Pulmonary arteriovenous malformations in patients with previous brain abscess: a cross-sectional population-based study

BACKGROUND AND PURPOSE

Pulmonary arteriovenous malformations (PAVMs) may cause recurrent brain abscess. The primary aim was to determine the prevalence of PAVM amongst survivors of brain abscess. The proportion with cardiac right-to-left shunts was also assessed post hoc.

METHODS

This was a cross-sectional population-based study of adult (≥18 years) survivors of cryptogenic bacterial brain abscess in Denmark from 2007 through 2016. Patients were invited for bubble-echocardiography to detect vascular right-to-left shunting and, if abnormal, subsequent computed tomography thorax for diagnosis of PAVM. Data are presented as n/N (%) or median with interquartile range (IQR).

RESULTS

Study participation was accepted by 47/157 (30%) eligible patients amongst whom two did not appear for scheduled bubble-echocardiography. The median age of participants was 54 years (IQR 45-62) and 19/57 (33%) were females compared with 59 years (IQR 48-68, p = 0.05) and 41/85 females (48%, p = 0.22) in non-participants. Bubble-echocardiography was suggestive of shunt in 10/45 (22%) participants and PAVM was subsequently confirmed by computed tomography in one patient with grade 1 shunting. The corresponding prevalence of PAVM was 2% (95% confidence interval 0.06-11.8) amongst all examined participants. Another 9/45 (20%) were diagnosed with patent in persistent foramen ovale (n = 8) or atrial septum defect (n = 1), which is comparable with the overall prevalence of 25% amongst adults in the Danish background population.

CONCLUSIONS

Undiagnosed PAVM amongst adult survivors of cryptogenic bacterial brain abscess is rare but may be considered in select patients. The prevalence of cardiac right-to-left shunts amongst brain abscess patients corresponds to the prevalence in the general population.

Implementation of early palliative care in an oncologic outpatient clinic - an observational study of the first year

BACKGROUND

As earlier studies found that early onset specialized palliative care (ESPC) results in better quality of life (QoL), less hospitalization and chemotherapy toward end-of life, we implemented ESPC in our oncology outpatient clinic. The aim of this study was to describe reasons for referral, interventions performed and the satisfaction among the oncologic staff.

MATERIAL AND METHODS

The outpatient ESPC clinic was established in the department of oncology. Prespecified selected data was obtained from the patients records. All patients were asked to fill in a questionnaire concerning their symptoms and QOL. A survey among the oncologic personnel concerning their perception of the clinic was conducted. All data were consecutively collected in a share point database.

RESULTS

We included 134 patients. The primary referral symptoms were pain (69%) or psychological/existential challenges (23%). 55% of patients filled in an EORTC questionnaire and rated a median (QoL) of 3.4. Interventions initiated were on based on the following symptoms: pain (70%), constipation (53%), nausea (15%), dyspnea (10%) and depression (7%). Median waiting time was 13 days. Of the 134 patients referred to the ESPC clinic 101 was admitted. Symptoms and problems were resolved in the ESPC clinic for 81 of the 101 admitted patients (80%), i.e., after one consultation for 25 patients and after a follow up course in the clinic for 56 patients. A survey among the staff at the Department of Oncology demonstrated a high degree of satisfaction with the ESPC clinic.

CONCLUSIONS

We report experiences from implementation of ESPC in our outpatient oncologic clinic, where 81 (80%) of the admitted patients could be finished after one or a few follow up contacts, as their symptoms had been resolved. There was a high degree of satisfaction with the clinic among the oncologic staff.

Severity of anaemia and association with all-cause mortality in patients with medically managed left-sided endocarditis

OBJECTIVE

To assess the prevalence and severity of anaemia in patients with left-sided infective endocarditis (IE) and association with mortality.

METHODS

In the Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis trial, 400 patients with IE were randomised to conventional or partial oral antibiotic treatment after stabilisation of infection, showing non-inferiority. Haemoglobin (Hgb) levels were measured at randomisation. Primary outcomes were all-cause mortality after 6 months and 3 years. Patients who underwent valve surgery were excluded due to competing reasons for anaemia.

RESULTS

Out of 400 patients with IE, 248 (mean age 70.6 years (SD 11.1), 62 women (25.0%)) were medically managed; 37 (14.9%) patients had no anaemia, 139 (56.1%) had mild anaemia (Hgb <8.1 mmol/L in men and Hgb <7.5 mmol/L in women and Hgb ≥6.2 mmol/L) and 72 (29.0%) had moderate to severe anaemia (Hgb <6.2 mmol/L). Mortality rates in patients with no anaemia, mild anaemia and moderate to severe anaemia were 2.7%, 3.6% and 15.3% at 6-month follow-up and 13.5%, 20.1% and 34.7% at 3-year follow-up, respectively. Moderate to severe anaemia was associated with higher mortality after 6 months (HR 4.81, 95% CI 1.78 to 13.0, p=0.002) and after 3 years (HR 2.14, 95% CI 1.27 to 3.60, p=0.004) and remained significant after multivariable adjustment.

CONCLUSION

Moderate to severe anaemia was present in 29% of patients with medically treated IE after stabilisation of infection and was independently associated with higher mortality within the following 3 years. Further investigations are warranted to determine whether intensified treatment of anaemia in patients with IE might improve outcome.

The epidemiology of infective endocarditis with focus on non-device related right-sided infective endocarditis: A retrospective register-based study in the region of Southern Denmark

AIMS

Non-device related right-sided infective endocarditis (ND-RSIE) is not well characterized. We aimed to characterize patients with infective endocarditis (IE) with emphasis on the epidemiology, clinical characteristics and complications of ND-RSIE.

METHODS

In this population-based cohort study, we identified patients with IE using ICD-10 codes from the Danish National Hospital Register in the Region of Southern Denmark between January 2007 and May 2017. Hospital records were reviewed, and characteristics and outcomes recorded.

RESULTS

We included 1243 confirmed IE episodes of which 82% were left-sided IE, 11% were cardiac device right sided infective endocarditis (RSIE) and 7% were ND-RSIE. Patients with ND-RSIE were considerably younger, had less comorbidity and had a lower 30-day mortality (6%) compared with patients with device RSIE (24%) and left-sided IE (26%) (p<0.01). ND-RSIE was associated with underlying heart disease, involvement of the tricuspid valve (57%), Staphylococcus species (53%) and complications (61%). Forty percent of ND-RSIE occurred among people who inject drugs (PWID) for whom significant differences were observed compared with non-PWID with regards to tricuspid valve involvement (96% vs. 32%), causative microorganisms (Staphylococcus aureus 79% vs. 27%), complications (86% vs. 45%), recurrence (29% vs. 11%) and 30-day mortality (0% vs. 7%).

CONCLUSION

ND-RSIE is relatively rare and differs with regards to epidemiology, clinical characteristics and complications compared with left-sided IE and cardiac device RSIE, but has a favourable prognosis. Forty percent of ND-RSIE occurs among PWID, which is associated with frequent complications but a very low mortality.

Whole-genome sequencing of bloodstream Staphylococcus aureus isolates does not distinguish bacteraemia from endocarditis

Most Staphylococcus aureus isolates can cause invasive disease given the right circumstances, but it is unknown if some isolates are more likely to cause severe infections than others. S. aureus bloodstream isolates from 120 patients with definite infective endocarditis and 121 with S. aureus bacteraemia without infective endocarditis underwent whole-genome sequencing. Genome-wide association analysis was performed using a variety of bioinformatics approaches including SNP analysis, accessory genome analysis and k-mer based analysis. Core and accessory genome analyses found no association with either of the two clinical groups. In this study, the genome sequences of S. aureus bloodstream isolates did not discriminate between bacteraemia and infective endocarditis. Based on our study and the current literature, it is not convincing that a specific S. aureus genotype is clearly associated to infective endocarditis in patients with S. aureus bacteraemia.

[Fulminant perimyocarditis following tonsillitis]

Fulminant perimyocarditis is a rare and potentially fatal condition that may mimick myocardial infarction. The long-term prognosis is favourable, once the patient has survived the index admission, and recurrence is extremely rare. This case describes a 35-year-old man, who experienced recurrence twice within six months. Due to the risk of a potentially fatal outcome, patients should be followed closely with clinical controls of infection parameters and echocardiography.