Vertebral osteomyelitis due to Mycobacterium abscessus subsp. massiliense with paravertebral abscess: A case report and review

The incidence of vertebral osteomyelitis (VO) caused by non-tuberculosis mycobacteria (NTM) without immunocompetence is extremely rare. Herein, we reported on a case of VO caused by NTM. A 38-year-old man was admitted to our hospital with persisting low back and leg pain which had lasted for a year. Before coming to our hospital, the patient was treated with antibiotics and iliopsoas muscle drainage. The biopsy confirmed the presence of a NTM, Mycobacterium abscessus subsp. massiliense. Several tests were conducted which showed the infection had progressively increased, such as vertebral endplate destruction on plain radiography, computed tomography scan, and epidural and paraspinal muscle abscesses on magnetic resonance imaging. The patient underwent radical debridement, anterior intervertebral fusion with bone graft, and posterior instrumentation with antibiotic administration. A year later, the patient's low back and leg pain was relieved without any analgetic. VO due to NTM is rare but can be treated with multimodal therapy.     

Vertebral osteomyelitis caused by Mycobacteroides abscessus subsp. abscessus resulting in spinal cord injury due to vertebral body fractures

Nontuberculous mycobacteria (NTM) rarely cause vertebral osteomyelitis; however, the clinical characteristics of vertebral osteomyelitis caused by NTM are poorly understood due to its rarity. A 74-year-old man with lung cancer was treated with prednisolone for immune checkpoint inhibitor-associated immune-related adverse events. He had been experiencing mild back pain without febrile episodes for five months, and was admitted to the hospital for worsening back pain and progressive paraplegia. Magnetic resonance imaging showed spinal cord compression at T4-5 due to fractures of the T5 and T7 vertebral bodies. The culture of a sample of pus from the T7 vertebral body obtained at the time of spinal fusion surgery yielded the Mycobacteroides abscessus (M. abscessus) complex. The patient was diagnosed with vertebral osteomyelitis caused by M. abscessus complex and treated with clarithromycin, amikacin, and imipenem; clarithromycin was later replaced by sitafloxacin because of inducible macrolide resistance. However, his neurologic deficits were irreversible, and he died due to a deteriorating general condition. The strain was identified up to subspecies level as M. abscessus subsp. abscessus by hsp65 and rpoB sequencing and nucleic acid chromatography. Although vertebral osteomyelitis due to NTM is rare, delayed diagnosis can lead to serious complications or poor outcomes. A prolonged clinical course, less frequent fever, vertebral destruction or spinal deformity, neurological deficits, or immunosuppressed conditions might be suggestive of NTM vertebral osteomyelitis.     

Susceptibility of Campylobacter fetus subsp. jejuni to Twenty Antimicrobial Agents

One hundred recent clinical isolates of Campylobacter fetus subsp. jejuni were tested by an agar dilution technique for susceptibility to each of 20 antimicrobial agents. Doxycycline and gentamicin were the most active of the drugs examined, inhibiting all strains at concentrations achievable in serum. Although the median minimal inhibitory concentration of erythromycin was low, 8% of the isolates were highly resistant. All isolates of Campylobacter fetus subsp. jejuni were relatively resistant to the beta-lactam antibiotics. Some strains were highly resistant to metronidazole and tinidazole.     

Susceptibility of Campylobacter fetus subsp. jejuni to Twenty-Nine Antimicrobial Agents

The activity of 29 antimicrobial agents was tested against 95 strains of Campylobacter fetus subsp. jejuni isolated from human stools. Furazolidone and gentamycin were the most active agents. The tetracyclines, erythromycin, and chloramphenicol were very active against most of the strains, but with each antibiotic a few resistant strains were found. The penicillins were relatively inactive, and the cephalosporins tested were only active against occasional strains.     

Antimicrobial susceptibility of Campylobacter jejuni and Campylobacter fetus subsp. fetus to eight cephalosporins with special reference to species differentiation.

Agar dilution antimicrobial susceptibility testing showed that Campylobacter jejuni was significantly more resistant than Campylobacter fetus subsp. fetus (intestinalis) to cephalosporin C, cephaloridine, cephalothin, cefazolin, and cefamandole. No species differences in susceptibility were noted with cephalexin, cefotaxime, and cefoxitin. Rapid species differentiation on the basis of an antibiogram could be achieved with the disk diffusion method. C jejuni failed to produce a zone of inhibition around a 30-microgram cephalothin disk but produced a significant zone around a 30-microgram nalidixic acid disk. C. fetus subsp. fetus (intestinalis) produced exactly the reverse pattern.     

Pathogenesis of Campylobacter fetus infections. Failure of encapsulated Campylobacter fetus to bind C3b explains serum and phagocytosis resistance.

Campylobacter fetus ssp. fetus strains causing systemic infections in humans are highly resistant to normal and immune serum, which is due to the presence of high molecular weight (100,000, 127,000, or 149,000) surface (S-layer) proteins. Using serum-resistant parental strains (82-40 LP and 23D) containing the 100,000-mol wt protein and serum-sensitive mutants (82-40 HP and 23B) differing only in that they lack the 100,000-mol wt protein capsule, we examined complement binding and activation, and opsono-phagocytosis by polymorphonuclear leukocytes. C3 consumption was similar for all four strains but C3 was not efficiently bound to 82-40 LP or 23D even in the presence of immune serum, and the small amount of C3 bound was predominently the hemolytically inactive iC3b fragment. Consumption and binding of C5 and C9 was significantly greater for the unencapsulated than the encapsulated strains. Opsonization of 82-40 HP with heat-inactivated normal human serum caused greater than 99% killing by human PMN. Similar opsonization of 82-40 LP showed no kill, but use of immune serum restored killing. Findings in a PMN chemiluminescence assay showed parallel results. Association of 32P-labeled 82-40 HP with PMN in the presence of HINHS was 19-fold that for the 82-40 LP, and electron microscopy illustrated that the difference was in uptake rather than in binding. These results indicate that presence of the 100,000-mol wt protein capsule on the surface of C. fetus leads to impaired C3b binding, thus explaining serum resistance and defective opsonization in NHS, mechanisms that explain the capacity of this enteric organism to cause systemic infections.     

In vitro susceptibilities of 40 Campylobacter fetus subsp. jejuni strains to niridazole and metronidazole.

The activities of niridazole and metronidazole were compared by an agar dilution method against 40 strains of Campylobacter fetus subsp. jejuni of human origin. Niridazole had a markedly higher activity than metronidazole.     

In vitro susceptibility of Campylobacter fetus subsp. jejuni to N-formimidoyl thienamycin, rosaramicin, cefoperazone, and other antimicrobial agents

The activities of 11 antimicrobial agents against 36 strains of Campylobacter fetus subsp. jejuni were studied by a broth microdilution method. All strains were susceptible to 7 of the 11 antimicrobial agents. Of the newer agents tested N-formimidoyl thienamycin (MK0787) and rosaramicin had very good activity, whereas cefotaxime, moxalactam, and cefoperazone had poorer activity.     

应用罗伊适应模式减轻乳腺癌术后患者抑郁状态的效果观察

目的 探讨应用罗伊适应模式减轻乳腺癌术后患者抑郁状态的效果。方法 选取我院2017年8月-2019年12月乳腺癌术后患者130例,随机分为观察组和对照组,各65例。对照组给予常规的护理措施,观察组患者在常规护理基础上给予罗伊适应模式,观察两组患者入院时、术后干预1周及出院前1天的心理状态,对比两组患者的抑郁程度及自护能力情况,并记录。结果 观察组患者抑郁症状优于对照组,自护能力优于对照组,差异有统计学意义（均P＜0.05）。结论 应用罗伊适应模式,能有效减轻乳腺癌术后患者抑郁状态,提升患者自护能力,促进术后功能康复,降低并发症的发生,改善乳腺癌术后患者生活质量。     

乳腺癌患者保乳术后调强放射治疗的护理

总结13例乳腺癌患者保乳术后运用调强放疗技术进行治疗的护理体会。放疗前做好心理护理、详细解释及呼吸训练;放疗过程中注意并发症的观察及护理,出现放射性肺炎,急性放射性食管炎时进行对症处理;加强放疗区皮肤保护。13例患者均达到良好的治疗效果,未发生严重并发症,顺利完成治疗。     

早期乳腺癌56例保乳手术临床疗效观察

目的 探讨早期乳腺癌保留乳房手术治疗的效果.方法 将符合保乳手术的120例按随机及患者意愿原则分为保乳手术组及改良根治手术组,手术后两组患者均实施术后辅助化疗及放疗,对雌激素受体、孕激素受体阳性者行内分泌治疗.术后随访24～84个月.比较两组围手术期指标,并发症的差异,比较两组患者乳房外形及患者满意度;比较术后两年间两组焦虑自评量表和抑郁自评量表差异;同时比较两组患者的远期疗效.结果 ①保乳手术组手术时间、术中平均出血量、术后平均引流量及住院天数均优于改良根治术组（P＜0.05）;②两组皮下积液、皮瓣坏死、上肢水肿、后遗患侧上肢功能障碍及后遗神经痛等并发症差异无统计学意义（P＞0.05）;③两组局部复发率、远处转移率及5年总生存率比较无统计学差异（P＞0.05）;④保乳组的乳房外形美容明显优于改良根治术组（P＜0.05）,保乳组对其乳房外形满意度明显高于改良根治术组（P＜0.05）,保乳组患者在焦虑或抑郁等负性情感方面明显弱于改良根治手术组（P＜0.05）.结论 早期乳腺癌保留乳房手术治疗效果好,可明显改善患者术后生存质量,值得推广应用.     

Long-term clinical performance of flapless implant surgery compared to the conventional approach with flap elevation: A systematic review and meta-analysis

BACKGROUND The conventional implant approach involves flap elevation,which may result in increased soft tissue and bone loss and postoperative morbidity.The flapless surgical technique,aided by three-dimensional medical imaging equipment,is regarded as a possible alternative to the conventional approach to alleviate the above issues.Several studies have been performed regarding the role of flapless implant surgery.However,the results are inconsistent and there is no robust synthesis of long-term evidence to better inform surgeons regarding which type of surgical technique is more beneficial to the long-term prognosis of patients in need of implant insertion.AIM To compare the long-term clinical performance after flapless implant surgery to that after the conventional approach with flap elevation.METHODS PubMed,EMBASE,Cochrane Central Register of Controlled Trials,and grey literature databases were searched from inception to 23 September 2019.Randomised controlled trials(RCTs)and cohort studies comparing the long-term clinical performance after flapless implant surgery to that after the conventional approach over a follow-up of three years or more were included.Meta-analyses were conducted to estimate the odds ratios(ORs)or mean differences(MDs)and their 95%confidence intervals(CIs)between the long-term implant survival rate,marginal bone loss,and complication rate of the flapless and conventional groups.Subgroup analyses were carried out to account for the possible effects of the guided or free-hand method during flapless surgery.RESULTS Ten articles,including four RCTs and six cohort studies,satisfied the eligibility criteria and nine of them were included in the meta-analysis.There was no significant difference between the long-term implant survival rate[OR=1.30,95%CI(0.37,4.54),P=0.68],marginal bone loss[MD=0.01,95%CI(-0.42,0.44),P=0.97],and complication rate[OR=1.44,95%CI(0.77,2.68),P=0.25]after flapless implant surgery and the conventional approach.Moreover,subgroup analyses revealed that there was no statistically significant difference between the implant survival rate[guided:OR=1.52,95%CI(0.19,12.35),P=0.70];free-hand:n=1,could not be estimated,marginal bone loss[guided:MD=0.22,95%CI(-0.14,0.59),P=0.23;free-hand:MD=-0.27,95%CI(-1.10,0.57),P=0.53],or complication rate[guided:OR=1.16,95%CI(0.52,2.63),P=0.71;free-hand:OR=1.75,95%CI(0.66,4.63),P=0.26]in the flapless and conventional groups either with use of the surgical guide or by the free-hand method.CONCLUSION The flapless surgery and conventional approach had comparable clinical performance over three years or more.The guided or free-hand technique does not significantly affect the long-term outcomes of flapless surgery.     

Prospective assessment of chemotherapy-induced peripheral neuropathy due to weekly paclitaxel in patients with advanced or metastatic breast cancer (CSP-HOR 02 study)

Goals of work  The aim of this study was to prospectively evaluate chemotherapy-induced peripheral neuropathy (CIPN) using a patient-based instrument, the Patient Neurotoxicity Questionnaire (PNQ) and a physician-based instrument, the National Cancer Institute-Common Toxicity Criteria (NCI-CTC) in patients with advanced or metastatic breast cancer who were treated with weekly paclitaxel. Materials and methods  CIPN symptoms were prospectively assessed in 35 patients using the PNQ, NCI-CTC, and the Functional Assessment of Cancer Therapy (FACT)-Taxane including neurotoxicity component (Ntx) at the baseline, and 8 and 16 weeks after starting chemotherapy. Results  For sensory neuropathy symptoms, the reported incidence of CIPN was significantly increased during active treatment in terms of both the PNQ and NCI-CTC assessments. In contrast, there was a notable increase of patient motor neuropathy symptoms that were elucidated only by the PNQ. The PNQ grades of CIPN were widely distributed in the patient population as compared with the NCI-CTC grades for both sensory and motor neuropathy. The sensory PNQ grade was correlated with sensory NCI-CTC grade (r = 0.58) and Ntx (r = 0.51), and the motor PNQ grade was correlated with Ntx (r = 0.57). Conclusions  The PNQ appears to be more sensitive and responsive than the NCI-CTC for CIPN; the PNQ appears to have diagnostic validity for evaluating CIPN in patients who are receiving neurotoxic chemotherapy.     

A rare case of silicone mammary implant infection by Streptomyces spp. in a patient with breast reconstruction after mastectomy: taxonomic characterization using molecular techniques

A Streptomyces sp. isolated from a patient who had had breast reconstruction after a mastectomy was identified at the species level by comparative sequence analysis of 16S ribosomal DNA (rDNA) and the hypervariable α-region of the 16S rDNA.     

A case of streptococcal toxic shock syndrome due to Group G streptococci identified as Streptococcus dysgalactiae subsp. equisimilis

A 79-year-old man with a 3-month history of lymphedema of the lower limbs, and diabetes mellitus, was admitted to our hospital for suspected deep venous thrombosis. Several hours after admission, leg pain and purpura-like skin color appeared. On the 2nd hospital day, he was referred to our department for possible acute occlusive peripheral artery disease (PAD) and skin necrosis with blisters; however, computed tomography with contrast showed no occlusive lesions. He had already developed shock and necrotizing deep soft-tissue infections of the left lower leg. Laboratory findings revealed renal dysfunction and coagulation system collapse. Soon after PAD was ruled out, clinical findings suggested necrotizing deep soft-tissue infections, shock state, disseminated intravascular coagulation, and multiple organ failure. These symptoms led to a high suspicion of the well-recognized streptococcal toxic shock syndrome (STSS). With a high suspicion of STSS, we detected Group G β-hemolytic streptococci (GGS) from samples aspirated from the leg bullae, and the species was identified as Streptococcus dysgalactiae subsp. equisimilis (SDSE) by 16S-ribosomal RNA sequencing. However, unfortunately, surgical debridement was impossible due to the broad area of skin change. Despite adequate antimicrobial therapy and intensive care, the patient died on the 3rd hospital day. The M-protein gene (emm) typing of the isolated SDSE was revealed to be stG6792. This type of SDSE is the most frequent cause of STSS due to GGS in Japan. We consider it to be crucial to rapidly distinguish STSS from acute occlusive PAD to achieve life-saving interventions in patients with severe soft-tissue infections.     

母乳中抗生素对新生儿肠道正常菌群建立的影响

目的 证实母乳中的抗生素影响新生儿肠道正常菌群的建立。方法 采用K-B法对母乳标本中抗生素进行定性检测，同时对新生儿4-5天粪便标本进行涂片G染色及普通细菌培养。结果132例使用了头孢类及青霉素类母乳中，116例检出含抗生素。其喂养的新生儿中，68％粪便涂片G染色以9球菌为主，每个油镜视野50-100个菌。培养仅17％生长大肠埃希菌，其余的为葡萄球菌及其它G^-杆菌。单独或混合生长。母乳中无抗生素喂养的新生儿粪便涂片G染色，以9杆菌为主。少数为G＋杆菌及G^-杆菌，每个油镜视野200-300个菌，培养全部生长大肠埃希菌或大肠埃希菌与粪肠球菌。结论 母乳中抗生素破坏新生儿肠道正常菌群的建立极为明显．可能是部分新生儿长期迁延性腹泻的原因。     

Decreases in pain at rest and movement-related pain during zoledronic acid treatment in patients with bone metastases due to breast or prostate cancer: a pilot study

Background In patients with bone metastases, pain may be absent or moderate at rest, but may be exacerbated by different movements or positions. No study has evaluated separately pain at rest and on movement in patients with bone metastases undergoing treatment with zoledronic acid (ZA). Aim The aim of this prospective observational study was to evaluate the reduction in intensity of pain at rest and in movement-related pain after treatment with up to six infusions of ZA 4 mg every 28 days in patients with painful bone metastases due to breast or prostate cancer cared for at the Oncological Units and Pain Therapy and Palliative Care Unit of the NCI of Milano. Materials and methods Pain was assessed by a six-level verbal rating scale (0–5 score) at baseline and on each infusion as well as at follow-up visits (2 weeks after every infusion). The two main endpoints (estimated reduction in pain and movement-related pain) were defined as the difference between the baseline score and the average of all the post-treatment scores for each patient. To allow for the potential confounding effect of analgesic consumption, patients without any increase in analgesic consumption during zoledronic acid treatment were also analyzed as a separate subgroup. Results Forty-eight patients with breast (34) or prostate cancer (14) were enrolled. At baseline, 100% of the patients had pain on movement, in 65% of them, the intensity ranged from moderate to very severe, in 61% of the patients, the intensity of pain on movement was higher than the intensity of pain at rest (average difference 0.89; 95% CI, 0.5–1.30). The estimated mean intensity reduction of pain at rest and on movement was: (a) 0.62 (95% CI, 0.28–0.98) and 0.79 (95% CI, 0.43–1.14), respectively, during the first 90 days of ZA treatment; (b) 0.59 (95% CI, 0.23–0.96) and 0.86 (95% CI, 0.49–1.23), respectively, during the entire treatment and follow-up period. Analgesic consumption decreased or was stable on average in 31 and 27%, respectively, of available follow-up data. In the 14 patients with decreased or stable analgesic consumption, pain reduction was 0.61 and 1.01, respectively. Conclusions In this study, at baseline, all the patients with painful bone metastases experience movement-related pain, and during zoledronic acid treatment, a decrease for both pain at rest and on movement was obtained.