Cost analysis of an outbreak of Clostridium difficile infection ribotype 027 in a Dutch tertiary care centre.

BACKGROUND: The economic impact of Clostridium difficile infection (CDI) on the healthcare system is significant. From May 2013 to May 2014, an outbreak of C. difficile ribotype 027 occurred in a Dutch tertiary care hospital, involving 72 patients. The primary aim of this study was to provide insight into the financial burden that this CDI outbreak brought upon this hospital. METHODS: A retrospective analysis was performed to estimate the costs of a one-year-long C. difficile ribotype 027 outbreak. Medical charts were reviewed for patient data. In addition, all costs associated with the outbreak control measures were collected. FINDINGS: The attributable costs of the whole outbreak were estimated to be €1,222,376. The main contributing factor was missed revenue due to increased length of stay of CDI patients and closure of beds to enable contact isolation of CDI patients (36%). A second important cost component was extra surveillance and activities of the Department of Medical Microbiology and Infection Control (25%). CONCLUSION: To the authors' knowledge, this is the first study to provide insight into the attributable costs of CDI in an outbreak setting, and to delineate the major cost items. It is clear that the economic consequences of CDI are significant. The high costs associated with a CDI outbreak should help to justify the use of additional resources for CDI prevention and control.

How do spinal segments move?

PURPOSE: To study and clarify the kinematics of spinal segments following cyclic torques causing axial rotation (T(z) (t)), lateral-flexion (T(x) (t)), flexion/extension (T(y) (t)). METHODS: A 6D--Measurement of location, alignment, and migration of the instantaneous helical axis (IHA) as a function of rotational angle in cervical, thoracic, and lumbar segments subjected to axially directed preloads. RESULTS: IHA retained an almost constant alignment, but migrated along distinct centrodes. THORACIC SEGMENTS: IHA was almost parallel to T(z) (t), T(x) (t), or T(y) (t), stationary for T(x) (t) or T(y) (t), and migrating for T(z) (t) along dorsally opened bows. IHA locations hardly depended on the position or size of axial preload. LUMBAR SEGMENTS: IHA was also almost parallel to T(z) (t), T(x) (t), or T(y) (t). In axial rotation IHA-migration along wide, ventrally or dorsally bent bows depending on segmental flexional/extensional status. Distances covered: 20-60mm. In lateral-flexion: IHA-migration to the left/right joint and vice versa. In flexion/extension IHA-migration from the facets to the centre of the disc. CERVICAL SEGMENTS: In flexion/flexion IHA was almost stationary for and parallel to T(y) (t). In axial rotation or lateral-flexion IHA intersected T(z) (t)/T(x) (t) under approximately -30 degrees /+30 degrees. CONCLUSIONS: Generally joints alternate in guidance. Lumbar segments: in axial rotation and lateral-flexion parametrical control of IHA-position and IHA-migration by axial preload position. Cervical segments: kinematical coupling between axial rotation and lateral-flexion. The IHA-migration guided by the joints should be taken into account in the design of non-fusion implants. FE-calculations of spinal mechanics and kinematics should be based on detailed data of curvature morphology of the articulating surfaces of the joint facets.

[Biomechanics of the tibiofemoral joint and knee braces]. / Zur Biomechanik des Tibiofemoralgelenks und deren Umsetzung bei Knieorthesen.

We investigated whether the kinematics of modern knee braces reflect the natural movement of the knee, especially with regard to the roll-glide ratio. Seven commercially available modern knee braces were analyzed in a new measuring unit with a 6-D positional registration system, which had been developed for this study. The results were compared to the theoretically postulated joint movements. All knee braces produced a roll-glide ratio different from the natural movement of the knee. Only the Townsend brace protected the anterior cruciate ligament at the beginning of the movement.Biomechanically, none of the knee braces tested provided efficient protection for the knee movement. We propose a new functional external joint, which allows restoration of the natural roll-glide mechanism of the articulating surfaces.

[An optical method for determining deformation and form changes in polyethylene surfaces of explanted acetabular cups of hip endoprostheses]. / Ein optisches Verfahren zur Bestimmung des Abriebs und der Gestaltsänderung der Polyethylenoberfläche explantierter Pfannen von Hüftendoprothesen.

AIM: Most methods used for the determination of volumetric wear of polyethylene cups are based on the assumption that the head of the prosthesis penetrates the cup in "cylindrical" fashion. The new accurate optical method is independent of this disputable assumption. METHOD: The articulating surface of the cup is scanned with light and a data set of 60,000 pixels obtained in this way is stored in a computer. Data obtained from used cups were compared with those obtained from unused cups. The volumetric wear was calculated directly by threefold integration. To assess the changes in surface shape, the data are fitted by an ellipsoid whose long axis defines the mean direction of load. A total of 18 retrieved and 3 unused cups of different types were studied. RESULTS: The unused acetabular cups deviated only slightly from ideal hemispheres. The surfaces showed rotational symmetry, and an undulation having an amplitude of 0.1 mm between dome and equator. For all explanted cups, the assumption of cylindrical penetration of the head into the polyethylene was shown not to represent the true situation. The cup expands in all directions, and the volumetric wear is underestimated by 50% with the traditional methods. The data suggest that long-term survival may be jeopardized when the main direction of loading is centered on the dome of the cup. Ceramic heads were associated with smaller rates of volumetric wear. CONCLUSION: The new optical method is characterised by short measuring times, precision and simple application. Analysis of the wear patterns of polyethylene components using this technique may contribute to a further understanding of the complex mechanisms of aseptic loosening.

[Biomechanical principles in diarthroses and synarthroses. IV: the mechanics of lumbar vertebrae. A pilot study]. / Biomechanische Prinzipien in Diarthrosen und Synarthrosen. Teil IV: Zur Mechanik der Wirbelsäule im Lendenbereich. Eine Pilotstudie.

UNLABELLED: Theoretical considerations help define the requirements for an apparatus that is to localize the instantaneous helical axes (IHA) of axial rotations of lumbar segments. RESULT: Since the range of axial rotation of an L3/4 segment is in only approximately +/- 1.5 degrees the rotational angle intervals have to be smaller than 0.3 degree with an resolution less than 0.03 degree in order to be able to determine the loci of the IHAs. For the first time in vitro measurements are presented that satisfy this requirement. The data prove that the guidance by the artt. zygapophysiales critically influence the possible positions of the IHA. Comparatively, ligaments and intervertebral disk play a marginally role. During axial torques Tz the IHAs lie dorsal to the intervertebral disk and migrate from one joint to the other depending on axial rotation (length of migration: approximately 3-4 cm). The IHAs lie almost parallel to the axial torque vector. When the joints are removed the IHA is stationary and almost perpendicular to the intervertebral disk and intersects the disk's central region. The screw inclination (pitch) of the instantaneous screw movement is proportional to the rotational angle. Therefore, depending on the direction of rotation, one obtains left or right handed screw movements. This means: axial torsional load leads to an increase in thickness of the intervertebral disk. During preloads that produces extensions the fixed centrodes (paths of axis migration) of intact segments are dorsally beaten out, whereas during flexional loads they are ventrally beaten out. Then, the IHAs migrate through the canalis vertebralis. By the concept "dimeric link chain" the different shapes of the fixed centrode are traced back to the morphology of curvature of the articulating surfaces. The measurements suggest the hypothesis that the distinct nonlinearity of the load displacement curves (s-shape of alpha = alpha (Tz) funktion is an affection of IHA migration. Comparatively, the influence of ligaments can be neglected. The measurements suggest the hypothesis that the hysteresis of the load displacement curves (neutral zone) is an artefact that does not appear in vivo. Altogether, the experiments prove that the loci of the IHAs are determined by the interplay of preload, structure of the applied force system and morphology of curvature of the articulating surfaces. By that the possibility is clinically given to calculate the multitude of possible movements as function of muscle activity when in the individual the shape and the position of the articulating surfaces are measured in vivo (by NMR-methods e.g.). A physically based classification of pathological cases seems to be possible.

Siblings in foster care: success and failure.

This article reports on a retrospective study of 59 joint placements of siblings in foster homes, involving a total of 137 children. An overall picture is presented of the agencies' considerations in making these placements. The number of prematurely terminated placements in this group amounted to 14 (23.7%). Several factors that appear related to premature termination are discussed.