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Kogan A, Wieder-Finesod A, Frogel J, Peled-Potashnik Y, Ram E, Raanani E, Sternik L. Surgical treatment on infective endocarditis: impact of diabetes on mortality. Cardiovasc Diabetol 2022; 21:120. [PMID: 35773698 PMCID: PMC9248198 DOI: 10.1186/s12933-022-01557-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 06/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (DM) is a frequent co-morbidity among patients suffering from infective endocarditis (IE). The aim of the study was to evaluate the impact of type 2 DM on the early-, intermediate- and long-term mortality of patients who underwent surgical treatment of endocarditis. METHODS We performed an observational cohort study in the large tertiary center in Israel during 14 years. All data of patients who underwent surgical treatment of endocarditis, performed between 2006 and 2020 were extracted from the departmental database. Patients were divided into two groups: Group I (non-diabetic patients), and Group II (diabetic patients). RESULTS The study population includes 420 patients. Group I (non-diabetic patients), comprise 326 patients, and Group II (diabetic patients), comprise 94 patients. Mean follow-up duration was 39.3 ± 28.1 months. Short-term, 30-day and in-hospital mortality, also intermediate-term mortality (1- and 3-year) was higher in the DM group compared with the non-DM group, but did not reach statistical significance: 11.7% vs. 7.7%. (p = 0.215); 12.8% vs. 8.3% (p = 0.285); 20.2% vs. 13.2% (p = 0.1) and 23.4% vs. 15.6% (p = 0.09) respectively. Long-term, 5-year mortality was significantly higher in the DM group, compared to the non-DM group: 30.9% vs. 16.6% (p = 0.003). Furthermore, predictors for long-term mortality included diabetes (CI 1.056-2.785, p = 0.029), as demonstrated by regression analysis. CONCLUSIONS Diabetic patients have trend to increasing mortality at the short- and intermediate period post-surgery for IE, but this is not statistically significant. Survival of diabetic patients deteriorates after more than three years follow surgery. Diabetes is an independent predictor for long-term, 5-year mortality after surgical treatment of endocarditis, regardless of the patients age and comorbidities. Trial registration Ethical Committee of Sheba Medical Centre, Israel on 02.12. 2014, Protocol 4257.
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Affiliation(s)
- Alexander Kogan
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Wieder-Finesod
- Infectious Disease Unit, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Frogel
- Department of Anesthesiology, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Peled-Potashnik
- Division of Cardiology, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eilon Ram
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Biezma MI, Muñoz P, De la Villa S, Fariñas-Álvarez MC, Arnáiz de las Revillas F, Gutierrez-Carretero E, De Alarcón A, Rodríguez-García R, Llopis J, Goenaga MÁ, Gutierrez-Villanueva A, Plata A, Vidal L, Martínez-Sellés M. Infective Endocarditis in Diabetic Patients: A Different Profile with Prognostic Consequences. J Clin Med 2022; 11:jcm11092651. [PMID: 35566777 PMCID: PMC9103728 DOI: 10.3390/jcm11092651] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 02/08/2023] Open
Abstract
Background. Infective Endocarditis (IE) is a severe condition. Diabetes mellitus (DM) has been associated with a poor prognosis in other settings. Our aim was to describe the profile and prognosis of IE with and without DM and to analyze the prognostic relevance of DM-related organ damage. Methods. Retrospective analysis of the Spanish IE Registry (2008−2020). Results. The cohort comprises 5590 IE patients with a mean age of 65.0 ± 15.5 years; 3764 (67.3%) were male. DM was found in 1625 patients (29.1%) and 515 presented DM-related organ damage. DM prevalence during the first half of the study period was 27.6% vs. 30.6% in the last half, p = 0.015. Patients with DM presented higher in-hospital mortality than those without DM (521 [32.1%] vs. 924 [23.3%], p < 0.001) and higher one-year mortality (640 [39.4%] vs. 1131 [28.5%], p < 0.001). Among DM patients, organ damage was associated with higher in-hospital (200 [38.8%] vs. 321 [28.9%], p < 0.001) and one-year mortality (247 [48.0%] vs. 393 [35.4%], p < 0.001). Multivariate analyses showed an independent association of DM with in-hospital (odds ratio [OR] = 1.34, 95% confidence interval [CI]: 1.16−1.55, p < 0.001) and one-year mortality (OR = 1.38, 95% CI: 1.21−1.59, p < 0.001). Among DM patients, organ damage was independently associated with higher in-hospital (OR = 1.37, 95% CI: 1.06−1.76, p = 0.015) and one-year mortality (OR = 1.59, 95% CI = 1.26−2.01, p < 0.001) Conclusions. The prevalence of DM among patients with IE is increasing and is already above 30%. DM is independently associated with a poor prognosis, particularly in the case of DM with organ damage.
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Affiliation(s)
| | - Patricia Muñoz
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
- CIBERES (CIBER Enfermedades Respiratorias)—Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Sofía De la Villa
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain
| | - Mª Carmen Fariñas-Álvarez
- Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, IDIVAL (Instituto de Investigación Sanitaria Valdecilla), CIBER de Enfermedades Infecciosas-CIBERINFEC (CB21/13/00068), Instituto de Salud Carlos III, Universidad de Cantabria, 39008 Santander, Spain
| | - Francisco Arnáiz de las Revillas
- Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, IDIVAL (Instituto de Investigación Sanitaria Valdecilla), CIBER de Enfermedades Infecciosas-CIBERINFEC (CB21/13/00068), Instituto de Salud Carlos III, Universidad de Cantabria, 39008 Santander, Spain
| | - Encarnación Gutierrez-Carretero
- Cardiac Surgery Service, CIBERCV (CIBER Enfermedades Cardiovasculares), Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocío Seville, 41013 Sevilla, Spain
| | - Arístides De Alarcón
- Cardiac Surgery Service, CIBERCV (CIBER Enfermedades Cardiovasculares), Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocío Seville, 41013 Sevilla, Spain
| | - Raquel Rodríguez-García
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Universidad de Oviedo, 33011 Oviedo, Spain
| | - Jaume Llopis
- Department of Genetics, Microbiology and Statistics, University of Barcelona, 08007 Barcelona, Spain
| | - Miguel Ángel Goenaga
- Servicio de Enfermedades Infecciosas, Hospital Universitario Donosti, 20014 San Sebastian, Spain
| | - Andrea Gutierrez-Villanueva
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Universitario Puerta de Hierro, 28222 Majadahonda, Spain
| | - Antonio Plata
- UGC Enfermedades Infecciosas, Microbiología y Medicina Preventiva, IBIMA (Instituto de Investigación Biomédica de Málaga), Hospital Regional Universitario de Málaga, 29010 Malaga, Spain
| | - Laura Vidal
- Servicio de Cardiología, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Manuel Martínez-Sellés
- Escuela de Doctorado, Universidad Europea de Madrid, 28670 Madrid, Spain;
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV (CIBER Enfermedades Cardiovasculares), Universidad Complutense, 28040 Madrid, Spain
- Correspondence:
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Cuervo G, Escrihuela-Vidal F, Gudiol C, Carratalà J. Current Challenges in the Management of Infective Endocarditis. Front Med (Lausanne) 2021; 8:641243. [PMID: 33693021 PMCID: PMC7937698 DOI: 10.3389/fmed.2021.641243] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/01/2021] [Indexed: 12/17/2022] Open
Abstract
Infective endocarditis is a relatively rare, but deadly cause of sepsis, with an overall mortality ranging from 20 to 25% in most series. Although the classic clinical classification into syndromes of acute or subacute endocarditis have not completely lost their usefulness, current clinical forms have changed according to the profound epidemiological changes observed in developed countries. In this review, we aim to address the changing epidemiology of endocarditis, several recent advances in the understanding of the pathophysiology of endocarditis and endocarditis-triggered sepsis, new useful diagnostic tools as well as current concepts in the medical and surgical management of this disease. Given its complexity, the management of infective endocarditis requires the close collaboration of multidisciplinary endocarditis teams that must decide on the diagnostic approach; the appropriate initial treatment in the critical phase; the detection of patients needing surgery and the timing of this intervention; and finally the accurate selection of patients for out-of-hospital treatment, either at home hospitalization or with oral antibiotic treatment.
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Affiliation(s)
- Guillermo Cuervo
- Infectious Diseases Department, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
| | - Francesc Escrihuela-Vidal
- Infectious Diseases Department, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - Carlota Gudiol
- Infectious Diseases Department, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain.,Insitut Català d'Oncologia, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Bellvitge University Hospital, University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Instituto de Salud Carlos III, Madrid, Spain
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Abe T, Eyituoyo HO, De Allie G, Olanipekun T, Effoe VS, Olaosebikan K, Mather P. Clinical outcomes in patients with native valve infective endocarditis and diabetes mellitus. World J Cardiol 2021; 13:11-20. [PMID: 33552399 PMCID: PMC7821010 DOI: 10.4330/wjc.v13.i1.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/18/2020] [Accepted: 12/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is a lack of data on the clinical outcomes in patients with native valve infective endocarditis (NVIE) and diabetes mellitus (DM).
AIM To investigate (1) trends in the prevalence of DM among patients with NVIE; and (2) the impact of DM on NVIE outcomes.
METHODS We identified 76385 with NVIE from the 2004 to 2014 National Inpatient Sample, of which 22284 (28%) had DM. We assessed trends in DM from 2004 to 2014 using the Cochrane Armitage test. We compared baseline comorbidities, microorganisms, and in-patients procedures between those with vs without DM. Propensity match analysis and multivariate logistic regression were used to investigate study outcomes in in-hospital mortality, stroke, acute heart failure, cardiogenic shock, septic shock, and atrioventricular block.
RESULTS Crude rates of DM increased from in 22% in 2004 to 30% in 2014. There were significant differences in demographics, comorbidities and NVIE risk factors between the two groups. Staphylococcus aureus was the most common organism identified with higher rates in patients with DM (33.1% vs 35.6%; P < 0.0001). After propensity matching, in-hospital mortality (11.1% vs 11.9%; P < 0.0001), stroke (2.3% vs 3.0%; P < 0.0001), acute heart failure (4.6% vs 6.5%; P = 0.001), cardiogenic shock (1.5% vs 1.9%; P < 0.0001), septic shock (7.2% vs 9.6%; P < 0.0001), and atrioventricular block (1.5% vs 2.4%; P < 0.0001), were significantly higher in patients with DM. Independent predictors of mortality in NVIE patients with DM include hemodialysis, congestive heart failure, atrial fibrillation, staphylococcus aureus, and older age.
CONCLUSION There is an increasing prevalence of DM in NVIE and it is associated with poorer outcomes. Further studies are crucial to identify the clinical, and sociodemographic contributors to this trend and develop strategies to mitigate its attendant risk.
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Affiliation(s)
- Temidayo Abe
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA 30310, United States
| | - Harry Onoriode Eyituoyo
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA 31207, United States
| | - Gabrielle De Allie
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA 30310, United States
| | - Titilope Olanipekun
- Department of Internal Medicine, Morehouse School of Medicine, Atlanta, GA 30310, United States
| | - Valery Sammah Effoe
- Department of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30310, United States
| | - Kikelomo Olaosebikan
- Department of Medicine, University of Debrecen Medical and Health Science Center, Debrecen 4032, Hungary
| | - Paul Mather
- Department of Cardiovascular Disease, University of Pennsylvania, Pennsylvania, PA 19104, United States
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5
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García-Granja PE, López J, Vilacosta I, Sarriá C, Domínguez F, Ladrón R, Olmos C, Sáez C, Vilches S, García-Arribas D, Cobo-Marcos M, Ramos A, Maroto L, Gómez I, Carrasco M, García-Pavía P, San Román JA. Predictive model of in-hospital mortality in left-sided infective endocarditis. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2020; 73:902-909. [PMID: 31848066 DOI: 10.1016/j.rec.2019.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/11/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION AND OBJECTIVES Infective endocarditis (IE) is a complex disease with high in-hospital mortality. Prognostic assessment is essential to select the most appropriate therapeutic approach; however, international IE guidelines do not provide objective assessment of the individual risk in each patient. We aimed to design a predictive model of in-hospital mortality in left-sided IE combining the prognostic variables proposed by the European guidelines. METHODS Two prospective cohorts of consecutive patients with left-sided IE were used. Cohort 1 (n=1002) was randomized in a 2:1 ratio to obtain 2 samples: an adjustment sample to derive the model (n=688), and a validation sample for internal validation (n=314). Cohort 2 (n=133) was used for external validation. RESULTS The model included age, prosthetic valve IE, comorbidities, heart failure, renal failure, septic shock, Staphylococcus aureus, fungi, periannular complications, ventricular dysfunction, and vegetations as independent predictors of in-hospital mortality. The model showed good discrimination (area under the ROC curve=0.855; 95%CI, 0.825-0.885) and calibration (P value in Hosmer-Lemeshow test=0.409), which were ratified in the internal (area under the ROC curve=0.823; 95%CI, 0.774-0.873) and external validations (area under the ROC curve=0.753; 95%CI, 0.659-0.847). For the internal validation sample (observed mortality: 29.9%) the model predicted an in-hospital mortality of 30.7% (95%CI, 27.7-33.7), and for the external validation cohort (observed mortality: 27.1%) the value was 26.4% (95%CI, 22.2-30.5). CONCLUSIONS A predictive model of in-hospital mortality in left-sided IE based on the prognostic variables proposed by the European Society of Cardiology IE guidelines has high discriminatory ability.
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Affiliation(s)
- Pablo Elpidio García-Granja
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario Valladolid, Valladolid, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
| | - Javier López
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario Valladolid, Valladolid, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Isidre Vilacosta
- Servicio de Cardiología, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Madrid, Spain
| | - Cristina Sarriá
- Servicio de Medicina Interna, Hospital Universitario La Princesa, Madrid, Spain
| | - Fernando Domínguez
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Raquel Ladrón
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Carmen Olmos
- Servicio de Cardiología, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Madrid, Spain
| | - Carmen Sáez
- Servicio de Medicina Interna, Hospital Universitario La Princesa, Madrid, Spain
| | - Silvia Vilches
- Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Daniel García-Arribas
- Servicio de Cardiología, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Madrid, Spain
| | - Marta Cobo-Marcos
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Antonio Ramos
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Luis Maroto
- Servicio de Cirugía Cardiaca, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdSSC), Madrid, Spain
| | - Itziar Gómez
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Manuel Carrasco
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Pablo García-Pavía
- CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Universidad Francisco de Vitoria (UFV), Pozuelo de Alarcón, Madrid, Spain
| | - J Alberto San Román
- Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario Valladolid, Valladolid, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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6
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García-Granja PE, López J, Vilacosta I, Sarriá C, Domínguez F, Ladrón R, Olmos C, Sáez C, Vilches S, García-Arribas D, Cobo-Marcos M, Ramos A, Maroto L, Gómez I, Carrasco M, García-Pavía P, San Román JA. Modelo predictivo de mortalidad hospitalaria en endocarditis infecciosa izquierda. Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2020.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Samura T, Yoshioka D, Toda K, Sakaniwa R, Yokoyama J, Suzuki K, Miyagawa S, Yoshikawa Y, Hata H, Takano H, Matsumiya G, Monta O, Sakaguchi T, Fukuda H, Sawa Y. Emergency valve surgery improves clinical results in patients with infective endocarditis complicated with acute cerebral infarction: analysis using propensity score matching†. Eur J Cardiothorac Surg 2020; 56:942-949. [PMID: 31502643 DOI: 10.1093/ejcts/ezz100] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To date, the optimal timing for patients with infective endocarditis (IE) with acute cerebral infarction (CI) to undergo valve surgery is unknown. Although some previous studies have reported that early valve surgery for IE patients within 1 or 2 weeks after CI could be performed safely, an initial strategy has not been identified because of the unmatched cohorts in previous studies. This study aimed to assess the feasibility and safety of early surgery within a few days after cerebral infarction by using propensity score matching. METHODS Between 2009 and 2017, 585 patients underwent valve surgery for patients with active IE at 14 institutions. Among these, 152 had preoperative acute CI. Early surgery was defined as surgery within 3 days after the diagnosis of CI. Of these 152 patients, 67 underwent early valve surgery (early group), whereas 85 underwent delayed valve surgery (delayed group). Of the patients, 45 in each group were analysed using propensity score matching. The primary outcome was in-hospital death after valve surgery, and secondary outcomes included neurological complications. We compared the clinical results of these matched patients. RESULTS Hospital mortality was lower in the early group (2% vs 16%, P = 0.058). The rate of postoperative intracranial haemorrhage in the early and delayed groups was 4% in both groups. The postoperative modified Rankin scale was not significantly different [early group: 0 (0-2); delayed group: 0 (0-2)]. Incidence of neurological deterioration did not differ significantly between the groups. The survival rates after the first discharge at 1, 3 and 5 years after valve operation were 100%, 97% and 97% in the early group and 91%, 83% and 80% in the delayed group, respectively (P = 0.029). CONCLUSIONS Early valve surgery for patients with IE within 3 days after a CI measuring <2 cm in size improved clinical results without increasing the incidence of postoperative neurological complications.
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Affiliation(s)
- Takaaki Samura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryoto Sakaniwa
- Department of Public Health, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Advanced Clinical Advanced Clinical Epidemiology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junya Yokoyama
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kota Suzuki
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroki Hata
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Takano
- Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | | | | | | | | | | | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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de Miguel-Yanes JM, Jiménez-García R, Hernández-Barrera V, de Miguel-Díez J, Méndez-Bailón M, Muñoz-Rivas N, Pérez-Farinós N, López-de-Andrés A. Infective endocarditis according to type 2 diabetes mellitus status: an observational study in Spain, 2001-2015. Cardiovasc Diabetol 2019; 18:161. [PMID: 31752887 PMCID: PMC6868776 DOI: 10.1186/s12933-019-0968-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/12/2019] [Indexed: 02/06/2023] Open
Abstract
Background The main aims of this study were to describe trends and outcomes during admission for infective endocarditis (IE) in people ≥ 40 years old with or without type 2 diabetes distributed in five time-periods (2001–2003; 2004–2006; 2007–2009; 2010–2012 and 2013–2015), using Spanish national hospital discharge data. Methods We estimated admission rates by diabetes status. We analyzed comorbidity, therapeutic procedures, and outcomes. We built Poisson regression models to compare the adjusted time-trends in admission rates. Type 2 diabetes cases were matched with controls using propensity score matching (PSM). We tested in-hospital mortality (IHM) in logistic regression analyses. Results We identified 16,626 hospitalizations in patients aged ≥ 40 years for IE in Spain, 2001–2015. The incidence of IE increased significantly from 6.0/100,000 per year to 13.1/100,000 per year (p < 0.001) in the population with type 2 diabetes, and from 3.9/100,000 per year to 5.5/100,000 per year (p < 0.001) in the population without diabetes, over the study period. The adjusted incidence of IE was 2.2-times higher among patients with diabetes than among those without diabetes (IRR = 2.2; 95% CI 2.1–2.3). People with type 2 diabetes less often underwent heart valve surgery than people without diabetes (13.9% vs. 17.3%; p < 0.001). Although IHM decreased significantly in both groups over time, it represented 20.8% of IE cases among diabetes patients and 19.9% among PSM matched controls (p = 0.337). Type 2 diabetes was not associated with a higher IHM in people admitted to the hospital for IE (OR = 1.1; 95% CI 0.9–1.2). Conclusion Incidence rates of IE in Spain, among those with and without T2DM, have increased during the period 2001–2015 with significantly higher incidence rates in the T2DM population. In our population based study and after PSM we found that T2DM was not a predictor of IHM in IE.
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Affiliation(s)
- José M de Miguel-Yanes
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 46, Doctor Esquerdo, 28007, Madrid, Spain
| | - Rodrigo Jiménez-García
- Preventive Medicine and Public Health Teaching and Research Unit, School of Medicine, Complutense University, 58, Isaac Peral, 28040, Madrid, Spain.
| | - Valentín Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas s/n, 28922, Alcorcón, Madrid, Spain
| | - Javier de Miguel-Díez
- Respiratory Care Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 46, Doctor Esquerdo, 28007, Madrid, Spain
| | - Manuel Méndez-Bailón
- Internal Medicine Department, Hospital Universitario Clínico San Carlos, Universidad Complutense de Madrid, Profesor Martín Lagos, s/n, 28040, Madrid, Spain
| | - Nuria Muñoz-Rivas
- Internal Medicine Department, Hospital Universitario Infanta Leonor, 80, Avenida Gran Vía del Este, 28031, Madrid, Spain
| | - Napoleón Pérez-Farinós
- Public Health and Psychiatry Department, Faculty of Medicine, Universidad de Malaga, 32, Bulevar Louis Pasteur, 28071, Málaga, Spain
| | - Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avenida de Atenas s/n, 28922, Alcorcón, Madrid, Spain
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9
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Lin CJ, Chua S, Chung SY, Hang CL, Tsai TH. Diabetes Mellitus: An Independent Risk Factor of In-Hospital Mortality in Patients with Infective Endocarditis in a New Era of Clinical Practice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16122248. [PMID: 31242695 PMCID: PMC6617149 DOI: 10.3390/ijerph16122248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 12/15/2022]
Abstract
Infective endocarditis (IE) is a severe disease with a hospital mortality rate of 17–25%. Early identification of IE patients with high risk of mortality may improve their clinical outcomes. Patients with diabetes mellitus (DM) who develop infective diseases are associated with worse outcomes. This study aimed to define the impact of DM on long-term mortality in IE patients. A total of 412 patients with definite IE from February 1999 to June 2012 were enrolled in this observational study and divided into 2 groups: group 1, patients with DM (n = 72) and group 2, patients without DM (n = 340). The overall in-hospital mortality rate for both groups combined was 20.2% and was higher in group 1 than in group 2 (41.7% vs. 16.5%, p < 0.01). Compared to patients without DM, patients with DM were older and associated with higher incidence of chronic diseases, less drug abuse, higher creatinine levels, and increased risk of Staphylococcus aureus infection (all p < 0.05). Moreover, they were more likely to have atypical clinical presentation and were associated with longer IE diagnosis time (all p < 0.05). In multivariable analysis, DM is an independent and significant predictor of mortality. The prognosis of IE patients with DM is still poor. Early identification and more aggressive treatment may be considered in IE patients with DM.
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Affiliation(s)
- Cheng-Jei Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
- Chang Gung University College of Medicine, Kaohsiung, Taiwan, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
| | - Sarah Chua
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
- Chang Gung University College of Medicine, Kaohsiung, Taiwan, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
| | - Sheng-Ying Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
- Chang Gung University College of Medicine, Kaohsiung, Taiwan, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
| | - Chi-Ling Hang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
- Chang Gung University College of Medicine, Kaohsiung, Taiwan, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
| | - Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
- Chang Gung University College of Medicine, Kaohsiung, Taiwan, No.123, DAPI Rd. Niaosong District, Kaohsiung City 83301, Taiwan.
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10
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Wei XB, Liu YH, Huang JL, Chen XL, Yu DQ, Tan N, Chen JY, He PC. Prediabetes and diabetes are both risk factors for adverse outcomes in infective endocarditis. Diabet Med 2018; 35:1499-1507. [PMID: 29908070 DOI: 10.1111/dme.13761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2018] [Indexed: 12/23/2022]
Abstract
AIM Diabetes is a risk factor in infective endocarditis. However, few studies have focused on the prognostic value of prediabetes in infective endocarditis. This analysis aimed to explore the relationship between prediabetes and outcomes for people with infective endocarditis. METHODS Diabetes and prediabetes definitions were based on the American Diabetes Association 2014 criteria. A total of 866 people who had been consecutively diagnosed with infective endocarditis between January 2009 and July 2015 were included in the analysis. They were divided into three groups: normoglycaemia (n = 469), prediabetes (n = 246) and diabetes (n = 151). Univariate and multivariate analyses were used to identify risk factors for adverse outcomes. RESULTS Overall in-hospital mortality was 8.5% (74 of 866), and differed significantly among the normoglycaemia, prediabetes and diabetes groups (3.4%, 12.6% and 17.9%, respectively; P < 0.001). Compared with the normoglycaemia group, the adjusted odds ratio for in-hospital death was 2.42 [95% confidence interval (CI) 1.11-5.31; P = 0.027) for prediabetes and 3.39 (95% CI 1.48-7.80; P = 0.004) for diabetes. The cumulative long-term death rate was significantly higher in the prediabetes or diabetes groups than in the normoglycaemia group (log-rank = 34.82; P < 0.001). CONCLUSION In addition to diabetes, prediabetes was also associated with a higher risk of in-hospital and long-term mortality among people with infective endocarditis. Therefore, attention should be paid to this population.
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Affiliation(s)
- X-B Wei
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Y-H Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - J-L Huang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - X-L Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - D-Q Yu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - N Tan
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - J-Y Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - P-C He
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Second People's Hospital of Nanhai District, Guangdong General Hospital's Nanhai Hospital, Foshan, China
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11
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Severe liver failure rather than cirrhosis is associated with mortality in patients with infectious endocarditis: a retrospective case-control study. Eur J Gastroenterol Hepatol 2018; 30:1216-1223. [PMID: 29727379 DOI: 10.1097/meg.0000000000001155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Data on infectious endocarditis (IE) in patients with liver cirrhosis (LC) are sparse. We aimed to describe the characteristics and predictors of mortality from IE in patients with LC. PATIENTS AND METHODS Overall, 101 patients with LC and 101 controls with IE matched for sex, age, date of IE, and diabetes were retrospectively selected in 23 liver units between 2000 and 2013. RESULTS Mean age was 60.8±10.5 and 60.6±11.5 years in LC and controls, respectively. Causes of cirrhosis (Child-Pugh A/B/C: 10.4%/41.7%/47.9%, MELD score: 17±7.8) were excess alcohol intake (79.6%), viral hepatitis (17.3%), and metabolic syndrome (14.3%). Previous history of cardiopathy was found in 24.8% of LC (prosthetic valve 8.9%) and 37.6% of controls (P=0.07). The most frequent bacteria involved were gram-positive cocci. LC had significantly fewer aminoglycosides (P=0.0007), rifamycin (P=0.03), and valve surgery (P=0.02) than controls. The proportion of patients who died following cardiac surgery was similar between the two groups (9.7% for LC vs. 8.7% for controls, P=1). In-hospital mortality for Child-Pugh C patients was significantly higher than controls (61.4 vs. 23%, P<0.001), but not for Child-Pugh A (33.3%) or B patients (25.0%). A Child-Pugh score of above C10 was the best predictor of in-hospital mortality. In LC, Child-Pugh score (odds ratio=1.5; 95% confidence interval: 1.2-2.0; P=0.002) and history of decompensation (odds ratio=3.1; 95% confidence interval: 1.1-9.0; P=0.003) were independent predictive factors for in-hospital mortality. CONCLUSION Severe liver failure but not cirrhosis is the strongest predictive factor of mortality related to IE in LC. Use of aminosides and rifamycin should be reassessed in LC, and cardiac surgery should be considered for selected patients.
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12
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Oliver L, Lavoute C, Giorgi R, Salaun E, Hubert S, Casalta JP, Gouriet F, Renard S, Saby L, Avierinos JF, Maysou LA, Riberi A, Grisoli D, Casalta AC, Collart F, Raoult D, Habib G. Infective endocarditis in octogenarians. Heart 2017; 103:1602-1609. [DOI: 10.1136/heartjnl-2016-310853] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 02/17/2017] [Accepted: 02/20/2017] [Indexed: 11/04/2022] Open
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13
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Langlois V, Lesourd A, Girszyn N, Ménard JF, Levesque H, Caron F, Marie I. Antineutrophil Cytoplasmic Antibodies Associated With Infective Endocarditis. Medicine (Baltimore) 2016; 95:e2564. [PMID: 26817911 PMCID: PMC4998285 DOI: 10.1097/md.0000000000002564] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/17/2015] [Accepted: 12/28/2015] [Indexed: 12/23/2022] Open
Abstract
To determine the prevalence of antineutrophil cytoplasmic antibodies (ANCA) in patients with infective endocarditis (IE) in internal medicine; and to compare clinical and biochemical features and outcome between patients exhibiting IE with and without ANCA.Fifty consecutive patients with IE underwent ANCA testing. The medical records of these patients were reviewed.Of the 50 patients with IE, 12 exhibited ANCA (24%). ANCA-positive patients with IE exhibited: longer duration between the onset of first symptoms and IE diagnosis (P = 0.02); and more frequently: weight loss (P = 0.017) and renal impairment (P = 0.08), lower levels of C-reactive protein (P = 0.0009) and serum albumin (P = 0.0032), involvement of both aortic and mitral valves (P = 0.009), and longer hospital stay (P = 0.016). Under multivariate analysis, significant factors for ANCA-associated IE were: longer hospital stay (P = 0.004), lower level of serum albumin (P = 0.02), and multiple valve involvement (P = 0.04). Mortality rate was 25% in ANCA patients; death was because of IE complications in all these patients.Our study identifies a high prevalence of ANCA in unselected patients with IE in internal medicine (24%). Our findings further underscore that ANCA may be associated with a subacute form of IE leading to multiple valve involvement and more frequent renal impairment. Because death was due to IE complications in all patients, our data suggest that aggressive therapy may be required to improve such patients' outcome.
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Affiliation(s)
- Vincent Langlois
- From the Department of Internal Medicine, Institute for Biochemical Research, IFRMP, University of Rouen (VL, AL, NG, HL, IM); Department of Infectious diseases (FC); and Department of Biostatistics (J-F M), CHU Rouen, France
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14
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Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075-3128. [PMID: 26320109 DOI: 10.1093/eurheartj/ehv319] [Citation(s) in RCA: 3169] [Impact Index Per Article: 352.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
MESH Headings
- Acute Kidney Injury/diagnosis
- Acute Kidney Injury/therapy
- Ambulatory Care
- Aneurysm, Infected/diagnosis
- Aneurysm, Infected/therapy
- Anti-Bacterial Agents/therapeutic use
- Antibiotic Prophylaxis
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/therapy
- Clinical Laboratory Techniques
- Critical Care
- Cross Infection/etiology
- Dentistry, Operative
- Diagnostic Imaging/methods
- Embolism/diagnosis
- Embolism/therapy
- Endocarditis/diagnosis
- Endocarditis/therapy
- Endocarditis, Non-Infective/diagnosis
- Endocarditis, Non-Infective/therapy
- Female
- Fibrinolytic Agents/therapeutic use
- Heart Defects, Congenital
- Heart Failure/diagnosis
- Heart Failure/therapy
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/therapy
- Humans
- Long-Term Care
- Microbiological Techniques
- Musculoskeletal Diseases/diagnosis
- Musculoskeletal Diseases/microbiology
- Musculoskeletal Diseases/therapy
- Myocarditis/diagnosis
- Myocarditis/therapy
- Neoplasms/complications
- Nervous System Diseases/diagnosis
- Nervous System Diseases/microbiology
- Nervous System Diseases/therapy
- Patient Care Team
- Pericarditis/diagnosis
- Pericarditis/therapy
- Postoperative Complications/etiology
- Postoperative Complications/prevention & control
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Prognosis
- Prosthesis-Related Infections/diagnosis
- Prosthesis-Related Infections/therapy
- Recurrence
- Risk Assessment
- Risk Factors
- Splenic Diseases/diagnosis
- Splenic Diseases/therapy
- Thoracic Surgical Procedures
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15
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Affiliation(s)
- Craig Laing
- Craig Laing is an NP at Christiana Care Cardiology Consultants, Christiana Care Health System, in Newark, Del
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16
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Panizzi P, Stone JR, Nahrendorf M. Endocarditis and molecular imaging. J Nucl Cardiol 2014; 21:486-95. [PMID: 24797384 PMCID: PMC4106242 DOI: 10.1007/s12350-014-9902-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Peter Panizzi
- Department of Drug Discovery and Development, Harrison School of Pharmacy, Auburn University, Auburn, AL 36849, USA
| | - James R. Stone
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Simches Research Building, 185 Cambridge St., Boston, MA 02114, USA
| | - Matthias Nahrendorf
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Simches Research Building, 185 Cambridge St., Boston, MA 02114, USA
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