Eradication of Mycobacterium abscessus infection in cystic fibrosis with initiation of Elexacaftor/Tezacaftor/Ivacaftor.

Mycobacterium abscessus is a nontuberculous mycobacterium that is often multi-drug resistant, difficult to eradicate and associated with a rapid decline in lung function in cystic fibrosis (CF). Elexacaftor/Tezacaftor/Ivacaftor (ETI) is a combination CFTR modulator that improves lung function and decreases exacerbations, but limited data exists about its impact on respiratory infections. A 23-year-old male with CF (F508del, unknown) was diagnosed with Mycobacterium abscessus subspecies abscessus infection. He completed 12-weeks of intensive therapy, followed by oral continuation therapy. Antimicrobials were later discontinued for optic neuritis secondary to linezolid. He remained off antimicrobials with persistently positive sputum cultures. He then initiated ETI, and bronchoscopy eight months later suggested eradication of M. abscessus. By modulating CFTR protein function, ETI may improve innate airway defence mechanisms, facilitating the clearance of infections such as M. abscessus. This case highlights the potential positive implications of ETI on the challenging treatment of M. abscessus infections in CF.

Women have worse long-term outcomes after coronary artery bypass grafting than men.

BACKGROUND: Multiple studies have shown that women have worse in-hospital outcomes than men after coronary artery bypass grafting (CABG). The impact of sex on long-term results following CABG, however, is not as well established. OBJECTIVE: To compare long-term results in men and women undergoing CABG. METHODS: A total of 3404 patients underwent isolated CABG between 1995 and 1999 with follow-up until 2000. Univariate comparisons between men and women were carried out based on pre- and intraoperative variables and short- and long-term adverse outcomes. Long-term adverse outcomes were defined as all-cause mortality or rehospitalization for any cardiac cause, and were risk-adjusted using multivariate modelling techniques. RESULTS: Compared with men, women undergoing CABG were, on average, older (67.8 years versus 64.2 years), more likely to have diabetes (P<0.0001) and hypertension (P<0.0001), and more likely to present for surgery with urgent/emergent status (P<0.0001). Intra-operatively, women had fewer bypasses (3.0 versus 3.3; P<0.0001) and were less likely to receive a left internal mammary artery graft (P=0.0001). While rates of in-hospital mortality were comparable between women and men (2.9% versus 2.2%; P=0.22), women were more likely to experience a long-term adverse event (30.2% versus 23.5%; P<0.0001). After adjusting for clinical differences between men and women, sex emerged as an independent predictor of long-term adverse outcomes following CABG (hazard ratio = 1.18, P=0.03). CONCLUSIONS: Women presented for CABG with more comorbid illness, advanced symptoms and greater urgency than did men. After adjusting for differences in clinical presentation, sex emerged as an independent predictor of long-term adverse outcomes following CABG.

Isolated pulmonic valve endocarditis.

A 61-year-old man with no known cardiac history presented with septic arthritis of the right knee secondary to group B Streptococcus. During follow-up, echocardiography revealed a 1.8 cm x 1.2 cm mobile vegetation on the pulmonary valve. Despite parenteral antimicrobial therapy, the patient developed recurrent pulmonary emboli with enlargement of the vegetative mass, necessitating surgical debridement and replacement of the pulmonary valve. A diagnosis of pulmonic valve endocarditis should be considered in the differential diagnosis of any febrile patient with multiple pulmonary emboli.

Anticoagulation in atrial fibrillation. Is there a gap in care for ambulatory patients?

OBJECTIVE: Atrial fibrillation (AF) substantially increases risk of stroke. Evidence suggests that anticoagulation to reduce risk is underused (a "care gap"). Our objectives were to clarify measures of this gap in care by including data from family physicians and to determine why eligible patients were not receiving anticoagulation therapy. DESIGN: Telephone survey of family physicians regarding specific patients in their practices. SETTING: Nova Scotia. PARTICIPANTS: Ambulatory AF patients not taking warfarin who had risk factors that made anticoagulation appropriate. MAIN OUTCOME MEASURES: Proportion of patients removed from the care gap; reasons given for not giving the remainder anticoagulants. RESULTS: Half the patients thought to be in the care gap had previously unknown contraindications to anticoagulation, lacked a clear indication for anticoagulation, or were taking warfarin. Patients' refusal and anticipated problems with compliance and monitoring were among the reasons for not giving patients anticoagulants. CONCLUSION: Adding data from primary care physicians significantly narrowed the care gap. Attention should focus on the remaining reasons for not giving eligible patients anticoagulants.