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Anterior cervical discectomy and fusion (ACDF) and anterior lumbar interbody fusion (ALIF) are common surgical procedures for degenerative disc disease of the cervical and lumbar spine. Over the years, many bone graft options have been developed and investigated aimed at complimenting or substituting autograft bone, the traditional fusion substrate. Here, we summarise the historical context, biological basis and current best evidence for these bone graft options in ACDF and ALIF.

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Object Autologous bone from the iliac crest is commonly used for spinal fusion. However, its use is associated with significant donor site morbidity, especially pain. Reconstructive procedures of the iatrogenic defect have been investigated as a technique to alleviate these symptoms. The goal of this study was to assess the effects of reconstruction versus no reconstruction following iliac crest harvest in adults undergoing spine surgery. Methods The authors searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4); MEDLINE (1948–Oct 2011); EMBASE (1947–Oct 2011); and the reference lists of articles. Randomized controlled trials (RCTs) or nonrandomized controlled trials (NRCTs) were included in the study. Two independent reviewers selected the studies, extracted data using a standardized collection form, and assessed for risk of bias. Results Three RCTs (96 patients) and 2 NRCTs (82 patients) were included. These had a moderate to high risk of bias. The results suggest that iliac crest reconstruction may be useful in reducing postoperative pain, minimizing functional disability, and improving cosmesis. No pattern of other clinical, radiological, or resource outcomes was identified. Conclusions Although the available evidence is suboptimal, this systematic review supports the notion that iliac crest reconstruction following harvest for spinal fusion may reduce postoperative pain, minimize functional disability, and improve cosmesis.

New Delhi metallo-betalactamase-producing Enterobacteriaceae in an Australian child who had not travelled overseas TO THE EDITOR: The editorial by Looke and colleagues in the 18 March 2013 issue of the Journal highlighted the increasing threat of gram-negative resistance. 1 Since its description in 2009, 2 gram-negative bacteria carrying the gene for New Delhi metallo-beta-lactamase-1 (NDM-1) production have been observed globally. To date, a small number of cases have been reported in adults in Australia. 3-5 3-5 In all cases, patients travelled to the Indian subcontinent; many required hospitalisation for their infection. We report the fi rst case of NDM-1producing Enterobacteriaceae in a young infant who had not travelled outside Australia. An Australian-born 3-week-old boy presented to hospital in 2013 with a 4-day history of cough, rhinorrhoea and vomiting. His mother had visited Pakistan and Afghanistan in 2011 and 2012, respectively. The mother had no relevant medical history and had not attended hospitals in either country. She had lived in Australia exclusively during pregnancy. Culture of a clean-catch urine sample grew more than 10 8 colonyforming units (CFU) per litre of Klebsiella pneumoniae (amoxycillin resistant, otherwise susceptible). The child was diagnosed with a urinary tract infection and treated with ceftriaxone and gentamicin followed by oral combined trimethoprim and sulfamethoxazole (co-trimoxazole). The child's symptoms resolved and imaging showed no structural anomaly. The child represented at 5 weeks of age with irritability and vomiting. A urine sample was taken, and the culture grew > 10 8 CFU/L of Enterobacter cloacae. Susceptibility testing was performed using agar dilution, Vitek2 and Etests (bioMérieux). Using Clinical and Laboratory Standards Institute breakpoints, the isolate was resistant to all β-lactam antibiotics, including meropenem, aminoglycosides, quinolones, cotrimoxazole and nitrofurantoin. The minimum inhibitory concentrations to colistin, tigecycline and fosfomycin were < 2 mg/L, < 4 mg/L and < 16 mg/L, respectively. Polymerase chain reaction-based investigation of β-lactamase production provided positive results for bla NDM-1 and bla CTX-M genes. The child was successfully treated with oral fosfomycin (100 mg/kg/day). This case highlights the emerging impact of NDM-1-producing bacteria. Given that the likely source was the mother or another household contact, this is an example of vertical or horizontal transmission in a country with low community prevalence of NDM-1-producing bacteria. In addition to an increased risk for patients previously receiving medical care overseas or returning from countries where there is a high risk of infection with gram-negative bacteria producing NDM-1, their children and household contacts are also at increased risk.

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