Incidence and risk factors for dental pathology in patients planned for elective total hip or knee arthroplasty.

BACKGROUND AND AIMS: To prevent severe prosthetic joint infections, a dental examination is usually recommended prior to arthroplasty, even sometimes regarded resource- and time-consuming. The aim of this study was to determine whether a risk factor-based algorithm could be created to send only selected patients for dental clearance. MATERIALS AND METHODS: A prospective study of 952 patients scheduled for elective arthroplasty was performed. Patients filled out a questionnaire regarding potential risk factors for dental infections, and dentists documented patients' oral health and interventions performed (data available for 731 patients). RESULTS: Of the patients, 215 (29.4%) failed dental clearance; a total of 432 teeth were extracted, 32 patients (4.4%) required root canal treatment, and 37 patients (5.1%) had severe periodontitis. Independent risk factors for failure were history of root canal treatment (odds ratio: 2.282, 95% confidence interval: 1.346-3.869, p = 0.020), use of tobacco products (odds ratio: 1.704, 95% confidence interval: 1.033-2.810, p = 0.037), dental visit indicated by oral symptoms within 3 months (odds ratio: 1.828, 95% confidence interval: 1.183-2.827, p = 0.007), or visit to a dentist within 6 months (odds ratio: 1.538, 95% confidence interval: 1.063-2.224, p = 0.022). Regular dental examination was a preventive factor (odds ratio: 0.519, 95% confidence interval: 0.349-0.773, p = 0.001). However, based on the examined risk factors, no sufficiently large group of patients at lesser risk for dental infections could be identified. CONCLUSION: Because of the high need for dental care revealed by our unselected patient population, the inspection and treatment of dental pathology of all patients are important interventions prior to elective arthroplasty.

Increase of prostate biopsy-related bacteremic complications in southern Finland, 2005-2013: a population-based analysis.

BACKGROUND: The most severe manifestations of prostate biopsy complications are bacteremic infections. These complications are increasing alarmingly. METHODS: A retrospective cohort study of 17 183 transrectal prostate biopsies performed at the Helsinki and Uusimaa hospital district in southern Finland during 2005-2013. Biopsies were linked to a database of positive blood cultures, yielding 111 bacteremic cases, and yearly bacteremia rates were determined. By multiple regression analysis, demographic risk factors of the whole biopsy cohort for developing bacteremia or fluoroquinolone (FQ)-resistant bacteremia were studied. Clinical risk factors for bacteremia caused by an FQ-resistant organism and for serious bacteremic outcomes were studied by univariate and multivariate analyzes. RESULTS: The average bacteremia rate was 0.7% (111 of 17 183 biopsies) and an increase was observed from 0.5% in 2005 (95% confidence interval (CI): 0.3-0.9) to 1.2% in 2012 (95% CI 0.8-1.8); 53.2% were caused by an FQ-resistant organism. In univariate regression analysis, previous biopsy sessions and increasing calendar year of biopsy associated with the risk of developing bacteremia (odds ratio (OR) 1.232, 95% CI: 1.020-1.488, P=0.030 and OR 1.164, 95% CI: 1.079-1.255, P<0.001, respectively), but only increasing calendar year of biopsy remained statistically significant (OR 1.155, 95% CI: 1.070-1.247, P<0.001) in multivariate analysis. Foreign travel within 3 months was associated with FQ resistance in multivariate analysis (OR 7.158, 95% CI: 1.042 to infinite, P=0.045). The study failed to show any significant clinical risk factors for serious bacteremic outcomes (requiring intensive care, developing deep infection foci or death). CONCLUSIONS: The postbiopsy bacteremia rate doubled during the study period and half of the cases were caused by FQ-resistant organisms. Recent foreign travel increased the risk for FQ resistance. Future research efforts should be aimed at better identifying risk factors, targeted prophylaxis and reducing the need for biopsies.

Disease burden of prosthetic joint infections after hip and knee joint replacement in Finland during 1999-2004: capture-recapture estimation.

We evaluated the Finnish Hospital Infection Program (SIRO) conducting incidence surveillance for prosthetic joint infection (PJI) from 1999 to 2004. We estimated its sensitivity using capture-recapture methods and assessed the disease burden of PJIs after hip (THA) and knee (TKA) arthroplasties (N = 13 482). The following three data sources were used: SIRO, the Finnish Arthroplasty Register (FAR), and the Finnish Patient Insurance Center (FPIC), which were cross-matched, and 129 individual PJIs were identified. After adjusting for the positive predictive value of SIRO (91%) a log-linear model including an interaction term between FAR and FPIC provided an estimated PJI rate of 1.6% [95% confidence interval (CI): 1.2-2.4] for THA and 1.3% (1.1-1.6) for TKA. Sensitivity for SIRO varied from 36% to 57%. The annual disease burden was 2.1 PJIs per 100 000 population after THA and 1.5 after TKA. The true disease burden of PJIs may be heavier than the rates from national sentinel surveillance systems usually suggest.

Patient outcomes after simultaneous bilateral total hip and knee joint replacements.

Simultaneous arthroplasties are increasingly being performed during one single anaesthetic event. No national nosocomial surveillance systems have yet reported data on this issue. We compared patient populations undergoing bi- and unilateral total hip (THA) and total knee (TKA) arthroplasties in terms of two outcome variables, deep surgical site infections (SSI) and mortality, by analysing surveillance data from the Finnish Hospital Infection Programme (SIRO). A total of 8201 patients underwent 9831 total arthroplasties during 2001-2004. Of the prosthetic joints, 7.2% were inserted in a bilateral operation (range by hospital, 0.6-19.2%; range by procedure type, 5.2-9.9%). Patients who underwent bilateral operations were younger; more often males, and their ASA score was lower than those who underwent unilateral procedures. The rate of deep SSI in bi- and unilateral THAs and in bi- and unilateral TKAs was 0, 0.5, 1.0 and 0.9%, respectively. Following bilateral operations, four deep SSIs were detected, all from bilateral TKAs, three of which were on the second operative side. In these three cases, single doses of antimicrobial prophylaxis were administered 115, 155 and 218 min before incision (median time in unilateral operations: 47 min). According to multi-variate analysis, bilateral operations were not an independent risk factor for deep SSIs. Mortality did not differ between bi- and unilateral THAs or TKAs. Our surveillance data indicate that simultaneous bilateral surgery did not increase the risk of deep SSIs or death after THA and TKA. Bilateral operations may, however, require specific guidelines regarding antimicrobial prophylaxis.

Incidence and risk factors for nosocomial infections caused by fluoroquinolone-resistant Escherichia coli.

The aim of the retrospective case-control study presented here was to elucidate the incidence, risk factors, and outcomes of nosocomial infections caused by quinolone-resistant Escherichia coli (QREC). During the 3-year period studied, 51 nosocomial QREC infections were found, and the characteristics of these cases were compared with those of 102 control patients with quinolone-susceptible nosocomial infections. In the multivariate analysis, risk factors were identified as prior quinolone therapy (odds ratio [OR], 18.49; 95% confidence interval [CI], 5.53-61.82; P value <0.001), urinary tract abnormalities (OR, 6.69; 95% CI, 1.68-26.63; P=0.007), and prior therapy with other antimicrobial agents (OR, 3.57; 95% CI, 1.38-9.27; P=0.009). No difference in mortality or in length of hospital stay was found. Prudent use of quinolones, especially in patients with urinary tract abnormalities, is probably the best way to avoid an increase in the incidence of QREC infections, but further studies on interventions with restricted use of quinolones are necessary to demonstrate the effectiveness and safety of this strategy.

Prevalence of low vitamin B12 and high homocysteine in serum in an elderly male population: association with atrophic gastritis and Helicobacter pylori infection.

BACKGROUND: Deficiency of vitamin B12 raises the serum and tissue levels of homocysteine. Atrophic corpus gastritis results in impaired secretion of intrinsic factor and may lead to malabsorption of vitamin B12 in the intestine. We examined how common an undiagnosed vitamin B12 deficiency is among elderly men in the general population and, in particular, how often this deficiency is related to atrophic corpus gastritis. METHODS: The serum level of pepsinogen I (S-PGI) was assayed in a population-based sample of 12,252 men (age 51-65 years) from two cities in Finland. In this sample, all 635 men with S-PGI < 25 microg/l formed Series A ('males with atrophic corpus gastritis'). Series C (controls--'males without atrophic corpus gastritis)' with a non-atrophic gastric corpus was formed as a random sample of men (n = 402) with S-PGI > or = 50 microg/l. Serum levels of vitamin B12 (S-B12), folate (S-Fol), total homocysteine (S-Hcy) and Helicobacter pylori antibodies (S-HpAb) were assayed in all, or in large subsamples, of the men in Series A and C. RESULTS The men in Series A had significantly lower S-B12 and S-Fol levels than those in Series C. In Series A, 172 of 613 men tested (28%) had S-B 12 < 170 pmol/ 1, and 133 men (22%) had S-B 12 in the range 170-219 pmol/l. The corresponding prevalences were 7% (P < 0.001) and 17% (P < 0.001) in Series C, respectively. The mean S-Hcy was significantly higher in Series A in men with low S-B12 than the mean S-Hcy in Series C in men with normal S-B12. The prevalence of S-Hcy > 15 ,micromol/l was 27% in Series A and 15% in Series C (P < 0.05; chi2 = 4.63). Among subjects with S-B 12 < 220 pmol/l, 46% (104 of 226 men tested) in Series A and 16% (16 of 99) in Series C had S-Hcy > or = 15 micromol/l (P < 0.001). The mean S-Hcy was significantly (P < 0.001) higher in men with S-B12 in the range 170-219 pmol/l in Series A (mean 14.6 +/- 5.0 micromol/l) than in Series C (11.3 +/- 3.0 micromol/l). It was extrapolated that 2.5% of men in the age group 51-65 years in the present study population had a low S-B12 (< 220 pmol/l) level that associated with atrophic corpus gastritis. Of these men, 72% (128 of 179 tested) had an elevated S-HpAb level. CONCLUSIONS: Low S-B12 related to atrophic corpus gastritis is relatively common (prevalence 2.5%) among elderly males in the general population. An ongoing H. pylori infection occurs in three-fourths of these cases.

Lacrimal plugs as a therapy for contact lens intolerance.

We investigated whether canalicular occlusion with a lacrimal plug could increase objective and/or subjective comfort in contact lens (CL) wearers (n = 9) with both a history of lens intolerance and relative tear fluid deficiency. A modified Schirmer test (MST) was performed with the lids closed and under topical anaesthesia. Patients with values of < or = 10 mm/5 min were included. The plugs were inserted into the inferior canaliculus of the eye with the lower MST result; the contralateral eye served as a control. Conjunctival hyperaemia, Rose-Bengal and fluorescein scores, as well as subjective irritation, decreased significantly in plugged eyes at the 1 month follow-up visit but had returned to the pre-operative level at the 3 month visit. Tear fluid plasmin activity was elevated prior to plug insertion. Plasmin activity of the plugged eye was significantly lower at the 1 month visit but neither tear fluid flow (in the collection capillary) nor plasmin release showed any changes. The mean MST value improved significantly, whereas conjunctival chemosis and limbal hyperaemia showed no improvement at the 1 or 3 month follow-up visits after inferior punctual occlusion. Occlusion of the lower canaliculus with a lacrimal plug seems to induce a relatively short-lasting subjective and objective benefit for CL wearers. Plug escape or adaptive changes in lacrimal fluid secretion/elimination rate probably took place during the follow-up. The association of increased plasmin activity with tear deficiency might lead to enhanced tissue proteolysis, and thus contribute to CL-related ocular surface changes.

Urinary kallikrein excretion in normal and hypertensive pregnancy at term.

To study the urinary kallikrein excretion before the delivery of term pregnancy we measured its excretion preterm (between 32-36 gestational week) in 13 patients with normotensive pregnancy and 17 patients with pregnancy-induced hypertension and one to five days before the delivery at term in 18 and 22 patients, respectively. In normotensive pregnancy urinary kallikrein excretion remained unchanged during the late third trimester until delivery (12.6 +/- 1.7 ncat in 24 hours in preterm, 10.8 +/- 1.2 before delivery). In pregnancy-induced hypertension and particularly in pre-eclampsia urinary kallikrein excretion was lower than in normotensive pregnancy and the decrease became more marked as the time of delivery approached (respective values: in pregnancy induced hypertension 9.2 +/- 1.2 and 7.0 +/- 0.7; in pre-eclampsia 7.6 +/- 1.3 and 7.3 +/- 0.9). The decrease in urinary kallikrein excretion suggests progressive disturbances in the interactions of renal vasoactive systems (the kallikrein-kinin system, the renin-angiotensin system and prostaglandins) with resultant changes in renal hemodynamics.