Vascular access strategy for delivering long-term antimicrobials to patients with infective endocarditis: device type, risk of infection and mortality.

BACKGROUND: This paper reports the use of different vascular access devices and the incidence of intravascular catheter-related infection (CRI) in patients receiving intravenous antibiotics for infective endocarditis (IE). AIM: To examine whether rates of infection vary with type of vascular access device, and assess the impact of CRI on mortality in IE. METHODS: A prospective observational service evaluation of all inpatients who received intravenous antibiotics for IE was performed. In total, 114 inpatients were evaluated. All cases of CRI [including exit-site infection, intravascular catheter-related bloodstream infection (CRBSI) and mortality] were recorded. Tunnelled and non-tunnelled central venous catheters (CVCs), and peripherally inserted cannulae were used for antibiotic delivery. FINDINGS: There were 15 episodes of CRI, 11 of which were CRBSI (all associated with CVC use). The remainder comprised uncomplicated exit-site infections. Use of tunnelled CVCs [hazard ratio (HR) 16.95, 95% confidence interval (CI) 2.13-134.93; P = 0.007] and non-tunnelled CVCs (HR 24.54, 95% CI 2.83-212.55; P = 0.004) was associated with a significantly increased risk of CRI. Risk of mortality increased significantly with Staphylococcus aureus as the cause of IE (P < 0.001) and CRBSI (P = 0.034). CONCLUSION: Risk of CRI in patients with IE is linked to the type of vascular access device used. Rates of CRBSI were greatest with CVCs, while peripheral venous cannulae were not associated with CRBSI or serious sequelae. Many patients (40%) tolerated complete treatment courses delivered via peripheral cannulae. These findings confirm the importance of device selection in reducing the risk of CRI; a potentially modifiable variable that impacts on outcome and mortality in IE.

Epididymal and prostatic histoplasmosis in a renal transplant recipient from southern India.

An unusual case of epididymal and prostatic histoplasmosis is reported from Karnataka State of southern India, in a 37-year-old male renal transplant recipient, who had presented with gastrointestinal histoplasmosis a year before the second presentation and had responded successfully to 9 months' treatment with itraconazole. The patient presented a second time with high-grade fever and pain in the scrotum and the lower abdomen. Ultrasound of the abdomen revealed a retrotrigonal abscess, which was confirmed on computed tomography scan of the pelvis. Pus was drained via transrectal route and biopsy specimens were taken from the epididymis and the prostate. Histopathology revealed the picture suggestive of histoplasmosis, and the pus on culture confirmed the infection with Histoplasma capsulatum. To our knowledge, only 5 cases of epididymal histoplasmosis have been reported in the literature, our case being the second report from India and sixth in the world; prostatic histoplasmosis is also a rare occurrence.

The MRI appearances of early vertebral osteomyelitis and discitis.

AIM: To describe the magnetic resonance imaging (MRI) appearances in patients with a clinical history suggestive of vertebral osteomyelitis and discitis who underwent MRI very early in their clinical course. MATERIALS AND METHODS: A retrospective review of the database of spinal infections from a spinal microbiological liaison team was performed over a 2 year period to identify cases with clinical features suggestive of spinal infection and an MRI that did not show features typical of vertebral osteomyelitis and discitis. All patients had positive microbiology and a follow up MRI showing typical features of spinal infection. RESULTS: In four cases the features typical of spinal infection were not evident at the initial MRI. In three cases there was very subtle endplate oedema associated with disc degeneration, which was interpreted as Modic type I degenerative endplate change. Intravenous antibiotic therapy was continued prior to repeat MRI examinations. The mean time to the repeat examination was 17 days with a range of 8-22 days. The second examinations clearly demonstrated vertebral osteomyelitis and discitis. CONCLUSION: Although MRI is the imaging method of choice for vertebral osteomyelitis and discitis in the early stages, it may show subtle, non-specific endplate subchondral changes; a repeat examination may be required to show the typical features.

Viper bite causing an isolated lower motor neuron-type of facial palsy.

We describe an unusual case of viper (Daboia russelii) bite in a 48-year-old man from the state of Karnataka in southern India. He presented in a hypotensive state with a left lower motor neuron-type of facial palsy, necrosis at the site of the bite and acute renal failure. His laboratory parameters revealed renal failure and deranged coagulation parameters. He was treated with intravenous antibiotics and polyvalent antiserum venom, and dialysed in view of the renal failure. His renal function and coagulation abnormalities improved, and the facial palsy recovered with the treatment. The snake bite located away from the face, the facial palsy occurring a few hours after the venom injection and the rapid recovery following antivenin administration, support that the palsy was a direct result of systemic envenomation. To the best of our knowledge, an isolated lower motor neuron-type of facial palsy as a manifestation of systemic toxicity of a viper bite, has not been previously reported.

Management and outcomes of acute coronary syndrome with minimal myocardial necrosis: analysis of a large prospective registry from a non-interventional centre.

The aim of this study was to assess the clinical risk of minimal myonecrosis below the cut-off for acute myocardial infarction (MI) in comparison with other grades of acute coronary syndrome (ACS). One-thousand four hundred and sixty seven consecutive patients with ACS admitted between May 2001 and April 2002 were studied in a non-interventional centre. Patients were divided into unstable angina (UA) (cTnT < 0.01 microg/l), non-ST elevation ACS with minimal myonecrosis (0.01 or= 0.1 microg/L) and ST elevation myocardial infarction (STEMI). UA (n = 638) was associated with the fewest events at 6 months (2% cardiac death or MI). Patients with any myonecrosis (n = 829) had worse outcomes (6-month cardiac death or MI 18.3-23.3%). Compared with ACS patients with minimal myonecrosis, UA patients were at significantly lower risk (OR 0.21, 95% CI 0.12-0.45, p < 0.001), NSTEMI patients were at similar risk (OR 1.45, 95% CI 0.89-2.35, p = 0.13), and STEMI patients were at higher risk (OR 2.12 95% CI 1.26-3.85, p = 0.008) in adjusted analyses. Nearly 85% of cardiac deaths occurred within 6 months. The risk of adverse events was higher among patients managed by non-cardiologists (OR 1.66, 95% CI 1-2.75, p = 0.049). Patients with non-ST elevation ACS and minimal myonecrosis are a high-risk group more comparable with NSTEMI and clearly distinguishable from patients with UA.

The relationship between QT intervals and mortality in ambulant patients with chronic heart failure. The united kingdom heart failure evaluation and assessment of risk trial (UK-HEART)

AIMS: Mortality in patients with heart failure remains high and is difficult to predict. QT interval parameters on a 12-lead ECG have been shown to predict arrhythmic events in patients with a variety of myocardial diseases. There is some, but not consistent, evidence that QT interval parameters may act as predictors of mortality, in particular sudden death, in patients with heart failure. In an adequately powered prospective study we have studied QT interval parameters in patients with stable chronic heart failure in order to determine whether they are predictive of all-cause mortality or mode of death. METHODS AND RESULTS: Five hundred and fifty-four ambulant outpatients with chronic heart failure were recruited. A 12-lead ECG, chest radiograph, echocardiogram, 24 h ambulatory electrocardiogram and serum for biochemical analysis were obtained at baseline. Patients were followed for 471+/-168 days. QT intervals were measured in all leads blinded to patient's characteristics and outcome, were corrected for heart rate, and the maximum QT intervals, and QT dispersion (range of QT intervals) were determined. The same parameters were determined for JT intervals. The primary end-point was all-cause mortality, secondary end-points were sudden cardiac death and death due to progressive heart failure. Multivariate analysis with the Cox's proportional hazards model was used to determine which variables were independently related to outcome. Four hundred and ninety-five patients had analysable ECGs at study entry and of these 71 died during follow-up. The heart rate corrected QT dispersion and maximum QT interval were significant univariate predictors of all-cause mortality (P=0.026 and <0.0001 respectively), and also of sudden death and progressive heart failure death, but were not related to outcome in the multivariate analysis. The independent predictors of all-cause mortality were cardiothoracic ratio (P=0.0003), creatinine (P=0.0009), heart rate (P=0.007), echocardiographically derived left ventricular end-diastolic dimension (P=0.007) and ventricular couplets on 24 h electrocardiographic monitoring (P=0.015). CONCLUSION: In an adequately powered prospective study none of the QT or JT parameters were shown to be independent predictors of outcome in patients with mild to moderate congestive heart failure. These variables do not therefore add to the prognostic information which can be gained from simple radiographic, biochemical, echocardiographic and Holter data in this group of patients.

Prospective study of heart rate variability and mortality in chronic heart failure: results of the United Kingdom heart failure evaluation and assessment of risk trial (UK-heart).

BACKGROUND: Patients with chronic heart failure (CHF) have a continuing high mortality. Autonomic dysfunction may play an important role in the pathophysiology of cardiac death in CHF. UK-HEART examined the value of heart rate variability (HRV) measures as independent predictors of death in CHF. METHODS AND RESULTS: In a prospective study powered for mortality, we recruited 433 outpatients 62+/-9.6 years old with CHF (NYHA functional class I to III; mean ejection fraction, 0.41+/-0.17). Time-domain HRV indices and conventional prognostic indicators were related to death by multivariate analysis. During 482+/-161 days of follow-up, cardiothoracic ratio, SDNN, left ventricular end-systolic diameter, and serum sodium were significant predictors of all-cause mortality. The risk ratio for a 41.2-ms decrease in SDNN was 1.62 (95% CI, 1.16 to 2.44). The annual mortality rate for the study population in SDNN subgroups was 5.5% for >100 ms, 12.7% for 50 to 100 ms, and 51.4% for <50 ms. SDNN, creatinine, and serum sodium were related to progressive heart failure death. Cardiothoracic ratio, left ventricular end-diastolic diameter, the presence of nonsustained ventricular tachycardia, and serum potassium were related to sudden cardiac death. A reduction in SDNN was the most powerful predictor of the risk of death due to progressive heart failure. CONCLUSIONS: CHF is associated with autonomic dysfunction, which can be quantified by measuring HRV. A reduction in SDNN identifies patients at high risk of death and is a better predictor of death due to progressive heart failure than other conventional clinical measurements. High-risk subgroups identified by this measurement are candidates for additional therapy after prescription of an ACE inhibitor.

QT sensing rate responsive pacing during subacute bacterial endocarditis: a case report.

A 63-year-old woman treated with a QT sensing rate responsive pacemaker following aortic valve replacement developed late subacute bacterial endocarditis. During febrile periods, associated with systemic upset, pacing was physiological as evidenced by an increased heart rate during pyrexia and a decrease when afebrile.

Haemodynamic dose-response actions of cicloprolol in left ventricular dysfunction due to ischaemic heart disease.

Cicloprolol is a cardioselective beta-1 partial agonist; its haemodynamic and radionuclide (nuclear stethoscope) effects were determined in 22 patients with impaired left ventricular function due to coronary artery disease. Following a 20 min stable control period, the effects of four doses of cicloprolol (0.025, 0.025, 0.05 and 0.1 mg/kg at 10 min intervals) were measured at rest 5-10 min after each intravenous injection. The effects of the cumulative 0.2 mg/kg dosage were assessed during supine bicycle exercise and compared with a control exercise period. At rest there were significant increases in systolic arterial without change in mean blood pressure. The heart rate and cardiac index were unchanged. There was a significant increase in left ventricular ejection fraction with a reduction in filling pressure and volume. Patients with resting heart rate below 75 beats/min and with ejection fraction greater than 35% showed the greatest improvement. During supine bicycle exercise, ejection fraction was increased compared to control (31 +/- 2 to 36 +/- 2; P less than 0.01), cardiac volume reduced and exercise tachycardia attenuated. These data suggest that cicloprolol may be of value where beta-blockade is considered in the presence of underlying left ventricular dysfunction due to ischaemic heart disease.