Correspondence
outcomes for this population. In view of the very large size of the surgical population, such measures might lead to a substantial reduction in the number of deaths. We declare that we have no conflicts of interest.
*Rupert Pearse, Andreas Hoeft, Rui P Moreno, Paolo Pelosi, Andrew Rhodes [email protected] Adult Critical Care Unit, Barts and the London School of Medicine and Dentistry, Queen Mary’s University of London, Royal London Hospital, London E1 1BB, UK (RP); Department of Anaesthesiology, University of Bonn, Bonn, Germany (AH); UCINC, Hospital de São José, Centro Hospitalar de Lisboa Central, EPE, Lisbon, Portugal (RPM); IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy (PP); and St George’s University of London, London, UK (AR) 1
2
3
4
5
Pearse RM, Moreno RP, Bauer P, et al, for the European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology. Mortality after surgery in Europe: a 7 day cohort study. Lancet 2012; 380: 1059–65. Noordzij PG, Poldermans D, Schouten O, Bax JJ, Schreiner FA, Boersma E. Postoperative mortality in The Netherlands: a populationbased analysis of surgery-specific risk in adults. Anesthesiology 2010; 112: 1105–15. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: 139–44. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360: 1418–28. Pearse R, Moreno RP, Bauer P, et al. Mortality after surgery in Europe—Authors’ reply. Lancet 2013; 381: 370–71.
E anophelis outbreak in an intensive-care unit We read with interest Jeanette Teo and colleagues’ report (Sept 7, p 855)1 of the first outbreak of Elizabethkingia anophelis identified by 16SrRNA sequencing and whole-genome alignment. The subgroup of isolates had been previously identified as Elizabethkingia meningoseptica on the basis of matrixassisted laser desorption-ionisation time-of-flight (MALDITOF) mass spectrometry analysis. The history of this microorganism starts with its description as a cause of 2064
infant meningitis by Elizabeth O King at the US Centers for Disease Control and Prevention (CDC). She first isolated an organism referred to as CDC group IIa in 1959 and named it Flavobacterium meningosepticum. It was subsequently renamed Chryseobacterium meningosepticum, and classified in the new genus Elizabethkingia, in 2005.2 We believe that modern techniques (such as MALDITOF and sequencing) might generate more and more pseudo first outbreaks. Outbreaks of F meningosepticum, C meningosepticum, and E meningoseptica have been described in several patient settings, including intensive-care units.3–5 Thus, what is new here, except the name? To be considered as new outbreaks, future reports should describe a new source or pathway of transmission and not merely one that appears new because of the diagnostic methods presently used. We declare that we have no conflicts of interest.
*Andreas Voss, Jan Kluytmans, Eli Perencevich [email protected] Radboud University Nijmegen Medical Centre and Canisius-Wilhelmina Hospital, Department of Medical Microbiology and Infectious Diseases, 6500 GS Nijmegen, Netherlands (AV); VU University Medical Center Amsterdam and Amphia Hospital Breda, Department of Medical Microbiology, Breda, Netherlands (JK); and University of Iowa, Carver College of Medicine Department of Internal Medicine, Iowa City, IA, USA (EP) 1
2
3
4
5
Teo J, Tan SYY, Tay M, et al. First case of E anophelis outbreak in an intensive-care unit. Lancet 2013; 382: 855–56. Kim KK, Kim MK, Ju Lim JH, Park HY, Lee ST. Transfer of Chryseobacterium meningosepticum and Chryseobacterium miricola to Elizabethkingia gen. nov. as Elizabethkingia meningoseptica comb. nov. and Elizabethkingia miricola comb. nov. Int J Syst Evol Microbiol 2005; 55: 1287–93. Pokrywka M, Viazanko K, Medvick J, et al. A Flavobacterium meningosepticum outbreak among intensive care patients. Am J Infect Control 1993; 21: 139–45. Hoque SN, Graham J, Kaufmann ME, Tabaqchali S. Chryseobacterium (Flavobacterium) meningosepticum outbreak associated with colonization of water taps in a neonatal intensive care unit. J Hosp Infect 2001; 47: 188–92. Maraki S, Scoulica E, Manoura A, Papageorgiou N, Giannakopoulou C, Galanakis E. A Chryseobacterium meningosepticum colonization outbreak in a neonatal intensive care unit. Eur J Clin Microbiol Infect Dis 2009; 28: 1415–19.
Authors’ reply Andreas Voss and colleagues have alluded to the fact that 16SrRNA sequencing in the early 2000s allowed Elizabethkingia to be placed separately from the genus of Chryseobacterium. Next-generation sequencing has facilitated a higher level of differentiation between two very distinct species of Elizabethkingia, namely Elizabethkingia meningoseptica and Elizabethkingia anophelis.1,2 Our analyses identifying the intensivecare unit outbreak strain as E anophelis is not just a reclassification of an old species as Voss and colleagues suggest. E anophelis is an entirely separate species with infection potential. E anophelis is presently understudied but should not be considered irrelevant in the clinical setting. Our sequencing data suggest the presence of a substantial number of virulence determinants, and studies to assess E anophelis’ virulence potential in animal are in progress. Investigation of novel outbreaks when paired with comparative genome sequencing data provides important information to understand transmission of a pathogen, and especially so for rare organisms. Comparative genomics is a crucial approach in the discovery of virulence determinants and genetic markers of uncharacterised bacterial species. Genome-based approaches can be associated with other omics-based approaches (eg, transcriptomics and proteomics) 3 to analyse bacterial physiology and pathogenesis mechanisms. An intriguing and important issue is the transmission pathway of E anophelis. We speculate that malaria carriage in patients might be at the origin of E anophelis transmission in the hospital setting, which we are investigating. We declare that we have no conflicts of interest.
Sean Yang-Yi Tan, Jeanette Teo, *Liang Yang [email protected]
www.thelancet.com Vol 382 December 21/28, 2013
Correspondence
1
2
3
Teo J, Tan SYY, Tay M, et al. First case of E anophelis outbreak in an intensive-care unit. Lancet 2013; 382: 855–56. Matyi SA, Hoyt PR, Hosoyama A, Yamazoe A, Fujita N, Gustafson JE. Draft genome sequences of Elizabethkingia meningoseptica. Genome Announc 2013; 1: 4. Tan SY, Chua SL, Liu Y, et al. Comparative genomic analysis of rapid evolution of an extreme-drug-resistant Acinetobacter baumannii clone. Genome Biol Evol 2013; 5: 807–18.
Mortality after hip replacement Linda Hunt and colleagues (Sept 28, p 1097)1 assessed 90-day mortality after total hip arthroplasty for osteoarthritis. There is no strong evidence indicating that mortality and morbidity after hip replacement remain higher than in the general population 90 days after surgery. A recent study2 suggested that the risk of myocardial infarction after hip replacement is high during the first 2 weeks after surgery and decreases after 6 weeks. Hunt and colleagues’ study 1 indicated that the use of chemical prophylaxis, posterior approach, and spinal anaesthesia reduce the mortality rate. Chemical prophylaxis includes a large variety of drugs— including warfarin and aspirin. The authors’ claim of a protective effect of chemical prophylaxis on mortality should be interpreted with caution; it is not a green light for aggressive postoperative prophylaxis for low-risk patients at the expense of increased risk of postoperative complications, particularly surgical-site infection.3,4 Less invasive surgical approaches, including direct anterior approach, are used by the new generation of surgeons in the USA, while older surgeons mainly use a posterior approach. In view of the sharp learning curve of minimally invasive approaches, an initial increase in the rate of complications can be expected which could explain the better www.thelancet.com Vol 382 December 21/28, 2013
outcomes of the posterior approach in Hunt and colleagues’ study.1 Despite growing evidence about the benefits of neuraxial anaesthesia for joint replacement, surprisingly it is used in only about 25% of operations in the USA.5 Shifting from general to neuraxial anaesthesia is among the few modalities that would make joint replacement safer in the near future. JP is a consultant for Zimmer, Smith and Nephew, Convatech, TissueGene, Ceramtec, 3M, PRN, Medtronic, and Pfizer, and has stock options with Hip Innovation Technology and CD Diagnostics. MRR declares that he has no conflicts of interest.
*Javad Parvizi, Mohammad R Rasouli [email protected] Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA (JP); and Rothman Institute of Orthopaedics, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran (MRR) 1
2
3
4
5
Hunt LP, Ben-Shlomo Y, Clark EM, et al. 90-day mortality after 409 096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013; 382: 1097–104. Lalmohamed A, Vestergaard P, Klop C, et al. Timing of acute myocardial infarction in patients undergoing total hip or knee replacement: a nationwide cohort study. Arch Intern Med 2012; 172: 1229–35. Sachs RA, Smith JH, Kuney M, Paxton L. Does anticoagulation do more harm than good?: a comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. J Arthroplasty 2003; 18: 389–95. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res 2013; published online July 2. DOI:10.1007/ s11999-013-3135-z. Memtsoudis SG, Sun X, Chiu YL, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013; 118: 1046–58.
Morality in the NHS marketplace On Nov 5, 2013, the outgoing chief executive of the National Health Service (NHS) Sir David Nicholson announced that “privatisation and competition were not proving to be a success”.1 In the wake of the Health and Social Care Act, the role of the NHS has come under increasing moral scrutiny. Here, we
postulate that the health-care market is morally questionable on two counts. First, in its present form, the healthcare market might curtail individual liberty. The UK commissioning model currently resembles a wholesale market more closely than a retail market, with the need for a commissioning middleman. Moreover, each commissioner contracts with a fairly narrow range of providers, thereby limiting patient choice. Theoretically, providers might tender to obtain substantial market share and then exploit the inevitable wiggle room in contracts that cannot cover every eventuality. In accordance with the inverse care law, providers might prioritise patients according to lowest risk rather than greatest need. Ultimately, at the level of the patient– doctor relationship, trust might be distorted by perceived financial motives. Second, market theory is not necessarily applicable to health care and should not be exercised without a burden of proof. Although the marketplace is intended to enable more efficient resource allocation, evidence that the market brings efficiency savings in the health-care setting is poor.2 Here, productivity gains are limited by a reliance on human interaction.3 Similarly, the ability of public–private partnerships to generate economic value for healthcare commissioners has fallen. Changes in global banking regulations have led to restrictions in long-term lending, with the resulting liquidity deficit increasing interest rates on project finance to historically high levels.4 For the NHS to retain its moral credibility, it must remain patientcentric, considering patients as pivotal members of clinical teams— eg, through open access to patient records. The market focus should be exchanged for one of collaboration, in which commissioners, patient representatives, and providers seek to work together. In recognising that not every health-care need can be met, there is a need for rationing,
Mike Kemp/In Pictures/Corbis
Singapore Centre on Environmental Life Sciences Engineering (SCELSE) and School of Biological Sciences, Nanyang Technological University, Singapore 637551, Singapore (SY-YT, LY); and Department of Laboratory Medicine, Microbiology Unit, National University Hospital, Singapore, Singapore (JT)
2065
outcomes for this population. In view of the very large size of the surgical population, such measures might lead to a substantial reduction in the number of deaths. We declare that we have no conflicts of interest.
*Rupert Pearse, Andreas Hoeft, Rui P Moreno, Paolo Pelosi, Andrew Rhodes [email protected] Adult Critical Care Unit, Barts and the London School of Medicine and Dentistry, Queen Mary’s University of London, Royal London Hospital, London E1 1BB, UK (RP); Department of Anaesthesiology, University of Bonn, Bonn, Germany (AH); UCINC, Hospital de São José, Centro Hospitalar de Lisboa Central, EPE, Lisbon, Portugal (RPM); IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy (PP); and St George’s University of London, London, UK (AR) 1
2
3
4
5
Pearse RM, Moreno RP, Bauer P, et al, for the European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology. Mortality after surgery in Europe: a 7 day cohort study. Lancet 2012; 380: 1059–65. Noordzij PG, Poldermans D, Schouten O, Bax JJ, Schreiner FA, Boersma E. Postoperative mortality in The Netherlands: a populationbased analysis of surgery-specific risk in adults. Anesthesiology 2010; 112: 1105–15. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372: 139–44. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360: 1418–28. Pearse R, Moreno RP, Bauer P, et al. Mortality after surgery in Europe—Authors’ reply. Lancet 2013; 381: 370–71.
E anophelis outbreak in an intensive-care unit We read with interest Jeanette Teo and colleagues’ report (Sept 7, p 855)1 of the first outbreak of Elizabethkingia anophelis identified by 16SrRNA sequencing and whole-genome alignment. The subgroup of isolates had been previously identified as Elizabethkingia meningoseptica on the basis of matrixassisted laser desorption-ionisation time-of-flight (MALDITOF) mass spectrometry analysis. The history of this microorganism starts with its description as a cause of 2064
infant meningitis by Elizabeth O King at the US Centers for Disease Control and Prevention (CDC). She first isolated an organism referred to as CDC group IIa in 1959 and named it Flavobacterium meningosepticum. It was subsequently renamed Chryseobacterium meningosepticum, and classified in the new genus Elizabethkingia, in 2005.2 We believe that modern techniques (such as MALDITOF and sequencing) might generate more and more pseudo first outbreaks. Outbreaks of F meningosepticum, C meningosepticum, and E meningoseptica have been described in several patient settings, including intensive-care units.3–5 Thus, what is new here, except the name? To be considered as new outbreaks, future reports should describe a new source or pathway of transmission and not merely one that appears new because of the diagnostic methods presently used. We declare that we have no conflicts of interest.
*Andreas Voss, Jan Kluytmans, Eli Perencevich [email protected] Radboud University Nijmegen Medical Centre and Canisius-Wilhelmina Hospital, Department of Medical Microbiology and Infectious Diseases, 6500 GS Nijmegen, Netherlands (AV); VU University Medical Center Amsterdam and Amphia Hospital Breda, Department of Medical Microbiology, Breda, Netherlands (JK); and University of Iowa, Carver College of Medicine Department of Internal Medicine, Iowa City, IA, USA (EP) 1
2
3
4
5
Teo J, Tan SYY, Tay M, et al. First case of E anophelis outbreak in an intensive-care unit. Lancet 2013; 382: 855–56. Kim KK, Kim MK, Ju Lim JH, Park HY, Lee ST. Transfer of Chryseobacterium meningosepticum and Chryseobacterium miricola to Elizabethkingia gen. nov. as Elizabethkingia meningoseptica comb. nov. and Elizabethkingia miricola comb. nov. Int J Syst Evol Microbiol 2005; 55: 1287–93. Pokrywka M, Viazanko K, Medvick J, et al. A Flavobacterium meningosepticum outbreak among intensive care patients. Am J Infect Control 1993; 21: 139–45. Hoque SN, Graham J, Kaufmann ME, Tabaqchali S. Chryseobacterium (Flavobacterium) meningosepticum outbreak associated with colonization of water taps in a neonatal intensive care unit. J Hosp Infect 2001; 47: 188–92. Maraki S, Scoulica E, Manoura A, Papageorgiou N, Giannakopoulou C, Galanakis E. A Chryseobacterium meningosepticum colonization outbreak in a neonatal intensive care unit. Eur J Clin Microbiol Infect Dis 2009; 28: 1415–19.
Authors’ reply Andreas Voss and colleagues have alluded to the fact that 16SrRNA sequencing in the early 2000s allowed Elizabethkingia to be placed separately from the genus of Chryseobacterium. Next-generation sequencing has facilitated a higher level of differentiation between two very distinct species of Elizabethkingia, namely Elizabethkingia meningoseptica and Elizabethkingia anophelis.1,2 Our analyses identifying the intensivecare unit outbreak strain as E anophelis is not just a reclassification of an old species as Voss and colleagues suggest. E anophelis is an entirely separate species with infection potential. E anophelis is presently understudied but should not be considered irrelevant in the clinical setting. Our sequencing data suggest the presence of a substantial number of virulence determinants, and studies to assess E anophelis’ virulence potential in animal are in progress. Investigation of novel outbreaks when paired with comparative genome sequencing data provides important information to understand transmission of a pathogen, and especially so for rare organisms. Comparative genomics is a crucial approach in the discovery of virulence determinants and genetic markers of uncharacterised bacterial species. Genome-based approaches can be associated with other omics-based approaches (eg, transcriptomics and proteomics) 3 to analyse bacterial physiology and pathogenesis mechanisms. An intriguing and important issue is the transmission pathway of E anophelis. We speculate that malaria carriage in patients might be at the origin of E anophelis transmission in the hospital setting, which we are investigating. We declare that we have no conflicts of interest.
Sean Yang-Yi Tan, Jeanette Teo, *Liang Yang [email protected]
www.thelancet.com Vol 382 December 21/28, 2013
Correspondence
1
2
3
Teo J, Tan SYY, Tay M, et al. First case of E anophelis outbreak in an intensive-care unit. Lancet 2013; 382: 855–56. Matyi SA, Hoyt PR, Hosoyama A, Yamazoe A, Fujita N, Gustafson JE. Draft genome sequences of Elizabethkingia meningoseptica. Genome Announc 2013; 1: 4. Tan SY, Chua SL, Liu Y, et al. Comparative genomic analysis of rapid evolution of an extreme-drug-resistant Acinetobacter baumannii clone. Genome Biol Evol 2013; 5: 807–18.
Mortality after hip replacement Linda Hunt and colleagues (Sept 28, p 1097)1 assessed 90-day mortality after total hip arthroplasty for osteoarthritis. There is no strong evidence indicating that mortality and morbidity after hip replacement remain higher than in the general population 90 days after surgery. A recent study2 suggested that the risk of myocardial infarction after hip replacement is high during the first 2 weeks after surgery and decreases after 6 weeks. Hunt and colleagues’ study 1 indicated that the use of chemical prophylaxis, posterior approach, and spinal anaesthesia reduce the mortality rate. Chemical prophylaxis includes a large variety of drugs— including warfarin and aspirin. The authors’ claim of a protective effect of chemical prophylaxis on mortality should be interpreted with caution; it is not a green light for aggressive postoperative prophylaxis for low-risk patients at the expense of increased risk of postoperative complications, particularly surgical-site infection.3,4 Less invasive surgical approaches, including direct anterior approach, are used by the new generation of surgeons in the USA, while older surgeons mainly use a posterior approach. In view of the sharp learning curve of minimally invasive approaches, an initial increase in the rate of complications can be expected which could explain the better www.thelancet.com Vol 382 December 21/28, 2013
outcomes of the posterior approach in Hunt and colleagues’ study.1 Despite growing evidence about the benefits of neuraxial anaesthesia for joint replacement, surprisingly it is used in only about 25% of operations in the USA.5 Shifting from general to neuraxial anaesthesia is among the few modalities that would make joint replacement safer in the near future. JP is a consultant for Zimmer, Smith and Nephew, Convatech, TissueGene, Ceramtec, 3M, PRN, Medtronic, and Pfizer, and has stock options with Hip Innovation Technology and CD Diagnostics. MRR declares that he has no conflicts of interest.
*Javad Parvizi, Mohammad R Rasouli [email protected] Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA (JP); and Rothman Institute of Orthopaedics, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran (MRR) 1
2
3
4
5
Hunt LP, Ben-Shlomo Y, Clark EM, et al. 90-day mortality after 409 096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet 2013; 382: 1097–104. Lalmohamed A, Vestergaard P, Klop C, et al. Timing of acute myocardial infarction in patients undergoing total hip or knee replacement: a nationwide cohort study. Arch Intern Med 2012; 172: 1229–35. Sachs RA, Smith JH, Kuney M, Paxton L. Does anticoagulation do more harm than good?: a comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. J Arthroplasty 2003; 18: 389–95. Raphael IJ, Tischler EH, Huang R, Rothman RH, Hozack WJ, Parvizi J. Aspirin: an alternative for pulmonary embolism prophylaxis after arthroplasty? Clin Orthop Relat Res 2013; published online July 2. DOI:10.1007/ s11999-013-3135-z. Memtsoudis SG, Sun X, Chiu YL, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013; 118: 1046–58.
Morality in the NHS marketplace On Nov 5, 2013, the outgoing chief executive of the National Health Service (NHS) Sir David Nicholson announced that “privatisation and competition were not proving to be a success”.1 In the wake of the Health and Social Care Act, the role of the NHS has come under increasing moral scrutiny. Here, we
postulate that the health-care market is morally questionable on two counts. First, in its present form, the healthcare market might curtail individual liberty. The UK commissioning model currently resembles a wholesale market more closely than a retail market, with the need for a commissioning middleman. Moreover, each commissioner contracts with a fairly narrow range of providers, thereby limiting patient choice. Theoretically, providers might tender to obtain substantial market share and then exploit the inevitable wiggle room in contracts that cannot cover every eventuality. In accordance with the inverse care law, providers might prioritise patients according to lowest risk rather than greatest need. Ultimately, at the level of the patient– doctor relationship, trust might be distorted by perceived financial motives. Second, market theory is not necessarily applicable to health care and should not be exercised without a burden of proof. Although the marketplace is intended to enable more efficient resource allocation, evidence that the market brings efficiency savings in the health-care setting is poor.2 Here, productivity gains are limited by a reliance on human interaction.3 Similarly, the ability of public–private partnerships to generate economic value for healthcare commissioners has fallen. Changes in global banking regulations have led to restrictions in long-term lending, with the resulting liquidity deficit increasing interest rates on project finance to historically high levels.4 For the NHS to retain its moral credibility, it must remain patientcentric, considering patients as pivotal members of clinical teams— eg, through open access to patient records. The market focus should be exchanged for one of collaboration, in which commissioners, patient representatives, and providers seek to work together. In recognising that not every health-care need can be met, there is a need for rationing,
Mike Kemp/In Pictures/Corbis
Singapore Centre on Environmental Life Sciences Engineering (SCELSE) and School of Biological Sciences, Nanyang Technological University, Singapore 637551, Singapore (SY-YT, LY); and Department of Laboratory Medicine, Microbiology Unit, National University Hospital, Singapore, Singapore (JT)
2065
