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Background@#and Purpose We compared the outcomes of endovascular therapy (EVT) in an extended time window in patients with large-vessel occlusion (LVO) between patients with and without pre-stroke disability. @*Methods@#In this prespecified analysis of the multinational CT for Late Endovascular Reperfusion study (66 participating sites, 10 countries between 2014 and 2022), we analyzed data from patients with acute ischemic stroke with a pre-stroke modified Rankin Scale (mRS) score of 0–4 and LVO who underwent EVT 6–24 hours from the time last seen well. The primary outcome was the composite of functional independence (FI; mRS score 0–2) or return to the pre-stroke mRS score (return of Rankin, RoR) at 90 days. Outcomes were compared between patients with pre-stroke disability (pre-stroke mRS score 2–4) and those without (mRS score 0–1). @*Results@#A total of 2,231 patients (median age, 72 years; median National Institutes of Health Stroke Scale score, 16) were included in the present analysis. Of these, 564 (25%) had pre-stroke disability. The primary outcome (FI or RoR) was observed in 30.7% of patients with pre-stroke disability (FI, 16.5%; RoR, 30.7%) compared to 44.1% of patients without (FI, 44.1%; RoR, 13.0%) (P<0.001). In multivariable logistic regression analysis with inverse probability of treatment weighting, pre-stroke disability was not associated with significantly lower odds of achieving FI or RoR (adjusted odds ratio 0.73, 95% confidence interval 0.43–1.25). Symptomatic intracranial hemorrhage occurred in 6.3% of both groups (P=0.995). @*Conclusion@#A considerable proportion of patients with late-presenting LVO and pre-stroke disability regained pre-stroke mRS scores after EVT. EVT may be appropriate for patients with pre-stroke disability presenting in the extended time window.

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INTRODUCTION: Clostridioides difficile is a major pathogen responsible for hospital-associated diarrhoea. This study investigated the molecular epidemiology and antibiotic resistance of C. difficile isolates in five Algerian hospitals. METHODOLOGY: Between 2016 and 2019, faecal specimens were collected from in-patients and were cultured for C. difficile. Isolates were characterised by toxin genes detection, Polymerase Chain Reaction (PCR)-ribotyping, Multilocus Sequence Typing (MLST), antimicrobial susceptibility testing against a panel of antibiotics, and screened for antimicrobial resistance genes. RESULTS: Out of 300 patient stools tested, 18 (6%) were positive for C. difficile by culture, and were found to belong to 11 different ribotypes (RT) and 12 sequence types (ST): RT 085/ST39, FR 248/ST259, FR 111/ST48, RT 017/ST37, RT 014/ST2, RT 014/ST14, FR 247/new ST, RT 005/ST6, RT 029/ST16, RT 039/ST26, RT 056/ST34 and RT 446/ST58. MLST analysis assigned the isolates to two clades, 1 and 4. Clade 4 was more homogeneous, as it mainly included non-toxigenic isolates. Three toxin gene profiles were detected, two toxigenic, A+B+CDT- (33.3%) and A-B+CDT- (11%); and one non-toxigenic, A-B-CDT- (55.5%). All C. difficile isolates were susceptible to metronidazole, vancomycin and moxifloxacin. CONCLUSIONS: Overall prevalence of C. difficile in our healthcare settings was 6%. Antibiotic resistance rates ranged from 72.2% (clindamycin) to 16.6% (tetracycline). This study highlighted a relatively high genetic diversity in term of ribotypes, sequence types, toxin and antibiotic resistance patterns, in the C. difficile isolates. Further larger studies are needed to assess the true extent of C. difficile infections in Algeria.

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This study examined the combined effect of hydraulic retention time (HRT), organic loading rate (OLR) and heat pretreatment of manure (70 °C, 1 h) on the fate of E. coli, enterococci, C. perfringens, C. difficile, and on chemical parameters (volatile fatty acids and ammonia) that may inactivate pathogens. Semi-continuous mesophilic anaerobic reactors were fed with pig manure and horse feed. The operating conditions were 2, 3, 4 COD.L-1.d-1 (OLR), 24, 35, 46 days (HRT) and use or not of a thermal pretreatment. The levels of the chemical parameters did not reach concentrations capable of inactivating the four bacteria. Anaerobic digestion led to a Log10 removal > 3 (E. coli), 0.9-2.1 (enterococci), 0.1-0.6 (C. perfringens) and 0-1 (C. difficile). Increasing HRT only reduced the concentration of E. coli in the digestate. Increasing OLR reduced the Log10 removal of enterococci and C. difficile. The heat pretreatment led to non-detection of E. coli in the digestate, reduced the concentration of C. perfringens by 0.8-1.3 Log10 and increased the concentration of C. difficile by 0.04-0.7 Log10. Enterococci, not detected in the heated manure, were present in the digestate. The distribution of genes encoding virulence factors of C. difficile (tcdA and tcdB) and C. perfringens (cpa, cpb2 and cpb) was not impacted by anaerobic digestion or by the heat pretreatment. Enterococci, C. perfringens, C. difficile were present in the digestate at relatively stable concentrations regardless of the operating conditions, indicating that even with heat pretreatment, the biosafety of digestate cannot be guaranteed in mesophilic conditions.

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In a previous monocentric study in preterm neonates (PN), we described a high Clostridioides difficile colonization rate (74%) with two uncommon non-toxigenic strains (NTCD) belonging to PCR-ribotype (RT) (CE)847 and (CE)032. To determine the extent of carriage of both NTCD in other spatio-temporal settings, strains isolated in PN stools from two multicenter cohorts were characterized by PCR-ribotyping, MLVA and MLST. We also evaluated the protective role of two NTCD from these RT against C. difficile infection in a hamster caecitis model. Animals were administered either each NTCD alone (n = 7), or followed by a 027 strain (n = 9). A control group received only the 027 strain (n = 8). Clinical activity and colonization by C. difficile in stools were monitored daily until death or sacrifice at D20. We isolated 18 RT(CE)032 (ST-83) strains and 2 RT(CE)847 (ST-26) strains among 247 PN from both cohorts. Within each RT, strains were genetically related. The survival rate was significantly increased when animals received a RT(CE)847 or (CE)032 strain before the 027 strain (4/9 deaths, p = 0.029; 1/9 death, p = 0.0004, respectively). We describe two predominant uncommon NTCD strains, in a PN population from different healthcare facilities. Both NTCD provide a potential protection against C. difficile infection.

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Clostridioides difficile strains were isolated from manure and digestate samples from five biogas plants in France. The objective of this study was to characterize these isolates using PCR ribotyping, wgMLST, a multiplex PCR targeting genes encoding for the main virulence factors, i.e. tcdA, tcdB, cdtA and cdtB, and antimicrobial susceptibility assays. The 54 strains characterized were all positive for tcdA and tcdB and 83% (45/54) were positive for the binary toxin genes. PCR ribotypes 126 (59%) and 078 (37%) were predominant, and wgMLST analysis of 18 isolates showed close proximity of strains within a single biogas plant. Samples from the biogas plant supplied with cattle and poultry manure displayed the largest variety in PCR ribotypes. The in vitro activities of nine antimicrobial agents were determined. All the strains were susceptible to vancomycin and metronidazole, which are currently considered first-line treatments for C. difficile infection in humans. All the strains were resistant to clindamycin. The results of this study show that a high percentage of C. difficile strains present in the French biogas plants investigated are toxigenic strains from PCR ribotypes also commonly found in humans.

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The objective of this study was to evaluate the Amplidiag C. difficile+027® assay, a new molecular method that detects toxin B gene in stool samples and identifies the hypervirulent 027 strain, to diagnose Clostridium difficile infections. The assay was compared to the reference method i.e. toxigenic culture. Amplidiag C. difficile+027® assay was prospectively evaluated from 309 diarrheal stool specimens of patients suspected of C. difficile infection. Forty-five (14.6%) stools were positive by toxigenic culture and 11 (3.6%) stools gave discordant results with the molecular method. PR027 was not recovered during the study. After resolving the discrepant results, the sensitivity, specificity, positive and negative predictive values of Amplidiag C. difficile+027® assay were 91.1% [CI 95% 77.9-97.1], 99.6% [CI 95% 97.6-100], 97.6% [CI 95% 85.9-99.9] and 98.5% [CI 95% 96-99.5], respectively compared to toxigenic culture. This assay is sensitive compared to the toxigenic culture.

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Calprotectin and lactoferrin are released by the gastrointestinal tract in response to infection and mucosal inflammation. Our objective was to assess the usefulness of quantifying faecal lactoferrin and calprotectin concentrations in Clostridium difficile infection (CDI) patients with or without free toxins in the stools. We conducted a single-centre 22-month case-control study. Patients with a positive CDI diagnosis were compared to two control groups: group 1 = diarrhoeic patients negative for C. difficile and matched (1:1) to CDI cases on the ward location and age, and group 2 = diarrhoeic patients colonised with a non-toxigenic strain of C. difficile. Faecal lactoferrin and calprotectin concentrations in faeces were determined for patients with CDI and controls. Of 135 patients with CDI, 87 (64.4%) had a positive stool cytotoxicity assay (free toxin) and 48 (35.6%) had a positive toxigenic culture without detectable toxins in the stools. The median lactoferrin values were 26.8 µg/g, 8.0 µg/g and 15.8 µg/g in CDI patients and groups 1 and 2, respectively. The median calprotectin values were 218.0 µg/g, 111.5 µg/g and 111.3 µg/g, respectively. Among patients with CDI, faecal lactoferrin and calprotectin levels were higher in those with free toxins in their stools (39.2 vs. 10.2 µg/g, p = 0.003 and 274.0 vs. 166.0 µg/g, p = 0.051, respectively). Both faecal calprotectin and lactoferrin were higher in patients with CDI, especially in those with detectable toxin in faeces, suggesting a correlation between intestinal inflammation and toxins in stools.

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BACKGROUND: Hydration and anticoagulation are the standard of care for cerebral venous sinus thrombosis (CVST) but some patients remain refractory to medical management and warrant more aggressive therapy. Here we present the technique of endovascular transvenous manual aspiration thrombectomy (MAT) in six patients. OBJECTIVE: Present an alternative technique for endovascular transvenous thrombectomy in a series of CVST patients. METHODS: We reviewed the records of six patients with medically refractory CVST. Transvenous access via the femoral vein was used to advance an aspiration catheter of varying internal diameter (0.044, 0.054, 0.057, 0.070, 0.072) up to and through the thrombus. Tissue plasminogen activator was administered in select cases. Manual aspiration with a 20 ml syringe applied to the catheter hub was applied as the catheter was slowly retracted. Presentation, technique, and outcome were evaluated. RESULTS: Clinical presentation included vomiting, dehydration, mental status changes, headaches, and acute motor deficits. On imaging, four of the six patients had hemorrhage, edema, and mass effect present before treatment, while two had edema only. All patients demonstrated continued deterioration despite early and aggressive medical anticoagulation therapy, warranting aggressive intervention. Aspiration of the superior sagittal sinus, transverse sinuses, straight sinus, sigmoid sinus, and internal jugular vein were performed in this series. There were no procedural complications. Revascularization was achieved in all instances. A modified Rankin Scale score of 1-3 was attained in 5/6 patients, while one patient died. CONCLUSIONS: In this series, transvenous MAT was a safe, simple, and effective revascularization technique to treat patients with CVST who remained refractory to medical management.

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