Gram-negative osteomyelitis: clinical and microbiological profile

Introduction: Despite the growing interest in the study of Gram-negative bacilli (GNB) infections, very little information on osteomyelitis caused by GNB is available in the medical literature. Objectives and methods: To assess clinical and microbiological features of 101 cases of osteomyelitis caused by GNB alone, between January 2007 and January 2009, in a reference center for the treatment of high complexity traumas in the city of Sao Paulo. Results: Most patients were men (63%), with median age of 42 years, affected by chronic osteomyelitis (43%) or acute osteomyelitis associated to open fractures (32%), the majority on the lower limbs (71%). The patients were treated with antibiotics as inpatients for 40 days (median) and for 99 days (median) in outpatient settings. After 6 months follow-up, the clinical remission rate was around 60%, relapse 19%, amputation 7%, and death 5%. Nine percent of cases were lost to follow-up. A total of 121 GNB was isolated from 101 clinical samples. The most frequently isolated pathogens were Enterobacter sp. (25%), Acinetobacter baumannii (21%) e Pseudomonas aeruginosa (20%). Susceptibility to carbapenems was about 100% for Enterobacter sp., 75% for Pseudomonas aeruginosa and 60% for Acinetobacter baumannii. Conclusion: Osteomyelitis caused by GNB remains a serious therapeutic challenge, especially when associated to nonfermenting bacteria. We emphasize the need to consider these agents in diagnosed cases of osteomyelitis, so that an ideal antimicrobial treatment can be administered since the very beginning of the therapy. (C) 2012 Elsevier Editora Ltda. All rights reserved.

NONSPECIFIC INFECTIOUS DISEASES IN PREHISTORIC SAN PEDRO DE ATACAMA, NORTHERN CHILE

The region of San Pedro de Atacama, Northern Chile, has undergone several cultural and social changes after humans settled in Atacama Desert around 500 BC. The Atacameno people experienced the highest degree of social and cultural changes between 400 and 900 AD when they were assimilated into the Tiwanaku trade and political web that influenced most of the Central-Southern Andes. Under the influence of Tiwanaku, San Pedro de Atacama experienced its greatest economic development. Prior analyses of local human skeletal remains have shown a significant increase in the stature of the local population during the same period. In this paper, we investigate the impact of the Tiwanaku influence on the local epidemiological profile using the incidence of periostitis and osteomyelitis as indicators of biological stress. Surprisingly, the best epidemiological condition occurred during the final phase of influence of Tiwanaku (910-960 AD), and not during the apex influence (480-920 AD), as expected by the archaeological context. We suggest that population growth and aggregation may have counteracted the benefits of improved nutrition during the peak Tiwanaku influence. A severe drought occurred between 1,100 and 1,400 AD in Northern Chile. This could also explain the marked increase of bone infections in the post-Tiwanaku period (920-1,240 AD).

Skeletal abnormalities in humpback whales Megaptera novaeangliae stranded in the Brazilian breeding ground

Skeletal tissues of 49 humpback whales Megaptera novaeangliae that stranded between 2002 and 2011 along the Abrolhos Bank seashore and its adjacent waters in Brazil were studied. Twelve (24.5%) animals presented pathological changes in one or more bones. Degenerative changes and developmental malformations were most frequent (10.2% each), followed by inflammatory/infectious and traumatic lesions (8.2% each). Infectious diseases led to severe lesions of the caudal vertebrae of 2 whales. In one of these individuals, the lesions involved 6 caudal vertebrae, leading to ankylosis of 3 vertebrae. Degenerative changes were observed in the vertebral columns of 3 animals, involving the joints of 13 ribs of 1 individual, and in the humerus of 1 whale. Traumatic lesions, such as osseous callus in the ribs, were observed in 4 animals. In 1 whale, the rib showed severe osteomyelitis, possibly resulting from the infection of multiple fractures. Developmental abnormalities such as spina bifida on 3 cervical vertebrae of 1 whale, fusion of spinal processes on thoracic vertebrae of 1 individual and fusion of the first 2 ribs unilaterally or bilaterally in 4 animals were found. Chronic infectious conditions found in the axial skeleton may have restrained spinal mobility and had detrimental effects on the general health of the animals, contributing to stranding and death. To our knowledge, this is the first systematic study on skeletal lesions in stranded humpback whales.

Post-operative mediastinitis in a Heart Hospital of Recife: contributions for nursing care

The objective of this study was to determine the prevalence of post-operative mediastinitis with the purpose to contribute to nursing care knowledge. To do this, an analysis was performed on 896 medical records of patients who underwent heart surgery involving sternotomy at the Cardiology Emergency Room of Recife-PE, in the period between June 2007 and June 2009. The following variables were considered: gender, age, type of surgery, personal history, length of stay, use of antibiotics, and culture of the surgical wound. A high death rate from mediastinitis was observed (33.3%). Several risk factors were identified, including: systemic arterial hypertension (80.9%); smoking (61.9%); diabetes mellitus (42.8%); and obesity (33.3%), most of which (76.2%) were identified in patients who underwent surgery for myocardial revascularization. It is concluded that mediastinitis is a serious infection that needs continuous nursing supervision and preventive measures to assure an early diagnosis and, thus, reduce mortality.

DEVELOPMENT OF AN EXPERIMENTAL MODEL OF INFECTED BONE VOID IN THE ULNA OF RABBITS

Objective: Develop a model that allowed the study of bone regeneration in infection conditions. Method: A 15 mm defect was surgically created in the rabbit ulna and inoculated with 5x10(8) colony-forming units (CFU) of S. aureus. Surgical debridement was performed two weeks after and systemic gentamicin was administered for four weeks. Animals were followed up to 12 weeks to evaluate infection control and bone regeneration. Result: Bone regeneration was inferior to 25% of the defect in radiological and histological analysis. Conclusion: Infected bone defect of 15 mm in the rabbit ulna was unable to achieve full regeneration without further treatment. Level of Evidence V, Experimental Study.

Fatores de risco pré-operatórios para mediastinite após cirurgia cardíaca: análise de 2768 pacientes

INTRODUÇÃO: A esternotomia mediana longitudinal é a via de acesso mais utilizada no tratamento das doenças cardíacas. As infecções profundas da ferida operatória no pós-operatório das cirurgias cardiovasculares são uma complicação séria, com alto custo durante o tratamento. Diferentes estudos têm encontrado fatores de risco para o desenvolvimento de mediastinite e as variáveis pré-operatórias têm tido especial destaque. OBJETIVO: O objetivo deste estudo é identificar fatores de risco pré-operatórios para o desenvolvimento de mediastinite em pacientes submetidos a revascularização do miocárdio e a substituição valvar. MÉTODOS: Este estudo observacional representa uma coorte de 2768 pacientes operados consecutivamente. O período considerado para análise foi de maio de 2007 a maio de 2009 e não houve critérios de exclusão. Foi realizada análise univariada e multivariada pelo modelo de regressão logística das 38 variáveis pré-operatórias eleitas. RESULTADOS: Nesta série, 35 (1,3%) pacientes evoluíram com mediastinite e 19 (0,7%) com osteomielite associada. A idade média dos pacientes foi de 59,9 ± 13,5 anos e o EuroSCORE de 4,5 ± 3,6. A mortalidade hospitalar foi de 42,8%. Na análise multivariada, foram identificadas três variáveis como preditoras independentes de mediastinite: balão intra-aórtico (OR 5,41, 95% IC [1,83 -16,01], P=0,002), hemodiálise (OR 4,87, 95% IC [1,41 - 16,86], P=0,012) e intervenção vascular extracardíaca (OR 4,39, 95% IC [1,64 - 11,76], P=0,003). CONCLUSÃO: O presente estudo demonstrou que necessidade do suporte hemodinâmico pré-operatório com balão intra-aórtico, hemodiálise e intervenção vascular extracardíaca são fatores de risco para o desenvolvimento de mediastinite após cirurgia cardíaca.

Radiologic findings of osteoarticular infection in paracoccidioidomycosis

To report the radiological abnormalities of osteoarticular involvement in paracoccidioidomycosis (PCM). After institutional board approval, the medical records and conventional radiology findings of 19 patients with osseous PCM were retrospectively reviewed. Number, distribution, and lesion characteristics were evaluated in consensus by two experienced musculoskeletal radiologists. The mean age of patients was 16.1 years (range 4-49 years), 11 male and eight female. MSK involvement was the only or the primary presentation of the disease in eight of 19 patients (42.1%). In total, 51 focal bone lesions were detected, being 41 in long bones. In long bones lesions, 19 of 41 (46.4%) were metaphyseal, 12 of 41 (29.3%) meta-epiphyseal, and 12 of 41 (29.3%) diaphyseal. The most common presentation was a geographic osteolytic bone lesion (62.7%), without marginal sclerosis (82.4%) and without periosteal reaction (90.2%). Articular involvement was present in six of 19 patients (31.6%), being two cases of primary arthritis. All encountered bone lesions were osteolytic. Metaphyseal or meta-epiphyseal osteomyelitis of a long bone was the most prevalent osteoarticular manifestation of paracoccidioidomycosis. PCM osteoarticular involvement could be solitary or multifocal, occurs almost exclusively in the acute/subacute clinical form, and it is more common in children and in juvenile patients. Axial skeleton involvement, arthritis, or a disseminated osseous pattern of infection may occasionally occur in this fungal disease.

Association of laser phototherapy with PRP improves healing of bisphosphonate-related osteonecrosis of the jaws in cancer patients: A preliminary study

The aim of this study was to compare retrospectively the effect of three different treatments on the healing outcome of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in cancer patients. Twenty-two cancer patients were treated for BRONJ with one of the following protocols: clinical (pharmacological therapy), surgical (pharmacological plus surgical therapy), or PRP plus LPT (pharmacological plus surgical plus platelet rich plasma (PRP) plus laser phototherapy (LPT). The laser treatment was applied with a continuous diode laser (InGaAlP, 660 nm) using punctual and contact mode, 40 mW, spot size 0.042 cm(2), 6 J/cm(2) (6 s) and total energy of 0.24 J per point. The irradiations were performed on the exposed bone and surrounding soft tissue. The analysis of demographic data and risk factors was performed by gathering the following information: age, gender, primary tumor, bisphosphonate (BP) used, duration of BP intake, history of chemotherapy, use of steroids, and medical history of diabetes. The association between the current state of BRONJ (with or without bone exposure) and other qualitative variables was determined using the chi-square or Fisher's exact test. In all tests, the significance level adopted was 5%. Most BRONJ lesions occurred in the mandible (77%) after tooth extraction (55%) and in women (72%). A significantly higher percentage of patients reached the current state of BRONJ without bone exposure (86%) in the PPR plus LPT group than in the pharmacological (0%) and surgical (40%) groups after 1-month follow-up assessment. These results suggest that the association of pharmacological therapy and surgical therapy with PRP plus LPT significantly improves BRONJ healing in oncologic patients. Although prospective studies with larger sample sizes are still needed, this preliminary study may be used to inform a better-designed future study. (C) 2011 Elsevier Ltd. All rights reserved.