Functional outcome of total knee arthroplasty following tibial plateau fractures: a systematic review.

BACKGROUND: Posttraumatic osteoarthritis (PTOA) following a tibial plateau fracture (TPF) is a debilitating disease which often affects a young and active patient population for whom good knee function is essential. Frequently, total knee arthroplasty (TKA) is the only surgical option. The aim of this systematic review was to evaluate functional outcome for TKA in PTOA patients, together with several secondary outcome parameters. METHODS: A systematic review according to the PRISMA guidelines was conducted. Studies were included that reported on patient-reported outcome measures, range of motion or objective functional analysis after TKA because of PTOA following TPF. RESULTS: After analyzing 105 studies, 5 were included for the final review. In total, 162 patients with a TKA for PTOA were included of whom 125 (77%) were managed operatively for their TPF. All studies reported improvements in functional outcome after TKA, with two studies showing no significant differences between PTOA patients and a matched cohort of primary OA patients. Reported complication and re-intervention rates were higher for TKA patients with PTOA. CONCLUSION: The results of this review indicate the TKA for PTOA after a TPF provides satisfactory functional outcome, with results similar to those of matched primary OA patients. TKA should, therefore, be considered a viable treatment option to improve function, but both patients and orthopedic surgeons should be aware of the higher complication rates in this patient population.

Monitors to improve indoor air carbon dioxide concentrations in the hospital: A randomized crossover trial.

BACKGROUND: Ventilation has emerged as an important strategy to reduce indoor aerosol transmission of coronavirus disease 2019. Indoor air carbon dioxide (CO2) concentrations are a surrogate measure of respiratory pathogen transmission risk. OBJECTIVES: To determine whether CO2 monitors are necessary and effective to improve ventilation in hospitals. METHODS: A randomized, placebo (sham)-controlled, crossover, open label trial. Between February and May 2021, we placed CO2 monitors in twelve double-bed patient rooms across two geriatric wards. Staff were instructed to open windows, increase the air exchange rate and reduce room crowding to maintain indoor air CO2 concentrations ≤800 parts per million (ppm). RESULTS: CO2 levels increased during morning care and especially in rooms housing couples (rooming-in). The median (interquartile range, IQR) time/day with CO2 concentration > 800 ppm (primary outcome) was 110 min (IQR 47-207) at baseline, 82 min (IQR 12-226.5) during sham periods, 78 min (IQR 20-154) during intervention periods and 140 min (IQR 19.5-612.5) post-intervention. The intervention period only differed significantly from the post-intervention period (P = 0.02), mainly due to an imbalance in rooming-in. Significant but small differences were observed in secondary outcomes of time/day with CO2 concentrations > 1000 ppm and daily peak CO2 concentrations during the intervention vs. baseline and vs. the post-intervention period, but not vs. sham. Staff reported cold discomfort for patients as the main barrier towards increasing ventilation. DISCUSSION: Indoor air CO2 concentrations in hospital rooms commonly peaked above recommended levels, especially during morning care and rooming-in. There are many possible barriers towards implementing CO2 monitors to improve ventilation in a real-world hospital setting. A paradigm shift in hospital infection control towards adequate ventilation is warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04770597.

Molecular detection of Helicobacter pylori and clarithromycin resistance in gastric biopsies: a prospective evaluation of RIDA®GENE Helicobacter pylori assay.

Background: Empirical treatment of Helicobacter pylori (HP) depends on the local prevalence of clarithromycin resistance but data are lacking and culturing of HP is time-consuming. We evaluated RIDA®GENE Helicobacter pylori assay (r-biopharm), a quantitative PCR assay for detecting HP and clarithromycin resistance mutations in gastric biopsies.Material/methods: Gastric biopsies were obtained from each of 436 consecutive patients referred for gastroscopic investigation and results of qPCR were compared to culture and immunohistochemical staining (IHCS).Results: Of 436 samples, 47 were positive for HP by PCR (11%), 42 by culture (9.7%) and 44 by IHCS (10%). Compared to culture, sensitivity and specificity of the qPCR were 100% and 99%, respectively, and 96% and 99% compared to IHCS. The sensitivity and specificity for clarithromycin resistance detection were 92% and 97%, respectively.Conclusions: RIDA®GENE Helicobacter pylori assay reliably and rapidly detects HP and its resistance to clarithromycin in human gastric biopsies.

Feasibility of using point-of-care lung ultrasound for early triage of COVID-19 patients in the emergency room.

PURPOSE: Diagnostic value of point-of-care lung ultrasound (POCUS) in detection of coronavirus disease (COVID-19) in an emergency setting is currently unclear. In this study, we aimed to compare diagnostic performance, in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy, of POCUS lung, chest CT, and RT-PCR for clinically suspected COVID-19 infections in patients submitting to the emergency room (ER). MATERIAL AND METHODS: This retrospective study enrolled 93 patients with a suspected COVID-19 infection, admitted to the ER between March 28th and April 20th, 2020. Test subjects showed one or more symptoms of an acute respiratory infection, for which consequent COVID-19 testing was achieved using POCUS lung, chest CT, and RT-PCR. CT images were analyzed by 2 radiologists blinded to RT-PCR results. POCUS lung was performed by three emergency medical doctors, and reports were analyzed by the researcher, blinded to clinical information, US imaging, CT, and RT-PCR test results. RESULTS: Compared with RT-PCR, POCUS lung demonstrated outstanding sensitivity and NPV (93.3% and 94.1% respectively) while showing poor values for specificity, PPV, and accuracy (21.3%, 19.2%, and 33.3% respectively). In contrast, similar inquiries using chest CT as index test, excellent sensitivity, specificity, NPV, and accuracy (80.0%, 86.7%, 95.6%, and 85.6%, respectively) were reported, beside a moderate value for PPV (54.5%). CONCLUSION: POCUS may provide early ER triage with a useful, rapid, low-threshold, and safe screening tool in evaluating possible COVID-19 infections. Due to limited specificity, suggestive POCUS lung findings should be confirmed with RT-PCR or chest CT.

Frailty and Mortality in Hospitalized Older Adults With COVID-19: Retrospective Observational Study.

OBJECTIVES: To determine the association between frailty and short-term mortality in older adults hospitalized for coronavirus disease 2019 (COVID-19). DESIGN: Retrospective single-center observational study. SETTING AND PARTICIPANTS: Eighty-one patients with COVID-19 confirmed by reverse-transcriptase polymerase chain reaction (RT-PCR), at the Geriatrics department of a general hospital in Belgium. MEASUREMENTS: Frailty was graded according to the Rockwood Clinical Frailty Scale (CFS). Demographic, biochemical, and radiologic variables, comorbidities, symptoms, and treatment were extracted from electronic medical records. RESULTS: Participants (N = 48 women, 59%) had a median age of 85 years (range 65-97 years) and a median CFS score of 7 (range 2-9); 42 (52%) were long-term care residents. Within 6 weeks, 18 patients died. Mortality was significantly but weakly associated with age (Spearman r = 0.241, P = .03) and CFS score (r = 0.282, P = .011), baseline lactate dehydrogenase (LDH; r = 0.301, P = .009), lymphocyte count (r = -0.262, P = .02), and RT-PCR cycle threshold (Ct, r = -0.285, P = .015). Mortality was not associated with long-term care residence, dementia, delirium, or polypharmacy. In multivariable logistic regression analyses, CFS, LDH, and RT-PCR Ct (but not age) remained independently associated with mortality. Both age and frailty had poor specificity to predict survival. A multivariable model combining age, CFS, LDH, and viral load significantly predicted survival. CONCLUSIONS AND IMPLICATIONS: Although their prognosis is worse, even the oldest and most severely frail patients may benefit from hospitalization for COVID-19, if sufficient resources are available.

Accuracy and Reproducibility of Low-Dose Submillisievert Chest CT for the Diagnosis of COVID-19.

PURPOSE: To demonstrate the accuracy and reproducibility of low-dose submillisievert chest CT for the diagnosis of coronavirus disease 2019 (COVID-19) infection in patients in the emergency department. MATERIALS AND METHODS: This was a Health Insurance Portability and Accountability Act-compliant, institutional review board-approved retrospective study. From March 14 to 24, 2020, 192 patients in the emergency department with symptoms suggestive of COVID-19 infection were studied by using low-dose chest CT and real-time reverse transcription polymerase chain reaction (RT-PCR). Image analysis included the likelihood of COVID-19 infection and the semiquantitative extent of lung involvement. CT images were analyzed by two radiologists blinded to the RT-PCR results. Reproducibility was assessed using the McNemar test and intraclass correlation coefficient. Time between CT acquisition and report was measured. RESULTS: When compared with RT-PCR, low-dose submillisievert chest CT demonstrated excellent sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for diagnosis of COVID-19 (86.7%, 93.6%, 91.1%, 90.3%, and 90.2%, respectively), in particular in patients with clinical symptoms for more than 48 hours (95.6%, 93.2%, 91.5%, 96.5%, and 94.4%, respectively). In patients with a positive CT result, the likelihood of disease increased from 43.2% (pretest probability) to 91.1% or 91.4% (posttest probability), while in patients with a negative CT result, the likelihood of disease decreased to 9.6% or 3.7% for all patients or those with clinical symptoms for >48 hours. The prevalence of alternative diagnoses based on chest CT in patients without COVID-19 infection was 17.6%. The mean effective radiation dose was 0.56 mSv ± 0.25 (standard deviation). Median time between CT acquisition and report was 25 minutes (interquartile range: 13-49 minutes). Intra- and interreader reproducibility of CT was excellent (all intraclass correlation coefficients ≥ 0.95) without significant bias in the Bland-Altman analysis. CONCLUSION: Low-dose submillisievert chest CT allows for rapid, accurate, and reproducible assessment of COVID-19 infection in patients in the emergency department, in particular in patients with symptoms lasting longer than 48 hours. Chest CT has the additional advantage of offering alternative diagnoses in a significant subset of patients.© RSNA, 2020.

Prognostic Value and Reproducibility of AI-assisted Analysis of Lung Involvement in COVID-19 on Low-Dose Submillisievert Chest CT: Sample Size Implications for Clinical Trials.

PURPOSE: To compare the prognostic value and reproducibility of visual versus AI-assisted analysis of lung involvement on submillisievert low-dose chest CT in COVID-19 patients. MATERIALS AND METHODS: This was a HIPAA-compliant, institutional review board-approved retrospective study. From March 15 to June 1, 2020, 250 RT-PCR confirmed COVID-19 patients were studied with low-dose chest CT at admission. Visual and AI-assisted analysis of lung involvement was performed by using a semi-quantitative CT score and a quantitative percentage of lung involvement. Adverse outcome was defined as intensive care unit (ICU) admission or death. Cox regression analysis, Kaplan-Meier curves, and cross-validated receiver operating characteristic curve with area under the curve (AUROC) analysis was performed to compare model performance. Intraclass correlation coefficients (ICCs) and Bland- Altman analysis was used to assess intra- and interreader reproducibility. RESULTS: Adverse outcome occurred in 39 patients (11 deaths, 28 ICU admissions). AUC values from AI-assisted analysis were significantly higher than those from visual analysis for both semi-quantitative CT scores and percentages of lung involvement (all P<0.001). Intrareader and interreader agreement rates were significantly higher for AI-assisted analysis than visual analysis (all ICC ≥0.960 versus ≥0.885). AI-assisted variability for quantitative percentage of lung involvement was 17.2% (coefficient of variation) versus 34.7% for visual analysis. The sample size to detect a 5% change in lung involvement with 90% power and an α error of 0.05 was 250 patients with AI-assisted analysis and 1014 patients with visual analysis. CONCLUSION: AI-assisted analysis of lung involvement on submillisievert low-dose chest CT outperformed conventional visual analysis in predicting outcome in COVID-19 patients while reducing CT variability. Lung involvement on chest CT could be used as a reliable metric in future clinical trials.

First case of Candida auris infection in Belgium in a surgical patient from Kuwait.

Objective and importance: Candida auris is a relatively new yeast species and an emerging opportunistic pathogen. It was first reported in 2009 in East Asia, as a difficult-to-identify Candida species of uncertain clinical relevance. In recent years, it has appeared globally as a cause of invasive infections, not infrequently eliciting nosocomial outbreaks. Species identification in clinical laboratories has been challenging, as traditional phenotypic and biochemical methods have been generally unreliable. Clinical management is often complicated by multidrug resistance in many isolates. Additionally, C. auris has demonstrated an unusual ability for persistence in the hospital environment and in asymptomatic patients. We present the first Belgian case of C. auris infection along with a brief review of the literature.Clinical presentation: A patient was referred from Kuwait for surgical treatment after a complicated bariatric procedure. Few days after transferral, she developed a catheter-related blood stream infection with C. auris. We obtained a low-confidence identification of C. auris with the Bruker Biotyper MALDI-TOF MS system (Bruker Corporation, Billerica, MA, U.S.A.), and of Candida haemulonii with the Vitek YST identification system, version 7.01 (bioMérieux, Marcy-L'Etoile, France). Definite identification was obtained using Internal Transcribed Spacer (ITS) sequencing. As most C. auris isolates, our strain was resistant to fluconazole, and the patient was eventually treated with catheter removal and anidulafungin therapy. We documented persistence of C. auris clones with acquired echinocandin resistance in our patient up to 18 months after the infection.Conclusion: Clinicians and microbiologists should be aware of this globally emerging yeast, that poses important challenges in identification, treatment and hospital infection control.

Hospital Laboratory Survey for Identification of Candida auris in Belgium.

Candida auris is a difficult-to-identify, emerging yeast and a cause of sustained nosocomial outbreaks. Presently, not much data exist on laboratory preparedness in Europe. To assess the ability of laboratories in Belgium and Luxembourg to detect this species, a blinded C. auris strain was included in the regular proficiency testing rounds organized by the Belgian public health institute, Sciensano. Laboratories were asked to identify and report the isolate as they would in routine clinical practice, as if grown from a blood culture. Of 142 respondents, 82 (57.7%) obtained a correct identification of C. auris. Of 142 respondents, 27 (19.0%) identified the strain as Candida haemulonii. The remaining labs that did not obtain a correct identification (33/142, 23.2%), reported other yeast species (4/33) or failed to obtain a species identification (29/33). To assess awareness about the infection-control implications of the identification, participants were requested to indicate whether referral of this isolate to a reference laboratory was desirable in a clinical context. Over one-third of all respondents (54/142, 38.0%) stated that they would not send the isolate to a reference laboratory, neither for epidemiological reasons nor for identification confirmation or antifungal susceptibility testing. This comprised 41.5% of the laboratories that submitted an identification of C. auris (34/82). Awareness among Belgian microbiologists, therefore, remains inadequate more than two years after C. auris' emergence in European clinics. Our data confirm high rates of misidentifications with commonly used identification methods. Programs for raising awareness in European hospitals may be warranted.

Laboratory diagnosis of urinary tract infections: Towards a BILULU consensus guideline.

Urinary tract infections (UTI) are very common throughout life and account for the majority of the workload in the clinical microbiology laboratory. Clear instructions for the interpretation of urine cultures by the laboratory technicians are indispensable to obtain standardized, reliable, and clinically useful results. In literature, there is often a lack of evidence-based practice in processing urinary samples in the laboratory. In this consensus document, the BILULU Study Group presents a practical approach for the implementation of existing guidelines for the culture of urine in the microbiology laboratory and offers answers for issues where no clear solution is available in the guidelines.

OPAT: proof of concept in a peripheral Belgian hospital after review of the literature.

Since its introduction in the 1970s in the United States, outpatient parenteral antibiotic/antimicrobial therapy (OPAT) has been adopted internationally for long-term intravenous (IV) treatment of stable infectious diseases. The aim is to provide a safe and successful completion of IV antimicrobial treatment at the ambulatory care center or at home without complications and costs associated with hospitalization. OPAT implementation has been accelerated by progress in vascular access devices, newly available antibiotics, the emphasis on cost-savings, as well as an improved patient comfort and a reduced incidence of health care associated infections with a similar outcome. OPAT utilization is supported by an extensive published experience and guidelines of the British Society of Antimicrobial Chemotherapy and the Infectious Diseases Society of America for adults as well as for children. Despite these recommendations and its widespread adoption, in Belgium OPAT is only fully reimbursed and established for cystic fibrosis patients. Possible explanations for this unpopularity include physician unfamiliarity and a lack of uniform funding arrangements with higher costs for the patient. This article aims to briefly review benefits, risks, indications, financial impact for supporting OPAT in a non-university hospital as standard of care. Our experience with OPAT at the ambulatory care center of our hospital and its subsequent recent introduction in the home setting is discussed.

Multicenter evaluation of the revised RIDA® QUICK test (N1402) for rapid detection of norovirus in a diagnostic laboratory setting.

The updated RIDA® QUICK (N1402) immunochromatographic assay (R-Biopharm) for detection of norovirus was evaluated during a prospective, multicenter study using 771 stool samples from patients with gastroenteritis. Compared to real-time reverse transcriptase polymerase chain reaction (RT-rtPCR) as gold standard, the RIDA® QUICK had an overall sensitivity of 72.8% (91/125) and a specificity of 99.5% (640/643). Genotype analysis of the polymerase (ORF1) and capsid (ORF2) region of the genome indicated that the RIDA® QUICK assay could detect a broad range of genotypes including new variants (15 of 125 positive samples) which were detected by an in-house SYBR®Green RT-rtPCR, but not by the RIDA® GENE PCR PG1415 (R-Biopharm) and mostly not by the RIDA® GENE PCR PG1405 and the Xpert® Norovirus assay (Cepheid). The RIDA® QUICK can be used to reliably confirm norovirus in stool samples, but a negative result does not definitively exclude the presence of norovirus.

Multi-center evaluation of the novel fully-automated PCR-based Idylla™ BRAF Mutation Test on formalin-fixed paraffin-embedded tissue of malignant melanoma.

The advent of BRAF-targeted therapies led to increased survival in patients with metastatic melanomas harboring a BRAF V600 mutation (implicated in 46-48% of malignant melanomas). The Idylla(™) System (Idylla(™)), i.e., the real-time-PCR-based Idylla(™) BRAF Mutation Test performed on the fully-automated Idylla(™) platform, enables detection of the most frequent BRAF V600 mutations (V600E/E2/D, V600K/R/M) in tumor material within approximately 90 min and with 1% detection limit. Idylla(™) performance was determined in a multi-center study by analyzing BRAF mutational status of 148 archival formalin-fixed paraffin-embedded (FFPE) tumor samples from malignant melanoma patients, and comparing Idylla(™) results with assessments made by commercial or in-house routine diagnostic methods. Of the 148 samples analyzed, Idylla(™) initially recorded 7 insufficient DNA input calls and 15 results discordant with routine method results. Further analysis learned that the quality of 8 samples was insufficient for Idylla(™) testing, 1 sample had an invalid routine test result, and Idylla(™) results were confirmed in 10 samples. Hence, Idylla(™) identified all mutations present, including 7 not identified by routine methods. Idylla(™) enables fully automated BRAF V600 testing directly on FFPE tumor tissue with increased sensitivity, ease-of-use, and much shorter turnaround time compared to existing diagnostic tests, making it a tool for rapid, simple and highly reliable analysis of therapeutically relevant BRAF mutations, in particular for diagnostic units without molecular expertise and infrastructure.

Comparison of six different calprotectin assays for the assessment of inflammatory bowel disease.

BACKGROUND AND OBJECTIVES: Faecal calprotectin is a valuable noninvasive marker for inflammatory bowel disease (IBD). The aim of our study was to determine the correlation between six different calprotectin assays and compare their performance for diagnosis and follow up of IBD. METHODS: Thirty-one patients with suspected IBD and 31 patients in follow up were included. We determined calprotectin by means of three rapid immmunochromatographic tests, two enzyme-linked immunosorbent assays, and one automated fluoroimmunoassay. Results were correlated with endoscopic and histological findings. RESULTS: Although all methods correlated significantly, slopes and intercepts differed extensively, with up to 5-fold quantitative differences between assays. Sensitivity and specificity for diagnosis of IBD were 82-83 and 84-89%, respectively. For follow up, sensitivity in detecting mild ulcerative colitis was 71-100%. In moderate-to-severe ulcerative colitis, sensitivity was 100% for all assays. Specificity was 67-86% in both subgroups. In Crohn's disease, only moderate-to-severe disease could be differentiated from remission, with sensitivity 83-86% and specificity 75% for all tests. CONCLUSIONS: All calprotectin assays showed comparable clinical performance for diagnosis of IBD. For follow up, performance was acceptable, except for mild Crohn's disease. Because of the large quantitative differences, further efforts are needed to standardize calprotectin assays.

The preanalytical optimization of blood cultures: a review and the clinical importance of benchmarking in 5 Belgian hospitals.

Bloodstream infections remain a major challenge in medicine. Optimal detection of pathogens is only possible if the quality of preanalytical factors is thoroughly controlled. Since the laboratory is responsible for this preanalytical phase, the quality control of critical factors should be integrated in its quality control program. The numerous recommendations regarding blood culture collection contain controversies. Only an unambiguous guideline permits standardization and interlaboratory quality control. We present an evidence-based concise guideline of critical preanalytical determinants for blood culture collection and summarize key performance indicators with their concomitant target values. In an attempt to benchmark, we compared the true-positive rate, contamination rate, and collected blood volume of blood culture bottles in 5 Belgian hospital laboratories. The true-positive blood culture rate fell within previously defined acceptation criteria by Baron et al. (2005) in all 5 hospitals, whereas the contamination rate exceeded the target value in 4 locations. Most unexpected, in each of the 5 laboratories, more than one third of the blood culture bottles were incorrectly filled, irrespective of the manufacturer of the blood culture vials. As a consequence of this shortcoming, one manufacturer recently developed an automatic blood volume monitoring system. In conclusion, clear recommendations for standardized blood culture collection combined with quality control of critical factors of the preanalytical phase are essential for diagnostic blood culture improvement.

Performance of a new chromogenic medium, BBL CHROMagar MRSA II (BD), for detection of methicillin-resistant Staphylococcus aureus in screening samples.

Two chromogenic media for the detection of MRSA were compared: BBL CHROMagar MRSA II (BD) and MRSA ID agar (bioMérieux). Following overnight nonselective enrichment, 1,919 screening samples were inoculated on both chromogenic agars. After 24 h, the sensitivities of both media were high and comparable. Both media showed an important decrease in specificity after 48 h of incubation (decreases of 8% for MRSA II and 10% for MRSA ID), but MRSA II was significantly more specific at both time points.

Evaluation of the Copan ESwab transport system for the detection of methicillin-resistant Staphylococcus aureus: a laboratory and clinical study.

Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as an important pathogen. Successful detection starts with the selection of an appropriate specimen collection device. The Copan ESwab, a new swab, was compared with a commonly used Copan Venturi swab for the recovery of MRSA. In vitro assessment was performed according to the Clinical and Laboratory Standards Institute (CLSI) M40-A protocol. For the clinical evaluation, 24 patients with known MRSA carriage were included. The ESwab fulfilled the CLSI acceptance criteria for MRSA viability. In the clinical study, both swabs performed equally in qualitative terms of positive and negative. However, the in vitro and in vivo evaluation revealed at least 3.6-fold higher recovery of viable MRSA with the ESwab as compared with the Venturi swab. In conclusion, the ESwab may contribute to improve the quality of a MRSA screening protocol.