Genome-wide transcriptome study in skin biopsies reveals an association of E2F4 with cadasil and cognitive impairment

CADASIL is a small vessel disease caused by mutations in NOTCH3 that lead to an odd number of cysteines in the EGF-like repeat domain, causing protein misfolding and aggregation. The main symptoms are migraine, psychiatric disturbances, recurrent strokes and dementia, being executive function characteristically impaired. The molecular pathways altered by this receptor aggregation need to be studied further. A genome-wide transcriptome study (four cases paired with three healthy siblings) was carried out, in addition to a qRT-PCR for validation purposes (ten new cases and eight new controls). To study the expression profile by cell type of the significant mRNAs found, we performed an in situ hybridization (ISH) (nine cases and eight controls) and a research in the Single-nuclei Brain RNA-seq expression browser (SNBREB). Pathway analysis enrichment was carried out with Gene Ontology and Reactome. Neuropsychological tests were performed in five of the qRT-PCR cases. The two most significant differentially expressed mRNAs (BANP, p-value = 7.23 × 10-4 and PDCD6IP, p-value = 8.36 × 10-4) were selected for the validation study by qRT-PCR. Additionally, we selected two more mRNAs (CAMK2G, p-value = 4.52 × 10-3 and E2F4, p-value = 4.77 × 10-3) due to their association with ischemic neuronal death. E2F4 showed differential expression in the genome-wide transcriptome study and in the qRT-PCR (p = 1.23 × 10-3), and it was upregulated in CADASIL cases. Furthermore, higher E2F4 expression was associated with worse executive function (p = 2.04 × 10-2) and attention and information processing speed (IPS) (p = 8.73 × 10-2). In situ hibridization showed E2F4 expression in endothelial and vascular smooth vessel cells. In silico studies indicated that E2F4 is also expressed in brain endothelial cells. Among the most significant pathways analyzed, there was an enrichment of vascular development, cell adhesion and vesicular machinery terms and autophagy process. E2F4 is more highly expressed in the skin biopsy of CADASIL patients compared to controls, and its expression is present in endothelial cells and VSMCs. Further studies are needed to understand whether E2F4 could be useful as a biomarker, to monitor the disease or be used as a therapeutic target.

Preoperative oral antibiotic prophylaxis reduces Pseudomonas aeruginosa surgical site infections after elective colorectal surgery: a multicenter prospective cohort study

Background

Healthcare-associated infections caused by Pseudomonas aeruginosa are associated with poor outcomes. However, the role of P. aeruginosa in surgical site infections after colorectal surgery has not been evaluated. The aim of this study was to determine the predictive factors and outcomes of surgical site infections caused by P. aeruginosa after colorectal surgery, with special emphasis on the role of preoperative oral antibiotic prophylaxis.

Methods

We conducted an observational, multicenter, prospective cohort study of all patients undergoing elective colorectal surgery at 10 Spanish hospitals (2011–2014). A logistic regression model was used to identify predictive factors for P. aeruginosa surgical site infections.

Results

Out of 3701 patients, 669 (18.1%) developed surgical site infections, and 62 (9.3%) of these were due to P. aeruginosa. The following factors were found to differentiate between P. aeruginosa surgical site infections and those caused by other microorganisms: American Society of Anesthesiologists’ score III–IV (67.7% vs 45.5%, p = 0.001, odds ratio (OR) 2.5, 95% confidence interval (95% CI) 1.44–4.39), National Nosocomial Infections Surveillance risk index 1–2 (74.2% vs 44.2%, p < 0.001, OR 3.6, 95% CI 2.01–6.56), duration of surgery ≥75thpercentile (61.3% vs 41.4%, p = 0.003, OR 2.2, 95% CI 1.31–3.83) and oral antibiotic prophylaxis (17.7% vs 33.6%, p = 0.01, OR 0.4, 95% CI 0.21–0.83). Patients with P. aeruginosa surgical site infections were administered antibiotic treatment for a longer duration (median 17 days [interquartile range (IQR) 10–24] vs 13d [IQR 8–20], p = 0.015, OR 1.1, 95% CI 1.00–1.12), had a higher treatment failure rate (30.6% vs 20.8%, p = 0.07, OR 1.7, 95% CI 0.96–2.99), and longer hospitalization (median 22 days [IQR 15–42] vs 19d [IQR 12–28], p = 0.02, OR 1.1, 95% CI 1.00–1.17) than those with surgical site infections due to other microorganisms. Independent predictive factors associated with P. aeruginosa surgical site infections were the National Nosocomial Infections Surveillance risk index 1–2 (OR 2.3, 95% CI 1.03–5.40) and the use of oral antibiotic prophylaxis (OR 0.4, 95% CI 0.23–0.90).

Conclusions

We observed that surgical site infections due to P. aeruginosa are associated with a higher National Nosocomial Infections Surveillance risk index, poor outcomes, and lack of preoperative oral antibiotic prophylaxis. These findings can aid in establishing specific preventive measures and appropriate empirical antibiotic treatment.

Daptomycin plus fosfomycin versus daptomycin monotherapy in treating MRSA: protocol of a multicentre, randomised, phase III trial

INTRODUCTION

Despite the availability of new antibiotics such as daptomycin, methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia continues to be associated with high clinical failure rates. Combination therapy has been proposed as an alternative to improve outcomes but there is a lack of clinical studies. The study aims to demonstrate that combination of daptomycin plus fosfomycin achieves higher clinical success rates in the treatment of MRSA bacteraemia than daptomycin alone.

METHODS AND ANALYSIS

A multicentre open-label, randomised phase III study. Adult patients hospitalised with MRSA bacteraemia will be randomly assigned (1:1) to group 1: daptomycin 10 mg/kg/24 h intravenous; or group 2: daptomycin 10 mg/kg/24 h intravenous plus fosfomycin 2 gr/6 g intravenous. The main outcome will be treatment response at week 6 after stopping therapy (test-of-cure (TOC) visit). This is a composite variable with two values: Treatment success: resolution of clinical signs and symptoms (clinical success) and negative blood cultures (microbiological success) at the TOC visit. Treatment failure: if any of the following conditions apply: (1) lack of clinical improvement at 72 h or more after starting therapy; (2) persistent bacteraemia (positive blood cultures on day 7); (3) therapy is discontinued early due to adverse effects or for some other reason based on clinical judgement; (4) relapse of MRSA bacteraemia before the TOC visit; (5) death for any reason before the TOC visit. Assuming a 60% cure rate with daptomycin and a 20% difference in cure rates between the two groups, 103 patients will be needed for each group (α:0.05, ß: 0.2). Statistical analysis will be based on intention to treat, as well as per protocol and safety analysis.

ETHICS AND DISSEMINATION

The protocol was approved by the Spanish Medicines and Healthcare Products Regulatory Agency (AEMPS). The sponsor commits itself to publishing the data in first quartile peer-review journals within 12 months of the completion of the study.

TRIAL REGISTRATION NUMBER

NCT01898338.

Predictive factors for mortality in patients with methicillin-resistant Staphylococcus aureus bloodstream infection: impact on outcome of host, microorganism and therapy

Mortality related to methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) remains high, despite changes in the epidemiology. To analyze the current predictive factors for mortality we conducted a prospective study in a large cohort of patients with MRSA-BSI from 21 Spanish hospitals. Epidemiology, clinical data, therapy and outcome were recorded. All MRSA strains were analysed, including susceptibility to antibiotics and molecular characterization. Vancomycin MICs (V-MIC) were tested by the E-test and microdilution methods. Time until death was the dependent variable in a Cox regression analysis. Overall, 579 episodes were included. Acquisition was nosocomial in 59% and vascular catheter was the most frequent source (38%). A dominant PFGE genotype was found in 368 (67%) isolates, which belonged to Clonal Complex (CC)5 and carried SCCmecIV and agr2. Microdilution V-MIC50 and V-MIC90 were 0.7 and 1.0 mg/L, respectively. Initial therapy was appropriate in 66% of episodes. Overall mortality was observed in 179 (32%) episodes. The Cox-regression analysis identified age >70 years (HR 1.88), previous fatal disease (HR 2.16), Pitt score >1 (HR 3.45), high-risk source (HR 1.85) and inappropriate initial treatment (HR 1.39) as independent predictive factors for mortality. CC5 and CC22 (HR 0.52 and 0.45) were associated with significantly lower mortality rates than CC8. V-MIC ≥1.5 did not have a significant impact on mortality, regardless of the method used to assess it.

[Psychogenic urinary retention. Diagnostic-therapeutic approach]

OBJECTIVE

The influence of psychogenic factors on voiding generally manifests as an irritative syndrome and rarely in the form of acute or chronic urinary retention. The diagnosis and treatment of this uncommon urological pathology are reviewed and our experience is presented.

METHODS

We conducted a retrospective study on 5 patients with psychogenic urinary retention (3 males and 2 females), aged 20 to 28 years (mean age 23.4), that had been treated at our urological services over the last 6 years. Three patients (2 males and 1 female) had a history of depression, one patient had a somatic form of disorder (mimicking) and one patient was diagnosed as having schizophrenia one year after he had presented with urinary retention. The physical and neurological examinations were normal in all 5 patients and the radiological evaluation was normal in all but one patient who had bilateral hydronephrosis. The pressure/flow test disclosed absence of detrusor muscle contraction in all 5 patients; 3 had incomplete voiding by abdominal pressure and had more than 500 ml residual urine. All patients received psychiatric therapy, and intermittent catheterization and urinary rehabilitation until residual urine less than 100 ml was achieved.

CONCLUSIONS

The importance of the urodynamic study in the diagnosis of this condition is underscored. Definitive diagnosis can only be established after discarding other pathologies. The initial treatment must always be conservative; irreversible surgical procedures must not be performed. Treatment is by intermittent catheterization, urinary rehabilitation and supportive psychiatric therapy.

[Xanthogranulomatous pyelonephritis in renal allograft. Report of a case and review of the literature]

Clinic report case of a kidney-transplanted female who, after one year of normal functioning, developed xantogranulomatous pyelonephritis in the renal allograft. Clinical presentation was mesorenal tumoration causing pyelocaliecstasis, which coincided with a progressive decline of renal function due to interstitial rejection. Diagnosis by eco-doppler imaging, CAT, arteriography, renogram and descending pyelography were non-specific in relation to the process benignant or malignant nature. Surgical examination with obtention of biopsy was not conclusive with regard to diagnosis and so, during a second surgery, transplanctectomy was chosen. The histological examination showed that the expansive process of the allograft corresponded to a case of xantogranulomatous pyelonephritis. After reviewing the existing literature, only 4 cases were found reporting this rare condition in a renal allograft.

[Ureteral obstruction caused by periureteral venous dilatation secondary to infrarenal caval obstruction]

Presentation of a case report of a female patient with single right kidney and background of left nephrectomy 21 years earlier due to hypertension who presented to the clinic after an episode of oliguria with lower limbs oedema and renal failure. Renal ultrasound evidenced moderate hydronephrosis, and backward pyelography showed medialization and lumbar ureter compression. CAT examination confirmed the ureteropyelocalycectasis as well as the reduction of the infrarenal lower cava vein to a fibrous cord with internal calcification. Axillary cavography and venography through both femorals demonstrated absence of the infrarenal cava vein segment and existence of a large replacement venous network. During surgery it became evident that the latter was displacing a retrovenous right lumbar ureter medially. Ureterolysis and ureter section with transposition, and termino-terminal anastomosis were performed. The morphological and functional results were excellent with recovery of the renal function (normal serum creatinine) which is still maintained after 7 years follow-up. As a consequence of this case, a review was made of different cava vein anomalies with repercussion in the urine excretory tract.

[Epidemic outbreak of shigellosis following water intake]

BACKGROUND

To describe the clinical, epidemiologic and microbiologic characteristics of an outbreak of shigellosis.

METHODS

Twenty-six patients affected by shigellosis were studied. Upon identification of the outbreak, a questionnaire was carried out in relatives to determine the attack-rate. Studies of the isolated strains included biotype, antibiotype, and in 8 selected strains, plasmid and ribotyping profile.

RESULTS

From September 23 to October 21 1991, 26 patients (42% males, 54% under the age of 14 years), 23 of whom drunk water from two nearby fountains were attended for acute gastroenteritis and positive stool culture with isolation of Shigella sonnei strains with identical biochemical pattern and sensitivity. Only 2 required hospital admission and all recovered well. Forty-five percent of the 80 individuals who had drunk water from the fountains were affected. The attack-rate was higher in children (67%) than in adults (27%) (p < 0.001). The plasmid profile was identical in the strains studied. The only discriminative endonuclease used for the ribotyping was Sal I, which allowed the strains corresponding to the outbreak to be differentiated from those used as controls.

CONCLUSIONS

An outbreak of shigellosis due to water ingestion is herein reported. The usefulness of plasmid profile as an epidemiologic marker of Shigella is confirmed. Only one of the four enzymes used for the ribotyping was discriminative. A greater susceptibility to infection was observed in children.

[Clinical impact of idiopathic bladder instability]

Idiopathic vesical instability (I.V.I.), defined as the detrusor's spontaneous contraction during vesical filling or at its end, with a pressure higher than 15 cm H2O, is a urodynamic concept of unknown origin related to clinical disorders such as urinary incontinence, urgency-frequency syndrome, vesicoureteral reflux, repeat urinary infections, upper urological diseases due to pseudo-obstruction and morphological changes in vesicourethral X-rays. From January 1988 to January 1994, 2500 patients have been urodynamically examined. In 24% cases the diagnosis arrived at was vesical instability, 72% of them being I.V.I. I.V.I. was present as single diagnosis in 53% of prostate post-surgical incontinence, 71% of enuresis, 11% of clinically labelled stress incontinence, 46% of non-subsidiary incontinence, 16% of patients examined for prostatism, 55% of vesicoureteral reflux and 59% of repeat urinary infections.

Ciprofloxacin and trimethoprim-sulfamethoxazole versus placebo in acute uncomplicated Salmonella enteritis: a double-blind trial

The role of ciprofloxacin and trimethoprim-sulfamethoxazole (TMP-SMZ) was evaluated in empiric treatment of uncomplicated Salmonella enteritis in a comparative, double-blind trial. Patients were randomized to receive ciprofloxacin (500 mg), TMP-SMZ (160/800 mg), or placebo orally twice daily for 5 days. There were 65 evaluatable patients with acute, uncomplicated, culture-confirmed Salmonella enteritis. Duration of diarrhea, abdominal pain, or vomiting and time to defervescence were not significantly different for patients treated with ciprofloxacin, TMP-SMZ, or placebo; there also were no significant differences with respect to full resolution of symptoms for ciprofloxacin versus placebo (point estimate, 0.2 days; 95% confidence interval [CI], -0.5 to 0.9 days) or for TMP-SMZ versus placebo (point estimate, 0.2 days; 95% CI, -1.0 to 0.6 days). The rate of clearance of salmonellae from stools was not significantly different among the groups.

Antibodies to Rickettsia conorii in dogs: seasonal differences

Eight dogs, having showed positivity to Rickettsia conorii in serum samples obtained during the spring and summer, were studied again by means of a second determination during the next winter, 4-10 months later. Serum titer became negative in six dogs, persisted high in one, and fell from 1:640 to 1:40 in another dog. This seasonal difference suggests a short persistence of antibodies in dogs after contact with R. conorii in the Mediterranean area.

Production and Degradation of Oxalic Acid by Brown Rot Fungi

Our results show that all of the brown rot fungi tested produce oxalic acid in liquid as well as in semisolid cultures. Gloeophyllum trabeum , which accumulates the lowest amount of oxalic acid during decay of pine holocellulose, showed the highest polysaccharide-depolymerizing activity. Semisolid cultures inoculated with this fungus rapidly converted 14 C-labeled oxalic acid to CO 2 during cellulose depolymerization. The other brown rot fungi also oxidized 14 C-labeled oxalic acid, although less rapidly. In contrast, semisolid cultures inoculated with the white rot fungus Coriolus versicolor did not significantly catabolize the acid and did not depolymerize the holocellulose during decay. Semisolid cultures of G. trabeum amended with desferrioxamine, a specific iron-chelating agent, were unable to lower the degree of polymerization of cellulose or to oxidize 14 C-labeled oxalic acid to the extent or at the rate that control cultures did. These results suggest that both iron and oxalic acid are involved in cellulose depolymerization by brown rot fungi.

Randomized trial of doxycycline versus josamycin for Mediterranean spotted fever

We undertook a randomized clinical trial comparing therapeutic efficacy of the 1-day doxycycline regimen with the 5-day josamycin regimen for Mediterranean spotted fever. All 59 patients recovered uneventfully, and results did not significantly differ between the two schedules. One-day doxycycline therapy is an effective, easy, and inexpensive treatment. Josamycin is a useful therapeutic alternative that may be particularly convenient for pregnant women and patients with a history of allergy to tetracyclines.

[Acute digestive complications in leukemic children. Apropos of a case of cecal necrosis]

A caecal necrosis attributed to a hemorrhagic infarct from the ileocaecal vascular thrombosis associated with lymphoblastic infiltration. Early surgical operation with supportive hematological measures is required when a acute abdomen is suspected cue to the poor prognosis of this complication when untreated.