Blood culture-negative infective endocarditis: are we looking hard enough?

INTRODUCTION

Infective endocarditis is a common cardiac condition, with significant mortality. Blood culture-negative endocarditis is an important subgroup of endocarditis that holds significant morbidity and mortality.

METHOD

We performed an updated review of the literature. We searched the databases of Web of Science, MEDLINE, EMBAS and Scopus for the latest clinical guidelines and literature on blood culture negative endocarditis to provide a narrative synthesis of the literature.

RESULTS

There is significant heterogeneity in causes and complications of culture-negative infective endocarditis, due to an insensitivity in available clinical diagnostic pathways. Despite significant advances in diagnostic tools, the diagnostic criterion for infective endocarditis (the modified Duke's criterion) remains insensitive to the detection of culture-negative infective endocarditis.

CONCLUSION

The natural history of BCNE and our diagnostic resources are changing. It is time our criterion did too. Remembering, BCNE holds significant morbidity and mortality-the absence of organism of culture should not reassure, rather concern clinicians. Every effort should be made to accurately identify organisms.

Completion pneumonectomy via sternotomy and complete intrathoracic liver migration in metastatic osteosarcoma

Pulmonary metastasectomy is the well-accepted surgical management for recurrent osteosarcoma in the lung. A pneumonectomy is seldom performed, even more so via a sternotomy. We report an unusual case of a pneumonectomy via median sternotomy for a pulmonary metastasis with complete migration of the liver into the intrathoracic space, a complication rarely observed. The patient remains disease-free on follow-up, 21 years following the initial diagnosis. Aggressive approaches for metastasectomy, despite clinician hesitation in the age of minimally invasive surgery, can yield excellent outcomes for a cancer with otherwise poor prognosis.

Comparison of Lung Cancer Surgery Outcomes in Queensland for Indigenous and Nonindigenous Australians

Introduction

Indigenous Australians (Aboriginal and Torres Strait Islander) have lower overall survival from lung cancer compared with nonindigenous Australians. Indigenous Australians receive higher rates of chemotherapy and/or radiotherapy. The equity of peri-operative care and thoracic surgical outcomes in Australian indigenous populations have not been contemporarily evaluated.

Methods

We performed a retrospective registry analysis of the Queensland Cardiac Outcomes Registry Thoracic Database evaluating all adult lung cancer resections across Queensland from January 1, 2016 to April 20, 2022. Evaluating the time from diagnosis to surgery, operative data, and postoperative morbidity and mortality comparing Aboriginal and/or Torres Strait Islander people with nonindigenous Australians.

Results

There were 31 patients (2.56%) of 1208 who identified as indigenous. The mean age at surgery was 68.2 years versus 66 years in the indigenous and nonindigenous, respectively (p = 0.23). There was female predominance among indigenous patients (n = 28, 90.32%, p < 0.01) and the average body mass index was lower (22.52 versus 27.09, p < 0.01). There was no variation in the surgical parameters or histopathologic distribution of cancer type between groups. Multivariable logistic regression analysis suggested that indigenous patients were at elevated risk of blood transfusion (relative risk 3.9, p = 0.014, OR = 9.01, 95% confidence interval [CI]: 2.25-36.33, p < 0.01) and had greater transfusion requirements (risk ratio 4.08, p = 0.0116 and OR = 12.67, 95% CI: 2.25-71.49, p < 0.01); however, the influence of low absolute number of transfusions must be acknowledged here. Indigenous status was not associated with increased intensive care unit admission (OR = 1.79, 95% CI: 0.17-18.80, p = 0.62), return to operating theater (OR = 2.1, 95% CI: 0.24-18.15, p = 0.50), new atrial fibrillation (OR = 0.52, 95% CI: 0.07-4.01, p = 0.55), prolonged air leak (OR = 0.29, 95% CI: 0.04- 2.16, p = 0.228), or pneumonia postoperatively (OR = 4.77, 95% CI: 0.55-41.71, p = 0.16). With only three deaths, no meaningful trends were observed. Time from diagnosis to surgery was comparable in the indigenous and nonindigenous groups (88.6 d, 95% CI: 54.26-123.24 versus 86.2 d, 81.40-91.02, p = 0.87). Postoperative length of stay was not numerically or statistically different between groups. (indigenous 7.54 d versus nonindigenous 7.13 d, p = 0.90).

Conclusions

Indigenous patients are more likely to receive a blood transfusion than nonindigenous patients during lung resection. Reassuringly, the perioperative care provided to indigenous Australians undergoing lung resection in Queensland seems to be comparable to that of the nonindigenous population.

Pulmonary valve papillary fibroelastoma: to PE or not to PE

Pulmonary valve (PV) fibroelastomas are a rare pathology, with limited anecdotal literature surrounding them. Consequently, the natural history is unclear; however, two features have remained salient; they are asymptomatic and found incidentally. Here, we describe a 52-year-old female, presenting with symptoms suggestive pulmonary embolism (PE). Pulmonary angiography revealed a filling deficit in the pulmonary trunk (PT), adjacent to the PV. Subsequent investigation found a large PV fibroelastoma. The presence of symptoms is likely secondary to right ventricular outflow tract obstruction from the lesions large size. We describe our investigation and management of the lesion. The reporting of this case challenges the existing knowledge of PV fibroelastomas.

The influence of the COVID-19 pandemic on lung cancer surgery in Queensland

BACKGROUND

The coronavirus disease-19 (COVID-19) pandemic poses unprecedented challenges to global healthcare. The contemporary influence of COVID-19 on the delivery of lung cancer surgery has not been examined in Queensland.

METHODS

We performed a retrospective registry analysis of the Queensland Cardiac Outcomes Registry (QCOR), thoracic database examining all adult lung cancer resections across Queensland from 1/1/2016 to 30/4/2022. We compared the data prior to, and after, the introduction of COVID-restrictions.

RESULTS

There were 1207 patients. Mean age at surgery was 66 years and 1115 (92%) lobectomies were performed. We demonstrated a significant delay from time of diagnosis to surgery from 80 to 96 days (P < 0.0005), after introducing COVID-restrictions. The number of surgeries performed per month decreased after the pandemic and has not recovered (P = 0.012). 2022 saw a sharp reduction in cases with 49 surgeries, compared to 71 in 2019 for the same period.

CONCLUSION

Restrictions were associated with a significant increase in pathological upstaging, greatest immediately after the introduction of COVID-restrictions (IRR 1.71, CI 0.93-2.94, P = 0.05). COVID-19 delayed the access to surgery, reduced surgical capacity and consequently resulted in pathological upstaging throughout Queensland.

Thoracic Surgery and the Elderly; Is Lobectomy Safe in Octogenarians?

PURPOSE

Non-small cell lung cancer is the most common malignancy of the elderly, with 5-year survival estimates of 16.8%. The prognostic benefit of surgical resection for early lung cancer is irrefutable and maintained irrespective of age, even in patients over 75 years. Concerningly, despite the prognostic benefit of surgery there are deviations from standard treatment protocols with increasing age due to concerns of increased morbidity and mortality with surgery, without evidence to support this.

METHOD

A state-wide retrospective registry study of Queensland's Cardiac Outcomes Registry's (QCOR) Thoracic Database examining the influence of age on the safety of Lung Resection (1 January 2016-20 April 2022).

RESULTS

This included 1,232 patients, mean age at surgery was 66 years (range 14-91 years), with 918 thoracotomies performed. Three deaths occurred within 30-days (0.24%). Octogenarians (n=60) had lower rates of smoking (26% vs 6%), respiratory, cardiovascular, and cerebrovascular disease suggesting this subset of patients is carefully selected. Octogenarian status was not associated with an increased all-cause morbidity (p=0.09) or 30-day mortality (p=0.06). Further to this it was not associated with re-operation (4.4% vs 8.3%, p=0.1), increased postoperative stay (6.66 vs 6.65 days, p=0.99) or myocardial infarction. An independent predictor of morbidity was male sex (OR 1.58, CI 1.2-2.1 p=0.001).

CONCLUSION

Age ≥80 years did not increase surgical morbidity or mortality in the appropriately selected patient and should not be a barrier to referral for consideration of surgical resection.

Video-assisted thoracoscopic sympathectomy for Harlequin syndrome

Harlequin syndrome is an exceedingly rare condition, characterized by unilateral facial flushing and hyperhidrosis. Postulated to be dysregulated sympathetic nervous system stimulation of the dermal vasculature and blood vessels of the face. There is no clear unifying pathological cause. Due to its heterogeneity and rarity, very little is known about the treatment of it. Hereafter, we describe our experience in successfully curing right-sided Harlequin syndrome through video-assisted thoracoscopic sympathectomy.

Measurement of colony-stimulating factors in synovial fluid: potential clinical value

In this study, 100 synovial fluid (SF) samples from patients with a variety of arthritides were assayed for levels of colony-stimulating factors (CSFs) using a human bone-marrow bioassay and enzyme immunoassays for granulocyte (G-) and granulocyte-macrophage (GM-) CSFs. GM-CSF was found more frequently in samples from rheumatoid arthritis (RA) subjects (49%) than in non-RA samples (29%). Absence of GM- but not G- or bioassay CSFs characterised samples from subjects with psoriatic arthritis and ankylosing spondylitis (n = 14). There was strong evidence of an antagonistic relationship between levels of G- and GM-CSFs in samples from RA patients, an effect independent of drug treatment. However, treatment with non-steroidal anti-inflammatory agents (NSAIDs) may affect reported CSF concentrations: G-CSF levels were significantly lower in samples from subjects not taking NSAIDs. These results suggest that SF-CSF estimations using commercially available assays could provide useful diagnostic clues for clinicians, but careful interpretation is warranted particularly in patients on long-term NSAID treatment.

Diclofenac inhibits monocyte superoxide production ex vivo in rheumatoid arthritis

Effects of the nonsteroidal anti-inflammatory drug, diclofenac, on stimulated monocyte superoxide production were assessed directly in vitro and following treatment of patients with rheumatoid arthritis ex vivo. Diclofenac inhibited superoxide generation provoked by serum treated zymosan (STZ) and fluoride anion (F) but not by phorbol myristate acetate (PMA) in vitro. Following patient therapy, inhibition of superoxide production occurred when STZ and PMA, but not F were used as stimuli. No changes were seen in control subjects. The contrasting profiles of inhibition seen in vitro and ex vivo suggest an indirect effect on superoxide production during clinical use of the agent. These data are consistent with the hypothesis that anti-inflammatory drugs may act in rheumatoid arthritis by inhibiting phagocyte superoxide anion production.

Detection and partial characterization of human B cell colony stimulating activity in synovial fluids of patients with rheumatoid arthritis

The joint fluids of 37 patients with rheumatoid arthritis, eight patients with traumatic injuries to their joints, two patients with Reiter's syndrome and three patients with psoriatic arthritis were tested for the presence of B cell colony stimulating activity (B cell CSA). B cell CSA was found in all of the joint fluids from the patients with rheumatoid arthritis but in none of the joint fluids from patients with traumatic injuries to their joints or in the joint fluids from the patients with Reiter's syndrome. A trace of B cell CSA was found in the joint fluid of one of the three patients with psoriatic arthritis. There was a positive correlation (r = 0.796) between the amount of rheumatoid factor present in the joint fluids and the titre of B cell CSA. This correlation was highly significant (P less than 0.001). The B cell CSA was localized to component(s) with molecular weight ranges 115-129 kD and 64-72 kD and an isoelectric point of 6.8. Its activity was sensitive to reduction with 2-mercaptoethanol and to the oxidising action of potassium periodate.