Prognosis of prosthetic valve infective endocarditis due to Streptococcus spp., a retrospective multi-site study to assess the impact of antibiotic treatment duration

PURPOSE

The duration of antibiotic treatment for prosthetic valve endocarditis caused by Streptococcus spp. is largely based on clinical observations and expert opinion rather than empirical studies. Here we assess the impact of a shorter antibiotic duration.

OBJECTIVES

To assess the impact of antibiotic treatment duration for streptococcal prosthetic valve endocarditis on 12-month mortality as well as subsequent morbidity resulting in additional cardiac surgical interventions, and rates of relapse and reinfection.

METHODS

This retrospective multisite (N= 3) study examines two decades of data on patients with streptococcal prosthetic valve endocarditis receiving either 4 or 6 weeks of antibiotics. Overall mortality, relapse, and reinfection rates were also assessed for the entire available follow-up period.

RESULTS

The sample includes 121 patients (median age 72 years, IQR [53; 81]). The majority (74%, 89/121) received a ß-lactam antibiotic combined with aminoglycoside in 74% (89/121, median bi-therapy 5 days [1; 14]). Twenty-eight patients underwent surgery guided by ESC-guidelines (23%). The 12-month mortality rate was not significantly affected by antibiotic duration (4/40, 10% in the 4-week group vs 3/81, 3.7% in the 6-week group, p=0.34) or aminoglycoside usage (p=0.1). Similarly, there were no significant differences between the 2 treatment groups for secondary surgical procedures (7/40 vs 21/81, p=0.42), relapse or reinfection (1/40 vs 2/81 and 2/40 vs 5/81 respectively).

CONCLUSIONS

Our study found no increased adverse outcomes associated with a 4-week antibiotic duration compared to the recommended 6-week regimen. Further randomized trials are needed to ascertain the optimal duration of treatment for streptococcal endocarditis.

Prevalence of 2-year "No evidence of disease activity" (NEDA-3 and NEDA-4) in relapsing-remitting multiple sclerosis. A real-world study

BACKGROUND

No evidence of disease activity (NEDA) is becoming a gold standard in the evaluation of disease modifying therapies (DMT) in relapsing-remitting multiple sclerosis (RRMS). NEDA-3 status is the absence of relapses, new activity on brain MRI, and disability progression. NEDA-4 meets all NEDA-3 criteria plus lack of brain atrophy.

OBJECTIVE

Aim of this study was to investigate the prevalence of two-year NEDA-3, NEDA-4, six-month delayed NEDA-3 (6mdNEDA-3), and six-month delayed NEDA-4 (6mdNEDA-4) in a cohort of patients with RRMS. Six-month delayed measures were introduced to consider latency of action of drugs.

METHODS

Observational retrospective monocentric study. All the patients with RRMS starting DMT between 2015 and 2018, and with 2-year of follow-up, were included. Annualized brain volume loss (a-BVL) was calculated by SIENA software.

RESULTS

We included 108 patients, the majority treated with first line DMT. At 2-year follow-up, 35 % of patients were NEDA-3 (50 % 6mdNEDA-3), and 17 % NEDA-4 (28 % 6mdNEDA-4). Loss of NEDA-3 status was mainly driven by MRI activity (70 %), followed by relapses (56 %), and only minimally by disability progression (7 %).

CONCLUSION

In our cohort 2-year NEDA status, especially including lack of brain atrophy, was hard to achieve. Further studies are needed to establish the prognostic value of NEDA-3 and NEDA4 in the long-term follow-up.

Hybrid electronic-photonic sensors on a fibre tip

Most sensors rely on a change in an electrical parameter to the measurand of interest. Their direct readout via an electrical wire and an electronic circuit is, in principle, technically simple, but it is subject to electromagnetic interference, preventing its application in several industrial environments. Fibre-optic sensors can overcome these limitations because the sensing region and readout region can be spaced apart, sometimes by kilometres. However, fibre-optic sensing typically requires complex interrogation equipment due to the extremely high wavelength accuracy that is required. Here we combine the sensitivity and flexibility of electronic sensors with the advantages of optical readout, by demonstrating a hybrid electronic-photonic sensor integrated on the tip of a fibre. The sensor is based on an electro-optical nanophotonic structure that uses the strong co-localization of static and electromagnetic fields to simultaneously achieve a voltage-to-wavelength transduction and a modulation of reflectance. We demonstrate the possibility of reading the current-voltage characteristics of the electro-optic diode through the fibre and therefore its changes due to the environment. As a proof of concept, we show the application of this method to cryogenic temperature sensing. This approach allows fibre-optic sensing to take advantage of the vast toolbox of electrical sensing modalities for many different measurands.

Optimising mopane worm (Gonimbrasia belina) processing for improved nutritional and microbial quality

Mopane worms (Gonimbrasia belina) is an important source of food and contribute to the nutrition of people who consume them. However, the traditional processing methods may have detrimental effects on the nutritional value and should also guarantee microbial quality. In this study, the nutritional composition and microbial quality of mopane worms processed under different boiling time (0-20 min) and drying temperature (40-60 °C) conditions were investigated and optimised using response surface methodology. An increase in the boiling time at the lowest drying temperature resulted in an increase in protein content and reduction in coliform counts. The optimum conditions of boiling for 20 min and drying at 40 °C resulted in mopane worms with a protein content of 49.4% DW and coliform counts <1.5 log cfu/g. In addition, high concentrations of crude fibre (13.6% DW) and fat (20.2% DW), as well as Fe (19.0 mg/100 g) and Zn (17.9 mg/100 g) were also recorded. A decrease in the total bacterial count, Escherichia coli and yeasts and moulds at the boiling time ≥20 min irrespective of the drying temperature suggested that exposure to heat reduced the microbial growth and contamination. Reduction of the mopane worms' moisture content (<7%) due to drying further slowed down the rate of microbial growth. The optimal processing conditions (boiling for 20 min and drying at 40 °C) are recommended for pretreatment of mopane worms prior to further processing into various products.

Use of the Janssen (Johnson & Johnson) COVID-19 Vaccine: Updated Interim Recommendations from the Advisory Committee on Immunization Practices - United States, December 2021

On February 27, 2021, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the adenovirus-vectored COVID-19 vaccine (Janssen Biotech, Inc., a Janssen Pharmaceutical company, Johnson & Johnson), and on February 28, 2021, the Advisory Committee on Immunization Practices (ACIP) issued an interim recommendation for its use as a single-dose primary vaccination in persons aged ≥18 years (1,2). On April 13, 2021, CDC and FDA recommended a pause in the use of Janssen COVID-19 vaccine after reports of thrombosis with thrombocytopenia syndrome (TTS), a rare condition characterized by low platelets and thrombosis, including at unusual sites such as the cerebral venous sinus (cerebral venous sinus thrombosis [CVST]), after receipt of the vaccine.* ACIP rapidly convened two emergency meetings to review reported cases of TTS, and 10 days after the pause commenced, ACIP reaffirmed its interim recommendation for use of the Janssen COVID-19 vaccine in persons aged ≥18 years, but included a warning regarding rare clotting events after vaccination, primarily among women aged 18-49 years (3). In July, after review of an updated benefit-risk assessment accounting for risks of Guillain-Barré syndrome (GBS) and TTS, ACIP concluded that benefits of vaccination with Janssen COVID-19 vaccine outweighed risks. Through ongoing safety surveillance and review of reports from the Vaccine Adverse Event Reporting System (VAERS), additional cases of TTS after receipt of Janssen COVID-19 vaccine, including deaths, were identified. On December 16, 2021, ACIP held an emergency meeting to review updated data on TTS and an updated benefit-risk assessment. At that meeting, ACIP made a recommendation for preferential use of mRNA COVID-19 vaccines over the Janssen COVID-19 vaccine, including both primary and booster doses administered to prevent COVID-19, for all persons aged ≥18 years. The Janssen COVID-19 vaccine may be considered in some situations, including for persons with a contraindication to receipt of mRNA COVID-19 vaccines.

Leveraging Vaccines to Reduce Antibiotic Use and Prevent Antimicrobial Resistance: A World Health Organization Action Framework

This Action Framework identifies priority actions to prevent antimicrobial-resistant (AMR) through expanding the use of licensed vaccines, developing new vaccines that contribute to the prevention and control of AMR, and expanding knowledge about the impact of vaccines on AMR.

National Public Health Burden Estimates of Endocarditis and Skin and Soft-Tissue Infections Related to Injection Drug Use: A Review

BACKGROUND

Despite concerns about the burden of the bacterial and fungal infection syndromes related to injection drug use (IDU), robust estimates of the public health burden of these conditions are lacking. The current article reviews and compares data sources and national burden estimates for infective endocarditis (IE) and skin and soft-tissue infections related to IDU in the United States.

METHODS

A literature review was conducted for estimates of skin and soft-tissue infection and endocarditis disease burden with related IDU or substance use disorder terms since 2011. A range of the burden is presented, based on different methods of obtaining national projections from available data sources or published data.

RESULTS

Estimates using available data suggest the number of hospital admissions for IE related to IDU ranged from 2900 admissions in 2013 to more than 20 000 in 2017. The only source of data available to estimate the annual number of hospitalizations and emergency department visits for skin and soft-tissue infections related to IDU yielded a crude estimate of 98 000 such visits. Including people who are not hospitalized, a crude calculation suggests that 155 000-540 000 skin infections related to IDU occur annually.

DISCUSSION

These estimates carry significant limitations. However, regardless of the source or method, the burden of disease appears substantial, with estimates of thousands of episodes of IE among persons with IDU and at least 100 000 persons who inject drugs (PWID) with skin and soft-tissue infections annually in the United States. Given the importance of these types of infections, more robust and reliable estimates are needed to better quantitate the occurrence and understand the impact of interventions.

916. National Estimates of the Proportion of Bacterial Pathogens Expressing Resistant Phenotypes in US Hospitals, 2012-2017

Background

In 2019, CDC updated national estimates of antibiotic resistance. In this abstract we provide national estimates of and trends in proportion of bacterial pathogens expressing resistant phenotypes (%R), specifically: MRSA, VRE, CRE, ESBL, CRAsp, and MDR Pseudomonas, see Figure.

Methods

We measured incidence of clinical cultures yielding the bacterial species of interest among hospitalized adults in hospitals submitting data to the Premier Healthcare Database, Cerner Health Facts and BD Insights Research Database from 2012- 2017. Community-onset (CO) cultures were obtained ≤ day 3 of hospitalization; hospital-onset (HO) were obtained ≥ day 4. We determined hospital-specific %R for each species. We generated national estimates using a raking procedure to generate weighted adjustments to match the distribution for all U.S. acute care hospitals based on U.S. census division, bed size, teaching status, and urban/rural designation. We applied a weighted means survey procedure to calculate national estimates for each year. We used weighted multivariable logistic regression adjusting for hospital characteristics to examine trends.

Results

From 2012-2017, the overall number of hospitals contributing data was 890 (over 20% of U.S. hospital hospitalizations annually). National estimates and trends of %R are shown in the Figure. Between 2012-2017, significant annual decreases in %R were observed for MRSA, VRE, CRAsp, and MDR Pseudomonas. CRE %R did not change. Overall ESBL %R increased by 44% (CO=49% increase, HO=27% increase).

Conclusion

Reductions in %R were observed among MRSA, VRE, CRAsp, and MDR Pseudomonas, suggesting that prevention efforts focused in health care settings are having a disproportionate effect on resistant strains. However, %R remains unacceptably high for all pathogens we studied, and %R among ESBL-producing Enterobacteriaceae has increased, most prominently among CO infections. Continued focus on currently recommended intervention strategies as well as new ones for community onset infections is needed.

Disclosures

All Authors: No reported disclosures

Assessment of Health Care Exposures and Outcomes in Adult Patients With Sepsis and Septic Shock

IMPORTANCE

Current information on the characteristics of patients who develop sepsis may help in identifying opportunities to improve outcomes. Most recent studies of sepsis epidemiology have focused on changes in incidence or have used administrative data sets that provided limited patient-level data.

OBJECTIVE

To describe sepsis epidemiology in adults.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study reviewed the medical records, death certificates, and hospital discharge data of adult patients with sepsis or septic shock who were discharged from the hospital between October 1, 2014, and September 30, 2015. The convenience sample was obtained from hospitals in the Centers for Disease Control and Prevention Emerging Infections Program in 10 states (California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee). Patients 18 years and older with discharge diagnosis codes for severe sepsis or septic shock were randomly selected. Data were analyzed between May 1, 2018, and January 31, 2019.

MAIN OUTCOMES AND MEASURES

The population's demographic characteristics, health care exposures, and sepsis-associated infections and pathogens were described, and risk factors for death within 30 days after sepsis diagnosis were assessed.

RESULTS

Among 1078 adult patients with sepsis (569 men [52.8%]; median age, 64 years [interquartile range, 53-75 years]), 973 patients (90.3%) were classified as having community-onset sepsis (ie, sepsis diagnosed within 3 days of hospital admission). In total, 654 patients (60.7%) had health care exposures before their hospital admission for sepsis; 260 patients (24.1%) had outpatient encounters in the 7 days before admission, and 447 patients (41.5%) received medical treatment, including antimicrobial drugs, chemotherapy, wound care, dialysis, or surgery, in the 30 days before admission. A pathogen associated with sepsis was found in 613 patients (56.9%); the most common pathogens identified were Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, and Clostridioides difficile. After controlling for other factors, an association was found between underlying comorbidities, such as cirrhosis (odds ratio, 3.59; 95% CI, 2.03-6.32), immunosuppression (odds ratio, 2.52; 95% CI, 1.81-3.52), vascular disease (odds ratio, 1.54; 95% CI, 1.10-2.15), and 30-day mortality.

CONCLUSIONS AND RELEVANCE

Most adults experienced sepsis onset outside of the hospital and had recent encounters with the health care system. A sepsis-associated pathogen was identified in more than half of patients. Future efforts to improve sepsis outcomes may benefit from examination of health maintenance practices and recent health care exposures as potential opportunities among high-risk patients.

FRI0439 PET-CT IN THE ASSESSMENT OF OSTEOARTICULAR INFECTIONS ASSOCIATED WITH INFECTIVE ENDOCARDITIS

Background:

Five to eleven percent of infective endocarditis (IE) are associated with a musculoskeletal infection. Thanks to its good sensitivity, the use of PET-CT in this pathology makes it possible to confirm the diagnosis by seeking valvular hypermetabolism but also by mapping distant septic foci.

Objectives:

The main objective of our study was to assess the prevalence of osteoarticular fixation (OAF) with PET-CT, symptomatic or not, in patients with IE. The secondary objectives were to determine predictive factors for osteoarticular infections such as the type of valve damage (native or prosthetic) and germ.

Methods:

This study was carried out on the basis of a prospective cohort of patients admitted in the department of cardiology in Henri Mondor Hospital for IE suspicion between August 2015 and July 2019. Demographic, clinical, bacteriological, imaging and therapeutic data have been collected. Patients matching Duke’s modified criteria according to ESC 2015 (Duke + IE) and / or a cardiac fixation according to standard whole-body PET-CT were included in the analysis. All of the PET-CT scans were reviewed by a nuclear medicine specialist to confirm whether or not there was a heart condition and to look for septic-looking OAF.

Results:

From this cohort, we included 90 IE Duke + patients and 42 patients with cardiac PET-CT fixation (including 31 IE Duke +). In the IE Duke + group, we found OAF in 18 patients (20%), 39% of whom were asymptomatic. There were 9 spondylodiscitis (4 on the cervical level, 7 on the thoracic level, and 2 on the lumbar level), 5 glenohumeral arthritis, 2 coxofemoral arthritis, 1 sternoclavicular arthritis and 1 sacroiliac arthritis. The IE affected the aortic valve in 50% of the cases and the mitral valve in 22%. In other cases, the infection involved the internal automatic defibrillator (ICD) or the pacemaker. The valves were prosthetic in 73% of the cases. The bacterial ecology was mainly represented by Enterococcus faecalis (39%) then staphylococcus aureus (17%) against 14% and 13% respectively in the entire IE Duke + group. In the group with cardiac PET-CT fixation, OAF was found in 10 patients (40%), 70% of whom were asymptomatic. Among them, there were 5 spondylodiscitis (2 cervico- thoracic and 3 exclusively thoracic), 2 glenohumeral arthritis (20%), 2 coxofemoral arthritis and 1 sternoclavicular arthritis. The IE affected the aortic valve in 60% of the cases, mitral in 30% of the cases and it was an infection on ICD in 10% of the cases. The main germs found were Enterococcus faecalis (30% of cases) and Staphylococcus epidermidis (20% of cases).

Conclusion:

In patients with IE, PET-CT seems to be interesting in detection of osteoarticular infections, and consequently, could impact the diagnosis and the treatment modalities. In our cohort, 1 patient in 5 had an OAF and nearly 40% of them were asymptomatic. The overrepresentation of enterococcus is consistent with recent data in the literature

References:

[1]Dahl A, Iversen K, Tonder N, Hoest N, Arpi M, Dalsgaard M, et al. Prevalence of Infective Endocarditis in Enterococcus faecalis Bacteremia. J Am Coll Cardiol. 16 juill 2019;74(2):193‑201.

Disclosure of Interests:

Benjamin HUGUES: None declared, Bérivan EMSEN: None declared, Julien TERNACLE: None declared, Raphaëlle HUGUET: None declared, Antonio FIORE: None declared, Raphaëlle LEPEULE: None declared, Xavier Chevalier: None declared, Mukedaisi ABULIZI: None declared, Florent Eymard Consultant of: Regenlab

Multidrug-Resistant Bacterial Infections in U.S. Hospitalized Patients, 2012-2017

BACKGROUND

Multidrug-resistant (MDR) bacteria that are commonly associated with health care cause a substantial health burden. Updated national estimates for this group of pathogens are needed to inform public health action.

METHODS

Using data from patients hospitalized in a cohort of 890 U.S. hospitals during the period 2012-2017, we generated national case counts for both hospital-onset and community-onset infections caused by methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum cephalosporin resistance in Enterobacteriaceae suggestive of extended-spectrum beta-lactamase (ESBL) production, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant acinetobacter species, and MDR Pseudomonas aeruginosa.

RESULTS

The hospital cohort in the study accounted for 41.6 million hospitalizations (>20% of U.S. hospitalizations annually). The overall rate of clinical cultures was 292 cultures per 1000 patient-days and was stable throughout the time period. In 2017, these pathogens caused an estimated 622,390 infections (95% confidence interval [CI], 579,125 to 665,655) among hospitalized patients. Of these infections, 517,818 (83%) had their onset in the community, and 104,572 (17%) had their onset in the hospital. MRSA and ESBL infections accounted for the majority of the infections (52% and 32%, respectively). Between 2012 and 2017, the incidence decreased for MRSA infection (from 114.18 to 93.68 cases per 10,000 hospitalizations), VRE infection (from 24.15 to 15.76 per 10,000), carbapenem-resistant acinetobacter species infection (from 3.33 to 2.47 per 10,000), and MDR P. aeruginosa infection (from 13.10 to 9.43 per 10,000), with decreases ranging from -20.5% to -39.2%. The incidence of carbapenem-resistant Enterobacteriaceae infection did not change significantly (from 3.36 to 3.79 cases per 10,000 hospitalizations). The incidence of ESBL infection increased by 53.3% (from 37.55 to 57.12 cases per 10,000 hospitalizations), a change driven by an increase in community-onset cases.

CONCLUSIONS

Health care-associated antimicrobial resistance places a substantial burden on patients in the United States. Further work is needed to identify improved interventions for both the inpatient and outpatient settings. (Funded by the Centers for Disease Control and Prevention.).

1890. Missed Clinical Opportunities to Prevent Infections and Treat Substance Use Disorder (SUD) in People Who Inject Drugs (PWID)

Background

The age-adjusted rate of drug overdose deaths in the United States tripled from 1999 to 2016. Public health surveillance data indicate that an increasing proportion of infections due to bacterial and fungal pathogens is associated with injection drug use (IDU). We describe healthcare encounters (HCEs) of PWID as potential opportunities to prevent infections related to IDU by identifying risks and treating SUD, including with medication-assisted treatment (MAT) for opioid use disorder.

Methods

At six hospitals in western New York, we abstracted medical records from hospital admissions and emergency department (ED) visits for PWID (i.e., IDU in the preceding year) who had positive cultures for Staphylococcus aureus (any clinical specimen, April–July 2017), group A Streptococcus (invasive specimens, all of 2017) or Candida spp. (blood specimens, all of 2017). We reviewed hospital admission and ED records for 1 year preceding the positive culture to identify visits during which opportunities to prevent infection and treat SUD by addressing SUD and IDU were missed.

Results

We identified 99 PWID with positive cultures. The median age was 33 years (range 19–68) and 61 were female. Sixty-nine had a skin and soft-tissue infection, 44 had a bloodstream infection, and 20 had both. Thirty-one PWID left against medical advice during a hospital admission or an ED visit. Seventy-nine PWID were hospitalized, of whom 4 died. Ninety-five used opioids and 71 used cocaine in the preceding year. Seventy-five PWID had an HCE in the 12 months prior to the index visit, with a median of two HCE per person (interquartile range 1–4); 53 of PWID had a previous HCE for infection and 28 for opioid overdose. SUD was documented during a prior HCE at the same hospital for 61 PWID, but only 10 (16%) were offered MAT during any prior HCE and for 24 (39%) there was no documentation that any form of treatment for SUD was offered.

Conclusion

In this cohort, PWID frequently had one or more healthcare encounters documented at the same hospital in the year prior to a serious bacterial or fungal infection. These prior HCEs were often for infections or overdose that signaled the need for MAT, demonstrating that there are critical missed opportunities to identify risks, prevent infection, and treat SUD.

Disclosures

All Authors: No reported Disclosures.

CDC Safety Training Course for Ebola Virus Disease Healthcare Workers

Response to sudden epidemic infectious disease emergencies can demand intensive and specialized training, as demonstrated in 2014 when Ebola virus disease (EVD) rapidly spread throughout West Africa. The medical community quickly became overwhelmed because of limited staff, supplies, and Ebola treatment units (ETUs). Because a mechanism to rapidly increase trained healthcare workers was needed, the US Centers for Disease Control and Prevention developed and implemented an introductory EVD safety training course to prepare US healthcare workers to work in West Africa ETUs. The goal was to teach principles and practices of safely providing patient care and was delivered through lectures, small-group breakout sessions, and practical exercises. During September 2014-March 2015, a total of 570 participants were trained during 16 course sessions. This course quickly increased the number of clinicians who could provide care in West Africa ETUs, showing the feasibility of rapidly developing and implementing training in response to a public health emergency.

Anti-stiction coating for mechanically tunable photonic crystal devices

A method to avoid the stiction failure in nano-electro-opto-mechanical systems has been demonstrated by coating the system with an anti-stiction layer of Al₂O₃ grown by atomic layer deposition techniques. The device based on a double-membrane photonic crystal cavity can be reversibly operated from the pull-in back to its release status. This enables to electrically switch the wavelength of a mode over ~50 nm with a potential modulation frequency above 2 MHz. These results pave the way to reliable nano-mechanical sensors and optical switches.

Baropodometry on patients after total knee arthroplasty

PURPOSE

It is well known that total knee replacement surgery decreases pain and improves function, but the effect on postural assessment needs to be studied better with the use of new technological devices. Total knee arthroplasty (TKA) improves motor coordination and stability of the knee. On the other hand, changing joint functionality can modify the balance. The aim of this trial is to record and analyze the static and dynamic baropodometric data of patients in the first few months following joint replacement. For the physiatrist, this tool can be useful to check if the rehabilitation treatment protocols and times are correct.

METHODS

We designed a prospective observation longitudinal study to assess postural stability following TKA. Between December 2014 and May 2015, sixty consecutive patients were recruited through local orthopedic physician offices and hospitals. The patients scheduled to undergo TKA were recruited and were monitored before surgery (T0) and at 1 (T1), 3 (T2) and 6 months (T3) after knee surgery. The correction of varus/valgus deviation at X-ray and the Knee Society Score were performed to verify the functional recovery. We used static and dynamic baropodometric analysis to evaluate postural assessment.

RESULTS

After surgery, there was a significant improvement in physiological alignment of knee axes (p < 0.0001) and of Knee and Function Scores (excellent, mean values 80.5 and 80.7, respectively, p < 0.0001). The static analysis showed that the center of gravity and the pressure on the foot of the operated limb were corrected toward the physiological center (p < 0.0001) and the body weight displaced to the forefeet and to the hindfeet reduced bilaterally (p < 0.0001). The type of footprint did not change. The dynamic analysis confirmed the significant normalization of the pressure on the foot of the operated limb at all follow-ups (p < 0.0001). The percentage of load was reduced on the operated limb (p = 0.0096) and speed of step, cadence and semi-step length increased (p < 0.0001).

CONCLUSION

These data show the progressive recovery of stability after TKA from the immediate postoperative to the subsequent months. The clinical and functional improvement correlated with a load redistribution between the two limbs. The baropodometry could be an excellent noninvasive method for monitoring effects of rehabilitation treatment.

Ultralow Surface Recombination Velocity in Passivated InGaAs/InP Nanopillars

The III-V semiconductor InGaAs is a key material for photonics because it provides optical emission and absorption in the 1.55 μm telecommunication wavelength window. However, InGaAs suffers from pronounced nonradiative effects associated with its surface states, which affect the performance of nanophotonic devices for optical interconnects, namely nanolasers and nanodetectors. This work reports the strong suppression of surface recombination of undoped InGaAs/InP nanostructured semiconductor pillars using a combination of ammonium sulfide, (NH₄)₂S, chemical treatment and silicon oxide, SiO_x, coating. An 80-fold enhancement in the photoluminescence (PL) intensity of submicrometer pillars at a wavelength of 1550 nm is observed as compared with the unpassivated nanopillars. The PL decay time of ∼0.3 μm wide square nanopillars is dramatically increased from ∼100 ps to ∼25 ns after sulfur treatment and SiO_x coating. The extremely long lifetimes reported here, to our knowledge the highest reported to date for undoped InGaAs nanostructures, are associated with a record-low surface recombination velocity of ∼260 cm/s. We also conclusively show that the SiO_x capping layer plays an active role in the passivation. These results are crucial for the future development of high-performance nanoscale optoelectronic devices for applications in energy-efficient data optical links, single-photon sensing, and photovoltaics.

Waveguide-coupled nanopillar metal-cavity light-emitting diodes on silicon

Nanoscale light sources using metal cavities have been proposed to enable high integration density, efficient operation at low energy per bit and ultra-fast modulation, which would make them attractive for future low-power optical interconnects. For this application, such devices are required to be efficient, waveguide-coupled and integrated on a silicon substrate. We demonstrate a metal-cavity light-emitting diode coupled to a waveguide on silicon. The cavity consists of a metal-coated III–V semiconductor nanopillar which funnels a large fraction of spontaneous emission into the fundamental mode of an InP waveguide bonded to a silicon wafer showing full compatibility with membrane-on-Si photonic integration platforms. The device was characterized through a grating coupler and shows on-chip external quantum efficiency in the 10⁻⁴–10⁻² range at tens of microamp current injection levels, which greatly exceeds the performance of any waveguide-coupled nanoscale light source integrated on silicon in this current range. Furthermore, direct modulation experiments reveal sub-nanosecond electro-optical response with the potential for multi gigabit per second modulation speeds.

Despite much progress, nanoscale light sources suitable for photonic integration are lacking. Here, the authors present a metal-cavity nanopillar LED on a silicon substrate working at telecommunications wavelengths, which demonstrates compatibility with membrane-on-Si photonic integration platforms.

Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care Factors and Opportunities for Prevention

BACKGROUND

Sepsis is a serious and often fatal clinical syndrome, resulting from infection. Information on patient demographics, risk factors, and infections leading to sepsis is needed to integrate comprehensive sepsis prevention, early recognition, and treatment strategies.

METHODS

To describe characteristics of patients with sepsis, CDC and partners conducted a retrospective chart review in four New York hospitals. Random samples of medical records from adult and pediatric patients with administrative codes for severe sepsis or septic shock were reviewed.

RESULTS

Medical records of 246 adults and 79 children (aged birth to 17 years) were reviewed. Overall, 72% of patients had a health care factor during the 30 days before sepsis admission or a selected chronic condition likely to require frequent medical care. Pneumonia was the most common infection leading to sepsis. The most common pathogens isolated from blood cultures were Escherichia coli in adults aged ≥18 years, Klebsiella spp. in children aged ≥1 year, and Enterococcus spp. in infants aged <1 year; for 106 (33%) patients, no pathogen was isolated. Eighty-two (25%) patients with sepsis died, including 65 (26%) adults and 17 (22%) infants and children.

CONCLUSIONS

Infection prevention strategies (e.g., vaccination, reducing transmission of pathogens in health care environments, and appropriate management of chronic diseases) are likely to have a substantial impact on reducing sepsis. CDC, in partnership with organizations representing clinicians, patients, and other stakeholders, is launching a comprehensive campaign to demonstrate that prevention of infections that cause sepsis, and early recognition of sepsis, are integral to overall patient safety.

Effects of the self-myocardial retroperfusion with aortic-coronary sinus shunt on cardiac output and ischemic events in high-risk patients undergoing OPCAB surgery

AIM

Despite controversies, off-pump coronary artery bypass (OPCAB) surgery has become a routine procedure. Obvious advantages have been demonstrated in high-risk patients. However, OPCAB surgery has limitations in specific high-risk situations with hazards of operative deleterious events. We describe an innovative procedure of self-myocardial retroperfusion (SMR) with an aortic-coronary sinus shunt (ACSS). We prospectively evaluated the protective effects and benefits of SMR in high-risk coronary patients with impaired LVEF.

METHODS

Eighteen consecutive high-risk (ES>10) coronary patients (mean age: 65.94 years; range: 34-85; mean ES: 26.97%) with LVEF≤35% who were not eligible for IABP were assigned for OPCAB surgery. Following sternotomy, the cardiac indexes (CI) were measured before, during SMR and after completion of coronary artery bypasses. Operative events with and without SMR were accurately collected, and postoperative cardiac Troponin T release was measured.

RESULTS

OPCAB procedures were performed in all patients. Intraoperative use of SMR significantly increased CI (P=3.1041810.10-8) and reversed deleterious operative events (ECG changes/low cardiac output). Hospital mortality was 0%. Incidence of transient atrial fibrillation was 33.33%. Neither stroke nor renal insufficiency was observed. The mean graft number/patient was 2.05. Mean postoperative cardiac Troponin T value was 0.79 μg/L. Beating heart preservation optimized by SMR contributed to reduce ischemia-reperfusion injury, as validated by an immediate increase of CI after completion of coronary bypasses (P=3.35009.10-9).

CONCLUSION

The concept of SMR with an ACSS during OPCAB procedures definitely improved CI and reversed ischemic features in high-risk patients and should be considered as an operative temporary myocardial assistance.

Position-Dependent Local Detection Efficiency in a Nanowire Superconducting Single-Photon Detector

We probe the local detection efficiency in a nanowire superconducting single-photon detector along the cross-section of the wire with a far subwavelength resolution. We experimentally find a strong variation in the local detection efficiency of the device. We demonstrate that this effect explains previously observed variations in NbN detector efficiency as a function of device geometry.

Role of TachoSil® in distal pancreatectomy: a single center experience

AIM

Distal pancreatectomies (DP) are associated with high risk of postoperative complications, and in many series higher morbidity rate than duodenopancreatectomies has been reported. To evaluate the role of a collagen sponge with human fibrinogen and thrombin film (TachoSil®) in limiting the incidence of complications after DP.

METHODS

From 1996 to 2013, 221 patients have been submitted to distal pancreatectomy (± splenectomy) in our Division. A retrospective analysis has been conducted in a group of 36 consecutive and prospectively collected DP treated with intraoperative placement of TachoSil® on pancreatic stump from 2010 to 2013 (group 1). A control series of 36 consecutive patients (group 2) was matched 1:1 from hystorical database. The variables considered in the analysis were: age, gender, ASA score, pancreatic texture (hard vs. soft), histology, operative time, postoperative mortality, morbility (postoperative pancreatic fistula - POPF, postoperative hemorrage - PPH, delayed gastric emptying - DGE) and hospital stay. Differences between POPF, PPH, DGE and hospital stays between grops were investigated with χ² and t-Student test. Univariate analysis was conducted to determine factors related to POPF development. Statistical analysis was performed using freeware Microsoft Excel based program.

RESULTS

Post operative mortality was 0% in both groups. POPF were registered in 36.1% (13/36) and 41.6 % (15/36) in groups 1 and 2, respectively (P=n.s.); in group 1 we didn't observe grade C POPF, while 4 patients in control group developed grade C POPF (P<0,05). No differences were found between two groups in terms of incidence of PPH and DGE. The median duration of postoperative hospital stay in group 1 was 21.8 (7-189) days compared with 31.13 (9-249) days in group 2 (P<0.001).

CONCLUSION

The use of TachoSil® seems to be associated with lower incidence of grade C POPF but larger controlled trials are needed to surely assess the usefulness of TachoSil® in pancreatic surgery in order to reduce pancreatic specific complications and their severity.

Prognostic factors of extracorporeal shock wave therapy for tendinopathies

INTRODUCTION

Extracorporeal shock wave therapy is very widely used for the management of tendinopathies and plantar fasciitis.

AIM

The aim of the study is to determine whether there are prognostic factors that may influence the outcome of extracorporeal shock wave therapy for these diseases.

METHODS

Three hundred fifty-five patients were analyzed 2 months after shock wave treatment for rotator cuff tendinitis, epicondylitis, Achilles tendinopathy, trocanteritis, jumper's knee or plantar fasciitis. We recorded the epidemiological, clinical and treatment protocol, and these data were correlated with treatment outcome.

RESULTS

Clinical improvement was achieved in 45.9 % of these patients. We discovered that laterality different to the dominant limb (p < 0.0001) and repeated shock wave treatments (p = 0.004) are prognostic factors in an unsuccessful therapy, while being male (p = 0.015) and a high body mass index (p = 0.004) are factors for success. We found no differences in relation to age, diet, blood type, work or sport activity, presence of co-morbidities, drugs, type of tendinopathy, density of energy delivered and other physiotherapy treatment. Knowledge of these prognostic factors may lead to improved insight for physicians and physiotherapists to predict the extent of the recovery and adjust rehabilitation and patient expectations accordingly.

hERG1 channels drive tumour malignancy and may serve as prognostic factor in pancreatic ductal adenocarcinoma

Background:

hERG1 channels are aberrantly expressed in human cancers. The expression, functional role and clinical significance of hERG1 channels in pancreatic ductal adenocarcinoma (PDAC) is lacking.

Methods:

hERG1 expression was tested in PDAC primary samples assembled as tissue microarray by immunohistochemistry using an anti-hERG1 monoclonal antibody (α-hERG1-MoAb). The functional role of hERG1 was studied in PDAC cell lines and primary cultures. ERG1 expression during PDAC progression was studied in Pdx-1-Cre,LSL-Kras^G12D/+,LSL-Trp53^R175H/+ transgenic (KPC) mice. ERG1 expression in vivo was determined by optical imaging using Alexa-680-labelled α-hERG1-MoAb.

Results:

(i) hERG1 was expressed at high levels in 59% of primary PDAC; (ii) hERG1 blockade decreased PDAC cell growth and migration; (iii) hERG1 was physically and functionally linked to the Epidermal Growth Factor-Receptor pathway; (iv) in transgenic mice, ERG1 was expressed in PanIN lesions, reaching high expression levels in PDAC; (v) PDAC patients whose primary tumour showed high hERG1 expression had a worse prognosis; (vi) the α-hERG1-MoAb could detect PDAC in vivo.

Conclusions:

hERG1 regulates PDAC malignancy and its expression, once validated in a larger cohort also comprising of late-stage, non-surgically resected cases, may be exploited for diagnostic and prognostic purposes in PDAC either ex vivo or in vivo.

A decade with nucleic acid-based microbiological methods in safety control of foods

In the last decade, nucleic acid-based methods gradually started to replace or complement the culture-based methods and immunochemical assays in routine laboratories involved in food control. In particular, real-time polymerase chain reaction (PCR) was technically developed to the stage of good speed, sensitivity and reproducibility, at minimized risk of carry-over contamination. Basic advantages provided by nucleic acid-based methods are higher speed and added information, such as subspecies identification, information on the presence of genes important for virulence or antibiotic resistance. Nucleic acid-based methods are attractive also to detect important foodborne pathogens for which no classical counterparts are available, namely foodborne pathogenic viruses. This review briefly summarizes currently available or developing molecular technologies that may be candidates for involvement in microbiological molecular methods in the next decade. Potential of nonamplification as well as amplification methods is discussed, including fluorescent in situ hybridization, alternative PCR chemistries, alternative amplification technologies, digital PCR and nanotechnologies.

Efficacy of TachoSil® as a sutureless hemostatic patch to repair a perforation of the interventricular groove during endocardial radiofrequency ablation

Catheter ablation is a well-established therapeutic option for management of recurrent ventricular tachycardia in patients with ischemic/non-ischemic heart disease and procedural complications include a mortality rate of up to 3% and a risk of major complications up to 10%. Cardiac perforation following a catheter ablation is rare but serious complication and occurs in 1% of ventricular ablation procedures. The appropriate surgical repair may be challenging and need cardiopulmonary bypass support according to the location of the lesion and the hemodynamic status of the patient. We report the case of a free wall right ventricular perforation of the interventricular groove with cardiac tamponade following catheter ablation for recurrent ventricular tachycardia. Due to the proximity of the left anterior descending artery and the extreme fragility of tissues, the patient was treated successfully by a sutureless patch technique using a fibrin tissue-adhesive collagen fleece (TachoSil®). This technique is a safe and effective surgical option to repair a ventricular perforation especially when the ventricular tissues are fragile. It is simple and enable to realize surgical repair also if the localization of tear is difficult to access and without the need for cardiopulmonary bypass support if hemodynamic conditions are stable.

Experimental test of theories of the detection mechanism in a nanowire superconducting single photon detector

We report an experimental test of the photodetection mechanism in a nanowire superconducting single photon detector. Detector tomography allows us to explore the 0.8-8 eV energy range via multiphoton excitations. High accuracy results enable a detailed comparison of the experimental data with theories for the mechanism of photon detection. We show that the temperature dependence of the efficiency of the superconducting single photon detector is determined not by the critical current but by the current associated with vortex unbinding. We find that both quasiparticle diffusion and vortices play a role in the detection event.

Mapping the 3D distribution of CdSe nanocrystals in highly oriented and nanostructured hybrid P3HT-CdSe films grown by directional epitaxial crystallization

Highly oriented and nanostructured hybrid thin films made of regioregular poly(3-hexylthiophene) and colloidal CdSe nanocrystals are prepared by a zone melting method using epitaxial growth on 1,3,5-trichlorobenzene oriented crystals. The structure of the films has been analyzed by X-ray diffraction using synchrotron radiation, electron diffraction and 3D electron tomography to afford a multi-scale structural and morphological description of the highly structured hybrid films. A quantitative analysis of the reconstructed volumes based on electron tomography is used to establish a 3D map of the distribution of the CdSe nanocrystals in the bulk of the films. In particular, the influence of the P3HT-CdSe ratio on the 3D structure of the hybrid layers has been analyzed. In all cases, a bi-layer structure was observed. It is made of a first layer of pure oriented semi-crystalline P3HT grown epitaxially on the TCB substrate and a second P3HT layer containing CdSe nanocrystals uniformly distributed in the amorphous interlamellar zones of the polymer. The thickness of the P3HT layer containing CdSe nanoparticles increases gradually with increasing content of NCs in the films. A growth model is proposed to explain this original transversal organization of CdSe NCs in the oriented matrix of P3HT.

Electromechanical tuning of vertically-coupled photonic crystal nanobeams

We present the design, the fabrication and the characterization of a tunable one-dimensional (1D) photonic crystal cavity (PCC) etched on two vertically-coupled GaAs nanobeams. A novel fabrication method which prevents their adhesion under capillary forces is introduced. We discuss a design to increase the flexibility of the structure and we demonstrate a large reversible and controllable electromechanical wavelength tuning (> 15 nm) of the cavity modes.

Usefulness of ultrasounds in the management of breast phyllodes tumors

INTRODUCTION

Breast phyllodes tumors (PT) are uncommon fibroepithelial lesions having potential malignant features. These tumors have characteristic features, like pleomorphism, mitoses and overgrowth of the stroma with possible infiltrative margins. The clinical behaviour could be unpredictable, since the relatively high recurrence rate despite correct surgical strategy. Conventional diagnostic examinations show high sensitivity and specificity, but cannot demonstrate the differences between benign and malignant PT. MRI is not more effective.

PATIENTS AND METHODS

Sixteen patients affected by PT have been surgically treated at our Institution. All patients received mammography and ultrasonography (US) as preoperative diagnostic work-up.

RESULTS

in 13 patients, US was effective in preoperative diagnosis of PT. Mammography was uneffective in detecting breast lesions in 5 cases, while in 11 cases mammographic findings presented benign features, with a round opacity with moderate tissue density and well-defined wall.

CONCLUSION

US remains the most useful diagnostic test in detecting PT. However, there is no test effective in identifying malignat PT. In case of suspicion, fine needle biopsy should be performed.

Modified detector tomography technique applied to a superconducting multiphoton nanodetector

We present an experimental method to characterize multi-photon detectors with a small overall detection efficiency. We do this by separating the nonlinear action of the multiphoton detection event from linear losses in the detector. Such a characterization is a necessary step for quantum information protocols with single and multiphoton detectors and can provide quantitative information to understand the underlying physics of a given detector. This characterization is applied to a superconducting multiphoton nanodetector, consisting of an NbN nanowire with a bowtie-shaped subwavelength constriction. Depending on the bias current, this detector has regimes with single and multiphoton sensitivity. We present the first full experimental characterization of such a detector.

Public health impact of including two lineages of influenza B in a quadrivalent seasonal influenza vaccine

The annual trivalent influenza vaccine (TIV) includes viruses representing three influenza strains - one A/H1N1, one A/H3N2, and one B, although two antigenically distinct lineages of influenza B (Victoria and Yamagata) co-circulate annually in the United States. Predicting which lineage of influenza B will predominate during a season is challenging, and cross-protection by immunization against the other lineage is expected to be low. One proposed alternative is to produce a quadrivalent influenza vaccine (QIV) including an influenza B virus from each of the two circulating lineages. We estimated the additional public health benefit of QIV compared with TIV by calculating the expected impact on influenza-related health outcomes (illness, hospitalization, and death) over ten influenza seasons (1999/2000-2008/2009). We included data on the annual incidence of influenza-associated outcomes, virologic circulation, vaccine coverage, and vaccine effectiveness. We also considered annual vaccine production capacity, since available resources would have produced four vaccine viruses instead of three, potentially resulting in fewer doses of QIV. Use of QIV could have reduced annual cases (range: 2200-970,000), hospitalizations (range: 14-8200), and deaths (range: 1-485) in the US. During earlier seasons, adjusting production capacity for a fourth virus in QIV could have resulted in reduced overall influenza vaccine availability and net increases in influenza-associated outcomes. However, in recent seasons, the expected supply of QIV is likely to exceed the doses of vaccine actually administered. The potential net impact of QIV on influenza-associated outcomes is expected to vary between seasons, depending on annual variability in the incidence of influenza caused by the two influenza B lineages, vaccine coverage, and effectiveness. The additional protection provided by including a second lineage of influenza B could result in a modest reduction in influenza-associated outcomes.