ObjectiveTo evaluate the relation between penicillin allergy and development of meticillin resistant Staphylococcus aureus (MRSA) and C difficile.DesignPopulation based matched cohort study.SettingUnited Kingdom general practice (1995-2015).Participants301 399 adults without previous MRSA or C difficile enrolled in the Health Improvement Network database: 64 141 had a penicillin allergy and 237 258 comparators matched on age, sex, and study entry time.Main outcome measuresThe primary outcome was risk of incident MRSA and C difficile. Secondary outcomes were use of β lactam antibiotics and β lactam alternative antibiotics.ResultsAmong 64 141 adults with penicillin allergy and 237 258 matched comparators, 1365 developed MRSA (442 participants with penicillin allergy and 923 comparators) and 1688 developed C difficile (442 participants with penicillin allergy and 1246 comparators) during a mean 6.0 years of follow-up. Among patients with penicillin allergy the adjusted hazard ratio for MRSA was 1.69 (95% confidence interval 1.51 to 1.90) and for C difficile was 1.26 (1.12 to 1.40). The adjusted incidence rate ratios for antibiotic use among patients with penicillin allergy were 4.15 (95% confidence interval 4.12 to 4.17) for macrolides, 3.89 (3.66 to 4.12) for clindamycin, and 2.10 (2.08 to 2.13) for fluoroquinolones. Increased use of β lactam alternative antibiotics accounted for 55% of the increased risk of MRSA and 35% of the increased risk of C difficile.ConclusionsDocumented penicillin allergy was associated with an increased risk of MRSA and C difficile that was mediated by the increased use of β lactam alternative antibiotics. Systematically addressing penicillin allergies may be an important public health strategy to reduce the incidence of MRSA and C difficile among patients with a penicillin allergy label.

BackgroundRepresentative data on the gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) in Asian patients is rare, especially in China. This study aims to create a GEP-NENs profile of Chinese patients.MethodsThis was a hospital-based, nation-wide, and multi-center 10-year (2001-2010) retrospective study which collected GEP-NEN patients’ information in tertiary referral hospitals. All 2010 inpatient GEP-NEN cases with confirmed pathology in the selected hospitals were included. The primary GEP-NEN sites were measured and the epidemiological and clinical information of each tumor site were compared.ResultsThe most common primary sites for GEP-NEN were the pancreas (31.5%) and rectum (29.6%), followed by the cardia (11.6%) and body (15.4%) of stomach. Small intestinal and colonic NENs took up a relatively small proportion of all patients. Pancreatic and rectal NENs, rather than cardiac and gastric body NENs, tended to be found in younger (P<0.001), female (P<0.001), urban (P<0.001) residents with a higher education level (P=0.032) and were also diagnosed at earlier stage (P<0.001) and lower grade (P<0.001). Surgery remained the primary treatment method in all groups.ConclusionsMore studies on the commonality and heterogeneity of GEP-NENs are warranted to improve diagnosis efficiencies and treatment outcomes.

Hypertension is a major risk factor for cardiovascular and cerebrovascular diseases.To effectively prevent end-organ damage, maintain vascular integrity and reduce morbidity and mortality, it is essential to decrease and adequately control blood pressure (BP) throughout each 24-hour period. Exaggerated early morning BP surge (EMBS) is one component of BP variability (BPV), and has been associated with an increased risk of stroke and cardiovascular events, independently of 24-hour average BP. BPV includes circadian, short-term and long-term components, and can best be documented using out-of-office techniques such as ambulatory and/or home BP monitoring. There is a large body of evidence linking both BPV and EMBS with increased rates of adverse cardio-and cerebrovascular events, and end-organ damage. | 325 SOGUNURU et al.external behavioral and environmental factors. Therefore, a holistic approach to primary and secondary prevention is essential for avoiding end-organ damage. Although there are inconsistencies in current definitions and parameters of BPV, ongoing and future research should facilitate better scientific understanding, which in turn will help to optimize strategies for the detection and treatment of arterial hypertension to reduce adverse outcomes. Existing available technology and future advances in digital non-invasive miniaturized sensors could help early detection of hypertension and its variability for planning appropriate therapeutic strategies. ACK N OWLED G M ENTSEditing assistance was provided by Nicola Ryan, independent medical writer, funded by Pfizer.

The growth, morphology, and life cycle of two marine myxobacterial isolates, halotolerant Myxococcus fulvus strain HW-1 and halophilic Haliangium ochraceum strain SMP-2, were studied as models to determine the living patterns of myxobacteria in the ocean. The growth, morphology, and development of halotolerant strain HW-1 shifted in response to salinity. The optimal seawater concentration for growth of HW-1 was 0 to 80% (salinity, 0.1 to 2.9%), and the strain grew poorly in media with a salinity of more than 4%. The cells became shorter as the seawater concentration increased. The fruiting body structure was complete only on agar prepared with low concentrations of seawater or salts (less than 60% seawater; salinity, 2.1%), and rudimentary structures or even simple cell mounds appeared as the seawater concentration increased. In contrast, the halophilic strain SMP-2 was unable to grow without NaCl. The cell length and the morphology of the fruiting body-like structure did not change in response to salts. In seawater liquid medium, the cells of both strains were confirmed to be able to form myxospores directly from vegetative cells, but they could not do so in medium containing a low seawater concentration (10% or less). HW-1 cells from medium containing a high concentration of seawater grew independent of cell density, while cells from medium containing a low concentration of seawater (10% or less) showed density-dependent growth. SMP-2 cells showed density-dependent growth under all salinity conditions. The results suggest that the halotolerant myxobacteria are the result of degenerative adaptation of soil myxobacteria to the marine environment, while the halophilic myxobacteria form a different evolutionary group that is indigenous to the ocean.Gram-negative unicellular myxobacteria are phylogenetically located in the ␦ division of the Proteobacteria (19-21, 24), and they are notable among prokaryotes for their complicated social behavior (2, 18). Myxobacterial cells move by gliding in swarms on solid surfaces, feed by cooperatively digesting macromolecules as well as whole microorganisms, and form multicellular fruiting bodies on solid surfaces. The resting cells, or myxospores, develop within fruiting bodies. Fruiting bodies develop only on solid surfaces (18), and terrestrial myxobacteria do not usually tolerate an NaCl concentration greater than 1% (15). The myxobacteria are typically considered to be soil microorganisms and are common in many terrestrial environments (1, 14). On the other hand, myxobacteria can be isolated from marine samples (6,7,8,9,13,14,25), as proven by the 16S rRNA gene fragments amplified from marine samples (4, 11) and permanently cold marine sediments (12). Depending on their adaptation to salinity, the marine myxobacterial isolates include three types: nonhalotolerant isolates, halotolerant isolates, and halophilic isolates. The nonhalotolerant isolates are the isolates that are unable to grow with a salt concentration greater than 1.0% (15). They are presumed to have germinated...