Cutibacterium acnes is a low-virulence pathogen that can cause prosthetic valve endocarditis (PVE), presenting significant diagnostic challenges due to its slow growth and indolent clinical course. We report a case of a 57-year-old male with a history of tissue aortic valve replacement, who presented with 6 months of intermittent fever and a nonproductive cough. Initial tests showed elevated inflammatory markers and moderate aortic regurgitation, but no vegetations were identified on transthoracic or transoesophageal echocardiography. After 13 months of symptoms, a PET scan showed significant FDG uptake around the bioprosthetic valve, and a single blood culture grew C. acnes. Transoesophageal echocardiography revealed abnormal rocking motion of the valve and severe paravalvular regurgitation, suggesting near-complete valve dehiscence. The patient underwent redo surgery for aortic root and valve replacement, and intraoperative cultures confirmed C. acnes infection. This case highlights the importance of considering low-virulence pathogens like C. acnes in patients with prolonged, nonspecific symptoms and initially negative cultures. Advanced imaging, particularly PET/CT, is crucial for early diagnosis and intervention. Early recognition and appropriate treatment are vital for preventing severe complications such as valve dehiscence and tissue destruction.
INTRODUCTION:The Wells score, which is a 9-item clinical rule, is used to assess the diagnostic probability of deep vein thrombosis (DVT) in suspected patients. However, the accuracy of the Wells rule has not been investigated in Ghanaians. METHODS:In a cross-sectional design, 138 suspected DVT patients underwent pretest probability of DVT using the Wells rule. Thereafter, a compressive duplex ultrasound study (CDUS) was performed on both legs to confirm the presence of DVT. Using the CDUS as the gold standard, the accuracy and reliability of the Wells rule were assessed as sensitivity, specificity, predictive values and accuracy diagnostic odds. Youden's index was used to determine the optimal cutoff of Wells score to predict DVT. RESULTS:The prevalence of DVT was 38.8% and it was associated with localized tenderness [OR (95% CI) = 3.4 (1.49 - 7.76), p = 0.003], calf swelling [3.72 (1.7 - 8.12), p = 0.001] and previous DVT [4.69 (1.74 - 12.61), p = 0.001]. The sensitivity, specificity, and accuracy diagnostic odds ratio for the 2-level Wells score were 38.3%, 93.3%, 73.9% and 8.44 respectively. From the receiver operator characteristic analysis, the area under curve for the 2-level Wells score was 0.76 and the optimal Wells score cut-point for diagnosing DVT based on Youden's index was >1, with sensitivity, specificity, positive and negative predictive values of 69.4%, 72.1%, 58.6% and 80.5% respectively. CONCLUSION:The prevalence of DVT in suspected patients in our study population was 38.8% and associated with localized tenderness, calf swelling and previous DVT. Reducing the cut-point of the Wells score to 1 increased the sensitivity and accuracy of the Wells rule in our study population.
BACKGROUND:Posterior spinal fixation (PSF) of the lumbosacral region is a commonly performed procedure for managing various spinal pathologies. Deep vein thrombosis (DVT) is a potential complication that can lead to serious outcomes such as thromboembolism. This study aimed to determine the prevalence of DVT and identify associated risk factors in patients undergoing lumbosacral PSF at Firoozgar Hospital, Tehran. METHODS:This prospective cohort study included patients who underwent lumbosacral PSF for degenerative diseases or trauma. All participants underwent lower limb color Doppler ultrasonography before surgery to rule out preexisting DVT. Postoperatively, they were monitored for clinical signs of DVT for two weeks and underwent a follow-up Doppler ultrasound. Demographic and clinical data were collected and analyzed using univariate and multivariate statistical methods to identify risk factors associated with DVT. RESULTS:DVT occurred in 5 of 109 patients (4.6%), of which 3 (2.8%) were symptomatic and 2 (1.8%) asymptomatic on routine postoperative ultrasound. DVT occurrence was significantly associated with factors including motor impairment, neurological deficits, duration of preoperative hospitalization, intraoperative blood loss, and the need for transfusion. Additional factors such as level of consciousness, severity of pain, time to postoperative mobilization, duration of surgery, age, underlying medical conditions, surgical history and cause, number of spinal fusion levels, and BMI also showed significant associations with DVT. No significant correlation was found with gender or preoperative anticoagulant use. CONCLUSION:Identifying risk factors for DVT in patients undergoing lumbosacral PSF can help inform targeted preventive strategies and improve patient outcomes. These findings underscore the importance of early mobilization, careful perioperative management, and individualized risk assessment in spinal surgery patients.
BACKGROUND:While hospitalists play a central role in inpatient care, the association between years of hospitalist experience and patient outcomes remains unclear. This study examined whether hospitalist experience is linked to clinical outcomes, including readmission rates, inpatient mortality, and patient satisfaction scores within a single academic medical center. METHODS:We conducted a retrospective cohort study of 59 hospitalists and 22,098 patient discharges between May and December 2023. Hospitalist experience was grouped as <2 years, 2-5 years, and >5 years. Patient data were extracted from the EPIC Clarity database. Outcomes included length of stay (LOS), 72-hour and 30-day readmissions, inpatient mortality, and patient satisfaction. Unadjusted regression models with provider-level random effects evaluated associations between hospitalist experience and outcomes. RESULTS:Among 14,804 unique patients, the mean LOS was 5.16 ± 8.15 days, with a 30-day readmission rate of 13.7% and inpatient mortality of 10.8%. Patient satisfaction scores averaged 8.7/10. Hospitalists with >5 years of experience had significantly shorter LOS (-0.67 days; 95% CI: -1.24 to -0.10; p <0.05) compared to those with ≤5 years. No significant associations were observed between hospitalist experience and readmissions, mortality, or satisfaction scores. CONCLUSIONS:Greater hospitalist experience is associated with reduced length of stay, but is not associated with readmission rates, inpatient mortality, or patient satisfaction scores. Future longitudinal, multi-institutional studies are warranted to better understand the relationship between hospitalist experience and diverse performance metrics.
BACKGROUND:Preoperative anxiety is linked to various adverse effects on anesthesia, intraoperative vital signs, and postoperative outcomes. Despite its widespread impact, managing preoperative anxiety is not consistently implemented, partly due to concerns over the efficacy and side effects of anxiolytic drugs. Previous clinical trials on the anxiolytic effect of melatonin showed conflicting results regarding its effect. Furthermore, they involved placing the patients in settings that deviate of real-world clinical practice. OBJECTIVE:We sought to assess the efficacy of melatonin as a preoperative anxiolytic in real-world settings. METHODS:This is a triple-blinded, randomized, controlled clinical trial that enrolled 87 patients aged 18 to 65 planned for elective surgery under general anesthesia. They were divided into three groups to receive melatonin, diazepam, or a placebo and were placed in the same waiting rooms as other non-enrolled patients. Preoperative anxiety was assessed at baseline and one-hour post-treatment using the Visual Analog Scale (VAS) and Amsterdam Preoperative Anxiety and Information Scale (APAIS). Secondary outcomes included changes in orientation and sedation levels. RESULTS:Of the 87 enrolled participants, 76 completed the second assessment. The median age of the participants was 38 years (IQR = 18.5), and 50.6% were females. Our study showed no significant effect of melatonin on preoperative anxiety, sedation, or orientation compared to diazepam or placebo. CONCLUSION:Our study highlights the need for incorporating other factors in future clinical trials on preoperative anxiety to better translate the results into a real-world setting. CLINICAL TRIAL REGISTRATION NUMBER:NCT06103188.
