A Multidisciplinary Infection Control Bundle to Reduce the Number of Spinal Cord Stimulator Infections.

OBJECTIVE: To investigate the effect of a quality improvement project that resulted in an infection control bundle to reduce the number of spinal cord stimulator (SCS) infections. MATERIALS AND METHODS: The study was performed in a single center for neuromodulation from January 1, 2014, through May 31, 2016. In response to a high number of surgical site infections (SSIs) after SCS surgery, a multidisciplinary team analyzed the surgical process and developed an infection prevention bundle consisting of five items: 1) showering and decolonization for five days prior to surgery and showering in the hospital on the morning of surgery; 2) performing the SCS implantation as the first in the daily operating room (OR) program; 3) maintaining a minimal number of people in the OR; 4) providing home care nurses with a folder with SCS wound care instructions including pictures; 5) giving oral specific wound care instructions to patients. The number of infections was calculated for the baseline, implementation, and sustainability phases. RESULTS: A total of 410 SCS surgeries were performed during the study period. In the preintervention phase, 26/249 (10.4%) SCS surgeries were infected. During the implementation and sustainability phase, 2/59 (3.4%) and 1/102 (1.0%) SCS surgeries were infected, respectively. The reduction in the number of infections in pre and postintervention phase was statistically significant (p = 0.003). CONCLUSION: Multidisciplinary measures to reduce SSIs reduced the number of SCS associated infections in our study setting.

Highly sensitive assays are mandatory for the differential diagnosis of patients presenting with symptoms of mast cell activation: diagnostic work-up of 38 patients.

Mastocytosis is a heterogeneous disease caused by excessive mast cell (MC) proliferation. Diagnosis of systemic mastocytosis (SM) is based on the presence of major and minor criteria defined by the World Health Organization. Symptoms of MC activation can also occur in patients without SM or without allergic or inflammatory disease. These MC activation syndromes (MCAS) can be divided into primary (monoclonal) MCAS (MMAS) vs. secondary and idiopathic MCAS. In this single center study, the diagnostic work-up of 38 patients with a clinical suspicion of SM and/or with elevated basic tryptase levels is presented. Clinical symptoms, biochemical parameters, results of bone marrow investigation, flow cytometric immunophenotyping, and molecular analysis were retrospectively reviewed. Twenty-three patients were found to have a monoclonal MC disorder of which 19 were diagnosed with SM and 4 with MMAS. In 13/19 SM patients, multifocal MC infiltrates in the bone marrow were found (major criterion), while in 6 the diagnosis was based on the presence of ≥3 minor criteria. Flow cytometric analysis of bone marrow showed CD25 expression of MCs in all patients with SM and MMAS (range: 0.002-0.3% of cells). In bone marrow, the KIT D816V mutation was detected in all SM patients but in only 2 patients with MMAS (range: 0.007-9% mutated cells). Basic tryptase elevation was demonstrated in 16/19 patients with SM but also in 9/19 patients without SM. Our study reveals the heterogeneity of primary MC disorders and the importance of sensitive assays in patients suspected of having SM.

Inflammation of unknown origin versus fever of unknown origin: two of a kind.

OBJECTIVES: A vast literature exists on fever of unknown origin (FUO), characterized by prolonged and perplexing fevers >38.3 degrees C. In contrast, no studies are available to guide the approach to inflammation of unknown origin (IUO), defined as prolonged and perplexing inflammation with temperatures <38.3 degrees C. We aimed to determine the diagnostic yield, the case-mix, and the outcome of patients with IUO, relative to patients with FUO. METHODS: We matched 57 patients with IUO to 57 patients with FUO of the same gender (54% male) and a similar age (median: 67 years). RESULTS: A diagnosis was established in 35 patients with IUO (61%) and in 33 patients with FUO (58%) (p=.70). The case-mix did not differ significantly (p=.43). Non-infectious inflammatory disorders were the dominant diagnostic category in the IUO group (16 patients), while in the FUO group, similar numbers of malignancies [10], infections [9], and non-infectious inflammatory diseases [9] were diagnosed. (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scan contributed comparably to the diagnosis in both groups (in 18 of 50, 36%, patients with IUO and in 13 of 40, 33%, patients with FUO) (p=.83). In both groups, 7 patients (12%) died during an average follow-up of 1 year. CONCLUSION: Diagnostic yield, case-mix, contribution of FDG-PET scan and vital outcome were similar in patients with IUO and FUO. These data suggest that the 38.3 degrees C boundary may be arbitrary and that the diagnostic approaches used in FUO can be applied to IUO.