Prescriptions of homeopathic remedies at the expense of the German statutory health insurance from 1985 to 2021: scientific, legal and pharmacoeconomic analysis

The prescription of homeopathic remedies at the expense of the statutory health insurance (SHI) system in Germany has been criticized for years due to a lack of evidence. Now, on the planned abolition of the reimbursement of homeopathic medicines in Germany, the debate on this topic has been reignited. The aim of this paper is to show the costs and their development over time incurred by homeopathic remedies in the healthcare system from 1985 to 2021. For this purpose, 15 selected homeopathic medicines were chosen from the drug prescription report (Arzneiverordnungsreport) and analyzed with regard to their development of DDD (Defined Daily Dose) using data from the Wissenschaftliches Institut der Ortskrankenkassen (WidO, Scientific Institute of the General Local Health Insurance Funds) and compared with their respective rational pharmacological alternatives. The price comparison was based on the DDD costs and the pharmacy retail price of the smallest packaging in each case. The clinical study situation for the preparations was also analyzed. For this purpose, the clinical studies provided by the manufacturer and those on PubMed were divided into evidence levels and analyzed. In addition, the presentation of homeopathic remedies on company websites, in online pharmacies, in specialist information and package leaflets was analyzed with regard to side effects, interactions, indication, and information on the alleged effect/proof of efficacy. In many media, information on homeopathic medicines remained incomplete, and non-compliance with the Therapeutic Product Advertising Act (Heilmittelwerbegesetz) was noted. Naming of the products if often very suggestive, too. Manufacturers' claims of efficacy go far beyond what can be considered proven in terms of evidence-based medicine and the quality of most clinical studies is poor. Homeopathic remedies are on average significantly more expensive than their rational pharmacological alternatives. Furthermore, DDD costs have continued to rise over the years analyzed. In aggregate, from a pharmacoeconomic, legal, and scientific perspective, abolition of reimbursement of homeopathic medicines in Germany at the expense of the SHI system is well justified.

Pacing mode survival in patients with single chamber atrial pacemaker for sinus node dysfunction

BACKGROUND

Single chamber atrial pacemaker should be sufficient for patients with sinus node dysfunction (SND) with normal atrioventricular (AV) conduction. However, most patients undergo dual chamber pacemaker implantation because of concern of new onset AV block. The annual incidence of new AV block has been reported from 0.6 to 4.4 % in various studies.

OBJECTIVES

Our aim is to assess mode survival in sinus node dysfunction with normal AV conduction patients implanted with AAIR.

METHODS

Patients who underwent single chamber atrial pacemaker implantation for SND with normal AV conduction between January 2014 and December 2021 were followed up for pacemaker device change, new onset AV block, bundle branch block, atrial fibrillation (AF), lead complications, reoperation and mortality rate.

RESULTS

A total of 113 patients underwent single chamber atrial pacemaker implantation for SND during the study period. Mean age was 55.6 ± 12.7 years. During a mean follow up of 48.7 ± 24.9 months, none of the patients required pacemaker device change to VVIR/DDDR. Nine patients underwent reoperation, 5 for lead dislodgment, 1 for high threshold, 1 for pocket site erosion and 3 for pulse generator change. None developed AV block or AF with slow ventricular rate. Only 4 patients developed AF (3 paroxysmal,1 permanent). There were 3 deaths during follow up and none were sudden deaths.

CONCLUSION

Single chamber atrial pacing is an acceptable mode of pacing in patients with SND in developing countries. Development of AV conduction abnormalities is rare in this relatively younger population.

Assessment of Antimicrobial Consumption in Multi-Field Hospitals with Pediatric Inpatients: Conventional vs. Novel Pediatric-Adjusted Methodologies

BACKGROUND

the objective of this study was to propose a methodology for the assessment of antimicrobial consumption (AMC) in pediatric inpatients and to estimate variances in consumption levels in multi-field hospitals with pediatric inpatients, calculated by means of the pediatric-adjusted methodology vs. the conventional methodology.

METHODS

the pediatric-adjusted methodology based on the conventional ATC/DDD method and children's DDDs (cDDD) for antimicrobials were proposed and validated in a series of probabilistic sensitivity analyses of real clinical data extracted from the receipt notes of three multi-field hospitals. Differences in AMC in multi-field hospitals with pediatric inpatients, calculated by means of the proposed methodology vs. the conventional methodology, were assessed for a virtual cohort of inpatients, with the pediatric share increasing by 1%.

RESULTS

in children ≤12 years old, assessment by the standard methodology resulted in a 59% underestimation of AMC from the levels based on prescribed doses, vs. a 25% underestimation for the proposed methodology. In a mixed-age virtual population of inpatients, the underestimation of consumption levels rose to 321% for the ATC/DDD methodology compared to the proposed one.

CONCLUSIONS

the proposed methodology demonstrated a higher accuracy of AMC estimates compared to the conventional one and can be considered for the quantification of antimicrobial utilization in pediatric institutions and multi-field hospitals with a substantial share of pediatric inpatients.

Review of DDT, DDE, DDD, DDMU and DDMS Toxicity Data for Organisms Used in Estuarine and Marine Sediment Toxicity Tests

The open literature was searched for laboratory toxicity data for marine/estuarine organisms exposed to dichlorodiphenyltrichloroethane (DDT) and its degradation products of dichlorodiphenyldichloroethylene (DDE), dichlorodiphenyldichloroethane (DDD), dichlorodiphenylchloroethylene (DDMU), and dichlorodiphenylchloroethane (DDMS). The goal of the review was to determine water-column toxicity values that could be used for porewater-based assessment of sediment toxicity. Data for individual compounds (and isomers thereof) in this group were very limited; most available data were for mixtures of multiple compounds, some defined and others undefined. Further, the majority of relevant studies involved exposure to spiked or field-contaminated sediment (rather than waterborne exposure), which requires inferring concentration in porewater from bulk sediment. Comparing data on the basis of effect concentrations for water or inferred concentration in sediment pore water, the lower reported effect concentrations were in the range of 0.05 to 0.1 µg/L, generally in studies of longer duration and/or evaluating sub-lethal effects. Because field exposures are generally to mixtures of these compounds in varied proportions, additional data on chemical-specific toxicity would aid in pore-water based toxicity assessment for marine/estuarine sediments contaminated with DDT-related chemicals.

Impact of the COVID-19 Pandemic on Ambulatory Care Antibiotic Use in Hungary: A Population-Based Observational Study

The COVID-19 pandemic and related restrictions have potentially impacted the use of antibiotics. We aimed to analyze the use of systemic antibiotics (J01) in ambulatory care in Hungary during two pandemic years, to compare it with pre-COVID levels (January 2015-December 2019), and to describe trends based on monthly utilization. Our main findings were that during the studied COVID-19 pandemic period, compared to the pre-COVID level, an impressive 23.22% decrease in the use of systemic antibiotics was detected in ambulatory care. A significant reduction was shown in the use of several antibacterial subgroups, such as beta-lactam antibacterials, penicillins (J01C, -26.3%), and quinolones (J01M, -36.5%). The trends of antibiotic use moved in parallel with the introduction or revoking of restriction measures with a nadir in May 2020, which corresponded to a 55.46% decrease in use compared to the previous (pre-COVID) year's monthly means. In general, the systemic antibiotic use (J01) was lower compared to the pre-COVID periods' monthly means in almost every studied pandemic month, except for three months from September to November in 2021. The seasonal variation of antibiotic use also diminished. Active agent level analysis revealed an excessive use of azithromycin, even after evidence of ineffectiveness for COVID-19 emerged.

Changes in the Use of Antibiotics for Methicillin-Resistant Staphylococcus aureus Bloodstream Infections in Children: A 5-Year Retrospective, Single Center Study

Monitoring antibiotic use in the pediatric population is a challenge, especially when determining a relationship between specific pathogens, infections, and antibiotic use. We retrospectively analyzed the consumption of anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs from 2017 to 2021 at Istituto Giannina Gaslini by means of defined daily dose (DDD) adopted for adults by World Health Organization. We observed a statistically significant increase in the use of daptomycin and ceftaroline, combined with a decrease in the use of vancomycin. In the same period, we observed an increase in the proportion of bloodstream infections due to MRSA with vancomycin minimally inhibitory concentration (MIC mg/L) = 1, that represented the 100% of cases in 2021. This aspect was combined with the observation that in the 59% of cases, where vancomycin plasma concentrations were evaluated, it was not possible to achieve a ratio of the 24-h area under the concentration-time curve and MIC (AUC_0-24/MIC) of vancomycin ≥ 400 mg/L. This study confirms that DDD can be used in pediatrics to monitor antibiotic consumption in relationship with infections epidemiology. Moreover, it describes the presence of vancomycin MIC creep for MRSA also in pediatrics and the difficulties in obtaining effective vancomycin plasma concentrations in children.

A Pathway for the Diagnosis and Treatment of Lumbar Spinal Stenosis

Lumbar spinal stenosis is a prevalent condition with varied presentation. Most common in older populations, symptoms typically include back, buttock, and posterior thigh pain. Diagnosis is typically based on physical examination and clinical history, but confirmed on imaging studies. Nonsurgical management includes nonsteroidal anti-inflammatories, physical therapy, and epidural injections. If nonoperative management fails or patient presentation involves worsening symptoms, surgical intervention, most commonly in the form of a laminectomy, may be indicated. Recent literature has demonstrated improved pain and functional outcomes with surgery compared with conservative treatment in the middle to long term.

Clearly weighing the evidence in read-across can improve assessments of data-poor chemicals

This paper provides a systematic weight-of-evidence method for read-across analyses of data-poor chemicals. The read-across technique extrapolates toxicity from analogous chemicals for which suitable test data are available to a target chemical. To determine that a candidate analogue is the 'best' and is sufficiently similar, the evidence for similarity of each candidate analogue to the target is weighed. We present a systematic weight of evidence method that provides transparency and imposes a consistent and rigorous inferential process. The method assembles relevant information concerning structure, physicochemical attributes, toxicokinetics, and toxicodynamics of the target and analogues. The information is then organized by evidence types and subtypes and weighted in terms of properties: relevance, strength, and reliability into weight levels, expressed as symbols. After evidence types are weighted, the bodies of evidence are weighted for collective properties: number, diversity, and coherence. Finally, the weights for the types and bodies of evidence are weighed for each analogue, and, if the overall weight of evidence is sufficient for one or more analogues, the analogue with the greatest weight is used to estimate the endpoint effect. We illustrate this WoE approach with a read-across analysis for screening the organochlorine contaminant, p,p'-dichlorodiphenyldichloroethane (DDD), for noncancer oral toxicity.

The Impact of the SARS-Cov2 Pandemic on a Persuasive Educational Antimicrobial Stewardship Program in a University Hospital in Southern Italy: A Pre-Post Study

Objectives: We evaluated the effect of the pandemic on the disruption of a persuasive educational antimicrobial stewardship program (ASP) conducted in a university hospital in southern Italy. Methods: In March 2020, the ASP, which began in January 2017 and was carried out at different times in 10 wards, was stopped due to the COVID-19 pandemic. We conducted an observational study with interrupted time series analysis to compare the antibiotic consumption and costs, average length of hospital stay and in-hospital mortality between 12 months before and 9 months after the interruption. Results: Four medical, four surgical wards and two ICUs were included in the study, for a total of 35,921 patient days. Among the medical wards we observed after the interruption a significant increase in fluoroquinolone use, with a change in trend (CT) of 0.996, p = 0.027. In the surgical wards, we observed a significant increase in the overall consumption, with a change in level (CL) of 24.4, p = 0.005, and in the use of third and fourth generation cephalosporins (CL 4.7, p = 0.003). In two ICUs, we observed a significant increase in piperacillin/tazobactam and fluoroquinolone consumption (CT 9.28, p = 0.019, and 2.4, p = 0.047). In the wards with a duration of ASP less than 30 months, we observed a significant increase in antibiotic consumption in the use of piperacillin/tazobactam and fluoroquinolones (CT 12.9, p = 0.022: 4.12, p = 0.029; 1.004, p = 0.011). Conclusions: The interruption of ASP during COVID-19 led to an increase in the consumption of broad-spectrum antibiotics, particularly in surgical wards and in those with a duration of ASP less than 30 months.

Antimicrobial consumption in intensive care unit patients at level 1 trauma centre in India

PURPOSE

Increase in the antimicrobial resistance causes a concern globally. To mitigate the rapidly rising antimicrobial resistance in the health system globally antimicrobial stewardship programs (AMSP) have been advocated. Therefore, we aim to measure aggregate antibiotic consumption by both Defined Daily Dosage (DDD) and Days of Therapy (DOT) methods.

METHODS

As a part of Indian Council of Medical Research initiative to develop local AMSP, this prospective study of six months was conducted at a level -1 Trauma Centre of AIIMS, New Delhi. In this, we have included all the patients of polytrauma and neurosurgical Intensive care units between April to October 2019. Consumption of antibiotics data were collected manually daily by infection control practitioners. Data were presented as Days of Therapy (DOT) and Defined Daily Dose (DDD).

RESULTS

During the six months of study, antimicrobial consumption of ICU was compared with empirical therapy v/s culture-based therapy. Overall average antimicrobial consumption for the six months for both empirical therapy and culture-based therapy DDD/1000 patient days was 531.8 and 460.7 whereas DOT/1000 patient days 489.9 and 426.04 respectively.

CONCLUSIONS

Antimicrobial Stewardship activities aim to ensure judicious consumption of antimicrobials. Such data will be of value in establishing, evaluating and monitoring the function of the AMSP in the healthcare settings.

Drug Policies Skyline during COVID-19 Pandemic

The COVID-19 pandemic has produced an extraordinary care setting where physicians played, and continue to play, a critical role in containing viral spread and treating affected patients. Frontline workers have been receiving day-to-day new information about therapeutic advances. The purpose of the study is to analyse COVID-19 drug consumption trends in both acute and intensive care settings comparing Defined Daily Doses and the release of scientific clinical data from January to December 2020.

Fecal Excretion of Mycobacterium leprae, Burkina Faso

Mycobacterium leprae was detected by optical microscopy, fluorescent in situ hybridization, and molecular detection in feces collected for the diagnosis of Entamoeba coli enteritis in a leprosy patient in Burkina Faso. This observation raises questions about the role of fecal excretion of M. leprae in the natural history and diagnosis of leprosy.

Elemental mapping of labelled biological specimens at intermediate energy loss in an energy-filtered TEM acquired using a direct detection device

The technique of colour EM that was recently developed enabled localisation of specific macromolecules/proteins of interest by the targeted deposition of diaminobenzidine (DAB) conjugated to lanthanide chelates. By acquiring lanthanide elemental maps by energy‐filtered transmission electron microscopy (EFTEM) and overlaying them in pseudo‐colour over the conventional greyscale TEM image, a colour EM image is generated. This provides a powerful tool for visualising subcellular component/s, by the ability to clearly distinguish them from the general staining of the endogenous cellular material. Previously, the lanthanide elemental maps were acquired at the high‐loss M_4,5 edge (excitation of 3d electrons), where the characteristic signal is extremely low and required considerably long exposures. In this paper, we explore the possibility of acquiring the elemental maps of lanthanides at their N_4,5 edge (excitation of 4d electrons), which occurring at a much lower energy‐loss regime, thereby contains significantly greater total characteristic signal owing to the higher inelastic scattering cross‐sections at the N_4,5 edge. Acquiring EFTEM lanthanide elemental maps at the N_4,5 edge instead of the M_4,5 edge, provides ∼4× increase in signal‐to‐noise and ∼2× increase in resolution. However, the interpretation of the lanthanide maps acquired at the N_4,5 edge by the traditional 3‐window method, is complicated due to the broad shape of the edge profile and the lower signal‐above‐background ratio. Most of these problems can be circumvented by the acquisition of elemental maps with the more sophisticated technique of EFTEM Spectrum Imaging (EFTEM SI). Here, we also report the chemical synthesis of novel second‐generation DAB lanthanide metal chelate conjugates that contain 2 lanthanide ions per DAB molecule in comparison with 0.5 lanthanide ion per DAB in the first generation. Thereby, fourfold more Ln³⁺ per oxidised DAB would be deposited providing significant amplification of signal. This paper applies the colour EM technique at the intermediate‐loss energy‐loss regime to three different cellular targets, namely using mitochondrial matrix‐directed APEX2, histone H2B‐Nucleosome and EdU‐DNA. All the examples shown in the paper are single colour EM images only.

The effectiveness and heterogeneity of carbon emissions trading scheme in China

Some developed economies have run emission trading scheme (ETS) to mitigate carbon emissions. However, we know little about the effectiveness and heterogeneity of ETS in a context of developing economy. This paper evaluates the effectiveness and heterogeneity of China's pilot ETS, the first ETS run in a developing economy. Difference-in-difference (DID) and difference-in-difference-in-difference (DDD) methods are employed to analyze provincial industrial-level data. The heterogeneity of ETS effects is also explored from regional and industrial perspectives. The empirical results show that the pilot ETS can effectively reduce pilot industries' carbon emissions. The reduction effect of the pilot ETS has a substantial heterogeneity for different pilot provinces and industries. Carbon emissions are reduced by the pilot ETS through technological innovation and the adjustment of industrial structure. The empirical results suggest that policymakers may consider establishing a national ETS and differentiating carbon quota allowance in covered regions and industries in the current pilot ETS.

Measuring Medicine Use: Applying ATC/DDD Methodology to Real-World Data

Medicines are essential for the treatment of acute, communicable, and non-communicable diseases. The World Health Organization developed a toolkit for drug (medicine) utilization studies to assist in reviewing and evaluating the prescribing, dispensing, and use of medicines. There is a growing need for rigorous studies of medicine use in low- and middle-income countries (LMIC) using standard approaches, especially in the context of universal health coverage. This commentary provides a succinct summary of how to use the WHO anatomical therapeutic chemical (ATC)/defined daily dose (DDD) methodology in pharmacoepidemiological studies, with a focus on LMIC contexts. We drew on information from WHO resources and published literature, citing examples and case studies. We encourage readers to publish their drug utilization studies, although we caution about predatory journals. We recommend the use of the RECORD-PE initiative which focuses on methods for doing pharmacoepidemiological research and evaluating the quality of published papers.

Adipose Tissue Levels of DDT as Risk Factor for Obesity and Type 2 Diabetes Mellitus

BACKGROUND

Exposure to dichlorodiphenyltrichloroethane (DDT), a potent lipophilic organochlorine pesticide, has long been linked as a risk factor for type 2 diabetes mellitus (T2DM). However, its presence in the adipose tissues of the T2DM subjects has not been explored in the Indian population, where this long-banned pesticide is still in use. The present study was conducted to evaluate the possible association of DDT and its metabolites in obese and non-obese T2DM subjects.

METHODS

Subjects with normal glucose tolerance (n = 50) and T2DM (n = 50) were divided into equal numbers in obese and non-obese groups. Their plasma glucose levels, HbA₁c, and lipid profile were measured. The adipose tissues were collected intraoperatively, and DDT and its metabolites were measured using a gas chromatograph equipped with an electron capture detector.

RESULTS

Obese subjects, irrespective of their glycemic status, and T2DM subjects had higher concentrations of DDT. p, p' DDT was found to increase the odds for diabetes, and o, p' DDT for central obesity. p, p' DDD was also strongly correlated with central obesity, glycemic parameters, and triglycerides.

CONCLUSION

The excess deposition of p, p' DDD, o, p' DDT, and p, p' DDT in obese subjects may proceed to T2DM by disrupting triglycerides and glycemic parameters.

Phase detection limits in off-axis electron holography from pixelated detectors: gain variations, geometric distortion and failure of reference-hologram correction

We investigate the effect that recording off-axis electron holograms on pixelated detectors, such as charge-coupled devices (CCD) and direct-detection devices (DDD), can have on measured amplitudes and phases. Theory will be developed for the case of perfectly uniform interference fringes illuminating an imperfect detector with gain variations and pixel displacements. We will show that both these types of defect produce a systematic noise in the phase images that depends on the position of the holographic fringes with respect to the detector. Subtracting a reference hologram from the object hologram will therefore not remove the phase noise if the initial phases of the two holograms do not coincide exactly. Another finding is that pi-shifted holograms are much less affected by gain variations but show no improvement concerning geometric distortions. The resulting phase errors will be estimated and simulations presented that confirm the theoretical developments.

Allogeneic mesenchymal precursor cells treatment for chronic low back pain associated with degenerative disc disease: a prospective randomized, placebo-controlled 36-month study of safety and efficacy

BACKGROUND CONTEXT PURPOSE

Evaluate the safety and efficacy of a single intradiscal injection of STRO-3+ adult allogeneic mesenchymal precursor cells (MPCs) combined with hyaluronic acid (HA) in subjects with chronic low back pain (CLBP) associated with degenerative disc disease (DDD) through 36-month follow-up.

STUDY DESIGN/SETTING

A multicenter, randomized, controlled study conducted at 13 clinical sites (12 in the United States and 1 in Australia).

SUBJECT SAMPLE

A total of 100 subjects with chronic low back pain associated with moderate DDD (modified Pfirrmann score of 3-6) at one level from L1 to S1 for at least 6 months and failing 3 months of conservative treatment, including physical therapy were randomized in a 3:3:2:2 ratio to receive 6 million MPCs with HA, 18 million MPCs with HA, HA vehicle control, or saline control (placebo) treatment.

OUTCOME MEASURES

Subjects were clinically and radiographically evaluated at 1, 3, 6, 12, 24, and 36 months postinjection. Subject-reported outcomes including adverse events, LBP on a Visual Analog Scale (VAS), Oswestry Disability Index (ODI), SF-36 and Work Productivity and Activity Index were collected.

METHODS

Clinical and radiographic measures were collected at each visit. All randomized subjects were included in the safety assessments and analyzed based on the treatment received. Safety assessments included assessments of AEs, physical and radiographic examinations and laboratory testing. Efficacy assessments evaluated changes in VAS, ODI, and modified Pfirrmann (MP) scores between all active and control groups, respectively. Assessments included least squares mean (Mean), LS mean change from baseline (Mean Change) and responder analyses in order to assess the clinical significance of observed changes from baseline. The population for efficacy assessments was adjusted for the confounding effects of post-treatment interventions (PTIs). This study was conducted under an FDA Investigational New Drug application sponsored and funded by Mesoblast.

RESULTS

There were significant differences between the control and MPC groups for improvement in VAS and ODI. The PTI-corrected VAS and ODI Means and Mean Change analyses; the proportion of subjects with VAS ≥30% and ≥50% improvement from baseline; absolute VAS score ≤20; and ODI reduction ≥10 and ≥15 points from baseline showed MPC therapy superior to controls at various time points through 36 months. Additionally, the proportion of subjects achieving the minimally important change and clinically significant change composite endpoints for the MPC groups was also superior compared with controls at various time points from baseline to 36 months. There were no significant differences in change in MP score from baseline across the groups. There were also no statistically significant differences in change in modified MP score at the level above or below the level treated between study arms. Both the procedure and treatment were well tolerated and there were no clinical symptoms of immune reaction to allogeneic MPCs. There was a low rate of Treatment Emergent Adverse Events (TEAEs) and Serious Adverse Events, and the rates of these events in the MPC groups were not significantly different from the control groups. One TEAE of severe back pain was possibly related to study agent and one TEAE of implantation site infection was considered to be related to the study procedure.

CONCLUSIONS

Results provide evidence that intradiscal injection of MPCs could be a safe, effective, durable, and minimally invasive therapy for subjects who have CLBP associated with moderate DDD.

Prevalence of antimicrobial use in a tertiary academic hospital: a venue for antimicrobial stewardship programs

OBJECTIVE

To quantify antimicrobial use in inpatients setting as part of antimicrobial stewardship program surveillance.

METHOD

Antimicrobial use was obtained using a pre-designed data collection form in this point prevalence study. Setting: The study was conducted in a tertiary academic hospital in the North of Jordan on 13 August 2018. Main outcome measures: antimicrobial use was determined using two methods: defined daily use (DDD) and days of therapy (DOT).

RESULTS

This study identified antimicrobial use in 144 patients. Carbapenems, glycopeptides, and piperacillin-tazobactam were the most utilized antimicrobials in the inpatients' setting in both measures DDD and DOT. The highest prescription rate of antibiotics was in the internal medicine wards (49.8 DDD/100 admissions), followed by surgery wards (33.2 DDD/100 admissions) and intensive care unit (20.6 DDD/100 admissions).

CONCLUSION

This surveillance study addressed patterns of antimicrobial usage in inpatients settings in a tertiary care hospital in Jordan. This practice is feasible and could be adopted routinely by antimicrobial stewardship programs.

Prevalence of antimicrobial use in a tertiary academic hospital: a venue for antimicrobial stewardship programs

OBJECTIVE

To quantify antimicrobial use in inpatients setting as part of antimicrobial stewardship program surveillance.

METHOD

Antimicrobial use was obtained using a pre-designed data collection form in this point prevalence study. Setting: The study was conducted in a tertiary academic hospital in the North of Jordan on 13 August 2018. Main outcome measures: antimicrobial use was determined using two methods: defined daily use (DDD) and days of therapy (DOT).

RESULTS

This study identified antimicrobial use in 144 patients. Carbapenems, glycopeptides, and piperacillin-tazobactam were the most utilized antimicrobials in the inpatients' setting in both measures DDD and DOT. The highest prescription rate of antibiotics was in the internal medicine wards (49.8 DDD/100 admissions), followed by surgery wards (33.2 DDD/100 admissions) and intensive care unit (20.6 DDD/100 admissions).

CONCLUSION

This surveillance study addressed patterns of antimicrobial usage in inpatients settings in a tertiary care hospital in Jordan. This practice is feasible and could be adopted routinely by antimicrobial stewardship programs.

Two-Year Clinical and Radiographic Outcomes of Expandable Interbody Spacers Following Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Prospective Study

BACKGROUND

The advantages of minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF) are well documented and include decreased blood loss, shorter length of hospital stay, and reduced perioperative costs. Clinical evidence for the use of expandable interbody spacers in conjunction with MIS TLIF, however, is scarce. This study sought to examine the clinical and radiographic outcomes of patients undergoing MIS TLIF with an expandable spacer.

METHODS

Forty patients from 4 institutions who underwent MIS TLIF with an expandable spacer were included in this study and followed for 24 months. Investigator assessment of the surgical technique was reported. Patient self-reported outcomes included Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and Short Form 36 (SF-36) physical and mental component scores. Disc height, foraminal height, segmental and lumbar lordosis, and fusion were also assessed.

RESULTS

Investigators reported that intraoperative insertion, impaction, number of passes through the neural structures, and fit were better with an expandable spacer than a static spacer. Significant improvements in VAS, ODI, and SF-36 were reported as early as 6 weeks postoperatively and maintained through 24 months. Mean intervertebral and foraminal heights improved significantly from the preoperative time interval to as early as 6 weeks postoperatively and maintained through 24 months. There were no cases of spacer migration, subsidence, or collapse.

CONCLUSIONS

The use of an expandable interbody spacer in combination with MIS TLIF resulted in positive investigator assessments, immediate and progressive symptom relief, significant radiographic improvements, and no spacer-related complications.

Antimicrobial Use in Broilers Reared at Different Stocking Densities: A Retrospective Study

Simple Summary

Broiler farms are authorized to house animals at different stocking densities (kg live weight/m²) provided that ammonia, carbon dioxide, temperature, and humidity levels are kept under specific limits set by European Union legislation. The role of stocking density on poultry health and welfare, and consequently on antimicrobial use, is still under debate. Herewith, we analyze veterinary prescription data for 2017 pertaining to a representative sample of Italian broiler farms that were authorized to house animals at 33 or 39 kg/m². The prescribed amounts of antimicrobials in each farm were converted into a total of Defined Daily Doses per year, a non-dimensional unit proposed by the European Medicines Agency (EMA). No differences in terms of antimicrobial use, mortality, and feed conversion rates were noted between the two considered groups, suggesting a minor role of stocking density on animal health and welfare.

Abstract

According to the Directive 2007/43/EC, broiler farms can house animals up to 39 kg/m², provided that specific environmental requirements are met. However, limited information is available about the effects of stocking density (SD) on broiler health and welfare, including the need for antimicrobial use. In this study, annual data on mortality, feed conversion rate, and antimicrobial use (AMU) are compared between broiler farms with stocking densities of 39 kg/m² (N = 257) and 33 kg/m² (N = 87). These farms were distributed throughout Italy and belonged to the same integrated poultry company. Antimicrobial use data were obtained from each farm and production cycle; AMU was expressed using the defined daily doses (DDD) method proposed by EMA. The annual AMU per farm was calculated as the median AMU over all cycles. Stratified analysis by sex and geographical area (Italy vs Northern Italy) showed no significant effect of stocking density on broiler mortality, feed conversion rate, and AMU. However, a higher AMU variability among farms with 39 kg/m² stocking density vs. those with 33 kg/m² was found. This study indicates that AMU does not apparently vary between animals reared at different stocking densities in intensive farms.

The Impact of an Antibiotic Stewardship Program on the Consumption of Specific Antimicrobials and Their Cost Burden: A Hospital-wide Intervention

Background

Inappropriate use of antimicrobials (AM) is a major concern worldwide that leads to the propagation of antimicrobial resistance (AMR). In addition to its clinical implications, AMR imposes an economic burden on communities, especially developing countries with more infectious diseases and less available resources. Antimicrobial stewardship programs (ASPs) have been found to be effective in reducing AMR. This study was designed to evaluate the effect of implementing an ASP in reducing AM consumption, its economic burden, and AMR as a consecutive result.

Materials and Methods

Consumption of caspofungin, amphotericin B, voriconazole, colistin, linezolid, vancomycin, and carbapenems was compared in a prospective cross-sectional study between two time periods introduced as pre- and post-ASP. Drug use density presented as anatomical therapeutic chemical (ATC)/defined daily doses (DDD) and normalized per 1000 bed days, cost savings, and AMR patterns were evaluated.

Results

A total of 9400 AM prescriptions were analyzed during a 2-year period. Consumption measured in DDD/1000 bed days dropped by 24.8, 25.0, 35.3, 47.0, 39.2, 10.5, and 23.2 percent for amphotericin B, caspofungin, colistin, voriconazole, meropenem, imipenem, and vancomycin, respectively. Linezolid consumption increased by 26.8% after implementing ASP. The expenditure of target AMs in the average value of USD decreased by 41.3% after the intervention compared to the time before using ASP (P-value=0.001). Implementing ASP also increased AM susceptibility of Pseudomonas aeruginosa, while the susceptibility of methicillin-resistant Staphylococcus aureus did not change significantly.

Conclusion

The results of this study suggest that establishment of ASP can lead to a reduction in improper administration of AMs and their expenditure resulting in economic benefit and lowering AMR at hospitals with minimum resources. Clinical pharmacists' role was critical to the success of this ASP and was uniquely empowered at our center.

Characteristics of Microbial Factors of Healthcare-Associated Infections Including Multidrug-Resistant Pathogens and Antibiotic Consumption at the University Intensive Care Unit in Poland in the Years 2011-2018

Introduction: In recent years, an increase in healthcare-associated infections (HAIs) caused by resistant pathogens, which is a clinically troublesome trend, has been observed. The aim of the study was to analyze the microbial factors of HAIs and the drug resistance of microorganisms to selected antibiotics and their consumption. Material and Methods: The retrospective study included 3708 patients hospitalized in the intensive care unit (ICU) of the University Teaching Hospital in Wroclaw, who were diagnosed with 742 HAIs in the period from 1 January 2011 to 31 December 2018. The aim of the study was the analysis of microorganisms isolated in the respective clinical forms of HAIs, including the occurrence of “alert pathogens”, presence of multidrug-resistant (MDR) strains, and consumption of selected antibiotics. Findings: During the study period, 846 microorganisms were cultured in patients with HAIs, and among them, Acinetobacter baumannii MDR represented 31.8%; Klebsiella pneumoniae ESBLs, 11.3%; Pseudomonas aeruginosa MDR, 4.1% and MRSA, 2.2%; and Enterococcus spp. vancomycin-resistant enterococci (VRE), 1.3%. Among all the pathogens, Gram-negative bacteria (GNB) were dominant (71.6%). Gram-positive bacteria and fungi accounted for 21.6% and 7%, respectively. The total number of strains responsible for ventilator-associated pneumonia (VAP), urinary tract infection (UTI), and central line-associated blood stream infection (CLA-BSI) was as follows: 458 (54.1%), 274 (32.4%), and 114 (13.5%), respectively. Among the etiological factors of VAP, there was a prevalence of A. baumannii MDR (41.9%), as well as in the case of UTI (21.9%). With regards to CLA-BSI, MRCNS (29.8%) was the dominant pathogen. The “alert pathogens” accounted for 54.7% of all the analyzed strains. The MDR strains represented 72.6% and 9.7% among A. baumannii and P. aeruginosa, respectively. In the years 2011 vs. 2018, an increase in infections with MDR bacilli was observed, 34.6% vs. 61.0% (p = 0.0008), respectively, including A. baumannii MDR 16.54% vs. 34.56 % (p = 0.0009) and Enterobacterales ESBL+/AMPC 11.8% vs. 15.44 % (p = 0.3921). Resistance to methicillin was confirmed in 35.2% of S. aureus strains. Resistance to vancomycin was found among 30.9% of Enterococcus spp. The observed period was marked by an increase in the consumption of carbapenems: 197.7 vs. 235.9 defined daily dose (DDD)/1000 patients-days. Conclusions: Gram-negative bacteria were found to be dominant pathogens in healthcare-associated infections. The most frequently cultured pathogens were multidrug-resistant A. baumannii, K. pneumoniae ESBL(+), and P. aeruginosa. The study showed an increase in the incidence of “alert pathogens” and MDR bacilli, as well as the tendency of a growing resistance to antibiotics during the observed period. Microbiological analysis of HAIs and the consumption of antibiotics is the necessary element of the proper antibiotic policy in hospitals.

Does Emission Trading Boost Carbon Productivity? Evidence from China's Pilot Emission Trading Scheme

As the country with the largest carbon emissions globally, the effective operation of China’s carbon emissions trading scheme (ETS) is of great importance to the global community in terms of mitigating climate change. This paper considers China’s pilot ETS launched in 2013 as a quasi-natural experiment. Exploring provincial industrial-level data that are more in line with the ETS coverage, the difference-in-difference-in-difference (DDD) model is used to evaluate the impact of the ETS on carbon productivity. Considering different pilot regions and industries, we also analyze the heterogeneous effect of ETS. Moreover, the mediating effects of technical progress and capital investment are explored. We find that China’s pilot ETS boosted carbon productivity. Among pilot regions, the best policy effectiveness appeared in Beijing, while the weakest effectiveness appeared in Chongqing. Among the pilot industries, the pilot ETS had better effectiveness in petrochemical and electric power industries and weaker effectiveness in building materials and transportation industries. Additionally, the pilot ETS promoted carbon productivity through both technological progress and capital investment, and the former contributed more. Our findings can provide empirical references and policy implications for nationwide implementation of ETS to further promote low-carbon economic transformation.

Consumption of psychotropic medicines at a referral hospital in Namibia: findings and implications

SETTING

In Namibia, the burden of mental illnesses is estimated at 25.6% and is expected to double by 2025. Few studies in sub-Saharan Africa estimate the consumption rates of psychotropic medicines as a proxy of irrational use.

AIM

The consumption rate of psychotropic medicines at a referral hospital was determined.

METHODS

A hospital-based retrospective medicine utilization analysis of Facility Electronic Stock Card (FESC) psychotropic medication was conducted at Intermediate Hospital Katutura over a 7 year period, 2011-2017. Data on consumption and expenditure on psychotropic medicines were abstracted from FESC and analysed using descriptive statistics in SPSS v22. The main outcomes were consumption rates, daily Defined Dose, (DDD) and/or expenditure.

RESULTS

Of the 580 351,4 DDD of psychotropic medicines consumed, 84% were anti-psychotics, 9.2% anti-depressants and 6.8% anxiolytics. Anti-psychotics (48.8%) and anxiolytics (47.9%) had the highest consumption by cost relative to anti-depressants (3.3%). The most consumed antidepressants were imipramine (62%) by DDD and fluoxetine (55.8%) by cost. The most consumed anti-psychotics were chlorpromazine (74.6%) by DDD and haloperidol (68.4%) by cost respectively. Diazepam (79.4%) and hydroxyzine (94.2%) were most consumed sedative-hypnotics by DDD and cost respectively.

CONCLUSION

The consumption of new psychotropics contributes to higher costs. There is need for cost-effectiveness analysis of new versus conventional psychotropics to optimize treatment, outcomes and costs.

Use of antimicrobials in beef cattle: an observational study in the north of Italy

Antimicrobial resistance is a worldwide issue whereby a more prudent use of medications is needed, especially for those antimicrobials (AM) classified as 'highest priority critically important antimicrobials' (HPCIAs) which are likely contributors to the development of resistance. So far, data on antimicrobial use (AMU) in EU are mainly reported at sales level while information on real use, mostly in beef production, is poor. The most reliable indicator to measure AMU is the treatment incidence (TI100) calculated by using the Defined Daily Dose Animal (DDDA) as stated by the European Medicines Agency (EMA). Although Italy ranks second among EU countries with regard to the AM sales in livestock production, data on AMU of the Italian beef production is still lacking, whereby the aim of this study was to provide information on the current scenario of AMU in Italian beef cattle. Data were collected from January 2016 to April 2019 from specialized beef fattening farms located in the north of Italy yielding a final dataset of 1376 batches. Data on performance and AM agents used in the study were collected and TI100 indexes per batch were calculated according to both Italian and EMA's DDDA. A Kruskal-Wallis test was used to check for differences between years and seasons. Results showed a significant variation between years and seasons with a reduction of TI100 based on Italian DDDA as time progressed (P < 0.05). However, about 40% of the total amount of treatments administered were HPCIAs with macrolides accounting for the 27.7% of the total amount. The most common reasons of administration of AM were respiratory diseases (68.9%) and lameness (17.6%). Penicillins was the class of AM used on the highest proportion of batches (84.4%) showing that broad-spectrum AM were widely exploited among herds. In summary, despite a general reduction of AMU in beef cattle over time, a great use of HPCIAs was still observed suggesting that AM stewardship for Italian beef production should pay particular emphasis on the reduction of HPCIAs use. This shows how overall knowledge on where efforts need to be optimized is important to develop targeted strategies for a more responsible AM stewardship. Results of the current study may also contribute to define national and EU benchmark criteria for AMU, as a comparison with studies carried out in other countries or on other food-producing sectors is still challenging to achieve.

Does command-and-control regulation promote green innovation performance? Evidence from China's industrial enterprises

Many developing countries including China have launched command-and-control regulation (CCR) to achieve sustainable development. However, we know little about whether CCR promotes green innovation performance. This study empirically analyses the impact of CCR, which is represented by China's eleventh Five-Year Plan (FYP) environmental regulation, on enterprise green innovation performance and use green innovation efficiency as the measure of innovation. Super-SBM DEA model, difference-in-differences (DID) and difference-in-difference-in-differences (DDD) methods are employed to investigate 496 industrial enterprises in China's A-share market for the 2002-2017 period. Moreover, we distinguish each treat group from the control group by using continuous variables and consider enterprise features in the analysis. The results find that, in general, the eleventh FYP environmental regulation negatively influences enterprise green innovation efficiency in a short-term through reducing cash flows. More specifically, the eleventh FYP CCR generates a detrimental effect on small enterprises, state-owned enterprises, and enterprises in China's western and eastern regions. Overall, this empirical analysis suggests that the government should consider the effect of CCR on economy and focus on the heterogeneity of enterprises during designing environmental policies.

Antimicrobial use on Italian Pig Farms and its Relationship with Husbandry Practices

The analysis of antimicrobial use (AMU) data in livestock allows for the identification of risk factors for AMU, thereby favoring the application of responsible AMU policies on-farm. Herewith, AMU in 36 finishing pig farms in northern Italy from 2015-2017 was expressed as defined daily doses for Italian pigs (DDDita) per population correction unit (DDDita/100kg). A retrospective analysis was then conducted to determine the effects of several husbandry practices on AMU. Overall, AMU ranged between 12 DDDita/100kg in 2015 and 8 DDDita/100kg in 2017, showing no significant trends, due to the large variability in AMU between farms. However, a 66% AMU reduction was observed in 19 farms during 2015-2017. Farm size, number of farm workers, air quality, average pig mortality, and presence of undocked pigs on the farm had no significant effects on AMU. Rather, welfare-friendly farms had 38% lower AMU levels (p < 0.05). In conclusion, animal welfare management seems to be relatively more important than farm structure and other managerial characteristics as drivers of AMU in finishing pig farms.

Meta-Analyses Support Previous and Novel Autism Candidate Genes: Outcomes of an Unexplored Brazilian Cohort

Large genomic databases of neurodevelopmental disorders (NDD) are helpful resources of genomic variations in complex and heterogeneous conditions, as Autism Spectrum Disorder (ASD). We evaluated the role of rare copy number variations (CNVs) and exonic de novo variants, in a molecularly unexplored Brazilian cohort of 30 ASD trios (n = 90), by performing a meta-analysis of our findings in more than 20,000 patients from NDD cohorts. We identified three pathogenic CNVs: two duplications on 1q21 and 17p13, and one deletion on 4q35. CNVs meta-analysis (n = 8,688 cases and n = 3,591 controls) confirmed 1q21 relevance by identifying duplications in other 16 ASD patients. Exome analysis led the identification of seven de novo variants in ASD genes (SFARI list): three loss-of-function pathogenic variants in CUL3, CACNA1H, and SHANK3; one missense pathogenic variant in KCNB1; and three deleterious missense variants in ATP10A, ANKS1B, and DOCK1. From the remaining 12 de novo variants in non-previous ASD genes, we prioritized PRPF8 and RBM14. Meta-analysis (n = 13,754 probands; n = 2,299 controls) identified six and two additional patients with validated de novo variants in PRPF8 and RBM14, respectively. By comparing the de novo variants with a previously established mutational rate model, PRPF8 showed nominal significance before multiple test correction (P = 0.039, P-value adjusted = 0.079, binomial test), suggesting its relevance to ASD. Approximately 60% of our patients presented comorbidities, and the diagnostic yield was estimated in 23% (7/30: three pathogenic CNVs and four pathogenic de novo variants). Our uncharacterized Brazilian cohort with tetra-hybrid ethnic composition was a valuable resource to validate and identify possible novel candidate loci. Autism Res 2020, 13: 199-206. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We believed that to study an unexplored autistic population, such as the Brazilian, could help to find novel genes for autism. In order to test this idea, with our limited budget, we compared candidate genes obtained from genomic analyses of 30 children and their parents, with those of more than 20,000 individuals from international studies. Happily, we identified a genetic cause in 23% of our patients and suggest a possible novel candidate gene for autism (PRPF8).

Consumption of Anti-Epileptic Drugs in Primary Health Care in Albania, 2004-2016

BACKGROUND

Epilepsy is a serious neurological condition requiring sometimes lifelong pharmacological treatment, and continuous specialist monitoring.

AIM

To investigate the use of Anti-Epileptic Drugs (AEDs) in epilepsy, with focus on the exposure of AEDs, differences and changes in prescription patterns over time; to evaluate the relation between the consumption data of AED and the level of epileptic morbidity for the period 2004-2016.

STUDY DESIGN

Official data regarding the consumption of AEDs within Albania were collected retrospectively. Every year of the period, 2004-2016 has been considered separately.

METHODS

The data were assembled from Health Insurance Institute (HII) in Tirana, Albania and analysed for the period 2004-2016. The consumption of drugs was expressed as several Defined Daily Dose (DDDs)/1000 inhabitants/day. Also, for all the period under study 2004-2016, we analysed the data of import and domestic production of drugs, which represent the real consumption of drugs in the country. These data were subsequently involved in a comparative analysis with the utilisation data according to the HII, as well as through performing international comparisons of the consumption of AEDs drugs.

RESULTS

Epilepsy morbidity data indicate that there exists a correlation statistically significant between this disease and the trend of consumption of AEDs.

CONCLUSION

The present study suggests that the level of consumption for AEDs in Albania is very low when compared globally; with a decrease in the consumption of classic antiepileptic drugs and a parallel increase in the consumption of new generation drugs.

Dysproteinemia and the Kidney: Core Curriculum 2019

Dysproteinemic kidney diseases occur when B- or plasma cell clones produce pathogenic monoclonal immunoglobulins or light chains that cause kidney damage. The clinical presentation of these disorders ranges from sub-nephrotic-range proteinuria or microscopic hematuria with preserved kidney function to severe nephrotic syndrome to severe acute kidney injury or rapidly progressive glomerulonephritis. These monoclonal immunoglobulins can cause a variety of histologic patterns of injury, including cast nephropathy, glomerular and tubular deposition diseases, amyloidosis, and inflammatory glomerulonephritis. The underlying clonal disorder may meet criteria for overt multiple myeloma or systemic lymphoma. In recent years, there has been increased recognition and study of dysproteinemic kidney diseases that occur in the setting of smaller clonal plasma and B-cell populations, which are classified as monoclonal gammopathies of renal significance. Regardless of clonal cell burden, the goal of treatment is to achieve a hematologic response (ie, improvement or resolution of the monoclonal protein) by eradicating the underlying clone. Organ-specific responses are dependent on achieving hematologic response. Without appropriate treatment, many of these disorders are associated with high rates of progressive kidney disease and end-stage kidney disease. In this installment of AJKD's Core Curriculum in Nephrology, we review the pathogenesis, diagnosis, and treatment of dysproteinemic kidney diseases.

Evidence of impacts from DDT in pelican, cormorant, stork, and egret eggs from KwaZulu-Natal, South Africa

DDT remains in use for malaria control in South Africa. We quantified DDTs in aquatic bird eggs from the highly biodiverse northern KwaZulu-Natal, a province of South Africa where DDT has been used for more than 80 years for malaria control. Pelican eggs had the highest ΣDDT concentration (7200 ng/g lipid mass; lm), Little Egret eggs had 6900 ΣDDT lm, African Openbill eggs had 3400 ng/g lm ΣDDT, and White-breasted Cormorant had 2400 ng/g lm. All species had non-significantly different mean concentrations of o,p'-DDT, p,p'-DDT, and ΣDDT, but with significant differences for p,p-DDE, o,p'-DDD, p,p'-DDD, %DDT, %DDD, and %lipid. The thinnest pelican eggshell (0.40 mm) had a ΣDDT concentration of 3300 ng/g lm.; the thickest shell (0.96 mm) had the lowest ΣDDT concentration at 29 ng/g lm; a 58% difference. Linear regressions of concentrations with shell thickness for the pelican eggs were significant for p,p'-DDE and p,p'-DDD, indicating risk of reproductive impairment. Compositional profiles indicate different food webs for the different species. DDT concentrations were lower than from another DDT-sprayed locality in South Africa, possible linked to differences in hydrology and rainfall. We conclude that significant ecotoxic threats associated with DDT remain in this area, and possibly threatens birds from less polluted areas. Our findings suggest continued negative human health and environmental impacts from DDT. There is an urgency to move away from DDT as quickly as possible; alternatively, to implement practices that prevent emissions of DDT to the environment while protecting human life.

Autologous mesenchymal stromal cells embedded in tricalcium phosphate for posterolateral spinal fusion: results of a prospective phase I/II clinical trial with long-term follow-up

BACKGROUND

Posterolateral spinal fusion with autologous bone graft is considered the "gold standard" for lumbar degenerative disc disease (DDD) when surgical treatment is indicated. The potential role of mesenchymal stromal cells (MSCs) to replace the bone graft in this setting has not been fully addressed.

OBJECTIVE

To analyze the safety, feasibility and potential clinical efficacy of the implantation of autologous MSCs embedded with tricalcium phosphate as a therapeutic alternative to bone graft in patients with DDD during posterolateral spine fusion.

STUDY DESIGN

Phase I/II single-arm prospective clinical trial.

METHODS

Eleven patients with monosegmental DDD at L4-L5 or L5-S1 level were included. Autologous bone marrow-derived MSC were expanded in our Good Manufacturing Practice (GMP) Facility and implanted during spinal surgery embedded in a tricalcium phosphate carrier. Monitoring of patients included a postoperative period of 12 months with four visits (after the 1st, 3rd, 6th, and 12th month), with clinical and radiological assessment that included the visual analog scale (VAS), the Oswestry disability index (ODI), the Short-Form Health Survey (SF-36), the vertebral fusion grade observed through a simple Rx, and the evaluation of possible complications or adverse reactions. In addition, all patients were further followed up to 5 years for outcome.

RESULTS

Median age of patients included was 44 years (range 30-58 years), and male/female ratio was (6/5) L4-L5 and L5-S1 DDD was present five and six patients, respectively. Autologous MSCs were expanded in all cases. There were no adverse effects related to cell implantation. Regarding efficacy, both VAS and ODI scores improved after surgery. Radiologically, 80% of patients achieved lumbar fusion at the end of the follow-up. No adverse effects related to the procedure were recorded.

CONCLUSIONS

The use of autologous MSCs for spine fusion in patients with monosegmental degenerative disc disease is feasible, safe, and potentially effective.

TRIAL REGISTRATION

no. EudraCT: 2010-018335-17 ; code Identifier: NCT01513694 ( clinicaltrials.gov ).

Lumbar Total Disc Replacement by the Lateral Approach-Up to 10 Years Follow-Up

OBJECTIVE

This study aimed to analyze radiologic and clinical results with a minimum 5 years follow-up (FUP) of lateral lumbar total disc replacement for the treatment of symptomatic lumbar degenerative disc disease.

METHODS

We performed a prospective, single-center, clinical, and radiologic study. Patients were treated with lumbar total disc replacement (extreme lateral total disc replacement) by a lateral transpsoas approach. From 2005 to 2012, 60 patients were enrolled (31 male, 29 female; total, 66 levels; average age, 42.8 years [standard deviation (SD), 9.7 years, range, 22-64 years]; mean body mass index, 26.0 [SD, 3.4]). Clinical end points included visual analog scale and Oswestry Disability Index questionnaires, complications, and reoperation. Radiographic end points included heterotopic ossification (McAfee classification), adjacent level disease, and prosthesis migration or subluxation.

RESULTS

The mean surgical duration was 122 minutes (SD, 45 minutes) with mean 58 mL (SD, 21 mL) of estimated blood loss. No intraoperative complication occurred. The exceptions were 1 patient with postanesthesia apnea and 2 patients with quadriceps motor deficit (resolved within 4 months with physiotherapy). Of 60 patients, 9 were missed to FUP and 51 (85%) were enrolled in the study, with mean FUP of 92 months (range, 60-122 months). In total, 5 levels (9%; 5 of 55) required to be fused. Both removal of the prostheses and interbody fusion were performed by the lateral transpsoas approach. One patient experienced CrCo allergy (at 2 months); 4 experienced persistent pain from different causes (at 7, 9, 24, and 88 months). Five patients (10%) presented with progression at adjacent levels and 2 (4%) required surgery. One patient required sacroiliac fusion at 63 months. There were no complications during the retrieval surgeries. One partial disc migration occurred but the patient refused retrieval. There was no bone bridging in 9% of the discs (grade 0 heterotopic ossification): grade I, 22%; grade II, 31%; grade III, 20%; grade IV (fusion), 18%. Most heterotopic ossification cases (93%) occurred in the lateral aspect of the disc space, and mostly at the contralateral side of the surgical approach. Patient-reported outcomes significantly improved (P < 0.01) at the last FUP. Visual analog scale back pain score was preoperatively 8.5, early postoperatively 2.5, and at last FUP 3.1. Oswestry Disability Index was preoperatively 55%, early postoperatively 31%, and at last FUP 21%.

CONCLUSIONS

This study presents mid-term to long-term results of extreme lateral total disc replacement artificial disc for the treatment of lumbar degenerative disease, with fast mobilization, sustained pain relief, and improved physical function. Despite the low rate of ALDis, some discs evolved to ankyloses and others were retrieved. Lumbar artificial disc replacement by the lateral approach seems to be a safe and effective treatment.

Polyetheretherketone (PEEK) Rods for Lumbar Fusion: A Systematic Review and Meta-Analysis

Background

The purpose of this systematic review is to evaluate the safety and effectiveness of polyetheretherketone (PEEK) rod systems in patients receiving lumbar interbody fusion treatment. Meta-analyses of relevant clinical data were also conducted when possible.

Methods

Relevant studies were identified by searching the PubMed, EMBASE, and Cochrane Library databases. Clinical studies evaluating the safety and/or effectiveness of the PEEK rod spinal stabilization system in patients receiving lumbar spinal fusion procedure were included. Studies regarding dynamic stabilization and hybrid stabilization (fixed and dynamic; eg, topping-off technique) were not included in this analysis. The analyses included patients who had a lumbar fusion procedure with PEEK rods or titanium rods as a control reference (only for controlled studies). Fusion success, functional and pain improvement, and safety data were evaluated, if reported.

Results

The search yielded 5 studies (1 prospective and 4 retrospectives) that included 177 participants (156 received PEEK rods, and 21 received titanium rods). Meta-analysis of interbody fusion success rate in PEEK rod patients yields the estimate of 95.6% (confidence interval: 91.6% to 98.4%). Functional outcomes in PEEK rod patients demonstrated clinically significant improvement when comparing postoperative to preoperative scores, with an average improvement of 67.4% ± 8.5%. Similarly, pain improvement was clinically significant with an average visual analog scores-back pain and visual analog scores-leg pain improvement percentages of 68.9% ± 8.6% and 76.6% ± 1.5%, respectively. Rod fracture was not reported in any of the studies. The rates of screw fracture and loosening were 3/114 (2.6%) and 1/50 (2.0%), respectively. In the controlled study, no statistically significant difference was reported in the fusion success rate, function improvement, pain improvement, or device-related events between subjects treated with PEEK rods and the subjects treated with titanium rods.

Conclusions

Experience with PEEK rod systems has shown satisfactory clinical outcomes. Therefore, these results support the use of PEEK rod systems as supplemental fixation during lumbar fusion procedures.

Reliable estimation of antimicrobial use and its evolution between 2010 and 2013 in French swine farms

Background

There has been a strong implication of both the French swine industry and the national authorities on reducing the use of antimicrobials in swine production since 2010. The annual monitoring of antimicrobial sales by the French Veterinary Medicines Agency (Anses-ANMV) provides estimates but not detailed figures on actual on-farm usage of antimicrobials in swine production.

Results

In order to provide detailed information on the 2010 and 2013 antimicrobial use in the French swine industry, the methodology of cross-sectional retrospective study on a representative sample of at least 150 farms has been elected. The analysis of the collected data shows a strong and significant decrease in antimicrobial exposure of pigs between 2010 and 2013. Over three years, the average number of days of treatment significantly decreased by 29% in suckling piglets and by 19% in weaned piglets. In fattening pigs, the drop (− 29%) was not statistically significant. Only usage in sows did increase over that period (+ 17%, non-significant), which might be associated with the transition to group-housing of pregnant sows that took place at the time. Also, over that period, the use of third- and fourth generation cephalosporins in suckling piglets decreased by 89%, and by 82% in sows, which confirms that the voluntary moratorium on these classes of antimicrobials decided at the end of 2010 has been effectively implemented.

Conclusions

The methodology of random sampling of farms appears as a precise and robust tool to monitor antimicrobial use within a production animal species, able to fulfil industry and national authorities’ objectives and requirements to assess the outcome of concerted efforts on antimicrobial use reduction. It demonstrates that the use of antimicrobials decreased in the French swine industry between 2010 and 2013, including the classes considered as critical for human medicine.

Total Disc Replacement Versus Anterior-Posterior Interbody Fusion in the Lumbar Spine and Lumbosacral Junction: A Cost Analysis

STUDY DESIGN

Prospective observational cohort study.

OBJECTIVES

To analyze clinical and economic results in patients with degenerative disc disease in the lumbar area for patients who received combined anterior and posterior fusion or total disc replacement (TDR).

METHODS

The study included 75 patients, 38 in the fusion group and 37 in the TDR group, who received either anterior/posterior fusion or TDR for lumbar disc disease from January 2005 to December 2008 with a minimum follow-up of 24 months. We collected data with regard to clinical parameters, demographics, visual analogue scale scores, Oswestry Disability Index scores, SF-36 and SF-6D data, surgery time, amount of blood loss, transfusion of blood products, number of levels, duration of hospital stay, and complications. For cost analysis, general infrastructure, theatre costs, as well as implant costs were examined, leading to primary hospital costs. Furthermore, average revision costs were examined, based on the actual data. Statistical analysis was performed using t tests for normal contribution and Mann-Whitney test for skew distributed values. The significance level was set to .05.

RESULTS

There was a higher surgery time, more blood loss, and longer hospital stay for the fusion group, compared with the TDR group. In addition, the hospital costs for the primary procedure and revision were 35% higher in the fusion group. The clinical data in terms of SF-36 and SF-6D showed no difference between these 2 groups.

CONCLUSIONS

TDR is a good alternative to anterior and posterior lumbar fusion in terms of short follow-up analysis for clinical data and cost analysis. General advice cannot be given due to missing data for long-term costs in terms of surgical treatment of adjacent level or further fusion techniques.

Effects of an antimicrobial restriction system on appropriate carbapenem use in a hospital without infectious diseases consultation

Background

Gram-negative bacteria are becoming increasingly resistant to carbapenems and are related to the use of carbapenems. Thus, the main objective of this study was to compare the appropriateness of prescribing carbapenem before and after using an antimicrobial restriction system without infectious diseases consultation.

Materials and methods

A retrospective cross-sectional before and after study was conducted in Lamphun Hospital to limit the prescription of carbapenems. Data were obtained by a review of the medical records and electronic databases from the period September 2014 to January 2015 (before) and from September 2015 to January 2016 (after).

Results

A total of 360 antibacterial prescriptions were analyzed. The appropriateness of prescribing was higher after using the antimicrobial restriction (55.0%) than before using the antimicrobial restriction system (38.3%; p=0.001). The amount of carbapenem in the defined daily dose per 1,000 bed days increased by 3.48% after using the antimicrobial restriction system when compared with before using the antimicrobial restriction system, which was not statistically significant (p=0.611). The incidence rates of nosocomial infections caused by resistance of Enterobacteriaceae to ertapenem before and after the intervention to limit antimicrobial therapy was found to have decreased from 4.80 to 0.95 infections per 1,000 patient days, respectively (p=1.00). The expenditure for carbapenems in the average value of baht per patient was found to have decreased by 36.33% after using the antimicrobial restriction system when compared with before using the antimicrobial restriction system (p=0.001).

Conclusion

These results suggest that antimicrobial restriction systems can increase the appropriateness of prescribing antibiotics. The expenditure for carbapenem was found to decrease after using the antimicrobial restriction system when compared with before using the antimicrobial restriction system, even without infectious diseases consultation. However, the amount of carbapenem in the defined daily dose per 1,000 bed days was not found to reduce after using the antimicrobial restriction system.

Antimicrobial consumption on Austrian dairy farms: an observational study of udder disease treatments based on veterinary medication records

Background

Antimicrobial use in livestock production is an important contemporary issue, which is of public interest worldwide. Antimicrobials are not freely available to Austrian farmers and can only be administered to livestock by veterinarians, or by farmers who are trained members of the Animal Health Service. Since 2015, veterinarians have been required by law to report antimicrobials dispensed to farmers for use in food-producing animals. The study presented here went further than the statutory framework, and collected data on antimicrobials dispensed to farmers and those administered by veterinarians.

Methods

Seventeen veterinary practices were enrolled in the study via convenience sampling. These veterinarians were asked to contact interested dairy farmers regarding participation in the study (respondent-driven sampling). Data were collected from veterinary practice software between 1st October 2015 and 30th September 2016. Electronic data (89.4%) were transferred via an online interface and paper records (10.6%) were entered by the authors. Antimicrobial treatments with respect to udder disease were analysed by number of defined daily doses per cow and year (nDDD_vet/cow/year), based on the European Medicines Agency technical unit, Defined Daily Dose for animals (DDD_vet). Descriptive statistics and the Wilcoxon rank sum test were used to analyse the results.

Results

Antimicrobial use data from a total of 248 dairy farms were collected during the study, 232 of these farms treated cows with antibiotics; dry cow therapy was excluded from the current analysis. The mean number of DDD_vet/cow/year for the antimicrobial treatment of all udder disease was 1.33 DDD_vet/cow/year. Of these treatments, 0.73 DDD_vet/cow/year were classed as highest priority critically important antimicrobials (HPCIAs), according to the World Health Organization (WHO) definition. The Wilcoxon rank sum test determined a statistically significant difference between the median number of DDD_vet/cow/year for acute and chronic mastitis treatment (W = 10,734, p < 0.001). The most commonly administered antimicrobial class for the treatment of acute mastitis was beta-lactams. Intramammary penicillin was used at a mean of 0.63 DDD_vet/cow/year, followed by the third generation cephalosporin, cefoperazone, (a HPCIA) at 0.60 DDD_vet/cow/year. Systemic antimicrobial treatments were used at a lower overall level than intramammary treatments for acute mastitis.

Discussion

This study demonstrated that Austrian dairy cows in the study population were treated with antimicrobial substances for udder diseases at a relatively low frequency, however, a substantial proportion of these treatments were with substances considered critically important for human health. While it is vital that sick cows are treated, reductions in the overall use of antimicrobials, and critically important substances in particular, are still possible.

Treatment of lumbar degenerative disc disease-associated radicular pain with culture-expanded autologous mesenchymal stem cells: a pilot study on safety and efficacy

Background

Degenerative disc disease (DDD) is a common cause of lower back pain with radicular symptoms and has a significant socioeconomic impact given the associated disability. Limited effective conservative therapeutic options result in many turning to surgical alternatives for management, which vary in the rate of success and also carry an increased risk of morbidity and mortality associated with the procedures. Several animal based studies and a few human pilot studies have demonstrated safety and suggest efficacy in the treatment of DDD with mesenchymal stem cells (MSCs). The use of bone marrow-derived MSCs for the treatment of DDD is promising and in the present study we report on the safety and efficacy findings from a registry based proof of concept study using a percutaneous intradiscal injection of cultured MSCs for the management of DDD with associated radicular symptoms.

Methods

Thirty-three patients with lower back pain and disc degeneration with a posterior disc bulge diagnosed on magnetic resonance imaging (MRI) met the inclusion criteria and were treated with culture-expanded, autologous, bone marrow-derived MSCs. Prospective registry data was obtained at multiple time intervals up to 6 years post-treatment. Collected outcomes included numeric pain score (NPS), a modified single assessment numeric evaluation (SANE) rating, functional rating index (FRI), measurement of the intervertebral disc posterior dimension, and adverse events.

Results

Three patients reported pain related to procedure that resolved. There were no serious adverse events (i.e. death, infection, or tumor) associated with the procedure. NPS change scores relative to baseline were significant at 3, 36, 48, 60, and 72 months post-treatment. The average modified SANE ratings showed a mean improvement of 60% at 3 years post-treatment. FRI post-treatment change score averages exceeded the minimal clinically important difference at all time points except 12 months. Twenty of the patients treated underwent post-treatment MRI and 85% had a reduction in disc bulge size, with an average reduction size of 23% post-treatment.

Conclusions

Patients treated with autologous cultured MSCs for lower back pain with radicular symptoms in the setting of DDD reported minor adverse events and significant improvements in pain, function, and overall subjective improvement through 6 years of follow-up.

NCT03011398. A Clinical Registry of Orthobiologics Procedures. https://clinicaltrials.gov/ct2/show/NCT03011398?term=orthobiologics&rank=1

Impact of a mixed educational and semi-restrictive antimicrobial stewardship project in a large teaching hospital in Northern Italy

BACKGROUND

The overuse of antimicrobials favors the dissemination of antimicrobial resistance, as well as invasive fungal diseases and Clostridium difficile infections (CDI). In this study, we assessed the impact of a mixed educational and semi-restrictive antimicrobial stewardship (AMS) project in a large teaching hospital in Italy.

METHODS

The AMS project was conducted from May 2014 to April 2016. It consisted of two initiatives in two consecutive periods: (1) educational activities; (2) semi-restrictive control of antimicrobial prescribing through a computerized software. The primary endpoint was consumption of antibacterials and antifungals. Secondary endpoints were incidence of CDI, methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), carbapenem-resistant Klebsiella pneumoniae (CRKP) BSI, and Candida BSI.

RESULTS

During the study period, a statistically significant reduction in consumption was observed for antibacterials (-1.45 defined daily doses (DDD)/1000 patient-days monthly, 95% confidence intervals [CI] -2.38 to -0.52, p 0.004), mainly driven by reductions in the use of fluoroquinolones, third/fourth generation cephalosporins, and carbapenems. No decrease in consumption of antifungals was observed (-0.04 DDD/1000 patient-days monthly, 95% CI -0.34 to +0.25, p 0.750). A statistically significant trend towards reduction was observed for incidence of CRKP BSI (incidence rate ratio 0.96, 95% CI 0.92-0.99, p 0.013). No statistically significant variations in trends were observed for CDI, MRSA BSI, and Candida BSI.

CONCLUSIONS

The mixed AMS project was effective in reducing the use of major antibacterials and the incidence of CRKP BSI. Further research is needed to assess the extent of long-term benefits of semi-restrictive approaches.

Circannual variation of mitotane and its metabolites plasma levels in patients with adrenocortical carcinoma

OBJECTIVES

Mitotane is the reference drug for the adrenocortical carcinoma treatment; its pharmacological activity seems to depend on drug transformation in two active metabolites: o,p'-DDE (dichlorodiphenylethene) and o,p'-DDA (dichlorodiphenylacetate). Mitotane and metabolites are lipophilic agents; thus, they tend to accumulate into adipose tissues (white and brown), which change their prevalence seasonally. Aim of the work was to evaluate mitotane and metabolites plasma levels variation over the year, in adrenocortical cancer patients treated with Lysodren^® for at least 6 months.

METHODS

We enrolled a group of 86 adrenocortical carcinoma diagnosed patients, who underwent radical surgery and started mitotane as adjuvant treatment. For drug and metabolites plasma level (from samples collected ~12 h after the dose administration of mitotane, just before the subsequent administration) determination, a validated chromatographic method was used.

KEY FINDINGS

Results showed an evidence of a seasonal trend for the three substance (o,p'-DDD, o,p'-DDE and o,p'-DDA) plasma levels, in terms of acrophases and lower values. Furthermore, it came out that male patients need a higher significant mitotane drug dose than female patients to reach mitotane therapeutic window.

CONCLUSIONS

In conclusion, this is the first study assessing a mitotane plasma level variation over the year, but further studies in larger cohorts are required.

Evaluation of effects of an operational multidisciplinary team on antibiotic use in the medium to long term at a French university hospital

Background Antibiotic-resistant bacteria are a major public health problem throughout the world. In 2006, in accordance with the national guidelines for antibiotic use, the CHRU of Nancy created an operational multidisciplinary antibiotic team at one of its sites. In 2011, a cluster-controlled trial showed that the operational multidisciplinary antibiotic team (the intervention) had a favourable short-term effect on antibiotic use and costs. Objective Our objective was to determine whether these effects continued over the medium to long term (that is, 2-7 years after creation of the operational multidisciplinary antibiotic team, 2009-2014). Setting The 1800-bed University Hospital of Nancy (France). Method The effect in the medium to long term is measured according to the same criteria and assessed by the same methods as the first study. A cluster controlled trial was performed on the period 2009-2014. The intervention group comprised 11 medical and surgical wards in settings where the operational multidisciplinary antibiotic team was implemented and the control group comprised 6 wards without this operational team. Main outcome measure Consumption of antibiotics overall and by therapeutic class (in defined daily doses per 1000 patient-days) and costs savings (in €). Results The reduction in antibiotic use and costs continued, but at a lower rate than in the short term (11% between 2009 and 2014 compared with 33% between 2007 and 2009) at the site of the intervention. The principal decreases concerned fluoroquinolones and glycopeptides. At the site without an operational multidisciplinary antibiotic team (the control group), total antibiotic use remained stable. Between 2009 and 2014, costs fell 10.5% in the intervention group and 5.7% in the control group. Conclusion This study shows that it is possible to maintain the effectiveness over time of such an intervention and demonstrates its role in defining a hospital's antibiotic policy.

Antimicrobial consumption, costs and resistance patterns: a two year prospective study in a Romanian intensive care unit

Background

Due to the vulnerable nature of its patients, the wide use of invasive devices and broad-spectrum antimicrobials used, the intensive care unit (ICU) is often called the epicentre of infections. In the present study, we quantified the burden of hospital acquired pathology in a Romanian university hospital ICU, represented by antimicrobial agents consumption, costs and local resistance patterns, in order to identify multimodal interventional strategies.

Methods

Between 1^st January 2012 and 31^st December 2013, a prospective study was conducted in the largest ICU of Western Romania. The study group was divided into four sub-samples: patients who only received prophylactic antibiotherapy, those with community-acquired infections, patients who developed hospital acquired infections and patients with community acquired infections complicated by hospital-acquired infections. The statistical analysis was performed using the EpiInfo version 3.5.4 and SPSS version 20.

Results

A total of 1596 subjects were enrolled in the study and the recorded consumption of antimicrobial agents was 1172.40 DDD/ 1000 patient-days.

The presence of hospital acquired infections doubled the length of stay (6.70 days for patients with community-acquired infections versus 16.06/14.08 days for those with hospital-acquired infections), the number of antimicrobial treatment days (5.47 in sub-sample II versus 11.18/12.13 in sub-samples III/IV) and they increased by 4 times compared to uninfected patients. The perioperative prophylactic antibiotic treatment had an average length duration of 2.78 while the empirical antimicrobial therapy was 3.96 days in sample II and 4.75/4.85 days for the patients with hospital-acquired infections. The incidence density of resistant strains was 8.27/1000 patient-days for methicilin resistant Staphylococcus aureus, 7.88 for extended spectrum β-lactamase producing Klebsiella pneumoniae and 4.68/1000 patient-days for multidrug resistant Acinetobacter baumannii.

Conclusions

Some of the most important circumstances collectively contributing to increasing the consumption of antimicrobials and high incidence densities of multidrug-resistant bacteria in the studied ICU, are represented by prolonged chemoprophylaxis and empirical treatment and also by not applying the definitive antimicrobial therapy, especially in patients with favourable evolution under empirical antibiotic treatment. The present data should represent convincing evidence for policy changes in the antibiotic therapy.

Correlation between prescribed daily dose, seizure freedom and defined daily dose in antiepileptic drug treatment

Background Although defined daily doses (DDD) for antiepileptic drugs (AED) have been assigned only in combination therapy, based on the literature, most patients take them in monotherapy. Furthermore, discrepancies between DDD and prescribed daily dose (PDD) were observed. Objective First, to determine PDDs of AEDs and to reveal PDD/DDD ratio among seizure free versus not seizure free patients in everyday clinical practice. Second, to test the applicability of 75% cut-off of DDD to achieve seizure freedom. Furthermore, to find out what factors might influence PDD. Setting Outpatient data files at a Hungarian university hospital were studied. Methods A retrospective, 20-year cross-sectional database was compiled from 1282 epileptic outpatients' files. Main outcome measure Seizure freedom and PDD were used as outcome measures. Results The mean DDD% of all prescribed AEDs increased steadily from monotherapy, through bitherapy towards polytherapy (p < 0.0001). Most seizure free patients took AEDs in doses in the range of ≤75% of DDDs in monotherapy and bitherapy. Older AEDs (carbamazepine and valproate) were given in a significantly higher mean dose in bitherapy in the seizure free group. Among the newer types, only levetiracetam and lamotrigine had a significantly higher DDD% in mono-, bi-, and polytherapy. Confirmed by logistic regression analysis, gender, age, type of epilepsy, and number of AEDs had a significant impact on the value of 75% DDD. Conclusion No significant unfavourable impact of the lower ratio of PDD/DDD on the outcome of achieving seizure freedom has been confirmed. As a measure of seizure freedom, 75% of DDD may be used, although individual therapy must be emphasised. Precisely quantified DDD would provide a more accurate calculation of other derived values.

Clinical outcomes after minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion for treatment of degenerative lumbar disease: a systematic review and meta-analysis

The surgical procedures used for arthrodesis in the lumbar spine for degenerative lumbar diseases remain controversial. This systematic review aims to assess and compare clinical outcomes along with the complications and fusion of each technique (minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) or minimally invasive lateral lumbar interbody fusion (MIS LLIF)) for treatment of degenerative lumbar diseases. Relevant studies were identified from Medline and Scopus from inception to July 19, 2016 that reported Oswestry Disability Index (ODI), back and leg pain visual analog score (VAS), postoperative complications, and fusion of either technique. Fifty-eight studies were included for the analysis of MIS-TLIF; 40 studies were included for analysis of LLIF, and 1 randomized controlled trial (RCT) study was included for comparison of MIS-TLIF to LLIF. Overall, there were 9506 patients (5728 in the MIS-TLIF group and 3778 in the LLIF group). Indirect meta-analysis, MIS-TLIF provided better postoperative back and leg pain (VAS), disabilities (ODI), and risk of having complications when compared to LLIF technique, but the fusion rate was not significantly different between the two techniques. However, direct meta-analysis between RCT study and pooled indirect meta-analysis of MIS-TLIF have better pain, disabilities, and complication but no statistically significant difference when compared to LLIF. In LLIF, the pooled mean ODI and VAS back pain were 2.91 (95% CI 2.49, 3.33) and 23.24 (95% CI 18.96, 27.51) in MIS approach whereas 3.14 (95% CI 2.29, 4.04) and 28.29 (95% CI 21.92, 34.67) in traditional approach. In terms of complications and fusion rate, there was no difference in both groups. In lumbar interbody fusion, MIS-TLIF had better ODI, VAS pain, and complication rate when compared to LLIF with direct and indirect meta-analysis methods. However, in terms of fusion rates, there were no differences between the two techniques.

Parkinsonian axial signs in schizophrenia

INTRODUCTION

We have recently demonstrated evidence of nigro-striatal denervation, disease progression and response to levodopa in a subgroup of patients with schizophrenia who developed parkinsonism.

OBJECTIVE

In the present study, we investigated whether axial parkinsonian signs might be an early manifestation of parkinsonism in schizophrenia not necessarily related to chronic administration of antipsychotic drugs (AP) drugs.

METHODS

From a baseline cohort of 299 schizophrenic patients who did not satisfy the diagnostic criteria for parkinsonism (presence of at least two of the following appendicular signs: bradykinesia, tremor, rigidity), we identified a group of patients who manifested two out of three axial parkinsonian signs (abnormality of trunk posture, hypomimia and short-step gait). Accordingly, we obtained two sub-groups of patients with schizophrenia, with (Schiz-Axial, N = 26), and without parkinsonian axial signs (Schiz-NO-Axial, N = 273). Clinical and demographical variables were compared between groups. The motor section of the Unified Parkinson's disease rating scale (UPDRS) was employed to measure motor disability.

RESULTS

Schiz-Axial patients were significantly older (p = 0.007) and had longer disease duration (p = 0.04) compared to Schiz-NO-Axial. The two groups did not differ for variables related to AP treatment. Total UPDRS motor score (p < 0.0001) as well as limb (p < 0.0001) and axial (p < 0.0001) UPDRS sub-scores were increased in Schiz-Axial patients compared to Schiz-NO-Axial.

CONCLUSIONS

Our findings provide evidence that axial parkinsonian signs might be an early manifestation of parkinsonism in schizophrenia associated to older age and longer disease duration.

Tracking pesticide use in the Saint Lawrence River and its ecological impacts during the World Exposition of 1967 in Montreal, Canada

We analyzed dated sediment cores for evidence of Rhothane (dichlorodiphenyldichloroethane; DDD) applications to the Saint Lawrence River at Montreal, QC, Canada for the World Exposition of 1967 (Expo 67). More than 16,000kg of this pesticide were applied between 1965 and 1967 to abate nuisance shadflies that threatened visitor enjoyment. Concentrations of DDD and DDE in Lake Saint-François, 70km upstream of Expo 67, reached 12.2 and 11.5μg/kg dry weight (dw), respectively, with clear peaks between 1945 and 1970, consistent with historical use patterns; DDT was not detected. In Lake Saint-Pierre, ~100km downstream, DDD and DDE concentrations were 2 to 5 times higher, exceeding sediment quality guidelines, and DDT concentrations were as high as 3.8μg/kg. Once normalized for grain size and organic carbon, peaks of DDD, DDE and DDT were observed between 1945 and 1990 in the sediment record. Ratios of DDD to DDE were 1.0 or less in Lake Saint-François, consistent with their formation as degradation products of DDT. In contrast, ratios exceeded 1.0 in Lake Saint Pierre between 1965 and 1970, coinciding with Rhothane applications at Expo 67. Downstream, subfossil diatom assemblages showed little response to DDD inputs, but the abundance of some chironomid taxa increased while others decreased in tandem with elevated DDD concentrations. Overall, contamination of river sediments and impacts on insect communities by DDD applications at Expo 67 were still evident in sediment records 100km downstream of Montreal.

Minimally invasive transaxial lumbosacral interbody fusion: a ten year single-centre experience

PURPOSE

Our aim was to evaluate mid- and long-term results in a cohort of patients who underwent minimally invasive transaxial lumbosacral fixation and to identify clinical and other parameters that can aid in proper patient selection.

METHODS

Over a period of ten years, we assessed 164 patients who had a complete follow-up of a minimum of one year (average 54 months). On follow-up, we recorded clinical status, fusion status, visual analogue scale (VAS), Oswestry Lower Back Pain Disability Index (ODI) scores and patient satisfaction.

RESULTS

There were no intra- or peri-operative complications. Overall clinical success rate was 73.8 %. Only sex (female), working status (still working), body mass index (BMI) (lower) and presence of Modic II changes (absent) were correlated with a good result.

CONCLUSIONS

Transaxial fixation is a safe, minimally invasive technique that can offer good results in patients with single-level degenerative disc disease (DDD) at the lumbosacral level, with minimal operative risk.