Risk scores' performance and their impact on operative decision-making in left-sided endocarditis: a cohort study

The accuracy of contemporary risk scores in predicting perioperative mortality in infective endocarditis (IE) remains controversial. The aim is to evaluate the performance of existent mortality risk scores for cardiovascular surgery in IE and the impact on operability at high-risk thresholds. A single-center retrospective review of adult patients diagnosed with acute left-sided IE undergoing surgery from May 2014 to August 2019 (n = 142) was done. Individualized risk calculation was obtained according to the available mortality risk scores: EuroScore I and II, PALSUSE, Risk-E, Costa, De Feo-Cotrufo, AEPEI, STS-risk, STS-IE, APORTEI, and ICE-PCS scores. A cross-validation analysis was performed on the score with the best area under the curve (AUC). The 30-day survival was 96.5% (95%CI 91-98%). The score with worse area under the curve (AUC = 0.6) was the STS-IE score, while the higher was for the RISK-E score (AUC = 0.89). The AUC of the majority of risk scores suggested acceptable performance; however, statistically significant differences in expected versus observed mortalities were common. The cross-validation analysis showed that a large number of survivors (> 75%) would not have been operated if arbitrary high-risk threshold estimates had been used to deny surgery. The observed mortality in our cohort is significantly lower than is predicted by contemporary risk scores. Despite the reasonable numeric performance of the analyzed scores, their utility in judging the operability of a given patient remains questionable, as demonstrated in the cross-validation analysis. Future guidelines may advise that denial of surgery should only follow a highly experienced Endocarditis Team evaluation.

Effect of feeding fresh forage plantain (Plantago lanceolata) or ryegrass-based pasture on methane emissions, total-tract digestibility, and rumen fermentation of nonlactating dairy cows

Plantain (Plantago lanceolata) is an herb used to reduce the forage deficit of ryegrass-based pastures during the summer. This herb is being promoted for its reduced environmental impact in terms of nitrogen emissions, particularly reducing urinary nitrogen. However, the effect of plantain on emissions of enteric CH₄, the main greenhouse gas produced from ruminant-based production systems, is not known. The aim of the present trial was to determine CH₄ emissions and rumen fermentation characteristics of nonlactating dairy cows fed 100% plantain (PLT) or 100% perennial ryegrass (RG; Lolium perenne) in 2 experiments (E1 and E2). The forages were in a vegetative growth stage in E1 and were in a reproductive growth stage in E2. Methane emissions from 16 cows in each experiment were measured in respiration chambers for 2 d. Methane emissions per unit of dry matter intake (CH₄ yield) were 15 and 28% less for cows fed PLT than those fed RG in E1 and E2, respectively. Dry matter digestibility of PLT was 7 and 27% less than that of RG in E1 and E2, respectively, and CH₄ per unit of dry matter digested was similar for PLT and RG in both experiments. There were only minor (but some significant) differences in rumen fermentation characteristics between cows fed PLT and RG in both experiments. In conclusion, CH₄ yield was lower for cows fed PLT compared with those fed RG in both experiments and this reduction was largely explained by the lesser dry matter digestibility of PLT.

Extracellular Polymeric Substances (EPS) produced by Streptomyces sp. biofilms: Chemical composition and anticancer properties

The extracellular polymeric substances (EPS) have shown free radical scavenging and antitumor activity against both breast and colon cell lines. In this regard, actinobacteria have become an increasingly popular sources of EPS. Therefore, in this study four Streptomyces strains isolated from contaminated soil (M7, A5, A14 and MC1) were evaluated for determining its biofilm-forming capacity including under pesticide stress. In addition, chemical composition of EPS and its cytotoxic effects over 4T1 breast cancer cell and Caco-2 human tumor colon cells were evaluated. The results demonstrated that Streptomyces sp. A5 had the highest capability to develop biofilm more than other strains tested, even under pesticide stress. Moreover, this strain produced EPS with a total protein/total polysaccharide rate of 1.59 ± 0.05. On the other hand, cytotoxicity assays of EPS showed that Streptomyces sp. A5 display a higher toxic effect against 4T1 Breast cancer cells (96.2 ± 13.5 %), Caco-2 (73.9 ± 6.4 %) and low toxicity (29.9 % ± 9.1 %) against non-transformed intestinal cells (IEC-18). Data do not show cytotoxic effect relationship with biofilm-forming capabilities of strains, nor the chemical composition of EPS matrix. The gene that codes for polysaccharide deacetylase, parB-like and transRDD proteins, were identified. These results contribute to the knowledge about the variability of chemical composition and potential cytotoxic properties of EPS produced by Streptomyces biofilms. It proposes interesting future challenges for linking Streptomyces-based pesticide remediation technology with the development of new antitumor drugs.

Predictive factors for requiring heart transplantation in patients with hypertrophic cardiomyopathy: data from a referral center

Background

Heart transplant (HT) remains the last treatment option for patients with non-obstructive hypertrophic cardiomyopathy (HCM) who develop end-stage heart failure (HF). Early identification of patients who may require a HT in the future is crucial in order to advise them, establish the appropriate follow-up and determine the appropriate time to include them in the waiting list.

Objectives

Our study sought to find predictive factors related with requiring HT during follow-up in patients with HCM.

Methods

Consecutive patients with HCM referred to a HCM monographic clinic from 2018 to 2020 (HCM controls) and transplanted patients due to HCM in the same tertiary HT hospital since 2003 (cases) were included. Baseline (on the date of HCM diagnosis) and longitudinal data regarding clinical, genetic, ECG and echocardiographic variables were retrospectively evaluated. Follow-up was registered from HCM diagnosis to HT (in cases) or last medical check up (controls).

Results

A total of 157 patients (24 HCM-HT cases and 133 HCM controls) were included (45±19 yo; 57% male). At the time of MCH diagnosis (Table), cases were significantly younger than controls, were more frequently symptomatic and showed significantly higher BNP levels and more advanced diastolic dysfunction (larger left atrium, higher E/A ratio and lower e'); also, HCM-HT reported more family history and had higher proportion of pathogenic mutations (being MYH7 the most frequently involved). Left ventricular (LV) systolic function was slightly reduced in HCM-HT cases. In contrast, HCM controls were more frequently diagnosed by casual findings or family screening and had more LV outflow tract obstruction at first medical evaluation. LV maximal wall thickness (MWT) did not differ between groups. During a median follow-up since HCM diagnosis of 6.2 years (median follow-up of 8.9 and 7.1 years in cases and controls, respectively), HCM-HT cases presented a higher incidence of sustained ventricular tachycardia or ICD therapy (HR=4.0; CI95%:1.6–10.0 p=0.03) and HF admissions (HR=3.9; CI95%:1.8–8.1 p<0.001). There were no cardiovascular deaths during follow-up.

Conclusions

The presence of symptoms in a young non-obstructive HCM patient, along with family history and a pathogenic mutation, should advice clinicians a closer follow-up and early transfer to a HT referral center, especially if associated with diastolic dysfunction and high BNP values.

Funding Acknowledgement

Type of funding sources: None. Table 1

SEDAR/SECCE ECMO management consensus document

ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.

COVID-19: from epidemiology to treatment

The COVID-19 pandemic has greatly impacted the daily clinical practice of cardiologists and cardiovascular surgeons. Preparedness of health workers and health services is crucial to tackle the enormous challenge posed by SARS-CoV-2 in wards, operating theatres, intensive care units, and interventionist laboratories. This Clinical Review provides an overview of COVID-19 and focuses on relevant aspects on prevention and management for specialists within the cardiovascular field.

Does acetabular coverage influence the clinical outcome of arthroscopically treated cam-type femoroacetabular impingement (FAI)?

Aims

What represents clinically significant acetabular undercoverage in patients with symptomatic cam-type femoroacetabular impingement (FAI) remains controversial. The aim of this study was to examine the influence of the degree of acetabular coverage on the functional outcome of patients treated arthroscopically for cam-type FAI.

Patients and Methods

Between October 2005 and June 2016, 88 patients (97 hips) underwent arthroscopic cam resection and concomitant labral debridement and/or refixation. There were 57 male and 31 female patients with a mean age of 31.0 years (17.0 to 48.5) and a mean body mass index (BMI) of 25.4 kg/m² (18.9 to 34.9). We used the Hip2Norm, an object-oriented-platform program, to perform 3D analysis of hip joint morphology using 2D anteroposterior pelvic radiographs. The lateral centre-edge angle, anterior coverage, posterior coverage, total femoral coverage, and alpha angle were measured for each hip. The presence or absence of crossover sign, posterior wall sign, and the value of acetabular retroversion index were identified automatically by Hip2Norm. Patient-reported outcome scores were collected preoperatively and at final follow-up with the Hip Disability and Osteoarthritis Outcome Score (HOOS).

Results

At a mean follow-up of 2.7 years (1 to 8, sd 1.6), all functional outcome scores significantly improved overall. Radiographically, only preoperative anterior coverage had a negative correlation with the improvement of the HOOS symptom subscale (r = -0.28, p = 0.005). No significant difference in relative change in HOOS subscale scores was found according to the presence or absence of radiographic signs of retroversion.

Discussion

Our study demonstrated the anterior coverage as an important modifier influencing the functional outcome of arthroscopically treated cam-type FAI. Cite this article: Bone Joint J 2018;100-B:831-8.

Sheep from low-methane-yield selection lines created on alfalfa pellets also have lower methane yield under pastoral farming conditions

Selection lines of sheep with low and high CH yield (g/kg DMI; CH/DMI) are being developed on the basis of feeding pelleted alfalfa hay at 2.0 times maintenance ME requirements in respiration chambers, but their divergence under predominant grazing conditions, as in New Zealand, is not known. The objectives of this study were to determine CH emissions and rumen fermentation characteristics in sheep from low and high CH/DMI selection lines while grazing pasture. Two grazing experiments were conducted with 42 selection line ewes in March 2013 (Exp. 1) and 98 selection line progeny ewe hoggets in October/November 2014 (Exp. 2), with CH emissions estimated by the SF tracer technique and DMI estimated by titanium oxide in combination with natural long-chain -alkanes. Total daily CH production (g/d) was similar between high and low CH/DMI selection line sheep in Exp. 1 and lower for low CH/DMI progeny compared with high CH/DMI progeny in Exp. 2 ( < 0.05). The CH/DMI tended to be 20% lower for low CH/DMI line sheep compared with high CH/DMI selection line sheep in Exp. 1 ( < 0.10) and was 15% lower for the low CH/DMI line in Exp. 2 ( < 0.01). Total VFA concentration and concentrations (m) of acetate, butyrate, and isobutyrate plus isovalerate were lower ( < 0.05) for low CH/DMI line sheep compared with high CH/DMI selection line sheep in both experiments. The current study indicates that differences in CH/DMI and VFA concentrations in selection line sheep, previously established on alfalfa pellets, are also present to a similar magnitude when grazing pasture.

Methane emissions differ between sheep offered a conventional diploid, a high-sugar diploid or a tetraploid perennial ryegrass cultivar at two allowances at three times of the year

Elevated water-soluble carbohydrate (WSC) concentration in the diet may affect rumen fermentation and consequently reduce methane (CH4) emissions. The objective of the present study was to determine CH4 emissions from male sheep (8 per treatment) in respiration chambers for 48 h and fed either a conventional diploid (CRG), a high-sugar diploid (HSG) or a tetraploid (TRG) perennial ryegrass cultivar, each offered at 0.7 or 1.0 kg dry matter (DM)/day during periods in early spring 2013 (P1), early autumn 2014 (P2) and late spring 2014 (P3). There was a significant (P < 0.001) interaction between cultivar and period for CH4 yield (g/kg DM intake). In P1 yield was 9% lower (P = 0.007) for sheep fed HSG than for sheep fed CRG or TRG, in P2 yield was 16% lower (P < 0.001) for sheep fed TRG than that for sheep fed CRG or HSG, and in P3 yield was 15% lower (P < 0.001) for sheep fed TRG than that for sheep fed CRG, with HSG-fed sheep being intermediate and not significantly different from either CRG or TRG. Despite there being a cultivar × period interaction, overall, CH4 yield was lower for sheep fed HSG or TRG than for sheep fed CRG (P < 0.001). There were no cultivar × level of feed offer interactions and, overall, yield of CH4 was 9% higher (P = 0.003) for sheep offered 0.7 than for sheep offered 1.0 kg DM/day. In each period, one or other of the high-WSC diploid (HSG) or tetraploid cultivars (TRG) gave lower CH4 yields than did the control diploid (CRG), suggesting that CH4 yield is reduced by characteristics of these cultivars. However, the effect was not consistently associated with either cultivar and could not be attributed to higher forage water-soluble carbohydrate concentrations.

Prolonged incubation time does not increase sensitivity for the diagnosis of implant-related infection using samples prepared by sonication of the implants

We have designed a prospective study to evaluate the usefulness of prolonged incubation of cultures from sonicated orthopaedic implants. During the study period 124 implants from 113 patients were processed (22 osteosynthetic implants, 46 hip prostheses, 54 knee prostheses, and two shoulder prostheses). Of these, 70 patients had clinical infection; 32 had received antibiotics at least seven days before removal of the implant. A total of 54 patients had sonicated samples that produced positive cultures (including four patients without infection). All of them were positive in the first seven days of incubation. No differences were found regarding previous antibiotic treatment when analysing colony counts or days of incubation in the case of a positive result. In our experience, extending incubation of the samples to 14 days does not add more positive results for sonicated orthopaedic implants (hip and knee prosthesis and osteosynthesis implants) compared with a conventional seven-day incubation period.

Cite this article: Bone Joint J 2013;95-B:1001–6.

Sonication of intramedullary nails: clinically-related infection and contamination

BACKGROUND AND AIM

Sonication is currently considered the best procedure for microbiological diagnosis of implant-related osteoarticular infection, but studies in nail-related infections are lacking. The study aim was to evaluate implant sonication after intramedullary nail explantation, and relate it to microbiological cultures and clinical outcome.

PATIENTS AND METHODS

A study was performed in two University Hospitals from the same city. Thirty-one patients with implanted nails were prospectively included, whether with clinical infection (8 cases) or without (23 cases). Retrieved nails underwent sonication according a previously published protocol. The clinical and microbiological outcome patient was related to the presence of microorganisms in the retrieved implant.

RESULTS

Positive results appeared in 15/31 patients (9 with polymicrobial infections) almost doubling those clinically infected cases. The most commonly isolated organisms were Staphylococcus epidermidis (19.2 %) and Staphylococcus aureus (15.4 %). A significant relationship was found between the presence of positive cultures and previous local superficial infection (p=0.019). The presence of usual pathogens was significantly related to clinical infection (p=0.005) or local superficial infection (p=0.032). All patients with positive cultures showed pain diminution or absence of pain after nail removal (15/15), but this only occurred in 8 (out of 16) patients with negative cultures.

CONCLUSIONS

In patients with previously diagnosed infection or local superficial infection, study of the hardware is mandatory. In cases where pain or patient discomfort is observed, nail sonication can help diagnose the implant colonization with potential pathogens that might require specific treatment to improve the final outcome.

Surgical treatment of trans-scaphoid, transcapitate, transtriquetral, perilunate fracture-dislocation with open reduction, internal fixation and lunotriquetral ligament repair

This paper presents a rare case of trans-scaphoid, transcapitate, transtriquetral, perilunate fracture-dislocation of the right wrist as a result of a motorcycle accident. Open reduction and internal fixation of the scaphoid and capitate with one screw was performed and the lunotriquetral ligament was repaired using a suture anchor.