Adherent bacterial colonization in the pathogenesis of osteomyelitis.

Direct scanning electron microscopy of material obtained during surgical debridement of osteomyelitic bone showed that the infecting bacteria grew in coherent microcolonies in an adherent biofilm so extensive it often obscured the infected bone surfaces. Transmission electron microscopy showed this biofilm to have a fibrous matrix, to contain some host cells, and to contain many bacteria around which matrix fibers were often concentrated. Many bacterial morphotypes were present in these biofilms, and each bacterium was surrounded by exopolysaccharide polymers, which are known to mediate formation of microcolonies and adhesion of bacteria to surfaces in natural ecosystems and in infections related biomaterials. The adherent mode of growth may reduce the susceptibility of these organisms to host clearance mechanisms and antibiotic therapy and thus may be a fundamental factor in acute and chronic osteomyelitis.

[HIV Disclosure to the Child/Adolescent in Central and West Francophone Africa]. / Annonce à l'enfant et à l'adolescent de son statut VIH en Afrique francophone centrale et de l'Ouest.

We report the attitudes and practices of health care workers involved in the disclosure process to adolescents living with HIV (ALHIV) in a network including West and Central African French-speaking countries, and the experiences of young living with HIV (YLHIV). During a three-day workshop in Abidjan, Côte d'Ivoire, caregivers (doctors, psychologists, social workers) from 19 pediatric HIV treatment sites shared their practices and difficulties, and four YPLHIV their own disclosure experience. Thirty five participants from eight West/Central African countries (Benin, Burkina Faso, Ivory Coast, Cameroon, Mali, Democratic Republic of Congo, Senegal, Togo) contributed: 14 doctors, eight psychologists, six counselors, three social workers. The experience of the centers was variable, but the age at disclosure was late: 34% of 1296 adolescents between 10 and 12 years of age knew their status. The median age at disclosure was 13 years (range: 11-15 years). The practice of the disclosure was often complex, because of multiple factors (fear of the parents of the breaking of the secrecy, lack of communication between professionals). The individual disclosure was the main practice. Four centers practiced HIV disclosure in group sessions to facilitate mirror support, and one used peer-to-peer support. YPLHIV have advocated for an earlier disclosure, from 10 years. In West and Central Africa, the process of HIV disclosure remains complex for parents and caregivers, and occurs too late. The development of a good practice guideline for HIV disclosing adapted to socio-cultural contexts should help to improve this process.

Nous rapportons les attitudes et pratiques des soignants en Afrique francophone concernant l'annonce du statut VIH aux adolescents, et les témoignages de jeunes vivant avec le VIH (jvVIH). Lors d'un atelier de trois jours à Abidjan, Côte d'Ivoire, en novembre 2016, les soignants (médecins, psychologues, travailleurs sociaux) de 19 sites de prise en charge pédiatrique du VIH ont partagé leurs pratiques et difficultés et 4 jvVIH leur vécu de l'annonce. Au total, 35 participants de 8 pays d'Afrique de l'Ouest/centrale (Bénin, Burkina Faso, Côte d'Ivoire, Cameroun, Mali, République démocratique du Congo, Sénégal, Togo) ont contribué : 14 médecins, 8 psychologues, 6 conseillers, 3 travailleurs sociaux. L'expérience des centres était variable, mais l'âge à l'annonce restait tardif : 34 % des 1 296 adolescents âgés entre 10 et 12 ans connaissaient leur statut. L'âge médian à l'annonce était de 13 ans (étendue : 11-15 ans). La pratique de l'annonce s'avérait complexe, en raison de multiples facteurs (crainte des parents de la rupture du secret, manque de communication entre professionnels). L'annonce individuelle était la pratique majoritairement adoptée. Quatre centres pratiquaient une annonce en séances de groupe pour faciliter le soutien en miroir, et un avait recours à l'appui de pairs-adolescents. Les jvVIH ont plaidé pour une annonce plus précoce, dès 10 ans. En Afrique de l'Ouest/centrale francophone, le processus de l'annonce reste complexe pour parents et soignants, et l'annonce trop tardive. L'élaboration d'un guide de bonnes pratiques de l'annonce du VIH, adapté aux contextes socio-culturels devrait permettre d'améliorer ce processus.

Immunological responsiveness to interleukin-2-producing brain tumors can be restored by concurrent subcutaneous transplantation of the same tumors.

The central nervous system shows tolerance for activated host immune reactions, and this relative unresponsiveness may lessen the efficacy of an immunotherapy for brain tumors. Using interleukin-2 (IL-2)-producing 9L rat gliosarcoma cells (9L/IL-2), we examined whether secretion of IL-2 from subcutaneous (s.c.) and/or intracerebral (i.c.) tumors can elicit augmented immunological responses to brain tumors. Syngeneic rats could reject 9L/IL-2 cells inoculated s.c., but developed 9L/IL-2 brain tumors by i.c. inoculation. The growth of i.c. 9L/IL-2 tumors was, however, significantly retarded compared with that of i.c. wild-type tumors. The growth of i.c. wild-type tumors was significantly suppressed when the rats concurrently received 9L/IL-2 cells s.c. Moreover, most of the rats that were inoculated i.c. with 9L/IL-2 cells did not develop brain tumors when concurrently injected s.c. with 9L/IL-2 cells. Immunohistochemical analysis on i.c. 9L/IL-2 tumors, when the rats were concurrently inoculated s.c. with 9L/IL-2 cells, revealed that migration of CD4+ or CD8+ T cells, monocytes/microglias, and macrophages was markedly augmented to a similar level as found in the s.c. 9L/IL-2 tumors. These results showed that systemic immune responses to brain tumor were induced in an immunologically privileged site by concurrent s.c. inoculation of the same tumors that produce IL-2. The present study may also raise the possibility of a therapeutic strategy for brain tumors by the combinatory expression of IL-2 gene using s.c. immunization followed by direct gene transfer into brain tumors.

Surgical biomaterials and differential colonization by Staphylococcus epidermidis.

The data presented in this communication demonstrate preferential colonization of certain biomaterials by Staphylococcus epidermidis. Using a laminar flow biomaterial colonization chamber and surgical-grade biomaterials (stainless steel, aluminium ceramic, methyl methacrylate and high-density polyethylene), the pattern of colonization was quantitated using plate count techniques and electron microscopy. Under comparable conditions, methyl methacrylate was colonized by S. epidermidis in greater numbers than the other biomaterials. Increased bacterial colonization and slime production on methyl methacrylate was time-dependent and 15 times higher than on stainless steel and aluminium and four times higher than on high-density polyethylene. The data reveal that certain biomaterials may promote infection by favouring colonization by potential pathogens. This variable should be explored extensively in an in vivo setting because of its implication in clinical infections.

Can prenatal vitamin K1 (phylloquinone) supplementation replace prophylaxis at birth?

OBJECTIVE: To assess the effect of prenatal vitamin K1 on the coagulation status of newborns. METHODS: We measured noncarboxylated prothrombin and performed the Normotest in two groups of 5-day-old infants whose mothers were given oral vitamin K1, 10 mg/day for 2 weeks at least 10 days before delivery, or were untreated. RESULTS: Noncarboxylated prothrombin was found in one of 74 treated women and 13 of 186 controls, a nonsignificant difference. The mean (+/- standard deviation) Normotest value was 59.6 +/- 10.1% (range 38.9-84.4) for the treated group and 53.4 +/- 9.9% (range 16.3-89.9) for the controls, a statistically significant difference (P < .001). CONCLUSION: Based on the Normotest results, we suggest that vitamin K crosses the placenta and persists to activate the vitamin K-dependent coagulant factors until at least the fifth day of life. Thus, prenatal vitamin K1 administration may replace prophylaxis at birth.

Evaluation of outcome and QOL in patients with craniofacial resection for malignant tumors involving the anterior skull base.

The purpose of this study was to retrospectively evaluate the effectiveness of anterior craniofacial resection in the treatment of nasal and paranasal malignant tumors involving anterior skull base. Between 1992 and 1998, 13 patients with nasal or paranasal malignant tumors underwent this surgical procedure. The site and time of metastasis or recurrence, and survival outcome were retrospectively surveyed. Current status of long-surviving patients and their subjective assessment of the surgical treatment were also evaluated through questionnaires. Median follow-up period was 52 months. Nine patients (69%) were alive with no evidence of disease. Of these patients, eight had survived for more than three years. Recurrence or metastasis occurred in four patients (31%). The mean time interval between surgery and recurrence or metastasis was 11 months. According to the results of questionnaires to long-surviving patients, 89% patients had some complaints. In particular, complaints of unsightly appearance were manifested by all these patients. When the patients themselves evaluated their current conditions resulting from this surgical treatment, 63% were dissatisfied. These results suggest that this surgical treatment is valid for selected patients in regard to survival outcome. When the effectiveness of this treatment is evaluated, however, psychological and functional issues should not be taken lightly.

Chaos and fractals which 1/f spectrum below 10(-2) Hz demonstrates full-term fetal heart rate changes during active phase.

Human fetal heart rate changes were analysed using power spectral density (PSD). The data for analysis were obtained from 25 normal fetuses between the 37th and 40th week of gestation. Pulse interval distribution showed an almost Gaussian distribution. PSD was calculated by first Fourier transform technique, and showed the particular fluctuation below 10(-2) Hz to be inversely proportional to frequency (so called '1/f spectrum') during the active phase after the 37th week of gestation. These results revealed that the 1/f spectrum of the human heart rate had already appeared below 10(-2) Hz in full term of pregnancy.

The use of autologous blood in the surgical treatment of spinal disorders.

A program of autologous blood transfusion in 101 patients who underwent spinal surgery was analyzed. Autologous transfusion was achieved by intraoperative blood salvage using a cell saver and with predeposited blood. The techniques of predeposition of blood included freezing the blood and using a storage solution. Forty-eight patients had scoliosis and received mainly cryopreserved autologous blood and 53 patients had other spinal diseases. Surgery was performed using only autologous blood transfusion in more than 90% of all patients cases. The program was well tolerated by the patients and easily managed by the blood center staff. There were no severe complications associated with this program. The use of instrumentation and extensive spinal fusion were found to be factors associated with increased intraoperative blood loss. This finding suggests that instrumentation surgery and extensive spinal fusion are indications for autologous blood transfusion. Cryopreserved autologous blood transfusion is an effective method for storing a sufficient volume of blood for scoliosis surgery without affecting the patients' preoperative hemodynamic status.

A new method using top views of the spine to predict the progression of curves in idiopathic scoliosis during growth.

STUDY DESIGN: A prospective longitudinal study of 51 patients with idiopathic scoliosis using spinal stereoradiographs was performed. The top view, which was obtained from stereoscopic anteroposterior and lateral radiographs, was analyzed for predicting the progression of spinal deformity. OBJECTIVES: To show that the top view facilitates prediction of curve progression in idiopathic scoliosis at the initial examination. SUMMARY OF BACKGROUND DATA: Four progression factors were set up using the top view and were analyzed statistically for predicting progression. No previous study has assessed this concept. METHODS: Fifty-one patients with idiopathic thoracic scoliosis or combined thoracic and lumbar scoliosis were studied longitudinally. There were 24 untreated patients and 27 patients treated with braces. Four potential progression factors were evaluated using the top view: 1) the ratio of the frontal size and the sagittal size in the top view, 2) the magnitude and direction of the vector describing the plane of maximum curvature in the thoracic spine, 3) the magnitude and direction of the vector describing the plane of maximum curvature in the lumbar spine, and 4) the balance of these vectors between the thoracic and lumbar curve. All cases were classified into five groups according to these four factors. RESULTS: The probability of the progression was evaluated statistically, and the prevalence of curve progression was found in each group. The probability of progression of a scoliosis curve increased according to the increase of these four factors. No significant difference was found between Cobb angle at the initial examination and that at skeletal maturity in untreated patients with a small risk of progression. The patients with a large risk of progression and who were treated with braces showed progression of curvature despite brace treatment. CONCLUSION: The present study has evaluated factors relating to progression in scoliosis using the top view. These results may help predict the risk of progression in idiopathic scoliosis.

Evaluation of the risk of instrumentation as a foreign body in spinal tuberculosis. Clinical and biologic study.

The risk of persistence and recurrence of infection in posterior spinal instrumentation surgery for spinal tuberculosis was studied clinically and microbiologically. Eleven patients with thoracic, thoracolumbar, and lumbar spinal tuberculosis treated by debridement, anterior fusion, and combined posterior instrumentation surgery were analyzed. Seven patients had tuberculosis in both anterior and posterior spinal elements. There were no cases of persistence or recurrence of infection after surgery, and instrumentation provided immediate stability and protected against development of kyphotic deformity. The adherence properties of Mycobacterium tuberculosis to stainless steel (SUS 316) was evaluated experimentally. The results showed that posterior instrumentation surgery was not a hazard to spinal tuberculosis infection when combined with radical debridement and intensive anti-tuberculosis chemotherapy.

Dysphagia complications in ankylosing spinal hyperostosis and ossification of the posterior longitudinal ligament. Roentgenographic findings of the developmental process of cervical osteophytes causing dysphagia.

This is the first report of the process of formulation of a cervical osteophyte causing dysphagia. The patient had ankylosing spinal hyperostosis and OPLL and was followed radiographically for a long time before the onset of dysphagia. The radiological observation suggested that dysphagia was produced when the immobile part of the esophagus was compressed by the anterior projecting cervical osteophyte. The immobility of the esophagus is an important factor in determining whether dysphagia occurs. Another possible contributing factor to dysphagia in this patient was the ossification of the cervical anterior and posterior longitudinal ligaments. The OPLL affected intervertebral segmental motion and induced the formation of anterior projecting cervical osteophytes.

Herniation of calcified cervical intervertebral disc causes dissociated motor loss in a child.

Herniation of the calcified nucleus pulposus is a rare complication of intervertebral disc calcification in children. Surgical intervention is rarely indicated in the majority of such cases. This paper reports a 12-year-old boy with a calcified nucleus pulposus at C7-T1 which had ruptured into the spinal canal, causing dissociated motor loss. Anterior discectomy and fusion were performed and the patient's muscle weakness markedly improved after surgery.

Tortuosity of the vertebral artery in patients with cervical spondylotic myelopathy. Risk factor for the vertebral artery injury during anterior cervical decompression.

STUDY DESIGN: The case report presented herein shows tortuosity of the vertebral artery in a patient with cervical myelopathy. This case led the authors to evaluate 22 other patients who also had undergone anterior cervical fusion. They were studied before operation by either magnetic resonance imaging angiography or selective vertebral angiography. OBJECTIVES: To analyze the radiographs, computed tomography, magnetic resonance imaging, and angiography findings to detect any tortuosity of the vertebral artery in patients with cervical myelopathy to show the risk factors of vertebral artery injury during anterior decompression. SUMMARY OF BACKGROUND DATA: Complications of vertebral artery laceration during cervical anterior decompression are rare, so this injury and abnormality in the course of vertebral artery in patients with cervical myelopathy receive little attention. METHODS: The tortuosity of the vertebral artery was assessed by angiography, magnetic resonance imaging, and computed tomography. RESULTS: Mild vertebral artery tortuosity was observed in 10 patients and loop formation in three associated with cervical spondylotic changes. CONCLUSIONS: This study suggests that vertebral artery loop formation is developed associated with cervical spondylotic changes. During the anterior decompression of cervical spondylotic myelopathy or radiculopathy, the looped vertebral artery could be injured by an excessive wide rejection of the bone or disc material. In the case of vertebral artery migration, the looped vertebral artery can even be injured by routine procedures.

Treatment of cervical cord compression, caused by hereditary multiple exostosis, with laminoplasty: a case report.

STUDY DESIGN: Case report. OBJECTIVES: Successful excision of the exostosis within the spinal canal. SUMMARY OF BACKGROUND DATA: Myelopathy caused by exostosis within the spinal canal developed in a 13-year-old boy with hereditary multiple exostosis. METHODS: Spinous process-splitting laminoplasty with an ultrasonic knife was performed to remove the mass and minimize the possibility of postlaminectomy kyphosis. RESULTS: The spinal canal exostosis with cervical cord compression was excised successfully with laminoplasty. After surgery there has been no recurrence of tumor, and the stability of the cervical spine has been preserved. CONCLUSION: This is the first report of laminoplasty as a useful surgical approach for intraspinal exostosis to prevent postoperative cervical instability.

Ritodrine-induced agranulocytosis.

This is the first reported case of development of agranulocytosis induced by continuous intravenous infusion of a large quantity of ritodrine hydrochloride for tocolysis. It is suspected that the pathophysiological mechanism is a dose-related toxic reaction and a cell loss maturation process of myelocytes.

The inhibition of bacterial adhesion to a tobramycin-impregnated polymethylmethacrylate substratum.

Tobramycin sulfate powder (1.2 g) was mixed with Palacos polymethylmethacrylate (PMMA) bone cement (40 g) to produce 100 discs containing 5.9 mg tobramycin per disc. These discs were used to evaluate the inhibition of bacterial adhesion to an antibiotic-laden biomaterial. Tobramycin-impregnated PMMA discs and control discs containing no tobramycin were exposed in vitro to Staphylococcus epidermidis. Colonization was quantitated using plate count techniques and electron microscopy. Tobramycin-impregnated surfaces reduced adhesive bacteria colonization by 1 log relative to control discs. These observations suggest that tobramycin-impregnated PMMA may not be significantly effective in preventing colonization of the biomaterial substratum and PMMA may be a poor choice as a drug delivery vehicle in biomaterial and compromised tissue-centered infections.

Clinical outcome of microendoscopic posterior decompression for spinal stenosis associated with degenerative spondylolisthesis--minimum 2-year outcome of 37 patients.

A clear consensus for the optimal surgical treatment for spinal stenosis associated with degenerative spondylolisthesis (DS) has not appeared. In general, decompression and fusion are recommended. However, the symptoms of spinal stenosis are the main complaints in almost all patients with DS, and whether or not routine concomitant fusion is necessary in the surgical treatment for DS is still discussed controversially. The authors have treated almost all the patients with spinal stenosis associated with DS by microendoscopic posterior decompression (MEPD) procedures since 2001. In the present study, we examined the minimum 2-year outcome in 37 patients surgically treated with the MEPD procedures for spinal stenosis associated with DS. At the mean of 38 months after surgery, the overall results were excellent in 54% of the patients, good in 19%, fair in 13.5%, and poor in 13.5%, based on the Japanese Orthopedic Association lumbar score, a visual analogue scale, and the Roland-Morris disability questionnaire. Although the progression of spondylolisthesis and the increase of segmental sagittal motion after surgery were seen in 7 patients (19%), only one patient required secondary fusion during the follow-up period. A sufficient decompression with the preservation of the posterior structures of the spine was observed in almost the patients after surgery. In conclusion, the MEPD is a minimally invasive procedure developing a sufficient decompression with the preservation of the spinal stability. Thus, the MEPD is one of the useful procedures in the surgical treatment of spinal stenosis associated with DS. However, further follow-up studies should be performed to evaluate the long-term outcome for evaluation of the true validity of the MEPD for DS.

Surgical complications of microendoscopic procedures for lumbar spinal stenosis.

Microendoscopic discectomy (MED) is one of the minimally invasive endoscopic procedures for treating lumbar disc herniation. We have applied MED techniques to posterior decompression procedures for treating lumbar spinal stenosis (LSS). In the present study, we examined the surgical complications in 114 consecutive patients surgically treated with MED procedures for LSS. Intraoperative complications occurred in 9 patients. Six patients (5.3%) experienced a dural tear, and three (2.6%) had a fracture of an inferior facet. Early postoperative complications occurred in 13 patients. Twelve patients (10.5%) experienced transient neurological complications. The clinical outcomes at the mean 28-month follow-up were not affected by these surgical complications. Other major complications such as nerve injury and surgical site infection were not observed. Most of the complications occurred in the initial series of patients, and the incidence of complications decreased with an increase in the surgeon's experience and the application of several preventive measures against the complications. The surgeon should undergo training when MED techniques are applied in surgical treatment in order to recognize the specific complications associated with such procedures and apply preventive measures against these complications.