Modern techniques have reduced the frequency of infections that are associated with prosthetic joints, but such infections continue to pose difficult problems in clinical management. Advances in understanding biofilms and the pathogenesis of microbial interactions with the implant have led to more rational approaches to therapy. This review offers guidance in establishing the diagnosis correctly and an algorithm summarizing the appropriate medical and surgical options.

/pdf/prosthetic-joint-infections-qrunwr5dn0.pdf

Prosthetic-Joint Infections

结节病易误诊,据王洪武等~([1])收集国内18篇关于此病误诊的文献,误诊率高达63.2%,当然有误诊就会有误治,如孙永昌等~([2])报道26例结节病在影像学检查诊断的第一印象中拟诊结核5例,其中就有2例完成规范的抗结核治疗,为此应引起临床对本病诊治的重视。

Sarcoidosis

Melioidosis, caused by the gram-negative saprophyte Burkholderia pseudomallei, is a disease of public health importance in southeast Asia and northern Australia that is associated with high case-fatality rates in animals and humans. It has the potential for epidemic spread to areas where it is not endemic, and sporadic case reports elsewhere in the world suggest that as-yet-unrecognized foci of infection may exist. Environmental determinants of this infection, apart from a close association with rainfall, are yet to be elucidated. The sequencing of the genome of a strain of B. pseudomallei has recently been completed and will help in the further identification of virulence factors. The presence of specific risk factors for infection, such as diabetes, suggests that functional neutrophil defects are important in the pathogenesis of melioidosis; other studies have defined virulence factors (including a type III secretion system) that allow evasion of killing mechanisms by phagocytes. There is a possible role for cell-mediated immunity, but repeated environmental exposure does not elicit protective humoral or cellular immunity. A vaccine is under development, but economic constraints may make vaccination an unrealistic option for many regions of endemicity. Disease manifestations are protean, and no inexpensive, practical, and accurate rapid diagnostic tests are commercially available; diagnosis relies on culture of the organism. Despite the introduction of ceftazidime- and carbapenem-based intravenous treatments, melioidosis is still associated with a significant mortality attributable to severe sepsis and its complications. A long course of oral eradication therapy is required to prevent relapse. Studies exploring the role of preventative measures, earlier clinical identification, and better management of severe sepsis are required to reduce the burden of this disease.

https://ams.kku.ac.th/suchat/Mellioidosis/Melioidosis%20Epidemiology%20Pathophysiology,and%20Management.pdf

Melioidosis: Epidemiology, Pathophysiology, and Management

This report updates, expands, and replaces the previously published CDC "Guideline for Prevention of Nosocomial Pneumonia". The new guidelines are designed to reduce the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health-care settings (e.g., ambulatory and long-term care institutions) and other facilities where health care is provided. Among the changes in the recommendations to prevent bacterial pneumonia, especially ventilator-associated pneumonia, are the preferential use of oro-tracheal rather than naso-tracheal tubes in patients who receive mechanically assisted ventilation, the use of noninvasive ventilation to reduce the need for and duration of endotracheal intubation, changing the breathing circuits of ventilators when they malfunction or are visibly contaminated, and (when feasible) the use of an endotracheal tube with a dorsal lumen to allow drainage of respiratory secretions; no recommendations were made about the use of sucralfate, histamine-2 receptor antagonists, or antacids for stress-bleeding prophylaxis. For prevention of health-care--associated Legionnaires disease, the changes include maintaining potable hot water at temperatures not suitable for amplification of Legionella spp., considering routine culturing of water samples from the potable water system of a facility's organ-transplant unit when it is done as part of the facility's comprehensive program to prevent and control health-care--associated Legionnaires disease, and initiating an investigation for the source of Legionella spp. when one definite or one possible case of laboratory-confirmed health-care--associated Legionnaires disease is identified in an inpatient hemopoietic stem-cell transplant (HSCT) recipient or in two or more HSCT recipients who had visited an outpatient HSCT unit during all or part of the 2-10 day period before illness onset. In the section on aspergillosis, the revised recommendations include the use of a room with high-efficiency particulate air filters rather than laminar airflow as the protective environment for allogeneic HSCT recipients and the use of high-efficiency respiratory-protection devices (e.g., N95 respirators) by severely immunocompromised patients when they leave their rooms when dust-generating activities are ongoing in the facility. In the respiratory syncytial virus (RSV) section, the new recommendation is to determine, on a case-by-case basis, whether to administer monoclonal antibody (palivizumab) to certain infants and children aged <24 months who were born prematurely and are at high risk for RSV infection. In the section on influenza, the new recommendations include the addition of oseltamivir (to amantadine and rimantadine) for prophylaxis of all patients without influenza illness and oseltamivir and zanamivir (to amantadine and rimantadine) as treatment for patients who are acutely ill with influenza in a unit where an influenza outbreak is recognized. In addition to the revised recommendations, the guideline contains new sections on pertussis and lower respiratory tract infections caused by adenovirus and human parainfluenza viruses and refers readers to the source of updated information about prevention and control of severe acute respiratory syndrome.

/pdf/guidelines-for-preventing-health-care-associated-pneumonia-3ebalxrxyl.pdf

Guidelines for Preventing Health-Care-- Associated Pneumonia, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee

Prosthetic joint infection (PJI) is a tremendous burden for individual patients as well as the global health care industry. While a small minority of joint arthroplasties will become infected, appropriate recognition and management are critical to preserve or restore adequate function and prevent excess morbidity. In this review, we describe the reported risk factors for and clinical manifestations of PJI. We discuss the pathogenesis of PJI and the numerous microorganisms that can cause this devastating infection. The recently proposed consensus definitions of PJI and approaches to accurate diagnosis are reviewed in detail. An overview of the treatment and prevention of this challenging condition is provided.

/pdf/prosthetic-joint-infection-20eesbrxfa.pdf

Prosthetic Joint Infection

Objective. —To evaluate critically Carl Wunderlich's axioms on clinical thermometry. Design. —Descriptive analysis of baseline oral temperature data from volunteers participating inShigellavaccine trials conducted at the University of Maryland Center for Vaccine Development, Baltimore. Setting. —Inpatient clinical research unit. Participants. —One hundred forty-eight healthy men and women aged 18 through 40 years. Main Measurements. —Oral temperatures were measured one to four times daily for 3 consecutive days using an electronic digital thermometer. Results. —Our findings conflicted with Wunderlich's in that 36.8°C (98.2°F) rather than 37.0°C (98.6°F) was the mean oral temperature of our subjects; 37.7°C (99.9°F) rather than 38.0°C (100.4°F) was the upper limit of the normal temperature range; maximum temperatures, like mean temperatures, varied with time of day; and men and women exhibited comparable thermal variability. Our data corroborated Wunderlich's in that mean temperature varied diurnally, with a 6 AM nadir, a 4 to 6 PM zenith, and a mean amplitude of variability of 0.5°C (0.9°F); women had slightly higher normal temperatures than men; and there was a trend toward higher temperatures among black than among white subjects. Conclusions. —Thirty-seven degrees centigrade (98.6°F) should be abandoned as a concept relevant to clinical thermometry; 37.2°C (98.9°F) in the early morning and 37.7°C (99.9°F) overall should be regarded as the upper limit of the normal oral temperature range in healthy adults aged 40 years or younger, and several of Wunderlich's other cherished dictums should be revised. (JAMA. 1992;268:1578-1580)

A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich.

Sinus-tract cultures were compared with cultures of operative specimens from 40 patients with chronic osteomyelitis. Thirty-five patients (87.5%) had a single pathogen isolated from their operative specimens. Only 44% of the sinus-tract cultures contained the operative pathogen. Isolation of Staphyloccus aureus from sinus tracts correlated with the presence of S aureus in the operative specimen. However, less than half of the sinus-tract cultures obtained from patients with S aureus osteomyelitis contained this organism. Isolation of bacteria other than S aureus from sinus tracts had a low likelihood of predicting the pathogen isolated from bone. A presumptive diagnosis of S aureus osteomyelitis is justified if S aureus is isolated from an associated sinus tract. A bacteriologic diagnosis of chronic osteomyelitis based on isolation of common pathogens other than S aureus from sinus tracts must be verified by an appropriate operative culture. ( JAMA 239:2772-2775, 1978)

https://jamanetwork.com/journals/jama/articlepdf/1203821/jama_239_26_018.pdf

Diagnostic Value of Sinus-tract Cultures in Chronic Osteomyelitis

Background In March 2011, the Institute of Medicine (IOM) issued a new set of standards for clinical practice guidelines intended to enhance the quality of guidelines being produced. To our knowledge, no systematic review of adherence to such standards has been undertaken since one published over a decade ago. Methods Two reviewers independently screened 130 guidelines selected at random from the National Guideline Clearinghouse (NGC) website for compliance with 18 of 25 IOM standards. Results The overall median number (percentage) of IOM standards satisfied (out of 18) was 8 (44.4%), with an interquartile range of 6.5 (36.1%) to 9.5 (52.8%). Fewer than half of the guidelines surveyed met more than 50% of the IOM standards. Barely a third of the guidelines produced by subspecialty societies satisfied more than 50% of the IOM standards surveyed. Information on conflicts of interest (COIs) was given in fewer than half of the guidelines surveyed. Of those guidelines including such information, COIs were present in over two-thirds of committee chairpersons (71.4%) and 90.5% of co-chairpersons. Except for US government agency–produced guidelines, criteria used to select committee members and the selection process were rarely described. Committees developing guidelines rarely included an information scientist or a patient or patient representative. Non-English literature, unpublished data, and/or abstracts were rarely considered in developing guidelines; differences of opinion among committee members generally were not aired in guidelines; and benefits of recommendations were enumerated more often than potential harms. Guidelines published from 2006 through 2011 varied little with regard to average number of IOM standards satisfied. Conclusion Analysis of a random sample of clinical practice guidelines archived on the NGC website as of June 2011 demonstrated poor compliance with IOM standards, with little if any improvement over the past 2 decades.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/1384245/iiq120072_1628_1633.pdf

Failure of clinical practice guidelines to meet institute of medicine standards: Two more decades of little, if any, progress.

cal thermometry, few physicians could identify the source or explain the pertinacity of the belief that 98.6°F (37.0°C) has special meaning vis-a `-vis normal body temperature. Fewer still could cite the origin of the thermometer or trace the evolution of modern concepts of clinical thermometry. Although many would have some knowledge of the fundamentals of thermoregulation and the role played by exogenous and endogenous pyrogens in the induction of fever, few would have more than a superficial knowledge of the broad biological activities of pyrogenic cytokines or know of the existence of an equally complex and important system of endogenous cryogens. A distinct minority would appreciate the obvious paradoxes inherent in an enlarging body of data concerned with the question of fever’s adaptive value. The present review considers many of these issues in the light of current data.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/209609/ira71067.pdf

Concepts of Fever

Because no systematic analysis of drug fever has been done, there has been no means for testing the validity of published characterizations of this clinical entity. We reviewed the clinical characteristics of 51 episodes of drug fever in 45 patients hospitalized at two Dallas hospitals between 1959 and 1986, and 97 episodes reported in the English literature between 1966 and 1986. Unlike characterizations found in textbooks and review articles, we found relative bradycardia in a minority of cases reviewed; little risk associated with rechallenge unless underlying cardiovascular disease was present; no characteristic fever pattern; a highly variable lag time between the initiation of the offending agent and the onset of fever; an infrequent association with either rash or eosinophilia; and no apparent association of drug fever with systemic lupus erythematosus, atopy, female sex, or advanced age.

Drug Fever: A Critical Appraisal of Conventional Concepts: An Analysis of 51 Episodes in Two Dallas Hospitals and 97 Episodes Reported in the English Literature

Philip A. Mackowiak

Papers

A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich.

Diagnostic Value of Sinus-tract Cultures in Chronic Osteomyelitis

Failure of clinical practice guidelines to meet institute of medicine standards: Two more decades of little, if any, progress.

Concepts of Fever

Drug Fever: A Critical Appraisal of Conventional Concepts: An Analysis of 51 Episodes in Two Dallas Hospitals and 97 Episodes Reported in the English Literature