Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines.

Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patient's target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes.

A newly described vancomycin-resistant ST412 Enterococcus faecium predominant in Greek hospitals.

A total of 359 vancomycin-resistant enterococci (344 Enterococcus faecium and 15 E. faecalis) collected during 2007 from eight tertiary-care hospitals in Greece were analysed for genotypic characteristics. Four common clones, ST412, ST203, ST16 and ST17, were identified among E. faecium and one clone, ST28, among E. faecalis strains.

Use of real-time PCR to detect human papillomavirus-16 viral loads in vaginal and urine self-sampled specimens.

Increasing the accuracy of self-sampling methods to detect oncogenic human papillomavirus (HPV) infection would contribute to the wider application of these approaches. In this study, 120 women were tested for HPV-16 by conventional and quantitative real-time PCR (QRT-PCR) in cervical and self-sampled vaginal and urine specimens. QRT-PCR had a higher detection rate, and the HPV viral load in all three sampling sites correlated with the severity of disease, as determined by histology. The vaginal and urine viral loads correlated with HPV-16 positivity according to both conventional and QRT-PCR, and were proportional to the cervical viral load.

Perioperative anaemia management: consensus statement on the role of intravenous iron.

A multidisciplinary panel of physicians was convened by Network for Advancement of Transfusion Alternatives to review the evidence on the efficacy and safety of i.v. iron administration to increase haemoglobin levels and reduce blood transfusion in patients undergoing surgery, and to develop a consensus statement on perioperative use of i.v. iron as a transfusion alternative. After conducting a systematic literature search to identify the relevant studies, critical evaluation of the evidence was performed and recommendations formulated using the Grades of Recommendation Assessment, Development and Evaluation Working Group methodology. Two randomized controlled trials (RCTs) and six observational studies in orthopaedic and cardiac surgery were evaluated. Overall, there was little benefit found for the use of i.v. iron. At best, i.v. iron supplementation was found to reduce the proportion of patients requiring transfusions and the number of transfused units in observational studies in orthopaedic surgery but not in cardiac surgery. The two RCTs had serious limitations and the six observational limited by the selection of the control groups. Thus, the quality of the available evidence is considered moderate to very low. For patients undergoing orthopaedic surgery and expected to develop severe postoperative anaemia, the panel suggests i.v. iron administration during the perioperative period (weak recommendation based on moderate/low-quality evidence). For all other types of surgery, no evidence-based recommendation can be made. The panel recommends that large, prospective, RCTs be undertaken to evaluate the efficacy and safety of i.v. iron administration in surgical patients. The implementation of some general good practice points is suggested.

Effect of the proton motive force inhibitor carbonyl cyanide-m-chlorophenylhydrazone (CCCP) on Pseudomonas aeruginosa biofilm development.

AIMS: Proton motive force (PMF) inhibition enhances the intracellular accumulation of autoinducers possibly interfering with biofilm formation. We evaluated the effect of the PMF inhibitor carbonyl cyanide-m-chlorophenylhydrazone (CCCP) on Pseudomonas aeruginosa biofilm development. METHODS AND RESULTS: Four epidemiologically unrelated P. aeruginosa isolates were studied. A MexAB-oprM overproducing strain was used as control. Expression of gene mexB was examined and biofilm formation after incubation with 0, 125 and 25 micromol l(-1) of CCCP was investigated. Mean values of optical density were analysed with one-way analysis of variance and t-test. Two isolates subexpressed mexB gene and only 25 micromol l(-1) of CCCP affected biofilm formation. Biofilms of the other two isolates and control strain PA140 exhibited significantly lower absorbance (P ranging from < 001 to < 0.05) with either 12.5 or 25 micromol l(-1) of CCCP. CONCLUSIONS: The PMF inhibitor CCCP effect was correlated with the expression of MexAB-OprM efflux system and found to compromise biofilm formation in P. aeruginosa. SIGNIFICANCE AND IMPACT OF THE STUDY: These data suggest that inhibition of PMF-dependent trasporters might decrease biofilm formation in P. aeruginosa.

Factors that motivate and hinder blood donation in Greece.

Donations in Greece are insufficient to cover the high transfusion needs arising from large numbers of thalassaemia and sickle cell anaemia patients and the implementation of new surgical techniques. Efforts to achieve self-sufficiency, and to render blood supplies safer and manageable must focus on recruiting and retaining more volunteer donors and on converting the large pool of replacement donors. The aim of the study was to gain insight into public perception regarding the risks of donation and transfusion and to identify the factors that would motivate more people in Greece to regularly donate blood. Questionnaires were distributed to 1,600 donors at the blood bank and visitors to hospitals at 11 locations across the country. Data on demographics, donation behaviour, incentives, risk perception and attitudes towards donation and transfusion were analysed separately for volunteer and replacement donors and non-donors. The results showed that women and young people donate the least in Greece. Also, many donors do not donate because they are not reminded to. A small percentage of donors confessed to having concealed part of the truth to background questions. Overall, incentives to donate were considered important and included future availability of blood for self or family, paid leave from work and free blood tests. Recruitment and retention efforts should include better communication with current donors, and raising awareness among eligible donors. Staff should be educated in soliciting information from potential donors, and incentives should be better aligned to avoid conflict with ethical values and ensure honesty in the prescreening process.

Evaluation and comparison of fluorescence polarization assay with three of the currently used serological tests in diagnosis of human brucellosis.

Fluorescence polarization assay (FPA) is a method that has been used for the diagnosis of brucellosis in animals for many years. To test its possible usefulness for the diagnosis of human brucellosis, 230 sera from patients with clinical signs of brucellosis and positive serological tests (Rose Bengal, Standard Agglutination Test, iELISA), and 305 sera from a healthy population with no clinical/epidemiological/serological evidence were examined with FPA. By using ROC analysis, the cut-off value was estimated at 99 mP, with 93.5% sensitivity (95% CI 89.5-96.3) and 96.1% specificity (95% CI 93.2-97.9). The pairwise comparison of ROC curves between FPA and iELISA and between FPA and RBT revealed no significant statistic difference (P < 0.05). On the contrary it revealed a significant statistic difference between FPA and SAT (P > 0.05). SAT also had the lowest sensitivity (81.7%) among the three tests used in case definition while iELISA had a sensitivity of 90.8% and RBT a sensitivity of 88.7%. The Kappa analysis showed that FPA has a very good agreement (0.92) with the "status of the disease" and with iELISA (0.837). According to our results, FPA seems to be a valuable method for the diagnosis of brucellosis in humans. Taking into consideration the advantages of the method such as the speed of results obtaining, the objectivity of results interpretation, as well as the cost, FPA could be considered as a replacement for other established methods. However, further studies are needed to assess the reproducibility of FPA.

VAD-doxil versus VAD-doxil plus thalidomide as initial treatment for multiple myeloma: results of a multicenter randomized trial of the Greek Myeloma Study Group.

BACKGROUND: We have previously demonstrated that vincristine, liposomal doxorubicin and dexamethasone (VAD-doxil) is equally effective with VAD-bolus yielding objective response rates of 61% as first-line treatment in multiple myeloma (MM). In a phase II study, the addition of thalidomide to VAD-doxil (TVAD-doxil) proved feasible and increased response rate to 74%. The aim of the present multicenter prospective randomized clinical trial was to compare the efficacy and toxicity of VAD-doxil and TVAD-doxil in previously untreated MM patients. PATIENTS AND METHODS: We enrolled 232 newly diagnosed MM patients aged <75 years, 115 randomized to VAD-doxil (arm A) and 117 to TVAD-doxil (arm B). Patients in arm A received vincristine 2 mg i.v. and liposomal doxorubicin 40 mg/m(2) i.v., on day 1 and dexamethasone 40 mg p.o. daily on days 1-4, 9-12 and 17-20 for the first cycle and on days 1-4 for the next three cycles. Patients in arm B received additionally thalidomide 200 mg p.o. daily, at bedtime. Treatment was administered every 28 days. RESULTS: On an intention-to-treat basis, at least partial response was observed, in 62.6% and in 81.2% of patients randomized to arms A and B, respectively (P = 0.003). Progression-free survival (PFS) at 2 years was 44.8% in arm A and 58.9% in arm B (P = 0.013). Overall survival (OS) at 2 years was 64.6% and 77%, in arms A and B, respectively (P = 0.037). Considering overall toxicity, constipation, peripheral neuropathy, dizziness/somnolence, skin rash and edema were significantly higher in arm B compared with arm A (P < 0.01), but grade 3-4 toxicities were low and similar in both arms. CONCLUSIONS: The addition of thalidomide to VAD-doxil increases response and PFS rates and probably OS in previously untreated myeloma patients. The superiority of efficacy counterbalances the higher overall toxicity of TVAD-doxil.

Low genetic diversity of the intrinsic OXA-51-like class D carbapenemases among Acinetobacter baumannii clinical isolates in Greece.

This study examined the geographical distribution and diversity of the intrinsic OXA-51-like class D carbapenemases among Acinetobacter baumannii clones recovered in three major Greek regions from 2000 to 2005. The blaOXA-66 allele was exclusively detected among clonally distinct A. baumannii isolates recovered in the regions of Thessaloniki and Larissa. This sequence was also the most widespread among A. baumannii isolates in Athens, while less frequent were blaOXA-69 and blaOXA-65 alleles. These findings highlight the high prevalence of a specific blaOXA-51-like allele in Greece, possibly indicating that our A. baumannii clones might have originated from a common ancestor. However, the possibility that blaOXA-51-like variants, with blaOXA-66 predominating, are widely disseminated among several unrelated A. baumannii strains cannot be excluded.

Evaluation of high-risk human papillomavirus types PCR detection in paired urine and cervical samples of women with abnormal cytology.

BACKGROUND: During the last decade, increasing efforts have focused on HPV detection in self-obtained samples, to increase the overall proportion of patients participating in cervical cancer screening procedures. OBJECTIVES: A clinical evaluation study of an optimized protocol for PCR detection of high-risk human papillomavirus (HPV) types in urine compared with cervical samples in consecutive women referred to the colposcopy clinic with abnormal cervical cytology. STUDY DESIGN: Paired urine and cervical specimens were collected from 100 consecutive women referred to the colposcopy clinic with abnormal cervical cytology and normal urine parameters. In-house and a commercial PCR method for the detection of HPV types 16 and 18, and a commercial multiplex PCR for HPV types 6, 11, 16, 18, and 33 were performed. All HPV cervix-positive/urine-negative paired urine samples were spiked with serial dilutions of cell lines infected with HPV 16 or 18 to test the sensitivity of HPV detection in these urine samples. RESULTS: In all but two cases HPV type 16 was detected. In cancer cases, the urine/cervix HPV detection sensitivity was 88.8%; in cases with high-grade lesions it was 76.5%; and in cases with low-grade lesions it was 45.5%. In all concordant cases the same HPV type was detected in both samples. The urine/cervix HPV detection sensitivity was higher when urine samples contained two or more epithelial cells per field in urine microscopy. HPV detection in 9 cervix-positive but urine-negative urine samples spiked with serial dilutions of HPV-positive cell lines showed that in these cases urine PCR inhibitors did not affect PCR amplification. CONCLUSIONS: A higher urine/cervix HPV detection sensitivity in cancer and high-grade lesions suggests that urine testing could be used to detect HPV mainly when these lesions are present.

Evaluation of HPV 16 PCR detection in self- compared with clinician-collected samples in women referred for colposcopy.

OBJECTIVES: A clinical prospective evaluation study was conducted to evaluate PCR detection of high-risk human papillomavirus (HPV) type 16 in self-sampled vaginal compared with clinician-collected cervical specimens. METHODS: Paired vaginal and cervical specimens were collected from 137 consecutive women referred for colposcopy because of abnormal cervical cytology. In-house and a commercial PCR method for HPV type 16 were used. Self-sampled vaginal HPV 16 detection was compared to histology and physician-collected cervical specimens. RESULTS: Of the 137 patients, 98 had proven abnormal histology and were included in the analysis. Overall, using the cervix HPV detection as reference method, the self-sampled vaginal sample showed sensitivity 91.8%, specificity 96.1% and agreement kappa (kappa) 0.881. Using the histology as reference, all 11 cervical cancer cases were HPV-16-positive in both cervical and vaginal samples, and in 43 high-grade lesions, detection sensitivity in cervix was 72.1% (kappa 0.588) and vagina 67.4% (kappa 0.516). HPV 16 detection did not differ (P=0.27) between clinician-collected cervical and self-sampled vaginal specimens. CONCLUSIONS: The self-collected vaginal sample is highly concordant with the physician-collected cervical sample in HPV 16 detection.

Outbreak of multiple clones of imipenem-resistant Acinetobacter baumannii isolates expressing OXA-58 carbapenemase in an intensive care unit.

OBJECTIVES: To investigate the resistance mechanisms and the genetic relationship of imipenem-resistant Acinetobacter baumannii isolates recovered in the intensive care unit (ICU) of a tertiary care hospital. METHODS: Imipenem-resistant A. baumannii clinical and environmental isolates were collected in the ICU of the Red Cross General Hospital, Athens, Greece between March and October 2002. The isolates were tested by Etest MBL, PCR, RT-PCR and sequencing for carbapenemase-encoding genes, PFGE and synergy experiments using meropenem and the efflux pump inhibitor carbonyl cyanide chlorophenylhydrazone. RESULTS: During the study period, 15 clinical and two environmental imipenem-resistant (MIC 8 to >128 mg/L) A. baumannii isolates were recovered. PFGE showed six different clones that included both clinical and environmental isolates. All 17 isolates were negative by Etest MBL and PCR for genes bla(IMP), bla(VIM), bla(SPM), bla(OXA-23-like) and bla(OXA-24-like). Genes bla(OXA-51-like) and bla(OXA-58-like) were amplified from 15 and 14 isolates, respectively. Sequencing of bla(OXA-51-like) amplicons identified bla(OXA-66) (nine cases) and bla(OXA-69) (six cases), whereas bla(OXA-58-like) sequences were classical bla(OXA-58). Reverse transcriptase-PCR showed that bla(OXA-51-like) genes were expressed in 12 and bla(OXA-58) in 10 isolates; in these isolates, inhibition of OXA enzymes by 200 mM of NaCl reduced carbapenem MICs by up to 4-fold. Overexpression of proton-gradient dependent efflux pumps did not contribute to carbapenem resistance in any isolate. Similarly, although AmpC expression was demonstrated in eight isolates, inhibition of AmpC with cloxacillin did not reduce the MICs of carbapenems significantly. CONCLUSIONS: These findings indicate wide dissemination of OXA-58 carbapenemase, which contributes, at least partially, to the imipenem resistance of unrelated A. baumannii isolates in our ICU.

The value of a single combined measurement of VEGF, glycodelin, progesterone, PAPP-A, HPL and LIF for differentiating between ectopic and abnormal intrauterine pregnancy.

BACKGROUND: To evaluate whether serum concentrations of the non-placental markers vascular endothelial growth factor (VEGF), glycodelin (GLY) and progesterone (P) and the novel placental markers pregnancy-associated plasmaprotein A (PAPP-A), human placental lactogen (HPL) and leukaemia inhibiting factor (LIF) differ in ectopic pregnancy (EP) when compared with abnormal intrauterine pregnancy (aIUP). METHODS: A prospective clinical study was conducted at the University Hospital of Larissa, Greece. The study included 50 patients admitted with failed pregnancy and suspected ectopic pregnancy that were treated with curettage or laparoscopy and classified as histologically confirmed EPs (n = 27) or histologically confirmed aIUPs (n = 21) (mean gestational age of 7.15 and 7.3 weeks, respectively). Two suspected EPs proved to be normal IUPs and were excluded. VEGF, GLY, P, beta-HCG, PAPP-A, HPL and LIF were measured by enxyme-linked immunosorbent assay (ELISA) methods in a single pre-operative blood sample. RESULTS: The median VEGF concentration was 227.2 pg/ml in the EP group versus 107.2 pg/ml in the aIUP group (P < 0.001), with a suggested threshold value of 174 pg/ml for their differential diagnosis. LIF, P, PAPP-A, HPL and GLY serum measurements did not differ significantly between EP and aIUP. CONCLUSION: VEGF serum levels might be a useful marker in differentiating between EPs and aIUPs.

Spread of efflux pump-overexpressing, non-metallo-beta-lactamase-producing, meropenem-resistant but ceftazidime-susceptible Pseudomonas aeruginosa in a region with blaVIM endemicity.

OBJECTIVES: To investigate the resistance mechanisms of meropenem-resistant, ceftazidime-susceptible Pseudomonas aeruginosa isolates, in a clinical setting where VIM-2 or VIM-4 metallo-beta-lactamase (MBL)-producing pseudomonads are common. METHODS: During May to December 2003, 13 consecutive meropenem-resistant, ceftazidime-susceptible P. aeruginosa isolates were recovered from separate patients at the University Hospital of Larissa, Thessaly, Greece. The isolates were studied by Etest MBL, PCR for blaVIM, blaIMP and blaSPM genes and PFGE. Experiments were performed to detect synergy between meropenem or other antimicrobials and the efflux pump inhibitor carbonyl cyanide-m-chlorophenylhydrazone (CCCP). The isolates were also tested by PCR and RT-PCR for the expression of the genes mexB and mexY, which encode the efflux pumps MexAB-OprM and MexXY-OprM. RESULTS: Twelve of the isolates, belonging to six distinct PFGE types, gave negative results in the MBL Etest and lacked genes encoding MBLs but exhibited synergy between meropenem and CCCP, indicating that efflux pump activity contributed to the meropenem resistance. All 12 isolates were positive for mexB and 11 were also positive for mexY genes. RT-PCR showed that 10 and five isolates over-expressed mexB and mexY, respectively. One isolate was blaVIM-2-positive and did not show synergy with CCCP, or harbour mexB or mexY. CONCLUSIONS: In our hospital, where MBL-producing P. aeruginosa were previously prevalent, meropenem resistance due to the overexpression of efflux pumps has also now emerged. Early recognition of this resistance mechanism should allow the use of alternative beta-lactams, such as ceftazidime, which would be inactive even against phenotypically susceptible MBL producers.

Substantially increased faecal carriage of vancomycin-resistant enterococci in a tertiary Greek hospital after a 4 year time interval.

OBJECTIVES: In a tertiary Greek hospital with no documented vancomycin-resistant enterococci (VRE) infections, a cross-sectional study was conducted in order to determine the degree of VRE faecal carriage among adult patients hospitalized in high-risk units. METHODS: Specimens for the surveillance were collected from separate patients in two periods (January-May 1999 and January-May 2003); 258 specimens were submitted during the first period and 149 during the second period. RESULTS: Three patients (1.2%) were colonized with VRE during the first period, whereas 52 (34.9%) were colonized during the second period. Two VRE isolates of the first period were Enterococcus faecalis and one Enterococcus faecium, whereas those of the second period were E. faecium except for three E. faecalis and two Enterococcus gallinarum. All VRE isolates apart from the two E. gallinarum isolates were positive for the vanA gene. The 48 vancomycin-resistant E. faecium were classified into eight clonal types, one of those predominating with 29 isolates; the remaining included one to nine isolates. The five vancomycin-resistant E. faecalis formed four distinct clonal types. CONCLUSIONS: The study reports a substantially higher prevalence of VRE carriage when the surveillance was repeated after a 4 year time interval. Urgent infection control measures are needed to prevent emergence of VRE outbreaks in our hospital setting.