Carbapenemase genes in clinical and environmental isolates of Acinetobacter spp. from Quito, Ecuador

Carbapenem-resistant Acinetobacter spp. is associated with nosocomial infections in intensive care unit patients, resulting in high mortality. Although Acinetobacter spp. represent a serious public health problem worldwide, there are a few studies related to the presence of carbapenemases in health care facilities and other environmental settings in Ecuador. The main aim of this study was to characterize the carbapenem-resistant Acinetobacter spp. isolates obtained from four hospitals (52) and from five rivers (27) close to Quito. We used the disc diffusion and EDTA sinergy tests to determine the antimicrobial susceptibility and the production of metallo β-lactamases, respectively. We carried out a multiplex PCR of gyrB gene and the sequencing of partial rpoB gene to bacterial species identification. We performed molecular screening of nine carbapenem-resistant genes (blaSPM, blaSIM, blaGIM, blaGES, blaOXA-23, blaOXA-24, blaOXA-51, blaOXA-58, and blaOXA-143) by multiplex PCR, followed by identification using sequencing of blaOXA genes. Our findings showed that carbapenem-resistant A. baumannii were the main species found in health care facilities and rivers. Most of the clinical isolates came from respiratory tract samples and harbored blaOXA-23, blaOXA-366, blaOXA-72, blaOXA-65, blaOXA-70, and blaOXA-143-like genes. The river isolates harbored only the blaOXA-51 and probably blaOXA-259 genes. We concluded that the most predominant type of carbapenem genes among isolates were both blaOXA-23 and blaOXA-65 among A. baumannii clinical isolates.

Development and First Clinical Use of an Extracorporeal Artificial Multiorgan System in Acute-on-Chronic Liver Failure Patients

Multiple organ failure (MOF) is a common and deadly condition. Patients with liver cirrhosis with acute-on-chronic liver failure (AOCLF) are particularly susceptible. Excess fluid accumulation in tissues makes routine hemodialysis generally ineffective because of cardiovascular instability. Patients with three or more organ failures face a mortality rate of more than 90%. Many cannot survive liver transplantation. Extracorporeal support systems like MARS (Baxter, Deerfield, IL) and Prometheus (Bad Homburg, Germany) have shown promise but fall short in bridging patients to transplantation. A novel Artificial Multi-organ Replacement System (AMOR) was developed at the University of Washington Medical Center. AMOR removes protein-bound toxins through a combination of albumin dialysis, a charcoal sorbent column, and a novel rinsing method to prevent sorbent column saturation. It removes excess fluid through hemodialysis. Ten AOCLF patients with over three organ failures were treated by the AMOR system. All patients showed significant clinical improvement. Fifty percent of the cohort received liver transplants or recovered liver function. AMOR was successful in removing large amounts of excess body fluid, which regular hemodialysis could not. AMOR is cost-effective and user-friendly. It removes excess fluid, supporting the other vital organs such as liver, kidneys, lungs, and heart. This pilot study's results encourage further exploration of AMOR for treating MOF patients.

A retrospective cohort study of socioeconomic deprivation and post-liver transplant survival in adults

The Area Deprivation Index is a granular measure of neighborhood socioeconomic deprivation. The relationship between neighborhood socioeconomic deprivation and recipient survival following liver transplantation (LT) is unclear. To investigate this, the authors performed a retrospective cohort study of adults who underwent LT at the University of Washington Medical Center from January 1, 2004, to December 31, 2020. The primary exposure was a degree of neighborhood socioeconomic deprivation as determined by the Area Deprivation Index score. The primary outcome was posttransplant recipient mortality. In a multivariable Cox proportional analysis, LT recipients from high-deprivation areas had a higher risk of mortality than those from low-deprivation areas (HR: 1.81; 95% CI: 1.03-3.18, p =0.04). Notably, the difference in mortality between area deprivation groups did not become statistically significant until 6 years after transplantation. In summary, LT recipients experiencing high socioeconomic deprivation tended to have worse posttransplant survival. Further research is needed to elucidate the extent to which neighborhood socioeconomic deprivation contributes to mortality risk and identify effective measures to improve survival in more socioeconomically disadvantaged LT recipients.

The First Collective Examination of Immunosuppressive Practices Among American Intestinal Transplant Centers

Background

Unlike other solid organs, no standardized treatment algorithms exist for intestinal transplantation (ITx). We established a consortium of American ITx centers to evaluate current practices.

Methods

All American centers performing ITx during the past 3 y were invited to participate. As a consortium, we generated questions to evaluate and collect data from each institution. The data were compiled and analyzed.

Results

Ten centers participated, performing 211 ITx during the past 3 y (range, 3-46; mean 21.1). Induction regimens varied widely. Thymoglobulin was the most common, used in the plurality of patients (85/211; 40.3%), but there was no consensus regimen. Similarly, regimens for the treatment of acute cellular rejection, antibody-mediated rejection, and graft-versus-host disease varied significantly between centers. We also evaluated differences in maintenance immunosuppression protocols, desensitization regimens, mammalian target of rapamycin use, antimetabolite use, and posttransplantation surveillance practices. Maintenance tacrolimus levels, stoma presence, and scoping frequency were not associated with differences in rejection events. Definitive association between treatments and outcomes, including graft and patient survival, was not the intention of this initial collaboration and is prevented by the lack of patient-level data and the presence of confounders. However, we identified trends regarding rejection episodes after various induction strategies that require further investigation in our subsequent collaborations.

Conclusions

This initial collaboration reveals the extreme heterogeneity of practices among American ITx centers. Future collaboration will explore patient-level data, stratified by age and transplant type (isolated intestine versus multivisceral), to explore the association between treatment regimens and outcomes.

Identification of the Genotypes Circulating in the Ecuadorian Population Infected with the Hepatitis C Virus (HCV)

INTRODUCTION

The hepatitis C virus (HCV) is responsible for 1.5 million new infections, and around 290 thousand deaths worldwide. 15 to 30% of the patients that go into a chronic phase of the disease will develop cirrhosis or hepatocellular carcinoma within 20 years and is the leading etiology for liver transplantation. HCV genetic characteristics display a remarkable genetic diversity, which divides HCV into 8 genotypes and 67 subgenotypes; the treatment and probability of chronic HCV depend on these genotypes and subgenotypes. In Ecuador, there is no available information regarding HCV genotypes and subgenotypes; therefore, this study aims to provide an overview of the main genotypes circulating in Ecuador.

METHODS

In a cross-sectional and descriptive study using the Ecuadorian Ministry of Health (MSP) registry of patients already diagnosed with Hepatitis C (HCV) between 2017 and 2019. From 51 patients identified by health ministry, blood samples from a total of 15 subjects (named HCV1 to HCV15) were collected using an appropriate venipuncture technique. Pandemic-related circumstances avoid reaching all patients identified by health ministry.

RESULTS

After the amplification of 11 samples from patients living in the Ecuadorian territory, the genotypes of HCV obtained were distributed as follows: 6 samples corresponding to subgenotype 2b (54.5%), 2 samples corresponding to subgenotype 1a (18.2%), 2 samples corresponding to subgenotype 4d (18.2%) and 1 corresponding to sample 1b (9.1%).

CONCLUSION

These results represent the first epidemiological approach to genotype distribution in Ecuador, and it contributes to better management of patients. We emphasize the importance of the development of better strategies from the Healthcare Ministry of Ecuador (MSP) for the identification, treatment and tracking of HCV patients.

Bloodstream infections and antibiotic resistance at a regional hospital, Colombia, 2019-2021

Objectives

To assess antibiotic susceptibility of World Health Organization (WHO) priority bacteria (Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Salmonella spp., Staphylococcus aureus, and Streptococcus pneumoniae) in blood cultures at the Orinoquía regional hospital in Colombia.

Methods

This was cross-sectional study using routine laboratory data for the period 2019-2021. Data on blood samples from patients suspected of a bloodstream infection were examined. We determined: the total number of blood cultures done and the proportion with culture yield; the characteristics of patients with priority bacteria; and the type of bacteria isolated and antibiotic resistance patterns.

Results

Of 25 469 blood cultures done, 1628 (6%) yielded bacteria; 774 (48%) of these bacteria were WHO priority pathogens. Most of the priority bacteria isolated (558; 72%) were gram-negative and 216 (28%) were gram-positive organisms. Most patients with priority bacteria (666; 86%) were hospitalized in wards other than the intensive care unit, 427 (55%) were male, and 321 (42%) were ≥ 60 years of age. Of the 216 gram-positive bacteria isolated, 205 (95%) were Staphylococcus aureus. Of the 558 gram-negative priority bacteria isolated, the three most common were Escherichia coli (34%), Klebsiella pneumoniae (28%), and Acinetobacter baumannii (20%). The highest resistance of Staphylococcus aureus was to oxacillin (41%). For gram-negative bacteria, resistance to antibiotics ranged from 4% (amikacin) to 72% (ampicillin).

Conclusions

Bacterial yield from blood cultures was low and could be improved. WHO priority bacteria were found in all hospital wards. This calls for rigorous infection prevention and control standards and continued surveillance of antibiotic resistance.

High level of infection prevention and control in surveyed hospitals in Colombia, 2021

Objective

This study aimed to determine the performance of infection prevention and control (IPC) programs in eight core components in level 2 and level 3 hospitals across all provinces in Colombia.

Methods

This cross-sectional study used self-assessed IPC performance data voluntarily reported by hospitals to the Ministry of Health and Social Protection during 2021. Each of the eight core components of the World Health Organization's checklist in the Infection Prevention and Control Assessment Framework contributes a maximum score of 100, and the overall IPC performance score is the sum of these component scores. IPC performance is graded according to the overall score as inadequate (0-200), basic (201-400), intermediate (401-600) or advanced (601-800).

Results

Of the 441 level 2 and level 3 hospitals, 267 (61%) reported their IPC performance. The median (interquartile range [IQR]) overall IPC score was 672 (IQR: 578-715). Of the 267 hospitals reporting, 187 (70%) achieved an advanced level of IPC. The median overall IPC score was significantly higher in private hospitals (690, IQR: 598-725) than in public hospitals (629, IQR: 538-683) (P < 0.001). Among the core components, scores were highest for the category assessing IPC guidelines (median score: 97.5) and lowest for the category assessing workload, staffing and bed occupancy (median score: 70). Median overall IPC scores varied across the provinces (P < 0.001).

Conclusions

This countrywide assessment showed that 70% of surveyed hospitals achieved a self-reported advanced level of IPC performance, which reflects progress in building health system resilience. Since only 61% of eligible hospitals participated, an important next step is to ensure the participation of all hospitals in future assessments.

Battle royale: Immune response on biofilms – host-pathogen interactions

The research interest of the scientific community in biofilm-forming microorganisms is growing due to the problems caused by their infections affecting humans and animals, mainly because of the difficulty of the host immune system in eradicating these microbial complex communities and the increasing antimicrobial resistance rates worldwide. This review describes the virulence factors and their interaction with the microbial communities of four well-known and highly biofilm-forming pathogens, more exactly, Pseudomonas aeruginosa, Escherichia coli, Staphylococcus spp., and Candida spp. The innate and adaptive immune responses caused by the infection with these microorganisms and their evasion to the host immune system by biofilm formation are discussed in the present work. The relevance of the differences in the expression of certain virulence factors and the immune response in biofilm-associated infections when compared to planktonic infections is usually described as the biofilm architecture protects the pathogen and alters the host immune responses, here we extensively discussed these mechanisms.

Antioxidant, anti-tyrosinase, and anti-angiogenic activities of dragon fruit (Hylocereus spp.)

The potential health benefits of native and exotic fruits have been the subject of many recent studies in the Philippines as fruits are chief sources of biologically active substances such as polyphenols, carotenoids, anthocyanins and flavonoids. Dragon fruit (Hylocereus spp.), an exotic fruit originating from South America, has become increasingly popular in the Philippines these past few years. Relatively new to the country, its full health benefits are yet to be discovered. In this study, the anti-tyrosinase and antioxidant activities of the methanolic and aqueous extracts of the flesh and peel of red and white dragon fruits were evaluated while the anti-angiogenic potential of the ethanolic and aqueous extracts of the flesh and peel of white dragon fruit were screened using the duck embryo chorioallantoic membrane (CAM) assay. The methanolic extract of the red dragon fruit peel showed potent inhibition against the diphenolase activity with the percentage of inhibition being significantly higher than that of Rutin at 20 mg/mL. Furthermore, it exhibited better antioxidant activity than ascorbic acid in the radical scavenging assay as well as the ability to chelate with ferrous ions and reduce the ferric ion. The observed activities may be attributed to its high total phenolic content and the observed presence of tannins. In CAM assay, treated duck embryo showed evident suppression of veins at increasing concentrations of ethanolic and aqueous extracts of the white dragon fruit flesh and the aqueous extract of the white dragon fruit peel (250 ppm to 2000 ppm), with almost no vascularization at 2000 ppm; the trends of vascularization were almost comparable to that of quercetin, a known anti-angiogenic compound. These results contribute to the increasing repertoire of potential health benefits of dragon fruit.

Identifying Liver Transplant Candidates at Risk of Wait List Removal Due to Nonadherence Using a Quality-of-Life Survey: A Competing Risk Analysis

OBJECTIVES

We investigated whether the Liver Disease Health-Related Quality of Life Short Form or the Area Deprivation Index could be used to help identify liver transplant candidates at risk of delisting due to nonadherence.

MATERIALS AND METHODS

We conducted a retrospective study of 358 adults (≥18 years old) listed for liver transplant at the University of Washington Medical Center from September 1, 2012, to August 30, 2017, who completed the Liver Disease Health-Related Quality of Life Short Form prior to listing. Wait list removal because of substance use or lack of attendance to clinical appointments was prospectively determined by a multidisciplinary transplant committee. A competing risk analysis was used to estimate risk of delisting for nonadherence.

RESULTS

Among 358 liver transplant candidates, delisting occurred in 23 patients (6.4%) for nonadherence, 205 (57.3%) for transplant, 79 (22.1%) because of death or too sick, and 51 (14.2%) for other reasons. In the multivariable competing risk analysis, Liver Disease Health-Related Quality of Life Short Form responses indicating "poor memory" (subdistribution hazard ratio: 3.53; 95% CI, 1.49-8.36; P = .004) and "poor future outlook" (subdistribution hazard ratio: 2.94; 95% CI, 1.07-8.07; P = .03) were associated with higher risk of delisting for nonadherence. Female sex (subdistribution hazard ratio: 0.31; 95% CI, 0.10-0.93; P = .04) and previous abdominal surgery (subdistribution hazard ratio: 0.36; 95% CI, 0.14-0.92; P = .03) were associated with lower risk of delisting for nonadherence. The Area Deprivation Index was not associated with wait list removal.

CONCLUSIONS

Liver Disease Health-Related Quality of Life Short Form responses indicating "poor memory" and "poor future outlook" were associated with increased risk of wait list removal due to nonadherence. Proactively identifying patients at high risk of nonadherence may help transplant programs better direct resources toward helping patients improve adherence and avoid delisting.

Impact of Portable Normothermic Blood-Based Machine Perfusion on Outcomes of Liver Transplant: The OCS Liver PROTECT Randomized Clinical Trial

Question

Can oxygenated portable normothermic perfusion of deceased donor livers for transplant improve outcomes compared with the current standard of care using ischemic cold storage?

Findings

In this multicenter randomized clinical trial of 300 recipients of liver transplants with the donor liver preserved by either normothermic perfusion or conventional ischemic cold storage, normothermic machine perfusion resulted in decreased early liver graft injury and ischemic biliary complications and greater organ utilization.

Meaning

In this study, portable normothermic oxygenated machine perfusion of donor liver grafts resulted in improved outcomes after liver transplant and in more livers being transplanted.

Importance

Ischemic cold storage (ICS) of livers for transplant is associated with serious posttransplant complications and underuse of liver allografts.

Objective

To determine whether portable normothermic machine perfusion preservation of livers obtained from deceased donors using the Organ Care System (OCS) Liver ameliorates early allograft dysfunction (EAD) and ischemic biliary complications (IBCs).

Design, Setting, and Participants

This multicenter randomized clinical trial (International Randomized Trial to Evaluate the Effectiveness of the Portable Organ Care System Liver for Preserving and Assessing Donor Livers for Transplantation) was conducted between November 2016 and October 2019 at 20 US liver transplant programs. The trial compared outcomes for 300 recipients of livers preserved using either OCS (n = 153) or ICS (n = 147). Participants were actively listed for liver transplant on the United Network of Organ Sharing national waiting list.

Interventions

Transplants were performed for recipients randomly assigned to receive donor livers preserved by either conventional ICS or the OCS Liver initiated at the donor hospital.

Main Outcomes and Measures

The primary effectiveness end point was incidence of EAD. Secondary end points included OCS Liver ex vivo assessment capability of donor allografts, extent of reperfusion syndrome, incidence of IBC at 6 and 12 months, and overall recipient survival after transplant. The primary safety end point was the number of liver graft–related severe adverse events within 30 days after transplant.

Results

Of 293 patients in the per-protocol population, the primary analysis population for effectiveness, 151 were in the OCS Liver group (mean [SD] age, 57.1 [10.3] years; 102 [67%] men), and 142 were in the ICS group (mean SD age, 58.6 [10.0] years; 100 [68%] men). The primary effectiveness end point was met by a significant decrease in EAD (27 of 150 [18%] vs 44 of 141 [31%]; P = .01). The OCS Liver preserved livers had significant reduction in histopathologic evidence of ischemia-reperfusion injury after reperfusion (eg, less moderate to severe lobular inflammation: 9 of 150 [6%] for OCS Liver vs 18 of 141 [13%] for ICS; P = .004). The OCS Liver resulted in significantly higher use of livers from donors after cardiac death (28 of 55 [51%] for the OCS Liver vs 13 of 51 [26%] for ICS; P = .007). The OCS Liver was also associated with significant reduction in incidence of IBC 6 months (1.3% vs 8.5%; P = .02) and 12 months (2.6% vs 9.9%; P = .02) after transplant.

Conclusions and Relevance

This multicenter randomized clinical trial provides the first indication, to our knowledge, that normothermic machine perfusion preservation of deceased donor livers reduces both posttransplant EAD and IBC. Use of the OCS Liver also resulted in increased use of livers from donors after cardiac death. Together these findings indicate that OCS Liver preservation is associated with superior posttransplant outcomes and increased donor liver use.

Trial Registration

ClinicalTrials.gov Identifier: NCT02522871

Impact of Donor and Recipient Clinical Characteristics and Hepatic Histology on Steatosis/Fibrosis Following Liver Transplantation

BACKGROUND

Deceased donor and recipient predictors of posttransplant steatosis/steatohepatitis and fibrosis are not well known. Our aim was to evaluate the prevalence and assess donor and recipient predictors of steatosis, steatohepatitis, and fibrosis in liver transplantation recipients.

METHODS

Using the immune tolerance network A-WISH multicenter study (NCT00135694), donor and recipient demographic and clinical features were collected. Liver biopsies were taken from the donor liver at transplant, and from recipients per protocol and for-cause (ie, abnormal transaminases and to rule out rejection) and were interpreted by a central pathologist.

RESULTS

One hundred eighty-three paired donor/recipients liver biopsies at the time of transplant and posttransplant follow-up (median time 582 d; average time to last biopsies was 704 d [SD ± 402 d]) were analyzed. Donor steatosis did not influence recipient steatosis or fibrosis. Ten of 183 recipients had steatohepatitis on the last biopsy. Recipient body mass index at the time of liver biopsy was the most influential factor associated with posttransplant steatosis. Both donor and recipient metabolic syndrome features were not associated with graft steatosis. Untreated hepatitis C viral (HCV) infection was the most influential factor associated with the development of allograft fibrosis.

CONCLUSIONS

In a large experience evaluating paired donor and recipient characteristics, recipient body mass index at the time of liver biopsy was most significantly associated with posttransplant steatosis. Untreated HCV etiology influenced graft fibrosis. Thus relative to untreated HCV, hepatic fibrosis in those with steatosis/steatohepatitis is less common though long-term follow-up is needed to determine the course of posttransplant fibrosis. Emphasis on recipient weight control is essential.

Association of Donor and Recipient Cytomegalovirus Serostatus on Graft and Patient Survival in Liver Transplant Recipients

Among solid organ transplant recipients, donor cytomegalovirus (CMV) seropositive (D+) and recipient seronegative (R-) status are associated with an increased risk of graft loss and mortality after kidney or lung transplantation. Whether a similar relationship exists among liver transplant recipients (LTR) is unknown. We assessed graft loss and mortality among adult LTRs from January 1, 2010, to March 14, 2020, in the Organ Procurement and Transplantation Network database. We used multivariable mixed Cox proportional hazards regression to analyze the association of donor and recipient CMV serostatus group with graft loss and mortality, with donor seronegative (D-) and recipient seronegative (R-) as the reference group. Among 54,078 LTRs, the proportion of D-R-, D- and recipient seropositive (R+), D+R-, and D+R+ was 13.4%, 22.5%, 22%, and 42%, respectively. By unadjusted Kaplan-Meier survival curve estimates, survival by the end of follow-up was 73.3%, 73.5%, 70.1%, and 69.7%, among the D-R-, D-R+, D+R-, and D+R+ groups, respectively. By multivariable Cox regression, the CMV D+R- serogroup, but not other serogroups, was independently associated with increased risks of graft loss (adjusted hazard ratio [aHR], 1.13; 95% confidence interval [CI], 1.05-1.22) and mortality (aHR, 1.13; 95% CI, 1.05-1.22). The magnitude of the association of the CMV D+R- serostatus group with mortality was similar when the Cox regression analysis was restricted to the first year after transplant and beyond the first year after transplant: aHR, 1.13 (95% CI, 1.01-1.27) and aHR, 1.13 (95% CI, 1.02-1.25), respectively. Even in an era of CMV preventive strategies, CMV D+R- serogroup status remains independently associated with increased graft loss and mortality in adult LTRs. Factors in addition to direct CMV-associated short-term mortality are likely, and studies to define the underlying mechanism(s) are warranted.

Adapting for the COVID-19 pandemic in Ecuador, a characterization of hospital strategies and patients

The World Health Organization (WHO) declared coronavirus disease-2019 (COVID-19) a global pandemic on 11 March 2020. In Ecuador, the first case of COVID-19 was recorded on 29 February 2020. Despite efforts to control its spread, SARS-CoV-2 overran the Ecuadorian public health system, which became one of the most affected in Latin America on 24 April 2020. The Hospital General del Sur de Quito (HGSQ) had to transition from a general to a specific COVID-19 health center in a short period of time to fulfill the health demand from patients with respiratory afflictions. Here, we summarized the implementations applied in the HGSQ to become a COVID-19 exclusive hospital, including the rearrangement of hospital rooms and a triage strategy based on a severity score calculated through an artificial intelligence (AI)-assisted chest computed tomography (CT). Moreover, we present clinical, epidemiological, and laboratory data from 75 laboratory tested COVID-19 patients, which represent the first outbreak of Quito city. The majority of patients were male with a median age of 50 years. We found differences in laboratory parameters between intensive care unit (ICU) and non-ICU cases considering C-reactive protein, lactate dehydrogenase, and lymphocytes. Sensitivity and specificity of the AI-assisted chest CT were 21.4% and 66.7%, respectively, when considering a score >70%; regardless, this system became a cornerstone of hospital triage due to the lack of RT-PCR testing and timely results. If health workers act as vectors of SARS-CoV-2 at their domiciles, they can seed outbreaks that might put 1,879,047 people at risk of infection within 15 km around the hospital. Despite our limited sample size, the information presented can be used as a local example that might aid future responses in low and middle-income countries facing respiratory transmitted epidemics.

Incidence, clinical patterns, and risk factors of postpartum uterine diseases in dairy cows from high-altitude tropical herds

The cow's uterus sustains bacterial contamination and active inflammation after calving as part of the normal physiological process of uterine involution. Although the definition, incidence, and risk factors for postpartum uterine diseases (PUD) have been documented in annual calving systems with high-producing cows on total mixed ration, the literature contains little information for other production systems. The objective of this study was to quantify the incidence risk and factors associated with metritis, clinical endometritis, and cytological endometritis in high-altitude tropical dairy herds in a pasture-based system. A total of 248 cows from 5 commercial dairy herds in northern Antioquia, Colombia, were enrolled in this prospective observational longitudinal cohort study. Data collection and PUD diagnosis were performed at d 0, 3, 10, 17, 24, 31, 38, 45, and 52 (±1) after parturition. Between 60 and 70 d, cows were systematically enrolled in a synchronization protocol, and herds were visited monthly for pregnancy diagnosis until 180 ±15 d. The multivariable logistic regression model of variables associated with PUD occurrence included (a) parity, season of calving, transition diet, and body condition score at calving; (b) blood calcium, phosphorus, and magnesium concentrations, and milk urea nitrogen, β-hydroxybutyrate and fat-to-protein ratio; and (c) dystocia, retained placenta, and delayed uterine involution. The incidences of puerperal metritis, clinical metritis (MET), clinical endometritis (CE), and cytological endometritis (CYTO) were 2.8, 25, 29, and 26%, respectively. Retained placenta and dystocia were associated with MET, and MET was associated with CE. Low blood calcium concentration at calving was associated with CYTO. Overall, 51.2% of the cows suffered at least 1 category of PUD during the first 60 d postpartum (DPP). However, cows also suffered from different consecutive clinical events of PUD (MET, CE, and CYTO) during the follow-up period (0 to 180 ±15 DPP). These events could be grouped into 4 types (which were referred to as "clinical patterns") based on interactions between MET, CE, and CYTO.

Cycle Threshold Values in the Context of Multiple RT-PCR Testing for SARS-CoV-2

Purpose

Discharge or follow up of confirmed coronavirus disease 2019 (COVID-19) cases depend on accurate interpretation of RT-PCR. Currently, positive/negative interpretations are based on amplification instead of quantification of cycle threshold (Ct) values, which could be used as proxies of patient infectiousness. Here, we measured Ct values in hospitalized confirmed COVID-19 patients at different times and its implications in diagnosis and follow up.

Patients and Methods

Observational study between March 17th-May 12th, 2020 using multiple RT-PCR testing. A cohort of 118 Hispanic hospitalized patients with confirmed COVID-19 diagnosis in a reference hospital in Quito, Ecuador. Multiple RT-PCR tests were performed using deep nasal swab samples and the assessment of SARS-CoV-2 genes N, RdRP, and E.

Results

Patients’ median age was of 49 years (range: 24–91) with a male majority (62.7%). We found increasing levels of Ct values in time, with a mean Ct value of 29.13 (n = 61, standard deviation (sd) = 5.55) for the first test and 34.38 (n = 60, sd = 4), 35.52 (n = 20, sd = 2.85), and 36.12 (n = 6, sd = 3.28), for the second, third, and fourth tests, respectively. Time to RT-PCR lack of amplification for all tests was of 34 days while time to RT-PCR Ct values >33 was of 30 days.

Conclusion

Cycle thresholds can potentially be used to improve diagnosis, management and control. We found that turnover time for negativity can be large for hospitalized patients and that 11% cases persisted with infectious Ct values for more time than the current isolation recommendations.

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Characterization of blaKPC-2-Harboring Klebsiella pneumoniae Isolates and Mobile Genetic Elements from Outbreaks in a Hospital in Ecuador

Aim: To investigate the mobile genetic elements harboring bla_KPC gene in carbapenem-resistant Klebsiella pneumoniae recovered during a 6-month outbreak in a high-complexity hospital from Ecuador. Results: A total of 62 isolates belonging to ST258 pilv-I-positive (n = 45), ST25 serotype K2 (n = 8), ST348 (n = 6), ST42 (n = 1), ST196 (n = 1), and ST1758 (n = 1) were collected from intensive care unit (ICU), neurosurgery, burn unit, internal medicine, pneumology, and neurology. Pulsed-field gel electrophoresis analysis showed two major clusters of ST258 and ST25 related to bloodstream infections and pneumonia circulating in ICU. The PCR assay showed that in non-ST258 isolates, the bla_KPC-2 gene were located on the Tn4401a transposon inserted in the transferable pKpQIL-like IncFII_K2 plasmid; the whole-genome sequencing of ST258 clone showed two plasmids, the bla_KPC-2 gene was located on nonconjugative IncR plasmid, whereas the IncFIB/IncFII plasmid lacked ß-lactamase genes. We found an IncM plasmid in bla_KPC-2-harboring Klebsiella pneumoniae ST1758 clone. Conclusions: These findings highlight the presence of pKpQIL-like plasmids in non-ST258 and nonconjugative plasmids in ST258 isolates causing hospital outbreaks.

A study of fluid dynamics and human physiology factors driving droplet dispersion from a human sneeze

Recent studies have indicated that COVID-19 is an airborne disease, which has driven conservative social distancing and widescale usage of face coverings. Airborne virus transmission occurs through droplets formed during respiratory events (breathing, speaking, coughing, and sneezing) associated with the airflow through a network of nasal and buccal passages. The airflow interacts with saliva/mucus films where droplets are formed and dispersed, creating a route to transmit SARS-CoV-2. Here, we present a series of numerical simulations to investigate droplet dispersion from a sneeze while varying a series of human physiological factors that can be associated with illness, anatomy, stress condition, and sex of an individual. The model measures the transmission risk utilizing an approximated upper respiratory tract geometry for the following variations: (1) the effect of saliva properties and (2) the effect of geometric features within the buccal/nasal passages. These effects relate to natural human physiological responses to illness, stress, and sex of the host as well as features relating to poor dental health. The results find that the resulting exposure levels are highly dependent on the fluid dynamics that can vary depending on several human factors. For example, a sneeze without flow in the nasal passage (consistent with congestion) yields a 300% rise in the droplet content at 1.83 m (≈6 ft) and an increase over 60% on the spray distance 5 s after the sneeze. Alternatively, when the viscosity of the saliva is increased (consistent with the human response to illness), the number of droplets is both fewer and larger, which leads to an estimated 47% reduction in the transmission risk. These findings yield novel insight into variability in the exposure distance and indicate how physiological factors affect transmissibility rates. Such factors may partly relate to how the immune system of a human has evolved to prevent transmission or be an underlying factor driving superspreading events in the COVID-19 pandemic.

Biofiltration of butyric acid: Monitoring odor abatement and microbial communities

The objective of this study is to evaluate comparatively the odor removal efficacy of two biofilters operated under different conditions and to identify taxonomically the microbial communities responsible for butyric acid degradation. Both biofiltration systems, which were filled with non-inoculated wood chips and exposed to gas streams containing butyric acid, were evaluated under different operational conditions (gas airflow and temperature) from the physical-chemical, microbiological and olfactometric points of view. The physical-chemical characterization showed the acidification of the packing material and the accumulation of butyric acid during the biofiltration process (<60 days). The removal efficacy was found to be 98-100% during the first 20 days of operation, even at high odor concentration. Changes in the operational temperature increased the odor load factor from 400 to 1400 ou_E/m²·s, which led to the reduction of microbiota in the packing material, and a drastic drop of the odor removal efficacy. However, the progressive increase in gas airflow improved the biodegradation efficacy of butyric acid up to 88% with odor loadings as high as 33,000 ou_E/m³, while a linear relationship between odor inlet load and removal capacity was also found. The analysis of the microbial community showed that Proteobacteria was the most abundant phylum along the biofiltration time (58-92%) and regardless of the operational conditions. Finally, principal component analysis applied to the physical-chemical and microbiological data set revealed significant differences between the two biofilters under study.

Molecular characterization of Trypanosoma cruzi and Leishmania spp. coinfection in mammals of Venezuelan coendemic areas

BACKGROUND & OBJECTIVES

Trypanosoma cruzi and Leishmania spp. are protozoans that cause American trypanosomiasis and leishmaniasis, respectively. In endemic foci where both diseases coincide, coinfection can occur. The objective of this work was the characterization of the parasites involved in coinfection in several endemic areas of Venezuela.

METHODS

Molecular characterization was done in 30 samples of several species of mammals (Didelphis marsupialis, Equus mulus, Rattus rattus, Canis familiaris, Felis catus, and Sciurus granatensis) from the states of Anzoategui, Cojedes and Capital District diagnosed with T. cruzi and Leishmania spp. coinfections. For the typing of T. cruzi DTUs, the markers of miniexon, 24Sa rDNA, 18Sa rDNA, and hsp60-PCR-RFLP (EcoRV) were used. Infection by Leishmania spp. was characterized by miniexon multiplex PCR for complexes of Leishmania and ITS1-PCR-RFLP (HaeIII, HhaI, and RsaI) for the identification of the species.

RESULTS

The T. cruzi TcI was present in 100% of the coinfected mammals, which included 76.7% of triple infection by T. cruzi TcI-complex-L. (L) mexicana-L. infantum/chagasi, 13.3% of double infection by T. cruzi TcI-L. mexicana and 10% of double infection by T. cruzi Tcl-L. infantum/chagasi.

INTERPRETATION & CONCLUSION

These results suggest that the double or triple infection is a phenomenon existing in almost all the coendemics areas and mammals studied, which might influence the mechanisms of adaptation and pathogenicity of these parasites.

Differential immunomodulatory effect of vitamin D (1,25 (OH)2 D3) on the innate immune response in different types of cells infected in vitro with infectious bursal disease virus

It has been demonstrated that vitamin D (Vit D) included in diets offers a beneficial effect by improving innate immune responses in chickens. However, its mechanisms of action and the effect on immunosuppressive pathogens, such as infectious bursal disease virus, are not yet known. In the present study, we have studied the immunomodulatory effect of Vit D on the innate immune response in 3 cell lines: fibroblast cells (DF-1), macrophages (HD11), and B cells (DT-40) infected with IBDV (intermediate vaccine) at 2 multiplicity of infections (MOI) (1 and 0.1). Genes associated with innate immune responses (TLR-3, TLR-21, MDA-5, MyD88, TRIF, IRF-7, INF-α, INF-β, PKR, OAS, viperin, IL-1β, IL-6, and IL-12) were evaluated at different time points (3, 6, 12, 24, and 36 h after infection, h.p.i). Virus production reached a maximum at 24 h.p.i., which was significantly (P < 0.05) higher in DF-1 cells, followed by HD-11 and DT-40 cells. Mainly in HD-11 cells, there was a significant (P < 0.05) effect of Vit D supplementation on receptors TLR-3, TLR-21, and MDA-5 after 12 h.p.i, independent of MOI. DT-40 cells showed the highest antiviral activity, with a significant (P < 0.05) effect on IRF-7, IFN-β, OAS, and PKR gene expression, where expression of IRF-7 and IFN-β correlated positively with Vit D supplementation, while OAS and PKR were independent of Vit D. Proinflammatory cytokines were significantly (P < 0.05) upregulated and found to be Vit D and MOI dependent. In conclusion, this study demonstrated the capacity of IBDV to trigger a strong innate immune response in chicken cells and contributes to the understanding of the activation pathways of innate immunity induced by IBDV and further shows the benefitial effect of Vit D supplementation as an immunomodulator.

Genome sequencing of the first SARS-CoV-2 reported from patients with COVID-19 in Ecuador

SARS-CoV-2, the etiological agent of COVID-19 was first described in Wuhan in December 2019 and has now spread globally. Ecuador was the second country in South America to report confirmed cases. The first case reported in Quito, the capital city of Ecuador, was a tourist who came from the Netherlands and presented symptoms on March 10th, 2020 (index case). In this work we used the MinION platform (Oxford Nanopore Technologies) to sequence the metagenome of the bronchoalveolar lavage (BAL) from this case reported, and subsequently we sequenced the whole genome of the index case and other three patients using the ARTIC network protocols. Our data from the metagenomic approach confirmed the presence of SARS-CoV-2 coexisting with pathogenic bacteria suggesting coinfection. Relevant bacteria found in the BAL metagenome were Streptococcus pneumoniae, Mycobacterium tuberculosis, Staphylococcus aureus and Chlamydia spp. Lineage assignment of the four whole genomes revealed three different origins. The variant HEE-01 was imported from the Netherlands and was assigned to B lineage, HGSQ-USFQ-018, belongs to the B.1 lineage showing nine nucleotide differences with the reference strain and grouped with sequences from the United Kingdom, and HGSQ-USFQ-007 and HGSQ-USFQ-010 belong to the B lineage and grouped with sequences from Scotland. All genomes show mutations in their genomes compared to the reference strain, which could be important to understand the virulence, severity and transmissibility of the virus. Our findings also suggest that there were at least three independent introductions of SARS-CoV-2 to Ecuador.

Environmental performance of an industrial biofilter: Relationship between photochemical oxidation and odorous impacts

Biological techniques are widely used to treat gaseous streams derived from waste treatment plants. The generation of volatile organic compounds (VOCs) is one of the principal pollution sources in composting facilities from which nuisance odours are released. In addition, the generation of photochemical smog with other gases such as NO_X can produce ozone at ground level due to their photochemical ozone creation potential (POCP). In this work, the performance of an industrial biofilter was evaluated from an environmental point of view. Specifically, this study evaluated the potential impact in terms of photochemical oxidation and odour emission derived from composting in a vessel under four different aeration conditions. Gas chromatography-time-of-flight mass spectrometry (GC-TOFMS) was used to perform the chemical characterisation of the gaseous streams, while dynamic olfactometry was used to carry out the sensorial analysis. A total of 95 compounds belonging to 12 different families of VOCs were selected. Principal component analysis revealed the influence of each VOC family on each impact category and explained 88% of the total variance. Multivariate regression was used to study the correlation between photochemical oxidation and odour impact, which has never been reported before. The correlations obtained (r ≥ 0.97) evidenced the direct relationship between these two impacts. Photochemical oxidation and odour emission were proven to be important environmental impacts derived from composting facilities, whose abatement might be carried out by biofiltration systems.

Diverse Escherichia coli lineages from domestic animals carrying colistin resistance gene mcr-1 in an Ecuadorian household

OBJECTIVE

The aim of this study was to detect potential animal reservoirs of Escherichia coli carrying the mcr-1 gene in an Ecuadorian household.

METHODS

The mobile colistin-resistance gene, mcr-1, was first detected in Ecuador in a commensal E. coli isolate from a boy. A cross-sectional study was performed to detect the possible source of colistin-resistant E. coli in the boy's household. Faecal swabs and soil faecal samples were collected from companion animals. Samples were plated on selective media to isolate colistin-resistant E. coli and isolates were submitted to PCR detection of mcr-1, pulsed field gel electrophoresis (PFGE), and multi-locus sequences typing (MLST). Moreover, the genomes of all the isolates were sequenced.

RESULTS

Three different colistin-resistant E. coli sequence types (ST3941, 1630 and 2170), corresponding to three PFGE patterns, were obtained from a chicken and two dogs; these isolates were different from the human isolate (ST609). By whole-genome sequencing, the mcr-1.1 gene was found on IncI2 plasmids with very high nucleotide identity.

CONCLUSIONS

Our results indicate a polyclonal dissemination of mcr-1.1 in the environment surrounding the first MCR-producing E. coli strain reported in Ecuador. Our findings support the idea of lateral dissemination of mcr-1.1 gene between unrelated E. coli isolates.

Carbapenem-Resistant Klebsiella pneumoniae: Microbiology Key Points for Clinical Practice

Carbapenemase–producing Klebsiella pneumoniae strains (Cp-Kpn) represent a challenge for clinical practitioners due to their increasing prevalence in hospital settings and antibiotic resistance. Clinical practitioners are often overwhelmed by the extensive list of publications regarding Cp-Kpn infections, treatment, characteristics, identification, and diagnosis. In this perspective article, we provide key points for clinical practitioners to consider for improved patient management including identification of risk factors and strategies for treatment. Additionally, we also discuss genetic underpinnings of antibiotic resistance, implementation of an antimicrobial stewardship program (ASP), and use of automated systems for detection of Cp-Kpn. Collectively, implementation of such key points would enhance clinical practices through providing practical knowledge to health professionals worldwide.

Metabolite Exchange between Mammalian Organs Quantified in Pigs

Mammalian organs continually exchange metabolites via circulation, but systems-level analysis of this shuttling process is lacking. Here, we compared, in fasted pigs, metabolite concentrations in arterial blood versus draining venous blood from 11 organs. Greater than 90% of metabolites showed arterial-venous differences across at least one organ. Surprisingly, the liver and kidneys released not only glucose but also amino acids, both of which were consumed primarily by the intestine and pancreas. The liver and kidneys exhibited additional unexpected activities: liver preferentially burned unsaturated over more atherogenic saturated fatty acids, whereas the kidneys were unique in burning circulating citrate and net oxidizing lactate to pyruvate, thereby contributing to circulating redox homeostasis. Furthermore, we observed more than 700 other cases of tissue-specific metabolite production or consumption, such as release of nucleotides by the spleen and TCA intermediates by pancreas. These data constitute a high-value resource, providing a quantitative atlas of inter-organ metabolite exchange.

Molecular typing of a large nosocomial outbreak of KPC-producing bacteria in the biggest tertiary-care hospital of Quito, Ecuador

OBJECTIVES

Klebsiella pneumoniae is an opportunistic pathogen associated with nosocomial infections worldwide. Isolates with a K. pneumoniae carbapenemase (KPC)-producing phenotype show reduced susceptibility to first-choice antibiotics. Between 2012-2013, the largest public tertiary-care hospital in Quito (Ecuador) reported an outbreak of KPC-producing bacteria with more than 800 cases. We developed a molecular epidemiological approach to analyse the clonality of K. pneumoniae isolates recovered from selected hospital services and patient samples.

METHODS

A retrospective cohort study was performed based on microbial isolates and their corresponding records from the hospital and referred to Instituto Nacional de Investigación en Salud Pública (INSPI). From 800 isolates that were collected between 2012-2013, a total of 100 isolates were randomly selected for this study. Antimicrobial susceptibility testing was performed according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Genotypic detection and phylogenetic relationship analysis were performed by multilocus sequence typing (MLST). The bla_KPC carbapenemase gene was also amplified by PCR and was sequenced using Sanger sequencing.

RESULTS

Molecular analysis showed that the outbreak had a polyclonal origin with two predominant genotypes, comprising sequence types ST25 and ST258, present in 38 and 36 cases, respectively. These genotypes were found in all studied hospital services including general surgery, intensive care unit and emergency. Thebla_KPC-5 gene was the most prevalent bla_KPC variant in this study.

CONCLUSION

These data indicate that KPC-producing polyclonal K. pneumoniae are frequent causes of nosocomial hospital outbreaks in South America. Similar genotypes have been reported in Colombia, Argentina, Brazil, North America and Asia.

Outcomes of immunosuppression minimization and withdrawal early after liver transplantation

The Immune Tolerance Network ITN030ST A-WISH assessed immunosuppression withdrawal in liver transplant recipients with hepatitis C or nonimmune nonviral liver disease. Of 275 recipients enrolled before transplantation, 95 were randomly assigned 4:1 to withdrawal (n = 77) or maintenance (n = 18) 1- to 2-years posttransplant. Randomization eligibility criteria included stable immunosuppression monotherapy; adequate liver and kidney function; ≤Stage 2 Ishak fibrosis; and absence of rejection on biopsy. Immunosuppression withdrawal followed an 8-step reduction algorithm with ≥8 weeks per level. Fifty-two of 77 subjects (67.5%) reduced to ≤50% of baseline dose, and 10 of 77 (13.0%) discontinued all immunosuppression for ≥1 year. Acute rejection and/or abnormal liver tests were treated with increased immunosuppression; 5 of 32 rejection episodes required a methylprednisolone bolus. The composite end point (death or graft loss; grade 4 secondary malignancy or opportunistic infection; Ishak stage ≥3; or >25% decrease in glomerular filtration rate within 24 months of randomization) occurred in 12 of 66 (18%) and 4 of 13 (31%) subjects in the withdrawal and maintenance groups. Early immunosuppression minimization is feasible in selected liver recipients, while complete withdrawal is successful in only a small proportion. The composite end point comparison was inconclusive for noninferiority of the withdrawal to the maintenance group.

The Impact of Increased Allocation Priority for Children Awaiting Liver Transplant: A Liver Simulated Allocation Model (LSAM) Analysis

OBJECTIVE

The aim of the study was to investigate the impact of prioritizing infants, children, adolescents, and the sickest adults (Status 1) for deceased donor livers. We compared outcomes under two "SharePeds" allocation schema, which prioritize children and Status 1 adults for national sharing and enhanced access to pediatric donors or all donors younger than 35 years, to outcomes under the allocation plan approved by the Organ Procurement and Transplant Network in December 2017 (Organ Procurement and Transplantation Network [OPTN] 12-2017).

METHODS

The 2017 Liver Simulated Allocation Model and Scientific Registry of Transplant Recipients data on all US liver transplant candidates and liver offers 7/2013 to 6/2016 were used to predict waitlist deaths, transplants, and post-transplant deaths under the OPTN 12-2017 and SharePeds schema.

RESULTS

Prioritizing national sharing of pediatric donor livers with children (SharePeds 1) would decrease waitlist deaths for infants (<2 years, P = 0.0003) and children (2-11 years, P = 0.001), with no significant change for adults (P = 0.13). Prioritizing national sharing of all younger than 35-year-old deceased donor livers with children and Status 1A adults (SharePeds 2) would decrease waitlist deaths for infants, children, and all Status 1A/B patients (P < 0.0001 for each). SharePeds 1 and 2 would increase the number of liver transplants done in infants, children, and adolescents compared to the OPTN-2017 schema (P < 0.00005 for all age groups). Both SharePeds schema would increase the percentage of pediatric livers transplanted into pediatric recipients.

CONCLUSIONS

Waitlist deaths could be significantly decreased, and liver transplants increased, for children and the sickest adults, by prioritizing children for pediatric livers and with broader national sharing of deceased donor livers.

Accessibility of substituted cysteines in TM2 and TM10 transmembrane segments in the Plasmodium falciparum equilibrative nucleoside transporter PfENT1

Infection with Plasmodium species parasites causes malaria. Plasmodium parasites are purine auxotrophic. They import purines via an equilibrative nucleoside transporter (ENT). In P. falciparum, the most virulent species, the equilibrative nucleoside transporter 1 (PfENT1) represents the primary purine uptake pathway. This transporter is a potential target for the development of antimalarial drugs. In the absence of a high-resolution structure for either PfENT1 or a homologous ENT, we used the substituted cysteine accessibility method (SCAM) to investigate the membrane-spanning domain structure of PfENT1 to identify potential inhibitor-binding sites. We previously used SCAM to identify water-accessible residues that line the permeation pathway in transmembrane segment 11 (TM11). TM2 and TM10 lie adjacent to TM11 in an ab initio model of a homologous Leishmania donovani nucleoside transporter. To identify TM2 and TM10 residues in PfENT1 that are at least transiently on the water-accessible transporter surface, we assayed the reactivity of single cysteine-substitution mutants with three methanethiosulfonate (MTS) derivatives. Cysteines substituted for 12 of 14 TM2 segment residues reacted with MTS-ethyl-ammonium-biotin (MTSEA-biotin). At eight positions, MTSEA-biotin inhibited transport, and at four positions substrate transport was potentiated. On an α helical wheel projection of TM2, the four positions where potentiation occurred were located in a cluster on one side of the helix. In contrast, although MTSEA-biotin inhibited 9 of 10 TM10 cysteine-substituted mutants, the reactive residues did not form a pattern consistent with either an α helix or β sheet. These results may help identify the binding site(s) of PfENT1 inhibitors.

Living liver donation improves patient and graft survival in the pediatric population

BACKGROUND

The utilization of living donor grafts resulted in an increased availability of liver for pediatric recipients, and accordingly, this was associated with a significantly decreased waiting time before liver transplantation as well as reduced pre-transplant mortality. We hypothesized that the use of living donors in pediatric LT may lead to improved graft and patient survival, when compared to LT using deceased donors.

METHODS

Retrospective cohort analysis of pediatric recipients (aged <18 years) registered in the UNOS database who received a primary liver transplant between February 2002 and December 2016. Covariates predictive of survival by multivariable analyses were included in the Cox proportional hazards regression models to determine predictors of patient and graft survival.

RESULTS

A total of 6312 children received a primary LT from a LD (n = 800) or a deceased donor (n = 5517; partial graft n = 1784 and whole graft n = 3733). Vascular and biliary complications were similar. Kaplan-Meier graft and patient survival rates were superior in LD recipients compared with recipients of deceased whole and reduced graft (Figures 1 and 2). In the multivariable analysis, LD were an independent predictor of improved patient and graft survival.

CONCLUSION

The use of LD in children is associated with improved patient and graft survival. The option of LD should be introduced early on in the evaluation of every pediatric patient being evaluated for liver transplant.

Ambiente físico y respuestas fisiológicas de ovinos bajo sombra en horas de máxima radiación

Con el objeto de describir la relación entre las variables climáticas y las respuestas fisiológicas, 20 ovejas fueron asignadas a: Con Sombra (CS): sombra artificial (12:00 - 14:00 h) en corral con techo de malla sombra (70%); Sin Sombra (SS): sin ofrecimiento de sombra. Se determinó radiación solar (RS; W/m2), temperatura ambiental (°C), humedad relativa (%), temperatura de globo negro (TGN; °C) e índice de temperatura-humedad (ITH; unidades), temperatura superficial (TS; °C; termómetro infrarrojo), temperatura corporal (TC; °C; termómetro digital), frecuencia respiratoria (FR; mov/min; observación directa) y coeficiente de tolerancia al calor (CTC; unidades) (PROC MIXED; SAS).Adicionalmente, los datos fueron analizados por componentes principales (InfoStat/E, 2008).CS presenta una menor TS (35,9) en comparación con SS (38,9; P ≤ 0,01); igual ocurre en TC (P ≤ 0,01). La FR en CS (112,3) fue superior a SS (139,6; P ≤ 0,01). El CTC fue mayor en SS (7,8) vs. CS (5,8; P ≤ 0,01), indicando mejor bienestar térmico en CS. La TS en lomo, cadera y/o costado presenta alta relación con TC. TGN > 42,8 y de RS > 529,1 podrían indicar reducciones del bienestar térmico. Basado en la TC y FR, el punto de quiebre del ITH en ovinos es > 80.

A data-driven patient blood management strategy in liver transplantation

BACKGROUND AND OBJECTIVES

Blood utilization during liver transplant has decreased, but remains highly variable due to many complex surgical and physiologic factors. Previous models attempted to predict utilization using preoperative variables to stratify cases into two usage groups, usually using entire blood units for measurement. We sought to develop a practical predictive model using specific transfusion volumes (in ml) to develop a data-driven patient blood management strategy.

MATERIALS AND METHODS

This is a retrospective evaluation of primary liver transplants at a single institution from 2013 to 2015. Multivariable analysis of preoperative recipient and donor factors was used to develop a model predictive of intraoperative red-blood-cell (pRBC) use.

RESULTS

Of 256 adult liver transplants, 207 patients had complete transfusion volume data for analysis. The median intraoperative allogeneic pRBC transfusion volume was 1250 ml, and the average was 1563 ± 1543 ml. Preoperative haemoglobin, spontaneous bacterial peritonitis, preoperative haemodialysis and preoperative international normalized ratio together yielded the strongest model predicting pRBC usage. When it predicted <1250 ml of pRBCs, all cases with 0 ml transfused were captured and only 8·6% of the time >1250 ml were used. This prediction had a sensitivity of 0·91 and a specificity of 0·89. If predicted usage was >2000 ml, 75% of the time blood loss exceeded 2000 ml.

CONCLUSION

Patients likely to require low or high pRBC transfusion volumes were identified with excellent accuracy using this predictive model at our institution. This model may help predict bleeding risk for each patient and facilitate optimized blood ordering.

Pediatric liver transplantation for hepatocellular cancer and rare liver malignancies: US multicenter and single-center experience (1981-2015)

A tenth of all pediatric liver transplantations (LTs) are performed for unresectable liver malignancies, especially the more common hepatoblastoma (HBL). Less understood are outcomes after LT for the rare hepatocellular carcinoma, nonhepatoblastoma embryonal tumors (EMBs), and slow growing metastatic neuroendocrine tumors of childhood. Pediatric LT is increasingly performed for rare unresectable liver malignancies other than HBL. We performed a retrospective review of outcomes after LT for malignancy in the multicenter US Scientific Registry of Transplant Recipients (SRTR; n = 677; 1987-2015). We then reviewed the Children's Hospital of Pittsburgh (CHP; n = 74; 1981-2014) experience focusing on LT for unresectable hepatocellular cancer (HCC), EMBs, and metastatic liver tumors (METS). HBL was included to provide reference statistics. In the SRTR database, LT for HCC and HBL increased over time (P < 0.001). Compared with other malignancies, the 149 HCC cases received fewer segmental grafts (P < 0.001) and also experienced 10-year patient survival similar to 15,710 adult HCC LT recipients (51.6% versus 49.6%; P = 0.848, not significant [NS], log-rank test). For 22 of 149 cases with incidental HCC, 10-year patient survival was higher than 127 primary HCC cases (85% [95% confidence interval (CI), 70.6%-100%] versus 48.3% [95% CI, 38%-61%]; P = 0.168, NS) and similar to 3392 biliary atresia cases (89.9%; 95% CI, 88.7%-91%). Actuarial 10-year patient survival for 17 EMBs, 10 METS, and 6 leiomyosarcoma patients exceeded 60%. These survival outcomes were similar to those seen for HBL. At CHP, posttransplant recurrence-free and overall survival among 25 HCC, 17 (68%) of whom had preexisting liver disease, was 16/25 or 64%, and 9/25 or 36%, respectively. All 10 patients with incidental HCC and tumor-node-metastasis stage I and II HCC survived recurrence-free. Only vascular invasion predicted poor survival in multivariate analysis (P < 0.0001). A total of 4 of 5 EMB patients (80%) and all patients with METS (neuroendocrine-2, pseudopapillary pancreatic-1) also survived recurrence-free. Among children, LT can be curative for unresectable HCC confined to the liver and without vascular invasion, incidental HCC, embryonal tumors, and metastatic neuroendocrine tumors. Liver Transplantation 23 1577-1588 2017 AASLD.

Short communication: Molecular epidemiology of Streptococcus agalactiae differs between countries

Group B Streptococcus or Streptococcus agalactiae continue to be challenging for milk quality programs in countries with emerging dairy industries, such as Colombia, where high prevalence has been reported. Molecular typing of isolates is needed to understand the variability and epidemiology of this pathogen and to develop effective control and eradication programs. We characterized the molecular profile of Strep. agalactiae isolated from cows with subclinical mastitis in 21 Colombian dairy herds and measured diversity within and between herds using multilocus sequence typing. Isolates belonged to sequence type 248 [clonal complex (CC) 103; n = 30), ST1 (CC1; n = 6) or ST22 (CC22; n = 4)], whereas members of CC67/61, the dominant type in North America, were not detected. Presence of multiple clonally unrelated sequence type within a herd was common, which contrasts with the situation in European countries and suggests introduction from multiple sources. Our results demonstrate that conclusions from molecular epidemiological studies in 1 region cannot necessarily be extrapolated to other regions, and no single bovine-adapted CC of Strep. agalactiae exists in Colombia. Improvements in internal and external biosecurity will be needed to reduce Strep. agalactiae prevalence in Colombian dairy herds.

Household Microbial Water Quality Testing in a Peruvian Demographic and Health Survey: Evaluation of the Compartment Bag Test for Escherichia coli

AbstractThe Joint Monitoring Program relies on household surveys to classify access to improved water sources instead of measuring microbiological quality. The aim of this research was to pilot a novel test for Escherichia coli quantification of household drinking water in the 2011 Demographic and Health Survey (DHS) in Peru. In the Compartment Bag Test (CBT), a 100-mL water sample is supplemented with chromogenic medium to support the growth of E. coli, poured into a bag with compartments, and incubated. A color change indicates E. coli growth, and the concentration of E. coli/100 mL is estimated as a most probable number. Triplicate water samples from 704 households were collected; one sample was analyzed in the field using the CBT, another replicate sample using the CBT was analyzed by reference laboratories, and one sample using membrane filtration (MF) was analyzed by reference laboratories. There were no statistically significant differences in E. coli concentrations between the field and laboratory CBT results, or when compared with MF results. These results suggest that the CBT for E. coli is an effective method to quantify fecal bacteria in household drinking water. The CBT can be incorporated into DHS and other national household surveys as a direct measure of drinking water safety based on microbial quality to better document access to safe drinking water.