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The current thesis aims to address the prognosis and management of patients who have injuries necessitating orthopaedic surgery. In Chapter 1 I introduce the thesis, and in Chapter 5 I offer conclusions and summarize the contribution of the work. In Chapter 5, I address the scope, rationale, key findings, limitations and implications. Chapter 2 is a systematic review and meta-analysis investigating the effectiveness of antibiotic prophylaxis in patients with open fracture of the extremities. The results demonstrate moderate quality evidence of an important reduction in the infection rate in patients receiving, versus not receiving, antibiotic prophylaxis. We found no difference in infection rate with longer (3 to 5 days) versus shorter (1 day) duration of antibiotics – this finding warrants only low confidence. Chapter 3 is a systematic survey of current practice and recommendations regarding antibiotic prophylaxis in open fracture management. Authors of publications over the last decade strongly support early systemic antibiotics prophylaxis for patients with open fractures of extremities. In practice, most used systemic antibiotics with both gram-positive and gram-negative coverage, and continued the administration for 2 to 3 days. Most recommendations suggested gram-positive coverage for less severe injuries, and administration duration of no more than 3 days (half suggested 1 day). For more severe injuries, most recommendations suggested broad antimicrobial coverage continued for 2 to 3 days. Chapter 4 is a longitudinal study investigating predictors of persistent post-surgical pain after tibia fracture. We found significant independent associations between resolution of pain and male sex, non-smoking and alcohol consumption. Age, obesity, type of fracture (closed versus open), additional injuries, and post-operative weight-bearing status did not predict resolution of pain. Our findings suggest that clinicians should be particularly alert to the possibility of troublesome post-operative pain in female smokers who do not drink alcohol. Clinicians may consider counselling patients to discontinue smoking, inform them that they are at nearly double the risk of incidence of troublesome post-operative pain (in addition to the long-term adverse health consequences of smoking). / Thesis / Doctor of Philosophy (PhD) / Antibiotic prophylaxis reduces infection with 10% fewer event rate than the group without antibiotic prophylaxis (low to moderate confidence in estimates). The optimal antibiotic regimens and duration remain uncertain. There is a higher risk of persistent post-surgical pain in female smokers who do not use alcohol, following tibia fractures.

Thesis (Ph.D)--Malmö University, 2009. / Includes bibliographical references. Also available on the Internet.

Background: The aim of surgical antibiotic prophylaxis (SAP) is to prevent surgical site infection (SSI) by administering an appropriate antimicrobial agent perioperatively. However, SAP may be associated with adverse effects and incurs added costs. The primary objective of this prospective study is to establish whether clinicians are adhering to existing perioperative antibiotic prophylaxis guidelines in terms of indication, dosage and timing of SAP. Secondary objectives are to determine the proportion of patients receiving inappropriate antibiotics; and to evaluate correct practice concerning re-dosing and duration of SAP. Methods: A cross-sectional prospective audit of the anaesthetic records and prescription charts of surgical patients was conducted at Groote Schuur Hospital, a tertiary level teaching hospital in Cape Town, South Africa, over a period of one week. Data were collected by anaesthetists – blinded to the study objectives – and the investigators; then captured on Excel spread sheets and compared to existing SAP guidelines. Descriptive statistics and binary logistic regression were used for analysis. Results: Of the 192 patients consented, 180 questionnaires were completed for data analysis. The median age of participants was 44.5 years (IQR: 31.5-58), with a preponderance of females (58.7%). SAP was administered in 149 cases (82.8%) and withheld in 31 (17.2%). This was appropriate in 91.9% (137/149) and 77.4% (24/31) respectively. Twelve patients (6.7%) received inappropriate antibiotics and in seven (3.9%) it was inappropriately withheld. Of the 156 patients who should have received SAP, choice of drug was correct in 121 (77.6%), dosage in 110 (70.5%) and timing in 87 (55.8%). Absolute compliance was achieved in 44.4% (80/180). Errors were mostly related to timing, re-dosing and duration of SAP. Conclusion: Anaesthetists and surgeons at Groote Schuur Hospital demonstrate variable adherence to surgical antibiotic prophylaxis guidelines. Interventions aimed at improving compliance are warranted.

Objective: To determine whether echocardiography affects the decisions to use beta blockers or to recommend bacterial endocarditis prophylaxis in patients suspected of having mitral valve prolapse (MVP). Design: Retrospective review of echocardiograms and clinical records. Setting: Military tertiary care hospital. Patients: 127 patients with clinically suspected MVP (105) or incidentally discovered MVP (22). Main results: Beta blockers were used more often in patients with suspected MVP and positive echocardiograms (45%) than in patients with normal echocardiograms (13%, p<0.001). Bacterial endocarditis prophylaxis was recommended more often in patients with suspected MVP and positive echocardiograms (65%) than in patients with normal echocardiograms (11%, p<0.001). Presence or absence of a murmur did not influence the decision to recommend bacterial endocarditis prophylaxis. Patients in whom MVP was incidentally discovered were unlikely to receive either beta blockers or the recommendation for bacterial endocarditis prophylaxis. Conclusions: The results of echocardiography affect the decisions to use beta blockers or to recommend bacterial endocarditis prophylaxis in patients with suspected MVP.

A literatura apresenta vários artigos que estudam o tipo e a frequência de alterações bucais em pessoas transplantadas renais, mas é escassa em pesquisas que proporcionem evidências científicas sobre o risco de tratamento odontológico invasivo induzir infecção local ou à distância em receptores de transplante. A escassez de estudos que abordam manejo clínico em procedimentos odontológicos invasivos em pacientes transplantados reflete o empirismo e a falta de homogeneidade nas recomendações das equipes transplantadoras em relação ao manejo odontológico ideal do indivíduo receptor de transplante renal. Este volume apresenta um compilado de três trabalhos científicos que abordaram manejo do indivíduo transplantado renal e a avaliação do desfecho clínico após procedimentos odontológicos invasivos. As pesquisas foram executadas no Centro de Atendimento a Pacientes Especiais (CAPE) da Faculdade de Odontologia da USP. Todas tiveram aprovação do comitê de ética em pesquisa. A primeira pesquisa buscou conhecer, por meio de questionário, as condutas dos cirurgiões dentistas frente ao tratamento odontológico de pacientes transplantados renais. O segundo estudo avaliou retrospectivamente a incidência de complicações após exodontias em pacientes transplantados renais, realizadas no CAPE, por diferentes dentistas, que foram precedidas ou não por antibioticoterapia profilática. O terceiro estudo teve por objetivo avaliar a reparação alveolar após extrações de dentes erupcionados de forma prospectiva, em pacientes transplantados e controles, sem receberem antibioticoterapia profilática. Os resultados mostraram que a maioria dos dentistas entrevistados se sentem inseguros em realizar tratamento odontológico em pacientes transplantados renais e prescrevem antibiótico profilático excessivamente, e com posologia empírica. Foi constatado por meio do estudo retrospectivo que o uso ou não de antibiótico profilático antes de exodontias em indivíduos transplantados renais não afeta o desfecho pós-operatório. Por fim, os resultados do terceiro estudo evidenciaram que não há diferença na epitelização e no reparo alveolar pós-exodôntico entre indivíduos transplantados renais e não transplantados, quando submetidos à exodontias simples, sem o uso de antibiótico profilático. / The literature presents several papers regarding type and frequency of oral manifestations in renal transplant recipients, but there is a lack of studies that give scientific evidence about the risk of invasive dental treatment to induce local or distant site infection in renal transplant individuals. The lack of studies that focus on clinic management in invasive dental procedures reflects the empiricism and lack of standardization on the recommendations given by the transplant team regarding the ideal dental management of the renal transplant recipient. This volume presents a compilation of three scientific papers that approach the management of renal transplant recipient and the assessment of clinical outcomes after invasive dental procedures. The researches were performed at the Special Care Dentistry Center (SCDC), of School of Dentistry, University of Sao Paulo. All studies had ethical approval. The first study sought to know, through a questionnaire, the conducts of dentists regarding dental treatment on renal transplant recipients. The second was a retrospective study, that assessed post-operative complications following dental extractions performed at SCDC, that was preceded or not by antibiotic prophylaxis. The third was a prospective study, which assessed the socket healing after dental extractions of erupted teeth, on renal transplant recipients and control individuals, without antibiotic prophylaxis. The results show that most dentists interviewed feel insecure on performing dental treatment on renal transplanted patients as these practitioners prescribe prophylactic antibiotics excessively and based on empirical therapeutic posology. It was verified through the retrospective study that the antibiotic prophylactic prescription or non-prescription preceding an invasive dental procedure does not affect the post-operative outcome for renal transplant recipients. Finally, the results of the third study evidenced that there is no difference in post-extraction epithelization and thus healing between renal transplant recipients and non-transplanted individuals, without using antibiotic prophylaxis.

Este estudo teve como objetivo desenvolver e validar micrométodo simples e sensível para quantificação de cefuroxima plasmática utilizando CLAE-UV com a finalidade de aplicação no monitoramento das concentrações de cefuroxima de pacientes submetidos à cirurgia de revascularização do miocárdio (RM) com CEC no esquema de doses administradas em bolus. Os tempos de retenção para o fármaco e padrão interno (guaifenesina) foram 5,3 e 8,7 minutos respectivamente, com um tempo de corrida de 15 minutos, utilizando coluna de fase reversa C18 (25 cmX4,6 mm, 5 micra) e fase móvel binária constituída de tampão acetato de amônio e trietilamina 0,025 M pH 4,2 e acetonitrila (80:20, v/v), fluxo de 1,0 mL/min, detecção no ultravioleta, &#955;=274nm em sistema isocrático de eluição. A validação deste método analítico investigada através dos limites de confiança apresentou sensibilidade de 0,1 &#181;g/mL (LD) e limite inferior de quantificação (LIQ) de 0,20 &#181;g/mL, linearidade na faixa compreendida 0,2 &#181;g/mL a 200 &#181;g/mL e 4,37% e 2,95% para precisão intra- e inter-dias, respectivamente. Boa exatidão (98,75%) e alta seletividade foram registradas para o método. Através de um protocolo de estudo para antibioticoprofilaxia das infecções cirúrgicas investigaram-se dez pacientes com indicação de cirurgia eletiva de revascularização do miocárdio com circulação extracorpórea. Realizou-se o monitoramento das concentrações plasmáticas após a dose de ataque de 1,5 g, seguido da manutenção realizada através de bolus em tres doses de 0,75 g 6/6 horas. Uma vez que as concentrações plasmáticas de cefuroxima obtidas na sexta hora (vale) foram inferiores à recomendada 16 &#181;g/mL (4x MIC), recomenda-se o aumento de 0,75 g 6/6 horas para 1,5 g mantendo-se o intervalo entre doses de forma a atingir aquela requerida na antibioticoprofilaxia das cirurugias cardíacas. / The objective of the study was to validate na analytical method to determine cefuroxime in plasma by high performance liquid chromatography (HPLC - UV) for clinical purposes in surgical patients submitted to elective cardiac surgery of myocardial revascularization with cardiopulmonary bypass after drug administration as IV boluses. Retention times for the analite and its internal standard (guaifenesin) were 5.3 and 8.7 minutes, respectively; run time was 15 minutes, using a reversed phase colunm C18 (250X4.6 mm, 5 micron) and a binary mobile phase of ammonium acetate/trietilamine 0.025 M pH 4.2 and acetonitrile (80:20, v/v), flow rate 1 mL/min, ultraviolet detector, &#955;=274nm isocratic elution system. Validation of confidence limits presented 0.1 &#181;g/mL sensitivity (LD) and lower limit of quantification (LLOQ) of 0.20 &#181;g/mL, linearity in the range 0.2 &#181;g/mL to 200 &#181;g/mL and 4.37% e 2.95% for intra- / interday precisions, respectively. Good accuracy (98.75%) and high selectivity were obtained. The study protocol for antibiotic prophylaxis of surgical infections was designed for ten patients with indication of elective cardiac surgery of myocardial revascularization with cardiopulmonary bypass. Loading dose of 1.5 g followed by maintenance dose of 0.75 g every six hours by IV boluses were applied and plasma drug monitoring was done. Based on data obtained cefuroxime plasma concentrations at time dose interval were lower than 16 &#181;g/mL (4x MIC) at the trough, consequently it is recommended to increase the maintainance dose from 0.75 g 6/6 h up to 1.5 g 6/6h, to reach the minimum required for the antibiotic prophylaxis of cardiac surgeries.

SAMMANFATTNING Bakgrund: Trots att abort är ett vanligt förekommande fenomen, är antalet utförda aborter väldigt varierande världen över. Det redovisas att i genomsnitt ett av fem havandeskap avbryts samt att infektioner av varierande grad kan uppstå vid indicerad abort. Syfte: Syftet med denna litteraturöversikt var att beskriva förekomsten av postoperativa infektioner samt nyttan av antibiotikaprofylax i samband med en kirurgisk abort. Metod: Litteraturöversikten baserades på 16 vetenskapliga originalartiklar av kvantitativ ansats (randomiserade kontrollerade studier). Artiklarna analyserades, redovisades, granskades och sammanfogades till denna studies resultat. Resultat: De vanligaste förekommande postoperativa infektionerna efter kirurgisk abort var klamydia, gonorré och bakteriell vaginos vilka förekom i genomsnitt till 9,2 %. Doxycyklin visade sig vara den bästa kostnadseffektiva och profylaktiska behandlingen i jämförelse med andra antibiotikaläkemedel som ingår i studierna. Slutsats: Denna litteraturöversikt bekräftar resultatet från tidigare forskning att profylaktisk antibiotikabehandling vid kirurgisk abort eventuellt kan minska förekomsten av postoperativa infektioner.   Nyckelord: kirurgisk abort, antibiotikaprofylax, infektion, omvårdnad, vårdlidande. / ABSTRACT Background: Abortion is a recurring phenomenon; the total number of performed procedures varies greatly around the world. The statistics show that about one in five pregnancies is terminated. It is reported that infections of different degree will occur with induced abortion. Purpose: The purpose of this review is to study the frequency of postoperative infections and the usefulness of antibiotic prophylaxis when surgical abortion is performed. Methods: The literature review is based on 16 original scientific articles of randomized controlled trials in quantitative studies. The articles were analysed, reported, reviewed and merged into this study result. Results: The most common post-operative infections after surgical abortion were chlamydia, gonorrhoea and bacterial vaginosis, which averaged to 9,2 %. Doxycycline proved to be the best cost-effective and prophylactic treatment in comparison to other antibiotic drugs included in the studies. Conclusion: This review confirms the results of earlier research showing that antibiotic prophylaxis can possibly reduce the number of postoperative infections.   Keywords: abortion, abortion induced, antibiotic prophylaxis, infection.

Estudos sobre profilaxia antibiótica em pacientes imunossuprimidos submetidos a procedimentos cruentos odontológicos são bastante escassos, no entanto já existe um consenso de que estes pacientes são sabidamente de risco para infecção de sítio cirúrgico odontológico e que, portanto, necessitam de profilaxia antibiótica. Não é definido, no entanto, o regime profilático ideal para estes pacientes. O objetivo deste estudo é comparar a duração de antibioticoprofilaxia através de dois esquemas para prevenção de infecção após procedimentos odontológicos cruentos em pacientes imunossuprimidos transplantados renais ou hepáticos e em pacientes imunossuprimidos por quimioterapia. Este ensaio clínico foi randomizado e avaliou pacientes consecutivos com neoplasia e que fizeram uso de quimioterapia anti-neoplásica no último mês e pacientes transplantados de órgãos sólidos com medicação imunossupressora anti-rejeição, que necessitavam de exodontia e/ou raspagem periodontal como tratamento odontológico. O atendimento foi realizado na Divisão de Odontologia do Hospital das Clínicas da Faculdade Medicina da Universidade de São Paulo e foram incluídos pacientes da rotina do ambulatório que atendiam aos critérios de inclusão para participarem do protocolo da pesquisa e que concordaram em participar, assinando o Termo de Consentimento Livre e Esclarecido. Os pacientes foram randomizados para um dos dois grupos de regime profilático (grupo 1 - uma cápsula de 500mg de amoxicilina duas horas antes do procedimento odontológico; grupo 2 duas cápsulas de 500mg de amoxicilina, sendo a primeira duas horas antes do procedimento e a segunda oito horas após a primeira) e realizaram exame de sangue para avaliação da cultura hematológica após a realização do procedimento, sendo acompanhados durante um mês. A amostra calculada foi de 414 pacientes, sendo 207 em cada grupo. Os dados foram analisados através do programa SPSS Windows (versão 13.0, Chicago IL) e a partir daí foi obtida uma tabela descritiva e utilizado o teste qui-quadrado para comparação das variáveis entre os dois grupos. O nível de significância foi de p< ou = 0,05. Foi realizada também uma análise multivariada. A amostra foi analisada durante o período de novembro de 2006 a novembro de 2007. Não ocorreram os seguintes desfechos: infecção do sítio cirúrgico, antibiótico introduzido pelo médico no pós-operatório em até 30 dias após o procedimento odontológico e morte até o 15º dia após o procedimento odontológico. Os desfechos encontrados foram: necessidade de tomar analgésico após o 3º dia e até o 15º dia após o procedimento (3 no grupo 1 e 1 no grupo 2) e internação hospitalar até o 15º dia após o procedimento (2 no grupo 1 e 1 no grupo 2). A análise multivariada não alterou os resultados. Este estudo não demonstrou uma diferença entre utilizar uma ou duas doses de amoxicilina como profilaxia em procedimentos invasivos dentários em pacientes imunosuprimidos / Studies about antibiotic prophylaxis in immunosuppressed patients submitted to odontological invasive procedures are scarse, however there is already a consensus that these patients are in risk for post-operative infection in dentistry and that, therefore, they need antibiotic prophylaxis. It is not defined, however, the best prophylactic regimen for these patients. The aim of this study was to compare two regimens of antimicrobial prophylaxis in dental invasive procedures in immunosuppressed patients by chemotherapy for cancer or solid organ transplants. This is a randomized controlled study and it evaluated consecutive patients with cancer and that were submitted to chemotherapy in the last month and solid organ transplanted patients who needed exodontia or periodontal scaling and root planning as odontological treatment. This study was done in the Divisão de Odontologia of Hospital das Clínicas of Faculdade Medicina of the Universidade de São Paulo and it was included patients from the routine of the ambulatory who presented all the inclusion criteria and signed the informed consent. Patients were randomly assigned to one of the groups of prophylactic regimens (group 1 amoxicillin 500mg administered orally two hours before the procedure; group 2 amoxicillin 500mg administered orally two hours before the procedure and a second dose eight hours later) and had blood sample collected for culture immediately after the procedure, being followed up for one month. The total sample size was of 414 patients, being 207 in each group. Data were analyzed using the software SPSS Windows (version 13.0, Chicago IL). The characteristics of the patients of the 2 groups were compared using the chi-square test. The two groups were compared as to each outcome. A multivariate analysis was performed evaluating the groups as to the occurrence of any of the outcomes, by multiple logistic regression. The sample was evaluated between november of 2006 and november of 2007. The following outcomes did not occur: surgical site infection; systemic use of an antimicrobial drug within 30 days after the procedure and death by any reason within 15 days after the procedure. The other outcomes were: use of medication against pain after 3rd day after the procedure (three in group 1 and one in group 2) and hospitalization for any reason within 15 days after the procedure (two in group 1 and one in group 2). The multivariate analyses did not alter the results. This study did not demonstrate a difference between using one or two doses of amoxicillin as prophylaxis in invasive odontological procedures in immunosuppressed patients

Orientador: Alessandro Lia Mondelli / Resumo: A infecção de sítio cirúrgico é a complicação mais frequente em pacientes cirúrgicos e sua incidência pode ser diminuída com a profilaxia antimicrobiana realizada adequadamente. Sua importância na prevenção dessa infecção tem se tornado um tema relevante e emergencial para uma assistência adequada e segura. Este estudo objetivou avaliar o uso adequado da profilaxia antimicrobiana e a ocorrência de infecção de sítio cirúrgico de acordo com protocolo da Comissão de Controle de Infecção Relacionada à Assistência à Saúde (CCIRAS). Trata-se de um estudo de coorte, prospectivo, com seguimento de trinta dias em hospital de ensino do interior de São Paulo, Brasil. Para elegibilidade da amostra foram selecionados pacientes acima de 18 anos submetidos a cirurgias de todas as especialidades cirúrgicas, sejam eletivas e de urgência/emergência, que receberam profilaxia antimicrobiana. A coleta de dados foi através de software desenvolvido para este fim que comparou a profilaxia antimicrobiana realizada com a preconização do protocolo instituicional, identificando os acertos e inadequações para cada item avaliado. A infecção de sítio cirúrgico foi avaliada pela CCIRAS do hospital, a qual realiza a vigilância dos pacientes pós-alta através de ligações telefônicas. A amostra constituiu de 415 pacientes com cirurgias principalmente eletivas. A conformidade com todos os quesitos avaliados da profilaxia antimicrobiana foi de 1,7%. Verificamos que a cada inadequação da profilaxia antimicrobiana ... (Resumo completo, clicar acesso eletrônico abaixo) / Mestre