Management of acute respiratory complications from influenza A (H1N1) infection: experience of a tertiary-level Intensive Care Unit.

BACKGROUND: The novel influenza A (H1N1) pandemic was associated with an epidemic of critical illness. METHODS: We describe the clinical profiles of critically ill patients with severe complications due to microbiologically confirmed pandemic influenza A (H1N1) infection admitted to a medical ICU in Monza, Italy, over a 6-month period. RESULTS: From August 2009 to January 2010, 19 patients (13 adults and 6 children) required ICU admission. Nine subjects were referred to our hospital from other ICUs. In all patients, with the exception of a case of severe septic shock, the cause of ICU admission was acute respiratory failure. Other nonpulmonary organ failures were common. A trial of non-invasive ventilation was attempted in 13 cases and was successful in four of them. The majority of the patients required invasive mechanical ventilation. In the 7 most severely hypoxemic patients, we applied veno-venous ECLS, with a very high rate of success. The median ICU stay was 9 days (range 1-78 days). Sixteen out of 19 (84%) patients survived. CONCLUSION: In the majority of our patients, critical illness caused by pandemic influenza A (H1N1) was associated with severe hypoxemia, multiple organ failure, requirement for mechanical ventilation and frequent use of rescue therapies and ECLS support.

Different microbial biofilm formation on polymethylmethacrylate (PMMA) bone cement loaded with gentamicin and vancomycin.

We studied the in vitro effects of gentamicin and vancomycin alone and in combination added to polymethylmethacrylate (PMMA) cement specimens on the bacterial adhesion of multiresistant clinical isolates. The PMMA specimens (discs) loaded with gentamicin (1.9%) or vancomycin (1.9%) or with a combination of the two were placed in Mueller-Hinton Broth inoculated with bacterial strains. After incubation, bacterial growth was determined by optical density (OD(540)) and sub-cultures. The biofilm PMMA-associated dye (crystal violet) was measured. Antibiotic concentrations in broth were determined by fluorescence polarisation immunoassay. All antibiotic-loaded PMMA cement specimens released high, inhibitory concentrations of gentamicin and vancomycin. However, differences in strain growth and adhesion were recorded. The clinical isolates Met-R/Gent-R CoNS showed no adhesion to gentamicin-loaded specimens for 24 h; strains with Gent-Intermediate susceptibility exhibited growth after 48 h but reduced adhesion. Some Gent-R strains exhibited growth and adhesion to antibiotic-loaded specimens similar to controls (plain discs). Only the VRSA strain (Staphylococcus aureus 5/7) and Escherichia coli were able to grow and adhere to vancomycin-loaded specimens after 24 h of incubation. The specimens loaded with the gentamicin + vancomycin combination showed a synergistic inhibitory effect against all tested strains (no bacterial growth). The degree of bacterial adhesion to PMMA cement loaded with gentamicin or vancomycin may be reduced in spite of a normal growth rate and is different for the tested strains. The effect of gentamicin and vancomycin on bacterial growth and adhesion to PMMA bone cement depends on the antibiotic concentrations, on the characteristics of each specific strain and on its ability to produce biofilm and adhere to antibiotic-loaded PMMA bone cement.

[Computer-assisted surgery (CAS) in transpedicular lumbar fusion. Experiences of the Spinal Neurosurgery Department]. / Die computer-assistierte Chirurgie (CAS) der transpedikulären lumbalen Fusion. Erfahrungen in der Neurochirurgie der Spine Unit.

A well-known problem occurring with lumbar fusion is the incorrect placement of the pedicular screws. Previous studies have shown a rate of incorrect insertion of the screws ranging from 10 to 40%. An incorrectly inserted screw with medial perforation through the pedicle may cause an acute injury of the root passing medially to the pedicle. In case of wrong laterally placed screw the root exiting along the lateral wall of pedicle can be damaged. As a rule, a neurological deficit due to such an injury is irreversible. Vascular lesions are much rarer. Screws malposition, no matter in which direction the insertion should be wrong, leads very often to failed fusion. To reduce the rate of incorrectly placed transpedicular screws, computed tomography based navigation has been introduced. It allows the surgeon multidimensional control of the screw position in virtual reality and real time during insertion. The experience with the first 109 patients in which transpedicular lumbar fusion was performed this way in the Neurosurgical Dpt of the Spine Unit in the Schulthess Clinic in Zurich is described. The computed assisted surgery (CAS) takes slightly more time than the conventional procedure. The significantly increased accuracy of pedicle screw insertion repays this disadvantage generously.

Surgical treatment of cervical myelopathy of unclear aetiology.

In some cases neither the clinical pattern nor the findings of magnetic resonance imaging (MRI) can help to determine the cause of a cervical myelopathy. The differential diagnosis of such cases as a rule includes spondylotic myelopathy, a solitary focus of multiple sclerosis and an intramedullary tumour in early stage. Worsening of signs and symptoms due to the circumscribed lesion of the spinal cord can require surgical treatment, even if no certain diagnosis could be stated thus far. The question is how to choose a surgical procedure which is beneficial for all three kinds of spinal cord pathology in their initial stage, which at the same time does not jeopardise spine and spinal cord and allows secondary surgery if needed after the precise nature of the lesion has been assessed. Ventral decompression and fusion with or without dorsal decompression seems to be a convincing procedure.

Release of gentamicin and vancomycin from temporary human hip spacers in two-stage revision of infected arthroplasty.

AIM: Evaluation of the delivery of gentamicin and vancomycin from polymethylmethacrylate (PMMA) spacers before and after implantation for the treatment of total hip replacement infections. METHODS: Twenty industrially produced spacers containing gentamicin (1.9%) were utilized. Vancomycin (2.5%) mixed with PMMA cement was used to fill holes drilled in the cement of 14 of the 20 spacers immediately before implantation. The spacers were removed from 20 patients 3-6 months after implantation and then immersed in phosphate buffer at 37 degrees C for 10 days. Antibiotic concentrations were determined by fluorescence polarization immunoassay. RESULTS: Gentamicin and vancomycin were still present in all the spacers removed from the patients. The release of gentamicin alone and in combination with vancomycin was in the range 0.05%-0.4% of the initial amount present, whereas the release of vancomycin was in the range 0.8%-3.3%. The release kinetics showed a similar pattern for both drugs. After a high initial release of drug, a reduced, but constant, elution was observed over the next few days. CONCLUSIONS: The delivery of gentamicin and vancomycin from PMMA cement was high initially, with sustained release over several months. Incorporation of vancomycin into the surface of the spacers permitted spacers to be prepared with multiple antibiotics present and without adversely affecting the release kinetics of the agents. The gentamicin-vancomycin combination shows potential for the treatment of infection following total hip replacement in specific patients.

Community level risk factors for numbers of landmine victims in Chad and Thailand.

STUDY OBJECTIVE: To determine commonalities of landmine victim risk factors in two very different countries. DESIGN AND SETTING: Data on 249 communities in Chad and 530 in Thailand were collected during 2000-2001 as part of the Global Landmine Survey. Community level variables were analysed in a series of Poisson mixture models with number of landmine victims as the dependent variable. Models developed for each country were tested on the other to investigate similarities and robustness of identification of risk factors. MAIN RESULTS: Increased community level risk was associated with population size, closeness to another community with victims, emplacement in the previous two years, blocked water or pasture, and the proximity of unexploded ordnance or anti-tank mines. In Chad, risk factors tended to be more related to identifying communities that had crossed a threshold between near zero and moderate risk; Thailand, factors were more related to increases in victim rates. CONCLUSIONS: Current systems of collecting data on community characteristics and landmine victims can provide meaningful risk factor information. Remediation approaches that focus on blockage of important resources and areas of recent, high intensity conflicts may be the most beneficial in reducing the numbers of victims.

Release of antibiotics from polymethylmethacrylate cement.

The increase in resistance rates to antibiotics of bacteria isolated from infected hip joints, particularly staphylococci, prompted us to investigate the usefulness of antibiotic combinations such as gentamicin plus vancomycin. Cylinder test specimens of polymethylmethacrylate (PMMA) cement (Cemex, Tecres) containing gentamicin alone, vancomycin alone and both drugs in combination, were studied. The antibiotic concentrations were determined using a microbiological method and fluorescence polarization immunoassay (FPIA). The release of gentamicin alone, vancomycin alone and in combination from PMMA cement was prompt. The combination revealed synergistic antimicrobial activity against Escherichia coli and Enterococcus faecalis. FPIA showed that gentamicin and vancomycin delivery rates from PMMA cement were different. Gentamicin alone and in combination with vancomycin presented similar release rates from PMMA cement (1.50%). Vancomycin release from PMMA cylinders impregnated with the combination was lower (0.51%) than that from cylinders with vancomycin alone (1.16%). Vancomycin showed a 34.1% loss of microbiological activity at 37 degrees C after 10 days of incubation; the reduction corresponded to 15.0% when measured by FPIA. Results obtained with test specimens are indicative for the preparation of antibiotic-impregnated cements for different human prostheses.

[Clinical aspects, etiology, pathogenesis, diagnosis and therapy of aseptic bone necrosis--a current analysis of the literature]. / Klinik, Atiologie, Pathogenese, Diagnostik und Therapie der aseptischen Knochennekrosen--eine aktuelle Literaturanalyse.

With continuous proliferation of magnetic resonance imaging early detection of avascular bone necrosis becomes progressively important for treatment of early disease stages. The last decades intensified research on the field of ostoenecrosis has lead to different etiopathogenetic models and to new treatment options. Thereby long term results of known operative interventions are now available. Those can be used as a standard of treatment, new innovative techniques (e.g. mosaic arthoplasty or chondrocyte transplantation) might also be added. The goal of this paper is to give a comprehensive review about Osteonecrosis, Osteochondrosis and Osteochondritis dissecans. Respectively the latest literature results we are able to subordinate these to one unit with mechanical stress as a significant etiological factor in common. Knowledge derived form single literature marks are perhaps comprehended to general picture.

Thoracic myelopathy due to enlarged ossified yellow ligaments. Case report and review of the literature.

Enlarged ossified yellow ligaments are a rare and poorly understood cause of thoracic myelopathy. The authors report the case of a patient in whom thoracic myelopathy was caused by enlarged ossified yellow ligaments.

[Lumbago and radicular complaints: not always a herniated disk or degenerative stenosis of the spinal canal. A differential diagnosis of infrequent diseases]. / Lumbago und radikuläre Beschwerden: nicht immer Diskushernie und degenerative Wirbelkanalstenose. Eine Differentialdiagnose seltener Krankheiten.

Low back ache and pain in the legs are not always due to disc displacement and lumbar spinal degenerative changes. Some infrequent, but really not very rare diseases are presented in order to avoid mistakes which can have serious consequences for the patients. Degenerative changes of the lumbar spine are very common, not only in aged people. A superficial examination of the patient with back ache and/or pain in the legs can lead to a fallacious tie-up between such lesions and disturbances and complaints which are not connected to them.

Teratoma of the conus medullaris.

Intramedullary teratoma is a rare neoplasm. To our knowledge only 10 cases have been reported so far, eight of mature teratoma and two of immature. We present a new case of mature teratoma located in the conus medullaris. After 2 years increasing complaints and worsening neurologic deficits, the neoplasm was discovered by magnetic resonance imaging and was completely resected surgically. Similar cases are reviewed and the clinical, radiological, surgical and morphological aspects of this lesion will be discussed. In the majority of cases, the tumour has an indolent growth rate and recovery after resection is good.

Lumbago and radicular complaints: not always a disc hernia or degenerative stenosis of the spinal canal. A differential diagnosis of infrequent diseases.

Low back ache and pain in the legs are not always due to disc displacement and lumbar spinal degenerative changes. Some infrequent, but really not very rare diseases are presented in order to avoid mistakes which can have serious consequences for the patients. Degenerative changes of the lumbar spine are very common, not only in aged people. A superficial examination of the patient with back ache and/or pain in the legs can lead to a fallacious tie-up between such lesions and disturbances and complaints which are not connected to them.