Medicine
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A resurgence of endocarditis due to Pseudomonas aeruginosa was seen in 10 injection drug users (IDUs) in Detroit between 2006 and 2008 (6 men, 4 women; mean age, 48.1 yr). All patients tested negative for the human immunodeficiency virus (HIV). Five patients had left-sided endocarditis of the mitral valve and/or the aortic valve; 3 of 5 patients had prosthetic valve endocarditis. ⋯ Tricuspid repair/reconstruction or valvulectomy with valve replacement plus combined antipseudomonal regimen may be the optimal therapy for refractory right-sided endocarditis. This approach not only may prevent the development of severe and permanent impairment of right ventricular function, which is a complication of valvulectomy alone without valve replacement, but also may cure the infection. For left-sided disease, surgery is recommended if blood cultures remain positive for 7 days on appropriate antimicrobial therapy or if Pseudomonas bacteremia recurs after completion of a 6-week course of the combined regimen.
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The long-term cardiovascular outcomes of a population-based cohort presenting to the emergency department (ED) with chest pain and classified with a clinical risk stratification algorithm are not well documented. The Olmsted County Chest Pain Study is a community-based study that included all consecutive patients presenting with chest pain consistent with unstable angina presenting to all EDs in Olmsted County, Minnesota. Patients were classified according to the Agency for Health Care Policy and Research (AHCPR) criteria. ⋯ At 7.3 and at 16.6 years of follow-up, biomarkers were not incrementally predictive of cardiovascular risk. In conclusion, a widely applicable rapid clinical algorithm using AHCPR criteria can reliably predict long-term mortality and cardiovascular outcomes. This algorithm, when applied in the ED, affords an excellent opportunity to identify patients who might benefit from a more aggressive cardiovascular risk factor management strategy.