Prosthetic joint infections secondary to rapidly growing Mycobacterium fortuitum

Infection is an uncommon but catastrophic complication of joint arthroplasty, usually requiring removal of the implant. In a 30-year-old woman a knee arthroplasty was infected with the rapidly growing mycobacterium Mycobacterium fortuitum. Review of other reports of arthroplasties infected with this organism illustrates the problem, diagnosis, and treatment. M. fortuitum is widely distributed in nature, and although usually of low pathogenicity, it can cause infection in conditions of reduced local tissue resistance, i.e. hypodermic abscesses, implant inflammations, and trauma. Only six cases of M. fortuitum prosthetic joint infection have been previously described. Persistent drainage characterized cases in which the prosthesis was left in place. Although antibiotic treatment temporarily suppressed the signs and symptoms of infection, cure required removal of the prosthesis, as in the present case. Diagnosis of M. fortuitum infection is difficult because acid-fast stains of the organisms are often negative. Routinely bacterial cultures are continued for less than about five days, a period not long enough for growth of M. fortuitum. M. fortuitum infections should be considered in draining prosthetic joints with negative bacterial cultures and in those that have had repeated glucocorticoid intraarticular injections.     

Activated charcoal in oral ethanol absorption: lack of effect in humans

Activated charcoal has been recommended for use in poisonings by ethanol, other toxic alcohols and glycols, but it has been avoided with therapeutic use of oral ethanol. Six healthy young adults drank a dose of ethanol designed to give a peak concentration of 125 mg/dl on two different days after overnight fasting. Each individual drank the same dose on both occasions; but on one of these days, the subjects drank an aqueous slurry of 60 g of superactive charcoal prior to ethanol ingestion. We compared the pharmacokinetic profile of ethanol with and without activated charcoal treatment. The fraction of ethanol absorbed was similar on both protocols. The mean peak ethanol concentration after pretreatment with activated charcoal was 8% greater than ethanol alone (p = 0.08). Thus oral activated charcoal does not significantly impair ethanol absorption and can be used in patients requiring oral ethanol. Our results do not support the use of activated charcoal in overdose of ethanol alone. Extending our results to poisonings by other toxic alcohols and glycols, the use of activated charcoal to reduce their absorption deserves evaluation.     

Lidocaine diffusion in five tissue expanders: an in vitro and in vivo study.

Previous work in our laboratory has demonstrated that tissue expanders are permeable to lidocaine. In this two-part study, we assessed the in vitro lidocaine diffusion in the following five common tissue expanders: Dow Corning, McGhan, Cox-Uphoff, Hyer-Schulte (Mentor), and Surgitek. In part 1, we demonstrated that wall thickness appeared to be the major determinant for diffusion. Part 2 reports an in vivo study of lidocaine diffusion from tissue expanders used for breast reconstruction. We initially determined that there is incomplete mixing between the valve and connecting tubing and the contents of the expanders, over the period of 1 week. We subsequently examined the lidocaine diffusion from seven tissue expanders placed in a submuscular position for breast reconstruction. The rate of lidocaine diffusion was highly variable, but on average was about 3% per day.     

Current policy for allocation of donor livers in the Netherlands advantages primary sclerosing cholangitis patients on the liver transplantation waiting list—a retrospective study

Studies from the USA and Nordic countries indicate primary sclerosing cholangitis (PSC) patients have low mortality on the liver transplantation (LTx) waiting list. However, this may vary among geographical areas. Therefore, we compared waiting list mortality and post‐transplant survival between laboratory model for end‐stage liver disease (LM) and MELD exception (ME)‐prioritized PSC and non‐PSC candidates in a nationwide study in the Netherlands. A retrospective analysis of patients waitlisted from 2006 to 2013 was conducted. A total of 852 candidates (146 PSC) were waitlisted of whom 609 (71.5%) underwent LTx and 159 (18.7%) died before transplantation. None of the ME PSC patients died, and they had a higher probability of LTx than LM PSC [HR obtained by considering ME as a time‐dependent covariate (HR^ME 9.86; 95% CI 6.14–15.85)] and ME non‐PSC patients (HR^ME 4.60; 95% CI 3.78–5.61). After liver transplantation, PSC patients alive at 3 years of follow‐up had a higher probability of relisting than non‐PSC patients (HR 7.94; 95% CI 1.98–31.85) but a significantly lower mortality (HR 0.51; 95% CI 0.27–0.95). In conclusion, current LTx prioritization advantages PSC patients on the LTx waiting list. Receiving ME points is strongly associated with timely LTx.     

Donor‐specific anti‐HLA antibodies are not associated with nonanastomotic biliary strictures but both are independent risk factors for graft loss after liver transplantation

Donor‐specific alloantibodies (DSA) have been associated with rejection and shorter graft survival after orthotopic liver transplantation (OLT). We examined the role of DSA in nonanastomotic biliary strictures (NAS) after OLT. Patients receiving first OLT who developed NAS (n = 68) and a control group without NAS (n = 83), with pre‐OLT and 12 months post‐OLT serum samples, were included. DSA were specified using the Luminex single antigen test. Risk factors for NAS and graft survival were analyzed. The presence of preformed DSA was not significantly different between patients with NAS and controls (P = .89). After 12 months, 26.5% of NAS patients and 16.9% of controls had generated de novo DSA (P = .15). Neither de novo class I DSA nor de novo class II DSA were associated with NAS. De novo DSA generally developed after the diagnosis of NAS. Time‐dependent regression analysis identified both NAS (aHR 8.05, CI 3.28 – 19.77, P < .01) and de novo class II DSA (aHR 2.84, CI 1.38 – 5.82, P < .01) as independent risk factors for graft loss. Preformed or de novo DSA were not associated with the development of NAS. However, NAS as well as de novo class II DSA were independent risk factors for graft loss after OLT.     

Significance of lipopolysaccharide-binding protein (an acute phase protein) in monitoring critically ill patients

Introduction  

The present study was conducted to assess the value of serum concentration of lipopolysaccharide-binding protein (LBP) in patients with systemic inflammatory response syndrome (SIRS), sepsis and septic shock with respect to its ability to differentiate between infectious and noninfectious etiologies in SIRS and to predict prognosis.     

Determining the Accuracy of a Rapid Point-of-care Test for Determining Rh(D) Phenotype

Objectives: To determine the sensitivity, specificity, and accuracy of a point-of-care method for identifying Rh(D) phenotype. Methods: Rh(D) was determined using preserved whole blood via standard laboratory methods. Comparison testing was conducted using the HealthTEST Rh(D) card (Akers Laboratories, Thorofare, NJ). Results of the card test were visually interpreted and recorded. To achieve sensitivity and specificity of 99% (95% confidence interval [CI] = 98% to 100%), 380 Rh-positive and 380 Rh-negative samples were required. During card testing, convenience sampling was used. Card results were compared with official results, and statistical analysis was conducted. Results: In identifying Rh(D)-positive phenotype, the card had a sensitivity of 98.9% and a specificity of 99.7% (95% CI = 0.99 ± 0.01). For Rh(D)-negative phenotype, the card had a sensitivity of 99.7% and a specificity of 98.9% (95% CI = 0.99 ± 0.01). Conclusions: In identifying type D (Rh positive or Rh negative), the card achieves sensitivity, specificity, and accuracy to warrant further study.