Surgery for active culture-positive endocarditis: determinants of early and late outcome

BACKGROUND

The purpose of this study was to describe a single unit experience in the surgical treatment of active culture-positive endocarditis and identify determinants of early and late outcome.

PATIENTS AND METHODS

One hundred eighteen consecutive patients with positive blood culture up to 3 weeks before operation (or positive valve culture) and macroscopic evidence of lesions typical for endocarditis, undergoing operation between January 1973 and December 1996 in Southampton, were evaluated. The aortic valve was infected in 53 (48.9%), the mitral in 46 (39%), both aortic and mitral in 12 (10.1%), the tricuspid in 4 (3.9%), and the pulmonary valve in 3 (2.5%). Native valve endocarditis was present in 83 (70.3%) and prosthetic valve endocarditis in 35 (29.7%). Streptococci and staphylococci were the most common pathogens. Mean follow-up was 5.6 years (range, 0 to 25 years).

RESULTS

Operative mortality was 7.6% (9 patients). Endocarditis recurred in 8 (6.7%). A reoperation was required in 12 (10.2%). There was 24 late deaths, 17 of them cardiac. Actuarial freedom from recurrent endocarditis, reoperation, late cardiac death, and long-term survival at 10 years were 85.9%, 87.2%, 85.2%, and 73.1%, respectively. On multiple regression analysis the following were independent adverse predictors: pulmonary edema (p = 0.007) and impaired left ventricular function (p = 0.02) for operative mortality; prosthetic valve endocarditis (p = 0.01) for recurrent infection; myocardial invasion by the infection (p = 0.01) and reoperation (p = 0.04) for late cardiac death; and coagulase-negative staphylococcus (p = 0.02), annular abscess (p = 0.02), and longer intensive care unit stay (p = 0.02) for long-term survival.

CONCLUSIONS

Operation for active culture-positive endocarditis carries an acceptable mortality. Freedom from recurrent infection, reoperation, and long-term survival are satisfactory. In our data, patients' hemodynamic status at operation was the major determinant of operative mortality. Prosthetic valve endocarditis, coagulase-negative staphylococcus, and annular or myocardial infectious invasion were the critical adverse determinants of late outcome.

Public reaction to Victoria's "2 Fruit 'n' 5 Veg Every Day" campaign and reported consumption of fruit and vegetables

BACKGROUND

The Victorian "2 Fruit 'n' 5 Veg Every Day" campaign was aimed at increasing awareness of the need to eat more fruit and vegetables and encouraging increased consumption of these foods in the Australian state of Victoria. The demand-side component of the campaign, which had television advertising as a centerpiece, ran from 1992 to 1995.

METHODS

Annual postcampaign telephone surveys of approximately 500 Victorians ages 20 and over were conducted with the aim of examining public awareness of the campaign, beliefs about desirable eating habits for fruit and vegetables, and reported consumption of these foods.

RESULTS

Over the years, patterns in the level of public awareness, reported consumption, and beliefs about appropriate levels of consumption have tended to parallel changes in the level of mass media investment. During the campaign's most intense period of promotional activity, significant increases in all of these variables occurred.

CONCLUSIONS

The results suggest that significant achievements can be made with relatively small-budget mass media promotion of dietary recommendations, especially when part of a more comprehensive program. However, campaigns may need to be adequately resourced for several years if sustained change is to be achieved.

Cadaveric allograft microbiology

This study aims to determine the contamination rate of cadaveric bone allograft and blood cultures retrieved from 119 donors within Leicester between 1990 and 2003. A contamination rate of 27% was present, with 120 of 437 bone allografts culturing positive at the time of retrieval. Similarly, a contamination rate of 37% was present, with 40 of 107 blood samples culturing positive. The time interval between death and procurement did not influence blood contamination. Coagulase-negative Staphylococcus was the commonest organism isolated in both blood and bone cultures. One donor had Clostridium grown in their blood culture. The available evidence confirms similar contamination rates with other studies. The majority of organisms isolated were skin commensals with a low rate of contamination of highly pathogenic organisms such as Clostridium.

A study of diaphyseal fracture repair using tissue isolation techniques

The repair of an osteotomy of the rabbit tibia was studied by arterial radiography and by histology following selective isolation of the potential sources of the fracture callus. The periosteum was isolated by reaming and nailing the medullary cavity and the bone marrow was isolated by applying a Silastic sheath around the shaft. The results revealed certain features of periosteal and medullary healing.

An investigation of the contribution of the extraosseous tissues to the diaphyseal fracture callus using a rabbit tibial fracture model and in situ immunocytochemical localisation of osteocalcin

The extraosseous tissue contribution to diaphyseal fracture callus has been investigated using a rabbit tibial fracture model and osteocalcin immunocytochemistry. The extraosseous tissues were isolated for study by reaming and nailing an osteotomy and excising 2 cm of periosteum on either side of the osteotomy. Specimens obtained from the healing fractures at 1 and 2 weeks after operation, respectively, were decalcified and stained for osteocalcin, a bone-specific protein, using an indirect immunoperoxidase method. The positively stained osteogenic cells appeared to be derived exclusively from the remnant of the periosteum.

An experimental study of the patterns of periosteal and endosteal damage in tibial shaft fractures using a rabbit trauma model

After fractures were manually produced in rabbit tibia, soft-tissue damage was assessed both visually and by vascular radiography. Transverse fractures produced circumferential laceration of the periosteum and complete transection of the marrow. Sprial fractures produced longitudinal periosteal laceration and incomplete marrow damage. These results indicate that soft-tissue damage in transverse fractures may be qualitatively different from that in spiral fractures. Perfusion studies revealed that although the nutrient artery may be interrupted by fracture, its main trunks on either side of, and up to, the fracture line may still be filled via available collateral channels.

Review of the Tumor Microenvironment in Basal and Squamous Cell Carcinoma

It is widely known that tumor cells of basal and squamous cell carcinoma interact with the cellular and acellular components of the tumor microenvironment to promote tumor growth and progression. While this environment differs for basal and squamous cell carcinoma, the cellular players within both create an immunosuppressed environment by downregulating effector CD4+ and CD8+ T cells and promoting the release of pro-oncogenic Th2 cytokines. Understanding the crosstalk that occurs within the tumor microenvironment has led to the development of immunotherapeutic agents, including vismodegib and cemiplimab to treat BCC and SCC, respectively. However, further investigation of the TME will provide the opportunity to discover novel treatment options.

Association of alopecia areata with alcohol use disorder, attention-deficit hyperactivity disorder and insomnia: a case-control analysis using the All of Us research programme

Although recent research has shown a clear link between alopecia areata (AA) and anxiety and depression, the association of AA with other psychiatric comorbidities has been poorly studied. In this National Institutes of Health database study, we show AA to be significantly associated with alcohol use disorder, attention–deficit hyperactivity disorder and insomnia. Dermatologists may be uniquely situated to screen for these previously under-recognized comorbidities and refer people to mental health services when appropriate.

Beta-Blocker Use Is Associated With Worse Relapse-Free Survival in Patients With Head and Neck Cancer

PURPOSE

Although beta-blockers (BBs) have been hypothesized to exert a beneficial effect on cancer survival through inhibition of beta-adrenergic signaling pathways, clinical data on this issue have been inconsistent. We investigated the impact of BBs on survival outcomes and efficacy of immunotherapy in patients with head and neck squamous cell carcinoma (HNSCC), non-small-cell lung cancer (NSCLC), melanoma, or squamous cell carcinoma of the skin (skin SCC), independent of comorbidity status or cancer treatment regimen.

METHODS

Patients (N = 4,192) younger than 65 years with HNSCC, NSCLC, melanoma, or skin SCC treated at MD Anderson Cancer Center from 2010 to 2021 were included. Overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were calculated. Kaplan-Meier and multivariate analyses adjusting for age, sex, TNM staging, comorbidities, and treatment modalities were performed to assess the effect of BBs on survival outcomes.

RESULTS

In patients with HNSCC (n = 682), BB use was associated with worse OS and DFS (OS: adjusted hazard ratio [aHR], 1.67; 95% CI, 1.06 to 2.62; P = .027; DFS: aHR, 1.67; 95% CI, 1.06 to 2.63; P = .027), with DSS trending to significance (DSS: aHR, 1.52; 95% CI, 0.96 to 2.41; P = .072). Negative effects of BBs were not observed in the patients with NSCLC (n = 2,037), melanoma (n = 1,331), or skin SCC (n = 123). Furthermore, decreased response to cancer treatment was observed in patients with HNSCC with BB use (aHR, 2.47; 95% CI, 1.14 to 5.38; P = .022).

CONCLUSION

The effect of BBs on cancer survival outcomes is heterogeneous and varies according to cancer type and immunotherapy status. In this study, BB intake was associated with worse DSS and DFS in patients with head and neck cancer not treated with immunotherapy, but not in patients with NSCLC or skin cancer.

Surgical treatment of infective mitral valve endocarditis: predictors of early and late outcome

BACKGROUND AND AIMS OF THE STUDY

The study aim was to review our experience in surgical treatment of infective mitral valve endocarditis, and to identify predictors of early and late outcome.

METHODS

Ninety-one consecutive patients (52 males, 39 females, mean age 55.6 years) underwent surgery between 1973 and 1997 for endocarditis of isolated mitral (n = 65, 71%), mitral and aortic (n = 25, 28%) and mitral, aortic and tricuspid valves (n = 1, 1%). Native valve endocarditis (NVE) was present in 60 patients (66%) and prosthetic valve endocarditis (PVE) in 31 (34%). The main indications for surgery were heart failure in 32 patients, valve dysfunction in 23, vegetations in 21, and persistent sepsis in 11. Eighty-six patients (95%) were in NYHA classes III-IV, and 58 (64%) had active culture-positive endocarditis at surgery. Mechanical valves were implanted in 73 patients and bioprosthetic valves in 13; valves were repaired in five patients. The impact of 46 parameters on early and late outcome was defined by means of univariate and multivariate statistical analysis. Follow up was complete (mean 5.5 years; range: 0-23.1 years; total 507.3 patient-years).

RESULTS

Operative mortality rate was 11% (n = 10). Recurrent infection was recorded in five patients (6%), and reoperation was required in eight (9%). Freedom from recurrent infection and reoperation at 10 years was 89.1% and 87.8% respectively. There were 22 late deaths, 15 from cardiac causes. Actuarial survival rates for all patients at 5, 10 and 15 years were 73.0%, 62.7% and 58.7% (for hospital survivors, the corresponding rates were 81.9%, 69.7% and 66.0%). On multiple logistic regression and Cox proportional hazards models, the following were independent predictors: preoperative pulmonary edema (p = 0.01) for operative mortality; PVE (p = 0.02) for recurrence; younger age (p = 0.02) and PVE (p = 0.02) for reoperation; male gender (p = 0.004) and longer ITU stay for survival (if all patients were included); male gender (p = 0.01) and myocardial invasion by infection (p = 0.02) for survival (if only the hospital survivors were analyzed).

CONCLUSION

Surgery for infective mitral valve endocarditis carries a relatively high, though acceptable, risk but provides satisfactory freedom from recurrent infection, reoperation and improved long-term survival. Analysis of these data demonstrated that the preoperative hemodynamic status was the major predictor of in-hospital outcome, PVE increased the risk for recurrent infection and reoperation, whereas male gender and myocardial invasion by the infective process critically reduced the probability of long-term survival. The type of offending pathogen, the activity of infection and the involvement of more than one valve did not appear to influence early and/or late outcome.

An investigation of the routes of venous drainage from the bone marrow of the human tibial diaphysis

The routes of venous drainage from the diaphyseal marrow of the human tibia have been investigated by roentgenologic techniques following perfusion with an aqueous barium sulphate suspension. Plain roentgenographs immediately after perfusion revealed that the dye promptly escaped from the marrow into the general systemic circulation through a number of large transcortical routes. The periosteal veins were shown as a delicate network of venules lying on the external surface of the shaft. The perfused dye appeared diffusely scattered throughout the whole width of the medullary canal and extended from metaphysis to metaphysis suggesting the marrow to be an open circulatory system with ill-defined boundaries. A central venous sinus, as commonly perceived, was not demonstrated. Microradiographs revealed an extensive network of cortical sinusoids and venules that were continuous with similar vessels within the marrow and on the external surface of the bone. The injected dye also perfused the haversian venules. Intersinusoidal shunts, fine efferent vessels that did not combine to form larger venules, were observed within the marrow. The principal nutrient veins and their radicles were not demonstrated by this technique.

Cutaneous Squamous Cell Carcinoma of the Head and Neck: Pathological Features and What They Mean for Prognosis and Treatment

Cutaneous squamous cell carcinoma (cSCC) is one of the most common cancers worldwide, with an incidence that has increased over the past 30 years. Although usually curable with excision, cSCC can become widely metastatic and aggressive with poor outcomes. Whereas the clinical and radiographic extent of any cancer will always guide selection of treatment modality, pathological features of cSCC also play an important role in determining prognosis and, subsequently, the need for further therapy. Therefore, reviewing and summarizing the current literature regarding pathological prognostic indicators of cSCC is essential to improving clinical outcomes. The present literature review yielded depth of invasion, surgical margins, perineural invasion, extranodal extension, lymphovascular invasion, tumor grade, tumor subtype, premalignant lesions, and molecular markers as key prognostic indicators, all with varying recommendations for adjuvant therapy. Notably, some of these factors have not been incorporated into either the American Joint Committee on Cancer staging system (8th edition) or National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology for cSCC. This review highlights a need for further research into these prognostic indicators and their role in determining the need for adjuvant treatment in head and neck cSCC.

Non-Melanoma Skin Cancer Detection in the Age of Advanced Technology: A Review

Skin cancer is the most common cancer diagnosis in the United States, with approximately one in five Americans expected to be diagnosed within their lifetime. Non-melanoma skin cancer is the most prevalent type of skin cancer, and as cases rise globally, physicians need reliable tools for early detection. Artificial intelligence has gained substantial interest as a decision support tool in medicine, particularly in image analysis, where deep learning has proven to be an effective tool. Because specialties such as dermatology rely primarily on visual diagnoses, deep learning could have many diagnostic applications, including the diagnosis of skin cancer. Furthermore, with the advancement of mobile smartphones and their increasingly powerful cameras, deep learning technology could also be utilized in remote skin cancer screening applications. Ultimately, the available data for the detection and diagnosis of skin cancer using deep learning technology are promising, revealing sensitivity and specificity that are not inferior to those of trained dermatologists. Work is still needed to increase the clinical use of AI-based tools, but based on the current data and the attitudes of patients and physicians, deep learning technology could be used effectively as a clinical decision-making tool in collaboration with physicians to improve diagnostic efficiency and accuracy.

An investigation of the routes of venous escape from the diaphyseal marrow of the canine and rabbit long bones

The routes of venous escape from the diaphyseal marrow have been demonstrated by directly perfusing the marrow cavity of canine and rabbit long bones with barium sulphate suspension. Plain radiographs immediately after perfusion revealed prompt escape of dye into the systemic veins via a number of large transcortical emissary veins. A central venous sinus as usually described was not found; instead the dye occupied the whole of the medullary cavity extending from metaphysis to metaphysis. This suggests that the marrow is an open circulatory system with ill-defined boundaries. Radiographs of thin sections of the perfused bone after decalcification, which permitted visualisation of the fine vessel arrangements, revealed numerous haversian venules. These drained the marrow into a separate extraosseous venous network on the surface of the bone.