Association of Vegetation Size With Valve Destruction, Embolism and Mortality.

AIM: The mortality of patients with infective endocarditis (IE) is high. The management of patients with large vegetations is controversial. This study sought to investigate the association of vegetation size on outcomes including valve destruction, embolism and mortality. METHODS AND RESULTS: One hundred and forty-two (142) patients with definite IE and transoesophageal echocardiography (TEE) imaging available for analysis were identified and data retrospectively reviewed. Vegetation length, width and area were measured. Severe valve destruction was defined as the composite of one or more of severe valve regurgitation, abscess, pseudoaneurysm, perforation or fistula. Associations with 6-month mortality were identified by Cox regression analysis. Eighty (80) (56.3%) patients had evidence of valve destruction on TEE. Vegetation length ≥10 mm and vegetation area ≥50 mm2 were significantly associated with increased risk of valve destruction, (both odds ratio OR 1.21, p=0.03 and p=0.02 respectively). Thirty-nine (39) (72.2%) patients who had an embolic event, did so prior initiation of antibiotics. Six (6)-month mortality was 18.3%. In the surgically managed group, vegetation size was not associated with mortality. In the medically managed group, vegetation area (mm2) was associated with increased mortality (HR 1.01, p<0.01) along with age (HR 1.06, p=0.03). CONCLUSION: Vegetation length ≥10 mm or area ≥50 mm2 are associated with increased risk of valve destruction. Vegetation size may also predict mortality in medically managed but not surgically managed patients with IE. Further studies to evaluate whether surgery in patients with large vegetation size improves outcomes is warranted.

Data recording aids in acute admissions.

PURPOSE: Clinical data capture and transfer are becoming more important as hospital practices change. Medical record pro-formas are widely used but their efficacy in acute settings is unclear. This paper aims to assess whether pro-forma and aide-memoire recording aids influence data collection in acute medical and surgical admission records completed by junior doctors. DESIGN/METHODOLOGY/APPROACH: During October 2007 to January 2008, 150 medical and 150 surgical admission records were randomly selected. Each was analysed using Royal College of Physicians guidelines. Surgical record deficiencies were highlighted in an aide-memoire printed on all A4 admission sheets. One year later, the exercise was repeated for 199 admissions. FINDINGS: Initial assessment demonstrated similar data capture rates, 77.4 per cent and 75.9 per cent for medicine and surgery respectively (Z = -0.74, p = 0.458). Following the aide-memoire's introduction, surgical information recording improved relatively, 70.5 per cent and 73.9 per cent respectively (Z = 2.01, p = 0.045). One from 11 aide-memoire categories was associated with improvement following clinical training. There was an overall fall in admission record quality during 2008-9 vs 2007-8. RESEARCH LIMITATIONS/IMPLICATIONS: The study compared performance among two groups of doctors working simultaneously in separate wards, representing four months' activity. PRACTICAL IMPLICATIONS: Hospital managers and clinicians should be mindful that innovations successful in elective clinical practice might not be transferable to an acute setting. ORIGINALITY/VALUE: This audit shows that in an acute setting, over one-quarter of clinical admission data were not captured and devices aimed at improving data capture had no demonstrable effect. The authors suggest that in current hospital practice, focussed clinical training is more likely to improve patient admission records than employing recording aids.

Does pre-operative chemoradiotherapy cause wound complications after abdominoperineal excision for rectal cancer? An observational study.

INTRODUCTION: Neo-adjuvant chemoradiotherapy is commonly used before surgery for rectal cancer. Very low rectal cancers are still treated by abdominoperineal excision of the rectum (APER). Perineal wound complications are common after APER. There is evidence that radiotherapy increases wound complications. We wished to examine the effect of preoperative radiotherapy (SCPRT) and long course chemoradiotherapy (LCCRT) on perineal wound complications. METHODS: We undertook a review of all patients undergoing APER at one institution between 2000 and 2010. Details of SCPRT, LCCRT and both minor and major wound complications were identified by retrospective notes review. RESULTS: Of 74 patients suitable for analysis, 38 (51%) had recorded wound complications, with 23 (31%) having major wound complications. 43 patients (58%) underwent LCCRT and 11 (15%) SCPRT. Overall wound complications were more common in the LCCRT group than those receiving no treatment (58% vs 30%, p = 0.03), and major wound complications more common after SCPRT than LCCRT (45% vs 35%, p = 0.04) or no treatment (45% vs 10%, p = 0.04). Use of mesh led to more wound complications (71% vs 41%), but almost all of these patients received LCCRT. CONCLUSIONS: Pre-operative LCCRT and SCPRT are both associated with increased perineal wound complications after APER.

Drug induced neutropaenia--a trigger for necrotising fasciitis?

The authors present a case of necrotising fasciitis of the peristomal area, in a patient who had undergone a previous ileostomy for ulcerative colitis. This was associated with neutropaenia, secondary to carbimazole, which had been commenced a few weeks previously for thyrotoxicosis. The authors therefore, stress the importance of monitoring patients closely for possible side effects and complications, while they are on immunosuppressive medication.