History Of Invasive Procedures Research Articles

Long-term cardiovascular outcomes and mortality with enzyme replacement therapy in patients with mucopolysaccharidosis type II.

Mucopolysaccharidosis type II (MPS II) is a rare multisystemic lysosomal disorder in which cardiac issues can lead to serious dysfunction and an increased risk of fatal cardiac failure. However, studies on major adverse cardiac event (MACE) outcomes in MPS II are lacking. This study evaluated the cardiovascular outcomes and impact of enzyme replacement therapy (ERT) in patients with MPS II in South Korea. In this national cohort study, utilizing data from the National Health Insurance Database, we evaluated 127 patients with MPS II over a 14-year period to investigate the effects of ERT on MACE and all-cause mortality. We tracked MACE incidence, defined by hospitalizations for cardiovascular events, from diagnosis and adjusted the hazard ratios for MACE using Cox modeling. Over an average follow-up period of 7.3 years, we identified 16 cases of MACE among patients (17.35 per 1000 person-years; 95% confidence interval, 10.74-26.83). Patients receiving ERT exhibited a significantly lower incidence of MACE than untreated patients, with cumulative incidences showing a marked difference of 8.3 years. Notably, initiating ERT at earlier stages post-diagnosis was associated with improved outcomes, underscoring the importance of timely treatment. The key risk factors for MACE included specific arrhythmias, a history of invasive procedures, and depression. Early ERT significantly reduced MACE risk and increased survival in patients with MPS II. This underscores the importance of prompt treatment initiation and comprehensive care to address key risk factors and advocates for an expanded therapeutic strategy to enhance MPS II outcomes.

Assessment of bacterial profile, antimicrobial susceptibility status, and associated factors of isolates among hospitalized patients at Dessie Comprehensive Specialized Hospital, Northeast Ethiopia

BackgroundAntimicrobial resistant bacteria among hospitalized patients are becoming a major public health threat worldwide, mainly in developing countries. Infections by these multidrug resistant pathogens cause high rate of mortality, prolong hospital stays, and affect individual and country economies in greater amounts. Thus, this study aimed to assess the bacterial profile, antimicrobial susceptibility status, and associated factors of isolates from hospitalized patients at the Dessie Comprehensive Specialized Hospital.MethodologyThis hospital-based cross-sectional study was conducted between February and April 2021. Consecutive sampling was used to select the study participants. All bacterial isolates were identified using standard bacteriological techniques. Antibiotic susceptibility testing was performed using disk diffusion technique. The data was analyzed using SPSS version 25. Descriptive statistics and logistic regression were used. A P-value of less than 0.05 was considered statistically significant.ResultsOf 384 clinical samples (blood, urine, stool, wound, vaginal discharge, and ear discharge) processed 180 (46.9%) were culture positive. Overall, Escherichia coli was the predominant isolate (41; 22.8%), followed by Staphylococcus aureus (36; 20%). Most of the isolates were from blood (70; 38.9%). The level of overall drug resistance of the gram-negative bacteria isolates for ampicillin, tetracycline, and cotrimoxazole was (104; 88.1%), (79; 75.9%), and (78; 75.0%), respectively. The overall multidrug rate of isolates was 143 (79.4%). Variables such as history of invasive procedures, chronic underlying diseases, history of hospitalization, and habit of eating raw animal products were statistically significant for the acquisition of bacterial infection.Conclusions and recommendationE. Coli and S. aureus were the most common isolates. Most of the isolates were resistant to commonly prescribed antibiotics. And also, consumption of raw animal products, chronic underlying disease, previous hospitalization, history of invasive procedures, and educational status were associated with the acquisition of bacterial infections. Therefore, routine antimicrobial susceptibility testing, proper patient management, wise use of antibiotics in clinical settings and health education are recommended.

Endogenous endophthalmitis with iridolenticular involvement – a case report and systematic review

Endogenous endophthalmitis (EE) is a sight- and life-threatening disease. EE associated with the involvement of iris and crystalline lens is an uncommon presentation. We reported a case of EE with iridolenticular involvement in a 19-year-old woman with a history of candidemia. Therapeutic vitrectomy with lensectomy was performed, and the patient was treated with intravitreal meropenem and amphotericin B. She was discharged with 6 weeks of oral fluconazole. At follow-up, her vision was 20/60 with aphakic correction. We also conducted a systematic review of the current literature to analyse the clinical features, risk factors, and outcomes of EE with iridolenticular involvement. The systematic review included 10 cases, and found that Candida albicans was the main causative organism. Intravenous drug use and a history of invasive procedures were important risk factors. 70% of the cases required vitrectomy and lensectomy. Post treatment, majority of the cases (80%) had a good visual prognosis of better than 20/60. Our results suggested that in cases of EE with iridolenticular involvement, early surgical removal of the infectious nidus via vitrectomy and lensectomy is recommended for a good visual outcome. A high level of suspicion is crucial in diagnosing the disease, and early aggressive therapy is fundamental.

Prevalence, Antimicrobial Susceptibility Patterns, and Risk Factors Associated with Enterococci among Pediatric Patients at Dessie Referral Hospital, Northeastern Ethiopia.

Background Enterococcus species, which is previously considered as medically not important, now becomes one of the leading causes of nosocomial infections. Even though it becomes the most public health concern and emerging multidrug-resistant pathogen, there is no enough data in the study area. Objective To determine the prevalence, antimicrobial resistance pattern, and associated risk factors of enterococci infection in pediatric patients. Methods A hospital-based cross-sectional study was conducted from February to May 2019 at Dessie Referral Hospital, Northeastern Ethiopia. A total of 403 pediatric patients were included in the study, and a pretested structured questionnaire was used to collect sociodemographic and risk factor-related data. Clinical samples such as urine, blood, wound swabs, discharges, and other body fluids were collected aseptically and inoculated on to Bile Esculin Azide Agar, and colony characteristics, Gram stain, catalase, salt, and temperature tolerance tests were employed for bacterial identification. Antimicrobial sensitivity tests were performed using the modified Kirby-Bauer disk diffusion method. Data was entered into SPSS software version 25 and descriptive statistics; bivariate and multivariate logistic regression analyses were performed. In all cases, a P value ≤ 0.05 with corresponding 95% confidence interval were considered as statistically significant. Result The overall prevalence of enterococci was 2.7% (11/403). Of which, the highest number of enterococci infection was recovered from urine sample (54.5%) followed by blood (27.3%), wound swab (9.1%), and other body fluids (9%). The overall multidrug resistance rate was 54.5%. Higher drug resistance pattern was observed against tetracycline, chloramphenicol, and amoxicillin/clavulanate. Having history of invasive procedure (P < 0.001), chronic illness (P < 0.001) and previous admission history of the children (P < 0.001) were statistically significant associated risk factors for pediatrics enterococci infection. Conclusion The prevalence of enterococci from pediatric patients in this study was relatively low compared to other studies. Significant rates of MDR and VRE were identified, and the risk of infection became high when children had a history of different chronic illnesses and history of admission and underwent invasive treatment procedures. Therefore, efforts should be made to prevent enterococci infections and spread of multidrug-resistant enterococci.

Fecal Carriage and Molecular Epidemiology of Carbapenem-Resistant Enterobacteriaceae from Inpatient Children in a Pediatric Hospital of Shanghai.

PurposeTo determine the epidemiology characteristics of intestinal colonization of carbapenem-resistant Enterobacteriaceae (CRE) among inpatients in a pediatric hospital in China.MethodsA retrospective study was conducted from April to December 2019. Medical records were reviewed to extract the clinical information. Antimicrobial susceptibility was performed by broth microdilution method. Drug resistance determinants and plasmid types were analyzed using polymerase chain reaction (PCR) assays. Multilocus sequence typing (MLST) and Enterobacterial repetitive intergenic consensus sequences PCR (ERIC-PCR) were employed to determine the genetic relationships between strains.ResultsA total of 90 CRE strains were isolated, with a fecal carriage rate of 8.6% (90/1052), and mainly distributed in E. aerogenes (n=30), K. pneumoniae (n=25) and E. coli (n=23). More than 50% of CRE colonizers had a history of invasive procedures and antibiotic exposures. As high as 91.1% (82/90) of CRE isolates carried carbapenemase genes, with blaNDM-5 (n=56) being the most common, and mainly found in E. aerogenes (51.8%, 29/56) and E. coli (32.1%, 18/56) isolates, which primarily belonged to ST4 (100%, 29/29) and ST692 (55.6%, 10/18), respectively. Followed by blaKPC-2 (n=12), and all found in K. pneumoniae ST11 isolates. Other carbapenemase genes including blaNDM-1, blaIMP-4 and blaIMP-26. Meanwhile, ESBL genes (blaCTX-M, blaTEM-1 and blaSHV) and AmpC genes (blaDHA-1 and blaEBC) were also detected. All CRE isolates showed high resistance to cephalosporins and carbapenemases (97.8%-100.0%) but remained susceptible to tigecycline (98.9%). IncX3 was a major plasmid type in NDM-containing strains (91.3%), and 91.7% of KPC-2-producing K. pneumoniae harboring IncFII and IncFIB plasmids. The ERIC-PCR revealed that several strains with identical STs were genetically similar.ConclusionThis study revealed a major intestinal colonization of ST4 NDM-5 E. aerogenes, ST11 KPC-2 K. pneumoniae and ST692 NDM-5 E. coli strains among inpatients in a pediatric hospital. Infection control measures should be implemented immediately to prevent the spread of these strains in clinical settings.

Isolation of Morganella Morganii and Providencia Species from Clinical Samples in a Tertiary Care Hospital in North India.

The members of the tribe Proteeae, Morganella and Providencia are being increasingly recognized as important pathogens. The spectrum of disease caused by them is wide and in reported cases, the mortality is high. Previously both of these pathogens were considered to be rare pathogens as the potential to cause nosocomial transmission and infection was not much studied. But their phenomenal evolution and increase in multidrug-resistance (MDR) strains of these pathogens are posing a major threat toward public health throughout the world. This present study was carried out from July 2018 to December 2018 on all the pus and body fluid samples that were received in the Department of Microbiology. Samples were processed as per the standard Microbiological guidelines and also were analyzed for their antimicrobial susceptibility profile as per Clinical Laboratory Standards Institute. Out of 8425 samples received, 2140 were culture positive, amongst which 19 samples (0.89%) were positive for Providencia species (9) and Morganella morganii(10). The male : female ratio of these 19 patients was 2.8 : 1 and maximum patients (13) belonged to 20-60 years. As far as risk factors are concerned, maximum patients were diabetics (7) followed by abnormal liver function tests (6), concomitant UTI (6), history of invasive procedure (5), prior exposure to antibiotics (5) and urinary catheterization (4). About 6 were polymicrobial infections. Antibiotic susceptibility patterns revealed that Providencia strains were sensitive to ampicillin- sulbactum (77.7%) and amikacin (77.7%), while all Morganella strains were 100% sensitive to tobramycin and piperacillintazobactam. This study heralds in need for more research in this area as infections caused by these two pathogens are on the rise. Moreover, resistance to antimicrobials is also an increasingly common problem thus delaying the treatment and prognosis of the disease.

English

Hepatitis B infection (HBV) infection is a serious public health problem worldwide and its co-infection with human immune deficiency virus (HIV) is common due to shared routes of transmission. An increased mortality due to accelerated hepatic disease progression and the frequent hepatotoxicity caused by antiretroviral therapy are the challenges in the clinical management of HIV. Epidemiological studies on HBV and HBV/HIV co infection are scarce in Ethiopia, particularly at the study area. The aim of this study was to determine the magnitude of HBV, its risk factors and co-infection with HIV among clients of a voluntary counseling and testing (VCT) center in Southern Ethiopia. A facility based cross-sectional study was conducted from 1st February 2016 to 15th March among clients of Nigist Eleni Memorial Hospital VCT Center. Data were collected by face-to-face interview and specific formula sheet as well recorded results of laboratory diagnosis of blood sample from each participant. Both descriptive and inferential statistics were used for data analysis. Multivariable logistic regression modeling was done to identify predictors of HBV. Overall, 331 participants were included in the study. The prevalence of HBV was 8.8%, HBV/HIV co-infection was found in 3.6%. Individuals with a history of multiple sexual partner [AOR = 10.3; 95% CI, 3.71 - 28.83], previous history of invasive procedure [adjusted odds ratio (AOR) = 10.88; 95% CI, 3.84 - 30.86] and history of surgical procedure [AOR = 9.2; 95% CI, 3.1 - 27.88] were identified as in dependent predictors of HBV infection. High HBV infection and HBV/HIV co-infection was found in the study. Previous history of surgical procedure, invasive procedure and multiple sexual partners were identified as independent predictor of HBV infection. Key words: Hepatitis B virus (HBV), human immune deficiency virus, HBV-HIV co-infection, risk factors, Hosanna.

Correlates of posttraumatic stress disorder in adults with congenital heart disease.

The aims of this study were to compare the level of posttraumatic stress disorder between adults with and without congenital heart disease, and to examine the correlates of posttraumatic stress disorder (e.g., sociodemographics). Cross-sectional. Two university-affiliated heart hospitals in Tehran, Iran. A sample of 347 adults with congenital heart disease aged 18-64 years (52% women), and 353 adults without congenital heart disease matched by sex and age (±2 years) was recruited. The PTSD Scale: Self-report version was used to assess the diagnosis and severity of posttraumatic stress disorder. Hierarchical multivariate logistic regression analyses were performed to explore correlates of likely posttraumatic stress disorder diagnosis among each group of participants. The posttraumatic stress disorder in the patients was comparable to those of the control group, except for increased arousal (P = .027) which was scored higher among the patients. Over 52% of adults with congenital heart disease met the criteria for a likely posttraumatic stress disorder diagnosis compared with 48% of adults without congenital heart disease. The regression analyses among patients revealed that elevated depressive symptoms (OR = 1.27) and a positive history of cardiac surgery (OR = 2.02) were significantly associated with posttraumatic stress disorder. The model could explain 29% of the variance in posttraumatic stress disorder. The high and comparable prevalence of posttraumatic stress disorder among patients and nonpatients highlight the significance of the context in which adults with congenital heart disease may face other/additional stressors than disease-related ones, an issue that clinicians need also take into account. Furthermore, the association of posttraumatic stress disorder with elevated depressive symptoms warrant a comprehensive psychological assessment and management of adults with congenital heart disease, in particular among those with a history of invasive procedures.

Bacteremia and other body site infection caused by hypervirulent and classic Klebsiella pneumoniae.

To investigate bacteremia and other body site infection caused by hypervirulent Klebsiella pneumoniae (hvKP), a recently recognized pathogen of invasive infection, and classic Klebsiella pneumoniae (cKP), a very common organism associated with many kinds of nosocomial infection. Clinical information obtained from patients with both bacteremia and other body site infections caused by hvKP and/or cKP was retrospectively reviewed. Homo-hvKP (or homo-cKP) was defined as homologous hvKP (or cKP) strains from different body sites in each individual patient according to string test, virulence gene amplification and PFGE pattern. MLST was carried on to understand the correlation of sequence type with capsular polysaccharide type for Klebsiella pneumoniae from blood. Sixty-four hvKP and 101 cKP strains were isolated from blood and other body sites of 76 patients who had bacteremia accompanied by other site infection. Among these patients, 27 were infected with homo-hvKP, 32 were with homo-cKP, 12 were with heterogeneous cKP, and five were with both hvKP and cKP. Patients with bacteremia and liver abscesses caused by homo-hvKP accounted for 51.9%, and 92.6% of homo-hvKP infected patients did not receive any invasive procedures before bacteremia. However, patients with bacteremia and biliary tract infection caused by homo-cKP accounted for 34.4%, and 78.1% of homo-cKP infected patients had history of invasive procedures before bacteremia. More homo-hvKP strains (59.3%) than homo-cKP strains (34.4%) were isolated from blood earlier than other sites. HvKP strains were statistically more susceptible to the tested antimicrobials than cKP strains. An outbreak of carbapenem-resistant cKP infection and possible gene transfer of KPC-2 from cKP to hvKP were brought to notice. Both hvKP and cKP could cause bacteremia and other body site infection. But patients with hvKP bacteremia usually suffered from liver abscess without previous invasive procedures, most patients with cKP bacteremia had history of invasive medical procedures.

Epidemiology and risk factors for faecal extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage derived from residents of seven nursing homes in western Shanghai, China.

Nursing homes (NHs) have been implicated as significant reservoirs of antibiotic-resistant organisms causing severe infectious disease. We investigated the prevalence and molecular epidemiology of, and risk factors for, faecal carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E). A multicentre cross-sectional study was conducted in seven NHs in Shanghai between March 2014 and May 2014. Antimicrobial susceptibility testing and polymerase chain reaction were used to detect genes coding for ESBLs and carbapenemases. NH records at individual-resident level and facility level were examined for potential risk factors. Four hundred and fifty-seven Enterobacteriaceae isolates were collected of which 183 (46·92%) were colonized by ESBL-E. CTX-M enzymes (198/200, 99%) predominated, with CTX-M-14 (84/200, 42%) the most common types. Two carbapenemase producers harboured blaKPC-2. Resistance rates to carbapenems, TZP, AK, FOS, CL and TGC were low. History of invasive procedures [odds ratio (OR) 2·384, 95% confidence interval (CI) 1·318-4·310, P = 0·004], narrow-spectrum cephalosporins (OR 1·635, 95% CI 1·045-2·558, P = 0·031) and broad-spectrum cephalosporins (OR 3·276, 95% CI 1·278-8·398, P = 0·014) were independently associated with ESBL-E carriage. In conclusion, NH residents have a very high prevalence of faecal carriage of ESBL-E. Continuous and active surveillance is important, as are prudent infection control measures and antibiotic use to prevent and control the spread of these antibiotic-resistant strains.

Opening the medial tibiofemoral compartment by pie-crusting the superficial medial collateral ligament at its tibial insertion: A cadaver study

BackgroundArthroscopic treatment of tears in the middle and posterior parts of the medial meniscus can be difficult when the medial tibiofemoral compartment is tight. Passage of the instruments may damage the cartilage. The primary objective of this cadaver study was to perform an arthroscopic evaluation of medial tibiofemoral compartment opening after pie-crusting release (PCR) of the superficial medial collateral ligament (sMCL) at its distal insertion on the tibia. The secondary objective was to describe the anatomic relationships at the site of PCR (saphenous nerve, medial saphenous vein). Material and methodWe studied 10 cadaver knees with no history of invasive procedures. The femur was held in a vise with the knee flexed at 45°, and the medial aspect of the knee was dissected. PCR of the sMCL was performed under arthroscopic vision, in the anteroposterior direction, at the distal tibial insertion of the sMCL, along the lower edge of the tibial insertion of the semi-tendinosus tendon. Continuous 300-N valgus stress was applied to the ankle. Opening of the medial tibiofemoral compartment was measured arthroscopically using graduated palpation hooks after sequential PCR of the sMCL. ResultsThe compartment opened by 1mm after release of the anterior third, 2.3mm after release of the anterior two-thirds, and 3.9mm after subtotal release. A femoral fracture occurred in 1 case, after completion of all measurements. Both the saphenous nerve and the medial saphenous vein were located at a distance from the PCR site in all 10 knees. DiscussionPCR of the sMCL is chiefly described as a ligament-balancing method during total knee arthroplasty. This procedure is usually performed at the joint line, where it opens the compartment by 4–6mm at the most, with some degree of unpredictability. PCR of the sMCL at its distal tibial insertion provides gradual opening of the compartment, to a maximum value similar to that obtained with PCR at the joint space. The lower edge of the semi-tendinosus tendon is a valuable landmark for PCR of the distal sMCL.

Molecular and Epidemiological Characterization of IMP-Type Metallo-β-Lactamase-Producing Enterobacter cloacae in a Large Tertiary Care Hospital in Japan

IMP-type metallo-β-lactamase enzymes have been reported in different geographical areas and in various Gram-negative bacteria. However, the risk factors and epidemiology pertaining to IMP-type metallo-β-lactamase-producing Enterobacter cloacae (IMP-producing E. cloacae) have not been systematically evaluated. We conducted a retrospective, matched case-control study of patients from whom IMP-producing E. cloacae isolates were obtained, in addition to performing thorough molecular analyses of the clinically obtained IMP-producing E. cloacae isolates. Unique cases with IMP-producing E. cloacae isolation were included. Patients with IMP-producing E. cloacae were matched to uninfected controls at a ratio of 1 to 3. Fifteen IMP-producing E. cloacae cases were identified, with five of the isolates being obtained from blood, and they were matched to 45 uninfected controls. All (100%) patients from whom IMP-producing E. cloacae isolates were obtained had indwelling devices at the time of isolation, compared with one (2.2%) uninfected control. Independent predictors for isolation of IMP-producing E. cloacae were identified as cephalosporin exposure and invasive procedures within 3 months. Although in-hospital mortality rates were similar between cases and controls (14.3% versus 13.3%), the in-hospital mortality of patients with IMP-producing E. cloacae-caused bacteremia was significantly higher (40%) than the rate in controls. IMP-producing E. cloacae isolates were frequently positive for other resistance determinants. The MICs of meropenem and imipenem were not elevated; 10 (67%) and 12 (80%) of the 15 IMP-producing E. cloacae isolates had a MIC of ≤ 1 μg/ml. A phylogenetic tree showed a close relationship among the IMP-producing E. cloacae samples. Indwelling devices, exposure to cephalosporin, and a history of invasive procedures were associated with isolation of IMP-producing E. cloacae. Screening for carbapenemase production is important in order to apply appropriate clinical management and infection control measures.

Prevalence of Hepatitis B surface antigen (HBsAg) among visitors of Shashemene General Hospital voluntary counseling and testing center

BackgroundHepatitis B virus (HBV) infection is significant health problem, as it can lead to chronic hepatitis, liver cirrhosis, and hepatic carcinoma. Due to shared routes of transmission, HBV and human immunodeficiency virus (HIV) co-infection is common and is an emerging concern in the clinical management of patients because of increased mortality, accelerated hepatic disease progression, and the frequent hepatotoxicity caused by anti-retroviral therapy. The aim of this study was to determine the prevalence of Hepatitis B surface antigen (HBsAg) and its risk factors, among individuals visiting Shashemene General Hospital VCT center.FindingsInstitution based cross-sectional study was performed from November 3, 2008 to December 29, 2008 and 384 voluntary counseling and testing (VCT) clients were investigated. Data on socio demographic and HBV risk factors was collected using structured questionnaires. Blood samples were collected and screened for hepatitis B surface antigen (HBsAg) and HIV by commercially available rapid test kits. The prevalence of HBsAg in this study group was 5.7%. Fourteen percent of HIV positive subjects (8/57) and 4.3% (14/327) of HIV negative subjects were positive for HBsAg. Significantly high prevalence of HBsAg was observed among individuals who had history of invasive procedures, like tooth extraction, abortion and ear piercing; history of hospital admission, history of unsafe inject and HIV positives.ConclusionsAlthough HBsAg prevalence is much higher among subjects who are HIV positive (14.0% versus 4.3%), the prevalence of HBsAg in HIV negative subjects is high enough to warrant a recommendation to screen all clients at VCT centers irrespective of HIV status.

Hafnia alvei pyelonephritis in a renal transplant recipient: case report and review of an under‐recognized nosocomial pathogen

We describe the first case to our knowledge of Hafnia alvei pyelonephritis in a renal transplant recipient. Clinicians should consider this under-recognized pathogen when clinically evaluating immunosuppressed patients with a history of invasive procedures.

Enhanced surveillance of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in children in the UK and Ireland

ObjectiveTo determine the incidence and demographic features of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in children in the UK and Ireland and to characterise MRSA isolated from cases.DesignProspective surveillance study.SettingChildren aged...

Fatal intracranial haemorrhage associated with the administration of low-molecular-weight-heparin in a child

Strokes due to cardioembolism are in general severe and prone to early recurrence. Current recommendations for children with cardioembolic stroke include treatment for 5 to 7 days with low-molecular-weight-heparin (LMWH) [7]. We present a case of fatal intracranial haemorrhage associated with LMWH therapy in a child. A 14-month-old boy with Down syndrome had an acute stroke. The CT scan showed a non-haemorrhagic infarct of the entire right middle cerebral artery territory without signs of septic emboli or aneurysms. Echocardiography revealed a thrombus in the left atrium. Clotting evaluation showed, except for a mild thrombocytopenia of 90·10/l, no abnormalities (APTT 41 s, INR 1.21). Anticoagulation therapy was started with subcutaneous nadroparine (110 IE/kg) twice daily [8]. In addition, antibiotics for a later confirmed endocarditis, were started. After 2 days, the intracardiac thrombus was no longer detectable whereas the nadroparine was continued. In addition, his platelet count normalised. Six days later he had a cardiac arrest for which he was successfully resuscitated. A CT scan showed a massive intraventricular and subarachnoidal haemorrhage not related to the earlier ischaemic infarction. Clotting evaluation immediately after the incident revealed a platelet count of 234·10/l, an APTT of 60 s, and an INR of 1.68. Eventually, treatment was discontinued because he met brain death criteria. Other causes for the intracranial haemorrhage like effect of other medication were unlikely and there was also no history of invasive procedures or trauma during hospitalisation. In addition, impaired haemostasis was not found. Reported major bleeding complications during LMWH therapy for thromboembolic events in paediatric patients are approximately 5% [1, 5,6]. In a single-institution cohort study of 146 courses of therapeutic LMWH (enoxaparin) for various types of thrombotic diseases, two deaths were directly related to the safety and efficacy of enoxaparin [1]. In the REVIVE trial LMWH (reviparin-sodium), one death was reported in the LMWH group which was not related to the therapy [6]. In general, LMWH therapy is considered to be safe; however, recently significant and potentially fatal haemorrhagic complications have been reported in adults comparable with this case report [4]. An important issue is to carefully (re)evaluate when to start LMWH therapy in children with cardioembolic stroke. The aim of secondary prophylaxis is to balance the risk of recurrent embolism and haemorrhagic transformation of an infarction [2,7]. Studies in adults clearly show that there is no support for routine immediate anticoagulation of acute (cardioembolic) stroke. Anticoagulants do not decrease death or dependency, change progression, or prevent early recurrence in acute stroke due to cardioembolism [2]. Recommendations for antithrombotic therapy in cardioembolic stroke in paediatric patients do not correspond with this [7]. Treatment recommendations are based on grade 2C evidence, obtained in small case series or case reports [3]. Unfortunately, there have been no randomised clinical trials for primary prevention, short-term treatment, or secondary prevention of ischaemic stroke in infants and children. A properly designed clinical trial is therefore urgently required to address these issues and to determine the true incidence of major bleeding and to identify potential risk factors. M. van Heerde AE F. B. Plotz (&) Department of Paediatric Intensive Care, VU University Medical Centre, PO Box 7057, 1007 MB Amsterdam, The Netherlands E-mail: fb.plotz@vumc.nl Tel.: +31-20-4442413 Fax: +31-20-4443045

Epidural spinal abscess following dental extraction – a rare and potentially fatal complication

A 20-year-old woman was referred to the maxillofacial unit by her orthodontist for the extraction of four erupted first premolar teeth as a prelude to orthodontic treatment. The extractions were carried out under general anaesthesia with endotracheal intubation as a day case. There were no anaesthetic or surgical complications. All four teeth were free of caries and required uncomplicated forceps extraction. The patient returned to the unit 3 days later complaining of a stiff neck on the right side. This had started the day after the dental extractions. A constant throbbing pain had kept her awake at night. Examination showed tenderness of the right sternocleidomastoid and trapezius muscles. There were no intraoral signs of infection. A cervical collar was provided and the patient prescribed simple analgesics, rest, and home massage for musculoskeletal pain. On the fifth postoperative day the patient presented to the accident and emergency department with increasing pain in the right side of the neck. Clinical examination showed no neurological deficit and plain radiographs showed no abnormality. A diagnosis of occipital neuralgia as a result of positioning for general anaesthesia was made and physiotherapy and analgesia advised. The patient returned to the accident and emergency unit on the tenth postoperative day complaining of continuing deterioration with increasing neck pain and tingling in the right arm. There was no neurological deficit but tenderness over the cervical spine was noted. Further analgesia and physiotherapy were recommended. Three days later (the 13th postoperative day) she collapsed at home and was admitted to hospital as an emergency. She had increased pain in her neck, numbness of the right arm, and weakness of the right arm and leg. She held her neck stiffly and had bruises on the right arm and leg. She had a fever of 38.9 ◦C. Neurological examination showed reduced sensation in the right arm, greater in the ulna nerve distribution than in the radial. Power in the right arm and leg was reduced to grade 1/5 with right ankle clonus. The right pupil was constricted with little reaction to light. There was no history of urinary or faecal incontinence. She was admitted for blood tests, a lumbar puncture, and computed tomography (CT) of the head. The laboratory findings included a serum C-reactive protein concentration of 532 mg/l, erythrocyte sedimentation rate of 66 mm/in the first hour, and a white cell count of 11.5× 109/l. Cefotaxime and flucloxacillin were given intravenously for presumed bacterial meningitis. The CT showed no evidence of any intracranial lesion. The cerebrospinal fluid had 20 white cells/mm3, predominantly lymphocytes, and total protein concentration of 4.15 g/l, suggestive of severe infection. Magnetic resonance imaging (Fig. 1) was done later the same day and confirmed a large spinal epidural abscess extending from the third to the sixth cervical vertebrae predominantly on the right side. The patient was transferred to the regional neurosurgical unit and had right hemilaminectomy of C1, C2, and C3 vertebrae. A few drops of pus were noted, which yielded Streptococcus milleri on culture. There was no infective focus for metastatic spread and no history of invasive procedures that were likely to cause a transient bacteraemia other than the recent dental extractions. A further elective procedure was carried out 5 months later and C4, C5, and C6 hemilaminectomy and vertebrectomy were done with iliac crest bone grafting and buttress plate placement. Twenty-three months after the dental extractions, she presented again with a throbbing frontal headache. CT confirmed a frontal intracranial haemorrhage which was thought to have been related to her previous infection. The patient died.

Epidemiology of hepatitis C virus infection in patients with renal disease.

This study was carried out to determine the prevalence of hepatitis C virus (HCV) antibodies and the epidemiologic factors associated with HCV infection in patients with chronic renal failure before the onset of ESRD. Sex, age, type of renal disease, level of renal function, and history of blood transfusions and invasive procedures were analyzed in 226 patients with renal disease, compared with a population of 1,244 normal subjects and 124 patients with impaired immunity (patients having autoimmune diseases and receiving chemotherapy treatment). Eighteen seropositive patients with renal disease (prevalence, 7.9%) were found, which was significantly higher than the prevalence in the normal population (1.03% in blood donors, 0.98% in pregnant women; P < 0.001, chi 2). There was no significant association of sex, number of blood transfusions, or history of invasive procedures with the presence of HCV antibodies. The prevalence of HCV antibodies was higher (16.6%) in patients with glomerulonephritis compared with patients diagnosed with interstitial nephritis, pyelonephritis, nephrosclerosis, diabetes mellitus, polycystic kidney, and miscellaneous renal diseases (P < 0.01, chi 2). There was a higher prevalence of HCV antibodies in patients with creatinine clearance lower than 30 mL/min (13%) compared with patients with creatinine clearance higher than 30 mL/min (2.7%) (P < 0.01, chi 2). These data suggest that HCV infection may be associated with the pathogenesis of glomerulonephritis. Alternatively, glomerulonephritis or severe renal insufficiency may increase the likelihood of HCV infection.