Chronic osteomyelitis increases long-term mortality risk in the elderly: a nationwide population-based cohort study

Age-related dysregulation of CXCL9/10 in monocytes is linked to impaired innate immune responses in a mouse model of Staphylococcus aureus osteomyelitis

BACKGROUND

Age-associated impairments in innate immunity are believed to be a causative factor responsible for severe pathogenesis of Staphylococcus aureus (S. aureus) infection in the bone tissue. However, the basis for age-associated decline in innate immune response upon S. aureus infection remains poorly understood.

RESULTS

Our transcriptional data (GEO: GSE166522) from a mouse model of S. aureus osteomyelitis show up-regulated CXCL9 and CXCL10 (CXCL9/10), which is further confirmed in vitro and in vivo by the present study. Notably, monocytes are a main source for CXCL9/10 production in bone marrow upon S. aureus challenge, but this response declines in middle-aged mice. Interestingly, conditional medium of bone marrow monocytes from middle-aged mice has a strikingly decreased effect on bactericidal functions of neutrophils and macrophages compares with that from young mice. We further show that activation of CXCL9/10-CXCR3 axis between monocytes and macrophages/neutrophils promotes the bactericidal function of the cells, whereas blocking the axis impairs such function. Importantly, treatment with either exogenous CXCL9 or CXCL10 in a middle-aged mice model enhances, while pharmacological inhibition of CXCR3 in young mice model impairs, bacterial clearance and bone marrow structure.

CONCLUSIONS

These findings demonstrate that bone marrow monocytes act as a critical promotor of innate immune response via the CXLCL9/10-CXCR3 axis upon S. aureus infection, and that the increased susceptibility to S. aureus infection in skeleton in an aged host may be largely attributable to the declined induction of CXCR9/10 in monocytes.

Multifunctional scaffolds for bone repair following age-related biological decline: Promising prospects for smart biomaterial-driven technologies

The repair of large bone defects due to trauma, disease, and infection can be exceptionally challenging in the elderly. Despite best clinical practice, bone regeneration within contemporary, surgically implanted synthetic scaffolds is often problematic, inconsistent, and insufficient where additional osteobiological support is required to restore bone. Emergent smart multifunctional biomaterials may drive important and dynamic cellular crosstalk that directly targets, signals, stimulates, and promotes an innate bone repair response following age-related biological decline and when in the presence of disease or infection. However, their role remains largely undetermined. By highlighting their mechanism/s and mode/s of action, this review spotlights smart technologies that favorably align in their conceivable ability to directly target and enhance bone repair and thus are highly promising for future discovery for use in the elderly. The four degrees of interactive scaffold smartness are presented, with a focus on bioactive, bioresponsive, and the yet-to-be-developed autonomous scaffold activity. Further, cell- and biomolecular-assisted approaches were excluded, allowing for contemporary examination of the capabilities, demands, vision, and future requisites of next-generation biomaterial-induced technologies only. Data strongly supports that smart scaffolds hold significant promise in the promotion of bone repair in patients with a reduced osteobiological response. Importantly, many techniques have yet to be tested in preclinical models of aging. Thus, greater clarity on their proficiency to counteract the many unresolved challenges within the scope of aging bone is highly warranted and is arguably the next frontier in the field. This review demonstrates that the use of multifunctional smart synthetic scaffolds with an engineered strategy to circumvent the biological insufficiencies associated with aging bone is a viable route for achieving next-generation therapeutic success in the elderly population.

Chronic osteomyelitis risk is associated with NLRP3 gene rs10754558 polymorphism in a Chinese Han Population

BACKGROUND

Single nucleotide polymorphisms (SNPs) in the nucleotide-binding domain leucine-rich repeat protein-3 (NLRP3) gene are reported to be linked to many inflammatory disorders. However, uncertainty persists over the associations between these SNPs and susceptibilities to chronic osteomyelitis (COM). This study aimed to investigate potential relationships between NLRP3 gene SNPs and the risks of developing COM in a Chinese Han cohort.

METHODS

The four tag SNPs of the NLRP3 gene were genotyped in a total of 428 COM patients and 368 healthy controlsusing the SNapShot technique. The genotype distribution, mutant allele frequency, and the four genetic models (dominant, recessive, homozygous, and heterozygous) of the four SNPs were compared between the two groups.

RESULTS

A significant association was found between rs10754558 polymorphism and the probability of COM occurence by the heterozygous model (P = 0.037, odds ratio [OR] = 1.541, 95% confidence interval [CI] = 1.025-2.319), indicating that rs10754558 may be associated with a higher risk of developing COM.In addition, possible relationship was found between rs7525979 polymorphism and the risk of COM development by the outcomes of homozygous (P = 0.073, OR = 0.453, 95% CI = 0.187-1.097) and recessive (P = 0.093, OR = 0.478, 95% CI = 0.198-1.151) models, though no statistical differences were obtained.

CONCLUSIONS

Outcomes of the present study showed, for the first time, that rs10754558 polymorphism of the NLRP3 gene may increase the risk of COM development in this Chinese Han population, with genotype CG as a risk factor. Nonetheless, this conclusion requires verification from further studies with a larger sample size.

Indications for and outcomes of major lower limb amputations at a tertiary-referral centre in Australia

OBJECTIVES

Major amputations are classically associated with significant morbidity and mortality. With the increasing prevalence of risk factors for amputation, namely, diabetes and peripheral arterial disease, we sought to identify the major indications for lower limb amputation in an Australian cohort. A secondary aim was to assess the outcomes, namely, mortality, of amputees over the previous decade.

METHODS

This study assessed all patients undergoing major lower limb amputations between 2012 and 2020. Variables analysed included comorbidities, indication for amputation, in-hospital complications and mortality, duration of hospital stay, and out-patient mortality.

RESULTS

317 amputations were performed on 269 patients. 55% of amputations were below knee, 45% above knee, with one through-knee amputation. Indications included ischaemia (55.2%), infection (30.6%), malignancy (6.9%), trauma (4.4%), and chronic pain or instability (2.5%). In-patient mortality rate was 7.6%, with mortality rates of 21.5% at one year, and 70.1% at 10 years. Post-operative complications occurred in 43% of amputations. Rural, regional, and remote (RRR) patients did not suffer disproportionately from major amputations, however, were more likely to require amputations for ischaemia. Patients undergoing amputation for infective causes demonstrated lower mid-term mortality rates compared to those undergoing amputations for ischaemia (56.1 vs 60.4% at 5 years, p = 0.007).

CONCLUSION

Major amputations continue to be associated with significant morbidity and mortality, both in the short and long term. Patients undergoing amputations for ischaemic causes demonstrate poorer outcomes than their infective counterparts, with outcomes being even worse in RRR populations. Prevention of amputations via intense management of comorbidities would benefit both patients and the healthcare system.

Risk Factors for Postoperative Osteomyelitis among Patients after Bone Fracture: A Matched Case-Control Study

The healthcare burden of osteomyelitis is increasing. Postoperative and posttraumatic osteomyelitis account for 80% of all cases of osteomyelitis. The aim of this study was to find risk factors for postoperative osteomyelitis in Kazakhstan. We included 245 patients admitted to the National Scientific Center of Traumatology and Orthopedics from 2018 to 2020. Cases were matched with controls in a 1:4 ratio. Exact matching was performed by gender, ICD-10, and ICD-9 codes. The main variables included socio-demographics, diagnosis at admission, characteristics of fractures, comorbidities, complications, hospitalization milestones, and osteomyelitis characteristics. Descriptive analyses, along with bivariate analysis and multivariate conditional logistic regression, were performed. Open fracture (adjOR = 6.25; 95%CI 1.64−23.79), the presence of complications of initial fracture (adjOR = 3.46, 95%CI 1.13−10.56), comminuted fracture form (adjOR = 1.87; 95%CI 0.73−4.75), a positive history of diabetes or blood glucose >7 g/L (adjOR = 4.25; 95%CI 1.26−14.3), incision or wound length of more than 10 cm (adjOR = 6.53; 95%CI 1.1−38.6), additional implanted medical item (adjOR = 1.23; 95% CI 1.1−1.47), and unemployment or being retired (adjOR = 4.21; 95%CI 1.74−10.18) were found to be significant predictors of postoperative osteomyelitis. Almost all our findings are concordant with previous studies, except for the type of fracture. Different authors report conflicting results on the latter potential risk factor. Therefore, prospective studies on this issue are required.

Microbial resistance to nanotechnologies: An important but understudied consideration using antimicrobial nanotechnologies in orthopaedic implants

Microbial resistance to current antibiotics therapies is a major cause of implant failure and adverse clinical outcomes in orthopaedic surgery. Recent developments in advanced antimicrobial nanotechnologies provide numerous opportunities to effective remove resistant bacteria and prevent resistance from occurring through unique mechanisms. With tunable physicochemical properties, nanomaterials can be designed to be bactericidal, antifouling, immunomodulating, and capable of delivering antibacterial compounds to the infection region with spatiotemporal accuracy. Despite its substantial advancement, an important, but under-explored area, is potential microbial resistance to nanomaterials and how this can impact the clinical use of antimicrobial nanotechnologies. This review aims to provide a better understanding of nanomaterial-associated microbial resistance to accelerate bench-to-bedside translations of emerging nanotechnologies for effective control of implant associated infections.

International Lower Limb Collaborative (INTELLECT) study: a multicentre, international retrospective audit of lower extremity open fractures

Sixty-two centres in 16 countries contributed with 2,694 open fractures cases to an international, multi-centric, retrospective cohort study involving different healthcare settings. The INTELLECT study results show that there are significant disparities on the management of open lower limb fractures internationally. A timely, multidisciplinary, guideline-directed care is a protective factor for developing infective complications, non-union and requiring an amputation.

Prevalence of psychological comorbidities in bone infection

OBJECTIVE

Bone infections represent a major complication in orthopedic and trauma surgery. Concomitant psychological disorders can significantly influence treatment outcomes. However, these are often overlooked. Therefore, we aimed to determine the nationwide epidemiology of fracture-related infection (FRI) and osteomyelitis in combination with psychological comorbidities.

METHODS

A dataset provided by the Federal Statistical Office (Destatis) consisting of annual, Germany-wide ICD-10 diagnosis codes from 2009 to 2019 was analysed. Incidences of the codes "T84.6, infection and inflammatory reaction due to internal fixation device" and "M86.-, osteomyelitis" were quantified. Proportions of secondary diagnoses of the chapter F of the ICD-10 were determined.

RESULTS

Incidences were 19.1/100,000 inhabitants for osteomyelitis and 10.5/100,000 inhabitants for FRI. Patients with psychological comorbidities constituted 14.6% of osteomyelitis cases and 26.5% of FRI cases, respectively. Between 2009 through 2019, the proportion of patients with a concomitant "F" diagnoses of the ICD-10 increased by 27.3% for osteomyelitis and by 24.1% for FRI. Most prevalent secondary diagnoses were organic, including symptomatic, mental disorders (F0), affective disorder (F3) and mental and behavioral disorders due to psychoactive substance use (F1), whereby the latter decreased over the years.

CONCLUSION

The implementation of prevention strategies, interdisciplinary approaches and psychological support in orthopaedics and trauma surgery is warranted.

[Augmentation in surgical sepsis : Chances and limitations in the treatment of osteitis with calcium hydroxyapatite containing antibiotics]

BACKGROUND

The surgical treatment of osteitis or fracture-related infections (FRI) is often associated with large bone defects. The treatment of these defects remains a major challenge in trauma surgery. Within the concept of tissue engineering, the development of various hybrid bone graft substitutes, such as calcium hydroxyapatite with added antibiotics, is continuously progressing.

OBJECTIVE

Chances and limitations in the treatment of osteitis with calcium hydroxyapatite containing antibiotics.

MATERIAL AND METHODS

Overview of the results of a 2-stage (infection) pseudarthrosis model on rat femurs treated with Cerament® G (Bonesupport, Lund, Schweden). Evaluation of the clinical experiences based on three case examples of osteitis treated with calcium hydroxyapatite containing antibiotics (Cerament® G or Cerament® V).

RESULTS

After establishment of a 2‑stage pseudarthrosis model on the rat femur, the osteoconductive and osteoinductive potential of calcium hydroxyapatite containing antibiotics could be confirmed. In the clinical application, the use of Cerament® G seems to lead to a more favorable outcome in small cavitary defects. The recurrence rates are higher than previously described, especially for larger segmental defects.

CONCLUSION

Taking the clinical and experimental results into consideration, a stricter evaluation of the indications for the use of Cerament® G is necessary to achieve the best possible outcome for patients.

Silver ion-doped calcium phosphate-based bone-graft substitute eliminates chronic osteomyelitis: An experimental study in animals

Despite the latest technologies and advances in microbiology and orthopedic surgery, chronic osteomyelitis is still a challenging disorder. Antibiotic resistance and bacterially induced bone destruction can have very serious consequences. We hypothesized that calcium phosphate-based bone graft substitution with silver ion doping would simultaneously treat bone infection and the bony defect in the chronic osteomyelitis. An unicortical 10-mm-diameter bone was harvested in the proximal tibial metaphysis of 24 rabbits. After contaminating the wounds with an infective dose of methicillin-resistant Staphylococcus aureus (MRSA), osteomyelitis was proven radiographically and microbiologically in all rabbits. Animals were than divided into three groups. The first group received vancomycin-impregnated bone cement beads (comparative control group), the second/experimental group received silver ion-doped calcium phosphate beads and the third group received pure calcium phosphate beads (negative controls). Radiographs, intraosseous cultures, and histopathological examinations were performed on postoperative Week 10. The cultures showed no evidence of intramedullary infection in the silver ion-doped calcium phosphate beads group, but they were positive for MRSA in four of the six rabbits in the vancomycin- impregnated bone cement beads group and in all of the eight rabbits in the pure calcium phosphate beads group. Quantitative assessment of histopathological examination showed lowest total damage score in silver ion-doped calcium phosphate beads group (p < .001). Percentage of osteoid tissue + bony tissue was also higher in this group compared with other groups. In the final radiological examinations, it was observed that the changes caused by osteomyelitis in the bone tissue in the silver ion-doped calcium phosphate beads group were much improved compared with the vancomycin-impregnated bone cement beads group. Silver ion doped calcium phosphate-based bone-graft substitute offer the ability to stimulate bone growth, combat infection, and, ultimately, treat experimental chronic osteomyelitis in an animal model.

Chronic osteomyelitis caused by Achromobacter xylosoxidans following orthopaedic trauma: A case report and review of the literature

Background

Achromobacter xylosoxidans is an opportunistic environmental aerobe. In cases where A. xylosoxidans infects humans, it most commonly manifests as bacteraemia in the immunosuppressed. A. xylosoxidans causing chronic osteomyelitis is rare, particularly in the immunocompetent and young.

Case

We present the case of a 23-year-old man with chronic osteomyelitis of the right femur caused by co-infection of A. xylosoxidans and Staphylococcus aureus. Five years earlier, he had sustained a right femur fracture and was treated with intramedullary fixation at a peripheral hospital in a developing nation. Past medical history was otherwise unremarkable. Management comprised of surgical debridement and culture-directed antibiotic therapy, resulting in clinical cure.

Conclusion

In the context of local trauma and previous surgery, osteomyelitis caused by atypical pathogens must be considered. A multidisciplinary approach commensurate with duration and severity of infection and tailored to the causative organism is paramount.

Salmonella Osteomyelitis of the Rib Mimicking a Mammary Tumor: A Case Report

Salmonella infection predominantly causes four clinical syndromes: enteric fever, gastroenteritis, bacteremia, and asymptomatic carrier state. Salmonella osteomyelitis is an extremely rare manifestation of salmonella infection except in children with hemoglobinopathies. Salmonella osteomyelitis has been reported to mostly affect the diaphysis of long bones and lumbar spine. Here, we describe a case of salmonella osteomyelitis of the right 6th rib in a 74-year-old woman who presented with breast pain, swelling, high fever and local heat. Her medical history showed myocardial infarction; namely, at the age of 71, the patient had undergone the drug-eluting stent placement in the left anterior descending artery. A computed tomography (CT) scan at the first visit to another hospital showed a mass in the chest that invaded the ribs. ¹⁸F-fluorodeoxyglucose-positron emission tomography-computed tomography imaging showed a lesion suspected to be a mammary malignant tumor. A needle biopsy revealed mesenchymal cells and suspected mammary sarcoma. However, the osteomyelitis of the rib was diagnosed when pyogenic tissue was observed during an open biopsy. The bacterial culture examination identified Salmonella enterica. Surgical drainage and antibiotic treatment were performed. Importantly, there was no evidence for any underlying disease that could lead to an immunocompromised status of the patient. To our knowledge, this is the first report of salmonella osteomyelitis of the rib presenting in an older female that required differentiation from a mammary tumor. Clinicians should consider rib osteomyelitis when they find swelling and local heat in the female's breast tissue and detect no cancerous tissue.

Bovine Hydroxyapatite-Based Bone Scaffold with Gentamicin Accelerates Vascularization and Remodeling of Bone Defect

Osteomyelitis is an infectious disease which is also a major complication of bone defects. This study aims to determine the effect of bovine hydroxyapatite-gelatin-based bone implants with gentamicin as an antibiotic (BHA-GEL-GEN implant) on the regeneration of bone defects in vivo. The BHA-GEL-GEN and BHA-GEL implants were made by direct compression. In vivo study was carried out with Wistar rats. The rats were divided into three groups: negative control, BHA-GEL implant, and BHA-GEL-GEN implants. The defect model used was the burr hole defect model with diameter 2.2 mm and 2 mm deep. After 2, 7, 14, and 28 days, the rats were sacrificed. Bone integrity was carried out using X-ray radiography. Radiological examination was performed using haematoxylin and eosin (HE) staining and immunohistochemical techniques with anti-vascular endothelial growth factor (VEGF) and anti-alkaline phosphatase (ALP) antibodies. Based on the radiograph, the implanted group had accelerated bone growth in the defect area. Semiquantitative data from HE staining showed that the implanted group had accelerated migration of osteoclasts, osteoblasts, and osteocytes in the defect area. The immunoreactive score showed that the BHA-GEL-GEN group had higher VEGF expression compared to two other groups. The three groups did not provide a significant difference in ALP expression. In conclusion, the BHA-GEL-GEN implant causes accelerated bone defects repair by accelerating tissue vascularity and does not interfere with the bone remodeling process. Therefore, the BHA-GEL-GEN implant is potentially a biomedical material for osteomyelitis therapy.

A retrospective cohort study comparing clinical outcomes and healthcare resource utilisation in patients undergoing surgery for osteomyelitis in England: a case for reorganising orthopaedic infection services

Aims: An investigation of the impact of a multidisciplinary bone infection unit (BIU) undertaking osteomyelitis surgery with a single-stage protocol on clinical outcomes and healthcare utilisation compared to national outcomes in England. Patients and Methods: A tertiary referral multidisciplinary BIU was compared to the rest of England (ROE) and a subset of the 10 next busiest centres based on osteomyelitis treatment episode volume (Top Ten), using the Hospital Episodes Statistics database (HES). A total of 25 006 patients undergoing osteomyelitis surgery between April 2013 and March 2017 were included. Data on secondary healthcare resource utilisation and clinical indicators were extracted for 24 months before and after surgery. Results: Patients treated at the BIU had higher orthopaedic healthcare utilisation in the 2 years prior to their index procedure, with more admissions (p< 0.001) and a mean length of stay (LOS) over 4 times longer than other groups (10.99 d, compared to 2.79 d for Top Ten and 2.46 d for the ROE, p< 0.001). During the index inpatient period, the BIU had fewer mean theatre visits (1.25) compared to the TT (1.98, p< 0.001) and the ROE (1.64, p= 0.001). The index inpatient period was shorter in the BIU (11.84 d), 33.6 % less than the Top Ten (17.83 d, p< 0.001) and 29.9 % shorter than the ROE (16.88 d, p< 0.001). During follow-up, BIU patients underwent fewer osteomyelitis-related reoperations than Top Ten centres (p= 0.0139) and the ROE (p= 0.0137). Mortality was lower (4.71 %) compared to the Top Ten (20.06 %, p< 0.001) and the ROE (22.63 %, p< 0.001). The cumulative BIU total amputation rate was lower (6.47 %) compared to the Top Ten (15.96 %, p< 0.001) and the ROE (12.71 %, p< 0.001). Overall healthcare utilisation was lower in the BIU for all inpatient admissions, LOS, and Accident and Emergency (A&E) attendances. Conclusion: The benefits of managing osteomyelitis in a multi-disciplinary team (MDT) specialist setting included reduced hospital stays, lower reoperation rates for infection recurrence, improved survival, lower amputation rates, and lower overall healthcare utilisation. These results support the establishment of centrally funded multidisciplinary bone infection units that will improve patient outcomes and reduce healthcare utilisation.

Shorter Telomere Length in Peripheral Blood Leukocytes Is Associated with Post-Traumatic Chronic Osteomyelitis

Background: This study investigated the association between post-traumatic chronic osteomyelitis (COM) and peripheral leukocyte telomere length (PLTL) and explored factors associated with PLTL in COM. Methods: A total of 56 patients with post-traumatic COM of the extremity and 62 healthy control subjects were recruited. The PLTL was measured by real-time PCR. Binary logistic regression analysis was used to identify factors in correlation with telomere length. Sex, age, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and infection duration were included as independent variables in the logistic regression model. Results: Post-traumatic COM patients had significantly shorter PLTLs (5.39 ± 0.40) than healthy control subjects (5.69 ± 0.46; p < 0.001). Binary logistic regression analysis showed that PLTL had a statistically significant association with age (B = -0.072; p = 0.013) and CRP (B = -0.061; p = 0.033). The logistic regression model was statistically significant and explained 31.4% (Nagelkerke R²) of the change in telomere length and correctly classified 69.6% of the cases. Conclusions: Patients with post-traumatic COM have shorter PLTLs than healthy subjects. The PLTL erosion of post-traumatic COM was partially explained by age and CRP.

Chronic pain and use of analgesics in the elderly: a nationwide population-based study

INTRODUCTION

Chronic pain may cause many comorbidities in the elderly; however, nationwide data about this issue remain insufficient. We conducted this study to address the data gap.

MATERIAL AND METHODS

We identified geriatric participants (≥ 65 years) with chronic pain between 2000 and 2013 from the Taiwan National Health Insurance Research Database. The causes of chronic pain and use of analgesics between two sexes and among three age subgroups were compared.

RESULTS

A total of 21,018 participants were identified with the mean age (standard deviation) of 72.7 years (5.6) and the female percentage of 50.8%. The prevalence of chronic pain in the elderly was 21.5%, and it was higher in the females than males. The proportions of each age subgroup were 65-74 (66.8%), 75-84 (29.4%), and ≥ 85 years (3.8%). Common causes of chronic pain were osteoarthritis (21.9%), spinal disorders (19.0%), peripheral vascular diseases (12.4%), and osteoporosis (11.4%). Non-steroidal anti-inflammatory drugs were the most common medication, followed by acetaminophen and opioids. The most commonly used opioid was morphine. The use of opioids increased with age.

CONCLUSIONS

This study delineated the causes of chronic pain and use of analgesics in a geriatric population, which may help further studies about this issue in the future.

Long-term mortality in older adults with chronic pain: a nationwide population-based study in Taiwan

PURPOSE

This study was conducted to clarify the long-term mortality in the older population with chronic pain (CP), which is still unclear.

METHODS

We identified 17,568 older participants (aged ≥ 65 years) with CP and an identical number of comparison cohort without CP matched 1:1 by age and sex between 1996 and 2000 from the Taiwan National Health Insurance Research Database. Causes of CP, underlying comorbidities, living areas, and mortality were collected for analyses. The long-term mortality and the causes of mortality were compared between the two cohorts through follow-up since 2000 until 2015.

RESULTS

The mean age (± standard deviation) was 73.5 ± 5.7 years, and female participants comprised 55.1% in both cohorts. The most common causes of CP were osteoarthritis (24.2%), spinal disorders (22.4%), peripheral vascular diseases (14.0%), and osteoporosis (9.5%). Older participants with CP had an increased rate of long-term mortality compared to that among their counterparts without CP after adjusting for the underlying comorbidities and the causes of CP (adjusted hazard ratio [AHR]: 1.18; 95% confidence interval [CI] 1.14-1.21). The increased mortality rate was observed even after the follow-up of 6 years (AHR 1.15; 95% CI 1.10-1.20). No significant difference was observed in the causes of mortality between the two cohorts. The most common cause of mortality was malignancy, followed by cardiovascular and cerebrovascular diseases.

CONCLUSIONS

Chronic pain was associated with an increased rate of long-term mortality in the older population. Early detection and intervention for treating CP are suggested for this population.

A bibliometric analysis of acupuncture research in Taiwan from 1988 to 2017

BACKGROUND

Since Taiwan's national health insurance system provides residents with easy and affordable access to clinical acupuncture treatment, this study sought to analyze trends in the publication of acupuncture-related research in Taiwan from 1988 to 2017, using a bibliometric method.

METHODS

Data on the scholarly literature from 1988 to 2017 were retrieved through Web of Science searches for the keywords acupunct*, acupoint*, electroacupunct*, electro-acupunct*, acupre*, auricular acupunc*, and auricular needle* in study titles.

RESULTS

A total of 539 acupuncture-related articles published from 1988 to 2017 were identified and analyzed. The articles had an h-index of 38 and were cited in subsequent studies 7250 times, meaning that Taiwan ranked sixth in the production of such publications among countries/regions globally. Among those articles, 99 (18.4%) had no subsequent citations, six (1.1%) were highly cited (over 100 citations), and 141 (26.1%) were cited 4 to 10 times. The highly cited articles discussed the possible pathways of acupuncture stimulation and efficacy, and received 1103 (15.2%) of the citations.

CONCLUSION

The China Medical University in Taichung, Taiwan, was the most active educational institution in Taiwan in terms of acupuncture-related research. Professor Lin Jaung-Geng was the leading acupuncture-related researcher, having the most publications, citations, and the highest h-index value. These results provided a context for analyzing the strengths of the existing research and informing prospective strategies for further studies.

Management of Post-Traumatic Osteomyelitis in the Lower Limb: Current State of the Art

Osteomyelitis (OM) of the lower limb represents a large unmet global healthcare burden. It often arises from a contiguous focus of infection and is a recognized complication of open fractures or their surgical treatment, arthroplasty, and diabetic foot ulcers. Historically, this debilitating condition is associated with high rates of recurrence and secondary amputation. However, excellent long-term outcomes are now achieved by adopting a multidisciplinary approach with meticulous surgical debridement, skeletal and soft tissue reconstruction, and tailored antimicrobial treatment. This review focuses on the modern evidence-based management of post-traumatic OM in the lower limb from a reconstructive plastic surgery perspective, highlighting the latest developments and areas of controversy.

Interleukin-1 Beta Gene Polymorphism rs16944 May Associate with Increased Susceptibility to Extremity Chronic Osteomyelitis in Chinese Han Population

Background

Previous studies had indicated that interleukin-1 beta (IL-1β) gene single nucleotide polymorphisms (SNPs) associate with different inflammatory diseases. However, potential links between these polymorphisms and susceptibility to extremity chronic osteomyelitis (COM) remain unclear. This study aimed to investigate relationships between IL-1β gene polymorphisms (rs16944, rs1143627, rs1143634, and rs2853550) and risks of developing extremity COM in Chinese Han population.

Methods

Altogether 233 extremity COM patients and 200 healthy controls were genotyped for the four tag SNPs of the IL-1β gene using the SNapShot genotyping method. Comparisons were performed regarding genotype distribution, mutant allele frequency, and four genetic models (dominant, recessive, homozygous, and heterozygous models) of the four SNPs between the two groups.

Results

Significant associations were identified between rs16944 polymorphism and the risk of developing COM by dominant model (P = 0.026, OR = 1.698, 95% CI 1.065-2.707) and heterozygous model (P = 0.030, OR = 1.733, 95% CI 1.055-2.847). Although no statistical differences were found of rs1143627 polymorphism between the two groups, there existed a trend that rs1143627 may be linked to an elevated risk of developing COM by outcomes of dominant (P = 0.061), homozygous (P = 0.080) and heterozygous (P = 0.095) models. However, no statistical correlations were found between rs1143634 and rs2853550 polymorphisms and susceptibility to COM in Chinese Han population.

Conclusions

To our knowledge, we reported for the first time that IL-1β gene rs16944 polymorphism may contribute to the increased susceptibility to extremity COM in Chinese Han population, with genotype of AG as a risk factor.

Incidence and risk factors of osteomyelitis in adult and pediatric systemic lupus erythematosus: a nationwide, population-based cohort study

OBJECTIVE

The objective of this paper is to investigate the incidence rate, risk factors and outcome of osteomyelitis among patients with systemic lupus erythematosus (SLE).

MATERIALS AND METHODS

We conducted a cohort study using data for patients enrolled in the Taiwan National Health Insurance Database from 2000 to 2012. Patients with SLE and age- and sex-matched controls without SLE were enrolled. Primary endpoint was the first occurrence of osteomyelitis. Risks of osteomyelitis in SLE patients were analyzed with Cox proportional hazards regression models, including age, sex, comorbidities and medications.

RESULTS

Among 24,705 SLE patients (88.4% women, mean age 35.8 years) with a median follow-up of 9.1 years, 386 patients had osteomyelitis. The incidence rate ratio (IRR) of osteomyelitis in the SLE group vs the control group was 8.52 (95% confidence interval (CI) 7.24-10.05). The SLE group had higher incidence rates of osteomyelitis than the control group, especially in pediatric subgroups (IRR 41.1 95% CI 18.57-107.35). Compared to controls, SLE patients experienced osteomyelitis at a younger age (42.3 vs 58.1 years) but did not have an increased risk of mortality (hazard ratio 0.7; 95% CI 0.21-2.38). Age >60 years, male gender, malignancy within five years, prior bone fracture and higher daily prednisolone dose (>7.5 mg) cumulatively for >180 days increased risk for osteomyelitis.

CONCLUSIONS

SLE patients have a higher IRR of osteomyelitis than controls. Pediatric and elder SLE patients, patients with a history of bone fracture, malignancy within five years and higher-dose glucocorticoid use have a higher risk of osteomyelitis and should be carefully monitored.

Encapsulation of green tea polyphenol by pH responsive, antibacterial, alginate microgels used for minimally invasive treatment of bone infection

The treatment of bone infection requires drug carriers take large number of cargo, be antibacterial, promote proliferation and differentiation of osteoblasts. Herein, we proposed a strategy of preparing pH responsive, antibacterial, multistage structured microspheres encapsulated with green tea polyphenol used for minimally invasive treatment of bone infection. Tea polyphenol (TP) were encapsulated by porous silica nanospheres (SiO₂ NSs). Then, sodium alginate (SA) microgel spheres (MSs) were prepared to encapsulate a lot of TP loaded SiO₂ NSs. The outer layer of obtained TP@SiO₂@SA microgel spheres were further wrapped by pH sensitive CaCO₃. Mineral out-layer of the composite microspheres is used to neutralize the acidic environment caused by bacterial infection. At the same time, encapsulated TP is released pH sensitively to resist oxidative stress. Our results exhibited excellent drug delivery properties including drug loading efficiency (DLE) of 92.96% and drug loading content (DLC) of 19.62%. Besides, results demonstrated that TP@SiO₂@SA@CaCO₃ MSs can effectively kill Staphylococcus aureus and promote proliferation and differentiation of osteoblasts under stimulation of H₂O₂ at pH = 5.5.

Geriatric influenza death (GID) score: a new tool for predicting mortality in older people with influenza in the emergency department

Although influenza may cause death in the geriatric population, the best method for predicting mortality in this population is still unclear. We retrospectively recruited older people (≥65 yr) with influenza visiting the emergency department (ED) of a medical center between January 1, 2010, and December 31, 2015. We performed univariate and multivariate logistic regression to identify independent mortality predictors and then developed a prediction score. Four hundred nine older ED patients with a nearly equal sex ratio were recruited. Five independent mortality predictors were identified: severe coma (Glasgow Coma Scale score ≤8), past histories of cancer and coronary artery disease, elevated C-reactive protein levels (>10 mg/dl), and bandemia (>10% band cells). We divided the patients into three mortality risk and disposition groups: (1) low risk (1.1%; 95% confidence interval [CI], 0.5-3.0%); (2) moderate risk (16.7%; 95% CI, 9.3-28.0%); and (3) high risk (40%; 95% CI, 19.8-64.2%). The area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness of fit of the GID score were 0.86 and 0.578, respectively. The GID score is an efficient and simple tool for predicting mortality in older ED patients with influenza. Further studies are warranted to validate its use.

Chronic Osteomyelitis Increases the Incidence of Type 2 Diabetes in Humans and Mice

Background: To compare the risk of type 2 diabetes (T2DM) between patients with and without chronic osteomyelitis (COM), both in humans and in mice, and to explore risk factors in COM patients who developed T2DM.

Methods: One hundred seven patients with COM and 114 patients without COM were consecutively enrolled and retrospectively analysed. Clinical data concerning the time to develop diabetes, glucose metabolism, lipid metabolism, inflammatory factors, mental health and frequency of specialist visits were collected. A mouse model of osteomyelitis was used to verify the presence of impaired glucose metabolism and depression. All data were processed by SPSS.

Results: The incidence of T2DM was 2.37-fold higher in patients with COM than in those without. In COM patients, subjects with T2DM (DDM) had higher BMI, less exercise and more frequent visits to specialists than those without (Con). Glucose and lipid metabolism were worse in patients with DDM. Patients with DDM had higher levels of white blood cells (12.9±2.1×109/L vs. 11.7±2.2×109/L, p=0.027), CRP (28.4±4.5 mg/L vs. 22.0±4.8 mg/L, p<0.001), TNF-α (13.5±5.0 pg/mL vs. 9.4±2.6 pg/mL, p= 0.003) and IL-6 (12.9±3.2 pg/mL vs. 9.2±2.7 pg/mL, p<0.001). Significantly increased fasting blood glucose concentrations and impairment of oral glucose tolerance tests were also observed in mice modelling osteomyelitis, which were accompanied by elevated TNF-α and IL-6 levels. Furthermore, the proportion of depression (63.2% vs. 35.2%, p=0.003) and severe anxiety (31.6% vs. 9.1%, p=0.002) were significantly higher in the DDM group. Osteomyelitis mice showed obvious depressive-like behaviours. The levels of TNF-α, IL-6, CRP, BMI, and LDL; lack of exercise; SAS; HAQ; and SF36 assessment were risk factors for the development of T2DM in COM patients.

Conclusions: Chronic osteomyelitis increased the incidence of T2DM in both humans and mice. Inflammation, mental illness and lack of exercise were risk factors for the occurrence of T2DM in osteomyelitis. Comprehensive consideration of patient history, including metabolism and mental health, is needed in planning future treatment.

Septic arthritis significantly increased the long-term mortality in geriatric patients

Background

The elderly are predisposed to septic arthritis (SA) because of the aging nature and increasing comorbidities. SA may in turn increase the long-term mortality in the geriatric patients; however, it remains unclear. We conducted this prospective nationwide population-based cohort study to clarify this issue.

Methods

Using Taiwan National Health Insurance Research Database (NHIRD), we identified 1667 geriatric participants (≥ 65 years) with SA and 16,670 geriatric participants without SA matched at a ratio of 1:10 by age, sex, and index date between 1999 and 2010. A comparison of the long-term mortality between the two cohorts through follow-up until 2011 was performed.

Results

Geriatric participants with SA had a significantly increased mortality than those without SA [Adjusted hazard ratio (AHR): 1.49, 95% confidence interval (CI): 1.34–1.66], particularly the old elderly (≥ 85 years, AHR: 2.12, 95% CI: 1.58–2.84) and males (AHR: 1.54, 95% CI: 1.33–1.79). These results were stated after adjustment for osteoarthritis, diabetes, gout, renal disease, liver disease, cancer, rheumatoid arthritis, systemic lupus erythematosus, alcoholism, and human immunodeficiency virus infection. The increased mortality risk was highest in the first month (AHR: 3.93, 95% CI: 2.94–5.25) and remained increased even after following up for 2–4 years (AHR: 1.30, 95% CI: 1.03–1.65). After Cox proportional hazard regression analysis, SA (AHR: 1.37, 95% CI: 1.20–1.56), older age (≥ 85 years, AHR: 1.79, 95% CI: 1.59–2.02, 75–84 years, AHR: 1.65, 95% CI: 1.53–1.78), male sex, diabetes, renal disease, liver disease, cancer, and gout were independent mortality predictors. There was no significant difference in the mortality for SA between upper limb affected and lower limb affected.

Conclusions

This study delineated that SA significantly increased the long-term mortality in geriatric participants. For the increasing aging population worldwide, strategies for the prevention and treatment of SA and concomitant control of comorbidities are very important.

Predisposing factors for recurrence of chronic posttraumatic osteomyelitis: a retrospective observational cohort study from a tertiary referral center in Brazil

BACKGROUND

The incidence of posttraumatic osteomyelitis (PTO) is increasing despite new treatment strategies. Assessment of patients' outcomes following PTO is challenging due to multiple variables. The study goals are to determine the frequency of recurrence following PTO treatment and identify factors predisposing patients to treatment failure.

METHODS

Between August 01, 2007 to August 30, 2012, a single-center retrospective cohort study was performed among 193 patients diagnosed with PTO following orthopedic surgery for fracture care. Bone and soft tissues were collected for cultures and PTO was defined according to CDC/NHSN criteria. Patient, injury, surgery-associated variables, and microbiological records were reviewed for risk factors associated to recurrence of PTO. Univariate and multivariable analyses using logistic regression were performed, with p <0.05 considered significant.

RESULTS

Thirty-eight patients (20%) of 192 diagnosed and treated for PTO failed their treatment. Factors associated with recurrence were age between 61 and 80 years [hazard ratio (HR) = 6.086, 95% confidence interval (CI) = 2.459;15.061, p = <0.001], age above 80 years [HR = 9.975 (95% CI = 3.591;27.714), p = <0.001], intraoperative blood transfusion [HR = 2.239 (95% CI = 1.138;4.406), p = 0.020], and positive culture for Pseudomonas aeruginosa [HR = 2.700 (95% CI = 1.370;5.319), p = 0.004].

CONCLUSIONS

Risk factors associated with recurrence of PTO are difficult to measure. The present study revealed that elderly patients, intraoperative blood transfusions, and infection due to P. aeruginosa were independently associated with recurrence of PTO. These factors should warn clinicians of a higher failure rate following treatment of PTO. Trial registration: ISRCTN71648577. Registered 18 May 2017. Retrospectively registered.

Design, Synthesis, and Antimicrobial Evaluation of a Novel Bone-Targeting Bisphosphonate-Ciprofloxacin Conjugate for the Treatment of Osteomyelitis Biofilms

Osteomyelitis is a major problem worldwide and is devastating due to the potential for limb-threatening sequelae and mortality. Osteomyelitis pathogens are bone-attached biofilms, making antibiotic delivery challenging. Here we describe a novel osteoadsorptive bisphosphonate-ciprofloxacin conjugate (BV600022), utilizing a "target and release" chemical strategy, which demonstrated a significantly enhanced therapeutic index versus ciprofloxacin for the treatment of osteomyelitis in vivo. In vitro antimicrobial susceptibility testing of the conjugate against common osteomyelitis pathogens revealed an effective bactericidal profile and sustained release of the parent antibiotic over time. Efficacy and safety were demonstrated in an animal model of periprosthetic osteomyelitis, where a single dose of 10 mg/kg (15.6 μmol/kg) conjugate reduced the bacterial load by 99% and demonstrated nearly an order of magnitude greater activity than the parent antibiotic ciprofloxacin (30 mg/kg, 90.6 μmol/kg) given in multiple doses. Conjugates incorporating a bisphosphonate and an antibiotic for bone-targeted delivery to treat osteomyelitis biofilm pathogens constitute a promising approach to providing high bone-antimicrobial potency while minimizing systemic exposure.