History Of Intravenous Drug Abuse Research Articles

OUTCOMES OF PRIMARY JOINT REPLACEMENT IN PATIENTS WHO ARE INTRAVENOUS DRUG USERS: A SYSTEMATIC REVIEW

Arthroplasty in patients who are intravenous drug abusers presents a complex challenge, frequently requiring intervention at a younger age. The cohort suffer increased complication rates due to significant co-morbidities and poor engagement in medical services, in comparison to other patients undergoing lower limb arthroplasty. Multiple small studies show arthroplasty in this patient cohort is associated with high complication and mortality rates.A search of electronic databases were undertaken with the assistance of the library services from the Rotherham NHS Foundation Trust, including Chocraine, SCOPUS and PubMed.Abstracts were reviewed and relevant studies extracted for full review. Full text articles were reviewed based on strict inclusion and exclusion criteria.Searches identified Two thousand and forty-four papers; twenty-seven studies were identified for full review of the paper based on the inclusion criteria above. From this, nine studies were deemed appropriate to for data extraction.These nine papers present one hundred and thirty-two cases of lower limb arthroplasty, fifty nine Total Knee Arthroplasty and seventy three Total Hip Arthroplasty. From this the authors examined incidences of implant failure due to infection, revision, mortality, dislocation, aseptic loosening, peri-prosthetic fracture, or other causes. Of these, 58% of patients (n = 77) with a history of intravenous drug abuse suffered some form of significant complication; 4% of this cohort (n = 5) were lost to follow up. Infection was reported in 32% of cases and a mortality rate of 4.7%.The rising demand of lower limb arthroplasty for intra-venous drug abusers presents a very real problem for the modern Orthopaedic surgeon. Within the studies examined, more than half report implant failure. This study synthesises the available literature regarding treatment of these patients to help facilitate decision making and informed consent.

Risk Factors Associated with Pyogenic Spinal Infections among Intravenous Drug Users and Nonusers.

To identify the differences in patient factors, presentation, treatment course, and outcomes of intravenous drug users (IVDA) vs. nonusers (non-IVDA) presenting with pyogenic spinal infections. Study Design/Setting. Retrospective case series. We identified all cases involving spinal infections at our institution between May 2017 and January 2023. Postsurgical infections were excluded, and patients were separated into IVDA and non-IVDA groups. The patient charts were reviewed and analyzed for statistical or clinically significant differences using RStudio (2019 version 3.6.2). Our institutional review board approved this study, IRB# 2020-277, iRISID-2023-1384. Fifty patients (29 males and 21 females) with primary pyogenic spinal infections were included in our study. There were fourteen patients (28.0%) in the IVDA group. The mean age in the IVDA group was 50.6 vs. 61.9 years (p < 0.05) in the non-IVDA group. The average length of stay (LOS) in the IVDA group was 15.8 vs. 14.0 days (p = 0.54) in the non-IVDA group, with no significant difference in readmissions or disposition. Twenty-three non-IVDA patients were diagnosed with diabetes, while eight IVDA patients had a psychiatric diagnosis (other than substance abuse). There were no significant differences in microbial isolate or the duration of antibiotics. In our study population, there is a high incidence of intravenous drug abuse (IVDA), psychiatric disease, diabetes, and chronic kidney disease. Analysis shows a trend of two distinct patient populations. Patients without a history of IVDA were significantly older than those with IVDA and significantly more likely to have medical comorbidities including hyperlipidemia, diabetes, chronic kidney disease, and malignancy than those with IVDA history. Patients with IVDA were younger with significantly higher rates of smoking and psychiatric disorders. IVDA patients struggled to receive continued psychiatric/addiction treatment after discharge, an area for significant improvement. Due to a small sample size and single urban institution setting, this study may be underpowered to demonstrate differences in healthcare resource consumption.

Simultaneous Multifocal Intracranial Haemorrhages Associated with Staphylococcus Aureus Endocarditis: A Plausible Role for Diclofenac Administration.

Intracranial haemorrhage may complicate infective endocarditis, caused by ruptured mycotic aneurysms or haemorrhagic transformation of brain septic emboli. The risk of intracranial bleeding may increase with the use of non-steroidal anti-inflammatory agent (NSAIDs). We report on a 53-year-old male patient with a past history of intravenous drug abuse, who was treated with diclofenac (75 mg IM) for a few hours of preceding fever and arthralgia. Seven hours later he was hospitalised with impaired consciousness and hemiparesis. Evaluation revealed multiple intracranial haemorrhages, at least one originating from a mycotic aneurysm. Repeated blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA), and echocardiography revealed a vegetation on the mitral valve, establishing the diagnosis of bacterial endocarditis. The abrupt simultaneous multifocal intracranial bleeds shortly following the administration of NSAIDs for a few hours of febrile disease, one clearly originating from a mycotic aneurism, are exceptional. This raises a possibility of a role for diclofenac the intracranial bleeding diathesis in this unique clinical presentation. Intracranial haemorrhage in the set-up of undiagnosed infective endocarditis (IE) might be added to the long list of potential adverse outcomes of NSAID administration, and the possibility of IE should be considered before their administration for febrile disease of undetermined cause. Intracranial haemorrhage in the set-up of undiagnosed infective endocarditis might be added to the long list of potential adverse outcomes of NSAID administration.The possibility of infective endocarditis should be considered before the administration of NSAIDs for febrile disease of an undetermined cause.

Right ventricular pneumatosis and extensive multi-territory air emboli in an intravenous drug user: a case report

Abstract Background Air emboli are a life-threatening diagnosis, which may form through a range of mechanisms. In this case, we describe the case of extensive multi-territory air emboli in a patient with a history of intravenous drug abuse. Case summary This case describes a 41-year-old male who presented with confusion following fall with long lie. He was diagnosed with hyperkalaemia, renal failure, rhabdomyolysis, and compartment syndrome, and he developed extensive multi-territory air emboli. Air embolism was identified in arterial, venous, subcutaneous, and mediastinal territories. Echocardiography demonstrated right ventricular dilation and dysfunction, consistent with air visualized in the right coronary artery on computed tomography. The patient was transferred to the intensive care unit for close cardiac and neurological monitoring and supportive organ care, and ultimately made an uneventful recovery by 6 weeks without apparent complications from the air emboli. Discussion The presence of multi-territory air emboli has previously been described in the setting of surgery, manipulation of intravascular catheters, pulmonary barotrauma, and in sepsis with gas-forming organisms. It has not previously been reported in intravenous drug use or sterile rhabdomyolysis. Computed tomography imaging and echocardiography are useful to diagnose air emboli and their haemodynamic impact. Our patient’s case provides a novel example of multi-territory air emboli in a unique scenario.

Clinical Profile of Necrotising Soft Tissue Infection Patients in a North Indian Hospital

Background: Necrotizing soft tissue infections (NSTIs) or necrotizing fasciitis are infections of the subcutaneous tissue and fascia with variable involvement of the overlying skin and underlying muscle. They can be initiated by trivial injuries and can be idiopathic. Material &amp; Methods: It is an retrospective observational study conducted in our surgical unit of a tertiary care centre, from January 2017 to December 2022, were observed for age, gender, occupation, socioeconomic status, body mass index (BMI) clinical features, radiological findings (size, site, status, involvement of tissue compartments and bone). A total of 118 patient records were analyzed. Results: 60% patients were over 50 years of age and 64.2% were males. 69.85 cases had body mass index more than 30 kg/m2. 50.9% patients had history of alcohol abuse and 32.1% cases gave history of intravenous drug abuse. 73.6% cases had foul smelling discharge on presentation while fever and sepsis was seen in 64.2% and 52.8% cases, respectively. Lower limb and perineal involvement was seen in more than two third of the cases. 69.4% cases were anaemic while 44.1% had hypoalbuminemia. More than 85% cases had leucocytosis. 40.7% cases required ionotropes and 22.03% cases needed ventilatory support on admission. Diabetes mellitus was the most common associated co morbidity, seen in 53.4% cases. Conclusion: The necrotizing soft tissue infections are a significant health problem and carry high mortality and morbidity rates. The condition carries high association with modifiable risk factors like anaemia, hypoalbuminemia, diabetes mellitus and obesity.

Disseminated Kaposi’s sarcoma as the sole clinical manifestation in an intravenous drug abuse patient with acquired immunodeficiency syndrome

A 31-year-old married acquired immunodeficiency syndrome (AIDS) male patient with clonal differentiation 4 count of 162 cells/mm3 and history of intravenous drug abuse presented with multiple discrete hyperpigmented and violaceus papules and plaques distributed on the trunk, upper and lower extremeties, medial canthi of the right eye, and the glans penis. He had also generalized lymphadenopathy. Biopsy of the papules and lymph node showed features of Kaposi’s sarcoma (KS). There were no other systemic or cutaneous manifestations. We are reporting an interesting case of AIDS acquired through I/V drug abuse and presenting only with dessiminated KS and no other features.

Mechanical extraction of a pulmonary valve vegetation in a patient with endocarditis.

A 44-year-old male known with small ventricular septal defect, but no previous history of intravenous drug abuse presented to an outside hospital with fever, chills, and back pain. A chest computed tomography showed multifocal nodular and consolidative pulmonary opacities with borderline enlarged mediastinal lymph nodes (Panel, A). Blood cultures grew Staphylococcus lugdunensis; given suspicion of infective endocarditis causing septic pulmonary emboli, he was transferred to our hospital. Transoesophageal echocardiography (TEE) on admission showed highly mobile masses attached to the native tricuspid (B) and to the sub-pulmonary area of the right ventricular outflow tract along with posterior leaflet perforation of the tricuspid valve with mild-to-moderate regurgitation (C). The sub-pulmonary lesion was in the path of the high-velocity left-to-right jet through the ventricular septal defect (D; Supplementary data online, Video S1), explaining the unusual location. Patient had persistent bacteremia despite appropriate antibiotic therapy and eventually developed haemoptysis and acute respiratory failure requiring intubation. At repeat TEE showed interval increase in the size of the sub-pulmonic vegetations. In the absence of haemodynamically significant lesions, the multidisciplinary team recommended percutaneous transcatheter mechanical vegectomy rather than surgical intervention.

Acute Pulmonary Embolism with Multiple Septic Emboli and Pulmonary Infarcts in an IV Drug Abuser with Right-Sided Endocarditis: A Case Report

This case report describes the imaging findings of septic pulmonary embolism (SPE) in a 30-year-old male with a history of intravenous drug abuse for one year. The patient initially presented with high grade fever, shortness of breath, and cough in the emergency department of our institution. The patient was evaluated by chest X-ray, blood cultures, echocardiography, and CT pulmonary angiography which confirmed the diagnosis of SPE, and the causative organism was confirmed to be Staphylococcus aureus. In this case report, we discuss the Chest X-ray findings, and characteristic CT imaging findings of SPE and describe the role of different imaging modalities in the timely diagnosis and management of this highly fatal condition.

Abstract 10996: Clinical Characteristics and Outcomes of Infective Endocarditis Among Intravenous Drug Abusers - A Single-Center Experience

Introduction: There are limited data regarding intravenous drug abuse (IVDA) associated with infective endocarditis (IE). The study aimed to compare IVDA to non-IVDA-associated IE regarding the differences in clinical profile, microbiology, echocardiography, and clinical outcomes among patients admitted with IE. Methods: 90 patients from January 2019 to December 2021 who met the Modified Duke ‘‘definitive’’ criteria for IE were included. Demographic, clinical, and laboratory data were collected. All patients underwent transthoracic echocardiography and transesophageal echocardiogram whenever indicated. In-hospital morbidity and mortality were reported. Results: Among the 90 patients included, 24 (26.7%) had a history of IVDA. IVDA-group were younger (27 vs 40 years, P&lt;0.0001), males (95.8% vs 69.7%, P=0.01), and more likely to have concomitant HCV and HIV infections compared to non-IVDA-group (50% vs 3%, P&lt;0.0001). Methicillin-resistant staphylococcus aureus (MRSA) percentage was higher in IVDA-group (54.2% vs 16.7%, P= 0.0004). Tricuspid value was the most common valve (79.2%) affected in IVDA-group whereas mitral followed by aortic valves were most commonly involved in non-IVDA-group (43.9% and 31.8% respectively). Embolic events at admission were more frequent in IVDA-group (83.3% vs 15.2%, P&lt;0.0001). Septic shock and embolic events (58.3%, 37.5% consecutively) are the most common causes of in-hospital morbidity among IVDA-group. In-hospital mortality was significantly higher among IVDA-group compared to non-IVDA-group (58.3% vs 25.8%, P=0.04). Conclusion: The demographic, microbiological, and echocardiographic profile is quite different in IVDA and non-IVDA-group. Larger studies are required to confirm these data, especially in low- and middle-income countries.

Frequency of Hepatitis C Virus and Human Immunodeficiency Virus Coinfection among Intravenous Drug Abusers; Experience from A Single Rehabilitation Center

Objectives: To determine the frequency of Hepatitis C virus and Human Immunodeficiency Virus (HIV) Coinfection among Intravenous drug abusers in a rehabilitation Centre.&#x0D; Study Design: Cross-sectional analytical study.&#x0D; Place and Duration of Study: Medical and Rehabilitation Centre of District Jail, Lahore Pakistan, from Jul to Dec 2019.&#x0D; Methodology: A total of 220 participants with a history of intravenous drug abuse were screened for Human immunodeficiency virus, Hepatitis C virus, and hepatitis B virus, with positive cases confirmed by polymerase chain reaction tests.&#x0D; Results: The median was age 27(8.0) years. Only 12 (5.5) had above higher secondary education. Injectable heroin and metamphetamine used by the respondents were 182 (82.7) and 41 (22.5), respectively. Human immunodeficiency virus infection was present in 163 (74.1), Hepatitis C infection in 149 (67.7), Hepatitis B infection in 9 (4.09), and co-infection of human immunodeficiency and hepatitis C virus infections in 118 (53.6) respectively. Human immunodeficiency virus infection showed a significant association with education level (p&lt;0.01) and drug use (p=0.01). Hepatitis C infection showed association with marital status (p=0.04), religion (p&lt;0.01) and drugs used, while Co-infection showed association with religion and drug used (p=0.01 and p=0.004 respectively).&#x0D; Conclusion: Intravenous drug users have a significantly higher prevalence of Human immunodeficiency and hepatitis C infection and their co-infection, occurring in more than half of injectable users. In addition, these infections show significant association with education status, marital status and type of injectable drug used.

An Unusual Presentation of an Appendiceal Adenocarcinoma

Question: An 84-year-old woman presented with a 2-week history of a lump in the right groin that had gradually become more swollen and tender (Figure A). The patient had no significant or relevant past medical history, including no history of intravenous drug abuse, and no personal or family history of cancer. On examination, the patient had a firm, tender, swelling in the right groin area with surrounding cellulitis but no obvious fluctuance. The patient was afebrile on admission with a neutrophil count of 7.0, white cell count of 10.0, and a slightly elevated C-reactive protein count of 52.0.

P333 INFECTIVE ENDOCARDITIS ON TRICUSPID VALVE CAUSED BY S. AUREUS METHICILLIN RESPONSIVE: RESOLUTION AND RECURRENCE OF DISEASE

Abstract Introduction Tricuspid valve endocarditis accounts for 5–10% of endocarditis cases and is more frequent in intravenous drug abusers. Recurrence of endocarditis occurs not infrequently in patients treated with conservative therapy. Clinical Case In June 2021, a 32–year–old man with a history of intravenous drug abuse came to our observation. He had been presenting for about a week high fever with shaking shivering resistant to antipyretic and antibiotic therapy and laboratory tests with neutrophilic leukocytosis with increase in CRP and procalcitonin. Trans–thoracic echocardiogram was performed and it showed mild tricuspid regurgitation with the presence of filamentous mobile isoechoic formations adhering to the valve leaflets compatible with endocarditic vegetations. A trans–esophageal echocardiogram was performed that confirmed the transthoracic finding of endocarditis on the tricuspid valve with evidence of 11 mm mobile oval vegetation adhering to the posterior flap; blood cultures were positive for methicillin susceptible S. Aureus and antibiotic therapy with oxacillin was administered as a continuous infusion for 6 weeks. The cardiac surgery center was consulted and the surgeons did not indicate any intervention because of the normofunction of the tricuspid valve and the absence of embolic phenomena on total body CT. Subsequent laboratory tests showed negative inflammation indices and negative surveillance blood cultures. Control ETE was planned with the confirmation of complete resolution of endocardial lesions. In September the patient affered the emergency room for an accidental fall from a work vehicle: transthoracic and trans–esophageal echocardiograms were repeated for the concomitant finding of hyperpyrexia and cough with an increase in CRP and procalcitonin. They showed the presence of new larger endocarditic lesions on tricuspid valve with moderate regurgitation. Blood cultures were negative. Antibiotic therapy with oxacillin was reintroduced and the patient was transferred to the infectious disease clinic in prevision of cardiac surgery.

External Review and Validation of a Spinal Epidural Abscess Predictive Score for Clinical Failure

Spinal epidural abscess (SEA) is a rare but serious pathology that may result in delayed neurologic injury despite treatment with antibiotic therapy or surgery. Given this, the development of predictive scores for risk stratification has value in clinical decision making; however, external validation is necessary to understand their generalizability and reliability. A retrospective review was conducted of all patients presenting with SEA at a single institution. Patients were reviewed and graded according to the proposed SEA predictive score by Baum etal. Clinical failure was defined as documented laboratory or radiographic progression requiring surgical intervention, increased deformity requiring surgical intervention, or repeat surgical intervention if prior surgical intervention was undertaken as the initial treatment strategy. Brier score and receiver operating characteristic were used to calculate reliability. There were 224 patients presenting with primary spinal infections with associated SEA. Of these, 209 patients had no history of intravenous drug abuse. Clinical failure was demonstrated in 52 of 209 patients (24.9%). Antibiotic treatment alone compared with antibiotic therapy and surgical treatment on initial presentation was found to have a significantly greater chance of clinical failure (odds ratio= 3.0930, P= 0.01). The proposed epidural abscess prediction score did not correlate with clinical outcomes with a Brier score of 0.229 and receiver operating characteristic area under the curve of 0.5944. The proposed risk stratification scale for patients was not correlated with risk of clinical failure. Additionally, patients treated with antibiotics and surgical intervention on initial presentation had a significantly lower clinical failure rate.

Pedicled Soleus Muscle Flap for Salvage Therapy of Chronic Limb-Threatening Tibial Osteomyelitis: A Case Report

The resurgence of opiate and intravenous drugs abuse in the United States has presented a renewed challenge to surgeons in community-based hospital settings. Patients often present with complex wounds, and when complicated by concomitant osteomyelitis, these wounds require special attention and diligent care. Local rotational flaps have been used in the salvage therapy of limb-threatening lower extremity trauma for years, and have been adapted in part for the use in patients with chronic, limb-threatening osteomyelitis. The use of local rotational flaps for coverage of chronic osteomyelitis is a viable, proven, and well-founded surgical technique with excellent results. Within our hospital setting, we have seen an explosion of patients presenting with chronic, limb-threatening wounds related to intravenous and subcutaneous injection of a variety of illicit drugs.Here, we describe a case of a 24-year-old female with a history of intravenous drug abuse (IVDA) who presented with an extensive left lower extremity wound which had been progressing for several years. The patient was acutely intoxicated but otherwise healthy. Due to extensive tissue loss and osteomyelitis, initial evaluation deemed her leg unsalvageable. However, given the immense morbidity associated with lower extremity amputation the plastic surgery team felt that salvage should be attempted in this young woman. She underwent numerous tissue debridements, washouts, cadaveric skin grafting, and a pedicled soleus muscle flap with eventual autologous skin grafting. The patient was kept in the hospital during this time to allow her to detox and undergo psychiatric evaluation and therapy. This approach allowed her to regain nearly full use of her limb, gain employment, as well as abstain from further drug use.As the opioid epidemic continues in inner cities throughout the United States, the increased burden on local medical centers to care for chronic limb-threatening wounds will continue to rise. Locoregional flaps provide good results but may not be suitable for unreliable patients struggling with addiction. However, in motivated patients, our approach of inpatient detox and delayed reconstruction has shown promising results.

Cerebral Venous Thrombosis as The Sole Presenting Manifestation of Human Immunodeficiency Virus and Hepatitis B Virus Co-Infection.

Cerebral venous thrombosis (CVT) following either human immunodeficiency virus (HIV) infection or hepatitis B virus (HBV) infection is a very rare condition. Moreover, it has never been reported as the presenting manifestation of HIV and HBV co-infection, even more so when the patient had a normal CD4 count and no demonstrable opportunistic infections. We aimed to report the first case of an adult Indian male, an intravenous drug abuser who developed CVT as the presenting manifestation of HIV-HBV co-infection. Patient data were obtained from medical records from the Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research & SSKM Hospital, Kolkata, West Bengal, India. A 25-year-old male with a history of intravenous drug abuse and a normal CD4 count developed CVT as the presenting manifestation of HIV-HBV co-infection. His CD4 count was normal, and he had no demonstrable opportunistic infections. He had an uneventful recovery of the condition (CVT) following the institution of conventional anticoagulation therapy alongside anti-retroviral therapy. Whether illicit drug abuse or HIV/HBV infection itself or all in combination led to this thrombotic event cannot be precisely established. Notwithstanding, we recommend serologic testing for HIV and HBV in patients suffering from CVT with high-risk behavior.

Repurposed oral tapentadol as an intravenous drug of abuse in opioid dependence

We present to you a case series of a group of individuals who presented to us with a history of intravenous drug abuse of repurposed oral tapentadol. Tapentadol is a synthetic benzenoid with a dual mode of action, as an agonist for the μ-opioid receptor and a norepinephrine reuptake inhibitor, with potential anti-nociceptive activity. The prevalence of current opioid use in India is reported to be 4% in males and 0.2% in females. Limited availability and difficulty in procuring the recommended drugs for detoxification and maintenance therapy in opioid dependence give reasons to consider treatment alternatives for the same. This case series aims to address the need and effectiveness of evidence-based treatment in opioid dependence.

Management of Brachial Artery Pseudoaneurysms in Intravenous Drug Abusers

ObjectiveTo determine the outcomes of the ligation and excision of brachial artery pseudoaneurysm in IV drug abusers without revascularization. MethodologyThis retrospective observational study was conducted at the vascular surgery department Shaheed Muhtarma Benazir Bhutto trauma center Karachi from January 2019 to June 2020. All the patients with a history of intravenous drug abuse presented with pulsatile mass at or near cubital fossa, diagnosed as pseudoaneurysm, age ranging from 18-70 years, and of either gender were included in the study. Patients with pseudo-aneurysm secondary to trauma, hemodialysis, arteriovenous fistula, location other than cubital fossa, and whom primary revascularization was performed were excluded. The recorded data entered and analyzed using SPSS 20.0 (IBM Corp., Armonk, NY).ResultsA total of 20 intravenous drug addicts were included in the study. The mean age was of 31.10 ± 7.80 years, and the mean duration of addiction was 2.24 ± 1.16 years. The right arm is affected in almost two-thirds of patients. The most common presentation in the emergency department was ruptured pseudo-aneurysm with bleeding (65%), followed by oozing with pulsatile mass (30%), and infected pulsatile mass (5%). The outcome was Limb salvage (100%), and none of the patients had developed threatened ischemia of the arm or required amputation.ConclusionThe ligation and excision of the pseudo-aneurysm, without revascularization, is a safe and effective treatment option for the management of pseudoaneurysm of the brachial artery secondary to intravenous drug addiction.

A narrative review of echocardiography in infective endocarditis of the right heart.

Infective endocarditis (IE) is characterized by bacterial or fungal masses that form in the cardiac chambers and valves, and in severe cases invade the endocardium or intra-cardiac vessels. Right-sided IE accounts for 5% to 10% of cases, with a low mortality cited at 6%. A history of intravenous drug abuse (IVDU) is present in 90% of isolated right-sided IE cases, with normal intra-cardiac anatomy prior to infection in approximately 80%. Nevertheless, up to 50% of patients require early surgical intervention which is associated with significant peri-operative morbidity. Echocardiography is the gold standard for diagnosis with a sensitivity of 80% for the transthoracic modality and 95% for transesophageal studies; it provides important clinical information regarding the severity of infection and development of secondary complications. This includes identification of active infective vegetations, healed IE, prosthetic valve IE, and abscess formation and rupture. Prompt clinical, microbiologic, and imaging assessment of patients with suspected left or right-sided IE is of paramount importance and is reflected in the modified Duke criteria, the well-validated algorithm for accurate and timely diagnosis of IE. Data suggests the criteria sensitivity may be decreased in right-sided IE only, and thus, care must be taken to perform skilled and detailed echocardiographic assessments of the right heart in suspected cases. Herein we provide a review of IE of the right heart, with a focus on pathophysiology and its echocardiographic presentation and characteristics.

Mycobacterium Abscessus Native Tricuspid Valve Endocarditis. Is a Six-Week Course of Combination Antibiotic Therapy Enough?

A 24-year-old Caucasian woman with a history of intravenous drug abuse and multiple hospital admissions for substance abuse related medical problems presented with pneumonia and was discharged home on oral antibiotics. Three days later, her blood culture grew acid fast bacilli, which was subsequently identified as M. abscessus subspecies abscessus. Transthoracic and transesophageal echocardiogram (TTE and TEE respectively) was suggestive of tricuspid valve (TV) endocarditis. CT scan of the chest showed evidence of septic pulmonary emboli, pneumonic consolidation and pleural effusion requiring chest tube placement. BAL and blood cultures grew Mycobacterium abscessus while pleural fluid cultures remained sterile. She was treated with a combination antibiotic therapy and completed a six-week course with resolution of her symptoms and microbiological cure. We present this rare case of M. abscessus native tricuspid valve endocarditis associated with lung infection treated with a short course of combination antibiotic therapy.

Association of a preoperative dental screening approach with 90-day mortality after cardiac valve surgery

Objectives Preoperative dental screening (PDS) before valvular surgery has been adopted widely by cardiac surgeons to prevent poor outcomes associated with infections of oral origin. However, there is limited evidence to guide PDS protocols. This study was designed to compare a focused approach versus a comprehensive approach to PDS to determine its association with 90-day mortality. Study Design A retrospective cohort analysis was performed on 1835 adult patients who underwent elective valvular surgery and PDS at the Massachusetts General Hospital (MGH) and the Brigham and Women's Hospital (BWH) from January 2009 to December 2016. Patients with a history of intravenous drug abuse were excluded. At the MGH (n = 692), PDS involved a detailed dental examination, including diagnostic radiography and definitive therapy for teeth with active and/or chronic disease (comprehensive protocol). At the BWH (n = 1143), PDS consisted of minimal number of diagnostic radiographs limited to symptomatic teeth and intervention only when active signs of disease were observed (focused protocol). Univariate and multivariate analyses were performed to compare 90-day mortality rates after surgery with the 2 different approaches. Results There were no differences in demographic characteristics and baseline comorbidities between the 2 study sites. At the MGH, 340 (49.2%) of 692 patients received dental clearance at the initial visit, with 94.2% (n = 652) undergoing radiography. Dental findings included carious teeth (n = 250; 36.2%), root tips (n = 118; 17%), periodontically hopeless teeth (n = 48; 6.9%), and periapical infections (n = 149; 21.6%); 40 patients (5.8%) were symptomatic. Extractions were performed in 151 patients (21.8%), and 15 (2.2%) had postoperative complications. At the BWH, 1097 of 1143 patients (96%) received dental clearance at the initial visit, with 3.3% (n = 38) undergoing radiography. Dental findings included carious teeth (n = 197; 17.2%), root tips (n = 135; 11.8%), periodontically hopeless teeth (n = 27; 2.4%), and periapical infections (n = 20; 1.7%); 16 patients (1.4%) were symptomatic. Extractions were performed in 38 patients (3.3%), and 4 (0.4%) had postoperative complications. There was no significant differences in 90-day mortality rates between the 2 study sites (10% vs 8.4%; P = .317). This remained unchanged in a multivariate model after adjusting for demographic characteristics and baseline comorbidities (odds ratio [OR] focused vs comprehensive: 1.32; 95% confidence interval [CI] 0.91–1.93); P = .14). Conclusions Despite the differences in PDS protocols at both study sites, there was no significant difference in 90-day mortality rates after valvular surgery. Further randomized comparative prospective studies are needed to validate and expand on these findings.