The use of vacuum-assisted closure in spinal wound infections with or without exposed dura

Introduction

The treatment of postoperative deep spinal wound infection involves debridement and intravenous antibiotics. Authors have previously reported success in a small series of patients treated with vacuum-assisted closure (VAC) therapy, but its use over exposed dura is controversial and the outcome has not been reported in large series.

Purpose

To review the outcomes following the treatment of postoperative spinal infections with VAC therapy, particularly those with exposed dura.

Methods

This is a review of prospectively collected data in 42 patients, all of whom had deep postoperative spinal infections. 30 of these patients had exposed dura. All patients had an initial debridement followed by application of VAC Whitefoam (with exposed dura) or grey Granufoam (where no dura was exposed). Pressure was set at 50 mmHg with exposed dura or 125 mmHg where no dura was exposed. All patients underwent a minimum 6 week course of antibiotics. We report on the number of visits to theatre required for dressing changes and debridement and the eventual outcomes.

Results

Five patients required a flap reconstruction. Two patients died before definitive final closure due to other complications (pneumonia and stroke). In all the other patients, their wounds healed fully. A mean of 2.3 infection surgeries were required to eradicate infection and achieve wound closure.

Conclusions

This is one of the largest studies which confirms the safety and efficacy of VAC dressings in patients with spinal wound infections, even when the dura is exposed.

Graphical abstract

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Evaluation of Denka-Seiken turbidimetric high-sensitivity C-reactive protein assay.

C-reactive protein measured with a high sensitivity method (hsCRP) is an important prognostic indicator in patients with an acute coronary syndrome. We evaluated hsCRP measurement with regard to its precision, functional sensitivity, linearity, and interferences using Denka-Seiken CRP II Latex X2 turbidimetric method on two chemistry autoanalyzers: Olympus AU 640 and Hitachi 747. The coefficients of variation (CV) for within-run and between-run precision of hsCRP were satisfactory on both autoanalyzers. Functional sensitivities, expressed as concentrations associated with 10% total interassay CV, were 0.19 mg/l for the Hitachi 747 analyzer and 0.41 mg/l for the Olympus AU 640. The assay was linear up to 300 mg/l with a wide measuring range, which suggested the possibility of using this hsCRP measurement as an inflammation marker and as a risk marker for coronary heart disease (CHD). No significant interference was observed up to a triglyceride concentration of 34 mmol/l, and up to hemoglobin concentration of 4 g/l. The determination of hsCRP by turbidimetric method was satisfactory and acceptable for CHD risk assessment, as well as for use as a marker of inflammation.     

Enhancement of T helper type 1 immune responses against hepatitis B virus core antigen by PLGA nanoparticle vaccine delivery.

Currently, there is a need for therapeutic vaccines that are effective in inducing robust T helper type 1 (Th1) immune responses capable of mediating viral clearance in chronic hepatitis B infection. Hepatitis B therapeutic vaccines were designed and formulated by loading the hepatitis B core antigen (HBcAg) into poly(D,L-lactic-acid-co-glycolic acid) (PLGA) nanoparticles with or without monophospholipid A (MPLA), a Th1-favoring immunomodulator. These particles were around 300 nm in diameter, spherical in shape and had approximately 50% HBcAg encapsulation efficiency. A single immunization with a vaccine formulation containing (MPLA+HBcAg) coformulated in PLGA nanoparticles induced a stronger Th1 cellular immune response with a predominant interferon-gamma (IFN-gamma) profile than those induced by HBcAg alone, free (HBcAg+MPLA) simple mixture or HBcAg-loaded nanoparticles in a murine model. More importantly, the level of HBcAg-specific IFN-gamma production could be increased further significantly by a booster immunization with the (HBcAg+MPLA)-loaded nanoparticles. In summary, these results demonstrated that codelivery of HBcAg and MPLA in PLGA nanoparticles promoted HBcAg-specific Th1 immune responses with IFN-gamma production. These findings suggest that appropriate design of the vaccine formulation and careful planning of the immunization schedule are important in the successful development of effective HBV therapeutic vaccines.     

Pre-emptive Treatment of HCV after Living Donor Liver Transplantation with Direct-Acting Antiviral Agents

Background

Hepatitis C virus (HCV) universally recurs after liver transplantation (LT). Although the introduction of direct-acting antiviral agents (DAAs) has revolutionized the treatment of HCV infection, no optimal treatment for HCV recurrence after LT has been developed.

Methods

This study retrospectively evaluated the efficacy of DAAs as a pre-emptive treatment for recurrent HCV infection after living donor liver transplantation (LDLT). From January 2010 to December 2016, 70 patients received pegylated interferon (PegIFN) and 35 patients were treated with DAA-based regimens to treat recurrent HCV after LDLT. All antiviral treatments were pre-emptive.

Results

Genotype 1b was the most common HCV type (61.9%). Twenty-two recipients in the DAA group were treated with ledipasvir/sofosbuvir, nine received daclatasvir plus asunaprevir, three received sofosbuvir, and one received sofosbuvir plus daclatasvir. All 35 patients (100%) in the DAA group achieved a sustained virologic response (SVR), a percentage significantly higher than that (71.4%) in the PegIFN group (p?<?0.001). In the PegIFN group, the 1-, 3-, and 5-year graft survival rates were 85.7, 73.9, and 70.7%, respectively, whereas those in the DAA group were 100, 100, and 100%, respectively (p?=?0.008).

Conclusion

DAA-based regimens are an effective treatment for HCV recurrence after LDLT, resulting in an improved SVR and better graft survival than PegIFN.

     

Clinic blood pressure responses to two amlodipine salt formulations, adipate and besylate, in adult Korean patients with mild to moderate hypertension: a multicenter, randomized, double-blind, parallel-group, 8-week comparison

BACKGROUND: The commercially available formulation of amlodipine is conjugated with besylate salt to increase water solubility. Recently, a new amlodipine salt formulation has been developed in which the free base of amlodipine is conjugated with a chemically different salt, adipate. OBJECTIVE: The goal of this study was to compare the antihypertensive effect and tolerability of amlodipine adipate with those of amlodipine besylate in patients with mild to moderate hypertension. METHODS: This was a multicenter, randomized, doubleblind, parallel-group study in which patients received 8 weeks of treatment with either amlodipine adipate or amlodipine besylate. The primary efficacy variable was noninferiority of the difference in mean changes from baseline in trough diastolic blood pressure (DBP) after 8 weeks of treatment. Secondary efficacy variables included mean changes in DBP, systolic blood pressure (SBP), and response rate (defined as the proportion of patients whose DBP was <90 mm Hg or whose DBP had decreased from baseline by > or =10 mm Hg). The incidence of adverse events (AEs) was also assessed. RESULTS: Two hundred eleven patients were randomly assigned to receive amlodipine adipate (n = 106) or amlodipine besylate (n = 105). Study patients were primarily female (54.5%), with a mean (SD) age of 52.2 (9.6) years and a mean body weight of 67.1 (10.2) kg; there were no between-group differences in demographic profiles. After 4 weeks of randomized treatment, 58 (27.5%) patients (29 [27.4%] amlodipine adipate, 29 [27.6%] amlodipine besylate) had not achieved a mean DBP <90 mm Hg, and their dose was doubled. Mean DBP changes at 8 weeks were -15.2 (7.3) mm Hg in the amlodipine adipate group and -14.2 (7.4) mm Hg in the amlodipine besylate group (P = NS). Because the 95% CI for the difference in mean DBP changes between groups (-0.53 to 2.55) was within the prespecified lower limit (-4 mm Hg), amlodipine adipate was considered noninferior to amlodipine besylate. Mean SBP changes were -24.9 (12.1) mm Hg in the amlodipine adipate group and -22.0 (14.7) mm Hg in the amlodipine besylate group (P = NS). The response rates were 92.0% for amlodipine adipate and 95.4% for amlodipine besylate (P = NS). The overall incidence of clinical AEs was 20.8% in the amlodipine adipate group and 25.7% in the amlodipine besylate group (P = NS). Drug-related clinical AEs occurred in 5.7% and 12.4% of patients in the respective treatment groups (P = NS). Serum uric acid levels decreased significantly from base-line in both groups (P < 0.001). CONCLUSIONS: Eight weeks of treatment with amlodipine adipate produced significant reductions from baseline in blood pressure in these patients with mild to moderate hypertension. The efficacy of amlodipine adipate was not inferior to that of amlodipine besylate. Tolerability was comparable between the 2 treatment groups.     

Short-Term Outcomes and Influencing Factors After Ankle Fracture Surgery

The present study investigated the factors influencing the early clinical outcomes after ankle fracture surgery. We included 88 patients, who had undergone implant removal surgery at 1 year after ankle fracture surgery, with ankle computed tomographic (CT) scans obtained before ankle fracture surgery and at implant removal available. We collected demographic information, including age, sex, the presence of diabetes mellitus, level of trauma energy, and fracture classification from the medical records. We also recorded the fracture height using the radiographs and CT images. The medial joint space and articular incongruity were assessed on the follow-up radiographs and CT scans. Bone attenuation was measured by placing a circular region of interest around the ankle joint on the preoperative CT image. The postimplant removal outcomes were assessed using 2 functional questionnaires, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and Foot and Ankle Outcome Score (FAOS). Significant factors related to the AOFAS ankle-hindfoot scale scores and FAOS were identified through univariate analysis using age, sex, radiographic measurements, and CT findings as explanatory variables, followed by multiple regression analysis. On multiple regression analysis, the total FAOS was independently related to the AO classification (p?=?.003) and Lauge-Hansen classification (p?=?.003). The total AOFAS ankle-hindfoot scale score was related to articular incongruity (p?=?.044). The early clinical outcomes after ankle fracture surgery were affected by involvement of the ankle joint fracture rather than the lateral malleolus fracture height. Female sex and the presence of postoperative articular incongruity correlated with inferior early clinical outcomes.     

Clinical significance of healthcare-associated infections in community-onset Escherichia coli bacteraemia

BACKGROUND: The increasing antimicrobial resistance of Escherichia coli infection is of great concern, even for community-onset infections. METHODS: We conducted a retrospective cohort study of patients with E. coli bacteraemia who visited the emergency department of the Samsung Medical Center from February 2002 to December 2005 to identify the risk factors for mortality and association between healthcare-associated (HCA) infection and mortality. We classified community-onset E. coli bacteraemia into community-acquired (CA) and HCA infections. RESULTS: A total of 508 patients with E. coli bacteraemia were enrolled (mean age, 61.8 +/- 14.3 years; male/female, 191:317). The HCA E. coli bacteraemia had significantly higher severity of illness and higher antimicrobial resistance rate than CA bacteraemia. The overall 30-day mortality rate was 13.6% (69/508) and the mortality of HCA infections was significantly higher than that of CA infections (26.4% versus 9.6%, P < 0.001). In multivariate analysis, high Charlson's co-morbidity index (OR 4.84, 95% CI 2.14-10.95, P < 0.001), high Pitt bacteraemia score (OR 32.03, 95% CI 13.08-74.43, P < 0.001), presentation with acute renal failure (OR 4.11, 95% CI 1.90-8.89, P < 0.001) and HCA bacteraemia (OR 2.34, 95% CI 1.09-5.01, P = 0.030) were found to be the significant risk factors for 30-day mortality in E. coli bacteraemia. CONCLUSIONS: The mortality rate of HCA E. coli bacteraemia was higher than twice that of CA bacteraemia and HCA bacteraemia was one of the significant risk factors for mortality, even after adjusting for a large number of potential confounders.