High spinal cord injury precipitating syncope: a rare indication for pacemaker insertion.

The current evidence for vasovagal syncope management is that cardiac pacing is only indicated in a highly select group of patients where symptoms can be linked to bradycardic episodes. High spinal cord injury can lead to autonomic dysfunction and sympathetic nervous system hypoactivity. A high spinal cord injury can theoretically precipitate profound bradycardia leading to haemodynamic instability and syncope. A patient in his 50s with a history of C2 spinal injury was admitted to our tertiary centre for management of what was initially thought to be septic shock causing hypotension and syncope. With evidence to suggest this patient's presentation may be profound reflex syncope in the context of unopposed parasympathetic signalling, consensus was reached to implant a permanent pacemaker. Remarkably, the patient's haemodynamics stabilised and there were no further episodes of syncope.

Evolving mortality rates in people who inject drugs: An Australian tertiary hospital observational study on infective endocarditis.

BACKGROUND: Injection drug use (IDU) associated infective endocarditis (IE) is clinically challenging due to social issues this population endures. Rates of IDU are rising globally, however, there is a lack of clear guidelines for IDU associated IE. The aim of this study is to assess the epidemiology of the IDU and non-IDU populations and compare their long-term outcomes to help guide future management. METHODS: An observational cohort study was conducted on all 350 patients treated for IE at St Vincent's Hospital Melbourne between 1999 and 2015. Follow up was performed until death or January 2021. Primary outcome was all-cause mortality. RESULTS: IDU patients are younger (p<0.001), more likely to have concurrent infections (p<0.001), and other addiction disorders (p<0.001), while non-IDU patients are older with a higher level of comorbid illnesses (p<0.001). IDU and non-IDU patients received similar management during their admissions and experienced similar levels of in-hospital outcomes, except for non-IDU patient being more likely to develop pneumonia post-surgery (p = 0.03). IDU patients are more likely to become reinfected (p = 0.034) but have better long-term survival, with survival estimates at 15-years being 64.98% (95%CI: 50.94-75.92%) for IDU patients compared to 26.67% (95%CI: 19.76-34.05%) for non-IDU patients (p<0.001). CONCLUSION: Despite having higher levels of reinfection, IDU patients have better long-term survival compared to non-IDU patients. Therefore, we suggest IDU patients should not have blanket restrictions on the management they are offered unless at the individual level there is a contraindication to therapy.

Multivalve infective endocarditis in intravenous drug using patients: an epidemiological study.

BACKGROUND: Infective endocarditis (IE) remains a life-threatening condition. Intravenous drug use (IVDU) adds to the clinical challenge associated with IE due to clinical aberrations caused by the social issues associated with this population. AIM: To improve survival, this study aimed to characterize the contemporary IVDU-associated IE population seen at our tertiary hospital, determine their long-term outcomes and find risk factors associated with mortality. DESIGN: Retrospective observational cohort study. METHODS: A total of 79 patients accounting for 89 presentations were treated for IVDU-associated IE at St Vincent's Hospital Melbourne (SVHM) between 1999 and 2015. Patients were followed-up until death or January 2021. The primary outcome was all-cause mortality and Kaplan-Meier survival analysis was used to calculate long-term survival estimates. Cox proportional hazards analysis was used to examine risk factors for mortality. RESULTS: The IVDU population treated at SVHM had a high rate of multivalvular IE, at 18.98%. Multivariate analysis revealed that multivalvular IE is significantly associated with an increased risk of mortality in a dose-dependent relationship (two valves affected: HR = 4.73, P = 0.006, three valves affected: HR = 14.19, P = 0.014). The IVDU population has survival estimates of 83.78% (95%CI: 73.21-90.45%) at 1-year and 64.98% (95%CI: 50.94-75.92%) at 15-years. CONCLUSION: IVDU patients have high rates of multivalvular endocarditis, which is associated with increased risk of mortality and difficult to identify on echocardiography. Clinicians should be suspicious of multivalve involvement in the IVDU population and decisions related to medical management/intervention should be made with the understanding that these patients are at a higher risk of death.