Active surveillance testing to identify and isolate asymptomatic carriers of toxigenic Clostridium difficile has been limited by the lack of a test that is sensitive, specific, and timely enough to serve as an infection control tool. We tested DNA preamplified from perirectal surveillance specimens in a liquid medium selective for C. difficile by using a modified commercial real-time PCR assay. All fermenting specimens were subcultured, and isolates were tested for toxigenicity. Culture-positive toxigenic isolates served as the gold standard for comparison with the broth preamplification/PCR assay. The limit of detection for the assay was 1 CFU. Relative to toxigenic anaerobic culture, the sensitivity, specificity, and positive and negative predictive values of this assay were 70/70 (100.0%), 422/426 (99.1%), 70/74 (94.6%), and 422/422 (100.0%), respectively. These data demonstrate that selective broth preamplification and real-time PCR of perirectal swab specimens constitute a practical approach to the detection of asymptomatic C. difficile carriage.Anaerobic culture of rectal swabs has previously been shown to be as sensitive as stool culture for the detection of Clostridium difficile (6) and was used as the primary screen for C. difficile carriage in a study by McFarland et al. (7). Although this method is suitable for surveillance studies, anaerobic culture of rectal swabs for C. difficile followed by confirmation of toxin production by a cytotoxicity assay (toxigenic culture) is labor-intensive, with a turnaround time of 5 to 10 days, too long to be of use in real-time diagnosis or to guide infection control isolation decisions.The development of FDA-approved commercial real-time PCR assays for C. difficile has improved the timeliness of diagnosis of C. difficile infections (CDI) relative to that with both toxigenic culture and cell culture cytotoxicity assays, but the sensitivity of PCR assays has ranged between 77.3 and 86% compared to toxigenic culture (4, 9, 13-15). We sought to develop a PCR-based test that combines the sensitivity of toxigenic culture with the timeliness of real-time PCR and that could be performed on swab specimens in a clinical microbiology lab. MATERIALS AND METHODSSetting. All specimens tested were perirectal swabs (BBL CultureSwab Plus Amies medium without charcoal; Becton Dickinson, Sparks, MD) obtained for vancomycin-resistant enterococcus (VRE) surveillance testing at UPMC Presbyterian, a 766-bed tertiary-care teaching facility affiliated with the University of Pittsburgh Schools of the Health Sciences. The criteria for VRE screening were as follows: for admission cultures, VRE testing was performed for patients admitted from other hospitals or from long-term care facilities or patients admitted to rehabilitation and transitional care units; for weekly cultures, patients in contact isolation for methicillin-resistant Staphylococcus aureus (MRSA), C. difficile, or other multidrug-resistant organisms (MDRO), patients whose length of stay exceeded 20 days, patients whose length o...

This study further characterizes the association between video game playing and surgical performance. Improvements following the intervention were made in the most basic of surgical skills, most notably with the nondominant hand, suggesting that short-term playing of the Wii could improve bimanual dexterity and expedite the acquisition of basic surgical skills.

This review of the literature will focus on the indications, surgical techniques, and outcomes for expandable transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), and lateral lumbar interbody fusion (LLIF) operations. The expandable TLIF cage has become a workhorse for common degenerative pathology, whereas expandable ALIF cages carry the promise of greater lordotic correction while evading the diseased posterior elements. Expandable LLIF cages call upon minimally invasive techniques for a retroperitoneal, transpsoas approach to the disc space, obviating the need for an access surgeon and decreasing risk of injury to the critical neurovascular structures. Nuances between expandable and static cages for all 3 TLIF, ALIF, and LLIF operations are discussed in this review.

Background: Fluorescence-guided surgery (FGS) using 5-aminolevulic acid (5-ALA) is a widely used strategy for delineating tumor tissue from surrounding brain intraoperatively during high-grade glioma (HGG) resection. 5-ALA reaches peak plasma levels ~4 h after oral administration and is currently approved by the FDA for use 2–4 h prior to induction to anesthesia.Objective: To demonstrate that there is adequate intraoperative fluorescence in cases undergoing surgery more than 4 h after 5-ALA administration and compare survival and radiological recurrence to previous data.Methods: Retrospective analysis of HGG patients undergoing FGS more than 4 h after 5-ALA administration was performed at two institutions. Clinical, operative, and radiographic pre- and post-operative characteristics are presented.Results: Sixteen patients were identified, 6 of them female (37.5%), with mean (SD) age of 59.3 ± 11.5 years. Preoperative mean modified Rankin score (mRS) was 2 ± 1. All patients were dosed with 20 mg/kg 5-ALA the morning of surgery. Mean time to anesthesia induction was 425 ± 334 min. All cases had adequate intraoperative fluorescence. Eloquent cortex was involved in 12 cases (75%), and 13 cases (81.3%) had residual contrast enhancement on postoperative MRI. Mean progression-free survival was 5 ± 3 months. In the study period, 6 patients died (37.5%), mean mRS was 2.3 ± 1.3, Karnofsky score 71.9 ± 22.1, and NIHSS 3.9 ± 2.4.Conclusion: Here we demonstrate that 5-ALA-guided HGG resection can be performed safely more than 4 h after administration, with clinical results largely similar to previous reports. Relaxation of timing restrictions could improve procedure workflow in busy neurosurgical centers, without additional risk to patients.

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