Appropriateness of antibiotic treatment in intravenous drug users, a retrospective analysis

<p>Abstract</p> <p>Background</p> <p>Infectious disease is often the reason for intravenous drug users being seen in a clinical setting. The objective of this study was to evaluate the appropriateness of treatment and outcomes for this patient population in a hospital setting.</p> <p>Methods</p> <p>Retrospective study of all intravenous drug users hospitalized for treatment of infectious diseases and seen by infectious diseases specialists 1/2001–12/2006 at a university hospital. Treatment was administered according to guidelines when possible or to alternative treatment program in case of patients for whom adherence to standard protocols was not possible. Outcomes were defined with respect to appropriateness of treatment, hospital readmission, relapse and mortality rates. For statistical analysis adjustment for multiple hospitalizations of individual patients was made by using a generalized estimating equation.</p> <p>Results</p> <p>The total number of hospitalizations for infectious diseases was 344 among 216 intravenous drug users. Skin and soft tissue infections (n = 129, 37.5% of hospitalizations), pneumonia (n = 75, 21.8%) and endocarditis (n = 54, 15.7%) were most prevalent. Multiple infections were present in 25%. Treatment was according to standard guidelines for 78.5%, according to an alternative recommended program for 11.3%, and not according to guidelines or by the infectious diseases specialist advice for 10.2% of hospitalizations. Psychiatric disorders had a significant negative impact on compliance (compliance problems in 19.8% of hospitalizations) in multiple logistic regression analysis (OR = 2.4, CI 1.1–5.1, p = 0.03). The overall readmission rate and relapse rate within 30 days was 13.7% and 3.8%, respectively. Both non-compliant patient behavior (OR = 3.7, CI 1.3–10.8, p = 0.02) and non-adherence to treatment guidelines (OR = 3.3, CI 1.1–9.7, p = 0.03) were associated with a significant increase in the relapse rate in univariate analysis. In 590 person-years of follow-up, 24.6% of the patients died: 6.4% died during hospitalization (1.2% infection-related) and 13.6% of patients died after discharge.</p> <p>Conclusion</p> <p>Appropriate antibiotic therapy according to standard guidelines in hospitalized intravenous drug users is generally practicable and successful. In a minority alternative treatments may be indicated, although associated with a higher risk of relapse.</p

Water relations of evergreen and drought-deciduous trees along a seasonally dry tropical forest chronosequence

Seasonally dry tropical forests (SDTF) are characterized by pronounced seasonality in rainfall, and as a result trees in these forests must endure seasonal variation in soil water availability. Furthermore, SDTF on the northern Yucatan Peninsula, Mexico, have a legacy of disturbances, thereby creating a patchy mosaic of different seral stages undergoing secondary succession. We examined the water status of six canopy tree species, representing contrasting leaf phenology (evergreen vs. drought-deciduous) at three seral stages along a fire chronosequence in order to better understand strategies that trees use to overcome seasonal water limitations. The early-seral forest was characterized by high soil water evaporation and low soil moisture, and consequently early-seral trees exhibited lower midday bulk leaf water potentials (ΨL) relative to late-seral trees (−1.01 ± 0.14 and −0.54 ± 0.07 MPa, respectively). Although ΨL did not differ between evergreen and drought-deciduous trees, results from stable isotope analyses indicated different strategies to overcome seasonal water limitations. Differences were especially pronounced in the early-seral stage where evergreen trees had significantly lower xylem water δ18O values relative to drought-deciduous trees (−2.6 ± 0.5 and 0.3 ± 0.6‰, respectively), indicating evergreen species used deeper sources of water. In contrast, drought-deciduous trees showed greater enrichment of foliar 18O (∆18Ol) and 13C, suggesting lower stomatal conductance and greater water-use efficiency. Thus, the rapid development of deep roots appears to be an important strategy enabling evergreen species to overcome seasonal water limitation, whereas, in addition to losing a portion of their leaves, drought-deciduous trees minimize water loss from remaining leaves during the dry season

Flecting Osteotomy of the Distal Tibia for Salvage of an Asymmetric Osteoarthritic Ankle Joint

Category: Ankle Arthritis Introduction/Purpose: Deformity of the distal tibia in the sagittal plane with increased posterior tilt of the articular surface (recurvatum deformity) results in altered biomechanics and high contact pressure in the anterior tibiotalar joint with consecutive osteoarthritis (OA). As the talus becomes anteriorly extruded out of ankle mortise, the distance between its center of rotation and longitudinal axis of tibia is typically seen to be increased. In an attempt to restore physiologic load of such misaligned ankles in the sagittal plane, we have started to use a correcting osteotomy of the distal tibia to realign the center of rotation of talus and tibial axis. The aim of this study was to analyze the radiological and clinical outcome in a consecutive series of patients. Methods: 39 patients (female, 12; male 27; age 47 [28 to 72, SD 10.6] years) were treated with a flecting osteotomy of the distal tibia for a symptomatic misalignment in the sagittal plane with the use of an anterior opening wedge osteotomy (n = 28), posterior closing wedge osteotomy (n = 9), or dome-shaped osteotomy from medially (n = 2). If necessary, simultaneous corrections in the frontal plane were performed to address additional valgus/varus deformities. Standard weight-bearing radiographs were used pre- and postoperatively to evaluate the tibial anterior surface angle (TAS), tibiotalar surface angle (TTS), tibial lateral surface angle (TLS), calcaneal pitch and talar offset ratio (TOR). A four-staged flecting score was used to classify the grade of OA of the tibiotalar joint in the sagittal plane, also taking the coronal joint congruency into account. Results: The cumulative survival rate of the joint was 77% (95% CI: 48-86%) after 3 years, with 9 patients needing a joint sacrificing procedure (total ankle arthroplasty, 7; ankle fusion, 2). In the remaining 30 patients, pain decreased 2.0 points on the VAS (p <0.001), and the AOFAS hindfoot score improved by 17 points (p<0.001). The ROM did not change significantly. Patient satisfaction with the outcome was good in 68% and moderate in 25%, 7% were not satisfied. The mean TLS increased by 6.6 (SD 5.84) degrees, the mean TOR decreased 0.239 (SD 0.1814). TAS, TTS and calcaneal pitch did not change significantly. Ten ankles (26%) showed an improvement, 22 (56%) no change and 7 (18%) a worsening in the flecting score. Conclusion: The flecting osteotomy of the distal tibia was found to be an effective method to restore the tibiotalar joint congruency through moving the tibia axis anteriorly to the center of rotation of the talus, and lengthening the lever arm of the Achilles tendon. Besides normalizing the joint reaction forces of the tibiotalar joint, the procedure was also found to be effective to stabilize the talus against anterior extrusion. However, with a failure rate of 23%, there is need for further studies to determine the indication and limitation of this procedure

Flecting Osteotomy of the Distal Tibia for Salvage of an Asymmetric Osteoarthritic Ankle Joint

Category: Ankle Arthritis Introduction/Purpose: Deformity of the distal tibia in the sagittal plane with increased posterior tilt of the articular surface (recurvatum deformity) results in altered biomechanics and high contact pressure in the anterior tibiotalar joint with consecutive osteoarthritis (OA). As the talus becomes anteriorly extruded out of ankle mortise, the distance between its center of rotation and longitudinal axis of tibia is typically seen to be increased. In an attempt to restore physiologic load of such misaligned ankles in the sagittal plane, we have started to use a correcting osteotomy of the distal tibia to realign the center of rotation of talus and tibial axis. The aim of this study was to analyze the radiological and clinical outcome in a consecutive series of patients. Methods: 39 patients (female, 12; male 27; age 47 [28 to 72, SD 10.6] years) were treated with a flecting osteotomy of the distal tibia for a symptomatic misalignment in the sagittal plane with the use of an anterior opening wedge osteotomy (n = 28), posterior closing wedge osteotomy (n = 9), or dome-shaped osteotomy from medially (n = 2). If necessary, simultaneous corrections in the frontal plane were performed to address additional valgus/varus deformities. Standard weight-bearing radiographs were used pre- and postoperatively to evaluate the tibial anterior surface angle (TAS), tibiotalar surface angle (TTS), tibial lateral surface angle (TLS), calcaneal pitch and talar offset ratio (TOR). A four-staged flecting score was used to classify the grade of OA of the tibiotalar joint in the sagittal plane, also taking the coronal joint congruency into account. Results: The cumulative survival rate of the joint was 77% (95% CI: 48-86%) after 3 years, with 9 patients needing a joint sacrificing procedure (total ankle arthroplasty, 7; ankle fusion, 2). In the remaining 30 patients, pain decreased 2.0 points on the VAS (p <0.001), and the AOFAS hindfoot score improved by 17 points (p<0.001). The ROM did not change significantly. Patient satisfaction with the outcome was good in 68% and moderate in 25%, 7% were not satisfied. The mean TLS increased by 6.6 (SD 5.84) degrees, the mean TOR decreased 0.239 (SD 0.1814). TAS, TTS and calcaneal pitch did not change significantly. Ten ankles (26%) showed an improvement, 22 (56%) no change and 7 (18%) a worsening in the flecting score. Conclusion: The flecting osteotomy of the distal tibia was found to be an effective method to restore the tibiotalar joint congruency through moving the tibia axis anteriorly to the center of rotation of the talus, and lengthening the lever arm of the Achilles tendon. Besides normalizing the joint reaction forces of the tibiotalar joint, the procedure was also found to be effective to stabilize the talus against anterior extrusion. However, with a failure rate of 23%, there is need for further studies to determine the indication and limitation of this procedure