Partial oral antibiotic treatment of endocarditis in patients who inject drugs: a case series.

BACKGROUND: Recent literature has demonstrated that partial oral antibiotic treatment of infectious endocarditis is non-inferior to IV therapy in select patients. Despite the rising incidence of injection drug use-related endocarditis, partial oral therapy has not been well studied in persons who inject drugs. OBJECTIVES: To evaluate the rate of relapsed infection and 90 day mortality in patients with infectious endocarditis treated with partial oral antibiotic therapy. METHODS: Consecutive patients with infectious endocarditis treated with partial oral antibiotic therapy were identified by study investigators and reviewed by independent clinicians. The decision to use partial oral antibiotic therapy was made by the institution's multidisciplinary endocarditis team. RESULTS: In 11 cases of infective endocarditis treated with partial oral antibiotic therapy, 9 of which were complicated by injection drug use, there were no relapsed infections with the primary organism. Five patients underwent surgical valve replacement, and the median duration of oral antibiotic therapy was 23 days. All patients survived to in-hospital discharge and 90 days post-discharge. Ten patients followed up with an infectious diseases provider after discharge. CONCLUSIONS: These data add to existing literature demonstrating non-inferior outcomes with partial oral antibiotic treatment when compared with IV antibiotic treatment alone in patients with endocarditis, including persons who inject drugs.

Postoperative bleeding after laparoscopic Roux en Y gastric bypass: predictors and consequences.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common, safe and effective bariatric procedure. Bleeding is a significant source of postoperative morbidity. We aimed to determine the incidence, outcomes, and predictors of postoperative bleeding after LRYGB. METHODS: LRYGB patients included in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset were identified. Preoperative and intraoperative factors were tested for associations with bleeding using univariable and multivariable logistic regression analysis. Outcomes of length of stay, in-hospital mortality, 30-day mortality, discharge disposition, and 30-day complications among patients with and without clinically significant postoperative bleeding were compared using multivariable regression. RESULTS: In the 43,280 LRYGB patients included in this analysis, postoperative bleeding occurred in 652 (1.51%) patients. Of these, 165 (25.3%) underwent a re-operation and 97 (14.9%) underwent an unplanned endoscopy for 'bleeding'. Postoperative bleeding was associated with a longer median postoperative length of stay (4 vs. 2 days), higher in-hospital mortality (1.23 vs. 0.04%), higher 30-day mortality (1.38 vs. 0.15%), discharge to an extended-care facility (3.88 vs. 0.6%), and higher rates of major complications (all P < 0.05). Independent predictors of postoperative bleeding included; a history of renal insufficiency (OR 2.55, 95% CI 1.43-4.52), preoperative therapeutic anticoagulation (OR 2.44, 95% CI 1.69-3.53), and revisional surgery (OR 1.45, 95% CI 1.06-1.97). Intraoperative associated factors included conversions (OR 3.37, 95% CI 1.42-7.97), and drain placement (OR 1.40, 95% CI 1.18-1.67). Robotic approaches resulted in independently lower postoperative bleeding rates (OR 0.50, 95% CI 0.32-0.77). CONCLUSIONS: Postoperative bleeding occurs in 1.5% of patients undergoing a LRYGB and is associated with significantly increased morbidity and mortality. We have identified patient and operative factors that are independently associated with postoperative bleeding.

Staple Line Treatment and Bleeding After Laparoscopic Sleeve Gastrectomy.

BACKGROUND AND OBJECTIVES: Staple line treatment during laparoscopic sleeve gastrectomy (LSG) remains a controversial issue among bariatric surgeons. The objective of this study was to compare rates of postoperative bleeding (POB) among various methods of staple line reinforcement. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 dataset was queried for patients undergoing an LSG. Patients were stratified by staple line treatment groups-no treatment (NT), suture oversewing (OVERSEW), buttressing by a commercial product (BUTTRESS), and both buttress and oversew (COMBINATION). The primary outcome was POB. Multivariable logistic regression was used to compare POB rates among the treatment groups. RESULTS: In the 98,142 LSG patients meeting selection criteria, 623 (0.63%) patients had POB and 181 (0.18%) required reoperation. POB occurred in 0.80% for the NT group, 0.68% for the OVERSEW group, 0.57% for the BUTTRESS group, and 0.55% for the COMBINATION group. On multivariable analyses, all treatment groups were less likely to have POB compared with the NT group-OVERSEW (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.54-0.98), BUTTRESS (OR 0.70, 95% CI 0.57-0.84), and COMBINATION (OR 0.66, 95% CI 0.50-0.89) (all P < .01). Subset analysis revealed no difference between BUTTRESS and OVERSEW (OR 0.95, 95% CI 0.71-1.26, P = .71). CONCLUSIONS: Relative to an NT staple line, the use of OVERSEW or BUTTRESS can decrease the rates of POB by up to 30%. The use of these techniques should be strongly considered by the bariatric surgeon.

Themes and gaps in research for opioid use and misuse pertinent to orthopaedic injury patients.

INTRODUCTION: Prescription opioid use and misuse has accelerated rapidly in the United States over the past 2 decades. Orthopaedic surgeons are the third highest prescribers of opioids, and thus are contributing to this problem at a significant rate. Despite a surge in the number of publications on this issue, there has been little emphasis in the literature on disentangling the various factors contributing to opioid use and misuse among fracture patients. The goal of this study was to describe areas of focus and identify knowledge gaps present in the current literature on this important issue. METHODS: We employed a scoping review technique due to its ability to successfully address a broad research question. In order to better understand the type of information deemed relevant by opioid researchers, we further analyzed our search results by sorting the publications into the following categories: consumer-focused, provider-focused, focus on substitutes, industry-focused, and focus on regulations (at the institution, profession, and government level). RESULTS: The search strategies generated 8760 citations; of these, 1166 publications satisfied our inclusion criteria. Around 607 of these final abstracts were marked as "extremely relevant" (52%) and the other 559 (48%) were marked "relevant." About 36.4% of the total included articles applied to the providers and 19.6% provided information on the consumer. A total of 25.2% of the included papers concerned substitutes for opioids, 15.7% focused on regulatory power in the opioid industry, and 14% considered opioids as an industry, including power of both current stakeholders and potential new entrants. DISCUSSION: The present study provides a thorough summary of existing literature on opioid use and misuse relevant to musculoskeletal trauma patients. Furthermore, the categorical division of the literature provides a unique perspective into the drivers contributing to the opioid epidemic, and may assist in development of effective interventions to reduce excessive opioid use following traumatic injuries. Our review allowed us to identify important aspects of the opioid industry and various drivers of abuse that were absent from the literature including involvement of the pharmaceutical industry on the opioid epidemic, the involvement of insurance companies in opioid distribution, and the use of nonopioid alternative medications such as nonsteroidal anti-inflammatory drugs (NSAIDs).

Pdlim7 Regulates Arf6-Dependent Actin Dynamics and Is Required for Platelet-Mediated Thrombosis in Mice.

Upon vessel injury, platelets become activated and rapidly reorganize their actin cytoskeleton to adhere to the site of endothelial damage, triggering the formation of a fibrin-rich plug to prevent further blood loss. Inactivation of Pdlim7 provides the new perspective that regulation of actin cytoskeletal changes in platelets is dependent on the encoded PDZ-LIM protein. Loss-of-function of Pdlim7 triggers hypercoagulopathy and causes significant perinatal lethality in mice. Our in vivo and in vitro studies reveal that Pdlim7 is dynamically distributed along actin fibers, and lack of Pdlim7 leads to a marked inability to rearrange the actin cytoskeleton. Specifically, the absence of Pdlim7 prevents platelets from bundling actin fibers into a concentric ring that defines the round spread shape of activated platelets. Similarly, in mouse embryonic fibroblasts, loss of Pdlim7 abolishes the formation of stress fibers needed to adopt the typical elongated fibroblast shape. In addition to revealing a fundamental cell biological role in actin cytoskeletal organization, we also demonstrate a function of Pdlim7 in regulating the cycling between the GTP/GDP-bound states of Arf6. The small GTPase Arf6 is an essential factor required for actin dynamics, cytoskeletal rearrangements, and platelet activation. Consistent with our findings of significantly elevated initial F-actin ratios and subsequent morphological aberrations, loss of Pdlim7 causes a shift in balance towards an increased Arf6-GTP level in resting platelets. These findings identify a new Pdlim7-Arf6 axis controlling actin dynamics and implicate Pdlim7 as a primary endogenous regulator of platelet-dependent hemostasis.