Admission inflammatory markers and isolation of a causative organism in patients with spontaneous spinal infection

Introduction

The purpose of this study was to investigate the significance of the inflammatory markers on admission in the isolation of a causative pathogen in patients with spinal infection. Spinal infection is treated frequently at spinal units and can encompass a broad range of clinical entities. Its diagnosis is often delayed because of the difficulty of identifying the responsible pathogen.

Methods

Patients with spinal infection treated in our institution over a period of eight years were identified and their notes studied retrospectively. Admission C-reactive protein (CRP), white cell count (WCC) as well as co-morbidities and mode of pathogen identification were recorded. Overall, 96 patients were included in the study.

Results

The CRP levels on admission were correlated significantly with the overall potential for isolation of a pathogen (p<0.0001) and positive biopsy cultures (p=0.0016). Admission WCC levels were associated significantly with the overall potential for isolation of a pathogen (p=0.0003) and positive biopsy cultures (p=0.0023). Both CRP and WCC levels were significantly negatively correlated with the duration of the preceding symptoms (p=0.0003 and p<0.0001 respectively). Delay in presentation was significantly negatively correlated with organism isolation (p=0.0001). Multivariate analyses identified the delay in presentation as the strongest independent variable for organism isolation (p=0.014) in cases of spontaneous spinal infection when compared with the admission CRP level (p=0.031) and WCC (p=0.056).

Conclusions

In spontaneous spinal infection, delay in presentation is the strongest independent variable for organism isolation. High inflammatory marker levels on admission are a useful prognostic marker for the overall potential of isolating a causative organism either by blood cultures or by biopsy in patients with negative blood cultures. Furthermore, the admission inflammatory marker levels allow for treating surgeons to counsel their patients of the likelihood of achieving a positive microbiological yield from biopsy.     

Iliac occlusions: stenting or crossover grafting? An examination of patency and cost.

OBJECTIVES: Percutaneous transluminal angioplasty with stenting is perceived to be a less invasive and cheaper option for the treatment of iliac artery occlusion than surgical reconstruction. We have carried out a prospective observational study of all patients undergoing an iliac stent or femorofemoral crossover graft for iliac artery occlusion to assess the cost effectiveness of the two approaches in a district general hospital. METHODS: Fifty-one patients underwent primary angioplasty with stenting and 87 patients crossover grafting. Patients were all assessed 2 months after their procedure and then at intervals over the following years. RESULTS: In 13 cases, it was impossible to place the stent successfully. In a further 10 patients, major complications occurred which were mainly thromboembolic. Fifteen patients underwent crossover grafting after failure to insert a stent, or after stent occlusion. No major complications occurred following crossover grafting. The median length of stay following successful stenting was 1 day; the following crossover grafting was 4 days. The mean stay was higher in each group (2.5 and 5.8 days) and is a more accurate parameter for estimation of cost, which for iliac stenting is estimated at pound1912 versus pound3072 for crossover grafting. The mean additional cost of those patients sustaining complications after stenting was pound2481. On an basis, patency following stent insertion at 6 months was 52%; patency after bypass was 100% (p <0.0001). If any complication occurs after stenting, the cost advantage of the procedure is lost. In those patients without complication, the initial cost benefit of iliac stenting is lost within 6 months, as patients require further intervention, usually as a crossover graft, when the stent occludes. Crossover grafting is a durable low-risk procedure. CONCLUSIONS: We suggest that stenting of occluded iliac arteries should be reserved for those patients with limited life expectancy. Patients who are younger and fitter should be offered femorofemoral crossover grafting as a primary procedure until research enables identification of those patients who are most likely to maintain long-term patency after stenting.     

Prevalence of abdominal aortic aneurysm in patients with occlusive peripheral vascular disease

Over a 1-year period, 242 patients with peripheral vascular disease underwent abdominal ultrasonography to detect the presence of an abdominal aortic aneurysm. In 34 (14 per cent) an abdominal aortic aneurysm was found; half of these aneurysms were greater than 4 cm in diameter. In addition, 16 patients had ectatic aortas. Abdominal aortic aneurysms were more common in men than in women (17 versus 8 per cent). Patients with claudication were as likely to have an abdominal aortic aneurysm as those with rest pain or gangrene. The presence of aortoiliac occlusive disease increased the chance of an aneurysm being present (P less than 0.02). Patients with occlusive peripheral vascular disease are a high-risk group with regard to the development of an abdominal aortic aneurysm. Patients with proximal occlusive disease represent a subgroup at even higher risk.     

Idiopathic Headaches: Relationship to Life Events

SYNOPSIS
228 patients were interviewed using Paykel's list. The aim of this study was to detect possible differences among vascular, tension and tension-vascular headaches with special attention to stressing events preceding the onset of headache.
The statistical analysis of the results showed significant differences among the groups studied for the weight of life events in the 10 years prior to the onset of headache. Minor differences emerged for the year immediately prior to the headache onset. Particular differences were also observed in the distribution of life events with the aid of qualitative analysis.
Worthy of notice is the fact that the migraineurs tested resuIted to be less damaged by stress than the other patients.     

Recent Developments in the Diagnosis and Management of Patients with Transient Ischaemic Attacks and Minor Ischaemic Strokes

Appropriate management of the patient with transient focal neurologicalsymptoms must start with accurate clinical diagnosis. Wideruse of clear diagnostic criteria and symptom checklists, andbetter knowledge of the clinical features of the ‘funnyturns’ which are not related to transient focal cerebralischaemia could reduce the present variability in clinical diagnosisof trarsient ischaemic attacks. More accurate clinical diagnosiscontributes to better selection of the most appropriate investigationstrategy for each patient. A basic minimum standard of investigationis outlined and perhaps provides a suitable template for audit.Patients with transient ischaemic attacks which are definitelyin the carotid distribution may be eligible for entry in trialsof carotid endarterectomy. Prudent use of duplex ultrasoundstudies of the carotid arteries in patients with appropriatesymptoms is an effective way to reduce the costs of investigationsand their complications (i.e. the number of strokes associatedwith cerebral angiography). Digital venous subtraction angiographyhas, by comparison, many disadvantages as a screening tool.Advances in management include: recent statistical overviewswhich have emphasized the need to consider blood pressure andplasma cholesterol reduction in a large proportion of patients,and the value of long term anti-platelet therapy in reducingthe risks of stroke, myocardial infarction and vascular deathin both males and females. The value of anticoagulants in patientswith atrial fibrillation and transient ischaemic attacks orminor stroke is being tested in current trials.     

Management of synchronous arterial occlusions using intra-arterial thrombolysis.

Three patients presented with multiple acute arterial occlusions in separate limb vessels. The diagnosis was confirmed by angiography. Each patient was successfully treated by simultaneous infusion of low-dose intra-arterial streptokinase into each occlusion. All of the patients were improved clinically and in two patients completely normal pressure indices were restored.     

Percutaneous fluoroscopically guided placement of peritoneal dialysis catheters--a 10-year experience

Peritoneal dialysis (PD) catheters maybe inserted surgically or percutaneously. Since 1997, 209 patients in our unit have had a PD catheter inserted percutaneously with fluoroscopic guidance. Data on all these PD catheters were collected prospectively on a PROTON computer database. 5/209 (2.4%) insertion attempts were abandoned. 204 catheters were successfully placed giving an initial technical success of 97.6%. 200/204 catheters were used for dialysis. 13/200 (6.5%) catheters developed early exit site infections; 12/13 were successfully treated and dialysis proceeded uneventfully. 3/200 (1.5%) catheters developed early peritonitis; 1/3 was removed as antibiotic treatment was unsuccessful. 10/200 (5%) catheters developed an early leak; 2/10 did not resolve with conservative therapy and were removed. 14/200 (7%) catheters did not allow sufficient fluid entry for PD; all 14 had migrated out of the pelvis and were removed. In total, 18/200 (9%) catheters were removed in the first 2 months due to these early complications. The remaining 182/200 (91%) were fully functional for PD. Technical survival (excluding patient death with a functioning catheter and successful kidney transplantation) at 1, 2, and 5 years was 77%, 61%, and 31%, respectively. Our 10 year experience of PD catheters inserted percutaneously with fluoroscopic guidance demonstrates a high technical success and a low complication rate. The data presented may be used as the standard for this technique.     

NbActiv4 medium improvement to Neurobasal/B27 increases neuron synapse densities and network spike rates on multielectrode arrays

The most interesting property of neurons is their long-distance propagation of signals as spiking action potentials. Since 1993, Neurobasal/B27™ has been used as a serum-free medium optimized for hippocampal neuron survival. Neurons on microelectrode arrays (MEA) were used as an assay system to increase spontaneous spike rates in media of different compositions. We find spike rates of 0.5 s⁻¹ (Hz) for rat embryonic hippocampal neurons cultured in Neurobasal/B27, lower than cultures in serum-based media and offering an opportunity for improvement. NbActiv4™ was formulated by addition of creatine, cholesterol and estrogen to Neurobasal/B27 that synergistically produced an eightfold increase in spontaneous spike activity. The increased activity with NbActiv4 correlated with a twofold increase in immunoreactive synaptophysin bright puncta and GluR1 total puncta. Characteristic of synaptic scaling, immunoreactive GABA_Aβ puncta also increased 1.5-fold and NMDA-R1 puncta increased 1.8-fold. Neuron survival in NbActiv4 equaled that in Neurobasal/B27, but with slightly higher astroglia. Resting respiratory demand was decreased and demand capacity was increased in NbActiv4, indicating less stress and higher efficiency. These results show that NbActiv4 is an improvement to Neurobasal/B27 for cultured networks with an increased density of synapses and transmitter receptors which produces higher spontaneous spike rates in neuron networks.     

Remote superficial femoral artery endarterectomy: medium-term results.

BACKGROUND: the aim of this study is to determine the medium-term results following successful remote superficial-femoral endarterectomy (RSFE). SETTING: district general hospital in United Kingdom. METHODS: RSFE comprises a single incision over the origin of the superficial femoral artery. The endarterectomy is carried out in a closed fashion from above. The cut end of distal atheroma is secured with a stent. Twenty-five limbs were followed up with three monthly duplex scans and angiography if any abnormality was suggested. All patients presented with intermittent claudication; in addition three had rest pain and three ulceration or gangrene. The length of atheromatous core removed was 10-30 cm. RESULTS: all patients had a follow-up of at least one year (range 12-27 months). Eleven arteries developed 14 stenoses. Nine became apparent within nine months of RSFE. The cumulative risk of stenoses developing in patent arteries was 24% at 6 and 63% at 12 months. Eleven angioplasties (PTA) of these stenoses were undertaken. Nine of these remain patent at a median of 12 months after PTA. At one year primary patency was 10 of 25 (40%), primary-assisted patency 18 of 25 (72%) and secondary patency 19 of 25 (76%) and at two years 29%, 57% and 57% respectively. CONCLUSIONS: RSFE is worth considering for superficial femoral artery occlusive disease, particularly in high-risk patients without suitable vein and with limited life expectancy. Careful duplex surveillance is important. Until stenoses can be prevented, the widespread use of RSFE cannot be recommended.