Declining incidence of keratinocyte carcinoma in organ transplant recipients.

BACKGROUND: All organ transplant populations are predisposed to increased rates of keratinocyte carcinoma (KC). Since this increased risk was first appreciated, immunosuppressive regimens have changed and organ transplant recipients (OTRs) have been aggressively screened for KC. There is a perception that these measures have impacted on KC incidence but there is a paucity of population-based studies on post-transplant rates of basal cell carcinoma (BCC). OBJECTIVES: To identify trends in incidence rates for KC following solid organ transplantation over the past two decades. METHODS: This nationwide, population-based study included all solid OTRs transplanted between 1994 and 2014. Patient data were matched to national cancer registry data to determine the standardized incidence ratio (SIR) of KC in solid OTRs compared with the general population. RESULTS: In total 3580 solid OTRs were included. The total follow-up time was 28 407 person-years (median follow-up 7·11 years). The overall SIRs for squamous cell carcinoma (SCC) and BCC were 19·7 and 7·0, respectively. Our study documents a progressive fall in the SIRs for SCC and BCC from peak SIRs (95% confidence intervals) in 1994-1996 of 26·4 (21·5-32·4) and 9·1 (7·4-11·3) to 6·3 (2·3-16·7) and 3·2 (1·4-7·1) in 2012-2014, respectively. The ratio of SCC to BCC has remained at 3 to 1 over the last two decades. CONCLUSIONS: Our study is the first to demonstrate a significant reduction over the past two decades in the incidences of both SCC and BCC following solid organ transplantation. The SCC-to-BCC ratio was maintained, demonstrating that both are reducing equally. This trend coincided with temporal changes in immunosuppressive protocols and the introduction of skin cancer prevention programmes. What's already known about this topic? Prior studies have shown that the risk of cutaneous squamous cell carcinoma (SCC) has declined over recent decades following solid organ transplantation. It is not known whether the risk of basal cell carcinoma (BCC) has reduced in line with this. What does this study add? Our study documents a progressive fall in the risk of SCC and BCC following solid organ transplantation over the last two decades. The SCC-to-BCC ratio was maintained, demonstrating that both are reducing equally. The trends observed in our study coincided with temporal changes in immunosuppressive protocols and the introduction of cancer prevention programmes, suggesting that these factors have positively impacted on the risk of keratinocyte carcinoma in this cohort.

Radiological remission and recovery of thirst appreciation after infliximab therapy in adipsic diabetes insipidus secondary to neurosarcoidosis.

BACKGROUND: Neurosarcoidosis is a rare and aggressive variant of systemic sarcoidosis which may result in hypothalamic-pituitary dysfunction. We report a case of hypothalamic hypopituitarism secondary to neurosarcoidosis complicated by adipsic diabetes insipidus (ADI). Initiation of anti-tumour necrosis factor-α (TNF-α) therapy resulted in both radiological disease remission and recovery of osmoregulated thirst appreciation after 3 months. CASE SUMMARY: A 22-year-old man was referred to the endocrinology service with profound weight gain, polyuria and lethargy. Biochemical testing confirmed anterior hypopituitarism while posterior pituitary failure was confirmed by hypotonic polyuria responding to desmopressin. Magnetic resonance imaging (MRI) demonstrated extensive hypothalamic infiltration; neurosarcoidosis was confirmed histologically after excisional cervical lymph node biopsy. Osmoregulated thirst appreciation was normal early in the disease course despite severe hypotonic polyuria. However, subsequent subjective loss of thirst appreciation and development of severe hypernatraemia in the setting of normal cognitive function indicated onset of ADI. MANAGEMENT: Clinical management involved daily weighing, regular plasma sodium measurement, fixed daily fluid intake and oral desmopressin. We initiated immunosuppressive therapy with pulsed intravenous anti-TNF-α therapy (infliximab) after multidisciplinary team consultation. OUTCOME: Infliximab therapy resulted in successful radiological disease remission and complete recovery of osmoregulated thirst appreciation. This was confirmed by subjective return of thirst response and maintenance of plasma sodium in the normal range in the absence of close biochemical monitoring.

Repeat endocarditis: analysis of risk factors based on the International Collaboration on Endocarditis - Prospective Cohort Study.

Repeat episodes of infective endocarditis (IE) can occur in patients who survive an initial episode. We analysed risk factors and 1-year mortality of patients with repeat IE. We considered 1874 patients enrolled in the International Collaboration on Endocarditis - Prospective Cohort Study between January 2000 and December 2006 (ICE-PCS) who had definite native or prosthetic valve IE and 1-year follow-up. Multivariable analysis was used to determine risk factors for repeat IE and 1-year mortality. Of 1874 patients, 1783 (95.2%) had single-episode IE and 91 (4.8%) had repeat IE: 74/91 (81%) with new infection and 17/91 (19%) with presumed relapse. On bivariate analysis, repeat IE was associated with haemodialysis (p 0.002), HIV (p 0.009), injection drug use (IDU) (p < 0.001), Staphylococcus aureus IE (p 0.003), healthcare acquisition (p 0.006) and previous IE before ICE enrolment (p 0.001). On adjusted analysis, independent risk factors were haemodialysis (OR, 2.5; 95% CI, 1.2-5.3), IDU (OR, 2.9; 95% CI, 1.6-5.4), previous IE (OR, 2.8; 95% CI, 1.5-5.1) and living in the North American region (OR, 1.9; 95% CI, 1.1-3.4). Patients with repeat IE had higher 1-year mortality than those with single-episode IE (p 0.003). Repeat IE is associated with IDU, previous IE and haemodialysis. Clinicians should be aware of these risk factors in order to recognize patients who are at risk of repeat IE.

Serum D-dimer concentrations in nephrotic syndrome track with albuminuria, not estimated glomerular filtration rate.

BACKGROUND: The nephrotic syndrome is associated with an increased risk of venous and arterial thrombosis. There are little published data on the distribution, interpretation or determinants of serum D-dimer levels in patients with the nephrotic syndrome. We aimed to describe this relationship. METHODS: This was a cross-sectional study of 100 patients with the nephrotic syndrome. Multivariate linear regression was used to evaluate for independent predictors of elevated D-dimer levels. Patients were observed for a period of 2 years after the baseline measurement of D-dimer level to assess for subsequent clinically evident thrombosis. RESULTS: On univariate linear regression, D-dimer elevation was associated with age in years ß (95% CI) 0.02 (0.016, 0.03), log-transformed urinary protein:creatinine ratio in g/g 0.439 (0.32, 0.558) and inversely with serum albumin in g/l -0.05 (-0.073, -0.035) and estimated glomerular filtration rate (eGFR) in ml/min/1.73 m(2) -0.01 (-0.016, -0.003). On multivariate linear regression, age in years ß (95% CI) 0.019 (0.012, 0.026), serum albumin in g/l -0.023 (-0.043, -0.003), and log-transformed urinary protein:creatinine ratio in g/g 0.266 (0.124, 0.408) were independently associated with elevated D-dimer levels. CONCLUSION: D-dimer levels are commonly raised in the nephrotic syndrome in the absence of clinically evident thrombosis, and are independently associated with age, degree of proteinuria and serum albumin, but not with eGFR. Baseline levels of D-dimer did not predict subsequent episodes of clinically evident thrombosis after 2 years of follow-up.

Revisiting the effect of referral bias on the clinical spectrum of infective endocarditis in adults.

Referral bias occurs because of the clustering of patients at tertiary care centers. This may result in the distortion of observed clinical manifestations of rare diseases. This analysis evaluates the effect of referral bias on the epidemiology of infective endocarditis (IE) in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS). This is a prospective multicenter cohort study comparing transferred and non-transferred patients with IE. Factors independently associated with transfer status were evaluated using multivariable logistic regression. A total of 2,760 patients were included in the analysis, of which 1,164 (42.2%) were transferred from other medical centers. Transferred patients more often underwent surgery for IE (odds ratio [OR] = 2.5; 95% confidence interval [CI] 1.9-3.2). They were also more likely to have complications such as stroke (OR = 1.5; 95% CI 1.3-1.9), heart failure (OR = 1.4; 95% CI 1.1-1.6), and new valvular regurgitation (OR = 1.3; 95% CI 1.1-1.6). The in-hospital mortality rates were similar in both groups. Patients with IE who require surgery and suffer complications are referred to tertiary hospitals more frequently than patients with an uncomplicated course. Hospital transfer has no obvious effect on the in-hospital mortality. Referral bias should be taken into consideration when describing the clinical spectrum of IE.

Seasonal peaks in Escherichia coli infections: possible explanations and implications.

Escherichia coli is a common cause of infections in all populations and countries of the world, causing an enormous burden of disease. In this issue of Clinical Microbiology and Infection, Al-Hasan et al. describe seasonal peaks in the incidence of E. coli bloodstream infection (BSI) during the summer for a population of 125 000 in Minnesota, USA. We discuss the probability that similar seasonal peaks in the incidence of E. coli BSI occur in other populations and geographical regions. Second, we discuss possible underlying explanations for these findings in terms of seasonal changes in human behaviour and the effect of temperature on the ability of E. coli to survive in the environment. Finally, we discuss some of the possible implications of E. coli BSI being a seasonal illness. More specifically, we discuss how better understanding the reasons for seasonality may potentially help us to better understand the dominant routes by which human populations are exposed to clonal groups of E. coli associated with urinary tract infection.

Coagulase-negative staphylococcal prosthetic valve endocarditis--a contemporary update based on the International Collaboration on Endocarditis: prospective cohort study.

OBJECTIVE: To describe the contemporary features of coagulase-negative staphylococcal (CoNS) prosthetic valve endocarditis (PVE). DESIGN: Observational study of prospectively collected data from a multinational cohort of patients with infective endocarditis. Patients with CoNS PVE were compared to patients with Staphylococcus aureus and viridans streptococcal (VGS) PVE. SETTING: The International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) is a contemporary cohort of patients with infective endocarditis from 61 centres in 28 countries. PATIENTS: Adult patients in the ICE-PCS with definite PVE and no history of injecting drug use from June 2000 to August 2005 were included. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Heart failure, intracardiac abscess, death. RESULTS: CoNS caused 16% (n = 86) of 537 cases of definite non-injecting drug use-associated PVE. Nearly one-half (n = 33/69, 48%) of patients with CoNS PVE presented between 60 days and 365 days of valve implantation. The rate of intracardiac abscess was significantly higher in patients with CoNS PVE (38%) than in patients with either S aureus (23%, p = 0.03) or VGS (20%, p = 0.05) PVE. The rate of abscess was particularly high in early (50%) and intermediate (52%) CoNS PVE. In-hospital mortality was 24% for CoNS PVE, 36% for S aureus PVE (p = 0.09) and 9.1% for VGS PVE (p = 0.08). Meticillin resistance was present in 68% of CoNS strains. CONCLUSIONS: Nearly one-half of CoNS PVE cases occur between 60 days and 365 days of prosthetic valve implantation. CoNS PVE is associated with a high rate of meticillin resistance and significant valvular complications.

Obesity and mode of delivery in primigravid and multigravid women.

Our objective was to study the effects of maternal body mass index (BMI) on the mode of delivery for primigravid and multigravid women. A retrospective cohort study was conducted at the University College Hospital Galway, Ireland, of 5162 women delivered from 2001 to 2003. BMI at the first antenatal appointment was calculated. Comparisons were made between each of the five BMI categories separately for primigravid and multigravid women in relation to gestation at delivery, age, mode of delivery, and birthweight. There were 5162 deliveries during the time period of the study; 2006 were primigravid and 3156 were multigravid women. Overall, 2.6% of women were underweight, 49.2% were normal weight, 22.8% were overweight, 19.8% were obese, and 5.6% were morbidly obese. In comparison with women of normal weight, for overweight and obese women, there was a progressive reduction in vaginal delivery rate with increasing BMI. For morbidly obese primigravida, this reduction was by 33.5% (from 83.1% to 55.3%, chi2 = 39.84, P < 0.001), and for multigravida was by 23.6% (from 86% to 65.7%, chi2 = 53.05, P < 0.001). Obesity conferred a two- to threefold increased risk of delivery by emergency caesarean section for both primigravid (obese, relative risk [RR] 2.16, 95% confidence interval [CI] 1.72 to 2.73; morbidly obese, RR 2.30, CI 1.61 to 3.37) and multigravid women (obese, RR 1.97, CI 1.45 to 2.67; morbidly obese, RR 2.44, CI 1.61 to 3.69). We concluded that increasing maternal BMI exerts a progressive adverse effect on vaginal delivery rates for both primigravid and multigravid women. Obese primigravida should be counseled antenatally about the 30% risk of emergency caesarean section.

Echocardiographic risk stratification for early surgery with endocarditis: a cost-effectiveness analysis.

BACKGROUND: Despite widespread acceptance of echocardiography for diagnosis of infective endocarditis, few investigators have evaluated its utility as a risk-stratification tool to aid therapeutic decision-making. METHODS: A decision tree and Markov analysis model were constructed using published and institutional data to estimate the cost-effectiveness of an echocardiographic risk-stratification strategy for infective endocarditis. The models compared surgery for high-risk patients based on clinical factors ("standard care") and surgery for high-risk patients based on echocardiographic findings ("echocardiography-guided"). RESULTS: The cost per patient for standard care and echocardiography-guided strategies was $47,766 and $53,669, respectively. The expected quality-adjusted life years (QALY) for standard care and echocardiography-guided strategies were 5.86 years and 6.10 years, respectively. Compared with standard care, the echocardiography-guided strategy cost an additional $23,867 per QALY saved. In one-way sensitivity analyses, the incremental cost of this strategy remained <$50,000/QALY across a broad range of scenarios. Baseline stroke risk had the greatest effect on cost-effectiveness. For populations with stroke risk less than 3.65%, the echocardiography-guided strategy was not cost-attractive (ICER >$50,000/QALY). At stroke risk between 3.65% and 14%, the ICER for the echocardiography-guided strategy was attractive (<$50,000 /QALY). The echocardiography-guided strategy became economically dominant at any baseline stroke risk greater than 18.3%. CONCLUSION: Echo-guided risk stratification for early surgery in patients with large vegetations is a cost-attractive treatment strategy for IE, as it improves outcome for an incremental cost <$50,000/QALY.

Enterococcal prosthetic valve infective endocarditis: report of 45 episodes from the International Collaboration on Endocarditis-merged database.

Enterococcal prosthetic valve infective endocarditis (PVE) is an incompletely understood disease. In the present study, patients with enterococcal PVE were compared to patients with enterococcal native valve endocarditis (NVE) and other types of PVE to determine differences in basic clinical characteristics and outcomes using a large multicenter, international database of patients with definite endocarditis. Forty-five of 159 (29%) cases of definite enterococcal endocarditis were PVE. Patients with enterococcal PVE were demographically similar to patients with enterococcal NVE but had more intracardiac abscesses (20% vs. 6%; p=0.009), fewer valve vegetations (51% vs. 79%; p<0.001), and fewer cases of new valvular regurgitation (12% vs. 45%; p=0.01). Patients with either enterococcal PVE or NVE were elderly (median age, 73 vs. 69; p=0.06). Rates of in-hospital mortality, surgical intervention, heart failure, peripheral embolization, and stroke were similar in both groups. Patients with enterococcal PVE were also demographically similar to patients with other types of PVE, but mortality may be lower (14% vs. 26%; p=0.08). Notably, 93% of patients with enterococcal PVE came from European centers, as compared with only 79% of patients with enterococcal NVE (p=0.03). Thus, patients with enterococcal PVE have higher rates of myocardial abscess formation and lower rates of new regurgitation compared to patients with enterococcal NVE, but there are no differences between the groups with regard to surgical or mortality rates. In contrast, though patients with enterococcal PVE and patients with other types of PVE share similar characteristics, mortality is higher in the latter group. Importantly, the prevalence of enterococcal PVE was higher in the European centers in this study.

Enterococcal endocarditis: 107 cases from the international collaboration on endocarditis merged database.

PURPOSE: To describe clinical features and outcomes of enterococcal left-sided native valve endocarditis and to compare it to endocarditis caused by other pathogens. SUBJECTS AND METHODS: Patients in the International Collaboration on Endocarditis-Merged Database were included if they had left-sided native valve endocarditis. Demographic characteristics, clinical features, and outcomes were analyzed. Multivariable analysis evaluated enterococcus as a predictor of mortality. RESULTS: Of 1285 patients with left-sided native valve endocarditis, 107 had enterococcal endocarditis. Enterococcal endocarditis was most frequently seen in elderly men, frequently involved the aortic valve, tended to produce heart failure rather than embolic events, and had relatively low short-term mortality. Compared to patients with non-enterococcal endocarditis, patients with enterococcal endocarditis had similar rates of nosocomial acquisition, heart failure, embolization, surgery, and mortality. Compared to patients with streptococcal endocarditis, patients with enterococcal endocarditis were more likely to be nosocomially acquired (9 of 59 [15%] vs 2 of 400 [1%]; P <.0001) and have heart failure (49 of 107 [46%] vs 234 of 666 [35%]; P = 0.03). Compared to patients with S. aureus endocarditis, patients with enterococcal endocarditis were less likely to embolize (28 of 107 [26%] vs 155 of 314 [49%]; P <.0001) and less likely to die (12 of 107 [11%] vs 83 of 313 [27%]; P = 0.001). Multivariable analysis of all patients with left-sided native valve endocarditis showed that enterococcal endocarditis was associated with lower mortality (odds ratio [OR] 0.49; 95% confidence interval [CI] 0.24 to 0.97). CONCLUSIONS: Enterococcal native valve endocarditis has a distinctive clinical picture with a good prognosis.

Risk factors for postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus.

Risk factors for developing postoperative mediastinitis (POM) due to methicillin-resistant Staphylococcus aureus (MRSA) were analyzed in a case-case control study of patients who underwent median sternotomy during the period from 1994 through 2000. Three patient groups were studied. The first consisted of 64 patients with POM due to MRSA; the second consisted of 79 patients with POM due to methicillin-susceptible S. aureus (MSSA); and the third consisted of 80 uninfected control patients. In multivariable analysis, patients who were diabetic (adjusted OR, 2.86; 95% CI, 1.22-6.70), female (OR, 2.70; 95% CI, 1.25-5.88), and >70 years old (OR, 3.43; 95% CI, 1.53-7.71) were more likely to develop POM due to MRSA. In contrast, the only independent risk factor associated with POM due to MSSA was obesity (OR, 2.49; 95% CI, 1.25-4.96). Antimicrobial prophylaxis consisted primarily of cephalosporin antibiotics (administered to 97% of the patients). Changes in perioperative antimicrobial prophylaxis, in addition to other interventions, should be considered for prevention of POM due to MRSA in targeted, high-risk populations.

Risk factors for infective endocarditis in patients with enterococcal bacteremia: a case-control study.

BACKGROUND: Based on previous studies, enterococcal infective endocarditis (IE) is considered a unimicrobial, community-acquired disease of older Caucasian men. PATIENTS AND METHODS: We evaluated the relationship between enterococcal bacteremia and IE by comparing clinical and demographic characteristics of all cases of enterococcal IE within an 8-year period (n = 41) with controls randomly chosen from patients with enterococcal bacteremia without IE. RESULTS: By univariate and multivariable analyses, the presence of a prosthetic valve (PV) and infection with Enterococcus faecalis were significantly associated with IE, while age, gender, race, polymicrobial infection and community-acquired infection were not. Almost an equal number of women and men had enterococcal IE. Cases of enterococcal IE were commonly nosocomial (39%) and polymicrobial (17%). CONCLUSIONS: Enterococcal endocarditis can no longer be considered exclusively a unimicrobial, community-acquired disease of Caucasian men. Instead, our data suggest that the presence of a PV and infection by E. faecalis are associated with an increased risk for IE.

Stroke location, characterization, severity, and outcome in mitral vs aortic valve endocarditis.

OBJECTIVE: To characterize the incidence and clinical features of patients with infective endocarditis (IE) and stroke. METHODS: The authors reviewed the records of 707 patients diagnosed with definite or possible IE between January 1984 and November 1999. Stroke was confirmed by application of strict definitions and classified by type, pathophysiology, vascular territory, and severity. The authors determined mortality rates for the initial hospitalization and 12 months after admission. RESULTS: Strokes occurred in 68 (9.6%) of 707 patients with IE, 38 (17%) of 218 patients with mitral valve endocarditis (MVE), 14 (9%) of 149 patients with aortic valve endocarditis (AVE), and 16 (5%) of 340 patients with other forms of IE (OR for MVE vs AVE = 2.0, 95% CI 1.1 to 3.9). Among the patients with MVE or AVE and stroke, there were no significant relationships between site of vegetation and length of hospitalization, stroke severity, mortality during the initial hospitalization, or 12-month mortality. Fifty-two percent of patients with stroke and IE died within 1 year of admission. CONCLUSIONS: The overall incidence of stroke in patients with IE (9.6%) is lower than previous reports (21 to 39%). Patients with MVE had a greater risk of stroke than patients with AVE. Fifty-two percent of patients died within 1 year of admission for IE.

Vascular access infections in patients undergoing dialysis with special emphasis on the role and treatment of Staphylococcus aureus.

Access-related infections are the most important causes of the loss of vascular access for dialysis. These infections also may lead to devastating consequences, including sepsis with multiorgan failure; endocarditis; or metastatic infections such as vertebral osteomyelitis, epidural abscess, or endophthalmitis. A small percentage of these complications are fatal; overall, dialysis-related bloodstream infections are the second leading cause of death in patients undergoing hemodialysis, accounting for up to 10% of all deaths, and approximately three-fourths of all deaths caused by infection in patients undergoing dialysis. Moreover, vascular placement and complications account for approximately one fourth of all admissions and hospital days among patients on dialysis.

Cardiac conduction abnormalities in endocarditis defined by the Duke criteria.

BACKGROUND: Cardiac conduction abnormalities occur in endocarditis and have been associated with infection extension and increased mortality. There have been no prospective studies of electrocardiographic (ECG) conduction changes in endocarditis. We examined the incidence of ECG changes in a large prospective cohort with suspected endocarditis and correlated changes with echocardiographic evidence of invasive infection and mortality. METHODS: One hundred thirty-seven of 1396 (10%) suspected cases of endocarditis were classified as "definite" or "possible" by the Duke criteria and had an interpretable ECG. ECG conduction changes were classified as old (pre-existing hospitalization), new (evident on admission or developed during hospitalization), or indeterminate. New or indeterminate abnormalities were considered "ECG conduction changes." Echocardiogram results were reviewed to identify infected valves and invasive infection. RESULTS: ECG conduction changes were present in 36 of 137 (26%) patients. Patients with ECG conduction changes were more often male (69% vs 46%, P =.005) and had prosthetic valves (47% vs 23%, P <.001). There were no significant differences in microbiology results or treatment with cardiac surgery. In 76 (55%) patients, at least one infected valve was identified by echocardiography; 15 of 76 (20%) patients were determined to have evidence of invasive infection. Eight of 15 (53%) invasive infections exhibited ECG conduction changes compared with 16 of 61 (26%) isolated valve infections (P =.046). Eleven of 36 (31%) patients with ECG conduction changes died during hospitalization compared with 15 of 101 (15%) patients without changes (P =.039). CONCLUSIONS: ECG conduction changes commonly occur in endocarditis despite more sensitive diagnostic criteria and are associated with increased mortality and invasive infection.

The risk of stroke and death in patients with aortic and mitral valve endocarditis.

BACKGROUND: Previous studies have generated inconsistent results when attempting to define predictors of stroke and death in patients with endocarditis. We sought to examine the relationship between vegetation 2-dimensional size and stroke in those with infective endocarditis (IE) and to identify differences between aortic valve (AV) and mitral valve (MV) IE with regard to clinical characteristics, echocardiographic findings, stroke, and death. METHODS: We used the Duke Endocarditis Database to examine 145 episodes of definite IE involving the AV, n = 62, or MV, n = 83. A logistic regression model was developed to analyze important variables in predicting stroke, and a Cox proportional hazards model was used in predicting mortality. RESULTS: The mitral valve was infected in 57% of the cases. Vegetations were more commonly detected in patients with MV IE (92.8% vs 66.1%, P =.001) and these MV vegetations were significantly larger (P <.05). Thirty-four of 145 episodes (23.4%) were complicated by stroke. MV IE was associated with a greater stroke rate, 32.5% versus 11.3% (P =.003). Strokes tended to occur early in the course of illness, particularly in MV IE. In the multivariable model, the independent predictors of stroke were MV IE (P =.04) and vegetation length (P =.03). Independent predictors of 1-year mortality were age (P =.02) and vegetation area (P =.048). CONCLUSION: Stroke is more common in patients with MV IE. Vegetation 2-dimensional size and characteristics are important predictors of stroke and mortality. These findings may lead to predictive models that allow physicians to identify high-risk patients who need aggressive treatment strategies to prevent long-term morbidity and mortality.