Direct access to magnetic resonance imaging improved orthopaedic knee referrals in the Netherlands.

BACKGROUND: The use of magnetic resonance imaging (MRI) in primary care is under debate, and the majority of GPs have no experience with MRI. OBJECTIVES: To examine for which patients with knee injury an MRI is ordered and does direct access to MRI in primary care influence the GP referral to an orthopaedic surgeon? METHODS: Consecutive patients with knee injury who underwent an MRI examination ordered by their GP were included. On the application form for MRI, the GPs indicated their referral intention in advance, as if MRI had not been available. Six months after the MRI scan, written interviews with the GPs were used to collect data on referrals and orthopaedic intervention. The number of patients finally referred to an orthopaedic surgeon in secondary care after MRI was compared with the number of intended referrals. RESULTS: Of the 588 included, GPs referred fewer patients to the orthopaedic surgeon after receiving the MRI results than they would have done prior to MRI (60% versus 82.8%, P < 0.0001). The reduction was 16.1% for patients older than 50 years and 28.1% for patients younger than 50 years. Orthopaedic intervention was performed in 62.9% of all referred patients. Of the 101 patients whom the GP did not intend to refer prior to MRI, 48 were referred to an orthopaedic surgeon based on the MRI findings. CONCLUSION: In patients with knee injury, direct access to MRI of the knee in a primary care setting significantly reduced referrals to an orthopaedic surgeon. LEVEL OF EVIDENCE: Three prospective cohort.

Treatment with clarithromycin prior to coronary artery bypass graft surgery does not prevent subsequent cardiac events.

BACKGROUND: Recently, it has been suggested that Chlamydia pneumoniae possibly plays a possible role in the pathogenesis of atherosclerosis. We investigated whether treatment with clarithromycin prior to coronary artery bypass graft (CABG) surgery would prevent subsequent cardiovascular events and mortality. METHODS: Patients who were scheduled for CABG surgery were randomly assigned to receive either clarithromycin or placebo until the day of surgery in a double-blind trial. During the 2 years of follow-up, mortality and cardiovascular events were assessed. RESULTS: Follow-up at 2 years was achieved for 473 patients. The mean duration of treatment was 16 days. Patient characteristics at baseline were well balanced between the 2 treatment groups. Mortality was equal in the 2 groups: 10 (4.2%) of 238 patients in the clarithromycin group and 9 (3.8%) of 235 patients in the placebo group (relative risk, 1.10; 95% CI, 0.42-2.89; P=1.0). Also, there were no significant differences in the proportion of patients who experienced cardiovascular events during the follow-up period: 20 (8.4%) of 238 patients in the clarithromycin group and 19 (8.1%) of 235 patients in the placebo group (relative risk, 1.04; 95% CI, 0.55-1.98; P=1.0). The overall rate of such events was 58 (12.3%) of 473 patients. CONCLUSIONS: Treatment with clarithromycin in patients scheduled for CABG surgery did not reduce the subsequent occurrence of cardiovascular events or mortality during a 2-year follow-up period.

[Summary of the practice guideline 'Traumatic knee problems' (first revision) from the Dutch College of General Practitioners]. / De NHG-Standaard 'Traumatische knieproblemen' (eerste herziening): samenvatting.

Most traumatic knee problems have a favourable prognosis and can be treated by the general practitioner. The course of knee symptoms and the impairment of knee function are more important for decisions about the management of knee problems than the results of physical examination of the knee. The additional value of general practitioner referral for MRI of the knee has not been established yet. Reasons for urgent referral to an orthopaedic specialist are: a knee fracture, an acutely locked knee, and a patellar dislocation.

Effect of clarithromycin treatment on Chlamydia pneumoniae in vascular tissue of patients with coronary artery disease: a randomized, double-blind, placebo-controlled trial.

Several small clinical trials have indicated that antibiotic treatment of Chlamydia pneumoniae infection is associated with a better outcome in patients with coronary artery disease (CAD). It has not been demonstrated whether antibiotic treatment eradicates C. pneumoniae from vascular tissue. The aim of the present study was to assess the effect of clarithromycin on the presence of C. pneumoniae in the vascular tissue of patients with CAD. Patients who had CAD and who were waiting for coronary artery bypass graft surgery were enrolled in a randomized, double-blind, placebo-controlled trial. Patients were treated with clarithromycin at 500 mg or placebo once daily from the day of inclusion in the study until surgery. Several vascular tissue specimens were obtained during surgery. The presence of C. pneumoniae in vascular tissue specimens was examined by immunohistochemical staining (IHC) and two PCR assays. Chlamydia immunoglobulin G (IgG) titers were determined by an enzyme-linked immunosorbent assay at the time of inclusion in the study and 8 weeks after surgery. A total of 76 patients were included, and 180 vascular tissue specimens were obtained (80 specimens from the group treated with clarithromycin and 100 specimens from the group treated with placebo). Thirty-five patients received clarithromycin (mean duration, 27 days; standard deviation [SD], 12.2 days), and 41 patients received placebo (mean duration, 27 days; SD, 13.9 days). IHC detected the C. pneumoniae major outer membrane protein antigen in 73.8% of the specimens from the group treated with clarithromycin and 77.0% of the specimens from the group treated with placebo (P was not significant). Chlamydia lipopolysaccharide antigen was found in only one specimen from the group that received placebo. C. pneumoniae DNA was not detected in any specimen. Baseline Chlamydia-specific IgG titers were equally distributed in both groups and were not significantly different after treatment. There was no indication of an active C. pneumoniae infection in vascular tissue. Chlamydia-specific IgG titers remained unchanged throughout the study in both the antibiotic- and the placebo-treated patients.

Effect of clarithromycin on inflammatory markers in patients with atherosclerosis.

Atherosclerosis can to a certain extent be regarded as an inflammatory disease. Also, inflammatory markers may provide information about cardiovascular risk. Whether macrolide antibiotics, especially clarithromycin, have an anti-inflammatory effect in patients with atherosclerosis is not exactly known. To study this phenomenon, a placebo-controlled, randomized, double-blind study was performed. A total of 231 patients with documented coronary artery disease received a daily dose of either 500 mg of slow-release clarithromycin or placebo until the day of surgery. Levels of inflammatory markers (C-reactive protein, interleukin-2 receptor [IL-2R], IL-6, IL-8, and tumor necrosis factor alpha) were assessed during the preoperative outpatient visit, on the day of surgery, and 8 weeks after surgery. Also, changes in the levels of inflammatory markers between visits were determined by delta calculations. Baseline patient characteristics were balanced between the two treatment groups: the average age was 66 years (standard deviation [SD] = 9.0), 79% of the patients were male, and the average number of tablets used was 16 (SD = 9.3). The inflammatory markers of the groups as well as the delta calculations were not significantly changed. Treatment with clarithromycin did not influence the inflammatory markers in patients with atherosclerosis.

Emergence and persistence of macrolide resistance in oropharyngeal flora and elimination of nasal carriage of Staphylococcus aureus after therapy with slow-release clarithromycin: a randomized, double-blind, placebo-controlled study.

To investigate the effect of slow-release (SR) clarithromycin on colonization and the development of resistance in oropharyngeal and nasal flora, a double-blind, randomized, placebo-controlled trial was performed with 8 weeks of follow-up. A total of 296 patients with documented coronary artery disease were randomized in the preoperative outpatient clinic to receive a daily dose of SR clarithromycin (500 mg) (CL group) or placebo tablets (PB group) until the day of surgery. Nose and throat swabs were taken before the start of therapy, directly after the end of therapy, and 8 weeks later. The presence of potential pathogenic bacteria was determined, and if they were isolated, MIC testing was performed. Quantitative culture on media with and without macrolides was performed for the indigenous oropharyngeal flora. In addition, analysis of the mechanism of resistance was performed with the macrolide-resistant indigenous flora. Basic patient characteristics were comparable in the two treatment groups. The average number of tablets taken was 15 (standard deviation = 6.4). From the throat swabs, Haemophilus parainfluenzae was isolated and carriage was not affected in either of the treatment groups. Nasal carriage of Staphylococcus aureus, however, was significantly reduced in the CL group (from 35.3 to 4.3%) compared to the PB group (from 32.4 to 30.3%) (P < 0.0001; relative risk [RR], 7.0; 95% confidence interval [CI], 3.1 to 16.0). Resistance to clarithromycin was present significantly more frequently in H. parainfluenzae in the CL group after treatment (P = 0.007; RR, 1.6; 95% CI, 1.1 to 2.3); also, the percentage of patients with resistance to macrolides in the indigenous flora after treatment was significantly higher in the CL group (31 to 69%) (P < 0.0001; RR, 1.9; 95% CI, 1.4 to 2.5). This persisted for at least 8 weeks. This study shows that besides the effective elimination of nasal carriage of S. aureus, treatment with SR clarithromycin for approximately 2 weeks has a marked and sustained effect on the development of resistance in the oropharyngeal flora for at least 8 weeks.