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.

Prevalence and factors associated with fibromyalgia in Mexican patients with systemic lupus erythematosus

In total, 189 consecutive women diagnosed with SLE were evaluated using the ACR 1990 criteria for fibromyalgia. Patients were classified into three subgroups. The fibromyalgia group (FM) included patients experiencing pain on palpation in at least 11 of the 18 tender points examined, as well as having a history of widespread pain for at least three months. Patients who were noted to have pain in fewer than four quadrants with less than 11 of 18 tender points were considered to have regional pain (RP). All patients who did not meet criteria for either FM or RP were classified as having no pain (NP). Measurement of SLE disease activity, sleep complaints, depression, fatigue severity and health status were performed. Only 18 of the SLE patients (9.5%) (95% CI 5.3-14%) fulfilled the ACR criteria for the classification of FM. Of the patients, 106 (56.1%) fulfilled criteria for RP and had a number of tender points of 5.4 +/- 3.4, and the rest of the patients (34.4%) had no tenderness at specific tender point sites. Age, body mass index, educational level and disease duration were comparable between the groups. FM and RP groups had different patterns of symptoms prevalence, with dysmenorrhea being more distinctive for FM. Sleep disturbances were more severe in the FM than in the RP group. Daytime complaints such as sleepiness, fatigue and depression were similar for RP and FM groups, but patients with FM reported more disability. Fibromyalgia is not common in Mexican patients with SLE and has a different pattern of symptoms in RP and NP patients. These data add evidence that ethnicity can play an important role in FM manifestations.

Objective and subjective sleep disturbances in patients with systemic lupus erythematosus

OBJECTIVE

To assess objective and subjective evidence of sleep disorders in patients with systemic lupus erythematosus (SLE) and to examine correlations between parameters of lupus activity, depression, and sleep disturbances.

METHODS

Fourteen SLE patients and 11 normal control subjects of similar age underwent all-night polysomnography on 3 consecutive nights. The patients and controls were also evaluated for daytime sleepiness by the Multiple Sleep Latency Test and completed a sleep disorders questionnaire and the Beck Depression Inventory.

RESULTS

The polysomnographic data showed that sleep in SLE patients was characterized by respiratory and movement disorders. These intrinsic primary sleep disorders are related to the symptom of restless, poor sleep at night. Lupus patients were more sleepy during the day, and their sleepiness was related to sleep fragmentation, with more arousals and stage transitions than the control group. Disease activity was associated with decreases in sleep efficiency and delta sleep and with increases in sleep fragmentation. Depression was not correlated with the activity of the disease.

CONCLUSION

There is an enhanced presence of sleep disorders in patients with SLE. The most frequent primary sleep disorders are respiratory and movement disorders.

[Cytokines and the liver]

The cytokines are proteins synthetized by lymphoid and monocyte/macrophage system cells in response to a wide variety of infectious stimulus, featuring bacterial endotoxins. These proteins have immunoregulatory effects and have been implicated in inflammation and fibrosis. In this review we refer to the interleukin-1, interleukin-6 and tumor necrosis factor because of their elevated basal levels in acute and chronic hepatopaties and in response to lipopolisacharide mainly in alcoholic liver disease.

Pathogenic and free-living protozoa cultured from the nasopharyngeal and oral regions of dental patients

Protozoa of nose, mouth, and pharynx of 30 randomly chosen female caries patients at an odontological clinic of the National Autonomous University of Mexico, were surveyed by culture from swabs. Culture tubes of swabs from each patient were observed every other day during 5 weeks. Pathogenic protozoa found included Entamoeba histolytica Schaudinn, 1903; Naegleria fowleri Carter, 1970; Acanthamoeba castelanii Douglas, 1930; Acanthamoeba culbertsoni Singh & Das, 1970; and Balantidium coli (Malmsten, 1857) Stein, 1862. This isolation of pathogens suggests that healthy patients may be healthy carriers of cysts of protozoa, mainly amoebae, responsible for several diseases, including primary amoebic meningoencephalitis. Small pathogenic free-living amoebae have not been isolated before from females in Mexico. Many species of free-living protozoa were also cultured from swabs from the patients.

Insensitivity to interferon of NK cells from patients with systemic lupus erythematosus

Natural cytotoxicity (NK) by fresh E-rosette-negative (ER-) cells from normal donors was increased after overnight incubation with purified IFN alpha and with supernatants containing IFN gamma. ER- cells from 61% of 23 patients with systemic lupus erythematosus did not show increased cytotoxicity after treatment with IFN alpha. Similarly, ER- cells from nine of 18 patients that were treated with IFN gamma-containing supernatants failed to show increased cytotoxicity. The patients who did not show enhanced cytotoxic responses to IFN had higher mean indices of disease activity than responding patients.

Long-term evaluation of colchicine in the treatment of scleroderma

Fifteen patients with PSS, 4 with CRST syndrome, and 4 with localized scleroderma have been treated with colchicine at the maximum tolerated individual doses for an average of 39 months (range 19--57). All but 2 of the 19 patients with generalized scleroderma and 3 of those with localized scleroderma improved. Patients who had had scleroderma for less than 5 yr when begun on colchicine, and those who received total doses of colchicine of more than 1,438 mg, scored a significantly higher mean response index than those with longer disease duration, or those who received less colchicine.

Immunofluorescent skin band test in the differential diagnosis of systemic lupus erythematosus

Forty-four uninvolved skin biopsies from lupus patients and 43 with various connective tissue diseases and nephritides other than lupus were tested for the presence of immunoglobulin deposition in the dermal-epidermal junction. Results were examined to determine their relationship to renal and clinical activity. Lupus band test (LBT) was positive in 30 (60%) SLE patients regardless of renal or clinical status. DNA-binding (p less than 0.01) and ANA (p less than 0.002) correlated to LBT. None of the other nephritides and only 2 with other connective tissue diseases were positive. LBT is a good aid in the differential diagnosis of SLE regardless of clinical or renal activity.

[Reynold's syndrome. A case report (author's transl)]

One case of the association of primary biliar cirrhosis and systemic sclerosis progressive (SSP) is described (Reynold's syndrome). This association has been reported in 21 patients. In our case the signs of liver disease precede two years the appearence of SSP. A review of the patients with Reynold's syndrome reported is done and compared with the present case. Diagnostic approach and management of this association is also discussed.