Trends in the epidemiology of osteomyelitis: a population-based study, 1969 to 2009.

BACKGROUND: The epidemiology of osteomyelitis in the United States is largely unknown. The purpose of this study was to determine long-term secular trends in the incidence of osteomyelitis in a population-based setting. METHODS: The study population comprised 760 incident cases of osteomyelitis first diagnosed between January 1, 1969, and December 31, 2009, among residents of Olmsted County, Minnesota. The complete medical records for each potential subject were reviewed to confirm the osteomyelitis diagnosis and to extract details on anatomical sites, infecting organisms, etiological risk factors, and outcomes. RESULTS: The overall age and sex-adjusted annual incidence of osteomyelitis was 21.8 cases per 100,000 person-years. The annual incidence was higher for men than for women and increased with age (p < 0.001). Rates increased with the calendar year (p < 0.001) from 11.4 cases per 100,000 person-years in the period from 1969 to 1979 to 24.4 per 100,000 person-years in the period from 2000 to 2009. The incidence remained relatively stable among children and young adults but almost tripled among individuals older than sixty years; this was partly driven by a significant increase in diabetes-related osteomyelitis from 2.3 cases per 100,000 person-years in the period from 1969 to 1979 to 7.6 cases per 100,000 person-years in the period from 2000 to 2009 (p < 0.001). Forty-four percent of cases involved Staphylococcus aureus infections. CONCLUSIONS: The reasons for the increase in osteomyelitis between 1969 and 2009 are unclear but could comprise a variety of factors, including changes in diagnosing patterns or increases in the prevalence of risk factors (e.g., diabetes) in this population.

The importance of early life in childhood obesity and related diseases: a report from the 2014 Gravida Strategic Summit.

Obesity and its related non-communicable diseases (NCDs), such as type 2 diabetes, heart disease and cancer, impose huge burdens on society, particularly the healthcare system. Until recently, public health and policy were primarily focused on secondary prevention and treatment of NCDs. However, epidemiological and experimental evidence indicates that early-life exposures influence the risk of childhood obesity and related diseases later in life, and has now focused attention on the health of both mother and child. During pregnancy and the early neonatal period, individuals respond to their environment by establishing anatomical, physiological and biochemical trajectories that shape their future health. This period of developmental plasticity provides an early window of opportunity to mitigate the environmental insults that may increase an individual's sensitivity to, or risk of, developing obesity or related diseases later in life. Although much investigation has already occurred in the area of Developmental Origins of Health and Disease research, the science itself is still in its infancy. It remains for researchers to tackle the important outstanding questions and translate their knowledge into workable solutions for the public good. The challenge, however, is to decide which areas to focus on. With these opportunities and challenges in mind, the 2014 Gravida Summit convened to examine how its early-life research program can determine which areas of research into mechanisms, biomarkers and interventions could contribute to the international research strategy to fight childhood obesity and its related diseases.

Lower growth rate from recent redshift space distortion measurements than expected from Planck.

We perform a metastudy of recently published redshift space distortion (RSD) measurements of the cosmological growth rate, f(z)σ8(z). We analyze the latest results from the 6dFGS, BOSS, LRG, WiggleZ, and VIPERS galaxy redshift surveys, and compare the measurements to expectations from Planck. In this Letter we point out that the RSD measurements are consistently lower than the values expected from Planck, and the relative scatter between the RSD measurements is lower than expected. A full resolution of this issue may require a more robust treatment of nonlinear effects in RSD models, although the trend for a low σ8 agrees with recent constraints on σ8 and Ω(m) from Sunyaev-Zeldovich cluster counts identified in Planck.

Surgical outcomes and predictors of stroke in a North American white and African American moyamoya population.

BACKGROUND: The majority of moyamoya surgical series have been confined to Asian and pediatric populations. Few have studied demographics, risk factors, and outcomes in adult North American populations. OBJECTIVE: To examine outcomes after revascularization for moyamoya in white and African American adults and to assess for predictors of recurrent stroke. METHODS: A retrospective review of 75 non-Asian patients undergoing 110 procedures at the Mayo Clinic was performed. Demographics, known moyamoya associations, cerebrovascular risk factors, and autoimmune diseases were recorded. Primary outcomes for vascular events were assessed with Kaplan-Meier analysis. Fisher exact methods were used to evaluate for associations with recurrent events. RESULTS: Mean age was 42 years, and mean follow-up was 47 months. Seventy-one of the 75 patients were white. The majority had bilateral disease (n = 49). Perioperative ischemic events occurred in 5 patients (4.5%). The 5- and 10-year event rates were 5.8% and 9.9%. Significant associations were found with a history of thyroid disease (P = .05) and recurrent stroke. A trend was also found between hypertension and autoimmune disease with recurrent stroke. CONCLUSION: Outcomes were favorable with revascularization in this subset with moyamoya. A significant association between a history of thyroid disease and recurrent stroke was found. Additionally, high prevalences of autoimmune disease, hypertension, and thyroid disease were found in our cohort, suggesting that they may play a role in the pathophysiology and progression of moyamoya disease in this population. A new classification for moyamoya is proposed based on these data.

Transposed brachiobasilic fistula or PTFE arm graft - alternative or complementary?

PURPOSE: Our primary aims were (1) to examine the patency of transposed brachiobasilic (TBB) fistulae compared to arm arteriovenous graft (AVG) without prior transposition, and (2) to examine the patency of AVG with and without prior transposition. METHODS: Single institution; analysis of prospectively collected data between January 2001 and January 2007. Dedicated database and medical records were reviewed and results analyzed with SPSS. RESULTS: Ninety-one patients underwent 111 procedures (52 TBB: 39 AVG as index); 28 TBB failed with 17 (60%) being replaced with an ipsilateral AVG. TBB compared to AVG (without prior TBB) had significantly (log rank <0.05 ) better primary, primary assisted and secondary patency. Secondary patency at 2 yrs was 47% to 33%, respectively. Ipsilateral AVG after TBB to primary AVG had superior patency rates (secondary patency at 2 yrs 52 vs. 33%) but did not reach significance (log rank =0.073). Combined secondary patency of TBB and AVG after TBB was 81% at 2 yrs. CONCLUSIONS: The TBB offers an autogenous fistula in the upper arm which has superior patency rates to an arm AVG. Once a TBB has failed an ipsilateral AVG is technically feasible and may offer better patency than a primary AVG.

The accuracy of clinical data: a comparison between central and local data collection.

BACKGROUND: The recent liberalisation of public access to information, including surgical performance, emphasises the necessity for accurate data collection. The Information and Statistics Division of the Scottish Executive (ISD) collect such data for each patient episode, but there is concern about the reliability of this information compared with that collected in local surgical departmental audit. AIM: To determine if diagnostic and operative details were consistent between local audited and national non-audited data sets. METHODS: Three surgical units comprising eight consultants were studied. Epidemiological, diagnostic and operative data for each consultant were accessed from the eScrips Internet resource (ISD Data) and from the departmental database. A unique patient number and date of birth matched individual patient episodes and the correlation between datasets graded for accuracy and consistency. RESULTS: 8375 individual data entries were recorded (ISD 4642, local databases 3733). 3402 pairs, 6408 (76.5%) of the total, matched accurately. 742 (16%) of the ISD entries were duplicates, and in 21% of unpaired entries the wrong consultant was recorded. Overall a clinically acceptable match occurred in 86.9% of paired entries for diagnosis and 84.0% for operation. The highest match with ISD data for diagnosis (88.8%) and operation (91.8%) occurred in the unit which holds a weekly audit meeting to validate information. DISCUSSION: There are significant discrepancies in surgical data between the local audit databases and central data. There is significant duplication of entries and inaccurate consultant allocation in ISD data. The promulgation of inaccurate information could threaten reputation or career and clinicians should play a more active role in ensuring clinical data are correct.

Surgical revascularisation in patients with severe limb ischaemia induces a pro-thrombotic state.

Platelet and coagulation activation are implicated in the increased incidence of ischaemic events seen in patients with peripheral arterial disease. This study aimed to assess the effect of surgical revascularisation on platelet aggregation and coagulation in patients with severe limb ischaemia (SLI). Twenty-two patients had blood samples taken: prior to surgery, on reperfusion, 2, 24 and 48 h post-surgery. Platelet aggregation through COX-mediated and thrombin receptor activator peptide (TRAP)-stimulated GPIIb/IIIa pathways was measured by the Ultegra point of care system. Thrombin-antithrombin III Complex (TAT) and D-dimer were measured by ELISA. COX-mediated aggregation increased significantly at reperfusion and remained elevated at 24 h [median increase from baseline of 9% (range -16 to 33%) P = 0.011]. TRAP-stimulated aggregation increased significantly at reperfusion and remained elevated at 2 h post-surgery [median increase 18% (range -71 to 45%); P = 0.007]. TAT levels were significantly elevated from reperfusion and remained so at 48 h (P < 0.003), whereas D-dimer only increased at 24 h (P = 0.014). For the first time, we have demonstrated that in patients with SLI, platelet aggregation is increased following surgery and there is a mismatch in the balance between the coagulation and fibrinolytic pathways despite the use of aspirin and heparin. Thus in the early post-operative these patients exhibit a pro-thrombotic state.

A preliminary study on the effects of exercising to maximum walking distance on platelet and endothelial function in patients with intermittent claudication.

BACKGROUND: Platelet and endothelial activation has been shown to be increased in patients with intermittent claudication (IC). Recent studies have suggested that exercise may induce further platelet activation. The aims of this study were to investigate the effect of exercising to maximum walking distance on platelet and endothelial function in patients with intermittent claudication who were receiving statin and aspirin therapy compared with age matched healthy controls. METHODS: Platelet aggregation through COX-mediated and thrombin receptor activator peptide (TRAP)-stimulated GPIIb/IIIa pathways was measured by the Ultegra point of care system in 20 patients with IC on aspirin and 20 healthy volunteers before, immediately and 1h after exercising to treadmill maximal walking distance (MWD). Soluble P-selectin, vWF and sICAM were measured using an enzyme linked immuno-sorbent assay technique. RESULTS: Baseline platelet aggregation was significantly reduced in patients with IC compared to volunteers (p<0.05). In patients, exercising to MWD significantly reduced platelet aggregation (COX, median -5% [range -24 to 13%]; p = 0.02; GPIIIa/IIb, median -13% [range -72 to 33%]; p = 0.02) immediately post-exercise which returned to baseline values at 1 h. There was no change in the healthy volunteers following the same median duration of exercise. Baseline sP-selectin levels were higher in the patients with IC compared to the healthy volunteers [Median values (interquartile range), 42.72 (33.28-54.24) versus 29.16 (24.40-34.10), p = 0.0003] but there were no differences in vWF levels. Both sP-selectin and vWF levels increased significantly in the control and patient group following exercise (p<0.005). sICAM were higher at baseline in the patients with IC but were unchanged following exercise [Median values (interquartile range),560.9 (405.5-739.4) versus 467.0 (325.7-643.4), p<0.05]. CONCLUSION: This study is the first to show that platelet aggregation is reduced immediately following treadmill exercise to maximum walking distance in patients with IC despite a rise in sP-selectin and vWF, suggesting endothelial activation. The inhibition of platelet aggregation after exercise in subjects on antiplatelet and statin therapy suggests that exercise is unlikely to exacerbate platelet thrombus formation in patients with IC.

Management of secondary risk factors in patients with intermittent claudication.

OBJECTIVES: The first line management of patients with intermittent claudication is "best medical therapy" i.e., smoking cessation, exercise, antiplatelet therapy and risk factors modification. The aim of this study was to assess the current management of risk factors in primary care and to compare General Practitioner (GP) attitudes and actual management. DESIGN AND METHODS: Postal questionnaire of all 336 GPs in the referral area (Grampian, Scotland). Questionnaire and measurement of serum cholesterol, blood glucose and HbA1c of new clinic patients (n = 104) with claudication referred by general practitioners. RESULTS: A 73% GP response rate was obtained. Ninety-five percent of GPs would treat risk factors. The vast majority would prescribe aspirin, yet 28% of patients were on no anti-platelet therapy. Eighty-nine percent of GPs would advise an increase in exercise but only 14% of patients recalled being told to do so. One in seven of the GPs would not check serum cholesterol, 18% considered cholesterol lowering therapy to be primary prevention and 41% would only treat levels above 5.5 mmol/l. Eighty-five percent of patients were on a statin or had a cholesterol above 5 mmol/L. Seventy-seven percent of GPs would check glucose levels, and 14% of patients were found to be previously undiagnosed diabetics. CONCLUSIONS: Risk factors in claudicants are suboptimally managed. Urgent guidelines for the specific management of claudicants by general practitioners, as well as strategies to ensure their implementation, are required.

The role of chromatic contrast and luminance polarity in stereoscopic segmentation.

We have investigated whether our ability to discriminate the stereoscopic depth of random-dot targets set amongst random-depth distractors is facilitated when target and distractors differ in particular combinations of colour and luminance polarity. For flat-plane targets, stereo-thresholds were found to be lower with a target-distractor colour/luminance difference, but only when that difference enabled the target elements to be identified in the monocular image, either by virtue of being less numerous than the distractors, or because the subject knew beforehand the target's colour/luminance. If neither of these conditions prevailed, stereoscopic thresholds were no different when target and distractors were segregated by colour/luminance than if they were not. For sine-wave disparity grating stimuli, in which subjects were required to discriminate the orientation of the depth corrugations, no advantage was found when target and distractors were segregated by colour/luminance under any condition. These results suggest that segregation by colour/luminance is only beneficial to the stereoscopic processing of random-element stimuli when the task can be performed by attending to a small number of target elements. A corollary to this conclusion is that stereopsis mechanisms do not automatically pre-filter the image into different colour/luminance maps.

Stereotactically delivered cranial radiation therapy: a ten-year experience of linac-based radiosurgery in the UK.

In 1989, linear accelerator (linac)-based cranial stereotactic radiation therapy ('radiosurgery') was introduced in the UK at St Bartholomew's Hospital; a new, relocatable stereotactic frame was first used at the same time, allowing fractionated stereotactic radiotherapy. In the first decade of clinical practice using this technology, some 200 patients with blood vessel tumours/malformations have been treated, together with another 200 suffering from other conditions. The usefulness of this technique for cerebral arteriovenous malformations (AVM) has been demonstrated, and also a significant cure rate for AVM of >3 cm diameter (which is larger than for those previously reported after treatment on the gamma unit), albeit attended by a higher complication rate. The epilepsy associated with AVM is much improved by successful radiotherapy. The usefulness of radiosurgery for glomus tumours has been confirmed and new data published on the efficacy of the technique for haemangioblastoma, with new radiation therapy strategies designed for patients with von Hippel-Lindau disease. The acoustic neuroma treatment results have included improvements in hearing (a result not reported in the gamma unit literature), which are ascribed to the lower internal dose gradient within the target volume. Fractionation will, it is argued, also lead to sparing of the special sensory cochlear nerve. The risks of radiosurgery to the brainstem for chordoma of the mid-clivus are reduced by using a 'spacer' technique for the prepontine space. For meningiomas involving the cavernous sinus, conventionally fractionated radiotherapy is recommended when the meningeal base diameter exceeds 3.0 cm and radiosurgery (utilizing fractionation where appropriate) is advised for smaller lesions. Thus far, radiosurgery indications for pituitary adenomas have been restricted to recurrences after conventional radiotherapy, usually those in the cavernous sinus. In therapy for recurrent craniopharyngioma, it is argued that fractionation delivered via the relocatable frame will be important, particularly when the disease envelops the optic chiasma. For semicystic/semisolid craniopharyngiomas, the stereotactic delivery of colloidal yttrium-90 into a cystic element is useful, while stereotactic radiosurgery is delivered to the solid component. Staff at this centre consider that radiosurgery for low-grade gliomas, perhaps as boost therapy after conventional fractionation, is worthy of more research. We have been extremely selective in the use of radiosurgery for brain metastases (2% of patients, compared with about 30% in some Gamma Knife units), but future indications may become broader, probably using it as a booster technique after whole-brain conventionally-fractionated radiotherapy. Positron emission tomography scanning, co-registered with magnetic resonance imaging, allows the 'boost' concept in radiosurgery to become a sophisticated and accurate reality. Post-radiosurgical sequelae have been placed within a standard framework classification. New observations are being made with regard to subacute reactions: late-responding intrinsic and extra-axial tumours may swell in the subacute period, prior to shrinkage, and be attended by symptomatic surrounding brain oedema.

Stereotactic radiosurgery. VI. Posterior displacement of the brainstem facilitates safer high dose radiosurgery for clival chordoma.

The current 'best treatment method' for clival chordoma is regarded as radical surgical resection followed by radiation therapy; radiosurgery usually plays a major part in the radiation therapy programme. From primate radiation biology studies and from clinical observations, the brainstem is known to be the most radiosensitive part of the central nervous system. The tolerance of the brainstem to high single radiosurgical doses of radiation is limited (all the more so in programmes such as our own where conventionally fractionated radiotherapy precedes radiosurgery or the patient has relapsed after conventional radiotherapy--as in the patient reported here). In this report we describe the operative displacement of the brainstem posteriorly at time of resection such that the proportion of the prescribed postoperative radiosurgical dose received by the brainstem is greatly reduced (by the order of 50%). The gains perceived to accrue from this technique are quantified from isodosimetric considerations not only in dose sparing to the brainstem, but importantly in that the dose to the clival chordoma may be highly significantly increased without exceeding current accepted tolerance brainstem dose limits. Two patients have received this joint surgical/radiosurgical approach to date; the second case is presented here in detail.

Screening for diabetes on a vascular ward: lessons from an audit.

Owing to the high prevalence of diabetes mellitus in patients with peripheral arterial disease, screening for this disorder is necessary on a vascular ward. Our current practice of random plasma glucose (RPG) testing on every admission was reviewed. This test, although crude, excludes diabetes if the cutoff level is set as low as 6.0 mmol/L. A total of 36% of our patients had an abnormal result, but this was not further acted upon. A further 19% had no test result recorded at all. This practice is inadequate and has resulted in the following implementations: (1) every patient with clinical evidence of arterial disease should have their RPG level measured; (2) patients with a level > 6.0 mmol/L should have a fasting plasma glucose level estimated; and (3) patients with an abnormal fasting plasma glucose level should be referred to the diabetic clinic.

Infrageniculate vein bypass graft for critical limb ischaemia: one surgeon's experience.

The results of 63 patients under the care of one surgeon who underwent a bypass, using vein, for critical limb ischaemia are presented. Thirty-two operations were to the crural vessels and the results are compared with those for 31 infrageniculate femoropopliteal bypasses. All patients were entered into a graft surveillance programme. There were no graft failures after 1 year in the femoropopliteal group with primary, primary assisted and secondary patency rates of 86, 90 and 93% respectively at 3 years. In the femorocrural group the rates were 55, 60 and 64% respectively. The difference in secondary patency was considered statistically significant (P < 0.01). Mortality rate of the femoropopliteal group was 31% at 3 years compared with 53% for the femorocrural group (n.s.). Five patients underwent major amputation, all of whom were in the femorocrural group. Failures, interventions and the effect of graft surveillance are discussed and the high mortality rate is highlighted.

Proliferation, ploidy and prognosis in uterine smooth muscle tumours.

DNA ploidy, mitotic rate (per 10 high power fields), mitotic index (per 1000 tumour nuclei), Ki-67 labelling index and S phase fraction were measured in 23 uterine leiomyosarcomas and 10 tumours of uncertain malignant potential. Correlations were calculated by Spearmann rank correlation. Univariate survival analysis was performed by log rank analysis and multivariate analysis performed by the Cox linear regression method. Ki-67 index and S phase fraction were significantly higher in leiomyosarcomas than in tumours of uncertain malignant potential. There was significant correlation between mitotic rate, mitotic index, Ki-67 index and S phase fraction in cases of leiomyosarcoma. Fifteen of 22 leiomyosarcomas and one of 10 tumours of uncertain malignant potential were DNA aneuploid. On univariate analysis of all the smooth muscle tumours, DNA ploidy, presence of significant nuclear atypia and presence of coagulative tumour cell necrosis were associated with outcome. Only DNA ploidy was associated with outcome in the group of leiomyosarcomas. On multivariate analysis of all of the smooth muscle tumours, DNA ploidy, age and grade of atypia were independently associated with outcome. No single factor was independently predictive of outcome in the group of leiomyosarcomas. Alternative indices of cell proliferation correlate with mitotic rate in uterine leiomyosarcoma and do not provide additional useful prognostic information. DNA ploidy, age and grade of atypia are independently associated with outcome in uterine smooth muscle tumours and measurement of DNA ploidy may be useful in identification of cases with an adverse prognosis.

Prospective audit of discharge summary errors.

During an 8-month interval of prospective audit, 63 of 637 (10 per cent) vascular discharge summaries were found to contain 94 errors. These comprised 11 (12 per cent) general errors, 21 (22 per cent) diagnostic errors, 19 (20 per cent) operative data errors, 19 (20 per cent) cases of incorrect clinical text information, 14 (15 per cent) missed complications and 10 (11 per cent) concerning follow-up arrangements. Overall, 2 per cent of consultant discharge summaries contained errors compared with 7 per cent for the senior registrar, 10 per cent for registrars and 17 per cent for senior house officers. Given that the majority of discharge summaries are currently prepared by junior staff, this study suggests that verification of the accuracy of clinical and management data should be an essential component of departmental audit meetings.

Overexpression of the c-myc proto-oncogene occurs frequently in uterine sarcomas.

Overexpression of the c-myc proto-oncogene occurs in carcinoma of the ovary, endometrium, and cervix, and is associated with an adverse prognosis, but little is known about the pattern of c-myc expression in uterine sarcomas. This study investigates the expression of c-myc in uterine smooth muscle tumors and malignant mixed müllerian tumors. Twenty-three leiomyosarcomas, 10 leiomyomas, and 9 malignant mixed müllerian tumors were examined for c-myc overexpression by immunohistochemistry. Differences in mitotic rate and in survival were compared in c-myc positive and negative cases of leiomyosarcoma. Overexpression of c-myc was seen in 6/12 leiomyomas, 11/23 leiomyosarcomas, and 9/9 malignant mixed müllerian tumors. Positive staining was restricted to a perinuclear location in all of the leiomyomas and one leiomyosarcoma. Diffuse cytoplasmic staining was seen in the remaining 10 positive leiomyosarcomas. Positive staining was seen in both epithelial and stromal elements of malignant mixed müllerian tumors, including homologous and heterologous areas of stromal differentiation. There was no significant difference in mitotic rate or in survival between c-myc positive and negative cases of leiomyosarcoma. Overexpression of c-myc occurs in many uterine leiomyosarcomas and the majority of malignant mixed müllerian tumors. Overexpression of c-myc also occurs in benign uterine smooth muscle tumors but with a different pattern than that seen in malignant tumors. This overexpression does not correlate with survival and the significance of overexpression of c-myc in these tumors is unclear.