Duodenoscopy: an amplifier of cross-transmission during a carbapenemase-producing Enterobacteriaceae outbreak in a gastroenterology pathway.

Carbapenemase-producing Klebsiella pneumoniae (OXA-48 CPE) were identified in five patients who underwent an endoscopy with the same duodenoscope in October 2015. The endoscope was the only epidemiological link between these cases. A transient contamination of the duodenoscope following a failure in the disinfection process may have been the cause of transmission.

nm23 expression in malignant ascitic effusions of serous ovarian adenocarcinoma.

The aim of this study was to evaluate nm23 expression as detected in malignant cells of neoplastic ascites and to verify its relationship with the presence of tissue nm23 and p53 in primitive neoplasia. Using an immunocytochemical assay with a specific anti-nm23 polyclonal antibody, nm23 expression was evaluated in ascitic effusions of 45 patients with ovarian serous adenocarcinoma and ascites in normal and/or hyperplastic mesothelial cells from 37 women with various neoplasms (12 ovarian neoplasms) free of malignant cells as controls. nm23 and p53 tissue expression was also detected in 21 corresponding tumor samples, including 11 bilateral lesions. nm23 was expressed in 57% of malignant effusions compared to 43% in controls: the two groups were not correlated. nm23 in effusions agreed with tissue expression (p=0.02) but a direct correlation was not demonstrated. The incidence of nm23 was more frequent in stage III than in stage IV disease (p=0.08) and was associated with mutated p53 expression (p=0.01). Using the Wilcoxon test for unpaired data, a higher incidence (p=0.05) of p53-positive tumors in bilateral cancers was found while a higher expression of nm23 in effusions of patients with monolateral lesions was observed (p=0.08). The presence of p53 was correlated with that of nm23 in both cytologic (p=0.005) and histological samples (p=0.01). Our findings, together with the diversity in biological behaviour present in various tumors, suggest that nm23 is a family of genes with differing biological functions which act as tumor-specific inhibiting factors within a complex process also involving other genes. Due to the analogies and correlations between nm23 and p53, the role of nm23 as a potential predictive factor of response to chemotherapy and in DNA repair is emphasized.

The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study.

BACKGROUND: In 1989, a group of sixty-seven asymptomatic individuals with no history of back pain underwent magnetic resonance imaging of the lumbar spine. Twenty-one subjects (31%) had an identifiable abnormality of a disc or of the spinal canal. In the current study, we investigated whether the findings on the scans of the lumbar spine that had been made in 1989 predicted the development of low-back pain in these asymptomatic subjects. METHODS: A questionnaire concerning the development and duration of low-back pain over a seven-year period was sent to the sixty-seven asymptomatic individuals from the 1989 study. A total of fifty subjects completed and returned the questionnaire. A repeat magnetic resonance scan was made for thirty-one of these subjects. Two neuroradiologists and one orthopaedic spine surgeon interpreted the original and repeat scans in a blinded fashion, independent of clinical information. At each disc level, any radiographic abnormality, including bulging or degeneration of the disc, was identified. Radiographic progression was defined as increasing severity of an abnormality at a specific disc level or the involvement of additional levels. RESULTS: Of the fifty subjects who returned the questionnaire, twenty-nine (58%) had no back pain. Low-back pain developed in twenty-one subjects during the seven-year study period. The 1989 scans of these subjects demonstrated normal findings in twelve, a herniated disc in five, stenosis in three, and moderate disc degeneration in one. Eight individuals had radiating leg pain; four of them had had normal findings on the original scans, two had had spinal stenosis, one had had a disc protrusion, and one had had a disc extrusion. In general, repeat magnetic resonance imaging scans revealed a greater frequency of disc herniation, bulging, degeneration, and spinal stenosis than did the original scans. CONCLUSIONS: The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. Individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality on the original, 1989 scans. Clinical correlation is essential to determine the importance of abnormalities on magnetic resonance images.

Fungal infections of the spine. Report of eleven patients with long-term follow-up.

BACKGROUND: Fungal infections of the spine are noncaseating, acid-fast-negative infections that occur primarily as opportunistic infections in immunocompromised patients. We analyzed eleven patients with spinal osteomyelitis caused by a fungus, and we developed suggestions for treatment. METHODS: All patients with a fungal infection of the spine treated by the authors over a sixteen-year period at three teaching institutions were evaluated. There was a total of eleven patients. Medical records and roentgenograms were available for every patient. Long-term follow-up of the nine surviving patients was performed by direct examination by the authors or by the patient's primary physician. RESULTS: For ten of the eleven patients, the average delay in the diagnosis was ninety-nine days. Nine patients were immunocompromised secondary to diabetes mellitus, corticosteroid use, chemotherapy for a tumor, or malnutrition. The sources of the spinal infections included direct implantation from trauma (one patient), hematogenous spread (four patients), and local extension (two patients). The infection followed elective spine surgery in three patients, and the cause was unknown in one. Paralysis secondary to the spine infection developed in eight patients. Ten patients were treated with surgical debridement. All eleven patients were treated with systemic antifungal medications for a minimum of six weeks. One patient died of generalized sepsis at thirty-three days, and another patient died of gastrointestinal hemorrhage at five months. After an average of 6.3 years of follow-up, the infection had resolved in all nine surviving patients. CONCLUSIONS: Treatment of fungal spondylitis is often delayed because of difficulty with the diagnosis. Delay in the diagnosis led to poorer results in terms of neurologic recovery in our study. Performing fungal cultures whenever a spinal infection is suspected might hasten the diagnosis. Patients should be given a guarded prognosis and informed of the many possible complications of the disease.

Pain sensitivity as a correlate of clinical status in individuals with chronic low back pain.

STUDY DESIGN: A cross-sectional study of baseline correlates of clinical pain and functional status in consecutive patients being treated for chronic low back pain. OBJECTIVES: To determine if an individual's global pain sensitivity, measured by experimental pain threshold to pressure at various regions of the body, is associated with baseline measures of clinical pain and physical functioning. SUMMARY OF BACKGROUND DATA: Previous studies have demonstrated that in individuals with chronic low back pain, clinical pain and functional status are significantly associated with demographic, structural, and psychosocial factors. However, a large portion of variance remains unexplained. Because pain sensitivity (tenderness) has been shown to occur as a continuum in the population, the authors sought to determine if such sensitivity might be associated with clinical status in chronic low back pain, beyond what is known regarding demographic, structural, and psychosocial factors. METHODS: Forty-five patients with chronic low back pain were assessed for a variety of demographic, structural, and psychosocial factors, which previously have been shown to contribute to clinical status. In addition, all patients underwent testing for pain tolerance and threshold at various areas of the body. RESULTS: Age, degree of structural abnormality observed on magnetic resonance imaging, and depressive symptoms were all significantly correlated with either clinical pain or functional status. Pain sensitivity, the target of this investigation, accounted for significant proportions of variance in functional status and pain, even after controlling for demographic, structural, and psychosocial variables. CONCLUSIONS: These pilot data suggest that an individual's experimental pain threshold (a measure of tenderness) is associated with baseline functional status and pain in cases of chronic low back pain and may represent an important domain warranting further investigation.

Clinical evaluation of low back pain.

To properly diagnose and treat low back pain, a thorough history and physical examination are the cornerstones. The most important diagnoses for the physician to be aware of are cauda equina syndrome, back strain, herniated disc, stenosis, and spondylolisthesis.

Spondylolisthesis in the elite football player: an epidemiologic study in the NCAA and NFL.

Although spondylolisthesis in and of itself is not a contraindication to participation or successful performance in football, having spondylolisthesis may well predispose to symptoms and be associated with a worse prognosis. The purpose of this study was to determine the reported prevalence, treatment approach, outcomes, and perceptions regarding prognosis of elite football players with spondylolisthesis by their National Collegiate Athletic Association (NCAA) and National Football League (NFL) team physicians. A questionnaire regarding the prevalence, treatment, results, and perceptions regarding prognosis related to spondylolisthesis in football players was submitted to each team orthopaedic surgeon of the 28 NFL and the Final Associated Press ranked top-25 NCAA Division I teams at the conclusion of the 1993-1994 season. All questionnaires were returned for review. The prevalence of players with known spondylolisthesis currently participating in elite football was 1% in both the NCAA and NFL. Fifty-two percent of NCAA and 43% of NFL team physicians were aware of at least one athlete with spondylolisthesis currently playing. Only six college and two NFL team physicians were aware of athletes surgically treated for spondylolisthesis. Sixty-four percent of NFL team physicians and 36% of college team physicians believed that the presence of spondylolisthesis implies a poor prognosis. Ninety-six percent of professional team physicians downgraded the rating of players with known spondylolisthesis before the NFL draft.

[Secretory IgA of the cervical mucus in neoplastic and nonneoplastic conditions of the uterine cervix]. / IgA secretorie del muco cervicale in condizioni neoplastiche e non neoplastiche della cervice uterina.

In 39 women affected by cervical intraepithelial neoplasia (CIN) concentration of the cervical mucus secretory IgA (sIgA) was significantly higher than in 414 controls matched for age, reproductive status and smoking habit (196 healthy women; 109 with "specific" and "aspecific" cervicitis or cervico-vaginitis; 51 with benign epithelial disorders of the cervix; 40 with adenomatous cervical polyp and 18 with early invasive exocervical squamous carcinoma). CIN carried the highest proportion of cases with sIgA detectable or beyond the cut-off value and sIgA concentration was inversely related to CIN grade. Present data confirm our preliminary investigation on the cervical total IgA and explain that any increased levels of these IgA are induced by the secretory and not serum fraction of this immunoglobulin. We still don't know the exact meaning and value of the present results. It is only possible to suppose that they are the expression of a vigorous local immune activation adverse to CIN, which is elevated for as long as the architecture of cervical glandular epithelia is preserved.

Alexithymia, immunity and cervical intraepithelial neoplasia: replication.

BACKGROUND: In a previous study [Psychother Psychosom 1994;61:199-204] we investigated the relationship between alexithymia, carcinogenesis and immunity in a group of women who were unconscious sufferers from precancerous lesions of the cervix (CIN). The results of this study showed a high level of association between alexithymia and CIN and, an even more interesting fact, between alexithymia and reduced levels of immunity. METHODS: The aim of the present study is to check the results of the previous one by testing a larger group (43 women affected by cervical dysplasia and 67 healthy women) and by the use of a self-administered test for detection of alexithymia, the well-validated Twenty-Item Toronto Alexithymia Scale (TAS-20). RESULTS: The results confirm that women suffering from CIN have higher average TAS-20 ratings (55) than normal women (47.32) and that the level of alexithymia detected in the group of women suffering from dysplasia (42.5%) is higher than that of normal women (12.85%). Moreover, the present study confirms that alexithymic women have lower rates of a number of lymphocyte subsets than non-alexithymic women. CONCLUSIONS: This study fully confirms the results of our previous work and those of a number of other studies: (1) personality might be one of the factors jointly responsible for the outbreak of cancer; (2) the immune system appears to play an important part as a mediator between personality and cancer.

Orientation of the lumbar facet joints: association with degenerative disc disease.

The orientation of the lumbar facet joints was studied with magnetic resonance imaging in 140 subjects to determine if there is an association between facet tropism and intervertebral disc disease or between the orientation of the facet joints and degenerative spondylolisthesis. The 140 subjects were divided into four groups: sixty-seven asymptomatic volunteers, forty-six of whom did not have a herniated disc on magnetic resonance scans (Group I) and twenty-one who did (Group II); forty-six symptomatic patients who had a herniated disc confirmed operatively (Group III); and twenty-seven patients who had degenerative spondylolisthesis at the interspace between the fourth and fifth lumbar vertebrae (Group IV). Axial scans were made at each lumbar level and digitized, and the facet joint angle was measured by two independent observers with use of image analysis software in a personal computer. The technique of measurement of the facet angles on magnetic resonance scans was validated with a subset of subjects who also had computed tomography scans made. Similar values were obtained with the two methods (r = 0.92; p = 0.00001). For the forty-six asymptomatic volunteers who did not have a herniated disc on the magnetic resonance scans (Group I), the median facet tropism was 5 to 6 degrees and was more than 10 degrees in 24 per cent (eleven) of the subjects. There was no association between increased facet tropism and disc degeneration. At the level of the fourth and fifth lumbar vertebrae, the median facet tropism was 10.3 degrees in the symptomatic patients who had a herniated disc at the same level and 5.4 degrees in the asymptomatic volunteers (Group I) (p = 0.05). The mean orientation of the lumbar facet angles relative to the coronal plane was more sagittal at all levels in the patients who had degenerative spondylolisthesis. The greatest difference was at the level of the fourth and fifth lumbar vertebrae (p = 0.000001). The mean facet angle was 41 degrees (95 per cent confidence interval, 37.6 to 44.6 degrees) in the asymptomatic volunteers and 60 degrees (95 per cent confidence interval, 52.7 to 67.1 degrees) in the patients who had degenerative spondylolisthesis. Furthermore, both the left and the right facet joints were more sagittally oriented in the patients who had degenerative spondylolisthesis. An individual in who both facet-joint angles at the level of the fourth and fifth lumbar vertebrae were more than 45 degrees relative to the coronal plane was twenty-five times more likely to have degenerative spondylolisthesis (95 per cent confidence interval, seven to ninety-eight times). The increase in facet angles at levels other than that of the spondylolisthesis suggests that increased facet angles represent variations in anatomy rather than a secondary result of spondylolisthesis.

Patient-controlled analgesia after laparoscopic and open cholecystectomy.

Laparoscopic cholecystectomy (LC) offers advantages over open cholecystectomy (OC) of more rapid patient recovery. The comparative amount of pain that patients must endure after each of these procedures is not clear. We retrospectively analysed the use of patient-controlled analgesia (PCA) of an unselected sample of patients having either LC or OC procedures to quantitate morphine use, as well as pain and sedation scores in the postoperative period. The hospital charts, anaesthetic records and the PCA records of 40 patients having either LC (n = 19) or OC (n = 21) were analysed retrospectively. The use of PCA morphine was standardized and consisted of a loading dose of 5 mg, bolus doses of 1.5 mg and a lockout period of five minutes. By the morning of postoperative day one, OC patients had used 38.0 +/- 11.7 (mean +/- SD) mg compared with 23.7 +/- 15.3 mg in LC patients (P < 0.05). The rates of PCA morphine use in the first two postoperative hours were 4.66 +/- 2.6 mg.hr-1 and 7.04 +/- 2.7 mg.hr-1 for LC and OC patients, respectively (P < 0.05). The rates of morphine use averaged over the day of surgery were 1.28 +/- 0.8 mg.hr-1 and 2.33 +/- 0.8 mg.hr-1 for LC and OC patients (P < 0.05). Despite higher PCA morphine use in OC patients, their pain scores were higher while their sedation scores were comparable. These data suggest that laparoscopic cholecystectomy is associated with less pain than open cholecystectomy in the day after surgery.

Feasibility and reliability of flow-cytometry (fcm) DNA analysis of fresh and fixed urine samples.

The qualitative results of FCM DNA analysis on fresh and fixed urine specimens (28 and 97, respectively) from 68 normal subjects and 10 patients with a past history of bladder cancer were compared. FCM DNA evaluability was not significantly different in fresh and fixed samples (63% vs 73%, respectively) whereas mean CV was significantly higher (7.3% vs 5.7%, respectively; p=0.04). A double FCM analysis on fresh and fixed urine was also performed in 16 cases. In this subgroup, the percentage of evaluable histograms from fixed urine specimens was slightly higher than that from fresh specimens. Aneuploid cases were found only in the fixed urine samples but the CVs from fresh and fixed cell suspensions did not differ. The absence of inflammatory cells with cytological analysis of the same samples was associated with low percentages of FCM evaluability and higher CVs. The use of fixed samples improves the quality of FCM DNA analysis permitting its use for screening programs.

A comparison of simple identification tests to distinguish cerebrospinal fluid from local anaesthetic solution.

Local anaesthetic solution is sometimes used to enlarge the epidural space in preparation for the insertion of an indwelling epidural catheter and during subsequent checking a small volume of fluid may be aspirated. Twelve anaesthetists were asked to distinguish 0.1 ml plain bupivacaine 0.25% from 0.1 ml simulated cerebrospinal fluid (CSF) solution. The distinction was based on differences in the physicochemical properties of the two test solutions, namely, temperature, presence of glucose, pH, and turbidity when mixed with thiopentone. Temperature difference resulted in correct identification of the two solutions in 75% of cases, the presence of glucose in 92%, pH in 83%, and turbidity in 25% of cases. No single test resulted in correct identification by all the anaesthetists. We suggest that more than one physicochemical test is required to identify correctly the nature of the small volume of liquid which may be aspirated from an epidural catheter.

A quality-based protocol for management of musculoskeletal injuries. A ten-year prospective outcome study.

Musculoskeletal injuries in the workplace are recognized as a major health and economic problem; however, little has been done to develop strategies that emphasize both quality and cost control. The purpose of this ten-year perspective investigation was to evaluate the use of quality-based standardized diagnostic and treatment protocols as part of an unbiased injury surveillance system. The program was evaluated in a public utility company with more than 5300 employees, and resulted in a measurable and long-term improvement in all outcome parameters measured: (1) The number of days lost from work and the number of new injuries reported fell by 55 and 51%, respectively. (2) The average time lost per injury dropped by 40%. (3) The number of surgeries performed decreased by 67%, and the operative success rate increased dramatically. (4) Finally, as an added benefit, there was a 60% reduction in expenditures for lost time and replacement wages, resulting in a cumulative ten-year savings of more than 4.1 million dollars. The program accomplished the goal of ensuring quality care in a prospective concurrent fashion. As an additional benefit, the program also reduced unjustified lost time and compensation costs through early functional return, efficient use of diagnostic studies, and avoidance of surgery whenever possible. Future emphasis on health-care delivery in the workers' compensation setting should concentrate on high-quality medical care, which will, in turn, lead to secondary cost savings.

The lumbar spine in the aging athlete.

The relative importance of an elderly individual's chosen athletic endeavor should not be underestimated. These athletes have high expectations of their physical abilities. A lumbar spine syndrome can be a severe physical and psychologic setback. The ideal goal in the treatment of this population is to make an accurate diagnosis and provide expeditious treatment that allows the athlete to return to a satisfactory level of competition. The described algorithm is useful in attaining this goal. In addition, patient education is particularly important in preventing reinjury.