Recent Advances in the Diagnosis and Treatment of Clostridium Difficile Infection.

Clostridium difficile infection (CDI) has become the most frequently reported health care-associated infection in the United States [1]. As the incidence of CDI rises, so too does the burden it produces on health care and society. In an attempt to decrease the burden of CDI and provide the best outcomes for patients affected by CDI, there have been many recent advancements in the understanding, diagnosis, and management of CDI. In this article, we review the current recommendations regarding CDI testing and treatment strategies.

Birth weight and incidence of surgical obstetric brachial plexus injury.

OBJECTIVES: (1) To analyze the birth weight of obstetric brachial plexus injury (OBPI) patients requiring one or more reconstructive surgeries and (2) to analyze whether there is any difference in the severity of the injury, and the outcome of the surgery between the macrosomic and nonmacrosomic OBPI patients. STUDY DESIGN: An observational cohort study was performed on 100 consecutive patients treated with surgery at the Texas Nerve and Paralysis Institute. Ninety of the 100 patients underwent the modified Quad surgery, which improves the shoulder abduction and overall shoulder function. All OBPI patients in our study were assessed preoperatively and postoperatively by evaluating video recordings of active shoulder abduction. RESULTS: Using a 4000 g definition of macrosomia, 52% of patients would be considered macrosomic, and using a 4500 g definition of macrosomia, 18% of patients are considered macrosomic in our study. Permanent injury occurs also in average-birth-weight children. CONCLUSIONS: A significant percentage (48%-82% depending on definition of macrosomia) of OBPI patients requiring major reconstructive surgery had birth weights which would put them in the "normal" birth weight category. In addition, we found that there was no significant difference in the severity of the injury, and the outcome of the modified Quad surgical procedure between macrosomic and nonmacrosomic OBPI patients. However, there was a significant improvement in shoulder movement in both macrosomic and nonmacrosomic patients after modified Quad surgery.

Risk factors at birth for permanent obstetric brachial plexus injury and associated osseous deformities.

Purpose. To examine the most prevalent risk factors found in patients with permanent obstetric brachial plexus injury (OBPI) to identify better predictors of injury. Methods. A population-based study was performed on 241 OBPI patients who underwent surgical treatment at the Texas Nerve and Paralysis Institute. Results. Shoulder dystocia (97%) was the most prevalent risk factor. We found that 80% of the patients in this study were not macrosomic, and 43% weighed less than 4000 g at birth. The rate of instrument use was 41% , which is 4-fold higher than the 10% predicted for all vaginal deliveries in the United States. Posterior subluxation and glenoid version measurements in children with no finger movement at birth indicated a less severe shoulder deformity in comparison with those with finger movement. Conclusions. The average birth weight in this study was indistinguishable from the average birth weight reported for all brachial plexus injuries. Higher birth weight does not, therefore, affect the prognosis of brachial plexus injury. We found forceps/vacuum delivery to be an independent risk factor for OBPI, regardless of birth weight. Permanently injured patients with finger movement at birth develop more severe bony deformities of the shoulder than patients without finger movement.

Assessment of triangle tilt surgery in children with obstetric brachial plexus injury using the pediatric outcomes data collection instrument.

BACKGROUND: The benefits of triangle tilt surgery in children with OBPI have been previously validated through measurements of statistical improvements in Mallet scores and in glenohumeral congruity. The purpose of the current study was to evaluate the effectiveness of triangle tilt surgery through the application of the Pediatric Outcomes Data Collection Instrument, a well validated questionnaire designed to evaluate function and comfort in children with musculoskeletal disorders. METHODS: OBPI patients between 2 and 10 years of age who came to our institute for routine office visits between May 2009 and October 2009 were considered to participate in the study. Among the patient group, the first 130 completed surveys who met the study criteria were included in the study. The Pediatric Outcomes Data Collection Instrument was completed by the parents of patients who have undergone triangle tilt surgery (Group 1: N=63) or those who were considered candidates for this procedure (Group 2: N=67). The results were compared between the two patient groups and analyzed using the unpaired student's t-test. Later, 23 patients from the group 2, underwent triangle tilt surgery (Group 3). We collected post-op data, compared and analyzed the outcome of the surgery in these patients to their own pre-op PODCI scores, using the paired student's t test. RESULTS: In patients who have undergone triangle tilt surgery, significantly higher PODCI scores were observed in the parameters of upper extremity function (p<0.05), sports/physical function (p<0.05), basic mobility (p<0.0001) and global functioning (p<0.05), when compared to patients who have not undergone triangle tilt surgery. Further, PODCI scores in group 3 patients were significantly higher after surgery in the parameters of upper extremity function (p <0.03), Pain/Comfort (p <0.05), basic mobility (p<0.0002) and global functioning (p<0.03), when compared to before triangle tilt surgery. CONCLUSION: The results of the Pediatric Outcomes Data Collection Instrument demonstrate the functional benefits of triangle tilt surgery in patients with obstetric brachial plexus injury.

Triangle tilt surgery as salvage procedure for failed shoulder surgery in obstetric brachial plexus injury.

PURPOSE: The study was conducted to review the effects of triangle tilt surgery in children with OBPI (obstetric brachial plexus injury) who had previously undergone several operative procedures at other hospitals before presenting at our institute. METHODS: The study included a group of 48 OBPI patients who had undergone previous operative procedures at outside hospitals by other surgeons. Patients were assessed for shoulder function using their radiological reports and the modified Mallet functional scale. The same patients underwent the triangle tilt procedure at our institution and were re-evaluated for shoulder function. RESULTS: The results of the study showed an increase in Mallet scores from 11.88 points to 15.17 points (p < 0.01), improvement in PHHA (percentage of humeral head anterior to the glenoid) from 14% to 25% (p < 0.05), enhancement in glenoid version from -32 degrees to -25 degrees (p < 0.01), and a decrease in the SHEAR (scapular hypoplasia, elevation, and rotation) deformity after surgery. CONCLUSION: The data obtained demonstrated that the triangle tilt procedure significantly enhanced shoulder function and glenohumeral congruity in these patients as evidenced by the improvements in Mallet scores, PHHA, glenoid version, and SHEAR deformity.