Infective endocarditis remains an important clinical entity with an incidence of 1.7–10/100 000 person years (Marks et al, 2015). Despite improvements in health care, it still results in significant ...morbidity and in-hospital mortality approaches 16% (Marks et al, 2015). There are likely multiple causes including late diagnosis, poor response to therapy and the challenges in identifying the causative pathogen and instigating the correct treatment. This is particularly the case for causative organisms that are difficult to culture or identify using routine laboratory methods.
An example of this is Streptococcus intermedius, which belongs to the S. milleri group along with other two species (S. anginosus group and S. constellatus). It is a commensal organism that can turn into an opportunistic pathogen (Whiley et al, 1992). It is a rare cause of infective endocarditis and may initially present with abscesses in the liver, spleen or brain which may mimic fungal infection (Woo et al, 2004; Rashid et al, 2007; Tran et al, 2008). Difficulty in identifying this organism has led to the development of molecular testing to aid diagnosis. To the authors' knowledge, there are very few cases in the literature of infective endocarditis caused by S. intermedius that have been confirmed using 16S polymerase chain reaction (Woo et al, 2004). This article describes a patient presenting with S. intermedius infective endocarditis which was diagnosed using this method.
An interesting case of a patient presenting to the emergency department with chest pain and an electrocardiogram (ECG) revealing ST elevation is presented. On closer examination another explanation ...for this ECG appearance is discussed indicating that emergency revascularisation was not indicated.
Summary Objective Osteoarticular infection often requires prolonged antibiotic therapy as an adjunct to surgery. We report our experience using pristinamycin, an oral streptogramin, when conventional ...antibiotics were poorly tolerated or inappropriate because of multi-drug resistant organisms (MDROs). Methods We retrospectively identified, from pharmacy records, all patients prescribed pristinamycin between 1/1/2004 and 31/12/2006. We collected clinical and microbiological data. Results Twenty-one patients were identified (13 male and eight female patients, age range 18–83 years). Sixteen patients (76%) had infection due to MDROs and five (24%) were intolerant of conventional antibiotics. Ten patients received other concurrent oral antibiotics. Eleven of 21 (52%) patients remained free of recurrent infection off antibiotics at a mean follow up duration of 13 months, (range 4–25 months). Suppression of infection while still on therapy was achieved in a further four patients (19%) with a mean follow up of 11.5 months (range 5–15 months). Six patients (29%) failed therapy, all requiring a further surgical procedure. Conclusion Oral pristinamycin was a well tolerated and useful adjunctive treatment in this group with complex orthopaedic infection. Pristinamycin can be considered in patients with osteoarticular infection due to Gram-positive organisms when antibiotic multi-resistance or intolerance makes conventional therapies impossible. Summary We report our experiences of using pristinamycin in the management of 21 patients with Gram-positive MDRO osteoarticular infection or who were unable to tolerate more conventional regimens. Our results show that pristinamycin is well tolerated with outcomes comparable to those of other agents described in the literature on osteoarticular infection.
Abstract Cardiovascular disease is the leading cause of death in simultaneous pancreas kidney transplantation (SPKT) patients. SPKT is increasingly being undertaken to manage patients with advanced ...diabetic nephropathy and type 1 diabetes mellitus. Traditionally, invasive angiography has been used as a tool to diagnose significant coronary disease and inform decision making with regard to coronary revascularization prior to transplantation. In our retrospective analysis of 167 consecutive patients who underwent SPKT in our center, we show that using myocardial perfusion scintigraphy (MPS) as the first-line screening tool is highly sensitive without exposing the patient to undue investigative procedural risks (or an unacceptably high false-negative rate) and it provides 1-year cardiovascular outcomes that are comparable with those of patients managed via the more traditional but riskier invasive route.
Most of the information available on cloud computing is either highly technical, with details that are irrelevant to non-technologists, or pure marketing hype, in which the cloud is simply a selling ...point. This book, however, explains the cloud from the user's viewpoint -- the business user's in particular. Nayan Ruparelia explains what the cloud is, when to use it (and when not to), how to select a cloud service, how to integrate it with other technologies, and what the best practices are for using cloud computing. Cutting through the hype, Ruparelia cites the simple and basic definition of cloud computing from the National Institute of Science and Technology: a model enabling ubiquitous, convenient, on-demand network access to a shared pool of configurable computing resources. Thus with cloud computing, businesses can harness information technology resources usually available only to large enterprises. And this, Ruparelia demonstrates, represents a paradigm shift for business. It will ease funding for startups, alter business plans, and allow big businesses greater agility. Ruparelia discusses the key issues for any organization considering cloud computing: service level agreements, business service delivery and consumption, finance, legal jurisdiction, security, and social responsibility. He introduces novel concepts made possible by cloud computing: cloud cells, or specialist clouds for specific uses; the personal cloud; the cloud of things; and cloud service exchanges. He examines use case patterns in terms of infrastructure and platform, software information, and business process; and he explains how to transition to a cloud service. Current and future users will find this book an indispensable guide to the cloud.
Abstract
Introduction
The incidence of stroke in young patients is increasing and is associated with significant morbidity, mortality and socioeconomic cost. Identifying potential underlying causes ...is central to their overall management to reduce recurrence and improve long-term outcomes. A proportion of these patients are found to have an underlying cardiac cause including atrial fibrillation (AF), patent foramen ovale (PFO) or an intracardiac source of embolus. This area has recently gained greater interest with evidence demonstrating a significant reduction in recurrent ischaemic events following PFO closure. The identification of these patients however, requires extensive investigation and has implications relating to cardiology resources. Outside of clinical trials the true incidence of these patients in a “real-world” population is poorly defined.
Purpose
The aim of this study was to determine the proportion of strokes attributable to cardiac causes in young patients presenting with ischaemic stroke.
Methods
The Sentinel Stroke National Audit Programme (SSNAP) database of a large UK stroke service was used to identify patients ≤55 years old presenting with stroke between 1/1/15 and 31/12/17. Clinical letters, imaging reports and laboratory reports were reviewed. Patients were then categorised by cause of stroke using the Trial of Acute Stroke Treatment (TOAST) criteria. Cardiac causes of stroke were defined as: AF, PFO and intracardiac source of embolus. Patients presenting with a haemorrhagic stroke or where an alternate diagnosis to stroke was more likely were excluded.
Results
During the study period, 206 patients were identified as having suffered a stroke. 35 patients were excluded resulting in a final study population of 171 patients (Figure). 24% (41/171) were identified as having a cardiac cause of stroke including 9.4% (16/171) PFO, 8.8% (15/171) intracardiac source of embolus and 5.8% (10/171) atrial fibrillation. 50.3% (86/171) were thought to have other causes: 24.6% (42/171) small vessel disease; 9.4% (16/171) large artery atherosclerosis; and 16.4% (28/171) other determined aetiology including 5.1% (8.8/171) with arterial dissection. 25.7% (44/171) presented with a stroke but with no clear underlying cause found.
Causes of stroke in young patients
Conclusion
A high proportion (24%) of strokes in young patients were found to be likely secondary to a cardiac cause. With the significant benefit of intervention (medical or procedural) in this patient group, the resource provision allocated to this population does appear to be warranted and further demonstrates the importance of close interdisciplinary links between cardiologists and stroke physicians.
Abstract
Background/Introduction
The balloon expandable Edwards Sapien-S3 and Ultra, and the self-expanding Medtronic Evolut-Pro and Evolut-R 34mm represent the main volume of transcatheter aortic ...valve implantation (TAVI) procedures conducted worldwide.
Purpose
In the present study, we aim to compare the peri-procedural and one-year clinical outcomes between these last generation devices.
Methods
Consecutive patients from the ATLAS (Athens-Tokyo-London Aortic Stenosis) registry, who had undergone TAVI with either the S3/Ultra or Evolut-Pro/R 34mm device, in four centers were retrospectively studied. In-hospital procedural characteristics and outcomes were recorded and compared. Kaplan-Meier estimated 1-year all-cause mortality was compared between groups.
Results
In total, 692 patients (352pts treated with S3/Ultra and 340pts with Evolut-Pro/R34mm device) were included in the analysis. Baseline demographics (age, coronary artery disease risk factors, logistic Euroscore and aortic valve hemodynamics) were similar between the two groups.
In terms of peri-procedural and short-term outcomes, patients treated with the Evolut-Pro/R34mm device had significantly lower peak (25.4±3.6mmHg for S3/Ultra vs 14.9±0.6mmHg for the self-expanding valves, p=0.002) and mean (10.7±0.3mmHg S3/Ultra vs 7.9±0.4mmHg Evolut PRO/R34, p<0.001) gradients at discharge.
Conversely, the S3 demonstrated significantly lower rates of at least moderate residual aortic regurgitation (AR) post-operatively (0.3% vs 4.8% for S3 and Evolut-Pro/R34mm respectively, p=0.001). Interestingly, the rate of new permanent pacemaker (PPM) required after the implantation in pacemaker-free patients on baseline, was higher for the S3/Ultra cohort compared to the self-expanding valve group (17.6% vs 11.7% respectively, p=0.054), however not reaching statistical significance yet. As expected, the need for balloon post dilatation of the implanted prosthesis was less among the S3/Ultra patients (5.5% vs 26.1%, p=0.001).
One-year Kaplan-Meier estimated survival was similar between the two groups (85.9% for S3 vs. 90% for Evolut-Pro/R34mm, plog-rank=0.071). Hazard ratio for all-cause mortality (Pro/R34 vs. S3/Ultra) after adjustment for gender and previous MI was similar between the groups (HR=0.73; 95% CI 0.47 to 1.14, p=0.165).
Conclusions
Real life comparison of the last generation balloon expandable and self-expanding devices demonstrates similar 1-year all-cause mortality. The S3/Ultra platforms, as compared to the Evolut-Pro/R34mm, demonstrate less paravalvular leak, at the expense of higher transvalvular gradients. Long-term follow-up and future larger trials are required to establish any potential long-term difference in clinical outcomes and prognosis.
Funding Acknowledgement
Type of funding source: None
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