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.     

Surgical interventions for anterior shoulder instability in rugby players: A systematic review

AIM: To systematically evaluate the evidence-based literature on surgical treatment interventions for elite rugby players with anterior shoulder instability.METHODS: We conducted a systematic review according to the PRISMA guidelines. A literature search was performed in PubMed, EMBASE and Google Scholar using the following search terms: “rugby” and “shoulder” in combination with “instability” or “dislocation”. All articles published from inception of the included data sources to January 1^st 2014 that evaluated surgical treatment of elite rugby players with anterior shoulder instability were examined.RESULTS: Only five studies were found that met the eligibility criteria. A total of 379 shoulders in 376 elite rugby union and league players were included. All the studies were retrospective cohort or case series studies. The mean Coleman Methodological Score for the 5 studies was 47.4 (poor). Owing to heterogeneity amongst the studies, quantitative synthesis was not possible, however a detailed qualitative synthesis is reported. The overall recurrence rate of instability after surgery was 8.7%, and the mean return to competitive play, where reported, was 13 mo.CONCLUSION: Arthroscopic stabilization has been performed successfully in acute anterior instability and there is a preference for open Latarjet-type procedures when instability is associated with osseous defects.     

Urinary tract infection in infants and children evaluated by ultrasound

Fifty-nine pediatric patients with urinary tract infection (UTI) underwent renal ultrasonography, excretory urography, and voiding cystourethrography. The imaging procedures were analyzed retrospectively to determine their relative effectiveness in detecting abnormalities that might predispose the patient to UTI. Voiding cystourethrography provided valuable information, particularly the presence or absence of vesicoureteral reflux, that could not be obtained from the other procedures. Excretory urography was less specific than ultrasonography in the majority of patients, with the exception of those who had renal scarring. The authors recommended ultrasonography as the initial imaging procedure in the evaluation of children with UTI. When the sonogram is normal, excretory urography is not considered necessary, but voiding cystourethrography is thought to be essential. If sonography is abnormal, excretory urography and/or other follow-up studies are indicated.     

Inhibition and complexation of activated protein C by two major inhibitors in plasma

To determine the major physiologic inhibitors of activated protein C (APC), plasma was incubated with APC or with Protac C and subjected to immunoblotting. APC:inhibitor complexes gave two major bands reacting with antiprotein C antibodies when immunoblotted on nondenaturing gels, and additional minor bands that varied between serum and plasma. Formation of one of the two major bands of APC:inhibitor complex, but not the other, was stimulated by heparin and only this band reacted with antibodies to the previously described APC inhibitor that is here designated PCI-1. Plasma immunodepleted of PCI-1 formed complexes with APC as visualized with antiprotein C but not anti-PCI-1 antibodies, and exhibited heparin-independent inhibition of APC activity, providing evidence for the existence of a second major physiologic APC inhibitor, PCI-2. Formation of APC:PCI-2 complexes in PCI-1-depleted plasma paralleled inhibition of APC amidolytic activity. PCI-2 was separated from PCI-1 and partially purified using column chromatography. PCI-2 formed inactive complexes of approximately 110,000 molecular weight (mol wt) with APC suggesting PCI-2 has an approximate mol wt of 50,000. Thus, inhibition of APC in plasma involves two major distinct 50,000 mol wt inhibitors, the heparin-dependent PCI-1 and the heparin- independent PCI-2.     

Activation and complexation of protein C and cleavage and decrease of protein S in plasma of patients with intravascular coagulation

Activated protein C (APC) is inhibited by two major plasma inhibitors (PCIs). To find evidence for in vivo complexation of APC, immunoblotting studies were performed on plasmas of 85 patients with suspected disseminated intravascular coagulation (DIC). Samples from 62 of these patients contained 5% to 35% of protein C antigen in APC:inhibitor complexes, indicating that protein C activation and inhibition had occurred. In 24 normal plasmas, no detectable APC:PCI complexes were observed (less than 5%). Patients with higher levels of complexes had more abnormal coagulation test data for DIC. The major band of APC complexes detected by anti-protein C antibodies did not react with antibodies to the heparin-dependent protein C inhibitor (PCI- 1) previously described. Rather, APC was complexed with another recently described plasma protein C inhibitor, PCI-2. Immunoblotting studies for protein S, the cofactor for APC, revealed that the majority of the DIC patient plasmas contained a higher than normal proportion of protein S in cleaved form, suggesting that protein S may have been proteolytically inactivated. Protein S total antigen levels were also found to be low in DIC patients, excluding those with malignancy. These studies support the hypothesis that the protein C pathway is activated during DIC.