Implementation of an infection prevention bundle and increased physician awareness improves surgical outcomes and reduces costs associated with spine surgery.

OBJECTIVE Previous studies have demonstrated the efficacy of infection prevention protocols in reducing infection rates. This study investigated the effects of the development and implementation of an infection prevention protocol that was augmented by increased physician awareness of spinal fusion surgical site infection (SSI) rates and resultant cost savings. METHODS A cohort clinical investigation over a 10-year period was performed at a single tertiary spine care academic institution. Preoperative infection control measures (chlorohexidine gluconate bathing, Staphylococcus aureus nasal screening and decolonization) followed by postoperative infection control measures (surgical dressing care) were implemented. After the implementation of these infection control measures, an awareness intervention was instituted in which all attending and resident neurosurgeons were informed of their individual, independently adjudicated spinal fusion surgery infection rates and rankings among their peers. During the course of these interventions, the overall infection rate was tracked as well as the rates for those neurosurgeons who complied with the preoperative and postoperative infection control measures (protocol group) and those who did not (control group). RESULTS With the implementation of postoperative surgical dressing infection control measures and physician awareness, the postoperative spine surgery infection rate decreased by 45% from 3.8% to 2.1% (risk ratio 0.55; 95% CI 0.32-0.93; p = 0.03) for those in the protocol cohort, resulting in an estimated annual cost savings of $291,000. This reduction in infection rate was not observed for neurosurgeons in the control group, although the overall infection rate among all neurosurgeons decreased by 54% from 3.3% to 1.5% (risk ratio 0.46; 95% CI 0.28-0.73; p = 0.0013). CONCLUSIONS A novel paradigm for spine surgery infection control combined with physician awareness methods resulted in significantly decreased SSI rates and an associated cost reduction. Thus, information sharing and physician engagement as a supplement to formal infection control measures result in improvements in surgical outcomes and costs.

Cost-Effectiveness of Postoperative Ketamine in Chiari Decompression.

INTRODUCTION: In Chiari I patients, postoperative pain and discomfort frequently slow the transition back to the home setting. OBJECTIVE: We sought to determine the effect of standardized ketamine infusion protocols on hospital length of stay (LOS). METHODS: This retrospective cohort study reviewed 100 consecutive adult patients undergoing Chiari I decompression. Fifty-nine patients were placed on a 2-3 mg/hr ketamine drip until postoperative day 1. This group was compared with a group who received 2-3 mg/hr of ketamine until postoperative day 2 (19 patients) and patients who did not receive ketamine at all (22 patients). Clinical characteristics, opioid use, LOS, and relative hospitalization costs were assessed. All narcotic amounts were converted into milligram equivalents of morphine. RESULTS: LOS of the short-ketamine group was 46.5 hours when compared with the long-ketamine group (66.8 hours) and no-ketamine group (56.9 hours). There was a statistically significant difference when comparing the short-ketamine group with the long-ketamine group and no-ketamine group together (P < 0.001), as well as when compared individually (P = 0.001 and 0.004). The mean cost of hospitalization was 20% less when a short-ketamine protocol was used (P < 0.001). Mean morphine milligram equivalents used postoperatively were 148 mg in the short-ketamine group, 196 mg in the long-ketamine group, and 187 mg in the no-ketamine group (P = 0.65). No adverse events from ketamine were noted. CONCLUSIONS: Ketamine at subanesthetic levels may be an effective tool to facilitate early return home postoperatively and may significantly reduce medical costs.

Reducing Surgical Infections and Implant Costs via a Novel Paradigm of Enhanced Physician Awareness.

BACKGROUND: Studies have demonstrated that physicians are often unaware of prescription drug, laboratory, diagnostic, and surgical supply costs. OBJECTIVE: To investigate the effects of increased physician awareness on infection incidence and surgical device cost containment. METHODS: Within our institution, physicians were informed of individual, independently adjudicated, craniotomy and ventricular shunt infection incidence and rankings among peers, after which a protocol aimed at reducing skin bacterial burden was implemented for craniotomies. Physicians were also made aware of the costs for shunts and dural substitutes as well as available alternatives. RESULTS: The combined craniotomy and ventricular shunt infection incidence significantly decreased by 37.5% from 3.2% over May 2011 to April 2015 (132 infections/4137 procedures) to 2.1% over May 2015 to April 2016 (26 infections/1250 procedures; P = .041). The average annual cost savings was $234 175 from preventing postoperative craniotomy infections and $121 125 from preventing postoperative ventricular shunt infections. Total supply costs of ventricular shunts significantly decreased by 26% from $2345 per procedure in fiscal year 2015 to $1747 per procedure in fiscal year 2016 (P < .001). Total supply cost of dural grafts significantly decreased by 54% from $191 per procedure in fiscal year 2015 to $88 per procedure in fiscal year 2016 (P < .001). In total, all initiatives in this study resulted in an estimated annual savings of $567 062. CONCLUSION: Physician awareness of outcomes and costs resulted in increasing the quality of care, while at the same time reducing the cost.

Occurrence of entomopathogenic nematodes in Polish soils / Ocorrência de nematoides entomopatogênicos em solos da Polônia

ABSTRACT: Entomopathogenic nematodes ( Steinernematidaeand Heterorhabditidae) were studied in Polish soils according to the: season, habitat and altitude. In total, 167 soil samples were taken from 111 localities in Poland along north-south transect. Entomopathogenic nematodes were isolated from 53 soil samples (31.7%). Nematodes species were identified genetically from 16 samples, and in all other 37 samples nematodes were determined to the genus level. Three species of the genus Steinernema ( Steinernema kraussei, S. feltiae, S. carpocapsae) and one of the genus Heterorhabditis( Heterorhabditis megidis) were recorded. Steinernema feltiaewas the most common species. There was not a significant association between the occurrence of nematodes and season or altitude. The type of habitat significantly (P<0.05) affected the occurrence of nematodes. Nematodes were most frequent in samples collected from coniferous forests (20 findings).

RESUMO: Os nematoides entomopatogênicos ( Steinernematidaee Heterorhabditidae) foram estudados em solo polonês de acordo com estação, habitat e altitude. Foram coletadas um total de 167 amostras de solo em 111 localidades diferentes ao longo da trajeto Norte-Sul da Polônia. Os nematoides entomopatogênicos foram extraídos em 53 das amostras de solo (31,7%). As espécies de nematoides foram geneticamente identificadas a partir de 16 amostras, as outras 37 amostras foram usadas para determinar o gênero. Três espécies do gênero Steinernema( Steinernema kraussei, S. feltiae, S. carpocapsae) e uma espécie do gênero Heterorhabditis( Heterorhabditis megidis) foram identificadas. A espécie mais comum foi a S. feltiae. Não foi encontrada uma relação significativa entre a presença de nematoides com a estação do ano e a altitude. O tipo de habitat afetou significativamente (P<0,05) a ocorrência de nematoides. Os nematoides foram encontrados mais frequentemente em amostras recolhidas em florestas de coníferas (20 no total).

Prognostic importance of the extent of coronary revascularisation in patients with acute coronary syndromes and multivessel disease: one-year prospective follow-up.

BACKGROUND: Interventional treatment improves prognosis in patients with acute coronary syndromes (ACS). However, despite introduction of percutaneous coronary intervention (PCI), the risk of cardiovascular events in patients with multivessel coronary artery disease (MVD) remains significant. AIM: To evaluate the risk of complications and the prognostic value of MVD in patients with ACS during 1-year follow-up. METHODS: A group of 153 patients with ACS was followed up at a single cardiology unit with round-the-clock PCI capability. Treatment of ACS, the extent of revascularisation, and complications occurring during hospitalisation and 1-year follow-up were analysed. The end points of the study were defined as death from all causes, cardiac death, recurrent ACS and a composite end point (deaths from cardiac causes and recurrent ACS). RESULTS: During 1-year follow-up, 11 (7.2%) patients died, including 10 patients with MVD without complete revascularisation. Recurrent ACS occurred in 18 (12%) patients, including 13 patients with MVD without complete revascularisation. Presence of a residual significant coronary stenosis in incompletely revascularised patients with MVD was an important risk factor for all-cause mortality and occurrence of a composite endpoint in comparison to MVD patients who underwent complete revascularisation (p = 0.028 and p = 0.046, respectively) and patients with single-vessel disease (p = 0.006 and p = 0.003, respectively). CONCLUSIONS: Incomplete revascularisation during the acute phase of ACS was associated with an increased risk of complications and a significantly increased risk of all-cause mortality and the combined rate of cardiovascular deaths and recurrent ACS. Single-stage PCI of all significant stenoses in MVD patients resulted in better outcomes.

Use of Ubp1 protease analog to produce recombinant human growth hormone in Escherichia coli.

BACKGROUND: Numerous bacterial human growth hormone (hGH) expression methods under conventional fermentation and induction conditions have been described. Despite significant progress made in this area over the past several years, production of recombinant hGH by using cellular expression systems still requires further optimization. Fusion of the ubiquitin (Ub) tag to the hGH protein allowed to increase of the overall efficiency of the biosynthesis and improve the protein stability. Ub is a protein composed of 76 amino acid residues with a molecular mass of 8.6 kDa, expressed in all eukaryotes. This protein is an element of the universal protein modification system, which does not occur in bacteria, and is a useful carrier for heterologous proteins obtained through expression in Escherichia coli. Purification of Ub-fusion proteins is easier than that of unconjugated recombinant proteins, and Ub can be removed by deubiquitinating proteases (DUBs or UBPs). RESULTS AND CONCLUSION: In the present study the UBPD2C protease, a stable UBP1 analog, was produced as a recombinant protein in E. coli and used for production of recombinant human growth hormone (rhGH). hGH was expressed as a fusion protein with Ub as a tag. Our findings show that the UBPD2C protease is very effective in removing the Ub moiety from recombinant Ub-fused hGH. The described approach enables obtaining a considerable yield of rhGH in a purity required for pharmaceutical products.

The effect of initial dose on the recovery and final yields of Heterorhabditis megidis (Rhabditida: Heterorhabditidae) in larvae of the great wax moth, Galleria mellonella.

The aim of this study was to determine the effect of different initial doses of the infective juveniles (IJs) (50 IJs, 200 IJs, 1000 IJs) of Heterorhabditis megidis Poinar (Rhabditida: Heterorhabditidae) strain IsM15/09 on recovery, final yields and percent final yields in larvae Galleria mellonella ( L.). Percent recovery was not directly related to initial dose. Final yields also did not change with the initial dose. However, percent yields was highly negatively correlated with initial dose of nematodes and was the highest with the 50 IJs dose. Additional point of the study was to investigate whether the nematodes are able to produce progeny from one hermaphroditic individual. The results showed that the invasive larvae resumed growth and transformed into hermaphroditic individuals that reproduced without cross-fertilisation.

[Multiple mononeuropathy in the course of the Churg-Strauss syndrome--a case study]. / Mnoga mononeuropatia w przebiegu zespolu Churga i Strauss - opis przypadku.

The Churg-Strauss syndrome (CSS) is a systemic vasculitis. The symptoms of CSS normally occur between the ages of 20 and 40. We present a case of a 60-year-old man with the CSS evolving in three phases. The initial symptoms included bronchial asthma and inflammation of the ethmoid sinuses. Later, the patient was diagnosed with peripheral blood eosinophilia, pulmonary changes, skin changes and neurological symptoms that progressed to multiple mononeuropathy. Electrophysiological tests confirmed progressive damage of the peripheral nervous system. An improvement of the patient's neurological state was observed after application of corticosteroids and rehabilitation. CSS is one of the causes of multiple mononeuropathy and should be taken into account in differential diagnosis. In patients with bronchial asthma, hypereosinophilia and progressive damage of many nerves, the syndrome is diagnosed in accordance with the criteria defined by the American College of Rheumatology.

Uprighting partially impacted permanent second molars.

Impaction of the lower second molar is not a common problem, but it is very challenging for both orthodontist and oral surgeon. Treatment options depend on the degree of tooth inclination, the position of the third molars, and the desired type of movement, which may be surgical and/or orthodontic in nature. A good treatment alternative is surgical uncovering with orthodontically-assisted eruption. A case of successful uprighting using a 0.017 x 0.025-inch titanium molybdenum alloy (TMA) tip-back cantilever is presented. Different aspects of uprighting impacted second molars are discussed in light of the literature. The iatrogenic character of lower second molar impaction is emphasized.