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We investigate the factors associated with the occurrence and abundance of external and blood parasites in African penguins (Spheniscus demersus), an endangered seabird that breeds exclusively on the coasts of Namibia and South Africa. External parasites were collected using the dust-ruffling method from 171 African Penguins admitted at a rehabilitation facility in the Western Cape, South Africa. Additionally, blood smears were obtained upon admission and weekly during rehabilitation and examined for blood parasites. Fleas Parapsyllus longicornis humboldti, ticks Ornithodoros capensis and lice Austrogoniodes demersus were recovered from 93, 63 and 40%, respectively, of the penguins upon admission to the centre. Rescue location and age group were identified as significant determinants of flea abundance, whereas month of admission was a significant determinant of tick abundance. Blood parasites were also common on admission, with Babesia being the most frequent (46% prevalence) whereas Borrelia was recorded sporadically (1.2%) and Plasmodium was recorded once. The prevalence and abundance of ticks on admission was positively associated with Babesia infection on admission. Our findings demonstrate the variability and contributing factor of parasite infections in an endangered species of penguin, and highlight the need for additional research on the parasite–host dynamics involving these potential disease vectors.
To investigate the manipulation of electromagnetic properties of two-dimensional materials, this effort characterizes charge transfer behavior of colloidal COF-5 (covalent organic framework) in the presence of various metal ions. A series of metal chloride compounds was introduced to COF-5 in solution and solid film phases and the interaction of the material with electromagnetic radiation was monitored across the visible region using electronic absorption spectroscopy. Notable changes were observed, quantified, and discussed for copper (II) chloride (CuCl2), chromium (III) chloride (CrCl3), and iron (III) chloride (FeCl3) with COF-5. Ligand-to-metal and metal-to-ligand charge transfer are explored as a possible mechanism for the observed electronic behaviors.
Background: Spinal muscular atrophy (SMA) is a children’s neuromuscular disorder. Although motor neuron loss is a major feature of the disease, we have identified fatty acid abnormalities in SMA patients and in preclinical animal models, suggesting metabolic perturbation is also an important component of SMA. Methods: Biochemical, histological, proteomic, and high resolution respirometry were used. Results: SMA patients are more susceptible to dyslipidemia than the average population as determined by a standard lipid profile in a cohort of 72 pediatric patients. As well, we observed a non-alcoholic liver disease phenotype in apreclinical mouse model. Denervation alone was not sufficient to induce liver steatosis, as a mouse model of ALS, did not develop fatty liver. Hyperglucagonemia in Smn2B/-mice could explain the hepatic steatosis by increasing plasma substrate availability via glycogen depletion and peripheral lipolysis. Proteomic analysis identified mitochondrion and lipid metabolism as major clusters. Alterations in mitochondrial function were revealed by high-resolution respirometry. Finally, low-fat diets led to increased survival in Smn2B/-mice. Conclusions: These results provide strong evidence for lipid metabolism defects in SMA. Further investigation will be required to establish the primary mechanism of these alterations and understand how they lead to additional co-morbidities in SMA patients.
Background: SMA is a neurodegenerative disease caused by biallelic deletion/mutation of SMN1. Copies of a similar gene (SMN2) modify disease severity. In a phase 1 study, SMN GRT onasemnogene abeparvovec (AVXS-101) improved outcomes of symptomatic SMA patients with two SMN2 copies (2xSMN2) dosed ≤6 months. Because motor neuron loss can be insidious and disease progression is rapid, early intervention is critical. This study evaluates AVXS-101 in presymptomatic SMA newborns. Methods: SPR1NT is a multicenter, open-label, phase 3 study enrolling ≥27 SMA patients with 2–3xSMN2. Asymptomatic infants ≤6 weeks receive a one-time intravenous AVXS-101 infusion (1.1x1014 vg/kg). Safety and efficacy are assessed through study end (18 [2xSMN2] or 24 months [3xSMN2]). Primary outcomes: independent sitting for ≥30 seconds (18 months [2xSMN2]) or assisted standing (24 months [3xSMN2]). Results: From April–September 2018, 7 infants received AVXS-101 (4 female; 6 with 2xSMN2) at ages 8–37 days. Mean baseline CHOP-INTEND score was 41.7 (n=6), which increased by 6.8, 11.0, 18.0, and 22.5 points at day 14 (n=4), month 1 (n=3), 2 (n=3), and 3 (n=2). Updated data available at the time of the congress will be presented. Conclusions: Preliminary data from SPR1NT show rapid motor function improvements in presymptomatic SMA patients.
Introduction: Competency-based skills development has driven the evolution of medical education. Simulation-based education is established as an essential tool to supplement clinical encounters and it provides the opportunity for low-stakes practice of common and high-acuity low-occurrence (HALO) procedures and scenarios. This is particularly important for emergency medicine trainees working to build confidence, knowledge, and skills in the field. Methods: In the procedural training sessions, learners rotate through 6 small-group stations over a 3-hour period. Skills topics are determined from faculty input, prior session feedback, and literature reviews. Topics included chest tubes, airway intervention, lumbar punctures and trauma interventions. Online content and brief written materials are used for pre-session learning. The small groups use hands-on faculty-guided training, with real-time feedback. Printed materials supplement key learning points at the stations. A combination of low-fidelity task trainers and simulated patients are used for practice and demonstration. R3 EM residents have the opportunity to mentor junior learners. Brief participant surveys are distributed at each session to gather qualitative and quantitative feedback. Results: Feedback forms were completed by 79/85 (92.9%) learners over a period of 4 years (2015-2018). Participants included medical students (11.8%), EM residents (52.9%), and non-EM residents (35.3%). 84.8% (67/79) gave positive qualitative feedback on the sessions, citing points such as the beneficial practice opportunities, quality of instruction, and utility of the models. Updated surveys (N = 26) used a 5-point Likert scale (1 = disagree strongly; 5 strongly agree) in addition to qualitative feedback. Participants indicated that sessions were valuable, and informative (M = 4.692, SD = 0.462; M = 4.270, SD = 0.710). They reported increased understanding of procedures discussed, and they were likely to recommend the session (M = 4.301, SD = 0.606; M = 4.808, SD = 0.394). Conclusion: The ongoing evaluation of our mentor guided hands-on low-fidelity and hybrid simulation-based procedural skills sessions facilitates meaningful programmatic changes to best meet the needs of EM learners. Sessions also provide a forum for EM resident mentorship of junior learners. Feedback indicates learners enjoyed the sessions and found this to be an engaging and effective instructional modality.
OBJECTIVES/SPECIFIC AIMS: The study aims to identify patient and provider factors associated with delay in diagnostic resolution after an abnormal screening mammogram, with an emphasis on whether patients who spoke Chinese as their primary language sustained longer times to resolution. Primary outcome is to identify what proportion of patients achieve diagnostic resolution after abnormal screening mammogram within 90 days. Secondary outcome is to identify whether Chinese-speaking patients experience longer times to diagnostic resolution. METHODS/STUDY POPULATION: We performed a single-center retrospective cohort study at Tufts Medical Center (TMC), a tertiary care hospital that serves as the primary referral site for the Chinatown neighborhood in Boston. We included patients who underwent screening mammogram between 10/1/2015-9/30/2016 which was resulted as BIRADS-0 (non-diagnostic). Diagnostic resolution was defined as BIRADS-1, 2, or 3 imaging or definitive biopsy. We collected data on patient demographics (age, insurance plan, race/ethnicity, primary language, history of cancer), provider characteristics (referring provider location), and post-referral testing. Insurance was categorized as private-only or subsidized. Poverty was categorized using the American Fact Finder database, with a binary variable of <20% of ≥20% people in poverty for a given zip code. We performed descriptive statistics for all variables. We will perform multivariable Cox regression analyses to determine whether Chinese-speaking patients experience longer time to diagnostic resolution, adjusting for age, referring provider type, insurance status, poverty, and breast cancer history. We will use p<0.05 for our threshold for significance. RESULTS/ANTICIPATED RESULTS: We identified 386 patients who met inclusion criteria. Over half (55.9%) of patients were Caucasian, the mean age of study patients was 59 years, and 22% of patients were classified as poor. English was the most commonly spoken primary language (77.7%), while 15.3% of patients identified a Chinese dialect as their primary language. Most patients solely used private insurance for their medical care (73.1%). Majority of patients (83%) presented after undergoing a routine screening mammography, but a considerable proportion (14.4%) had prior breast cancer or a palpable mass. Most patients were referred for their screening mammogram by a hospital-based provider at TMC (85%), of which 77% of TMC referrals were from primary care. We also noted a limited number of referrals from community health centers, private practices and other PCP’s (Table 1). We will calculate median time to diagnostic resolution after screening mammogram and the proportion of patients who achieve resolution within 90 days. We will also calculate time to initiation of diagnostic workup, and whether this differed among Chinese-speaking patients, subsidized patients, or among those who were referred from outside of TMC. We will complete Cox multivariable analysis to identify if Chinese-speaking patients experience longer time to diagnostic resolution, adjusting for age, insurance status, Primary care provider location, poverty, and prior history of breast cancer. We will a priori test for an interaction between primary care provider within Tufts and Chinese as primary language to identify if a PCP within TMC modifies the relationship between Chinese language and time to resolution. DISCUSSION/SIGNIFICANCE OF IMPACT: The proposed study will identify whether disparities exist in time to achieving diagnostic resolution. Specifically, we will identify if patients who are primarily Chinese-speaking experience longer time to resolution. Our results will potentially provide the foundation for a patient navigation program to attenuate existing disparities by providing additional support for Chinese speaking patients in breast imaging workup.
The present review evaluated the effectiveness of environmental-based interventions aimed at improving the dietary and physical activity behaviours and body composition indices of adults in institutions.
A systematic review was conducted. Electronic databases (MEDLINE, Embase, PsycINFO, CINAHL, The Cochrane Library, Web of Science, ProQuest Dissertation and Theses, Scopus and Athena) were searched for relevant articles published between database inception and October 2017. Searching, selecting and reporting were undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.
Military establishments and maritime workplaces.
Adults in institutions, aged 18–45 years.
A total of 27842 articles were screened for eligibility, nine studies (reported in eleven articles) were included in the review. Five studies used multilevel strategies and four used environmental strategies only. Duration of follow-up ranged from 3 weeks to 10 years. Eight of the studies reported significant positive effects on dietary behaviours, but effect sizes varied. The study that targeted physical activity had no effect on activity levels but did have a significant positive effect on physical fitness. No evidence was identified that the studies resulted in improvements in body composition indices.
The evidence base appears to be in favour of implementing environmental interventions in institutions to improve the dietary behaviours of adults. However, due to the small number of studies included in the review, and the variable methodological quality of the studies and intervention reporting, further well-designed evaluation studies are required.
Rhinonyssids are obligate haematophagous mites that parasitize the nasal cavity of vertebrates, and occur in a wide range of birds worldwide. Two species of nasal mites are known to occur in penguins: Rhinonyssus sphenisci, which has been recorded from Humboldt and Magellanic penguins (Spheniscus humboldti and S. magellanicus, respectively), and Rhinonyssus schelli, which has been recorded in Adélie and Gentoo penguins (Pygoscelis adeliae and P. papua, respectively). We examined the nasal cavity of African penguins (Spheniscus demersus) that died while under care at a rehabilitation centre (N = 40) or that were found dead at breeding colonies (N = 67). Nasal mites were found in the nasal cavity and/or paranasal of sinuses of 21 penguins, some of which had signs of mild-to-moderate sinusitis. Prevalence was higher in juveniles (29%) and adults (27%) than in chicks (10%). Mean intensity was 5.9 ± 12.9 mites per infected host (range 1–60). The mites presented morphological characteristics that were at times consistent with either R. sphenisci or R. schelli, and therefore we conservatively classified them as ‘R. sphenisci sensu lato’. Our morphometric results raise the question of whether the specific status of R. schelli is justified.
Introduction: Safe and efficient provision of quality healthcare requires maintenance of knowledge and skills relevant to daily practice. This is particularly relevant in rural and remote locations where high-acuity low-occurrence procedures and clinical scenarios present even less frequently. Simulation based training is widely used to supplement clinical exposure and practice but effective delivery of this approach to the rural/ remote practitioner must address barriers of time, cost and geographical separation. Mobile tele-simulation is an innovative approach that may help in bridging the gap through delivery of effective mentoring using telemedicine technologies and tailored educational content. Methods: To help direct the iterative design cycle for the mobile tele-simulation unit, input from potential future users was felt to be essential. The Delphi method was employed to reach consensus among study participants on four key questions: 1) What applications would the MTU be best suited for?, 2) What technical requirements and teaching tools would be needed to make the MTU successful?, 3) Which fields, besides EM/medical education, may benefit from partnerships with the final MTU?, 4) What research studies could be developed using the MTU? It was decided in advance that two rounds would be the maximum due to time constraints of the larger MTU projects. The first questionnaire focused on demographics and the four questions above. Independent reviewers analyzed, compiled and compared responses. Participants were sent the updated list, asked to confirm their responses and then to rank the responses highest to lowest priority. Results: Fifteen of 17 first round participants completed the questions, giving an 88.2% response rate. All shared a simulation background. 66% were physicians, 13.3% medical students, and 20% staff at Memorials Simulation Center. 66% had been involved with simulation-based education less than 5 years, and the others greater than 5 year. 13 of 15 (86.7%) responded in round 2. Consensus was not reached statistically using Kendalls W test for each of the four questions. However, there were several responses that showed higher median ranks than the others under each question. Application use: rural healthcare training, and medical professional training Technical factors: reliable learner-mentor connection, and competent technical support Non-technical factors: knowledgeable mentor and content relevant to locations practice, Research studies: training needs assessment from rural sites, and learners experience compared to stationary simulation center Conclusion: Input from a heterogeneous group of simulation users was sought to help prioritize key features in the development of the Mobile Tele-simulation Unit. Although statistically the study did not reach consensus, valuable feedback was compiled and pragmatically applied in the iterative development cycle.
Introduction/Innovation Concept: Rural and remote practice of emergency medicine presents unique challenges, particularly when faced with infrequently encountered cases and procedures. Simulation-based training is a valuable tool in the acquisition and maintenance of knowledge and skills; however, simulators are often located in larger centers and they are not widely outside these centers due to geographic, cost and time constraints. Mobile tele-simulation has the potential to overcome barriers but challenges such as comfort, technical issues and ability to teach desired content via tele-simulation must be addressed. We are developing a mobile-tele-simulation unit (MTU) prototype that will enable emergency medicine practitioners and trainees to access simulation-based instruction in rural and remote settings. Methods: Through application of a mixed-methods approach with input of a multidisciplinary team we are iteratively developing an MTU prototype to assess key factors in design and function, including: technical issues, environmental features, and human factors. The Delphi method is being used to collect input from experts on key design components and feedback is also being collected from trainees after participating in trial deployments of the MTU in different educational and environmental settings. Curriculum, Tool, or Material: The effective application of the MTU in a variety of learning settings will be optimized through ongoing evaluation in the iterative design cycle. Feedback to ensure a quality learning experience in the MTU will direct features of physical design and technical performance that can be applied in deployment of the unit. In addition, challenges to the delivery of module content and instructional modality/ features of lessons to be executed will be important considerations as we move toward developing content that can effectively be taught using the MTU. Conclusion: To ensure effective use of tele-simulation in the delivery of a meaningful simulation experience to rural and remote trainees a number of important challenges must be overcome. We describe our evolving multidisciplinary mixed-methods approach to develop an effective mobile tele-simulation unit.
Cattle manure value chains play important biological and economic roles in smallholder crop–livestock systems in developing countries, but relative to other livestock products our understanding of the nature and impact of manure sales is limited. In regions with an active manure trade, farmers face a choice between manure use on-farm and sales, which affects nutrient flows and participant incomes. We analyzed the manure value chain operating in south-central Vietnam as an example of the function and role of manure trade in crop–livestock systems. Lowland cattle farmers sell manure through a network of chain participants, including small-scale collectors, lowland and highland traders, to pepper, coffee, dragon fruit and rubber farms in the central highlands and southeast coast. We collected and summarized quantitative data (e.g., manure-related labor, manure transactions, and fertilizer and manure use) gathered in semi-structured interviews with value-chain participants [lowland cattle owners (n = 101), traders (n = 27) and end users (n = 72)]. Lowland cattle owners were selected by stratified random sampling, and subsequent participants were identified in preceding interviews. One key finding concerns the seasonality of the manure value chain: most manure flowed between February and August (lowland dry season and period of peak highland demand) from lowland communes to highland coffee and pepper farms for use as organic soil amendments. Fewer sales occurred, at a lower price, to southeast coastal dragon fruit farms and rubber companies. Value addition to manure occurred via drying, bagging, collection, transport and composting. The presence of local traders facilitated market sales for smallholder cattle owners, and prices through the value chain generally reflected costs for value addition. The geographic distribution of cattle relative to agricultural land influenced the flow of manure, with net outflows from regions with higher animal density to regions with lower density and higher value crop production. Manure trade was an important source of supplementary income for farmers and a primary livelihood activity for traders. Value chain participant net incomes ranged from near US$100 yr−1 for lowland farmers to over US$13,000 yr−1 for traders, and returns to labor were just over US$0.50 h−1 for lowland farmers and US$2 h−1 for traders. The quantitative information generated during our descriptive assessment provides an important first step toward manure value chain improvement, indicates survey methods that can be applied in other areas, and identifies next steps necessary to evaluate chain evolution and resilience.
Toxigenic strains of Vibrio cholerae serogroups O1 and O139 have caused cholera epidemics, but other serogroups – such as O75 or O141 – can also produce cholera toxin and cause severe watery diarrhoea similar to cholera. We describe 31 years of surveillance for toxigenic non-O1, non-O139 infections in the United States and map these infections to the state where the exposure probably originated. While serogroups O75 and O141 are closely related pathogens, they differ in how and where they infect people. Oysters were the main vehicle for O75 infection. The vehicles for O141 infection include oysters, clams, and freshwater in lakes and rivers. The patients infected with serogroup O75 who had food traceback information available ate raw oysters from Florida. Patients infected with O141 ate oysters from Florida and clams from New Jersey, and those who only reported being exposed to freshwater were exposed in Arizona, Michigan, Missouri, and Texas. Improving the safety of oysters, specifically, should help prevent future illnesses from these toxigenic strains and similar pathogenic Vibrio species. Post-harvest processing of raw oysters, such as individual quick freezing, heat-cool pasteurization, and high hydrostatic pressurization, should be considered.
We demonstrate that the second-Stokes output from a diamond Raman laser, pumped by a femtosecond Ti:Sapphire laser, can be used to efficiently excite red-emitting dyes by two-photon excitation at 1,080 nm and beyond. We image HeLa cells expressing red fluorescent protein, as well as dyes such as Texas Red and Mitotracker Red. We demonstrate the potential for simultaneous two-color, two-photon imaging with this laser by using the residual pump beam for excitation of a green-emitting dye. We demonstrate this for the combination of Alexa Fluor 488 and Alexa Fluor 568. Because the Raman laser extends the wavelength range of the Ti:Sapphire laser, resulting in a laser system tunable to 680–1,200 nm, it can be used for two-photon excitation of a large variety and combination of dyes.
Bystander cardiopulmonary resuscitation (CPR) improves the likelihood of survival from out-of-hospital cardiac arrest (OHCA), yet it is performed in only 30% of cases. The 2010 guidelines promote chest-compression-only bystander CPR—a change intended to increase willingness to provide CPR.
1) To determine whether the Canadian general public is more willing to perform chest-compression-only CPR compared to traditional CPR; 2) to characterize public knowledge of OHCA; and 3) to identify barriers and facilitators to bystander CPR.
A 32-item survey assessing resuscitation knowledge, and willingness to provide CPR were disseminated in five Canadian regions. Descriptive statistics were used to characterize response distribution. Logistic regression analysis was applied to assess shifts in intention to provide CPR.
A total of 428 completed surveys were analysed. When presented with a scenario of being a bystander in an OHCA, a greater proportion of respondents were willing to provide chest-compression-only CPR compared to traditional CPR for all victims (61.5% v. 39.7%, p<0.001), when the victim was a stranger (55.1% v. 38.8%, p<0.001), or when the victim was an unkempt individual (47.9% v. 28.5%, p<0.001). When asked to describe an OHCA, 41.4% said the heart stopped beating, and 20.8% said it was a heart attack. Identified barriers and facilitators included fear of litigation and lack of skill confidence.
This study identified gaps in knowledge, which may impair the ability of bystanders to act in OHCA. Most respondents expressed greater willingness to provide chest-compression-only CPR, but this was mediated by victim characteristics, skill confidence, and recognition of a cardiac arrest.
Diurnal preference is an individual's preference for daily activities and sleep timing and is strongly correlated with the underlying circadian clock and the sleep-wake cycle validating its use as an indirect circadian measure in humans. Recent research has implicated DNA methylation as a mechanism involved in the regulation of the circadian clock system in humans and other mammals. In order to evaluate the extent of epigenetic differences associated with diurnal preference, we examined genome-wide patterns of DNA methylation in DNA from monozygotic (MZ) twin-pairs discordant for diurnal preference. MZ twins were selected from a longitudinal twin study designed to investigate the interplay of genetic and environmental factors in the development of emotional and behavioral difficulties. Fifteen pairs of MZ twins were identified in which one member scored considerably higher on the Horne–Ostberg Morningness–Eveningness Questionnaire (MEQ) than the other. Genome-wide DNA methylation patterns were assessed in twins’ buccal cell DNA using the Illumina Infinium HumanMethylation450 BeadChips. Quality control and data pre-processing was undertaken using the wateRmelon package. Differentially methylated probes (DMPs) were identified using an analysis strategy taking into account both the significance and the magnitude of DNA methylation differences. Our data indicate that DNA methylation differences are detectable in MZ twins discordant for diurnal preference. Moreover, downstream gene ontology (GO) enrichment analysis on the top-ranked diurnal preference associated DMPs revealed significant enrichment of pathways that have been previously associated with circadian rhythm regulation, including cell adhesion processes and calcium ion binding.
The incidence of recreational water-associated outbreaks in the United States has significantly increased, driven, at least in part, by outbreaks both caused by Cryptosporidium and associated with treated recreational water venues. Because of the parasite's extreme chlorine tolerance, transmission can occur even in well-maintained treated recreational water venues (e.g. pools) and a focal cryptosporidiosis outbreak can evolve into a community-wide outbreak associated with multiple recreational water venues and settings (e.g. childcare facilities). In August 2004 in Auglaize County, Ohio, multiple cryptosporidiosis cases were identified and anecdotally linked to pool A. Within 5 days of the first case being reported, pool A was hyperchlorinated to achieve 99·9% Cryptosporidium inactivition. A case-control study was launched to epidemiologically ascertain the outbreak source 11 days later. A total of 150 confirmed and probable cases were identified; the temporal distribution of illness onset was peaked, indicating a point-source exposure. Cryptosporidiosis was significantly associated with swimming in pool A (matched odds ratio 121·7, 95% confidence interval 27·4–∞) but not with another venue or setting. The findings of this investigation suggest that proactive implementation of control measures, when increased Cryptosporidium transmission is detected but before an outbreak source is epidemiologically ascertained, might prevent a focal cryptosporidiosis outbreak from evolving into a community-wide outbreak.
We investigated the prevalence of β-lactamase genes and plasmid-mediated quinolone resistance (PMQR) determinants in 51 carbapenem-resistant Enterobacteriaceae (CRE) from five teaching hospitals in central China. The prevalence of carbapenem resistance in Enterobacteriaceae was 1·0% (51/5012). Of 51 CRE, 31 (60·8%) isolates were positive for one tested carbapenemase gene, while 10 (19·6%) were simultaneously positive for two tested carbapenemase genes. The positive rates of blaKPC-2, blaNDM-1, blaIMP-4, blaIMP-26 and blaIMP-8 were 54·9%, 17·6%, 11·8%, 11·8% and 3·9%, respectively. Of 10 CRE with two carbapenemase genes, three, five, one and one were positive for blaKPC-2 and blaIMP-4, blaKPC-2 and blaIMP-26, blaKPC-2 and blaIMP-8, and blaKPC-2 and blaNDM-1, respectively. Eight of nine blaNDM-1-positive isolates lacked carbapenemases by the modified Hodge test, while 27/28 isolates harbouring blaKPC-2 were positive for carbapenemases determined by this test; 41·2% of the CRE-positive isolates also harboured ESBL genes in various combinations (three and two positive for blaKPC-2 also carried blaDHA-1 and blaCMY-2). The positive rates of qnrS1, qnrA1, qnrB and aac-(6/)-Ib-cr in CRE were 25·5%, 9·8%, 23·5% and 15·7%, respectively. In particular, 7/9 isolates harbouring blaNDM-1 were positive for these quinolone resistance genes, of which five carried qnrS1 and two carried qnrS1 and qnrB4. All but two of 29 Klebsiella pneumoniae isolates were grouped into 20 clonal clusters by PFGE, with the predominant cluster accounting for four blaKPC-2-positive isolates distributed in the same hospital. We conclude that there is a high prevalence of blaNDM-1 and PMQR determinants in CRE isolates in central China. Multiple resistance determinants in various combinations co-exist in these strains and we report for the first time the co-existence of blaKPC-2 and blaIMP-26 in a strain of Klebsiella oxytoca.