Abdelghani El Rafei

Efficacy of Antitoxin Therapy in Treating Patients With Foodborne Botulism: A Systematic Review and Meta-analysis of Cases, 1923–2016

Background Botulism is a rare, potentially severe illness, often fatal if not appropriately treated. Data on treatment are sparse. We systematically evaluated the literature on botulinum antitoxin and other treatments. Methods We conducted a systematic literature review of published articles in PubMed via Medline, Web of Science, Embase, Ovid, and Cumulative Index to Nursing and Allied Health Literature, and included all studies that reported on the clinical course and treatment for foodborne botulism. Articles were reviewed by 2 independent reviewers and independently abstracted for treatment type and toxin exposure. We conducted a meta-analysis on the effect of timing of antitoxin administration, antitoxin type, and toxin exposure type. Results We identified 235 articles that met the inclusion criteria, published between 1923 and 2016. Study quality was variable. Few (27%) case series reported sufficient data for inclusion in meta-analysis. Reduced mortality was associated with any antitoxin treatment (odds ratio [OR], 0.16; 95% confidence interval [CI], .09-.30) and antitoxin treatment within 48 hours of illness onset (OR, 0.12; 95% CI, .03-.41). Data did not allow assessment of critical care impact, including ventilator support, on survival. Therapeutic agents other than antitoxin offered no clear benefit. Patient characteristics did not predict poor outcomes. We did not identify an interval beyond which antitoxin was not beneficial. Conclusions Published studies on botulism treatment are relatively sparse and of low quality. Timely administration of antitoxin reduces mortality; despite appropriate treatment with antitoxin, some patients suffer respiratory failure. Prompt antitoxin administration and meticulous intensive care are essential for optimal outcome.

Effect of the American Heart Association 2007 Guidelines on the Practice of Dental Prophylaxis for the Prevention of Infective Endocarditis in Olmsted County, Minnesota

Objective: To determine the adherence of dental providers to the 2007 American Heart Association (AHA) infective endocarditis prevention guidelines regarding antibiotic drug administration before invasive dental procedures. Patients and Methods: The study included all adults (≥18 years old) with a moderate‐risk (MR) or high‐risk (HR) cardiac condition who received dental care at participating dental offices from January 1, 2005, through June 1, 2015, in Olmsted County, Minnesota. Data collected included the date and type of dental procedure performed and receipt of antibiotic prophylaxis (AP). Results: A total of 1351 patients underwent 8854 dental visits at participating dental offices during the study period; 1236 patients had an MR cardiac condition and 115 had an HR condition. The percentage of visits in which antibiotic drugs were used for indicated dental procedures in the MR group declined from 64.6% before to 8.6% after publication of the 2007 AHA guidelines (P<.001); for the HR group, AP declined from 96.9% before to 81.3% after publication of the guidelines (P=.02). Conclusion: In this historical cohort in Olmsted County there was a statistically significant reduction in AP in the MR group before invasive dental procedures. In addition, there was an unanticipated significant reduction in AP in the HR group after publication of the 2007 AHA guidelines. These findings can be used to provide feedback and education to medical and dental professionals who are involved in decision making regarding the use of dental prophylaxis for their patients.

Beta-haemolytic streptococcal endocarditis: clinical presentation, management and outcomes

Abstract Background Beta-haemolytic streptococcal (BHS) endocarditis is rare, but well-recognised for its high morbidity and mortality. This study sought to further characterise clinical features, management and outcomes of BHS endocarditis. Methods Retrospective review of all adultpatients (≥ 18 years old) with BHS endocarditis treated at the Mayo Clinic from 1 January 2000 to 31 December 2014. Results Forty-nine cases of BHS endocarditis were identified with a mean (± SD) age of 64 (±14.9) years and 65% were males. The infection was community acquired in 92% of the cases, with a median (IQR) time to diagnosis from symptom onset of 6 days (5–10). Associated conditions included the presence of a prosthetic valve (41%), malignancy (33%) and diabetes mellitus (DM) (31%). Median (IQR) vegetation size was 12 mm (9–17 mm). In a univariate analysis patients with DM had larger vegetations, median (IQR) = 17 mm (10.5–26 mm) compared to non-diabetic patients, median (IQR) = 11 mm (8–15 mm) (p = 0.01). Septic brain emboli occurred in 43% of cases. Eighteen patients (37%) underwent early (within 30 days) surgery. All-cause 1 month and 6 month mortality rates were 25% and 31%, respectively. Conclusion BHS endocarditis has an acute onset and is complicated by relatively large vegetations with a high rate of systemic embolisation. DM was the second most common associated medical condition and patients with DM had larger vegetations. Despite medical and surgical advances, mortality due to BHS endocarditis remains high, particularly within 30 days of diagnosis.

Utility of Brain Magnetic Resonance Imaging in the Surgical Management of Infective Endocarditis

BACKGROUND Brain magnetic resonance imaging (MRI) is frequently obtained in patients with infective endocarditis, yet its utility in predicting outcomes for valve replacement surgery in patients is unknown. The objective of this study was to determine how brain MRI findings impact clinical management and outcomes. METHODS Demographic and clinical data from electronic medical records at Mayo Clinic were retrospectively reviewed for patients hospitalized with definite or possible infective endocarditis according to the modified Duke criteria between January 1, 2007 and December 31, 2014. There were 364 patients included in the study. RESULTS Cardiac valve replacement surgery was performed in 195 of 364 (53.6%) patients, and 95 (48.7%) of the surgical patients underwent preoperative MRI, which was associated with preoperative neurologic symptoms in 56 of 95 (58.9%) patients (odds ratio = 12.92; 95% confidence interval, 5.98-27.93; P <.001). Postoperative neurologic complications occurred in 24 of 195 (12.3%) patients, including new ischemic stroke in 4 of 195 (2.1%) and new intracerebral hemorrhage in 3 of 195 (1.5%). No patients with microhemorrhages developed postoperative hemorrhage. No significant differences existed in rates of postoperative complications between patients with and those without preoperative MRI. There were no substantial associations between preoperative MRI findings and postoperative neurologic complications, functional outcomes as described by the modified Rankin Scale score, or 6-month mortality. CONCLUSIONS In patients undergoing valve replacement surgery, preoperative MRI findings were not associated with differences in postoperative outcomes, irrespective of finding or timing of valve replacement surgery.

IMPACT OF THE AMERICAN HEART ASSOCIATION’S 2007 GUIDELINES ON THE PRACTICE OF DENTAL PROPHYLAXIS FOR THE PREVENTION OF INFECTIVE ENDOCARDITIS IN HIGH RISK PATIENTS: OLMSTED COUNTY, MINNESOTA

The American Heart Association (AHA) published updated infective endocarditis (IE) prevention guidelines in 2007 and continued to recommend antibiotic prophylaxis (AP) prior to invasive dental procedures for “high risk” (HR) IE patients. We therefore evaluated dental office records in Olmsted

FIVE-YEAR MORTALITY OF INFECTIVE ENDOCARDITIS IN A POPULATION-BASED COHORT

Infective endocarditis (IE) although uncommon, is characterized by high short-term morbidity and mortality. Long-term outcomes of IE deserve additional evaluation. We therefore report the 5-year mortality from a population-based cohort with a focus on pathogen-specific outcomes. We Included Olmsted