Thoracentesis to alleviate pleural effusion in acute heart failure: study protocol for the multicentre, open-label, randomised controlled TAP-IT trial.

INTRODUCTION: Pleural effusion is present in half of the patients hospitalised with acute heart failure. The condition is treated with diuretics and/or therapeutic thoracentesis for larger effusions. No evidence from randomised trials or guidelines supports thoracentesis to alleviate pleural effusion due to acute heart failure. The Thoracentesis to Alleviate cardiac Pleural effusion Interventional Trial (TAP-IT) will investigate if a strategy of referring patients with acute heart failure and pleural effusion to up-front thoracentesis by pleural pigtail catheter insertion in addition to pharmacological therapy compared with pharmacological therapy alone can increase the number of days the participants are alive and not hospitalised during the 90 days following randomisation. METHODS AND ANALYSIS: TAP-IT is a pragmatic, multicentre, open-label, randomised controlled trial aiming to include 126 adult patients with left ventricular ejection fraction ≤45% and a non-negligible pleural effusion due to heart failure. Participants will be randomised 1:1, stratified according to site and anticoagulant treatment, and assigned to referral to up-front ultrasound-guided pleural pigtail catheter thoracentesis in addition to standard pharmacological therapy or to standard pharmacological therapy only. Thoracentesis is performed according to local guidelines and can be performed in participants in the pharmacological treatment arm if their condition deteriorates or if no significant improvement is observed within 5 days. The primary endpoint is how many days participants are alive and not hospitalised within 90 days from randomisation and will be analysed in the intention-to-treat population. Key secondary outcomes include 90-day mortality, complications, readmissions, and quality of life. ETHICS AND DISSEMINATION: The study has been approved by the Capital Region of Denmark Scientific Ethical Committee (H-20060817) and Knowledge Center for Data Reviews (P-2021-149). All participants will sign an informed consent form. Enrolment began in August 2021. Regardless of the nature, results will be published in a peer-reviewed medical journal. TRIAL REGISTRATION NUMBER: NCT05017753.

Rheumatoid arthritis mimicking infective endocarditis with severe aortic regurgitation and aortic root abscess: a case report.

BACKGROUND: Rheumatoid arthritis (RA) may involve the cardiovascular system and can cause significant structural cardiac disease. RA mimicking infective endocarditis (IE) is rarely reported. CASE SUMMARY: A 46-year-old man with a medical history of seropositive RA attended a planned outpatient visit for infliximab treatment. The pre-infusion examination revealed a pulse of 41 b.p.m. and the following electrocardiogram showed 3rd degree atrioventricular block. A temporary pacemaker was inserted, and subsequent transthoracic and transoesophageal echocardiograms showed severe aortic valve regurgitation with thickened cusps and thus raised suspicion of infective aortic endocarditis with root abscess. The patient underwent surgery with valve and root replacement the next day. What was thought to be IE, proved to be suppurative and granulomatous inflammation with sporadic necrosis and hyaline fibrosis, compatible with a rheumatoid nodule linked to the patient's RA diagnosis. DISCUSSION: IE is a disease with high mortality and morbidity. In some cases of IE perivalvular cavities develop, most commonly abscesses and/or pseudoaneurysms, which necessitates surgery. Several conditions may mimic IE: for example, malignant and benign tumours, rheumatic diseases, and common age-related valve calcification. In patients with valvular vegetations that are 'culture-negative', alternative pathologies should be considered.

Evaluation of tools to assess psychological distress: how to measure psychological stress reactions in citizen responders- a systematic review.

BACKGROUND: Dispatched citizen responders are increasingly involved in out-of-hospital cardiac arrest (OHCA) resuscitation which can lead to severe stress. It is unknown which psychological assessment tools are most appropriate to evaluate psychological distress in this population. The aim of this systematic review was to identify and evaluate existing assessment tools used to measure psychological distress with emphasis on citizen responders who attempted resuscitation. METHODS: A systematic literature search conducted by two reviewers was carried out in March 2018 and revised in July 2018. Four databases were searched: PubMed, PsycInfo, Scopus, and The Social Sciences Citation Index. A total of 504 studies examining assessment tools to measure psychological distress reactions after acute traumatic events were identified, and 9 fulfilled the inclusion criteria for further analysis. The selected studies were assessed for methodological quality using the Scottish Intercollegiate Guidelines Network. RESULTS: The Impact of Event Scale (IES) and The Impact of Event Scale-Revised (IES-R) were the preferred assessment tools, and were used on diverse populations exposed to various traumatic events. One study included lay rescuers performing bystander cardiopulmonary resuscitation and this study used the IES. The IES and the IES-R also have proven a high validity in various other populations. The Clinical administered PTSD scale (CAPS) was applied in two studies. Though the CAPS is comparable to both the IES-R and the IES, the CAPS assess PTSD symptoms in general and not in relation to a specific experienced event, which makes the scale less suitable when measuring stress due to a specific resuscitation attempt. CONCLUSIONS: The IES and the IES-R seem to be solid measures for psychological distress among people experiencing an acute psychological traumatic event. However, only one study has assessed psychological distress among citizen responders in OHCA for which the IES-R scale was used, and therefore, further research on this topic is warranted.

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.

The relationship between cerebrovascular complications and previously established use of antiplatelet therapy in left-sided infective endocarditis.

BACKGROUND: Cerebrovascular complications (CVC) in infective endocarditis (IE) are common. The only established treatments to reduce the incidence of CVC in IE are antibiotics and in selected cases early cardiac surgery. Potential effects of previously established antiplatelet therapy are under debate. METHODS: In a prospective cohort study in Sweden and Demark, the influence of previously established antiplatelet therapy on CVC incidence and mortality in IE was assessed using logistic regression models. RESULTS: Among 684 left-sided definite IE episodes, 23.0% were seen in patients on established antiplatelet therapy (96% acetylsalicylic acid). Patients on antiplatelet therapy were older and significantly more often had a history of congestive heart failure prior to IE diagnosis. No difference in CVC rate was seen between patients with and without ongoing antiplatelet therapy (23.6% vs 25.0%, adjusted odds ratio (AOR) 0.8, 95% confidence interval (CI) 0.48-1.5). Ischemic stroke, which occurred in 115 episodes (16.8%), was the most common cerebral lesion, and haemorrhagic complications were seen in 16 (2.3%) patients without correlation to chronic antiplatelet therapy. Unadjusted 1-y mortality was higher for patients on previously established antiplatelet therapy (33.8% vs 24.1%, odds ratio (OR) 1.6, 95% CI 1.1-2.4), but after adjustment for covariables associated with mortality an opposite statistical trend was seen (AOR 0.7, 95% CI 0.4-1.1). CONCLUSIONS: The incidence of symptomatic CVC in IE patients was not reduced by previously established antiplatelet therapy. One-y mortality was higher in patients on antiplatelet therapy in univariate analysis, but after multivariable modelling this association was lost.

[Streptococcus pneumoniae endocarditis diagnosed with polymerase chain reaction]. / Dyrkningsnegativ Streptococcus pneumoniae endokarditis diagnosticeret med polymerasekaedereaktion.

A 60-year old man was admitted with sepsis and meningitis of unknown aetiology. Underlying aortic valve endocarditis was diagnosed by echocardiography and severe insufficiency led to aortic valve replacement. Application of broad-range PCR to cusp tissue revealed a DNA product, and a diagnosis of Streptococcus pneumoniae endocarditis was obtained by DNA sequencing.