Infective endocarditis: a retrospective cohort study

BACKGROUND

Infective endocarditis (IE) is a potentially life-threatening infection of the heart's endocardial surface. Despite advances in the diagnosis and management of IE, morbidity and mortality remain high.

AIM

To characterize the demographics, bacteriology and outcomes of IE cases presenting to an Irish tertiary referral centre.

DESIGN

Retrospective cohort study.

METHODS

Patients were identified using Hospital Inpatient Enquiry and Clinical Microbiology inpatient consult data, from January 2005 to January 2014. Patients were diagnosed with IE using Modified Duke Criteria. Standard Bayesian statistics were employed for analysis and cases were compared to contemporary international registries.

RESULTS

Two hundred and two patients were diagnosed with IE during this period. Mean age 54 years. Of these, 136 (67%) were native valve endocarditis (NVE), 50 (25%) were prosthetic valve endocarditis (PVE) and 22 (11%) were cardiovascular implantable electronic device-associated endocarditis. Culprit organism was identified in 176 (87.1%) cases and Staphylococcal species were the most common (57.5%). Fifty-nine per cent of NVE required surgery compared to 66% of PVE. Mean mortality rate was 17.3%, with NVE being the lowest (12.5%) and PVE the highest (32%). Increasing age was also associated with increased mortality. Fifty-three (26.2%) patients had embolic complications.

CONCLUSIONS

This Irish cohort exhibited first-world demographic patterns comparable to those published in contemporary international literature. PVE required surgery more often and was associated with higher rates of mortality than NVE. Embolic complications were relatively common and represent important sequelae, especially in the intravenous drug user population. It is also pertinent to aggressively treat older cohorts as they were associated with increased mortality.

Oral health status of community dwelling adults aged 50 years and over in Ireland. A cross-sectional analysis of the Wave 3 TILDA cohort

Background: Little is known about the current oral health status of adults in Ireland. The aim of this study was to measure the oral health status of community dwelling adults aged 50 years and over in Ireland, and to compare the current status to previous surveys of oral health in adults.  Methods: The Irish Longitudinal Study on Ageing (TILDA) Wave 3 provided an opportunity to assess the oral health of a subset of TILDA participants. Respondents attending for health assessments at the TILDA centre were offered an oral health examination. The World Health Organization examination criteria were used. Results: Out of the 3111 people who were offered the oral health assessment (OHA), 2525 were examined. Adults below 50 years of age (n=17) and 4 respondents whose oral health data were unavailable at time of analysis were omitted, giving a final sample of 2504 respondents.  Among the OHA sample, 9.9% (249) were edentate; 11.5% (159) of females and 8% (90) of males. Of those aged 65 years and older, 15.6% were edentate compared with 40.9% in 2000-02. The mean number of teeth present in those aged 65 years or older was 14.9 for males and 14.2 for females compared with 9.9 and 7.4, respectively, in 2000-02. 56.8% of the dentate sample had 10 or more tooth contacts. The mean DMFT of those aged 50 years or more was 18.5 and the Root Caries Index (RCI) was 6.3. For adults aged 65 years and over, the mean DMFT decreased from 25.9 to 20.1 and the Root Caries Index decreased from 11.6 to 9.1, between 2000-02 and 2014-15. Conclusion: The results suggest an improvement in oral health status of community dwelling adults aged 50 years and over in Ireland as compared to the previous Irish survey of 2000-02.

Novel multiresistance cfr plasmids in linezolid-resistant methicillin-resistant Staphylococcus epidermidis and vancomycin-resistant Enterococcus faecium (VRE) from a hospital outbreak: co-location of cfr and optrA in VRE

Background

Linezolid is often the drug of last resort to treat infections caused by Gram-positive cocci. Linezolid resistance can be mutational (23S rRNA or L-protein) or, less commonly, acquired [predominantly cfr, conferring resistance to phenicols, lincosamides, oxazolidinones, pleuromutilins and streptogramin A compounds (PhLOPSA) or optrA, encoding oxazolidinone and phenicol resistance].

Objectives

To investigate the clonality and genetic basis of linezolid resistance in 13 linezolid-resistant (LZDR) methicillin-resistant Staphylococcus epidermidis (MRSE) isolates recovered during a 2013/14 outbreak in an ICU in an Irish hospital and an LZDR vancomycin-resistant Enterococcus faecium (VRE) isolate from an LZDR-MRSE-positive patient.

Methods

All isolates underwent PhLOPSA susceptibility testing, 23S rRNA sequencing, DNA microarray profiling and WGS.

Results

All isolates exhibited the PhLOPSA phenotype. The VRE harboured cfr and optrA on a novel 73 kb plasmid (pEF12-0805) also encoding erm(A), erm(B), lnu(B), lnu(E), aphA3 and aadE. One MRSE (M13/0451, from the same patient as the VRE) harboured cfr on a novel 8.5 kb plasmid (pSEM13-0451). The remaining 12 MRSE lacked cfr but exhibited linezolid resistance-associated mutations and were closely related to (1-52 SNPs) but distinct from M13/0451 (202-223 SNPs).

Conclusions

Using WGS, novel and distinct cfr and cfr/optrA plasmids were identified in an MRSE and VRE isolate, respectively, as well as a cfr-negative LZDR-MRSE ICU outbreak and a distinct cfr-positive LZDR-MRSE from the same ICU. To our knowledge, this is the first report of cfr and optrA on a single VRE plasmid. Ongoing surveillance of linezolid resistance is essential to maintain its therapeutic efficacy.

Post-influenzal triazole-resistant aspergillosis following allogeneic stem cell transplantation

Influenza virus infection is now recognised as a risk factor for invasive pulmonary aspergillosis (IPA). Delays in diagnosis contribute to delayed commencement of antifungal therapy. In addition, the emergence of resistance to first-line triazole antifungal agents puts emphasis on early detection to prevent adverse outcomes. We present 2 allogeneic stem cell transplant patients who developed IPA due to triazole-resistant Aspergillus fumigatus following influenza infection. We underline the challenges faced in the management of these cases, the importance of early diagnosis and need for surveillance given the emergence of triazole resistance.

An assessment of professionalism on students' Facebook profiles

INTRODUCTION

With the advent of social media, healthcare professionals not only need to be conscious of professionalism in their face-to-face interactions but also in the electronic environment. The aim of this study was to assess the level of online professionalism on Facebook profiles available for public viewing of students from a dental school.

MATERIALS AND METHODS

A search was performed via a new Facebook account of all students in the University Dental School (dental hygiene, dental nursing, dental science and dental technology). Profiles were categorised as 'private' or 'public'. Demographic details and photographs/comments of unprofessional behaviour were recorded for each individual Facebook profile. Each profile was subsequently scored with regard to professionalism based on a previously published score.

RESULTS

There are a total of 287 students in the dental school. Of these, 62% (n = 177) had a Facebook account. Three per cent (n = 6) had a public account (fully accessible) whilst 97% (n = 171) had a private account (limited access); 36% (n = 63) of students mentioned the dental school/hospital on their profile; 34% (n = 60) had questionable content on their profile whilst 3% (n = 6) had definite violations of professionalism on their profile; and 25% (n = 44) had unprofessional photographs on their profile. Of those with unprofessional content, 52% (n = 23) of these had a documented affiliation with the dental school also visible on their profile.

CONCLUSION

There was a concerning level of unprofessional content visible on students' Facebook profiles. Students need to be fully aware of their professional responsibility in the setting of social media.

Multidisciplinary Management of Hypodontia

Patients with hypodontia require a wide range of treatment, ranging from single tooth replacement to the restoration of multiple edentulous spaces in both arches. Treatment should involve an interdisciplinary team, as no dental speciality possesses the range of expertise required to optimally treat this patient population. This paper presents principles of treatment, key factors of assessment and multidisciplinary approaches to management of the hypodontia patient, including contributions from conservative dentistry.

Microplastics in Sewage Sludge: Effects of Treatment

Waste water treatment plants (WWTPs) are receptors for the cumulative loading of microplastics (MPs) derived from industry, landfill, domestic wastewater and stormwater. The partitioning of MPs through the settlement processes of wastewater treatment results in the majority becoming entrained in the sewage sludge. This study characterized MPs in sludge samples from seven WWTPs in Ireland which use anaerobic digestion (AD), thermal drying (TD), or lime stabilization (LS) treatment processes. Abundances ranged from 4196 to 15 385 particles kg^-1 (dry weight). Results of a general linear mixed model (GLMM) showed significantly higher abundances of MPs in smaller size classes in the LS samples, suggesting that the treatment process of LS shears MP particles. In contrast, lower abundances of MPs found in the AD samples suggests that this process may reduce MP abundances. Surface morphologies examined using scanning electron microscopy (SEM) showed characteristics of melting and blistering of TD MPs and shredding and flaking of LS MPs. This study highlights the potential for sewage sludge treatment processes to affect the risk of MP pollution prior to land spreading and may have implications for legislation governing the application of biosolids to agricultural land.

Efficacy of the Nance appliance as an anchorage-reinforcement method

INTRODUCTION

The Nance appliance is widely considered to be an efficient method of anchorage reinforcement; however, much of the perceived advantage is based on clinical judgment. The aim of this study was to assess the amounts of anchorage loss and desired tooth movement associated with the Nance appliance.

METHODS

The mandibular arches of 7 beagle dogs were used. The first and third premolars were extracted. Reference miniscrews were placed at the first premolar sites as stable references to measure the amounts of anchorage loss and desired tooth movement. Four beagles were fitted with custom-made Nance appliances on the fourth premolars and orthodontic bands on the second premolars (Nance group). Three beagles were fitted with orthodontic bands on the second and fourth premolars with no anchorage reinforcement (control group). The second premolars were retracted over 15 weeks in both groups. The amounts of second premolar movement (desired tooth movement) and fourth premolar movement (anchorage loss) were recorded at 5, 10, and 15 weeks. The percentages of desired tooth movement and anchorage loss to the total space closure were calculated.

RESULTS

The mean desired tooth movement was significantly more in the Nance group than in the control group at 10 weeks (P <0.05) but was not significantly different at 5 and 15 weeks. The mean percentages of anchorage loss to the total space closure at 15 weeks were 45.7% in the control group and 28.8% in the Nance group. The Nance group had 16.9% less anchorage loss and 16.6% more desired tooth movement than did the control group at 15 weeks (P <0.05). Most of the anchorage loss (80%) in the Nance group occurred during the first 10 weeks.

CONCLUSIONS

The Nance appliance did not provide absolute anchorage, but there was significantly less anchorage loss with it than in the control group. The majority of anchorage loss occurred during the first 10 weeks in the Nance group.

Ongoing challenges responding to behavioural and psychological symptoms of dementia

BACKGROUND

Mid- to late-stage dementia is often characterized by behavioural and psychological symptoms, including, but not limited to physical and verbal aggression.

INTRODUCTION

Although there is a considerable research about the prevalence, aetiology, and management of behavioural and psychological symptoms of dementia, there is limited research about the experience of caring for people with such symptoms in long-term aged care facilities.

AIM

The aims of the study were to describe: (i) nurses' experiences of caring for people with behavioural and psychological symptoms of dementia in long-term aged care facilities, and (ii) strategies nurses used to deal with these symptoms.

METHODS

A qualitative exploratory and descriptive design, involving focus group interviews with 30 nurses from three long-term aged care units in Australia. The transcripts were analysed using inductive content analysis.

RESULTS

The findings revealed five interrelated themes: (i) working under difficult conditions, (ii) behavioural and psychological symptoms of dementia: an everyday encounter, (iii) making sense of behavioural and psychological symptoms of dementia, (iv) attempting to manage behavioural and psychological symptoms of dementia, and (v) feeling undervalued.

CONCLUSION

This study highlighted the difficult conditions under which nurses worked and the complexity of caring for individuals who have behavioural and psychological symptoms of dementia.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Organizational efforts to enhance the quality of care for individuals with behavioural and psychological symptoms of dementia in long-term aged care facilities should extend beyond staff education to heed nurses' concerns about organizational barriers to interpersonal care.

Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder

Borderline personality disorder (BPD) is a complex disorder that is difficult to treat. However, dialectical behaviour therapy (DBT), developed by Dr. Marsha Linehan in the early 1990s, has emerged as a promising treatment option for those diagnosed with BPD. DBT is a multi-pronged treatment approach delivered normally in outpatient settings over 12 months and requires highly skilled and trained therapists. Many trials have provided evidence to support the use of DBT in the treatment of BPD. However, outcome measures vary and are mostly limited to measurable behavioural outcomes such as incidences of deliberate self-harm or suicidal thoughts. Two recent Cochrane reviews conclude that DBT does benefit those with BPD, but more robust evidence is needed. DBT training for health care professionals also has the potential to shift health care professionals' attitudes from one of therapeutic pessimism to one of optimism.

Infection of the Beard area. Kerion: a review of 2 cases

Folliculitis barbae is a common condition of both infective and non-infectious aetiology. It most frequently presents as a superficial folliculitis, with fine pustules appearing at the opening of hair follicles in the beard area, often associated with shaving; known as Bockhart impetigo and usually due to infection caused by Staphylococcus aureus. If untreated, the infection and inflammation can progress, leading to a more deeply seated infection known as sycosis barbae. Perifollicular nodules, termed furuncles, may appear and when these are multiple and coalesce, a deep-seated, communicating, pustulating plaque called a carbuncle develops, often with associated systemic upset. Such an appearance, which can prompt incision and drainage, should not, however, be assumed to be solely due to staphylococcal infection. Particularly in the context of a history of close animal contact or a lack of response to antibiotic treatment, a diagnosis of tinea barbae should be considered and investigated. Prompt treatment with antifungal agents and often systemic steroids is required once the diagnosis is made. This will help reduce an exacerbation of the pronounced destruction that results from the immune response to the fungal infection, known as a kerion, which would be compounded by surgical intervention. In this article, we review two such cases and review the investigation and management of the disease.

Infectious disease outbreaks in competitive sports, 2005-2010

CONTEXT

Old, evolving, and new infectious agents continually threaten the participation of competitors in sports.

OBJECTIVE

To provide an update of the medical literature on infectious disease outbreaks in sport for the last 5 years (May 2005-November 2010).

MAIN OUTCOME MEASURE(S)

A total of 21 outbreaks or clusters were identified.

RESULTS

Methicillin-resistant Staphylococcus aureus (n = 7, 33%; mainly community acquired) and tinea (trichophytosis: n = 6, 29%) were the most common pathogens responsible for outbreaks. Skin and soft tissue was the most common site of infection (n = 15, 71%).

CONCLUSIONS

The majority of outbreaks reported occurred in close-contact sports, mainly combat sports (ie, wrestling, judo) and American football. Twelve outbreaks (57%) involved high school or collegiate competitors. Common community outbreak pathogens, such as influenza virus and norovirus, have received little attention.