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Ruyssen-Witrand A, Mouterde G, Dernis E, Gaudin P, Wendling D, Cantagrel A, Claudepierre P, Fautrel B, Maillefert JF, Saraux A, Schaeverbeke T, Tebib J, Pham T, Le Loët X. Tolérance des glucocorticoïdes dans la polyarthrite rhumatoïde : élaboration de recommandations pour la pratique clinique, à partir d’une analyse systématique de la littérature et de l’opinion d’experts. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1169-8330(08)70010-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Maragh SLH, Brown MD. Prospective evaluation of surgical site infection rate among patients with Mohs micrographic surgery without the use of prophylactic antibiotics. J Am Acad Dermatol 2008; 59:275-8. [PMID: 18638628 DOI: 10.1016/j.jaad.2008.03.042] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 03/26/2008] [Accepted: 03/26/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Antibiotics may be indiscriminately given to patients undergoing Mohs micrographic surgery (MMS) for the prevention of surgical site infections, despite a low risk of infection in these patients. OBJECTIVE We sought to evaluate the rate of wound infections among patients undergoing MMS without the use of prophylactic antibiotics. METHODS We prospectively evaluated 1000 consecutive patients undergoing MMS for nonmelanoma skin cancer or modified MMS/"slow Mohs" for lentigo maligna melanoma in situ. RESULTS The overall wound infection rate among 1000 patients with 1115 tumors was 0.7% (8/1115 tumors). Five (62.5%) of 8 infections occurred on the nose with an overall 1.7% (5/302) nose infection rate. Seven (87.5%) of 8 infections occurred after flap reconstruction with an overall 2.4% (7/296) flap closure infection rate. Four (50%) of 8 infections occurred in patients requiring more than one Mohs stage for tumor clearance with a 0.8% (4/487) overall infection rate in cases requiring multiple Mohs stages. Two (25%) of 8 infections had cultures positive for oxacillin-resistant Staphylococcus aureus. No wound infections occurred in cases involving the lips or ears, skin-graft closures, or below-knee or modified MMS procedures. LIMITATIONS This was a prospective single institution uncontrolled study. CONCLUSION Rates of infections among patients undergoing MMS or modified MMS are exceedingly low. Indiscriminate use of antibiotics increases patient risk to adverse drug reactions and antibiotic resistance. Administration of antibiotics to patients undergoing MMS should be on a case-by-case basis according to the known risk factors combined with clinical judgment.
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Affiliation(s)
- Sherry L H Maragh
- Department of Dermatology, Division of Dermatologic Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York, USA
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Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, Paulus HE, Mudano A, Pisu M, Elkins-Melton M, Outman R, Allison JJ, Suarez Almazor M, Bridges SL, Chatham WW, Hochberg M, MacLean C, Mikuls T, Moreland LW, O'Dell J, Turkiewicz AM, Furst DE. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. ACTA ACUST UNITED AC 2008; 59:762-84. [PMID: 18512708 DOI: 10.1002/art.23721] [Citation(s) in RCA: 993] [Impact Index Per Article: 62.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Hirao M, Hashimoto J, Tsuboi H, Nampei A, Nakahara H, Yoshio N, Mima T, Yoshikawa H, Nishimoto N. Laboratory and febrile features after joint surgery in patients with rheumatoid arthritis treated with tocilizumab. Ann Rheum Dis 2008; 68:654-7. [PMID: 18519424 PMCID: PMC2663710 DOI: 10.1136/ard.2008.090068] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To understand the acute phase responses to surgical intervention in patients with rheumatoid arthritis (RA) treated with the anti-interleukin (IL)6 receptor antibody, tocilizumab. METHODS In a retrospective 1:1 pair-matched case-control study, 22 tocilizumab-treated RA cases and 22 cases treated with conventional disease-modifying antirheumatic drugs (DMARDs) and matched for type of surgery, age and sex were evaluated for body temperature every day, and blood C-reactive protein (CRP) levels and white blood cell (WBC), neutrophil and lymphocyte counts on days -1, 1, 3 and weeks 1 and 2 after joint surgery. Safety issues were also monitored. RESULTS No complications of infection or delay of wound healing occurred in either patient group. Tocilizumab partially, but significantly, suppressed the increase in body temperature on postoperative days 1 and 2, compared with DMARDs (average (SD) maximum increase in temperature was 0.45 (0.1) degrees C in the tocilizumab group and 0.78 (0.1) degrees C in the DMARD group; p<0.01). Tocilizumab completely suppressed the increase in CRP after surgery, whereas all cases treated with DMARDs showed a significant increase of CRP at postoperative day 1 (5.5 (0.6) mg/dl; p<0.001). WBC, neutrophil and lymphocyte counts showed no remarkable change after surgery, and there was no significant difference in any cell counts between the patient groups. CONCLUSIONS Within this small number of cases, safe operations on patients were performed during tocilizumab treatment. Tocilizumab suppressed fever and increase of CRP after surgery, whereas there was no influence on the transition in number of leukocytes. This characteristic postoperative response should be considered during tocilizumab treatment.
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Affiliation(s)
- M Hirao
- Department of Orthopaedics, Osaka University Graduate School of Medicine, Suita City, Osaka, Japan
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The place of methotrexate perioperatively in elective orthopedic surgeries in patients with rheumatoid arthritis. Clin Rheumatol 2008; 27:1217-20. [DOI: 10.1007/s10067-008-0888-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Revised: 03/11/2008] [Accepted: 03/19/2008] [Indexed: 11/26/2022]
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Perioperative Management of Medications for Psoriasis and Psoriatic Arthritis. Dermatol Surg 2008. [DOI: 10.1097/00042728-200804000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hernandez C, Emer J, Robinson JK. Perioperative management of medications for psoriasis and psoriatic arthritis: a review for the dermasurgeon. Dermatol Surg 2008; 34:446-59. [PMID: 18248470 DOI: 10.1111/j.1524-4725.2007.34091.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Psoriasis affects an estimated 3% of the world's population. Many are on chronic immunosuppressive therapy for the cutaneous and joint manifestations of this disorder. The management of these medications in the perioperative period is controversial. Psoriasis and psoriatic arthritis medications can affect wound healing, hemostasis, and infection risk during cutaneous surgery. OBJECTIVES The objective of this article is to provide a critical review of various medications used for care of the psoriatic patient and their potential effect on cutaneous surgical procedures. CONCLUSIONS This review summarizes current understanding of wound healing, hemostatic effects, and infectious risks regarding many psoriasis medications including nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, corticosteroids, various immunosuppressants, and biologic response modifiers. Recommendations vary depending on the agent in question, type of procedure, and comorbid conditions in the patient. Caution is advised when using many of the medications reviewed due to lack of human data of their effects in the perioperative period.
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Affiliation(s)
- Claudia Hernandez
- Department of Dermatology, University of Illinois at Chicago, Chicago, Illinois 60612-7300, USA
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58
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Abstract
This article reviews total ankle replacement for rheumatoid ankle arthritis. The benefits of preserving the mobility of the ankle joint for the patient who has rheumatoid arthritis are undisputed. Recent reports have consistently shown that patient satisfaction following ankle replacement is high and prosthetic survival is more than 90% at five years and in many instances more than 80% at 10 years. Ankle replacement is contraindicated when there is severe coronal plane deformity.
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Affiliation(s)
- Peter L R Wood
- Wrightington Hospital Wigan, Hall Lane, Appley Bridge, Wigan, WN6 9EP, UK.
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59
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Abstract
This article reviews rheumatoid arthritis, a chronic disease that primarily targets the joints, its treatment and antirheumatic drugs.
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Affiliation(s)
- Marlyn Lorenzo
- Mercy Medical Center, 301 St. Paul Place, Suite 411, Baltimore, MD 21202, USA
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Affiliation(s)
- Steven L Moran
- Division of Plastic Surgery, Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Pieringer H, Stuby U, Biesenbach G. Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment? Semin Arthritis Rheum 2007; 36:278-86. [PMID: 17204310 DOI: 10.1016/j.semarthrit.2006.10.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2006] [Revised: 10/08/2006] [Accepted: 10/29/2006] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To review published data on the perioperative management of antirheumatic treatment and perioperative outcome in patients with rheumatoid arthritis (RA). METHODS The review is based on a MEDLINE (PubMed) search of the English-language literature from 1965 to 2005, using the index keywords "rheumatoid arthritis" and "surgery". As co-indexing terms the different disease-modifying antirheumatic drugs (DMARDs) as well as nonsteroidal anti-inflammatory drugs (NSAIDs) and "glucocorticoids" were used. In addition, citations from retrieved articles were scanned for additional references. Furthermore, because the number of published articles is so limited, relevant abstracts presented at congresses were included in the analysis. RESULTS Continuation of methotrexate (MTX) appears to be safe in the perioperative period. Only a limited number of studies address the use of leflunomide and the results are conflicting. Because of the very long drug half-life, its discontinuation would need to be of long duration and is probably not necessary. Data on hydroxychloroquine do not show increased risks of infection. Regarding sulfasalazine, there are no studies from which definite answers could be drawn on whether it should be withheld perioperatively. Preliminary data show that the risk of infections during treatment with TNF-blocking agents may be lower than initially expected. The only available recommendation (Club Rhumatismes et Inflammation, CRI) suggests discontinuing the drugs before surgery for several weeks, depending on the risk of infection and the drug used. They should not be restarted until wound healing is complete. To avoid the antiplatelet effect during surgery, NSAIDs other than aspirin should be withheld for a duration of 4 to 5 times the drug half-life. Patients with chronic glucocorticoid therapy and suppressed hypothalamic-pituitary-adrenal (HPA) axis need perioperative supplementation. CONCLUSIONS While continuation of MTX likely is safe, data on other DMARDs are sparse. In particular, more data on the perioperative use of the biologic agents are needed.
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Affiliation(s)
- Herwig Pieringer
- Section of Rheumatology, 2nd Department of Medicine, General Hospital Linz, Linz, Austria.
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Abstract
Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structures, are often on multiple medications to control disease activity. These medications may have significant toxicities and side effects. Over the course of their lifetime, patients with this disease often require orthopedic procedures, including total joint arthroplasty, and the medications they are taking present management issues specific to the perioperative period. As many of these medications are immunosuppressive, the concern for postoperative infection and delayed wound healing are particularly worrisome. We conducted a review of the available literature pertaining to the perioperative use of the most commonly prescribed medications for RA. Although the existing data directly addressing perioperative complications in orthopedic surgery is sparse, information on relevant complications resulting from the general use of these drugs may be used as a basis for conservative recommendations.
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Murata K, Yasuda T, Ito H, Yoshida M, Shimizu M, Nakamura T. Lack of increase in postoperative complications with low-dose methotrexate therapy in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Mod Rheumatol 2006; 16:14-9. [PMID: 16622718 DOI: 10.1007/s10165-005-0444-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2005] [Accepted: 10/24/2005] [Indexed: 01/12/2023]
Abstract
To determine the potential contribution of intermittent low-dose methotrexate (MTX) treatment (2-8 mg/week) to postoperative complications, we studied 122 patients with rheumatoid arthritis (RA) who had 201 surgical procedures. The patients with treatment with MTX were allocated to two groups: those who continued MTX (group A, 77 procedures) and those who discontinued MTX more than 1 week (group B, 21 procedures). The patients who had no treatment with MTX were allocated to group C (103 procedures). The incidence of postoperative infection, poor wound healing, and flare-up of RA was compared between the three groups. Postoperative infection occurred in 3.9%, 4.8%, and 3.9% in groups A, B, and C, respectively. Poor wound healing was experienced in 1.3%, 9.5%, and 7.8% in groups A, B, and C, respectively. At 4 weeks postoperatively, 3.9%, 14.3%, and 6.8% of flares were seen in groups A, B, and C, respectively. No significant difference was found in the patients with or without perioperative use of MTX. From these results, it is unlikely that continuation of intermittent low-dose MTX treatment increases the risk of postoperative complications in patients with RA. Continued treatment with MTX during perioperative period could suppress disease flares, especially in severe RA patients.
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Affiliation(s)
- Koichi Murata
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Maragh SL, Otley CC, Roenigk RK, Phillips PK. Antibiotic Prophylaxis in Dermatologic Surgery: Updated Guidelines. Dermatol Surg 2006; 31:83-91. [PMID: 15720101 DOI: 10.1111/j.1524-4725.2005.31014] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antibiotic prophylaxis in dermatologic surgery is poorly understood, and data on its use are lacking. Prophylaxis is indicated for the prevention of endocarditis and prosthesis infection, as well as surgical site infection. OBJECTIVE We review essential considerations for the use of antibiotic prophylaxis in dermatologic surgery and provide clear guidelines for practical implementation. METHODS Guidelines were developed after review of the literature and consultation with infectious disease specialists and subspecialists in the areas of cardiac, orthopedic, and neurosurgical infectious disease at Mayo Clinic. RESULTS Three factors affect the decision to use prophylactic antibiotics in dermatologic surgery: (1) the underlying indication for prophylaxis (patient risk stratification), (2) the condition of the skin, and (3) the specific procedure planned. Thorough preoperative evaluation and surgical planning are critical in identifying and optimizing patient and environmental risk factors that may increase the risk of infection. Appropriate antibiotic selections with site-specific consideration and appropriate timing of antibiotic administration are key factors in providing effective prophylaxis. CONCLUSIONS Low rates of infection associated with dermatologic surgical procedures warrant selective use of antibiotic prophylaxis. The proposed guidelines reflect current standards of practice.
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Affiliation(s)
- Sherry L Maragh
- Division of Dermatologic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Busti AJ, Hooper JS, Amaya CJ, Kazi S. Effects of perioperative antiinflammatory and immunomodulating therapy on surgical wound healing. Pharmacotherapy 2006; 25:1566-91. [PMID: 16232020 DOI: 10.1592/phco.2005.25.11.1566] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with various rheumatologic and inflammatory disease states commonly require drugs known to decrease the inflammatory or autoimmune response for adequate control of their condition. Such drugs include nonsteroidal antiinflammatory drugs (NSAIDs), cyclooxygenase (COX)-2 inhibitors, corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and biologic response modifiers. These drugs affect inflammation and local immune responses, which are necessary for proper wound healing in the perioperative setting, thereby potentially resulting in undesirable postoperative complications. Such complications include wound dehiscence, infection, and impaired collagen synthesis. The end result is delayed healing of soft tissue and bone wounds. The current literature provides insight into the effect of some of these drugs on wound healing. For certain drugs, such as methotrexate, trials have been conducted in humans and direct us on what to do during the perioperative period. Whereas with other drugs, we must rely on either small-animal studies or extrapolation of data from human studies that did not specifically look at wound healing. Unfortunately, no clear consensus exists on the need and optimum time for withholding therapy before surgery. Likewise, clinicians are often uncertain of the appropriate time to resume therapy after the procedure. For those drugs with limited or no data in this setting, the use of pharmacokinetic properties and biologic effects of each drug should be considered individually. In some cases, discontinuation of therapy may be required up to 4 weeks before surgery because of the long half-lives of the drugs. In doing so, patients may experience an exacerbation or worsening of disease. Clinicians must carefully evaluate individual patient risk factors, disease severity, and the pharmacokinetics of available therapies when weighing the risks and benefits of discontinuing therapy in the perioperative setting.
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Affiliation(s)
- Anthony J Busti
- Texas Tech University Health Sciences Center School of Pharmacy, Dallas-Ft. Worth Regional Campus, Dallas, Texas 75216, USA.
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66
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Abstract
Wrist involvement is common in patients with rheumatoid arthritis. Individual patient assessment is important in determining functional deficits and treatment goals. Patients with persistent disease despite aggressive medical management are candidates for surgery. Soft-tissue procedures offer good symptomatic relief and functional improvement in the short term. Extensor and flexor tendons may rupture because of synovial infiltration and bony irritation. When rupture occurs, direct repair usually is not possible. However, when joints that are motored by the ruptured tendon are still functional, tendon transfer or grafting may be considered. Because of the progressive nature of the disease, dislocation and end-stage arthritis often require stabilization with bony procedures. The distal radioulnar joint is usually affected first and is commonly treated with either the Darrach or the Sauvé-Kapandji procedure. Partial wrist fusion offers a compromise between achieving stability of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers reliable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of total wrist replacement are still being evaluated.
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Affiliation(s)
- Steven R Papp
- University of Ottawa, Ottawa Civic Hospital, Ottawa, ON, Canada
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67
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Abstract
Currently, there is little information regarding treatment of shoulder sepsis in patients with rheumatoid arthritis. This study examines the prognosis and outcome after operative treatment of native shoulder infection in patients with rheumatoid arthritis. Seventeen patients were retrospectively reviewed (20 shoulders) after surgical intervention for shoulder sepsis between 1982 and 2002. Nine patients (12 shoulders) were associated with multiple joint infections. The most common isolated organism from cultures was Staphylococcus aureus in 15 shoulders. Three patients died during initial admission to the hospital (at 7 days, 5 months, and 6 months) because of multisystem organ failure and multiple joint infections. Fourteen patients (15 shoulders) survived for followup, with two excellent, six satisfactory, and seven unsatisfactory results. Mean active elevation was 100 degrees. Further surgery was required in three patients: one synovectomy and two shoulder arthrodeses. In this study, patients with shoulder sepsis with rheumatoid arthritis were found to have a high rate of multiple joint sepsis and unsatisfactory shoulder function.
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Affiliation(s)
- Adam M Smith
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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