Comparison of suspected and confirmed internal EVD-related infections: a prospective multi-centre U.K. observational study

Background

Diagnosis of internal external ventricular drain (EVD)-related infections (iERI) is an area of diagnostic difficulty. Empiric treatment is often initiated on clinical suspicion. There is limited guidance around antimicrobial management of confirmed versus suspected iERI.

Methods

Data on patients requiring EVD insertion were collected from 21 neurosurgical units in the United Kingdom from 2014 to 2015. Confirmed iERI was defined as clinical suspicion of infection with positive cerebrospinal fluid (CSF) culture and/or Gram stain. Cerebrospinal fluid, blood, and clinical parameters and antimicrobial management were compared between the 2 groups. Mortality and Modified Rankin Scores were compared at 30 days post-EVD insertion.

Results

Internal EVD-related infection was suspected after 46 of 495 EVD insertions (9.3%), more common after an emergency insertion. Twenty-six of 46 were confirmed iERIs, mostly due to Staphylococci (16 of 26). When confirmed and suspected infections were compared, there were no differences in CSF white cell counts or glucose concentrations, nor peripheral blood white cell counts or C-reactive protein concentrations. The incidence of fever, meningism, and seizures was also similar, although altered consciousness was more common in people with confirmed iERI. Broad-spectrum antimicrobial usage was prevalent in both groups with no difference in median duration of therapy (10 days [interquartile range {IQR}, 7–24.5] for confirmed cases and 9.5 days [IQR, 5.75–14] for suspected, P = 0.3). Despite comparable baseline characteristics, suspected iERI was associated with lower mortality and better neurological outcomes.

Conclusions

Suspected iERI could represent sterile inflammation or lower bacterial load leading to false-negative cultures. There is a need for improved microbiology diagnostics and biomarkers of bacterial infection to permit accurate discrimination and improve antimicrobial stewardship.

Internal carotid blood flow and cerebral hemispheric perfusion in patients with subarachnoid haemorrhage: a study of the quantix/ND™ system and CT perfusion technology

OBJECTIVE

To assess whether carotid blood flow measurements predict abnormalities in cerebral hemispheric perfusion.

DESIGN

The Quantix/NDTM system was used to measure carotid artery blood flow in nine patients with subarachnoid haemorrhage who underwent CT perfusion scanning.

RESULTS

No significant correlation was found between internal carotid artery blood flow and ipsilateral cerebral hemispheric perfusion (013, p>0.05) but there was a statistically significant correlation between total internal carotid and global cerebral perfusion (0.63, p<0.05).

CONCLUSIONS

This is the first report comparing the Quantix/NDTM system with CT perfusion. Our data do not show a statistically significant correlation between extracranial blood flow and cerebral hemispheric perfusion. This is in contrast to two previous studies where Quantix/NDTM measurements were compared with measurements of cerebral perfusion using the Xenon clearance technique.

Cerebral trypsinogen expression in human and rat cerebrospinal fluid

Trypsinogen was identified in cerebrospinal fluid (CSF), where it has not previously been reported and its activation state in experimental subarachnoid haemorrhage (SAH) in rats and in neurosurgical patients was determined. Trypsinogen activation peptide (TAP) release provided an equimolar marker for trypsinogen. Total TAP was significantly reduced to 26% of the baseline level (P<0.02) following experimental SAH in 15 rats but not in ten sham operated controls (P=0.3). TAP was also measured in patients with ruptured (n=11) and unruptured (n=9) aneurysms who underwent craniotomy to clip an aneurysm. Postoperatively there was a significant fall in TAP concentration (P<0.005) in both groups. Trypsinogen, as identified by CSF levels of TAP, is activated by SAH in rats and by craniotomy for aneurysmal clipping in patients.

High sensitivity mass spectrometric methods for obtaining intact molecular weights from gel-separated proteins

The molecular weight measurement of intact Escherichia coli proteins separated by isoelectric focusing-immobilized pH gradient (IEF-IPG) gels and analyzed by mass spectrometry is presented. Two methods are discussed: (i) electrospray ionization (ESI) mass spectrometry (MS) of extracted proteins, and (ii) matrix-assisted laser desorption/ionization (MALDI)-MS analysis directly from IEF-IPG gels. Both ESI and MALDI methods yield sub-picomole sensitivity and good mass measurement accuracy. The use of an array detector for ESI-MS was essential to discriminate against contaminating background ions and to selectively detect high mass protein ions. MALDI-MS offers high-throughput analysis of one- and potentially two-dimensional (2-D) gels. The "virtual 2-D" gel method with first-dimensional IEF separation and the second dimension as molecular mass determination by MS, is a particularly promising method for protein analysis due to its ultra high sensitivity and correspondence to classical 2-D gels. Further sensitivity enhancements for the MALDI-MS method are provided by post acceleration detection optimized for high mass time-of-flight analysis.

Rapid molecular mass and structural determination of plant cell wall-derived oligosaccharides using off-line high-performance anion-exchange chromatography/mass spectrometry

A method has been developed for the rapid molecular mass determination and structural elucidation of mixtures of oligosaccharides derived from plant cell walls. The oligosaccharides were fractionated using gel permeation chromatography and 'analytical' high-performance anion-exchange chromatography (HPAEC), neutralized, dried and the mixtures of eluent salt and oligosaccharides were per-O-acetylated directly. The derivatized oligosaccharides were isolated by dissolution in dichloromethane and the salts were removed by aqueous partitioning. The per-O-acetylated oligosaccharides were analysed using electrospray (ES) and matrix-assisted laser desorption/ionization time of flight mass spectrometry (MS). Exploiting the fact that acid-catalysed per-O-acetylation of oligosaccharides can be achieved even under the extremely salty conditions that are found in post-column neutralized HPAEC fractions, and combining this derivatization step with off-line ESMS, allow rapid screening for molecular mass and thus yield information on the composition of the various oligosaccharides in these complex mixtures. Subsequent per-O-methylation of the per-O-acetylated, salt-free fractions and collision-induced dissociation tandem mass spectrometric analysis was used for additional sequence and branching determination of the oligosaccharides.

Complications of varicose vein surgery

A retrospective review was carried out of patients who had undergone surgery for varicose veins over an 8 year period between 1985 and 1993. We wished to determine the incidence of various complications so that the risks of surgery could be openly discussed with patients. A total of 973 limbs were operated upon in 599 patients (413 F, 186 M; mean age 49 years). All patients were under the care of a single consultant vascular surgeon who was present at 92% of operations and all patients were reviewed postoperatively. There was no perioperative mortality. Wound complications (haematoma, cellulitis or abscess) occurred in 2.8% of limbs and minor neurological disturbance (numbness or tingling) in 6.6%. Leakage of lymph from the groin occurred in five patients, all of whom had undergone exploration for groin recurrence. Major complications included three cases of deep venous thrombosis (0.5%), one pulmonary embolus, and one foot-drop. There was one major vascular injury, the common femoral vein being damaged in a patient having a third operation on the groin for persistent recurrence. Vein patch repair was performed and patency was maintained. The overall incidence of major complications was 0.8%. Minor complications occurred in 17% of patients. It is unlikely that major complications can be eliminated. In this retrospective review there will be some under-reporting, but we are confident that this is restricted to minor complications.

Fragmentation of complex carbohydrates following ionization by matrix-assisted laser desorption with an instrument fitted with time-lag focusing

Matrix-assisted laser desorption/ionization time-of-flight spectra of carbohydrates recorded with an instrument using time-lag focusing (delayed extraction) were found to exhibit fragment ions, whereas, in the non time-lag-focusing mode, fragment ions were not observed. Fragment ions consisted both of glycosidic and cross-ring cleavage products whose absolute, but not relative abundance increased with the delay time and indicated that they were formed within the ion source. Only the glycosidic cleavage ions were present in post-source decay spectra and their abundance was inversely correlated with the delay time. The results indicated that the cross-ring cleavages were predominately the products of fast reactions whereas the glycosidic cleavages occurred over a longer time frame.

Postoperative subdural empyema caused by Propionibacterium acnes--a report of two cases

Two patients with postoperative subdural empyema following burr hole evacuation of chronic subdural haematoma are reported, both caused by Propionibacterium acnes. The need to consider this diagnosis in patients developing recurrent symptoms after surgical drainage of chronic subdural haematoma is emphasized.

Comparison of fragmentation modes for the structural determination of complex oligosaccharides ionized by matrix-assisted laser desorption/ionization mass spectrometry

Fragment ions from underivatized N-linked oligosaccharides ionized by matrix-assisted laser desorption/ionization mass spectrometry were obtained by spontaneous fragmentation on a magnetic sector mass spectrometer, by post-source decay (PSD) on a reflectron time-of-flight (TOF) instrument and by collision-induced dissociation on a magnetic sector instrument fitted with an orthagonal-TOF analyser. Spontaneous fragmentation on the magnetic sector instrument produced ions mainly by glycosidic cleavage together with two abundant ions formed by cross-ring cleavage of the reducing-terminal residue. The PSD spectra were similar, the majority of ions being formed by glycosidic cleavage. Internal fragment ions were abundant. High-energy collision-induced dissociation spectra recorded with the orthagonal-TOF analyser, differed considerably from the other types of spectra, particularly in the appearance of major fragment ions produced by cross-ring cleavages of most of the constituent monosaccharide residues. These ions allowed much sequence and branching information to be obtained from the oligosaccharide.