Association between digoxin use and gastrointestinal bleeding in contemporary continuous flow left ventricular assist device support.

BACKGROUND: Assess the association between digoxin use and gastrointestinal bleeding (GIB) in a multicenter continuous flow left ventricular assist device (LVAD) cohort. METHODS: Patients implanted with continuous flow LVADs with data on GIB and digoxin use from two centers were included in the analysis (n = 649). GIB events were captured up to 2 years of follow-up. Digoxin use was defined as digoxin prescribed at discharge or within the first 3 months after LVAD implantation. A negative binomial regression model was performed to determine the association between digoxin use and number of GIB events over the follow-up period. RESULTS: Mean age of the cohort was 57 years (±14) and 45% (293/649) were bridge to transplant (BTT). Digoxin was prescribed in 33% of patients. Digoxin use was associated with an unadjusted 32% reduction in the incidence of rate of all cause GIB (IRR 0.68, 95% CI 0.46-0.99, p = 0.049). After adjusting for age, sex, Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile, renal function, and implanting center there was still a 34% reduction in the incidence rate (IRR 0.67, 95% CI 0.45-0.99, p = 0.048). When limiting the analysis to those with likely arteriovenous malformation associated GIB, the association strengthened (unadjusted: IRR 0.48, 95 % CI 0.26-0.89, p = 0.02, adjusted: IRR 0.47, 95 % CI 0.25-0.9, p = 0.022). CONCLUSIONS: In this multicenter study, inclusive of contemporary devices, digoxin use was associated with reduced GIB events. Prospective data will be required to confirm this association.

Variable Significance of Brain MRI Findings in Infective Endocarditis and Its Effect on Surgical Decisions.

OBJECTIVE: To determine how brain magnetic resonance imaging (MRI) findings impact clinical outcomes in patients with infective endocarditis (IE) and to propose a management algorithm for patients with neurologic symptoms who are candidates for valve surgery (VS). PATIENTS AND METHODS: Data from our center were retrospectively reviewed for patients hospitalized with IE between January 1, 2007, and December 31, 2014. Outcomes were postoperative intracerebral hemorrhage (ICH), 6-month mortality, and functional outcome at last follow-up as described by the modified Rankin Scale (mRS) score. Good outcome was defined as an mRS score of 2 or less. RESULTS: A total of 361 patients with IE were identified, including 127 patients (35%) who had MRI. One hundred twenty-six of 361 patients (35%) had neurologic symptoms, which prompted MRI in 79 of 127 patients (62%); 74 of 79 (94%) had acute or subacute MRI abnormalities. One patient with subarachnoid and multifocal ICH on MRI developed postoperative ICH. Patients with VS despite MRI abnormalities had lower 6-month mortality (odds ratio [OR], 0.17; 95% CI, 0.06-0.48; P<.001) and better functional outcome (OR, 4.43; 95% CI, 1.51-13.00; P=.005). Irrespective of VS, lobar or posterior fossa ICH on MRI was associated with 6-month mortality (OR, 3.58; 95% CI, 1.22-10.50; P=.02) and territorial ischemic stroke was inversely associated with good mRS (OR, 0.29; 95% CI, 0.13-0.66; P=.002). In neurologically asymptomatic patients who had VS, MRI findings did not impact 6-month mortality or functional outcomes. CONCLUSION: Magnetic resonance imaging detects a large number of abnormalities in patients with IE. Preoperative lobar hematoma and large territorial stroke determine outcome irrespective of VS. When indicated, VS increases the odds of a good outcome despite MRI abnormalities.

Comparison of Dual ß-Lactam therapy to penicillin-aminoglycoside combination in treatment of Enterococcus faecalis infective endocarditis.

BACKGROUND: Dual ß-lactam therapy and a penicillin-aminoglycoside combination are first line regimens in the treatment of penicillin-susceptible Enterococcus faecalis infective endocarditis (EFIE). Our aim was to compare ampicillin plus ceftriaxone (A+C) to ampicillin plus gentamicin (A+G) in the treatment of EFIE. METHODS: This was a retrospective cohort study of adults (≥18 years) patients diagnosed with EFIE at Mayo Clinic campuses in Rochester, Minnesota, and Phoenix, Arizona and treated with either A+C or A+G. Main outcome measurements were 1 year mortality, nephrotoxicity, and EFIE relapse rates. RESULTS: Eighty-five cases of EFIE were included in this investigation. The majority (n=67, 79%) of patients received A+G while 18 (21%) patients received A+C as initial treatment. On admission, patients who received A+C had a higher Charlson Comorbidity Index (median [IQR], 4 [3, 4 vs. 2 [1, 4]; P=.008) and a higher baseline serum creatinine (median [IQR], 1.2 [0.9, 1.6] vs. 0.9 [0.8, 1.2] mg/dL, P=.020). The 1 year mortality rates were similar for both treatment groups, 17% vs. 17%, P=.982. Each group had 1 case of relapsing EFIE. Patients who received A+G had worse kidney function outcome demonstrated by a greater increase in serum creatinine at end of therapy (median [IQR] difference, +0.4 [0.2, 0.8] vs. -0.2 [-0.3, 0.1] mg/dL, P≤.001). CONCLUSION: A+C appears to be a safe and efficacious regimen in the treatment of EFIE. Patients treated with A+C had lower rates of nephrotoxicity and no differences in relapse rate and 1-year mortality as compared to that of the A+G group.

Utility of Brain Magnetic Resonance Imaging in the Surgical Management of Infective Endocarditis.

BACKGROUND: Brain magnetic resonance imaging (MRI) is frequently obtained in patients with infective endocarditis, yet its utility in predicting outcomes for valve replacement surgery in patients is unknown. The objective of this study was to determine how brain MRI findings impact clinical management and outcomes. METHODS: Demographic and clinical data from electronic medical records at Mayo Clinic were retrospectively reviewed for patients hospitalized with definite or possible infective endocarditis according to the modified Duke criteria between January 1, 2007 and December 31, 2014. There were 364 patients included in the study. RESULTS: Cardiac valve replacement surgery was performed in 195 of 364 (53.6%) patients, and 95 (48.7%) of the surgical patients underwent preoperative MRI, which was associated with preoperative neurologic symptoms in 56 of 95 (58.9%) patients (odds ratio = 12.92; 95% confidence interval, 5.98-27.93; P <.001). Postoperative neurologic complications occurred in 24 of 195 (12.3%) patients, including new ischemic stroke in 4 of 195 (2.1%) and new intracerebral hemorrhage in 3 of 195 (1.5%). No patients with microhemorrhages developed postoperative hemorrhage. No significant differences existed in rates of postoperative complications between patients with and those without preoperative MRI. There were no substantial associations between preoperative MRI findings and postoperative neurologic complications, functional outcomes as described by the modified Rankin Scale score, or 6-month mortality. CONCLUSIONS: In patients undergoing valve replacement surgery, preoperative MRI findings were not associated with differences in postoperative outcomes, irrespective of finding or timing of valve replacement surgery.

Effect of the American Heart Association 2007 Guidelines on the Practice of Dental Prophylaxis for the Prevention of Infective Endocarditis in Olmsted County, Minnesota.

OBJECTIVE: To determine the adherence of dental providers to the 2007 American Heart Association (AHA) infective endocarditis prevention guidelines regarding antibiotic drug administration before invasive dental procedures. PATIENTS AND METHODS: The study included all adults (≥18 years old) with a moderate-risk (MR) or high-risk (HR) cardiac condition who received dental care at participating dental offices from January 1, 2005, through June 1, 2015, in Olmsted County, Minnesota. Data collected included the date and type of dental procedure performed and receipt of antibiotic prophylaxis (AP). RESULTS: A total of 1351 patients underwent 8854 dental visits at participating dental offices during the study period; 1236 patients had an MR cardiac condition and 115 had an HR condition. The percentage of visits in which antibiotic drugs were used for indicated dental procedures in the MR group declined from 64.6% before to 8.6% after publication of the 2007 AHA guidelines (P<.001); for the HR group, AP declined from 96.9% before to 81.3% after publication of the guidelines (P=.02). CONCLUSION: In this historical cohort in Olmsted County there was a statistically significant reduction in AP in the MR group before invasive dental procedures. In addition, there was an unanticipated significant reduction in AP in the HR group after publication of the 2007 AHA guidelines. These findings can be used to provide feedback and education to medical and dental professionals who are involved in decision making regarding the use of dental prophylaxis for their patients.

Efficacy of Antitoxin Therapy in Treating Patients With Foodborne Botulism: A Systematic Review and Meta-analysis of Cases, 1923-2016.

Background: Botulism is a rare, potentially severe illness, often fatal if not appropriately treated. Data on treatment are sparse. We systematically evaluated the literature on botulinum antitoxin and other treatments. Methods: We conducted a systematic literature review of published articles in PubMed via Medline, Web of Science, Embase, Ovid, and Cumulative Index to Nursing and Allied Health Literature, and included all studies that reported on the clinical course and treatment for foodborne botulism. Articles were reviewed by 2 independent reviewers and independently abstracted for treatment type and toxin exposure. We conducted a meta-analysis on the effect of timing of antitoxin administration, antitoxin type, and toxin exposure type. Results: We identified 235 articles that met the inclusion criteria, published between 1923 and 2016. Study quality was variable. Few (27%) case series reported sufficient data for inclusion in meta-analysis. Reduced mortality was associated with any antitoxin treatment (odds ratio [OR], 0.16; 95% confidence interval [CI], .09-.30) and antitoxin treatment within 48 hours of illness onset (OR, 0.12; 95% CI, .03-.41). Data did not allow assessment of critical care impact, including ventilator support, on survival. Therapeutic agents other than antitoxin offered no clear benefit. Patient characteristics did not predict poor outcomes. We did not identify an interval beyond which antitoxin was not beneficial. Conclusions: Published studies on botulism treatment are relatively sparse and of low quality. Timely administration of antitoxin reduces mortality; despite appropriate treatment with antitoxin, some patients suffer respiratory failure. Prompt antitoxin administration and meticulous intensive care are essential for optimal outcome.

Cardiovascular Implantable Electronic Device Infections due to Propionibacterium Species.

INTRODUCTION: Propionibacterium species are part of the normal skin flora and often considered contaminants when identified in cultures. However, they can cause life-threatening infections, including prosthetic cardiovascular device infections. Clinical presentation and management of cardiovascular implantable electronic device (CIED) infection due to Propionibacterium species has not been well described. METHODS: Retrospective review of all cases of CIED infection due to Propionibacterium species admitted to Mayo Clinic between January 1, 1990 and December 31, 2014. Patient charts were reviewed for clinical, microbiological, and imaging data. Descriptive analysis was performed. RESULTS: We identified 14 patients with CIED infection due to Propionibacterium species, accounting for 2.3% of all CIED infections. Patients were predominantly male (n = 12, 86%). The median age at admission was 58.5 years (range 22-83). Twelve patients had implantable cardioverter defibrillators (ICDs) and two had permanent pacemaker systems. Twelve patients had generator pocket infection (86%). Two patients met clinical criteria for CIED-related infective endocarditis. Median time between last device manipulation and infection was 9 months (range 1-98). All patients were treated with complete device removal and antibiotic therapy. Six-month follow-up data were available for 10 patients (71%), with no relapses documented. CONCLUSION: CIED infections due to Propionibacterium species accounted for 2.3% of all device infections over a 25-year period. The most common infectious syndrome was generator pocket infection with delayed onset. There was an unanticipated predominance of ICDs in this cohort. Cure was achieved in all cases with complete device removal and antibiotic therapy.

Beta-haemolytic streptococcal endocarditis: clinical presentation, management and outcomes.

BACKGROUND: Beta-haemolytic streptococcal (BHS) endocarditis is rare, but well-recognised for its high morbidity and mortality. This study sought to further characterise clinical features, management and outcomes of BHS endocarditis. METHODS: Retrospective review of all adultpatients (≥ 18 years old) with BHS endocarditis treated at the Mayo Clinic from 1 January 2000 to 31 December 2014. RESULTS: Forty-nine cases of BHS endocarditis were identified with a mean (± SD) age of 64 (± 14.9) years and 65% were males. The infection was community acquired in 92% of the cases, with a median (IQR) time to diagnosis from symptom onset of 6 days (5-10). Associated conditions included the presence of a prosthetic valve (41%), malignancy (33%) and diabetes mellitus (DM) (31%). Median (IQR) vegetation size was 12 mm (9-17 mm). In a univariate analysis patients with DM had larger vegetations, median (IQR) = 17 mm (10.5-26 mm) compared to non-diabetic patients, median (IQR) = 11 mm (8-15 mm) (p = 0.01). Septic brain emboli occurred in 43% of cases. Eighteen patients (37%) underwent early (within 30 days) surgery. All-cause 1 month and 6 month mortality rates were 25% and 31%, respectively. CONCLUSION: BHS endocarditis has an acute onset and is complicated by relatively large vegetations with a high rate of systemic embolisation. DM was the second most common associated medical condition and patients with DM had larger vegetations. Despite medical and surgical advances, mortality due to BHS endocarditis remains high, particularly within 30 days of diagnosis.