RESUMEN
OBJECTIVE: To develop updated American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). METHODS: We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. RESULTS: This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. CONCLUSION: This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.
Asunto(s)
Antirreumáticos , Artritis Reumatoide , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Lupus Eritematoso Sistémico , Enfermedades Reumáticas , Reumatología , Cirujanos , Adulto , Antirreumáticos/uso terapéutico , Artritis Reumatoide/cirugía , Artroplastia de Reemplazo de Cadera/efectos adversos , Glucocorticoides/uso terapéutico , Humanos , Lupus Eritematoso Sistémico/tratamiento farmacológico , Enfermedades Reumáticas/tratamiento farmacológico , Enfermedades Reumáticas/cirugía , Estados UnidosRESUMEN
OBJECTIVE: This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). METHODS: A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. RESULTS: The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence. CONCLUSION: This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.
Asunto(s)
Antirreumáticos/administración & dosificación , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Atención Perioperativa/normas , Reumatología/normas , Artritis Juvenil , Artritis Psoriásica , Artritis Reumatoide , Procedimientos Quirúrgicos Electivos , Glucocorticoides/uso terapéutico , Humanos , Lupus Eritematoso Sistémico/tratamiento farmacológico , Piperidinas , Pirimidinas , Pirroles , Enfermedades Reumáticas/tratamiento farmacológico , Espondiloartritis/tratamiento farmacológico , Espondilitis Anquilosante , Cirujanos , Estados UnidosRESUMEN
BACKGROUND: Clinical observations suggest that Canadian-born (CB) travellers are prone to more severe malaria, characterized by higher parasite density in the blood, and severe symptoms, such as cerebral malaria and renal failure, than foreign-born travellers (FB) from areas of malaria endemicity. It was hypothesized that host cytokine and chemokine responses differ significantly in CB versus FB patients returning with malaria, contributing to the courses of severity. A more detailed understanding of the profiles of cytokines, chemokines, and endothelial activation may be useful in developing biomarkers and novel therapeutic approaches for malaria. MATERIALS AND METHODS: The patient population for the study (n = 186) was comprised of travellers returning to Toronto, Canada between 2007 and 2011. The patient blood samples' cytokine, chemokine and angiopoietin concentrations were determined using cytokine multiplex assays, and ELISA assays. RESULTS: Significantly higher plasma cytokine levels of IL-12 (p40) were observed in CB compared to FB travellers, while epidermal growth factor (EGF) was observed to be higher in FB than CB travellers. Older travellers (55 years old or greater) with Plasmodium vivax infections had significantly higher mean cytokine levels for IL-6 and macrophage colony-stimulating factor (M-CSF) than other adults with P. vivax (ages 18-55). Patients with P. vivax infections had significantly higher mean cytokine levels for monocyte chemotactic protein-1 (MCP-1), and M-CSF than patients with Plasmodium falciparum. Angiopoietin 2 (Ang-2) was higher for patients infected with P. falciparum than P. vivax, especially when comparing just the FB groups. IL-12 (p40) was higher in FB patients with P. vivax compared to P. falciparum. Il-12 (p40) was also higher in patients infected with P. vivax than those infected with Plasmodium ovale. For patients travelling to West Africa, IFN-γ and IL-6 was lower than for patients who were in other regions of Africa. CONCLUSION: Significantly higher levels of IL-12 (p40) and lower levels of EGF in CB travellers may serve as useful prognostic markers of disease severity and help guide clinical management upon return. IL-6 and M-CSF in older adults and MCP-1, IL-12 (p40) and M-CSF for P. vivax infected patients may also prove useful in understanding age-associated and species-specific host immune responses, as could the species-specific differences in Ang-2. Regional differences in host immune response to malaria infection within the same species may speak to unique strains circulating in parts of West Africa.
Asunto(s)
Citocinas/sangre , Malaria/inmunología , Viaje , Adolescente , Adulto , Anciano , Angiopoyetina 1/sangre , Canadá , Niño , Preescolar , Ensayo de Inmunoadsorción Enzimática , Factor de Crecimiento Epidérmico/sangre , Femenino , Humanos , Lactante , Masculino , Persona de Mediana Edad , Plasmodium falciparum/inmunología , Plasmodium ovale/inmunología , Plasmodium vivax/inmunología , Adulto JovenRESUMEN
OBJECTIVES: To report the clinical result of a series of patients who underwent intramedullary nailing (IMN) of tibial shaft fractures distal to a total knee arthroplasty (TKA). DESIGN: Retrospective case series. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Patients who sustained a tibial shaft fracture distal to a TKA treated with an IMN. INTERVENTION: IMN of tibial shaft fractures distal to a TKA. MAIN OUTCOME MEASUREMENTS: Postoperative weight-bearing status, readmissions, and complications or failure of treatment within 90 days; Knee Injury and Osteoarthritis Outcome Scores at the final follow-up; failure of treatment; and revision surgery. RESULTS: Nine patients were included. The average age was 71.4 years (range 55-87 years). All TKAs were cemented. The average distance between the tibial keel and the cortical density of the tibial tubercle was 24.1 mm (range 19.5-26.7 mm). Six nails were inserted using an infrapatellar portal, 2 were inserted using a suprapatellar portal, and 1 was inserted using a lateral parapatellar approach. The median nail diameter was 10 mm (range 9-12 mm). All fractures were healed at the final follow-up. There were no infections or arthroplasty-related complications. Knee Injury and Osteoarthritis Outcome Scores ranged from 100% to 74% (median 82%). CONCLUSION: Overall, we report on the largest cohort in the literature undergoing IMN of a tibial shaft fracture distal to a TKA. We demonstrate that IMN of diaphyseal tibial fractures distal to a TKA can be performed safely. We additionally demonstrate that this treatment is highly effective in achieving fracture union with no arthroplasty-related complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Fijación Intramedular de Fracturas , Traumatismos de la Rodilla , Osteoartritis , Fracturas de la Tibia , Humanos , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Fijación Intramedular de Fracturas/efectos adversos , Fracturas de la Tibia/diagnóstico por imagen , Fracturas de la Tibia/cirugía , Fracturas de la Tibia/complicaciones , Artroplastia de Reemplazo de Rodilla/efectos adversos , Estudios Retrospectivos , Traumatismos de la Rodilla/cirugía , Osteoartritis/etiologíaRESUMEN
OBJECTIVE: To develop updated guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). METHODS: We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. RESULTS: This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. CONCLUSION: This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.
Asunto(s)
Antirreumáticos , Artritis Reumatoide , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Lupus Eritematoso Sistémico , Enfermedades Reumáticas , Reumatología , Cirujanos , Adulto , Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Artritis Reumatoide/etiología , Artritis Reumatoide/cirugía , Glucocorticoides/uso terapéutico , Humanos , Lupus Eritematoso Sistémico/tratamiento farmacológico , Lupus Eritematoso Sistémico/etiología , Enfermedades Reumáticas/tratamiento farmacológico , Enfermedades Reumáticas/etiología , Estados UnidosRESUMEN
OBJECTIVE: To develop updated guidelines for the perioperative management of disease-modifying medications for patients with rheumatic diseases, specifically those with inflammatory arthritis (IA) and those with systemic lupus erythematosus (SLE), undergoing elective total hip arthroplasty (THA) or elective total knee arthroplasty (TKA). METHODS: We convened a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists, updated the systematic literature review, and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of evidence and the strength of recommendations using a group consensus process. RESULTS: This guideline updates the 2017 recommendations for perioperative use of disease-modifying antirheumatic therapy, including traditional disease-modifying antirheumatic drugs, biologic agents, targeted synthetic small-molecule drugs, and glucocorticoids used for adults with rheumatic diseases, specifically for the treatment of patients with IA, including rheumatoid arthritis and spondyloarthritis, those with juvenile idiopathic arthritis, or those with SLE who are undergoing elective THA or TKA. It updates recommendations regarding when to continue, when to withhold, and when to restart these medications and the optimal perioperative dosing of glucocorticoids. CONCLUSION: This updated guideline includes recently introduced immunosuppressive medications to help decision-making by clinicians and patients regarding perioperative disease-modifying medication management for patients with IA and SLE at the time of elective THA or TKA.
Asunto(s)
Antirreumáticos , Artritis Reumatoide , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Lupus Eritematoso Sistémico , Enfermedades Reumáticas , Reumatología , Cirujanos , Adulto , Antirreumáticos/uso terapéutico , Artritis Reumatoide/tratamiento farmacológico , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Glucocorticoides/uso terapéutico , Humanos , Lupus Eritematoso Sistémico/tratamiento farmacológico , Enfermedades Reumáticas/tratamiento farmacológico , Estados UnidosRESUMEN
OBJECTIVE: This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). METHODS: A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. RESULTS: The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence. CONCLUSION: This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.
Asunto(s)
Antirreumáticos/normas , Artroplastia de Reemplazo de Cadera/normas , Artroplastia de Reemplazo de Rodilla/normas , Atención Perioperativa/normas , Guías de Práctica Clínica como Asunto/normas , Reumatología/normas , Antirreumáticos/administración & dosificación , Artritis Reumatoide/tratamiento farmacológico , Artritis Reumatoide/cirugía , Manejo de la Enfermedad , Humanos , Atención Perioperativa/métodos , Reumatología/métodos , Cirujanos/normas , Estados UnidosRESUMEN
OBJECTIVE: This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). METHODS: A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. RESULTS: The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence. CONCLUSION: This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.
Asunto(s)
Antirreumáticos/uso terapéutico , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Productos Biológicos/uso terapéutico , Glucocorticoides/uso terapéutico , Inmunosupresores/uso terapéutico , Atención Perioperativa/métodos , Enfermedades Reumáticas/tratamiento farmacológico , Artritis Juvenil/tratamiento farmacológico , Artritis Psoriásica/tratamiento farmacológico , Artritis Reumatoide/tratamiento farmacológico , Humanos , Lupus Eritematoso Sistémico/tratamiento farmacológico , Ortopedia , Piperidinas/uso terapéutico , Inhibidores de Proteínas Quinasas/uso terapéutico , Pirimidinas/uso terapéutico , Pirroles/uso terapéutico , Reumatología , Sociedades Médicas , Espondilitis Anquilosante/tratamiento farmacológico , Estados UnidosRESUMEN
BACKGROUND: Multilocus sequence typing (MLST) is commonly used to understand the genetic background of invasive pneumococcal disease (IPD) isolates. This study was conducted to identify serotype and genetic change among IPD isolates in Canadian children following vaccine use. METHODS: Clinical isolates collected from children ≤5 years old of Ontario, Canada with IPD during 2007-2012 were characterized with serotyping, multilocus sequence typing and antimicrobial susceptibility testing. RESULTS: One year after 13-valent pneumococcal conjugate vaccine (PCV13) implementation, a decline in 19A and 7F was observed in 2012, coincident with the rise of serogroup 15 and 22F. Clonal complex (CC) 199, CC320 and CC695 are 3 major CCs in 19A (74%). From 2007 to 2012, clonal shift was detected in the 19A population as CC320 and CC199 declined, whereas CC695 rose to a majority. Genetically, serogroup 15 was composed of 2 CCs and 7 sequence types (STs), making it more diverse than serotypes 3, 7F and 22F. Interestingly, 60% of 15C isolates were a novel ST, suggesting high single nucleotide polymorphism frequency in house-keeping genes of 15C. Several newly appeared STs found in 19A and 15 indicate the possibility of recent serotype switching events. CONCLUSION: Genetic shift because of PCV13 impact may have resulted in the decline of 19A in IPD. Recent rise of serogroup 15 infections in children could be because of its selective advantage conferred by genetic diversity, frequent recombination in the population plus drug resistance potential related to CC63 genotype. Close monitoring of serotype replacement and genetic change in IPD among children post-PCV13 is warranted.
Asunto(s)
Bacteriemia/microbiología , Genotipo , Meningitis Neumocócica/microbiología , Infecciones Neumocócicas/microbiología , Streptococcus pneumoniae/clasificación , Antibacterianos/farmacología , Bacteriemia/epidemiología , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Meningitis Neumocócica/epidemiología , Pruebas de Sensibilidad Microbiana , Epidemiología Molecular , Tipificación de Secuencias Multilocus , Ontario/epidemiología , Infecciones Neumocócicas/epidemiología , Serotipificación , Streptococcus pneumoniae/efectos de los fármacos , Streptococcus pneumoniae/genética , Streptococcus pneumoniae/aislamiento & purificaciónRESUMEN
There is a remarkable similarity between the purposes and formats of the Society of Clinical Surgery and the Anesthetists' Travel Club. The Travel Club's founder, John Lundy, worked closely with two charter members of the Society of Clinical Surgery,William J. and Charles Mayo.