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A protracted outbreak of New Delhi metallo-beta-lactamase (NDM)-producing carbapenem-resistant Klebsiella pneumoniae, started in Tuscany, Italy, in November 2018 and continued in 2020 and through 2021. To understand the regional emergence and transmission dynamics over time, we collected and sequenced the genomes of 117 extensively drug-resistant, NDM-producing K. pneumoniae isolates cultured over a 20-month period from 76 patients at several health care facilities in South-East Tuscany. All isolates belonged to high-risk clone ST-147 and were typically non-susceptible to all first line antibiotics. Albeit sporadic, resistances to colistin, tigecycline and fosfomycin were also observed as a result of repeated, independent mutations. Genomic analysis revealed that ST-147 isolates circulating in Tuscany were monophyletic, highly genetically related (including a network of 42 patients from the same hospital and sharing nearly identical isolates) and shared a recent ancestor with clinical isolates from the Middle East. While the blaNDM–1 gene was carried by an IncFIB-type plasmid, our investigations revealed that the ST-147 lineage from Italy also acquired a hybrid IncH-type plasmid carrying the 16S methyltransferase armA gene as well as key virulence biomarkers often found in hypervirulent isolates. This plasmid shared extensive homologies with mosaic plasmids circulating globally including from ST-11 and ST-307 convergent lineages. Phenotypically, the carriage of this hybrid plasmid resulted in increased siderophore production but did not confer virulence to the level of an archetypical, hypervirulent K. pneumoniae in a subcutaneous model of infection with immunocompetent CD1 mice. Our findings highlight the importance of performing genomic surveillance to identify emerging threats.Significance StatementCarbapenem-resistant Klebsiella pneumoniae belong to the “critical priority” tier of bacterial pathogens as identified by the World Health Organization. Emerging “high-risk” lineages are responsible for difficult-to-treat, hospital-acquired infections and outbreaks around the globe. By integrating genomic and epidemiological data for isolates collected over 20 months, this study revealed both the high, regional prevalence and the rapid spread, within a single hospital, of K. pneumoniae ST-147 in Italy. Besides resistance to nearly all antibiotics, we showed that this lineage carried a hybrid plasmid harboring a set of biomarker genes previously linked to hypervirulence. Convergence of multidrug resistance and hypervirulence is a major concern and these findings highlight the need for robust, global surveillance to monitor the emergence of high-risk K. pneumoniae.

Electrocardiographic algorithms are particularly useful to differentiate, in the presence of a wide complex tachycardia, between supraventricular aberrancy and ventricular tachycardias (VT). There are numerous limitations to the sensitivity and specificity of these algorithms including the presence of accessory pathways, use of antiarrhythmic drugs, congenital heart diseases, electrolytes impairments, and artificial pacing. Once the diagnosis of VT has been reached, other algorithms can help in localizing the origin of the ventricular arrhythmia. These approaches are also limited by the anatomic structure of where the arrhythmia originates. This article illustrates the difficulties in applying common algorithms in many clinical circumstances.

PURPOSE We aimed to investigate whether transabdominal uterine artery (UtA) pulsatility index (PI) differs between monochorionic (MC) diamniotic and dichorionic (DC) twins and is useful to predict pregnancy complications. METHODS A total of 406 uncomplicated twin pregnancies (94 MC, 312 DC) were examined at 22+0 -24+6 weeks and compared for demographic characteristics, mean UtA PI, presence of notch, development of preeclampsia, fetal growth restriction (FGR), placental abruption, intrauterine fetal death and preterm delivery. Mann-Whitney and Fisher's exact tests were performed for continuous and categorical variables, respectively. Sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio were calculated for mean PI >95th percentile, presence of notch, and presence of either elevated PI or notch. RESULTS Median mean UtA PI was 0.68 in DC and 0.75 in MC pregnancies (P = .005). Bilateral notches were observed in one MC pregnancy; unilateral notch was seen in 8 DC (2.6%) and 5 MC diamniotic (5.3%) pregnancies. FGR occurred more frequently in DC twin pregnancies, while intrauterine fetal death in MC. Overall, the sensitivity of the parameters tested was low. Pregnancies with both PI above 95th percentile and presence of notch were all associated with complications, particularly FGR. CONCLUSION MC pregnancies have higher mean UtA PI. UtA screening in twins shows lower performances than in singletons for the detection of complications.

Funding Acknowledgements Type of funding sources: None. Background and Purpose. To distinguish the origin of outflow tract ventricular arrhythmias (OTVAs) with a V3 precordial transition is still a challenge. To date, numerous diagnostic algorithms have been described, mainly by analysis of leads V1 and V2, while a complete study of lead V3 has never been conducted. Methods. The ECG characteristics of 45 patients (Pts) with a left bundle branch block pattern OTVAs (LVOT 51.1%, RVOT 48.9%) who underwent successful catheter ablation were retrospectively analyzed. The region where the radiofrequency delivery resulted in the persistent suppression of the arrhythmia was identified as the site of origin. For every duration or amplitude variable and for derivative indices, the comparison of means (U Mann Whitney or t-test), the determination of the AUC by ROC curves, and the correlation with BMI and BSA were performed. The odds ratio was calculated for every variable with an AUC ≥ 0.700. The three best results are described. Results. Pts with a LVOT origin were older (59.91 ± 10.48 vs 50.95 ± 15.48, p = 0.027) and predominantly males (82.6% vs 54.5%, p = 0.042) but they shared similar BMI (24.74 ± 2.76 vs 24.09 ± 2.94, p = 0.45) and BSA (1.83 ± 0.12 vs 1.77 ± 0.16, p = 0.157). In leads V1 – V2 the duration but not the amplitude of the R wave showed a significant correlation with the BSA; no variable, with the exception of the S wave amplitude, exhibited an AUC ≥ 0.700. Criteria based on the prevalence of the R wave in those leads were very specific but not sensitive as a V1 – V2 duration index ≥ 50% and a V1 – V2 amplitude ratio ≥ 30% were present only in 13.04 and 26.08% respectively of patients with a LVOT origin. No measurement in lead V3 showed any correlation with auxological characteristics. The three best ECG variables were: 1) the V3 R wave duration index (R wave \ QRS duration); AUC 0.905, LVOT origin if ≥ 50%, OR 74.80 95% CI [7.97 – 701.48], p < 0.001; 2) the V3 R wave duration; AUC 0.900, LVOT origin if ≥ 80 msec, OR 47.25 95% CI [7.73 – 288.82], p < 0.001; 3) the V3 R wave percentage (amplitude of the R wave with respect to the global amplitude of the QRS, expressed as a percentage); AUC 0.888, LVOT origin if ≥ 50%, OR 36 95% CI [6.19 – 209.06], p < 0.001. Based on the V2 transition ratio calculation formula, we calculated the V3 transition ratio (AUC 0.843, LVOT origin if ≥ 1) which was very sensitive but less specific; OR 30 CI [3.32 – 270.37], p = 0.002. To multivariate analysis, only a V3 R wave percentage ≥ 50% proved to be an independent predictor of LVOT origin; OR 9 CI [2.08 – 38.78], p = 0.003, even if the criterion with the highest accuracy was a V3 duration index ≥ 50% (88.89%). Conclusions. Although it has been poorly analyzed in previous studies on the origin of OTVAs, the morphological characteristics of lead V3 seem to provide valid elements for the creation of diagnostic algorithms. Abstract Figure. Comparison of ECG characteristics

Significance Carbapenem-resistant Klebsiella pneumoniae belongs to the “critical-priority” tier of bacterial pathogens as identified by the World Health Organization. Emerging “high-risk” lineages are responsible for difficult-to-treat, hospital-acquired infections and outbreaks around the globe. By integrating genomic and epidemiological data for isolates collected over 20 mo, this study revealed both the high, regional prevalence and the rapid spread, within a single hospital, of K. pneumoniae ST-147 in Italy. Besides resistance to nearly all antibiotics, this lineage carried a hybrid plasmid harboring a set of biomarker genes previously linked to hypervirulence. Convergence of resistance and virulence determinants is a major concern and these findings highlight the need for robust, global surveillance to monitor the emergence of high-risk K. pneumoniae., A protracted outbreak of New Delhi metallo-β-lactamase (NDM)–producing carbapenem-resistant Klebsiella pneumoniae started in Tuscany, Italy, in November 2018 and continued in 2020 and through 2021. To understand the regional emergence and transmission dynamics over time, we collected and sequenced the genomes of 117 extensively drug-resistant, NDM-producing K. pneumoniae isolates cultured over a 20-mo period from 76 patients at several healthcare facilities in southeast Tuscany. All isolates belonged to high-risk clone ST-147 and were typically nonsusceptible to all first-line antibiotics. Albeit sporadic, resistances to colistin, tigecycline, and fosfomycin were also observed as a result of repeated, independent mutations. Genomic analysis revealed that ST-147 isolates circulating in Tuscany were monophyletic and highly genetically related (including a network of 42 patients from the same hospital and sharing nearly identical isolates), and shared a recent ancestor with clinical isolates from the Middle East. While the blaNDM-1 gene was carried by an IncFIB-type plasmid, our investigations revealed that the ST-147 lineage from Italy also acquired a hybrid IncFIB/IncHIB–type plasmid carrying the 16S methyltransferase armA gene as well as key virulence biomarkers often found in hypervirulent isolates. This plasmid shared extensive homologies with mosaic plasmids circulating globally including from ST-11 and ST-307 convergent lineages. Phenotypically, the carriage of this hybrid plasmid resulted in increased siderophore production but did not confer virulence to the level of an archetypical, hypervirulent K. pneumoniae in a subcutaneous model of infection with immunocompetent CD1 mice. Our findings highlight the importance of performing genomic surveillance to identify emerging threats.

Funding Acknowledgements NO FUNDING OnBehalf RHYTHM DETECT Registry Background The class of recommendation for S-ICD implantation in patients who have inadequate vascular access is I according to AHA-ACC-HRS Guidelines and IIb according to ESC Guidelines. Data are lacking about the use of S-ICD for patients in which a transvenous ICD is not a viable option because of the inability to deploy a transvenous lead. Purpose To describe current practice and to measure outcomes associated with S-ICD use in patients in which a transvenous ICD is not a viable option. Methods 942 consecutive patients underwent S-ICD implantation at 22 Italian centers from 2014 to 2019. We identified 101 (11%) patients who received S-ICD because of the reported impossibility of deploying a transvenous lead. Results 21 patients presented with inadequate vascular access but no previous device in place. One patient had a mechanical prosthesis in tricuspid position. The remaining 79 patients received the S-ICD after removal of a prior system implanted, and venous occlusion was diagnosed after lead extraction, or partially or completely failed lead removal. In 24 of these patients a functional transvenous pacing system was left in place for persisting pacing needs. Patients were 60 ± 15 years old, 85% were male, 77% had ischemic or non-ischemic dilated cardiomyopathy, ejection fraction was 36 ± 13%. At implantation, acute conversion test was performed in 64 patients and shock energy of ≤65J was successful in 62 (96.9%) patients. During a median follow-up of 18 months, 6 patients died for non-device related reasons and 1 patient underwent heart transplantation. One patient underwent device replacement for battery depletion and one patient underwent leadless pacemaker implantation. Minor complications (hematomas not requiring system revision) were reported in 2 patients. Appropriate therapies were delivered in 4 patients and 8 patients experienced inappropriate therapies (in 3 patients due to double counting during pacing); all resolved with device reprogramming. Conclusions: In current clinical practice, a minority of S-ICD patients receive the device because of inadequate vascular access. The profile of these patients is similar to that of the typical ICD population in the context of primary sudden death prevention, but many of them present with pacing indications. Acute and mid-term efficacy of S-ICD seemed high. Few complications occurred during follow-up. Particular attention must be paid to device programming for those patients with concomitant pacing systems, in order to prevent inappropriate therapies.

Acanthamoeba spp. is a free-living amoeba, frequently involved in keratitis by contact lens in immunocompetent hosts. Anecdotal reports associate Acanthamoeba spp. as a cause of severe granulomatous encephalitis in immunocompromised and, less frequently, in immunocompetent subjects. Data regarding clinical and therapeutic management are scanty and no defined therapeutic guidelines are available. We describe an unusual case of non-granulomatous Acanthamoeba cerebellitis in an immunocompetent adult male, with abrupt onset of neurological impairment, subtle hemorrhagic infarction at magnetic resonance imaging, and initial suspicion of cerebellar neoplasm. Histopathological findings of excised cerebellar mass revealed the presence of necrosis and inflammation with structure resembling amoebic trophozoites, but without granulomas. Polymerase chain reaction from cerebellar tissue was positive for Acanthamoeba T4 genotype. Due to gastrointestinal intolerance to miltefosine, the patient was treated with long-term course of fluconazole and trimethoprim/sulphamethoxazole, obtaining complete clinical and neuroradiological resolution.

Bilirubin neurotoxicity has been studied for decades and has been shown to affect various mechanisms via significant modulation of gene expression. This suggests that vital regulatory mechanisms of gene expression, such as epigenetic mechanisms, could play a role in bilirubin neurotoxicity. Histone acetylation has recently received attention in the CNS due to its role in gene modulation for numerous biological processes, such as synaptic plasticity, learning, memory, development and differentiation. Aberrant epigenetic regulation of gene expression in psychiatric and neurodegenerative disorders has also been described. In this work, we followed the levels of histone 3 lysine 14 acetylation (H3K14Ac) in the cerebellum (Cll) of the developing (2, 9, 17 days after the birth) and adult Gunn rat, the natural model for neonatal hyperbilirubinemia and kernicterus. We observed an age-specific alteration of the H3K14Ac in the hyperbilirubinemic animals. The GeneOntology analysis of the H3K14Ac linked chromatin revealed that almost 45% of H3K14Ac ChiP-Seq TSS-promoter genes were involved in CNS development including maturation and differentiation, morphogenesis, dendritogenesis, and migration. These data suggest that the hallmark Cll hypoplasia in the Gunn rat occurs also via epigenetically controlled mechanisms during the maturation of this brain structure, unraveling a novel aspect of the bilirubin-induced neurotoxicity.

Vascular access site complications can follow diagnostic coronary and peripheral angiography. We compared the complication rates of the Catalyst vascular closure device, with the complication rates after manual compression in patients undergoing diagnostic angiographic procedures via femoral access. We studied 1,470 predominantly male patients undergoing diagnostic coronary and peripheral angiography. Catalyst closure devices were used in 436 (29.7%) patients and manual compression was used in 1,034 (70.3%) patients. The former were allowed to ambulate after 2 hours, while the latter were allowed to ambulate after 6 hours. Major complications occurred in 4 (0.9%) patients who had a Catalyst device and in 14 (1.4%) patients who had manual compression (odds ratio [OR]: 0.67, 95% confidence interval [CI]: 0.22–2.1, p = 0.49). Any complications occurred in 51 (11.7%) patients who had a Catalyst closure device and in 64 (6.2%) patients who had manual compression (OR: 2, CI: 1.4–3, p

We describe a case of persistent strongyloidiasis complicated by recurrent meningitis, in a human T cell lymphotropic virus type 1 (HTLV-1) seropositive Peruvian migrant adult resettled in Italy. He was admitted with signs and symptoms of acute bacterial meningitis, reporting four other meningitis episodes in the past 6 years, with an etiological diagnosis of Escherichia coli and Enterococcus faecium in two cases. He had been previously treated with several antihelmintic regimens not including ivermectin, without eradication of strongyloidiasis, and he had never been tested for HTLV before. During the described episode, the patient was treated for meningitis with broad-spectrum antibiotic therapy and 200 mug/kg/dose oral ivermectin once daily on day 1, 2, 15 and 16 with full recovery and no further episodes of meningitis. The presented case underlines several critical points concerning the management of poorly known neglected diseases such as strongyloidiasis and HTLV infection in low-endemic areas. Despite several admissions for meningitis and strongyloidiasis, the parasitic infection was not adequately treated and the patient was not previously tested for HTLV. The supply of ivermectin and the choice of treatment scheme was challenging since ivermectin is not approved in Italy and there are no standardized guidelines for the treatment of severe strongyloidiasis in HTLV seropositive subjects.

Recently we reported an association between pediatric obstructive sleep apnea syndrome (OSAS) and Group A streptococcus (GAS) sub-acute chronic tonsil colonization. We showed that GAS may contribute to tonsil hyperplasia via a streptolysin O (SLO)-dependent cysteinyl leukotrienes (CysLTs) production, which can trigger T and B cell proliferation. In the present study, we characterized the GAS strains isolated from pediatric OSAS patients in comparison with a panel of age and sex matched GAS strains unrelated to OSAS, but isolated in the same area and during the same period ranging from 2009 to 2013. We found that slaA gene, previously reported to be associated to CysLTs production pathway, was significantly associated to GAS OSAS strains. Moreover, the most numerous group (32%) of the GAS OSAS strains belonged to M75 type, and 6 out of 7 of these strains harbored the slaA gene. Multilocus Sequence Typing (MLST) experiments demonstrated that the clone emm75/ST49/ smeZ, slaA was associated to OSAS cases. In conclusion, we found an association between slaA gene and the GAS OSAS strains, and we showed that the clone emm75/ST49 harboring genes smeZ and slaA was exclusively isolated from patients affected by OSAS, thus suggesting that this genotype might be associated to the pathogenesis of OSAS, although further studies are needed to elucidate the possible role of SlaA in tonsil hypertrophy development.

Publicly available multi-omic databases, in particular if associated with medical annotations, are rich resources with the potential to lead a rapid transition from high-throughput molecular biology experiments to better clinical outcomes for patients. In this work, we propose a model for multi-omic data integration (i.e., genetic variations, gene expression, genome conformation, and epigenetic patterns), which exploits a multi-layer network approach to analyse, visualize, and obtain insights from such biological information, in order to use achieved results at a macroscopic level. Using this representation, we can describe how driver and passenger mutations accumulate during the development of diseases providing, for example, a tool able to characterize the evolution of cancer. Indeed, our test case concerns the MCF-7 breast cancer cell line, before and after the stimulation with estrogen, since many datasets are available for this case study. In particular, the integration of data about cancer mutations, gene functional annotations, genome conformation, epigenetic patterns, gene expression, and metabolic pathways in our multi-layer representation will allow a better interpretation of the mechanisms behind a complex disease such as cancer. Thanks to this multi-layer approach, we focus on the interplay of chromatin conformation and cancer mutations in different pathways, such as metabolic processes, that are very important for tumor development. Working on this model, a variance analysis can be implemented to identify normal variations within each omics and to characterize, by contrast, variations that can be accounted to pathological samples compared to normal ones. This integrative model can be used to identify novel biomarkers and to provide innovative omic-based guidelines for treating many diseases, improving the efficacy of decision trees currently used in clinic.

The treatment of visceral leishmaniasis (VL) is poorly standardized in Italy in spite of the existing evidence. All consecutive patients with VL admitted at 15 Italian centers as inpatients or outpatients between January 2004 and December 2008 were retrospectively considered; outcome data at 1 year after treatment were obtained for all but 1 patient. Demographic characteristics, underlying diseases, diagnostic procedures, treatment regimens and outcomes, as well as side effects were recorded. A confirmed diagnosis of VL was reported for 166 patients: 120 (72.3%) immunocompetent, 21 (12.6%) patients with immune deficiencies other than HIV infection, and 25 (15.1%) coinfected with HIV. Liposomal amphotericin B (L-AmB) was the drug almost universally used for treatment, administered to 153 (92.2%) patients. Thirty-seven different regimens, including L-AmB were used. The mean doses were 29.4 ± 7.9 mg/kg in immunocompetent patients, 32.9 ± 8.6 mg/kg in patients with non-HIV-related immunodeficiencies, and 40.8 ± 6.7 mg/kg in HIV-infected patients ( P < 0.001). The mean numbers of infusion days were 7.8 ± 3.1 in immunocompetent patients, 9.6 ± 3.9 in non-HIV-immunodeficient patients, and 12.0 ± 3.4 in HIV-infected patients ( P < 0.001). Mild and reversible adverse events were observed in 12.2% of cases. Responsive patients were 154 (93.3%). Successes were 98.4% among immunocompetent patients, 90.5% among non-HIV-immunodeficient patients, and 72.0% among HIV-infected patients. Among predictors of primary response to treatment, HIV infection and age held independent associations in the final multivariate models, whereas the doses and duration of L-AmB treatment were not significantly associated. Longer treatments and higher doses of L-AmB were not able to significantly modify treatment outcomes either in the immunocompetent or in the immunocompromised population.

The involvement of pathogenic bacteria in obstructive sleep apnoea syndrome (OSAS) has yet to be elucidated. We investigated the possible role of group A streptococcus (GAS) in OSAS pathogenesis. In 40 tonsillectomized patients affected by OSAS and 80 healthy controls, significant (p p

Objectives Definition of the optimal pneumococcal vaccine strategy in HIV-infected adults is still under evaluation. We aimed to compare immunogenicity and safety of the 13-valent pneumococcal conjugate vaccine (PCV13) versus the 23-valent polysaccharide vaccine (PPSV23) in HIV-infected adults. Methods We performed a pilot, prospective controlled study enrolling HIV-infected pneumococcal vaccine-naïve outpatients, aged 18–65 years with CD4 counts ≥200 cells/μL. Eligible subjects were recruited into two parallel groups: group 1 (n = 50) received two doses of PCV13 eight weeks apart, and group 2 (n = 50) received one dose of PPSV23, as part of their standard of care. Anti-pneumococcal capsular polysaccharide immunoglobulin G concentrations were quantified by ELISA at baseline, 8, 24 and 48 weeks. Clinical and viro-immunological follow-up was performed at the same time points. Unvaccinated, age-matched HIV-negative adults (n = 100) were also enrolled as baseline controls. Results Pre-vaccination specific IgG titers for each pneumococcal antigen did not differ between study groups but they were constantly lower than those from the HIV-negative controls. After immunization, significant increases in IgG titers were observed in both study groups at each time point compared to baseline, but response to serotype 3 was blunted in group 1. Antibody titers for each antigen did not differ between study groups at week 48. Overall, the proportion of subjects achieving seroprotection and seroconversion to all serotypes was comparable between groups. A marked decrease in IgG levels over time was observed with both vaccines. No relevant adverse reactions were reported in either group. Conclusions In this population with favorable immune profile, no relevant differences were observed in immunogenicity between PCV13 and PPSV23. Both vaccines were safe and well tolerated. Trial Registration ClinicalTrials.gov NCT02123433

Vascular access site management is crucial to safe, efficient and comfortable diagnostic or interventional percutaneous coronary or peripheral interventions. In recent years, vascular closure devices have gained popularity and are being used for rapid hemostasis and early ambulation as an alternative to manual compression. However, controversy still exists over their superiority over manual compression. This review highlights the rationale and explores the current evidence regarding the use of vascular closure devices in percutaneous coronary and peripheral interventions.

Within a joint initiative with the Schulich School of Music at McGill University, the authors developed an original approach to raise awareness about hearing health by combining a participative assessment with a novel noise exposure risk indicator. The overall noise exposure is estimated using two complementary measurement systems addressing, respectively, the contribution determined by (i) the use of portable music players and (ii) music and non-music activities. The first system is a “listening-level measuring kiosk,” a freely accessible station on which students can place their own headphones or earphones and playback (at their preferred listening levels) music excerpts from their own playlist on an acoustical manikin. The second system is a personal, smartphone-based, “noise exposure” portable measurement device. Users start with an initial training and an audiometry screening, followed by the collection of exposure data during a 4-week assessment period. Personalized results are provided based on individual exposure profile and initial audiogram. The validation of the design of a novel noise exposure risk indicator is based on the feedback from a focus group of young musicians. This paper describes the measurement systems, assessment process, and preliminary results from the ongoing pilot studies.

We evaluated temporal fluctuations in macrolide resistance rates, analysing genetic determinants of resistance and clonal evolution in a population of 2744 S. pyogenes isolates collected in the period 2000–2013. The total resistance rate to erythromycin of the isolates was 17.9 %. A maximum of erythromycin resistance emerged in 2000 (38.6 %), followed by a significant decrease to 5.2 % in 2012 (P

Objective To report a case of visceral leishmaniasis treated with liposomal amphotericin B (LAB) after probable failure with amphotericin B lipid complex (ABLC). Case Summary A 62-year-old white renal transplant recipient was admitted for pyrexia, hepato-splenomegaly, and pancytopenia. Leishmania amastigotes were detected from bone marrow aspirate and in circulating blood monocytes and neutrophils. The patient, who weighed 56 kg, received ABLC at a starting dose of 200 mg/d (3.6 mg/kg of body weight per day) for 13 days, achieving a total dose of 2,600 mg (46 mg/kg) without clinical improvement. The patient was switched to 100 mg/d (1.8 mg/kg) of LAB for 10 days, after which a dose of 250 mg (4.5 mg/kg) was repeated on days 17,24,31, and 38. Twenty-four hours after the first dose of LAB, the patient showed an excellent clinical response. On the following days, there was a progressive increase in hemoglobin concentration and leukocyte and platelet counts. Three months later, the patient was asymptomatic. Discussion Although treatment with ABLC appears to be effective for the treatment of Indian patients with visceral leishmaniasis, experience with immunocompromised patients is limited. This is the first case of a renal transplant recipient in which ABLC was used to treat visceral leishmaniasis without remarkable efficacy, but with infusion-related adverse effects perhaps due to the use of higher doses. Conclusions A randomized comparative trial is needed to compare LAB with ABLC in the treatment of visceral leishmaniasis in patients who have received kidney allografts.

We report a successfully treated case of spondylodiscitis and bloodstream infection due to vancomycin heteroresistant Staphylococcus capitis, in an adult immunocompetent patient with multiple antibiotics intolerance. S. capitis is rarely involved in osteomyelitis and, to our knowledge, this is the first report of vancomycin heteroresistance phenomenon in an S. capitis strain causing spondylodiscitis.

We describe a case of a febrile patient returning from Senegal in which haemoscopic and molecular investigation confirmed tick-borne relapsing fever (TBRF), suggesting Borrelia crocidurae as the causative agent. This case emphasises the need to include TBRF in the differential diagnosis of fever following a journey from endemic countries, including malarial areas.

The popularity in Western countries of dishes based on raw fish has led to an increased incidence of anisakiasis, a human parasitic disease caused by the ingestion of live anisakid larvae. The entire digestive tract may be involved, but the stomach and the small intestine are the most frequently affected sites. We report a case of acute abdomen due to Anisakis simplex infection that caused small bowel obstruction.

Background Vascular access site complications can follow coronary and peripheral angioplasty procedures and be associated with significant morbidity. We compared the complication rates of the Angioseal closure device with complication rates after manual compression in patients undergoing coronary and peripheral interventional procedures. Methods and Results We studied 553 predominantly male patients undergoing percutaneous coronary, peripheral interventions, FFR or IVUS at a Veterans Administration Medical Center. The mean age was 64.6 years. Angioseal closure devices were used in 388 (70%) patients and manual compression was used in 165 (30%) patients. Major groin complications such as arteriovenous fistula, pseudoaneurysm or hematoma greater than 5 cm occurred in 16 (4.16%) patients who had an Angioseal closure device and 11 (6.67%) patients in whom manual compression was used for hemostasis (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.29-1.40; P=0.26). Other complications such as minor bleeding requiring additional manual compression, bruising, pain and swelling occurred in 32 (8.42%) patients who had an Angioseal closure device and 21 (12.4%) patients who had manual compression (OR 0.65, 95% CI 0.36-1.17; P=0.15). After adjustment for other comorbid factors such as age, type of anticoagulant used, peripheral vascular disease and chronic kidney disease, the association of major complications with the use of the Angioseal closure device remained similar to manual compression (OR 0.75, 95% CI 0.28-1.91; P=0.49). However, there was a trend for fewer minor complications with the closure device (OR 0.57, 95% CI 0.26-1.08; P=0.08). Conclusion In this cohort of predominantly male patients undergoing percutaneous coronary and peripheral intervention, the use of the Angioseal closure device was not associated with a decreased risk of major groin complications, but was associated with a trend for a decreased risk of minor complications compared to manual compression.

Summary. Background: Low ankle–brachial Index (ABI) identifies patients with symptomatic and asymptomatic peripheral arterial disease. The aim of this study was to correlate ABI value (normal or low) with 1-year clinical outcome in patients hospitalized for acute coronary syndromes or cerebrovascular diseases (CVD). Methods: ABI was measured in consecutive patients hospitalized because of acute myocardial infarction, unstable angina, stroke or transient ischemic attack (TIA). An ABI lower than or equal to 0.90 was considered abnormal. The primary outcome of the study was the composite of non-fatal acute myocardial infarction, non-fatal ischemic stroke, and death from any cause during the year following the index event. Results: An abnormal ABI was found in 27.2% of 1003 patients with acute coronary syndromes, and in 33.5% of 755 patients with acute CVD. After a median follow-up of 372 days, the frequency of the primary outcome was 10.8% (57/526) in patients with abnormal ABI and 5.9% (73/1232) in patients with normal ABI [odds ratio (OR) 1.96; 95% CI 1.36–2.81]. Death was more common in patients with abnormal ABI (OR 2.05; 95% CI 1.31–3.22). Cardiovascular mortality accounted for 81.7% of overall mortality. ABI was predictive of adverse outcome after adjustment for vascular risk factors in the logistic regression analysis (OR 1.93; 95% CI 1.24–3.01). The predictive value of ABI was mainly accounted for by patients hospitalized for acute coronary syndromes (adverse outcome: 12.8% in patients with abnormal ABI and 5.9% in patients with normal ABI, OR 2.35; 95% CI 1.47–3.76). Conclusions: An abnormal ABI can be found in one-third of patients hospitalized for acute coronary or cerebrovascular events and is a predictor of an adverse 1-year outcome.

The aim of this study was to compare a rapid immunological test and a PCR method with the conventional morphological technique for the identification of Cryptosporidium in faecal samples. Cryptosporidium was found in five samples by Kinyoun acid-fast stain. Five samples yielded positive results on immunoassay, three of which yielded negative results on microscopy. Thus, only two patients were positive for Cryptosporidium according to both methods. PCR analysis confirmed only one sample as positive. Non-homogeneous distribution of parasites in stool samples, lack of oocysts in the tested sample and antigenic diversity among Cryptosporidium species may explain the poor agreement among the three tests. Based on our experience, microscopy test with Kinyoun stain is the best and cheapest way to detect Cryptosporidium spp. in faecal samples. With this method, we have found a 5.4% prevalence of Cryptosporidium infection in our area, similar to those reported for other regions of Italy and Europe.

In July 2004 nearly 500 veterans aged 55 and older participated in the National Golden Age Games (GAG) in Fresno, CA. Since GAG participants are more physically active than their peers, this was a unique opportunity to elicit demographic and health status information and health attitudes from this unique group. We were especially interested in learning how these senior athletes felt about having diabetes. Our survey also queried attitudes about end of life concerns and choices. Forty-nine percent (240: 213 men and 27 women) of participants voluntarily and anonymously responded to a short written questionnaire distributed at the registration desk. Among those that responded 59% were 55-69 years old, 36% 70-80, and 9% > 81. Sixty percent were Caucasian, 27% African American, 7% Hispanic, and 7% Native American. The majority were from CA (27%), TX (15%), NY (9%), and IL (7%). Bowling, horseshoes, nine ball, shuffleboard, swimming, and table tennis were the most popular sports. Forty-six percent reported having cardiovascular disease, 42% had mental health problems, 40% arthritis, 35% hypertension, 30% diabetes, and 15% cancer. Of those with diabetes roughly two-thirds reported a score of 1-2 (on a scale of 1-5) as not being upset at all or only slightly upset about having diabetes, the amount of control they have over their diabetes, the uncertainty they experience in life as a result of diabetes, how upset they feel that their diabetes may worsen, about achieving good diabetes control, about their ability to cope with the disease, and that diabetes gets in the way of their life goals. However, 22% responded with a score of 4-5 that they were very upset to extremely upset that their diabetes may worsen. Eighty percent of those within the 60-69 age group responded as extremely upset to the latter question compared to 10% or less within the other age ranges. Seventy-four percent of all those surveyed indicated they had expressed their end of life preferences to their families and 60% had an advance directive. If severely ill with cancer, congestive heart failure, or emphysema 57% indicated they wanted to be kept comfortable. Of these 40% preferred to be at home and 17% in a hospice facility. In conclusion, the largest proportion of senior athletes reported cardiovascular and mental health problems. This may reflect that physical activity and social involvement are encouraged as therapeutic interventions for these disorders. These senior athletes seem to cope well with diabetes but concern of possible worsening is interestingly found most often in the 60-69 age group.

Representative consumer talcums and powders, including 20 body powders, baby powders, facial talcums, and also one pharmaceutical talc, were analyzed to determine their mineralogical and chemical composition. Where known, all were formulated prior to 1973. Of the 20 products 10 contained detectable amounts of tremolite and anthophyllite, principally asbestiform, while some also contained fragmented forms of these minerals. The amounts ranged from tenths of a percent to over 14% by weight; two contained detectable amounts of chrysotile asbestos fiber. Eight contained quartz, seven ranging from 2 to 5%, with one as high as 35%. The analyses showed that the consumer products examined were rarely the pure mineral talc, but rather were mixtures of various minerals; some samples consisted of three to five minerals, only one of which was talc. Other common mineral phases included chlorite, platy serpentine, pyrophyllitem mica, and carbonate minerals. Kaolin additive was identified in two products. The single pharmaceutical talc examined contained only a trace amount of quartz. The chemical composition of these products, including both major oxide and trace element content, correlated with their mineral components. Four samples contained substantial concentrations of nickel, cobalt, and chromium, suggesting latice substitution or the presence of trace mineral phases. Geological provenance of the talcs may be ascertained on the basis of chemistry. Possible adverse health effects from intermittent use of these products, especially those that contain asbestiform and fragmented anthophyllite and tremolite, chrysotile, quartz, and trace metals, are presently unknown and warrnat evaluation.

The diagonal ear-lobe crease, detectable especially after the age of 40, is still accepted as a sign of coronary heart disease risk. In the literature some authors report an association between anxiety and coronary heart disease. In our work a group of 143 patients with ear-lobe crease showed - in both sexes and in all examined decades (5th, 6th, 7th) - higher levels of anxiety than in the control group. The possible significance of the crease has been considered on the grounds of present knowledge of ear-acupuncture and the somatotopic mapping of CNS on the ear-lobe.

A case with mitral stenosis and atrial flutter in which atrial sounds were heard and recorded is reported. The mechanisms generating such sounds are discussed.