Search

Legends of supplementary figures

Table with the clinical information of the patients of our cohort

Gastric cancer remains one of the leading causes of global cancer mortality due to therapy resistance, with Helicobacter pylori (H. pylori) infection being a major risk factor. In this study, we report the significance of an elevation of the stem cell regulator SOX9 in bacteria-infected human gastritis and cancer samples, paralleling increased levels of TNFα. SOX9 elevation was more intense in specimens containing the pathogenically significant cagA+ strains of H. pylori. Notably, we found that SOX9 was required for bacteria-induced gastric cancer cell proliferation, increased levels of β-catenin, and acquisition of stem cell–like properties. Analysis of three large clinical cohorts revealed elevated SOX9 levels in gastric cancer with advanced tumor stage and poor patient survival. Functionally, SOX9 silencing in gastric cancer cells enhanced apoptosis and senescence, concomitantly with a blockade to self-renewal and tumor-initiating capability. Paralleling these effects, we also found SOX9 to mediate cisplatin chemoresistance associated with reduced disease-free survival. Mechanistic interactions between SOX9 and β-catenin expression suggested the existence of a regulatory role for SOX9 targeting the WNT canonical pathway. Taken together, our findings establish the significance of SOX9 in gastric cancer pathobiology and heterogeneity, with implications for targeting WNT–SOX9 signaling as a rational therapeutic strategy. Cancer Res; 76(22); 6735–46. ©2016 AACR.

Additional results showing the function of SOX9-beta-catenin in Gastric Cancer

Background Helicobacter pylori gastritis is considered to be an infectious disease, irrespective of an individual’s symptoms and stage of disease. Until now, most consensus recommendations were based on empirical treatments conditional on local antimicrobial susceptibility patterns. The aim of this study was to provide information about the primary and secondary antimicrobial resistance rates in Gipuzkoa, Basque Country, Spain, and to share the experience of H. pylori culture followed by susceptibility testing. Methods In total, 31,406 gastroduodenal biopsies and 2,641 string tests from patients over the age of 15 were plated on selective media, isolating H. pylori in 36.7% of biopsies and 50.7% of string tests. Antibiograms could be performed in 96.6% (12,399/12,835) of H pylori isolates. Overall, 10.8% (1,343/12,399) of antibiograms were obtained from second or subsequent samples from the same patient. PCRs were also used to detect H. pylori and its clarithromycin resistance. Results Primary resistance to amoxicillin and tetracycline was unusual, 0.6% and 0.2%, respectively. Primary resistances to clarithromycin and metronidazole remained constant through the 22-years of study, around 14% and 30% respectively. Primary resistance to levofloxacin tripled from 7.6% in 2000 to 21.7% in 2021 (p H. pylori followed by antimicrobial susceptibility testing, allowing physicians to follow a tailored treatment strategy.

Objective Real-time surveillance of SARS-CoV-2 variants of concern (VOC) is of essential public health importance. Rapid Antigen Detection Tests (RAgDT) have become first-line COVID-19 diagnostic methods in many regions, but this strategy can hamper the surveillance of the virus variants due to their decentralized performance. The aim of this study was to assess the usefulness of the remaining sample of a widely used RAgDT (Panbio) for the surveillance of the B.1.1.7 VOC using molecular methods. Methods Symptomatic individuals and asymptomatic close contacts of confirmed cases were routinely screened for SARS-CoV-2 infection using the RAgDT in Primary Health Care Centers. After performing the test, the extraction tubes containing the remaining biological material of RAgDT-positive cases were sent to the clinical microbiology laboratory where RT-PCRs detecting key mutations of the VOC were conducted. Results A valid result was obtained in 1770/1812 (97.7%) RAgDT-positive cases. Variant B.1.1.7 was detected in 34.7% of the patients, increasing from 0% to 87.7% between the weeks beginning January 4 and March 15, 2021. Conclusion The sample remaining after performing the Panbio RAgDT allowed to monitor the emergence and circulation of the B.1.1.7, greatly improving the population screened for the molecular study of SARS-CoV-2 variants.

Introduction The aim of this study was to know, through a national survey, the methods and techniques used for the diagnosis of Helicobacter pylori (Hp) in the different Clinical Microbiology Services/Laboratories in Spain, as well as antibiotic resistance data. Methods The survey requested information about the diagnostic methods performed for H. pylori detection in Clinical Microbiology laboratories, including serology, stool antigen, culture from gastric biopsies, and PCR. In addition, the performance of antibiotic susceptibility was collected. Data on the number of samples processed in 2016, positivity of each technique and resistance data were requested. The survey was sent by email (October–December 2017) to the heads of 198 Clinical Microbiology Laboratories in Spain. Results Overall, 51 centres from 29 regions answered the survey and 48/51 provided Hp microbiological diagnostic testing. Concerning the microbiological methods used to diagnose Hp infection, the culture of gastric biopsies was the most frequent (37/48), followed by stool antigen detection (35/48), serology (19/48) and biopsy PCR (5/48). Regarding antibiotic resistance, high resistance rates were observed, especially in metronidazole and clarithromycin (over 33%). Conclusion Culture of gastric biopsies was the most frequent method for detection of Hp, but the immunochromatographic stool antigen test was the one with which the largest number of samples were analyzed. Nowadays, in Spain, it concerns the problem of increased antibiotic resistance to ‘first-line’ antibiotics.

Objectives To perform a comprehensive description of the epidemiology of Streptococcus pyogenes invasive disease in the pediatric population in 2 regions of Spain (Catalonia and Gipuzkoa) through 12 years. Methods All S. pyogenes isolates causing invasive disease in pediatric patients between 2005 and 2016 were included. The emm-type and the presence of 13 exotoxin genes (speA, speB, speC, speF, speG, speH, speI, speJ, speK, speL, speM, smeZ, ssa and slo) were determined in all 93 available isolates and the Multi Locus Sequece Typing in 10% of isolates of each different emm-type. Results Overall, 103 cases of S. pyogenes invasive infections were detected: 77 in Catalonia and 26 in Gipuzkoa, being 50.5% females. The incidence rate per 100,000 children was 2.5 for Gipuzkoa and 2.6 for Catalonia, with no significant temporal trends. The median age was 30 months. The most frequent clinical presentations were: pneumonia (26.2%), bacteremia/sepsis (23.3%), septic arthritis/osteomyelitis (22.3%), cellulitis/mastoiditis (12.6%) and meningitis (6.8%). Eight children developed streptococcal toxic shock syndrome. Nine cases were preceded by varicella infection. The associated mortality rate was 3.9%. Three isolates were resistant to erythromycin, being one of them also resistant to clindamycin and 4 isolates were resistant to levofloxacine. Forteen different emm-types were detected being emm1/ST28 (40.9%) the most frequent clone in both regions followed by emm12/ST36-ST242, emm6/ST382, emm3/ST15, emm75/ST150 and emm4/ST38-39. speA gene was only detected in emm1 and emm3 isolates. Eight exotoxins were enough to assign an emm-type with a very high degree of accuracy (95%). The 30-valent vaccine would include 96.8% of isolates.

Background Enterovirus (EV) D68 is mainly associated with acute respiratory infection (ARI). Since 2014, when outbreaks in different countries were observed, this emerging virus was considered a potential threat to public health. Methods During 2015-2017, the presence of enterovirus RNA was investigated in all respiratory samples of children younger than 15 years of age with ARI, obtained for virologic studies in the Pediatric Emergency Care Units and wards of 2 hospitals in Gipuzkoa (Spain), using a commercial multiplex real-time polymerase chain reaction. When enterovirus was detected, a polymerase chain reaction to amplify a specific viral polyprotein (VP1) gene region of EV-D68 was performed. Results In 2016, EV-D68 circulation was associated to ARI, with the highest incidence in the spring months. EV-D68 was detected in 44 children, mean age 30.1 ± 31.7 months old, 23 (52.3%) of them females and 17 (38.6%) with underlying respiratory medical conditions. Thirty-two patients (72%) required hospital admission, receiving the discharge diagnosis of recurrent wheezing (37.5%), asthmatic crisis (37.5%) or bronchiolitis (12.5%). Seven children (15.9%) needed the support of the pediatric intensive care unit. When coinfections were excluded, children with EV-D68 infection presented with increased work of breathing, recurrent wheezing or asthmatic crisis, more frequently than those with ARI associated with EV non-D68. Moreover, clinical outcomes (hospitalization, respiratory support) were more severe. All 44 EV-D68 strains detected belonged to lineage B3. Conclusions EV-D68 circulated widely in Gipuzkoa during 2016 and was associated with severe ARI. In children with severe ARI of unknown etiology, the presence of EV-D68 should be considered.

The COVID-19 pandemic has shaken the world since the beginning of 2020. Spain is among the European countries with the highest incidence of the disease during the first pandemic wave. We established a multidisciplinar consortium to monitor and study the evolution of the epidemic, with the aim of contributing to decision making and stopping rapid spreading across the country. We present the results for 2170 sequences from the first wave of the SARS-Cov-2 epidemic in Spain and representing 12% of diagnosed cases until 14th March. This effort allows us to document at least 500 initial introductions, between early February-March from multiple international sources. Importantly, we document the early raise of two dominant genetic variants in Spain (Spanish Epidemic Clades), named SEC7 and SEC8, likely amplified by superspreading events. In sharp contrast to other non-Asian countries those two variants were closely related to the initial variants of SARS-CoV-2 described in Asia and represented 40% of the genome sequences analyzed. The two dominant SECs were widely spread across the country compared to other genetic variants with SEC8 reaching a 60% prevalence just before the lockdown. Employing Bayesian phylodynamic analysis, we inferred a reduction in the effective reproductive number of these two SECs from around 2.5 to below 0.5 after the implementation of strict public-health interventions in mid March. The effects of lockdown on the genetic variants of the virus are reflected in the general replacement of preexisting SECs by a new variant at the beginning of the summer season. Our results reveal a significant difference in the genetic makeup of the epidemic in Spain and support the effectiveness of lockdown measures in controlling virus spread even for the most successful genetic variants. Finally, earlier control of SEC7 and particularly SEC8 might have reduced the incidence and impact of COVID-19 in our country., This work was funded by the Instituto de Salud Carlos III project COV20/00140, Spanish 593 National Research Council project CSIC-COV19-021 and ERC StG 638553 to IC, and BFU2017- 594 89594R to FGC. MC is supported by Ramón y Cajal program from Ministerio de Ciencia and 595 grants RTI2018-094399-A-I00 and SEJI/2019/011. 596 We gratefully acknowledge Hospital Universitari Vall d'Hebron, Instituto de Salud Carlos 597 III, IrsiCaixa AIDS Research Lab and all the international researchers and institutions that 598 submitted sequenced SARS-CoV-2 genomes to the GISAID’s EpiCov™ Database, as an 599 important part of our analyses have been made possible by the share of their work.

The aim of this study was to know, through a national survey, the methods and techniques used for the diagnosis of Helicobacter pylori (Hp) in the different Clinical Microbiology Services/Laboratories in Spain, as well as antibiotic resistance data.The survey requested information about the diagnostic methods performed for Hp detection in Clinical Microbiology laboratories, including serology, stool antigen, culture from gastric biopsies, and PCR. In addition, the performance of antibiotic susceptibility was collected. Data on the number of samples processed in 2016, positivity of each technique and resistance data were requested. The survey was sent by email (October-December 2017) to the heads of 198 Clinical Microbiology Laboratories in Spain.Overall, 51 centers from 29 regions answered the survey and 48/51 provided Hp microbiological diagnostic testing. Concerning the microbiological methods used to diagnose Hp infection, the culture of gastric biopsies was the most frequent (37/48), followed by stool antigen detection (35/48), serology (19/48) and biopsy PCR (5/48). Regarding antibiotic resistance, high resistance rates were observed, especially in metronidazole and clarithromycin (over 33%).Culture of gastric biopsies was the most frequent method for detection of Hp, but the immunochromatographic stool antigen test was the one with which the largest number of samples were analyzed. Nowadays, in Spain, it concerns the problem of increased antibiotic resistance to 'first-line' antibiotics.

Background At present only monoclonal EIA (enzyme-immunoassay) stool antigen-tests have obtained optimal accuracy in the diagnosis of Helicobacter pylori. Our aim was to evaluate the accuracy of two stool antigen-tests, the validated Premier Platinum HpSA PLUS (EIA test) and the newly available ImmunoCard STAT! HpSA HD (rapid test) for the initial diagnosis and the confirmation of eradication of H. pylori infection. Patients and methods Patients with indication of H. pylori diagnosis, or confirmation after treatment were included. Data were coded to protect personal data and ensure blindness between tests. Accuracy was considered as coincident diagnosis with the gold standard (13C-urea breath test, UBT). The EIA was used as a bench standard. All stool tests were performed in duplicate. Results 264 patients completed the protocol (100 naive, 164 post-eradication). Average age was 52 years, 61% women, 11% ulcer. Positive diagnoses by UBT were 41% for naive and 17% for post-eradication. Overall ImmunoCard and EIA accuracies were respectively 91% (95% C . I . = 88–94%) and 89% (86–93%), sensitivities 72% (67–78%) and 72% (67–78%), and specificities 98% (96–100%), and 95% (92–97%). Concordance between ImmunoCard and EIA was 95% (93–98%). Discussion Our results indicate that the newly available ImmunoCard rapid stool antigen-test achieves 90% accuracy, with high specificity but suboptimal sensitivity. The ImmunoCard attained equivalent accuracies as the EIA bench standard, with 95% concordance.

In 2014–2016, we conducted a cross-sectional survey in 115 sheep, 104 beef and 82 dairy cattle herds to estimate Shiga toxin-producingEscherichia coli(STEC) prevalence, and collected data on human clinical cases of infection. Isolates were characterised (stx1,stx2,eae,ehxA) and serogroups O157 and O111 identified by PCR, and their antimicrobial resistance (AMR) profiles were determined by broth microdilution. STEC were more frequently isolated from beef cattle herds (63.5%) and sheep flocks (56.5%) than from dairy cattle herds (30.5%) (P< 0.001). A similar but non-significant trend was observed for O157:H7 STEC. In humans, mean annual incidence rate was 1.7 cases/100 000 inhabitants for O157 STEC and 4.7 for non-O157 STEC, but cases concentrated among younger patients. Distribution of virulence genes in STEC strains from ruminants differed from those from human clinical cases. Thus,stx2 was significantly associated with animal STEC isolates (O157 and non-O157),ehxA to ruminant O157 STEC (P= 0.004) andeaeto human non-O157 STEC isolates (P< 0.001). Resistance was detected in 21.9% of human and 5.2% of animal O157 STEC isolates, whereas all non-O157 isolates were fully susceptible. In conclusion, STEC were widespread in ruminants, but only some carried virulence genes associated with severe disease in humans; AMR in ruminants was low but profiles were similar to those found in human isolates.

Background Helicobacter pylori infection is associated with chronic gastritis, ulcers and gastric cancer. Antimicrobial resistance has increased worldwide affecting the efficacy of current treatments. Most guidelines recommend implementation of regional surveillance of primary antibiotic resistance of H pylori. Only a fraction of individuals infected with H pylori develop gastric diseases which are related to virulence factors of the bacteria. The aims of the study were to determine the primary antimicrobial resistance rates of H pylori and to know the virulence factors prevalence of strains circulating in Southern Europe. Materials and methods Susceptibility testing by Etest to clarithromycin, levofloxacin, metronidazole, amoxicillin and tetracycline was performed in 102 isolates (99 naive patients). The prevalence of virulence factors (cagA, vacA, oipA, babA and dupA) was evaluated in 102 H pylori isolates from patients with mild-disease symptoms and in 22 isolates from patients with severe-disease symptoms. Results Primary resistance rates were 12.1% to clarithromycin, 13.1% to levofloxacin, 24.2% to metronidazole and 0% to amoxicillin and tetracycline. Combined resistance to clarithromycin and levofloxacin was 3% and to clarithromycin and metronidazole 4%. Prevalence of virulence factors in the mild- and severe-disease group was 35.3% and 81.8% for cagA, 20.6% and 54.5% for cagA/vacAs1m1, 94.1% and 95.4% for babA2, 78.4% and 100% for oipA and 30.4% and 18.2% for dupA. Conclusions Primary antimicrobial resistance rates were under 15% for clarithromycin and levofloxacin. The prevalence of H pylori carrying the virulent genotype cagA/vacAs1m1 was higher than 20% in the mild-disease and 54% in the severe-disease symptom group.

Background Antibiotic resistance is the main cause for Helicobacter pylori therapy failure. Frequently, empirical regimens have been recommended in patients with various H. pylori eradication failures. In patients with H. pylori-resistant to various families of antibiotics, the treatment guided by antimicrobial susceptibility testing allows the achievement of good eradication rates. Aim To evaluate the effectiveness of susceptibility-guided antimicrobial treatment for H. pylori infection in patients with resistance to one or various families of antibiotics. Methods A total of 3170 consecutive patients infected by H. pylori during 2013-2017 were tested for antimicrobial susceptibility. 66.6% patients showed resistance to one antimicrobial, 18.9% to two, and 2.4% to three families of antibiotics. A cohort of 162 H. pylori-positive patients were enrolled in this study. Forty-three with single H. pylori resistance to clarithromycin (CLR) were treated with omeprazole (PPI), amoxicillin (AMX), and levofloxacin (LVX)-OAL (31 subjects) or omeprazole, AMX, and metronidazole (MTZ)-OAM (12 patients) and 77 patients with dual H. pylori resistance (51 to CLR and MTZ, 12 to CLR plus LVX, and 14 to MTZ plus LVX) received OAL or OBTM (PPI, bismuth subcitrate, tetracycline, and MTZ), OAM, and OAC, respectively. Other 42 patients with triple H. pylori resistance (CLR, LVX, and MTZ) were treated with PPI, AMX, and rifabutin-OAR (18 subjects), PPI, AMX, and doxycycline-OAD (8), OADB (7), OBTM (6), and ODBR (3). All subjects received standard doses for 10 days. Eradication rate was confirmed by 13 C-UBT. Adverse events were assessed by a questionnaire. Results Intention-to-treat analysis demonstrates that eradication rates using triple therapies in patients with H. pylori resistance to one and to two families of antibiotics were 93% and 94.8%, respectively. In subjects with H. pylori-resistant to three families of antibiotics, cure rate was higher in naive patients treated with OAR-10 days compared to those treated with bismuth-containing quadruple therapies (90% vs 75%). Adverse events were limited (18 of 162, 11.1%), all of them mild-moderate. Conclusions The implementation of susceptibility-guided triple therapy for 10 days leads to eradication rate ≥95% in naive patients with H. pylori resistance to one or two families of antimicrobials. In naive patients with H. pylori resistance to three families, OAR treatment achieved a 90% of eradication.

Background Nonbismuth quadruple (concomitant) regimen is recommended for first-line empirical Helicobacter pylori (HP) eradication treatment when clarithromycin resistance is more than 15–20%. Our objective was to evaluate the efficacy and tolerability of concomitant versus antimicrobial susceptibility-guided treatment in an area with high rates of clarithromycin resistance. Methods Three hundred consecutive HP-infected patients received antimicrobial susceptibility-guided therapy or empirical concomitant therapy for 10 days. The concomitant regimen was omeprazole (20 mg/12 hour), amoxicillin (1 g/12 hour), clarithromycin (500 mg/12 hour), and metronidazole (500 mg/12 hour) (OACM). Patients diagnosed by culture received one of three combinations of antibiotics based on susceptibility results: omeprazole, amoxicillin, and clarithromycin (OAC); omeprazole, amoxicillin, and levofloxacin (OAL); or omeprazole, amoxicillin, and metronidazole (OAM), at the aforementioned doses (and 500 mg/12 hour in the case of levofloxacin). Eradication was confirmed with a 13C urea breath test, 6 weeks after treatment. Adverse events and adherence were assessed with questionnaires and reviewing medication sachets. Results The mean age was 50 years, 59% were women, and 14% had peptic ulcers. Concomitant and antimicrobial susceptibility-guided eradication rates were, respectively, 87% and 94% by intention-to-treat (p = .08) and 89% and 95% (p = .08) per protocol per-protocol analysis. Adverse effects were reported in 31% of patients on OACM and 15% of those on susceptibility-guided therapy (p

Background The aim of this study was to determine the appropriateness of the recent recommendations for managing Helicobacter pylori infection in children in a university hospital in Southern Europe. Antimicrobial resistance and response to eradication therapy were also determined. Materials and Methods The presence of H. pylori was studied in 143 children: by gastric biopsy culture (GBC), 13C-urea breath test (UBT) and stool antigen immunochromatography test (SAIT) in 56 children; by GBC and UBT in 20, by GBC and SAIT in 18, and by GBC alone in 49. Antimicrobial susceptibility was determined by E-test. Infection was defined as a positive culture or positivity in both UBT and SAIT. Disease progression was studied in 118 patients. First evaluation of symptoms was carried out at 3–6 months after diagnosis and/or after treatment of the infection. Results H. pylori was detected in 74 from the 143 children analyzed (100% GBC positive, 98.1% UBT positive, and 58.1% SAIT positive). The main symptom was chronic abdominal pain (n = 121). Macroscopic antral nodularity was observed in 29.7% of infected patients and in 5.8% of uninfected patients, respectively. Resistance to clarithromycin and metronidazole was found in 34.7 and 16.7%, respectively. Eradication when susceptible antimicrobials were used occurred in 78.7% (48/61) versus 37.5% (3/8) when the treatment included a drug with resistance (p = .024). In patients with recurrent abdominal pain, symptoms resolved in 92.9% (39/42) patients with HP eradication versus 42.9% (6/14) without HP eradication (p

Objectives To survey antibiotic resistance among Streptococcus pyogenes isolates collected from 2005 to 2012, to characterize those showing erythromycin resistance and to analyse the association of certain emm types with erythromycin resistance or susceptibility. Methods Resistance determinants or mutations conferring erythromycin, clindamycin, tetracycline and fluoroquinolone resistance were analysed. All erythromycin-resistant isolates and a sample of erythromycin-susceptible isolates were emm typed. Multilocus sequence typing was performed for representative emm types. Results Antimicrobial susceptibility was studied for 12 346 S. pyogenes isolates. Erythromycin, clindamycin and tetracycline resistance showed a decreasing trend. In 2012, 2.8% of isolates were erythromycin resistant versus 7.5% in 2005 and 11.7% in 2006. Although 21 clones were involved, 4 clones accounted for almost 90% of erythromycin-resistant isolates. The emm12/ST36 clone, carrying the mef(A) gene, was the predominant (41.1%) erythromycin-resistant clone, with an incidence peak in 2008, followed by a gradual decline. The M phenotype predominated each year except for 2005, when two of the main erythromycin-resistant clones (emm11/ST403 and emm28/ST52) harboured an erm(B) gene. Erythromycin resistance was significantly higher in adults than in children. Skin isolates showed the highest erythromycin resistance rate; among these, perianal isolates frequently belonged to the emm28/ST52 clone. The emm type was not a predictor of erythromycin resistance; however, most emm11 and emm12 were erythromycin-resistant isolates. Macrolide consumption was similar throughout the study period. Only two isolates with a high level of levofloxacin resistance were detected. Conclusions Resistance was mainly related to the circulation of emm12/ST36, emm11/ST403, emm28/ST52 and emm4/ST39 clones, all of which declined throughout the study period.

Summary Objective To know the clinical entities caused by Streptococcus pyogenes as well as the characteristics of the isolates involved in them throughout a 7-year-study. Methods All S. pyogenes infectious episodes from the community recorded in the reference hospital of Gipuzkoa between 2005 and 2011 were included ( n = 11,342). A random selection of 10% of total isolates was characterized by emm- type, T-type and multilocus-sequence-type. Results Main clinical presentations were: pharyngitis ( n = 9467), otitis ( n = 797), dermal infections ( n = 506), and genital infections ( n = 374). Highest frequency of pharyngitis and otitis was detected in children aged 2–8 years old and 1-year old, respectively. Among 29 emm -types, 8 ( emm 4, emm 89, emm 3, emm 87, emm 1, emm 12, emm 6 and emm 75) grouped >70% of isolates. emm 4 was significantly associated with 0–4 year-old patients, and emm 89 and emm 77 with patients >64 years; by infection type, emm 4, emm 87 and emm 12 were associated with pharyngitis, emm 1 and emm 6 with otitis, emm 89 with dermal infections, and emm 77 with genital infections. Conclusions Predominant emm -type changed every year, although the diversity was similar throughout the study period. S. pyogenes pharyngitis maximum incidence presented at earlier age than expected. emm -type associations with age and specific clinical presentations were influenced by population immunity and strain tropism.

In March 2015, an atypical G3P[8] rotavirus with an equine-like VP7 gene was detected in Gipuzkoa (Basque Country, Spain) and spread contributing significantly to the seasonal epidemic. The strain was identified in fecal samples collected from 68 patients, mainly children from rural and urban settings with acute gastroenteritis, representing 14.9% of the 455 rotavirus strains genotyped between July 2014 and June 2015. Seven patients (10.3%) were hospitalized. Full genome analysis of six of these strains revealed a DS-1-like genotype constellation, G3-P[8]-I2-R2-C2-M2-A2-N2-T2-E2-H2, and showed that most genome segments shared the highest nucleotide sequence identity with strains isolated in Japan, Thailand, Australia and the Philippines. The strains of Gipuzkoa were similar to novel G3P[8] reassortant rotaviruses with an equine-like VP7 gene and a DS-1-like genetic backbone that emerged in the Asia-Pacific Region in 2013. The study highlights the circulation of these atypical rotaviruses outside the Asia-Pacific Region of origin, and their emergence in a European Region. Due to their unusual genotype constellation, these strains pose a challenge for the rotavirus strain surveillance, since G-/P-typing, the most commonly used classification system, cannot identify this type of intergenogroup reassortants.

Objectives Clarithromycin resistance (CLR-R) is the main reason for failure of Helicobacter pylori infection treatment, which is frequently empirically prescribed due to the erroneous belief that culture for susceptibility testing is difficult. The aim of this study was to determine CLR-R in a region of southern Europe and to evaluate the utility of a PCR sequencing assay applied on gastroduodenal biopsies in detecting H. pylori and clarithromycin (CLR) susceptibility. Methods The susceptibility of all H. pylori isolates obtained by culture during 2013–2015 was determined by Etest. During 2014–2015, H. pylori detection and CLR susceptibility were also studied by PCR followed by sequencing performed on gastroduodenal biopsies. Point mutations in the 23S rRNA gene were studied in all CLR-resistant isolates in 2014. Results Of 1986 H. pylori isolates obtained by culture (63 from children and 1923 from adults), 349 (17.6%) were CLR-resistant [21/63 (33.3%) in children and 328/1923 (17.1%) in adults; P 0.001], of which 31.5% were also resistant to levofloxacin. The main mutations detected were A2147G (79.8%), A2146G (17.2%) and A2146C (2%). Concordance between the PCR sequencing assay on biopsies and CLR susceptibility by Etest after culture was 89.8%. Conclusions CLR-R was high in Gipuzkoa, northern Spain. The molecular PCR method performed directly on biopsies was a good alternative to the traditional Etest susceptibility method and was an aid when culture was non-viable.

Gastric cancer remains one of the leading causes of global cancer mortality due to therapy resistance, with Helicobacter pylori (H. pylori) infection being a major risk factor. In this study, we report the significance of an elevation of the stem cell regulator SOX9 in bacteria-infected human gastritis and cancer samples, paralleling increased levels of TNFα. SOX9 elevation was more intense in specimens containing the pathogenically significant cagA+ strains of H. pylori. Notably, we found that SOX9 was required for bacteria-induced gastric cancer cell proliferation, increased levels of β-catenin, and acquisition of stem cell–like properties. Analysis of three large clinical cohorts revealed elevated SOX9 levels in gastric cancer with advanced tumor stage and poor patient survival. Functionally, SOX9 silencing in gastric cancer cells enhanced apoptosis and senescence, concomitantly with a blockade to self-renewal and tumor-initiating capability. Paralleling these effects, we also found SOX9 to mediate cisplatin chemoresistance associated with reduced disease-free survival. Mechanistic interactions between SOX9 and β-catenin expression suggested the existence of a regulatory role for SOX9 targeting the WNT canonical pathway. Taken together, our findings establish the significance of SOX9 in gastric cancer pathobiology and heterogeneity, with implications for targeting WNT–SOX9 signaling as a rational therapeutic strategy. Cancer Res; 76(22); 6735–46. ©2016 AACR.

Anti-N-methyl-D-aspartate receptor encephalitis is a neuroimmunologic disorder that has been increasingly diagnosed during the past 5 years. It provokes a predictable syndrome treated with several immunomodulatory agents, such as corticosteroids and/or biologics. We managed a child with this disease who developed Pneumocystis jirovecii pneumonia as a direct infectious complication of the use of rituximab.

Resumen Introduccion Adenovirus serotipo 4a es un virus respiratorio que causa ocasionalmente conjuntivitis. En el presente trabajo se describe un brote de conjuntivitis folicular que tuvo lugar en un centro gerontologico. Material y metodos Descripcion del brote e investigacion epidemiologica mediante encuesta. Para el estudio microbiologico se recogieron frotis conjuntivales con medios de transporte viral y bacteriano. Adenovirus se detecto mediante un ensayo de reaccion en cadena de la polimerasa en tiempo real. El serotipo se conocio mediante secuenciacion de un fragmento de los genes hexon y E1. Resultados En otono de 2008 se detecto un brote de conjuntivitis folicular por adenovirus serotipo 4a que afecto al 23% (69/300) de los residentes internos y al 5% (9/180) de los trabajadores de un centro gerontologico de Gipuzkoa. El cuadro clinico fue de duracion prolongada (11±5 dias). La asociacion temporal de los casos sugirio transmision de persona a persona. Las medidas higienicosanitarias establecidas (asepsia y lavado frecuente de manos, limpieza y desinfeccion de objetos y superficies) fueron efectivas, interrumpiendo la transmision de la enfermedad en un breve periodo. Conclusion La rapida deteccion, identificacion del agente causal e implantacion de las medidas de control adecuadas pueden disminuir de manera importante el impacto tanto en la salud como en el coste economico de este tipo de brotes.

SUMMARYThe incidence of hospitalization for acute gastroenteritis (AGE) is a useful parameter to assess the utility of the new rotavirus vaccines in high-income countries. Children hospitalized for AGE were identified by searching hospital discharge data and the records of the microbiology laboratory of Hospital Donostia. Rotavirus antigen was investigated in 96·1% of the 1114 children aged 1 month to P

Resumen Objetivo Estimar el valor predictivo negativo de la determinacion del virus del papiloma humano (VPH) a los 3 meses de la conizacion. Material y metodos Valorar el primer control a los 3 meses de las 208 conizaciones realizadas en el Hospital Donostia entre el 1 de enero de 2003 al 31 de diciembre de 2006. Resultados La determinacion del VPH en el primer control posconizacion muestra un valor predictivo negativo de 97,99% (intervalo de confianza [IC] del 95%, 95,40-100), el valor predictivo positivo es del 47,92% (IC del 95%, 32,74-63,09), la sensibilidad del 88,46% (IC del 95%, 74,26-100) y la especificidad de 85,38% (IC del 95%, 79,79-90,97). Conclusiones La negativizacion del VPH a los 3 meses de la realizacion de la conizacion ofrece una alta seguridad y puede reducir el numero de controles colpocitologicos.

The occurrence of viral coinfections in childhood pneumonia has received little attention, probably because suitable detection methods have been lacking. Between November 2004 and October 2006, the presence of 14 respiratory viruses in children aged less than 3 years old with community‐acquired pneumonia were investigated using molecular or immunochromatographic techniques and/or viral culture. A total of 315 children (338 episodes) were included, and hospitalization was required in 178 episodes. At least one virus was detected in 66.9% of the episodes and simultaneous detection of two or more viruses was frequent (27% of the episodes with viral detection). The most frequently detected virus was respiratory syncytial virus (n = 67: 33 subgroup A, 33 subgroup B, 1 not typed), followed by human bocavirus (n = 48), rhinovirus (n = 46), human metapneumovirus (n = 39: 13 genotype A2, 8 B1, 5 B2, 1 A1, 12 not genotyped) and parainfluenza viruses (n = 38: 1 type 1, 3 type 2, 22 type 3, 11 type 4 and 1 not typed). The 14 viruses investigated were found in viral coinfections, which were more frequent in children aged less than 12 months. Except for adenovirus, the incidence of which was low, the percentage of viral coinfection ranged between 28.2% and 68.8%. Children with viral coinfection more frequently required hospital admission than those with single viral infection. It is concluded that viral coinfections are frequent in children aged less than 3 years old with community‐acquired pneumonia and can be a poor prognostic factor. J. Med. Virol. 80:1843–1849, 2008. © 2008 Wiley‐Liss, Inc.

Numerous studies have been published on human metapneumovirus (HMPV) infection, but few have been population based. The main aim of this study was to estimate the incidence rate of hospitalization for community-acquired HMPV infection in infants and children aged

El genero Streptococcus es un grupo muy numeroso y heterogeneo de bacterias, algunas de las cuales son importantes patogenos para el ser humano. En el presente articulo revisaremos la nomenclatura, la clasificacion y los metodos para identificar a las distintas especies del genero Streptococcus , desde el punto de vista del trabajo habitual en un laboratorio de microbiologia clinica. Las especies de estreptococos mas frecuentemente patogenas en humanos (cepas betahemoliticas y Streptococcus pneumoniae ) pueden identificarse facilmente usando unas pocas pruebas fenotipicas y bioquimicas. Algunas especies, en cambio, son dificiles de identificar, incluso mediante tecnicas moleculares basadas en el analisis del gen 16SrRNA .

The aim of this study was to describe the genetic characteristics of Streptococcus pyogenes showing the MLS B phenotype of macrolide resistance from 1999 to 2005 in Spain and to highlight the substantial increase in these isolates in the last few years. The antimicrobial susceptibilities of 17,232 group A streptococci isolated from Madrid and Gipuzkoa from 1999 to 2005 were studied. The presence of the resistance genes ermA , ermB , mef , tetM , and tetO and the presence of the intTn and xis genes of the Tn 916 -Tn 1545 transposon family were studied in a sample of 739 MLS B -resistant isolates. The epidemiological relationships among these isolates were analyzed by emm typing, T typing, and multilocus sequence typing. Erythromycin resistance was found in 21.3% of the isolates analyzed (annual variation of 14.3% to 28.9%). Until 2003, most erythromycin-resistant isolates showed the M phenotype, but in 2004 and 2005, about 50% of isolates showed the MLS B phenotype. Among the MLS B -resistant isolates studied, 16 clones were identified. The most prevalent clone was a strange emm 11/T11/ST403 clone with a null yqiL allele. All but one of the 463 emm 11/T11/ST403 isolates carried the ermB , tetM , intTn , and xis genes. The second most prevalent MLS B -resistant clone was emm 28/T28/ST52, which comprised two subclones: one bacitracin-resistant, tetracycline-susceptible subclone carrying the ermB gene ( n = 115) and another bacitracin-susceptible, tetracycline-resistant subclone carrying the ermB and tetM genes ( n = 33). The rapid diffusion of these two clones, and especially of emm 11/T11/ST403, caused the large increase in MLS B -resistant S. pyogenes isolates in Spain, suggesting a potential ability for international dissemination.

Seventy-four Streptococcus pyogenes isolates showing the macrolide–lincosamide–streptogramin B (MLS B ) resistance phenotype carrying the ermA gene (72 of which showed the inducible resistance phenotype) were obtained between 1999 and 2004. Seven different sequence types (STs) and emm types were detected: emm 22/ST46 ( n = 33); emm 77/ST63 ( n = 22); emm 73/ST331 ( n = 10); emm 94/ST89 ( n = 6); and one isolate each of emm 28/ST52, emm 11/ST403 and emm 4/ST38. All ST46 isolates were susceptible to tetracycline and almost all reacted against the T12 type (all agglutinated into the T-pattern 3/12/13/B3264). Resistance to tetracycline was observed in all ST63 ( tetO +) and ST89 ( tetM +) isolates. Most of the ST63 isolates reacted against the T28 type (all agglutinated into the T-pattern 9/13/28). The 74 isolates were grouped into eight pulsed-field gel electrophoresis pulsotypes (one cluster for each emm /ST type, except for emm 77/ST63).

The aim of this study was to determine changes in the epidemiology of hepatitis A virus (HAV) infection in the Basque Country, Spain, and to evaluate their implications for vaccination strategies. A total of 1356 persons were enrolled in a study of the prevalence of anti-HAV in 2004 and compared with two previous studies (1986–1987 and 1992). The selection method and the characteristics of the population were similar in the three studies. A marked decline in the seroprevalence in all age groups (PP

Retapamulin in vitro activity against 400 Streptococcus pyogenes clinical isolates obtained from skin, pharynx, ear fluid, and blood samples recovered from 2007 to 2009 was studied. The isolates belonged to 26 different emm types, including isolates nonsusceptible to erythromycin ( n = 187), tetracycline ( n = 99), ciprofloxacin ( n = 59), and bacitracin ( n = 43). Results were compared to the activities of 16 other antibiotics for topical and systemic use. Retapamulin MICs ranged from ≤0.015 to 0.12 μg/ml, showing the highest intrinsic activity among the topical antimicrobial drugs studied.

Introduction: Circulating Chlamydia trachomatis genotypes that cause infection in our geographic area were studied with the aim of detecting possible epidemiological peculiarities. Methods: A total of 177 strains obtained between 2006 and 2008 were genotyped using a PCR with primers targeting the ompA gene, and later sequenced. Results: The most frequent genotypes were: E (45.3%), D (15.3%), G (10.2%) and F (9.6%). Other genotypes

The aim of this study was to determine whether the high levels of erythromycin resistance in Streptococcus pyogenes found in Spain are due to the introduction and spread of one or more clones. Phenotypic and genotypic techniques were used to characterize all erythromycin-resistant S. pyogenes (ErR) isolated in Gipuzkoa, Spain, in the last 10 years and 128 ErR isolated in Vitoria and Madrid during 1996. Of 437 ErR, 97% had the M phenotype; all 283 of the strains studied had the mefA determinant of resistance. After biotyping, T serotyping, emm typing, and genotyping, four major clones were detected. Clones B (biotype I, type T4, emm4, pulsed-field gel electrophoresis [PFGE] II) and D (biotype V, type T8.25, emm75, PFGE IV) comprised 78.8% of all ErR. The resistance of S. pyogenes to erythromycin was mainly due to an efflux mechanism of resistance (M phenotype); few clones were responsible for it.

Human metapneumovirus (hMPV) genotypes A and B show epidemiological and probably clinical differences. This report describes a fast and simple PCR–restriction fragment length polymorphism (PCR-RFLP) assay, involving digestion of the fusion protein gene with Tsp509I, that allows lineages A1, A2, B1 and B2 to be distinguished. The assay should help in elucidating the epidemiology of hMPV, and possibly in predicting the severity of clinical infection.