Cheiroarthropathy and tendinopathy in diabetes

Joint problems commonly occur in people with diabetes. Cheiroarthropathy affects the hands and results in painless limited finger joint extension, appearing to be associated with longer diabetes duration and the presence of microvascular complications. The prevalence of cheiroarthropathy seems to be falling, perhaps as a result of improvements in glycaemic management. Non-enzymatic glycation of collagen results in abnormally crosslinked protein resistant to degradation with subsequent increased build-up of collagen in joints. The management of cheiroarthropathy is predominantly conservative, with occupational and hand therapy at the forefront. Tendinopathy is more common in people with diabetes than those without, and is associated with obesity and insulin resistance. As with cheiroarthropathy, the exact causative mechanism of tendinopathy in diabetes is not known, but may be linked to inflammation, apoptosis and increased vascularity of affected tendons, driven by hyperinsulinaemia. Local fat pads have also been suggested to play a role in the pathogenesis of tendinopathy.

Surgical outcomes for chronic exertional compartment syndrome following improved diagnostic criteria

INTRODUCTION

Chronic exertional compartment syndrome (CECS) presents with pain during exercise, most commonly within the anterior compartment of the lower limb. A diagnosis is classically made from a typical history and the measurement of intramuscular compartmental pressure (IMCP) testing. Improved, more specific diagnostic criteria for IMCP testing allow clinicians to now be more certain of a diagnosis of CECS. Outcomes following surgical treatment in patients diagnosed using these more robust criteria are unknown.

METHODS

All patients undergoing fasciectomy for anterior compartment CECS at a single rehabilitation unit were identified between 2014 and 2017. Wilcoxen signed-rank test was used to compare military fitness grading and paired t-test was used to compare Foot and Ankle Ability Measure, FAAM Sport Specific and Exercise-Induced LimbPain-G outcome measures, presurgery and postsurgery.

RESULTS

There was a significant difference in fitness grading between presurgical and postsurgical intervention (Z = -2.68, p < 0.01) with 46 % of patients improving their occupational medical grading. All secondary measures of outcome, looking at clinical symptoms, also improved.

CONCLUSION

Almost half of the patients undergoing fasciectomy, following diagnosis using more specific criteria, will have an improvement in occupational medical grading. These outcomes represent the lower end of those reported in civilian populations. This is likely a result of a combination of factors, most notably the different diagnostic criteria followed and the more stringent criteria applied to military occupational grading, compared with civilian practice. Further work is now required to evaluate the impact of differing rehabilitation regimes on postoperative patients identified through this more specific diagnostic testing.

Barefoot plantar pressure measurement in Chronic Exertional Compartment Syndrome

BACKGROUND

Patients with Chronic Exertional Compartment Syndrome (CECS) have exercise-limiting pain that subsides at rest. Diagnosis is confirmed by intramuscular compartment pressure (IMCP) measurement. Accompanying CECS, subjective changes to gait (foot slap) are frequently reported by patients. This has not previously been investigated. The aim of this study was to investigate differences in barefoot plantar pressure (BFPP) between CECS cases and asymptomatic controls prior to the onset of painful symptoms.

METHODS

40 male military volunteers, 20 with symptoms of CECS and 20 asymptomatic controls were studied. Alternative diagnoses were excluded with rigorous inclusion criteria, magnetic resonance imaging and dynamic IMCP measurement. BFPP was measured during walking and marching. Data were analysed for: Stance Time (ST); foot progression angle (FPA); centre of force; plantarflexion rate after heel strike (IFFC-time); the distribution of pressure under the heel; and, the ratio between inner and outer metatarsal loading. Correlation coefficients of each variable with speed and leg length were calculated followed by ANCOVA or t-test. Receiver operating characteristic (ROC) curves were constructed for IFFC-time.

RESULTS

Caseshad shorter ST and IFFC-times than controls. FPA was inversely related to walking speed (WS) in controls only. The area under the ROC curve for IFFC-time ranged from 0.746 (95%CI: 0.636-0.87) to 0.773 (95%CI: 0.671-0.875) representing 'fair predictive validity'.

CONCLUSION

Patients with CECS have an increased speed of ankle plantarflexion after heel strike that precedes the onset of painful symptoms likely resulting from a mechanical disadvantage of Tibialis Anterior. These findings provide further insight into the pathophysiology of CECS and support further investigation of this non-invasive diagnostic. The predictive value of IFFC-time in the diagnosis of CECS is comparable to post-exercise IMCP but falls short of dynamic IMCP measured during painful symptoms.

Identifying environmental reservoirs of Clostridium difficile with a scent detection dog: preliminary evaluation

BACKGROUND AND AIM

Prompted by an article describing a dog trained to detect Clostridium difficile in patients, our institution evaluated a dog's ability to detect C. difficile scent from equipment and surfaces to assist in strategic deployment of adjunctive cleaning measures.

METHODS

An expert in drug and explosives scent dog handling trained a canine to identify odours from pure cultures and/or faecal specimens positive for C. difficile. Methods used to assess explosive and drug detection dogs were adapted and included evaluation of (i) odour recognition, using containers positive and negative for the scent of C. difficile, and of (ii) search capability, on a simulation ward with hidden scents. After demonstration that the canine could accurately and reliably detect the scent of C. difficile, formal assessments of all clinical areas began.

FINDINGS

Odour recognition (N = 75 containers) had a sensitivity of 100% and specificity of 97%. Search capability was 80% sensitive and 92.9% specific after removal of results from one room where dog and trainer fatigue influenced performance. Both odour recognition and search capability had an overall sensitivity of 92.3% and specificity of 95.4%. The clinical unit sweeps over a period of five months revealed a sensitivity of 100% in alerting on positive quality control hides. These clinical unit sweeps also resulted in 83 alerts during 49 sweep days.

CONCLUSION

A dog can be trained to accurately and reliably detect C. difficile odour from environmental sources to guide the best deployment of adjunctive cleaning measures and can be successfully integrated into a quality infection control programme.

Evaluation of two chromogenic media for the isolation and identification of urinary tract pathogens

Chromogenic media (CM) are available for urine specimens (US) to enable rapid identification of common urinary tract pathogens (UTP). Two CM, chromID™ CPS (CPS4) agar (bioMérieux, St. Laurent, QC) and UriSelect™ 4 (URS4) agar (Bio-Rad, Montreal, QC), were compared to the standard media (SM) for the isolation and identification of UTP. Over a 10-day period, US were inoculated to CPS4, URS4, and SM (BAP and MAC). CM interpretation was done according to the product inserts by one person blinded to the results of SM. SM were read by experienced technologists according to protocol and isolates were identified using BD Phoenix™. The results were grouped into significant (SG), mixed (MG), and no significant growth (NSG). A total of 903 US were studied. SM identified 239 SG, 112 MG, and 552 NSG cultures. The most common pathogens were Escherichia coli (38 %) and Enterococcus spp. (11 %). Comparing CM to SM, the exact agreement was 89.3 and 89.5 % for URS4 and CPS4, respectively. When grouped by clinical significance, agreement with SM was 93.0 and 93.1 % for URS4 and CPS4, respectively. CM were equivalent with respect to processing time. Advantages include decreased need for automated identification of certain species, particularly E. coli. In terms of workflow, CM enables same-day identification for almost 50 % of significant UTP. Overall, both CM compared well to SM and allowed for rapid preliminary identification of many UTP.

Nasal photodisinfection and chlorhexidine wipes decrease surgical site infections: a historical control study and propensity analysis

BACKGROUND

Pre-operative decolonization therapy (DcTx) using chlorhexidine (CHG) body washes and/or intranasal mupirocin can reduce surgical site infections (SSIs), but compliance is often suboptimal.

AIM

To assess the effectiveness of immediate DcTx using a novel approach of intranasal antimicrobial photodisinfection therapy (PDT) combined with CHG body wipes for the reduction of SSIs.

METHODS

Between 1(st) September 2011 and 31(st) August 2012, 3068 elective cardiac, orthopaedic, spinal, vascular, thoracic and neurosurgical patients were treated with CHG in the 24h preceding surgery, and received intranasal PDT in the pre-operative area. SSI surveillance methodology remained unchanged from previous years and patients were followed for one year. Results were compared with those for a four-year historical control group of 12,387 patients as well as those for a concurrent control group of 206 untreated patients.

FINDINGS

A significant reduction in the SSI rate was observed between treated patients and the historical control group [1.6% vs 2.7%, P = 0.0004, odds ratio (OR) 1.73, 95% confidence interval (CI) 1.2815-2.3453]. This significant reduction was maintained on intent-to-treat analysis (P = 0.021, OR 1.37, 95% CI 1.0476−1.7854) [corrected]. Overall compliance with DcTx was 94%. A 1:4 propensity score analysis of matched treated and untreated patients demonstrated that DcTx reduced the risk of SSIs significantly (P = 0.00026, z = 3.65).

CONCLUSION

The combination of CHG wipes and PDT immediately before surgery reduced SSIs, achieved excellent compliance, and was easily integrated into the pre-operative routine.

Carbapenem-resistant Gram-negative bacilli in Canada 2009-10: results from the Canadian Nosocomial Infection Surveillance Program (CNISP)

OBJECTIVES

To investigate the occurrence and molecular mechanisms associated with carbapenemases in carbapenem-resistant Gram-negative isolates from Canadian cases.

METHODS

Twenty hospital sites across Canada submitted isolates for a 1 year period starting 1 September 2009. All Enterobacteriaceae with MICs ≥ 2 mg/L and Acinetobacter baumannii and Pseudomonas aeruginosa with MICs ≥ 16 mg/L of carbapenems were submitted to the National Microbiology Laboratory (NML) where carbapenem MICs were confirmed by Etest and isolates were characterized by PCR for carbapenemase genes, antimicrobial susceptibilities, PFGE and plasmid isolation.

RESULTS

A total of 444 isolates (298 P. aeruginosa, 134 Enterobacteriaceae and 12 A. baumannii) were submitted to the NML of which 274 (61.7%; 206 P. aeruginosa, 59 Enterobacteriaceae and 9 A. baumannii) met the inclusion criteria as determined by Etest. Carbapenemase genes were identified in 30 isolates: bla(GES-5) (n = 3; P. aeruginosa), bla(KPC-3) (n = 7; Enterobacteriaceae), bla(NDM-1) (n = 2; Enterobacteriaceae), bla(VIM-2) and bla(VIM-4) (n = 8; P. aeruginosa) bla(SME-2) (n = 1; Enterobacteriaceae) and bla(OXA-23) (n = m9; A. baumannii). PFGE identified a cluster in each of Enterobacteriaceae, P. aeruginosa and A. baumannii corresponding to isolates harbouring carbapenemase genes. Three KPC plasmid patterns (IncN and FllA) were identified where indistinguishable plasmid patterns were identified in unrelated clinical isolates.

CONCLUSIONS

Carbapenemases were rare at the time of this study. Dissemination of carbapenemases was due to both dominant clones and common plasmid backbones.

Regulation of 11beta-hydroxysteroid dehydrogenase enzymes by dietary sodium in the rat

11Beta-hydroxysterold dehydrogenase enzymes (11beta-HSD1, 11beta-HSD2) regulate access of adrenocorticosteroids to receptors. 11Beta-HSD2 is a dehydrogenase that protects mineralocorticoid receptors from circulating glucocorticoid hormones, 11beta-HSD1 is a reductase that promotes formation of active hormone in glucocorticoid-sensitive tissues. Here we investigate whether low or high sodium diets affect 11beta-HSD enzyme activities and mRNA expression in liver and kidney tissues. 11Beta-HSD activity was measured as dehydrogenation of 3H-corticosterone by microsomes in the presence of NAD or NADP. In situ hybridisation techniques were used to assess expression of 11beta-HSD1 mRNA (liver and kidney) and 11beta-HSD2 mRNA (kidney). Dietary sodium did not affect 11beta-HSD2 mRNA expression in collecting tubules of the medulla: 11beta-HSD1 mRNA in proximal tubules of the inner cortex/outer medulla was lower after a high sodium diet. 11Beta-HSD1 mRNA in liver was unaffected by treatment. Renal enzyme activity with NAD (11beta-HSD2 cofactor) was lower following a high sodium diet (P < 0.05). In the presence of NADP (11beta-HSD1 co-factor), neither renal nor hepatic activities were affected. Dietary sodium restriction appears to increase 11beta-HSD activity by a non-genomic mechanism; this should enhance aldosterone specificity for mineralocorticoid receptors. 11Beta-HSD1 mRNA expression varies independent of enzyme activity and is not clearly related to altered glucocorticoid activity.

The impact of physician order entry on nursing roles

This study examines the impact of physician order entry (POE) on nurses perceptions of work, quality of care, and nurse/physician communication. Four hospitals that have implemented a computerized order-entry system with POE were compared with four similar hospitals using the same computerized system with clerk order entry only. Three factors were extracted from the 29 item survey using principal component extraction with varimax rotation that accounted for 16.5%, 12.4% and 8.7% of the variance respectively. Three scales were constructed from these factors measuring perceptions of impact of the information system on the quality of care, job, control, and nurse/physician communication. Nurses working in the POE environment rated their computer system as having greater impact on the quality of care and lower ratings of perceived control than those working in non-POE environments. No differences were found between nurses working in POE environments and those working in POE in terms of their ratings of frequency of contact and ease of access to physicians.

Successful implementation of an integrated physician order entry application: a systems perspective

Direct physician order entry is required for effective implementation of an integrated electronic medical record. This effort involves multi-level changes in the whole system of care, from physicians attitudes to interdepartmental relations. This study reports the findings of a follow-up study that quantified dimensions associated with successful implementation identified in a previous study. Results identified several implementation strategies associated with success. These include an interdisciplinary implementation group, involvement of large numbers of regular staff, early and intensive training and support, and 24 hour available assistance as important to success. In addition, attitudes of physicians and their level of involvement were found to be associated with success.

Dimensions associated with successful implementation of a hospital based integrated order entry system

Implementation of an integrated electronic medical record requires direct physician order entry. This application involves multi-level changes in the whole system of care, from physicians attitudes to interdepartmental relations. This study reports the results of the first round of a modified Delphi, where a diverse group of individuals were asked to identify the most important facilitating and impeding factors associated with implementation of an order entry application. From a Q-sort of their responses, we identified 20 systemic, behavioral, and attitudinal dimensions perceived to be causal factors in successful implementation. We also explored how these dimensions may influence success by comparing successful with unsuccessful hospitals in terms of the frequency with which these dimensions were differently mentioned by respondents. We found that although available functionality was the most commonly mentioned factor by all participants, hardware availability, physician involvement, administration support, and medical administration involvement were more often mentioned by successful hospitals than by less successful hospitals. These results suggest that these factors were not present in the less successful hospitals. We also found that the frequency of responses within each category varied depending on the institutional role of the individuals responding. Those involved in support tended to see organizational variables as more important than those in clinical positions, whereas clinicians viewed administrative support and involvement of the chief as more important. These findings support the notion that the changes involved in instituting a physician order entry system are system wide and involve individual as well as organizational factors.

Comparison of sleep staging by polygraph and color density spectral array

Color Density Spectral Array (CDSA) is a new technique that uses the fast Fourier transform and color graphics to provide a display of frequency, power, and time. CDSA sleep records provide an overview of sleep architecture as well as quantitative+ EEG data. To validate this technique, overnight sleep records from five patients were independently staged from polygraph recordings and overnight CDSA records. Observed agreement between the two techniques was 85-92% for approximately 1,100 epochs per night.

Representation of sleep stages by color density spectral array

Multiple-channel color density spectral array (CDSA) was used to graphically represent sleep stages. This technique uses color coding of Fast Fourier Transforms to provide a compact display of frequency, power, and real time. Distinct CDSA patterns correlate to the awake, non-REM, and REM sleep states. The graphic compression of sleep data could considerably shorten the time required to stage overnight sleep recordings.