL. Comparison of mRNA fingerprinting profiles, obtained from control and rust-inoculated plants, let to the isolation of 34 differentially displayed cDNAs. All these genes, except TaRr16, were up-regulated in the rust-inoculated resistant line. TaRr16 has constitutive expression in the rust-resistant line while no expression was detected in the rust-susceptible line. A number of those cDNAs revealed homology to genes previously identified in other plant-pathogen interactions. Two out of the 34 cDNAs, mapped in the distal part of chromosome 6BL and TaRr16, was genetically linked to the Lr3 gene. DNA sequence differences and differential expression between non-allelic copies of TaRr16, are also reported.

Screening for hepatocellular carcinoma in Alaska natives infected with chronic hepatitis B: a 16-year population-based study

The benefits of screening hepatitis B surface antigen (HBsAg)-positive carriers for hepatocellular carcinoma (HCC) in terms of long-term survival have not been established. We conducted a prospective 16-year, population-based cohort study to determine the impact of screening for HCC in 1,487 HBsAg-positive Alaska native carriers with alpha-fetoprotein (AFP) determinations every 6 months. Men and nonpregnant women with an elevated AFP level were evaluated for the presence of HCC by ultrasound (US) examination. The long-term survival rate for patients whose HCC was detected by the screening program was compared with a historical control group of Alaska native patients with HCC from the same population who were clinically diagnosed with HCC between 1969 and October 1982, through a National Cancer Institute-sponsored Cancer Registry. Between October 1982 and December 1998, 26,752 AFP determinations in HBsAg carriers were performed. One or more AFP elevations were found in 61 men and 39 nonpregnant women. HCC was diagnosed in 32 patients (24 men and 8 women). HCC tumors less than 6 cm were found in 23 patients; 22 patients had resections, and 1 patient refused a resection. Compared with 12 patients with hepatitis B virus (HBV)-related HCC diagnosed from 1969 to October 1982, before this program, the 5- and 10-year survival rate for the 32 patients with HCC were 42% (P =.008) and 30% (P =.07), respectively. Five- and 10-year tumor-free survival rates for carriers who had a normal AFP level on initial screening and subsequently developed HCC were 29% (P =.004) and 24% (P =.024), respectively. Screening of HBsAg carriers with semiannual AFP was effective in detecting most HCC tumors at a resectable stage and significantly prolonged survival rates when compared with historical controls in this population.

Abdominal pain in children: a case of acalculous cholecystitis

Acalculous cholecystitis is a rare disease in children. Most cases are associated with systemic infections or with autoimmune pathologies, but it may also occur without predisposing factors. A case observed in an otherwise healthy child is reported.

Mapping of the leaf rust resistance gene Lr3 on chromosome 6B of Sinvalocho MA wheat

The Lr3 gene for resistance to race 66 of Puccinia recondita present in hexaploid wheat cv. Sinvalocho MA was mapped on chromosome 6B, using intervarietal polymorphic RFLP loci and the Amp-B1 isozyme gene as a centromere marker. The RFLP markers were located mainly in two subregions of chromosome 6BL. Six RFLP loci clustered in the centromeric region and one other, Xmwg798, cosegregated with the Lr3 gene. C-banding analysis of the leaf rust resistant standard 'Sinvalocho MA' line and three naturally occurring susceptible lines of 'Sinvalocho MA' revealed a terminal deletion on 6BL that covered 20% of its length in one susceptible line. Because Xmwg798 was missing in this line, both Xmwg798 and Lr3 were allocated to the deleted segment. Distorted segregations were observed for the proximal markers, suggesting a selection against gametes carrying the centromeric region of 'Sinvalocho MA'.Key words: wheat, RFLP, Lr3 gene, chromosome 6B, C-banding.

[Sepsis caused by Haemophilus influenzae type B with septic arthritis in an infant]

Septic arthritis is a serious pyogenic infection that may lead to permanent orthopedic sequelae. Infants represent the most of the cases. It usually develops as a result of bacterial seeding into the capillary-rich synovium in the course of a bacteremic episode. Etiology changes according to different ages; in children after the neonatal period but younger than 24 months, Haemophilus influenzae is the most frequent causative organism. A case of sepsis due to Haemophilus influenzae type b (Hib) with septic arthritis in a patient 3 months old, is reported. The child was admitted to the hospital with a very high temperature (39 degrees C) for five days. His right wrist and ankle appeared swelling and hyperemic. He was affected by congenital cardiopathy from birth. He was not immunizated against Hib. The blood colture was positive for Hib. The leukocyte count was 21,400 cell/mm3 with 55% of polymorphonuclear cells. During the second day of recovery, the patient was transfused, because of the very low value of hemoglobin (5.2 g/dl). The child was treated with netilmycina and ceftriaxone for 15 days. The temperature fell in two days. The articular pathology resolved in nearly ten days. The case reported confirms the importance of septic arthritis as a pathology that necessarily requires an early diagnosis and treatment. The Haemophilus influenzae vaccine, is recommended especially in immunocompromised or cardiopathic subjects and before the age of 2 years.

[Forceps delivery and long term follow-up urinary incontinence]

553 patients undergoing complete urodynamic evaluation were investigated concerning mode of delivery. Forceps delivery was not associated with worsened urethral competence and significant risk of subsequent incontinence.

[Unstable bladder and Sjögren syndrome. Clinical case]

A female patient developed severe detrusor instability years after a diagnosis of Sjogren syndrome. A common etiology could be possible if an association with viral demyelinization in Sjogren patients is confirmed. Vaginal Sicca syndrome was present and responded to a topical androgen-oestriol association with definite cytologic improvement. Anticholinergics were tolerated and moderately effective. Low initial dose were slowly increased (over three months) to avoid excessive mouth dryness and avoid gastrooesophageal symptoms.

[Ultrasonographic and urodynamic evaluation in stress incontinence]

Transvaginal sonography can show partial urinary penetration in the urethra in patients with no clinical incontinence. The Fluid Bridge Test-Pressure urodynamically demonstrates the same phenomenon. We compared these two technics in women with stress urinary incontinence (SUI). 49 patients underwent urodynamic testing and transvaginal sonography; 18 had SUI, 20 were asymptomatic postoperatively (Burch procedure) and 11 were normal controls. Urodynamics consisted of filling cystometry with saline (infusion speed: ml 70/min) using transurethral Foley catheter (n degree 14 Fr), and a profilometric-pressure Bard catheter (10 Fr); micturitional cystometry; uroflowmetry; clino- and orthostatic urethral pressure profile (UPP) (extraction speed: cm 0.5-1/sec; infusion speed: cm 1.2/min); sphincteric electromyography (EMG); FBT-P with the Bard catheter only. During extraction patients were requested to cough (stress condition). If the urethra is incompetent pressure is transmitted to the water column connected to the pressure transducer, and a "spike" is observed. A competent urethra shows little pressure variation. Ultrasound (US) equipment consisted in a General Electric (RT 3600) sonograph with an electronic transvaginal probe (7.5 MHz) inserted in a gel-lubricated condom. The probe was positioned in the vaginal vestibule in direct proximity to the urethra. Axial and coronal scannings were performed. Echo-imagings were submitted to "post-processing" on US recording equipment. Fluid penetration in the urethra was evident if iperchogenic "turbulence" was observed on playback of the dynamic sonogram on a videocassette recorder (VCR) connected to the sonograph. The SUI group shows leakage of water under stress without detrusorial activity and dynamic UPP with reduced transmission of abdominal pressure on the urethra.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of methods for the diagnosis of urinary obstruction in women]

The International Continence Society does not offer secure guidelines for the diagnosis of micturitional obstruction. The problem has been extensively addressed in relation to male voiding difficulties. Little is known on the subject in female patients. Two criteria for the diagnosis of obstructed micturition are in clinical use. The Sussett formula divides the maximum micturitional pressure by the square of the corresponding maximum urinary flow rate. Two cutoffs, corresponding approximately to the 90th and 95th centiles can be used (0.15, and 0.5). A more complex graphic nomogram developed by Schafer plots maximum flow versus maximum detrusor pressure, identifying obstruction and detrusor dysfunction simultaneously according to the author. We feel that these methods, extensively tested on a male population, can both be used on a female population. We noticed that in some instances the results were different. 469 women referred for micturitional disturbances underwent pressure/flow studies. 62 (13.2%) were obstructed according to the Schafer nomogram, 103 (21.9%) and 31 (6.6%) respectively using the Sussett mathematical formula using two different cutoffs (0.15 and 0.5). The two methods identify the same patients only if micturitional pressures are normal (40 to 60 cmH2O) to high (over 60 cmH2O) and the Sussett formula is used with a higher (95th centile) cutoff. This means that both methods are clearly insufficient in the diagnosis of obstruction if detrusor function is impaired. This can happen in case of chronic retention due to detrusor failure after a long-standing obstruction or for primary failures due to central nervous system lesions. Extreme care should be exercised if pressure-flow studies indicate obstruction at low micturitional pressures.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute urinary obstruction in pregnancy]

Five cases of acute urinary obstruction during pregnancy are presented. A complete urodynamic workup, including pressure-flow studies showed high micturitional pressures with little or no flow, with at least 60% residual urine. Filling cystometry, urethral profilometry (static and dynamic), pelvic electromyography were normal. Two cases were due to uterine pelvic incarceration. One of these cases happened very early during pregnancy, because of extensive fibroids. Any cause of abnormal uterine enlargement can lead to early obstruction. Three cases were associated with paraurethral abscess (skenitis in 2 cases, urethral diverticulum in 1). Manual reduction in case of pelvic incarceration or surgical draining and antibiotic therapy in case of abscess were effective in all cases. Immediate catheterization is possible and indicated as soon as urinary obstruction is diagnosed. This prevents neuromuscular dysfunction due to excessive bladder distention. The transurethral catheter might work as a stent, and periurethral surgical drainage is probably safer with a catheter in place. Suprapubic catheterization is probably less useful in this respect. An indwelling catheter removes any urgency in treatment. Voiding difficulties can persist for some days after surgical treatment. Urodynamic testing performed in all indicated acute micturitional obstruction. Anyway, it added little to the clinical understanding of the problem, which was obvious, and the Authors feel that extensive urodynamic testing should be limited to cases presenting with a complex preexisting dysfunction or performed after treatment if symptoms do not disappear completely. All clinically doubtful cases should likewise be investigated. If periurethral abscess or incarceration are evident, simple evaluation of residual urine percentage should be sufficient in establishing the diagnosis.