Recent advances in the study of Q fever epidemiology, diagnosis and management.

Identification of inflammatory mediators and their modulation by strategies for the management of the systemic inflammatory response during cardiac surgery.

https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(14)61726-2/pdf

Fluorescence in situ hybridization to improve the diagnosis of endocarditis: a pilot study

Heart valve (HV) culture is one of the major Duke criteria for the diagnosis of definite infectious endocarditis (IE). However, previous series suggest that heart valve culture does not have good sensitivity (7.8 to 17.6%) and may be contaminated during manipulation. Our goal was to establish the value of routine cultures of heart valves in patients with and without IE. From 2004 to 2006, resected heart valves were systematically cultured according to standard procedures. The definition and etiology of IE were based on the Duke criteria and on valve PCR of specimens from blood culture-negative patients. Bacterial and fungal broad-range PCR was performed. A total of 1,101 heart valves were studied: 1,030 (93.6%) from patients without IE and 71 (6.4%) from patients with IE (42 patients). Overall, 321 (29.2%) cultures were positive (28/71 [39.4%] IE cases and 293/1,030 [28.4%] non-IE). All IE patients with negative heart valve cultures had received antimicrobial therapy. The yield of culture of heart valves for IE diagnosis was as follows: sensitivity, 25.4%; specificity, 71.6%; positive predictive value (PPV), 5.8%; and negative predictive value, 93.3%. Because of its poor sensitivity and PPV, valve cultures should not be performed for patients without a clinical suspicion of IE. For patients with confirmed IE, heart valve cultures should be interpreted with caution.

Heart Valves Should Not Be Routinely Cultured

Background
Coronary artery bypass graft surgery (CABG) replaces obstructed vessels with ones from other parts of the body. Alternatively, obstructions are remodelled using catheter-based techniques such as percutaneous coronary angioplasty with the use of stents. Though less invasive, stenting techniques are limited by the re-narrowing of treated vessels (restenosis). We examined evidence on cardiac-related outcomes occurring after CABG or stenting, with implications for resource use, resource allocation and informing patient choice.

Objectives
To examine evidence from randomised controlled trials (RCTs) on benefit of stents or CABG in reducing cardiac events in people with stable angina or acute coronary syndrome (ACS).

Search methods
CENTRAL (Issue 2 2004), EMBASE (1990 to 2004), MEDLINE (1990 to 2004) and handsearching to July 2004.

Selection criteria
Only RCTs comparing stents used with PTCA with CABG were included. Participants were adults with stable angina or ACS and unstable angina and had either single or multiple vessel disease. Published and unpublished sources were considered.

Data collection and analysis
Outcomes included composite event rate (major adverse cardiac event, event free survival), death, acute myocardial infarction (AMI), repeat revascularisation and binary restenosis as well as information on design and baseline characteristics. Quality assessment was completed independently. Meta-analyses are presented as odds ratios, 95% confidence intervals (CI) using a fixed-effect model. Heterogeneity between trials was assessed.

Main results
Nine studies (3519 patients) were included. Four RCTs included patients with multiple vessel disease, five focused on single vessel disease. Four studies reported beyond 1 year. No statistical differences were observed between CABG and stenting for meta-analysis of mortality or AMI, but there was heterogeneity. Composite cardiac event and revascularisation rates were lower for CABG than for stents. Odds ratios resulting from meta-analysis of event rate data at 1 year were, odds ratio 0.43 (95% CI 0.35 to 0.54) and at 3 years, odds ratio 0.37 (95% CI 0.29 to 0.48). Odds ratios for revascularisation at 1 year were, odds ratio 0.18 (95% CI 0.13 to 0.25) and at 3 years, odds ratio 0.09 (95% CI 0.02 to 0.34). Binary restenosis at 6 months (single vessel trials) favoured CABG, odds ratio 0.29 (95% CI 0.17 to 0.51).

Authors' conclusions
CABG is associated with reduced rates of major adverse cardiac events, mostly driven by reduced repeat revascularisation. However, the RCT data are limited by follow-up, unrepresentative samples and rapid development of both surgical techniques and stenting. Research on real-world patient population or patient level data meta-analyses may identify risk factors and groupings who may benefit most from one strategy over the other.

Percutaneous transluminal coronary angioplasty with stents versus coronary artery bypass grafting for people with stable angina or acute coronary syndromes.

Latent infective endocarditis: epidemiology and clinical characteristics of patients with unsuspected endocarditis detected after elective valve replacement.

BACKGROUND The Arterial Revascularization Therapies Study was a multicenter, randomized trial designed to compare percutaneous coronary intervention with stenting versus coronary artery bypass graft surgery in 1,205 patients with multivessel coronary artery disease. The most appropriate type of treatment for these patients is still a matter of considerable debate. OBJECTIVES To evaluate the clinical characteristics of patients enrolled in the ARTS trial in Israel in comparison to those worldwide, and to assess the 1 year outcome in these patients. METHODS Between April 1997 and June 1998, a total of 1,205 patients with multivessel coronary artery disease, who were considered to be equally treatable with both modalities, were randomized to either stenting (n = 600) or CABG (n = 605) at 67 centers around the world. In Israel, 53 patients at four participating medical centers were randomized to either PCI with stents (n = 27) or CABG (n = 26). RESULTS Clinical and angiographic characteristics were similar in the two groups, except for a significantly higher incidence of diabetic patients in Israel who were randomized to CABG, compared to those worldwide (35% vs. 16%, P = 0.01). Also, there were more patients with unstable angina in Israel (63 vs. 37%, P = 0.006). At 1 year follow-up, overall mortality and cerebrovascular accident rates were similar between the two groups and equivalent to results obtained around the world. There was a significantly higher incidence of myocardial infarction rates in patients randomized to stenting in Israel compared to patients worldwide (7.4 vs. 5.3%, P = 0.01) or to patients randomized to CABG in Israel (7.4 vs. 0%, P = 0.006). Similar to the overall ARTS results, there was a higher incidence of repeat revascularization procedures in patients assigned to the PCI with stenting arm (22.2 vs. 3.8%, P = 0.004) compared to those randomized to CABG, respectively. CONCLUSIONS The results of this analysis of the Israeli ARTS population indicate that coronary stenting and bypass surgery yield similar findings with regard to mortality and stroke and are comparable to those obtained in the whole study group. Likewise, coronary stenting was associated with an increased incidence of repeat revascularization procedures as compared to CABG. However, patients in Israel randomized to stenting had a higher rate of myocardial infarction as compared to the overall results and to patients who underwent CABG in Israel. The present analysis provides important data for the safety and efficacy of either stenting or bypass surgery in treating patients with multivessel disease in Israel.

Comparison of bypass surgery and stenting for the treatment of multivessel disease: results from the ARTS trial in Israel.

Objective:Majorsurgicalinterventionsuchas cardiacsurgeryhasbeen shownto have profoundeffectson theimmunesystem. We conducteda prospective study comparing the effects of coronary artery bypass grafting (CABG) versus isolated valve surgery. Methods: Blood samples were drawn from 59 patients undergoing either elective CABG or elective isolated valve replacement surgery. Samples were obtained preoperatively and on the first and third postoperative days. Total cell counts and differential counts were recorded. Several cellular immunity parameters were determined by flow cytometry. Results: On all postoperative days, significant increases in white blood cell (WBC) and monocyte counts were observed.Significantdecreasesinalllymphocytepopulationswerealsoobservedwithsimilardecreasesinbothhelper(CD4)andsuppressor(CD8) Tcells. An increase in activated Tcells was noted on day 1, returning to normal on the third postoperative day. Despite the significant decrease in human leucocyte antigen-DR (HLA-DR) antigen expression on monocytes on both the first and third postoperative days, a significant increase in monocyte activation as represented by increased CD11b and CD64 expression was detected. No significant difference was found for any of the measured parameters between the CABG group and the valve replacement group. Eight patients developed early wound infections, with no correlation with any of the measured parameters, including magnitude and duration of decrease in HLA-DR antigen expression on monocytes. Conclusions:Cardiacsurgery inducesboth a state of pro-inflammation andof immunesuppression. Thetwo major typesof cardiacsurgery induce similar effects to the immune system. None of the measured parameters was predictive for development of postoperative wound infection. # 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

/pdf/the-cellular-immunological-responses-of-patients-undergoing-hyvr1xjoly.pdf

The cellular immunological responses of patients undergoing coronary artery bypass grafting compared with those of patients undergoing valve replacement.

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Papers

Latent infective endocarditis: epidemiology and clinical characteristics of patients with unsuspected endocarditis detected after elective valve replacement.

Comparison of bypass surgery and stenting for the treatment of multivessel disease: results from the ARTS trial in Israel.

The cellular immunological responses of patients undergoing coronary artery bypass grafting compared with those of patients undergoing valve replacement.