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ObjectiveTo develop and validate a calculator to predict the risk of in-hospital mortality in patients with active infective endocarditis (IE) undergoing cardiac surgery.MethodsThousand two hundred and ninety-nine consecutive patients with IE were prospectively recruited (1996–2014) and retrospectively analysed. Left-sided patients who underwent cardiac surgery (n=671) form our study population and were randomised into development (n=424) and validation (n=247) samples. Variables statistically significant to predict in-mortality were integrated in a multivariable prediction model, the Risk-Endocarditis Score (RISK-E). The predictive performance of the score and four existing surgical scores (European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and II), Prosthesis, Age ≥70, Large Intracardiac Destruction, Staphylococcus, Urgent Surgery, Sex (Female) (PALSUSE), EuroSCORE ≥10) and Society of Thoracic Surgeons’s Infective endocarditis score (STS-IE)) were assessed and compared in our cohort. Finally, an external validation of the RISK-E in a separate population was done.ResultsVariables included in the final model were age, prosthetic infection, periannular complications, Staphylococcus aureus or fungi infection, acute renal failure, septic shock, cardiogenic shock and thrombocytopaenia. Area under the receiver operating characteristic curve in the validation sample was 0.82 (95% CI 0.75 to 0.88). The accuracy of the other surgical scores when compared with the RISK-E was inferior (p=0.010). Our score also obtained a good predictive performance, area under the curve 0.76 (95% CI 0.64 to 0.88), in the external validation.ConclusionsIE-specific factors (microorganisms, periannular complications and sepsis) beside classical variables in heart surgery (age, haemodynamic condition and renal failure) independently predicted perioperative mortality in IE. The RISK-E had better ability to predict surgical mortality in patients with IE when compared with other surgical scores.

Cardiac tamponade is a life-threatening condition, whose current specific cause and outcome are unknown. Our purpose was to analyze it. We performed a retrospective observational study with prospective follow-up data including 136 consecutive patients admitted with diagnosis of cardiac tamponade, from 2003 to 2013. We thoroughly recorded variables as clinical features, drainage/pericardiocentesis, fluid characteristics, and long-term events (new cardiac tamponade ± death). The median age was 65 ± 17 years (55% men). In the baseline characteristics, 70% were no smokers, 12% were on anticoagulation, and 13 had suffered a previous myocardial infarction. In the preceding month, 15 patients had undergone a cardiac catheterization, 5 cardiac surgery, and 5 pacemaker insertion. Fever was observed in 16% of patients and 21% displayed other inflammatory symptoms. In 81% of patients, pericardiocentesis was needed. The fluid was hemorrhagic or a transudate in the majority, with positive cytology in 15% and bacteria in 3.7%. Main causes were malignancy (32%), infection (24%), idiopathic (16%), iatrogenic (15%), postmyocardial infarction (7%), uremic (4%), and other causes (2%). After a maximum follow-up of 10.4 years, cardiac tamponade recurred in 10% of the cases (62% in the neoplastic group) and the 48% of patients died (89% in the neoplastic cohort). In conclusion, most cardiac tamponades are due to malignancy, having this specific cause a poorer outcome, probably as a manifestation of an advanced disease. The rest of causes, after an aggressive intensive management, have a good prognosis, especially the iatrogenic.

Background Primary healthcare management efficiency conditions the functioning of specialized care and has a direct impact on the outcomes of the health system and its sustainability. The objective of this research is to develop models to evaluate the efficiency, including health outcomes, of the primary healthcare centres (PHC) of the Clínico – La Malvarrosa Health District in Valencia. Methods To evaluate efficiency, Data Envelopment Analysis (DEA) was used with output orientation and variable returns to scale, with panel data from the years 2015 to 2019. In rates per 10,000 inhabitants, the inputs are: medical and nursing staff and pharmacy cost. The outputs are: number of consultations, hospital emergencies, referrals, avoidable hospitalisations, avoidable mortality and pharmaceutical prescription efficiency. As exogenous variables: the percentage of population over 65 years old, over 80 and case-mix. Three models were developed, all of them with the same inputs and different combinations of outputs related to: healthcare activity, outcomes, and both, in order to study the influence of the different approaches on efficiency. Each model is analysed both without exogenous variables and with each of them. Results The efficiency results vary depending on the model used, although certain PHCs are always on, or very close to, the efficient frontier, while others are always inefficient. When healthcare activity outputs are considered, efficiency scores improve and the number of efficient PHCs increases. However, in general, the PHC score decreases throughout the evaluated period. This decrease is more pronounced when only activity outputs are included. Conclusions DEA allows the inefficiencies of PHCs to be analysed and the efficient ones are clearly distinguished from the inefficient, although different efficiency scores are obtained depending on the model used. Evaluation can be according to healthcare activity, health outcomes or both, making it necessary to identify the expected objectives of the PHCs, as the perspective of the analysis influences the results.

Aim To compare the safety and efficacy of four energy-based vascular sealing and cutting instruments. Methods Blood vessels of various types and diameters were harvested from four pigs using four instruments: Harmonic ACE™ (Ethicon Endo-Surgery, Cincinnati, OH), LigaSure™ V and LigaSure Atlas™ (Valleylab, Inc., Boulder, CO; a division of Tyco Healthcare), and EnSeal™ vessel fusion system (SurgRx, Inc. Redwood City, CA). The diameters of the vessels, speed and adequacy of the cutting and sealing process, and bursting pressures were compared. An additional set of specimens was sealed and left in situ for up to 4 h after which the vessels were harvested and histopathologically analyzed for the degree of thermal injury. Results The bursting pressures were significantly higher with EnSeal™ compared to all other instruments ( p < 0.0001). The sealing process was significantly shorter with Harmonic ACE™ and significantly longer with LigaSure Atlas™ ( p <0.0001). The mean seal width was larger with the LigaSure Atlas™ compared to the other instruments, and it was smaller with EnSeal™ and Harmonic ACE™. Less radial adventitial collagen denaturation was present with EnSeal™ and LigaSure™ V than with the other two instruments; there were no significant differences in collagen denaturation although proximal thermal injury to the smooth muscle in the media of the vessel wall was less common with LigaSure Atlas™ than with the other instruments; however, the numbers were too small for statistical analysis. Conclusions The bursting pressures with EnSeal™ were significantly higher than with all the other instruments. Harmonic ACE™ was the fastest sealing instrument and LigaSure Atlas™ was slowest. EnSeal™ created less radial thermal damage to the adventitial collagen of the vessels and LigaSure Atlas™ created less thermal damage to the media of the vessels. The clinical significance of these findings is unknown.

Background Vancomycin is an effective first-line therapy primarily in methicillin-resistant Staphylococcus aureus (MRSA) infection and Clostridium difficile, however, it has been shown that its effectiveness and the reduction of nephrotoxicity depend on maintaining adequate therapeutic levels. Population pharmacokinetic (PopPk) models attempt to parameterize the behavior of plasma concentrations in different target populations and scenarios such as renal replacement therapy, to successful therapeutic outcome and avoid these side effects. Methods A scoping review was conducted following the guidelines of Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), through a search in PubMed, LILACS, OVID Medline, Scopus, Web of Science, SAGE Journals, Google Scholar and previous known registers of PopPk models in non-critically ill adult patients, published between 1998 and 2024. Results A total of 190 papers were fully screened, of which were included 36 studies conducted in different populations; 12 in general population, 23 in special populations (surgical, with impaired renal function, obese, elderly, with cancer and cystic fibrosis), and 1 in mixed population (general and with cancer). The main parameters in the models were renal clearance and volume of distribution. The principal covariables that affected the models were creatinine clearance and weight. All studies used internal evaluation and 4 of them used an external group. Discussion The technology for the development and implementation of PopPk models requires experts in clinical pharmacology and is limited to university and research centers. The software is mostly expensive and, in most cases, the pharmacokinetic models and the heterogeneity in the parameters and evaluation methods depend on which compartmental model, parameters, covariates and software have been used. Conclusions These models require validation in the clinical context and conducting experiments to adapt them for precision dosing in different subpopulations.

We analysed issues concerning the establishment of compulsory vaccination against COVID-19, as well as the role of misinformation as a disincentive—especially when published by health professionals—and citizen acceptance of measures in this regard. Data from different surveys revealed a high degree of hesitation rather than outright opposition to vaccines. The most frequent complaint related to the COVID-19 vaccination was the fear of side effects. Within the Spanish and European legislative framework, both compulsory vaccination and government regulation of FN (Fake News) appear to be feasible options, counting on sufficient legal support, which could be reinforced by additional amendment. However, following current trends of good governance, policymakers must have public legitimation. Rather than compulsory COVID-19 vaccination, an approach based on education and truthful information, persuading the population of the benefits of a vaccine on a voluntary basis, is recommended. Disagreements between health professionals are positive, but they should be resolved following good practice and the procedures of the code of ethics. Furthermore, citizens do not support the involvement of government authorities in the direct control of news. Collaboration with the media and other organizations should be used instead.

In-hospital mortality of patients with infective endocarditis (IE) remains exceedingly high. Quick recognition of parameters accurately identifying high-risk patients is of paramount importance. The objective of this study was to analyze the incidence and severity of thrombocytopenia at presentation and its prognostic impact in patients with native valve left-sided IE. We studied a cohort of 533 consecutive episodes of native valve left-sided IE prospectively recruited. We distinguished 2 groups: group I (n = 175), episodes who had thrombocytopenia at admission, and group II (n = 358) gathered all the episodes who did not. Thrombocytopenia at admission was defined as a platelet count of <150,000/μl. No differences were found in the need for surgery, but in-hospital mortality was significantly higher in patients with thrombocytopenia (p <0.001). Mortality rate was associated with the degree of thrombocytopenia (p <0.001). In the multivariable analysis, thrombocytopenia at admission was an independent predictor of higher mortality (p = 0.002). A synergistic interaction between thrombocytopenia and Staphylococcus aureus on mortality risk was also observed (p = 0.04). In conclusion, thrombocytopenia at admission is an early risk marker of increased mortality in patients with native valve left-sided IE. Mortality rates increased with increasing severity of thrombocytopenia. Thrombocytopenia at admission should be used as an early marker for risk stratification in patients with native valve IE to identify those at risk of complicated in-hospital evolution and increased mortality.

Infective endocarditis (IE) due to Streptococcus bovis has been classically associated with elderly patients, frequently involving >1 valve, with large vegetations and high embolic risk, which make it a high-risk group. Our aim is to analyze the current clinical profile and prognosis of S bovis IE episodes, in comparison to those episodes caused by viridans group streptococci and enterococci. We analyzed 1242 consecutive episodes of IE prospectively recruited on an ongoing multipurpose database, of which 294 were streptococcal left-sided IE and comprised our study group. They were classified into 3 groups: group I (n = 47), episodes of IE due to S bovis; group II (n = 134), episodes due to viridans group streptococci; and group III (n = 113), those episodes due to enterococci. The incidence of enterococci IE has significantly increased in the last 2 decades (6.4% [1996-2004] vs 11.1% [2005-2013]; P = .005), whereas the incidence of IE due to S bovis and viridans streptococci have remained stable (4% and 10%, respectively). Gender distribution was similar in the 3 groups. Patients with S bovis and enterococci IE were older than those from group II. Nosocomial acquisition was more frequent in group III. Concerning comorbidity, diabetes mellitus (36.7% vs 9.2% vs 26.8%; P < .001) was more common in groups I and III. Chronic renal failure was more prevalent in patients from group III (4.2% vs 1.5% vs 19%; P < .001). Prosthetic valve IE was more frequent in enterococcal IE. Infection upon normal native valves was more frequent in S bovis IE. Colorectal tumors were found in 69% of patients from this group. Vegetation detection was similar in the 3 groups. However, vegetation size was smaller in S bovis IE. During hospitalization, in-hospital complications and in-hospital mortality were higher in enterococci episodes. S bovis IE accounts for 3.8% of all IE episodes in our cohort; it is associated with a high prevalence of colonic tumors, with predominance of benign lesions, and affects patients without preexisting valve disease. It is related to small vegetations and a low rate of in-hospital complications, including systemic embolisms. In-hospital mortality is similar to that of viridans group streptococci.

Background/Objectives: This paper evaluates the incidence of thrombotic and/or hemorrhagic adverse events within 30 days after oral health procedures (OHPs) in patients taking antithrombotic agents. Secondary objectives were to determine proper antithrombotic management and its association with adverse events. Methods: As part of a multicenter multispecialty prospective observational study (ReQXAA), individuals with antithrombotic therapy and receiving at least one OHP were selected. Before OHP, participants were referred to their medical doctors to indicate the antithrombotic therapy management. Adverse events were evaluated thirty days after OHP by phone call. Proportions and odds ratios (ORs) were generated applying Fisher’s exact test, chi-square tests and multiple regression models. Results: A total of 138 patients underwent 144 OHPs. Fifteen adverse events (10.5%) were registered, among which the most frequent was slight bleeding (n = 13), which was followed by bleeding that required suspension of the antithrombotic agent (n = 1) and a myocardial infarction (n = 1). Antithrombotic management was appropriate in 122 (84.7%) cases. In 15.3% of the cases it was inappropriate, the main reason being the unnecessary interruption of the antithrombotic medication (n = 11; 50%). Inadequate management was associated with a higher incidence of adverse events (OR = 4.7; 95% confidence interval [1.3, 16.3]; p = 0.016) after adjusting for confounding factors. Conclusions: The incidence of adverse events 30 days after OHPs was low (10.5%). An inappropriate perioperative/periprocedural antithrombotic management occurred in 15.3% of the cases and was associated with a higher incidence of adverse events (OR = 4.7).

Native valve infective endocarditis (IE) in patients with normal valves has increased in the last decades. Whether patients with normal valves present a similar prognosis to those with pathologic valves is unresolved. Our aim is to describe epidemiologic and clinical differences between patients with left-sided IE and normal valves and those with native pathologic valves. We analyzed 945 consecutive episodes of IE, 435 of which involved left-sided nonprosthetic IE. They were classified into 2 groups: episodes in normal valves (normal group, n = 173) and episodes in pathologic valves (abnormal group, n = 262). Patients in the normal group were younger, Staphylococcus aureus and Streptococcus bovis were more frequently isolated, and vegetations were more frequently found. Heart failure, septic shock, and the need for surgery or death were more common. Multivariate analysis identified the following as factors independently associated with normal valve IE: age <65 years, S bovis, S aureus, heart failure, and vegetation detection. Factors independently associated with in-hospital events included S aureus, periannular complications, heart failure, and septic shock development. In conclusion, compared with patients with abnormal valve IE, patients with IE on normal valves were younger, had a more virulent microbiological profile, developed heart failure and septic shock more frequently, needed more surgical procedures, and had worse prognosis.