Occurrence of adverse events among patients with inflammatory bowel disease in the HealthCore Integrated Research Database

OBJECTIVES

Inflammatory bowel disease (IBD) is a chronic condition commonly requiring lifelong care. Both IBD and IBD-related treatments can cause significant morbidity, and it is often difficult to differentiate their relative etiologic contribution to adverse events (AEs). The objectives of this study were to assess the rates of select AEs among patients with IBD as a function of disease severity and of the use of anti-tumor necrosis factor alpha (anti-TNFα) medications.

METHODS

We conducted a retrospective cohort study of IBD patients in the HealthCore Integrated Research Database (HIRD(TM)) between January 2004 and January 2011 to determine rates of AEs in patients with mild and moderate to severe IBD. Key study endpoints were select prespecified malignant neoplasms, infections, and other AEs of interest.

RESULTS

A total of 33,386 IBD patients (52.7% ulcerative colitis; 47.3% Crohn's disease) met the inclusion criteria, and 60% had been followed for ≥1 year. Patients with moderate to severe IBD had increased rates of infections, lymphatic and digestive tract cancers, gastrointestinal (GI) perforations, and myocardial infarctions versus patients with mild IBD. Patients with IBD who used anti-TNFα therapies during the study had increased incidence of many types of infections, certain GI cancers (including rectal and anal cancer), intestinal perforations, and kidney stones compared with patients who had never used anti-TNFα therapies.

CONCLUSIONS

Results from this large US cohort provide descriptive information on AE rates in a population of IBD patients undergoing routine care, estimating background incidence rates of AEs that are not readily available in the published literature. Our study findings may be limited owing to a lack of generalizability and potential for misclassification due to reliance on medical diagnosis and treatment and procedure codes to identify disease, comorbidities, and treatments. Further research and validation of our findings in other populations and databases are needed.

Comparison of the microbiology and antibiotic treatment among diabetic and nondiabetic patients hospitalized for cellulitis or cutaneous abscess

BACKGROUND

Among diabetics, complicated skin infections may involve gram-negative pathogens; however, the microbiology of cellulitis and cutaneous abscess is not well established.

OBJECTIVE

To compare the microbiology and prescribing patterns between diabetics and nondiabetics hospitalized for cellulitis or abscess.

DESIGN

Secondary analysis of 2 published retrospective cohorts.

SETTING/PATIENTS

Adults hospitalized for cellulitis or abscess, excluding infected ulcers or deep tissue infections, at 7 academic and community facilities.

METHODS

Microbiological findings and antibiotic use were compared among diabetics and nondiabetics. Multivariable logistic regression was performed to identify factors associated with exposure to broad gram-negative therapy, defined as receipt of at least 2 calendar days of β-lactamase inhibitors, second- to fifth-generation cephalosporins, fluoroquinolones, carbapenems, tigecycline, aminoglycosides, or colistin.

RESULTS

Of 770 total patients with cellulitis or abscess, 167 (22%) had diabetes mellitus. Among the 38% of cases with a positive culture, an aerobic gram-positive organism was isolated in 90% of diabetics and 92% of nondiabetics (P = 0.59); aerobic gram-negative organisms were isolated in 7% and 12%, respectively (P = 0.28). Overall, diabetics were more likely than nondiabetics to be exposed to broad gram-negative therapy (54% vs 44% of cases, P = 0.02). By logistic regression, diabetes mellitus was independently associated with exposure to broad gram-negative therapy (odds ratio: 1.66, 95% confidence interval: 1.15-2.40).

CONCLUSION

In cases of cellulitis or abscess associated with a positive culture, gram-negative pathogens were not more common among diabetics compared with nondiabetics. However, diabetics were overall more likely to be exposed to broad gram-negative therapy suggesting this prescribing practice may not be not warranted.

Abdominal hollow viscus injuries are associated with spine and neurologic infections after penetrating spinal cord injuries

Penetrating spinal cord injuries are rare but potentially devastating injuries that are associated with significant morbidity. The objective of this study was to assess the impact of abdominal hollow viscus injuries (HVIs) on neurologic and spinal infectious complications in patients sustaining penetrating spinal cord injuries. We performed a 13-year retrospective review of a Level I trauma center database. Variables analyzed included demographics, injury patterns and severity, spine operations, and outcomes. Spine and neurologic infections (SNIs) were defined as paraspinal or spinal abscess, osteomyelitis, and meningitis. Multivariate analysis was performed to identify factors associated with SNI. Of 137 patients, there were 126 males (92%) with a mean age of 27 ± 10 years. Eight patients (6%) underwent operative stabilization of their spine. Fifteen patients (11%) developed SNI. There was a higher incidence of SNI among patients with abdominal HVI compared with those without (eight [26%] vs six [6%], P < 0.001). On multivariate analysis, after controlling for injury severity, solid abdominal injury and HVI, vascular injury, and spine operation, abdominal HVIs were independently associated with an increased risk for SNI (odds ratio, 6.88; 95% confidence interval, 2.14 to 22.09; P = 0.001). Further studies are required to determine the optimal management strategy to prevent and successfully treat these infections.

Hospital-based emergency department visits with dental conditions among children in the United States: nationwide epidemiological data

PURPOSE

To provide nationally representative estimates of hospital-based emergency department visits (ED) for dental caries, pulp and periapical lesions, gingival/periodontal lesions, and mouth cellulitis occurring among patients who were 21 years old and younger.

METHODS

Nationwide Emergency Department Sample (NEDS) for the year 2008 was used. All ED visits with dental conditions were included. Discharge patterns, demographics, disposition following ED visit, and hospital charges, were examined. NEDS is a uniform, stratified dataset, and can be projected to the national level.

RESULTS

A total of 215,073 ED visits with dental conditions occurred among children. These visits included diagnosis of dental caries (50 percent of visits), pulpal and periapical conditions (41 percent), gingival (15 percent) and periodontal diseases (five percent), and mouth abscess/cellulitis (three percent). Forty-two percent were covered by Medicaid, and 32 percent were uninsured. Mean charge per visit was $564, and total ED charge across the United States (US) was $104.2 million. Among those hospitalized following ED visits, total hospitalization charge across US was $162 million.

CONCLUSIONS

A substantial amount of hospital resources are spent treating dental conditions in the ED. A total of 43 percent of ED visits were covered by Medicaid, and 32 percent were uninsured.

Deep neck infections in children: experience in a tertiary care center in Turkey

The aim of this study was to elucidate the clinical presentations, diagnostic clues and management of deep neck infections (DNI) in pediatric patients. Demographic characteristics, clinical manifestations, predisposing factors, duration of symptoms before presentation, history of previous antibiotic use, duration of hospitalization, laboratory and radiographic evaluations, management, complications, and outcomes of 25 patients (19 male/6 female; mean age: 47.9±39.0 months) diagnosed with DNI were analyzed retrospectively. Retropharyngeal abscesses occurred especially in preschool children, whereas peritonsillar abscesses occurred especially in school children. Nine of 25 (36%) patients underwent surgical intervention in addition to medical therapy. Contrast-enhanced computed tomography provided additional information in half of the patients. DNIs should be considered in the differential diagnosis of children who present with fever and neck mass even in the absence of more specific findings. Medical treatment can be considered an option to surgical treatment by utilizing the advantages of imaging techniques and empirical antibiotics.

[Clinical characteristics and antimicrobial resistance of invasive group A β-hemolytic streptococcus infection in children]

OBJECTIVE

Group A β-hemolytic streptococcus (GAS) or Streptococcus pyogenes may be encountered in diverse clinical situations in children. A rising incidence of invasive group A streptococcus (IGAS) infections has been noted in children in the past three decades. The aim of this study was to summarize the clinical characteristics and antimicrobial resistance of IGAS in children, and to raise the level of diagnosis and treatment of this infection.

METHOD

The clinical data from 19 cases of IGAS younger than 14 years old seen from January 2004 to December 2011 treated in the authors' hospital were analyzed. IGAS infections are defined as the isolation of GAS from a normally sterile site in patients.

RESULT

The 19 cases were identified as IGAS infections, among whom 15 were male and 4 were female, and the ratio of them was 3.75. The age ranged from 1 day to 14 years, with a median age of 4 years. The course of disease was 4 h-10 days. The average length of stay was 12.2 days. In 13 cases the episodes of the infection occurred in winter and spring. In 18 cases the infection was community-acquired. Overall, 10 cases had neck or foot dorsum abscess, four cases had purulent peritonitis, and 3 cases were diagnosed as streptococcal toxic shock syndrome (STSS) complicated with empyema, pyopneumothorax occurred in 1 case and neonatal septicemia in another. Three cases had an underlying disease, including 2 cases wounded in a car accident and 1 case of congenital esophageal atresia and tracheoesophageal fistula. Before the isolation of GAS, 5 cases had stayed in ICUs, the length of ICU stay was 1-32 days, 4 cases had received intubation and mechanical ventilation, the ventilation time was 8 h-24 days, 2 cases had received major surgery; 5 cases had other pathogen coinfection, including 4 cases of abdominal pus at the same time and Escherichia coli was isolated, and 1 case had parainfluenza virus type I coinfection. Peripheral blood leucocyte increased in 18 cases, one case dropped off. The C-reactive protein (CRP) levels increased in all patients, including 16 cases who had 14-160 mg/L, 3 cases had levels higher than 160 mg/L. Twenty strains of GAS were isolated from 19 cases' sterile sites, of them 10 strains were isolated from abscess, 4 strains were isolated from blood and another 4 from ascites. Two strains were from the same patient at different times of pleural effusion. All 20 strains displayed a full susceptibility to cefazolin, levofloxacin and vancomycin, and the rates of resistance to both cefotaxime and penicillin were 10.0%. The rates of resistance to erythromycin and clindamycin were 55.0% and 70.0% respectively. Among the patients 3 cases were cured, 14 cases improved, and 2 cases died, of whom 1 case died of STSS secondary to multiple organ dysfunction, 1 case died of basic disease secondary to multiple organ dysfunction.

CONCLUSION

Skin and soft tissues were the most common IGAS infection sites in children, and IGAS infection also can lead to serious STSS and even can be life threatening. Penicillin and cephalosporin are still sensitive for children IGAS infections.

[Oral, pharyngeal and neck infections in specialized care]

BACKGROUND, MATERIAL AND METHODS

All cases of acute dental, oral and pharyngeal infections that were referred to Mikkeli Central Hospital during a 25-month period were retrospectively analyzed.

RESULTS

Thirty-nine percent of the total of 394 cases needed intravenous antibiotics. Tonsillar infections were most prevalent (27%), followed by peritonsillar abscesses (25%) and dental infections (20%). Twenty patients (5%) had cervical or submandibular cellulitis or abscess requiring immediate surgery and an average 8.5 days of in-patient treatment. The most prevalent (45%) bacteriological result was miscellaneous "normal flora".

CONCLUSIONS

Imminent oropharyngeal infection may require immediate surgery and intravenous antibiotics.

Health and economic burden of post-partum Staphylococcus aureus breast abscess

Objectives

To determine the health and economic burdens of post-partum Staphylococcus aureus breast abscess.

Study design

We conducted a matched cohort study (N = 216) in a population of pregnant women (N = 32,770) who delivered at our center during the study period from 10/1/03–9/30/10. Data were extracted from hospital databases, or via chart review if unavailable electronically. We compared cases of S. aureus breast abscess to controls matched by delivery date to compare health services utilization and mean attributable medical costs in 2012 United States dollars using Medicare and hospital-based estimates. We also evaluated whether resource utilization and health care costs differed between cases with methicillin-resistant and -susceptible S. aureus isolates.

Results

Fifty-four cases of culture-confirmed post-partum S. aureus breast abscess were identified. Breastfeeding cessation (41%), milk fistula (11.1%) and hospital readmission (50%) occurred frequently among case patients. Breast abscess case patients had high rates of health services utilization compared to controls, including high rates of imaging and drainage procedures. The mean attributable cost of post-partum S. aureus breast abscess ranged from $2,340–$4,012, depending on the methods and data sources used. Mean attributable costs were not significantly higher among methicillin-resistant vs. –susceptible S. aureus cases.

Conclusions

Post-partum S. aureus breast abscess is associated with worse health and economic outcomes for women and their infants, including high rates of breastfeeding cessation. Future study is needed to determine the optimal treatment and prevention of these infections.

Proportional mortality: A study of 152 goats submitted for necropsy from 13 goat herds in Quebec, with a special focus on caseous lymphadenitis

The objectives of this study were to determine the main causes of mortality, with a special focus on caseous lymphadenits as a cause of death or wasting in caprine herds from Quebec. Goats (n = 152) from 13 herds were submitted for necropsy; the cause of mortality, and the presence, location, and cause of abscesses (if present) were recorded. Proportional mortalities were distributed as: Clostridium perfringens type D enterotoxemia (17.1%), pneumonia (13.8%), paratuberculosis (10.5%), listeriosis (6.6%), pregnancy toxemia (5.3%), caprine arthritis-encephalitis (4.6%), and caseous lymphadenitis (3.9%). Caseous lymphadenitis was diagnosed in 24.3% of the submitted goats, but was not a major cause of wasting or mortality. Abscesses were localized internally in 54.1% of the cases. Paratuberculosis was diagnosed in 29 goats (16 as cause of death) and was considered a major cause of wasting and/or mortality.

Disseminated nocardiosis mimicking exacerbation of pulmonary sarcoidosis

Nocardiosis is a rare, mixed suppurative and granulomatous, bacterial infection that can affect various organs, but most commonly lungs. Clinical manifestation is usually uncharacteristic; can mimic fungal, parasitic and mycobacterial infections or malignancy. Presentation can be also similar to that of the other granulomatous diseases, among them sarcoidosis. We present an unusual case of disseminated nocardiosis in a patient diagnosed before with sarcoidosis and treated with glucocorticoids. Clinical symptoms initially mimicked exacerbation of pulmonary sarcoidosis. The course of disease was severe.

[Peculiarities of epidemiology of chronic tonsillitis under current conditions of providing specialized aid to the patients presenting with ENT diseases]

The objective of he present works was to analyse epidemiological parameters characterizing the prevalence of chronic tonsillitis morbidity and specific features of its local and systemic complications (the former included paratonsillar abscess, PA, while the latter acute rheumatic fever, ARF, and acute post-streptococcal glomerulonephritis, APSGN). The data subjected to the analysis comprised information collected by the Statistical Department of the Clinical Infectious Hospital No 1 for the past 10 years about the number of hospitalized patients having the diagnosis of tonsillitis in combination with PA and the data on the number of peritonsillar abscess drainage procedures performed between 2008 and 2010 (Statistical Department of S.P. Botkin City Clinical Hospital), the number of tonsillectomies, the prevalence of ARF and APSGN during the last 10 years (Medical Statistics Bureau of the Moscow Health Department), and the results of monitoring regular medical check-ups of the patients presenting with the above pathologies. The number of the patients hospitalized at the Clinical Infectious Hospital No 1 for the diagnosis of tonsillitis in combination with PA was shown to increase as well as the number of autopsies of the patients with PA performed at S.P. Botkin City Clinical Hospital. Simultaneously, the number of tonsillectomies in the clinics of Moscow Health Department decreased whereas the prevalence of ARF and APSGN and the number of the patients with chronic tonsillitis under dispensary observation for over 2 years increased. It is concluded that otorhinolaryngologists working in outpatient facilities must promptly identify indications for radical surgical sanitation of the pockets of chronic infection by means of bilateral tonsillectomy.

[Paratonsillar abscess in the patients presenting with the non-anginous form of chronic tonsillitis]

The present study was undertaken for the purpose of the comparative analysis of the degree of severity and inflammation-induced changes in palatine tonsils of the patients presenting with non-anginous forms of chronic tonsillitis both on the side of development of paratonsillitis and on the opposite side showing no visually visible signs of the acute inflammatory process. The secondary objective of the study was to compare pain syndrome during abscess-tonsillectomy and tonsillectomy proper, respectively. We analysed the causes behind the reduction of the total number of tonsillectomies for the treatment of chronic tonsillitis available from the accessible literature for the past 10 years. Moreover the analysis of medical records of the patients with chronic tonsillitis and delayed paratonsillar abscess was performed based on the results of the treatment of the patients admitted to the Otorhinolaryngological Department of the City Clinical Hospital No 1 during the period from 2002 and 2011. The severity of clinical manifestations of the inflammatory process was estimated based on the study of palatine tonsil biopsies removed during surgery using the radioautographic technique. The severity of pain syndrome during abscess-tonsillectomy and tonsillectomy proper was evaluated based on the McGill pain questionnaire. The results of the study confirmed apparent tonsillar inflammation in the patients presenting with chronic tonsillitis including its non-anginous forms.

Caries status among children in the West Rand District of Gauteng Province, South Africa

INTRODUCTION

There is a lack of data about the prevalence and clinical consequences of dental caries in the West Rand. However dental caries does appear to be a substantial public health problem in Gauteng.

OBJECTIVE

This study set out to determine the prevalence and clinical consequences of dental caries among school children in the West Rand district of Gauteng.

METHODOLOGY

This was a cross-sectional study comprised of 800 pre-school and primary school children six to eight years old. Cluster sampling was used to select the participating schools. The oral health status was determined by using the DMFT/dmft and PUFA/pufa indices.

RESULTS

Of the 800 children, 282 were in the four to five year old age group and 518 were six to eight years old. For four to five year olds the mean dmft score was 2.24 and the prevalence of caries 49%. The clinical consequence of caries was scored with a mean pufa index of 2.9 and the percentage of untreated decay was 47%. For six to eight year olds the mean DMFT/dmft scores were 0.1 and 2.4 respectively and the prevalence of caries 46%. The clinical consequence of caries scored with the PUFA/pufa index was 0.0 and 3.4 respectively and the percentage of untreated decay was 44%.

CONCLUSION

There are high levels of untreated caries in children in this district. The pufa scores ndicate that children suffer serious consequences of untreated decay.

Increased risk of neoplasm in appendicitis treated with interval appendectomy: single-institution experience and literature review

Appendicitis is a common diagnosis encountered by the acute care surgeon. Management of complicated appendicitis is controversial and often involves initial nonoperative therapy with interval appendectomy. This study reviews single-institutional experience with management of complicated appendicitis with interval appendectomy and addresses an unusually high occurrence of incidental appendiceal malignancies observed with a review of relevant literature. A retrospective review of all diagnoses of appendicitis was performed over 5 years at a tertiary care center. Patient demographics, time to surgery, operative technique, pathologic diagnosis, and clinical outcomes were examined. Three hundred fifteen patients were diagnosed with acute appendicitis. Of these, 24 (7.6%) were deemed complicated and did not undergo immediate appendectomy, and 18 ultimately underwent appendectomy at our institution and were included in analysis. There were no statistical demographic or symptomatic differences between the immediate and interval appendectomy patients. Ninety-nine per cent of the immediate appendectomy patients were treated laparoscopically; 78 per cent of the interval group underwent attempted laparoscopic treatment with 56 per cent completed without conversion to open (P < 0.01). Neoplasms were discovered in 1 per cent of the acute appendectomy group and 28 per cent of the interval appendectomy group (P < 0.0001). Two of the three neoplasms in the acute group were carcinoid, whereas three of the five neoplasms in the interval group were adenocarcinoma. Surgeons should consider appendiceal or colonic neoplasms in cases of complicated appendicitis when nonoperative management is considered. This is most important in patients older than 40 years, in those who forego interval appendectomy, or in those who could be lost to follow-up.

The rate of adverse events following BCG vaccination in Poland

PURPOSE OF THE STUDY

The purpose of the study was to evaluate the capacity of the surveillance system to respond to the schedule changes in the view of TB vaccination uptake. Complications of Bacillus Calmette-Guerin (BCG) vaccination in Poland are as elsewhere uncommon. In Poland, BCG vaccination with a vaccine produced with Mycobacterium bovis BCG Moreau has been a part of the National Immunization Program since 1955. In the beginning the immunization schedule involved several BCG revaccinations in children and youths, with the first dose given to neonates up to 1 month old followed by revaccinations at 2, 4, 7, 12, 15, and 18 years of life. In 90s, the number of BCG doses was reduced and since 2006, according to recommendations made by the WHO, a single BCG dose is given to neonates only.

METHODS

In the study we have analyzed data on adverse events following BCG vaccination registered within a period of 1994-2010, with attention to the periods before and after 2006, when different BCG vaccination schedules were used for immunization.

RESULTS

The frequency of adverse events following BCG vaccination in Poland oscillated within 1994-2000 and 2001-2010 periods around 0.2 per thousand and 0.6 per thousand respectively, and in half consisted of local lesions at the injection sites and in half--appeared in the form of the regional lymphadenopathy. The analysis of surveillance data revealed similar rates of adverse events following BCG vaccination in the periods of different BCG vaccination schedules, eg. before and after 2006.

CONCLUSIONS

Improvements in the data collecting manner from passive to active one and the introduction of the routine laboratory confirmation of the infection might evaluate the real prevalence of Mycobacterium bovis BCG infections and improve the treatment of adverse events following BCG vaccination cases.

Red breast as a presenting complaint at a breast center: an institutional review

BACKGROUND

The differential diagnosis of a red breast is extensive and includes both benign and malignant diseases. The literature documents patients who present with a red breast with delays in diagnosis of inflammatory cancer. We recorded our institutional experience prospectively in the evaluation, diagnosis, and treatment of a red breast.

METHODS

Data were collected prospectively on patients who presented with a red breast during a 14-month period. A retrospective review of final diagnosis and outcome was then conducted. A PubMed and Ovid Medline literature search were performed.

RESULTS

Twenty-two patients presented with a red breast. This number accounted for only 0.6% (22/3,762) of patients evaluated in our breast center during this time period. Final diagnoses were as follows: mastitis in 31.8%, breast abscess in 13.6%, erythematous changes secondary to radiation therapy in 13.6%, cellulitis in 9.1%, and venous hypertension in 9.1%. Other diagnoses included postradiation morphea, benign dermatologic inflammation, Paget disease of the breast, inflammatory breast cancer, and psoriasis (1 patient each). After treatment, 67% (17/22) patients had resolution of their symptoms and 18% (4/22) were improved. Only 1 (4.5%) of 22 patients had a change in diagnosis in a median follow-up of 8.8 months.

CONCLUSION

A red breast is an uncommon presenting complaint in patients evaluated at a breast center; however, the differential diagnosis is extensive. With appropriate diagnosis and treatment, most patients will have improvement or resolution of their symptoms. The diagnostic algorithm used by our breast center identified the cause of the red breast correctly in >95% of patients at presentation, and it can serve as a guide to evaluate patients with a red breast. This algorithm is in agreement with National Comprehensive Cancer Network guidelines.

An alternative to open incision and drainage for community-acquired soft tissue abscesses in children

BACKGROUND

The continually rising incidence of soft tissue abscesses in children has prompted us to seek an alternative to the traditional open incision and drainage (I&D) that would minimize the pain associated with packing during dressing changes and eliminate the need for home nursing care.

STUDY DESIGN

A retrospective review of all patients with soft tissue abscesses from November 2007 to June 2008 was conducted after institutional review board approval. Patients who were treated with open I&D were compared to those treated with placement of subcutaneous drains through the abscess cavities. Both groups received equivalent antibiotic treatment, and all patients were followed in outpatient clinics until infection resolved. The demographics, presenting temperature, culture results, and outcomes were compared between these 2 groups.

RESULTS

A total of 219 patients were identified; 134 of them underwent open I&D, whereas 85 were treated with subcutaneous drains. The demographics, anatomical location of the abscesses, and bacteriology were comparable between the 2 groups. There were equal number of patients in each group who presented with fever initially. Of those treated with open I&D, 4 had metachronous recurring abscesses within the same anatomical region and 1 patient required an additional procedure because of incomplete drainage. There were no recurrences or incomplete drainages in the subcutaneous drain group. The cosmetic appearance of the healed wound from subcutaneous drain placement during the immediate follow-up period is better than that of an open I&D.

CONCLUSIONS

Placement of a subcutaneous drain for community-acquired soft tissue abscesses in children is a safe and equally effective alternative to the traditional I&D.

Sonography-guided percutaneous microwave ablation of intrahepatic primary cholangiocarcinoma

OBJECTIVE

To evaluate the efficacy and safety of sonography-guided percutaneous microwave ablation of intrahepatic primary cholangiocarcinoma.

MATERIALS AND METHODS

From May 2006 to March 2010, 15 patients (11 men, 4 women; mean age, 57.4 years) with 24 histologically proven intrahepatic primary cholangiocarcinoma lesions (mean tumor size, 3.2±1.9 cm; range, 1.3-9.9 cm) were treated with microwave ablation.

RESULTS

Thirty-eight sessions were performed for 24 nodules in 15 patients. The follow-up period was 4-31 months (mean, 12.8±8.0 months). The ablation success rate, the technique effectiveness rate, and the local tumor progression rate were 91.7% (22/24), 87.5% (21/24), and 25% (6/24) respectively according to the results of follow-up. The cumulative overall 6, 12, 24 month survival rates were 78.8%, 60.0%, and 60.0%, respectively. Major complication occurred including liver abscess in two patients (13.3%) and needle seeding in one patient (6.7%). Both complications were cured satisfied with antibiotic treatment combined to catheter drainage for abscess and resection for needle seeding. The minor complications and side effects were experienced by most patients which subsided with supportive treatment.

CONCLUSION

Microwave ablation can be used as a safe and effective technique to treat intrahepatic primary cholangiocarcinoma.

Scalp abscess due to Salmonella typhimurium-- a case report

The incidence of non-typhoidal salmonellosis has markedly increased in the past decade. Localised infection develops in approximately 5-10% of persons with salmonella bacteraemia. In this report, a 4-year-old female child suffering from acute lymphoid leukaemia is presented with high grade intermittent fever. Pustular lesions were observed over the right side of the scalp. The scalp abscess was drained and pus was sent for culture and sensitivity. Culture grew Salmonella typhimurium. Blood culture also grew the same organism. She had an uneventful recovery after treatment.

Specifics of the renal abscess in nephrology: observations of a clinic from a county hospital in Western Romania

During the last years renal abscesses are being diagnosed with increasing frequency in Nephrology departments. Progresses achieved in imaging procedures permit a timely diagnosis of renal abscesses. At the same time modern antibiotic therapies permit the treatment of this disease in Nephrology departments. In the current paper we present some specifics of renal abscess management encountered in a Nephrology department in western Romania. We performed a retrospective analysis of 2793 patients with upper urinary tract infection hospitalised during 2002-2009 in our Nephrology Department, of whom 44 showed renal abscesses. Uropathic factors were identified less frequently, in 28% of the renal abscess cases, compared to cases in the literature where these have been reported in over 50% of the patients. General predisposing conditions were pregnancy in 7%, postviral cirrhosis in 4%, diabetes mellitus in 4%, surgically single kidney in 2%, polycystic kidney disease in 4% of the patients. We diagnosed renal abscesses in relatively young patients (mean age 38.73 +/- 19.64), fact that could be due to a decreased immune resistance of these patients. Renal function impairment was present in 17% of the patients. Urine cultures were positive in 25% with a predominance of E. coli and rarely of other germs (e.g. Citrobacter and Candida albicans). Therapy consisted of broad spectrum antibiotics applied to all patients. Two patients required the insertion of double J catheter. Five patients (11%) were referred to the Urology Department, where one patient underwent nephrectomy. Renal abscess was diagnosed and treated in the majority of cases in the Nephrology Department, and only in special cases is a referral to the Urology clinic required.

Retropharyngeal and parapharyngeal abscess in children--epidemiology, clinical features and treatment

OBJECTIVE

To describe the clinical presentation, diagnosis, management and complications of children with retropharyngeal abscesses (RPAs) and parapharyngeal abscesses (PPAs).

METHODS

A retrospective chart review was conducted at two tertiary care, pediatric hospitals in Israel. The medical records of all children <18 years who had been admitted with a diagnosis of RPA or PPA during an 11-year period (January 1997 to February 2008) were reviewed. Data on demographics, presenting symptoms, physical examination findings, imaging studies and interpretation, laboratory results, hospital course, medical treatment and surgical interventions were retrieved.

RESULTS

A total of 39 children were diagnosed as having RPA (n=26, 67%) or PPA (n=13, 33%). There was a predominance of boys (61.5%). The mean age of all the children at diagnosis was 4 years. The annual incidence increased over the 11-year period. The most common symptoms at presentation included fever (n=27, 70%) and neck pain (n=24, 62%). The physical examination revealed cervical lymphadenopathy in 30 children (77%), limitation of neck movements in 25 (64%), torticollis in 21 (54%), drooling in three (8%), and stridor in two (5%). Computerized tomographic (CT) scanning with contrast was performed in 37 patients (95%), of whom 17 underwent surgical drainage. Thirteen children were positively diagnosed as having an abscess by the finding of pus at surgery, of whom 12 had been found to have an abscess on their CT scan. All the patients received intravenous antibiotics. There was no significant difference in the duration of hospital stay between those who underwent surgery and those who were treated with antibiotics alone. There were no treatment failures and no complications in either of the two groups.

CONCLUSION

Children with RPA most commonly present with restricted neck movements, fever and cervical lymphadenopathy, and rarely with respiratory distress or stridor. Many patients with RPA and PPA can be treated successfully without surgery. CT scans are helpful in diagnosing and assessing the extent of the infection, but they are not always accurate.

Pediatric neck abscesses caused by methicillin-resistant Staphylococcus aureus: a retrospective study of incidence and susceptibilities over time

Since the early 2000s, studies have shown that the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections in the pediatric population has been increasing. Moreover, studies also have indicated a trend toward increased resistance to commonly used antibiotics over time. However, few studies have specifically focused on such trends in pediatric neck abscesses. We undertook a retrospective study of 109 patients to compare the incidence of pediatric neck abscesses caused by MRSA during two separate 5-year periods at Children's Hospital of New Orleans in an attempt to determine if the incidence was indeed increasing. We also analyzed differences in MRSA susceptibility to various antibiotics over the same two time periods-January 1997 through December 2001 (n = 22) and January 2002 through December 2006 (n = 87). We found a statistically significant increase in the incidence of MRSA between the first 5-year period and the second-from 25 to 70.3% (p = 0.0388). We did not find any significant difference in antibiotic susceptibility patterns between the two 5-year periods.

Acute mechanical intestinal obstructions

BACKGROUND

In this study, we evaluated our treatment modality and timing of surgery in acute mechanical intestinal obstruction (AMIO) patients who were admitted to the emergency room.

METHODS

Only patients with the diagnosis of AMIO were included in this study. Surgery was performed in patients with hemodynamic instability despite fluid resuscitation and peritoneal signs upon physical examination. Patients were divided into two groups. Adhesion cases were assigned to Group 1, while non-adhesion cases were assigned to Group 2. The decision to provide surgical or medical therapy was assessed 24 hours (h) after admission.

RESULTS

Twenty-two patients in Group 1 and 53 patients in Group 2 underwent surgical procedures. The difference between the groups was statistically different (p < 0.05). The mean monitoring time after admission to the hospital was 128.3 +/- 24.85 h and 43.1 +/- 15.51 h in Groups 1 and 2, respectively (p = 0.0001). In Group 2, 76.6% of the patients who were monitored for over 24 hours required surgery. In contrast, this rate was only 36% in Group 1 (p < 0.05).

CONCLUSION

Our clinical experience shows that medical therapy and monitoring over 24 hours is not a good substitute for surgical treatment of AMIO when the obstruction is not due to an adhesion.

Management of breast abscesses in nonlactating women

Breast abscess in nonlactating women is a rare clinic-pathological entity. A retrospective analysis of all cases of breast abscesses in nonlactating women in a community teaching hospital from 2000 to 2006 was performed. We analyzed their clinical characteristics, prevalence of diabetes mellitus (DM), surgical and medical management, and clinical outcome. We identified 116 breast abscesses in 98 nonlactating women; 89 per cent of patients were black. At presentation, 63 patients (64%) had a known history of DM and eight patients (8%) had newly diagnosed DM. Patients with DM had an increased length of hospital stay than nondiabetic women (P < 0.01). Most patients (70%) were treated with incision and drainage and antibiotics with a mean time of abscess resolution of 47 +/- 54 days. There was no correlation with breast abscess and smoking history. Glycemic control was suboptimal with 46 per cent of subjects receiving insulin therapy during the hospital stay. We found a high prevalence of DM (72%) in nonlactating women presenting with breast abscess. Diabetic women had a longer hospital stay and longer duration of the abscess compared with the patients without diabetes. Diabetes screening in nonlactating women with breast abscess and intensified glycemic control might improve clinical outcome.

Epidemiological features of Morel's disease in goats

Morel's disease caused by Staphylococcus aureus subsp. anaerobius was diagnosed for the first time in Poland in October 2006 in a goat flock. A second infected flock was found two months later. The course of the disease in both flocks was observed for 15-17 months. Clinical manifestation was confined to abscesses located near major superficial lymph nodes, mostly: superficial cervical, subiliac, parotid and mandibular. At necropsy no other lesions were found. The incubation period was estimated at 3 weeks. Clinical signs were seen both in young and adult goats and up to 7 abscesses in one animal were noted. Abscesses tended to persist for 1 to 5 months, then rupture and heal completely. The initial high in-flock point prevalence in both flocks (93.6% and 84.4%) dropped to approximately 10-30% during next 3-4 months. Until the end of the observation period the in-flock point prevalence remained at this level and only single abscesses were observed, mainly in young animals. No influence of the concurrent caprine arthritis encephalitis virus (CAEV) infection on the clinical course of Morel's disease was noticed. It is to be concluded that the clinical course of Morel's disease in a goat flock resembles caseous lymphadenitis (CLA). However, in Morel's disease abscesses occur more frequently in young goats and are located near, not inside, the lymph nodes, as in the case with CLA. Also, the incubation period of Morel's disease seems to be shorter (3 weeks versus 2-6 months in CLA).

Incidence and factors influencing the development of fistula-in-ano after incision and drainage of perianal abscesses

OBJECTIVE

The aims of the present study were to evaluate the incidence offistula-in-ano following incision and drainage of acute perianal abscess and to determine factors influencing the fistula formation.

MATERIAL AND METHOD

Patients with a first-time perianal abscess or intersphincteric abscess who underwent incision and drainage at Siriraj Hospital from January 2005 to June 2008 were reviewed Patients with coexisting fistula or perianal Crohn's disease were excluded. Incidence and risk factors for fistula formation were analyzed.

RESULTS

Sixty-four patients were reviewed (50 males, 14 females). The average age of the patients was 44 years (range 19-82). The average follow-up period was 30 months (range 10-53). Twenty patients (31%) developed fistula-in-ano following incision and drainage. Gender; smoking, alcohol consumption, fever; leukocytosis, and location of abscess were not predictive of fistula formation. Univariate analysis showed that patients aged under 40 years and non-diabetic patients tended to have a higher risk for developing the fistula (43% vs. 21%, OR 2.95, 95% CI 0.98-8.85; p = 0.05 and 38% vs. 13%, OR 4.2, 95% CI 0.85-20.83; p = 0.071, respectively). However, patients receiving perioperative antibiotics (ATB) were less likely to develop subsequent fistula in both univariate and multivariate analysis. The FIA rate in non-ATB group was 48% and only 17% in ATB group (OR 4.5, 95% CI 1.44-14.13; p = 0.01).

CONCLUSION

The incidence of fistula-in-ano following incision and drainage of perianal abscess was 31%. Patients aged under 40 years and non-diabetic patients appeared to have a higher risk for fistula formation. Administration of perioperative antibiotics significantly reduced the rate of subsequent fistula formation.

Perirectal abscess infections related to MRSA: a prevalent and underrecognized pathogen

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is not a commonly recognized pathogen isolated from perirectal abscesses. Complex perirectal abscesses of MRSA origin may present a significant challenge to the physician and result in treatment failure. The aim of our study was to determine the prevalence of MRSA in our patient population with perirectal abscesses and whether antibiotics coverage, if given, was adequate.

METHODS

We conducted a retrospective study of all adult patients who presented with a perirectal abscess. The bacteriology of the cultures taken from more than 100 patients during an 8-year period was examined. The prevalence of MRSA was specifically analyzed, and the sensitivities of the organisms isolated were then compared with any antibiotics prescribed to determine the adequacy of coverage.

RESULTS

In all, 124 patients were treated for perirectal abscess during the 8-year period. Fifty-nine percent of patients were taken to the operating room for incision and drainage, 52% of the patients had cultures taken of the abscess, and 35% of patients were given antibiotics coupled with incision and drainage. The antibiotics offered adequate coverage when compared with the sensitivities of the organisms 73% of the time. The prevalence of MRSA in our patient population was 19%, and when this organism was cultured, the patient only received adequate coverage 33% of the time.

CONCLUSION

The presence of MRSA in perirectal abscesses is underrecognized. Recent data has shown that incision and drainage combined with antibiotics offers a superior outcome in soft tissue abscesses caused by this organism. If cultures are not routinely taken at the time of incision and drainage, the institutional incidents of MRSA will remain unknown. Physicians must recognize that MRSA is a potential organism present in perirectal abscesses when considering antimicrobial therapy for complex abscesses.

Pelvic abscess in intrauterine device users

OBJECTIVE

To assess the causality between pelvic abscess formation and intrauterine device (IUD) use through a clinical study in a hospital.

METHOD

Sixty-two pelvic abscesses were retrospectively evaluated over a 7-year period. Patient records retrieved for the women enrolled in this study consisted of demographic characteristics, duration of IUD use and clinical management details.

RESULTS

All the women were monogamous Muslim women without any suspicious sexual contacts, immunosupressive states, or drug use at the time of IUD insertion. In 10 cases (16.1%), a history of pelvic surgery was present. The mean age of the women was 36.1 +/- 2.3 years (range 19-50 years). Of the 62 women, 14 (22.6%) were current IUD users. The mean time interval for women using IUD prior to the diagnosis of pelvic abscess was 5.7 +/- 1.2 years (range 1-14 years). In all cases, a pelvic mass and abdominal pain constituted the referral signs and symptoms. All women received an initial antibiotic regimen comprising penicillin (24 mU/day), clindamycin (900 mg/day) and gentamycin (240 mg/day) in divided doses. In 38 cases (61.3%), medical treatment yielded a satisfactory clinical outcome, defined as a decreas in mass volume together with pain relief and a decrease in leukocytosis. Twenty-four cases (38.7%) underwent a subsequent surgical procedure, either laparotomy (n = 19) or laparoscopy (n = 5). The type of surgery ranged from abscess drainage to more radical approaches such as total abdominal hysterectomy and/or unilateral or bilateral salpingo-oophorectomy. There were no differences between those women responding to medical therapy and those who did not respond in terms of mean age, percentage of past pelvic surgery, gravidity, parity and the size of pelvic abscess.

CONCLUSIONS

A substantial number of women with an IUD were diagnosed as having a pelvic abscess within a 7-year period at the university clinic. Despite current knowledge that pelvic inflammatory disease and pelvic abscess are rarely encountered in long-term IUD users, the presence of an IUD should be investigated in cases with an initial diagnosis of pelvic abscess based on clinical and ultrasonographic evaluation, demonstrating mostly acquisition via sexually transmitted disease.

Antibiotic resistance in Staphylococcus aureus-containing cutaneous abscesses of patients with HIV

PURPOSE

The aim of this study was to document the resistance patterns found in exudates from cutaneous abscesses of HIV-infected persons.

BASIC PROCEDURES

Patient records were reviewed on 93 culture and sensitivity tests performed on exudates taken from incised and drained abscesses of HIV-infected persons.

MAIN FINDINGS

Of the specimens, 84.6% were Staphylococcus aureus. Of these, 93.5% were penicillin resistant, 87% oxacillin resistant, 84.4% cephazolin resistant, 84.4% erythromycin resistant, 52.2% ciprofloxacin resistant, and 15.6% tetracycline resistant. Fifty-eight specimens were tested for clindamycin with 29.3% found resistant; 85.7% were methicillin-resistant S aureus (MRSA) (defined as resistant to both penicillin G and oxacillin). All specimens were resistant to multiple antibiotics including antimicrobials that might be considered for use in MRSA. No specimens were resistant to trimethoprim-sulfamethoxazole, rifampin, or vancomycin.

CONCLUSIONS

Empiric antimicrobial therapy of HIV-infected persons with cutaneous abscesses must be tailored to the high frequency of antimicrobial drug resistance including MRSA in this population.

Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures

Nowadays, the use of minimally invasive plate osteosynthesis (MIPO) in the management of fracture of the distal tibia is common. The various advantages of the MIPO technique, namely, preserving blood supply and better bone healing, have been described extensively in the literature. However, this technique is not without complication. Among all the complications, infection is one of the commonest. In the last 3 years, we have performed 48 cases of MIPO in treating distal tibia fractures. Our study was to evaluate the clinical outcome of these cases, with special attention to the infection rate and our experience in managing these infection cases. Our results showed that the average time until the patient started to bear full weight was 9.4 weeks. The average time for bony union was 18.7 weeks. There were 7 cases of late infection among these 48 cases. The rate was 15%. The presence of late infection had no obvious effect on the time to bony union. Twenty-five patients (52%) had the implants removed and the most common reason was skin impingement by the implant. The clinical presentation and management of these late infections are discussed. In conclusion, MIPO fixation of distal tibia fractures using a metaphyseal locking plate is safe and efficient. However, complications such as late wound infection and impingement are relatively common. The overall clinical outcome is still good despite the presence of these complications.

Ten-year series of splenic abscesses in a general hospital in Singapore

INTRODUCTION

Splenic abscess is an uncommon clinical problem. Traditionally, the "gold standard" treatment has been splenectomy. However, there is increasing use of non-operative treatments worldwide.

MATERIALS AND METHODS

A 10-year (1996-2005) retrospective review of case records from a single centre (an 800-bed general hospital) was performed. Information regarding demographics, clinical presentation, aetiological agents and management was gathered and analysed.

RESULTS

There were 21 cases from 1996 to 2005. Nineteen (90%) had multiple abscesses. Disseminated melioidosis was the most common aetiological agent (15 cases, 71%). Only 3 patients underwent splenectomy. The remainder were treated conservatively with antibiotics. Almost all the patients (19, 90%) also suffered from diabetes mellitus.

CONCLUSIONS

The most common aetiological agent encountered was Burkholderia pseudomallei. Diabetes mellitus may be an important co-factor in the pathogenesis of splenic abscesses. The majority of our patients were managed conservatively and splenectomy was only occasionally required.

The prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in skin abscesses presenting to the pediatric emergency department

BACKGROUND

Community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) infections have been increasing. The most common of these infections present as skin abscesses. The objectives of this study were to prospectively determine the prevalence of CA-MRSA in abscesses in the population of a pediatric emergency department, to determine antibiotic sensitivity patterns of the CA-MRSA isolates, and to describe the patient population that presented with skin abscesses.

METHODS

We conducted a prospective study of children under the age of 18 years who presented to our pediatric emergency department with a skin abscess that required incision and drainage. Pus from these abscesses was sent for culture to determine the causative agent, and antibiotic sensitivities were reported. Characteristics of the patient population that presented with these abscesses were examined.

RESULTS

Sixty-eight patients were enrolled over an 18-month period. Of these, 60 (88%) had cultures positive for Staphylococcus aureus (S. Aureus). Of these 60 patients, 51 (85%) were identified as CA-MRSA by their resistance patterns. All of the CA-MRSA isolates were sensitive to trimethoprim/sulfamethoxisole; 6 (10%) were either resistant or intermittently resistant to clindamycin.

LIMITATIONS

The study was conducted on a convenience sample of patients and enrolled a relatively small number of patients.

CONCLUSIONS

CA-MRSA is responsible for the vast majority of skin abscesses presenting to the pediatric emergency department. CA-MRSA isolates are likely to be sensitive to trimethoprim/sulfamethoxisole or clindamycin, although there is some resistance to clindamycin.

Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution

OBJECTIVE

Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis. However, the surgical techniques used for this condition remain controversial. We report our 10-year experience of managing this devastating disease, focusing on the multidisciplinary, minimally invasive operative procedures and the unique bacteriologic factors in Taiwan.

METHODS

Between January 1997 and January 2007, we retrospectively reviewed 18 patients with descending necrotizing mediastinitis who were treated in the National Taiwan University Hospital. Diagnosis and Endo classification were confirmed by computed tomography of the neck and chest.

RESULTS

Eight women and 10 men were included in this study. The mean age was 57.8 +/- 15.2 years. Cervical drainage was performed in the involved area in all patients. The methods for mediastinal drainage included transcervical (n = 10), video-assisted thoracic surgical drainage (n = 6), subxiphoid drainage (n = 1), and mediastinoscopy-assisted drainage (n = 1). We could not rescue 3 patients because of uncontrolled sepsis before surgery, for a mortality rate of 16.7%. Klebsiella pneumoniae uniquely represents the most common pathogen in diabetic patients (P = .01), leading to more complicated courses in older patients (P =.04) and requiring more surgical interventions (P =.05) than other pathogens.

CONCLUSION

Transcervical mediastinal drainage is first justified in patients with limited disease in the upper mediastinum. For those with involvement of the lower anterior mediastinum, an additional subxiphoid approach is suggested. Cervicotomy with video-assisted mediastinal drainage is an excellent combination for involvement of the posterior mediastinum and pleural space. Klebsiella pneumoniae uniquely represents the most important and threatening causative pathogen for diabetic patients with descending necrotizing mediastinitis.

Efficacy and safety of Seprafilm for preventing postoperative abdominal adhesion: systematic review and meta-analysis

BACKGROUND

There is no clear consensus on the efficacy and safety of hyaluronate-carboxymethylcellulose membrane (Seprafilm) for preventing postoperative abdominal adhesion. This study is a meta-analysis of the available evidence.

METHODS

A search of the MEDLINE, EMBASE, and the Cochrane Library identified eight studies that met the inclusion criteria for data extraction. Estimates of effectiveness were performed using fixed- and random-effects models. The effect was calculated as an odds ratio (OR) with 95% confidence intervals (CI) using the statistical software Review Manager Version 4.2. Level of significance was set at p < 0.05.

RESULTS

Outcomes of 4203 patients were studied. The incidence of grade 0 adhesions among Seprafilm-treated patients was statistically significantly more than that observed among control group patients (OR 95%CI, 3.74-20.34; p < 0.01). There was no significant difference in the incidence of grade 1 adhesions between Seprafilm and control groups (OR 95%CI, 0.58-2.71; p = 0.56). The severity of grade 2 and grade 3 adhesions among Seprafilm-treated patients was significantly less than that observed among control group patients (OR 95%CI, 0.22-0.93; p = 0.03; OR 95%CI, 0.09-0.63; p < 0.01, respectively). The incidence of intestinal obstruction after abdominal surgery was not different between Seprafilm and control groups (OR 95%CI, 0.78-1.23; p = 0.84). Using Seprafilm significantly increased the incidence of abdominal abscesses (OR 95%CI, 1.06-2.54; p = 0.03) and anastomotic leaks (OR 95%CI, 1.18-3.50; p = 0.01).

CONCLUSIONS

Our systematic review and meta-analysis showed that Seprafilm could decrease abdominal adhesions after general surgery, which may benefit patients, but could not reduce postoperative intestinal obstruction. At the same time, Seprafilm did increase abdominal abscesses and anastomotic leaks.

Acute rise in methicillin-resistant Staphylococcus aureus infections in a coastal community

OBJECTIVE

Describe the incidence of head and neck community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections over a 5-year period at a coastal tertiary medical center.

STUDY DESIGN

Retrospective chart review.

SUBJECTS AND METHODS

All patients presenting to the otolaryngology service with cultures taken from head and neck infections between 1999 and 2004 were eligible for inclusion. Statistical analysis was used to determine significance of the changing incidence of isolated organisms over the study period.

RESULTS

CA-MRSA infections rose from 21% to 64% over the 5-year period. The increasing trend in CA-MRSA infections reached statistical significance from 2003 to 2004. All CA-MRSA isolates were resistant to cefazolin and penicillin, but most were sensitive to clindamycin.

CONCLUSIONS

Our data demonstrates a striking increase in the incidence of CA-MRSA. We have tailored our treatment of cutaneous head and neck infections to include empiric treatment for CA-MRSA using clindamycin. Awareness and monitoring of this trend will be important for all practitioners involved in the care of these patients.

Rectal strictures in Crohn's disease and coexisting perirectal complications

BACKGROUND

The significance of the presence of rectal strictures in Crohn's disease has not been well studied. The aim of this study was to examine patients diagnosed with Crohn's disease associated with rectal strictures and to describe co-existing manifestations of perianal disease (abscesses, fistulae, or skin tags) and strictures located elsewhere in the colon or small intestine.

METHODS

A cohort of 70 Crohn's disease patients with rectal strictures were compared with controls without rectal strictures matched for age, gender, and duration of disease. Analysis was done to better elucidate the association of rectal strictures with location of disease and other perirectal complications.

RESULTS

The average age of both groups of our Crohn's disease patients was 54 years and the average duration of disease since diagnosis was 315 months for the patients and 314 months for the controls. 54% of patients were women and 46% were men. 61.4% of the study population had Crohn's colitis, whereas the remaining 38.6% of patients had ileo-colonic involvement. In contrast, the majority of the control population had ileo-colonic involvement (74.3%). Perirectal fistulae were present in 61% of patients with rectal strictures versus 34.3% of controls (p value = 0.001). Perirectal abscesses were present in 50% of rectal stricture patients vs. 17.1% of controls (p value < 0.001). Anal skin tags were observed in 23% of study patients vs. 15.7% of controls (p value = 0.275). 37% of patients with rectal strictures also had strictures more proximal in the colon as compared to 54% of controls (p value = 0.07). Only 10% of the study population had small bowel strictures vs. 55.7% of the controls (p value < 0.001).

CONCLUSIONS

This observational study of Crohn's disease patients suggests that the majority of patients with rectal strictures have colonic involvement and increased perianal fistulae and abscesses. Only a minority of patients was observed to have ileal or ileo-colonic disease, perianal skin tags, or strictures elsewhere. A future study will examine whether the severity of stricturing disease can tell us anything about the disease distribution, prognosis, or response to treatment. Patients with rectal strictures and associated perirectal disease may represent a specific phenotypic presentation of Crohn's disease that warrants further study and correlation with serological markers so as to better aid this subgroup of patients.

[Adverse events following BCG vaccination in infants and children up to 36 months of age]

The aim of the study is to evaluate frequency, treatment and clinical type of adverse reaction (AEFI) after BCG vaccination. Between January 2003 and December 2006, 64 children with AEFI after BCG vaccination were registered in the Pediatric Vaccination Centre in Lódź. Different types of AEFI were distinguished on the basis of Lotte's classification (1977). On the basis of 265 registered cases of adverse events after compulsory vaccination, 41.1% (109/265) of them appeared as a result of BCG vaccination. The AEFI clinical analysis showed that in children aged up to 36 months the most frequent symptoms were auxiliary lymphadenitis 67.2% (43/64) or local subcutaneous abscess. In 43.8% (28/64) of cases after BCG vaccination surgical treatment was needed, including 17.2% (11/64) of children who had lymphadenectomy. The majority of AEFI cases after BCG vaccination were observed in children up to 36 months. The AEFI clinical analysis showed that in children aged up to 36 months the most frequent symptoms were regional lymphadenopathy and local subcutaneous abscess. The second most important strategy in AEFI treatment is the cooperation with surgeons. Higher rates of local reaction may result from incorrect methods of BCG vaccine administration.

[Epidemiology and clinical characteristics of childhood parapneumonic empyemas]

Several studies have reported an increasing incidence of childhood parapneumonic empyemas in various countries.

AIM OF THE STUDY

The aim of our study was to estimate the annual incidence of complicated community-acquired pneumonias in children during a 9-year period in a French area and to describe the epidemiological and clinical characteristics of these complications.

POPULATION AND METHODS

We have listed the children from 28 days to 15 years old, hospitalized in the 2 children hospitals of the Isere district for a community-acquired pneumonia complicated with a pleural empyema or a pulmonary abscess from 1995 to 2003.

RESULTS

During the study period, 90 children were hospitalized for a complicated pneumonia including 83 pleural empyemas and 7 isolated lung abscess. The average number of cases was 4 per year from 1995 to 1998 then increased since 1999 to reach 34 cases in 2003, according to a linear model (P<0,001). The incidence of the complicated pneumonia, plotted to the paediatric population of the area has gone up from 0.5 per 100000 to 13 per 100000 children between 1995 and 2003.

CONCLUSION

The incidence of the complicated pneumonias in children increased since 1999 in a French area. Additional investigations are necessary to identify the causes of this increase.

Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences

INTRODUCTION

The initial nonoperative management of perforated appendicitis fails in 15% to 25% of children. These children have complications and increased hospitalization. The purpose of this study was to identify predictors of failure.

METHODS

Children with perforated appendicitis treated with antibiotics and intent for nonoperative management over a 4-year period were reviewed. Seventy-five children were identified and included in the study. Failure was defined as undergoing appendectomy before the initially planned interval.

RESULTS

Nine (12%) of the patients required appendectomy sooner than initially planned. Age, presenting symptoms, physical examination findings, and white blood cell (WBC) count were similar in both success and failure groups. Absence of abscess and presence of appendicolith were both predictors of failure in a multivariate analysis, which included the presence of small bowel obstruction. The failed group had a longer median total length of stay (18 days [range, 4-67] vs 8 days [range, 4-31]; P = .002) and underwent 3 times as many computed tomography scans as successes (3 [range, 2-7] vs 1 [range, 0-5]; P < .001).

CONCLUSION

Lack of abscess and presence of an appendicolith predict failure of nonoperative management of perforated appendicitis in children even when the effect of small bowel obstruction is accounted for. Children with these characteristics may benefit from alternative management strategies.

Value of laparoscopic appendectomy in perforated appendicitis

BACKGROUND

The purpose of this clinical study was to evaluate the efficacy of laparoscopic appendectomy in patients with perforated appendicitis.

METHODS

This study involved a total of 73 consecutive patients who had undergone appendectomy for perforated appendicitis between January 1999 and December 2004. While 39 patients underwent open appendectomy (OA) during the first 3 years, the remaining 34 patients underwent laparoscopic appendectomy (LA) during the last 3 years.

RESULTS

There was no case of LA converted to OA. No significant difference was found in the operating time between the two groups. Laparoscopic appendectomy was associated with less analgesic use, earlier oral intake restart (LA, 2.6 days; OA, 5.1 days), shorter median hospital stay (LA, 11.7 days; OA, 25.8 days), and lower rate of wound infections (LA, 8.8%; OA, 43.6%).

CONCLUSIONS

These results suggest that LA for perforated appendicitis is a safe procedure that may prove to have significant clinical advantages over conventional surgery.

[Corneal abscess presumed to be of bacterial origin]

AIM

To assess clinical, microbiological and therapeutical characteristics of patients presenting with a clinically diagnosed corneal abscess at the Nabeul Hospital Department of Ophthalmology (Tunisia).

METHODS

A retrospective study of patients presenting corneal abscess was conducted over 6 years. The clinical aspects, the microbial isolation, the treatment, and the outcome were analyzed.

RESULTS

sixty-one eyes of 61 patients were hospitalized from January 2000 to October 2006. The mean age was 59.2 years old. The mean delay for referral was 8.7 days. Risk factors were noted in 90% of cases: corneal trauma (24.6%), ocular surgery (19.7%) and chronic keratopathy (14.7%). Bacteriological cultures of corneal smears isolated an organism in 39.9% of cases. Coagulase-negative Staphylococcus (16.3%), streptococcus (13.1%), Pseudomonas aeruginosa (8.1%) were the most frequent species. Poor visual outcome was correlated with anterior chamber inflammation and initial low visual acuity.

CONCLUSION

Corneal trauma was the most common risk factor of corneal abcess. Early diagnosis and prompt treatment are important for successful management of bacterial keratitis to avoid corneal vision loss.

Evaluating adverse events after vaccination in the Medicare population

PURPOSE

Post-licensure observational studies using large linked databases can provide important data about whether adverse events are associated with vaccines, but databases that have been used may not have sufficient statistical power to examine rare events, and may underrepresent the elderly. We assessed the utility of Medicare data for evaluating adverse events after influenza and pneumococcal vaccines, by using an example involving selected clinical conditions, and evaluating aspects of data quality relevant to vaccine safety analyses.

METHODS

We used 2001 data from the National Claims History File and Enrollment Database to determine if hospitalization for urinary tract infection (not likely associated with vaccination) or for cellulitis and abscess of the upper arm and forearm is associated with vaccination.

RESULTS

For influenza vaccine, the 7-day period after vaccination did not demonstrate an elevation in hospitalization with cellulitis and abscess of the upper arm and forearm; for pneumococcal vaccine, a clear peak was evident. No increase in urinary tract infection was found after either influenza or pneumococcal vaccine. Having a prior Medicare claim for pneumococcal vaccine within 5 years was a risk factor for hospitalization with cellulitis and abscess of the upper arm and forearm (relative risk, 2.6; 95% confidence limits (CL), 1.3, 5.0).

CONCLUSIONS

Medicare data are a useful source for evaluating adverse events after vaccination. Screening analyses can be performed using administrative data, but medical record review to validate diagnoses will often be needed for rigorous study of vaccine-adverse event associations.

[Acute mastoiditis: increase of incidence and controversies in antibiotic treatment]

An important complication of acute otitis media is acute mastoiditis which responds to antibiotic therapy and myringotomy. Patients with acute mastoiditis were reviewed during 1996-2005 in the tertiary University Children's Hospital in Madrid. The number of patients with acute mastoiditis increased by about 2-fold during this period. Of 205 children with mastoiditis, ranging from 0.6-17 years of age, surgical treatment was needed in about 4.3% in 1996 and in 70% in 2005. In spite of 80% of the children having received antibiotics at the pediatric visit, the number of complications increased (periostitis, subperiosteal abscess), and the number of surgical interventions increased by 8-fold. Etiological agents were Streptococcus pneumoniae (28.5%) and Staphylococcus aureus (16.3%). Negative cultures were obtained in 53.6% of cases. Lack of response to conventional therapy may require more tympanocentesis procedures for a middle ear culture, and surgical therapy may be necessary more often, as is the tendency in our hospital.

Periannular complications in infective endocarditis involving prosthetic aortic valves

The periannular extension of infection in prosthetic valve endocarditis (PVE) is a serious complication of infective endocarditis associated with high mortality. Periannular lesions in PVE occasionally rupture into adjacent cardiac chambers, leading to aortocavitary fistulae and intracardiac shunting. It is unknown whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinctive clinical characteristics of patients with PVE and either aortocavitary fistulization or nonruptured abscesses. In a retrospective multicenter study of >872 PVE episodes, 150 patients (17%) with periannular complications in PVE in the aortic position were identified (29 with aortocavitary fistulization and 121 with nonruptured abscesses). Early-onset PVE was present in 73 patients (49%). Rates of heart failure (p = 0.09), ventricular septal defect (p <0.01), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 128 patients (83%). In-hospital mortality in the overall population was 39%. Multivariate analysis identified heart failure (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6 to 6.8), renal failure (OR 2.5, 95% CI 1.2 to 5.2), and co-morbidity (OR 2.4, 95% CI 1.1 to 5.1) as independent risk factors for death. Fistulous tract formation was not associated with increased in-hospital mortality (OR 1.6, 95% CI 0.7 to 3.7). The actuarial 5-year survival rate in surgical survivors was 100% in patients with fistulae and 78% in patients with nonruptured abscesses (log-rank p = 0.14). In conclusion, aortocavitary fistulous tract formation in PVE complicated with periannular complications is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscesses. Despite the frequent complications, fistulous tract formation in the current era of infective endocarditis is not an independent risk factor for mortality.

Periannular complications in infective endocarditis involving native aortic valves

The extension of infection in native valve infective endocarditis (IE) from valvular structures to the periannular tissue is incompletely understood. It is unknown, for example, whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinct clinical characteristics of patients with aortocavitary fistulae and nonruptured abscesses in native valve IE and to evaluate the impact of fistulization on the outcomes of patients with native aortic valve IE complicated with periannular lesions. In a retrospective multicenter study of 2,055 native valve IE episodes, 201 patients (9.8%) with periannular complications in aortic valve IE were identified (46 with aortocavitary fistulization and 155 with nonruptured abscesses). Rates of heart failure (p = 0.07), ventricular septal defect (p <0.001), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 172 patients (86%), and in-hospital mortality in the overall population was 29%. Multivariate analysis identified age >60 years (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.3 to 5.2), renal failure (OR 3.0, 95% CI 1.5 to 6.0), and moderate or severe heart failure (OR 2.5, 95% CI 1.2 to 5.2) as independent risk factors for death. There was a trend toward increased in-hospital mortality in patients with aortocavitary fistulae (OR 1.5, 95% CI 0.7 to 3.0). The actuarial 5-year survival rate in surgical survivors was 80% in patients with fistulae and 92% in patients with nonruptured abscesses (log-rank p = 0.6). In conclusion, aortocavitary fistulous tract formation in the setting of native valve IE is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscess. Despite these higher rates of complications, fistulous tract formation in the current era of IE is not an independent risk factor for mortality.

Reinterpreting ethnic patterns among white and African American men who inject heroin: a social science of medicine approach

BACKGROUND

Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.

METHODS AND FINDINGS

We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its "War on Drugs." African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off "dopesickness" rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.

CONCLUSIONS

Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.