[Periprosthetic joint infections: a practical overview for family physicians]. / Infections de prothèse articulaire: aspects pratiques à l'attention du médecin de premier recours.

Periprosthetic joint infection is a rare but serious complication. Its management requires the collaboration between general practitioner, orthopaedic surgeon and infectious disease specialist. A delay in the diagnosis can result in complications, requiring complex surgical procedures. Identification of the causative pathogen and its susceptibility pattern is crucial, because it guides both the choice of antimicrobial treatment and the surgical strategy. Antimicrobial treatment without proper micro- biological sampling must be avoided. Swabs from open wounds are not helpful, because microorganisms belonging to the skin flora will grow. The target audience of this review article on periprosthetic joint infections is the general practitioner.

Incidental maxillary sinus findings in orthodontic patients: a radiographic analysis using cone-beam computed tomography (CBCT).

UNLABELLED: To determine the frequency of incidental maxillary sinus findings using cone-beam computed tomography (CBCT) images made for orthodontic purposes. SETTING AND SAMPLE POPULATION: One hundred thirty-nine consecutive CBCTs from 134 patients treated at the Department of Orthodontics and Dentofacial Orthopedics, University of Bern, Bern, Switzerland. Indications for CBCT imaging included the localization of impacted teeth and root resorption related to impacted teeth. MATERIAL AND METHODS POPULATION: Two experienced observers reviewed the CBCT scans (fields of view: 4 × 4/6 × 6/8 × 8 cm) and recorded all incidental maxillary sinus findings according to standardized categories. The patient's age and gender, the size of the field of view, the season of CBCT image taking, and the thickness of the Schneiderian membrane were evaluated to identify potential influencing factors. RESULTS: In 65 CBCTs (46.8%), incidental maxillary sinus findings were found (interrater classification agreement of 95.7%/95% CI: 90.9-97.9%). Three types of incidental findings were diagnosed: flat mucosal thickening (23.7%), polypoid mucosal thickening (19.4%), and signs of acute sinusitis (3.6%). There was no correlation between the field of view of the CBCT and the number of incidental findings inside the field. There was no correlation between the season during which the CBCT was made and the number of incidental findings. The mean thickness of the mucosal lining in the maxillary sinus was 1.58 mm (95% CI: 1.17-1.98 mm). CONCLUSIONS: A high percentage of the CBCTs made for orthodontic diagnostic purposes exhibit incidental maxillary sinus findings not associated with the primary indication.

Bone and joint infections of the hand.

BACKGROUND: Little guidance is currently available for standardized diagnostic protocols and therapeutic recommendations for bone and joint infections (BJIs) of the hand. OBJECTIVES: To summarize the available data in the scientific English-language literature on the diagnosis and treatment of native BJIs of the hand. To illustrate these concepts from a narrative point of view in areas where there is lack of evidence. SOURCES: We performed a systematic PubMed and Internet search of studies that investigated hand BJIs in adult patients. CONTENT: Few studies have systematically investigated and validated diagnostic concepts, classifications or surgical treatment protocols. Most concepts derive from traditional intra-institutional experience, expert opinions and extrapolations from infections in large joints and long bones. Similarly, there is no uniformly accepted infection definition of BJIs of the hand. The best-documented literature is available for microbiological findings and antibiotic treatment duration in uncomplicated native joint arthritis of the fingers. Retrospective studies and one prospective randomized trial suggest that post-surgical targeted antibiotic therapy of 2 weeks results in a microbiological cure rate of ≥88%. IMPLICATIONS: Studies on diagnostic workup and infection definition and classification are urgently needed to compare inter-institutional outcome results and generate guidelines for the best patient care. For uncomplicated pyogenic arthritis of native joints, current evidence suggests that a 2-week course of antibiotic therapy following surgery cures the infection.

Spinal epidural abscess in clinical practice.

Spinal epidural abscess (SEA) is a rare but severe infection requiring prompt recognition. The major prognostic factor for a favourable outcome is early diagnosis, leading to appropriate treatment. In clinical practice, a diagnosis of SEA is often not considered, particularly in the early stages of the disease when neurological symptoms are not apparent. Knowledge of persons at risk, clinical features and the required diagnostic procedures may decrease the number of initially misdiagnosed cases. Clinical signs, duration of symptoms and the rate of neurological deterioration show a high inter-individual variability, and the classic triad (spinal pain, fever and neurological deficit) is often not found, especially not at first presentation to a physician. However, most patients complain of severe localized back pain. Inflammatory parameters in the blood are generally elevated, but not specific. Gadolinium-enhanced magnetic resonance imaging is the most sensitive, specific and accurate imaging method. Although neurosurgical decompression is still the treatment of choice in the majority of cases, less invasive procedures (e.g. computed tomography-guided needle aspiration) or antimicrobial treatment alone can be applied in selected cases. The choice of the most appropriate therapy should be discussed immediately after a confirmed diagnosis in consultation with infectious disease, radiology and spinal surgery specialists. The outcome of SEA is largely influenced by the severity and duration of neurological deficits prior to surgery, stressing the importance of early recognition.

Health State Utilities in Edentulous Patients: A Time Trade-off Approach.

BACKGROUND: Health is generally regarded as a very high good, and oral health may substantially affect the quality of life of patients. Oral health-related quality of life has usually been investigated by means of disease-specific descriptive instruments, such as the Oral Health Impact Profile and the General Oral Health Assessment Index. These instruments, however, do not enable a comparison of oral health-related quality of life with other medical diseases. Economic methods, such as the time trade-off technique, enable a comparison of the impact of oral health with other medical diseases and thus provide a means to build a bridge in quality-of-life assessments between medicine and dentistry. METHODS: We included in our study a total of 58 patients who received a complete denture in our clinic in the last 10 y (between January 2001 and May 2012) and who were ≥65 y old. Patient preferences for the edentulous and poorest imaginable oral health state were assessed via the time trade-off method. RESULTS: Edentulous patients rated their current oral health state as 0.73 (SD, 0.25) and the poorest oral health state as 0.43 (SD, 0.33) on a scale between 0 (death) and 1 (best possible health state). These results are comparable to patient preferences for other serious diseases, such as breast cancer (0.75), asymptomatic HIV infection (0.69), depression (0.44), and osteoarthritis of the hip (0.44). CONCLUSION: In conclusion, our results suggest that oral health may substantially affect quality of life no less than other medical diseases. KNOWLEDGE TRANSFER STATEMENT: Health is generally considered the highest good of humankind. In the present article, we show that oral health substantially affects quality of life. In particular, we show that loss of teeth (i.e., being edentulous) reduces quality of life no less than other systemic diseases. Treatment modalities for the edentulous patient may therefore substantially improve the patient's well-being and should be a research priority.

Debridement and implant retention in the management of hip periprosthetic joint infection: outcomes following guided and rapid treatment at a single centre.

AIMS: To analyse the effectiveness of debridement and implant retention (DAIR) in patients with hip periprosthetic joint infection (PJI) and the relationship to patient characteristics. The outcome was evaluated in hips with confirmed PJI and a follow-up of not less than two years. PATIENTS AND METHODS: Patients in whom DAIR was performed were identified from our hip arthroplasty register (between 2004 and 2013). Adherence to criteria for DAIR was assessed according to a previously published algorithm. RESULTS: DAIR was performed as part of a curative procedure in 46 hips in 42 patients. The mean age was 73.2 years (44.6 to 87.7), including 20 women and 22 men. In 34 hips in 32 patients (73.9%), PJI was confirmed. In 12 hips, the criteria for PJI were not fulfilled and antibiotics stopped. In 41 (89.1%) of all hips and in 32 (94.1%) of the confirmed PJIs, all criteria for DAIR were fulfilled. In patients with exogenous PJI, DAIR was performed not more than three days after referral. In haematogenous infections, the duration of symptoms did not exceed 21 days. In 28 hips, a single debridement and in six hips two surgical debridements were required. In 28 (87.5%) of 32 patients, the total treatment duration was three months. Failure was noted in three hips (9%). Long-term follow-up results (mean 4.0 years, 1.4 to 10) were available in 30 of 34 (88.2%) confirmed PJIs. The overall successful outcome rate was 91% in 34 hips, and 90% in 30 hips with long-term follow-up results. CONCLUSION: Prompt surgical treatment with DAIR, following strict diagnostic and therapeutic criteria, in patients with suspected periprosthetic joint infection, can lead to high rates of success in eradicating the infection. Cite this article: Bone Joint J 2017;99-B:330-6.

Course and outcome of Staphylococcus aureus bacteraemia: a retrospective analysis of 308 episodes in a Swiss tertiary-care centre.

Staphylococcus aureus bacteraemia (SAB) is associated with substantial morbidity and mortality worldwide. The charts of adult patients with SAB who were hospitalised in a Swiss tertiary-care centre between 1998 and 2002 were studied retrospectively. In total, 308 episodes of SAB were included: 2% were caused by methicillin-resistant strains; 49% were community-acquired; and 51% were nosocomial. Bacteraemia without focus was the most common type of community-acquired SAB (52%), whereas intravenous catheter-related infection predominated (61%) among nosocomial episodes of SAB. An infectious diseases (ID) specialist was consulted in 82% of all cases; 83% received appropriate antibiotic treatment within 24 h of obtaining blood cultures. Overall hospital-associated mortality was 20%. Community-acquired SAB was associated independently with a higher mortality rate than nosocomial SAB (26% vs. 13%; p 0.009). Independent risk-factors for a fatal outcome were age (p < 0.001), immunosuppression (p 0.007), alcoholism (p < 0.001), haemodialysis (p 0.03), acute renal failure (p < 0.001) and septic shock (p < 0.001). Consultation with an ID specialist was associated with a better outcome in univariate analysis (p < 0.001). Compared with a previous retrospective analysis performed at the same institution between 1980 and 1986, there was a 140% increase in community-acquired SAB, a 60% increase in catheter-related SAB, and a 14% reduction in mortality. In conclusion, mortality in patients with SAB remained high, despite effective antibiotic therapy. Patients with community-acquired SAB were twice as likely to die as patients with nosocomial SAB. Consultation with an ID specialist may reduce mortality in patients with SAB.

A cost-effectiveness analysis of implant overdentures.

Placement of dental implants may improve the retention and stability of complete dentures in edentulous patients. Treatment costs, however, substantially increase with implant treatment. We therefore performed a stochastic cost-effectiveness analysis, comparing implant-supported over-denture prostheses (4 implants), implant-retained overdentures (2 implants), and complete dentures, from the patient's perspective in Switzerland, to assess whether implant treatment in the mandible represents value for money spent. Twenty patients were included in each treatment group and were followed up for three years. Health outcomes were expressed in Quality-adjusted Prosthesis Years, and dental health care costs and time costs were recorded in year 2000 Swiss Francs (CHF 100 = US dollars 61). The cost per Quality-adjusted Prosthesis Year gained for implant treatment was CHF 9100 (2 implants) and CHF 19,800 (4 implants) over 3 years. Over a ten-year period, these threshold ratios were reduced to CHF 3800 (2 implants) and CHF 7100 (4 implants) per Quality-adjusted Prosthesis Year gained.

Galactomannan does not precede major signs on a pulmonary computerized tomographic scan suggestive of invasive aspergillosis in patients with hematological malignancies.

BACKGROUND: Detection of serum galactomannan (GM) antigen and presence of the halo sign on a pulmonary computerized tomographic (CT) scan have a high specificity but a low sensitivity to diagnose invasive aspergillosis (IA) in patients at risk for this disease. To our knowledge, the relationship between the time at which pulmonary infiltrates are detected by CT and the time at which GM antigens are detected by enzyme immunoassay (EIA) has not been studied. METHODS: In a prospective study, tests for detection of GM were performed twice weekly for patients with hematological malignancies who had undergone hematopoetic stem cell transplantation (HSCT) or had received induction and/or consolidation chemotherapy. A pulmonary CT scan was performed once weekly. Infiltrates were defined as either major or minor signs. IA was classified as proven, probable, or possible, in accordance with the definition stated by the European Organization for Research and Treatment of Cancer-Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group. RESULTS: We analyzed 161 episodes of infection in 107 patients (65 allogeneic HSCT recipients, 30 autologous HSCT recipients, and 66 induction and/or consolidation chemotherapy recipients). A total of 109 episodes with no IA, 32 episodes with possible IA, and 20 episodes with probable or proven IA were identified. Minor pulmonary signs were detected by CT in 70 episodes (43%), and major pulmonary signs were detected by CT in 11 episodes (7%). Univariate and multivariate analyses revealed no significant association between detection of GM by EIA and detection of abnormal pulmonary signs by CT. A significant association was found between GM levels and receipt of piperacillin-tazobactam. GM test results were not positive before major signs were seen on CT images. Only 7 (10%) of 70 patients with minor pulmonary signs had positive GM test results before detection of the greatest pathologic change by CT. CONCLUSIONS: We show that detection of GM by EIA does not precede detection of major lesions by pulmonary CT. In the clinical setting, the decision to administer mold-active treatment should based on detection of new pulmonary infiltrates on CT performed early during infection, rather than on results of EIA for detection of GM.

Dynamics of serum procalcitonin in patients after major neurosurgery.

Classical markers of infection cannot differentiate reliably between inflammation and infection after neurosurgery. This study investigated the dynamics of serum procalcitonin (PCT) in patients following major neurosurgery. PCT concentrations remained < 0.2 ng/mL during the post-operative course. In contrast, leukocyte and neutrophil counts, as well as C-reactive protein (CRP) levels, increased significantly post-operatively (leukocytes, range 7.1-23.7 x 10(9)/L, p < 0.001; neutrophils, range 70.8-94.5%, p < 0.001; CRP, median 14 mg/L, range 3-95 mg/L, p < 0.001). Analysis of PCT levels using assays with improved sensitivity may be useful in the diagnosis of neurosurgical patients with post-operative fever of unknown origin.

Percutaneous embolization of renal arteriovenous fistula.

Acquired renal arteriovenous fistula is a rare complication following a nephrectomy and its diagnosis may be made many years after the intervention. The closure of the fistula is advisable in most cases, since it represents a risk for heart failure and rupture of the vessel. There are an increasing number of publications describing different techniques of occlusion. The case of a 70-year-old woman with abdominal discomfort due to a large renal arteriovenous fistula, 45 years after nephrectomy, is presented and current literature is reviewed. Percutaneous embolization was performed by placing an occluding balloon through the draining vein followed by the release of nine coils through arterial access. One day after successful occlusion of the fistula, clinical symptoms disappeared.

Isoniazid prophylaxis for tuberculosis in HIV infection: a meta-analysis of randomized controlled trials.

OBJECTIVES: To evaluate the efficacy of isoniazid for the prevention of tuberculosis in tuberculin skin test-positive and negative individuals with HIV infection. DESIGN: Meta-analysis of randomized controlled trials. SETTING: Seven trials from Mexico, Haiti, the United States, Zambia, Uganda and Kenya. PATIENTS: Individuals free from tuberculosis, 2367 persons in the intervention and 2162 in the control groups. INTERVENTION: Comparison of isoniazid with placebo or no prophylaxis. METHODS: A systematic search of the literature was carried out from 1985 to October 1997 for randomized controlled trials of isoniazid prophylaxis in HIV-infected persons. Two reviewers evaluated the relevance of each candidate study and the validity of eligible trials. Studies were pooled using a random effect model, conducting secondary analyses for tuberculin skin test-positive and negative persons. RESULTS: Mean follow-up in trials varied between 0.4 and 3.2 years. Pooling all seven trials, a risk ratio was found for persons treated with isoniazid for developing tuberculosis of 0.58 [95% confidence interval (CI), 0.43-0.80] and 0.94 (95% CI, 0.83-1.07) for death. In groups of tuberculin skin test-positive and negative persons, the risk ratio of tuberculosis was 0.40 (95% CI, 0.24-0.65) and 0.84 (95% CI, 0.54-1.30), respectively, and the difference in the effectiveness of isoniazid versus placebo between these groups was statistically significant (P = 0.03, for the difference of summary estimates). Consistency of results was found across trials (P > 0.10, heterogeneity value) for all comparisons. CONCLUSIONS: Prophylaxis with isoniazid reduces the risk of tuberculosis in persons with HIV infection. The effect is restricted to tuberculin skin test-positive persons.

Cost effectiveness of highly active antiretroviral therapy in HIV-infected patients. Swiss HIV Cohort Study.

BACKGROUND: Highly active antiretroviral therapy (HAART) has become the most important strategy for treating HIV infection in developed countries; however, access to HAART might vary under different funding policies. The Swiss health care system provides unrestricted access to HAART for all patients who need these newer combination therapies. This study investigated the impact of this funding policy on the society and health care system. METHODS: A cost-effectiveness analysis with natural history data and productivity estimates was based on the Swiss HIV Cohort Study. A random sample of patient charts was used to estimate health care costs. In addition to a base-case scenario, a pessimistic and an optimistic scenario of natural disease history was developed. Costs were expressed in 1997 Swiss francs (100 CHF correspond to about US$67) and effects as projected years of life gained. RESULTS: In the analysis limited to health care costs, on the basis of projected survival in each scenario, the cost-effectiveness ratio was 33,000 CHF (base case), 14,000 CHF (optimistic), and 45,000 CHF (pessimistic) per year of life gained. When changes in productivity were included, cost savings occurred in the base-case and optimistic scenarios. The cost-effectiveness ratio was 11,000 CHF per year of life gained in the pessimistic scenario. CONCLUSIONS: HAART increases expected survival and health care costs. However, when productivity gains are included, society will probably save costs or pay a low price for substantial health benefits. The study provides strong arguments, from a societal perspective, to continue the current policy of providing unrestricted access to HAART in Switzerland. The presented results also suggest that this policy could be of interest for other developed countries. Decision makers in developed countries where access to HAART is limited should re-evaluate their policy for the benefit of the society at large.

Is bariatric surgery worth its costs?

Formal economic evaluations of obesity surgery have not been reported in the medical literature to date. In this article, we briefly review the most important types of health economic evaluations, namely cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. Bariatric surgery has the potential to substantially impact quality of life, morbidity, and mortality costs in patients with morbid obesity. Health economic studies that include these effects are needed.

Treatment of morbid obesity with the Swedish adjustable gastric band (SAGB): complication rate during a 12-month follow-up period.

BACKGROUND: The Swedish adjustable gastric band (SAGB) is used to treat morbid obesity. However, no quantitative data are available describing the follow-up of these patients with respect to the frequency and the complication rate of inflating and deflating the adjustable system. METHODS: We prospectively investigated 207 morbidly obese patients. All patients completed 12 months of follow-up and were seen in intervals of 1 to 3 months on an outpatient basis. RESULTS: A total of 207 patients had 1692 consultations (8.3 +/- 2.4 consultations per patient per year [mean +/- SD]), 920 port-a-cath punctions (4.6 +/- 2.0), 820 inflations (4.1 +/- 1.6), and 100 deflations (1.4 +/- 0.6). Complications related to the port-a-cath (n = 6, 2.9% of all patients) were 1 leakage of the tube (0.5%), 2 disconnections of the connecting tube (1.0%), and 3 reimplantations of the port-a-cath as a result of discomfort (1.4%). Complications related to the SAGB (n = 10, 4.8%) were 6 leakages of the band (2.9%), 2 penetrations (1.0%), 1 intraoperative perforation of the esophagus (0.5%), and 1 dystopically implanted SAGB (0.5%). Additionally, 9 minor early postoperative wound infections (4.3%) were recorded. CONCLUSIONS: Follow-up can be safely performed on an outpatient basis after implantation of a SAGB without infectious and other minor complications directly linked to the filling procedure.

Highly active antiretroviral therapy: pharmacoeconomic issues in the management of HIV infection.

The advent of highly active antiretroviral therapy (HAART), including protease inhibitors and/or non-nucleoside reverse transcriptase inhibitors, for the treatment of HIV infection has led to a dramatic decline of morbidity and mortality. The acquisition costs of HAART are substantial. However, these costs are partially offset by reduced inpatient care for opportunistic infections and other AIDS-related diseases. Furthermore, job productivity in patients infected with HIV is increased under HAART. In developed countries with a low unemployment rate, the discounted value of savings caused by increased productivity in earlier years exceeds the discounted value of later increases in costs resulting from morbidity. Therefore, HAART represents a very efficient treatment strategy that leads to overall cost savings when taking a societal perspective.

Sensitivity analysis on a chance node with more than two branches.

Sensitivity analysis is an essential part of decision analysis. The literature on medical decision analysis suggests the use of two-branch chance nodes in decision trees to avoid logical inconsistencies during sensitivity analysis. The authors show that the two-branch decomposition is not appropriate for sensitivity analysis when multiple outcomes from a single state cannot be disentangled into a sensible sequence of events. They recommend retaining the natural structure of the tree and propose two sensitivity-analysis methods for use on chance nodes with three or more branches.