Does Bone Morphogenetic Protein Use Reduce Pseudarthrosis Rates in Single-Level Transforaminal Lumbar Interbody Fusion Surgeries?

BACKGROUND

Recombinant human bone morphogenetic protein 2 (rhBMP-2, or BMP for short) is a popular biological product used in spine surgeries to promote fusion and avoid the morbidity associated with iliac crest autograft. BMP's effect on pseudarthrosis in transforaminal lumbar interbody fusion (TLIF) remains unknown.

OBJECTIVE

To assess the rates of pseudarthrosis in single-level TLIF with and without concurrent use of BMP.

METHODS

This was a retrospective cohort study conducted at a single academic institution. Adults undergoing primary single-level TLIF with a minimum of 1 year of clinical and radiographic follow-up were included. BMP use was determined by operative notes at index surgery. Non-BMP cases with iliac crest bone graft were excluded. Pseudarthrosis was determined using radiographic and clinical evaluation. Bivariate differences between groups were assessed by independent t test and χ 2 analyses, and perioperative characteristics were analyzed by multiple logistic regression.

RESULTS

One hundred forty-eight single-level TLIF patients were included. The mean age was 59.3 years, and 52.0% were women. There were no demographic differences between patients who received BMP and those who did not. Pseudarthrosis rates in patients treated with BMP were 6.2% vs 7.5% in the no BMP group (P = 0.756). There was no difference in reoperation for pseudarthrosis between patients who received BMP (3.7%) vs those who did not receive BMP (7.5%, P = 0.314). Patients who underwent revision surgery for pseudarthrosis more commonly had diabetes with end-organ damage (revised 37.5% vs not revised 1.4%, P < 0.001). Multiple logistic regression analysis demonstrated no reduction in reoperation for pseudarthrosis related to BMP use (OR 0.2, 95% CI 0.1-3.7, P = 0.269). Diabetes with end-organ damage (OR 112.6,95% CI 5.7-2225.8, P = 0.002) increased the risk of reoperation for pseudarthrosis.

CONCLUSIONS

BMP use did not reduce the rate of pseudarthrosis or the number of reoperations for pseudarthrosis in single-level TLIFs. Diabetes with end-organ damage was a significant risk factor for pseudarthrosis.

CLINICAL RELEVANCE

BMP is frequently used "off-label" in transforaminal lumbar interbody fusion; however, little data exists to demonstrate its safety and efficacy in this procedure.

LEVEL OF EVIDENCE: 3

Should Global Realignment Be Tailored to Frailty Status for Patients Undergoing Surgical Intervention for Adult Spinal Deformity?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes.

SUMMARY OF BACKGROUND DATA

The Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications.

MATERIALS AND METHODS

We included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score.

RESULTS

Baseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation.

CONCLUSION

This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity.

LEVEL OF EVIDENCE

III.

Long-term Morbidity in Patients Following Surgical Correction of Adult Spinal Deformity: Results from a Cohort with Minimum 5 Year Follow-up

STUDY DESIGN

Retrospective.

OBJECTIVE

To describe the rate of post-operative morbidity before and after 2-year follow-up for patients undergoing surgical correction of adult spinal deformity.

SUMMARY OF BACKGROUND DATA

Advances in modern surgical techniques for deformity surgery have shown promising short-term clinical results. However, the permanence of radiographic correction, mechanical complications, and revision surgery in adult spinal deformity (ASD) surgery remains a clinical challenge. Little information exists on the incidence of long-term morbidity beyond the acute post-operative window.

METHODS

ASD patients with complete baseline (BL) and 5-year (5Y) health related quality of life (HRQL) and radiographic data were included. Rates of adverse events, including proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and reoperations up to 5Y were documented. Primary and revision surgeries were compared. We used logistic regression analysis to adjust for demographic and surgical confounders.

RESULTS

Of 118 patients eligible for 5Y follow up, 99(83.9%) had complete follow-up data. The majority were female (83%), mean age 54.1 yrs and 10.4 levels fused and 14 undergoing 3-CO. 33 patients had a prior fusion and 66 were primary cases. By 5Y postop the cohort had a adverse event rate of 70.7% with 25(25.3%) sustaining a major complication and 26(26.3%) receiving reoperation. 38 (38.4%) developed PJK by 5Y and 3 (4.0%) developed PJF. The cohort had a significantly higher rate of complications (63.6% vs. 19.2%), PJK (34.3% vs. 4.0%), and reoperations (21.2% vs. 5.1%) before 2Y, all P<0.01. The most common complications beyond 2Y were mechanical complications.

CONCLUSIONS

While incidence of adverse events was high before two years, there was a substantial reduction in longer follow-up indicating complications after two years are less common. Complications beyond two years consisted mostly of mechanical issues.

The Effect of Inpatient Step Count on Complications in the Elderly Patient After Adult Spinal Deformity Surgery

BACKGROUND

The number of elderly patients undergoing adult spinal deformity (ASD) surgery has increased with the advent of new techniques and more nuanced understanding of global malalignment as patients age. The relationship between inpatient physical activity after ASD surgery and postoperative complications in elderly patients has not been reported; thus, we sought to investigate this relationship.

METHODS

We performed a medical record review of 185 ASD patients older than 65 years (age: 71.5 ± 4.7; body mass index: 30.0 ± 6.1, American Society of Anesthesiologists: 2.7 ± 0.5, and levels fused: 10.5 ± 3.4). We derived the number of feet walked over the first 3 days after surgery from physical therapy documentation and evaluated for association with 90-day perioperative complications. Patients who sustained an incidental durotomy were excluded from the study.

RESULTS

The 185 patients were divided into groups based on whether they were among the 50th percentile for number of feet walked (62 ft). Walking less than 62 ft after ASD surgery was associated with higher incidence of postoperative complications (54.3%, P = 0.05), cardiac complications (34.8%, P = 0.03), pulmonary complications (21.7%, P = 0.01), and ileus (15.2%, P = 0.03). Patients who developed any postoperative complication (106 ± 172 vs 211 ± 279 ft, P = 0.001), ileus (26 ± 49 vs 174 ± 248 ft, P = 0.001), deep venous thrombosis (23 ± 30 vs 171 ± 247 ft, P = 0.001), and cardiac complications (58 ± 94 vs 192 ± 261 ft) walked less than patients who did not.

CONCLUSION

Elderly patients who walked less than 62 ft in the first 3 days after ASD surgery have a higher rate of postoperative complications, specifically pulmonary and ileus compared with those patients who walked more. Steps walked after ASD surgery may be a helpful and practical addition to the surgeon's armamentarium for monitoring the recovery of their patients.

CLINICAL RELEVENCE

Monitoring the steps walked by patients after ASD surgery can be a practical and useful tool for surgeons to track and improve their patients' recovery.

LEVEL OF EVIDENCE: 3

External Validation of the National Surgical Quality Improvement Program Calculator Utilizing a Single Institutional Experience for Adult Spinal Deformity Corrective Surgery

BACKGROUND

Identify the external applicability of the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) risk calculator in the setting of adult spinal deformity (ASD) and subsets of patients based on deformity and frailty status.

METHODS

ASD patients were isolated in our single-center database and analyzed for the shared predictive variables displayed in the NSQIP calculator. Patients were stratified by frailty (not frail <0.03, frail 0.3-0.5, severely frail >0.5), deformity [T1 pelvic angle (TPA) > 30, pelvic incidence minus lumbar lordosis (PI-LL) > 20], and reoperation status. Brier scores were calculated for each variable to validate the calculator's predictability in a single center's database (Quality). External validity of the calculator in our ASD patients was assessed via Hosmer-Lemeshow test, which identified whether the differences between observed and expected proportions are significant.

RESULTS

A total of 1606 ASD patients were isolated from the Quality database (48.7 years, 63.8% women, 25.8 kg/m²); 33.4% received decompressions, and 100% received a fusion. For each subset of ASD patients, the calculator predicted lower outcome rates than what was identified in the Quality database. The calculator showed poor predictability for frail, deformed, and reoperation patients for the category "any complication" because they had Brier scores closer to 1. External validity of the calculator in each stratified patient group identified that the calculator was not valid, displaying P values >0.05.

CONCLUSION

The NSQIP calculator was not a valid calculator in our single institutional database. It is unable to comment on surgical complications such as return to operating room, surgical site infection, urinary tract infection, and cardiac complications that are typically associated with poor patient outcomes. Physicians should not base their surgical plan solely on the NSQIP calculator but should consider multiple preoperative risk assessment tools.

LEVEL OF EVIDENCE: 3

An emerging Panton-Valentine leukocidin-positive CC5-meticillin-resistant Staphylococcus aureus-IVc clone recovered from hospital and community settings over a 17-year period from 12 countries investigated by whole-genome sequencing

BACKGROUND

A novel Panton-Valentine leukocidin (PVL)-positive meticillin-resistant Staphylococcus aureus (MRSA) clonal complex (CC)5-MRSA-IVc ('Sri Lankan' clone) was recently described from Sri Lanka. Similar isolates caused a recent Irish hospital outbreak.

AIM

To investigate the international dissemination and diversity of PVL-positive CC5-MRSA-IVc isolates from hospital and community settings using whole-genome sequencing (WGS).

METHODS

Core-genome single nucleotide polymorphism (cgSNP) analysis, core-genome multi-locus sequence typing (cgMLST) and microarray-based detection of antimicrobial-resistance and virulence genes were used to investigate PVL-positive CC5-MRSA-IVc (N = 214 including 46 'Sri Lankan' clone) from hospital and community settings in 12 countries over 17 years. Comparators included 29 PVL-positive and 23 PVL-negative CC5/ST5-MRSA-I/II/IVa/IVc/IVg/V.

RESULTS

Maximum-likelihood cgSNP analysis grouped 209/214 (97.7%) CC5-MRSA-IVc into Clade I; average of 110 cgSNPs between isolates. Clade III contained the five remaining CC5-MRSA-IVc; average of 92 cgSNPs between isolates. Clade II contained seven PVL-positive CC5-MRSA-IVa comparators, whereas the remaining 45 comparators formed an outlier group. Minimum-spanning cgMLST analysis revealed a comparably low average of 57 allelic differences between all CC5/ST5-MRSA-IVc. All 214 CC5/ST5-MRSA-IVc were identified as 'Sri Lankan' clone, predominantly spa type t002 (186/214) with low population diversity and harboured a similar range of virulence genes and variable antimicrobial-resistance genes. All 214 Sri Lankan clone isolates and Clade II comparators harboured a 9616-bp chromosomal PVL-encoding phage remnant, suggesting both arose from a PVL-positive meticillin-susceptible ancestor. Over half of Sri Lankan clone isolates were from infections (142/214), and where detailed metadata were available (168/214), most were community associated (85/168).

CONCLUSIONS

Stable chromosomal retention of pvl may facilitate Sri-Lankan clone dissemination.

The psychological burden of disease among patients undergoing cervical spine surgery: Are we underestimating our patients' inherent disability?

BACKGROUND

Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations.

RESEARCH QUESTION

Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease?

MATERIALS AND METHODS

Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses.

RESULTS

47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m²). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001).

DISCUSSION AND CONCLUSION

Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated.

LEVEL OF EVIDENCE

Level III.

216 IMPROVING INPATIENT INFLUENZA VACCINATION RATES—THE VALUE OF AN ELECTRONIC PATIENT RECORD REMINDER SYSTEM

Background

Influenza vaccination, particularly for vulnerable, older adults, will have added importance this winter given the possibility of further waves of COVID-19 pandemic. Previous interventions at the study site noted poor awareness on the need for inpatient Influenza vaccination¹. This study examines a vaccination reminder process using an electronic patient record (EPR) to identify high-priority eligible inpatients.

Methods

The study site is a 900-bed university teaching hospital with all clinical notes accessed via an EPR.

We included a convenience sample of 750 adults aged≥50 years (mean age 75.9 +/− 0.4 years, 48% female) and high-priority for influenza vaccination (Age > 65 years and/or length of stay (LOS) >30 days) from October 1^st 2020 to January 12^th 2021.

A live electronic dashboard identified eligible inpatients for vaccination, prompting vaccination reminders to the clinical teams via the antimicrobial pharmacist.

Data was collected retrospectively. Logistic regression models reporting odds ratios were used to assess the association of these reminders with vaccine uptake.

Results

Over one third (35%, 264/750) of high-priority patients received the Influenza vaccine while inpatients, including 40% aged ≥80 years.

The reminder was sent on 41% (305/750) of patients and was associated with an almost 50% higher likelihood of vaccination after adjusting for other covariates (Odds Ratio 1.48 (95% CI 1.00–2.20); p = 0.048).

Other factors independently associated with vaccination were advancing age (Odds Ratio 2.69 (95% CI 1.12–6.47) for age ≥ 80 years); LOS (4% higher likelihood of vaccination for every additional day in hospital) and admission under geriatric medicine (Odds Ratio 3.71 (95% CI 2.45–5.62) when compared to other specialities).

Conclusion

Our study shows relatively low uptake of inpatient Influenza vaccination and strategies to improve uptake are required. Reminders sent to clinical teams using the EPR appear to be an effective means of increasing Influenza vaccination and should be considered as part of this year’s inpatient vaccination drive.

Not Frail and Elderly: How Invasive Can We Go in This Different Type of Adult Spinal Deformity Patient?

STUDY DESIGN

Retrospective review of a single-center spine database.

OBJECTIVE

Investigate the intersections of chronological age and physiological age via frailty to determine the influence of surgical invasiveness on patient outcomes.

SUMMARY OF BACKGROUND DATA

Frailty is a well-established factor in preoperative risk stratification and prediction of postoperative outcomes. The surgical profile of operative patients with adult spinal deformity (ASD) who present as elderly and not frail (NF) has yet to be investigated. Our aim was to examine the surgical profile and outcomes of patients with ASD who were NF and elderly.

METHODS

Patients with ASD 18 years or older, four or greater levels fused, with baseline (BL) and follow-up data were included. Patients were categorized by ASD frailty index: NF, Frail (F), severely frail (SF]. An elderly patient was defined as 70 years or older. Patients were grouped into NF/elderly and F/elderly. SRS-Schwab modifiers were assessed at BL and 1 year (0, +, ++). Logistic regression analysis assessed the relationship between increasing invasiveness, no reoperations, or major complications, and improvement in SRS-Schwab modifiers [Good Outcome]. Decision tree analysis assessed thresholds for an invasiveness risk/benefit cutoff point.

RESULTS

A total of 598 patients with ASD included (55.3 yr, 59.7% F, 28.3 kg/m2). 29.8% of patients were older than 70 years. At BL, 51.3% of patients were NF, 37.5% F, and 11.2% SF. Sixty-sis (11%) patients were NF and elderly. About 24.2% of NF-elderly patients improved in SRS-Schwab by 1 year and had no reoperation or complication postoperatively. Binary regression analysis found a relationship between worsening SRS-Schwab, postop complication, and reoperation with invasiveness score (odds ratio: 1.056 [1.01-1.102], P = 0.011). Risk/benefit cut-off was 10 (P = 0.004). Patients below this threshold were 7.9 (2.2-28.4) times more likely to have a Good Outcome. 156 patients were elderly and F/SF with 16.7% having good outcome, with a risk/benefit cut-off point of less than 8 (4.4 [2.2-9.0], P < 0.001).

CONCLUSION

Frailty status impacted the balance of surgical invasiveness relative to operative risk in an inverse manner, whereas the opposite was seen amongst elderly patients with a frailty status less than their chronologic age. Surgeons should perhaps consider incorporation of frailty status over age status when determining realignment plans in patients of advanced age.Level of Evidence: 3.

Patient Outcomes After Single-level Coflex Interspinous Implants Versus Single-level Laminectomy

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

The aim of this study was to compare postoperative outcomes of Coflex interspinous device versus laminectomy.

SUMMARY OF BACKGROUND DATA

Coflex Interlaminar Stabilization device (CID) is indicated for one- or two-level lumbar stenosis with grade 1 stable spondylolisthesis in adult patients, as an alternative to laminectomy, or laminectomy and fusion. CID provides stability against progressive spondylolisthesis, retains motion, and prevents further disc space collapse.

METHODS

Patients ≥18 years' old with lumbar stenosis and grade 1 stable spondylolisthesis who underwent either primary single-level decompression and implantation of CID, or single-level laminectomy alone were included with a minimum 90-day follow-up at a single academic institution. Clinical characteristics, perioperative outcomes, and postoperative complications were reviewed until the latest follow-up. χ2 and independent samples t tests were used for analysis.

RESULTS

Eighty-three patients (2007-2019) were included: 37 cases of single-level laminectomy (48.6% female) were compared to 46 single-level CID (50% female). CID cohort was older (CID 69.0 ± 9.4 vs. laminectomy 64.2 ± 11.0, P = 0.042) and had higher American Society of Anesthesiologists (ASA) grade (CID 2.59 ± 0.73 vs. laminectomy 2.17 ± 0.48, P = 0.020). CID patients had higher estimated blood loss (EBL) (97.50 ± 77.76 vs. 52.84 ± 50.63 mL, P = 0.004), longer operative time (141.91 ± 47.88 vs. 106.81 ± 41.30 minutes, P = 0.001), and longer length of stay (2.0 ± 1.5 vs. 1.1 ± 1.0 days, P = 0.001). Total perioperative complications (21.7% vs. 5.4%, P = 0.035) and instrumentation-related complication was higher in CID (10.9% vs. 0% laminectomy group, P = 0.039). There were no other significant differences between the groups in demographics or outcomes.

CONCLUSION

Single-level CID devices had higher perioperative 90-day complications, longer operative time, length of stay, higher EBL compared to laminectomies alone. Similar overall revision and neurologic complication rates were noted compared to laminectomy at last follow-up.Level of Evidence: 3.

Increased cautiousness in adolescent idiopathic scoliosis patients concordant with syringomyelia fails to improve overall patient outcomes

Background:

Adolescent idiopathic scoliosis (AIS) is a common cause of spinal deformity in adolescents. AIS can be associated with certain intraspinal anomalies such as syringomyelia (SM). This study assessed the rate o f SM in AIS patients and compared trends in surgical approach and postoperative outcomes in AIS patients with and without SM.

Methods:

The database was queried using ICD-9 codes for AIS patients from 2003–2012 (737.1–3, 737.39, 737.8, 737.85, and 756.1) and SM (336.0). The patients were separated into two groups: AIS-SM and AIS-N. Groups were compared using t-tests and Chi-squared tests for categorical and discrete variables, respectively.

Results:

Totally 77,183 AIS patients were included in the study (15.2 years, 64% F): 821 (1.2%) – AIS-SM (13.7 years, 58% F) and 76,362 – AIS-N (15.2 years, 64% F). The incidence of SM increased from 2003–2012 (0.9 to 1.2%, P = 0.036). AIS-SM had higher comorbidity rates (79 vs. 56%, P < 0.001). Comorbidities were assessed between AIS-SM and AIS-N, demonstrating significantly more neurological and pulmonary in AIS-SM patients. 41.2% of the patients were operative, 48% of AIS-SM, compared to 41.6% AIS-N. AIS-SM had fewer surgeries with fusion (anterior or posterior) and interbody device placement. AIS-SM patients had lower invasiveness scores (2.72 vs. 3.02, P = 0.049) and less LOS (5.0 vs. 6.1 days, P = 0.001). AIS-SM patients underwent more routine discharges (92.7 vs. 90.9%). AIS-SM had more nervous system complications, including hemiplegia and paraplegia, brain compression, hydrocephalous and cerebrovascular complications, all P < 0.001. After controlling for respiratory, renal, cardiovascular, and musculoskeletal comorbidities, invasiveness score remained lower for AIS-SM patients (P < 0.001).

Conclusions:

These results indicate that patients concordant with AIS and SM may be treated more cautiously (lower invasiveness score and less fusions) than those without SM.

Sports-related Cervical Spine Fracture and Spinal Cord Injury: A Review of Nationwide Pediatric Trends

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Assess trends in sports-related cervical spine trauma using a pediatric inpatient database.

SUMMARY OF BACKGROUND DATA

Injuries sustained from sports participation may include cervical spine trauma such as fractures and spinal cord injury (SCI). Large database studies analyzing sports-related cervical trauma in the pediatric population are currently lacking.

METHODS

The Kid Inpatient Database was queried for patients with external causes of injury secondary to sports-related activities from 2003 to 2012. Patients were further grouped for cervical spine injury (CSI) type, including C1-4 and C5-7 fracture with/without spinal cord injury (SCI), dislocation, and SCI without radiographic abnormality (SCIWORA). Patients were grouped by age into children (4-9), pre-adolescents (Pre, 10-13), and adolescents (14-17). Kruskall-Wallis tests with post-hoc Mann-Whitney U's identified differences in CSI type across age groups and sport type. Logistic regression found predictors of TBI and specific cervical injuries.

RESULTS

A total of 38,539 patients were identified (12.76 years, 24.5% F). Adolescents had the highest rate of sports injuries per year (P < 0.001). Adolescents had the highest rate of any type of CSI, including C1-4 and C5-7 fracture with and without SCI, dislocation, and SCIWORA (all P < 0.001). Adolescence increased odds for C1-4 fracture w/o SCI 3.18×, C1-4 fx w/ SCI by 7.57×, C5-7 fx w/o SCI 4.11×, C5-7 w/SCI 3.63×, cervical dislocation 1.7×, and cervical SCIWORA 2.75×, all P < 0.05. Football injuries rose from 5.83% in 2009 to 9.14% in 2012 (P < 0.001), and were associated with more SCIWORA (1.6% vs. 1.0%, P = 0.012), and football injuries increased odds of SCI by 1.56×. Concurrent TBI was highest in adolescents at 58.4% (pre: 26.6%, child: 4.9%, P < 0.001), and SCIWORA was a significant predictor for concurrent TBI across all sports (odds ratio: 2.35 [1.77-3.11], P < 0.001).

CONCLUSION

Adolescent athletes had the highest rates of upper/lower cervical fracture, dislocation, and SCIWORA. Adolescence and SCIWORA were significant predictors of concurrent TBI across sports. The increased prevalence of CSI with age sheds light on the growing concern for youth sports played at a competitive level, and supports recently updated regulations aimed at decreasing youth athletic injuries.

LEVEL OF EVIDENCE

3.

Multiple distinct outbreaks of Panton-Valentine leucocidin-positive community-associated meticillin-resistant Staphylococcus aureus in Ireland investigated by whole-genome sequencing

BACKGROUND

Panton-Valentine leucocidin (PVL)-positive community-associated meticillin-resistant Staphylococcus aureus (CA-MRSA) is increasingly associated with infection outbreaks.

AIM

To investigate multiple suspected PVL-positive CA-MRSA outbreaks using whole-genome sequencing (WGS).

METHODS

Forty-six suspected outbreak-associated isolates from 36 individuals at three separate Irish hospitals (H1-H3) and from separate incidents involving separate families associated with H2 were investigated by whole-genome multi-locus sequence typing (wgMLST).

FINDINGS

Two clusters (CH1 and CH2) consisting of 8/10 and 6/6 PVL-positive t008 ST8-MRSA-IVa isolates from H1 and H2, respectively, were identified. Within each cluster, neighbouring isolates were separated by ≤5 allelic differences; however, ≥73 allelic differences were identified between the clusters, indicating two independent outbreaks. Isolates from the H3 maternity unit formed two clusters (CH3-SCI and CH3-SCII) composed of four PVL-negative t4667 ST5-MRSA-V and 14 PVL-positive t002 ST5-MRSA-IVc isolates, respectively. Within clusters, neighbouring isolates were separated by ≤24 allelic differences, whereas both clusters were separated by 1822 allelic differences, indicating two distinct H3 outbreaks. Eight PVL-positive t127 ST1-MRSA-V+fus and three PVL-negative t267 ST97-MRSA-V+fus isolates from two distinct H2-associated families FC1 (N = 4) and FC2 (N = 7) formed three separate clusters (FC1 (t127), FC2 (t127) and FC2 (t267)). Neighbouring isolates within clusters were closely related and exhibited ≤7 allelic differences. Intrafamilial transmission was apparent, but the detection of ≥48 allelic differences between clusters indicated no interfamilial transmission.

CONCLUSION

The frequent importation of PVL-positive CA-MRSA into healthcare settings, transmission and association with outbreaks is a serious ongoing concern. WGS is a highly discriminatory, informative method for deciphering such outbreaks conclusively.

Hospital outbreak of linezolid-resistant and vancomycin-resistant ST80 Enterococcus faecium harbouring an optrA-encoding conjugative plasmid investigated by whole-genome sequencing

BACKGROUND

Linezolid is an antibiotic used to treat infections caused by multi-drug-resistant Gram-positive bacteria. Linezolid resistance in enterococci has been reported with increasing frequency, with a recent rise in resistance encoded by optrA, poxtA or cfr.

AIM

To investigate a hospital outbreak of linezolid- and vancomycin-resistant Enterococcus faecium (LVREfm) using whole-genome sequencing (WGS).

METHODS

Thirty-nine VREfm from patient screening (19 isolates, 17 patients) and environmental sites (20 isolates) recovered in October 2019 were investigated. Isolates were screened using polymerase chain reaction for optrA, poxtA and cfr, and underwent Illumina MiSeq WGS. Isolate relatedness was assessed using E. faecium core genome multi-locus sequence typing (cgMLST). One LVREfm underwent MinION long-read WGS (Oxford Nanopore Technologies) and hybrid assembly with MiSeq short-read sequences to resolve an optrA-encoding plasmid.

FINDINGS

Twenty isolates (51.3%) were LVREfm and optrA-positive, including the LVREfm from the index patient. A closely related cluster of 28 sequence type (ST) 80 isolates was identified by cgMLST, including all 20 LVREfm and eight linezolid-susceptible VREfm, with an average allelic difference of two (range 0-10), indicating an outbreak. Nineteen (95%) LVREfm harboured a 56,684-bp conjugative plasmid (pEfmO_03). The remaining LVREfm exhibited 44.1% sequence coverage to pEfmO_03. The presence of pEfmO_03 in LVREfm and the close relatedness of the outbreak cluster isolates indicated the spread of a single strain. The outbreak was terminated by enhanced infection prevention and control (IPC) and environmental cleaning measures, ceasing ward admissions and ward-dedicated staff.

CONCLUSION

WGS was central in investigating an outbreak of ST80 LVREfm. The rapid implementation of enhanced IPC measures terminated the outbreak.

Prognostic Value Of Blood Cultures as an Illness Severity Marker In Emergency Medical Admissions

BACKGROUND

Positive blood cultures predict mortality. The prognostic value of blood culture performance itself has not been fully defined.

METHODS

We evaluated medical admissions from 2002-2017. We defined blood culture category as 1) no culture 2) negative culture 3) positive culture. We employed a multivariable logistic regression model to evaluate outcomes.

RESULTS

We evaluated 78,568 blood cultures in 106,586 admissions. 30-day in-hospital mortality for no culture was 2.8% (95%CI 2.7, 2.9), culture negative 8.9% (95%CI 8.5, 9.3) and culture positive 16.7% (95%CI 15.5, 17.9). There was significant interaction between blood culture category and illness severity, OR 1.06 (95%CI 1.05, 1.08), and comorbidity, OR 1.09 (95%CI 1.09, 1.10).

CONCLUSION

Performance and results of blood cultures are independently associated with increased mortality.

PROMIS physical health domain scores are related to cervical deformity severity

Introduction

The aim of this study was to evaluate the association of available cervical alignment components through the Ames cervical deformity (CD) classification parameters with the Patient-Reported Outcomes Measurement Information System (PROMIS) physical health domain metrics.

Methods

Surgical CD patients (C2-C7 Cobb >10° or C2-C7 sagittal vertical axis [cSVA] >4 cm or T1 slope minus cervical lordosis (TS-CL) >15°) ≥18 years with available baseline (BL) radiographic and PROMIS were isolated in a single-center spine database. Patients were classified according to the Ames CD modifiers for cSVA and TS-CL (low deformity [Low], moderate deformity [Mod], and severe deformity [Sev]). Descriptives and univariate analyses compared population-weighted PROMIS scores for Pain Intensity (PI), Physical Function (PF), and Pain Interference (Int) across CD modifiers. Conditional tree analysis with logistic regression sampling determined the threshold of PROMIS scores for which the correlation with Ames radiographic cutoffs was most significant. Reported cutoff values for Mod (cSVA: 4-8 cm; TS-CL: 15-20°) and Sev (cSVA: >8 cm; TS-CL: >20°) disabilities were used.

Results

Two hundred and eight patients (58.8 years, female: 51%, 29.6 kg/m², Charlson Comorbidity Index: 1.19). BL cSVA modifier by severity: 83.2% Low, 16.8% Mod. No patients met criteria for severe cSVA. BL TS-CL modifier by severity: 18.8% Low, 22.1% Mod, 59.1% Sev. Mean baseline PROMIS scores were as follows: PI score: 89.6 ± 15.4, PF score: 11.9 ± 13.1, Int score: 56.9 ± 6.8. PI did not differ between cSVA and TS-CL severity. Mod cSVA patients and Mod/Sev TS-CL modifier groups trended toward lower PF scores and higher Int scores. A PI score of >96 (odds ratio [OR]: 0.658 [0.303-1.430]), a PF score of <14 (OR: 1.864 [0.767-4.531]), and an Int score of > 57.4 (OR: 1.878 [0.889-3.967]) were predictors of Mod cSVA. A PI score of >87 (OR: 1.428 [0.767-2.659]), a PF score of <14 (OR: 1.551 [0.851-2.827]), and an Int score of >56.5 (OR: 1.689 [0.967-2.949]) were predictors of Sev TS-CL.

Conclusions

PROMIS physical health domains were related to the Ames CD classification. Certain BL PROMIS thresholds can be connected to the severity of CD.

Infective endocarditis: a retrospective cohort study

BACKGROUND

Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high.

AIM

To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre.

DESIGN

Retrospective cohort study.

METHODS

Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries.

RESULTS

Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications.

CONCLUSIONS

This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

An assessment of professionalism on students' Facebook profiles

INTRODUCTION

With the advent of social media, healthcare professionals not only need to be conscious of professionalism in their face-to-face interactions but also in the electronic environment. The aim of this study was to assess the level of online professionalism on Facebook profiles available for public viewing of students from a dental school.

MATERIALS AND METHODS

A search was performed via a new Facebook account of all students in the University Dental School (dental hygiene, dental nursing, dental science and dental technology). Profiles were categorised as 'private' or 'public'. Demographic details and photographs/comments of unprofessional behaviour were recorded for each individual Facebook profile. Each profile was subsequently scored with regard to professionalism based on a previously published score.

RESULTS

There are a total of 287 students in the dental school. Of these, 62% (n = 177) had a Facebook account. Three per cent (n = 6) had a public account (fully accessible) whilst 97% (n = 171) had a private account (limited access); 36% (n = 63) of students mentioned the dental school/hospital on their profile; 34% (n = 60) had questionable content on their profile whilst 3% (n = 6) had definite violations of professionalism on their profile; and 25% (n = 44) had unprofessional photographs on their profile. Of those with unprofessional content, 52% (n = 23) of these had a documented affiliation with the dental school also visible on their profile.

CONCLUSION

There was a concerning level of unprofessional content visible on students' Facebook profiles. Students need to be fully aware of their professional responsibility in the setting of social media.

Microplastics in Sewage Sludge: Effects of Treatment

Waste water treatment plants (WWTPs) are receptors for the cumulative loading of microplastics (MPs) derived from industry, landfill, domestic wastewater and stormwater. The partitioning of MPs through the settlement processes of wastewater treatment results in the majority becoming entrained in the sewage sludge. This study characterized MPs in sludge samples from seven WWTPs in Ireland which use anaerobic digestion (AD), thermal drying (TD), or lime stabilization (LS) treatment processes. Abundances ranged from 4196 to 15 385 particles kg^-1 (dry weight). Results of a general linear mixed model (GLMM) showed significantly higher abundances of MPs in smaller size classes in the LS samples, suggesting that the treatment process of LS shears MP particles. In contrast, lower abundances of MPs found in the AD samples suggests that this process may reduce MP abundances. Surface morphologies examined using scanning electron microscopy (SEM) showed characteristics of melting and blistering of TD MPs and shredding and flaking of LS MPs. This study highlights the potential for sewage sludge treatment processes to affect the risk of MP pollution prior to land spreading and may have implications for legislation governing the application of biosolids to agricultural land.

Ongoing challenges responding to behavioural and psychological symptoms of dementia

BACKGROUND

Mid- to late-stage dementia is often characterized by behavioural and psychological symptoms, including, but not limited to physical and verbal aggression.

INTRODUCTION

Although there is a considerable research about the prevalence, aetiology, and management of behavioural and psychological symptoms of dementia, there is limited research about the experience of caring for people with such symptoms in long-term aged care facilities.

AIM

The aims of the study were to describe: (i) nurses' experiences of caring for people with behavioural and psychological symptoms of dementia in long-term aged care facilities, and (ii) strategies nurses used to deal with these symptoms.

METHODS

A qualitative exploratory and descriptive design, involving focus group interviews with 30 nurses from three long-term aged care units in Australia. The transcripts were analysed using inductive content analysis.

RESULTS

The findings revealed five interrelated themes: (i) working under difficult conditions, (ii) behavioural and psychological symptoms of dementia: an everyday encounter, (iii) making sense of behavioural and psychological symptoms of dementia, (iv) attempting to manage behavioural and psychological symptoms of dementia, and (v) feeling undervalued.

CONCLUSION

This study highlighted the difficult conditions under which nurses worked and the complexity of caring for individuals who have behavioural and psychological symptoms of dementia.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Organizational efforts to enhance the quality of care for individuals with behavioural and psychological symptoms of dementia in long-term aged care facilities should extend beyond staff education to heed nurses' concerns about organizational barriers to interpersonal care.

Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder

Borderline personality disorder (BPD) is a complex disorder that is difficult to treat. However, dialectical behaviour therapy (DBT), developed by Dr. Marsha Linehan in the early 1990s, has emerged as a promising treatment option for those diagnosed with BPD. DBT is a multi-pronged treatment approach delivered normally in outpatient settings over 12 months and requires highly skilled and trained therapists. Many trials have provided evidence to support the use of DBT in the treatment of BPD. However, outcome measures vary and are mostly limited to measurable behavioural outcomes such as incidences of deliberate self-harm or suicidal thoughts. Two recent Cochrane reviews conclude that DBT does benefit those with BPD, but more robust evidence is needed. DBT training for health care professionals also has the potential to shift health care professionals' attitudes from one of therapeutic pessimism to one of optimism.

Infection of the Beard area. Kerion: a review of 2 cases

Folliculitis barbae is a common condition of both infective and non-infectious aetiology. It most frequently presents as a superficial folliculitis, with fine pustules appearing at the opening of hair follicles in the beard area, often associated with shaving; known as Bockhart impetigo and usually due to infection caused by Staphylococcus aureus. If untreated, the infection and inflammation can progress, leading to a more deeply seated infection known as sycosis barbae. Perifollicular nodules, termed furuncles, may appear and when these are multiple and coalesce, a deep-seated, communicating, pustulating plaque called a carbuncle develops, often with associated systemic upset. Such an appearance, which can prompt incision and drainage, should not, however, be assumed to be solely due to staphylococcal infection. Particularly in the context of a history of close animal contact or a lack of response to antibiotic treatment, a diagnosis of tinea barbae should be considered and investigated. Prompt treatment with antifungal agents and often systemic steroids is required once the diagnosis is made. This will help reduce an exacerbation of the pronounced destruction that results from the immune response to the fungal infection, known as a kerion, which would be compounded by surgical intervention. In this article, we review two such cases and review the investigation and management of the disease.

Vitamin D3 correlates inversely with systemic dendritic cell numbers and bone erosion in chronic rhinosinusitis with nasal polyps and allergic fungal rhinosinusitis

Vitamin D(3) (VD(3) ) is a steroid hormone that regulates bone health and numerous aspects of immune function and may play a role in respiratory health. We hypothesized that T helper type 2 (Th2) disorders, chronic rhinosinusitis with nasal polyps (CRSwNP) and allergic fungal rhinosinusitis (AFRS) would have VD(3) deficiencies, resulting in increased mature dendritic cells (DCs) and bone erosion. We conducted a retrospective study examining VD(3) levels in patients with AFRS (n = 14), CRSwNP (n = 9), chronic rhinosinusitis without nasal polyps (CRSsNP) (n = 20) and cerebrospinal fluid leak repair (non-diseased controls) (n = 14) at time of surgery. Circulating immune cell levels were determined by immunostaining and flow cytometric analysis. Plasma VD(3) and immune regulatory factors (granulocyte-macrophage colony-stimulating factor and prostaglandin E(2) ) were measured by enzyme-linked immunosorbent assay. It was observed that CRSwNP and AFRS demonstrated increased circulating DCs, while chronic rhinosinusitis without nasal polyps displayed increased circulating macrophages. CRSwNP and AFRS were to found to have insufficient levels of VD(3) which correlated inversely with circulating numbers of mature DCs, DC regulatory factors and bone erosion. CRSsNP displayed no change in circulating DC numbers or VD(3) status compared to control, but did display increased numbers of circulating macrophages that was independent of VD(3) status. Lastly, VD(3) deficiency was associated with more severe bone erosion. Taken together, these results suggest support a role for VD(3) as a key player in the immunopathology of CRSwNP and AFRS.

Evaluation of Nasopharyngeal Oxygen, Nasal Prongs and Facemask Oxygen Therapy Devices in Adult Patients: A Randomised Crossover Trial

Nasopharyngeal oxygen (NPO) therapy may overcome some of the difficulties associated with nasal prongs and facemask oxygen delivery devices. In response to a lack of published studies of NPO therapy in adults, we conducted a prospective randomised crossover trial to compare the effectiveness of NPO, nasal prongs (NP) and facemasks (FM) when used in an adult population (n=37) from the intensive care unit and general hospital wards. We measured oxygen saturation (SpO 2 using pulse oximetry, oxygen flow (litres per minute), respiration rate (per minute) and comfort using a horizontal visual analogue scale. All three devices were effective in maintaining a Sp0 2 of ≥95% (NP 97.0±1.9, NPO 97.7±1.7, FM 98.8±1.3%). NPO therapy consumed less oxygen than NP and FM therapy (NP 2.6±1.0, NPO 2.2±0.9, FM 6.1 ±0.4 l/min, P <0.001). There was no significant difference in patients’ respiratory rates (NP 19.9±3.2, NPO 19.9±3.0, FM 19.8±3.1 per minute, P=0.491). In terms of comfort, patients rated NP higher than NPO and FM using a horizontal visual analogue scale (100 mm=most comfortable) (NP 65.5±14.3, NPO 62.8±19.4, FM 49.4 ± 21.4 mm, P <0.001). We conclude that for adult patients, nasal prongs and nasopharyngeal oxygen therapy consume less oxygen and provide greater comfort than facemasks while still maintaining Sp0 2 ≥95%.

The EPISA study: antimicrobial susceptibility of Staphylococcus aureus causing primary or secondary skin and soft tissue infections in the community in France, the UK and Ireland

OBJECTIVES

To provide information on the susceptibility of Staphylococcus aureus causing skin and soft tissue infections (SSTIs) in France, Ireland and the UK.

PATIENTS AND METHODS

One thousand three hundred and ninety patients attending their general practitioners for skin infections were recruited. Susceptibility to 11 antimicrobials using CLSI (formerly NCCLS) broth microdilution was determined for 646 S. aureus isolates detected in the evaluable patient population.

RESULTS

Susceptibility results were similar in the UK and Ireland, but differed in France. The largest difference between countries was observed for erythromycin and fusidic acid. In France, 67.8% of isolates were susceptible to erythromycin when compared with 88.6% in Ireland and 92.8% in the UK. However, 93.7% of French isolates were susceptible to fusidic acid, compared with 68.6% in Ireland and 75.6% in the UK. A diagnosis of impetigo was associated with reduced fusidic acid susceptibility.

CONCLUSIONS

Differences in the prevalence of certain diagnoses, particularly impetigo, rather than differences in antibiotic consumption may explain some of the observed differences in susceptibility seen between these countries.

Evaluation of the IDI-MRSA assay on the SmartCycler real-time PCR platform for rapid detection of MRSA from screening specimens

Rapid accurate detection is a prerequisite for the successful control of meticillin-resistant Staphylococcus aureus (MRSA). The IDI-MRSA real-time polymerase chain reaction (PCR) assay was designed to provide rapid results from nasal specimens collected in Stuart's liquid transport medium. This study has evaluated the IDI-MRSA kit for use in a clinical laboratory by investigating the following parameters: (1) limits of detection (LoD), (2) performance with Amies' gel-based transport medium, (3) ability to detect strains of MRSA in a collection representative of MRSA in Ireland since 1974 (n=113) and (4) performance in a clinical trial with swabs from nose, throat and groin/perineum sites from 202 patients. LoDs (colony-forming units per ml) of the IDI-MRSA kit, direct culture on MRSA-Select chromogenic agar (CA) and salt-enrichment culture (with subculture onto CA) were 10(3), 10(3) and 10(2), respectively. LoDs with Stuart's and Amies' transport media were comparable. All except one of the 113 MRSA isolates were detected by the kit but, when six control strains carrying staphylococcal cassette chromosome mec (SCCmec) type IV element subtypes IVa-d and SCCmec types V and V(T) were tested, the kit failed to detect MRSA carrying SCCmec V. The sensitivity and specificity for detection of MRSA from nose, throat and groin/perineum specimens were comparable with slightly lower sensitivities from throat and groin/perineum specimens compared with nasal swabs (90%, 97%; 89%, 99%; 88%, 99%, respectively). Overall sensitivity, specificity and positive and negative predictive values for specimens from all sites were 88%, 99%, 94% and 97%, respectively. Further developments to improve the sensitivity of this highly worthwhile assay are required.

Aseptic meningitis: a 2-year review of diagnoses reached in a tertiary neurological and infectious disease centre

BACKGROUND

Aseptic meningitis is a frequent diagnostic problem, with little data available regarding its prevalence and the commonly identified causes.

AIMS

To identify the common diagnostic tests requested, and their subsequent yields in obtaining a diagnosis in adult cases of aseptic meningitis in a tertiary neurological and infectious disease centre.

METHODS

Cases of aseptic meningitis were retrospectively reviewed for a 2-year period.

RESULTS

Of the 43 cases reviewed, a diagnosis based on subsequent microbiological, histological and immunological testing was obtained in 17 (40%). Altered levels of consciousness, and higher CSF protein levels were significantly more common in those patients attaining a definite diagnosis.

CONCLUSION

The median duration of admission to hospital in the undiagnosed group was 12 days, which may be improved with increased accuracy and availability of diagnostic techniques such as polymerase chain reaction.

Meticillin-resistant Staphylococcus aureus blood-stream infection among patients attending the emergency department of an urban tertiary-referral hospital

Meticillin-resistant Staphylococcus aureus (MRSA) is an important nosocomial pathogen but reports of community-acquired (CA) MRSA are increasing. This study determined the incidence of MRSA-blood-stream infection (BSI) among patients attending the Emergency Department (ED) of an urban tertiary-referral hospital between January 2004 and September 2005, the proportion of cases that were CA or health-care associated (HCA), the epidemiological types of isolates and the presence of pvl genes in CA-MRSA. Eighteen patients presented with MRSA-BSI; 16 cases were categorised as HCA and two as CA. Most patients were male, elderly and lived locally. Two patients (aged <30 years) had no recent previous HC exposure. Only one patient received appropriate empiric antimicrobial therapy. Isolates from patients with HCA-MRSA were similar to the predominant MRSA strain in Irish hospitals. The two CA-MRSA isolates exhibited different epidemiological types; one was pvl-positive. A significant cohort of patients present to the ED with MRSA-BSI. Careful consideration of appropriate empiric antimicrobial therapy for suspected staphylococcal infection is required.

Epidemiological typing of MRSA isolates from blood cultures taken in Irish hospitals participating in the European Antimicrobial Resistance Surveillance System (1999-2003)

Between 1999 and 2003, meticillin-resistant Staphylococcus aureus (MRSA) isolates recovered from blood cultures in Irish hospitals that participate in the European Antimicrobial Resistance Surveillance System were investigated by epidemiological typing using antibiogram-resistogram (AR) typing, biotyping, and DNA macrorestriction digestion using SmaI followed by pulsed-field gel electrophoresis (PFGE). PFGE patterns were assigned five-digit pulsed-field type (PFT) numbers, and PFTs of apparently related patterns were abbreviated to two-digit PFT groups (PFGs). AR and PFGE typing results were combined to produce AR-PFG types. Representative isolates of each AR-PFG type recovered in 2002 were typed by multilocus sequence typing and staphylococcal cassette chromosome (SCC) mec analysis. Isolates from 1999 and 2000 were also typed by phage typing. The extent to which epidemiological types of MRSA from blood cultures could be extrapolated to the total MRSA population was investigated by comparing results obtained with isolates from the total MRSA population versus those obtained with blood cultures during three study periods. Over the 5 years from 1999 to 2003, 1,580 blood culture isolates from 1,495 patients were analysed. Typeability and discriminatory indices were as follows: AR typing, 1 and 0.97; phage typing, 0.29 and 0.89; PFGE, 0.99 and 0.95; AR-PFG typing, 1 and 0.95. The most frequently occurring AR-PFG types were 06-01, 07-02, 13-00, and 14-00 and were exhibited by 57, 7, 14, and 12% of isolates, respectively. During the study period, the distribution of AR-PFG type changed markedly, with the prevalence of one type (AR-PFG 06-01) increasing by 880%, from 22% (39/181) in 1999 to 80% (343/430) in 2003. Investigation of whether epidemiological types among blood culture isolates of MRSA were representative of the total MRSA population showed that there was no significant difference in most instances. MLST and SCCmec typing showed that AR-PFG types 06-01, 07-02, 13-00, and 14-00 were ST22-MRSA-IV, ST36-MRSA-II, ST8-MRSA-IID, and ST8-MRSA-IIE, respectively.

Survey of recent medical graduates' knowledge and understanding of the treatment and prevention of infection

With the increasing interest in infection and antibiotic resistance amongst the general public, we undertook to assess the knowledge, and understanding of the treatment and prevention of common infections in medical graduates, about to commence their intern or pre-registration year. A multiple choice-type questionnaire, which included 19 questions, was circulated to 199 recent graduates of three Irish medical schools and 108 (54.3%) were returned. Approximately 60% of the questions were answered correctly. However, questions on the use of antibiotics were poorly answered compared with other questions. With changes in the curricula of many medical schools, there is a need for better education on infection and the use of antibiotics as well as more sophisticated and validated methods of assessment.

Inequalities in dementia care across Europe: key findings of the Facing Dementia Survey

The Facing Dementia Survey was undertaken to assess the awareness of and behaviours surrounding Alzheimer's disease (AD) and dementia among all key stakeholders in Europe. Interviews were conducted with more than 2500 persons, including caregivers, members of the general population, physicians, persons with AD and influencers of health care policy. Four key messages emerged from the results. First, AD often remains undiagnosed until symptoms become moderate or severe. This delay may be because of the difficulty of recognising the symptoms of early AD and the attribution of symptoms to so-called normal ageing, the fear of AD common among older people, inadequate screening tools for use by physicians and/or a delay in the confirmation of the diagnosis once suspicion is raised. Second, a majority of respondents perceive their governments as indifferent to the economic, social and treatment burdens associated with AD. Third, a substantial majority of caregivers, physicians and the general population appreciate the wide-ranging impact that AD can have on the quality of life of people who suffer from it and their informal caregivers. While most caregivers reported life-changing negative effects, a few also noted some positive aspects to their experience. Finally, survey results revealed that most caregivers and members of the general public do not have sufficient information about the benefits of treatment and care. The findings of the Facing Dementia Survey support the development of an agenda for change in dementia care across Europe.

Implications of the Facing Dementia Survey for the general population, patients and caregivers across Europe

The Facing Dementia Survey included interviews with approximately 1200 members of the general public, 600 persons who served as primary caregivers for a person with Alzheimer's disease (AD) and 96 persons with AD. Members of the general public and the caregivers indicated level of agreement on a 5-point scale to a series of attitudinal statements about the disease as well as other diagnostic questions. Persons with AD underwent a qualitative interview. Results indicate that Europeans are acutely aware of the potentially devastating consequences of AD, but few are familiar with the early-stage symptoms. Most members of the general population accept that early intervention and therapy are key to slowing the effects of the disease. Caregivers often delayed consulting a physician about a loved one's behaviour, partly because of uncertainty about early signs of AD. They also expressed doubt about the ability of physicians to make the diagnosis. Caregivers experience profound effects of AD in every area of their life--emotional, physical, social and financial. Persons with AD responded to their diagnosis in one of three ways: a fatalistic attitude, a belief that their problems are linked to old age or a lack of acceptance. Survey respondents from three populations were critical of the level of government investment in and support of AD.

Implications of the Facing Dementia Survey for health care professionals across Europe

Approximately 600 general practitioners, primary care physicians and specialists in six European nations (France, Germany, Italy, Poland, Spain and UK) who treat patients with Alzheimer's disease (AD) were interviewed during the Facing Dementia Survey. Compared with generalists, specialists displayed the most optimism regarding the effects of age, believing that health and memory do not inevitably deteriorate as one grows older. Most physician respondents agreed that the diagnosis of AD is too often delayed. A primary reason cited for this delay was the difficulty experienced by both physicians and the general public in identifying early signs of AD. Many physicians believed treatments are available that can slow the disease course. The vast majority surveyed in each nation believed that early treatment of AD can delay disease progression [mean, 87%; range, 68% (United Kingdom) to 96% (Poland)]. More than half of physicians who initiate treatment in France (66%), Germany (59%), Italy (82%), Poland (82%) and Spain (69%) said they institute treatment for AD immediately after diagnosis. The exception was the United Kingdom, where 48% initiated treatment immediately, whereas more than half waited at least a month to start therapy. To a large extent, physicians saw the governments of their countries as a hindrance rather than a help in caring for persons with AD.

Increasing resistance to ciprofloxacin among isolates of Neisseria gonorrhoea in Dublin

Neisseria gonorrhoeae cases are increasing in Ireland. Ciprofloxacin is often used as first line treatment for this infection in STI clinics. A retrospective study to analyze resistance in two Dublin clinics was undertaken. Cases were defined as patients from whom an isolate of N. gonorrhoea was recovered. All cases from two clinics between January 1997 and June 2003 were included. Antimicrobial resistance data was correlated with sex and sexuality. One thousand one hundred and eighty laboratory-confirmed cases were identified. Eighty seven percent were male. Sixty nine percent were MSM. Twenty seven percent of isolates demonstrated reduced susceptibility to penicillin and 6% to ciprofloxacin. Isolates with reduced susceptibility to ciprofloxacin increased year on year from 3.8% in 1997 to 15% in 2003. Prevalence of isolates of N. gonorrhoea with reduced susceptibility to ciprofloxacin has exceeded 10% in these clinics since 2002. In concordance with international guidelines, ceftriaxone became the treatment of choice for gonorrhoea in July 2003.

Targeting c-Myc-activated genes with a correlation method: detection of global changes in large gene expression network dynamics

This work studies the dynamics of a gene expression time series network. The network, which is obtained from the correlation of gene expressions, exhibits global dynamic properties that emerge after a cell state perturbation. The main features of this network appear to be more robust when compared with those obtained with a network obtained from a linear Markov model. In particular, the network properties strongly depend on the exact time sequence relationships between genes and are destroyed by random temporal data shuffling. We discuss in detail the problem of finding targets of the c-myc protooncogene, which encodes a transcriptional regulator whose inappropriate expression has been correlated with a wide array of malignancies. The data used for network construction are a time series of gene expression, collected by microarray analysis of a rat fibroblast cell line expressing a conditional Myc-estrogen receptor oncoprotein. We show that the correlation-based model can establish a clear relationship between network structure and the cascade of c-myc-activated genes.

Implications of the Facing Dementia Survey for policy makers and third-party organisations across Europe

The Facing Dementia Survey included qualitative interviews conducted with 60 persons who influence health care policies in six European countries (France, Germany, Italy, Poland, Spain and the United Kingdom). Respondents generally reinforced the perception of other survey participants that governments do not adequately fund research into the causes and cure of Alzheimer's disease (AD) and dementia. (AD is the most common cause of dementia, and throughout this discussion, issues raised in reference to AD apply also to dementia in general.) Access to care services and treatment remains highly restricted in some countries and may vary even within countries. Yet, AD presents an enormous but unappreciated social and economic burden for a growing segment of society. AD is associated with unique challenges to health care systems, because diagnosis is difficult and the disease has an enormous impact on the affected persons and their caregivers alike. Moreover, there is a lack of trained professionals to diagnose and manage the disease, a lack of human and financial resources to provide care and services for people with AD as well as their families and a lack of infrastructure to deliver needed services. These difficulties are compounded by inadequate education of both the general public and physicians. Pressure to change current governmental policy towards neurodegenerative diseases may come from the increasing prevalence of AD as the population ages and from broader awareness of the total societal costs of long-term care.

The influence of some different factors on the accuracy of shade selection

The purpose of this study was to elucidate some of the factors on which accurate shade taking depends. Custom shade tabs (0.5, 1.0 and 1.5 mm porcelain thickness) were fabricated from selected Vita and Shofu porcelains. Four main factors were investigated, namely, the difference between the two types of porcelain used, the effect of light quality, the effect of porcelain thickness and the experience of the observer. The chi-square test for independence at a probability level of P <0.05 was used to analyse the results. The results indicated that in ideal light there was no difference between the two porcelains (P=0.58). The experienced observers proved better than the novice observers in ideal light conditions (P=0.003). Thickness was also significant in the overall results (P=0.0001), in that thicker samples gave more accurate results. The results indicate that in adverse light, there was an overall difference between the two porcelains (P=0.046), but no difference between the experienced and novice observers. The thickness made no difference to the experienced or the novice observer in adverse light. These results indicate that the most influential factor on shade taking was the light quality (P <0.0001); better results were obtained overall for the ideal light situation. In ideal light thicker samples gave better results (P=0.0001).

Influence of preapheresis clinical factors on the efficiency of CD34+ cell collection by large-volume apheresis

We evaluated 120 leukapheresis procedures (93 patients), in order to detect clinical factors that influence the efficiency of CD34+ collection using Cobe Spectra trade mark cell separators. Hematocrit was >27% and platelet count >30 000/microl in >95% of patients. Platelet transfusions were given if the postprocedure count was &<20 000/microl. Multiple regression analysis was used to analyze putative factors, and a predictive equation defined by stepwise regression modeling. The mean efficiency was 0.59 (s.d. 0.27). Sex (M>F; P=0.01), the volume processed (inversely; P=0.01) and CD34+ cell count (inversely; P=0.04) were associated with efficiency, whereas hematocrit, platelet or leukocyte count, catheter type and patient weight were not. The effect size for predictive factors was small (R(2)=0.21). Adverse events were limited to hypocalcemia. We conclude that female sex, volume processed and CD34+ cell count adversely influence the efficiency of CD34+ cell leukapheresis. However, the impact of volume and CD34+ cell count is small, and likely to be offset by the influence of these same factors on overall yield. Leukapheresis appears to be safe and efficient for autologous blood and marrow transplantation patients with hematocrit >27% and platelet count >30 000/microl.