CblC/D defect combined with haemodynamically highly relevant VSD

An infant with combined methylmalonic aciduria and homocystinuria (cblC/D defect) presented with significant VSD. She underwent successful cardiac surgery at 53 days.     

Oritavancin for acute bacterial skin and skin structure infections

Introduction: Inpatient treatment of acute bacterial skin and skin structure infections (ABSSSIs) exerts a significant economic burden on the healthcare system. Oritavancin is a concentration-dependent, rapid bactericidal agent approved for the treatment of ABSSSIs. Its prolonged half-life with one-time intravenous (i.v.) dosing offers a potential solution to this burden. In addition, oritavancin represents an alternative therapy for Streptococci and multidrug-resistant Gram-positive bacteria including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Animal models have also shown promising results with oritavancin for other disease states including those that require long courses of i.v. therapy.

Areas covered: This review covers oritavancin’s basic chemistry, spectrum of activity, pharmacodynamics/pharmacokinetics and efficacy in clinical trials, and provides expert opinion on future directions. To compose this review, a search of PubMed was performed, and articles written in the English language were selected based on full text availability.

Expert opinion: If oritavancin is proven to be a cost-effective strategy for outpatient treatment and prevents complications of prolonged i.v. therapy, it will be sought as an alternative antibiotic therapy for ABSSSIs. In addition, further clinical data demonstrating efficacy in Gram-positive infections requiring prolonged therapy such as endocarditis and osteomyelitis could support oritavancin’s success in the current market.     

Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia

PURPOSE: Staphylococcus aureus is a common cause of bacteremia and of native valve infective endocarditis. However, the risk of endocarditis in patients with a prosthetic valve who develop S. aureus bacteremia is unclear. The aim of this study was to define the risk of prosthetic valve endocarditis in patients with S. aureus bacteremia. SUBJECTS AND METHODS: All patients with a prosthetic valve or ring who developed S. aureus bacteremia during the 94-month study period were prospectively evaluated. The modified Duke criteria were used for the diagnosis of endocarditis. Patients were followed up for 12 weeks after the initial diagnosis of S. aureus bacteremia. RESULTS: The overall rate of definite prosthetic valve endocarditis among the study patients was 26/51 (51%). The risk of endocarditis was similar in patients with late (>or=12 months after valve implantation) vs. early S. aureus bacteremia (<12 months after prosthetic valve implantation) (50% vs. 52%, P=1.0), mitral vs. aortic prostheses (62% vs. 48%, P=0.24), and mechanical vs. bioprosthetic valves (62% vs. 44%, P=0.29). The 12-week mortality was higher among patients with definite vs. possible endocarditis (62% vs. 28%, P=0.019). CONCLUSION: In this investigation, approximately half of all patients with prosthetic valves who developed S. aureus bacteremia had definite endocarditis. The risk of endocarditis was independent of the type, location, or age of the prosthetic valve. The mortality of prosthetic valve endocarditis is high. All patients with a prosthetic valve who develop S. aureus bacteremia should be aggressively screened and followed for endocarditis.     

Electrocardiographic and hemodynamic changes in experimental right ventricular infarction

To investigate the electrocardiographic and hemodynamic changes in isolated right ventricular infarction, 0.25 ml or 0.5 ml of metallic mercury was injected into the right coronary artery of 14 closed-chest dogs. At autopsy, at least 60% of the right ventricle was necrotic in every dog. Hemodynamic observations were made in 11 and electrocardiographic mapping was performed in all 14 dogs. Right atrial pressure rose in 10 and left atrial pressure in nine of the 11 dogs; early right atrial pressure did not exceed left atrial pressure, but late right atrial pressure was greater in four dogs. Although cardiac output and blood pressure fell significantly, circulation was maintained. Twelve of 14 dogs had transient ST-segment elevation in the right precordial leads, and 12 developed right bundle branch block. Abnormal Q waves or R waves of 1 mm or less appeared in the right precordial leads in 13 of the 14 dogs. Since right bundle branch block and abnormal Q waves in the right precordial leads have not been recognized as useful signs in human right ventricular infarction, further investigations are warranted to determine their value in clinical applications.     

System for Rapid Assessment of Pneumonia and Influenza-Related Mortality—Ohio, 2009–2010

Rapid mortality surveillance is critical for state emergency preparedness. To enhance timeliness during the 2009–2010 influenza A H1N1 pandemic, the Ohio Department of Health activated a drop-down menu within Ohio’s Electronic Death Registration System for reporting of pneumonia- or influenza-related deaths approximately 5 days postmortem. We used International Classification of Diseases—Tenth Revision (ICD-10) codes, available 2–3 months postmortem as the standard, and assessed their agreement with drop-down-menu codes for pneumonia- or influenza-related deaths. Among 56 660 Ohio deaths during September 2009–March 2010, agreement was 97.9% for pneumonia (κ = 0.85) and 99.9% for influenza (κ = 0.79). Sensitivity was 80.2% for pneumonia and 73.9% for influenza. Drop-down menu coding enhanced timeliness while maintaining high agreement with ICD-10 codes.     

Increase in Suicides Associated With Home Eviction and Foreclosure During the US Housing Crisis: Findings From 16 National Violent Death Reporting System States, 2005–2010

Objectives. We aimed to determine the frequency, characteristics, and precipitating circumstances of eviction- and foreclosure-related suicides during the US housing crisis, which resulted in historically high foreclosures and increased evictions beginning in 2006.Methods. We examined all eviction- and foreclosure-related suicides in the years 2005 to 2010 in 16 states in the National Violent Death Reporting System, a surveillance system for all violent deaths within participating states that abstracts information across multiple investigative sources (e.g., law enforcement, coroners, medical examiners).Results. We identified 929 eviction- or foreclosure-related suicides. Eviction- and foreclosure-related suicides doubled from 2005 to 2010 (n = 88 in 2005; n = 176 in 2010), mostly because of foreclosure-related suicides, which increased 253% from 2005 (n = 30) to 2010 (n = 106). Most suicides occurred before the actual housing loss (79%), and 37% of decedents experienced acute eviction or foreclosure crises within 2 weeks of the suicide.Conclusions. Housing loss is a significant crisis that can precipitate suicide. Prevention strategies include support for those projected to lose homes, intervention before move-out date, training financial professionals to recognize warning signs, and strengthening population-wide suicide prevention measures during economic crises.In 2010, 36 364 persons in the United States died by suicide (age-adjusted rate = 12.08 per 100 000 population), making it the second leading cause of death for US adults aged 25 to 34 years, and fourth for adults aged 35 to 54 years.1 Furthermore, the overall suicide rate in the United States has increased over the past decade,2 especially among adults aged 35 to 64 years.3 Suicide carries enormous costs to society, such as emotional trauma for friends and family members (including heightened risk of subsequently attempting suicide themselves), and medical and work loss costs estimated at $34.6 billion a year.Persons who engage in suicidal behavioral typically have multiple risk factors for suicide such as depression, substance abuse, or chronic or acute life stressors such as financial problems. In some instances, a precipitating event prompts an attempt in an already vulnerable person. Several studies of US and international economic cycles have found that suicides increase in step with adverse economic events.4,5 For example, a recent study examining the impact of austerity measures taken in England during the European financial crisis on unemployment and subsequent suicides attributed more than 1000 excess suicides to these economic conditions between 2008 and 2010.6 Another found that in Greece, one of the worst-hit economies in Europe, suicide mortality rates among men have increased by more than 22% since 2007.7 Similar trends were observed in several countries (e.g., Japan, Hong Kong, South Korea) following the Asian monetary crisis of 1997.8An analysis of US business cycles and suicide rates between 1928 and 2007 recently demonstrated that suicide rates in the United States have also generally increased and decreased along with economic conditions.4 The findings demonstrated that US suicide rates peaked during the Great Depression, and decreased during times of economic expansion and low unemployment. Working-age adults were most affected. One recent study attributed up to 25% of the US suicide rate increase seen over the past decade specifically to rising unemployment.9There were other important dimensions of the recent US economic downturn that may be associated with the observed increase in suicides. Beginning in late 2006, the US experienced a housing crisis characterized by historically high rates of home foreclosure10 and increased evictions.11 Media reports of suicides associated with eviction or foreclosure appeared in national news outlets during this time,12–14 although little information exists about the frequency or characteristics of these events. Although the full impact of the housing crisis on public health is not yet known, several studies have documented adverse effects associated with mortgage delinquency such as 2 or more times greater odds of major depression15,16 and 8 times greater odds of elevated depressive symptoms related to acute stress.17 In addition, a recent study found higher suicide rates in regions experiencing higher rates of foreclosure.18 These findings suggest that eviction or foreclosure may be related to elevated risk of suicide. However, to date, no study has described or directly investigated suicides associated with home eviction and foreclosure.We determined the frequency and circumstances of suicide deaths linked to eviction (i.e., renters evicted for financial reasons) and foreclosure (i.e., homeowners losing homes to foreclosure) in the years 2005 through 2010 with data from 16 states participating in the National Violent Death Reporting System (NVDRS). Within this sample, we also examined the extent to which eviction or foreclosure was perceived as a key stressor contributing to the decedent’s suicide versus acting in concert with other stressors. Furthermore, we calculated the frequency of eviction or foreclosure suicides relative to other suicides during this time period, and the percentage of all suicides associated with financial stressors that were eviction or foreclosure related.     

Cost effectiveness of carvedilol for heart failure

In this study, we examine the cost effectiveness of carvedilol for the treatment of chronic heart failure (CHF). We use a Markov model to project life expectancy and lifetime medical care costs for a hypothetical cohort of patients with CHF who were assumed alternatively to receive carvedilol plus conventional therapy (digoxin, diuretics, and angiotensin-converting enzyme inhibitors) or conventional therapy alone. Patients on carvedilol were assumed to experience a reduced risk of death and hospitalization for CHF, which is consistent with findings from the US Carvedilol Heart Failure Trials Program. The benefits of carvedilol were projected under 2 alternative scenarios. In the first ("limited benefits"), benefits were conservatively assumed to persist for 6 months, the average duration of follow-up in these clinical trials, and then end abruptly. In the other ("extended benefits"), they were arbitrarily assumed to persist for 6 months and then decline gradually over time, vanishing by the end of 3 years. We estimated our model using data from the US Carvedilol Heart Failure Trials Program and other sources. For patients receiving conventional therapy alone, estimated life expectancy was 6.67 years; corresponding figures for those also receiving carvedilol were 6.98 and 7.62 years under the limited and extended benefits scenarios, respectively. Expected lifetime costs of CHF-related care were estimated to be $28,756 for conventional therapy, and $36,420 and $38,867 for carvedilol (limited and extended benefits, respectively). Cost per life-year saved for carvedilol was $29,477 and $12,799 under limited and extended benefits assumptions, respectively. The cost effectiveness of carvedilol for CHF compares favorably to that of other generally accepted medical interventions, even under conservative assumptions regarding the duration of therapeutic benefit.