Blood-based frailty index in patients with acute ischemic stroke undergoing endovascular treatment.

INTRODUCTION: Frailty is a syndrome depicting vulnerability of multiple physiological systems to stressors. Frailty measures, such as Hospital Frailty Risk Score (HFRS), can be used to identify frailty and predict outcome more reliably. Our aim was to analyse a blood-based frailty index (FI-B) at admission for prediction outcome of patients with acute ischemic stroke (AIS) undergoing endovascular treatment (EVT). METHODS: We conducted a retrospective study of consecutive AIS patients undergoing EVT in a single tertiary centre during a period of five years. A set of eighteen blood parameters at admission were collected and nine of these were utilized to calculate FI-B. We analysed the relationship between FI-B and HFRS. We examined the baseline characteristics of the study population based on FI-B-tertiles. Multivariable regression models were employed to ascertain the association between FI-B and in-hospital mortality, 3-month mortality and 3-month functional outcome. RESULTS: The final study population comprised 489 patients, with a median age of 75.6 years, 49.5% of patients were male. The FI-B exhibited a weak positive correlation with HFRS (rho=0.113, p=0.016). Patients in higher FI-B-tertiles were older and more frequently presented with pre-stroke functional dependence and comorbidities. Moreover, an increasing FI-B was independently associated with increased likelihood of in-hospital mortality (adjusted odds ratio [aOR]=1.29, 95% confidence interval [95%CI]=1.14-1.47), 3-month mortality (aOR=1.26, 95%CI=1.11-1.43), and of increasing 3-month functional disability measured by utility-weighted modified Rankin Scale (common aOR=0.84, 95%CI=0.76-0.93). CONCLUSION: A frailty index based on blood values at admission was able to identify frailty in AIS patients undergoing EVT and was an independent predictor of short- and medium-term outcome after stroke.

Infectious Diseases Society of America 2023 Guidance on the Treatment of Antimicrobial Resistant Gram-Negative Infections.

BACKGROUND: The Infectious Diseases Society of America (IDSA) is committed to providing up-to-date guidance on the treatment of antimicrobial-resistant infections. This guidance document focuses on infections caused by extended-spectrum ß-lactamase producing Enterobacterales (ESBL-E), AmpC ß-lactamase-producing Enterobacterales (AmpC-E), carbapenem-resistant Enterobacterales (CRE), Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa), carbapenem-resistant Acinetobacter baumannii (CRAB), and Stenotrophomonas maltophilia. This updated document replaces previous versions of the guidance document. METHODS: A panel of six infectious diseases specialists with expertise in managing antimicrobial-resistant infections formulated questions about the treatment of infections caused by ESBL-E, AmpC-E, CRE, DTR-P. aeruginosa, CRAB, and S. maltophilia. Because of differences in the epidemiology of resistance and availability of specific anti-infectives internationally, this document focuses on the treatment of infections in the United States. RESULTS: Preferred and alternative suggested treatment approaches are provided with accompanying rationales, assuming the causative organism has been identified and antibiotic susceptibility results are known. Approaches to empiric treatment, transitioning to oral therapy, duration of therapy, and other management considerations are also discussed briefly. Suggested approaches apply for both adult and pediatric populations, although suggested antibiotic dosages are provided only for adults. CONCLUSIONS: The field of antimicrobial resistance is highly dynamic. Consultation with an infectious diseases specialist is recommended for the treatment of antimicrobial resistant infections. This document is current as of December 31, 2022 and will be updated periodically. The most current version of this document, including date of publication, is available at www.idsociety.org/practice-guideline/amr-guidance/.

Risk factors for progression of chronic kidney disease: An investigation in prepubertal children.

AIM: Previous studies on progression of chronic kidney disease (CKD) in children have included older post-pubertal subjects. This study attempted to evaluate risk factors for progression of CKD in pre-pubertal children. METHODS: An observational study of children aged 2-10 years with an eGFR within the limits of >30 and <75 mL/min/1.73 m2 was performed. Presenting clinical and biochemical risk factors, as well as diagnosis, were analysed for their association with progression to kidney failure, time to kidney failure and for the rate of decline of kidney function. RESULTS: One hundred and twenty-five children were studied of whom 42 (34%) had progressed to CKD stage 5 during the median period of follow up of 3.1 (IQR = 1.8-6) years. Hypertension, anaemia and acidosis at entry were associated with progression but they did not predict reaching the end point. Only glomerular disease, proteinuria and stage 4 kidney disease were independent predictors of kidney failure and the time to kidney failure. The rate of kidney function decline was greater in patients with glomerular than non-glomerular disease. CONCLUSIONS: Common modifiable risk factors, when present at initial evaluation, were not independently associated with CKD progression to kidney failure in prepubertal children. Only non-modifiable risk factors and proteinuria predicted eventual stage 5 disease. The physiological changes of puberty may be the major precipitator of kidney failure during adolescence.

Lateral Approach to the Cervical Spine to Manage Degenerative Cervical Myelopathy and Radiculopathy.

BACKGROUND: The cervical lateral approach can enlarge the spinal canal and foramen to achieve an effective neural decompression without needing spine stabilization. For this review, the authors' main objective was to illustrate the rationale, advantages, disadvantages, complications, and pitfalls of this technique, highlighting also areas for future development. MATERIALS AND METHODS: A Medline via PubMed database search was carried out by using both keywords, namely "cervical oblique corpectomy," "multilevel oblique corpectomy and foraminotomy," and "lateral vertebrectomy," and Medical Subject Headings (MeSH) terms from 1 January 1991, up to 31 December 2021. RESULTS: The analyzed articles suggested that the use of such a technique has declined over time; only 29 clinical studies met all the inclusion criteria and were retained for data analysis, including 1200 patients undergoing such an approach for the management of degenerative cervical myelopathies (DCMs) or of radiculopathies. The main etiopathogeneses were cervical stenosis, degenerative disk disease, or a mix of them-78% of which had a favorable outcome; the most frequent complications were transient and permanent Horner syndrome in 13.6% and 9.2% of cases, respectively. Long-term stability was reported in 97% of patients. CONCLUSION: Multilevel cervical oblique vertebrectomy and/or lateral foraminotomy allow wide neural structure decompression and optimal stability given that the physiological spinal motion is preserved.

Medicare Prescription Plans Limit Access to Recommended Drugs for Clostridioides difficile Infection.

We analyzed June 2021 Medicare Advantage/Part D enrollment and formulary data. Oral vancomycin and fidaxomicin, frontline Clostridioides difficile treatments, were in the formulary for 100% (42314676 of 42314676) and 84.1% (35598385 of 42314676) of enrollees, respectively. However, they were broadly accessible (formulary, unrestricted, tier 1 or 2) to only 14.4% (6104348 of 42314676) and 1.1% (483004 of 42314676), respectively.

Screening for Ocular Candidiasis Among Patients With Candidemia: Is It Time to Change Practice?

Ocular candidiasis (OC) complicates approximately 10% of candidemia and carries potentially severe morbidity. There are conflicting recommendations about the need for routine funduscopic examinations of candidemic patients. Indirect funduscopy is accurate and safe in diagnosing OC, and positive findings change recommended treatment. However, conclusive evidence that treatment changes improve outcomes is lacking. Bringing perspectives as infectious diseases physicians and ophthalmologists, we review controversies about OC and endorse routine screening during candidemia. We acknowledge difficulties in obtaining inpatient ophthalmologic consults and recommend studies to evaluate digital fundus photography and teleophthalmology as an alternative to funduscopic examinations by ophthalmologists in asymptomatic patients.

Infectious Diseases Society of America Guidance on the Treatment of AmpC ß-Lactamase-Producing Enterobacterales, Carbapenem-Resistant Acinetobacter baumannii, and Stenotrophomonas maltophilia Infections.

The Infectious Diseases Society of America (IDSA) is committed to providing up-to-date guidance on the treatment of antimicrobial-resistant infections. A previous guidance document focused on infections caused by extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa). Here, guidance is provided for treating AmpC ß-lactamase-producing Enterobacterales (AmpC-E), carbapenem-resistant Acinetobacter baumannii (CRAB), and Stenotrophomonas maltophilia infections. A panel of 6 infectious diseases specialists with expertise in managing antimicrobial-resistant infections formulated questions about the treatment of AmpC-E, CRAB, and S. maltophilia infections. Answers are presented as suggested approaches and corresponding rationales. In contrast to guidance in the previous document, published data on the optimal treatment of AmpC-E, CRAB, and S. maltophilia infections are limited. As such, guidance in this document is provided as "suggested approaches" based on clinical experience, expert opinion, and a review of the available literature. Because of differences in the epidemiology of resistance and availability of specific anti-infectives internationally, this document focuses on the treatment of infections in the United States. Preferred and alternative treatment suggestions are provided, assuming the causative organism has been identified and antibiotic susceptibility results are known. Approaches to empiric treatment, duration of therapy, and other management considerations are also discussed briefly. Suggestions apply for both adult and pediatric populations. The field of antimicrobial resistance is highly dynamic. Consultation with an infectious diseases specialist is recommended for the treatment of antimicrobial-resistant infections. This document is current as of 17 September 2021 and will be updated annually. The most current version of this document, including date of publication, is available at www.idsociety.org/practice-guideline/amr-guidance-2.0/.

Infectious Diseases Society of America 2022 Guidance on the Treatment of Extended-Spectrum ß-lactamase Producing Enterobacterales (ESBL-E), Carbapenem-Resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with Difficult-to-Treat Resistance (DTR-P. aeruginosa).

BACKGROUND: The Infectious Diseases Society of America (IDSA) is committed to providing up-to-date guidance on the treatment of antimicrobial-resistant infections. The initial guidance document on infections caused by extended-spectrum ß-lactamase producing Enterobacterales (ESBL-E), carbapenem-resistant Enterobacterales (CRE), and Pseudomonas aeruginosa with difficult-to-treat resistance (DTR-P. aeruginosa) was published on 17 September 2020. Over the past year, there have been a number of important publications furthering our understanding of the management of ESBL-E, CRE, and DTR-P. aeruginosa infections, prompting a rereview of the literature and this updated guidance document. METHODS: A panel of 6 infectious diseases specialists with expertise in managing antimicrobial-resistant infections reviewed, updated, and expanded previously developed questions and recommendations about the treatment of ESBL-E, CRE, and DTR-P. aeruginosa infections. Because of differences in the epidemiology of resistance and availability of specific anti-infectives internationally, this document focuses on the treatment of infections in the United States. RESULTS: Preferred and alternative treatment recommendations are provided with accompanying rationales, assuming the causative organism has been identified and antibiotic susceptibility results are known. Approaches to empiric treatment, duration of therapy, and other management considerations are also discussed briefly. Recommendations apply for both adult and pediatric populations. CONCLUSIONS: The field of antimicrobial resistance is highly dynamic. Consultation with an infectious diseases specialist is recommended for the treatment of antimicrobial-resistant infections. This document is current as of 24 October 2021. The most current versions of IDSA documents, including dates of publication, are available at www.idsociety.org/practice-guideline/amr-guidance/.

Remediation of Mucorales-contaminated Healthcare Linens at a Laundry Facility Following an Investigation of a Case Cluster of Hospital-acquired Mucormycosis.

BACKGROUND: In an investigation of hospital-acquired mucormycosis cases among transplant recipients, healthcare linens (HCLs) delivered to our center were found to be contaminated with Mucorales. We describe an investigation and remediation of Mucorales contamination at the laundry supplying our center. METHODS: We performed monthly RODAC cultures of HCLs upon hospital arrival, and conducted site inspections and surveillance cultures at the laundry facility. Remediation was designed and implemented by infection prevention and facility leadership teams. RESULTS: Prior to remediation, 20% of HCLs were culture-positive for Mucorales upon hospital arrival. Laundry facility layout and processes were consistent with industry standards. Significant step-ups in Mucorales and mold culture-positivity of HCLs were detected at the post-dryer step (0% to 12% [P = .04] and 5% to 29% [P = .01], respectively). Further increases to 17% and 40% culture-positivity, respectively, were noted during pre-transport holding. Site inspection revealed heavy Mucorales-positive lint accumulation in rooftop air intake and exhaust vents that cooled driers; intake and exhaust vents that were facing each other; rooftop and plant-wide lint accumulation, including in the pre-transport clean room; uncovered carts with freshly-laundered HCLs. Following environmental remediation, quality assurance measures and education directed toward these sources, Mucorales culture-positivity of newly-delivered HCLs was reduced to 0.3% (P = .0001); area of lint-contaminated rooftop decreased from 918 m2 to 0 m2 on satellite images. CONCLUSIONS: Targeted laundry facility interventions guided by site inspections and step-wise culturing significantly reduced Mucorales-contaminated HCLs delivered to our hospital. Collaboration between infection prevention and laundry facility teams was crucial to successful remediation.

Molecular Epidemiology, Natural History, and Long-Term Outcomes of Multidrug-Resistant Enterobacterales Colonization and Infections Among Solid Organ Transplant Recipients.

BACKGROUND: Multidrug-resistant Enterobacterales (MDR-E), including carbapenem-resistant and third-generation cephalosporin-resistant Enterobacterales (CRE, CefR-E), are major pathogens following solid organ transplantation (SOT). METHODS: We prospectively studied patients who underwent lung, liver, and small bowel transplant from February 2015 through March 2017. Weekly perirectal swabs (up to 100 days post-transplant) were cultured for MDR-E. Whole-genome sequencing (WGS) was performed on gastrointestinal (GI) tract-colonizing and disease-causing isolates. RESULTS: Twenty-five percent (40 of 162) of patients were MDR-E GI-colonized. Klebsiella pneumoniae was the most common CRE and CefR-E. Klebsiella pneumoniae carbapenemases and CTX-M were leading causes of CR and CefR, respectively. Thirty-five percent of GI colonizers developed MDR-E infection vs 2% of noncolonizers (P < .0001). The attack rate was higher among CRE colonizers than CefR-E colonizers (53% vs 21%, P = .049). GI colonization and high body mass index were independent risk factors for MDR-E infection (P ≤ .004). Thirty-day mortality among infected patients was 6%. However, 44% of survivors developed recurrent infections; 43% of recurrences were late (285 days to 3.9 years after the initial infection). Long-term survival (median, 4.3 years post-transplant) did not differ significantly between MDR-E-infected and MDR-E-noninfected patients (71% vs 77%, P = .56). WGS phylogenetic analyses revealed that infections were caused by GI-colonizing strains and suggested unrecognized transmission of novel clonal group-258 sublineage CR-K. pneumoniae and horizontal transfer of resistance genes. CONCLUSIONS: MDR-E GI colonization was common following SOT and predisposed patients to infections by colonizing strains. MDR-E infections were associated with low short- and long-term mortality, but recurrences were frequent and often occurred years after initial infections. Findings provide support for MDR-E surveillance in our SOT program.

Different Conformations Revealed by NMR Underlie Resistance to Ceftazidime/Avibactam and Susceptibility to Meropenem and Imipenem among D179Y Variants of KPC ß-Lactamase.

ß-Lactamase-mediated resistance to ceftazidime-avibactam (CZA) is a serious limitation in the treatment of Gram-negative bacteria harboring Klebsiella pneumoniae carbapenemase (KPC). Herein, the basis of susceptibility to carbapenems and resistance to ceftazidime (CAZ) and CZA of the D179Y variant of KPC-2 and -3 was explored. First, we determined that resistance to CZA in a laboratory strain of Escherichia coli DH10B was not due to increased expression levels of the variant enzymes, as demonstrated by reverse transcription PCR (RT-PCR). Using timed mass spectrometry, the D179Y variant formed prolonged acyl-enzyme complexes with imipenem (IMI) and meropenem (MEM) in KPC-2 and KPC-3, which could be detected up to 24 h, suggesting that IMI and MEM act as covalent ß-lactamase inhibitors more than as substrates for D179Y KPC-2 and -3. This prolonged acyl-enzyme complex of IMI and MEM by D179Y variants was not observed with wild-type (WT) KPCs. CAZ was studied and the D179Y variants also formed acyl-enzyme complexes (1 to 2 h). Thermal denaturation and differential scanning fluorimetry showed that the tyrosine substitution at position 179 destabilized the KPC ß-lactamases (KPC-2/3 melting temperature [Tm] of 54 to 55°C versus D179Y Tm of 47.5 to 51°C), and the D179Y protein was 3% disordered compared to KPC-2 at 318 K. Heteronuclear 1H/15N-heteronuclear single quantum coherence (HSQC) nuclear magnetic resonance (NMR) spectroscopy also revealed that the D179Y variant, compared to KPC-2, is partially disordered. Based upon these observations, we discuss the impact of disordering of the Ω loop as a consequence of the D179Y substitution. These conformational changes and disorder in the overall structure as a result of D179Y contribute to this unanticipated phenotype.

Advance social information allows red crossbills (Loxia curvirostra) to better conserve body mass and intestinal mass during food stress.

Animals prepare for fluctuations in resources through advance storage of energy, planned reduction in energy costs or by moving elsewhere. Unpredictable fluctuations in food, however, may be particularly challenging if animals cannot avoid negative impacts on body condition. Social information may help animals to cope with unpredictable resources if cues from individuals with low foraging success give advance warning about deteriorating conditions. This study investigates the impact of social information on behaviour and physiology of food-restricted captive red crossbills (Loxia curvirostra). Birds were restricted to two short feeding periods per day to simulate a decline in resources and were given social information from food-restricted neighbours either before (i.e. predictive) or during (i.e. parallel) the food-restriction period. Focal birds better conserved body mass during food restriction if social information was predictive of the decline in resources. Crossbills with predictive information ate more food, had larger intestinal mass and better conserved pectoral muscle size at the end of the restriction period compared to those with parallel social information. These data suggest that birds can use social information to alter behavioural and physiological responses during food shortage in ways that may confer an adaptive advantage for survival.

Vocal-Stress Diary: A Longitudinal Investigation of the Association of Everyday Work Stressors and Human Voice Features.

The human voice conveys plenty of information about the speaker. A prevalent assumption is that stress-related changes in the human body affect speech production, thus affecting voice features. This suggests that voice data may be an easy-to-capture measure of everyday stress levels and can thus serve as a warning signal of stress-related health consequences. However, previous research is limited (i.e., has induced stress only through artificial tasks or has investigated only short-term or extreme stressors), leaving it open whether everyday work stressors are associated with voice features. Thus, our participants (111 adult working individuals) took part in a 1-week diary study (Sunday until Sunday), in which they provided voice messages and self-report data on daily work stressors. Results showed that work stressors were associated with voice features such as increased speech rate and voice intensity. We discuss theoretical, practical, and ethical implications regarding the voice as an indicator of psychological states.

Temperature affects the biomechanical response of in vitro non-human primate lenses during lens stretching.

PURPOSE: To determine the effect of temperature on the accommodative response of non-human primate crystalline lenses during simulated accommodation. METHODS: Eight lenses from 7 cynomolgus monkeys (Macaca fascicularis, ages: 4.5-7.3 years; post-mortem time: 17.0 ± 16.4 h) were mounted in a lens stretcher. Stretching experiments were performed on each lens at 24 °C (room temperature), then the tissue was warmed to 35 °C (intraocular temperature) and the stretching experiments were repeated. The lens diameter, thickness, anterior and posterior surface radii of curvature, optical power, and the stretching force (load) were measured at each stretch position and the linear optomechanical relationships were quantified: load-lens diameter, load-thickness, power-load, load-anterior radius, and load-posterior radius. The rate of change for each parameter was quantified by performing a linear regression. The slopes of the linear regressions were compared at the two temperatures using a paired sample t-test. RESULTS: The average changes in the lens with stretching at 24 °C and 35 °C were: 3.07 ± 0.17 and 2.58 ± 0.15 for load-lens diameter (g/mm), -2.38 ± 0.20 and -2.00 ± 0.32 for load-thickness (g/mm), -13.35 ± 1.21 and -13.75 ± 1.26 for power-load (D/g), 0.41 ± 0.10 and 0.34 ± 0.05 for load-anterior radius of curvature (g/mm), and 1.35 ± 0.24 and 1.31 ± 0.35 for load-posterior radius of curvature (g/mm), respectively. The changes in load-diameter and load-thickness with lens stretching were significantly different for the two temperatures. CONCLUSIONS: Temperature influences the change in lens shape observed during simulated accommodation in non-human primate lenses. These results suggest that lens stretching experiments and other optomechanical measurement techniques on ex vivo crystalline lenses be conducted at 35 °C and that the temperature of the tissue sample be documented and maintained constant to ensure repeatability.

Surgical treatment of mechanical bowel obstruction: characteristics and outcomes of geriatric patients compared to a younger cohort.

PURPOSE: Mechanical bowel obstruction (MBO) is one of the most common indications for emergency surgery. Recent research justifies the method of attempting 3-5 days of nonoperative treatment before surgery. However, little is known about specific characteristics of geriatric patients undergoing surgery compared to a younger cohort. We aimed to analyze patients with MBO that required surgery, depending on their age, to identify potential targets for use in the reduction in complications and mortality in the elderly. METHODS: Thirty-day and in-hospital mortality were determined as primary outcome. We retrospectively identified all patients who underwent surgery for MBO at the University Hospital of Bonn between 2009 and 2019 and divided them into non-geriatric (40-74 years, n = 224) and geriatric (≥ 75 years, n = 88) patients, using the chi-squared-test and Mann-Whitney U test for statistical analysis. RESULTS: We found that geriatric patients had higher 30-day and in-hospital mortality rates than non-geriatric patients. As secondary outcome, we found that they experienced a longer length of stay (LOS) and higher complication rates than non-geriatric patients. Geriatric patients who suffered from large bowel obstruction (LBO) had a higher rate of bowel resection, stoma creation, and a higher 30-day mortality rate. The time from admission to surgery was not shown to be crucial for the outcome of (geriatric) patients. CONCLUSION: Geriatric patients suffering from mechanical bowel obstruction that had to undergo surgery had higher mortality and morbidity than non-geriatric patients. Especially in regard to geriatric patients, clinicians should treat patients in a risk-adapted rather than time-adapted manner, and conditions should be optimized before surgery.

Transcutaneous vagal nerve simulation to reduce a systemic inflammatory response syndrome and the associated intestinal failure: study protocol of a prospective, two-armed, sham-controlled, double-blinded trial in healthy subjects (the NeuroSIRS-Study).

PURPOSE: Surgery initiates pro-inflammatory mediator cascades leading to a variably pronounced sterile inflammation (SIRS). SIRS is associated with intestinal paralysis and breakdown of intestinal barrier and might result in abdominal sepsis. Technological progress led to the development of a neurostimulator for transcutaneous auricular vagal nerve stimulation (taVNS), which is associated with a decline in inflammatory parameters and peristalsis improvement in rodents and healthy subjects via activation of the cholinergic anti-inflammatory pathway. Therefore, taVNS might be a strategy for SIRS prophylaxis. METHODS: The NeuroSIRS-Study is a prospective, randomized two-armed, sham-controlled, double-blind clinical trial. The study is registered at DRKS00016892 (09.07.2020). A controlled endotoxemia is used as a SIRS-mimicking model. 2 ng/kg bodyweight lipopolysaccharide (LPS) will be administered after taVNS or sham stimulation. The primary objective is a reduction of clinical symptoms of SIRS after taVNS compared to sham stimulation. Effects of taVNS on release of inflammatory cytokines, intestinal function, and vital parameters will be analyzed. DISCUSSION: TaVNS is well-tolerated, with little to no side effects. Despite not fully mimicking postoperative inflammation, LPS challenge is the most used experimental tool to imitate SIRS and offers standardization and reproducibility. The restriction to healthy male volunteers exerts a certain bias limiting generalizability to the surgical population. Still, this pilot study aims to give first insights into taVNS as a prophylactic treatment in postoperative inflammation to pave the way for further clinical trials in patients at risk for SIRS. This would have major implications for future therapeutic approaches.

[Cochlear nerve continuity preservation during retrosigmoid ablative osteotomy of the internal auditory canal for advanced vestibular schwannomas]. / Kontinuitätserhalt des Nervus cochlearis bei der retrosigmoidalen ablativen Osteotomie des inneren Gehörgangs bei fortgeschrittenen Vestibularisschwannomen.

The data of 86 patients with retrosigmoid microsurgical resection of vestibular schwannoma in tumor stage Koos II-IV were evaluated. In more than two thirds of the cases it was shown that the cochlear nerve followed the facial nerve, which is easily identified by electroneurography, in recurrent similar patterns in the region of the internal auditory canal. Starting from the fundus, this facilitated early identification and thus preservation of continuity of the cochlear nerve in the course of the internal auditory canal. This was of particular importance when safe functional preservation could not be guaranteed due to tumor size or formation despite intraoperative derivation of somatosenoric potentials, but when the possibility of subsequent hearing rehabilitation with a cochlear implant should be granted. Preoperative MRI sequences gave an indication of the possible nerve courses in some cases, but intraoperative imaging in the internal auditory canal was superior to MRI.

[Interdisciplinary surgery to the central skull base-current status]. / Interdisziplinäre Chirurgie der zentralen Schädelbasis ­ aktueller Stand.

BACKGROUND: The skull base is a surgically complex unit and is often only accessible via combined access routes. Newly developed surgical techniques using microsurgical visualization procedures and active instruments ("powered instruments") as well as multiport accesses enable new, less traumatic surgical corridors. This requires close interdisciplinary cooperation between ENT and neurosurgeons. Currently established access routes to the central skull base are systematized based on the authors' own clinical experience, and discussed in relation to the entity and the current study situation. MATERIALS AND METHODS: A retrospective, qualitative, and descriptive evaluation of the surgical reports of patients with pathologies of the central skull base who were jointly treated by neurosurgery and otorhinolaryngologic/head and neck surgery between 2006 and 2019 was performed. RESULTS: The surgical access routes to the central skull base can be categorized as so-called multiport access routes, partly also in combination, as follows: transnasal-transsphenoidal, subfrontal, subtemporal, transzygomatic, transpterygonal, transpetrous, translabyrinthine, and suboccipital. The choice of access route was based on the location and type of pathology, its inflammatory or space-occupying (benign or malignant tumor) nature, and the possibilities of functional preservation and complete removal. CONCLUSION: Due to the complexity of central skull base structures, the different tumor entities, and the required expertise of different medical specialties, surgery of the central skull base remains a challenge and should only be performed at special competence centers certified according to the criteria of the German Society of Skull Base Surgery.

Impact of Revised Infectious Diseases Society of America and Society for Healthcare Epidemiology of America Clinical Practice Guidelines on the Treatment of Clostridium difficile Infections in the United States.

BACKGROUND: Our objective was to determine if oral vancomycin, fidaxomicin, and oral metronidazole use in the United States changed after publication of revised clinical practice guidelines for Clostridium difficile infection (CDI) in February 2018. METHODS: We obtained US antibiotic prescription data (IQVIA) from 2006-August 2019 and used guideline-recommended dosing regimens to estimate monthly numbers of 10-day treatment courses of vancomycin, fidaxomicin and metronidazole. Interrupted time-series analyses were performed, adjusted by month. We compared linear trends for monthly numbers of treatment courses in different time periods. RESULTS: Cumulative treatment courses of oral vancomycin and fidaxomicin increased by 54% (n = 226 166) and 48% (n = 18 518), respectively, in 18 months following guidelines compared with 18 months before; those of oral metronidazole decreased by 3% (n = 238 372). Monthly vancomycin and fidaxomicin use significantly increased throughout the period following revised guidelines (P < .0001 and P = .0002, respectively), whereas that of metronidazole decreased significantly (P < .0001). Monthly vancomycin use increased and metronidazole use decreased to a significantly greater extent after publication of revised guidelines than after publication of clinical trials establishing superiority of vancomycin over metronidazole (P < .0001). CONCLUSIONS: Revised practice guidelines have had a significant impact on CDI treatment in the US. Clinical trial data used for the revised guidelines were available since 2007-2014 and 2011-2012 for oral vancomycin and fidaxomicin, respectively. Guidelines or guidance documents for treating CDI and other infections should be updated in more timely fashion.

Single Dose of an mRNA Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Cov-2) Vaccine Is Associated With Lower Nasopharyngeal Viral Load Among Nursing Home Residents With Asymptomatic Coronavirus Disease 2019 (COVID-19).

In nursing home residents with asymptomatic COVID-19 diagnosed through twice-weekly surveillance testing, single-dose BNT162b2 vaccination (Pfizer-BioNTech) was associated with -2.4 mean log10 lower nasopharyngeal viral load than detected in absence of vaccination (P = .004). Since viral load is linked to transmission, single-dose mRNA SARS-CoV-2 vaccination may help control outbreaks.