Mutilating Purpura Fulminans in an Adult with Meningococcal Sepsis.

We report a dramatic case of meningococcal sepsis manifesting as purpura fulminans in an elderly diabetic woman. Hemodynamic instability and severe bilateral cutaneous lesions involving her hands and feet developed rapidly. Specific antibiotic therapy and the administration of inotropic and vasopressor drugs were initiated. The severity and extension of the cutaneous lesions (attributed to purpura fulminans) worsened because of the need for vasoconstrictors for the treatment of septic shock. Bilateral transmetatarsal and metacarpal amputations were required to stabilize the patient.

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES).

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

Prognostic assessment of valvular surgery in active infective endocarditis: multicentric nationwide validation of a new score developed from a meta-analysis.

OBJECTIVES: Several risk prediction models have been developed to estimate the risk of mortality after valve surgery for active infective endocarditis (IE), but few external validations have been conducted to assess their accuracy. We previously developed a systematic review and meta-analysis of the impact of IE-specific factors for the in-hospital mortality rate after IE valve surgery, whose obtained pooled estimations were the basis for the development of a new score (APORTEI). The aim of the present study was to assess its prognostic accuracy in a nationwide cohort. METHODS: We analysed the prognostic utility of the APORTEI score using patient-level data from a multicentric national cohort. Patients who underwent surgery for active IE between 2008 and 2018 were included. Discrimination was evaluated using the area under the receiver operating characteristic curve, and the calibration was assessed using the calibration slope and the Hosmer-Lemeshow test. Agreement between the APORTEI and the EuroSCORE I was also analysed by Lin's concordance correlation coefficient (CCC), the Bland-Altman agreement analysis and a scatterplot graph. RESULTS: The 11 variables that comprised the APORTEI score were analysed in the sample. The APORTEI score was calculated in 1338 patients. The overall observed surgical mortality rate was 25.56%. The score demonstrated adequate discrimination (area under the receiver operating characteristic curve = 0.75; 95% confidence interval 0.72-0.77) and calibration (calibration slope = 1.03; Hosmer-Lemeshow test P = 0.389). We found a lack of agreement between the APORTEI and EuroSCORE I (concordance correlation coefficient = 0.55). CONCLUSIONS: The APORTEI score, developed from a systematic review and meta-analysis, showed an adequate estimation of the risk of mortality after IE valve surgery in a nationwide cohort.

Successful retrieval of an irretrievable jugular tesio catheter using a fogarty arterial embolectomy catheter.

Long life expectancy and wide development of therapies have increased the number of patients under artificial treatment for lost kidney function or dialysis. Different options for vascular access are suitable for receiving this therapy. The use of tunneled catheters has consequently increased complications related to its use. A difficult retrieval of catheters caused by a hard fibrin sheath along its trajectory is a common drawback. Herein, we report a woman with suspicion of hemodialysis catheter infection and an irretrievable Tesio catheter. A novel technique using a Fogarty arterial catheter allowed a successful retrieval and avoided an aggressive management.

The changing face of prosthetic valve endocarditis at a tertiary-care hospital: 1986-2005.

INTRODUCTION AND OBJECTIVES: To investigate changes in the clinical characteristics, etiology and prognosis of prosthetic valve endocarditis at a tertiary-care hospital. METHODS: Retrospective cohort study of all patients diagnosed with prosthetic valve endocarditis using modified Duke criteria between 1986 and 2005. The analysis covered two time periods: January 1986 to December 1995 (P1) and January 1996 to December 2005 (P2). RESULTS: In total, 133 episodes of endocarditis occurred in 122 patients. Of these, 73 (54.9%) were diagnosed in P1 and 60 (45.1%) in P2, with incidences of 2.19% and 2.18%, respectively. The patients' mean age (SD) was 52.6+/-16.6 years in P1 and 66.2+/-11.5 years in P2 (P=.0001). Clinical characteristics were similar in the two study periods. The increase in Enterococcus infection was remarkable (12.5% in P2 vs. 4.9% in P1; relative risk [RR]=2.5; 95% confidence interval [CI], 0.7-9.6), as was the decrease in viridans group Streptococcus infection (12.5% in P2 vs. 31.1% in P1; RR=0.4; 95% CI, 0.2-0.9). Some 90.4% of patients (63/73) underwent surgery in P1, while 68.3% (41/60) underwent surgery in P2. The difference was significant (RR=0.8; 95% CI, 0.6-0.9). The in-hospital mortality rate was 28.8% in P1 and 30% in P2 (RR=1; 95% CI, 0.6-1.7). CONCLUSIONS: Changes in the epidemiology and microbiological etiology of prosthetic valve endocarditis were observed over the 20-year study period. Diagnostic and therapeutic approaches also changed, but mortality remained high.

Cambios en el perfil de la endocarditis sobre válvula protésica en un hospital de tercer nivel: 1986-2005 / The changing face of prosthetic valve endocarditis at a tertiary-care hospital: 1986-2005

Introducción y objetivos. Estudiar la evolución de las características clínicas, la etiología y el pronóstico de la endocarditis sobre válvula protésica en un hospital de tercer nivel. Métodos. Estudio de cohortes retrospectivo de todos los pacientes diagnosticados de endocarditis sobre válvula protésica desde 1986 a 2005 según los criterios de Duke modificados. Se analizaron dos periodos temporales: enero de 1986 a diciembre de 1995 (P1) y enero de1996 a diciembre de 2005 (P2).Resultados. Se estudiaron 133 episodios en 122 pacientes. En 73 episodios (54,9%) la endocarditis fue diagnosticada en el P1 y en 60 (45,1%), en el P2 (incidencia del 2,19 y el 2,18% respectivamente). La edad, media ± desviación estándar, fue de 52,6 ± 16,6 años en el P1 y 66,2 ± 11,5 años en el P2 (p = 0,0001). Las características clínicas fueron similares en ambos periodos de estudio. Fue llamativo el incremento de infecciones por enterococo (el 12,5% en el P2 y el 4,9% en elP1; riesgo relativo [RR] = 2,5; intervalo de confianza [IC]del 95%, 0,7-9,6) así como el descenso de las infecciones por estreptococos del grupo viridans (el 12,5% en el P2 y el 31,1% en el P1; RR = 0,4; IC del 95%, 0,2-0,9). Los pacientes intervenidos en el P1 fueron el 90,4%(63/73), mientras que en el P2 fueron el 68,3% (41/60),diferencias que resultaron estadísticamente significativas(RR = 0,8; IC del 95%, 0,6-0,9). La mortalidad intrahospitalaria fue del 28,8% en el P1 y el 30% en el P2 (RR = 1;IC del 95%, 0,6-1,7).Conclusiones. Durante los 20 años de estudio, se ha observado un cambio en la epidemiología y la etiología microbiológica de la endocarditis sobre válvula protésica. El abordaje diagnóstico y terapéutico también se ha modificado, aunque la mortalidad se ha mantenido elevada (AU)

Introduction and objectives. To investigate changes in the clinical characteristics, etiology and prognosis of prosthetic valve endocarditis at a tertiary-care hospital. Methods. Retrospective cohort study of all patients diagnosed with prosthetic valve endocarditis using modified Duke criteria between 1986 and 2005. The analysis covered two time periods: January 1986 to December 1995 (P1) and January 1996 to December 2005 (P2).Results. In total, 133 episodes of endocarditis occurred in 122 patients. Of these, 73 (54.9%) were diagnosed in P1and 60 (45.1%) in P2, with incidences of 2.19% and 2.18%,respectively. The patients’ mean age (SD) was 52.6±16.6years in P1 and 66.2±11.5 years in P2 (P=.0001). Clinical characteristics were similar in the two study periods. The increase in Enterococcus infection was remarkable (12.5%in P2 vs. 4.9% in P1; relative risk [RR]=2.5; 95% confidence interval [CI], 0.7-9.6), as was the decrease in viridans group Streptococcus infection (12.5% in P2 vs. 31.1% in P1;RR=0.4; 95% CI, 0.2-0.9). Some 90.4% of patients (63/73)underwent surgery in P1, while 68.3% (41/60) underwent surgery in P2. The difference was significant (RR=0.8; 95%CI, 0.6-0.9). The in-hospital mortality rate was 28.8% in P1and 30% in P2 (RR=1; 95% CI, 0.6-1.7).Conclusions. Changes in the epidemiology and microbiological etiology of prosthetic valve endocarditis were observed over the 20-year study period. Diagnostic and therapeutic approaches also changed, but mortality remained high (AU)