Streptococcus mutans infective endocarditis complicated by vertebral discitis following dental treatment without antibiotic prophylaxis.

We report what we believe is the first reported case of Streptococcus mutans endocarditis complicated by vertebral discitis. The case is particularly interesting and topical as it occurred in a patient with pre-existing cardiac valvular disease who had recently had a dental procedure without antibiotic prophylaxis following a dramatic shift in the UK guidelines.

Suprarenal clamping is a safe method of aortic control when infrarenal clamping is not desirable.

We evaluated the safety of suprarenal aortic clamping in patients with abdominal aortic aneurysm (AAA) treated by open aortic replacement by retrospectively reviewing all patients who underwent elective AAA replacement at a university hospital from 1993 until 2003. We reviewed 249 patient charts and divided them into three groups according to the clamp location during aortic replacement: group 1, infrarenal clamp group (n = 185); group 2, suprarenal clamp group (n = 52); and group 3, supraceliac clamp group (n = 12). Groups 1 and 2 were compared with respect to risk factors, intraoperative events, and postoperative events. Statistical analysis was done using Wilcoxon's rank-sum test, chi-squared test, and Fisher's exact test. Risk factors were comparable in groups 1 and 2 except for weight, which was higher in group 1. Intraoperative urine output, hypotensive episodes, and use of renal protective drugs were comparable in the two groups. Operation time, blood loss, and use of IV fluids were all significantly higher in group 2, while total aortic clamp time was higher in group 1. Postoperative events were comparable except for postoperative peak creatinine, intensive care unit length of stay, and postoperative length of stay, which were higher in group 2; however, discharge creatinine was comparable without a significant difference. Suprarenal clamping is a safe method of aortic control during open AAA replacement surgery. The selection of clamping site should be individualized according to the intraoperative anatomy. Supraceliac clamping is not necessarily the preferable method of aortic control when the infrarenal location is not suitable for clamping.

Can randomized trial outcomes for carotid endarterectomy be achieved in community-wide practice?

The benefit of carotid endarterectomy (CEA) is dependent upon achieving procedural outcomes comparable to those observed in randomized trials. We have extensively examined outcomes of the procedure in the community with a complete medical record (hospital chart) review of over 20,000 Medicare patients undergoing CEA in 10 states. In patients with comparable indications, overall risk of stroke or death of 6.9% in our Medicare studies was comparable to the 6.5% combined event rate in the North American Symptomatic Carotid Endarterectomy Trial. In asymptomatic patients, however, the overall Medicare study result of 3.8% was inferior to the benchmark perioperative combined event rate of 1.5% achieved in the Asymptomatic Carotid Atherosclerosis Study. Our data demonstrated that the randomized trial benchmarks could be achieved or even exceeded at a statewide level. Our studies also documented that evidence-based processes that can reduce perioperative stroke and death (eg, perioperative antiplatelet therapy, patching) are underutilized in the community. Overall process and outcomes assessment show considerable room for improvement. All surgeons performing CEA should use a system-based approach to ensure that all evidence-based processes are employed for patients undergoing CEA and should use indication stratification to document their own outcomes for the procedure.

Intravenous immunoglobulin for the prevention of infection in chronic lymphocytic leukemia. A randomized, controlled clinical trial.

In a double-blind study, we randomly assigned 84 patients with chronic lymphocytic leukemia who were judged to be at increased risk of bacterial infection to receive intravenous immunoglobulin G (400 mg per kilogram of body weight) or a placebo every three weeks for one year. Eligible patients had hypogammaglobulinemia, a history of infection, or both. The patients receiving immunoglobulin had significantly fewer bacterial infections during the study period than those receiving placebo (23 vs. 42; P = 0.01). This reduction was most striking in the patients who completed a full year of treatment (14 vs. 36; P = 0.001). The period from study entry to the first serious bacterial infection was significantly longer in the patients receiving immunoglobulin (P = 0.026). There was no significant difference between the two groups in the incidence of nonbacterial infection. Immunoglobulin therapy was tolerated well; there were no serious adverse reactions, and the incidence of minor reactions was low. We conclude that selected patients with chronic lymphocytic leukemia who are at risk of bacterial infection can be substantially protected from this complication by the regular intravenous administration of immunoglobulin.