The aim of this study was to describe the clinical signs, radiographic, endoscopic and CT findings, cytological and microbiological findings and treatments of pulmonary diseases in sea turtles, in order to obtain an accurate diagnosis that avoids unnecessary therapy and antibiotic-resistance phenomena. In total, 14 loggerheads (Caretta caretta), with clinical and/or radiographic findings of pulmonary pathology, were assessed through various combinations of clinical, radiological, CT, endoscopic examination and bronchoalveolar lavage, which recovered fluid for cytologic and microbiologic analysis. In all cases, radiographic examination led to a diagnosis of pulmonary disorders—4 unilateral and 10 bilateral. All bacteria cultured were identified as Gram-negative. Antibiotic resistance was greater than 70% for all beta-lactams tested. In addition, all bacterial strains were 100% resistant to colistin sulfate and tetracycline. Specific antibiotic therapies were formulated for seven sea turtles using Enrofloxacin, and for four sea turtles using ceftazidime. In two turtles, antibiotic therapy was not included due to the presence of antibiotic resistance against all the antibiotics evaluated. In both cases, the coupage technique and environmental management allowed the resolution of the lung disease without antibiotics. All 14 sea turtles were released back into the sea. Radiographic examination must be considered the gold standard for screening sea turtles that show respiratory signs or abnormal buoyancy. Susceptibility testing with antimicrobials allowed appropriate therapy, including the reduction of antibiotic-resistance.
Gram negative organisms are frequently isolated from Caretta caretta turtles, which can act as reservoir species for resistant microorganisms in the aquatic environment. C. caretta, which have no history of treatment with antimicrobials, are useful sentinel species for resistant microbes. In this culture-based study, commensal bacteria isolated from oral and cloacal samples of 98 healthy C. caretta were compared to clinical isolates from the wounds of 102 injured animals, in order to investigate the presence of AMR bacteria in free-living loggerheads from the Adriatic Sea. A total of 410 isolates were cultured. Escherichia coli and genera such as Serratia, Moraxella, Kluyvera, Salmonella were isolated only in healthy animals, while Acinetobacter, Enterobacter, Klebsiella and Morganella were isolated only from the wounds of the injured animals. When tested for susceptibility to ampicillin, amoxicillin + clavulanic acid, ceftazidime, cefuroxime, gentamicin, doxycycline, ciprofloxacin and enrofloxacin, the clinical isolates showed highly significant differences in AMR rates vs. commensal isolates for all the drugs tested, except for doxycycline. The detection of high AMR rates in loggerheads is of clinical and microbiological significance since it impacts both the choice of a proper antibiotic therapy and the implementation of conservation programs.
Objective: To evaluate dose to organs at risk, target coverage and treatment compliance in left-sided breast cancer patients (LSBCP) treated with deep inspiration breath-hold (DIBH) and intensity modulated radiation therapy (IMRT) technique in a contest of daily clinical practice. Methods: A total of 280 consecutive LSBCP referred for adjuvant radiotherapy were systematically screened for suitability of DIBH technique. 239 were able to comply with the requirement for DIBH. Whole breast or chest wall were irradiated in DIBH, monitored by Varian RPM™ Respiratory Gating System, and two tangential inverse-planned beams with dynamic dose delivery. Dose prescription was 42.4 Gy/16 fractions in 205 patients and 50 Gy/25 fractions in 34. 23 patients received local and nodal treatment. Boost to tumor bed, of 10 Gy/5 fractions was used in 135 patients. Relevant dose metrics for heart, left anterior descending (LAD) coronary artery, lungs, contralateral breast and planning target volume were retrospectively analyzed. Results: The average mean heart dose (MHD) for all patients was 0.94 Gy and mean maximum LAD dose was 13.82 Gy. MHD and LAD maximum dose were significantly higher in patients treated with conventional fractionation whether expressed in absolute dose (1.44 vs 0.85 Gy, p < 0.0005 and 20.78 vs 12.45 Gy, p < 0.0005 respectively) or in equivalent doses of 2 Gy fractionation (0.88 vs 0.52 Gy, p =< 0.0005 and 17.68 vs 10.63 Gy, p = 0.0002 respectively). In 57 patients (23.8%) the maximum LAD dose was >20 Gy. Mean V20 ipsilateral lung dose was 8.5%. Mean doses of contralateral breast and lung were 0.13 Gy and 0.09 Gy respectively. Mean planning target volume V95% coverage was 96.1%. Compliance rate of DIBH technique was 84.5% (239/280). Conclusion: DIBH and IMRT in daily clinical practice are feasible in high percentage of unselected patients and allows low levels of irradiation of organs at risk without compromising target coverage. However, despite low MHD a significant proportion of patients receives a maximum LAD dose superior to 20 Gy. Advances in knowledge: The value of MHD used exclusively is not able to describe entirely the risk of late heart toxicity, which can be better evaluated with the joint analysis of the maximum dose to LAD region. The vast majority of LSBCP referred to adjuvant radiotherapy in the setting of routine practice are able to comply with the requirement of DIBH.
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