Jimmy Chua

BACKGROUND: Optimal treatment of infections related to implantable electrophysiologic cardiac devices is poorly defined. OBJECTIVE: To describe the clinical presentation, treatment, and outcome of patients with such infections. DESIGN: Retrospective case series. SETTING: The Cleveland Clinic Foundation, Cleveland, Ohio. PATIENTS: 123 patients with infections involving implantable cardiac electrophysiologic devices. MEASUREMENTS: Demographic characteristics, clinical manifestations, time to diagnosis, management, and outcome. RESULTS: 87 patients with permanent pacemakers and 36 patients with implantable cardioverter defibrillators had infections. The most common signs and symptoms were pocket erythema and local pain. The most common pathogens were coagulase-negative staphylococci (68%) and Staphylococcus aureus (23%). In 117 patients (95%), all equipment was extracted and antibiotic therapy lasted a median of 28 days. Operative mortality was zero. Follow-up showed crude mortality and relapse rates of 8% and 3%, respectively. CONCLUSION: For infections related to implantable electrophysiologic devices, complete device removal and antimicrobial therapy allow timely, successful reimplantation at a remote anatomic site without substantial risk for operative mortality or recurrent infection.

A retrospective chart review of all patients seen at the Cleveland Clinic Foundation with infectious endogenous endophthalmitis between January 1982 and August 2000 revealed 34 affected eyes in 27 patients. During this time, the median incidence of endogenous endophthalmitis was 1.8 cases/year, and 48.1% of patients presented as outpatients. Twenty-six patients presented to an ophthalmologist, and the diagnosis was initially missed in almost half the cases. Eleven patients had an unremarkable physical exam except for eye findings. We found an equal incidence of bacterial and fungal endophthalmitis and a predominance of among the fungal etiologic agents. We did not, however, note a predominance of Gramnegative organisms seen mostly in reports from Asia. The microbiologic diagnosis was based on aqueous and vitreous cultures or positive eye histopathology stains in almost two-thirds of cases. The sensitivity of the Gram stain was poor, but its specificity and positive predictive value were excellent. The vitreous cultures obtained by vitrectomy instruments were more sensitive in making the diagnosis than the vitreous needle biopsy. Aside from blood cultures and eye specimen cultures, half the patients had an additional infectious focus, most frequently a urinary tract infection, whereas infectious endocarditis was seen in a small minority. Twelve patients had visual improvement with treatment with a final visual acuity better than 20/200 in 44% of the eyes. Good visual outcome was associated with visual acuity of 20/200 or better at diagnosis and with the absence of hypopyon.

Background: The isolation of a pathogen is vital in the diagnosis and treatment of a device infection. A swab culture, despite poor sensitivity, is the most common method used in specimen collection. Objective: To determine the relative value of swab and tissue specimen cultures in patients with implantable cardiac pacemakers and defibrillators. Design: Prospective patient cohort study. Setting: A 1,000‐bed tertiary referral center in Cleveland, Ohio. Patients: Consecutive patients with implantable cardiac pacemaker or defibrillator presenting for lead extraction from October 1, 2000 to March 31, 2001. Methods: Tissue and swab cultures were prospectively collected during pacemaker and implantable defibrillator surgeries that required lead extraction. Clinical manifestations, microbiology, and echocardiographic data were recorded in patients with and without a clinical diagnosis of device system infection. Results: Seventy‐one patients with implantable pacemaker (n = 49, 69%), implantable defibrillator (n = 18, 25%), or both devices (n = 4, 6%) requiring lead extraction had pocket swab and tissue cultures for analysis. Infection was evident clinically in 35 (49%) of the patients and absent in the remainder. The most common bacteria isolated were coagulase‐negative Staphylococcus (37%) and Staphylococcus aureus (10%). Patients with clinical infection had positive cultures more frequently (P = 0.002) by pocket tissue culture (n = 24, 69%) than by swab culture (n = 11, 31%). However, patients without clinical infections had positive cultures at similar rates by pocket tissue culture (n = 10, 28%) and by swab culture (n = 8, 22%; P = 0.48). Patients without clinical infection were not treated with other than perioperative antibiotics, and did not develop clinical infections. Conclusion: Pocket tissue cultures are more effective than pocket swab cultures for the isolation and identification of the infectious pathogens in cardiac device infections. Positive cultures by pocket swab or tissue cultures in the absence of clinical signs and symptoms of infection does not imply infection or the need for specific therapy.

BACKGROUND: Research surrounding COVID-19 (coronavirus disease 2019) is rapidly increasing, including the study of biomarkers for predicting outcomes. There is little data examining the correlation between serum albumin levels and COVID-19 disease severity. The purpose of this study is to evaluate whether admission albumin levels reliably predict outcomes in COVID-19 patients. METHODS: We retrospectively reviewed 181 patients from two hospitals who had COVID-19 pneumonia confirmed by polymerase chain reaction (PCR) testing and radiologic imaging, who were hospitalized between March and July 2020. We recorded demographics, COVID-19 testing techniques, and day of admission labs. The outcomes recorded included the following: venous thromboembolism (VTE), acute respiratory distress syndrome (ARDS), intensive care unit (ICU) admission, discharge with new or higher home oxygen supplementation, readmission within 90 days, in-hospital mortality, and total adverse events. A multivariate modified Poisson regression analysis was then performed to determine significant predictors for increased adverse events in patients with COVID-19 pneumonia. RESULTS: A total of 109 patients (60.2%) had hypoalbuminemia (albumin level < 3.3 g/dL). Patients with higher albumin levels on admission had a 72% decreased risk of developing venous thromboembolism (adjusted relative risk [RR]:0.28, 95% confidence interval [CI]:0.14-0.53, p<0.001) for every 1 g/dL increase of albumin. Moreover, higher albumin levels on admission were associated with a lower risk of developing ARDS (adjusted RR:0.73, 95% CI:0.55-0.98, p = 0.033), admission to the ICU (adjusted RR:0.64, 95% CI:0.45-0.93, p = 0.019), and were less likely to be readmitted within 90 days (adjusted RR:0.37, 95% CI:0.17-0.81, p = 0.012). Furthermore, higher albumin levels were associated with fewer total adverse events (adjusted RR:0.65, 95% CI:0.52-0.80, p<0.001). CONCLUSIONS: Admission serum albumin levels appear to be a predictive biomarker for outcomes in COVID-19 patients. We found that higher albumin levels on admission were associated with significantly fewer adverse outcomes, including less VTE events, ARDS development, ICU admissions, and readmissions within 90 days. Screening patients may lead to early identification of patients at risk for developing in-hospital complications and improve optimization and preventative efforts in this cohort.

BACKGROUND: Superwarfarin sodium exposure or poisoning is a growing public health problem. There were 5133 reported cases of superwarfarin exposure and poisoning in 1988 and 13 423 cases in 1995. Cases may be associated with accidental exposure, suicide attempts, or Munchausen syndrome, and may be difficult to diagnose. PATIENTS AND METHODS: Patients from northern Wisconsin with superwarfarin exposure or poisoning were examined at a tertiary referral center in rural Wisconsin to determine what led to their exposure and to review the clinical manifestations, diagnosis, treatment, and prevention of superwarfarin poisoning. RESULTS: Eleven cases satisfied the criteria for superwarfarin exposure or poisoning. All 7 children included in the study had accidentally ingested superwarfarin, 2 adults had Munchausen syndrome, and 1 teenager and 1 adult had attempted suicide using superwarfarin. Nine of the 11 cases had taken brodifacoum. The patients who had accidentally ingested superwarfarin or attempted suicide using it were easily diagnosed, while diagnosis was markedly delayed for the 2 patients with Munchausen syndrome. Full reversal of anticoagulation was quickly achieved in the cases of accidental ingestion and attempted suicide. We examined and treated the patients with Munchausen syndrome for months before establishing a diagnosis and fully reversing the anticoagulation. None of the patients in our study died of superwarfarin poisoning. CONCLUSIONS: Superwarfarin exposure or poisoning is a growing public health problem that should be part of the differential diagnosis of patients who present with a coagulopathy consistent with vitamin K deficiency in the absence of coumadin therapy, liver disease, or the use of an inhibitor, and whose conditions do not resolve with large doses of parenteral vitamin K1 therapy.