Fungal Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management.

Fungal endocarditis accounts for 1% to 3% of all infective endocarditis cases, is associated with high morbidity and mortality (>70%), and presents numerous challenges during clinical care. Candida spp. are the most common causes of fungal endocarditis, implicated in over 50% of cases, followed by Aspergillus and Histoplasma spp. Important risk factors for fungal endocarditis include prosthetic valves, prior heart surgery, and injection drug use. The signs and symptoms of fungal endocarditis are nonspecific, and a high degree of clinical suspicion coupled with the judicious use of diagnostic tests is required for diagnosis. In addition to microbiological diagnostics (e.g., blood culture for Candida spp. or galactomannan testing and PCR for Aspergillus spp.), echocardiography remains critical for evaluation of potential infective endocarditis, although radionuclide imaging modalities such as 18F-fluorodeoxyglucose positron emission tomography/computed tomography are increasingly being used. A multimodal treatment approach is necessary: surgery is usually required and should be accompanied by long-term systemic antifungal therapy, such as echinocandin therapy for Candida endocarditis or voriconazole therapy for Aspergillus endocarditis.

Extended Center for Vein Restoration study assessing comparative outcomes for the treatment of chronic venous insufficiency in Medicare- and non-Medicare-eligible patients.

BACKGROUND: We previously reported that chronic venous insufficiency treatment of Medicare-eligible patients achieved outcomes similar to those for non-Medicare-eligible patients. The goal of the present investigation was to assess the long-term treatment outcomes and the effect of race in a larger patient cohort. METHODS: From January 2015 to December 2019, we retrospectively reviewed the data from 131,268 patients who had presented for a lower extremity venous evaluation. We divided the patients into two groups by age: group A was aged ≥65 years and group B, <65 years. The treatments analyzed in each group were axial thermal ablation (TA), axial Varithena ablation (VA), TA plus phlebectomy, VA plus phlebectomy, and TA or VA with phlebectomy and ultrasound-guided foam sclerotherapy (UGFS). The treatment outcomes were assessed using the revised venous clinical severity score (rVCSS) and Chronic Venous Insufficiency Quality of Life 20-item questionnaire (CIVIQ-20) scores at the initial consultation and 1, 6, and 12 months after completion of the treatment plan. RESULTS: Of the 131,268 patients, 40,020 were in group A and 91,248 in group B, with an average age of 74.4 ± 6.6 and 49.9 ± 10.6 years, respectively. Of the 40,020 patients in group A, 15,697 (n = 25,234 limbs) had undergone TA and 1910 (n = 3222 limbs) had undergone VA. Of the 91,248 patients in group B, 35,220 (n = 53,717 limbs) had undergone TA and 2178 (n = 3672 limbs) had undergone VA. For the TA subgroups, all rVCSSs had significantly improved after treatment at each evaluation point (P ≤ .001). For the TA and VA plus phlebectomy with or without UGFS subgroup, the older patients (group A) required 6 months to develop the same degree of improvement as the younger patients (group B) at 1 month. When subdivided by race, all initial and 6-month rVCSSs and CIVIQ-20 scores within a race had improved and were better in group B, except for Asian and Hispanic patients (P ≤ .001). After TA or VA plus phlebectomy, with or without UGFS, the CIVIQ-20 outcomes had improved by 1 month in both groups, although the rVCSS lagged by 6 months in group A. No differences in the rVCSSs or CIVIQ-20 scores were observed between the groups treated with TA or VA. CONCLUSIONS: Medicare-eligible beneficiaries demonstrated improved outcomes similar to those of non-Medicare-eligible beneficiaries after ablation. When TA or VA plus phlebectomy with or without UGFS were examined, group A required 6 months to demonstrate rVCSSs equivalent to those of group B at 1 month. The CIVIQ-20 scores had improved by 1 month in both groups, regardless of the treatment modality. The difference in rVCSSs appeared to be driven by African American and white patients because Hispanic and Asian patients demonstrated equivalent results regardless of age. Patients treated with TA or VA demonstrated equivalent results.

Evaluating patient preferences for thermal ablation versus nonthermal, nontumescent varicose vein treatments.

OBJECTIVE: To measure patient preferences for attributes associated with thermal ablation and nonthermal, nontumescent varicose vein treatments. METHODS: Data were collected from an electronic patient preference survey taken by 70 adult participants (aged 20 years or older) at three Center for Vein Restoration clinics in New Jersey from July 19, 2019, through August 13, 2019. Survey participation was voluntary and anonymous (participation rate of 80.5% [70/87]). Patients were shown 10 consecutive screens that displayed three hypothetical treatment scenarios with different combinations of six attributes of interest and a none option. Choice-based conjoint analysis estimated the relative importance of different aspects of care, trade-offs between these aspects, and total satisfaction that respondents derived from different healthcare procedures. Market simulation analysis compared clusters of attributes mimicking thermal ablation and nonthermal, nontumescent treatments. RESULTS: Of the six attributes studied, out-of-pocket (OOP) expenditures were the most important to patients (37.2%), followed by postoperative discomfort (17.1%), risk of adverse events (16.3%), time to return to normal activity (11.0%), number of injections (10.0%), and number of visits (8.4%). Patients were willing to pay the most to avoid postoperative discomfort ($68.9) and risk of adverse events ($65.8). The market simulation analysis found that, regardless of the level of OOP spending, 60% to 80% of respondents favored attribute combinations corresponding with nonthermal, nontumescent procedures over thermal ablation, and that less than 1% of participants would forgo either treatment under no cost sharing. CONCLUSIONS: Patients are highly sensitive to OOP costs for minimally invasive varicose vein treatments. Market simulation analysis favored nonthermal, nontumescent procedures over thermal ablation.

Core Recommendations for Antifungal Stewardship: A Statement of the Mycoses Study Group Education and Research Consortium.

In recent years, the global public health community has increasingly recognized the importance of antimicrobial stewardship (AMS) in the fight to improve outcomes, decrease costs, and curb increases in antimicrobial resistance around the world. However, the subject of antifungal stewardship (AFS) has received less attention. While the principles of AMS guidelines likely apply to stewarding of antifungal agents, there are additional considerations unique to AFS and the complex field of fungal infections that require specific recommendations. In this article, we review the literature on AMS best practices and discuss AFS through the lens of the global core elements of AMS. We offer recommendations for best practices in AFS based on a synthesis of this evidence by an interdisciplinary expert panel of members of the Mycoses Study Group Education and Research Consortium. We also discuss research directions in this rapidly evolving field. AFS is an emerging and important component of AMS, yet requires special considerations in certain areas such as expertise, education, interventions to optimize utilization, therapeutic drug monitoring, and data analysis and reporting.

Racial disparities in the outcomes of superficial vein treatments for chronic venous insufficiency.

BACKGROUND: Chronic venous disease (CVD) affects >20 million people in the United States. Despite this huge prevalence, there are few data on whether the effectiveness of current CVD therapies for symptomatic superficial vein reflux is affected by race. The goal of this investigation was to evaluate CVD treatment outcomes in various races in the United States. METHODS: From January 2015 to December 2017, we retrospectively reviewed and prospectively collected data from 66,621 patients who presented for CVD evaluation. We divided patients into five racial groups: African American, Asian, Hispanic, other (race not recorded), and white. Presenting signs and symptoms, treatment modalities, number of procedures per patient, and preintervention and postintervention revised Venous Clinical Severity Scores (rVCSSs) were evaluated. All racial groups were stratified by Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class for subgroup analysis. RESULTS: The average age of the entire cohort was 56.8 ± 14.7 years, with 51,393 women (77%) and 15,228 men (23%). Prevalence by race was 17% African American, 3% Asian, 18% Hispanic, 8% others, and 55% white. There was a higher incidence of C0 disease in whites (44%) and African Americans (31%); C1 and C2 disease in whites (46% and 55%) and Hispanics (28% and 25%); and C3, C4, C5, and C6 disease in whites (60%, 57%, 58%, and 61%) and African Americans (19%, 17%, 19%, and 21%). Pain as an initial presenting symptom was more common in African Americans, Asians, and Hispanics (29%, 29%, and 31%). Swelling was highest in African Americans (18%) and cramping in Hispanics (14%). Skin changes and venous ulcers were most common in African Americans (16% and 21%) and whites (63% and 61%). With regard to the average number of procedures performed, Hispanics (1.98 ± 1.24) and others (2.07 ± 1.25) required fewer stand-alone ablations compared with whites (2.31 ± 1.56), Asians (2.36 ± 1.58), and African Americans (2.27 ± 1.56; P ≤ .0001. With the addition of phlebectomies to ablations, Hispanics (3.78 ± 2.08) continued to require fewer procedures, and Asians required the greatest number of phlebectomies compared with all groups (P ≤ .001). When ultrasound-guided foam sclerotherapy was added to ablation and phlebectomy, African Americans required more procedures compared with all races (4.38 ± 2.59; P ≤ .01). For stand-alone ablations, Hispanics (2.18 ± 2.34) and Asians (1.91 ± 2.35) demonstrated lower postprocedure rVCSSs compared with African Americans (2.79 ± 2.88) and whites (2.8 ± 2.85; P ≤ .0001). For ablations with phlebectomies, all races demonstrated similar results except for Hispanics (2.19 ± 2.14), who did better than whites (2.85 ± 2.75; P ≤ .002). For ablations with phlebectomies and ultrasound-guided foam sclerotherapy, all races had similar results (P ≤ .0001). CONCLUSIONS: In the United States, CVD is primarily observed in white women. There are differences in the incidence and prevalence of disease severity and symptom presentation based on race. The incidence of CVD decreases with age in all racial groups except whites. Hispanics required the fewest procedures and African Americans required the most for optimal results. Postintervention rVCSSs equalized in all races when ablations were combined with phlebectomies and ultrasound-guided foam sclerotherapy.

Improvement of gram-negative susceptibility to fluoroquinolones after implementation of a pre-authorization policy for fluoroquinolone use: A decade-long experience.

OBJECTIVE: Due to concerns over increasing fluoroquinolone (FQ) resistance among gram-negative organisms, our stewardship program implemented a preauthorization use policy. The goal of this study was to assess the relationship between hospital FQ use and antibiotic resistance. DESIGN: Retrospective cohort. SETTING: Large academic medical center. METHODS: We performed a retrospective analysis of FQ susceptibility of hospital isolates for 5 common gram-negative bacteria: Acinetobacter spp., Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Primary endpoint was the change of FQ susceptibility. A Poisson regression model was used to calculate the rate of change between the preintervention period (1998-2005) and the postimplementation period (2006-2016). RESULTS: Large rates of decline of FQ susceptibility began in 1998, particularly among P. aeruginosa, Acinetobacter spp., and E. cloacae. Our FQ restriction policy improved FQ use from 173 days of therapy (DOT) per 1,000 patient days to <60 DOT per 1,000 patient days. Fluoroquinolone susceptibility increased for Acinetobacter spp. (rate ratio [RR], 1.038; 95% confidence interval [CI], 1.005-1.072), E. cloacae (RR, 1.028; 95% CI, 1.013-1.044), and P. aeruginosa (RR, 1.013; 95% CI, 1.006-1.020). No significant change in susceptibility was detected for K. pneumoniae (RR, 1.002; 95% CI, 0.996-1.008), and the susceptibility for E. coli continued to decline, although the decline was not as steep (RR, 0.981; 95% CI, 0.975-0.987). CONCLUSIONS: A stewardship-driven FQ restriction program stopped overall declining FQ susceptibility rates for all species except E. coli. For 3 species (ie, Acinetobacter spp, E. cloacae, and P. aeruginosa), susceptibility rates improved after implementation, and this improvement has been sustained over a 10-year period.

The Center for Vein Restoration Study on presenting symptoms, treatment modalities, and outcomes in Medicare-eligible patients with chronic venous disorders.

BACKGROUND: Chronic venous disorders (CVDs) have been estimated to affect up to 20 million Americans. Despite this huge prevalence, the signs, symptoms, and treatment outcomes in patients 65 years of age and older are not well defined. Our goal was to determine the presentation and treatment outcomes in elderly patients compared with a cohort of patients younger than 65 years. METHODS: From January 2015 to December 2016, we retrospectively reviewed prospectively collected data from 38,750 patients with CVD from the Center for Vein Restoration's electronic medical record (NextGen Healthcare Information Systems, Irvine, Calif). We divided patients into two groups; group A patients were younger than 65 years, and group B patients were 65 years of age or older. Medical and surgical history, presenting symptoms, treatment modalities, and revised Venous Clinical Severity Score before and after intervention were evaluated. A multivariate logistic regression analysis was performed to determine the predictive value of presenting and associated symptoms. Groups A and B were subdivided by Clinical, Etiology, Anatomy, and Pathophysiology class for subgroup analysis. Data were analyzed with GraphPad Prism (GraphPad Software Inc, La Jolla, Calif) or SAS version 9.4 statistical software package (SAS Institute, Cary, NC). RESULTS: There were 27,536 patients in group A and 11,214 in group B. Women constituted 78% of all patients. Group B demonstrated a higher incidence of chronic diseases compared with group A (P ≤ .003). As initial presenting symptoms, pain, heaviness, fatigue, and aching were more common in group A than in group B (61% vs 55%, 30% vs 27%, 27% vs 24%, and 17% vs 12%, respectively; P ≤ .001). Swelling, skin discoloration, and venous ulceration were more common in group B than in group A (29% vs 23%, 12% vs 6%, and 5% vs 2%; P ≤ .001). Ablations were more commonly performed in group B patients with C4 to C6 disease (P ≤ .004). The revised Venous Clinical Severity Scores before and 1 month after intervention were similar between groups. Treatment improvement was statistically significant in both groups (P ≤ .001). Multivariate logistic regression analysis indicated that varices, bleeding, swelling, skin changes, venous ulceration, aching, heaviness, pain, fatigue, cramping, and restless legs were associated with the presence of CVD (P ≤ .001). CONCLUSIONS: Medicare beneficiaries presented with more chronic diseases and more severe disease. Initial and associated symptoms were highly associated with the presence of CVD. Despite requiring more interventions than patients younger than 65 years, Medicare beneficiaries demonstrated the same degree of clinical improvement. Medicare should not develop coverage policy decisions that prevent access to therapies that alleviate CVD-induced symptoms.

Projecting Critical Care Beyond the ICU: An Analysis of Tele-ICU Support for Rapid Response Teams.

BACKGROUND: The rapid response team (RRT) concept was developed to improve care for decompensating patients outside of the intensive care unit (ICU) setting. The tele-ICU service (eICU(®)) at Health First Hospitals (Brevard County, FL) has provided tele-critical care support for patients outside the ICU using a mobile platform (the eMobile platform) since 2012. In this study we sought to evaluate the ability of eMobile to support care administered by RRTs. MATERIALS AND METHODS: A retrospective review evaluating mobile cart activations for RRT calls was performed. Data on mobile cart deployments were recorded over a 33-month period from January 2012 through September 2014. RESULTS: Five hundred eighty mobile cart activations for critical care support were initiated by RRTs, and 577 were completed (>99%). For recorded gender, 223 patients (47%) were male, and 248 (53%) patients were female. Mean recorded age was 70 ± 16 years (median, 72 years). The most common patient conditions were respiratory distress (n = 190, 33%), altered mental status (n = 137, 24%) and hypotension (n = 59, 10%). The most common interventions were medication orders (n = 231, 40%) and laboratory studies (n = 92, 29%). For 566 eMobile calls with documented dispositions, 189 patients (33%) were managed without ICU upgrade. No adverse patient outcomes were recorded involving eMobile. Compared with the RRT program in 2009, the last year before testing of eMobile began (2010-2011), addition of tele-critical care support for calendar years 2012 and 2013 increased projected cost avoidance from unnecessary ICU transfers by a mean of 66% above the 2009 baseline. For Fiscal Year 2014, a projected cost avoidance analysis for unnecessary ICU transfers including costs of information technology (IT) support demonstrated a return on investment up to $1.66 for every $1 invested in IT support. CONCLUSIONS: Mobile critical care coupled with RRT is clinically effective and can generate meaningful cost avoidance.

Race and invasive fungal infection in solid organ transplant recipients.

Health disparities in access to solid organ transplantation (SOT) and graft survival are well recognized, but there are limited data on the relationship of race to risk of invasive fungal infection (IFI) among SOT recipients. We conducted a case-control study using data from the Transplant-Associated Infection Surveillance Network (TRANSNET) to investigate race and IFI. Cases (n = 1,214) and controls (n = 16,550) were compared on demographic variables using chi-square, and the relationship between race and IFI was assesses with unconditional logistic regression. Compared to White transplant patients, Blacks had similar odds of developing IFI (OR = .97, 95% Cl 0.82-1.15, P = .7125), while participants who identified as other ethnicity were less likely to develop IFI (OR = .56, 95% Cl .41-.75, P < .001). Blacks, when compared to White patients, were at increased odds of developing cryptococcal infection (OR 2.19, 95% CI 1.35-3.54, P = .002). Despite pharmacogenetic differences, Black transplant recipients were not more likely overall to develop IFI compared to White transplant recipients.