Analytical methods for the determination of DEHP plasticizer alternatives present in medical devices: a review

Until 2010, diethylhexylphthalate (DEHP) was the plasticizer most commonly used to soften PVC medical devices (MDs), because of a good efficiency/cost ratio. In flexible plasticized PVC, phthalates are not chemically bound to PVC and they are released into the environment and thus may come into contact with patients. The European Directive 2007/47/CE, classified DEHP as a product with a toxicity risk and restricted its use in MDs. MD manufacturers were therefore forced to quickly find alternatives to DEHP to maintain the elasticity of PVC nutrition tubings, infusion sets and hemodialysis lines. Several replacement plasticizers, so-called "alternative to DEHP plasticizers" were incorporated into the MDs. Nowadays, the risk of exposure to these compounds for hospitalized patients, particularly in situations classified "at risk", has not yet been evaluated, because migrations studies, providing sufficient exposure and human toxicity data have not been performed. To assess the risk to patients of DEHP plasticizer alternatives, reliable analytical methods must be first developed in order to generate data that supports clinical studies being conducted in this area. After a brief introduction of the characteristics and toxicity of the selected plasticizers used currently in MDs, this review outlines recently analytical methods available to determine and quantify these plasticizers in several matrices, allowing the evaluation of potential risk and so risk management.

Vitamin D status and parathyroid hormone concentrations influence the skeletal response to zoledronate and denosumab

Studies suggest that optimal vitamin D status is required for the maximal effect of antiresorptive agents. We investigated the relationship between vitamin D status, serum parathyroid hormone (PTH) concentrations, and change in bone mineral density (BMD) following iv zoledronate and denosumab. We carried out a retrospective analysis of 111 patients, mean age 70 (SD 13) years, 89 women and 22 men, prescribed zoledronate and 43 postmenopausal women treated with denosumab for osteoporosis. We measured BMD at the lumbar spine (LS) and total hip (TH), serum 25 (OH) vitamin D, PTH, and bone turnover markers (plasma CTX, P1NP) at 1 year. In patients on zoledronate, BMD increased at the LS and TH (mean LS change [SEM] = 2.6 % [0.5 %], mean TH change = 1.05 % [0.5 %], p < 0.05). A significant increase in BMD was seen at the LS only in the denosumab group (p = 0.001). Significant decreases in CTX and P1NP were observed at 12 months in both treatment groups. At baseline and at 12 months, 34 % and 23 % of the patients on zoledronate had a serum vitamin D of <50 nmol/L, respectively. The mean PTH concentration in patients with 25 (OH) vitamin D <50 nmol/L was 44 ng/L (SEM 16.6). Patients with PTH concentration <44 ng/L had significantly higher increases in TH BMD compared to those with PTH >44 ng/L (zoledronate 1.9 [0.83] vs. -0.43 [0.81], p = 0.04; denosumab 4.1 [0.054] vs. -1.7 [0.04], p = 0.004). Optimal vitamin D status and PTH concentrations improve the skeletal response to zoledronate and denosumab.

[Cutaneous mucormycosis caused by Rhizopus microsporus]

BACKGROUND

Mucormycosis are rare fungal infections occurring chiefly in the lung or the rhinocerebral compartment, particularly in patients with immunodeficiency or mellitus diabetes. We report the case of an elderly patient with cutaneous mucormycosis caused by Rhizopus microsporus.

PATIENTS AND METHODS

An 89-year-old man presented a skin lesion of the forearm rapidly becoming inflammatory and necrotic. The patient had been treated for 2months with oral corticosteroids for idiopathic thrombocytopenia. Histological and mycological examination of the skin biopsy revealed the presence of a filamentous fungus, R. microsporus. The outcome was unfavorable, despite prescription of high-dose liposomal amphotericin B.

DISCUSSION

Mucormycosis are infrequent opportunistic infections caused by angio-invasive fungi belonging to the Mucorales order. Cutaneous presentations are rare, and in rare cases the species R. microsporus is isolated in clinical samples. Diagnosis is based on histological examination highlighting the characteristic mycelium within infected tissue, together with ex vivo mycological identification using morphological and molecular methods. Treatment consists of liposomal amphotericin B combined with debridement surgery.

CONCLUSION

R. microsporus is a marginal fungal species rarely isolated in clinical practice, and even less in dermatology departments. This clinical case report highlights the severity of infection with this fungus, particularly in the absence of early surgery.

[Anti-infectious treatments in urology: general remarks]

OBJECTIVE

To define the general use of anti-infectious treatments in urology.

MATERIALS AND METHODS

A review of national guidelines and articles published on the subject in the Medline database, selected by keywords, depending on the scientific relevance was performed.

RESULTS

While the epidemiology clearly shows the non-reduction of the anti-infectious treatments use in France, the resistance increases to highlight foo-resistant germs. Urology is not an exception to this observation, and different means are set to improve the prescription made by urologists.

CONCLUSION

The epidemiological observation confirms the urgent need to improve the prescription of anti-infectious treatments particularly in urology.

Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection

We undertook a retrospective case-control study to assess the clinical variables associated with infections in open fractures. A total of 1492 open fractures were retrieved; these were Gustilo and Anderson grade I in 663 (44.4%), grade II in 370 (24.8%), grade III in 310 (20.8%) and unclassifiable in 149 (10.0%). The median duration of prophylaxis was three days (interquartile range (IQR) 1 to 3), and the median number of surgical interventions was two (1 to 9). We identified 54 infections (3.6%) occurring at a median of ten days (IQR 5 to 20) after trauma. Pathogens intrinsically resistant to the empirical antibiotic regimen used (enterococci, Enterobacter spp, Pseudomonas spp) were documented in 35 of 49 cases (71%). In multivariable regression analyses, grade III fractures and vascular injury or compartment syndrome were significantly associated with infection. Overall, compared with one day of antibiotic treatment, two to three days (odds ratio (OR) 0.6 (95% confidence interval (CI) 0.2 to 2.0)), four to five days (OR 1.2 (95% CI 0.3 to 4.9)), or > five days (OR 1.4 (95% CI 0.4 to 4.4)) did not show any significant differences in the infection risk. These results were similar when multivariable analysis was performed for grade III fractures only (OR 0.3 (95% CI 0.1 to 3.4); OR 0.6 (95% CI 0.2 to 2.1); and OR 1.7 (95% CI 0.5 to 6.2), respectively).

Infection in open fractures is related to the extent of tissue damage but not to the duration of prophylactic antibiotic therapy. Even for grade III fractures, a one-day course of prophylactic antibiotics might be as effective as prolonged prophylaxis.

Cite this article: Bone Joint J 2013;95-B:831–7.

Paediatric bone and joint infections are more common in boys and toddlers: a national epidemiology study

AIM

Little is known about bone and joint infections (BJIs) in children, despite the risk of growth disturbance. This study examined BJIs epidemiology using the French National Hospital Discharge Database (HD).

METHODS

Any child <15 years hospitalized with an HD diagnosis of BJI, alone or in combination with sepsis or orthopaedic procedure, was included. The majority of BJIs (96%) were haematogenic infections. We conducted descriptive analyses to evaluate epidemiological and economic outcomes of paediatric haematogenic BJIs.

RESULTS

There were 2592 paediatric patients with 2911 BJI hospitalizations and an overall incidence of 22 per 100 000. BJIs occurred more frequently in boys than girls (24 vs 19 per 100 000) and in toddlers. Septic arthritis (52%) and osteomyelitis (44%) were the most frequent infections, 16.6% of patients had a micro-organism coded (61% were Staphylococci) and 13% of had comorbidities. The mean hospital stay was 8.6 days, costing approximately €5200 per BJI stay.

CONCLUSION

This national study of paediatric BJIs in France showed a higher prevalence in toddlers and boys and demonstrated that the HD database can be used to study BJIs. However, the number of BJI cases was maybe overestimated by coding reactive arthritis as septic arthritis in the absence of bacterial evidence.

Short communication: in vivo deposition of [1-13C]vaccenic acid and the product of its Δ9-desaturation, [1-13C]rumenic acid, in the body tissues of lactating goats fed oils

This study was conducted in lactating goats with the aim of measuring the deposition of trans-11 18:1 (vaccenic acid, VA) and the product of its Δ(9)-desaturation, cis-9, trans-11 18:2 (rumenic acid, RA), in the major tissues that are involved in lipid metabolism in the lactating ruminant (i.e., mammary secretory tissue, liver, and omental and perirenal adipose tissues) and examining its potential link with variations in the expression of genes encoding Δ(9)-desaturase [stearoyl-CoA desaturases 1 and 5 (SCD1 and SCD5)]. Eight lactating goats were fed a diet supplemented with sunflower oil (n=4) or sunflower oil plus fish oil and additional starch (n=4), based on the hypothesis that these dietary treatments could affect Δ(9)-desaturase gene expression in specific tissues. A chemical tracer, 1.5 g of [1-13C]VA as nonesterified fatty acid, was delivered by jugular injection. Goats were slaughtered 4 d later, and tissue samples were collected for the measurement of [13C]VA and [13C]RA enrichment and SCD1 and SCD5 expression. The addition of fish oil and additional starch to a diet containing sunflower oil was associated with several changes in [13C]VA and [13C]RA enrichment. These results support previous studies suggesting that mammary secretory tissue is the primary site of Δ(9)-desaturation in lactating goats. In adipose tissues, the [13C]VA + [13C]RA enrichment was consistent with a net uptake of circulating fatty acids to reconstitute body reserves at the end of the lactation cycle. The putative uptake of [13C]RA synthesized by other tissues precludes any conclusion from being drawn regarding potential Δ(9)-desaturation in the liver of goats, despite the detection of SCD1 and SCD5 mRNA in this tissue. Finally, no significant effect of dietary treatment was observed for SCD1 or SCD5 mRNA abundance in the mammary secretory tissue or other body tissues.

Contribution of germline mutations in the BRCA and PALB2 genes to pancreatic cancer in Italy

Pancreatic adenocarcinoma (PC) is the third most common cancer associated with BRCA mutations. Most notice has been given to BRCA2, while the association between BRCA1 and PC is less widely reported. Recently, PALB2 has been implicated in both PC and breast cancer (BC) susceptibility. We selected 29 Italian PC patients from a case-control study of PC according to their personal and family history of both PC and breast/ovarian cancer (BC/OC) and tested them for presence of germline mutations in BRCA1, BRCA2 and PALB2. We identified no germline mutations or deletions in PALB2, but detected 7 BRCA mutations (4 in BRCA1 and 3 in BRCA2). These findings suggest that PALB2 does not play a major role in PC susceptibility in our population. As we found an almost equal frequency of germline mutations in BRCA1 and BRCA2, germline alterations in either of these genes may explain a subset of Italian families presenting both PC and BC/OC. Moreover, as we began the observation of these families from probands who are affected by PC, we provide here a direct assessment of the role of PALB2 and BRCA mutations in PC susceptibility.

Bone and joint infections in hospitalized patients in France, 2008: clinical and economic outcomes

BACKGROUND

Adult bone and joint infections (BJIs) often require repeated and prolonged hospitalizations and are considered as a serious public health issue.

AIM

To describe the epidemiology and economical outcomes of BJI in France.

METHODS

BJI hospitalizations with selected demographic, medical, and economic parameters from the French national hospital database for the year 2008 were identified. Overall patient characteristics and hospital stays for BJI underwent univariate analysis. Risk factors for device-associated infections were identified using multiple logistic regression modelling.

FINDINGS

Of all hospitalizations in France, 0.2% were BJI-related, representing 54.6 cases per 100,000 population, with a higher prevalence in males (sex ratio: 1.54). BJIs were more often native (68%) than device-associated (32%). The mean age was 63.1 years. Only 39% of hospital discharges had microbiological information coded; Staphylococcus spp. were isolated in 66% of those cases. Obesity, Staphylococcus spp., male sex and age >64 years were important risk factors for device-associated infections, whereas diabetes and ulcer sores were significantly associated with native infections. The case fatality was 4.6%. Intensive care unit stays were needed in 6% of cases. Readmissions to hospital occurred in 19% of cases, with significantly longer stays for device-associated infections than for native BJIs (18.9 vs 16.8 days). The cost of BJIs was €259 million, or about €7,000 per hospitalization in 2008.

CONCLUSIONS

This is the largest BJI study to date. The high economic burden of BJIs was mostly associated with more frequent and prolonged hospitalizations, high morbidity, and complexity of care.