Perioperative Inpatient Use of Selective Serotonin Reuptake Inhibitors Is Associated With a Reduced Risk of THA and TKA Revision.

BACKGROUND: Depression is common in the general population, and so it is likewise common among patients undergoing THA and TKA. Depression is associated with lower perioperative patient-reported outcomes and an increased risk of postoperative complications. Antidepressants are effective in managing symptoms of depression and may potentially contribute to better functional status and better clinical outcomes after THA and TKA. QUESTIONS/PURPOSES: We examined (1) whether perioperative depression is associated with all-cause revisions, revisions for aseptic loosening, revisions without infection, and periprosthetic joint infections (PJIs) in patients undergoing THA and TKA; and (2) whether perioperative antidepressant use reduces the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs in patients undergoing THA and TKA. METHODS: This was a retrospective study of adult patients (≥ 18 years) who underwent 20,112 primary and revision THAs and TKAs from January 1, 2002, through December 31, 2009, at a large US tertiary care hospital. Data on patient and surgery characteristics and outcomes (dates and types of revisions, death) were ascertained through the institutional joint registry. Perioperative antidepressant use was assessed by searching the daily medication administration records beginning at admission and ending at discharge. A diagnosis of depression was present in 4466 (22%), and antidepressants were administered at the time of 5077 (25%) surgical procedures. Multivariable Cox proportional hazard models were used to estimate associations between antidepressant use and the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs. RESULTS: Depression was associated with an increased risk of all-cause revisions (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.42-2.02; p < 0.001) and PJIs (HR, 2.23; 95% CI, 1.53-3.17; p < 0.001). Overall, perioperative antidepressant use was not associated with the risk of revision or PJI, but selective serotonin reuptake inhibitor (SSRI) users had a lower risk of all-cause revisions (HR, 0.77; 95% CI, 0.61-0.96; p = 0.001) and aseptic revisions (HR, 0.72; 95% CI, 0.56-0.93; p = 0.013). CONCLUSIONS: The presence of a depression diagnosis confers an increased risk of revision and PJI among patients undergoing THA and TKA, yet the risk is lower within the subset of patients who received SSRIs during the perioperative period. Future longitudinal studies with detailed antidepressant medication histories are warranted to better understand the potential biologic effects of SSRI on the risk of revision in patients undergoing THA and TKA. LEVEL OF EVIDENCE: Level III, therapeutic study.

Patient perceptions of osteomyelitis, septic arthritis and prosthetic joint infection: the psychological influence of methicillin-resistant Staphylococcus aureus.

INTRODUCTION: Patients form their own representations of their illness, which can be important determinants of their coping and influence outcome. Our aims were to (i) assess patient perceptions of osteomyelitis, septic arthritis and prosthetic joint infection, (ii) compare perceptions of methicillin-resistant Staphylococcus aureus (MRSA) with non-MRSA infection and (iii) investigate the emotional aspects of these infections. METHODS: A questionnaire was developed from the 'Illness Perception Questionnaire' of Weinman et al.with additional questions assessing emotional response. This was offered to all patients with osteomyelitis, septic arthritis and prosthetic joint infection attending the Liverpool Hospital Infectious Diseases Outpatient Clinic during a 3-month period. RESULTS: There were 91 respondents--25 with MRSA infection, 14 with MRSA colonization and 52 without MRSA. Seventy-nine per cent of all respondents felt that their infection was very serious and 76% felt their infection had had major consequences on their life. On multivariate analysis MRSA was associated with a greater emotional effect; the consequences and emotional effects of infection were greater in younger people and prosthetic joint infection was associated with less sense of control or cure. CONCLUSION: Osteomyelitis, septic arthritis and prosthetic joint infection have a significant effect on an individual. Ongoing support and education are important, particularly for the young, those with prosthetic joint infection and patients with MRSA.

[Encephalopathy associated with severe bacterial infections: "presuppurative encephalitis" or "toxi-infectious disorder"?]. / Encéphalopathie associée aux infections bactériennes sévères de l'enfant: "encéphalite présuppurative" ou "syndrome toxi-infectieux"?

Three children are reported, exhibiting encephalopathic symptoms in the course of a severe bacterial infection, though they had no sign of intracranial purulent collection nor metabolic disturbances: the first was associated with a appendicular peritonitis, the second with a purulent knee arthritis, the third with a pneumoccus septicemia. The elements are reviewed that favor either a true septic encephalitis, i.e. microscopic presuppurative foci, versus a toxiinfectious process, either by direct action of toxins or through intracerebral activation of pre-inflammatory cytokines. Whatever the mechanism involved in individual cases, the treatment is mainly based on prompt administration of the convenient antibiotics.

Case of a 29-year-old nurse with factitious disorder. The utility of psychiatric intervention on a general medical floor.

A 29-year-old nurse was treated for septic arthritis of the knee. She was suspected of producing this infection and others. The consultation-liaison team intervened early, and the patient was treated in individual outpatient psychotherapy for 1 year. Her course was complicated by criminal behavior and a suicide attempt, prompting relocation to her home town. The patient demonstrated a strong need to be nurtured, as noted in other cases of factitious disorders. An overview of factitious disorders is presented, and guidelines for managing these difficult patients in the hospital are provided.

The influence of social rank on the susceptibility of rats to Mycoplasma arthritidis.

Social ranks (A, O, rest) of adult male inbred rats housed in groups of four per cage were determined by repeated observations of their ejaculatory patterns under competitive conditions. Once ranked, they were intravenously infected. Fifteen clinical, hematological, and serological characters were continuously observed during 110 days. Body weight reduction, arthritis score, and specific IgG antibody titers were chosen as guideline characteristics and compared between different genotypes and social rank classes. Genotypic differences account for 60-80% of the individual differences and social rank differences account for 0-40% of the individual differences within isogenic animals. Social rank affects the individual genotypes in an opposite way. Rank A males are less susceptible in genotype DA but showed increased susceptibility in genotypes AS. In genotype LEW, influence of social rank on susceptibility to Mycoplasma arthritidis could not be verified. Specific IgG antibody titers are lower in ranks showing a higher degree of susceptibility.

Factitious septic arthritis.

Septic arthritis is an uncommon manifestation of factitious illness. We report 2 patients who developed septic arthritis of the knee after repeated self-administered intraarticular injections. Multiple unusual infective agents were isolated. These cases illustrate malingering and Munchausen syndrome, 2 examples from the spectrum of factitious disease syndromes.