The efficacy of 16S ribosomal DNA sequencing in the diagnosis of bacteria from blood, bone and synovial fluid samples of children with musculoskeletal infections.

BACKGROUND: Musculoskeletal infections are among the most common bacterial infections in children leading to hospitalization, invasive procedures and prolonged antibiotic administration. Blood, synovial and sometimes tissue cultures are essential for the diagnosis and treatment of musculoskeletal infections; 16S ribosomal DNA (rDNA) sequencing is a novel diagnostic tool for the detection of bacteria.While the yield of 16S rDNA sequencing in synovial fluid was previously assessed, data regarding the efficacy of this method from blood samples or partially treated children with suspected musculoskeletal infections is lacking.In this study we assessed the yield of 16S rDNA sequencing in blood, bone and synovial samples of children with musculoskeletal infections. METHODS: Blood, synovial and bone samples were collected from children with suspected musculoskeletal infections and analyzed for the presence of 16S rDNA, the results were then compared with the benchmark microbial cultures. RESULTS: During the study period, 41 children (18 boys and 23 girls) with suspected acute musculoskeletal infection were enrolled. A positive blood culture was found in 6/31 cases (19.4%) with methicillin-susceptible Staphylococcus aureus being the most commonly isolated bacterium. No significant 16S rDNA detection in blood samples was recorded.Synovial fluid culture was positive in 6/28 samples (21%), Kingella kingae being the most common pathogen. When using the 16S rDNA sequencing method, the rate of positive results in synovial fluid was higher with bacterial detection in 12/23 (52%) samples. The 16S rDNA sequencing method was also able to identify pathogens in samples taken from partially treated children where cultures were negative with 16S rDNA detection in 5/5 samples. CONCLUSION: Although 16S rDNA sequencing may increase the yield of bacterial detection in synovial samples of patients with musculoskeletal infections, there is no benefit from applying this method on blood samples. The 16S rDNA sequencing method may be particularly beneficial when antibiotic treatment was started prior to synovial fluid sampling. LEVEL OF EVIDENCE: Level-II diagnostic study.

Near-fatal air embolus during arthrography of the hip in a baby aged four months.

We describe a near-fatal event, probably due to air embolism, following an air arthrogram for developmental hip dysplasia in a baby aged four months. The sequence of events and the subsequent treatment are described. There is little information about this complication in the literature. The presumed mechanism and alternative methods for confirmation of placement of the needle are discussed. We no longer use air arthrography in children.

Subtalar arthrodesis with flexor digitorum longus transfer and spring ligament repair for treatment of posterior tibial tendon insufficiency.

The surgical treatment of flexible pes planovalgus deformities resulting from Stage 2 posterior tibial tendon insufficiency is controversial and many techniques have been proposed. We retrospectively reviewed the results of subtalar arthrodesis combined with spring ligament repair/reefing and flexor digitorum longus (FDL) transfer to the navicular. There were sixteen patients (seventeen feet) with an average follow-up of 27 months (9-52). All deformities were passively correctable. The average age was 56 yrs (39-78). All patients had failed conservative management, 88% had previously been treated with orthotics, and 53% had lateral pain from subfibular impingement. Two patients were noted to have degenerative changes of the subtalar joint. Successful subtalar joint fusion occurred in all patients with an average time to radiographic union of 10.1 weeks (5-24). The average AOFAS hindfoot score and Maryland foot score postoperatively was 82 and 86 respectively. Standing radiographic analysis demonstrated an average improvement in the AP talo-1st metatarsal angle of 6 degrees (24 degrees preoperative, 18 degrees postoperative). The talonavicular coverage angle improved an average of 17 degrees (34 degrees preoperative, 17 degrees postoperative). The lateral talo-1st metatarsal angle improved an average of 10 degrees (18 degrees preoperative, 8 degrees postoperative). The lateral talocalcaneal angle decreased an average of 21o (55 degrees preoperative, 34 degrees postoperative). The distance of the medial cuneiform to the floor on the lateral radiograph averaged 12mm preoperatively and 18mm postoperatively (avg. improvement 6mm). The combination of the flexor digitorum longus tendon transfer and spring ligament repair with subtalar arthrodesis is an effective and reliable procedure which provides excellent correction of hindfoot valgus as well as forefoot abduction and restoration of the height of the longitudinal arch. These results compare favorably with flexor transfer combined with either calcaneal osteotomy or lateral column lengthening.

Relationship between Quantec measurement and Cobb angle in patients with idiopathic scoliosis.

The Quantec Spinal Imaging System (QSIS) is a raster stereography used to measure three-dimensional trunk images. The Q angle, a coronal plane measurement generated by the Quantec Spinal Imaging System (QSIS), was compared with the Cobb angle in assessment of scoliosis curve magnitude. One hundred forty-nine patients with idiopathic scoliosis were evaluated using both the Quantec system and plane radiographs. The Cobb and Q angles demonstrated significant correlation in the thoracic region (r = 0.65, p < 0.05), lumbar region (r = 0.63, p < 0.05), and in the thoracolumbar region (r = 0.70, p < 0.05). The difference between the Q and Cobb angles was small when the Cobb angle was <21 degrees with less than 6 degrees of axial surface rotation, as measured by the QSIS method. For smaller curves with minimal rotation, there is close correlation between the Cobb angle and the Quantec angle.

Hindfoot coronal alignment: a modified radiographic method.

Accurate clinical evaluation of the alignment of the calcaneus relative to the tibia in the coronal plane is essential in the evaluation and treatment of hindfoot pathologic condition. Previously described radiographic views of the foot and ankle do not demonstrate the true coronal alignment of the calcaneus relative to the tibia. Some of these views impose on the patient an unnatural posture that itself changes hindfoot alignment, whereas other methods distort the coronal alignment by the angle of the x-ray beam. Our purpose was to develop a modified radiographic view and measurement method for determining an angular measurement of hindfoot coronal alignment based on a cadaver study of the radiographic characteristics of the calcaneus and motion analysis of standing subjects. The view was obtained by having the subject stand on a piece of cardboard to create a foot template. The template was then positioned so that each foot was x-rayed perpendicular to the cassette while still maintaining the natural base of support. A method using multiple ellipses was developed to determine more accurately the coronal axis of the posterior calcaneus. A study using cadavers was performed in which radio-opaque markers were placed on multiple bony landmarks on the calcaneus. The tibia was held fixed in a vertical position, and the foot was x-rayed using the above techniques in different degrees of rotation without changing the relation of the calcaneus to the tibia. The radiographs of the modified Cobey and our view were examined to verify which markers were visible at different angles of rotation and how the hindfoot alignment measurements changed with foot rotation. To define further the differences between the views, an analysis of postural stability was conducted while the subjects were standing with the feet in the positions for imaging both the Buck modification of the Cobey view and our hindfoot alignment view. The combined results of the cadaver, radiographic measurement, and postural stability segments of the study reveal that this coronal hindfoot alignment view and measurement method is reproducible, more closely measures "true" coronal hindfoot alignment, and is more clinically applicable because the alignment is measured while the patient is standing with a normal angle and base of stance. The modified radiographic measurement method relies on posterior calcaneal anatomic landmarks, is less affected by rotation of the foot and ankle, and is reproducible between observers.

Distress, personality, and mammography utilization among women with a family history of breast cancer.

The authors examined the impact of psychological distress and the personality construct of conscientiousness (as measured by the Neuroticism, Extraversion, and Openness-Five Factor Inventory) on mammography utilization among women who were at increased risk for breast cancer. Participants were 200 women who had at least 1 first degree relative with breast cancer. Overall, 80% of the participants had obtained a mammogram in the previous year. Analyses controlling for potential confounders (perceived risk, decisional balance, and physician recommendation for mammography), revealed that distress was negatively associated with mammography utilization among participants who were low in conscientiousness. Distress was not significantly related to mammography utilization among highly conscientious women. The results are discussed in terms of their implications regarding interventions designed to increase mammography utilization in this population.

Competency evaluations on the consultation-liaison service. Some overt and covert aspects.

Competency assessments are a growing function of the consultation-liaison (C-L) psychiatrist. Such consultation requests often mask a variety of psychosocial issues that are a source of frustration to the referring physician responding to the pressures of the changing health care delivery system in the acute care setting. This study identifies the issues and the outcome of psychiatric consultation in these patients. The implications of this burgeoning role for the C-L psychiatrist are also explored.

The chronically mentally ill on a general hospital consultation-liaison service. Their needs and management.

The consultation-liaison (C-L) psychiatrist often sees chronic mentally ill patients when they are admitted to the medical-surgical services of the general hospital. Little research has been directed to the special needs and concerns of these patients in the general hospital. This area has become more relevant now that many of these patients are no longer cared for in the safety of the state hospital setting, often making baseline medical histories inaccessible. They have an overall higher mortality rate than the general population, cannot give adequate histories, and their psychotic illness can mask an underlying medical illness. In this preliminary investigation of the problems of this special population, the authors examined the issues concerning nursing needs, length of hospital stay, medical diagnosis, and possible complicating problems encountered during these patients' hospital stays in the setting of an urban university hospital. The authors discuss the implications of the role of the C-L psychiatrist in addressing their patients' acute problems.

What, why, and how of consultation-liaison psychiatry. An analysis of the consultation process in the 1990s at five urban teaching hospitals.

There is controversy about the role and function of a consultation-liaison (C-L) psychiatrist, as reflected in the ongoing debate about what to call ourselves. To clarify the essential elements of our function, the authors analyzed the process and content of the entire consultation experience from the time of initial consultation to the time of discharge in 50 patients across 5 urban teaching hospitals. The common components of the C-L process, in this pilot study, were identified to be facilitative, consensus-seeking, and interpretative. Implications of these findings for the C-L psychiatrist's role in the general hospital are discussed.

Funding for consultation-liaison services in public sector-managed care plans. The experience of the Consultation-Liaison Association of Philadelphia.

Recently, the Commonwealth of Pennsylvania initiated plans to implement a mandated behavioral health carve-out program for Medicaid-eligible persons. The Consultation-Liaison Association of Philadelphia (CLAP) discovered that there was no provision for the coverage of psychiatric services for patients with concomitant medical illness. As a result, the authors responded by initiating a series of actions aimed at ensuring inclusion of such services as part of mental health services to be delivered. CLAP developed a brief position paper that includes a description of the need for such services, the types of services typically delivered, the impact of psychiatric input in the medical setting on costs and other outcomes, and a specific set of recommendations. These efforts have lead to the inclusion of consultation-liaison services in the new plan. A description of recent changes in Medicaid, including expansion of managed care plans, the status of mental health carve outs, and the possibility for inclusion of psychiatric consultations for the medically ill within these plans, is detailed.

Microbiological tolerance in orthopaedic infections: delayed response of septic arthritis and osteomyelitis of the hip due to infection with tolerant Staphylococcus aureus.

A 14-year-old boy presented to another hospital with a clinical picture of septic arthritis. After aspiration of purulent material from the joint, empiric antibiotic treatment was initiated and an arthrotomy was performed. Antibiotic treatment was then modified to nafcillin according to microbiological sensitivity results of the isolated Staphylococcus aureus as determined by minimal inhibitory concentration testing. One week later purulent drainage recurred and open drainage had to be repeated; an abscess anterior to the joint was noted. Once again the infection failed to resolve, and the patient was transferred to our institution where a third arthrotomy had to be performed. The organism isolated at the first aspiration was reexamined and found to have a minimal bactericidal concentration to minimal inhibitory concentration ratio of 32, implying a tolerant organism. The antibiotic treatment was modified to an antibiotic not subject to the tolerance phenomenon, and the infection resolved without additional surgical intervention.

Constant observation in a medical-surgical setting. The role of consultation-liaison psychiatry.

Constant observation (CO) is commonly used in general hospital settings to protect patients who are at risk for harming themselves or others. The role of consultation-liaison psychiatry in the implementation of this procedure is often assumed, but has not been well studied. The authors report the findings of a 6-month study of the use of CO in a general hospital and discuss its implications for quality of care and, possibly, cost-effectiveness.

Overdiagnosis of depression in the general hospital.

To test the hypothesis that depression is often inaccurately detected in medical settings, we examined the psychiatric consultations performed at two medical-surgical teaching hospitals. All records for the 4396 consultations seen in a 3-year period were retrospectively reviewed. Consultations were categorized by the reason for referral. These reasons were compared with the consulting psychiatrist's diagnosis. Diagnoses were grouped into "Depressed" and "Not Depressed" categories, depending on whether the psychiatric diagnoses implied any form of depressive illness (alone or in combination with other diagnoses). The majority of the referrals for psychiatric consultation (about 25% and 30% at the respective sites) were for presumed depression. Of these referrals for depression, approximately 40% were judged by the consultant to have no depressive diagnosis. Of the referrals for depression judged not to be depressed, the majority had other undiagnosed illnesses, particularly delirium, dementia, and anxiety disorders. The authors conclude that although numerous studies report that depression is unrecognized in medical patients, it may also be inappropriately suspected. This is of most concern when the presumption of depression delays other medical, neurological, or psychiatric evaluation.