Outcome of patients with streptococcal prosthetic joint infections with special reference to rifampicin combinations.

BACKGROUND: Outcome of patients with streptococcal prosthetic joint infections (PJIs) is not well known. METHODS: We performed a retrospective multicenter cohort study that involved patients with total hip/knee prosthetic joint (THP/TKP) infections due to Streptococcus spp. from 2001 through 2009. RESULTS: Ninety-five streptococcal PJI episodes (50 THP and 45 TKP) in 87 patients of mean age 69.1 ± 13.7 years met the inclusion criteria. In all, 55 out of 95 cases (57.9 %) were treated with debridement and retention of the infected implants with antibiotic therapy (DAIR). Rifampicin-combinations, including with levofloxacin, were used in 52 (54.7 %) and 28 (29.5 %) cases, respectively. After a mean follow-up period of 895 days (IQR: 395-1649), the remission rate was 70.5 % (67/95). Patients with PJIs due to S. agalactiae failed in the same proportion as in the other patients (10/37 (27.1 %) versus 19/58 (32.7 %); p = .55). In the univariate analysis, antibiotic monotherapy, DAIR, antibiotic treatments other than rifampicin-combinations, and TKP were all associated with a worse outcome. The only independent variable significantly associated with the patients' outcomes was the location of the prosthesis (i.e., hip versus knee) (OR = 0.19; 95 % CI 0.04-0.93; p value 0.04). CONCLUSIONS: The prognosis of streptococcal PJIs may not be as good as previously reported, especially for patients with an infected total knee arthroplasty. Rifampicin combinations, especially with levofloxacin, appear to be suitable antibiotic regimens for these patients.

[Evaluation of a teaching tool for learning the surgical technique of inguinal orchidopexy]. / Évaluation d'un outil pédagogique pour l'apprentissage de la technique chirurgicale d'abaissement testiculaire.

INTRODUCTION: Practical training of the surgery resident is based on the companionship currently hampered in particular by the increase of the number of residents in training. We created a teaching tool to promote learning and validation of a technique of classic urologic surgery, inguinal orchidopexy. The objective is to evaluate the applicability and the relevance of this tool. MATERIAL AND METHODS: The tool is a technical evaluation sheet made from reference documentation. The trainers evaluated the residents at 3 times of the semester (hetero-evaluation at 0, 3 and 6 months). Residents evaluated themselves monthly on the same items. RESULTS: Three trainers and 6 residents in surgery participated in the study between May and November 2013. The initial evaluation confirmed that the theoretical knowledge was acquired prior to the practical learning. The level of residents was very uneven at the beginning of the study but not at the end of the semester. The monthly evaluations gave a progressive and significant increase of notes. The notes of the intermediate and final hetero-evaluations rose gradually and they were always superior to those previous self-assessments (P<0.05). The tool was considered simple and useful for the participants. CONCLUSION: This tool is applicable and relevant to the technical teaching of inguinal orchidopexy in this population. A larger study would be helpful to confirm it. This type of tool could be applied to the simple and common surgery techniques to enrich the educational tools used in the training. LEVEL OF EVIDENCE: 4.

[Establishment of the intestinal microflora and regulation of bacterial translocation after caffeine citrate treatment during postnatal period in rat]. / Implantation de la microflore intestinale et régulation de la translocation bactérienne sous l'effet d'un traitement au citrate de caféine chez le raton en période néonatale.

To relieve respiratory problems such as apnea in newborns, caffeine citrate is the drug of choice because of its good tolerance and therapeutic index. However, its impact on the intestinal microbial ecosystem and on bacterial translocation in the neonatal period remains insufficiently investigated. Therefore, the objective of this study was to evaluate the effects of caffeine citrate on the establishment of the intestinal microflora and bacterial translocation in rats from birth to the 30th day of life. Newborn Wistar rats were divided into four groups of 14 animals, each subdivided into a control group receiving a placebo (12mL tap water/kg/day) and another treated with caffeine citrate (12mg/kg/day). The animals were nursed by their mothers and weighed daily. A group of 14 rats was killed at birth and after 10, 20, or 30 days of life. Organs in which translocation was assessed (liver, lungs, spleen, and kidneys) and various fragments of intestine (duodenum, jejunum, ileum, and colon) were surgically removed. The bacteriological analysis performed involved enumeration of the total microflora, staphylococci, enterobacteria, and lactobacilli. From the 10th day, caffeine was shown to significantly decrease the weight of treated animals as compared with controls (P<0.05). However, caffeine treatment did not drastically alter the kinetics of establishment of the intestinal microflora as only enterobacteria were found to be significantly lower in any intestinal segment of the treated group (P<0.05). Moreover, from the 20th day of life, caffeine citrate significantly downregulated bacterial translocation of both Gram-positive and -negative bacteria (P<0.05). This preliminary study on the effects of treatment with caffeine citrate may open opportunities in clinical pediatrics; the treatment will remain partially effective in preventing bacterial translocation in the neonatal period.

[Congenital mesoblastic nephroma: diagnosis and treatment of one case]. / Le néphrome mésoblastique congénital : diagnostic et prise en charge à partir d'un cas.

The congenital mesoblastic nephroma (CMN) described by Bolande et al. in 1967 is a renal tumor often discovered in neonatal period and early childhood. It's usually considered as a benign tumor with good prognostic for which nephrectomy is the reference treatment. But some cases of local recidives and metastatic sites had been described in the literature. For these reasons histologic analysis and quality of follow up are very important. In this observation we describe a neonatal kind of CMN and we discuss this pathology.

[Cystinuria in children: A report of 4 cases]. / Cystinurie chez l'enfant : à propos de 4 observations.

Cystinuria is an inherited autosomal-recessive disorder of renal reabsorption of the dibasic amino acids. It is the cause of about 6% of all kidney stones observed in children. Cystine is relatively insoluble at the physiological pH of urine. Cystine stones are characteristic and frequent recurrences are observed. We report on 4 cases and describe the initial presentation (obstructive renal failure, urinary sepsis, familial screening) and the medical and surgical management. Medical management is mainly based on hyperhydration and urine alkalinization. Long-term therapy with sulfhydryl agents to prevent formation of renal stones seems to be effective but adverse side effects are frequent, requiring the withdrawal of treatment. Urological management has evolved from surgical stone removal to minimally invasive procedures (extracorporeal shock wave lithotripsy, ureteroscopy).

Impact of colostomy on intestinal microflora and bacterial translocation in young rats fed with heat-killed Lactobacillus acidophilus strain LB.

A rat animal model of left colostomy was found to significantly impair the growth curve of rats. Assessment of the intestinal flora showed that colostomy mostly affects the cecal but not colonic microflora. Generally, the number of enterococci was increased in both ileum and cecum; cecal lactobacilli also rose, accounting for a promotion of lactic acid bacteria in colostomised rats. No significant differences between colostomised, laparotomised and control rats could be observed for the translocation of intestinal bacteria to internal organs of rats (i.e. spleen, kidneys, lungs or liver), whatever their diet. Heat-killed Lactobacillus acidophilus strain LB administration (dead probiotic bacteria) tended to exhibit a stimulatory effect on bifidobacteria, probably affecting the culture-medium fermentation substances included in the pharmaceutical product. This effect was abolished by laparotomy and colostomy. A trend towards a probiotic-like effect, not susceptible to colostomy, was also witnessed as counts of lactobacilli tended to increase in both cecum and colon of all animals fed with L. acidophilus LB.

[Change in management of ureteropelvic junction obstruction]. / Evolution de la prise en charge du syndrome de la jonction pyélo-urétérale.

PURPOSE: The aim of this study was to evaluate the change in ureteropelvic junction management, from surgical correction to observation of the hydronephrosis. We checked wether or not it was deleterious for kidney. MATERIALS AND METHODS: We retrospectively reviewed 96 charts between 1988 and 1998. Initial ultrasonography, and voiding cystourethrogram were available for all cases. Intravenous urography and diuretic renography were studied when available. Minimal follow-up of patients was one year. Patients were divided into three groups: surgery right away, surgery after observation, and observation only. RESULTS: Later was the diagnosis, more significant were the hydronephrosis and impairment of renal function (p < 0.01). In group operated on right away (69 cases), drainage improved, hydronephrosis decreased, but renal function did not improve significantly (p = 0.37). Sixteen patients were operated on after observation without deleterious effect for kidney. Eleven patients were only observed: hydronephrosis progressively decreased. Initial radiological results were not different between the last two groups (p > 0.05), and were not predictive of their course. CONCLUSION: Initial non operative management of hydronephrosis was not dangerous for renal function. It is advisable to detect at the earliest all signs of obstruction, because surgery improves renal drainage but not renal function.

The effects of mesenteric ischemia on ileal colonization, intestinal integrity, and bacterial translocation in newborn piglets.

The effects of mesenteric ischemia on ileal colonization, intestinal integrity, and bacterial translocation (BT) in newborn piglets were investigated in 362-day-old Pietrain piglets. Group I, controls were not operated upon; group II underwent a sham laparotomy; and group III underwent ligation of the mesenteric vessels in the distal ileum. After 3 days, the kidneys, spleens, livers, and ileal segments were harvested for microbial and histologic analyses. Two piglets in the ischemic group died; microscopic examination showed severe histologic lesions of the ischemic area. Escherichia coli counts were increased in the ischemic segment compared to the upper loop (P < 0.05). Ischemia favoured staphylococcal colonization, whereas in the sham group a drastic reduction of these organisms was observed (P < 0.005). BT to the kidneys, spleen, and liver occurred normally in the control group. Ischemia significantly increased the total microflora in the spleen and liver (P < 0.05) and furthered dissemination of Clostridium perfringens in the kidneys (P < 0.05); 50% of ischemic animals had proteolytic clostridia in this organ (P < 0.05). Moreover, the incidence of E. coli in the kidneys, spleen, and liver was significantly higher in the sham and ischemic groups than in the controls (P < 0.05). Ileal ischemia thus induced significant histologic lesions, and surgery rather than gut microflora controls translocation.

Metformin retention independent of renal failure in intestinal occlusion.

Metformin is eliminated by the kidneys, and metformin accumulation has always been noticed in oligo-anuric patients. We have reported an exception to the rule with the case of a metformin-treated patient having metformin accumulation contrasting with a mild increase in serum creatinine in the context of a volvulus of the sigmoid colon. This case prompted us to examine the association between intestinal occlusion and plasma metformin concentrations. For this purpose, we developed an experimental animal model of mechanical obstruction of the intestine. Rats were pre-treated during 3 weeks via drinking solution at a dose of approximately 100 mg/kg/day of metformin. They underwent at day 0 either sham-operation (n=7) or operation (n=8) to place a plastic tube around the ileum near the ileocaecal valve. Metformin administration was pursued on days 1, 2, and 3 giving a single dose of 100 mg/kg by intragastric gavage. Four days after the surgery, i.e. 24 h after the last metformin administration, the surviving intestinal obstructed rats (n=8) developed overt intestinal dilation but no biochemical abnormality compared to sham-operated animals (n=7; arterial lactate concentrations respectively 4.87 +/- 0.63 mmol/l and 3.97 +/- 0.30 mmol/l, NS, and serum creatinine concentrations 69.0 +/- 1.7 micromol/l and 68.7 +/- 1.9 micromol/l, NS). By contrast, there was a striking difference with regard to metformin concentrations, decreasing from 2.95 +/- 0.94 mg/l at day 0 to 0.12 +/- 0.03 mg/l at day 4 (p<0.001) in the sham-operated group but remaining unchanged (1.65 +/- 0.76 mg/l and 1.61 +/- 0.51 mg/l) in the operation group. In conclusion, this is the first experiment showing that intestinal occlusion may be responsible for metformin retention in the absence of renal failure. Whether this observation may be relevant to other drugs remains to be established.

[Thoracic injuries in children]. / Traumatismes thoraciques de l'enfant.

Chest trauma in children is rare but shows that trauma is severe and the mortality rate is high (30%). Multidisciplinary management of children includes an initial evaluation of respiratory distress, freeing the airways, placing an intercostal tube, stabilizing the chest wall, and analgesia. When vital signs are stable, secondary evaluation includes an etiologic, radiologic and biologic check-up, ending with the therapeutic strategy. Thoracotomy is rarely required, and for most children, only monitoring will be necessary, though this is important because of the risk of secondary decompensation and late diagnosis of potentially fatal lesions.

Management of pancreatic and duodenal injuries in pediatric patients.

Diagnosis of duodenal and pancreatic injuries is frequently delayed, and optimal treatment is often controversial. Fourteen children with duodenal and/or pancreatic injuries secondary to blunt trauma were treated between 1980 and 1997. The pancreas was injured in all but 1 child. An associated duodenal injury was present in 4. The preoperative diagnosis was suspected in only 6 patients based on clinical signs and ultrasonography. One patient was treated successfully conservatively; all the others required surgical management. At operation, three procedures were used: peripancreatic drainage, suture of the gland or duodenum with drainage, and primary distal pancreatic resection without splenectomy. A duodenal resection with reconstruction by duodeno-duodenostomy was performed in 1 case. The overall complication rate was 14%: 1 fistula and 1 pseudocyst. Pancreatic ductal transection was recognized 3 days after the initial laparotomy by endoscopic retrograde cholangiopancreatography (ERCP). The mortality was 7%; 1 patient died from septic and neurologic complications. When the diagnosis of pancreatic ductal injuries is a major problem, ERCP may be a useful diagnostic procedure. Pancreatic injuries without a transected duct may often be treated conservatively. The surgical or conservative management of duodenal hematomas is still controversial; other duodenal injuries often need surgical treatment.

Human recombinant growth hormone increases small bowel lengthening after massive small bowel resection in piglets.

BACKGROUND/PURPOSE: Dramatic improvement in small bowel lengthening and in weight gain has been demonstrated in newborn rats treated with human growth hormone (GH) after massive small bowel resection. The aim of this study was to confirm these results in another animal model and to specify the part food intake plays in small bowel lengthening induced by GH. METHODS: Twenty-five piglets underwent laparotomy at day 28 of life. Intestinal length was measured under general anesthesia, and animals had an 80% resection of small bowel, leaving a similar length of jejunum and ileon. There were no perioperative deaths. One animal died 3 days after surgery. Animals were assigned to five groups: (1) S (n = 4): sham, mere laparotomy; (2) GH-S (n = 4): sham and GH treatment (0.1 IU/kg/d subcutaneously); (3) R (n = 7): intestinal resection; (4) GH-R (n = 6); and (5) GH-R AdL (n = 4): intestinal resection and GH treatment. S, GH-R, and GH-R AdL had a free diet; GH-S and GH-R were pair-fed with S and R, respectively. Animals were killed 28 days later. RESULTS: Weight gain was not different in the two nonresected groups (S, 144 +/- 6% of initial weight; GH-S, 150 +/- 3%) and was significantly higher than in the resected groups (R, 67 +/- 28%; GH-R, 74 +/- 16%; GH-R AdL, 55 +/- 16%; NS). GH did not enhance small bowel lengthening in the nonresected groups; S, 41.9 +/- 23% and GH-S, 36.9 +/- 9%, in sharp contrast with the resected groups; R, 28 +/- 9 cm versus GH-R, 96 +/- 39 cm (P = .0008) and versus GH-R AdL, 89 +/- 41 cm (P = .003). Compared with initial length, the increase was R, 16.2 +/- 5%; GH-R, 56.5 +/- 24%; GH-R AdL, 51 +/- 25%. Villus height and diameter, average number of mitosis per field, intestinal muscular layer, wall thickness, and crypt ratio were higher in resected groups than in unresected ones, with no difference observed between resected groups. CONCLUSIONS: GH improves the postoperative intestinal adaptation process after massive small bowel resection in newborn piglets in terms of small bowel lengthening. In contrast to rats, GH did not improve weight gain. In addition, no difference was observed whether animals were on a free or a controlled diet.

Effect of BN 50727 on pathological findings and tissue platelet activating factor levels during ileal ischemia in newborn piglets.

The role of platelet activating factor (PAF), a potent ulcerogen mediator in the digestive tract, is thought to be important in the genesis of necrotizing enterocolitis. The aim of this study was to evaluate the role of PAF in the perpetuation and aggravation of gastrointestinal damage resulting from limited ischemia in the 2-day-old piglet using a natural PAF antagonist (BN 50727). Animals were separated into six groups: U4, controls; S, sham operated animals undergoing laparotomy; I4 and I9, ligation of the mesenteric vessels in the last ileal loop; IT4 and IT9, same procedure together with treatment with BN 50727 (50 mg/kg) orally before and after surgery and intraperitoneally during surgery. Animals were killed at day 4 in groups U4, S, I4 and IT4 and at day 9 in groups I9 and IT9, with histological studies and mediator measurements taken. Macroscopic and histological lesions of intestinal wall in groups I4, I9, IT4 and IT9 were similar to those of human neonatal necrotizing enterocolitis and did not vary according to the absence or the presence of BN 50727 treatment (P = .7, I4 v IT4 and P = .9, I9 v IT9). Peritoneal bands were significantly reduced in treated groups IT4 and IT9 as compared with untreated ones I4 and I9 (P = .003). Mucosal PAF levels in the terminal ileum were higher in group I4 than in groups U4 or I9. In the upper loop, mucosal PAF levels were comparable in all groups. An increase in stool PAF levels was observed only in group I9 (26.4 ng/g v 4.7 ng/g, I9 v U4 + S, P < .05), whereas values comparable to those observed in controls were detected in other groups (I4, 7.2 ng/g; IT4, 4.5 ng/g; IT9, 6.8 ng/g). Tumor necrosis factor alpha (TNF alpha) measurements did not exhibit any difference between groups. Using a PAF antagonist, the role of PAF in the aggravation of intestinal damage after ischemia was not remarkable because treatment did not induce any modifications of parietal intestinal lesions. PAF antagonists appeared to reduce significantly the local peritoneal consequences of local inflammation.

Evaluation of a hydrocolloid dressing.

A hydrocolloid dressing was compared to adhesive skin tapes on children's postoperative wounds. A total of 170 children of varying ages were randomised in two parallel groups, in nine centres of plastic, thoracic, gastrointestinal, urogenital and orthopaedic surgery. Skin closure was satisfactory in both groups, with 76 (89.4%) healthy closures without dehiscence in the hydrocolloid group and 81 (95.3%) in the control group; a relationship was found between partial closures/dehiscence and the type of surgical procedure. No product-related maceration, infection or adverse event was reported during the study and both groups showed very satisfactory cosmetic results.

Bacterial translocation, intestinal morphology, and enzyme activities after ileal ischemia in newborn piglets.

Intestinal ischemia was created after a limited laparotomy by ligation of the terminal mesenteric vessels in the last 10 cm of distal ileum in 2-day-old piglets. Five groups (each n = 15) were studied: 1 (unoperated control group, killed on day 4), 2 (sham control with laparotomy, killed on day 4), 3 (ischemia, killed on day 4), 4 (ischemia, killed on day 9), and 5 (unoperated control on day 9, not killed). All animals in groups 1, 2 and 5 survived. Two animals in group 3 and 1 in group 4 died (peritonitis and distal ileal perforation). In animals killed on day 9, less weight gain was observed in group 4 compared to the unoperated controls. Macroscopically, no alteration was found at laparotomy in the animals in group 1, whereas in group 2, 1 animal showed beginning peritonitis and another some degree of peritoneal adhesions in group 3, 1 piglet had an intestinal perforation and 4 had intestinal distention above the ischemic loop. In group 4, 7 animals had dilatation of the upper loops, 4 a complete stricture, and 3 peritonitis with complete necrosis of the distal ileum. Microscopic examination revealed severe lesions of the ischemic area in groups 3 and 4 and mild lesions of the upper loop. The kidney was contaminated by translocation of gram-positive cocci in 36% of cases in group 2. Germ carriage for staphylococci was estimated at 80% in the terminal ileum of animals in group 3 versus 8.3% in group 2. In groups 3 and 4, the translocation rate was 30% in the kidney and 40% in the liver. Low disaccharidase activities were found in ischemic areas in groups 3 and 4, with no difference in activity in the upper loops.

Evaluation of a hydrocolloid dressing.

A hydrocolloid dressing was compared to adhesive skin tapes on children's postoperative wounds. A total of 170 children of varying ages were randomised in two parallel groups, in nine centres of plastic, thoracic, gastrointestinal, urogenital and orthopaedic surgery. Skin closure was satisfactory in both groups, with 76 (89.4%) healthy closures without dehiscence in the hydrocolloid group and 81(95.3%) in the control group; a relationship was found between partial closures/dehiscence and the type of surgical procedure. No product-related maceration, infection or adverse event was reported during the study and both groups showed very satisfactory cosmetic results.

Stimulation by recombinant human growth hormone of growth and development of remaining bowel after subtotal ileojejunectomy in rats.

The impact of human recombinant growth hormone (GH) after massive small bowel resection was studied in 38 weaning female Wistar rats (65 +/- 5 days old; 193 +/- 26 g). Animals underwent a 80% small bowel resection, leaving in place similar lengths of jejunum and ileum. Animals were assigned to four groups: group A (n = 9), small bowel resection only; group B (n = 10), resection and treatment with 0.2 GH units (GHU) s.c. every other day; group C (n = 9), resection and 0.4 GHU; and group D (n = 10), laparotomy without intestinal resection. Twenty-eight days later, weight gain (percentage of initial weight) was 1 +/- 3 in group A, 12 +/- 8 in group B, 12 +/- 9 in group C, and 16 +/- 7 in group D; p < 0.001, groups B-D. Time to recover initial weight was 26.2 +/- 3.3 days in group A; 11.7 +/- 5.4 days in group B (p < 0.001); and 16 +/- 6.1 days in group C (p < 0.001 vs. A). The size of the intestinal remnant after the rats were killed was 1.3 +/- 0.6 cm (13 +/- 10% of initial length) in A; 5.15 +/- 2.4 cm (37 +/- 18%) in B (p < 0.01); 4.2 +/- 2.3 cm (33 +/- 20%) in C (p < 0.01 vs. A); and 4.4 +/- 3.5 cm (5.8 +/- 4.9%) in D (p < 0.001 vs A). Villus height and diameter, average number of mitosis per field, and muscular layer and wall thickness were greater in groups A, B, and C than in group D (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)