The Effectiveness of Gaseous Formaldehyde Decontamination Assessed by Biological Monitoring

The results of seven years experience of the effectiveness of routine gaseous formaldehyde decontamination of rooms, filter canisters and biological safety cabinets at ambient temperature are reported. The effectiveness of each decontamination was monitored biologically by the inactivation of Bacillus stearothermophilus spores at five locations in rooms and biological safety cabinets and at two locations in filter canisters. A greater than 104 reduction in viability was achieved for each group of five spore tests in 92% of room decontaminations and each group of five spore tests in 81% of biological safety cabinet decontaminations, and a greater than 104.7 reduction for both spore tests in 83% of filter canister decontaminations. This long-term study of 2,308 routine formaldehyde decontaminations of varying spaces in practical situations demonstrates the reliability of the procedure. The results confirm that previously-described methods can be applied with confidence for routine decontaminations of laboratory facilities and equipment.

Handling of Large Experimental Animals Infected with a Risk Group 4 Virus

The safe experimental handling of animals infected with a new Risk Category 4 virus posed significant biosafety challenges. Novel approaches for restraining, handling and inoculating horses, cats and large fruit-eating bats with equine morbillivirus were developed. Equipment was designed to allow staff working in encapsulating suits access to all parts of a large animal room capable of accommodating seven horses individually. Procedures were developed for the safe handling, anesthesia and euthanasia of experimental animals and for the disposal of infected horse carcasses. Comprehensive staff training for this demanding work included safety consciousness, teamwork and training in first aid and emergency procedures.

Optimising the quality and outcomes of treatments for diabetic foot infections

INTRODUCTION

Infection is the commonest foot complication that arises in people with diabetes and may lead to amputation and even death. The emergence of multidrug resistant bacteria, especially in Gram negative rods, may have a negative impact on the chances of cure in these patients.

AREAS COVERED

We searched the Medline and Pubmed databases for studies using the keywords 'diabetic foot infection' and 'diabetic foot osteomyelits' from 1980 to 2016. Expert commentary: Much has been done in the field of diabetic foot infection regarding pathophysiology, diagnosis and treatment. The construction of multidisciplinary teams is probably the most efficient way to improve the patients' outcome. The rational use of antibiotics and surgical skills are essential in these potentially severe infections. Each case of diabetic infection deserves to be discussed in the light of the current guidelines and the local resources. Because of the overal poor outcome of these infections, prevention remains a priority.

Association of severe placental inflammation with death prior to discharge and cerebral palsy in preterm infants

OBJECTIVE

The objective of our study was to identify placental patterns associated with death before discharge or cerebral palsy in a large cohort of preterm infants with a high follow-up rate at 2 years of corrected age.

DESIGN

Population-based monocentric study.

SETTINGS

Monocentric study in the maternity unit of the University Hospital of Angers, France between 24⁺⁰ and 33⁺⁶  weeks of gestation, between January 2008 and December 2011.

POPULATION

All singleton infants born alive with a placental examination were eligible.

METHODS

Clinical data (obstetric and neonatal) were collected prospectively through the LIFT cohort. Placental data were collected retrospectively from medical records. The main outcome measure was death before discharge or cerebral palsy.

RESULTS

We did not find any significant association between severe inflammatory lesions on the placenta and death [odds ratio (OR) 1.49; 95% CI 0.55-4.01; P = 0.43] or cerebral palsy (OR 1.41; 95% CI 0.43-4.62; P = 0.57). This lack of significant association persisted even after adjustment (aOR 0.9; 95% CI 0.20-2.30; P = 0.54; aOR 0.98; 95% CI 0.27-3.58; P = 0.97).

CONCLUSION

Our results do not provide evidence for a significant association between severe inflammatory placental lesions and either death before discharge or cerebral palsy at 2 years of corrected age in preterm infants born at <34 weeks of gestational age. Further studies remain necessary to confirm this result.

TWEETABLE ABSTRACT

We found no significant association between inflammatory placental lesions and death or cerebral palsy.

Evaluating the management of 493 patients presenting with bacteremia in 23 northern French hospitals

OBJECTIVES

We aimed to update the epidemiology of bacteremia and evaluate their management and short-term outcome.

METHODS

We conducted a prospective multicenter survey from October to November 2011. Consecutive patients with at least one positive blood culture (BC) were included in the study. We evaluated the type and adequacy of empirical and documented antibiotic therapy, time to active antibiotic therapy, compliance with guidelines, and 10-day outcome.

RESULTS

A total of 23 public and private hospitals and 633 patients (493 true pathogens and 140 contaminants) were included in the study. Patients' wards were medicine (57%), surgery (19%), intensive care (14%), onco/hematology (3.7%), pediatrics (3.4%), infectious diseases (1.8%), and obstetrics (1.2%). Main pathogens were Escherichia coli (36%), Staphylococcus aureus (16%), coagulase-negative staphylococci, and Klebsiella sp. (8% each). A total of 43 (8.7%) multidrug-resistant strains were observed, including 26 extended-spectrum beta-lactamase strains and 15 methicillin-resistant S. aureus strains. An antibiotic active against the isolated pathogen was used in 74% of empirical and 96% of documented therapies. Median time between BC and administration of an active drug was 0.61 day. Empirical antibiotic therapies were protocol-compliant in 77% of cases. Few (4%) patients with contaminated BC received an antibiotic therapy (all inappropriate). Day-10 mortality was 12.1%, higher in patients presenting with severe sepsis or septic shock (22.5%) than in patients presenting with non-severe bacteremia (7.1%; P<0.0001).

CONCLUSION

The management of bacteremia seems satisfactory in these volunteer hospitals but bacteremia remains a severe infection.

Contribution of the late sodium current to intracellular sodium and calcium overload in rabbit ventricular myocytes treated by anemone toxin

Pathological enhancement of late Na+ current ( INa) can potentially modify intracellular ion homeostasis and contribute to cardiac dysfunction. We tested the hypothesis that modulation of late INa can be a source of intracellular Na+ ([Na+]i) overload. Late INa was enhanced by exposing rabbit ventricular myocytes to Anemonia sulcata toxin II (ATX-II) and measured using whole cell patch-clamp technique. [Na+]i was determined with fluorescent dye Asante NaTRIUM Green-2 AM. Pacing-induced changes in the dye fluorescence measured at 37°C were more pronounced in ATX-II-treated cells than in control (dye washout prevented calibration). At 22–24°C, resting [Na+]i was 6.6 ± 0.8 mM. Treatment with 5 nM ATX-II increased late INa 8.7-fold. [Na+]i measured after 2 min of electrical stimulation (1 Hz) was 10.8 ± 1.5 mM and 22.1 ± 1.6 mM ( P < 0.001) in the absence and presence of 5 nM ATX-II, respectively. Inhibition of late INa with GS-967 (1 μM) prevented Na+i accumulation. A strong positive correlation was observed between the late INa and the pacing-induced increase of [Na+]i ( R2 = 0.88) and between the rise in [Na+]i and the increases in cytosolic Ca2+ ( R2 = 0.96). ATX-II, tetrodotoxin, or GS-967 did not affect [Na+]i in quiescent myocytes suggesting that late INa was solely responsible for triggering the ATX-II effect on [Na+]i. Experiments with pinacidil and E4031 indicate that prolongation of the action potential contributes to as much as 50% of the [Na+]i overload associated with the increase in late INa caused by ATX-II. Enhancement of late INa can cause intracellular Na+ overload in ventricular myocytes.

[Nutritional assessment in primary practice in elderly patients]

Undernutrition is frequent and often underdiagnosed among older adults in every setting (home, nursing home, hospital), and is associated with increased morbidity and mortality. In this context, a systematic periodical nutritional assessment is proposed in patients aged 75 years and over. Without a consensus, the most widely used diagnostic criteria is an unintentional weight loss of 5% over a month or 10% over 6 months. When undernutrition is present, multimodal interventions are provided to address each potentially contributing comorbid condition and to promote increased caloric intake. Follow-up and adaptation of interventions after 3 months are required.

Complications following intravesical bacillus Calmette-Guerin treatment for bladder cancer: a case series of 22 patients

BACKGROUND

Intravesical bacillus Calmette-Guerin (BCG) therapy is an effective and widely used treatment for superficial bladder carcinoma. Local complications are frequent whereas systemic complications are rare but can be serious, and their management is not well known.

METHODS

We describe retrospectively the records of 22 patients treated in 3 infectious disease departments, for complications related to intravesical BCG therapy as treatment of bladder cancer.

RESULTS

All the patients were male, with a median age of 68 years (range 56-88). Complications occurred after a median of 5 instillations (range 1-11) and were observed within 24 h following BCG instillation for 14 patients. Common symptoms were fever (n = 20), impaired general condition (n = 14), and shortness of breath (n = 7). Six patients had a systemic septic reaction leading to transfer into the intensive care unit for five of them. Lung infiltration was the most frequent presentation (n = 11). Mycobacterium bovis was isolated from only two patients, but histology showed the presence of a granuloma in nine patients. Antimycobacterial treatment was initialized in 17 patients; the outcome was favorable in 16 patients, with a median length of symptoms resolution of 22.5 days (range 5-425 days). Eleven patients received corticosteroids in addition to specific treatment and had a more rapid improvement. One patient died with disseminated BCGitis proved by biopsy.

CONCLUSIONS

Complications following intravesical BCG therapy are rare but can be severe and fatal. Histology seems to be the method that contributes most in confirmation of the diagnosis. Antimycobacterial therapy is effective, and probably more efficient when combined with corticosteroids, but the regimen and duration of the treatment are not standardized.

Point-of-care musculoskeletal ultrasound is critical for the diagnosis of hemarthroses, inflammation and soft tissue abnormalities in adult patients with painful haemophilic arthropathy

We previously demonstrated in adult patients with haemophilia (PWH) that hemarthrosis is present in only ~1/3rd of acutely painful joints by using point-of-care-musculoskeletal ultrasound (MSKUS). Therefore, other unrecognized tissue abnormalities must contribute to pain. Using high resolution MSKUS, employing grey scale and power Doppler, we sought to retrospectively (i) investigate soft tissue abnormalities in painful haemophilic joints and (ii) to determine to what extent MSKUS findings, functional or radiographic joint scores correlate with biomarkers of inflammation in PWH. Findings were correlated with Hemophilia Joint Health Scores (HJHS), Pettersson scores, high sensitivity C-reactive protein and von Willebrand factor activity and antigen levels. A total of 65 MSKUS examinations for acute and chronic joint pains were performed for 34 adult haemophilia patients, mostly for chronic joint pains (72.3%). The most prominent findings (66.5%) pertained to inflammatory soft tissue changes including synovitis, tendinitis, enthesitis, bursitis and fat pad inflammation. Effusions were present in 55.5% and 46.8% of MSKUS performed for acute and chronic pain, respectively. Of those, 90.0% were bloody during acute and 47.6% during persistent pains. While inflammatory biomarkers correlated well with overall HJHS and total Pettersson scores (P < 0.05), they did not differ between those patients with synovitis and those without. MSKUS is emerging as an important modality to diagnose treatable musculoskeletal abnormalities contributing to pain in haemophilic arthropathy, and therefore seems critical for a personalized approach to haemophilia care. The role of biomarkers in this setting remains less clear and requires further investigation.

[Vulnerable older patients in primary care how to identify them? Which ressources to mobilize? ]

Trust is essential to foster and preserve a long-term relationship between primary care physicians and their patients suffering from chronic diseases. However, this relation remains insufficient to successfully manage more complex situations, such as those of older patients with multiple diseases and disability. For the primary care physician, a significant limitation is the time required to plan and coordinate interventions supplied by different health and social care providers. This article describes a structured approach to support primary care physicians in this difficult task and help them to identify vulnerable older patients requiring to mobilize and coordinate health and social care resources. Current and future resources available to family physicians to complete this challenging task are further described.

[Preoperative assessment in elderly patients]

Age-related physiological changes and comorbidities affect older patients' tolerance to surgery. Pre-operative assessment in these patients requires, beside the usual physical evaluation, the systematic screening of common geriatric syndromes. Cognitive, gait and balance, nutritional, and functional impairments, all flag patients at higher risk for per- and postoperative complications. Preoperative assessment is an opportunity to detect these syndromes and propose preventative interventions (physical therapy, nutritional and cognitive support measures) likely to reduce the incidence of postoperative morbidity.

[Diabetes and dementia: the dangerous liaisons? ]

As population ages, a growing number of older patients present the constellation of diabetes and dementia. Numerous recent studies highlight that diabetes may increase the risk for Alzheimer and vascular dementia. Among patients with previous severe hypoglycemia, that risk may even double. Inversely demented patients have about three times higher risk of hypoglycemia. Given that spiral link between hypoglycemia and dementia, the latter should be considered as a possible complication of diabetes and consistently be screened for among older diabetic patients. Furthermore, the American Diabetes Association and American Geriatric Society consensus recommends a more flexible glycemic treatment goal of AIC among demented patients, with a target range between 8 and 9%.