Introduction: Prosthetic infection is a devastating complication of arthroplasty and carries significant economic burden. The objective of this study was to analyze the economic impact of prosthetic hip and knee infection in Portuguese National Health System.Material and Methods: Case-control study carried out from January 2014 to December 2015. The mean costs of primary arthroplasties and prosthetic revision surgeries for non-infectious reasons were compared with the costs of prosthetic infections treated with debridement and preservation of the prosthesis or with two-stage exchange arthroplasty.The reimbursement for these cases was also evaluated and compared with its real costs.Results:A total of 715 primary arthroplasties, 35 aseptic revisions, 16 surgical debridements and 15 revisions for infectious reasons were evaluated. The cost of primary arthroplasties was 3,230€ in the hips and 3,618€ in the knees. The cost of aseptic revision was 6,089€ in the hips and 7,985€ in the knees. In the cases treated with debridement and implant retention the cost was 5,528€ in the hips and 4,009€ in the knees. In cases of infections treated with a two-stage revision the cost was 11,415€ and 13,793€ for hips and knees, respectively.Conclusion: As far as we know this is the first study that analyzes the economic impact of prosthetic infection in the Portuguese context. Although direct compensation for treating infected cases is much lower than calculated costs, infected cases push the overall hospital case-mix-index upwards thus increasing financial compensation for the entire cohort of treated patients. This knowledge will allow for more informed decisions about health policies in the future.

Background Success of debridement, antibiotics and implant retention (DAIR) in early periprosthetic joint infection (PJI) largely depends on the presence of a mature biofilm. At what time point DAIR should be disrecommended is unknown. This multicenter study evaluated the outcome of DAIR in relation to time after index arthroplasty. Methods We retrospectively evaluated PJIs occurring within 90 days after surgery and treated with DAIR. Patients with bacteremia, arthroscopic debridements and a follow-up <1 year were excluded. Treatment failure was defined as 1) any further surgical procedure related to infection 2) PJI-related death, 3) long-term suppressive antibiotics. Results 769 patients were included. Treatment failure occurred in 294 patients (38%) and was similar between time-intervals from index arthroplasty to DAIR: week 1-2: 42% (95/226); week 3-4: 38% (143/378); week 5-6: 29% (29/100), week 7-12: 42% (27/65). Exchange of modular components was performed to a lesser extent in the early compared with the late post-surgical course (41% vs 63%, p<0.001). The causative microorganisms, comorbidities and duration of symptoms were comparable between time-intervals. Conclusions DAIR is a viable option in patients with early PJI presenting more than four weeks after index surgery as long as DAIR is performed at least within one week after the onset of symptoms and modular components can be exchanged.

Background Rifampin is generally advised in the treatment of acute staphylococcal periprosthetic joint infections (PJI). However, if, when, and how to use rifampinremains a matter of debate. We evaluated the outcome of patients treated with and without rifampin, and analyzed the influence of timing, dose and co-antibiotic. Methods Acute staphylococcal PJIs treated with surgical debridement between 1999 and 2017, and a minimal follow-up of 1 year were evaluated. Treatment failure was defined as the need for any further surgical procedure related to infection, PJI-related death or the need for suppressive antimicrobial treatment. Results A total of 669 patients were analyzed. Treatment failure was 32.2% (131/407) in patients treated with rifampin and 54.2% (142/262) in whom rifampin was withheld (P &lt; 0.001). The most prominent effect of rifampin was observed in knees (treatment failure 28.6% versus 63.9%, respectively, P &lt; 0.001). The use of rifampin was an independent predictor of treatment success in the multi-variate analysis (OR 0.30, 95% CI 0.20 – 0.45). In the rifampin group, the use of a co-antibiotic other than a fluoroquinolone or clindamycin (OR 10.1, 95% CI 5.65 – 18.2) and the start of rifampin within 5 days after surgical debridement (OR 1.96, 95% CI 1.08 – 3.65) were predictors of treatment failure. The dosing of rifampin had no effect on outcome. Conclusions Our data supports the use of rifampin in acute staphylococcal PJIs treated with surgical debridement, particularly in knees. Immediate start of rifampin after surgical debridement should probably be discouraged, but requires further investigation.

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Objective: Haemoglobin A1c (Hb A1c) is routinely used for monitoring glycemic control in patients with diabetes. Hb A1c seasonal fluctuations can be directly related to different biological, geographical and cultural influences. Our purpose was to evaluate seasonal variation of Hb A1c in a hospitalbased adult population over a period of 5 years. Materials and methods: We analyzed retrospectively monthly Hb A1c mean values (DCCT, %) based on all the assays performed to adult patients at a tertiary care university Portuguese hospital between 2008-2012. Results: We obtained 62,384 Hb A1c valid measurements, with a peak level found in January-February (7.1%), a trough in AugustOctober (6.8%) and an average peak-to-trough amplitude value of 0.3%. This trend was observed in both genders and age subgroups evaluated. Conclusions: There is a Hb A1c circannual seasonal pattern with peak levels occurring in winter months in this Portuguese population. This finding should be recognized in daily clinical practice to warrant better clinical and epidemiological interpretation of Hb A1c values. Arch Endocrinol Metab. 2015;59(3):231-5

Recebido a 2 de junho de 2014; aceite a 29 de agosto de 2014 Disponível na Internet a 11 de outubro de 2014 PALAVRAS-CHAVEÚlcera do pé diabético; Epidemiologia; Neuropatia periférica; Doença arterial periférica; Consulta multidisciplinar ResumoIntrodução: A diabetes mellitus é responsável por 70% das amputações não traumáticas do membro inferior e 85% destas são precipitadas por úlceras. Objetivo ---caracterização epidemiológica e resultado da intervenção dos utentes da consulta multidisciplinar do pé diabético. Materiais e métodos: Estudo observacional retrospetivo das primeiras consultas realizadas no âmbito da consulta multidisciplinar do pé diabético, durante um semestre. Revisão do processo clínico e avaliação das características epidemiológicas, investigação clínica realizada, meios complementares de diagnóstico e o resultado final (cicatrização da lesão, amputação major, não cicatrização em um ano ou morte). Resultados: Realizaram-se 361 primeiras consultas do pé diabético no período em estudo, 82,3% por ulceração (31,3% neuropáticos e 68,7% neuroisquémicos). Dos doentes seguidos, 78% obtiveram cicatrização das lesões (com ou sem amputação minor), 7,7% não obtiveram cicatrização da lesão após um ano de seguimento, 10,1% foram submetidos à amputação major e 4,2% faleceram durante o seguimento. Os doentes com doença arterial periférica apresentaram menor probabilidade de cicatrização (70,6 vs. 89,4%, p = 0,004) e risco aumentado de amputação major (15,7 vs. 1,5%, p = 0,003). A nefropatia diminuiu a probabilidade de cicatrização (50 vs. 82,6%, p = 0,008) e aumentou o risco de amputação major (29,1 vs. 6,9%, p = 0,008). Os doentes com dependência de terceiros apresentaram maior risco de amputação major (22,9 vs. 6,8%, p = 0,008). * Autor para correspondência. Correio eletrónico: vitormiguelferreira@hotmail.com (V. Ferreira).

Purpose: The levothyroxine absorption test (LT4AT) is an important tool for distinguishing hypothyroidism due to malabsorption from “pseudomalabsorption” conditions. Our aim was to review our institution’s LT4AT results and assess its role in the management of patients with refractory hypothyroidism. Methods: We performed a retrospective study of all patients evaluated for refractory hypothyroidism who underwent LT4AT in our tertiary center between 2014 to 2020. Its results and the impact on thyroid function management during follow-up were assessed. Results: Ten female patients were included with a mean age of 40 years (min-max: 26-62). Mean weight was 72kg (min-max: 43-88) and baseline LT4 dosage ranged from 2.5 to 5.3µg/kg per day. Most common cause of hypothyroidism were postsurgical in 50% (n=5) and autoimmune in 20% (n=2). During LT4AT, normal LT4 absorption was found in all but one individual (mean FT4 increase of 231%, min-max: 85-668). The only patient with objective LT4 absorption impairment (maximal increase of 48% by hour 5) presented also Helicobacter pylori gastritis and prior history of “intestinal surgery” during childhood. No adverse events were reported during any of the LT4ATs. During follow-up [median 11.5 months (IQR 23)], 3 patients obtained euthyroidism and 6 had improved their hypothyroidism state. Conclusions: The LT4AT is an effective and safe way to assess refractory hypothyroidism and provides valuable information to distinguish LT4 malabsorption from “pseudomalabsorption”. Our data suggest that most patients with suspicious LT4 malabsorption perform normally during LT4AT. This test provides relevant information for better management of patients with refractory hypothyroidism.

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