RESUMO
BACKGROUND: Interim spacer exchange may be performed in patients undergoing 2-stage exchange for periprosthetic joint infection. Several studies have demonstrated that interim spacer exchange is associated with poor outcomes. This study investigated the survivorship and risk factors for failure in patients with an interim spacer exchange. METHODS: Two institutional databases identified 182 patients who underwent spacer exchange from 2000 to 2017. Primary outcomes included progression to reimplantation, treatment success, and mortality. Bivariate analysis was performed to evaluate risk factors associated with failure. Kaplan-Meier curves using host and local grades were generated to evaluate for primary outcomes and differences in survivorship. RESULTS: The overall failure rate was 49% in patients with a spacer exchange. Most patients (60%) failed before 2 years. Higher comorbidity scores, elevated erythrocyte sedimentation rate, and non-White race were more prevalent in patients who failed. Negative cultures at the time of exchange were more prevalent in patients who did not fail. Failure rate was higher in immunocompromised conditions, and those who had revision prior to exchange. After considering clinically relevant variables, advanced host grade C was the single factor associated with treatment failure. Although survivorship curves were not significantly different between extremity local grades, higher host grades were associated with treatment failure. CONCLUSION: Almost 1 out of 2 patients with spacer exchange were found to fail the intended 2-stage revision arthroplasty. Benefits of delivering additional antibiotic load with a new spacer should be balanced against poor outcomes in patients with the aforementioned risk factors.
Assuntos
Artrite Infecciosa , Artroplastia de Quadril , Infecções Relacionadas à Prótese , Antibacterianos/uso terapêutico , Artrite Infecciosa/cirurgia , Humanos , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/cirurgia , Reoperação , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Colecistite Aguda , Coledocolitíase , Colangiopancreatografia Retrógrada Endoscópica , Colecistite Aguda/diagnóstico por imagem , Colecistite Aguda/cirurgia , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/cirurgia , Drenagem , Endossonografia , Vesícula Biliar/diagnóstico por imagem , Humanos , Ultrassonografia de IntervençãoRESUMO
BACKGROUND: Patients with native joint septic arthritis are one of the highest risk groups for developing complications following total joint arthroplasty (TJA), especially periprosthetic joint infection(PJI). There is a paucity of information on the risk factors for developing PJI and the optimal treatment modality of the native septic joint that can mitigate that risk. This multicenter study aimed to determine these risk factors, including prior treatment. METHODS: A retrospective study of 233 TJAs performed, following prior septic arthritis at five institutions, was conducted. Comorbidities, organism profile, prior surgery, etiology of septic arthritis, and other relevant variables were reviewed. The primary outcome was the development of PJI, defined by Musculoskeletal Infection Society criteria. Bivariate and multivariate analyses were performed to identify risk factors for PJI. RESULTS: Overall, the PJI rate was 12.4% in patients who underwent TJA after native septic arthritis. Predisposing risk factors for PJI included antibiotic-resistant organisms, male gender, diabetes, and a postsurgical cause of septic arthritis eg open reduction internal fixation. When controlling for potential confounders, multivariate analysis revealed that male gender, diabetes, and a postoperative etiology were predictors of PJI. The definitive treatment modality for the septic joint did not affect the rate of PJI for both arthroscopy vs irrigation and debridement (I&D), and two-stage exchange vs single-stage procedure. DISCUSSION: This study has identified several risk factors for developing PJI in patients with prior septic joint arthritis, some of which are modifiable. The initial treatment modality of the native septic joint has no bearing on the development of PJI after TJA.
Assuntos
Artrite Infecciosa , Artroplastia de Quadril , Infecções Relacionadas à Prótese , Artrite Infecciosa/epidemiologia , Artrite Infecciosa/etiologia , Artrite Infecciosa/cirurgia , Artroplastia , Humanos , Masculino , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/terapia , Estudos Retrospectivos , Fatores de RiscoRESUMO
INTRODUCTION: gastric varices hemorrhage is a severe complication of portal hypertension, with high mortality rates and few management alternatives, especially when there is a contraindication to transjugular intrahepatic portosystemic shunts (TIPS). The usual therapeutic options are the injection of cyanoacrylate, the insertion of coils or both. Hydrocoils are special coils coated with different types of expandable hydrogel polymers conventionally used in neurovascular interventionism. They allow rapid occlusion of vessel, forming a mesh that favors the local formation of thrombus and the development of a neointima on the gel cover. We consider the use of endoscopic ultrasound (EUS) guided hydrocoil insertion in gastric varices, without using cyanoacrylate. OBJECTIVE: this study aimed to evaluate the safety and effectivity of the application of EUS-guided hydrocoils in patients with gastric varices hemorrhage with TIPS contraindication. MATERIAL AND METHODS: this was a retrospective case series of four patients with TIPS contraindication after interventional radiologist evaluation. Linear echoendoscopes, fluoroscopy, 19G needles and hydrocoils (Azur®, Terumo) and Progreat® 3 Fr microcatheters were used. An interventional radiologist expert advised the procedures and endoscopic ultrasound confirmed the varix obliteration. RESULTS: technical and clinical success occurred in all patients involved in this study. There were no adverse effects related to the procedure or endoscopic equipment damage. CONCLUSIONS: the application of EUS-guided hydrocoils can be a safe and effective method in the short term for gastric varices bleeding in patients who are not candidates for TIPS. Besides, a complete obliteration of the vascular lumen could occur and thus, dispense with the use of cyanoacrylate. Further studies are needed to corroborate these preliminary results.
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Varizes Esofágicas e Gástricas , Endoscopia , Varizes Esofágicas e Gástricas/complicações , Varizes Esofágicas e Gástricas/diagnóstico por imagem , Varizes Esofágicas e Gástricas/terapia , Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Humanos , Hidrogéis , Polímeros , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: splenomegaly and/or focal splenic lesions (FSL) have limited histopathologic studies due to the risk posed by splenic punctures. Percutaneous biopsies with a fine needle are difficult, especially due to interposition of gases, ascites, obesity or a history of abdominal surgery. On the other hand, endoscopic ultrasound (EUS) takes advantage of the proximity of the gastric wall to the spleen in order to puncture and visualize the needle and its movements in real time. OBJECTIVE: to describe the initial experience and results obtained with EUS-FNA in patients with splenomegaly or FSL. MATERIALS AND METHODS: this was a descriptive observational study. EUS-FNA of the spleen was performed with a slow-pull technique, which avoided fanning with an average of 3 needle passes. Biopsies were sent in Cytorich RedTM solution for analysis by cytology and cell block. RESULTS: punctures were performed in 15 patients (9 females) and the median age was 67 years (range 44-86). Patients studied due to an enlarged spleen or splenic FSL, in the context of fever of an unknown origin, adenopathies and abnormal weight loss were included. A conclusive diagnosis was achieved by EUS-FNA in 10 patients (66.7 %), 4 were large cell type B non-Hodgkin's lymphoma and one Hodgkin's lymphoma. There were no immediate or delayed complications related to the procedure. CONCLUSIONS: EUS-guided splenic punctures appear to be safe, effective and may be necessary in some clinical settings in order to complete the etiologic filiation of splenomegaly of an uncertain origin or FSL and to rule out malignancy.
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Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico , Esplenopatias , Adulto , Idoso , Idoso de 80 Anos ou mais , Endossonografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Agulhas , Esplenopatias/diagnóstico por imagem , Esplenomegalia/diagnóstico por imagemRESUMO
BACKGROUND: Aspirin is established as an effective prophylaxis for venous thromboembolism (VTE) after THA; however, there is no consensus as to whether low- or regular-dose aspirin is more effective at preventing VTE. QUESTIONS/PURPOSES: (1) Is there a difference in the incidence of symptomatic VTE within 90 days of elective THA using low-dose aspirin compared with regular-dose aspirin? (2) Is there a difference in the risk of significant bleeding (gastrointestinal and wound bleeding) and mortality between low- and standard-dose aspirin within 90 days after surgery? METHODS: We retrospectively evaluated 7488 patients in our database who underwent THA between September 2012 and December 2016. A total of 3936 (53%) patients received aspirin alone for VTE prophylaxis after THA. During the study period, aspirin was prescribed as a monotherapy for VTE prophylaxis after surgery in low-risk patients (no history of VTE, recent orthopaedic surgery, hypercoagulable state, history of cardiac arrhythmia requiring anticoagulation, or receiving anticoagulation for any other medical conditions before surgery). Patients were excluded if aspirin use was contraindicated because of peptic ulcer disease, intolerance, or other reasons. Patients received aspirin twice daily (BID) for 4 to 6 weeks after surgery and were grouped into two cohorts: a low-dose (81 mg BID) aspirin group (n = 1033) and a standard-dose (325 mg BID) aspirin group (n = 2903). The primary endpoint was symptomatic VTE (deep vein thrombosis [DVT] and pulmonary embolism [PE]). Secondary endpoints included significant bleeding (gastrointestinal [GI] and wound) and mortality. Exploratory univariate analyses were used to compare confounders between the study groups. Multivariate regression was used to control for confounding variables (including age, sex, body mass index, comorbidities, and surgeon) as we compared the study groups with respect to the proportion of patients who developed symptomatic VTE, bleeding (GI or wound), and mortality within 90 days of surgery. RESULTS: The 90-day incidence of symptomatic VTE was 1.0% in the 325-mg group and 0.6% in the 81-mg group (p = 0.35). Symptomatic DVT incidence was 0.8% in the 325-mg group and 0.5% in the 81-mg group (p = 0.49), and the incidence of symptomatic PE was 0.3% in the 325-mg group and 0.2% in the 81-mg group (p = 0.45). Furthermore, bleeding was observed in 0.8% of the 325-mg group and 0.5% of the 81-mg group (p = 0.75), and 90-day mortality was not different (0.1%) between the groups (p = 0.75). After accounting for confounders, regression analyses showed no difference between aspirin doses and the 90-day incidence of symptomatic VTE (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.29-2.85; p = 0.85) or symptomatic DVT (OR, 0.96; 95% CI, 0.26-3.59; p = 0.95). CONCLUSIONS: We found no difference in the incidence of symptomatic VTE after THA with low-dose compared with standard-dose aspirin. In the absence of compelling evidence to the contrary, low-dose aspirin appears to be a reasonable option for VTE prophylaxis in otherwise healthy patients undergoing elective THA. LEVEL OF EVIDENCE: Level III, therapeutic study.
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Artroplastia de Quadril/efeitos adversos , Aspirina/administração & dosagem , Fibrinolíticos/administração & dosagem , Tromboembolia Venosa/prevenção & controle , Idoso , Artroplastia de Quadril/mortalidade , Aspirina/efeitos adversos , Feminino , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/mortalidadeRESUMO
Sump syndrome (SS) is associated with choledocho-duodenostomy (CDD) dysfunction, which occurs due to accumulation of detritus, biliary mud and food remains in the suprapapillary distal common bile duct. The prevalence is low after CDD. Currently, biliary drainage endoscopic ultrasound (EUS)-guided with a lumen-apposing metal stent (LAMS) is a new minimally invasive alternative for biliary stenosis for patients in whom endoscopy retrograde cholangial-pancreatography (ERCP) is not feasible. CDD via EUS-guided LAMS is increasing. Thus, SS has become a potential associated complication that was previously unreported in the literature.
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Coledocostomia/efeitos adversos , Endossonografia/efeitos adversos , Síndrome Pós-Colecistectomia/etiologia , Stents/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica , Coledocostomia/métodos , Colestase/terapia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
We present the case of a 79-year-old patient with multiple cardiovascular morbidities, classified as ASA III (American Society of Anesthesiology). An upper digestive endoscopy was performed due to chronic anemia and a subepithelial lesion was identified in the subcardial region of 30 x 25 mm, without other relevant findings.
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Cianoacrilatos/administração & dosagem , Endoscopia Gastrointestinal , Tumores do Estroma Gastrointestinal/terapia , Neoplasias Gástricas/terapia , Idoso , Terapia Combinada , Endoscopia Gastrointestinal/instrumentação , Humanos , Injeções Intralesionais , MasculinoRESUMO
BACKGROUND: The introduction of the Musculoskeletal Infection Society (MSIS) criteria for periprosthetic joint infection (PJI) in 2011 resulted in improvements in diagnostic confidence and research collaboration. The emergence of new diagnostic tests and the lessons we have learned from the past 7 years using the MSIS definition, prompted us to develop an evidence-based and validated updated version of the criteria. METHODS: This multi-institutional study of patients undergoing revision total joint arthroplasty was conducted at 3 academic centers. For the development of the new diagnostic criteria, PJI and aseptic patient cohorts were stringently defined: PJI cases were defined using only major criteria from the MSIS definition (n = 684) and aseptic cases underwent one-stage revision for a noninfective indication and did not fail within 2 years (n = 820). Serum C-reactive protein (CRP), D-dimer, erythrocyte sedimentation rate were investigated, as well as synovial white blood cell count, polymorphonuclear percentage, leukocyte esterase, alpha-defensin, and synovial CRP. Intraoperative findings included frozen section, presence of purulence, and isolation of a pathogen by culture. A stepwise approach using random forest analysis and multivariate regression was used to generate relative weights for each diagnostic marker. Preoperative and intraoperative definitions were created based on beta coefficients. The new definition was then validated on an external cohort of 222 patients with PJI who subsequently failed with reinfection and 200 aseptic patients. The performance of the new criteria was compared to the established MSIS and the prior International Consensus Meeting definitions. RESULTS: Two positive cultures or the presence of a sinus tract were considered as major criteria and diagnostic of PJI. The calculated weights of an elevated serum CRP (>1 mg/dL), D-dimer (>860 ng/mL), and erythrocyte sedimentation rate (>30 mm/h) were 2, 2, and 1 points, respectively. Furthermore, elevated synovial fluid white blood cell count (>3000 cells/µL), alpha-defensin (signal-to-cutoff ratio >1), leukocyte esterase (++), polymorphonuclear percentage (>80%), and synovial CRP (>6.9 mg/L) received 3, 3, 3, 2, and 1 points, respectively. Patients with an aggregate score of greater than or equal to 6 were considered infected, while a score between 2 and 5 required the inclusion of intraoperative findings for confirming or refuting the diagnosis. Intraoperative findings of positive histology, purulence, and single positive culture were assigned 3, 3, and 2 points, respectively. Combined with the preoperative score, a total of greater than or equal to 6 was considered infected, a score between 4 and 5 was inconclusive, and a score of 3 or less was not infected. The new criteria demonstrated a higher sensitivity of 97.7% compared to the MSIS (79.3%) and International Consensus Meeting definition (86.9%), with a similar specificity of 99.5%. CONCLUSION: This study offers an evidence-based definition for diagnosing hip and knee PJI, which has shown excellent performance on formal external validation.
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Artrite Infecciosa/diagnóstico , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Infecções Relacionadas à Prótese/diagnóstico , Reoperação/estatística & dados numéricos , Líquido Sinovial/química , Idoso , Área Sob a Curva , Artrite Infecciosa/etiologia , Sedimentação Sanguínea , Proteína C-Reativa/análise , Hidrolases de Éster Carboxílico , Testes Diagnósticos de Rotina , Medicina Baseada em Evidências , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Secções Congeladas , Humanos , Inflamação/cirurgia , Articulação do Joelho/cirurgia , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/etiologia , Sensibilidade e Especificidade , Adulto JovemRESUMO
Evidence supports the use of rhythmic external auditory signals to improve gait in PD patients (Arias & Cudeiro, 2008; Kenyon & Thaut, 2000; McIntosh, Rice & Thaut, 1994; McIntosh et al., 1997; Morris, Iansek, & Matyas, 1994; Thaut, McIntosh, & Rice, 1997; Suteerawattananon, Morris, Etnyre, Jankovic, & Protas , 2004; Willems, Nieuwboer, Chavert, & Desloovere, 2006). However, few prototypes are available for daily use, and to our knowledge, none utilize a smartphone application allowing individualized sounds and cadence. Therefore, we analyzed the effects on gait of Listenmee®, an intelligent glasses system with a portable auditory device, and present its smartphone application, the Listenmee app®, offering over 100 different sounds and an adjustable metronome to individualize the cueing rate as well as its smartwatch with accelerometer to detect magnitude and direction of the proper acceleration, track calorie count, sleep patterns, steps count and daily distances. The present study included patients with idiopathic PD presented gait disturbances including freezing. Auditory rhythmic cues were delivered through Listenmee®. Performance was analyzed in a motion and gait analysis laboratory. The results revealed significant improvements in gait performance over three major dependent variables: walking speed in 38.1%, cadence in 28.1% and stride length in 44.5%. Our findings suggest that auditory cueing through Listenmee® may significantly enhance gait performance. Further studies are needed to elucidate the potential role and maximize the benefits of these portable devices.