Seven years of preoperative BTA abdominal wall preparation and the Macquarie system for surgical management of complex ventral hernia.

PURPOSE: To assess 7-year outcomes after complex ventral hernia (CVH) repair using pre-operative Botulinum toxin A (BTA) injection and the Macquarie System of management. METHODS: Clinical examination and functional non-contrast abdominal CT scans were used to assess complications and recurrences encountered in a prospective series of 88 consecutive CVH repairs using pre-operative BTA injection (200 or 300 units) between November 2012 and December 2019. Pre-operative progressive pneumoperitoneum (PPP) and/or component separation (CS) were also used in some cases. RESULTS: All hernia defects (mean transverse width 12.9 ± 5.2 cm) were successfully closed using either laparoscopic or laparoscopic-assisted open techniques facilitated by pre-operative BTA injection. The mean pre-operative post-BTA lateral oblique length gain was 4.7 ± 2.2 cm/side (p < 0.001). In 43 patients with defects < 12 cm wide, closure was achieved using BTA-only in 33 (76.7%), BTA + PPP in 2 (4.7%), BTA + CS in 5 (11.6%) and BTA + PPP + CS in 3 (7.0%). In the remaining 45 patients with defects [Formula: see text] 12 cm wide, closure was achieved using BTA-only in 9 (20.0%), BTA + PPP in 11 (24.4%), BTA + CS in 5 (11.1%) and BTA + PPP + CS in 20 (44.4%). There was a significant correlation between increasing defect size and the need for 2 or more CVH closure procedures (χ2 = 25.28, p < 0.0005). There were no BTA complications. Two patients developed midline hernia recurrences. CONCLUSION: Pre-operative BTA injection of the abdominal wall is a safe procedure that facilitates hernia defect closure and reduces the need for CS, especially when defect size is less than 12 cm. BTA may also decrease the rate of hernia recurrence.

A PCR-based intergenic spacer region-capillary gel electrophoresis typing method for identification and subtyping of Nocardia species.

While 16S rRNA sequence-based identification of Nocardia species has become the gold standard, it is not without its limitations. We evaluated a novel approach encompassing the amplification of the Nocardia 16S-23S rRNA intergenic spacer (IGS) region followed by fragment analysis by capillary gel electrophoresis (CGE) of the amplified product for species identification of Nocardia. One hundred forty-five Nocardia isolates (19 species) and four non-Nocardia aerobic actinomycetes were studied. Reproducibility testing was performed in a subset (21%) of isolates. Ninety-five different electropherograms were identified, with heterogeneity within species being a general observation. Among common Nocardia species (e.g., Nocardia cyriacigeorgica, N. nova, N. farcinica), 2 or 3 dominant electropherogram subgroups were typical. While only a minority (8/19; 42%) of the different Nocardia species contained isolates displaying unique fragment sizes that were predictive of a particular species, virtually all isolates (142/145; 98%) could be assigned to the correct species using IGS-CGE typing based on the number and size of amplified fragments. The median number of fragments for each isolate was 2 (range, 1 to 5) with only a minority (17%) having a single fragment detected. The majority (93%) of amplified fragments were between 408 and 461 bp. The technique was also non-operator dependent, highly reproducible, and quicker and less expensive than 16S sequencing. In summary, PCR-based IGS-CGE typing is relatively simple, accurate, reproducible, and cost-effective and offers a potential alternative to 16S rRNA sequencing for identifying and subtyping Nocardia isolates.

Clinical and laboratory features of invasive community-onset methicillin-resistant Staphylococcus aureus infection: a prospective case-control study.

Differences between the features of invasive community-onset methicillin-resistant Staphylococcus aureus (cMRSA) and methicillin-susceptible S. aureus (cMSSA) infections are incompletely understood. Fifty-seven patients with invasive cMRSA infection were prospectively identified at two teaching hospitals; for each cMRSA case, two cases of invasive cMSSA infection acted as controls. The primary outcome was 30-day all-cause mortality. Patients with invasive cMRSA infection were more likely to be Aboriginal (25% vs. 14%, age-adjusted odds ratio [OR] 2.5, p = 0.037), reside in a long-term care facility and/or have been hospitalised in the previous year (51% vs. 34%, p = 0.04) and less likely to have endocarditis (2% vs. 12%, p = 0.02) or require admission to an intensive care unit or high-dependency area (7% vs. 21%, p = 0.02). All-cause mortality at 30 days was similar in the cMRSA and cMSSA groups (9% vs. 7%, p = 0.68). Panton-Valentine leukocidin (PVL) genes were detected in a similar proportion of cMRSA and cMSSA isolates (32% vs. 27%, p = 0.49) and the presence of PVL genes was associated with younger age (35 years vs. 55 years, p < 0.001), Aboriginal ethnicity (38% vs. 10%, p < 0.001), skin and soft-tissue infection (54% vs. 19%, p < 0.001), lower illness severity at presentation (SAPS II score 9 vs. 21, p = 0.001) and shorter hospitalisation (9 days vs. 24 days, p < 0.001). Patients with "PVL-positive" and "PVL-negative" S. aureus infection had similar 30-day all-cause mortality (4% vs. 9%, p = 0.28). Few clinical features differentiated patients with invasive cMRSA infection from those with infection caused by cMSSA. Invasive "PVL-positive" S. aureus infection was associated with less morbidity but similar mortality to "PVL-negative" infection.