Distinguishing community-acquired bacterial and viral meningitis: Microbes and biomarkers

Diagnostic tools to differentiate between community-acquired bacterial and viral meningitis are essential to target the potentially lifesaving antibiotic treatment to those at greatest risk and concurrently spare patients with viral meningitis from the disadvantages of antibiotics. In addition, excluding bacterial meningitis and thus decreasing antibiotic consumption would be important to help reduce antimicrobial resistance and healthcare expenses. The available diagnostic laboratory tests for differentiating bacterial and viral meningitis can be divided microbiological pathogen-focussed methods and biomarkers of the host response. Bacterial culture-independent microbiological methods, such as highly multiplexed nucleic acid amplification tests, are rapidly making their way into the clinical practice. At the same time, more conventional host protein biomarkers, such as procalcitonin and C-reactive protein, are supplemented by newer proteomic and transcriptomic signatures. This review aims to summarise the current state and the recent advances in diagnostic methods to differentiate bacterial from viral meningitis.

Meningitis in the Guise of Dementia: Lyme-Induced Normal Pressure Hydrocephalus

While the cause of altered mentation in the elderly may be multifactorial, infectious etiologies may be missed. This case report aims to detail an account of a patient with dementia, found to have Lyme meningitis in the setting of a normal pressure hydrocephalus (NPH). The patient smelled of urine and presented with ambulatory dysfunction, fitting the "wet, wacky, and wobbly" triad of NPH while also having subjective chills and leukocytosis. Non-contrast brain CT scan showed dilated ventricles. Cerebrospinal fluid (CSF) studies suggested aseptic meningitis. Serum studies using a modified two-tiered algorithm confirmed the diagnosis of Lyme disease. Treatment of the underlying condition with a prolonged course of doxycycline improved symptoms and clinical course. Review of the literature on the association between Lyme meningitis and NPH reveals that few cases of Lyme-related NPH have been reported worldwide and further research into the pathophysiology, diagnostic approach, treatment modalities, and management of NPH secondary to Lyme meningitis may be warranted.

Can "Aseptic" Looking TIBIA Non-union be Result of an Unrecognized Subclinical Infection?

Introduction

The usual cause of a distal tibial fracture is a high-energy trauma. Although multiple options are available for their treatment such as intramedullary nailing, open plating, and external fixator, each of these options might result in a non-union. Knowing the type of non-union not only allows us to guess the cause but also directs us toward the best possible treatment. Despite this, we might still get surprises on the operating table due to pre-operative misdiagnosis.

Case Report

Reporting a case of a 42-year-old male with a 15-month-old left distal tibia non-union. The index injury was a grade 1 distal third tibia fibula fracture which was fixed with a plate and screws 15 months back. All the clinical and biochemical signs hinted toward the diagnosis of an aseptic non-union and the treatment was planned accordingly. However, intraoperative findings were much different due to which the surgeons had to improvise and change the intervention to an antibiotic-coated nail.

Conclusion

Although each variety of non-union has its set of signs and symptoms, they can be misleading. Different etiologies can coexist making it difficult to give a perfect pre-operative diagnosis and management. Non-unions, especially in the tibia, thus need meticulous understanding of the underlying disease process and extensive treatment strategies.

Standards for aseptic techniques in medical aesthetic practices in the Benelux: Consensus recommendations

INTRODUCTION

While the demand for aesthetic procedures is rising, complications are rising alongside. Infection is a frequent complication, there is therefore an increased need for strict aseptic technique, particularly in procedures breaching the skin. The level of training of practitioners carrying out these procedures varies and there are no comprehensive guidelines on aseptic aesthetic practice in the Benelux region.

OBJECTIVE

Developing a step-by-step procedure for achieving and maintaining a high standard of aseptic conditions in a standard aesthetic practice in the Benelux region.

METHODS

A consensus group of 10 aesthetic medical practitioners (dermatologists, plastic surgeons, and cosmetic physicians) representing the Benelux region convened to discuss best practice for aseptic techniques in medical aesthetics. Step-by-step procedures were recommended to achieve optimal aseptic practice in private facilities and define important considerations for reducing infection risk. Recommendations were based on current evidence and extensive clinical experience.

RESULTS

Recommendations were made to achieve and maintain a high standard of asepsis and infection control. Guidance included maintaining high standard aseptic conditions of the injecting room, the injecting area on the patient, the injection procedure, the materials, and procedures commonly used to achieve aseptic conditions.

CONCLUSIONS

This expert consensus summary publication recommends aseptic procedures, setting a standard with the goal of minimizing rates of complications in aesthetic clinical practice in the Benelux region.

Management of septic and aseptic prepatellar bursitis: a systematic review

BACKGROUND

Despite contributing to significant morbidity in working-age adults, there is no consensus on the optimal treatment for prepatellar bursitis. Much of the existing literature combines prepatellar and olecranon bursitis. This systematic review aims to determine the optimal management of prepatellar bursitis.

STUDY DESIGN AND METHODS

A primary search of electronic published and unpublished literature databases from inception to November 2019 was completed. Articles over 25 years old, case reports with less than four patients, paediatric studies, and non-English language papers were excluded. Our primary outcome was recurrence after 1 year. Comparisons included endoscopic vs open bursectomy, duration of antibiotics. Methodological quality was assessed using the Institute of Health Economics and Revised Cochrane Risk of Bias scoring systems. Meta-analyses were conducted where appropriate.

RESULTS

In total 10 studies were included (N = 702). Endoscopic and open bursectomy showed no difference in recurrence after 1 year (OR 0.41, 95% CI 0.05-3.53, p = 0.67), and surgical complications (OR 1.44, 95% CI 0.34-6.08, p = 0.44). 80% endoscopically-treated patients were pain free after 1 year. Patients treated with antibiotics for less than 8 days were not significantly more prone to recurrence (2/17 vs 10/114, OR 0.66, 95% CI 0.13-3.29, p = 0.64) compared to 8 days plus at minimum 1 year post injury.

CONCLUSIONS

Our study represents the largest cohort of patients evaluating management strategies for prepatellar bursitis, and includes data not previously published. Endoscopic bursectomy is non-inferior to open bursectomy, enabling a shorter hospital stay. It also offers a relatively low risk of post-operative pain. Endoscopic bursectomy is a viable option to treat both septic and aseptic prepatellar bursitis. Our small cohort suggests recurrence and hospital stay are not improved with antibiotic treatment exceeding 7 days for septic prepatellar bursitis.

Pharmacy students' perceptions of an oncology pharmacy simulation

BACKGROUND AND PURPOSE

Cancer is on the rise both globally and in South Africa, with an estimated 70% increase in incidence in Sub-Saharan Africa by 2030. While oncology pharmacy is a highly specialized field of practice, there is currently no formal certification for oncology pharmacists in South Africa.

EDUCATIONAL ACTIVITY AND SETTING

To standardise the way in which oncology pharmacy is practiced within the country, the first-ever simulation-based oncology admixing training for pharmacy students in South Africa was developed at the University of the Witwatersrand. Following the simulation, a survey was conducted to determine the participants' perceptions of the simulation. Current and past pharmacy students were invited to complete a questionnaire. Data were collected through a self-administered cross-sectional REDCap (Research Electronic Data Capture) questionnaire using a Likert-like scale to determine the agreed with statements related to the simulation.

FINDINGS

A total of 81 participants completed the questionnaire. Participants provided favorable feedback related to the simulation's benefit, quality, and learning experience.

SUMMARY

Based on the perceptions of the participants, the purpose of the simulation exercise was achieved.

Aseptic meningoencephalitis after COVID-19 vaccination: A case report

Introduction

Several types of vaccine have been shown to significantly reduce the risk of severe coronavirus disease 2019 (COVID-19). This study aims to report the first case of meningoencephalitis after receiving the second dose of Pfizer COVID-19 vaccine.

Case report

A 62-year-old lady presented with headache, fever and rigor for 4 days. She had acute confessional state and inability to talk. She was conscious, disoriented, not obeying commands. Acyclovir vial IV 750 mg three times a day for 14 days were prescribed. She responded very well.

Discussion

Concern has been raised about the safety of vaccinations. The most common side effects of COVID-19 vaccinations are local responses at the injection site, followed by non-specific systemic symptoms such as headache, tiredness, myalgia, and fever. These may appear shortly after immunization and disappear in a short period of time.

Conclusion

Although extremely rare, aseptic meningoencephalitis could occur after COVID-19 vaccination. The patient could be managed conservatively with a good clinical outcome.

•

COVID-19 mostly causes respiratory disease.

•

Vaccinations have been shown to significantly reduce the risk of severe COVID-19 infection.

•

A suspicious cluster of significant neurological complications following vaccination have been established.

•

Development of meningoencephalitis after COVID-19 vaccination is an extremely rare condition.

The role of low-grade infection in the pathogenesis of apparently aseptic tibial shaft nonunion

PURPOSE

Aim of this study was to determine the rate of low-grade infection in patients with primarily as aseptic categorized tibial shaft nonunion and lack of clinical signs of infection.

METHODS

In a retrospective study between 2006 and 2013, all patients who underwent revision surgery for treatment of tibial shaft nonunion without clinical evidence of infection were assessed. Bacterial cultures harvested during nonunion revision, C-reactive protein (CRP) and/or white blood cell (WBC) values at hospital admission, outcome, and epidemiological data were analyzed.

RESULTS

In 88 patients with tibial shaft nonunion without any clinical signs of infection, bacterial samples remained negative in 51 patients. In 37 patients, microbiological diagnostic studies after long-term culturing demonstrated positive bacterial cultures whereas after short-term culturing for 2 days only 17 positive cultures were observed. In 12 cases a mixed culture with 2.3 different bacteria on average was detected. Among patients with negative bacterial cultures bone healing was achieved after 13.2 months. Nonunion with positive bacterial cultures required 19 (range 2-42) months until osseous healing (p = 0.009). Furthermore, nonunion with positive bacterial cultures require statistically more surgical revisions to achieve healing (2.9 ± 0.5 vs. 1.3 ± 0.1 additional procedure; (p = 0.003). Hematological studies carried out before surgical intervention did not demonstrate significant differences in CRP values (negative vs. positive cultures: 0.3 (range 0.3-2.8) mg/dl vs. 0.5 (range 0.3-5.7) mg/dl (p = 0.181) and in WBC values (negative vs. positive cultures: 7.4 (range 3.5-11.9) /nl vs. 7.3 (range 3.7-11.1) /nl (p = 0.723). Limitations of this study may include the varying amount of the at least four samples for microbiological diagnostics as well as the circumstance that for diagnosing low-grade infection swabs and tissue samples were included in this evaluation as being equivalent.

CONCLUSION

The pathogenesis of nonunion may originate from low-grade infection even in patients without clinical signs of infection. In addition, nonunion with positive bacterial cultures require statistically more surgical revisions to achieve healing. Therefore, during any revision surgery, multiple bacterial samples are intended to be harvested for long-term culturing. Particularly, in tibial shaft nonunion following Gustilo-Anderson type III open fractures, low-grade infection should be suspected.

TRIAL REGISTRATION NUMBER

DRKS00014657.

DATE OF REGISTRATION

04/26/2018 retrospectively registered.

Poor outcomes of revision total knee arthroplasty in patients with septic loosening compared to patients with aseptic loosening

Background

The purpose of this study was to compare the functional outcomes, activity levels, mortalities, implant survival rates, and complications in revision total knee arthroplasty (TKA) of patients with septic loosening with those in patients with aseptic loosening over a minimum 10-year follow-up period.

Methods

A cohort of 78 patients (36 septic loosening and 42 aseptic loosening) was selected between January 2008 and December 2009. The functional outcomes, activity levels, mortalities, implant survival rates, and complications of revision TKA in patients with septic and aseptic loosening were compared.

Results

The mean Knee Society knee scores in the septic and aseptic groups improved from 36.7 and 37.4 preoperatively to 65.3 and 76.8 points at the final follow-up, respectively (p < 0.05). Outdoor ambulatory patients at the final follow-up included 20 of 29 (69.0%) patients in the septic group and 35 of 39 (89.7%) patients in the aseptic group (p < 0.05). The cumulative mortality rates in the septic and aseptic groups were 19.4% (7/36) and 7.1% (3/42) (p = 0.102) at final follow-up, respectively. Kaplan–Meier survivorship analysis with re-revision of either component as an endpoint in the septic and aseptic groups estimated 86.5% and 95.5% chance of survival for 10 years, respectively.

Conclusions

Revision TKA in patients with septic loosening had worse functional outcomes and higher mortality over a minimum 10-year follow-up period compared with that in patients with aseptic loosening.

Level of evidence

IV.

Risk factors for mortality following one-stage septic hip arthroplasty - a case-control study

PURPOSE

Despite good clinical outcomes and a high success rate, there is a comparatively high mortality after one stage septic exchange of total hip arthroplasty. The aim of this study was to identify risk factors for mortality in the hospitalization period after one-stage septic exchange of THA.

METHODS

We retrospectively analyzed in our database all patients who had a one-stage septic exchange for periprosthetic infection of THA and died during hospitalization (n = 33). The control group was matched semi-randomly by surgical procedure (n = 121) who did not die during hospitalization. The two groups were analyzed for risk factors such as age, Charlson Comorbidity Index (CCI), and high-/low-virulence bacteria.

RESULTS

In the deceased group, 16 patients were female and 17 were male with a mean age at surgery of 73.2 years. In the control group, there were 55 females and 66 males with an average age at surgery of 68.2 years. Comparing the two groups, the deceased group had a significantly higher proportion of liver disease as well as higher rate of pulmonary embolism, apoplexy, and/or myocardial infarction, an increased CCI with an average of 6.5 and advanced age. Further demographic and surgery-related parameters especially high- or low-virulent germs were not identified as risk factors for mortality during the hospitalization period. The binominal logistic regression analysis showed that the probability of an inpatient death following one-stage septic exchange of THA increases by a factor of 3.079, with each additional point of the CCI.

CONCLUSION

In conclusion, advanced age and high CCI are the main risk factors for mortality after single-stage septic change of THA. However, high-virulence bacteria have no influence on the mortality during the hospitalization period after one-stage septic exchange of THA.

Factors predicting repeat revision and outcome after aseptic revision total knee arthroplasty: results from the New Zealand Joint Registry

PURPOSE

The number of Revision TKAs performed continues to increase; however there is limited data on risk factors for failure. Additionally, clinical decisions regarding when and how to revise a failed TKA may be as important as the technical aspects of the procedure. The purpose of this study was to analyze factors predicting repeat revision following aseptic revision TKA.

METHODS

Of 85,769 primary TKAs recorded on the New Zealand National Joint Registry, 1720 patients undergoing subsequent revision for aseptic indications between January 1999 and December 2015 were identified. Re-revision was recorded in 208 patients (12.1%). The analysis included demographic characteristics, surgeon revision case volume, surgical time, surgical ownership of index TKA as independent variables using logistic and linear regression. The primary outcome measure was incidence of subsequent re-revision and Oxford Knee Scores of revised TKAs (OKS). The secondary outcome measure was the influence of component exchange in major revisions on re-revision rate.

RESULTS

Younger patients undergoing a revision (HR 0.974) and male gender (HR 0.666) were predictors of re-revision. Elapsed time since index surgery (unstandardized coefficient 0.060) and lower ASA score (UC - 2.749) were significant predictors of OKS. Femoral component revision was a predictor of re-revision (HR 1.696) and had the lowest OKS, compared to tibial and all component revision (p = 0.003).

CONCLUSIONS

Repeat revision TKA is a rare and complex procedure influenced by a number of confounding factors. Using raw registry data, younger and male patients were found to be at a higher risk of re-revision after aseptic revision TKA. A longer time between primary TKA and revision was associated with better clinical outcomes. Isolated femoral component exchange led to worse outcomes both in terms of survivorship and functional scores.

LEVEL OF EVIDENCE

III.

cryoprotectant-included technologies

The protocol of aseptic cryoprotectant-free vitrification on human spermatozoa is well documented. However, data about the effect of permeable cryoprotectants at this procedure is limited. Presented study aimed to test the aseptic capillary vitrification technologies using permeable cryoprotectant-included or cryoprotectant-free media. Thirty-two normal samples were included and analyzed after vitrification in three different media and thawing. Three treatment groups were formed: Group 1, basic medium; Group 2, basic medium with 0.25 M sucrose; Group 3, basic medium with glycerol. Before plunging into liquid nitrogen, capillaries were filled by 10 μl of spermatozoa suspension and isolated from liquid nitrogen by location in hermetically closed 0.25 ml straws. Progressive motility, plasma membrane integrity, total motility/viability after 24, 48 and 72 h in vitro culture, apoptosis and mitochondrial membrane potential (ΔΨm) were determined after thawing at 42 °C. Progressive motility of spermatozoa in groups 1, 2, 3 was 24.9 ± 1.7%, 34.5 ± 2.8% and 34.0 ± 1.4%, respectively (P_1-2,3<0.05). The plasma membrane integrity of spermatozoa in groups 2 and 3 (48.4 ± 2.9% and 45.5 ± 3.9%, respectively) was higher than in Group 1 (33.3 ± 2.1%, P < 0.05). After 24 h, 48 h and 72 h in vitro culture, the total motility and viability of spermatozoa in Group 1 was significantly lower than Group 2 and Group 3. The apoptosis rate in Group 3 (44.5 ± 3.0%) and Group 2 (47.7 ± 4.1%) were lower than in Group 1 (52.5 ± 4.4%; P < 0.05). ΔΨm rates in Group 3 and Group 2 were higher than in Group 1 (P < 0.05) with no statistical differences between this parameter in Group 2 and Group 3 (P > 0.1). In conclusion, supplementation of medium for aseptic capillary technology for cryoprotectant-free vitrification of human spermatozoa by permeable cryoprotectant does not improve the quality of spermatozoa after warming.

Aseptic Cryoprotectant-Free Vitrification of Human Spermatozoa by Direct Dropping into a Cooling Agent

Spermatozoa cryopreservation is used for the management of infertility and some other medical conditions. Routinely applied cryopreservation techniques depend on permeating cryoprotectants and relatively slow freezing rates. Cryoprotectant-free vitrification is an alternative and cost-effective method that is based on rapid cooling of spermatozoa by direct plunging into a cooling agent to prevent lethal intracellular ice crystallization and the detrimental effects of high salt concentrations. One of the problems with this technique is that full sterilization of commercially produced liquid nitrogen, which could be contaminated with different pathogens, is not possible. Here we use a benchtop device for the production of sterile liquid air with the same temperature as liquid nitrogen (-195.7 °C). This has been used to develop aseptic technology for cryoprotectant-free vitrification of human spermatozoa.

Impact of cerebrospinal fluid syndromic testing in the management of children with suspected central nervous system infection

The aim of the study was to evaluate the impact of the use of BioFire® FilmArray® meningitis/encephalitis(FA-ME) panel which enables rapid automated CSF testing for 14 common viral, bacterial, and yeast pathogens that cause CNS infections, in the management of children with suspected CNS infection. A prospective cohort study was performed on children admitted to a tertiary pediatric hospital, over a period of 1 year, with possible CNS infection and CSF pleocytosis (> 15 cells/mm³). Children were randomized 1:1, either to use FA-ME or separate molecular CSF microbiological tests according to usual pediatric practice in the hospital. Length of hospital stay, duration of antimicrobials, and total cost of hospitalization were compared between groups. A total of 142 children were included in the study (71 cases). A pathogen was detected in 37/71(52.1%) children with the use of FA-ME and in 16/71(22.5%) in the control group (P value < 0.001). In aseptic meningitis cases a virus was detected in 27/61(44.2%) and in 11/66(16.7%) controls (P value < 0.001). Median (IQR) length of stay in cases and controls with aseptic meningitis was 5(4-8) and 8(6-10) days, respectively (P value < 0. 001). The median (IQR) duration of antimicrobials in cases and controls was 4(2-5.7) and 7(5-10) days, respectively (P value < 0.001). The hospitalization cost was calculated in cases and controls 1042€ (932-1372) and 1522€ (1302-1742), respectively (P value < 0.001). The use of FA-ME was able to reduce significantly the use of antimicrobials, the hospitalization days, and the total cost comparing to the control group in children with suspected CNS infection.

The value of cerebrospinal fluid lactate levels in diagnosing CSF infections in pediatric neurosurgical patients

PURPOSE

Diagnosis of cerebrospinal fluid (CSF) infections in patients following neurosurgical procedures can be challenging. CSF lactate (LCSF) has been shown to assist in differentiating bacterial from non-bacterial meningitis in non-neurosurgical patients. The use of lactate in diagnosing CSF-related infections following neurosurgical procedures has been described in adults. The goal of this study was to describe the role of LCSF levels in diagnosing CSF-related infections among neurosurgical children.

METHODS

We retrospectively collected data for all pediatric patients treated at a large tertiary pediatric neurosurgical department, for whom CSF samples were collected over a 2-year period. Lactate levels were correlated with other CSF parameters, surgical parameters, presence of CSF infection, and source of CSF sample (lumbar, ventricular, or pseudomeningocele).

RESULTS

A total of 215 CSF samples from 162 patients were analyzed. We found a correlation between lactate levels and other CSF parameters. Lactate levels displayed an inconsistent correlation with infection depending on sample origin. Irrespective of the CSF source, lactate levels could not sufficiently discriminate between those with or without infection. Lactate levels were correlated with recent surgery, and, in some of the subgroups, to the extent of blood in CSF.

CONCLUSIONS

LCSF levels are influenced by many factors, including the source of sample, recent surgery, and the presence of subarachnoid or ventricular blood secondary to surgery. The added value of LCSF for diagnosing CSF infections in children with a history of neurosurgical procedures is unclear and may be influenced by the extent of blood in the CSF.

Viral (aseptic) meningitis: A review

Viral meningitis is an inflammation of the meninges associated with acute onset of meningeal symptoms and fever, pleocytosis of the cerebrospinal fluid, and no growth on routine bacterial culture. It is sometimes associated with viral encephalitis and meningoencephalitis. Viruses reach the central nervous system (CNS) hematogenously or in a retrograde manner from nerve endings. The viral etiology varies according to age and country. Molecular diagnostics technology has helped improve the rate of pathogen detection reducing unnecessary antibiotic use and length of hospitalization. Most of the viral infections detailed in this article have no specific treatment other than supportive care. Many of the viruses discussed are preventable by vaccination and proper skin protection against transmitting vectors.

Effectiveness of architectural separation of septic and aseptic operating theatres for improving process quality and patient outcomes: a systematic review

BACKGROUND

Architectural division of aseptic and septic operating theatres is a distinct structural feature of surgical departments in Germany. Internationally, hygienists and microbiologists mainly recommend functional separation (i.e. aseptic procedures first) without calling for separate operating floors and rooms. However, patients with severe musculoskeletal infections (e.g. joint empyema, spondylodiscitis, deep implant-associated infections) may benefit from the permanent availability of septic operating capacities without delay caused by an ongoing aseptic surgical program. A systematic literature review on the influence of a structural separation of septic and aseptic operating theatres on process and/or outcome quality has not yet been conducted.

METHODS

Systematic literature search in PubMed MEDLINE, Ovid Embase, CINAHL and the Cochrane Library, screening of referenced citations, and assessment of grey literature.

RESULTS

A total of 572 articles were found through the systematic literature search. No head-to-head studies (neither randomised, quasi-randomised nor observational) were identified which examined the impact of structural separation of septic and aseptic operating theatres on process and/or outcome quality.

CONCLUSIONS

This review did not identify evidence in favour nor against architectural separation of septic or aseptic operating theatre. Specifically, there is no evidence of a harmful effect of architectural separation. Unless prospective studies, ideally randomised trials, will be available, it is unjustified to call for abolishing established hospital structures. Future investigations must address patient-centered endpoints, surgical site infections, process quality and hospital economy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (International prospective register of systematic reviews): CRD42018086568.

Infection prevention strategies for procedures performed outside operating rooms: A conceptual integrated model

No comprehensive guidelines or classification exist for infection prevention strategies for medical procedures performed outside operating rooms. We reviewed the available literature and used our clinical experience to develop a progressive, 5-tiered classification of procedures, encompassing clean, aseptic, sterile-superficial, sterile-invasive, and surgical-like procedures to address this need. We provide a description of these categories, along with relevant examples. We fully acknowledge the limitations of our work, which is intended as a starting point for future efforts and not to be definitive.

Nicotine consumption may lead to aseptic loosening in proximal mega-prosthetic femoral replacement

Background

Aseptic loosening after total hip arthroplasty is likely related to nicotine ingestion. However, aseptic loosening as a direct consequence of smoking habits has not been described with regard to proximal mega-prosthetic femoral replacement. The aim of the present study was to evaluate the association between nicotine consumption and aseptic loosening rates after proximal mega-prosthetic femoral replacement.

Materials and methods

A consecutive series of patients who received mega-prosthetic replacement of the proximal femur at our hospital between 2005 and 2015 were included. Their files were reviewed and evaluated for the influence of smoking on aseptic loosening rates. All living patients were invited to complete a functional follow-up assessment at our clinic.

Results

Twenty-six patients with 27 prostheses were included. Five patients were active smokers, and 21 patients were non-smokers. Aseptic loosening was observed in three patients in the smoking group, whereas none of the non-smokers developed aseptic loosening. Fisher’s exact test showed a relationship between nicotine consumption and aseptic loosening of the prostheses (p = 0.003).

Conclusions

Smoking increases the likelihood of aseptic loosening after proximal mega-prosthetic femoral replacement.

Level of evidence

Level 4 according to Oxford Centre of Evidence-Based Medicine 2011.

Electronic supplementary material

The online version of this article (doi:10.1007/s10195-016-0426-7) contains supplementary material, which is available to authorized users.

Chronic recurrent osteomyelitis: A diagnostic and therapeutic challenge

INTRODUCTION

Chronic recurrent osteomyelitis (CRO) is a rare disease characterised by unifocal or multifocal aseptic inflammatory bony lesions.

OBJECTIVE

To evaluate clinical features and response to treatment with non-steroidal anti-inflammatory drugs in patients with CRO.

MATERIALS AND METHODS

A retrospective assessment was conducted on 5 children with OCR over a period of 8 years. They had been diagnosed based on clinical, laboratory findings, histological study of injuries, and imaging test.

RESULTS

Multifocal disease was observed in 40% of cases, and unifocal in 60%. The large majority (80%) were male, with a mean age at diagnosis of 13 years (range: 11-15 years). The bones most frequently affected were the clavicle and tibia, representing 18.2%. The most common presenting symptom was pain in all patients, with fever being present in 20% of cases. Imaging studies such as CT and MRI were effective in 100%, and in all cases the biopsy reported a lymphoplasmacytic infiltrate. After a mean follow-up of 5.9 years, there was a good treatment response in 100%, with a mean recurrence at 5.25 months being observed.

CONCLUSIONS

The anodyne results of most clinical studies to assess CRO, and the similarity in clinical presentation of this with many infectious or tumour diseases makes its diagnosis a real challenge. On the other hand treatment with NSAIDs can be considered a good initial therapeutic option.

Atrophic, aseptic, tibial nonunion: how effective is modified Judet's osteoperiosteal decortication technique and buttress plating?

INTRODUCTION

Tibial nonunion is the most common nonunion encountered by the orthopedic surgeon. Repeated surgeries, cost, increased duration of hospital stay, disability, pain all contribute to the increased morbidity. Many methods have been used to treat nonunion of tibia with variable results and none of them are 100 % successful. Our objective was to determine the effectiveness of modification of Judet's decortication technique and buttress plating, without bone graft, in the treatment of aseptic, atrophic tibial nonunion. Also, to find the correlation between time of achieving union and time since injury to decortication.

MATERIALS AND METHODS

Ours is a retrospective study conducted at a Level I trauma center. A total of 35 cases of atrophic tibial nonunion, irrespective of the cause, was treated by modifying Judet's osteoperiosteal decortication and plating during the time period January 2006 to July 2013. Demographic data, range of motion, time of achieving union and clinico-radiological evaluation for union of fracture were included as main outcome measurements.

RESULTS

Union was achieved in all cases with a mean duration of 8.34 months. Pain and stiffness of joints were not reported in any case on long-term follow-up and the patients had satisfactory range of motion. Implant removal was done in three cases after fracture union.

CONCLUSION

Treatment of atrophic tibial nonunion is challenging and management of each nonunion has to be customized based on the biological and mechanical characteristics of the nonunion. Plating with osteoperiosteal decortication is an effective and simple technique, which in our hands has shown to result in 100 % union rates without the need of additional bone healing augmentation procedures like bone grafting.

LEVEL OF EVIDENCE

Level II.

Particle Disease: A Current Review of the Biological Mechanisms in Periprosthetic Osteolysis After Hip Arthroplasty

Background:

Inflammatory responses to wear debris cause osteolysis that leads to aseptic prosthesis loosening and hip arthroplasty failure. Although osteolysis is usually associated with aseptic loosening, it is rarely seen around stable implants. Aseptic implant loosening is a simple radiologic phenomenon, but a complex immunological process. Particulate debris produced by implants most commonly causes osteolysis, and this is called particle-associated periprosthetic osteolysis (PPO).

Objective:

The objective of this review is to outline the features of particle-associated periprosthetic osteolysis to allow the physician to recognise this condition and commence early treatment, thereby optimizing patient outcome.

Methods:

A thorough literature search was performed using available databases, including Pubmed, to cover important research published covering particle-associated PPO.

Results:

Although osteolysis causes bone resorption, clinical, animal, and in vitro studies of particle bioreactivity suggest that particle-associated PPO represents the culmination of several biological reactions of many cell types, rather than being caused solely by the osteoclasts. The biological activity is highly dependent on the characteristics and quantity of the wear particles.

Conclusion:

Despite advances in total hip arthroplasty (THA), particle-associated PPO and aseptic loosening continue to be major factors that affect prosthetic joint longevity. Biomarkers could be exploited as easy and objective diagnostic and prognostic targets that would enable testing for osteolysis after THA. Further research is needed to identify new biomarkers in PPO. A comprehensive understanding of the underlying biological mechanisms is crucial for developing new therapeutic interventions to reverse or suppress biological responses to wear particles.

Thermal and clinical performance of a closed device designed for human oocyte vitrification based on the optimization of the warming rate

Although it was qualitatively pointed out by Fahy et al. (1984), the key role of the warming rates in non-equillibrium vitrification has only recently been quantitatively established for murine oocytes by Mazur and Seki (2011). In this work we study the performance of a closed vitrification device designed under the new paradigm, for the vitrification of human oocytes. The vitrification carrier consists of a main straw in which a specifically designed capillary is mounted and where the oocytes are loaded by aspiration. It can be hermetically sealed before immersion in liquid nitrogen for vitrification, and it is warmed in a sterile water bath at 37 °C. Measured warming rates achieved with this design were of 600.000 ºC/min for a standard DMEM solution and 200.000 ºC/min with the vitrification solution for human oocytes. A cohort of 143 donor MII sibling human oocytes was split into two groups: control (fresh) and vitrified with SafeSpeed device. Similar results were found in both groups: survival (97.1%), fertilization after ICSI (74.7% in control vs. 77.3% in vitrified) and good quality embryos at day three (54.3% in control vs. 58.1% in vitrified) were settled as performance indicators. The pregnancy rate was 3/6 (50%) for the control, 2/3 (66%) for vitrified and 4/5 (80%) for mixed transfers.

Flow cytometry as a diagnostic tool for identifying total hip arthroplasty loosening and differentiating between septic and aseptic cases

PURPOSE

Implant loosening represents one of the major factors of total hip arthroplasty (THA) failure. The purpose of this study was to identify specific markers indicative of septic and aseptic loosening in patients that underwent THA.

METHODS

Flow cytometry was performed in blood samples of 20 patients with loosening (10 septic/10 aseptic). Additional ten healthy individuals served as a control group. The expression of surface receptors and cytoplasmic molecules in patients that underwent THA was quantified. CD62L, CD18, CD11a, CD11b and CD11c expressions were evaluated and correlated with the presence of loosening. Also, a comparison between septic and aseptic THA loosening characteristics was performed.

RESULTS

The mean fluorescence intensity (MFI) for CD18 was significantly decreased on all leukocytes subsets in both septic and aseptic loosening compared to control group (p < 0.005 in all occasions). Patients with aseptic loosening showed increased MFI for CD11b in granulocytes and for CD11c in monocytes and granulocytes compared to the control and aseptic group (p = 0.02 and p = 0.005, respectively). In patients with septic loosening, an increase in MFI for CD11c was observed in monocytes only compared to control group (p = 0.03). The comparison between aseptic and septic loosening showed significantly lower CD18 MFI value in granulocytes for aseptic loosening (p = 0.008).

CONCLUSIONS

CD11 and CD18 MFI values appear to be indicative of loosening in THAs. Flow cytometry markers can be used to identify THA loosening, as well as to differentiate between septic and aseptic cases.

Similar outcomes between two-stage revisions for infection and aseptic hip revisions

PURPOSE

Two-stage revision hip arthroplasty using an antibiotic-loaded spacer is the most widely performed procedure for infected hip arthroplasties. The clinical outcome of this type of surgery compared with aseptic joint revision with exchange of femoral and acetabular components is still controversial due to the relative lack of medium- to long-term follow-up. Therefore, we analysed clinical and radiological outcomes of septic two-stage revisions compared with aseptic hip revision surgeries.

METHODS

In this retrospective study we assessed 82 consecutive patients who underwent two-stage revision for septic total hip (45 patients) or one-stage aseptic revision arthroplasty (37 patients). The average follow-up was 53 months for the aseptic group and 55 months for the septic group. For clinical evaluation, we used the Harris Hip Score (HHS) and the Merle d'Aubigné and Postel score. The postoperative pain level was determined with the visual analogue pain scale.

RESULTS

The surgeries were performed 124 months (aseptic group) and 119 months (septic group) after primary total hip arthroplasty on average. The main indications for aseptic revision surgeries were aseptic loosening (96%), dislocation (2.2%), and periprosthetic fracture (2.2%). In the clinical outcome patients achieved 75.5 points in the aseptic group and 73.4 points in the septic group in the Harris Hip Score. The Merle d'Aubigné and Postel Score revealed 12.5 points for the aseptic group and 13.1 points for the septic group. Mean level of persisting pain was 0.8 (aseptic group) and 0.4 (septic group) on the visual analogue scale (VAS). Overall survival in the aseptic group was 85.6% at 9.8 years 82.7% at 10.1 years for the septic group, with a repeat revision rate of 8.1% and 6.7%, respectively.

CONCLUSIONS

Performing aseptic acetabular and femoral revision hip arthroplasty showed equal clinical outcomes in relation to septic two-stage revision hip surgeries. Our results showed a tendency for better outcome in comparison with the information given in the literature for septic and nonseptic exchange arthroplasties, including a lower rate of re-revisions.

Meningitis

Meningitis is defined as inflammation of the meninges, in almost all cases identified by an abnormal number of white blood cells in the cerebrospinal fluid and specific clinical signs/symptoms. Onset may be acute or chronic, and clinical symptoms of acute disease develop over hours to days. This article reviews the epidemiology, pathophysiology, clinical manifestations, diagnosis, and management of acute meningitis, and provides a list of key points for primary care practitioners. Aseptic and bacterial meningitis vary significantly and are discussed separately.

Clinical presentation of patients with aseptic meningitis, factors influencing treatment and hospitalization, and consequences of enterovirus cerebrospinal fluid polymerase chain reaction testing

INTRODUCTION

Clinical and laboratory features of enteroviral meningitis may overlap with those of bacterial meningitis. In the present retrospective review, we compared features of enteroviral (EV)-positive and -negative patients to determine those that were most influential in admission, discharge and in anti-infective administration.

METHODS

Data were analyzed from the records of 117 pediatric and adult patients who underwent cerebrospinal fluid (CSF) EV testing over a three-year period.

RESULTS

The oldest EV-positive patient was 34 years of age and the occurrence of the disease was highly seasonal. EV-positive patients were more likely to report fever, rash, photophobia, short onset and exposure to an ill contact. A positive polymerase chain reaction (PCR) result was associated with relatively short hospitalization. Seizure and neurological symptoms were more strongly associated with a negative PCR test result. CSF characteristics did not discriminate well between patients with positive and negative PCR tests. Patients with imperfect Glasgow Coma Scores or with neurological symptoms were more likely to be admitted to hospital than those without. Fever and recent onset predicted determinants of anti-infective use.

CONCLUSION

The present retrospective study confirms previous reports regarding seasonality and the young age of positive patients. Factors that indicate nonenteroviral etiology were appropriately also those that influenced hospitalization. Patients with EV meningitis were likely to be treated with empirical anti-infectives, and a substantial proportion continued to take antibiotics for more than 24 h after receiving the positive EV PCR test result.

INTRODUCTION

Clinical and laboratory features of enteroviral meningitis may overlap with those of bacterial meningitis. In the present retrospective review, we compared features of enteroviral (EV)-positive and -negative patients to determine those that were most influential in admission, discharge and in anti-infective administration.

METHODS

Data were analyzed from the records of 117 pediatric and adult patients who underwent cerebrospinal fluid (CSF) EV testing over a three-year period.

RESULTS

The oldest EV-positive patient was 34 years of age and the occurrence of the disease was highly seasonal. EV-positive patients were more likely to report fever, rash, photophobia, short onset and exposure to an ill contact. A positive polymerase chain reaction (PCR) result was associated with relatively short hospitalization. Seizure and neurological symptoms were more strongly associated with a negative PCR test result. CSF characteristics did not discriminate well between patients with positive and negative PCR tests. Patients with imperfect Glasgow Coma Scores or with neurological symptoms were more likely to be admitted to hospital than those without. Fever and recent onset predicted determinants of anti-infective use.

CONCLUSION

The present retrospective study confirms previous reports regarding seasonality and the young age of positive patients. Factors that indicate nonenteroviral etiology were appropriately also those that influenced hospitalization. Patients with EV meningitis were likely to be treated with empirical anti-infectives, and a substantial proportion continued to take antibiotics for more than 24 h after receiving the positive EV PCR test result.