bluuebunny/crossref_metadata_2025 huggingface dataset:
Myocarditis: imaging techniques
Authors: Yilmaz Ali , Florian Anca
Published: March 2018

The clinical presentation of myocarditis is multifaceted and electrocardiogram (ECG) changes as well as biomarkers tend to be non-specific. Therefore, the diagnosis of myocarditis can be challenging and should be based on an integrated approach including patient history, physical examination, non-invasive tests such as ECG and serum biomarkers, and non-invasive cardiac imaging. As myocarditis may lead to global ventricular dysfunction, regional wall motion abnormalities, and/or diastolic dysfunction, echocardiography should be routinely performed. However, hallmarks of acute myocarditis comprise structural changes such as cardiomyocyte swelling, an increase in extracellular space and water content, accumulation of inflammatory cells, potential necrosis or apoptosis of cardiomyocytes, and myocardial remodelling with fibrotic tissue replacement that can be depicted by cardiovascular magnetic resonance. Nuclear techniques are still not routinely recommended for the work-up of myocarditis—with the possible exception of suspected sarcoidosis—due to limited data, limited diagnostic specificity, limited availability, and risk from radiation exposure. This chapter focuses on those non-invasive cardiac imaging techniques that are used in daily clinical practice for work-up of suspected myocarditis. However, as research continues and novel imaging techniques become available, it is hoped that even more accurate and timely diagnosis of myocarditis will be possible in the near future.
Epidemiology and physiopathology
Authors: Iung Bernard
Published: March 2018

The incidence of infective endocarditis (IE) is estimated at between 15 and 60 cases per million inhabitants per year from population-based studies in industrialized countries. The presentation of IE has changed since patients are getting older and Staphylococcus is now becoming the microorganism most frequently responsible, which is partly attributable to healthcare-associated infections. The incidence of IE is higher in patients with heart valve prosthesis, previous endocarditis, and complex congenital heart disease. In developing countries, IE occurs in younger patients with a majority of rheumatic valve disease and is most frequently due to streptococci. IE is the consequence of bacteraemia on a diseased native valve or foreign material, leading to vegetation or tissue destruction, or both of these. The main consequences of these lesions are heart failure due to valvular regurgitation, embolic events due to vegetation migration, and perivalvular abscesses.
Co-morbidity (HFrEF and HFpEF): anaemia/iron deficiency
Authors: Tkaczyszyn Michal , Jankowska Ewa A. , Ponikowski Piotr
Published: March 2018

Anaemia is a frequent co-morbidity in patients with heart failure (HF), its prevalence increases with disease severity, and it is associated with poor outcomes. The aetiology of anaemia in HF is multifactorial, with the following common underlying causes: gastrointestinal bleeding, renal dysfunction, haemodilution, haematinic deficiencies, deranged steroid metabolism, bone marrow dysfunction and iron deficiency (ID). Erythropoiesis-stimulating agents to correct anaemia in HF did not improve mortality and raised safety concerns, thus are not recommended in these patients. ID in HF has been traditionally linked with anaemia; however, recent studies report a high prevalence also in non-anaemic patients and independent adverse clinical and prognostic consequences (decreased exercise capacity, poor quality of life, and higher mortality) of this co-morbidity. A number of studies have demonstrated that ID can be safely corrected with intravenous iron (ferric carboxymaltose) with symptomatic improvement. According to the recent European Society of Cardiology Guidelines, active screening for the presence of ID is recommended in all HF patients, and in symptomatic HF patients with reduced ejection fraction and with ID, intravenous ferric carboxymaltose should be considered to alleviate symptoms, and improve exercise capacity and quality of life. Ongoing trials are investigating the effect of ID correction on mortality and morbidity.
HFrEF other treatment: indications and results of implantable cardioverter defibrillator and cardiac resynchronization therapy
Authors: Kutyifa Valentina
Published: March 2018

Cardiac resynchronization therapy (CRT) with and without a cardioverter defibrillator has emerged as a mainstream therapy for heart failure patients with drug-refractory, mild to severe symptoms, severely reduced left ventricular ejection fraction, and a prolonged QRS duration, a marker of ventricular dyssynchrony. Acute effects of CRT include the immediate improvement of left ventricular filling time, decrease in mitral regurgitation, and elimination or reduction of left ventricular intraventricular dyssynchrony, accompanied by an improvement in left ventricular contractility, wall motion score, and cardiac output. The implantable cardioverter defibrillator (ICD) is a single- or dual-lead system implanted transvenously in the right ventricle. The ICD has been developed to detect and terminate life-threatening ventricular arrhythmias, and it has been tested in heart failure populations to reduce the risk of mortality. A newer technology, the subcutaneous ICD, completely eliminating the need for a transvenous right ventricular lead has recently been introduced, and current data suggest similar safety and efficacy to the transvenous ICD systems.
The sinus node: normal and abnormal chronotropic response and drug effects
Authors: Wilkoff Bruce L. , Coleman Corey
Published: March 2018

Augmentation of the heart rate serves as the primary driver for the heart to increase oxygen delivery during times of increased metabolic demand. Without the ability to increase the heart rate in response to metabolic demands, significant physical limitations develop. Multiple pathological processes and pharmacological agents can impair this chronotropic function of the heart and its natural pacemaker, the sinus node. Exercise testing serves as a useful diagnostic tool to both screen for and diagnose an abnormal chronotropic response. When present, an abnormal chronotropic response of the sinus node carries significant prognostic value regarding mortality and morbidity.
Asymptomatic pre-excitation
Authors: Chrispin Jonathan , Calkins Hugh
Published: March 2018

Manifest pre-excitation on the surface electrocardiogram (ECG) with a short PR interval and delta wave occurs in a very small percentage of the population based on epidemiological data. For the vast majority, this ECG finding will have no clinical manifestation and over time the ECG manifestation of pre-excitation may even go away. A small minority of individuals, however, develop clinical signs related to ventricular pre-excitation, most notably atrioventricular reentrant (reciprocating) tachycardia. This non-life-threatening arrhythmia is associated with clinical symptoms of palpitations, dyspnoea, and presyncope. Those with ventricular pre-excitation are at increased risk for atrial fibrillation. Multiple invasive electrophysiological and longitudinal studies have shown that those with atrial fibrillation and robust conduction down the atrioventricular accessory pathway are at an increased risk of sudden cardiac death from ventricular fibrillation. This chapter reviews the available and recommended strategies for assessing the patient with asymptomatic pre-excitation.
Sustained and non-sustained ventricular tachycardia and no associated heart disease (idiopathic ventricular tachycardia)
Authors: Bazan Victor , Rodriguez-Font Enrique , Marchlinski Francis E.
Published: March 2018

Patients with ventricular arrhythmias (VAs) and without underlying structural heart disease or baseline electrical disorders (‘idiopathic’ VAs) usually have a benign clinical course. Only rarely do these benign arrhythmias trigger polymorphic ventricular tachycardia and idiopathic ventricular fibrillation. Due to their focal origin and to the absence of underlying myocardial scar, the 12-lead electrocardiogram (ECG) very precisely establishes the right or left ventricular site of origin of the arrhythmia and can help regionalize the origin of ventricular tachycardia for ablation. A 12-lead ECG obtained during the baseline rhythm and 24 h ECG Holter monitoring are indicated in order to identify structural or electrical disorders leading to polymorphic ventricular tachycardia/ventricular fibrillation and to determine the VA burden. The most frequent origin of idiopathic VAs is the right ventricular outflow tract. Other origins include the left ventricular outflow tract, the left ventricular fascicles (fascicular ventricular tachycardias), the left and right ventricular papillary muscles, the crux cordis, the mitral and tricuspid annuli, and the right ventricular moderator band. Recognizing the typical anatomic sites of origin combined with a 12-lead ECG assessment facilitates localization. Antiarrhythmic drug therapy (including use of beta blockers) or catheter ablation may be indicated to suppress or eliminate idiopathic VAs, particularly if there are severe arrhythmia-related symptoms or if the arrhythmia burden is high and ‘tachycardia’-induced cardiomyopathy is suspected. Catheter ablation is frequently preferred to prevent lifelong drug therapy in young patients.
Pulmonary veno-occlusive disease and pulmonary capillary haemangiomatosis
Authors: Montani David , Girerd Barbara , Lau Edmund , Humbert Marc
Published: March 2018

Pulmonary veno-occlusive disease (PVOD) and pulmonary capillary haemangiomatosis (PCH) are rare causes of pulmonary hypertension, and they are now known to represent manifestations of a common disease characterized by fibrous remodelling of the small pulmonary veins and endothelial cell proliferation within the pulmonary capillaries. Heritable PVOD and PCH are caused by the same genetic defect of biallelic mutations of the EIF2AK4 gene. Other risk factors associated with the development of PVOD/PCH include chemotherapy treatment, organic solvent exposure, and systemic sclerosis.
Risk assessment and treatment goals in patients presenting with pulmonary arterial hypertension
Authors: Hoeper Marius M.
Published: March 2018

Risk stratification in patients with pulmonary arterial hypertension is based on a multidimensional approach that utilizes clinical features, World Health Organization functional class, exercise capacity, biomarkers, and evaluation of right ventricular function by imaging and/or invasive measurements. Risk assessment at the time of diagnosis determines the initial treatment strategy, while risk assessment during follow-up is performed to identify disease progression and the need for treatment modifications. A low-risk category is characterized by non-progressive disease, absence of signs of right heart failure and syncope, World Health Organization functional class I or II with normal or near normal exercise capacity, normal or near normal plasma levels of B-type natriuretic peptide, and well-preserved right ventricular function as determined by echocardiography, cardiovascular magnetic resonance imaging, or right heart catheterization. Achieving and maintaining a low-risk status is a major objective in the treatment of patients with pulmonary arterial hypertension.
Conclusion
Authors: Humbert Marc
Published: March 2018

Pulmonary hypertension is a fast-growing field in cardiopulmonary medicine. Thanks to recent advances summarized in the 2015 European Society of Cardiology/European Respiratory Society guidelines, evidence-based pulmonary hypertension management can now be provided to all pulmonary hypertension patients. There are, however, important gaps of evidence which should be clarified in future work.
Acute aortic syndrome: iatrogenic aortic trauma
Authors: Gil Iván J. Núñez , Guzmán Gisela I. Feltes
Published: March 2018

Iatrogenic aortic trauma, mainly aortic dissection, can be a severe condition with significantly different features compared with the spontaneous forms. In addition, during recent years, surgical and interventional procedures have been expanded. Thus, aortic iatrogenic complications in those settings, although infrequent, are currently not rare. Due to its low incidence, our main data derive from small case reports and registries.
Genetic diseases of the aorta: aortic diseases related to Marfan syndrome and other genetic abnormalities
Authors: Iung Bernard
Published: March 2018

Bicuspid aortic valve affects 1–2% of babies at birth and is frequently associated with thoracic aortic aneurysm but the risk of aortic dissection is low. Indications for aortic surgery are based on studies on natural history. Aortic surgery is recommended when the maximum aortic diameter is greater than 55 mm in patients with a bicuspid aortic valve. Intervention is indicated at an earlier stage when there are associated risk factors, in particular familial history of aortic dissection or rapid progression, or if there is an indication for aortic valve replacement. The choice between partial or total replacement of the aorta should be based on anatomy, but also take into account the patient’s age and operative risk.
Prognostic assessment
Authors: Becattini Cecilia , Agnelli Giancarlo
Published: March 2018

Prognostic assessment in patients with acute venous thromboembolism is essential to drive clinical management in terms of hospitalization or home treatment, and revascularization strategies or anticoagulation alone. In these patients, single predictors, combinations of predictors, or prognostic models can be used for prognostic assessment. Overall, the risk for short-term death is about tenfold higher after acute pulmonary embolism than after acute deep vein thrombosis. Localization of thrombosis (proximal or distal) and some clinical features are the main predictors of prognosis in patients with deep vein thrombosis. In patients with pulmonary embolism, prognostic assessment includes the evaluation of clinical features, findings at imaging (computed tomography angiography, echocardiography, and/or ultrasonography of the lower limbs), or biomarkers of right ventricular dysfunction or injury. The presence of shock or sustained hypotension is the main criterion for the identification of high-risk patients. Clinical models with high negative predictive value have been validated to identify patients at low risk for short-term death. Whether the assessment of right ventricular dysfunction in these patients can further improve the negative predictive value of clinical models remains to be defined. Right ventricular dysfunction as assessed by echocardiography or computed tomography angiography as well as right ventricular damage by troponin levels are associated with an about twofold increase in the risk for short-term death in intermediate risk patients. However, prognostic assessment in these patients requires further improvement before it can be used to drive decisions on treatment.
Treatment: anticoagulation
Authors: Becattini Cecilia , Agnelli Giancarlo
Published: March 2018

Anticoagulant treatment should be given for at least 3 months to all patients with venous thromboembolism (VTE) in the absence of absolute contraindications. Several parenteral (unfractionated or low-molecular-weight heparin, fondaparinux) and oral anticoagulants are currently available for the treatment of VTE according to a sequential regimen (parenteral pretreatment followed by oral anticoagulants) or to a single-drug approach (completely managed with a single anticoagulant agent). Despite similar pharmacokinetics across direct oral anticoagulants, dabigatran and edoxaban have been developed according to a sequential regimen, and apixaban and rivaroxaban according to a single-drug approach. Improved practicality (with no need for laboratory monitoring or dose adjustment) and promising safety results are the main reasons to prefer direct oral anticoagulants over conventional anticoagulation in patients without severe renal failure.
Chronic thromboembolic pulmonary hypertension
Authors: Lang Irene M. , Klepetko Walter , Matsubara Hiromi
Published: March 2018

Chronic thromboembolic pulmonary hypertension (CTEPH) and other pulmonary artery obstructions represent group 4 in the pulmonary hypertension classification. Angiosarcoma, other intravascular tumours, arteritides, congenital pulmonary arteries stenoses, and parasites (hydatidosis) remain rare differential diagnoses within group 4. CTEPH comprises an occlusive vascular remodelling process of major vessel pulmonary thromboembolism in combination with a pulmonary arteriopathy at the pre-capillary level. The gold standard treatment has been pulmonary endarterectomy that is able to restore normal pulmonary haemodynamics at rest. Because about half of the patients are felt to be unsuited for pulmonary endarterectomy, medical treatments and balloon pulmonary angioplasty have gained grounds in the management of patients with CTEPH.
Heart failure in women
Authors: Regitz-Zagrosek Vera
Published: March 2018

Heart failure in women frequently occurs at an older age than in men with less ischaemic aetiology and is more frequently characterized by preserved ejection function. Gene expression profiles in heart failure are different in both sexes. Sex-specific activation of ion channels may lead to differences in arrhythmia propensity, and QT prolongation. Women develop smaller and stiffer hearts under stress, whereas in men, eccentric hypertrophy seems to dominate. Imaging is crucial for the diagnosis, and cardiac dimensions should be normalized to body surface. Differences in medical therapy exist, and women are less frequently referred for resynchronization therapy and heart transplantation than men.
Ethnicity and coronary artery disease
Authors: Timmis Adam
Published: March 2018

In Western countries, health inequalities related to ethnicity are widely documented, particularly the increased coronary mortality of South Asians (people of Indian, Pakistani, Sri Lankan, and Bangladeshi origin) compared with indigenous white populations. Inequalities affecting black populations are more heterogeneous, with people of African or Caribbean origin in the United Kingdom experiencing relative protection against coronary disease that is not seen in black Americans, although both groups share a predisposition to hypertension and stroke. These health inequalities have been the subject of considerable research that has enhanced our understanding of cardiovascular disease while impacting importantly on its investigation and treatment.
Cardiovascular adaptation to exercise and sport: (according to type of sport, gender, and ethnicity)
Authors: Papadakis Michael , Sharma Sanjay
Published: March 2018

‘Athlete’s heart’ is associated with several structural and electrophysiological adaptations, which are reflected on the 12-lead electrocardiogram (ECG) and imaging studies. Most studies investigating cardiac remodelling in athletes are based on cohorts of white, adult, male athletes competing in the most popular sports. Evidence suggests, however, that sporting discipline and the athlete’s gender and ethnicity are important determinants of cardiovascular adaptation to exercise. Athletes competing in endurance sports demonstrate more pronounced adaptations in comparison to athletes performing static or resistance training. The ECG of endurance athletes is more likely to demonstrate repolarization anomalies in the anterior leads and ventricular dilatation on imaging studies, causing considerable overlap with arrhythmogenic right ventricular cardiomyopathy and dilated cardiomyopathy. Female athletes exhibit less pronounced adaptations compared to males, in terms of the prevalence of ECG changes and absolute cardiac dimensions. Importantly, female endurance athletes are more likely to demonstrate eccentric hypertrophy compared to males, suggesting that concentric remodelling or hypertrophy in female endurance athletes is unlikely to be the consequence of physiological adaptation to training. The most pronounced paradigm of ethnically distinct cardiovascular adaptation to exercise stems from black athletes, who exhibit a significantly higher prevalence of repolarization anomalies and left ventricular hypertrophy compared to white athletes, making the differentiation between athlete’s heart and hypertrophic cardiomyopathy challenging in this ethnic group.
Palliative and end-of-life care in elderly subjects with cardiovascular disease
Authors: Sobanski Piotr
Published: March 2018

Palliative care (PC) is holistic care that encompasses prevention, assessment, and treatment of symptoms, and addresses the psychological, social, and spiritual problems of ill people and their relatives with the goal of improving quality of life and, finally, dying. It is not an alternative but a supplement to curative treatment, making symptom alleviation and quality of life equally important goals for management and care as healing along the whole disease trajectory. The SENSE model describes elements of PC: Symptom management, dEcision-making, Networking, Support, and End-of-life care. People with heart disease, particularly those with advanced heart failure (HF), benefit from PC care. Pain, breathlessness, tiredness, depression, anxiety, and dry mouth are frequent symptoms among people with HF and could be effectively alleviated with PC. Many of these symptoms, almost constantly present in HF patients, are usually not specifically targeted by medical interventions. Preparedness for anticipatory death improves quality of life during dying for patients and their relatives, and improves satisfaction with care. The greatest challenge still lies in recognizing unmet PC needs and involving a PC team appropriately early, not simply in the very last hours of life. A number of specific issues, such as the modification of implantable cardioverter defibrillator activity or withdrawal of ventricular assist device support, can be addressed by preparing advance directives leading to protecting patients from unwished, usually futile, therapies when they become imminently dying and/or incompetent for decision-making. PC also gives support to cardiology teams in difficult communications on end-of-life issues. Modern PC manages or prevents suffering in people with advanced diseases, independent of diagnosis and prognosis and care for their relatives. It can be provided additionally to disease-specific management as a parallel care, or sometimes as the main care pathway in people close to death as end-of-life care. Parallel PC care should be needs driven; end-of-life care can additionally be prognosis driven. In the majority of cardiological patients PC can/should be delivered by the cardio team that has been treating the person to date and who applies the general PC rules (symptom and distress assessment and management). The PC specialist should ensure consultations in case of difficult/resistant problems, and take the lead in treatment only rarely, if needed. PC acknowledges four dimensions influencing a person’s quality of life: physical, psychological/emotional, spiritual, and social. Each of them needs to be addressed effectively which may require the involvement of a multidisciplinary team. A PC team can provide important support to the treatment team in analysing/solving complex management-related ethical issues.
Mitral stenosis
Authors: Vahanian Alec
Published: March 2018

Although the prevalence of rheumatic fever has greatly decreased in Western countries, mitral stenosis (MS) still results in significant morbidity and mortality worldwide. Echocardiography is the main method used to assess the severity and consequences of MS, as well as the extent of anatomic lesions. The treatment of MS has been revolutionized since the development of percutaneous mitral balloon commissurotomy (PMC) Intervention should be performed in symptomatic patients with clinically significant MS (moderate to severe) (valve area <1.5 cm²). Most patients with favourable valve morphology currently undergo PMC. Decision-making in patients with suboptimal anatomy must take into account the multifactorial nature of predicting the results of PMC. PMC is indicated when surgery is contraindicated, conversely surgery is indicated in patients who are unsuitable for PMC. Asymptomatic patients are not usually candidates for PMC, except in cases where there is increased risk of systemic embolism or haemodynamic decompensation.
Settings and stakeholders
Authors: Deaton Christi , Cupples Margaret , Kotseva Kornelia
Published: March 2018

Cardiovascular disease remains a leading cause of death and disability globally, and cardiovascular prevention should take place everywhere. Reducing the burden of cardiovascular disease requires a concerted effort in multiple settings (primary care, acute care, community, and home), and from multiple stakeholders such as government, public health, non-governmental organizations, healthcare, industry, and individuals. Primary care provides the majority of healthcare to populations, and is in an optimal position to screen and assess patients for cardiovascular risk and deliver cardiovascular prevention. Improving screening, risk assessment, and use of evidence-based guidelines requires collaboration between specialist cardiology services and primary care. Nurse-led and multiprofessional teams are effective in delivering prevention across a variety of settings. Prevention should be a priority prior to patient discharge from hospital following an acute cardiovascular event, and should encompass both medications and advice regarding lifestyle behaviours. Secondary prevention through specialized prevention programmes is needed by patients in order to reduce the risk of subsequent events. Cardiac rehabilitation is one of the most effective methods of delivering prevention and improving patient well-being following an acute event or procedure. There is a need to get more patients participating by using alternative methods of delivery and ensuring that women, older patients, and those with low fitness are encouraged and supported to attend. Stakeholders such as government, non-governmental organizations, and industry have important roles to play in improving public health. Healthcare providers should disseminate their research in lay language, and play a role in advising on and supporting public health measures.
Medical Students Have Limited Awareness, Knowledge, Beliefs, and Experiences of Pre-exposure Prophylaxis (PrEP) for HIV Prevention
Authors: Imp Brandon , Allen Elaine , Volk Jonathan , Bhowmick Tanaya ,   PrEP Medical Student Research Group
Published: March 2018

Background

While studies of healthcare professionals have shown increasing awareness, knowledge, positive beliefs, and prescribing practices of emtricitabine/tenofovir pre-exposure prophylaxis (PrEP) for HIV prevention, PrEP is still underutilized in clinical practice. PrEP knowledge is associated with increased prescription so early education of healthcare professionals is recommended, but the extent of PrEP education in medical school is unknown. In this analysis, we describe medical students’ awareness, knowledge, beliefs, and experiences regarding PrEP.

Methods

Medical students at 18 US allopathic medical schools completed a survey on knowledge, beliefs, and experiences of PrEP in May–June 2016. Knowledge was assessed with a 10-question quiz on PrEP facts. No incentives to complete the survey were offered. Data were summarized by frequency (%) for categorical variables and with means (SD) for continuous variables. Chi-squared tests were used to examine differences between knowledge of PREP and other categorical variables.

Results

The study population (N = 1588) included women (53%), non-Caucasians (27%), and non-heterosexuals (15%). Median age was 25 (range 21–53). Forty-eight home states, including D.C., and 21 home countries were represented. 18% of fourth-year students were never taught about PrEP in medical school, compared with 40% of first-year students (P < 0.001). Overall, 28% of students were unaware of PrEP. Those unaware believed patients without HIV will not adhere to PrEP (P < 0.001). Awareness was associated with knowing someone with HIV besides a patient and experience caring for HIV-infected, intravenous drug-using, and LGBTQ people (P < 0.001). Higher knowledge scores were associated with confidence in determining a patient’s candidacy for PrEP and, for third- and fourth-year students, having recommended PrEP in the clinical setting (P < 0.001). Overally, 57% believed that behavioral intervention should be tried before prescribing PrEP, 45% believed that patients would not adhere to PrEP, and 22% worried that PrEP is not effective.

Conclusion

We show in an 18-site study that medical students have limited awareness, knowledge, positive beliefs, and experiences of PrEP. Given these findings and the underutilization of PrEP by current practitioners, we recommend increasing the inclusion of PrEP in medical student education.

Disclosures

All authors: No reported disclosures.
Multidrug-Resistant Gram-Negative bacilli Prosthetic Joint Infection: A Worrisome Scenario
Authors: Ribeiro Taiana , Klautau Giselle , Salles Mauro ,   Infectology Santa Casa-SP
Published: March 2018

Background

The spectrum of the microbial etiology of prosthetic joint infections (PJIs) is changing, with a higher occurrence of Gram-negative bacilli (GNB) nowadays. In Latine America, GNB infections are usually caused by strains that produce multiple resistance mechanisms, making antimicrobial treatment increasingly difficult, especially for these biofilm-associated infections. We aimed to demonstrate the higher frequency of PJIs caused by GNB.

Methods

We performed a retrospective observational study with adult patients with a diagnosis of knee and hip PJIs. Patients included were submitted to an exchange of total hip and knee prostheses between September 2010 and December 2016, in two brazilian hospitals. It was included only patients with microbial diagnosis performed using either sonication fluid cultures of retrieved implant and conventional tissue cultures of periprosthetic tissues. The Infectious Disease Society of America (IDSA) definition was used to establish the diagnosis of PJIs. Multidrug-resistant (MDR) organisms were defined as acquired resistance to at least one agent in three or more antimicrobial categories.

Results

Were included 130 adult patients with a median age of 65.5 years, in which 60% were female. Infected hip arthroplasty was more frequent than knee infections (69% vs. 31%) and 61% were classified as late infection according to Zimmerli’s classification. One hundred twenty-three microorganisms were isolated on the tissue and sonication fluid culture. Despite the Coagulase-negative Staphylococci was the predominant microorganism (35%), Gram-negative bacilli had an expressive frequency of 30% of positivity on culture. Amongst them, 23% showed resistance to carbapenens and 38% were MDR-bacteria. The predominant microorganism was Pseudomonas spp., followed by Enterobacter spp., Acinetobacter spp., Escherichia coli, Stenotrophomonas maltophilia and Klebsiella pneumoniae, Proteus spp. and Serratia marcescens. There was no statistical difference on the resistance profile of the GNB isolated on tissue and sonicate fluid culture.

Conclusion

We have shown an alarming high frequency of MDR-Gram-negative bacilli PJIs in two Brazilian centers, performing microbial diagnosis using sonication and tissue cultures.

Disclosures

All authors: No reported disclosures.
Human Immunodeficiency Virus/Hepatits C Virus Coinfection in Spain: Elimination Is Feasible, but the Burden of Residual Cirrhosis Will Be Significant
Authors: Berenguer Juan , Jarrín Inmaculada , Pérez-Latorre Leire , Hontañón Víctor , Vivancos María J , Navarro Jordi , Téllez María J , Guardiola Josep M , Iribarren José A , Rivero-Juárez Antonio , Márquez Manuel , Artero Arturo , Morano Luis , Santos Ignacio , Moreno Javier , Fariñas María C , Galindo María J , Hernando María A , Montero Marta , Cifuentes Carmen , Domingo Pere , Sanz José , Domíngez Lourdes , Ferrero Oscar L , De la Fuente Belén , Rodríguez Carmen , Reus Sergio , Hernández-Quero José , Gaspar Gabriel , Pérez-Martínez Laura , García Coral , Force Lluis , Veloso Sergio , Losa Juan E , Vilaró Josep , Bernal Enrique , Arponen Sari , Ortí Amat J , Chocarro Ángel , Teira Ramón , Alonso Gerardo , Silvariño Rafael , Vegas Ana , Geijo Paloma , Bisbe Josep , Esteban Herminia , González-García Juan ,   GeSIDA 8514 Study Group
Published: March 2018

Background

We assessed the prevalence of antibodies against hepatitis C virus (HCV-Abs) and active HCV infection in patients infected with human immunodeficiency virus (HIV) in Spain in 2016 and compared the results with those of similar studies performed in 2002, 2009, and 2015.

Methods

The study was performed in 43 centers during October–November 2016. The sample was estimated for an accuracy of 2% and selected by proportional allocation and simple random sampling. During 2016, criteria for therapy based on direct-acting antiviral agents (DAA) were at least significant liver fibrosis, severe extrahepatic manifestations of HCV, and high risk of HCV transmissibility.

Results

The reference population and the sample size were 38904 and 1588 patients, respectively. The prevalence of HCV-Abs in 2002, 2009, 2015, and 2016 was 60.8%, 50.2%, 37.7%, and 34.6%, respectively (P trend <.001, from 2002 to 2015). The prevalence of active HCV in 2002, 2009, 2015, and 2016 was 54.0%, 34.0%, 22.1%, and 11.7%, respectively (P trend <.001). The anti-HCV treatment uptake in 2002, 2009, 2015, and 2016 was 23.0%, 48.0%, 59.3%, and 74.7%, respectively (P trend <.001). In 2016, HCV-related cirrhosis was present in 7.6% of all HIV-infected individuals, 15.0% of patients with active HCV, and 31.5% of patients who cleared HCV after anti-HCV therapy.

Conclusions

Our findings suggest that with universal access to DAA-based therapy and continued efforts in prevention and screening, it will be possible to eliminate active HCV among HIV-infected individuals in Spain in the short term. However, the burden of HCV-related cirrhosis will continue to be significant among HIV-infected individuals.
Williams and Morrone misunderstand and inadvertently support my argument: Mexico’s SNI systematically steers ecological research
Authors: Neff Mark W
Published: March 2018

My recent publication highlighting the unintended steering influences of publication incentives on the research agenda of Mexican ecological scientists elicited a vehement critique from two renowned Mexican ecologists, Williams and Morrone. The argument I advance is that Mexico’s National System of Researchers (SNI) unintentionally steers ecological researchers away from the knowledge needs of local, national, and regional users of scientific knowledge and relinquishes research priority-setting to individuals and institutions disconnected from Mexico’s knowledge needs. Rather than engaging with the substance of argument, these critics focus on what they believe to be factual errors. In their response, Williams and Morrone effectively but unintentionally confirm the premise, mechanism, and indeed the key factual claims in my article. I stand behind my analysis as published.
A young man with visual disturbances and a mild headache
Authors: Walker Jerimiah D.
Published: March 2018

Headaches are common presenting complaints in EDs throughout the United States. Most are benign and should be treated symptomatically. Certain historical risk factors and physical examination findings increase the likelihood of a secondary cause of headache and warrant further investigation with neuroimaging. Gross visual field testing is a critical component of the physical examination and should not be overlooked as a potential manifestation of a neurologic deficit. This article describes a patient whose headache and unilateral vision loss prompted neuroimaging that uncovered a pilocytic astrocytoma.
The Tanzanian assistant medical officer
Authors: Rick Tara J. , Moshi Doreen D.
Published: March 2018

Tanzania, in East Africa, has one of the lowest numbers of physician per population in the world, especially in rural areas where most people live. To address this shortage, assistant medical officers (AMOs) were developed in the 1960s. AMOs are trained in an abbreviated medical school program, work independently, remain the highest-trained practitioners in rural practice, and provide most emergency surgical obstetric care in nonurban settings. Although information on AMOs is limited, no evidence has emerged that their patient care outcomes differ from physicians. These healthcare professionals, similar to physician assistants, have expanded access to care in severely underserved areas of the country. With a growing demand for contemporary healthcare and stretched service delivery, more research is needed on the ameliorating effect AMOs have on Tanzanian healthcare, especially as the country considers converting AMO training programs to medical school programs.
The Importance and Quantification of Plutonium Binding in Human Lungs
Authors: Birchall Alan , Puncher Matthew , Hodgson Alan , Tolmachev Sergei Y.
Published: March 2018

Epidemiological studies have shown that the main risk arising from exposure to plutonium aerosols is lung cancer, with other detrimental effects in the bone and liver. A realistic assessment of these risks, in turn, depends on the accuracy of the dosimetric models used to calculate doses in such studies. A state-of-the-art biokinetic model for plutonium, based on the current International Commission on Radiological Protection biokinetic model, has been developed for this purpose in an epidemiological study involving the plutonium exposure of Mayak workers in Ozersk, Russia. One important consequence of this model is that the lung dose is extremely sensitive to the fraction (f
b) of plutonium, which becomes bound to lung tissue after it dissolves. It has been shown that if just 1% of the material becomes bound in the bronchial region, this will double the lung dose. Furthermore, f
b is very difficult to quantify from experimental measurements. This paper summarizes the work carried out thus far to quantify f
b. Bayesian techniques have been used to analyze data from different sources, including both humans and dogs, and the results suggest a small, but nonzero, fraction of < 1%. A Bayesian analysis of 20 Mayak workers exposed to plutonium nitrate suggests an f
b between 0 and 0.3%. Based on this work, the International Commission on Radiological Protection is currently considering the adoption of a value of 0.2% for the default bound fraction for all actinides in its forthcoming recommendations on internal dosimetry. In an attempt to corroborate these findings, further experimental work has been carried out by the US Transuranium and Uranium Registries. This work has involved direct measurements of plutonium in the respiratory tract tissues of workers who have been exposed to soluble plutonium nitrate. Without binding, one would not expect to see any activity remaining in the lungs at long times after exposure since it would have been cleared by the natural process of mucociliary clearance. Further supportive study of workers exposed to plutonium oxide is planned. This paper ascertains the extent to which these results corroborate previous inferences concerning the bound fraction.
A Review of Ceftolozane/Tazobactam for the Treatment of Infections Caused by Multidrug-Resistant Pathogens
Authors: Sebaaly Jamielynn , Woods Joseph Andrew , Wargo Kurt A.
Published: March 2018

Multidrug-resistant (MDR) gram-negative bacterial infection is a serious and growing public health threat, in part due to limited treatment options. A novel cephalosporin and β-lactamase inhibitor, ceftolozane/tazobactam, has a broad spectrum of activity against MDR pathogens and is approved for the treatment of complicated intra-abdominal infections in combination with metronidazole and complicated urinary tract infections, including pyelonephritis. This article reviews published data on the clinical pharmacology, spectrum of activity, pharmacokinetics/pharmacodynamics, clinical efficacy and safety, and dosing and administration of ceftolozane/tazobactam. Searches of MEDLINE from January 2000 to April 2017 were conducted using the following keywords: ceftolozane, tazobactam, and ceftolozane tazobactam. Additional references were identified from a review of the retrieved articles' citations. Ceftolozane is active against organisms producing AmpC β-lactamases and MDR Pseudomonas aeruginosa. The addition of tazobactam enhances activity against extended-spectrum β-lactamase–producing organisms. Data from phase III trials using ceftolozane/tazobactam for the treatment of complicated intra-abdominal infection and complicated urinary tract infections have yielded positive results. Ceftolozane/tazobactam has demonstrated noninferior or superior efficacy to comparators in clinical trials. It has a favorable safety profile and few drug-drug interactions. This novel combination agent has a role in treating MDR infections, particularly P. aeruginosa, although its use should be reserved for patients without other treatment options to limit the risk of resistance. Although case reports of successful treatment have been reported, further investigation is needed into the utility of ceftolozane/tazobactam for the treatment of bacteremia and pneumonia caused by MDR pathogens.
Personalized (N-of-1) Trials for Depression
Authors: Kronish Ian M. , Hampsey Meghan , Falzon Louise , Konrad Beatrice , Davidson Karina W.
Published: March 2018

Purpose/Background

Personalized (N-of-1) trials are single-patient, crossover-design trials that may be useful for personalizing the selection of depression treatments. We conducted a systematic review of published N-of-1 trials for depression to determine the feasibility and suitability of this methodology for personalizing depression care.

Methods/Procedures

Electronic databases were searched from database inception through October 2016. Studies were selected if they enrolled depressed patients, included a within-subject crossover design, and systematically assessed depressive symptoms during the N-of-1 trial.

Findings/Results

Five eligible studies reporting on 47 depressed patients (range, 1–18 patients) were identified. Two studies were conducted among adults with treatment-resistant depression, 1 study among depressed inpatients, and 2 studies among patients from special populations (geriatric nursing home, human immunodeficiency virus–associated encephalopathy). All studies evaluated the effects of pharmacologic treatments (methylphenidate, d-amphetamine, ketamine, and sulpiride). Three studies compared an off-label treatment with placebo, 1 study compared 2 off-label treatments, and 1 study compared escalating doses of an off-label treatment with placebo. All 4 studies with more than 1 participant demonstrated heterogeneous treatment effects. All studies produced data that could personalize treatment selection for individual patients. No studies reported on recruitment challenges, compliance with self-tracking, or satisfaction with participation.

Implications/Conclusions

The feasibility of N-of-1 trials for depression was demonstrated for a limited number of second-line pharmacologic treatments in treatment-resistant patients or in patients with comorbidities that would have excluded them from conventional randomized controlled trials. Additional research is needed to determine whether N-of-1 trials are suitable for improving the selection of depression treatments in clinical practice.
Prevention of Otic Barotrauma in Aviation: A Systematic Review
Authors: Ryan Peter , Treble Alexander , Patel Nirmal , Jufas Nicholas
Published: March 2018

Objective:

To conduct a systematic review of the published evidence relating to the prevention of otic barotrauma in aviation. In particular, this review sought to identify procedures, techniques, devices, and medications for the prevention of otic barotrauma as well as evaluate the evidence relating to their efficacy.

Data Sources:

Ten databases including Embase, MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched using the full historical range.

Study Selection:

English language articles including more than or equal to five participants or cases were included. Outcomes of interest were reduced severity or the successful prevention of otic barotrauma in participants undergoing gradual changes in pressure during air travel or its simulation.

Data Extraction:

Articles and data were extracted and analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and other international guidelines.

Conclusions:

This review highlights the lack of published evidence relating to what is a significant and increasingly common problem in otology. There is level 1 evidence that supports the efficacy of oral pseudoephedrine (120 mg) in preventing otic barotrauma in adults. However, oral pseudoephedrine (1 mg/kg) does not appear to be effective in children. There is insufficient evidence to support the efficacy of either nasal balloon inflation or pressure-equalizing ear plugs for the prevention of otic barotrauma. A recently reported, novel technique for insertion of temporary tympanostomy tubes is promising but requires further evaluation.
Development of an Ex-Situ Limb Perfusion System for a Rodent Model
Authors: Gok Emre , Alghanem Fares , Moon Ruth , Guy Erin , Rojas-Pena Alvaro , Bartlett Robert H. , Ozer Kagan
Published: March 2018

Ex-situ perfusion (ESP) is a promising method in preserving vascularized composite tissue allografts (VCAs) with potential to widen donor procurement to larger geographic areas. To optimize the method of preservation, we developed a small animal model to conduct biomolecular investigations. Twenty rat hind limbs (18.2 ± 1.3 g) were procured and connected to our custom-made ESP system. Perfusion pressure and flow parameters were measured with hourly blood gas analysis under near-normothermic (30–35˚C) conditions. Perfusate was prepared with swine hemoglobin (6–9 g/dL) and STEEN Solution. After 6 hours of perfusion, gastrocnemius muscles were evaluated for their histology and metabolomic profiling. Following 3 sets of experiments, perfusion was maintained at an average flow of 0.9 ± 0.24 mL/min and resulted in lactate levels of 3.78 ± 1.02 mmol/L. Metabolomic analysis revealed maintained cellular energy stores (total adenylates perfusion 0.698 ± 0.052 versus baseline 0.685 ± 0.091 umols/ug, p = 0.831), and histologic analysis revealed no evidence of barotrauma or myodegeneration. Rat hind limbs were viable after 6 hours of ESP on our miniaturized ESP system. This study is the first to document the ex-situ hind limb perfusion platform on a rodent model. These experimental findings have potential to guide future research to extend the viable duration of VCA preservation.
Factors Influencing Part-time Faculty Engagement With Online Nursing Programs
Authors: Reneau Margaret , Wallace Cara , Claywell Lora , Price Jill , Burdi Melissa , Trybulski Joanne
Published: March 2018

This research investigated factors that influenced the engagement of part-time faculty teaching in online nursing programs with their institutions. Of the 257 part-time faculty surveyed, the most significant factor was being supported in decisions regarding student issues, followed by institutional commitment to quality online education. Compensation was moderately influential; a negative factor was requiring too frequent meetings. Understanding factors that influence the engagement of part-time faculty teaching in online nursing programs can help leaders of online programs attract and retain experienced, highly skilled faculty.