Approach to septic arthritis

Prompt diagnosis and treatment of infectious arthritis can help prevent significant morbidity and mortality. The acute onset of monoarticular joint pain, erythema, heat, and immobility should raise suspicion of sepsis. Constitutional symptoms such as fever, chills, and rigors are poorly sensitive for septic arthritis. In the absence of peripheral leukopenia or prosthetic joint replacement, synovial fluid white blood cell count in patients with septic arthritis is usually greater than 50,000 per mm3. Isolation of the causative agent through synovial fluid culture is not only definitive but also essential before selecting antibiotic therapy. Synovial fluid analysis is also useful to help distinguish crystal arthropathy from infectious arthritis, although the two occasionally coexist. Almost any microorganism can be pathogenic in septic arthritis; however, septic arthritis is caused by nongonococcal pathogens (most commonly Staphylococcus species) in more than 80 percent of patients. Gram stain results should guide initial antibiotic choice. Vancomycin can be used for gram-positive cocci, ceftriaxone for gram-negative cocci, and ceftazidime for gram-negative rods. If the Gram stain is negative, but there is strong clinical suspicion for bacterial arthritis, treatment with vancomycin plus ceftazidime or an aminoglycoside is appropriate. Evacuation of purulent material with arthrocentesis or surgical methods is necessary. Special consideration should be given to patients with prosthetic joint infection. In this population, the intraarticular cutoff values for infection may be as low as 1,100 white blood cells per mm3 with a neutrophil differential of greater than 64 percent.     

My treatment approach to rheumatoid arthritis

The past decade has brought important advances in the understanding of rheumatoid arthritis and its management and treatment. New classification criteria for rheumatoid arthritis, better definitions of treatment outcome and remission, and the introduction of biologic response-modifying drugs designed to inhibit the inflammatory process have greatly altered the approach to managing this disease. More aggressive management of rheumatoid arthritis early after diagnosis and throughout the course of the disease has resulted in improvement in patient functioning and quality of life, reduction in comorbid conditions, and enhanced survival.     

Teichoic acid antibody measurement as an aid to the diagnosis of septic arthritis due to Staphylococcus aureus

Hitherto laboratory diagnosis of septic arthritis has been dependent on Gram films, bacteriological culture and leucocyte counts with varying amounts of success. Patients with septic arthritis, rheumatoid arthritis and other conditions in which joint inflammation is significant have been analysed for the presence of specific staphylococcal teichoic acid antibody (TAA) in serum and synovial fluid specimens as an alternative to provide improved diagnosis. Good correlation between a positive bacterial culture for Staphylococcus aureus and TAA was seen in those patients with staphylococcal septic arthritis. Serum proved to be a better source of the antibody than synovial fluid. Thepresence of immune complexes in synovial fluid may account for this difference in sensitivity.     

Nongonococcal bacterial septic arthritis. An update on diagnosis and management

Nongonococcal septic arthritis, particularly if caused by Staphylococcus aureus or Gram-negative bacilli, presents major dilemmas to the primary care physician. Patients with this disorder require prolonged regimens of parenteral antibiotics in high doses and intensive serial radiographic investigation for coexistent osteomyelitis. For patients with pyoarthrosis caused by Gram-negative bacilli, use of combination synergistic chemotherapy is recommended.     

Sternoclavicular septic arthritis due to haemophilus influenzae

We have reported a case of septic sternoclavicular arthritis illustrating a rare complication of infection with a relatively common pathogen, Haemophilus influenze. Early identification of the infecting organism and appropriate antibiotic therapy are essential to prevent further morbidity from the complications of this unusual pyoarthritis.     

Bilomas: A new approach to the diagnosis and treatment

Biloma, a newly described entity, appears to have gained a heightened clinical interest recently. During the past 18 months we have diagnosed 9 abnormal biliary collections. We discuss here the role of sonography and radionuclide cholescintigraphy in the evaluation of bilomas. The diagnosis of all cases was confirmed by ultrasoundguided percutaneous needle aspiration. Subsequently 7 patients were treated with catheter drainage, obviating the need for any surgery.     

Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED

Introduction

Early goal-directed therapy (EGDT) in septic shock defined by Rivers et al was proven to reduce mortality and validated by observational studies. However, criticism is centered in particular on the early requirement of a central venous catheter (CVC) and on central venous pressure (CVP) as an indicator of volume responsiveness. The present study is a pivotal study to investigate the reliability of a less invasive approach, which uses inferior vena cava (IVC) and lung ultrasounds (US) to guide the infusion of fluids and lactate clearance to monitor tissue perfusion.

Methods

We enrolled 51 patients with septic shock. As a marker of preload optimization, we measured IVC collapse in place of CVP and serum lactate clearance in place of central venous oxygen saturation as a marker of tissue perfusion. As outcomes, we considered the accomplishment of the noninvasive EGDT goals, the number of patients treated without the need of a CVC, the amount of fluids administered in the first 6 hours, the development of pulmonary edema, and the overall mortality rate.

Results

Inferior vena cava US evaluation resulted feasible in 92% of patients. Lung US was performed in 100% of cases. In the first 6 hours, only 61.7% of patients received a CVC, an average of 5.5 L of crystalloids were administered, and only 4 patients developed clinical overt pulmonary edema. Mortality was 34% at 28 days and 38.3% at 60 days.

Conclusions

Our approach to resuscitation in septic shock appears feasible in the emergency department and needs further study with a randomized controlled trial.     

采用关节镜技术治疗化脓性关节炎的个性化护理

目的：观察关节镜下治疗早中期化脓性关节炎的疗效。方法从2013~2014年在本院采取关节镜下清理病灶和术后无菌生理盐水+庆大霉素持续行关节腔冲洗的方法进行治疗26例化脓性关节炎,并根据治疗方法进行评估,采用个性化的护理。结果经临床治疗观察,治疗前后膝关节活动度和膝关节功能明显恢复。结论采用关节镜技术治疗早中期化脓性膝关节炎并结合个性化护理,能够做到创伤小,痛苦少,恢复快,大大缩短卧床时间,减轻了患者的经济负担。     

新生儿及小婴儿化脓性髋关节炎的超声诊断：病例系列研究

目的探讨新生儿及小婴儿化脓性髋关节炎的超声表现,评估其在早期诊断、治疗及随访中的作用。 方法选取2015年1月至2021年1月经深圳市儿童医院确诊为化脓性髋关节炎,年龄＜6个月的婴儿及新生儿患者22例,回顾性分析化脓性髋关节炎的临床资料、主要超声表现及影像学特征,以及治疗结局和超声随访复查结果。 结果22例化脓性髋关节炎患儿,其中男8例,女14例;年龄中位数52 d（1~180 d）。累及单侧髋关节21例、双侧1例。髋关节超声表现：髋关节滑膜增厚、关节腔积液21例（22个髋关节）,其中14例（15个髋关节）积液伴点状回声、1例积液呈絮状回声;髋关节周围软组织增厚、回声增强22例;股骨头关节面软骨回声欠光滑9例;股骨头髋臼关系异常5例（3例髋关节不稳定、2例脱位）。患儿经保守治疗10例,行手术治疗12例。最终治愈18例,超声复查显示股骨头变小1例,3例仍存在关节腔积液伴点状回声,其中进展为股骨头坏死2例,异位骨化1例。 结论新生儿及小婴儿化脓性髋关节炎超声声像图以关节腔积液伴髋关节脱位为主要表现。髋关节超声有助于化脓性髋关节炎的诊断、随访复查以及改善患儿预后。     

超声在类风湿关节炎诊疗中的应用进展

类风湿关节炎(RA)是一种以关节滑膜炎为特征的自身免疫性疾病,超声检查越来越多的应用于类风湿关节炎的临床诊疗中,灰阶二维超声在检测滑膜增厚、关节积液及骨侵袭方面具有较高的敏感性,彩色多普勒超声和超声造影可用于评估滑膜炎活动性。该文介绍了超声检查在类风湿关节炎诊疗中的应用情况。     

Emerging trends in diagnosis and treatment of rheumatoid arthritis

Rheumatoid arthritis is an inflammatory disease of the joints causing pain and stiffness, pathologically characterized by chronic synovitis. Without proper treatment, it progresses to cause joint deformity that results in significant loss of function. Extra-articular disease can also occur, which exacerbates morbidity and mortality associated with the disease. Patients from all age groups can acquire the disease, hence the additional categories of juvenile onset and elderly onset rheumatoid arthritis. Disease-modifying antirheumatic drugs are the mainstay of therapy, and should be initiated as early as possible in the course of the disease in consultation with a rheumatologist.     

干骺端骨髓炎伴化脓性膝关节炎的关节镜下治疗

目的 探讨关节镜技术在干骺端骨髓炎伴化脓性膝关节炎治疗中的应用.方法 对15例化脓性膝关节炎伴胫骨近端或股骨远端干骺端骨髓炎患者,在关节镜下行关节腔清理术,同时予干骺端病灶清创,关节内引流、置管并术后持续冲洗治疗.结果 术后2～6 d患者体温正常,平均4 d;随访6～24个月,CR复查骨髓炎病灶消失,Lysholm膝关节运动功能评定为(85.2±10.9)分.结论 关节镜技术治疗干骺端骨髓炎伴化脓性膝关节炎效果理想.