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• 30 patients with Takotsubo syndrome underwent coronary angiography and invasive evaluation of microvascular function. • 83 % of the patients had at least one abnormal coronary microvascular function parameter. • Resistive Reserve Ratio (RRR) may be a sensitive parameter to assess microvascular function. • Longer time from first symptoms to angiography positively correlated with higher levels of coronary flow reserve. • A non-emotional trigger for Takotsubo was associated with a pathological index of microcirculatory resistance (IMR). The pathophysiology of Takotsubo syndrome (TTS) remains incompletely understood. While coronary microvascular dysfunction (CMD) is a potential pathophysiologic mechanism, evidence is limited. We sought to evaluate CMD in patients with TTS. Consecutive patients diagnosed with TTS were included and underwent coronary angiography with invasive microvascular function evaluation, including fractional flow reserve, Coronary Flow Reserve (CFR), Index of Microcirculatory Resistance (IMR), and Resistive Reserve Ratio (RRR). Patients had an echocardiography evaluation during their index admission and at approximately 6 weeks. Thirty patients were included (mean age 74 ±9, 90 % female). Twenty-five patients (83 %) had at least one abnormal coronary microvascular function parameter. Abnormal parameters included CFR<2.5 in 20 patients (67 %), IMR>25 in 18 patients (60 %), and RRR<3.5 in 25 (83 %). Longer time from symptoms to angiography correlated with a higher CFR (r = 0.51, P<0.01), and had an area under the receiver operating characteristic curve of 0.793 (95 % CI 0.60-0.98) for pathologic CFR. Patients with emotional trigger had a lower rate of pathologic IMR compared with non-emotional trigger (36 % vs 81 %, p = 0.01). Follow up echocardiography performed at a median of 1.5 months (IQR 1.15-6) showed an improvement in left ventricular ejection fraction for all patients (from mean of 40 % to 57 %). CMD was present in most patients with TTS. The role of microvascular function in TTS may vary according to the clinical presentation and RRR may be more sensitive for the diagnosis of CMD in TTS. [ABSTRACT FROM AUTHOR]

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Coronary flow reserve (CFR) and microvascular resistance reserve (MRR) can, in principle, be derived by any method assessing coronary flow. The aim of this study was to compare CFR and MRR as derived by continuous (CFR cont and MRR cont) and bolus thermodilution (CFR bolus and MRR bolus). A total of 175 patients with chest pain and nonobstructive coronary artery disease were studied. Bolus and continuous thermodilution measurements were performed in the left anterior descending coronary artery. MRR was calculated as the ratio of CFR to fractional flow reserve and corrected for changes in systemic pressure. In 102 patients, bolus and continuous thermodilution measurements were performed in duplicate to assess test-retest reliability. Mean CFR bolus was higher than CFR cont (3.47 ± 1.42 and 2.67 ± 0.81 [ P < 0.001], mean difference 0.80, upper limit of agreement 3.92, lower limit of agreement −2.32). Mean MRR bolus was also higher than MRR cont (4.40 ± 1.99 and 3.22 ± 1.02 [ P < 0.001], mean difference 1.2, upper limit of agreement 5.08, lower limit of agreement −2.71). The correlation between CFR and MRR values obtained using both methods was significant but weak (CFR, r = 0.28 [95% CI: 0.14-0.41]; MRR, r = 0.26 [95% CI: 0.16-0.39]; P < 0.001 for both). The precision of both CFR and MRR was higher when assessed using continuous thermodilution compared with bolus thermodilution (repeatability coefficients of 0.89 and 2.79 for CFR cont and CFR bolus , respectively, and 1.01 and 3.05 for MRR cont and MRR bolus , respectively). Compared with bolus thermodilution, continuous thermodilution yields lower values of CFR and MRR accompanied by an almost 3-fold reduction of the variability in the measured results. [Display omitted] [ABSTRACT FROM AUTHOR]

Positron Emission Tomography (PET) Myocardial Perfusion Imaging (MPI) is a robust diagnostic and prognostic test in patients with suspected or known coronary artery disease (CAD). We aimed to assess the incremental prognostic value of myocardial flow reserve (MFR) using the latest generation of digital PET scanners. Consecutive patients with clinically indicated PET MPI for suspected or known CAD were included. Myocardial blood flow (MBF) in ml/min/g was obtained from dynamic images at rest and peak hyperemia, and the myocardial flow reserve (MFR) was calculated as the ratio of stress to rest MBF. Patients were followed from the date of PET imaging for the occurrence of the primary outcome (composite of all-cause death, myocardial infarction, and Percutaneous Coronary Intervention or Coronary Artery Bypass Graft occurring >90 days after imaging). Nested multivariable Cox regression models were used to assess the incremental prognostic role of MFR over traditional risk factors and PET relative perfusion parameters. The final cohort consisted of 3534 patients (mean age 67 ± 12 years, 48% female, 67% Caucasian, 53% obese, 55% hypertension, 32% diabetes, 42% dyslipidemia). During a median follow-up of 8.5 (3.0–15.4) months, 229 patients (6.5%, 6.4 per 1000 person-years) experienced the primary outcome. In nested multivariable Cox models, impaired MFR (MFR < 2) was significantly associated with the primary outcome (HR 2.9, 95% CI 2.0–4.1, p < 0.001) and significantly improved discrimination (Harrell's C 0.77, p = 0.002). MFR derived from digital PET scanners has an independent and incremental prognostic role in patients with suspected or known CAD. • PET MPI is a robust diagnostic and prognostic test for managing patients with suspected or established CAD. • Digital PET MPI has higher sensitivity at a lower radiotracer dose, radiation exposure (below 1milisilvert), and cost. • We aimed to assess the incremental prognostic value of MFR using the latest generation of digital PET scanners. • We found digital PET MFR has an independent and incremental prognostic role in patients with suspected or known CAD. [ABSTRACT FROM AUTHOR]

Objectives: Coronary flow reserve (CFR) is a strong predictor of cardiovascular events and prognosis in patients with coronary artery disease. This study aimed to evaluate preoperative factors associated with the unsuccessful restoration of CFR after coronary artery bypass grafting (CABG). Methods : Included in this study were the 65 patients who presented with functionally significant left anterior descending artery (LAD) lesions confirmed by both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), and who underwent successful CABG at our hospital within the study period. After CABG, graft patency was confirmed by coronary computed tomography angiography, and CFR in the LAD artery was measured by echocardiography. We defined postoperative CFR <2.5 as impaired CFR, and CFR ≥2.5 as preserved CFR. Results: Of the 65 patients, 14 patients (22%) showed impaired CFR, while 51 patients had preserved CFR. Patients with impaired CFR had significantly higher HbA1c (6.7% vs. 6.0%, P < 0.01), greater use of insulin (43% vs. 4%, P < 0.01), longer lesion length (33 mm vs. 25 mm, P = 0.044), and lower iFR (0.69 vs 0.81, P = 0.01) than those with preserved CFR, although both groups had comparable FFR (0.65 vs 0.64, P = 0.46). In receiver operating characteristic curve analysis, iFR had a significantly larger area under the curve than FFR in terms of the prediction of impaired CFR (0.74 vs 0.42, P = 0.01). Conclusions: Poorly-controlled preoperative diabetes, greater reliance on insulin, longer lesion length and lower iFR were associated with postoperative impaired CFR, suggesting the involvement of microvascular dysfunction. [Display omitted] • Coronary flow reserve (CFR) has been proposed as a powerful prognostic predictor. • CABG is basically an established treatment to improve CFR and prognosis. • There has been the cases of continued impairment of CFR after successful CABG. • Diabetes and longer lesion are the risk factors for continued impairment of CFR. • iFR was more predictive of postoperative CFR than FFR. [ABSTRACT FROM AUTHOR]

Linezolid (Oxazolidinones) is commonly used against a variety of Gram-positive infections, especially methicillin-resistant Staphylococcus aureus (MRSA). The emerging resistance to linezolid curtail the treatment of infections caused by MRSA and other Gram-positive bacteria. Presence of cfr gene plays a crucial role in Linezolid resistance. Present study was aimed to detect cfr gene among clinical MRSA isolates. The suspected Staphylococcus aureus isolates were processed through Kirby Bauer disc diffusion methods for the confirmation of MRSA strains. Phenotypic Linezolid resistance was determined through broth micro-dilution method. The plasmid and DNA of Linezolid resistant isolates were subjected to molecular characterization for the presence of cfr gene. Among 100 Staphylococcus aureus isolates, 85 of them were confirmed as MRSA isolates. Categorically, 65% MRSA isolates were sensitive to linezolid with MIC lower than 8 µg/ml, whereas, 35% of them were resistant to linezolid having MIC greater than 8 µg/ml. MIC level of 128 µg/ml was observed among 3.5% of the resistant isolates. Similarly, MIC level of 64 µg/ml, 32 µg/ml, 16 µg/ml and 8 µg/ml were noted for 3.5%, 4.7%, 8.2% and 15.3% isolates respectively. Linezolid resistance cfr gene was detected only in 9.4% of the resistant isolates. Multi drug resistance among MRSA isolates is keenly attributed to the presence of cfr gene as evident in the present study, and horizontal dissemination of cfr gene among MRSA strains is accredited to cfr -carrying transposons and plasmids. [ABSTRACT FROM AUTHOR]

• There is a higher incidence of severe fever with thrombocytopenia syndrome (SFTS) in selenium-deficient areas. • Mortality of SFTS is higher in severe selenium-deficient areas. • Insufficient serum selenium in humans is associated with poor prognosis in SFTS. Selenium deficiency can be associated with increased susceptibility to some viral infections and even more severe diseases. In this study, we aimed to examine whether this association applies to severe fever with thrombocytopenia syndrome (SFTS). An observational study was conducted based on the data of 13,305 human SFTS cases reported in mainland China from 2010 to 2020. The associations among incidence, case fatality rate of SFTS, and crop selenium concentration at the county level were explored. The selenium level in a cohort of patients with SFTS was tested, and its relationship with clinical outcomes was evaluated. The association between selenium-deficient crops and the incidence rate of SFTS was confirmed by multivariate Poisson analysis, with an estimated incidence rate ratio (IRR, 95% confidence interval [CI]) of 4.549 (4.215−4.916) for moderate selenium-deficient counties and 16.002 (14.706−17.431) for severe selenium-deficient counties. In addition, a higher mortality rate was also observed in severe selenium-deficient counties with an IRR of 1.409 (95% CI: 1.061−1.909). A clinical study on 120 patients with SFTS showed an association between serum selenium deficiency and severe SFTS (odds ratio, OR: 2.94; 95% CI: 1.00–8.67) or fatal SFTS (OR: 7.55; 95% CI: 1.14–50.16). Selenium deficiency is associated with increased susceptibility to SFTS and poor clinical outcomes. This is special type of abstract that is so short and could be inserted after main abstract of article, as a blurb or inserted as annotations into a Table of contents [Display omitted] [ABSTRACT FROM AUTHOR]

The microvascular resistance reserve (MRR) is an innovative index to assess the vasodilatory capacity of the coronary circulation while accounting for the presence of concomitant epicardial disease. The MRR has shown to be a valuable diagnostic and prognostic tool in the general coronary artery disease (CAD) population. However, considering the fundamental aspects of its assessment and the unique hemodynamic characteristics of women, it is crucial to provide additional considerations for evaluating the MRR specifically in women. The aim of this study was to assess the diagnostic and prognostic applicability of the MRR in women and assess the potential differences across different sexes. From the ILIAS Registry, we enrolled all patients with a stable indication for invasive coronary angiography, ensuring complete physiological and follow-up data. We analyzed the diagnostic value by comparing differences between sexes and evaluated the prognostic value of the MRR specifically in women, comparing it to that in men. A total of 1494 patients were included of which 26% were women. The correlation between MRR and CFR was good and similar between women (r = 0.80, p < 0.005) and men (r = 0.81, p < 0.005). The MRR was an independent and important predictor of MACE in both women (HR 0.67, 0.47–0.96, p = 0.027) and men (HR 0.84, 0.74–0.95, p = 0.007). The optimal cut-off value for MRR in women was 2.8 and 3.2 in men. An abnormal MRR similarly predicted MACE at 5-year follow-up in both women and men. The MRR seems to be equally applicable in both women and men with stable coronary artery disease. • The correlation between MRR and CFR was good and similar between women (r = 0.80, p < 0.005) and men (r = 0.81, p < 0.005). • The MRR was an independent and important predictor of MACE in both women (HR 0.67, 0.47–0.96, p = 0.027) and men (HR 0.84, 0.74–0.95, p = 0.007). • The optimal cut-off value for MRR in women was 2.8 and 3.2 in men. • The MRR seems to be equally applicable in both women and men with stable coronary artery disease. [ABSTRACT FROM AUTHOR]

Patients with coronavirus disease 2019 (COVID-19) who have underlying malignancy have a higher mortality rate compared with those without cancer, although the magnitude of such excess risk is not clearly defined. We performed a systematic review and pooled analysis to provide precise estimates of the mortality rate among patients with both cancer and COVID-19. A systematic literature search involving peer-reviewed publications, preprints and conference proceedings up to July 16, 2020, was performed. The primary end-point was the case fatality rate (CFR), defined as the rate of death among patients with cancer and COVID-19. The CFR was assessed with a random effects model, which was used to derive a pooled CFR and its 95% confidence interval (CI). Fifty-two studies, involving a total of 18,650 patients with both COVID-19 and cancer, were selected for the pooled analysis. A total of 4243 deaths were recorded in this population. The probability of death was 25.6% (95% CI: 22.0%–29.5%; I2 = 48.9%) in this patient population. Patients with cancer who develop COVID-19 have high probability of mortality. Appropriate and aggressive preventive measures must be taken to reduce the risk of COVID-19 in patients with cancer and to optimally manage those who do contract the infection. • Patients with both cancer and coronavirus disease 2019 (COVID-19) have a higher mortality than reported in the overall COVID-19-positive population. • We aim to provide precise mortality estimates among patients with cancer and COVID-19. • Pooled case mortality rate was 25.6% (95% CI: 22.0%–29.5%; I2 = 48.9%). • Aggressive measures must be taken to reduce risk of infection in patients with cancer. [ABSTRACT FROM AUTHOR]

Background and Objective: Since the first case of the pneumonia caused by 2019 novel coronavirus (COVID-19) is found in Wuhan, there have been more than 70,000 cases reported in China. This study aims to perform the meta-analysis of risk factors for the case fatality rate (CFR) of the 2019 novel coronavirus (COVID-19).Design and Methods: We have searched PubMed, Google scholar and medRxiv for the cohort studies involving risk factors for the CFR of COVID-19. This meta-analysis compares the risk factors of CFR between fatal patients and non-fatal patients.Results: Two cohort studies are included in this study. After comparing the patients between fatal cases and non-fatal cases, several important factors are found to significantly increase the CFR in patients with COVID-19, and include the age ranging 60-70 (OR = 1.85; 95% CI = 1.62 to 2.11; P < .00001) and especially≥70 (OR = 8.45; 95% CI = 7.47 to 9.55; P < .00001), sex of male (OR = 1.88; 95% CI = 1.30 to 2.73; P = .0008), occupation of retirees (OR = 4.27; 95% CI = 2.50 to 7.28; P < .00001), and severe cases (OR = 691.76; 95% CI = 4.82 to 99,265.63; P = .01). As the advancement of early diagnosis and treatment, the CFR after January 21 (or 22), 2020 is substantially decreased in COVID-19 than before (OR = 0.21; 95% CI = 0.19 to 0.24; P < .00001).Conclusions: Several factors are confirmed to significantly improve the CFR in patients with COVID-19, which is very important for the treatment and good prognosis of these patients. [ABSTRACT FROM AUTHOR]

• An extensively-drug-resistant Streptococcus suis isolate, SFJ44, was isolated from the nasal swab of an asymptomatic pig in Jiangsu, China in 2017. • This isolate harboured the phenicol-oxazolidinone resistance genes optrA and cfr , and the bacitracin resistance locus bcrABDR. • Circular intermediates of bcrABDR -IS Enfa1 were observed. • This isolate had a virulence level comparable to S. suis serotype 2 hypervirulent strain SC070731. One hundred and seven Streptococcus suis isolates were collected from healthy pigs or asymptomatic carriers in Jiangsu, China in 2016–2017. Thirty-eight percent of the isolates were linezolid-resistant and all carried the optrA gene. Among them, one isolate, SFJ44, was resistant to all 20 of the antibiotics tested, except for ceftiofur, and thus exhibited an extensively-drug-resistant phenotype. This isolate carried the optrA gene and the bacitracin resistance locus bcrABDR on an antibiotic-resistance-associated genomic island (ARGI1), and harboured the resistance genes cfr, aadE, sat4, spw -like, aphA3, mef (A) , msr (D) , erm (A)-like, erm (B), tetAB (P)', tet (M) and catQ on ARGI2∼4. The IS 1216E - bcrABDR -IS Enfa1 segment showed >99.9% sequence identity to corresponding sequences from other species. The cfr gene was located on ARGI4, and two IS 6 family insertion sequences, IS 1216E and IS Teha2 , were found upstream and downstream of cfr -ΔIS Enfa5 , respectively. A circular intermediate of bcrABDR -IS Enfa1 was detected, suggesting the role of IS Enfa1 in dissemination of bcrABDR. Other antibiotic resistance genes might be acquired from different Gram-positive pathogens. Infection of zebrafish showed that SFJ44 exhibited a virulence level comparable to serotype 2 hypervirulent strain SC070731, highlighting the need for surveillance of the pathogenicity of multi-drug-resistant S. suis isolates. This is the first report of the co-existence of optrA and cfr , and of the bcrABDR locus in streptococci. As it has been suggested that S. suis may act as an antibiotic resistance reservoir contributing to the spread of resistance genes to major streptococcal pathogens, the potential dissemination of these resistance genes among Gram-positive bacteria is of concern and routine surveillance should be strengthened. [ABSTRACT FROM AUTHOR]

The aim of this work was to study the influence of a high efficient halogen-free phenylphosphonic amide flame retardant (FP1) to epoxy resin (brand name RTM6) on the rheological, mechanical and water absorption properties of the carbon fiber/RTM6 epoxy composite (CFR). With a 8 wt% loading FP1 in RMT6, the processing of CFR/FP1 was able to use the equal condition with that of CFR since the viscosity of RTM6 was maintained at a similar level in the minimum viscosity temperature region. The addition of FP1 showed negligible impacts on the interlayer share strength (ILSS) and in-plane share strength (IPSS) of CFR. The interfacial strength between RTM6 matrix and carbon fiber was decreased due to the impact of FP1 on cross-linking density and polarity of RTM6. The flame retardant efficiency of FP1 showed difference in presence of carbon fiber or not in RTM6. RTM6/FP1 (8 wt%) had a LOI value of 38%, achieved a V-0 rating at thickness of 3.2 mm in UL 94 test and showed 60% reduction in peak of heat release rate. RTM6/carbon fiber/FP1 (8 wt%) had a LOI of 43%, while it showed reduced performance in UL 94 and cone calorimeter tests. [ABSTRACT FROM AUTHOR]

This paper proposes the application of curve-fitting regression (CFR) to wavelength-dispersive X-ray fluorescence as a novel way to quantify traces of heavy metals in pharmaceutical products. This approach compares favorably with traditional (e.g. ordinary least squares regression: OLS) and multivariate (e.g. partial least squares regression: PLS) methodologies. This work compares OLS, PLS and CFR regression using 4 performance indicators (R 2 cal , RMSEC, R 2 val and RMSEP) for the quantification of heavy metals in 7 pharmaceutical powders, each spiked with 3 heavy metals (nickel, cadmium and lead). Several t -tests were then performed on repeat samplings (obtained by bootstrapping) of these performance indicators to determine how CFR compares to the reference methods (OLS and PLS). CFR was found to outperform both OLS and PLS, as per unilateral t -tests with α  = 0.025, for the quantification of 86% of the datasets analyzed in this work. The overall absolute error for CFR in validation varies between 3 and 5 ppm depending on the heavy metal analyzed. [ABSTRACT FROM AUTHOR]

Abstract The cfr gene associated with linezolid resistance has attracted wide attention. However, little is known about its prevalence and mode of transmission in Enterococcus faecalis. In this study, we investigate the prevalence and genetic environment of the cfr gene in 91 E. faecalis isolates collected from swine faecal swabs in 30 farms in Guangdong Province, China in 2012. A relatively high prevalence of cfr was identified in E. faecalis isolates (11/91, 12.1%) by PCR. All the cfr- positive E. faecalis strains had a multidrug-resistance phenotype including erythrocin, tetracycline, gentamicin, kanamicin and ciprofloxacin, except vancomycin and linezolid. Molecular typing indicated that ST475 and ST16 were the most common types in cfr- positive E. faecalis strains. In addition, we demonstrated that all the cfr genes were located on plasmids by S1 -PFGE and Southern blotting. A 12 kb cfr- positive plasmid (pE30) was identified in most (9/11) E. faecalis strains, but it couldn't mediate resistance to linezolid in the transconjugant. Sequence analysis showed that the pE30 was a pCPPF5-like plasmid and the region surrounding the cfr gene was the same as a cfr -carrying IS Enfa5 -composite element in Streptococcus plasmid pStrcfr with 4 bp direct repeat (GTAT) on both sides. In conclusion, the cfr gene which had no linezolid resistance phenotype was present in multidrug-resistance E. faecalis strains, and the clonal spread of ST475 and ST16 strains and the horizontal transfer of the pCPPF5-like plasmids have contributed to the dissemination of cfr. Highlights • A relatively high prevalence of cfr was found in E. faecalis isolates from swine in China. • A prevent cfr -carrying pCPPF5-like plasmids was found and it contributed to 'non-linezolid resistance' phenotype in E. faecalis isolates. [ABSTRACT FROM AUTHOR]

The objective of this study was to investigate the prevalence of the cfr gene in Escherichia coli isolates from domestic animals in Northeast China and to characterize the cfr -containing plasmids. Between June 2015 and April 2016, 370 E. coli isolates were collected from pigs, chickens, and dairy cows in Northeast China. Among these, 111 were florfenicol resistant, including 109 isolates carrying the floR gene and 6 positives for cfr . The prevalence of cfr in E. coli isolates from the four northeast provinces in China was 1.6% (6/370), which was higher than that previously reported (0.08% and 0.5%). All six cfr -containing E. coli isolates were highly resistant to florfenicol (100%), cefotaxime (100%), and fosfomycin (100%). Complete sequence analysis of two cfr -carrying plasmids revealed high homology of the IncX4-type pEC14cfr plasmid with two other cfr -harboring plasmids, pSD11 and pGXEC6, found in swine E. coli isolates from southern China. pEC14cfr-like plasmids have been isolated in five provinces in southern and northern China. The isolation sites were up to 2700 kilometers apart, implying that pEC14cfr-like plasmids are likely to be national epidemic cfr -carrying plasmids that mediate the dissemination of cfr in China. Moreover, the genetic structure (IS 26 -IS 26 - cfr - rec - pre/mob - ramA -IS 26 ) of the second cfr -carrying plasmid, IncF14:A-:B- pEC295cfr, represents a novel genetic environment for cfr identified for the first time in the present study. Sequence homology analysis indicated that the cfr -carrying element was most likely introduced into a cfr -negative pEC12 plasmid backbone, which evolved into the cfr -carrying vector, pEC295cfr. Moreover, isolation of the IncF14:A-:B- pEC295cfr plasmid harboring cfr suggests that IncFII plasmids maybe have become additional effective vehicles for cfr dissemination. These results highlight the importance of surveying the prevalence of IncX4 and IncFII plasmids in gram-negative bacteria, especially in swine E. coli isolates. [ABSTRACT FROM AUTHOR]

The Cfr methyl transferase causes an RNA methylation of the bacterial ribosomes impeding reduced or abolished binding of many antibiotics acting at the peptidyl transferase center. It provides multi-resistance to eight classes of antibiotics, most of which are in clinical and veterinary use. The cfr gene is found in various bacteria in many geographical locations and placed on plasmids or associated with transposons. Cfr-related genes providing similar resistance have been identified in Bacillales, and now also in the pathogens Clostridium difficile and Enterococcus faecium . In addition, the presence of the cfr gene has been detected in harbours and food markets. [ABSTRACT FROM AUTHOR]

A novel transferable oxazolidinone-phenicol resistance gene, optrA , which confers resistance to linezolid, the next-generation oxazolidinone tedizolid, and also to chloramphenicol and florfenicol, has been identified in enterococcal and staphylococcal species. Here, we investigated the epidemiology of optrA in florfenicol-resistant Staphylococcus spp. isolates of pig origin, and characterized the genetic context of oxazolidinone resistance genes in 20 optrA -positive florfenicol- and methicillin-resistant S. sciuri isolates, 11 (55%) of which also harbored the multi-resistance gene cfr . Pulsed-field gel electrophoresis and direct repeat unit ( dru ) typing of the 20 optrA -positive S. sciuri isolates revealed 17 patterns and four distinct dru types, respectively. Nine and six different arrangements of the optrA and cfr gene regions, respectively, were identified among the isolates. The arrangements optrA - araC -Tn 558 or optrA -ΔTn 558 were present in all optrA -positive isolates, and in three of them, IS Enfa5 and cfr were located immediately downstream of optrA . The cfr -carrying segment in eight isolates was similar to the corresponding region of the staphylococcal plasmid pWo28-3, in which the coexistence of cfr and optrA was identified for the first time. [ABSTRACT FROM AUTHOR]

Conservation biologists and ecologists often make use of models to identify important biotic and abiotic factors that constrain species distributions for conservation decisions to be taken. In line with such practices, we developed species distribution models for four localized, Cape Floristic Region (CFR) endemic, flightless, congeneric Euloryma grasshopper species. We chose this group as use of these models has been little explored for narrow range endemics with specific traits. Euloryma larsenorum and E. lapollai are associated with fynbos only, while E. umoja and E. ottei are both associated with fynbos and vineyards. We used the Maximum Entropy algorithm, which showed that vegetation type and soil characteristics were the most important environmental factors affecting local distribution of Euloryma species in the CFR. The models also showed that Euloryma species have a very narrow habitat suitability range in the CFR. We also showed that there are no significant differences in the distribution of species associated with fynbos only as well as those associated with both fynbos and vineyards. E. larsenorum and E lapollai are likely to be the most affected species in the event of further habitat transformation from fynbos to agricultural production. This is not likely to be the case for E. umoja and E. ottei which can tolerate agriculture environment, although they might survive both sets of environments in accordance with their life history traits. [ABSTRACT FROM AUTHOR]

Abstract Linezolid-resistant enterococcus spp. are increasingly recognized by diagnostic laboratories. Resistance can be mediated by the expression of cfr, optrA or poxtA. We developed a multiplex-PCR to simultaneously detect all three genes. The PCR is suitable for microbiological diagnostics in order to restrict further spread of resistances in enterococci. [ABSTRACT FROM AUTHOR]

Rationale Sirtuin (SIRT3), a major nicotinamide adenine dinucleotide (NAD + )-dependent deacetylase in mitochondria, declines with aging and its ablation is associated with accelerated development of cardiovascular diseases. However, the role of SIRT3 in coronary microvascular function and post-MI recovery has not been completely understood. Objective The goal was to investigate whether ablation of SIRT3 causes coronary microvascular dysfunction, exacerbates post-myocardial ischemia (MI) cardiac dysfunction and impairs cardiac recovery. Methods and results Using endothelial cells (ECs) isolated from SIRT3 knockout (KO) mice, we revealed that the angiogenic capabilities were significantly reduced in SIRT3 deficient ECs. SIRT3 KO mice presented a pre-existing coronary microvascular dysfunction and microvascular rarefaction, as evidenced by a reduction in hyperemic peak diastolic blood flow velocity and coronary flow reserve (CFR), accompanied by loss of capillary-pericytes in the heart. Furthermore, SIRT3 KO mice subjected to myocardial ischemia by the ligation of left anterior descending coronary artery (LAD) exhibited more severe cardiac dysfunction together with decreased pericyte/EC coverage than that of wild type (WT) mice. In contrast, overexpression of SIRT3 preserved cardiac function in post-MI mice. Immunoblot analysis further showed that the expression of angiopoietin-1 (Ang-1), vascular endothelial growth factor (VEGF) and 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3 (PFKFB3) were significantly decreased in the SIRT3-deficient ischemic hearts than those of WT ischemic hearts. This was accompanied by higher levels of cleaved caspase-3 and apoptosis. Conclusion Our results reveal a potential mechanism by which SIRT3 deletion exacerbates post-MI cardiac dysfunction and impairment of cardiac recovery involving microvascular rarefaction and pre-existing coronary microvascular dysfunction. [ABSTRACT FROM AUTHOR]

Slow crystallization kinetics and a limited thermodynamical stability of the target crystal phase are characteristic to zeolite formation, representing some of the key obstructions for fast zeolite synthesis. In this paper, the possibility of accelerating NaA zeolite synthesis in a continuous flow reactor (CFR) is studied. The CFR reduces the thermal lag by increasing surface to volume ratio, expediting heat transfer and mass transfer. The properties of the CFR and the reference batch synthesized particles were similar as confirmed by X-ray diffraction, scanning electron microscopy, particle size measurement using laser scattering and water adsorption equilibria. The reduced residence time and reduction in thermal lag provided an ideal synthesis environment for NaA zeolite, without side products, yielding 160 g/h per liter reactor volume of dry NaA crystals synthesized in 16 min and 2–3 μm particles for a single CFR. In comparison, the batch process produces 33 g/h per liter reactor volume The effects of diluting with NaOH-solution and temperature were studied in the CFR, allowing to determine the optimal conditions. With the enhanced reaction kinetics gained from the increased temperature and molar composition, NaA synthesis is performed 10 times faster than in the optimal batch synthesis. The optimal conditions for the synthesis of NaA in the CFR were determined as: a gel composition of Na 2 O :4.75 – SiO 2 :1.93 – Al 2 O 3 :1.0 – H 2 O :192, at a synthesis temperature of 150 °C during 16 min without, aging of the gel mixture. This paper shows that the bottlenecks in NaA zeolite synthesis can be widened resulting in faster synthesis in a CFR, making it a feasible pathway for more controllable zeolite synthesis at higher mass production rates (160 g/(h l-reactor)) while reducing the risk of blockage in a continuous flow reactor. [ABSTRACT FROM AUTHOR]

The in vitro activity and spectrum of tedizolid and comparators were analyzed against 6884 Gram-positive clinical isolates collected from multiple US and European sites as part of the Surveillance of Tedizolid Activity and Resistance Program in 2011 and 2012. Organisms included 4499 Staphylococcus aureus , 537 coagulase-negative staphylococci (CoNS), 873 enterococci, and 975 β-hemolytic streptococci. The MIC values that inhibited 90% of the isolates within each group (MIC 90 ) were 0.25 μg/mL for Staphylococcus epidermidis and β-hemolytic streptococci and 0.5 μg/mL for S . aureus , other CoNS, and enterococci. Of 16 isolates with elevated tedizolid or linezolid MIC values (intermediate or resistant isolates), 10 had mutations in the genes encoding 23S rRNA (primarily G2576T), 5 had mutations in the genes encoding ribosomal proteins L3 or L4, and 5 carried the cfr multidrug resistance gene. Overall, tedizolid showed excellent activity against Gram-positive bacteria and was at least 4-fold more potent than linezolid against wild-type and linezolid-resistant isolates. Given the low overall frequency of isolates that would be resistant to tedizolid at the proposed break point of 0.5 μg/mL (0.19%) and potent activity against contemporary US and European isolates, tedizolid has the potential to serve as a valuable therapeutic option in the treatment of infections caused by Gram-positive pathogens. [ABSTRACT FROM AUTHOR]

There is an association between preeclampsia (PE) and excessive morbidity and mortality. Some recent studies have revealed the presence of endothelial dysfunction in PE patients with inflammatory activity. Moreover, it has been argued that the chronic inflammatory state involved in PE leads to an acceleration in atherosclerosis. Accordingly, our goal in this study is to determine whether there is any coronary microvascular dysfunction and increase in the intima–media thickness in patients who had mild PE 5 years before, without the presence of any traditional cardiovascular risk factors. The study included 33 mild PE patients (mild preeclampsia is classified as a blood pressure (BP) of 140/90 mm Hg or higher with proteinuria of 0.3 to 3 g/d) whose mean age was 33.7 years old, and 29 healthy women volunteers whose mean age was 36.1 years old. Each subject was examined using transthoracic echocardiography 5 years after their deliveries. During the echocardiographic examination, coronary flow reserve (CFR) and carotid intima–media thickness (IMT) were measured. There was a statistically lower CFR value in PE patients as compared with controls (2.39 ± 0.48 vs. 2.90 ± 0.49; P < .001). On the other hand, there was a significant increase in their IMT and high–sensitivity C–reactive protein (hs–CRP) values (respectively, 0.59 ± 0.15 vs. 0.46 ± 0.10; P < .001 and 3.80 ± 2.10 vs. 2.33 ± 1.79; P = .004). There was a negative correlation between the CFR values of the PE patients and hs-CRP (r = −0.568; P = .001) and IMT (r = −0.683, P < .001) results.We determined in the study that there was impaired CFR and increased carotid IMT in patients with PE, and, moreover, that these adverse effects were significantly correlated with hs-CRP. [ABSTRACT FROM AUTHOR]

• Identified occurrence of cfr -positive ST398 LA-MRSA and non-aureus staphylococci (NAS) in a pig farm. • The cfr -mediated linezolid resistance was more prominent in NAS, particularly in S. epidermidis. • Comparative genome analyses of ST398 LA-MRSA and NAS confirmed the presence of a 38-kb plasmid containing cfr and fexA. • First report of co-existence of cfr -positive ST398 LA-MRSA and NAS in a pig farm. Linezolid resistance, mediated by the cfr gene, which confers resistant phenotypes to phenicols, lincosamides, oxazolidinones, pleuromutilins, and streptogramin A antimicrobials, has emerged in S. aureus and non- aureus staphylococci (NAS). Moreover, due to the transferable potential via plasmids, the spread of cfr among staphylococci is of great concern. In the present study, we investigated the prevalence of cfr -mediated linezolid resistance in ST398 methicillin-resistant S. aureus (MRSA) and NAS strains isolated from a pig farm. Among the 26 staphylococci isolates collected from a pig farm, 14 cfr -harboring ST398 MRSA and NAS (S. epidermidis , S. pasteuri , S. cohnii , and S. rostri) strains were resistant to linezolid and also carried the fexA gene. Comparative genome analysis of cfr -carrying linezolid-resistant ST398 MRSA and NAS (S. pasteuri , S. cohnii , and S. epidermidis) strains revealed that the segments harboring cfr in different staphylococcal strains showed ≥ 99 % sequence identity and the corresponding region containing the cfr , fexA , and Tn 558 elements were located in a 38-kb plasmid, designated pSA12 of ST398 MRSA. These observations indicate that the cfr -carrying plasmids and/or fragments may be disseminated among staphylococci in a pig farm and possibly transmitted to staphylococci of human origin, subsequently posing a threat to public health. This is the first report of the co-existence of cfr in linezolid-resistant ST398 MRSA and NAS isolated from a pig farm in South Korea. [ABSTRACT FROM AUTHOR]

Abstract: Coronary Artery Disease (CAD) is responsible for most of the deaths in patients with cardiovascular diseases. Diagnostic coronary angiography analysis offers an anatomical knowledge of the severity of the stenosis. The functional or physiological significance is more valuable than the anatomical significance of CAD. Clinicians assess the functional severity of the stenosis by resorting to an invasive measurement of the pressure drop and flow. Hemodynamic parameters, such as pressure wire assessment fractional flow reserve (FFR) or Doppler wire assessment coronary flow reserve (CFR) are well-proven techniques to evaluate the physiological significance of the coronary artery stenosis in the cardiac catheterization laboratory. Between the two techniques mentioned above, the FFR is seen as a very useful index. The presence of guide wire reduces the coronary flow which causes the underestimation of pressure drop across the stenosis which leads to dilemma for the clinicians in the assessment of moderate stenosis. In such condition, the fundamental fluid mechanics is useful in the development of new functional severity parameters such as pressure drop coefficient and lesion flow coefficient. Since the flow takes place in a narrowed artery, the blood behaves as a non-Newtonian fluid. Computational fluid dynamics (CFD) allows a complete coronary flow simulation to study the relationship between the pressure and flow. This paper aims at explaining (i) diagnostic modalities for the evaluation of the CAD and valuable insights regarding FFR in the evaluation of the functional severity of the CAD (ii) the role of fluid dynamics in measuring the severity of CAD. [Copyright &y& Elsevier]

Abstract: A novel series of 3-O-carbamoyl erythromycin A derived analogs, labeled carbamolides, with activity versus resistant bacterial isolates of staphylococci (including macrolide and oxazolidinone resistant strains) and streptococci are reported. An (R)-2-aryl substituent on a pyrrolidine carbamate appeared to be critical for achieving potency against resistant strains. Crystal structures showed a distinct aromatic interaction between the (R)-2-aryl (3-pyridyl for 4d) substituent on the pyrrolidine and G2484 (G2505, Escherichia coli) of the Deinococcus radiodurans 50S ribosome (3.2Å resolution). [Copyright &y& Elsevier]

Abstract: The multidrug-resistance gene cfr was detected in coagulase-negative staphylococci from 3/401 pigs, 15/305 chickens, and 3/78 ducks from 31 different farms and one slaughterhouse in 2 provinces of China. Twenty of the 21 cfr-positive isolates were methicillin-resistant. Various SmaI-PFGE patterns were observed among the isolates of the same staphylococcal species and suggested horizontal transfer of cfr rather than clonal expansion. The detection of cfr on plasmids in the majority of the isolates supported this assumption. Analysis of the drug usage records of the farms strongly correlated with the resistance patterns of the cfr-positive isolates and suggested that antimicrobial use on farms supports the spread of the cfr gene. [Copyright &y& Elsevier]

Abstract: The LEADER program monitors the in vitro activity of linezolid and comparator agents across the United States using reference broth microdilution and supportive molecular susceptibility-based investigations. This report summarizes the data from the 2010 program, the seventh consecutive year. A total of 61 medical centers from the USA including 7 medical centers specializing in children''s healthcare provided a total of 6801 Gram-positive pathogens. The medical centers represented all 9 US Bureau of Census geographic regions. The organisms tested by reference broth microdilution were 3105 Staphylococcus aureus, 944 coagulase-negative staphylococci (CoNS), 934 Enterococci, 803 Streptococcus pneumoniae, 604 β-haemolytic streptococci, and 411 viridans group and other streptococci. The MIC90 value for each of the above 6 targeted groups of organisms was 1 μg/mL. The “all organism” linezolid-resistant and nonsusceptible rate was 0.38%, which has been constant at 0.34% (2009) to 0.45% (2006) for the last 4 years. For Staphylococcus aureus, only 0.06% of the isolates were linezolid-resistant (MIC, ≥8 μg/mL); however, 2 additional methicillin-resistant Staphylococcus aureus had a cfr and a MIC of only 4 μg/mL. Resistance to linezolid was detected in 7 enterococci (0.75%) and 14 CoNS isolates (1.48%). This also represents a stable rate of resistance noted since the 2006 LEADER program report. Of note, for the first time in the 7 years of the Leader Program a linezolid-resistant Streptococcus pneumoniae was encountered. Overall, the results of the LEADER program demonstrate that linezolid maintains excellent in vitro activity against target Gram-positive pathogens across the USA. The LEADER program continues to provide valuable reference and molecular-level monitoring of linezolid activity. [Copyright &y& Elsevier]

Abstract: Assessment of coronary flow reserve (CFR) with a commercially available pressure-sensor-tipped guide wire using the principle of thermal anemometry could provide major clinical benefits both in determining and in distinguishing between epicardial and microvascular coronary artery disease. In constant-temperature thermal anemometry, the electrical power required to maintain an element at a constant temperature is a measure for the local shear rate. Here, the feasibility of applying this thermoconvection method to a pressure-sensing guide wire is investigated using an in vitro model. A theoretical relation between electrical power and steady shear rate based on boundary layer theory was tested in an experimental set-up. In steady flow, a reproducible relation between electrical power and shear rate was obtained with an overheat temperature of 20K, which was in good agreement with theory. The relation between shear rate and flow, however, depends on geometry of the artery and position of the guide wire inside the vessel. Although this means that this thermoconvection method is less useful for absolute flow measurements, CFR could be assessed even for unsteady flow using the steady calibration curve with a mean relative difference of (3±5)% compared to CFR derived from the golden standard using an ultrasonic flow measurement device. [Copyright &y& Elsevier]

Abstract: The seventh year of the Zyvox® Annual Appraisal of Potency and Spectrum Program (2008) continues to monitor the in vitro activities of linezolid and comparator agents tested against Gram-positive pathogens in Latin America, Europe, Canada, and the Asia-Pacific region. Linezolid is an oxazolidinone approved for the treatment of vancomycin-resistant Enterococcus faecium infections, complicated skin and soft tissue infections, and nosocomial pneumonia caused by various Gram-positive species including methicillin-resistant Staphylococcus aureus (MRSA). Surveillance isolates were submitted from 64 medical centers (24 countries) for a total of 6121 strains. Each country was requested to send 200 consecutive isolates in 6 targeted pathogen categories to a central processing laboratory, except the United Kingdom, Japan, and China where more strains were processed (400, 400, and 800, respectively). Reference broth microdilution susceptibility testing methods were used to test the following organism groups: S. aureus (3240), coagulase-negative staphylococci (CoNS) (748), enterococci (864), Streptococcus pneumoniae (655), viridans group (297), and β-hemolytic streptococci (317). Eight linezolid-resistant (LZD-R) isolates were detected in 7 countries (Italy [2], France, China, Brazil, Sweden, Germany, and United Kingdom) among the enterococci (Enterococcus faecalis [3] and E. faecium [2]) and CoNS (3 Staphylococcus epidermidis). Five LZD-R isolates contained 23S rRNA mutations (G2576T or G2447T), and 2 strains had undeterminable resistance mechanisms. One CoNS (Italy) contained the mobile cfr gene. Vancomycin-resistant enterococci rates ranged from 0.0% in several countries to 59.4% in Taiwan. All streptococci were linezolid susceptible (MIC90, 1 μg/mL). In conclusion, the activity of linezolid remained uniform and stable across the sampled geographic regions studied when compared to the 2006 to 2007 results. Documented LZD-R remains rare (only 0.13% overall but highest for CoNS [0.41%] and enterococci [0.69%]) among the 24 countries sampled for the 6 different pathogen groups. Rates of clindamycin resistance and the frequency of MRSA varied by geographic region and between nations; therefore, like oxazolidinones, it requires continued surveillance for changing resistance patterns. [Copyright &y& Elsevier]

Abstract: The LEADER Program was initiated in 2004 and monitors emerging linezolid resistance in sampled US medical centers. This report summarizes the data obtained in 2008, the 5th consecutive year. A total of 57 institutions participated in 2008 representing all 9 US census regions with 100 target organisms per site (6113 isolates, 101.9% compliance to protocol design). The organisms tested by reference broth microdilution methods were Staphylococcus aureus (3156), coagulase-negative staphylococci (CoNS; 856), enterococci (901), Streptococcus pneumoniae (619), and viridans group (223) or β-hemolytic streptococci (358); also, D-test was used to determine inducible clindamycin resistance in Staphylococcus aureus. Linezolid remained very potent against all sampled species with MIC90 results ranging from 1 μg/mL (streptococci and CoNS) to 2 μg/mL (Staphylococcus aureus and enterococci). Only 0.36% of sampled strains were nonsusceptible to linezolid, a slight decrease from 0.45% and 0.44% in 2006 and 2007, respectively. The nonsusceptible strains (22) were Staphylococcus aureus (3), CoNS (14), and Enterococcus faecium (5) each with defined target mutations (G2576T in 19 strains; T2504A in 1 strain), mobile cfr element (1 strain Staphylococcus epidermidis with an identical pulsed-field gel electrophoresis pattern to a cfr-positive Staphylococcus epidermidis isolated from the same center in LEADER 2007), or an unknown (1 strain) mechanism. The mobile cfr resistance found in a Staphylococcus aureus strain in 2007 was not observed in 2008. In conclusion, linezolid activity sampled by the 5th year of this LEADER Program showed sustained potency and spectrum (99.64% susceptibility levels). The nonsusceptible strain isolation rates remained stable and the plasmid-mediated ribosomal-based resistance mechanism that emerged in Staphylococcus aureus and Staphylococcus epidermidis strains in 2007 showed no evidence of dissemination or increased prevalence. However, there was evidence of cfr persistence with the S. epidermidis strain. The LEADER Program continues to be an effective and sensitive surveillance tool to detect and monitor novel oxazolidinone resistance phenotypes and genotypes. [Copyright &y& Elsevier]

Staphylococcus aureus is an important food-related pathogen associated with bacterial poisoning that is difficult to treat due to its multidrug resistance. The cfr and lsa (E) genes both cause multiple drug resistance and have been identified in numerous Staphylococcus species, respectively. In this study, we found that a methicillin-resistant S. aureus (MRSA) strain, 2868B2, which was isolated from a sample of frozen dumplings in Hangzhou in 2015, co-carried these two different multidrug resistance genes. Further analysis showed that this strain was resistant to more than 18 antibiotics and expressed high-level resistance to florfenicol, chloramphenicol, clindamycin, tiamulin, erythromycin, ampicillin, cefepime, ceftazidime, kanamycin, streptomycin, tetracycline, trimethoprim-sulfamethoxazole and linezolid (MIC = 8 μg/mL). Whole genome sequencing was performed to characterize the genetic environment of these resistance genes and other genomic features. The cfr gene was located on the single plasmid p2868B2 (39,159 bp), which demonstrated considerable similarity to many plasmids previously identified in humans and animals. p2868B2 contained the insertion sequence (IS) element IS 21–558 , which allowed the insertion of cfr into Tn 558 and played an important role in the mobility of cfr. Additionally, a novel multidrug resistance region (36.9 kb) harbouring lsa (E) along with nine additional antibiotic resistance genes (ARGs) (aadD , aadE , aacA-aphD , spc , lnu (B), lsa (E), tetL , ermC and blaZ) was identified. The multidrug resistance region harboured four copies of IS 257 that were active and can mediate the formation of four circular structures containing ARGs and ISs. In addition, genes encoding various virulence factors and affecting multiple cell adhesion properties were identified in the genome of MRSA 2868B2. This study confirmed that the cfr and lsa (E) genes coexist in one MRSA strain and the presence of plasmid and IS 257 in the multi-ARG cluster can promote both ARG transfer and dissemination. Furthermore, the presence of so many ARGs and virulence genes in food-related pathogens may seriously compromise the effectiveness of clinical therapy and threaten public health, its occurrence should pay public attention and the traceability of these genes in food-related samples needs further surveillance. • The MDR genes cfr and lsa (E) were emerged simultaneously in one food-related MRSA for the first time. • The lsa (E)-carrying MRR was a novel structure and that was active. • This MRSA isolate harbours 16 important known ARGs in addition to cfr and lsa (E) and virulence determinants. [ABSTRACT FROM AUTHOR]

Abstract: Background: Rheumatoid arthritis (RA) is associated with excessive cardiovascular mortality. Recently, some studies have shown endothelial dysfunction in RA patients with high inflammatory activity. In addition, it has been suggested that the chronic inflammatory state of RA contributes to accelerated atherosclerosis. Therefore, we aimed to evaluate whether coronary microvascular dysfunction and increased carotid artery intima-media thickness exist in patients with a long history and well controlled disease activity of RA lacking traditional cardiovascular risk factors. Methods: Thirty RA patients (22 women; mean age 43.7±9.0) and 52 healthy volunteers (38 women; mean age 45.3±5.4) were included into the study. Using transthoracic echocardiography, each subject underwent echocardiographic examination including coronary flow reserve (CFR) and carotid intima-media thickness (IMT) measurement. Results: CFR values were statistically reduced for RA patients as compared to controls (2.4±0.5 vs. 2.7±0.4, P =0.002) whereas IMT values were significantly increased (0.6±0.1 vs. 0.5±0.1, P =0.001). In RA patients, CFR positively correlated with lateral Em/Am ratio (r =0.399, P =0.029), and negatively correlated with lateral isovolumic relaxation time (IVRT) (r =−0.744, P =0.005), IMT (r =−0.542, P =0.002) and RA disease duration (r =−0.495, P =0.005). Reflecting LV diastolic function, mitral E-wave deceleration time and isovolumic relaxation time were borderline significant between the groups, however lateral Em/Am ratio and lateral IVRT were statistically different. Conclusions: Patients with RA had impaired CFR and increased carotid IMT, and these injurious effects correlated significantly with disease duration. [Copyright &y& Elsevier]

: ObjectivesThe goal of this study was to detect transplant arteriopathy (Tx-CHD) by a reduced myocardial perfusion reserve (MPR) and resting endomyocardial/epimyocardial perfusion ratio (Endo/Epi ratio).: BackgroundTransplant arteriopathy often lacks clinical symptoms and is the reason for frequent surveillance angiography in heart transplant (Tx) recipients. Magnetic resonance perfusion imaging (MRPI) allows noninvasive assessment of transmural and selective endomyocardial and epimyocardial perfusion.: MethodsFifteen healthy volunteers (controls) and three groups (A, B, C) of Tx recipients were included. In controls and patients, MPR (hyperemic/resting perfusion) and Endo/Epi ratio were determined with MRPI after injection of gadolinium-diethylenetriamine pentaacetic acid at rest and during hyperemia (intravenous adenosine). Group A (n = 10) had no left ventricular (LV) hypertrophy and/or prior rejection, while patients in group B (n = 10) had at least one of these characteristics. Patients in group A and B had a normal coronary angiogram and a coronary flow reserve (CFR) of ≥2.5 (CFR = hyperemic/resting blood flow). Group C (n = 7) had Tx-CHD diagnosed by angiography and a reduced CFR (<2.5).: ResultsIn group C, MPR (1.7 ± 0.5) and Endo/Epi ratio (1.1 ± 0.2) were significantly reduced compared with controls (4.2 ± 0.7 and 1.6 ± 0.3; both p < 0.0001), group A (3.6 ± 0.7 and 1.6 ± 0.2; both p < 0.0001) and B (2.7 ± 0.9, p < 0.01 and 1.4 ± 0.1, p < 0.04). Transplant arteriopathy can be excluded by an MPR of >2.3 with sensitivity and specificity of 100% and 85%. If LV hypertrophy and prior rejection are excluded, Tx-CHD can be excluded by an Endo/Epi ratio of >1.3 with 100% and 80%.: ConclusionsMagnetic resonance perfusion imaging detects Tx-CHD by a decreased MPR. After exclusion of LV hypertrophy and prior rejection, resting Endo/Epi ratio alone might be sufficient to indicate Tx-CHD. [Copyright &y& Elsevier]

: ObjectivesWe sought to assess the clinical features of transient left ventricular (LV) apical ballooning.: BackgroundAlthough several cases regarding transient LV apical ballooning have been reported, the etiology remains unknown.: MethodsWe investigated 17 patients (14 women, median age 74 years old with a range of 54 to 91 years old) who fulfilled the following criteria: 1) transient LV apical ballooning; 2) ST-T segment change in several leads in electrocardiogram; and 3) no history of old myocardial infarction, valvular heart disease, subarachnoid hemorrhage, or pheochromocytoma.: ResultsEmotional and physical stress were observed in 16 patients (94%). Technetium-99m tetrofosmin tomographic imaging revealed decreased uptake at the apex of the left ventricle in 11 patients (85%) that later returned to uniform. No significant stenosis or angiographical slow flow in epicardial coronary arteries was observed (n = 9). Provocative focal vasospasm was induced in only one patient (14%) (n = 7). Moreover, no significant abnormality in the coronary microcirculation was detected by Doppler guidewire (n = 3) or contrast echocardiography (n = 1). No patients showed a rise in viral antibody titers. Biopsy specimens revealed interstitial fibrosis in six patients (100%) and slight cell infiltration in three others (50%) (n = 6).: ConclusionsThese findings suggested that neither abnormalities in the coronary circulation nor acute myocarditis was related to the etiology. Although neurogenic stunned myocardium induced by emotional or physical stress was suggested as the etiology, further investigations are necessary. [Copyright &y& Elsevier]

: ObjectivesThe purpose of this study was to assess rest and stress atrial coronary blood flow (CBF) velocity and flow reserve.: BackgroundBecause of the limitations of the methods used until now for assessing myocardial perfusion (MP) in the small mass of atrial tissue, data are lacking for human atrial MP.: MethodsSeventeen patients with suitable coronary anatomy underwent CBF velocity measurements with the use of a Doppler guide wire in the proximal left circumflex coronary artery (LCx) and left atrial circumflex branch (LACB), at baseline and after adenosine administration. All measurements were performed at resting heart rate and at 100 and 120 beats/min.: ResultsCoronary blood flow velocity in the LACB showed a predominant systolic pattern in contrast to the diastolic pattern of the LCx. There was a disproportionate increase in baseline time-averaged peak coronary flow velocity (cm/s) between the LACB and LCx during the two levels of pacing-induced stress (16.8 ± 5.5 vs. 16.2 ± 5.1 at rest; 22.9 ± 7.9 vs. 18.4 ± 5.2 at 100 beats/min; and 27.1 ± 8.0 vs. 20.4 ± 5.1 at 120 beats/min; significant interaction, p < 0.001), but there were no significant differences in coronary flow reserve (CFR).: ConclusionsCoronary blood flow in the left atrium is out of phase with that in the ventricular myocardium, showing a predominant systolic pattern. Although atrial and ventricular CFR show no significant differences at rest and with two levels of stress, the disproportionate increase in atrial blood flow velocity during stress indicates a peculiarity of atrial perfusion regulation. [Copyright &y& Elsevier]

This review article focuses on the morphological and functional alterations that characterize patients with myocardial bridges (MB) as well as the currently available diagnostic and treatment strategies. Because of incomplete understanding of the pathophysiology of MB, their clinical significance has been the subject of debate for the last quarter century. Investigational tools now available in the cardiac catheterization laboratory have helped clarify why symptoms and signs of ischemia can occur in such patients, especially when the only angiographic finding appears to be systolic compression or milking effect of a coronary vessel. Quantitative coronary angiography and intravascular ultrasound (IVUS) clearly demonstrate that the phasic systolic vessel compression visualized on the angiogram is coupled with a persistent diastolic diameter reduction. Intracoronary Doppler reveals increased flow velocities, retrograde systolic flow, and reduced coronary flow reserve. The clinical diagnosis can be established by significant percent lumen diameter and area narrowing, increased flow velocity, and by characteristic patterns such as the “half moon” phenomenon on IVUS and the early diastolic “finger tip” phenomenon on intracoronary Doppler. Successful medical, interventional, or surgical therapy leads not only to marked improvement or normalization of these alterations but also relief of angina and ischemia. [Copyright &y& Elsevier]

: ObjectivesWe designed a study to explore the effect of glycoprotein (GP) IIb/IIIa blockade on the atherosclerotic plaque and distal coronary vasculature.: BackgroundPlatelet GP IIb/IIIa blockers have been proven to be beneficial in acute ischemic syndromes. This effect has also been attributed to the prevention of microvascular obstruction, although the underlying mechanisms have not been fully defined.: MethodsEighteen patients with unstable refractory angina pectoris underwent cardiac catheterization and angioplasty. Trans-stenotic and microvascular resistances to flow were measured at baseline, during hyperventilation, and after intracoronary adenosine. Measurements were repeated early after abciximab administration and after successful percutaneous transluminal coronary angioplasty.: ResultsHyperventilation induced an ischemic attack in 12 of 18 patients and increased epicardial (12.8 ± 16.9 vs. 6.1 ± 6.1 mm Hg/ml per min, p < 0.05) and microvascular (9.9 ± 7.5 vs. 6.8 ± 5.8 mm Hg/ml per min, p < 0.05) coronary resistance. Abciximab had no significant effect on epicardial resistance, although it significantly reduced distal coronary resistance under all study conditions, including baseline (4.8 ± 4.8 mm Hg/ml per min, p < 0.01), hyperventilation (5.1 ± 5.4 mm Hg/ml per min, p < 0.01), and intracoronary adenosine (2.7 ± 3.0 vs. 4.3 ± 4.3 mm Hg/ml per min, p < 0.05). The hyperventilation test became negative in all patients after abciximab administration.: ConclusionsThese observations confirm the immediate beneficial effects of platelet GP IIb/IIIa blockade with abciximab in acute ischemic syndromes and suggest that improvement of microvascular function may play a central role in the mechanism of action of this drug. [Copyright &y& Elsevier]

: ObjectivesThe study was done to determine the effects of propranolol, enalaprilat, verapamil, and caffeine on the vasodilatory properties of the adenosine A2A-receptor agonist ATL-146e (ATL).: BackgroundATL is a new adenosine A2A-receptor agonist proposed as a vasodilator for myocardial stress perfusion imaging. Beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium blockers are commonly used for the treatment of coronary artery disease (CAD), and their effect on ATL-mediated vasodilation is unknown. Dietary intake of caffeine is also common.: MethodsIn 19 anesthetized, open-chest dogs, hemodynamic responses to bolus injections of ATL (1.0 μg/kg) and adenosine (60 μg/kg) were recorded before and after administration of propranolol (1.0 mg/kg, ATL only), enalaprilat (0.3 mg/kg, ATL only), caffeine (5.0 mg/kg, ATL only), and verapamil (0.2 mg/kg bolus, ATL and adenosine).: ResultsNeither propranolol nor enalaprilat attenuated the ATL-mediated vasodilation (225 ± 86% and 237 ± 67% increase, respectively, p = NS vs. control). Caffeine had an inhibitory effect (97 ± 28% increase, p < 0.05 vs. control). Verapamil blunted both ATL- and adenosine-induced vasodilation (63 ± 20% and 35 ± 7%, respectively, p < 0.05 vs. baseline), and also inhibited the vasodilation induced by the adenosine triphosphate-sensitive potassium (KATP) channel activator pinacidil.: ConclusionsBeta-blockers and ACE inhibitors do not reduce the maximal coronary flow response to adenosine A2A-agonists, whereas verapamil attenuated this vasodilation through inhibition of KATP channels. The inhibitory effect of verapamil and KATP channel inhibitors like glybenclamide on pharmacologic stress using adenosine or adenosine A2A-receptor agonists should be evaluated in the clinical setting to determine their potential for reducing the sensitivity of CAD detection with perfusion imaging. [Copyright &y& Elsevier]

: ObjectivesThis study sought to evaluate the diagnostic potential of contrast-enhanced transthoracic echocardiography (CE-TTE) during adenosine infusion, a noninvasive method for evaluating coronary flow reserve (CFR), in detecting restenosis after successful percutaneous transluminal coronary angioplasty (PTCA).: BackgroundRestenosis is the most important limitation of PTCA, and CFR can be impaired in patients with angiographically documented significant coronary stenosis.: MethodsWe performed 6 ± 2 months of follow-up of 53 patients after successful elective PTCA in the left anterior descending coronary artery (LAD). Coronary angiography was performed at the end of the planned follow-up period or even before, if clinically indicated. Thus, of the 53 patients, a total of 63 angiographic studies were performed; CE-TTE assessment of CFR was achieved before each of the 63 angiographic studies.: ResultsCoronary angiography revealed the presence of restenosis (defined as >50% stenosis at a previous PTCA site) in 32 angiographic examinations (group A) and no coronary restenosis in the remaining 31 examinations (group B). Coronary flow reserve was significantly reduced in group A compared with group B (1.65 ± 0.5 vs. 3.17 ± 0.8, p ≤ 0.001). A noninvasive CFR value ≤2 was 93% specific and 78% sensitive for detecting significant restenosis, with positive and negative diagnostic accuracies of 92% and 80%, respectively.: ConclusionsNoninvasive CFR assessment by CE-TTE is an accurate method of monitoring significant restenosis in the LAD when following up patients submitted to elective PTCA. [Copyright &y& Elsevier]

: ObjectivesWe sought to assess the mechanism and significance of different 201Tl redistribution patterns after successful primary stenting following acute myocardial infarction (AMI).: BackgroundThe mechanism of 201Tl reverse redistribution and the impact of different redistribution patterns on the recovery of contractility after successful reperfusion therapy for AMI remain unclear.: MethodsWe studied 41 consecutive patients with successful primary stenting for a first AMI. Patients underwent predischarge and six-month follow-up dipyridamole stress-reinjection single photon emission tomography (SPECT), coronary and left ventricular angiography. Intracoronary Doppler assessment of coronary flow reserve (CFR) was performed before discharge.: ResultsFour patient groups were identified according to predischarge SPECT: patients with I: nonreversible defects (n = 8), II: redistribution (n = 7), III: reverse redistribution (n = 21), IV: no defect (n = 5). At follow-up contractility recovery increased in a stepwise fashion from groups I to IV (19 ± 41%, 40 ± 53%, 70 ± 28%, 78 ± 33%, p = 0.01). Compared with patients with redistribution, those with reverse redistribution had lower infarct-related artery (IRA) CFR (2.2 ± 0.5 vs. 2.8 ± 0.9, p = 0.03) but higher contractility recovery.: ConclusionsVariable 201Tl redistribution patterns, early after successful stenting for AMI, may predict different degrees of late contractility recovery. The lower IRA CFR and the higher contractility recovery in areas with reverse redistribution suggest more severe microvascular dysfunction and less severe myocardial injury in such areas compared with those with redistribution. [Copyright &y& Elsevier]

: ObjectivesThis study was performed to evaluate hemodynamic alterations of stent implantation after Doppler flow–guided balloon angioplasty (BA).: BackgroundThere is controversy regarding the effect of stent implantation on coronary hemodynamics after suboptimal and optimal BA.: MethodsA total of 523 of 620 patients underwent Doppler-guided BA in the setting of a multicenter study and were analyzed before and after additional stent implantation. Balloon angioplasty was considered optimal when the diameter stenosis (DS) was ≤35% and coronary flow reserve (CFR) was >2.5 and suboptimal if these two criteria were not met. Coronary flow reserve was also measured in an angiographically normal artery to determine relative CFR. Patients were followed for 12 months to document major adverse cardiac events (MACE).: ResultsThe main difference between patients with suboptimal BA (n = 195 [51%]) and optimal BA (n = 184 [49%]) was a more pronounced increase in baseline blood flow velocity (15 ± 8 to 22 ± 11 vs. 14 ± 8 to 16 ± 10 cm/s, p < 0.01). Coronary flow reserve improved after stent implantation in both patient groups, owing to a reduction in residual lumen obstruction, as determined by angiographic (%DS) and Doppler flow criteria (hyperemic blood flow velocity, relative CFR), and was associated with a decrease in MACE (16% vs. 7% in optimal BA group, p = 0.08; and 27% vs. 11% in suboptimal BA group, p = 0.007).: ConclusionsStent implantation enhances CFR after suboptimal and optimal Doppler-guided BA, owing to a reduction in residual lumen obstruction—determined by angiographical and Doppler flow criteria—as the underlying mechanism for an improved clinical outcome. [Copyright &y& Elsevier]

: ObjectivesThe study compared flow reserve indices by magnetic resonance imaging (MRI) with quantitative measures of coronary angiography and positron emission tomography (PET).: BackgroundThe noninvasive evaluation of myocardial flow by MRI has recently been introduced. However, a comparison to quantitative flow measurement as assessed by PET has not been reported in patients with coronary artery disease (CAD).: MethodsTwo groups of healthy volunteers and 25 patients with angiographically documented CAD were examined by MRI and PET at rest and during adenosine stress. Dynamic MRI was performed using a multi-slice ultra-fast hybrid sequence and a rapid gadolinium-diethylenetriaminepenta-acetic acid bolus injection (0.05 mmol/l). Upslope and peak-intensity indices were regionally determined from first-pass signal intensity curves and compared to N-13 ammonia PET flow reserve measurements.: ResultsIn healthy volunteers, the upslope analysis showed a stress/rest index of 2.1 ± 0.6, which was higher than peak intensity (1.5 ± 0.3), but lower than flow reserve by PET (3.9 ± 1.1). Localization of coronary artery stenoses (>75%, MRI <1.2), based on the upslope index, yielded sensitivity, specificity and diagnostic accuracy of 69%, 89% and 79%, respectively. Upslope index correlated with PET flow reserve (r = 0.70). A reduced coronary flow reserve (PET <2.0, MRI <1.3) was detected by the upslope index with sensitivity, specificity and diagnostic accuracy of 86%, 84% and 85%, respectively.: ConclusionsMagnetic resonance imaging first-pass perfusion measurements underestimate flow reserve values, but may represent a promising semi-quantitative technique for detection and severity assessment of regional CAD. [Copyright &y& Elsevier]

: ObjectivesWe sought to analyze whether a microcirculatory dysfunction might be associated with isolated ventricular noncompaction (IVNC).: BackgroundIn IVNC, which is a cardiomyopathy thus far “unclassified” by the World Health Organization, heart failure and sudden cardiac death are common findings, but the pathophysiologic mechanisms are unknown.: MethodsIn 12 patients with IVNC and 14 control subjects, quantitative evaluation of regional myocardial perfusion (myocardial blood flow [MBF]) and coronary flow reserve (CFR, hyperemic/baseline MBF) was performed using positron emission tomography and 13N-ammonia. The left ventricular myocardium was divided into nine segments, and the two-dimensional echocardiogram in each patient with IVNC was compared with CFR in each segment. Noncompaction was defined as a two-layered structure with excessive trabeculation.: ResultsThe CFR in control subjects averaged 4.2 ± 0.9, providing a cut-off value ≥2.5, but it was 2.1 ± 0.8 in patients with IVNC. A perfusion scan defect was found in 14 of 24 segments with noncompaction, although no defect was found in 76 of 84 normal segments (overall agreement 83%, p < 0.0001 by the chi-square test). In 16 of 21 segments with noncompaction, a decreased CFR was found; but a decreased CFR was also found in 36 of 60 segments without noncompaction (p = NS). In 45 of the 57 segments with wall motion abnormalities, CFR was decreased, but it was preserved in 17 of the 24 segments with normal wall motion (agreement 77%, p < 0.0001).: ConclusionsIn patients with IVNC, a decreased CFR is not confined to noncompacted segments, but extends to most segments with wall motion abnormalities. Thus, coronary microcirculatory dysfunction is associated with IVNC. [Copyright &y& Elsevier]

: ObjectivesWe sought to assess the effect of glycoprotein (GP) IIb/IIIa blockade on myocardial platelet and polymorphonuclear leukocyte accumulation and on infarct size after coronary injury and transient coronary occlusion (CO) in pigs.: BackgroundIt has been suggested that platelet GP IIb/IIIa blockade might reduce the severity of microvascular damage after reperfusion.: MethodsSixteen thiopental-anesthetized, open-chest pigs, in whom platelets had been labeled with technetium-99m (99mTc) on the previous day, were submitted to catheter-induced left anterior descending coronary artery (LAD) injury followed by 55 min of CO and 5 h of reperfusion. Five minutes before reflow, the animals were blindly allocated to receive lamifiban (intravenous bolus of 250 μg/kg body weight and continuous infusion of 3 μg/kg per min) or saline.: ResultsLamifiban had a rapid and potent platelet anti-aggregatory effect, as demonstrated by significant prolongation of the bleeding time and profound (∼90%) inhibition of ex vivo platelet aggregation, and completely prevented the development of cyclic flow reductions of the LAD (0 vs. 5 ± 1, one of them followed by re-occlusion, in control animals, p = 0.005). However, compared with animals receiving placebo, those treated with lamifiban had a similar (p = NS) content of 99mTc platelets in the reperfused myocardium (288 ± 40% vs. 205 ± 27% of the value in the control region, respectively) and similar myeloperoxidase activity (0.50 ± 0.17 U/g vs. 0.47 ± 0.17 U/g, respectively) and infarct size (46.8 ± 12.0% vs. 49.8 ± 10.5% of the area at risk, respectively). Arteriolar platelet thromboemboli were very rarely seen on histologic analysis. Lamifiban did not modify platelet P-selectin expression in additional studies.: ConclusionsPlatelet GP IIb/IIIa blockade has a potent antithrombotic effect at the culprit lesion, but does not significantly reduce the magnitude of microvascular platelet accumulation or myocardial damage after transient CO. [Copyright &y& Elsevier]

[Display omitted] • Malnutrition, pre-existing childhood morbidities are risk factors of COVID-19 among under-five children. • Poor household environmental conditions aggravate susceptibility to COVID-19 among under-five children. • Identified the states and union territories which have in the high-risk and low-risk zone of COVID-19 in India. The novel Coronavirus disease 2019 (2019-nCoV) outbreak, caused by severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2), has become the worst serious global risk to humanity in the last century and linked with various risk factors. To find out the risk zone associated with Coronavirus disease among children under-five age using malnourished status, pre-existing morbidity conditions, poor household environmental conditions, and also with case fatality rate (CFR) and active case rate (ACR) of COVID-19 in India. Data was collected from the 4th round of the National Family Health Survey (NFHS)-4, 2015–16, and CFR and ACR of COVID-19 related data collected from the Ministry of Health and Family Welfare (MoHFW) on 18th May 2020. Mean, standard deviation, and Z-score statistical methods have been employed to identify the risk factors zone and Hot Spot analysis (Getis-Ord Gi) has been done. The states and union territories (UTs) which have a high composite vulnerability score (CVS) of COVID-19 among under-five children are in Meghalaya (CVS = 1), Uttar Pradesh (CVS = 0.93), Jharkhand (CVS = 0.86), Bihar (CVS = 0.74), Madhya Pradesh (CVS = 0.74), and Odisha (CVS = 0.55). The states and UTs which have low composite vulnerability score of COVID-19 among under-five children are in Sikkim (CVS = -0.90), Daman & Diu (CVS = -0.76) Lakshadweep (CVS = -0.74), Kerala (CVS = -0.72), Chandigarh (CVS = -0.71). The COVID-19 high-risk zones (hot spot: 99% Confidence interval [CI]) were observed in Madhya Pradesh, Uttar Pradesh, Jharkhand, Bihar, and Meghalaya states of India, which are spatially high clustered and the low-risk zones (cold spot: 95% CI) were observed in Kerala, Mizoram states of India. Well-built public health measures, including rapidly searching in high focus areas and testing of COVID-19, should be performed in vulnerable regions of COVID-19. [ABSTRACT FROM AUTHOR]

Staphylococcus epidermidis ( S. epidermidis ), one of the leading etiological agents of nosocomial infections poses a significant economic burden globally. Introduced in 2000, linezolid (LZD) has become an important antibiotic, used in nearly seventy countries worldwide to treat infections caused by Gram-positive pathogens such as meticillin-resistant Staphylococcus and Streptococcus species along with vancomycin-resistant enterococci. Resistance to LZD in clinical settings remains rare. Here, we report the emergence of meticillin resistant S. epidermidis (MRSE) clinical isolates from two voluntary general acute hospitals exhibiting higher than typically reported levels of LZD resistance (MIC>256 μg/ml). The MRSE ST-2 clone isolated from eight patients (2010–2011) not only possessed resistance-conferring mutations such as G2576T in domain V of 23S rRNA gene (as determined by HRM-PCR analysis) and R172C substitution in the ribosomal protein L3, but also carried the cfr gene (the only known transmissible mechanism of LZD resistance). All isolates possessed several key biofilm-associated genes (such as icaA , icaD , aap and atlE ) and resistance to multiple clinically significant antibiotics was recorded. This study reports the earliest incidence (2010) of clinical MRSE in the Republic of Ireland demonstrating multiple LZD resistance mechanisms both mutational and potentially transmissible, and characterises this emerging resistance from a molecular perspective. [ABSTRACT FROM AUTHOR]

The co-occurrence of mcr-like and carbapenemase-encoding genes have been reported mainly in humans and animals, whereas, in the environment, studies are gradually increasing due to the One Health approach. In this study, we investigated antimicrobial resistance genes (ARGs) in water and sand samples from marine environments in Brazil. Total DNA from 56 samples (33 sands and 23 waters) was obtained and 27 different ARGs were detected, highlighting the presence of mcr-9 , bla KPC and cfr genes. Additionally, the microbiological analysis revealed that sand samples of all analyzed beaches were not recommended for primary use, whereas water samples from most beaches were classified as unsuitable for bathing. The presence of clinically relevant ARGs in urban beaches suggests the presence of antimicrobial-resistant bacteria. Furthermore, to the best of our knowledge, this is the first report of mcr-9 and cfr genes in the environment from Brazil and recreational areas worldwide. • Diversity of clinically relevant antimicrobial resistance genes was found in urban beaches. • Antimicrobial resistance genes were highly prevalent in sand samples. • Co-occurrence of mcr-9 , bla KPC and cfr genes in recreational areas was highlighted. • Marine environments were strongly affected by anthropogenic activities. [ABSTRACT FROM AUTHOR]

• Performance of a chromogenic screening agar called CHROMagarTM LIN-R was assessed. • CHROMagarTM LIN-R was challenged with linezolid-resistant staphylococci (n = 68) and enterococci (n = 36). • The agar revealed a specificity of 100% and a sensitivity of 99%. • Species prediction from colony color on CHROMagarTM LIN-R plates was possible. The increasing number of nosocomial pathogens with resistances against last resort antibiotics like linezolid leads to a pressing need for the reliable detection of these drug-resistant bacteria. National guidelines on infection prevention, e.g., in Germany, have already recommend screening for linezolid-resistant bacteria, although a corresponding screening agar medium has not been provided. In this study we analyzed the performance and reliability of a commercial, chromogenic linezolid screening agar. The medium was capable to predict more than a hundred linezolid-resistant isolates of E. faecium, E. faecalis, S. aureus, S. epidermidis, and S. hominis with excellent sensitivity and specificity. All isolates were collected at the National Reference Centre between 2010 and 2020. [ABSTRACT FROM AUTHOR]

Abstract: The cfr gene was identified in 3 methicillin-resistant Staphylococcus epidermidis (MRSE) isolates of lineage ST22 implicated in a fatal human infection. MRSE isolates displayed an indistinguishable pulsed-field gel electrophoresis profile and SCCmec type III, and showed a multiresistance phenotype. The presence of cfr, fexA, aac(6′)-aph(2″), and dfrS1 genes was confirmed by polymerase chain reaction and sequencing. A mutation in 23S rRNA gene (C2534T) and amino acid changes and/or insertions in L3 and L4 proteins were detected. The cfr and fexA genes were located in a conjugative plasmid of approximately 45 kb and in the chromosome. [Copyright &y& Elsevier]