Suction drainage fluid culture during septic orthopaedic surgery, a retrospective study.

We evaluated the usefulness of suction drainage fluid culture after septic orthopaedic surgery to predict early surgical reintervention. We conducted a retrospective observational study, at the Groupe Hospitalier Paris Saint-Joseph between 2014 and 2019. All the patients undergoing septic orthopaedic surgery, with perioperative samples and a postoperative suction drainage device, were enrolled. We compared the group with positive or negative postoperative drainage fluid cultures, respectively, on surgical outcome. We included 246 patients. The drainage fluid culture was positive in 42.3% of the cases. Early surgical reintervention concerned 14.6% of the cases (n = 36), including 61.1% of patients with positive drainage fluid culture (n = 22/36). The risk factors associated with positive drainage fluid cultures were the debridement of the infected site (without orthopaedic device removal), an infection located at the spine, perioperative positive cultures to Staphylococcus aureus. The complete change of the orthopaedic device, and coagulase-negative staphylococci on the preoperative samples, was associated with negative drainage fluid cultures. Positive drainage fluid culture was predictive of early surgical reintervention, and coagulase-negative staphylococci in the preoperative samples and knee infection were predictive of surgical success. Postoperative drainage fluid cultures were predictive of early surgical reintervention. Randomized multicentric studies should be further conducted.

Divergent HIV-1 strains (CRF92_C2U and CRF93_cpx) co-circulating in the Democratic Republic of the Congo: Phylogenetic insights on the early evolutionary history of subtype C.

Molecular epidemiological studies revealed that the epicenter of the HIV pandemic was Kinshasa, the capital city of the Democratic Republic of the Congo (DRC) in Central Africa. All known subtypes and numerous complex recombinant strains co-circulate in the DRC. Moreover, high intra-subtype diversity has been also documented. During two previous surveys on HIV-1 antiretroviral drug resistance in the DRC, we identified two divergent subtype C lineages in the protease and partial reverse transcriptase gene regions. We sequenced eight near full-length genomes and classified them using bootscanning and likelihood-based phylogenetic analyses. Four strains are more closely related to subtype C although within the range of inter sub-subtype distances. However, these strains also have small unclassified fragments and thus were named CRF92_C2U. Another strain is a unique recombinant of CRF92_C2U with an additional small unclassified fragment and a small divergent subtype A fragment. The three remaining strains represent a complex mosaic named CRF93_cpx. CRF93_cpx have two fragments of divergent subtype C sequences, which are not conventional subtype C nor the above described C2, and multiple divergent subtype A-like fragments. We then inferred the time-scaled evolutionary history of subtype C following a Bayesian approach and a partitioned analysis using major genomic regions. CRF92_C2U and CRF93_cpx had the most recent common ancestor with conventional subtype C around 1932 and 1928, respectively. A Bayesian demographic reconstruction corroborated that the subtype C transition to a faster phase of exponential growth occurred during the 1950s. Our analysis showed considerable differences between the newly discovered early-divergent strains and the conventional subtype C and therefore suggested that this virus has been diverging in humans for several decades before the HIV/M diversity boom in the 1950s.

Integrating HIV testing and care into tuberculosis services in Benin: programmatic aspects.

SETTING: Between 2005 and 2008, the diagnosis and care of human immunodeficiency virus (HIV) infection and tuberculosis (TB) services were integrated in Benin. RESULTS: The appointment of a TB-HIV Coordinator by the National Tuberculosis Control Programme and quarterly supervisory visits to TB clinics have bolstered the implementation of integrated HIV-TB activities. HIV testing and cotrimoxazole preventive therapy were integrated smoothly into the TB services. The strategy chosen to facilitate access of HIV-positive TB patients to antiretroviral treatment contributed to greater integration over time, but perpetuated, for some, the burden of attending two facilities. CONCLUSION: The integration and decentralisation of TB and HIV care services at national level in Benin resulted in a high uptake of HIV services among TB patients.

Results of rapid and successful integration of HIV diagnosis and care into tuberculosis services in Benin.

SETTING: Benin, where 20 of 54 tuberculosis (TB) clinics caring for 80% of all TB patients began providing integrated human immunodeficiency virus (HIV) care in 2005. OBJECTIVE: To describe the characteristics and TB treatment outcomes of the first cohorts of TB-HIV patients, and to assess programmatic outcomes. METHODS: Retrospective cohort study using data from the TB register and the register of co-infected patients. RESULTS: During the study period, 8368 TB patients were registered, 7787 (93%) were tested for HIV and 1255 (16%) were HIV-positive, including 385 (32%) who already knew their positive status. Most patients (88%) were tested within 15 days of TB diagnosis. Female and young patients were overrepresented among the co-infected. Cotrimoxazole preventive therapy was administered to 1152 patients (95%) during anti-tuberculosis treatment, and antiretroviral treatment (ART) to 469 (42%). The likelihood of receiving ART increased as initial CD4 lymphocyte counts decreased. Fifteen per cent of TB-HIV patients died during anti-tuberculosis treatment. Patients already on ART prior to anti-tuberculosis treatment experienced the worst outcomes. Patients who initiated ART early during anti-tuberculosis treatment or in the timeframe recommended by the guidelines fared the best. CONCLUSION: HIV care has been successfully and sustainably integrated into TB services in Benin. However, ensuring the access of co-infected patients to more favourable treatment outcomes still represents significant challenges.

Xpert® MTB/RIF for national tuberculosis programmes in low-income countries: when, where and how?

Xpert ® MTB/RIF offers new and important possibilities for the diagnosis of sputum smear-negative tuberculosis (TB) and/or rifampicin (RMP) resistance, and many are encouraging rapid and widespread implementation. This simple test can be implemented almost everywhere, and it provides results within a few hours. In low-income countries (LICs), however, its cost, environmental limitations (stable and regular electricity, adequate room temperature) and difficulties involved in supply and maintenance are major obstacles. While it may be suitable for major reference hospitals, operational research is needed to evaluate the test and its additional yield above high-quality smear microscopy and clinical algorithms before its use at the peripheral level. In the meantime, direct microscopy should remain the initial diagnostic test for TB suspects. In most LICs, the prevalence of RMP resistance among new TB patients is very low; an Xpert MTB/RIF result indicating RMP resistance will thus always need confirmation by another test. In a population at high risk of RMP resistance (> 15%), however, the positive predictive value for RMP resistance by Xpert MTB/RIF is high, and identification of RMP resistance is an excellent proxy for multidrug-resistant TB (MDR-TB). The assay should be widely used for this purpose if, and only if, excellent MDR-TB management is available, both for ethical reasons and to reduce the risk of extensively drug-resistant TB.

Isoniazid preventive therapy for people living with HIV: public health challenges and implementation issues.

Isoniazid preventive therapy (IPT) is recognised as an important component of collaborative tuberculosis (TB) and human immunodeficiency virus (HIV) activities to reduce the burden of TB in people living with HIV (PLHIV). However, there has been little in the way of IPT implementation at country level. This failure has resulted in a recent call to arms under the banner title of the 'Three I's' (infection control to prevent nosocomial transmission of TB in health care settings, intensified TB case finding and IPT). In this paper, we review the background of IPT. We then discuss the important challenges of IPT in PLHIV, namely responsibility and accountability for the implementation, identification of latent TB infection, exclusion of active TB and prevention of isoniazid resistance, length of treatment and duration of protective efficacy. We also highlight several research questions that currently remain unanswered. We finally offer practical suggestions about how to scale up IPT in the field, including the need to integrate IPT into a package of care for PLHIV, the setting up of operational projects with the philosophy of 'learning while doing', the development of flow charts for eligibility for IPT, the development and implementation of care prior to antiretroviral treatment, and finally issues around procurement, distribution, monitoring and evaluation. We support the implementation of IPT, but only if it is done in a safe and structured way. There is a definite risk that 'sloppy' IPT will be inefficient and, worse, could lead to the development of multidrug-resistant TB, and this must be avoided at all costs.

The Perseus Exobiology mission on MIR: behaviour of amino acids and peptides in Earth orbit.

Leucine, alpha-methyl leucine and two peptides were exposed to space conditions on board the MIR station during the Perseus-Exobiology mission. This long duration space mission was aimed at testing the delivery of prebiotic building blocks. During this mission, two amino acids (leucine and alpha-methyl leucine) and two peptides (leucine-diketopiperazine and trileucine thioethylester) were exposed in Earth orbit for three months. Basalt, clay and meteorite powder were also mixed with the samples in order to simulate the effects of potential meteorite protection. Analysis of the material after the flight did not reveal any racemization or polymerisation but did provide information regarding photochemical pathways for the degradation of leucine and of the tripeptide. Amino acids appeared to be more sensitive to UV radiation than peptides, the cyclic dipeptide being found to be as particularly resistant. Meteorite powder which exhibits the highest absorption in Vacuum UltraViolet (VUV) afforded the best protection to the organic molecules whereas montmorillonite clay, almost transparent in VUV, was the least efficient. By varying the thickness of the meteorite, we found that the threshold for efficient protection against radiation was about 5 microm. The possible exogenous origin of biological building blocks is discussed with respect to the stability to the molecules and the nature of the associated minerals.

The cost of tuberculosis to patients in Sierra Leone's war zone.

OBJECTIVE: To evaluate how the extreme poverty of the patients and the poor salaries of the staff combined to increase the cost of treatment to patients within the subsidised national tuberculosis programme in Sierra Leone. DESIGN/SETTING: From September to December of 1994, semi-structured interviews were conducted with 72 patients and 17 staff of the National Leprosy and Tuberculosis Control Programme of Sierra Leone, a screening and treatment programme funded by international donors. RESULTS: Although some extra costs were indeed incurred within the subsidized national tuberculosis treatment programme, they were much lower than those incurred during the pre-programme period when the patients sought intermittent help from a wide range of traditional and biomedical sources within the plural healing continuum. The national politico-economic crisis, and the consequent poverty of most patients, impeded compliance with and sustainability of treatment, even within the formal subsidised treatment programme. CONCLUSIONS: More money was spent by patients on treatment in the months/years preceding entry into the national tuberculosis programme. Many factors retarded entry, including poor communications, misinformation, malpractice by health professionals, and displacement resulting from chronic internal warfare. The war intensified all factors that predispose to tuberculosis and retarded access to treatment. Supra-programme cost, or 'corruption,' was minimal due to the poverty of health professionals, with a few salient exceptions.

Delivery of extraterrestrial amino acids to the primitive Earth. Exposure experiments in Earth orbit.

A large collection of micrometeorites has been recently extracted from Antarctic old blue ice. In the 50 to 100 micrometers size range, the carbonaceous micrometeorites represent 80% of the samples and contain 2% of carbon. They might have brought more carbon to the surface of the primitive Earth than that involved in the present surficial biomass. Amino acids such as "-amino isobutyric acid have been identified in these Antarctic micrometeorites. Enantiomeric excesses of L-amino acids have been detected in the Murchison meteorite. A large fraction of homochiral amino acids might have been delivered to the primitive Earth via meteorites and micrometeorites. Space technology in Earth orbit offers a unique opportunity to study the behaviour of amino acids required for the development of primitive life when they are exposed to space conditions, either free or associated with tiny mineral grains mimicking the micrometeorites. Our objectives are to demonstrate that porous mineral material protects amino acids in space from photolysis and racemization (the conversion of L-amino acids into a mixture of L- and D-molecules) and to test whether photosensitive amino acids derivatives can polymerize in mineral grains under space conditions. The results obtained in BIOPAN-1 and BIOPAN-2 exposure experiments on board unmanned satellite FOTON are presented.

Prevalence of the human immunodeficiency virus among patients with tuberculosis in Sierra Leone, established from dried blood spots on filter paper.

SETTING: Sierra Leone National Tuberculosis Programme. OBJECTIVE: To evaluate serological testing in field conditions of dried blood spots (DBS) on filter paper for unlinked surveillance of human immunodeficiency virus (HIV) associated tuberculosis. DESIGN: DBS were first evaluated against sera in 359 consenting patients on the capital city's District Tuberculosis Register (DTR). DBS eluates were tested with repeated ELISA using different antigens. Serum samples were tested with ELISA and confirmed with LIA. The cost was compared with that of rapid/simple tests on whole blood. In a second phase, DBS were applied to an unlinked countrywide serosurvey of 582 patients from the DTRs. RESULTS: The specificity of DBS for HIV-1 and HIV-2 was 100% and sensitivity was 100% and 87.5%, respectively. The cost of the strategy was half that of rapid/simple tests on whole blood. In 1995, HIV-1 associated tuberculosis seroprevalence was 2.41%. CONCLUSION: The proposed method for the surveillance of HIV-1 associated tuberculosis in Africa is simple, cheap and accurate. Further investigations are necessary to evaluate its sensitivity for HIV-2, and to study the epidemiology of HIV-2 in Sierra Leone.

[Irreductible congenital dislocation of the hip at birth]. / Luxation congénitale de hanche irréductible à la naissance.

BACKGROUND: Rare congenital dislocation of hip (CDH) (0.03 for 1,000 births) are irreducible at birth; they are named teratologic in literature. However some of them are isolated without any pathological context, having a postural origin or due to an underlying disease. PATIENTS: Seventeen dislocated hips, irreducible at birth, were seen in 12 infants and included in this study. Clinical examination of these neonates was normal with the exception of signs of CDH. Postural abnormalities such as pes calcaneus, genu recurvatum, torticolis were seen in ten infants but none of the 12 had any manifestation of neurologic, dystrophic or malformative disease. However, manifestations of a disease able to explain the CDH such as congenital myopathy, cutis laxa, cortical atrophy, Klinefelter syndrome, appeared within the following months in four infants. Treatment of these CDH started in every case by an attempt of reduction by continuous traction and was efficient in eight cases. A redislocation occurred for four hips and this treatment was uneffective for five hips. Finally seven hips had to be treated by open reduction. Reduction was maintained for nine hips after closed treatment (one of them after a redislocation and a second time of orthopaedic treatment). One hip is still dislocated after failure of closed treatment. Stabilisation of the reduction was necessary by pelvic and/or femoral osteotomy in majority of cases. CONCLUSIONS: Morphological modifications of hip established from X-rays and during the surgical procedure are rather related to the age of the dislocation making inappropriate the term "teratologic". The irreducible and isolated CDH can be postural in origin but as well due to a disease whom manifestations will appear lately. Their treatment, orthopaedic or surgical, is difficult and the results often disappointing.

Leprosy among the Limba: illness and healing in the context of world view.

The study analyzes the traditional beliefs and practices concerning leprosy of the Limba people of Sierra Leone. It shows that this dialectally diverse ethnic group has two views of leprosy and its cause, and two varieties of stigma associated with the disease. The Limba have abandoned their traditional treatments for leprosy in response to an effective leprosy control programme, but retained their traditional world view, including its definition of illness, which holds a person seriously ill only when he has severe pain or disability. Thus, they seek treatment from the programme, but often at a relatively advanced stage of the disease. The study shows that the Limba have reinterpreted the notion of 'germs' as introduced by medical workers, and that leprosy control workers have their own misunderstandings of Limba beliefs and practices. The study points the way to improved communication between leprosy workers and Limba patients by focusing on the points at which their views differ, and by identifying concepts within Limba world view that can be adapted by leprosy workers to help convey their message. The study emphasizes the importance of world view as a key to understanding patient attitudes and behaviour in developing countries, and to making valid cross-cultural comparisons, but notes that it can take years for an investigator to understand the world view of a particular culture. It argues that in short-term research projects there is an advantage to working with an anthropologist who has in-depth knowledge of the culture, but who may not be a specialist in medical anthropology.

Evaluation of a broth microdilution antifungal susceptibility test with a pH indicator: comparison with the broth macrodilution procedures.

A broth microdilution antifungal susceptibility test with a pH indicator (bromocresol purple) in a synthetic medium was evaluated. This method measures cellular activity instead of simply a change in biomass. The variations of pH caused by fungal activity were measured by changes in optical densities at 450 nm. The MICs50 obtained were compared with the MICs found by the classical broth macrodilution procedure. In most cases broth micro- and macrodilution MICs were in agreement for amphotericin B, fluconazole, flucytosine and nystatin.

[Analysis of the results of treatment of Hansen's neuritis]. / Analyse de résultats du traitement des névrites hanséniennes.

The authors expose a retrospective study about 133 nervous contingents treated exclusivement by steroid-therapy. The objective is to study the influence on nerve-function recovery of the following parameters: clinic form, function (sensitive or motor) of the nerve, position of the nerve (ulnar, median...), nature of the antibiotherapy. The method is based on the comparison for average progress in relation with the initial score. It appears that tuberculoid nerves recovery is better and faster than the lepromatous one. But lepromatous nerves improvement keeps on the end of the second year. On the other hand, the results are not influenced by the nerve itself or its function. Concerning antibiotherapy, our results show à significant difference, in consideration of a better improvement in PCT-treated nerves. Nevertheless, these results have to be confirmed by a comparative experimentation.