Bacterial arthritis in an English health district: a 10 year review.

Bacterial arthritis continues to present a difficult clinical and therapeutic problem, necessitating prompt diagnosis and intensive therapy. This study comprises a 10 year review of the condition in an English health district, with particular reference to aetiology, presentation, treatment, and outcome. Although the causative organisms remain qualitatively unchanged, increasing numbers of patients are elderly, immunosuppressed, or have underlying arthropathy. Factors which influence outcome include age, causative organism, joint involved, and delay in diagnosis. Attention is drawn to the notably poor outcome of hip infections in the elderly.     

Current status of cardiac surgery: a 40 year review

Cardiac surgery has undergone dramatic advancements during the past 3 decades. The introduction of cardiopulmonary bypass and cardioplegic arrest ushered in the true era of open heart surgery. Bioprostheses and mechanical valves as well as techniques for valve reconstruction permit routine repair or replacement of stenotic and regurgitant native valves. Progress in the disciplines of mechanical and electrical engineering has led to the development of pocket watch-sized, physiologically responsive pacemakers as well as a variety of circulatory assist devices that include the intraaortic balloon pump, ventricular assist device and total artificial heart. The synthesis of cardiotonic and vasoactive drugs and advancements in anesthetic management, postoperative monitoring and nursing care greatly facilitate perioperative patient management. This summary of state of the art cardiac surgery begins with a brief historical background followed by a review of recent advances in six main categories: coronary artery disease, acquired valvular heart disease, congenital cardiac disease, cardiac transplantation, myocardial preservation and mechanical circulatory assistance. In conducting the review of recent literature, particular attention was directed to large clinical series that document the results of contemporary surgical procedures, novel therapeutic approaches to current clinical problems and unresolved controversies in the field of cardiac surgery. The abundance of surgical literature and constraints on the length of this article do not permit an exhaustive review. Apologies are extended to clinicians and laboratory investigators whose important contributions to the understanding and treatment of cardiac disease are not included herein.     

Staphylococcus aureus bacteraemia in children and neonates: a 10 year retrospective review

Rates of Staphylococcus aureus bacteraemia (SAB) are published performance indicators for hospital-acquired infection. In adults SAB is often associated with central venous catheters (CVC), mortality is high and up to 40% are MRSA. However, there is little data on SAB in neonates and children in the UK.

Aim

To describe the presentation, management and outcome of SAB on a neonatal and paediatric unit in a District General Hospital (DGH) over a 10 year period.

Method

Case notes of children < 16 years with SAB between May 1993 and April 2003 were studied. SAB which developed >48 h after admission was defined as hospital-acquired. Contamination was probable if the clinical picture was unsupportive of infection, or if repeat culture was negative and no treatment was given.

Results

Neonatal unit: Thirty-three of 40 episodes were reviewed (median gestation 32 weeks, median age 21 days). Three of 33 (9%) were contaminants. All SAB were hospital acquired. Twenty-six of 30 (87%) had non-specific presentation, but 15 developed a focus of infection (skin 12, chest 3). Seventeen (57%) infants had CVCs. Eight (27%) infants had MRSA bacteraemia, seven with CVCs. Three (10%) infants died.Paediatric unit: Sixty-four of 70 episodes were reviewed (median age 2 years). Thirteen of 64 (20%) were contaminants. Ten of 51 (20%) were hospital acquired. Presentations were with skin infection 18, bone/joint infection 13, non-specific 13, respiratory 8. Only two had MRSA, one with CVC. One (2%) child died, from an unrelated cause.

Conclusion

SAB on a paediatric unit shows a very different pattern compared to SAB in adults. The pattern on a neonatal unit is more similar to that in adults. Both children and neonates have a lower mortality and a lower incidence of MRSA, whilst paediatric SAB has a weaker association with CVC. The proportion of SAB which is hospital acquired is low on a paediatric unit, making SAB an unreliable performance indicator. Most SA in blood cultures are not due to contamination. Prospective studies are needed to determine appropriate investigation and treatment.     

Extra corporeal membrane oxygenation after pediatric cardiac surgery: a 10 year experience

Indications for extra corporeal membrane oxygenation (ECMO) after pediatric cardiac surgery have been increasing despite the absence of encouraging survival statistics. Modification of ECMO circuit led to the development of integrated ECMO cardiopulmonary bypass (CPB) circuit at the author's institute, for children undergoing repair of transposition of great arteries among other congenital heart diseases (CHD). In this report, they analyzed the outcome of children with CHD, undergoing surgical repair and administered ECMO support in the last 10 years. The outcome was analyzed with reference to the timing of intervention, use of integrated ECMO-CPB circuit, indication for ECMO support, duration of ECMO run and the underlying CHD. The results reveal a significantly improved survival rate with the use of integrated ECMO-CPB circuit and early time of intervention rather than using ECMO as a last resort in the management. The patients with reactive pulmonary artery hypertension respond favorably to ECMO support. In all scenarios, early intervention is the key to survival.