Long-term outcome of prosthetic joint infections treated with two-stage revision.

Long-term evaluation of prosthetic joint infection treated with two-stage revision. Retrospective analysis of 102 periprosthetic infections treated with two-stage revision from 2010 to 2012 in Albenga hospital, Italy. During the second stage, samples for microbiological tests were collected. Failure was defined as a persistence of infection during the second stage or as a relapse during follow-up. 102 cases (55 hip, 47 knee) were analyzed. Patients were evaluated for a median of 44 months. 8/102 (8%) had positive cultures at replacement. These patients were treated with long-term antibiotic treatment and in 3/8 (38%) infection was cured. 9 patients were loss to follow-up or died, 6 patients (6%) had a relapse a median of 16,3 months from replanting. Risk factors significantly related to failures were diabetes and infection due to methicillin-resistant staphylococci. Two stage revision requires continued follow up. Screening for infection at replacement suggests prolonged antibiotic treatment.

[Diagnosis in patients with a painful arthroplasty]. / Diagnosi differenziale in pazienti con protesi ortopedica dolorosa.

The differential diagnosis between asepting loosening or prosthetic joint infection is not always easy. Tc-99m-labelled leucocyte scans, frozen section and histology can help recognise doubtful cases. We report the experience of the Unit for Infectious Diseases and Septic Orthopaedics of the ASL-2 Liguria, Italy, with a Tc-99m-labelled leucocyte scan and intraoperative frozen section to choose the best therapeutic approach: one-stage or two-stage exchange or arthrodesis-arthroplastica. All cases underwent histology and intraoperative cultures to confirm the diagnosis, and the effectiveness of the approach was evaluated at follow up after 18 months. From January 2011 to December 2012, 36 patients were evaluated (21 hip and 15 knee arthroprosthesis). The Tc-99m-labelled leukocyte scan was positive in 31 and negative in 5 patients. Frozen section was negative in 7 patients. Five of them were patients with a negative Tc-99m-labelled leucocyte scan and were treated successfully with one-stage exchange, even if, in one of them, Enterococcus faecalis was isolated at replacement and suppressive antibiotic treatment was needed. The other 31 patients were treated with arthrodesis arthroplasty (3 patients) or a two-stage exchange. In this group the Tc-99m-labelled leucocyte scan was positive in all patients and the frozen section was positive in 29/31 cases with 6% false negative. Histology was positive in 27/31 with 13% of false negative. The sensitivity and specificity value was respectively 90% and 100% in the frozen section, 84% and 100% in histology. Cultures were positive in 23/31 cases. Patients subjected to two-stage exchange were evaluated again during prosthesis replacement but the results of the Tc-99m-labelled leucocyte scan and histology showed unclear results more frequently: the Tc-99m-labelled leucocyte scan was positive in two cases, the frozen section in three and histology in seven in spite of positive culture in three cases and one relapse in a patient with a frozen section and histology positive but negative culture. In the second step sensitivity and specificity were respectively 67% and 96% in the frozen section, 75% and 88% in histology. Finally, our experience suggests the utility of nuclear and histological tests during diagnostic work-up for differential diagnosis of aseptic loosening or prosthetic joint infection. The same tests produce more uncertain data when performed in two-stage exchange during the second step.

The ligurian human immunodeficiency virus clinical network: a web tool to manage patients with human immunodeficiency virus in primary care and multicenter clinical trials.

BACKGROUND: In recent years, Highly-Active Anti-Retroviral Therapies (HAARTs) have modified the Human Immunodeficiency Virus (HIV) life-cycle and the disease is now considered chronic. Consequently, a longitudinal and complex follow-up is now required for HIV positive patients during their lifetime. Moreover, patients often encounter various complications due to comorbidities, related to the immunodeficiency state and HAARTs' side effects. Thus, HIV positive patients are involved in multicenter clinical trials (MCTs) to improve treatments and discover a preventive vaccine. Therefore, physicians require proper instruments to access comprehensive patient data for managing patients during follow-ups, and tools for data collection and analysis in MCTs. OBJECTIVE: The Ligurian HIV Clinical Network aims to provide physicians with a Web-tool to administrate HIV positive patients' data within primary-care and to reuse the collected clinical information to perform MCTs in Northern Italy. METHODS: The key aspect of the system is a relational database which allows the storage of various types of clinical information (eg, related to HIV, cardiovascular, or hepatic diseases) in multiple formats. The modular design of the database permits a rapid insertion of new parameters without requiring any changes in the database structure. Furthermore, codes from biomedical ontologies controlled vocabularies ("Logical Observation Identifier Names and Codes", and "International Classification of Diseases 9") and ontologies ("Systematized Nomenclature of Medicine Clinical Terms"), units and normality ranges used by all partners participating in the project were collected to achieve a complete semantic interoperability. Accordingly, data can be automatically normalized through the z score formula and physicians can extract and correctly compare information with external statistical tools. Moreover, to respect patients' privacy and legal issues, a local identifier, determined through an HASH cryptography algorithm, is assigned to each patient during the registration process. The database is managed by a user-friendly Web-platform which allows quick access to information during medical examinations and the reusing of the collected data for present and future MCTs. Furthermore, a bidirectional middleware was created in order to import/export information through HL7 messaging. Hence, data can be manually entered by physicians or automatically collected within HL7-compliant Hospital Information systems. RESULTS: Presently, the direct storage of patients' information from the San Paolo Hospital (Savona, Italy), and San Martino and Galliera hospitals in Genoa is in a test phase. Currently, 8 centers of Infectious Diseases (located in Liguria and Piedmont) are participating in the project and almost 400 HIV positive patients have been recorded in the system. Patient data has been used for primary care and research purposes. Currently, there are 4 on-going MCTs and preliminary results have already been presented at International HIV congresses. CONCLUSIONS: The Web-platform allows effective management, sharing and reuse of information within primary care and clinical research. In the future it is planned to share the clinical information from this network with other HL7-compliant workgroups and to extend the platform to other infective diseases (eg, hepatitis).