The hidden side of infective endocarditis: Diagnostic and management of 500 consecutive cases in noncardiac surgery centers (2009-2018).

BACKGROUND: We aimed to describe infective endocarditis cases from noncardiac surgery centers, as current knowledge on infective endocarditis is derived mostly from cardiac surgery hospitals. METHODS: An observational retrospective study (2009-2018) was conducted in 9 noncardiac surgery hospitals in Central Catalonia. All adult patients diagnosed with definitive infective endocarditis were included. Transferred and nontransferred cohorts were compared, and a logistic regression model was used to ascertain the prognostic factors. RESULTS: Overall, 502 infective endocarditis episodes were included: 183 (36.5%) were transferred to the cardiac surgery center, whereas 319 were not, with (18.7%) and without (45%) surgical indications. Cardiac surgery was performed in 83% of transferred patients. In-hospital (14% vs 23%) and 1-year (20% vs 35%) mortality rates were significantly lower in transferred patients (P < .001). Among the patients not undergoing cardiac surgery despite an indication, 55 (54%) died within 1 year. The multivariate analysis identified the following independent predictive factors for in-hospital mortality: Staphylococcus aureus infective endocarditis (odds ratio: 1.93 [1.08, 3.47]), heart failure (odds ratio: 3.87 [2.28, 6.57]), central nervous system embolism (odds ratio: 2.95 [1.41, 5.14]), and Charlson score (odds ratio: 1.19 [1.09, 1.30]), whereas community acquisition (odds ratio: 0.52 [0.29, 0.93]), cardiac surgery (odds ratio: 0.42 [0.20, 0.87]), but not transfer (odds ratio: 1.23 [0.84, 3.95]) were identified as protective factors. One-year mortality was associated with S. aureus infective endocarditis (odds ratio: 1.82 [1.04, 3.18]), heart failure (odds ratio: 3.74 [2.27, 6.16]), and Charlson score (odds ratio: 1.23 [1.13, 1.33]), whereas cardiac surgery (odds ratio: 0.41 [0.21, 0.79]) was identified as a protective factor. CONCLUSION: Patients not transferred to a referral cardiac surgery center have a worse prognosis compared to those ultimately transferred, as cardiac surgery is associated with lower mortality rates.

Improving Recognition of Fracture Risk in People with Human Immunodeficiency Virus: Performance and Model Contribution of Two Common Risk Assessment Tools.

Current guidelines recommend screening people with HIV (PWH) for bone disease using predictive tools developed for the general population, although data on PWH are scarce. In this study, we assessed the performance of FRAX and QFracture scoring systems to predict the occurrence of fragility fractures in a prospective cohort of 17,671 adults with human immunodeficiency virus (HIV) included in the HIV/AIDS research network (CoRIS) in Spain. The survival estimates of fragility fractures during follow-up were calculated and FRAX and QFracture scores were computed at cohort inclusion. For both tools, discriminatory measures and the observed-to-expected (O/E) ratios were assessed. During a follow-up time of 42,411.55 person-years, 113 fragility fractures were recorded. Areas under the curve were 0.66 [95% confidence interval (95% CI) 0.61-0.71] for FRAX and 0.67 (95% CI 0.62-0.73) for QFracture for major osteoporotic fractures, and 0.72 (95% CI 0.57-0.88) and 0.81 (95% CI 0.68-0.95) for hip fracture, respectively. The O/E was 1.67 for FRAX and 5.49 for QFracture for major osteoporotic fractures, and 11.23 for FRAX and 4.87 for QFracture for hip fractures. Moreover, O/E raised as the risk increased for both tools and in almost all age groups. When using the recommended assessment thresholds, <6% and 10% of major osteoporotic and hip fractures would have been identified, respectively. In conclusion, FRAX and QFracture displayed acceptable discrimination, although both tools significantly underestimated the risk of fragility fractures in PWH. The recommended assessment thresholds may not be appropriate for this population as they were unable to identify individuals with fragility fractures during follow-up.

COVID-19 in hospitalized HIV-positive and HIV-negative patients: A matched study.

OBJECTIVES: We compared the characteristics and clinical outcomes of hospitalized individuals with COVID-19 with [people with HIV (PWH)] and without (non-PWH) HIV co-infection in Spain during the first wave of the pandemic. METHODS: This was a retrospective matched cohort study. People with HIV were identified by reviewing clinical records and laboratory registries of 10 922 patients in active-follow-up within the Spanish HIV Research Network (CoRIS) up to 30 June 2020. Each hospitalized PWH was matched with five non-PWH of the same age and sex randomly selected from COVID-19@Spain, a multicentre cohort of 4035 patients hospitalized with confirmed COVID-19. The main outcome was all-cause in-hospital mortality. RESULTS: Forty-five PWH with PCR-confirmed COVID-19 were identified in CoRIS, 21 of whom were hospitalized. A total of 105 age/sex-matched controls were selected from the COVID-19@Spain cohort. The median age in both groups was 53 (Q1-Q3, 46-56) years, and 90.5% were men. In PWH, 19.1% were injecting drug users, 95.2% were on antiretroviral therapy, 94.4% had HIV-RNA < 50 copies/mL, and the median (Q1-Q3) CD4 count was 595 (349-798) cells/µL. No statistically significant differences were found between PWH and non-PWH in number of comorbidities, presenting signs and symptoms, laboratory parameters, radiology findings and severity scores on admission. Corticosteroids were administered to 33.3% and 27.4% of PWH and non-PWH, respectively (P = 0.580). Deaths during admission were documented in two (9.5%) PWH and 12 (11.4%) non-PWH (P = 0.800). CONCLUSIONS: Our findings suggest that well-controlled HIV infection does not modify the clinical presentation or worsen clinical outcomes of COVID-19 hospitalization.

Validation Protocol of Vitamin D Supplementation in Patients with HIV-Infection.

Hypovitaminosis D and secondary hyperparathyroidism are frequent among HIV-infected patients. As there are no data about the best supplementation therapy both in treatment and in maintenance, we conducted an observational study of 300 HIV-infected patients for whom vitamin D and parathormone (PTH) had been measured in order to validate a protocol of vitamin D supplementation in patients with HIV-infection. Patients with vitamin D deficiency (defined as 25(OH)D < 10 ng/mL), insufficiency (defined as 25(OH)D < 20 ng/mL), or hyperparathyroidism (PTH > 65 pg/mL) were supplemented with cholecalciferol 16.000IU (0.266 mg) weekly (if deficiency) or fortnightly (if insufficiency or high PTH levels). Rates of normalization of 25(OH)D (levels above 20 ng/mL) and PTH levels (<65 pg/mL) were analyzed. Multivariate analysis of factors related to normalization was carried out. With a median follow-up of 2 years, 82.1% of patients with deficiency and 83.9% of cases with insufficiency reached levels above 20 ng/mL. However, only 67.2% of individuals with hyperparathyroidism at baseline reached target levels (<65 pg/mL). Independent factors for not achieving PTH objective were tenofovir (TDF) and protease inhibitors use. In HIV-infected patients with hypovitaminosis, the protocol of cholecalciferol supplementation normalized vitamin D levels regardless of antiretroviral regimen in a high proportion of patients but it was less effective to correct hyperparathyroidism.

Meta-analysis: comparative efficacy of H2-receptor antagonists and proton pump inhibitors for reducing aspiration risk during anaesthesia depending on the administration route and schedule.

H2-receptor antagonists (H2RA) and proton pump inhibitors (PPI) are widely used for aspiration prophylaxis in patients receiving general anaesthesia. Many randomized trials have compared these agents but it remains unclear which drug type is more effective in reducing the number of patients at risk of complications. The study aimed to compare their efficacy for decreasing the number of patients at risk of acid aspiration during general anaesthesia. Major databases were systematically searched. Randomized controlled trials comparing PPI and H2RA were selected. Sub-analyses were performed considering the dose, the dosing schedule, and the route of administration. Eighteen studies fulfilled the inclusion criteria. The main analysis showed a non-significant trend for H2RA being more effective than PPI. Only when both drugs were administered per os, as a single dose and immediately before surgery, was H2RA significantly more effective than PPI. By contrast, the effect of PPI and H2RA was similar when they were administered in two doses (the night before and on the morning of surgery) or when the drugs were given intravenously. A single H2RA dose before surgery is highly effective in reducing the number of patients at risk of acid aspiration. PPI administered in two oral doses or in a single intravenous infusion seems to be as effective as H2RA.

Larga supervivencia tras resección de metástasis craneal de hepatocarcinoma. Descripción de un caso y revisión de la literatura / Long survival after resection of cranial metastases from hepatocellular carcinoma. case report and review of the literature

En los últimos años, gracias a los recientes avances en el tratamiento del carcinoma hepatocelular (CHC), se ha incrementado la expectativa de vida de los pacientes con esta neoplasia. A su vez, las metástasis extrahepáticas de estos tumores, antes descritas ocasionalmente, son ahora más frecuentes en la práctica clínica diaria. La decisión en cuanto al tipo de actitud activa o pasiva en relación con estas lesiones metastásicas resulta, en ocasiones, un gran dilema para el clínico. Comentamos el caso de un paciente con CHC multifocal que presenta metástasis craneal de un tumor primario hepático y que, tras cirugía y radioterapia sobre la metástasis, presenta una supervivencia mayor a 3 años (AU)

The life expectancy of patients with hepatocellular carcinoma (HCC) has increased in the last few years due to recent treatment advances. However, extrahepatic metastases from tumors, previously described only occasionally, are becoming more frequent in clinical practice. The choice between an active or passive approach to these metastatic lesions can sometimes present clinicians with a difficult dilemma. We discuss the case of a male patient with multifocal HCC and cranial metastasis from a primary liver tumor and who, after surgery and radiotherapy over the metastatic lesion, has survived for more than 3 years (AU)

[Long survival after resection of cranial metastases from hepatocellular carcinoma. Case report and review of the literature]. / Larga supervivencia tras resección de metástasis craneal de hepatocarcinoma. Descripción de un caso y revisión de la literatura.

The life expectancy of patients with hepatocellular carcinoma (HCC) has increased in the last few years due to recent treatment advances. However, extrahepatic metastases from tumors, previously described only occasionally, are becoming more frequent in clinical practice. The choice between an active or passive approach to these metastatic lesions can sometimes present clinicians with a difficult dilemma. We discuss the case of a male patient with multifocal HCC and cranial metastasis from a primary liver tumor and who, after surgery and radiotherapy over the metastatic lesion, has survived for more than 3 years.