Long-term Outcomes of Injection Drug-related Infective Endocarditis Among People Who Inject Drugs.

OBJECTIVES: Infective endocarditis (IE) among people who inject drugs is associated with high rates of mortality and repeat episodes of endocarditis. We sought to report on longer-term clinical outcomes of patients with IE who were offered buprenorphine or methadone treatment for opioid use disorder (OUD) at their initial hospital admission. METHODS: Individuals with OUD hospitalized between 2013 and 2015 with IE were included for the retrospective study. The following data were extracted from the medical record: sociodemographic data, mortality, repeat episodes of endocarditis, and evidence of ongoing buprenorphine and methadone treatment. The impact of medication use on mortality and repeat episode of endocarditis was examined using survival analysis. RESULTS: Overall, 26 individuals were included in the study. The mean duration of follow-up was 45.0 months (SD 7.2, range 34.0-56.0). During the index admission, 8 received buprenorphine, 8 received methadone, and 10 declined medications. During the follow-up period, 4 (15.4%) individuals died and 10 (38.5%) individuals experienced a repeat episode of endocarditis. Survival analysis of mortality (log-rank P = 0.066) and repeat episode of endocarditis (log-rank P = 0.86) comparing those who received buprenorphine, received methadone, and declined medication did not differ significantly. CONCLUSIONS: Initiation of medication treatment alone may not be sufficient to impact long-term mortality and rates of repeat episode of endocarditis. More research is needed to identify optimal treatment strategies for people who inject drugs with IE.

"I Sleep, But My Heart Is Awake": Negotiating marginal states in life and death.

This article compares a six-week fetus to a brain-dead boy to illustrate multiple inconsistencies and flaws in various prominent frameworks for determination of death by neurological criteria ("brain death"). The authors critically examine the biological and normative assumptions that distinguish these ethically ambiguous "marginal states" at the beginning and end of life and find no consistent biological or ethical criteria that coherently define the fetus as alive and the boy as dead. The authors note important contradictions in how medicine, bioethics, and society treat these marginal states, despite their striking biological and philosophical similarities, and conclude that these contradictions are ultimately untenable. They propose that rigid societal policy regarding brain death be abandoned in favor of more permissive policy that resembles those governing actions at the beginning of life, such as around abortion and embryonic stem cell research.