Archive for June 28, 2012

Early Surgery versus Conventional Treatment for Infective Endocarditis

N Engl J of Med June 28, 2012 V.366 N.  P.2466-2473

Duk-Hyun Kang, M.D., Ph.D., Yong-Jin Kim, M.D., Ph.D., Sung-Han Kim, M.D., Ph.D., Byung Joo Sun, M.D., Dae-Hee Kim, M.D., Ph.D., Sung-Cheol Yun, Ph.D., Jong-Min Song, M.D., Ph.D., Suk Jung Choo, M.D., Ph.D., Cheol-Hyun Chung, M.D., Ph.D., Jae-Kwan Song, M.D., Ph.D., Jae-Won Lee, M.D., Ph.D., and Dae-Won Sohn, M.D., Ph.D.

BACKGROUND

The timing and indications for surgical intervention to prevent systemic embolism in infective endocarditis remain controversial. We conducted a trial to compare clinical outcomes of early surgery and conventional treatment in patients with infective endocarditis.

METHODS

We randomly assigned patients with left-sided infective endocarditis, severe valve disease, and large vegetations to early surgery (37 patients) or conventional treatment (39). The primary end point was a composite of in-hospital death and embolic events that occurred within 6 weeks after randomization.

RESULTS

All the patients assigned to the early-surgery group underwent valve surgery within 48 hours after randomization, whereas 30 patients (77%) in the conventional-treatment group underwent surgery during the initial hospitalization (27 patients) or during follow-up (3). The primary end point occurred in 1 patient (3%) in the early-surgery group as compared with 9 (23%) in the conventional-treatment group (hazard ratio, 0.10; 95% confidence interval [CI], 0.01 to 0.82; P=0.03). There was no significant difference in all-cause mortality at 6 months in the early-surgery and conventional-treatment groups (3% and 5%, respectively; hazard ratio, 0.51; 95% CI, 0.05 to 5.66; P=0.59). The rate of the composite end point of death from any cause, embolic events, or recurrence of infective endocarditis at 6 months was 3% in the early-surgery group and 28% in the conventional-treatment group (hazard ratio, 0.08; 95% CI, 0.01 to 0.65; P=0.02).

CONCLUSIONS

As compared with conventional treatment, early surgery in patients with infective endocarditis and large vegetations significantly reduced the composite end point of death from any cause and embolic events by effectively decreasing the risk of systemic embolism. (EASE ClinicalTrials.gov number, NCT00750373.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1112843

 

N Engl J of Med June 28, 2012 V.366 N.  P.2519-2521

EDITORIAL

Native-Valve Infective Endocarditis — When Does It Require Surgery?

Steven M. Gordon, M.D., and Gösta B. Pettersson, M.D., Ph.D.

From the Department of Infectious Disease, Medicine Institute (S.M.G.), and the Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute (G.B.P.), Cleveland Clinic, Cleveland.

Guidelines, not backed by evidence from randomized trials, strongly recommend urgent surgery for patients with infective endocarditis and congestive heart failure due to valvular regurgitation. Management algorithms for infective endocarditis have been developed, and a recent study showed that surgery is still required in 50% of patients who receive antibiotics. Experience shows that surgery in patients with active infective endocarditis is associated with low mortality …

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMe1205453

June 28, 2012 at 1:31 pm

Severe acquired toxoplasmosis in immunocompetent adult patients in French Guiana.

J Clin Microbiol. 2002 Nov  V.40 N.11 P.4037-44.

Carme B, Bissuel F, Ajzenberg D, Bouyne R, Aznar C, Demar M, Bichat S, Louvel D, Bourbigot AM, Peneau C, Neron P, Dardé ML.

Parasitologie-Mycologie, EA 3593 UFR de Médecine (Université Antilles Guyane) et Centre Hospitalier de Cayenne. Service de Médecine B, Centre Hospitalier de Cayenne, F 97306 Cayenne, France. b.carme@nplus.gf

Abstract

The most common presentation of symptomatic postnatally acquired toxoplasmosis in immunocompetent patients is painless cervical adenopathy. Acute visceral manifestations are associated in rare cases. We report 16 cases of severe primary toxoplasmosis diagnosed inFrench Guianaduring a 6.5-year period. All of the subjects were immunocompetent adults hospitalized with clinical presentations consisting of a marked, nonspecific infectious syndrome accompanied by an altered general status with at least one visceral localization, mainly pulmonary involvement (14 cases). Acute toxoplasmosis was diagnosed according to the results of serological tests suggestive of recent primary infection and the absence of an alternative etiology. Recovery was rapid following specific antitoxoplasmosis treatment. Thirteen of the 16 patients had consumed game in the 2 weeks before the onset of the symptoms, and in eight cases the game was considered to have been undercooked. Toxoplasma strains, which were virulent in mice, were isolated from three patients. Microsatellite analysis showed that all of these isolates exhibited an atypical multilocus genotype, with one allele found only for isolates of this region.

PDF

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC139686/pdf/0626.pdf

June 28, 2012 at 1:29 pm

Overcoming Barriers to Care for Hepatitis C

N Engl J of Med June 28, 2012 V.366 N.  P.2436-2438

Perspective

Paul J. Clark, M.B., B.S., M.P.H.–T.M., and Andrew J. Muir, M.D., M.H.S.

From the Department of Gastroenterology, Duke University Medical Center, and Duke Clinical Research Institute — both in Durham, NC.

Thanks to steady scientific and therapeutic advances related to hepatitis C virus (HCV), now is a time of much optimism regarding the care of HCV-infected patients. Many seminal developments have been documented, and the number of new agents and regimens being studied in clinical trials suggests that gains will continue to be made in the tolerability and efficacy of treatments for HCV infection. These advances raise the hope that we may overcome the barriers created by the relatively poor efficacy and tolerability of peginterferon alfa plus ribavirin, the historical backbone of treatment in hepatitis C. Although optimism is justified, so is some degree of caution, for as treatment improves, the true rate-limiting factor in achieving better outcomes may turn out to be access to diagnosis and treatment….

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMp1202608

June 28, 2012 at 1:25 pm


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