The fate of active left-side infective endocarditis with operative indication in absence of valve surgery.

OBJECTIVES: Although the benefits of surgery in infective endocarditis (IE) are clear, an unneglectable proportion of patients do not undergo surgery despite clear operative indication. Outcomes of these patients are poorly reported. With this study, we aim to analyze patient profiles, indication for surgery, decision-making, and outcomes of patients not undergoing surgery despite contemporary surgical indications. MATERIALS AND METHODS: Retrospective review of single institution database of patients with IE was done to identify patients that, although a clear surgical indication did not receive surgery. We aimed to review the most contemporary practice from June 2014 to December 2018. Only patients who were physically evaluated at our facility were included. Follow up was 100% complete. Kaplan-Meier methods were used to estimate survival and freedom from a composite outcome of death, stroke, and heart failure. RESULTS: Of the 174 patients with surgical indication during the review period, 46 (27%) did not undergo surgery. The reasons for not pursuing surgery were varied and usually multiple, with severe brain injury and end stage liver disease between the most common. The 30-day mortality was 63%, and the estimated survival at 6 months, 1 year, and 2 years was respectively 22%, 15%, and 10%. CONCLUSION: The mortality of this cohort of patients is extremely high. A multidisciplinary evaluation is of paramount importance in the decision-making process with shared responsibility for denial of operative options. In a perspective of correct healthcare resources allocation an early palliative care consult may need to be considered in some of those patients.

"Doc, I'm Going for a Walk": Liberalizing or Restricting the Movement of Hospitalized Patients-Ethical, Legal, and Clinical Considerations.

When patients are admitted to the hospital, they are generally expected to remain in or within close proximity to their assigned rooms in order to promote their safety and appropriate medical care. Although there are circumstances when patients may safely leave their hospital room or floor, guidance within the medical literature for the management of patient movement within the hospital are lacking. Excessive restrictions on patient movement may be seen as overly paternalistic, while lax requirements may interfere with high quality care, patient safety and efficient hospital practice. As a result, guidance in the form of institutional policy is warranted. Such policy development should take into consideration the potential clinical, legal, and ethical concerns in balancing the competing values of patients' preferences and respect for autonomy, while ensuring high quality, safe, and efficacious medical care. This paper will provide a framework for hospitals to create institution-specific patient movement policies that are fair, systematic, and transparent.

Validation of an Algorithm to Identify Infective Endocarditis in People Who Inject Drugs.

INTRODUCTION: Infective endocarditis is associated with high morbidity and mortality. Currently, there is concern that the incidence of infective endocarditis associated with people who inject drugs (PWID) is increasing. However, it is difficult to monitor population-wide trends in PWID-associated infective endocarditis, as there is no International Statistical Classification of Diseases, 10th Revision (ICD-10) code for injection drug use. To address this barrier, we sought to develop a validated algorithm using ICD-10 discharge diagnosis codes. MATERIALS AND METHODS: We constructed a cohort of patients whose hospital discharge diagnosis included infective endocarditis. We reviewed 100 patients with incident infective endocarditis from 2014 to 2016 for their infective endocarditis and injection drug use status. We calculated the operating characteristics for algorithms constructed using permutations of ICD-10 codes associated with injection drug use. We repeated this analysis in a cohort of 100 patients with incident infective endocarditis from 2009 to 2011 to examine the temporal stability of the operating characteristics of each algorithm. RESULTS: We found that a combination of hepatitis C virus, drug use, and mental/behavioral disorder codes yielded the highest sensitivity (93%) and positive predictive value (83%) of the algorithms analyzed. DISCUSSION: We have described the first algorithm, validated against chart review data, for identifying PWID-associated infective endocarditis cases using ICD-10 codes. The high sensitivity and positive predictive value indicate that this algorithm can be used for surveillance and research with confidence. CONCLUSIONS: This algorithm will enable researchers to examine epidemiological trends in PWID-associated infective endocarditis.

Validity, reliability and responsiveness of the Body Image Quality of Life Inventory in patients treated for infective endocarditis.

RATIONALE AND OBJECTIVES: Suffering through infective endocarditis (IE) can drastically alter a person's physical appearance, and body image-related concerns have been reported by patients. The extent and severity of the phenomenon has not previously been explored, as no quantitative measure has been validated in this patient population. The purpose of this study was thus to assess the validity, reliability and responsiveness of the Danish Body Image Quality of Life Inventory (BIQLI-DA) on patients treated for IE. METHODS: We evaluated the psychometric properties of the BIQLI-DA on data obtained in the CopenHeart IE trial, which is a randomised clinical trial evaluating the effects of comprehensive cardiac rehabilitation for patients treated for IE. We administered the BIQLI-DA as part of data collection at baseline and 6 months. We examined the psychometric properties through correlations to other measures, including body mass index, Medical Outcome Short Form 36 and Hospital Anxiety and Depression Scale. In addition, we examined internal consistency on item and scale level and performed anova group-by-time interaction to test for responsiveness. RESULTS AND STUDY LIMITATION: Participants were seventy patients with a mean age of 58 years and of which 83% were men. Results indicated convergent construct validity by confirming hypothesised associations to potentially related constructs. The BIQLI-DA was found to be highly internally consistent with a Cronbach's alpha of 0.96. Instrument responsiveness was indicated by a significant group-by-time interaction. Support for the validity of the BIQLI-DA might have been strengthened by a larger sample with more women. A more optimal design for testing responsiveness would possibly have allowed for clearer conclusions. CONCLUSIONS: The BIQLI-DA may be applicable in healthcare research as it seems to be valid, reliable and responsive; however, evidence should be strengthened through further exploration of instrument performance, particularly regarding responsiveness.

Medication-assisted treatment for hospitalized patients with intravenous-drug-use related infective endocarditis.

BACKGROUND AND OBJECTIVES: A feared complication of opioid use disorder (OUD) is intravenous drug use related infective endocarditis (IDU-IE). We report on our experience engaging hospitalized IDU-IE patients to initiate medication-assisted treatment (MAT). METHODS: A retrospective study (n = 29) using descriptive statistics. RESULTS: Overall, 9 (31.0%) successfully initiated buprenorphine maintenance during the hospitalization, and 9 (31.0%) accepted a referral to methadone maintenance following discharge. Eleven (37.9%) declined MAT altogether. DISCUSSION AND CONCLUSIONS: Hospitalizations may represent an important opportunity to engage IDU-IE patients to initiate MAT. SCIENTIFIC SIGNIFICANCE: The study provides preliminary support of engaging hospitalized IDU-IE patients to initiate MAT.

Insufficient living: experiences of recovery after infective endocarditis.

BACKGROUND: Infective endocarditis (IE) is a traumatic health event, and recovery is often associated with massive physical deconditioning and reduced quality of life. Patients also report reduced cognitive functioning and are at risk of developing anxiety and depression as well as posttraumatic stress disorder. Although studies have found that survivors of IE have impaired physical functioning and mental health, little is known about patient experiences contributing to these findings. OBJECTIVE: The aim of this study was to describe patient experiences of recovery after IE. SUBJECTS AND METHODS: Within a phenomenological-hermeneutical framework, a qualitative interview study was conducted that included 6 men and 5 women (aged 29-86 years). Patients were interviewed 3 to 6 months after discharge. Analysis consisted of 3 levels: naive reading, structured analysis, and critical interpretation and discussion. FINDINGS: The overall concept that emerged was "Insufficient Living." Patients all experienced a life after illness, which was perceived as insufficient. The overall concept can be interpreted in terms of the following 3 themes. The first was "an altered life," where participants described a phase of adaptation to a new life situation, which some perceived as manageable and temporary, whereas others found extremely distressing and prolonged. "Shocking weakness" was experienced physically, cognitively, and emotionally, and although it subsided quickly for a few, most experienced a persisting weakness and felt frustrated about the prolonged recovery phase. In "the road to recovery," support from relatives and healthcare professionals, as well as one's own actions, was emphasized as important in facilitating recovery. CONCLUSIONS: Recovery after IE is perceived as "Insufficient Living." Patients experience an altered life and shocking weakness, and on the road to recovery, support is needed. Research in follow-up care, supporting patients' ability to cope with potential physical and psycho-emotional consequences of IE, is encouraged as a result of these findings.

Treating the disease and meeting the person with the illness-patient perspectives of needs during infective endocarditis, a qualitative study.

BACKGROUND: Infective endocarditis (IE) is a rare but severe infectious disease. Patients with IE are treated for weeks in the hospital and have profound impairments to their health. New treatment modalities increase options for outpatient care. Little is known about how patients perceive their disease and hospitalisation. We aimed to explore the needs of patients with IE during hospitalisation and the first few months after discharge. METHODS: In this qualitative study, 20 patients (45-86 years of age) hospitalised due to IE in Swedish hospitals were interviewed a median of 112 (67-221) days after hospitalisation. Data were analysed with qualitative content analysis, identifying eight subcategories, two categories, and an overall theme. RESULTS: The overall theme illuminated a spectrum of needs of patients suffering from IE, between treating the disease and meeting the person with the illness. The needs encompassed eight axes with dual focus on both medical excellence and person-centred care. Medical excellence was needed to optimally treat, supervise, and offer follow-up on this rare and severe disease; patients longed to come home, and there were issues of reliability in the healthcare system. Person-centred care was requested, including individualised information leading to knowledge, reorientation, the beginning of health restoration, and being met as a unique person. Symptoms of fatigue, wasting, and cognitive and mental distress were often neglected by the caregiver. CONCLUSIONS: This explorative study shows the patient's needs as important areas in a spectrum between medical excellence and person-centred care. Care in specialised units secure quality. Early discharge is requested by patients. Multiprofessional individualizing outpatient care needs to develop with preserved safety and medical excellence. The disease trajectory after discharge progresses slowly, and the possibility of mitigating its progress is still unclear. Person-centred care, screening for delayed restoration and rehabilitation after endocarditis are important fields for future studies.

High readmission rates and mental distress after infective endocarditis - Results from the national population-based CopenHeart IE survey.

BACKGROUND: Infective endocarditis (IE) is a severe disease requiring lengthy hospitalisation. Little is known about patients' recovery after IE. The aims of this study in IE patients were; (i) to describe mortality, readmission, self-reported health and rehabilitation up to 1year post-discharge, (ii) to examine associations between self-reported health and readmission, and (iii) to investigate predictors of readmission and mortality. METHODS: All adults treated for IE in Denmark, January-June 2011 (N=347), were followed in registers. Eligible individuals (n=209) were invited to participate in a questionnaire survey (responders n=122). Responses were compared with those of a background reference population and a heart valve surgery population. Mortality and readmission data from registers 12months post-discharge were investigated. RESULTS: Patients discharged after treatment for IE had a mortality of 18% (95% confidence interval (CI): 14%-23%) one year post-discharge and 65% (95% CI: 59%-71%) had been readmitted, the majority (82%) acutely. Patients had lower self-reported health compared to the background population (physical component scale (PCS); mean (standard deviation (SD)): 42.2 (11.1) vs. 47.1 (12.1), (p=0.0004), mental component scale (MCS); 50.1 (11.7) vs. 53.8 (9.2), (p=0.006), and more were sedentary (29 vs. 15%), (p=0.002). Large proportions had clinical signs of anxiety and depression, 25% and 22% respectively, exceeding a hospital anxiety and depression scale (HADS) cut-off score of 8. Almost half (47%) had not been offered cardiac rehabilitation (CR). CONCLUSIONS: After IE, mortality and readmission rates were high and self-reported physical and mental health poor. These findings call for changes in in-hospital and post-discharge management.

[A case of mycotic endocarditis. Clinical, diagnostic and therapeutic considerations]. / Su di un caso di endocardite micotica. Considerazioni cliniche, diagnostiche e terapeutiche.

A case of endocarditis in 17 year old female with a psychomotor and neurovegetative disorder is presented. Serum and cultural data as well as the excellent response to treatment with 5-flucytosine seems to confirm the diagnosis of candida infection.

Clinician as patient: the gift of illness.

Most individuals have been touched by illness or have experienced illness themselves. This commentary illustrates how, as a clinician, my own life-threatening illness has informed the way I work within integrated care and general health care practice.

Patients perspective on endocarditis--an intermezzo in life.

BACKGROUND: Infective endocaditis (IE) is a life threatening disease with a mortality rate of 20-25%. There have been no previous reports, which describe the experience of health of patients suffering from IE. AIM: This study aimed to describe patients with IE's experience of health. This was done by having patients describe their experiences both before and during hospital admission, their experience of their physical symptoms, and their expectations for future health. METHODS: Qualitative interviews were conducted with 10 patients with IE (age 27-75) and transcribed. The analysis consisted of three levels. RESULTS: The overall concept that emerged was that IE is perceived as an intermezzo in life. The interviewees explain that a sudden unexpected physical change occurs that is difficult to understand and interpret. The concept "intermezzo in life" can be expounded as the following themes: Presage and appearance of IE, Reaction to IE, Living through IE, The little life with IE, Body change and Loved ones at a distance. CONCLUSION: IE is found to be a time of uncertainty and impenetrableness, where many things change, not least the perception of the body and self.

Survival and quality of life after aortic root replacement with homografts in acute endocarditis.

BACKGROUND: Treatment of prosthetic aortic valve endocarditis and native aortic valve endocarditis with abscess formation is associated with high mortality and morbidity. Aortic root replacement with a freestanding aortic homograft is an attractive alternative. We report outcome and quality of life after homograft replacement for infective endocarditis. METHODS: Sixty-two patients with infective prosthetic valve endocarditis (n = 31) or native valve endocarditis with abscess (n = 31), operated with homograft replacement were included. Thirty-day mortality, severe operative complications (dialysis, stroke, pacemaker implantation, myocardial infarction, and prolonged mechanical ventilation), midterm survival, reoperations, and quality of life were assessed after a mean follow-up of 37 ± 11 months. RESULTS: Nine patients (15%) died within 30 days and 22 patients (35%) had severe perioperative complications. Preoperative and perioperative variables univariately associated with early mortality were higher (Cleveland Clinic risk score [p = 0.014], extracorporeal circulation time [p = 0.003], prolonged inotropic support [p = 0.03], reoperation for bleeding [p = 0.01], and perioperative myocardial infarction [p < 0.001].) Cumulative survival was 82%, 78%, 75%, and 67% at one, three, five, and ten years, respectively. One patient was reoperated due to recurrence of endocarditis nine months after surgery and one after five years due to homograft failure. Quality of life, as assessed by the 36 item short-form health survey scales for physical and mental health, was not significantly different to an age-matched and gender-matched healthy control group. CONCLUSIONS: Severe acute aortic endocarditis treated with homograft replacement is still associated with a substantial early complication rate and mortality. Long-term survival and quality of life are satisfactory in patients surviving the immediate postoperative period.