[Changes in quality of life of glaucoma patients over a period of 8 years]. / Veränderungen der Lebensqualität von Glaukompatienten über einen Zeitraum von 8 Jahren.

PURPOSE: The quality of life (QoL) of glaucoma patients is affected by many factors. In particular, patient activity is compromised by the chronicity of the disease. In this study, we evaluated the change in QoL and its impact on activities over a period of 8 years. METHODS: A total of 43 patients with glaucomatous optic nerve damage were enrolled in this retrospective longitudinal observational study. Changes in intraocular pressure (IOP), best-corrected visual acuity (BCVA) and visual field (VF) parameters, number of IOP-lowering eye drops and IOP-lowering surgery were assessed over a period of 8 years. Assessment of QoL was obtained by patient-reported visual functioning using the Rasch-calibrated glaucoma activity limitation 9 (GAL-9) questionnaire at baseline and after 8 years. RESULTS: The BCVA of the better eye changed from 0.16 ± 0.22 to 0.21 ± 0.14 logMAR, whereas there was a change from 0.27 ± 0.25 to 1.39 ± 1.1 logMAR in the worse eye. The VF parameter mean deviation (MD) of the better eye changed from -2.39 ± 4.55 dB to -4.83 ± 5.09 dB, while it altered significantly from -8.86 ± 5.86 dB to -12.05 ± 8.07 dB in the worse eye. Values of GAL­9 changed from -2.39 ± 2.14 to -1.38 ± 2.78 (in the Rasch analysis, more negative values account for a better QoL), according to a sum score change from 79.17 ± 19.63 to 69.22 ± 27.95. This change showed a highly significant correlation with the MD at follow-up, especially with the worse eye (r = 0.43). The impact of the MD at follow-up on QoL could also be well predicted in a regression model. CONCLUSION: The QoL of glaucoma patients decreased significantly over time. Changes in the VF, particularly of the worse eye, have a great impact on reported functioning. Careful treatment, especially of the eye with greater glaucomatous damage, is mandatory.

Factors Associated with Self-Reported Dysphagia in Older Adults Receiving Meal Support.

OBJECTIVES: Dysphagia is common in older adults. However, there are no current estimates of dysphagia in community-dwelling older adults those receiving meal support. It is unknown whether dysphagia is associated with other measures of physical function (activities of daily living [ADL] ability or nutrition status). The study purposes were to determine the prevalence of self-reported dysphagia and to identify factors associated with self-reported dysphagia in community-dwelling older adults receiving meal support. DESIGN: A cross-sectional study. SETTING AND PARTICIPANTS: 476 community-dwelling older adults (78.5±0.51 years) across five Elder Nutrition Program meal services in Wisconsin participated in the study. MEASUREMENTS: Data were collected through administration of validated ADL and nutrition questionnaires (nutritional status, functional status with ADLs, chewing ability, dental conditions, and prior diagnoses of dysphagia, pneumonia, and dementia). For self-reported dysphagia, the validated 10-item eating assessment tool (EAT-10) was used. RESULTS: The prevalence of self-reported dysphagia (EAT-10 score of ≥ 3) was 20.4%. Multivariate logistic regression results indicated that poor nutritional status (OR=3.1, p=0.04), difficulty chewing (OR=2.2, p=0.03), prior dysphagia diagnosis (OR=34.8, p<0.001), prior pneumonia diagnosis (OR=2.1, p=0.04), and meal service site (OR=2.68, p=0.02) were associated with self-reported dysphagia. CONCLUSION: Approximately one in five community-dwelling older adults receiving meal support had self-reported dysphagia. Increased risk for poor nutrition, reduced chewing ability, prior dysphagia and pneumonia diagnosis, and meal service site were identified as factors associated with dysphagia on the EAT-10. Results highlight the need for further studies across more sites to identify dysphagia risk indicators in community-dwelling older adults receiving meal support state-wide.

Diagnostic yield of active case finding for tuberculosis at human immunodeficiency virus testing in Haiti.

SETTING: The Groupe Haïtien d'étude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) Centres, Port-au-Prince, Haiti, facilitate "test and treat" strategies by screening all patients for tuberculosis (TB) at human immunodeficiency virus (HIV) testing.OBJECTIVE: 1) To determine the proportion of patients with chronic cough at HIV testing diagnosed with TB, stratified by HIV test results; and 2) to evaluate the additional diagnostic yield of Xpert® MTB/RIF vs. sputum microscopy.DESIGN: We conducted a retrospective cohort analysis including all adults tested for HIV at GHESKIO from August 2014 to July 2015.RESULTS: Of 29 233 adult patients tested for HIV, 2953 (10%) were diagnosed as HIV-positive. Chronic cough lasting ≥2 weeks was reported by 1116 (38%) HIV-positive patients; 984 (88%) were tested and 265 (27%) were diagnosed with TB. Chronic cough was reported by 5985 (23%) HIV-negative patients; 5654 (94%) were tested and 1179 (21%) were diagnosed with TB. Of all bacteriologically confirmed cases, 27% were smear-negative and Xpert-positive. Among all TB patients, 81% were HIV-negative.CONCLUSIONS: Screening for TB at HIV testing was high-yield, among both HIV-infected and HIV-negative individuals. Testing for both diseases should be conducted among patients who present with chronic cough at HIV testing.

Ultrasound-guided vascular access in critical illness.

Over the past two decades, ultrasound (US) has become widely accepted to guide safe and accurate insertion of vascular devices in critically ill patients. We emphasize central venous catheter insertion, given its broad application in critically ill patients, but also review the use of US for accessing peripheral veins, arteries, the medullary canal, and vessels for institution of extracorporeal life support. To ensure procedural safety and high cannulation success rates we recommend using a systematic protocolized approach for US-guided vascular access in elective clinical situations. A standardized approach minimizes variability in clinical practice, provides a framework for education and training, facilitates implementation, and enables quality analysis. This review will address the state of US-guided vascular access, including current practice and future directions.

Prenatal Exposure to Famine and Risk for Development of Psychopathology in Adulthood: A Meta-Analysis.

Prenatal famine, resulting in intrauterine malnutrition, impacts offspring psychopathology later in adulthood. In addition, the specific impact of intrauterine malnutrition of different psychopathology differs by the timing of the exposure. Using a meta-analysis, the current study assessed the specific risk of developing affective, psychotic, and personality disorders. Studies were identified using PubMed and PsycINFO. Studies met the following criteria for inclusion in the analysis: availability in peer-reviewed English journals, use of human subjects, prenatal exposure to famine, and psychopathology in adulthood defined by diagnostic criteria as an outcome. Fixed effect relative risks (RRs) were calculated for affective, psychotic, and personality domains. Furthermore, timing of exposure was assessed as an effect modifier in our analysis, defined by the index trimester at the height of famine. Our meta-analysis found that adults exposed in utero during the 1st trimester were at a significant increased risk of psychotic disorders (RR=1.46, 95% CI=1.08, 1.97, p=0.014), and personality disorders (RR=2.31, 95% CI=1.36, 3.92, p=0.002). Those exposed during the 2nd trimester were at a significant increased risk of affective disorders (RR=1.45, 95% CI=1.22, 1.72, p<0.0001), and psychotic disorders (RR=1.46, 95% CI=1.13, 1.89, p=0.004). Similarly, those exposed in the 3rd trimester were at a significant increased risk of affective disorders (RR=1.33, 95% CI=1.13, 1.57, p=0.0001), and psychotic disorders RR=1.47, 95% CI=1.10, 1.97, p=0.010). Our findings suggest that there is differential risk across the different domains of psychopathology by trimester of exposures. This meta-analysis underscores the need for further investigation into the mechanisms underlying prenatal maternal nutrition and offspring psychopathology where magnitude of elevated risk differs by the exposure timing during pregnancy.

Outcomes across the tuberculosis care continuum among adolescents in Haiti.

Setting: GHESKIO (Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes) clinic, Port-au-Prince, Haiti. Objective: To evaluate tuberculosis (TB) care continuum outcomes among adolescents. Design: Among a retrospective cohort of 10-24 year olds diagnosed with active TB, we report completion of the following steps of the TB care continuum stratified by human immunodeficiency virus (HIV) status: diagnosis of microbiologically confirmed TB, initiation of anti-tuberculosis treatment, retention in care at 2 months on anti-tuberculosis treatment, and TB treatment success. Factors associated with attrition at each step were identified using multivariable regression. Results: A total of 1005 adolescents were diagnosed with active TB; 74 (7%) were HIV-positive at the time of TB diagnosis. HIV-positive patients had poorer outcomes than non-HIV-infected patients: 73% vs. 85% initiated anti-tuberculosis treatment (P < 0.01), 46% vs. 74% were retained in care at 2 months (P < 0.01), and 41% vs. 68% achieved TB treatment success (P < 0.01). Among those who initiated treatment, same-day initiation resulted in less treatment failure. Attrition before treatment initiation was associated with female sex and HIV coinfection. Attrition after treatment initiation was associated with age ⩾16 years and HIV coinfection. Conclusion: Outcomes across the TB care continuum are suboptimal among adolescents, with only two thirds of patients achieving treatment success. Interventions tailored to adolescents are needed to improve retention in care, particularly for those who are co-infected with HIV.

Contexte : Centre de santé, Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes, Port-au-Prince, Haïti.Objectif : Evaluer les résultats tout au long de la prise en charge de la tuberculose (TB) parmi les adolescents.Schéma : Parmi une cohorte rétrospective d'adolescents âgés de 10­24 ans ayant eu un diagnostic de TB active, nous rapportons le déroulement des étapes suivantes des soins de la TB stratifiés par statut virus de l'immunodéficience humaine (VIH) : diagnostic de TB confirmée par microbiologie ; mise en route du traitement de la TB ; rétention en soins à 2 mois sous traitement de TB ; et succès du traitement de TB. Les facteurs associés à l'attrition à chaque étape ont été identifiés grâce à une régression logistique multivariée.Résultats: Des 1005 adolescents qui ont eu un diagnostic de TB active, 74 (7%) ont été positifs au VIH au moment du diagnostic de TB. Les patients VIH positifs ont eu des résultats plus médiocres comparés aux patients non infectés par le VIH : 73% contre 85% ont mis en route le traitement de TB (P < 0,01), 46% contre 74% sont restés sous traitement à 2 mois (P < 0,01) et 41% contre 68% ont achevé le traitement avec succès (P < 0,01). Parmi ceux qui ont mis en route le traitement, une prise dès le premier jour a abouti à moins d'échec du traitement. L'attrition avant le début du traitement a été associée au sexe féminin et à la coinfection à VIH. L'attrition après mise en route du traitement a été associée à un âge ⩾16 ans et à la coinfection à VIH.Conclusion : Les résultats au niveau de la continuité des soins de TB sont sousoptimaux parmi les adolescents, dont seulement deux tiers achèvent le traitement avec succès. Des interventions adaptées aux adolescents sont requises pour améliorer la rétention en soins, particulièrement pour ceux qui sont coinfectés par le VIH.

Marco de Referencia: El centro du Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes de Port-au-Prince, en Haití.Objetivo: Evaluar los resultados del proceso asistencial continuo de la tuberculosis (TB) en los adolescentes.Método: En una cohorte retrospectiva de jóvenes de 10­24 años de edad con diagnóstico de TB activa, se comunican los resultados logrados en las siguientes etapas del proceso asistencial continuo de la TB, estratificados según la situación frente al virus de la inmunodeficiencia humana (VIH): diagnóstico de TB confirmada microbiológicamente; inicio del tratamiento antituberculoso; retención en la atención a los 2 meses del tratamiento; y el éxito del tratamiento antituberculoso. Se determinaron los factores asociados con el abandono en cada etapa mediante un modelo de regresión multivariante.Resultados: Se diagnosticó TB activa en 1005 adolescentes; 74 de ellos (7%) eran positivos frente al VIH en el momento del diagnóstico de TB. Los pacientes positivos frente al VIH presentaron desenlaces más desfavorables que los pacientes sin infección por el VIH (73% contra 85% inició el tratamiento antituberculoso, P < 0,01; 46% contra 74% continuaba en la atención a los 2 meses, P < 0,01; y 41% contra 68% alcanzó un tratamiento antituberculoso exitoso, P < 0,01). Los jóvenes que iniciaron tratamiento el mismo día de la consulta presentaron menos fracasos terapéuticos. El abandono antes de iniciar el tratamiento se asoció con el sexo femenino y la coinfección por el VIH. El abandono después de haber iniciado el tratamiento se asoció con la edad ⩾16 años y la coinfección por el VIH.Conclusión: Los resultados a lo largo de la continuidad asistencial de la TB son deficientes en los adolescentes, pues solo dos tercios de ellos alcanzan el éxito terapéutico. Se precisan intervenciones adaptadas a los adolescentes que mejoren la retención en los servicios de atención, sobre todo en los pacientes coinfectados por el VIH.

Patient positioning verification for proton therapy using proton radiography.

We present a proof of principle, experimental validation of the potential of proton 'Range Probes' (RP) for patient positioning verification in proton therapy. In this work, we have evaluated experimentally the accuracy of RP by using tissue-like samples and an in-house developed multilayer ionization chamber (MLIC). In addition we build on our previous, simulation based work to present first experimental measurements of RP through anthropomorphic phantoms to detect either rotational or translational positioning errors. For this, a technique has been proposed to characterize the residual integral depth dose curve (RIDDC) after range mixing. This parametrization has been used to evaluate the similarity between Monte Carlo calculated error scenarios of the database and the measured RIDDC, while considering the intrinsic uncertainties of both modalities in order to deduce the positioning error. Finally, the additional dose applied to the patient when using clinical RP with known fluence has been estimated by measuring the local dose of a single RP. In tissue phantoms, the prediction accuracy of the water equivalent path length was 0.70%, with the highest deviations being found in low density samples (up to 5.67%). In addition, the results of the patient positioning verification measurements demonstrated that using carefully selected RPs, 1D translational or rotational errors could be detected with an accuracy of 1 mm and 2°, respectively, and that these would be associated with a low additional dose burden to the patient. In summary, these promising results suggest that the RP method could be a simple, fast and low-dose tool for verifying patient set-up during proton therapy treatment.

[Current strategies in the treatment of ventricular tachycardia by catheter ablation : A review]. / Aktuelles Management der Therapie ventrikulärer Tachykardien durch Katheterablation : Eine Übersicht.

The treatment of ventricular tachycardia has recently undergone relevant changes as certain interventional treatment options, such as radiofrequency catheter ablation, have gained in importance. Numerous current publications have demonstrated the advantages of catheter ablation compared to conventional therapy with antiarrhythmic drugs in terms of effectiveness and morbidity. Improving the ablation technique and identifying those patient collectives who are most likely to benefit from ablation are still the objectives of current research. The treatment of ventricular tachycardia in the setting of different cardiac and non-cardiac conditions can be challenging and requires understanding of the current procedures and the recommendations for catheter ablation of ventricular tachycardia. This review succinctly summarizes the current research in this evolving field of interventional cardiology.

The devil we know: is the use of injectable agents for the treatment of MDR-TB justified?

For decades, second-line injectable agents (IAs) have been the cornerstone of treatment for multidrug-resistant tuberculosis (MDR-TB). Although evidence on the efficacy of IAs is limited, there is an expanding body of evidence on the serious adverse events caused by these drugs. Here, we present the results of a structured literature review of the safety and efficacy of IAs. We review the continued widespread use of these agents in the context of therapeutic alternatives-most notably the newer TB drugs, bedaquiline and delamanid-and from the context of human rights, ethics and patient-centered care. We conclude that there is limited evidence of the efficacy of IAs, clear evidence of the risks of these drugs, and that persons living with MDR-TB should be informed about these risks and provided with access to alternative therapeutic options.

Diagnostic yield of active case finding for tuberculosis and HIV at the household level in slums in Haiti.

SETTING: Haiti has the highest burden of tuberculosis (TB) in the Americas, with an estimated prevalence of 254 per 100 000 population. The Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes, GHESKIO) conducted active case finding (ACF) for TB at the household level in nine slums in Port-au-Prince. OBJECTIVE: We report on the prevalence of undiagnosed TB detected through GHESKIO's ACF campaign. DESIGN: From 1 August 2014 to 31 July 2015, we conducted a retrospective cohort analysis using GHESKIO's ACF campaign data. All individuals who reported chronic cough (cough 2 weeks) were tested for TB at GHESKIO, and those aged 10 years were included in the analyses. RESULTS: Of 104 097 individuals screened in the community, 5598 (5%) reported chronic cough and satisfied the study inclusion criteria. A total of 1110 (20%) were diagnosed with active TB disease (prevalence of 1066/100 000). Of the 5472 (98%) patients tested for human immunodeficiency virus (HIV), 528 (10%) were HIV-positive; 143 (3%) patients were diagnosed with both diseases. CONCLUSION: Household-level screening for cough with TB and HIV testing for symptomatic patients was a high-yield strategy, leading to the detection of a prevalence of undiagnosed disease exceeding national estimates by more than four-fold for TB, and by five-fold for HIV.

Partial cauda equina syndrome after an uneventful minimally invasive microdiscectomy in a patient with Crohn's disease.

Cauda equina syndrome is a serious condition resulting from dysfunction of the lumbosacral nerve roots and characterized by impairment of bladder, bowel, sexual and lower limb functions. We report the case of a 48-year-old woman who had Crohn's disease for more than twenty years. The patient was undergoing immunotherapy with infliximab and developed a partial cauda equina syndrome after an uneventful minimally invasive microdiscectomy (L5-S1) that completely cured her sciatica. A postoperative magnetic resonance imaging examination showed root clumping but no compressive lesion. We discuss a possible relationship between the cauda equina syndrome and the patient's active Crohn's disease, treatment and surgery.

Creating a Stable Oxide at the Surface of Black Phosphorus.

The stability of the surface of in situ cleaved black phosphorus crystals upon exposure to atmosphere is investigated with synchrotron-based photoelectron spectroscopy. After 2 days atmosphere exposure a stable subnanometer layer of primarily P2O5 forms at the surface. The work function increases by 0.1 eV from 3.9 eV for as-cleaved black phosphorus to 4.0 eV after formation of the 0.4 nm thick oxide, with phosphorus core levels shifting by <0.1 eV. The results indicate minimal charge transfer, suggesting that the oxide layer is suitable for passivation or as an interface layer for further dielectric deposition.

CD4 deficit and tuberculosis risk persist with delayed antiretroviral therapy: 5-year data from CIPRA HT-001.

SETTING: Port-au-Prince, Haiti. OBJECTIVE: To determine long-term effects of early vs. delayed initiation of antiretroviral therapy (ART) on immune recovery and tuberculosis (TB) risk in human immunodeficiency virus (HIV) infected individuals. DESIGN: Open-label randomized controlled trial of immediate ART in HIV-infected adults with CD4 counts between 200 and 350 cells/mm(3) vs. deferring ART until the CD4 count was <200 cells/mm(3). The primary comparisons were CD4 counts over time and risk for incident TB, with 5 years of follow-up. RESULTS: A total of 816 participants were enrolled, with 408 in each treatment arm. The early treatment group started ART within 2 weeks, while the deferred treatment group started ART a median of 1.3 years after enrollment. After 5 years, the mean CD4 count in the early treatment group was significantly higher than in the deferred treatment group (496 cells/mm(3), 95% confidence interval [CI] 477-515 vs. 373 cells/mm(3), 95%CI 357-389; P < 0.0001). TB risk was higher in the deferred treatment group (unadjusted HR 2.41, 95%CI 1.56-3.74; P < 0.0001) and strongly correlated with lower CD4 counts in time-dependent multivariate analysis. CONCLUSION: Delays in ART initiation for HIV-infected adults with CD4 counts of 200-350 cells/mm(3) can result in long-term immune dysfunction and persistent increased risk for TB.

Amplification of advanced modulation formats with a semiconductor optical amplifier cascade.

The convergence of optical metro networks and access networks extends the area of network coverage, and therefore requires the use of optical amplifiers. For this purpose, semiconductor optical amplifiers (SOA) would be attractive, because they are broadband, can be centered between 1250 nm and 1600 nm, and because they are cheap in production and operation. We show that signals encoded with advanced modulation formats such as BPSK, QPSK, 8PSK, and 16QAM can be amplified by a cascade of at least four SOAs. This enables high-capacity paths with a capacity in the order of Tbit/s for converged metro-access networks.

Increased growth of colorectal liver metastasis following partial hepatectomy.

Nearly 50 % of colorectal cancer (CRC) patients develop liver metastases with liver resection being the only option to cure patients. Residual micrometastases or circulating tumor cells are considered a cause of tumor relapse. This work investigates the influence of partial hepatectomy (PH) on the growth and molecular composition of CRC liver metastasis in a syngeneic rat model. One million CC531 colorectal tumor cells were implanted via the portal vein in WAG/Rij rats followed by a 30 % PH a day later. Control groups either received tumor cells followed by a sham-operation or were injected with a buffer solution followed by PH. Animals were examined with magnetic resonance imaging (MRI) and liver tissues were processed for immunolabeling and PCR analysis. One-third PH was associated with an almost threefold increase in relative tumor mass (MRI volumetry: 2.8-fold and transcript levels of CD44: 2.3-fold). Expression of molecular markers for invasiveness and aggressiveness (CD49f, CXCR4, Axin2 and c-met) was increased following PH, however with no significant differences when referring to the relative expression levels (relating to tumor mass). Liver metastases demonstrated a significantly higher proliferation rate (Ki67) 2 weeks following PH and cell divisions also increased in the surrounding liver tissue. Following PH, the stimulated growth of metastases clearly exceeded the compensation in liver volume with long-lasting proliferative effects. However, the distinct tumor composition was not influenced by liver regeneration. Future investigations should focus on the inhibition of cell cycle (i.e. systemic therapy strategies, irradiation) to hinder liver regeneration and therefore restrain tumor growth.

Outcomes of HIV-infected patients treated for recurrent tuberculosis with the standard retreatment regimen.

SETTING: The Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (the GHESKIO AIDS and TB Center) in Port-au-Prince, Haiti. OBJECTIVE: To measure the effectiveness of the standard TB retreatment regimen (2HRZES/1HRZE/5HRE) in human immunodeficiency virus (HIV) infected adults. DESIGN: Cohort study. RESULTS: Of 1318 HIV-infected patients with access to antiretroviral therapy following World Health Organization guidelines, 56 were diagnosed with recurrent pulmonary TB and retreated with the standard retreatment regimen: 10 patients (18%) died during retreatment, 3 (5%) defaulted, and 2 (4%) failed treatment. Forty-one patients (73%) achieved retreatment 'success' (cure, treatment completed). Of these, 8 (20%) died during follow-up, 5 (12%) were lost, and 5 (12%) had a second recurrence of TB. Only 26 (46%) of the 56 patients remained alive, in care, and TB-free after a median of 36 months of follow-up. CONCLUSION: HIV-infected patients treated for recurrent TB with the standard retreatment regimen have high mortality and poor long-term outcomes.

Linear semiconductor optical amplifiers for amplification of advanced modulation formats.

The capability of semiconductor optical amplifiers (SOA) to amplify advanced optical modulation format signals is investigated. The input power dynamic range is studied and especially the impact of the SOA alpha factor is addressed. Our results show that the advantage of a lower alpha-factor SOA decreases for higher-order modulation formats. Experiments at 20 GBd BPSK, QPSK and 16QAM with two SOAs with different alpha factors are performed. Simulations for various modulation formats support the experimental findings.

Outcome of periprosthetic distal femoral fractures following knee arthroplasty.

INTRODUCTION: The majority of periprosthetic fractures around the knee occur at the supracondylar region of the distal femur. Fixation of distal femoral fractures in osteoporotic bone with short segment remains a challenge, especially after total knee arthroplasty (TKA). Internal fixation of these fractures using locking plates has become popular. The purpose of this study was to evaluate a consecutive series of periprosthetic supracondylar femoral fractures treated with locked periarticular plate fixation with regard to surgical procedure, complications and clinical outcome. MATERIALS AND METHODS: From two academic trauma centres, 55 consecutive periprosthetic distal femoral fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association, AO/OTA 33) were retrospectively identified as having been treated with locked plate fixation. Of these, 36 fractures in 35 patients (86.1% female) met the inclusion criteria. Patients had an average age of 73.2 years (range 54-95 years). Fixation constructs for plate length and working length were delineated. Nonunion, infection and implant failure were used as complication variables. Demographics were assessed. Outcome was addressed radiographically and clinically according to Kristensen et al.(1) by range of motion and pain. RESULTS: Twenty-five of 36 fractures (69.4%) healed after the index procedure. Eight of 36 fractures (22.2%) developed a nonunion with three fractures (8.3%) leading to hardware failure. Nine of the 36 patients (25%) were radiographically diagnosed with notching of the anterior femoral cortex. Regarding technical aspects, distance from the anterior flange of the femoral component to fracture was significantly shorter in patients with compared to without anterior notching (t=3.68, p=0.02). Patients who underwent submuscular plate insertion compared to an extensive lateral approach had a reduced nonunion risk (χ(2)=0.05). No difference in infection rate was found for submuscular procedures compared with open procedures (χ(2)=0.85). Range of motion was reduced in most of the patients and 13.5% had a persistent loss of extension of 5°. More than 77% of the patients reported no or only mild pain during the last office visit. Range of motion loss did not influence pain. Successful treatment according to Cain et al.(2) was achieved in 83%. Using Kristensen's(1) criteria, 56% of the knees had acceptable flexion. CONCLUSION: Operative fixation of periprosthetic distal femoral fractures after TKA continues to be challenging. Notching of the anterior femoral cortex should be avoided. Loss of reduction and high failure rates still occur with locked plating and may be related to underlying factors. Indirect reduction and submuscular plate insertion technique reduce nonunion risk.

Active surveillance of antibiotic resistance prevalence in urinary tract and skin infections in the outpatient setting.

The aim of the study was to evaluate the need for active surveillance of antibiotic resistance in ambulatory infections. We measured the prevalence of antibiotic resistance in urinary tract infections (UTIs) (n = 1018) and skin infections (n = 213) diagnosed in outpatients between September 2008 and February 2009 in the Canton of Bern, Switzerland. Samples were stratified into 'solicited' (diagnostic work-up for study purpose only) and 'routine' (diagnostic work-up as part of standard care). Susceptibility patterns were compared for 463 Escherichia coli isolates from UTIs (231 solicited; 232 routine) and 87 Staphylococcus aureus isolates from skin infections (35 solicited; 52 routine). Overall, E. coli showed higher susceptibility to ampicillin, amoxicillin-clavulanic acid and norfloxacin in solicited than in routine samples. Among 15-45-year-old patients, susceptibility rates were comparable between solicited and routine samples for all antibiotics except for amoxicillin-clavulanic acid. However, among patients >45 years old, isolates from routine samples showed lower susceptibility to all ß-lactams tested and quinolones than those from solicited samples. Extended-spectrum ß-lactamase (ESBL)-producing E. coli isolates were rare (solicited, 0.4%; routine, 1.7%; p 0.4). Susceptibility patterns of S. aureus were comparable between solicited and routine samples. Therefore, in the outpatient setting, susceptibility rates for E. coli isolates differ by indication for urinary culture and age. Surveillance based on samples taken during standard care may underestimate susceptibility rates for uncomplicated infections, especially among the elderly. Reports of resistance data should include age stratification.