Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke.

BACKGROUND: The timing of cardiac surgery after stroke in infective endocarditis (IE) remains controversial. We examined the relationship between the timing of surgery after stroke and the incidence of in-hospital and 1-year mortalities. METHODS: Data were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers from June 2000 through December 2006. Multivariate logistic regression and Cox regression analyses were performed to estimate the impact of early surgery on hospital and 1-year mortality after adjustments for other significant covariates. RESULTS: Of the 857 patients with IE complicated by ischemic stroke syndromes, 198 who underwent valve replacement surgery poststroke were available for analysis. Overall, 58 (29.3%) patients underwent early surgical treatment vs 140 (70.7%) patients who underwent late surgical treatment. After adjustment for other risk factors, early surgery was not significantly associated with increased in-hospital mortality rates (odds ratio, 2.308; 95% confidence interval [CI], .942-5.652). Overall, probability of death after 1-year follow-up did not differ between 2 treatment groups (27.1% in early surgery and 19.2% in late surgery group, P = .328; adjusted hazard ratio, 1.138; 95% CI, .802-1.650). CONCLUSIONS: There is no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke. Further observational analyses that include detailed pre- and postoperative clinical neurologic findings and advanced imaging data (eg, ischemic stroke size), may allow for more refined recommendations on the optimal timing of valvular surgery in patients with IE and recent stroke syndromes.

The importance of pathogens in sepsis: Staphylococcus aureus story.

Different pathogens cause different outcomes for patients with sepsis. They influence intensive care unit (ICU) mortality, ICU length of stay (ICU LOS) and the need for mechanical ventilation (MV). We undertook a retrospective data-based analysis over a 6-y period. Seventy-eight patients with methicillin-sensitive Staphylococcus aureus (MSSA) and 74 patients with Escherichia coli (EC) sepsis were included in the study. ICU mortality for the MSSA group was 32 (41.0%) vs 26 (35.1%) for the EC group (p = 0.506; OR 1.28, 95% CI 0.67-2.48). There was no significant difference in ICU LOS (MSSA group: median 7.5, interquartile range (IQR) 4-14 days and EC: median 5, IQR 3-13.5 days; p = 0.214). Need for MV in the MSSA group was present in 45 (57.7%) patients vs 43 (58.1%) in the EC group. Univariate analysis did not show that MSSA was independently associated with ICU mortality (p = 0.506). Logistic regression analysis showed that after adjustment for APACHE II, the chance of ICU death doubled in the MSSA group (odds ratio 2.166; 95% confidence interval 1.004-4.858). The odds for ICU admission were 8 times higher in MSSA patients. MSSA sepsis should be considered as an independent factor for ICU mortality after adjustment for APACHE II.

[Lipopeptides and oxazolidinones--novel antibiotics in MRSA infection treatment]. / Lipopeptidi i oksazolidinoni--novi lijekovi u lijecenju MRSA-infekcija.

Last few years vancomycin-intermediate S. aureus and vancomycin-resistent S. aureus have emerged, giving us a task to reevaluate susceptiblity to vancomycin in treatment of methicillin-resistent S. aureus (MRSA) infections. It is also oportunity to review necessity for new generation of antibiotics in treatment of MRSA infections. Efficacy of vancomycin treatment in MRSA bacteriemia is associated with minimal inhibitory concentration (MIC) and speed of killing colonies. There is an increased probability of failure in treatment of MRSA bacteremia when there are high vancomycin MIC in vitro. That's one of the reasons why there is novel antibiotic therapy for MRSA investigated, especially daptomycin and linezolid. Daptomycin is lipopeptide and an important optional antibiotic in MRSA infections treatment: bacteremia and endocarditis, even the tricuspidal valve endocarditis. Linezolid, as novel oxazolidinon, has shown good activity against gram-positive bacteria, especially in treatment of nosocomial pneumonia and complicated skin and soft tissue infections caused by MRSA.

Liver involvement during influenza infection: perspective on the 2009 influenza pandemic.

Elevation of liver transaminase levels is a frequent observation during systemic infections. The aim of our study was to investigate liver damage during pandemic 2009 influenza A/H1N1 infection in comparison with seasonal influenza. Serum levels of aspartate aminotransferase, alanine aminotransferase, and gamma-glutamyl transpeptidase (GGT) were significantly higher in patients with pandemic influenza compared to seasonal influenza, which was strongly correlated with hypoxia. Moreover, a positive correlation between C-reactive protein and serum GGT, alkaline phosphatase, and lactate dehydrogenase was noticed. Our findings support the hypothesis that the pandemic 2009 influenza A/H1N1 is an illness with a significant immune response to infection leading to hepatocellular injury.

Safety and effectiveness of azithromycin in the treatment of respiratory infections in children.

OBJECTIVES: To describe clinical effectiveness of azithromycin in the management of respiratory tract infections in children up to 12 years of age; to examine duration of symptoms after commencement of therapy and to mark adverse events possibly caused by treatment with azithromycin. METHODS: The overall ITT population included 156 children (65 with acute pharyngitis/tonsillitis (AP), 32 with acute otitis media (AOM), and 59 with lower respiratory tract infections (LRTI)). Clinical effectiveness was based on results of improvement and cure after 3 day's treatment with azithromycin, calculating the clinical score for each diagnosis before treatment, at the 4th day (end of the therapy) and at the 12th or 28th day (end of the study). To better estimate patients' (parents') satisfaction with treatment, a diary was provided for each child and parents recorded the days when a child felt relief of symptoms. RESULTS: In this study azithromycin led to relief of symptoms after 3 days in 89.1% of patients. Antibiotics had been prescribed within 1 year prior to inclusion in 74.4% of patients and 29.5% had previously been treated with macrolides. Clinical effectiveness in the intention-to-treat (ITT) population was 94.8% and there were 5.2% failures. Overall, 18 (11.5%) patients reported 25 adverse events (AEs) and nine AEs were characterized as possibly, probably or definitely related to azithromycin. The most common adverse events were diarrhea in nine (5.8%) cases, vomiting in six (3.8%) and abdominal pain reported in four (2.6 %) patients. CONCLUSION: Results of this study show that azithromycin in the treatment of children with respiratory tract infections has high clinical effectiveness and a small number of adverse events. However, major limitations of the study are its design as a non-comparative, observational, postmarketing study and that the etiology of infections was not confirmed. Despite this, it can be concluded that azithromycin is a reliable antibiotic treatment for children's respiratory tract infections, giving fast resolution of symptoms with few adverse events in patients with presumed bacterial infections.

Climate for career choices: survey of medical students' motivation for studying, career preferences and perception of their teachers as role models.

BACKGROUND: To assess the educational climate at a medical school, we explored students' perception of their motives for study, the importance of students' personal characteristics for success in the study and profession of medicine, students' perceptions of professional and personal characteristics of their teachers, and students' preferences for their future careers in medicine. METHODS: We surveyed all students coming to the administration office to enroll for the following academic year (2nd to 6th year of study, n = 738) at Zagreb University Medical School, Croatia. Responses with answers to all questions (n = 482, 65% response rate) were analyzed. RESULTS: Students from both preclinical and clinical study years perceived their teachers to be formal: strict, authoritative, punctual, well prepared, and respectful of hierarchy. Similar formal characteristics were seen as important for success in their studies and in the medical profession. The strongest motivation for studying among students in all study years was task completion. Most of the students wanted a career in medical practice, with (n = 160, 33.2%) or without (n = 207, 42.9%) involvement in clinical research; a few (n = 3, 0.6%) wanted to do basic biomedical research, and an academic career was sought by 23.5% (n = 112). The choice of academic career was associated with grade point average (odds ratio [OR] = 1.75, 95% confidence interval [CI] = 1.10-2.88), higher scores on motivation scales for professional advancement (OR = 1.72; 95% CI = 1.12-2.63) and academic gains (OR = 1.58; 95% CI = 1.17-2.14). CONCLUSION: Medical students perceive formal characteristics and self-interests as dominant aspects of the educational climate at medical school, where they are motivated mostly by task completion. The change towards a climate of social sensitivity and pro-social behavior may require less frontal and more interactive teaching, with personal interaction between students and teachers.