Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

Treatment of persistent focalized Q fever: time has come for an international randomized controlled trial

Q fever is a worldwide zoonosis due to Coxiella burnetii, responsible for endocarditis and endovascular infections. Since the 1990s, the combination hydroxychloroquine + doxycycline has constituted the curative and prophylactic treatment in persistent focalized Q fever. This combination appears to have significantly reduced the treatment's duration (from 60 to 26 months), yet substantial evidence of effectiveness remains lacking. Data are mostly based on in vitro and observational studies. We conducted a literature review to assess the effectiveness of this therapy, along with potential alternatives. The proposed in vitro mechanism of action describes the inhibition of Coxiella replication by doxycycline through the restoration of its bactericidal activity (inhibited in acidic environment) by alkalinization of phagolysosome-like vacuoles with hydroxychloroquine. So far, the rarity and heterogeneous presentation of cases have made it challenging to design prospective studies with statistical power. The main studies supporting this treatment are retrospective cohorts, dating back to the 1990s-2000s. Retrospective studies from the large Dutch outbreak of Q fever (>4000 cases between 2007 and 2010) did not corroborate a clear benefit of this combination, notably in comparison with other regimens. Thus, there is still no consensus among the medical community on this issue. However insufficient the evidence, today the doxycycline + hydroxychloroquine combination remains the regimen with the largest clinical experience in the treatment of 'chronic' Q fever. Reinforcing the guidelines' level of evidence is critical. We herein propose the creation of an extensive international registry, followed by a prospective cohort or ideally a randomized controlled trial.

A Comparative Assessment of Dental Caries Experience in Relation to Nutritional Status among 6-12-year-old School-going Children and Those with Congenital Heart Disease in Bhubaneswar City

Aim

To assess the dental caries experience in relation to nutritional status among 6-12- year-old school-going children and those with congenital heart disease in Bhubaneswar city.

Materials and methods

A cross-sectional study was conducted among 6-12-year-old healthy school-going children and those with congenital heart disease for a period of 6 months (October 2019-March 2020) in Bhubaneswar, India. Type III clinical examination was carried out as per American Dental Association (ADA) specifications using plane mouth mirrors and community periodontal index (CPI) probes. Clinical oral examination and measurement of the weight and height of the child were performed by a single examiner. Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 21.0.

Results

The overall mean decayed missing filled primary teeth surfaces (dmfs) in primary dentition was higher (5.93 ± 10.224) in subjects with congenital heart disease (CHD) (group I) than in healthy controls (3.41 ± 6.192). The overall mean decayed missing filled permanent teeth surfaces (DMFS) in permanent dentition was 0.33 ± 1.105 in subjects with CHD (group I) and 0.24 ± 0.714 in group II. In group I, the majority of them (58.9%) were underweight, followed by 41.1% who were a healthy weight. However, in group II, 47.9% of the study subjects were healthy weight, 26.1% were underweight, 14.4% were obese, and 11.7% were overweight.

Conclusion

This study concluded that children with CHD have a higher dental caries experience and poor nutritional status as compared to healthy school-going children.

How to cite this article

Hazarika SJ, Jnaneswar A, Jha K. A Comparative Assessment of Dental Caries Experience in Relation to Nutritional Status among 6-12-year-old School-going Children and Those with Congenital Heart Disease in Bhubaneswar City. Int J Clin Pediatr Dent 2024;17(1):1-6.

How decisions are made: Antibiotic stewardship in dentistry

BACKGROUND

We performed a preimplementation assessment of workflows, resources, needs, and antibiotic prescribing practices of trainees and practicing dentists to inform the development of an antibiotic-stewardship clinical decision-support tool (CDST) for dentists.

METHODS

We used a technology implementation framework to conduct the preimplementation assessment via surveys and focus groups of students, residents, and faculty members. Using Likert scales, the survey assessed baseline knowledge and confidence in dental providers' antibiotic prescribing. The focus groups gathered information on existing workflows, resources, and needs for end users for our CDST.

RESULTS

Of 355 dental providers recruited to take the survey, 213 (60%) responded: 151 students, 27 residents, and 35 faculty. The average confidence in antibiotic prescribing decisions was 3.2 ± 1.0 on a scale of 1 to 5 (ie, moderate). Dental students were less confident about prescribing antibiotics than residents and faculty (P < .01). However, antibiotic prescribing knowledge was no different between dental students, residents, and faculty. The mean likelihood of prescribing an antibiotic when it was not needed was 2.7 ± 0.6 on a scale of 1 to 5 (unlikely to maybe) and was not meaningfully different across subgroups (P = .10). We had 10 participants across 3 focus groups: 7 students, 2 residents, and 1 faculty member. Four major themes emerged, which indicated that dentists: (1) make antibiotic prescribing decisions based on anecdotal experiences; (2) defer to physicians' recommendations; (3) have limited access to evidence-based resources; and (4) want CDST for antibiotic prescribing.

CONCLUSIONS

Dentists' confidence in antibiotic prescribing increased by training level, but knowledge did not. Trainees and practicing dentists would benefit from a CDST to improve appropriateness of antibiotic prescribing.

Effect of perioperative oral management on postoperative bloodstream infection in heart valve surgery patients

OBJECTIVE

There is a well-known relationship between oral hygiene and infective endocarditis. Epidemiological evidence regarding perioperative oral management (POM) for cancer surgery has been accumulated, but this evidence is not sufficient for cardiac surgery. Therefore, our purpose was to investigate whether POM can prevent postoperative complications in patients undergoing heart valve surgery.

SUBJECTS AND METHODS

Using single-arm medical information, we retrospectively enrolled 301 patients who underwent heart valve surgery between April 2010 and March 2019. The patient background was adjusted by the propensity score (PS). We then analyzed the impact of POM on postoperative bloodstream infection (PBSI), postoperative pneumonia, and mortality using PS inverse probability of treatment weighting (IPTW).

RESULTS

IPTW revealed that the POM group had a lower incidence of PBSI than the control group, with an odds ratio of 0.316 (p = 0.003). The mortality in the POM group was significantly lower than that in the control group (p = 0.023). Fourteen patients died in the present study and 6 of them were infection-related.

CONCLUSIONS

POM was significantly associated with decreased incidence of PBSI and mortality. The results suggest that POM is beneficial for the prevention of PBSI and mortality in patients undergoing heart valve surgery.

Antibiotic prophylaxis before dental procedures to prevent infective endocarditis: a systematic review

PURPOSE

Infective endocarditis (IE) is a severe bacterial infection. As a measure of prevention, the administration of antibiotic prophylaxis (AP) prior to dental procedures was recommended in the past. However, between 2007 and 2009, guidelines for IE prophylaxis changed all around the word, limiting or supporting the complete cessation of AP. It remains unclear whether AP is effective or not against IE.

METHODS

We conducted a systematic review whether the administration of AP in adults before any dental procedure, compared to the non-administration of such drugs, has an effect on the risk of developing IE. We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID, and EMBASE. Two different authors filtered articles independently and data extraction was performed based on a pre-defined protocol.

RESULTS

The only cohort study meeting our criteria included patients at high-risk of IE. Analysis of the extracted data showed a non-significant decrease in the risk of IE when high-risk patients take AP prior to invasive dental procedures (RR 0.39, p-value 0.11). We did not find other studies including patients at low or moderate risk of IE. Qualitative evaluation of the excluded articles reveals diversity of results and suggests that most of the state-of-the-art articles are underpowered.

CONCLUSIONS

Evidence to support or discourage the use of AP prior to dental procedures as a prevention for IE is very low. New high-quality studies are needed, even though such studies would require big settings and might not be immediately feasible.

Antibiotic Prophylaxis for Infective Endocarditis: A Survey of Practice Among Pediatric Cardiology Providers

The 2007 American Heart Association (AHA) guidelines limited antibiotic prophylaxis (AP) for infective endocarditis (IE) to fewer patients with predisposing cardiac conditions (PCC). We surveyed the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery (AAP SOCCS) on their recommendations for AP for a number of PCC and procedures. We report on those 173 respondents who follow the 2007 AHA guidelines. AP rates for high-risk PCCs clearly meeting AHA criteria ranged from 70.5-89.8%. Conversely, for PCCs which did not meet AHA criteria, prescribing rates varied from &lt;1% to 29.5%. PCC for which AP indication was unclear per guidelines, AP rates similarly varied from 9.9-39.8%. Similar variability is noted in AP for various procedures in setting of high-risk PCC. There is variability in AP prescribing practices among pediatric cardiologists based on both underlying PCC and noncardiac procedures in the setting of underlying cardiac disease.

Alternative Antibiotics in Dentistry: Antimicrobial Peptides

The rise of antibiotic resistant bacteria due to overuse and misuse of antibiotics in medicine and dentistry is a growing concern. New approaches are needed to combat antibiotic resistant (AR) bacterial infections. There are a number of methods available and in development to address AR infections. Dentists conventionally use chemicals such as chlorohexidine and calcium hydroxide to kill oral bacteria, with many groups recently developing more biocompatible antimicrobial peptides (AMPs) for use in the oral cavity. AMPs are promising candidates in the treatment of (oral) infections. Also known as host defense peptides, AMPs have been isolated from animals across all kingdoms of life and play an integral role in the innate immunity of both prokaryotic and eukaryotic organisms by responding to pathogens. Despite progress over the last four decades, there are only a few AMPs approved for clinical use. This review summarizes an Introduction to Oral Microbiome and Oral Infections, Traditional Antibiotics and Alternatives & Antimicrobial Peptides. There is a focus on cationic AMP characteristics and mechanisms of actions, and an overview of animal-derived natural and synthetic AMPs, as well as observed microbial resistance.

Effect of Subgingival Instrumentation on Neutrophil Elastase and C-Reactive Protein in Grade B and C Periodontitis: Exploratory Analysis of a Prospective Cohort Study

Background: Assessment of the effect of subgingival instrumentation (SI) on systemic inflammation in periodontitis grades B (BP) and C (CP). Methods: In this prospective cohort study, eight BP and 46 CP patients received SI. Data were collected prior to and 12 weeks after SI. Blood was sampled prior to, one day, 6, and 12 weeks after SI. Neutrophil elastase (NE), C-reactive protein (CRP), leukocyte count, lipopolysaccharide binding protein, interleukin 6 (IL-6) and IL-8 were assessed. Results: Both groups showed significant clinical improvement. NE was lower in BP than CP at baseline and 1 day after SI, while CRP was lower in BP than CP at baseline (p < 0.05). NE and CRP had a peak 1 day after SI (p < 0.05). Between-subjects effects due to CP (p = 0.042) and PISA (p = 0.005) occurred. Within-subjects NE change was confirmed and modulated by grade (p = 0.017), smoking (p = 0.029), number of teeth (p = 0.033), and PISA (p = 0.002). For CRP between-subjects effects due to BMI (p = 0.008) were seen. Within-subjects PISA modulated the change of CRP over time (p = 0.017). Conclusions: In untreated CP, NE and CRP were higher than in BP. SI results in better PPD and PISA reduction in BP than CP. Trial registration: Deutsches Register Klinischer Studien DRKS00026952 28 October 2021 registered retrospectively.

Complications related to dental extractions in patients with chronic kidney failure undergoing hemodialysis: a pilot study

OBJECTIVE

To clinically assess socket healing after tooth extraction and the occurrence of intra- and postoperative complications in patients with chronic kidney failure (CKF) receiving hemodialysis (HD) by comparing them with a control group.

STUDY DESIGN

This prospective study involved 48 patients with CKF receiving HD (study group [SG]) and 29 participants without CKF (control group [CG]) undergoing tooth extractions. No prophylactic antibiotic was administered to the participants. One calibrated dentist evaluated all individuals at 3, 7, 21, and 60 days after the tooth extractions and assessed hemostasis time, occurrence of local or distant infection, epithelialization, and deposition of alveolar bone.

RESULTS

In the SG, 87 teeth were extracted through 65 interventions, and in the CG, 76 teeth were extracted through 36 interventions. Bleeding beyond 30 minutes was observed in 12 interventions (18.5%) in SG participants and was controlled with local hemostatic agents. Neither group had individuals presenting with postoperative infectious complications at the surgical site or at a distance. After 21 days, we observed delayed epithelialization in 29.9% (26 of 87) of the individuals in the SG compared with 3.9% (3 of 37) of those in the CG (P < .001). After 60 days, all the sockets were epithelialized and showing radiographic signs of alveolar bone neoformation.

CONCLUSIONS

Individuals with CKF receiving hemodialysis tend to heal well after dental extractions. They did not have an increased risk of infectious complications after simple tooth extractions, but they showed prolonged bleeding events more often than control subjects. Additional research studies using larger sample sizes of patients with CKF receiving hemodialysis are needed to confirm our findings.

Managing Cardiac Patients: Dentists' Knowledge, Perceptions, and Practices

OBJECTIVES

Dental patients may require invasive treatment, and awareness of their medical conditions is essential for optimal care. We assessed the knowledge, perceptions, and attitudes of dentists practicing in Saudi Arabia (SA) and their associations with managing patients with common cardiac conditions.

METHODS

A national survey of knowledge and attitudes of practicing dentists towards patients with common cardiac conditions was conducted from May 2019 to July 2020 in SA. The survey comprised a newly developed, validated, electronic, self-administered English questionnaire.

RESULTS

Overall, 282 dentists completed the survey, of whom 45.5% perceived cardiac patients as difficult to manage, while 64.5% stated that they refer these patients to cardiologists before dental intervention. Regarding knowledge about cardiac conditions, 72% achieved an overall knowledge score <55%; however, their infective endocarditis scores were better. Consultants and specialists (P < .001), those with a PhD/board certification (P = .013), dentists with prior education on cardiac patient management (P = .002), and those working with a cardiologist (P = .016) scored higher on knowledge. Conversely, private dentists (P = .003) and those referring patients to cardiologists before treatment (P = .003) scored lower. Dentists' knowledge of cardiovascular diseases in women was low; only those who believed women experience a greater risk of cardiac complications achieved a higher score. Approximately 90.1% wished to receive education regarding cardiac patient management.

CONCLUSIONS

Knowledge of cardiac patient management was suboptimal in this study. Dentists perceived cardiac patients as difficult to manage, but wished to learn more regarding optimal management. Thus, postgraduate education programmes that promote optimal dental management strategies for cardiac patients are necessary.

Comparison of infective endocarditis risk between balloon and self-expandable valves following transcatheter aortic valve replacement: systematic review and meta-analysis

This study aimed to compare incidence of IE between BE and SE valves by performing a systematic review and meta-analysis of the literature. We comprehensively searched the databases of MEDLINE and EMBASE from inception to November 2019. Included studies were published observational studies that compared the risk of IE among patients undergoing TAVR employing BE versus SE valves, using the random-effects to calculate risk ratios and 95% confidence intervals (CIs).Ten cohort studies from April 2013 to November 2019 were included in this meta-analysis involving 13,478 subjects (6289 SE and 7189 BE types). Our study showed no statistical difference in IE rates between each type of valves (pooled OR 0.96, 95% CI: 0.68-1.35, p = 0.801 with I2 = 14.7%). There was no difference in IE rate between BE and SE valves following TAVR. Further studies are warranted to confirm our findings.

Discharge of Medically Complex Infants and Developmental Follow-up

At the time of discharge from the NICU, many infants have ongoing complex medical issues that will require coordinated, multispecialty follow-up. Discharge planning and transfer of care for infants with medical complexity require a multidisciplinary team effort that begins early during the NICU hospitalization. It is critical that the primary care physician is involved in this process because he or she will serve as the chief communicator and coordinator of care after discharge. Although some infants with medical complexity may be followed in specialized multidisciplinary NICU follow-up clinics, these are not universally available. The responsibility then falls to the primary care physician to coordinate with different subspecialties based on the infant's needs. Many infants with medical complexity are technology-dependent at the time of discharge and may require home oxygen, ventilators, monitors, or tube feeding. Prematurity, critical illness, and prolonged NICU hospitalization that lead to medical complexity also increase the risk of neurodevelopmental delay or impairment. As such, these infants will not only require routine developmental surveillance and screening by the primary care physician but also should be followed longitudinally by a neurodevelopmental specialist, either a developmental-behavioral pediatrician or a neonatologist with experience in neurodevelopmental assessment.

Temporal Trends of Infective Endocarditis in Olmsted County, Minnesota, Between 1970 and 2018: A Population-Based Analysis

Background

A population-based study of infective endocarditis (IE) in Olmsted County, Minnesota, provides a unique opportunity to define temporal and seasonal variations in IE incidence over an extended time period.

Methods

This was a population-based review of all adults (≥18 years) residing in Olmsted County, Minnesota, with definite or possible IE using the Rochester Epidemiology Project from January 1, 1970, through December 31, 2018. Poisson regression was used to characterize the trends in IE incidence; models were fitted with age, sex, calendar time, and season, allowing for nonlinearity and nonadditivity of their effects.

Results

Overall, 269 cases of IE were identified over a 49-year study period. The median age of IE cases was 67.2 years, and 33.8% were female. The overall age- and sex-adjusted incidence of IE was 7.9 cases per 100 000 person-years (95% CI, 7.0-8.9), with corresponding rates of 2.4, 2.4, 0.9, and 0.7 per 100 000 person-years for Staphylococcus aureus, viridans group streptococci (VGS), Enterococcus species, and coagulase-negative staphylococci IE, respectively. Temporal trends varied by age, sex, and season, but on average IE incidence increased over time (P = .021). Enterococcal IE increased the most (P = .018), while S. aureus IE appeared to increase but mostly in the winter months (P = .018). Between 1996 and 2018, the incidence of VGS IE was relatively stable, with no statistically significant difference in the trends before and after the 2007 AHA IE prevention guidelines.

Conclusions

Overall, IE incidence, and specifically enterococcal IE, increased over time, while S. aureus IE was seasonally dependent. There was no statistically significant difference in VGS IE incidence in the periods before and after publication of the 2007 AHA IE prevention guidelines.

Prevalence of bacteraemia following dental extraction - efficacy of the prophylactic use of amoxicillin and clindamycin

OBJECTIVES

To evaluate the efficacy of single-dose antibiotic prophylaxis (AP) in the prevention of bacteraemia following tooth extractions at our clinic.

MATERIAL AND METHODS

Fifty patients undergoing tooth extractions were enrolled. The need of AP was determined according to the health status and possible allergies of the patients. Blood culture samples were collected at baseline, 5 min after the first tooth extraction and 20 min after the last extraction.

RESULTS

The majority (76%) received prophylactic oral amoxicillin or intravenous ampicillin (AMX/AMP) (2 g), 12% received clindamycin (CLI) (600 mg) and 12% received no prophylaxis (NO AP). All baseline blood cultures were reported negative. The prevalence of bacteraemia was significantly higher in the CLI and NO AP groups compared to the AMX/AMP group 5 min after the first tooth extraction (p < .0001 and p = .015, respectively). Twenty minutes after the last extraction positive blood cultures were reported only for CLI (p = .0015) and NO AP groups. There was no significant difference in the prevalence of positive blood cultures between CLI and NO AP groups.

CONCLUSIONS

Appropriately administered AMX/AMP proved its efficacy in reducing both the prevalence and duration of bacteraemia following tooth extractions whereas CLI was not effective in preventing bacteraemia following tooth extractions.

Measuring Antibiotic Stewardship Programmes and Initiatives: An Umbrella Review in Primary Care Medicine and a Systematic Review of Dentistry

Antibiotic stewardship aims to tackle the global problem of drug-resistant infections by promoting the responsible use of antibiotics. Most antibiotics are prescribed in primary care and widespread overprescribing has been reported, including 80% in dentistry. This review aimed to identify outcomes measured in studies evaluating antibiotic stewardship across primary healthcare. An umbrella review was undertaken across medicine and a systematic review in dentistry. Systematic searches of Ovid Medline, Ovid Embase and Web of Science were undertaken. Two authors independently selected and quality assessed the included studies (using Critical Appraisal Skills Programme for the umbrella review and Quality Assessment Tool for Studies with Diverse Designs for the systematic review). Metrics used to evaluate antibiotic stewardship programmes and interventions were extracted and categorized. Comparisons between medical and dental settings were made. Searches identified 2355 medical and 2704 dental studies. After screening and quality assessment, ten and five studies, respectively, were included. Three outcomes were identified across both medical and dental studies: All focused on antibiotic usage. Four more outcomes were found only in medical studies: these measured patient outcomes, such as adverse effects. To evaluate antibiotic stewardship programmes and interventions across primary healthcare settings, measures of antibiotic use and patient outcomes are recommended.

Relationship between 18F-FDG Uptake in the Oral Cavity, Recent Dental Treatments, and Oral Inflammation or Infection: A Retrospective Study of Patients with Suspected Endocarditis

[18F]-fluorodeoxyglucose positron emission tomography ([18F]FDG PET/CT) has proven to be a useful diagnostic tool in patients with suspected infective endocarditis (IE), but is conflicting in relation to dental procedures.

QUESTIONS

Is there a correlation between [18F]FDG PET/CT findings, recent dental treatment, and an affected oral cavity? (2) Is there a correlation between infective endocarditis (IE), oral health status, and (extra)cardiac findings on [18F]FDG PET/CT?

METHODS

This retrospective study included 52 patients. All [18F]FDG PET/CT scans were examined visually by pattern recognition using a three-point scale and semi-quantified within the volume of interest (VOI) using SUVmax.

RESULTS

19 patients were diagnosed with IE (group 1), 14 with possible IE (group 2), and 19 without IE based on the modified Duke criteria (group 3). No correlation was found between visual PET and SUVmax and sites of oral inflammation and infection. The visual PET scores and SUVmax were not significantly different between all groups. A significant difference in the SUVmax of the valve between all groups was observed.

CONCLUSIONS

This study suggests that no correlation exists between the PET findings in the oral cavity and dental treatments or inflammation/infection. No correlation between IE, actual oral health status, and extra-cardiac findings was demonstrated. Additional research is needed to conclude whether [18F]FDG PET/CT imaging is a reliable diagnostic modality for oral inflammation and infection sites.

Acne on the Valve: Two Intriguing Cases of Cutibacterium Acnes Endocarditis

Cutibacterium acnes is a skin commensal which is most often regarded as a contaminant when detected on blood cultures. In rare instances, it may be the causative pathogen in severe systemic illnesses. Subacute endocarditis, especially of prosthetic valves and devices, is an important grave pathology caused by Cutibacterium acnes. Herein we report two cases of prosthetic valve endocarditis with varied presentations as valve dehiscence with a "rocking" prosthetic valve apparatus in one encounter and as a septic embolic stroke in the second encounter. Although a rare cause of endocarditis, it becomes an especially important entity in patients with prosthetic devices and should be high in the list of differentials.

Effect of nonsurgical periodontal therapy on haematological parameters in grades B and C periodontitis: an exploratory analysis

Aim

Assessment of the effect of nonsurgical periodontal therapy on haematological parameters in patients with grades B (BP) and C periodontitis (CP).

Methods

Eight BP and 46 CP patients received full-mouth periodontal debridement within 48 h, if positive for Aggregatibacter actinomycetemcomitans with adjunctive systemic antibiotics (4 BP, 17 CP). Clinical data were collected prior and 12 weeks after periodontal therapy. Blood was sampled prior to and 1 day as well as 6 and 12 weeks after the first SD visit. Erythrocyte count, haemoglobin value, haematocrit (HCT), mean erythrocyte volume (MCV), mean corpuscular haemoglobin (MCH), MCH concentration (MCHC), platelets (PLT) and heat shock protein 27 (Hsp27) were assessed.

Results

Both groups showed significant clinical improvement (p < 0.05). Using univariate analysis, MCV was noticeably lower in CP than BP at all examinations, HCT only at baseline. For CP, MCHC was noticeably higher 12 weeks after SD than at baseline and 1 day (p ≤ 0.005) and Hsp27 increased noticeably at 1 day (p < 0.05). Repeated measures analysis of variance revealed African origin to be associated with lower MCV and female sex with lower MCHC.

Conclusion

Based on multivariate analysis, periodontal diagnosis (BP/CP) was not associated with haematological parameters measured in this study or serum Hsp27. In CP, nonsurgical periodontal therapy improved MCHC 12 weeks after SD. Also in CP Hsp27 was increased 1 day after SD.

Investigation of the impact of the NICE guidelines regarding antibiotic prophylaxis during invasive dental procedures on the incidence of infective endocarditis in England: an electronic health records study

BACKGROUND

Infective endocarditis is an uncommon but serious infection, where evidence for giving antibiotic prophylaxis before invasive dental procedures is inconclusive. In England, antibiotic prophylaxis was offered routinely to patients at risk of infective endocarditis until March 2008, when new guidelines aimed at reducing unnecessary antibiotic use were issued. We investigated whether changes in infective endocarditis incidence could be detected using electronic health records, assessing the impact of inclusion criteria/statistical model choice on inferences about the timing/type of any change.

METHODS

Using national data from Hospital Episode Statistics covering 1998-2017, we modelled trends in infective endocarditis incidence using three different sets of inclusion criteria plus a range of regression models, identifying the most likely date for a change in trends if evidence for one existed. We also modelled trends in the proportions of different organism groups identified during infection episodes, using secondary diagnosis codes and data from national laboratory records. Lastly, we applied non-parametric local smoothing to visually inspect any changes in trend around the guideline change date.

RESULTS

Infective endocarditis incidence increased markedly over the study (22.2-41.3 per million population in 1998 to 42.0-67.7 in 2017 depending on inclusion criteria). The most likely dates for a change in incidence trends ranged from September 2001 (uncertainty interval August 2000-May 2003) to May 2015 (March 1999-January 2016), depending on inclusion criteria and statistical model used. For the proportion of infective endocarditis cases associated with streptococci, the most likely change points ranged from October 2008 (March 2006-April 2010) to August 2015 (September 2013-November 2015), with those associated with oral streptococci decreasing in proportion after the change point. Smoothed trends showed no notable changes in trend around the guideline date.

CONCLUSIONS

Infective endocarditis incidence has increased rapidly in England, though we did not detect any change in trends directly following the updated guidelines for antibiotic prophylaxis, either overall or in cases associated with oral streptococci. Estimates of when changes occurred were sensitive to inclusion criteria and statistical model choice, demonstrating the need for caution in interpreting single models when using large datasets. More research is needed to explore the factors behind this increase.

Oral Health Status of Hospitalized Patients With Type 2 Diabetes

BACKGROUND

Diabetes is associated with poor oral health, as well as reduced access to dental care. A large percentage of patients hospitalized in the United States carry a diagnosis of diabetes; however, the oral health status of patients with diabetes who are hospitalized is unknown.

METHODS

All patients meeting inclusion criteria on the general medicine service of a tertiary care hospital were invited to participate. Subjects were asked about their access to dental care and perceptions of their oral health. A dental hygienist conducted examinations, including decayed, missing, and filled teeth (DMFT) and periodontal screening and recording (PSR) indices on a subset of subjects.

RESULTS

The 105 subjects had a mean age of 69 ± 12 years and a median A1C of 7.5 ± 2.1%. Rates of comorbidity and polypharmacy were high. The mean number of DMFT was 23.0 ± 7.2, with 10.1 ± 7.2 missing teeth. Forty- four percent of subjects had a removable prosthesis. Sixty-eight percent had a PSR index ≥4 in at least one sextant, indicating moderate periodontal disease.

CONCLUSION

Rates of missing teeth, removable prostheses, and periodonal inflammation were high among hospitalized patients with diabetes, but patients did not perceive their oral health to be poor. Health care providers should be aware of the oral health risks of patients with diabetes during hospitalization, and dentists should consider screening patients with diabetes for recent hospitalization.

Preventing the recurrence of acute anorectal abscesses utilizing a loose seton: a pilot study

Introduction

This pilot study aimed to document our results of treating anorectal abscesses with drainage plus loose seton for possible coexisting high fistulas or drainage plus fistulotomy for low tracts at the same operation.

Methods

Drainage plus fistulotomy were performed only in cases with subcutaneous mucosa, intersphincteric, or apparently low transsphincteric fistula tracts. For all other cases with high transsphincteric fistula or those with questionable sphincter involvement, a loose seton was placed through the tract. Drainage only was carried out in 17 patients.

Results

Twenty-three patients underwent drainage plus loose seton. Drainage plus fistulotomy were performed in four cases. None of the patients developed recurrent abscess during a follow-up of 12 months. Not surprisingly, the incontinence scores were similar pre and post-operatively (p=0.564). Only minor complications occurred in 4 cases (14.8 percent). Secondary interventions following loose seton were carried out in 13 patients (48.1 percent). At 12 months, drainage only was followed by 10 recurrences (58.8 percent; p<0.0001, compared with concomitant surgery).

Conclusion

Concomitant loose seton treatment of high fistula tracts associated with anorectal abscess prevents abscess recurrence without significant complications or disturbance of continence. Concomitant fistulotomy for associated low fistulas also aids in the same clinical outcome. Concomitant fistula treatment with the loose seton may suffice in treating the whole disease process in selected cases. Even in patients with high fistula tracts, the loose seton makes fistula surgery simpler with a mature tract. Abscess recurrence is high after drainage only.

Problems in the orofacial region associated with Ehlers-Danlos and Marfan syndromes: a case series

Ehlers-Danlos syndrome (EDS) and Marfan syndrome (MFS) are characterised by hypermobility of joints and cardiovascular morbidity, and typical orofacial signs and symptoms are associated with both. Basic knowledge of these should prevent late-stage diagnosis and enable adequate management. This case series comprises all EDS and MFS patients who consulted the Department of Oral and Maxillofacial Surgery at University Hospitals Leuven between 2005 and 2017. Thirty patients had EDS or MFS, and in seven the diagnosis was made based on temporomandibular dysfunction or craniofacial dysmorphism. Non-facial symptoms led to diagnosis in the remaining patients. Twenty-five interventions were followed by two infections and one haemorrhage. One patient developed trismus. No major complications were reported. The complications we observed did not seem to differ from those often seen in patients who did not have EDS or MFS, possibly as a result of our strictly applied precautions and postoperative instructions. However, our study of relevant publications shows that patients with EDS and MFS are a vulnerable group.

Reduction of Streptococcus mutans by probiotic milk: a multicenter randomized controlled trial

OBJECTIVE

To investigate the effects of probiotics, Lactobacillus paracasei SD1, on the quantities of Streptococcus mutans in saliva and plaque samples of preschool children.

DESIGN

This randomized trial recruited 487 preschool children from eight childcare centers. Participants were assigned to receive a 6-month course of placebo milk daily (group I), probiotic milk either daily (group II) or three days a week (triweekly, group III). The absolute quantities of S. mutans and total lactobacilli in the saliva and plaque samples at baseline (T0), after intervention (T6), and 6 months after discontinuation (T12) were assessed by qPCR.

RESULTS

Of 487 children, 354 completed all follow-up periods. However, only 268 children (3.2 ± 0.8 years old; groups I = 86, II = 89, and III = 93) provided adequate saliva for qPCR. Whereas the quantities of S. mutans were significantly decreased in groups II and III compared to group I in the saliva and plaque samples at T6 and T12, those of total lactobacilli were significantly increased (p < 0.0167). There was no difference in the quantities of S. mutans or total lactobacilli between groups II and III at any period. Significant changes in the quantities of S. mutans and total lactobacilli lasted until T12 compared to T0 (p < 0.0167).

CONCLUSIONS

Probiotic administration daily or triweekly reduces S. mutans quantities, whereas it increases total lactobacilli quantities that persists at least 6 months after discontinuation in the saliva and plaque samples of preschool children.

CLINICAL RELEVANCE

Daily or triweekly consumption of L. paracasei SD1 supplemented in milk may help prevent dental caries in preschool children.

Congenital Heart Disease and Women's Health Across the Life Span: Focus on Reproductive Issues

From adolescence to older age, women with congenital heart disease (CHD) face unique challenges. In this review we explore the ways in which CHD affects women's sexual and reproductive health and, in turn, how their sexual and reproductive history affects the course of their CHD. In adolescence, special attention must be paid to menstrual irregularities and concerns of developing sexuality and self-image. Discussions about sexuality and reproduction are an important part of transition planning and must be done with an awareness of the adolescent's developing understanding and maturity. Pregnancy imposes a hemodynamic load on the heart which may lead to cardiac, obstetric, and fetal/neonatal complications in women with CHD. Prepregnancy counselling must include an assessment of maternal and fetal risk according to several well developed models. Counselling should also include discussions about fertility and alternatives to pregnancy when appropriate. Recommendations for contraception must be made according to the patient's cardiac lesion. In caring for women with CHD during pregnancy, a multidisciplinary cardio-obstetrics team is recommended to optimize care. More research is needed into the long-term impact of pregnancy on the prognosis of patients with CHD. As women with CHD increasingly survive into old age, more attention will need to be directed toward the treatment of menopause and acquired heart disease in this population.

Prevention of infective endocarditis and bacterial resistance to antibiotics: A brief review

The purpose of this statement is to debate the recommendations of the American Heart Association (AHA) for the prevention of infective endocarditis through an antibiotic prophylaxis protocol and its relation with bacterial resistance to antibiotics. Since dental infections involve biofilms that include several bacterial species (Gram-negative and Gram-positive), it is essential, from the dental point of view, to consider the frequency, magnitude, and duration of bacteremia associated with active dental infections before applying antibiotic prophylaxis. The actual guidelines for antibiotic prophylaxis should be revised according to recent evidence of bacterial resistance. Amoxicillin/clavulanic acid and moxifloxacin should be considered due to their effectiveness against bacteria associated with oral, GU, and GI infections and the low rates of antibiotic resistance associated with these antibiotics, instead of the actual protocol, which includes amoxicillin (2 g) or clindamycin (600 mg) administered an hour before the dental procedures. The breaking point to test the antibiotic bacterial resistance (ABR) had a wide range in the different studies that were analyzed, which could explain the widely varied ABR percentages reported for the various antibiotics used for antibiotic prophylaxis.

Invasive Procedures Associated With the Development of Infective Endocarditis

BACKGROUND

Various invasive medical procedures might induce bacteremia and, hence, act as triggers for infective endocarditis. However, empirical data in humans on the potential dangers of invasive medical procedures in this regard are very sparse. Due to lack of sufficient data, it is currently debated whether the risk for endocarditis with medical procedures is substantial or rather negligible.

OBJECTIVES

The purpose of this nationwide case-crossover study was to quantify the excess risk for infective endocarditis in association with invasive medical and surgical procedures.

METHODS

The authors identified all adult patients treated for endocarditis in hospitals in Sweden between January 1, 1998, and December 31, 2011. The authors applied a case-crossover design and compared the occurrence of invasive medical procedures 12 weeks before endocarditis with a corresponding 12-week time period exactly 1 year earlier. The authors considered all invasive nondental medical procedures except for those that are likely to be undertaken due to endocarditis or sepsis or due to infections that could possibly lead to endocarditis.

RESULTS

The authors identified 7,013 cases of infective endocarditis during the study period. Among others, several cardiovascular procedures, especially coronary artery bypass grafting; procedures of the skin and management of wounds; transfusion; dialysis; bone marrow puncture; and some endoscopies, particularly bronchoscopy, were strongly associated with an increased risk for infective endocarditis.

CONCLUSIONS

This study suggests that several invasive nondental medical procedures are associated with a markedly increased risk for infective endocarditis.

Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity

Cephalosporins are among the most commonly prescribed antibiotic classes due to their wide clinical utility and general tolerability, with approximately 1-3% of the population reporting a cephalosporin allergy. However, clinicians may avoid the use of cephalosporins in patients with reported penicillin allergies despite the low potential for cross-reactivity. The misdiagnosis of β-lactam allergies and misunderstanding of cross-reactivity among β-lactams, including within the cephalosporin class, often leads to use of broader spectrum antibiotics with poor safety and efficacy profiles and represents a serious obstacle for antimicrobial stewardship. Risk factors for cephalosporin allergies are broad and include female sex, advanced age, and a history of another antibiotic or penicillin allergy; however, cephalosporins are readily tolerated even among individuals with true immediate-type allergies to penicillins. Cephalosporin cross-reactivity potential is related to the structural R1 side chain, and clinicians should be cognizant of R1 side chain similarities when prescribing alternate β-lactams in allergic individuals or when new cephalosporins are brought to market. Clinicians should consider the low likelihood of true cephalosporin allergy when clinically indicated. The purpose of this review is to provide an overview of the role of cephalosporins in clinical practice, and to highlight the incidence of, risk factors for, and cross-reactivity of cephalosporins with other antibiotics.

Trends and Outcomes of Infective Endocarditis in Adults With Tetralogy of Fallot: A Review of the National Inpatient Sample Database

BACKGROUND

Lesion complexity and prosthetic valves are known risk factors for infective endocarditis in patients with congenital heart disease. Tetralogy of Fallot (TOF) is the most common complex/cyanotic congenital heart disease and often requires prosthetic valve implantation. Population-based risk of endocarditis in TOF patients is unknown.

METHODS

We reviewed the National Inpatient Sample (NIS) and identified admissions in TOF patients (>18 years), 2000 to 2014. The primary outcome was to describe incidence of endocarditis-related admissions. To assess trends, we divided the study period into tertiles: early (2000 to 2004), mid (2005 to 2009) and late (2010 to 2014) eras. The secondary outcome was to compare in-hospital mortality, complications, and health care resource utilization between admissions with and without endocarditis.

RESULTS

There were 393 (2.1%) endocarditis-related admissions among 18,353 admissions, and the incidence of endocarditis-related admissions increased over time: 1.9% (early era) vs 2.2% (mid-era) vs 2.4% (late era), P < 0.001. Overall in-hospital mortality was 6%. In addition to previously described risk factors for endocarditis, such as previous pacemaker/defibrillator or prosthetic valve implantation, we observed an association between endocarditis-related admissions and male gender, black race, and lower socioeconomic class. In comparison with admissions without endocarditis, the endocarditis-related admissions had higher in-hospital mortality, complications, and health care resource utilization measured by length of stay, inflation-adjusted hospitalization cost, and type of hospital discharge.

CONCLUSIONS

Incidence of endocarditis-related admissions increased over time and was associated with higher mortality, complications, and health care resource utilization. Further studies are required to investigate the observed temporal increase in incidence of endocarditis and explore new strategies to improve outcomes.

Antibiotic Prophylaxis for Dental Treatment in Patients with Immunodeficiency

Routine antibacterial prophylaxis is recommended before dental procedures in select patient populations. Currently, no guidelines are in place for routine prophylaxis before dental procedures in patients with primary immunodeficiency diseases. We review risk factors and provide recommendations on routine dental care and antibacterial prophylaxis in patients with primary immunodeficiency diseases.

Effects of an antimicrobial stewardship intervention on perioperative antibiotic prophylaxis in pediatrics

Purpose

This study aims to determine the effectiveness of an Antimicrobial Stewardship Program based on a Clinical Pathway (CP) to improve appropriateness in perioperative antibiotic prophylaxis (PAP).

Materials and methods

This pre-post quasi-experimental study was conducted in a 12 month period (six months before and six months after CP implementation), in a tertiary Pediatric Surgical Centre. All patients from 1 month to 15 years of age receiving one or more surgical procedures were eligible for inclusion. PAP was defined appropriate according to clinical practice guidelines.

Results

Seven hundred sixty-six children were included in the study, 394 in pre-intervention and 372 in post-intervention. After CP implementation, there was an increase in appropriate PAP administration, as well as in the selection of the appropriate antibiotic for prophylaxis, both for monotherapy (p = 0.02) and combination therapy (p = 0.004). Even the duration of prophylaxis decreased during the post-intervention period, with an increase of correct PAP discontinuation from 45.1 to 66.7% (p < 0.001). Despite the greater use of narrow-spectrum antibiotic for fewer days, there was no increase in treatment failures (10/394 (2.5%) pre vs 7/372 (1.9%) post, p = 0.54).

Conclusions

CPs can be a useful tool to improve the choice of antibiotic and the duration of PAP in pediatric patients.

State of the Art Management of Mechanical Heart Valves During Pregnancy

PURPOSE OF THE REVIEW

To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines.

RECENT FINDINGS

The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.

Antibiotic Prophylaxis and Incidence of Endocarditis Before and After the 2007 AHA Recommendations

BACKGROUND

The American Heart Association updated its recommendations for antibiotic prophylaxis (AP) to prevent infective endocarditis (IE) in 2007, advising that AP cease for those at moderate risk of IE, but continue for those at high risk.

OBJECTIVES

The authors sought to quantify any change in AP prescribing and IE incidence.

METHODS

High-risk, moderate-risk, and unknown/low-risk individuals with linked prescription and Medicare or commercial health care data were identified in the Truven Health MarketScan databases from May 2003 through August 2015 (198,522,665 enrollee-years of data). AP prescribing and IE incidence were evaluated by Poisson model analysis.

RESULTS

By August 2015, the 2007 recommendation change was associated with a significant 64% (95% confidence interval [CI]: 59% to 68%) estimated fall in AP prescribing for moderate-risk individuals and a 20% (95% CI: 4% to 32%) estimated fall for those at high risk. Over the same period, there was a barely significant 75% (95% CI: 3% to 200%) estimated increase in IE incidence among moderate-risk individuals and a significant 177% estimated increase (95% CI: 66% to 361%) among those at high risk. In unknown/low-risk individuals, there was a significant 52% (95% CI: 46% to 58%) estimated fall in AP prescribing, but no significant increase in IE incidence.

CONCLUSIONS

AP prescribing fell among all IE risk groups, particularly those at moderate risk. Concurrently, there was a significant increase in IE incidence among high-risk individuals, a borderline significant increase in moderate-risk individuals, and no change for those at low/unknown risk. Although these data do not establish a cause-effect relationship between AP reduction and IE increase, the fall in AP prescribing in those at high risk is of concern and, coupled with the borderline increase in IE incidence among those at moderate risk, warrants further investigation.

Investigation of bacteremia after debonding procedures

OBJECTIVE

The purpose of this study is to investigate the effect of debonding procedures after completion of orthodontic treatments on bacteremia.

MATERIALS AND METHODS

Twenty-eight patients who were treated with fixed orthodontic treatment at the Faculty of Dentistry's Department of Orthodontics at Gaziantep University and who had an indication of debonding were selected for this study, and blood samples were taken from these patients at different times and examined for bacteremia. Blood culture samples were taken from the antecubital veins of the patients prior to debonding (T₀), immediately after removing the bracket (T₁), and immediately after cleaning the composite residues and plaque deposits on the enamel surface (T₂). The blood samples were then inoculated in blood culture bottles and investigated for bacterial growth.

RESULTS

The results showed that there was no bacterial growth in the blood samples taken at T₀ and T₁, whereas 10 of the blood culture samples taken at T₂ showed bacterial growth including the following bacteria; Streptococcus viridans, Streptococcus mitis, Streptococcus parasanguinis, Streptococcus salivarius, Streptococcus oralis, Staphylococcus aureus, Actinomyces oris, Actinomyces naeslundii and Klebsiella pneumoniae.

CONCLUSION

It was concluded that patients in the risk group could develop bacteremia during debonding procedures. The presence of these bacteria in sterile blood suggested the possibility of bacterial endocarditis.

Inflammatory serum markers up to 5 years after comprehensive periodontal therapy of aggressive and chronic periodontitis

Aim

The aim of the study is to assess the long-term effect of active periodontal therapy on serum inflammatory parameters in patients with aggressive (AgP) and chronic (ChP) periodontitis in a non-randomised clinical study.

Methods

Twenty-five ChP and 17 AgP were examined clinically prior to (baseline), 12 weeks and 60 months after subgingival debridement of all pockets within 2 days. Systemic antibiotics were prescribed if Aggregatibacter actinomycetemcomitans was detected (10 AgP, 8 ChP), flap surgery was rendered if required. Neutrophil elastase (NE), C-reactive protein (CRP), lipopolysaccharide binding protein, interleukin 6, 8, and leukocyte counts were assessed at baseline, 12 weeks and 60 months.

Results

Clinical parameters improved significantly in both groups from 12 weeks to 60 months. Eleven AgP and 18 ChP patients received surgical treatment after the 12 weeks examination. Only 3 patients in each group attended ≥ 2 supportive maintenance visits per year. NE and CRP were significantly higher in AgP than ChP at baseline and 60 months (p < 0.01). For leukocyte counts in ChP, significant changes were observed (baseline: 6.11 ± 1.44 nl⁻¹; 12 weeks: 5.34 ± 1.40 nl⁻¹; 60 months: 7.73 ± 2.89 nl⁻¹; p < 0.05). Multiple regression analysis identified African origin, surgical treatment and female sex to correlate with better clinical improvement.

Conclusion

Despite comprehensive periodontal treatment, AgP patients exhibit higher NE and CRP levels than ChP patients up to 5 years after therapy.

Clinical relevance

Systemic inflammatory burden in AgP patients is higher than in ChP patients even 5 years after periodontal treatment.

Electronic supplementary material

The online version of this article (10.1007/s00784-018-2398-x) contains supplementary material, which is available to authorized users.

Paediatric dentistry- novel evolvement

Pediatric dentistry provides primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, together with special health care needs. This specialty encompasses a variety of skills, disciplines, procedures and techniques that share a common origin with other dental specialties however these have been modified and reformed to the distinctive requirements of infants, children, adolescents and special health care needs. Disciplines comprise of behavior guidance, care of the medically and developmentally compromised and disabled patient, supervision of orofacial growth and development, caries prevention, sedation, pharmacological management, and hospital dentistry including other traditional fields of dentistry. The skills apply to the ever-changing stages of dental, physical, and psychosocial development for treating conditions and diseases distinctive to growing individuals. Hence with the changing scope of practice it is imperative that the clinician stays updated with the current evidence based trends in practice, collaborates with other disciplines and Imparts quality oral health care tailored to the specific needs of every child.

Endodontics in Systemically Compromised Patients

A substantial number of people in today’s world are elderly and as the incidence of a number of pathologies increases with age, it is predicted to produce millions of individuals with systemic medical conditions that can affect oral health and subsequent dental treatment. The dental management of these medically compromised patients can be sometimes problematic in terms of oral complications, dental therapy, and emergency care. One of the challenges faced by dental specialists today is the assessment and management of these patients. As mentioned in detail in Chap. 12, geriatric patients are much more likely to be at least partially dentulous having a complex medical history and the use of multiple medications.

Is antibiotic prophylaxis to prevent infective endocarditis worthwhile?

Infective endocarditis (IE) is a rare condition which is associated with considerable morbidity and mortality. Almost 100 years ago, the links between endocarditis and procedures, particularly dental procedures, were postulated. Over 50 years ago the first guidelines recommending antibiotic prophylaxis (AP), with the aim of preventing IE developing after procedures, were proposed. However, there has only ever been circumstantial evidence in humans that AP prevents IE. The rarity of IE has made a randomised controlled clinical trial impractical to date. This article outlines the history of AP and reviews the evidence base for the use of AP to prevent IE.

Assessment of pathogenesis of infective endocarditis by plasma IgG antibody titer test against periodontal bacteria

Oral bacteria cause infective endocarditis (IE), so severe periodontitis is thought to be high risk for IE. We suggest the identification of high-risk patients by an IgG antibody titer test against periodontal bacteria might become common screening test.

Oral health of adult patients undergoing hematopoietic cell transplantation. Pre-transplant assessment and care

Hematopoietic cell transplantation (HCT) is now one of the frequent procedures used for treatment of malignant and non-malignant blood diseases, autoimmune disorders, and certain solid tumors. Despite improvements of therapeutic protocols, HCT still carries a high risk of non-relapse mortality due to early and late complications. Side effects of the therapy regimen frequently occur in the oral cavity and often significantly decrease the patients' quality of life. The complications may result from or may be exacerbated by improper oral preparation of the patient before transplantation. Therefore, it is mandatory that all patients referred to HCT undergo thorough dental examination and receive appropriate treatment before the procedure. It is also very important to develop an individual post-transplantation oral care protocol with special concerns to oral hygiene before implementation of the conditioning. This paper presents a review of dental management methods intended for patients before HCT proposed in literature as well as recommendations based on the experience of the Department of Comprehensive Dental Care and the Department of Conservative Dentistry of Warsaw Medical University and the Warsaw Institute of Hematology and Blood Transfusion. The article pays special attention to the problem of potential foci of infection and bleeding. It also presents protocol of oral hygiene in post-transplantation period, used by patients of Warsaw Medical University and Institute of Hematology and Blood Transfusion.

Non-invasive CT screening for pulmonary arteriovenous malformations in children with confirmed hereditary hemorrhagic telangiectasia: Results from two pediatric centers

BACKGROUND

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetic disorder that is caused by mutations in mainly two genes, that is ENG, encoding endoglin (HHT1), or ACVRL1, encoding activin receptor-like kinase 1 (ALK-1/HHT2). HHT is characterized by recurrent epistaxis, mucocutaneous telangiectasia, and vascular visceral dysplasia responsible for visceral arteriovenous malformations (AVM).

AIM

to report the experience of two university hospitals (Trousseau, Paris, and CHIC, Creteil) with screening children for HHT and pulmonary AVM (PAVM) using high resolution computed tomography (HRCT).

METHODS

parents with confirmed HHT were offered to have their children screened for the mutation identified in their family, and informed consent was obtained. Children carrying the same mutation as their parents underwent HRCT of the chest without contrast.

RESULTS

between 2008 and 2015, 99 children were screened for HHT mutations. Mutations were identified in 59 patients, that is 24 HHT1 and 35 HHT2. Radiologic and clinical screening was possible in 52 patients (21 HHT-1 and 31 HHT-2). Among those, PAVM was identified in 13 patients (25%; n = 8 HHT1; n = 5 HHT2), and four of them required embolization therapy.

CONCLUSION

This study highlights the usefulness of genetic screening in children with known HHT family. It also suggests that a non-invasive protocol such as HRTC is an efficient approach to detect non-symptomatic lesions that are present early on in children carrying the ENG (HHT1), but also the ACVRL1 mutations (HHT2). Pediatr Pulmonol. 2017;52:642-649. © 2017 Wiley Periodicals, Inc.

Effectiveness and safety of daptomycin in patients with infective endocarditis undergoing heart valve replacement: a subgroup analysis from real-world data

BACKGROUND

European Cubicin^® Outcomes Registry and Experience (EU-CORE) was a retrospective, non-interventional, multicenter registry that collected real-world clinical outcomes following daptomycin use for the treatment of Gram-positive infections. EU-CORE data from patients with infective endocarditis (IE) who underwent heart valve replacement were analysed.

METHODS

Clinical outcomes were assessed as success (cured or improved), failure, or non-evaluable. Adverse events (AEs) were recorded for up to 30 days after daptomycin treatment.

RESULTS

Of 610 patients with IE, 198 [32.5%; left-sided IE (LIE), 166 (83.8%); right-sided IE (RIE), 21 (10.6%); both LIE and RIE, 11 (5.6%)] underwent heart valve replacement. Other than cardiovascular disease, renal disease (18.2%), sepsis (16.2%), and diabetes mellitus (15.2%) were the most significant underlying diseases. Major pathogens in patients with positive culture results (68.0%) were Staphylococcus aureus [36.8%; methicillin-resistant S. aureus (MRSA), 12.8%] and coagulase-negative staphylococci (CoNS; 31.6%). Daptomycin treatment [median duration (range), 21 days (1-112)] resulted in high clinical success in patients with S. aureus (88.4%; MRSA, 80.0%) and CoNS (81.1%) infections, with an overall success rate of 83.3%. Clinical success rate was high (90.0%) in patients who received daptomycin dose >6 mg/kg/day. Overall clinical success rate in patients followed for up to 2 years was 90.7%. AEs and serious AEs possibly related to daptomycin were reported in 6 (3.0%) and 4 (2.0%) patients, respectively.

CONCLUSIONS

Daptomycin treatment was effective and well tolerated with a sustained response in patients with IE who underwent heart valve surgery. A trend towards better clinical outcomes was observed with higher daptomycin doses.

PAR-2 expression in the gingival crevicular fluid reflects chronic periodontitis severity

Recent studies investigating protease-activated receptor type 2 (PAR-2) suggest an association between the receptor and periodontal inflammation. It is known that gingipain, a bacterial protease secreted by the important periodontopathogen Porphyromonas gingivalis can activate PAR-2. Previous studies by our group found that PAR-2 is overexpressed in the gingival crevicular fluid (GCF) of patients with moderate chronic periodontitis (MP). The present study aimed at evaluating whether PAR-2 expression is associated with chronic periodontitis severity. GCF samples and clinical parameters, including plaque and bleeding on probing indices, probing pocket depth and clinical attachment level, were collected from the control group (n = 19) at baseline, and from MP patients (n = 19) and severe chronic periodontitis (SP) (n = 19) patients before and 6 weeks after periodontal non-surgical treatment. PAR-2 and gingipain messenger RNA (mRNA) in the GCF of 4 periodontal sites per patient were evaluated by Reverse Transcription Polymerase Chain Reaction (RT-qPCR). PAR-2 and gingipain expressions were greater in periodontitis patients than in control group patients. In addition, the SP group presented increased PAR-2 and gingipain mRNA levels, compared with the MP group. Furthermore, periodontal treatment significantly reduced (p <0.05) PAR-2 expression in patients with periodontitis. In conclusion, PAR-2 is associated with chronic periodontitis severity and with gingipain levels in the periodontal pocket, thus suggesting that PAR-2 expression in the GCF reflects the severity of destruction during periodontal infection.