Cluster of legionnaires’ disease in an Italian prison

Background: Legionella pneumophila (Lp) is the most common etiologic agent causing Legionnaires’ Disease (LD). Water systems offer the best growth conditions for Lp and support its spread by producing aerosols. From 2015 to 2017, the Regional Reference Laboratory of Clinical and Environmental Surveillance of Legionellosis of Palermo monitored the presence of Lp in nine prisons in Western Sicily. During this investigation, we compared Lp isolates from environmental samples in a prison located in Palermo with isolates from two prisoners in the same prison. Methods: We collected 93 water samples from nine Sicilian prisons and the bronchoalveolar lavages (BALs) of two prisoners considered cases of LD. These samples were processed following the procedures described in the Italian Guidelines for the Prevention and Control of Legionellosis of 2015. Then, genotyping was performed on 19 Lp colonies (17 from water samples and 2 from clinical samples) using the Sequence-Based Typing (SBT) method, according to European Study Group for Legionella Infections (ESGLI) protocols. Results: Lp serogroup (sg) 6 was the most prevalent serogroup isolated from the prisons analyzed (40%), followed by Lp sg 1 (16%). Most of all, in four penitentiary institutions, we detected a high concentration of Lp >104 Colony Forming Unit/Liter (CFU/L). The environmental molecular investigation found the following Sequence Types (STs) in Lp sg 6: ST 93, ST 292, ST 461, ST 728, ST 1317 and ST 1362, while most of the isolates in sg 1 belonged to ST 1. We also found a new ST that has since been assigned the number 2451 in the ESGLI-SBT database. From the several Lp sg 1 colonies isolated from the two BALs, we identified ST 2451. Conclusions: In this article, we described the results obtained from environmental and epidemiological investigations of Lp isolated from prisons in Western Sicily. Furthermore, we reported the first cluster of Legionnaires’ in an Italian prison and the molecular typing of Lp sg 1 from one prison’s water system and two BALs, identified the source of the contamination, and discovered a new ST

Immunohistochemical/histochemical double staining method in the study of columnar metaplasia of the oesophagus

Intestinal metaplasia in Barrett\u2019s oesopha- gus (BO) represents an important risk factor for oesophageal adenocarcinoma. Instead, few and controversial data are reported about the progression risk of columnar-lined oesophagus without intestinal metaplasia (CLO), posing an issue about its clinical management. The aim was to evaluate if some immunophenotyp- ic changes were present in CLO independently of the presence of the goblet cells. We studied a series of oesophageal biopsies from patients with endoscopic finding of columnar metapla- sia, by performing some immunohistochemical stainings (CK7, p53, AuroraA) combined with histochemistry (Alcian-blue and Alcian/PAS), with the aim of simultaneously assess the his- tochemical features in cells that shows an aber- rant expression of such antigens. We evidenced a cytoplasmic expression of CK7 and a nuclear expression of Aurora A and p53, both in goblet cells of BO and in non-goblet cells of CLO, some of which showing mild dysplasia. These find- ings suggest that some immunophenotypic changes are present in CLO and they can pre- cede the appearance of the goblet cells or can be present independently of them, confirming the conception of BO as the condition charac- terized by any extention of columnar epitheli- um. This is the first study in which a combined immunohistochemical/histochemical method has been applied to Barrett pathology

A NEW CASE OF LOUSE-BORNE RELAPSING FEVER IN SICILY: CASE REPORT AND MINI REVIEW

Body lice transport B. recurrentis from man to man and humans are the only host. The presence of lice in Italy and an increasing number of cases in migrants can contribute to the onset of autochthonous cases. In this paper, we report a new case of Louse-borne Relapsing Fever (LBRF) diagnosed among migrants in Sicily exactly one year after the first case was recorded. We reviewed all cases reported in Europe from February 2016 until now. Our study identified two new cases of LBRF in migrants arrived in Europe: one who came from Somalia and one from Mali. Here we report data on a new case in Sicily. The number of migrants and refugees to transit in Sicily has increased, and this has led to the introduction of infectious diseases. Therefore, in our opinion it is essential to upgrade control of the sanitation conditions of migrants

How Consistent Is Competent? Examining Variance in Psychomotor Skills Assessment

Purpose Direct assessment of trainee performance across time is a core tenet of competency-based medical education. Unlike variability of psychomotor skills across levels of expertise, performance variability exhibited by a particular trainee across time remains unexplored. The goal of this study was to document the consistency of individual surgeons\u27 technical skill performance. Method A secondary analysis of assessment data (collected in 2010-2012, originally published in 2015) generated by a prospective cohort of participants at Montreal Children\u27s Hospital with differing levels of expertise was conducted in 2017. Trained raters scored blinded recordings of a myringotomy and tube insertion performed 4 times by junior and senior residents and attending surgeons over a 6-month period using a previously reported assessment tool. Descriptive exploratory analyses and univariate comparison of standard deviations (SDs) were conducted to document variability within individuals across time and across training levels. Results Thirty-six assessments from 9 participants were analyzed. The SD of scores for junior residents was highly variable (5.8 out of a scale of 30 compared with 1.8 for both senior residents and attendings [F(2,19) = 5.68, P \u3c 0.05]). For a given individual, the range of scores was twice as large for junior residents than for senior residents and attendings. Conclusions Surgical residents may display highly variable performances across time, and individual variability appears to decrease with increasing expertise. Operative skill variability could be underrepresented in direct observation assessment; emphasis on an adequate amount of repetitive evaluations for junior residents may be needed to support judgments of competence or entrustment

VIRULENCE FACTORS AND ANTIMICROBIAL RESISTANCE OF ESCHERICHIA COLI ST131 IN COMMUNITY-ONSET HEALTHCARE-ASSOCIATED INFECTIONS IN SICILY, ITALY

Escherichia coli ST131 is an emerging resistant agent recently called \u201csuperbug\u201d in England. This strain is responsible of community-acquired urinary tract infections and nowadays showing increasing resistance to antibiotics like fluoroquinolones and cephalosporins. Survey of virulent bacterial clone is relevant to control its spreading in community. We aim to assess the circulation of resistant clones Escherichia coli ST131 outside of the hospital to prompt control of outbreak in our geographical area. We selected 105 E. coli resistant isolates from community-acquired urinary infections and performed a multiplex PCR to evaluate if they belonged to the ST131 type. We investigated their set of virulence factors; in particular, kpsMII, papA, sfaS, focG, iutA, papC, hlyD and afa genes, and finally, we evaluated beta lactamases genes and quinolone resistance determinants. E. coli ST 131 clone was present in 66.6% of our isolates and showed positivity to a wide range of resistance genes, in particular blaCTX-M-15 among beta lactamases and plasmid-related quinolone resistance genes (qnrA, qnrS and aac (6\u2019)-Ib-cr). Moreover, 81% of the strains showed positivity to at least one of the virulence factor genes. Our results suggested a high presence of E. coli ST131 in community. We suggest antibiotic stewardship for outpatient clinicians and facilities to contain the spread of \u201csuperbug\u201d agents

HELICOBACTER PYLORI AND EPSTEIN\u2013BARR CO-INFECTION IN GASTRIC DISEASE

The incidence of gastrointestinal diseases and in particular gastric cancer (GC) is high worldwide. Over the last few years, numerous studies have speculated that Helicobacter pylori (H. pylori) and Epstein-Barr virus (EBV) can be correlated with gastric cancerogenesis. Virulence factors of H. pylori can contribute to the variability of clinical outcomes: among the most important virulence factors is the pathogenicity island (CagPAI), vacA and oipA gene. EBV infection usually persists in B cells and induces an inflammatory reaction in cooperation with H. pylori. In Sicily, H. pylori and EBV infections are particularly prevalent, and to our knowledge no study has addressed this yet. The aim of our study was to examine the association of H. pylori and EBV infection in patients with gastric diseases in Sicily. Gastric biopsies were collected from 24 adult patients with chronic gastritis active (CGA) and from 24 adult patients without any gastric disease (NGD) who underwent upper gastrointestinal endoscopy. H. pylori infection was diagnosed by PCR for ureaseA gene while EBV-DNA was detected by Real time PCR for region Bam HI-W. Moreoever, we investigated the presence of CagPaI and the status of vacA and oipA genes. Percentage of resistance to Clarithromycin of H. pylori was evaluated also. We established that H. pylori and EBV infection was present in 42% of patients, while dual infection with H. pylori and EBV-DNA was present in 54% of the patients with CGA. In patients with NGD we found that H. pylori and EBV infection was present in 46% and in 21% of patients respectively, while co-infection was present in 33% of patients. CagPAI was present in only 20% of patients with GCA and in 9% of patients with NGD. As regards vacA alleles, s2i2m2 were predominant, present in 80% and 82% of patients with CGA and NGD respectively. The status \u201cON\u201d of oipA gene was present in the same percentage. Finally, we found that 38% of patients positive for H. pylori infection showed resistance to Clarithromycin. In our study, there was a strong association between the simultaneous presence of H. pylori and EBV infection in patients with CGA compared to patients with NGD. Furthermore, our data confirmed the high percentage of resistance among H. pylori strains circulating in Sicily, underlining the importance of establishing a therapy that is effective in eradicating them and reducing the frequency of coinfections and evolution towards gastric cancerogenesi

Great occipital nerve long-acting steroid injections in cluster headache therapy: an observational prospective study

Background: Injections targeting the occipital nerve are used to reduce headache attacks and abort cluster bouts in cluster headache patients. There is no widely accepted agreement over the optimal technique of injection, type and doses of steroids and/or anesthetics to use, as well as injection regimens. The aim of this study was to verify the effectiveness and safety of greater occipital nerve long-acting steroid injections in the management of episodic and chronic cluster headache. Methods: We conducted a prospective observational cohort study on episodic (ECH) and chronic cluster headache patients (CCH). ECH were included in the study at the beginning of a cluster period. Three injections with 60 mg methylprednisolone were performed on alternate days. We registered the frequency and intensity of attacks three days before and 3, 7 and 30 days after the treatment, the latency of cluster relapse, adverse events, scores evaluating anxiety (Zung scale), depression (Beck’s Depression Scale) and quality of life (Disability Assessment Schedule II, 12-Item Self-Administered Version). Primary outcome was the interruption of the cluster after the three injections. Responders conducted a follow-up period of 12 months. Results: We enrolled 60 patients, 47 with ECH and 13 with CCH. We observed a complete response in 47.8% (22/46) of episodic and 33.3% (4/12) of chronic patients. Moreover, a partial response (reduction of at least 50% of attacks) was obtained in further 10.8% (5/46) of episodic and in 33.3% (4/12) of chronic patients at 1 month. Median pain-free period was of 3 months for CCH responders. Only mild adverse events were reported in 38.3% (23/58) cases. Conclusions: We suggest three greater occipital nerve injections of 60 mg methylprednisolone on alternate days as useful therapy in episodic and chronic cluster headache. This leads to a long pain-free period in chronic forms. Adverse effects are mild and support its use as first choice. Trial registration: The study was inserted in AIFA observational studies register

Co-existence of virulence factors and antibiotic resistance in new Klebsiella pneumoniae clones emerging in south of Italy

Background: Endemic presence of Klebsiella pneumoniae resistant to carbapenem in Italy has been due principally to the clonal expansion of CC258 isolates; however, recent studies suggest an ongoing epidemiological change in this geographical area. Methods: 50 K. pneumoniae strains, 25 carbapenem-resistant (CR-Kp) and 25 susceptible (CS-Kp), collected from march 2014 to march 2016 at the Laboratory of Bacteriology of the Paolo Giaccone Polyclinic University hospital of Palermo, Italy, were characterized for antibiotic susceptibility and fully sequenced by next generation sequencing (NGS) for the in silico analysis of resistome, virulome, multi-locus sequence typing (MLST) and core single nucleotide polymorphism (SNP) genotypes Results: MLST in silico analysis of CR-Kp showed that 52% of isolates belonged to CC258, followed by ST395 (12%), ST307 (12%), ST392 (8%), ST348 (8%), ST405 (4%) and ST101 (4%). In the CS-Kp group, the most represented isolate was ST405 (20%), followed by ST392 and ST15 (12%), ST395, ST307 and ST1727 (8%). The in silico β-lactamase analysis of the CR-Kp group showed that the most detected gene was blaSHV (100%), followed by blaTEM (92%), blaKPC (88%), blaOXA (88%) and blaCTX-M (32%). The virulome analysis detected mrk operon in all studied isolates, and wzi-2 was found in three CR-Kp isolates (12%). Furthermore, the distribution of virulence genes encoding for the yersiniabactin system, its receptor fyuA and the aerobactin system did not show significant distribution differences between CR-Kp and CS-Kp, whereas the Klebsiella ferrous iron uptake system (kfuA, kfuB and kfuC genes), the two-component system kvgAS and the microcin E495 were significantly (p < 0.05) prevalent in the CS-Kp group compared to the CR-Kp group. Core SNP genotyping, correlating with the MLST data, allowed greater strain tracking and discrimination than MLST analysis. Conclusions: Our data support the idea that an epidemiological change is ongoing in the Palermo area (Sicily, Italy). In addition, our analysis revealed the co-existence of antibiotic resistance and virulence factors in CR-Kp isolates; this characteristic should be considered for future genomic surveillance studies

Structure of the human κ-opioid receptor in complex with JDTic

Opioid receptors mediate the actions of endogenous and exogenous opioids on many physiological processes, including the regulation of pain, respiratory drive, mood, and—in the case of κ-opioid receptor (κ-OR)—dysphoria and psychotomimesis. Here we report the crystal structure of the human κ-OR in complex with the selective antagonist JDTic, arranged in parallel dimers, at 2.9 Å resolution. The structure reveals important features of the ligand-binding pocket that contribute to the high affinity and subtype selectivity of JDTic for the human κ-OR. Modelling of other important κ-OR-selective ligands, including the morphinan-derived antagonists norbinaltorphimine and 5′-guanidinonaltrindole, and the diterpene agonist salvinorin A analogue RB-64, reveals both common and distinct features for binding these diverse chemotypes. Analysis of site-directed mutagenesis and ligand structure–activity relationships confirms the interactions observed in the crystal structure, thereby providing a molecular explanation for κ-OR subtype selectivity, and essential insights for the design of compounds with new pharmacological properties targeting the human κ-OR