青少年及成人先天性心脏病感染性心内膜炎的临床研究

感染性心内膜炎占青少年及成人先天性心脏病科住院人数的４～５％。本文研究了１７７例（１３～７４岁，平均年龄２６岁：男：女为１．５：１）２０５次感染性心内膜炎，以确定受感染之先天性心脏缺损之种类，诊断的延误，死亡率及外科治疗对预后的影响。１４９次心内膜炎发生在根治性心脏手术之前（组１），其中２１例病人接受过减状治疗：５６次发生在手术根治后病人（组２）。最常见受累的缺损为主动脉瓣疾患（４３次），小室间隔缺损（４１次）和法乐氏四联症（２４次）。牙科检治，手术中及延长的围术期治疗以及皮肤创伤感染是最常见的诱发因素，有明确细菌学培养结果者１３９人次，其中最常见的为草绿色链球菌，在组１为５５％，组２为４９％；金黄色葡萄球菌感染组２（２５％）比组１（１３％）高。诊断延误时间在组１明显长于组２。在感染活动期特别是金黄色葡萄球菌感染时外科紧急手术治疗有时是必须的。手术根治后的先天性心脏病患者凡遗留有任何血流动力学改变者都需要预防感染性心内膜炎（包括换瓣病人）。     

Clinical Outcomes of Infective Endocarditis in Injection Drug Users

Background

Rising rates of hospitalization for infective endocarditis (IE) have been increasingly tied to rising injection drug use (IDU) associated with the opioid epidemic.

Neocuspidization of the Pulmonary Valve with Autologous Pericardium in the Adult Patient with Ventricular Septal Defect and Infective Endocarditis: A Case Report and Review of the Literature

Congenital heart disease (CHD) is one of the risk factors for developing infective endocarditis (IE). Right-sided IE occurs in 5%–10% of endocarditis cases, and pulmonary valve (PV) is involved in less than 2% of such patients. Literature data are few, and optimal treatment methods, indications for surgery, and types of operative techniques are still under debate. We present an adult patient with a rare combination of the ventricular septal defect (VSD) and PV IE who underwent surgical treatment. Neocuspidization with autologous pericardium was utilized for the reconstruction of his PV. We discuss details of this novel surgical technique.     

Infective endocarditis in children with congenital heart disease: the changing spectrum, 1965--85

Thirty-five episodes of infective endocarditis in 35 childrenwith congenital heart disease, from January 1965 to December1984, were reviewed. The incidence of infective endocarditisin cyanotic congenital heart defects increased with a concomitantdecrease in the frequency of lesions with left to right shunt.The incidence of postoperative endocarditis decreased from 1:52during the first decade to 1:1033 during the second decade.The time interval between onset of symptoms and the establishmentof diagnosis and treatment shortened from 7.8 ± 3.2 weeks(mean ± SD) to 2.1±0.9 weeks. During the latterdecade, positive blood cultures were obtained in 100% of patients,as compared with 60% during the former decade (P 0.05). Echocardiographydemonstrated vegetations in 70% of the cases. Over the entiretime period, streptococcus viridans was the most frequent pathogen(46%) and staphylococcus aureus secondmostfrequent (17%). Sixpatients died, all were under two years of age and all had congestiveheart failure. Early surgical correction of the congenital heartdiseasemay offer the best form of prevention.     

Late Bacterial Endocarditis in an Intravenous Drug User With an Amplatzer Septal Occluder

Infective endocarditis of a fully endothelialized cardiac prosthesis, and especially the late presentation of endocarditis, challenges our current understanding of device-related complications. Late bacterial endocarditis associated with the Amplatzer Septal Occluder, a device frequently used to close atrial septal defects, has been documented only rarely. We report the case of an intravenous drug user who had late infective endocarditis associated with his Amplatzer Septal Occluder, secondary to methicillin-sensitive Staphylococcus aureus bacteremia nearly 14 years after device insertion. The patient recovered after surgical excision and débridement of the vegetative mass, which may be the first time that a surgical approach has been taken to treat this condition. This report corroborates the need for late screening of high-risk patients who have septal occluder devices.     

Race, Gender, Drug Use, and Participation in AIDS Clinical Trials: Lessons from a Municipal Hospital Cohort

OBJECTIVE: To determine whether participation rates of women, persons of color, and injection drug users in AIDS clinical trials are similar to those of other HIV/AIDS patients, and to examine whether differences in patients' knowledge of clinical trials or reasons for not participating explain differences in participation rates by gender, race, or drug use. DESIGN Cross-sectional survey of patients with HIV disease. SETTING: Ambulatory practice of a municipal teaching hospital. PATIENTS: Two hundred sixty patients receiving primary care for HIV disease. MEASUREMENTS AND MAIN RESULTS: Overall, 22.3% of patients had participated in a clinical trial. Women, patients of color, and drug users were significantly less likely to have ever participated in an AIDS clinical trial (p < .05). Multiple logistic regression confirmed being a person of color (odds ratio [OR] 2.14; 95% confidence interval [CI] 1.12-4.08) and injection drug use (OR 2.09; 95% CI 1.08-4.04) as significant predictors of nonparticipation in AIDS clinical trials (p < .05). Patients of color and women reported less knowledge of clinical trials, and were less likely to have been told about clinical trials for which they were eligible (p < .05). Patients of color were half as likely as whites to cite ineligibility as their reason for not participating (10.4% vs 22.4%), and more likely to hold unfavorable opinions of clinical research (50.7% vs. 40.5%). Reasons for nonparticipation did not differ by gender. CONCLUSIONS: Even when AIDS clinical trials are available on-site, persons of color, women, and drug users are less likely to participate. Educational efforts for patients and providers are needed to remedy continuing disparities in participation by race, gender, and risk factor group in AIDS clinical trials.     

Rothia dentocariosa Endocarditis: An Especially Rare Case in a Previously Healthy Man

Rothia dentocariosa is a rare gram-positive bacterial organism, one of the group of microbes that normally resides in the mouth and respiratory tract. R. dentocariosa rarely causes disease. Documented cases occur chiefly in patients with valvular or dental disease, or both. We report the case of a previously healthy 58-year-old man who presented with evidence of bacterial endocarditis caused by this organism—which originated from an elusive source. His endocarditis was successfully treated with mitral valve replacement and the administration of antibiotic agents.     

Ductal stent endocarditis resulting in a large aortic pseudoaneurysm

An infant with ductal dependent pulmonary blood flow who underwent neonatal ductal stenting and, 4 months later, developed ductal stent endocarditis due to Streptococcus gallolyticus subsp. pasteurianus was described. The infection was associated with a moderate aortic pseudoaneurysm and the patient was treated with antibiotics as well as surgical aortic pseudoaneurysm repair. This novel and unusual complication of ductal stent placement warrants reporting.     

Drug treatment and the conditionality of HIV treatment access: a qualitative study in a Russian city

Aims We explored social factors affecting access to antiretroviral HIV treatment (ART) among people who inject drugs (PWID) in a Russian city with a large HIV burden. Design Qualitative interview study. Setting Community settings in Ekaterinburg, Russian Federation. Participants 42 PWID living with HIV and 11 health practitioners. Measurements Thematic analyses of in-depth qualitative interviews. Findings Access to ART was felt by participants to be contingent upon their capacity to demonstrate a commitment to becoming 'drug free'. We identify, across interview accounts, a treatment access narrative of 'treat drugs before HIV'. This narrative is upheld by ART providers' concerns to maximize clinical outcome in the face of adherence doubts, as well as by would-be patients' perceptions of expectations placed upon them by the treatment system and their own doubts regarding treatment engagement. This has the effect of reproducing a habit of ART delay and disengaging people from the treatment system. Difficulties accessing ART, and the perceived rationing of treatment on account of untreated drug use, were experienced as 'moral discipline' for falling short of treatment 'deservedness'. Participants describe a 'Catch 22' system, where they are invited to treat their drug use in a setting where effective drug treatment was perceived as unavailable. Conclusions Inadequate drug treatment practices act as structural obstacles to realizing HIV treatment. Evidence internationally suggests that effective drug treatment, including opioid substitution therapy, improves access and adherence to antiretroviral treatment among people who inject drugs. Policy shifts are urgently needed in this setting to enable systemic improvements to drug treatment, especially given large HIV treatment demand.     

FDG-positron emission tomography (PET) has a role to play in the diagnosis and therapy of infective endocarditis and cardiac device infection

In recent years, molecular imaging with positron emission tomography (PET) and more recently, PET coupled with computed tomography (CT) have made a valuable impact in various clinical arenas, primarily within the field of oncology, but also in cardiovascular medicine, particularly in detecting coronary artery disease and myocardial viability. More recently, PET imaging has been proven useful in the diagnosis and evaluation of inflammation and infection at different organ sites. Application of PET in the case of Infective Endocarditis (IE) is still in its infancy and indeed the value of this application in the detection of vegetations is debated primarily due to sensitivity issues of the tracer in cardiac tissue and small vegetations. Interestingly, however, reports are now emerging highlighting the role that this application has played in the diagnosis, assessment of complications such as emboli and metastatic infection and the monitoring of therapeutic treatment of IE. More recently, PET/CT has proven valuable in the diagnosis and assessment of cardiac implantable electronic device (CIED)-related infection and its use has highlighted the contribution that this imaging modality may play in assessing the need for surgery in patients with such infections. This article reviews the literature with regard to the potential value of 2-deoxy-2-[¹⁸F]fluoro-D-glucose (¹⁸FDG)-PET, as well as the pitfalls and limitations of this imaging modality, in relation to cardiac infection. The emerging role ¹⁸FDG-PET/CT has in the diagnosis and monitoring of IE, particularly prosthetic valve IE and CIED-related infections should be considered, particularly in difficult cases.     

Syringe Acquisition and Use of Syringe Exchange Programs by Puerto Rican Drug Injectors in New York and Puerto Rico: Comparisons Based on Quantitative and Qualitative Methods

Quantitative and qualitative data are used to compare alternative sources of syringes, including syringe exchange programs (SEPs), accessed by 165 Puerto Rican injection drug users (IDUs) in East Harlem, New York (NY), and 115 in Bayamón, Puerto Rico (PR). IDUs in PR obtained, on average, 45.2% of their syringes from syringe sellers, 18.0% from pharmacies, and 17.6% from a SEP. By contrast, IDUs in NY obtained 55.0% of their syringes from SEPs and 22.9% from syringe sellers. Compared to their island counterparts, IDUs in NY received significantly more syringes from SEPs (NY, 104.5; PR, 9.2) in the prior 30 days, and were more likely to be referred by SEPs to drug treatment and HIV/TB-testing services. The results of this study suggest the need in Puerto Rico to eliminate restrictive syringe exchange policies, reform drug paraphernalia laws to protect SEP clients, and address police harassment related to carrying syringes.     

SBIRT Outcomes in Houston: Final Report on InSight, a Hospital District-Based Program for Patients at Risk for Alcohol or Drug Use Problems

Background: Screening, Brief Intervention, and Referral to Treatment (SBIRT) services have been implemented as the standard of care for patients in the Harris County Hospital District (HCHD). The present analysis addresses alcohol and drug use for patients admitted over a 39‐month period from July 1, 2005 through September 30, 2008. Methods: Patients were screened for alcohol and drug use at medical admission. Those who were positive received further assessment and were transitioned to receive services as appropriate. A sample of consenting patients who were positive and received services was contacted at 6 months for a follow‐up interview. Using an intent‐to‐treat (ITT) protocol, the analysis included all patients who were assigned for follow‐up, including those with completed follow‐ups as well as those who could not be contacted at follow‐up. Patients not contacted at follow‐up were assumed to have maintained their baseline drug and alcohol consumption levels. Results: Of 59,760 patients who were screened by generalists (primarily nurses, physicians, and medical care technicians), 15,241 (26%) were positive and received further assessment and services. The 6‐month follow‐up interview completion rate was 66%. The ITT sample consisted of all 1,937 patients who were assigned for follow‐up. There was an overall reduction in the number of patients reporting any days of heavy drinking from 70% at intake to 37% at 6‐month follow‐up and a reduction in the mean number of days of heavy drinking from 7.8 days at intake to 4.1 days at follow‐up. The number of patients reporting any days of drug use was 82% at intake versus 33% at follow‐up, and the mean number of days of drug use declined from 8.3 days at intake to 4.2 days at follow‐up. Conclusions: The results were consistent with but of greater magnitude than most other studies reporting positive outcomes for SBIRT patients. Drug use and heavy alcohol use were found to decrease substantially from admission to follow‐up. This finding holds good for all levels of drug or alcohol misuse severity, with the highest severity patients showing the largest decreases. Future studies are needed to control for potential regression to the mean effects and to develop improved understanding of differences in outcomes by race/ethnicity.