Infectious Mononucleosis: diagnosis and clinical interpretation.

EBV is the sole causative agent of the acute illness in humans described either as infectious mononucleosis (IM), or glandular fever. IM, when not clinically silent, can present in patients with at least two of the classic triad of symptoms of fever, pharyngitis, and lymphadenopathy. Challenges for the clinician arise when atypical cases present. Early, accurate and informed laboratory test results are vital for diagnosis, appropriate treatment, and management. A key challenge for the practitioner, particularly in cases where the illness can present atypically, is distinguishing bacterial tonsillitis infections from early acute IM. The ability to draw on timely, clear, and insightful laboratory results to distinguish viral from bacterial infection is vital. Correct and prompt diagnosis of IM can help prevent the unnecessary administration of antibiotics and mitigate the need for other expensive exploratory tests in cases of IM that present with splenomegaly, lymphadenopathy, or suspect haematological conditions. Good communication between the requesting clinician and those carrying out the investigative process, and between the different laboratory departments involved, is good practice and would ultimately benefit the patient. This communication will comprehensively review the aetiology, clinical presentation, and laboratory findings in IM with a view to promoting further research and so derive a standard diagnostic algorithm of the condition.

Effects of freshwater sponge Ephydatia fluviatilis on conjugative transfer of antimicrobial resistance in Enterococcus faecalis strains in aquatic environments.

Filter feeding is a biotic process that brings waterborne bacteria in close contact with each other and may thus support the horizontal transfer of their antimicrobial resistance genes. This laboratory study investigated whether the freshwater sponge Ephydatia fluviatilis supported the transfer of vancomycin resistance between two Enterococcus faecalis strains that we previously demonstrated to exhibit pheromone responsive plasmid conjugation. Microcosm experiments exposed live and dead colonies of laboratory-grown sponges to a vancomycin-resistant donor strain and a rifampicin-resistant recipient strain of Ent. faecalis. Enterococci with both resistance phenotypes were detected on double selection plates. In comparison to controls, abundance of these presumed transconjugants increased significantly in water from sponge microcosms. Homogenized suspensions of sponge cells also yielded presumed transconjugants; however, there was no significant difference between samples from live or dead sponges. Fluorescent in situ hybridization analysis of the sponge cell matrix using species-specific probes revealed the presence of enterococci clusters with cells adjacent to each other. The results demonstrated that sponge colonies can support the horizontal transfer of antimicrobial resistance although the mechanism underlying this process, such as binding of the bacteria to the sponge collagen matrix, has yet to be fully elucidated.

Risks for Surgical Site Infection after Infra-inguinal Bypass

Aims To define the burden of wound complications in patients with infra-inguinal bypass surgery. Methods A retrospective review of 50 consecutive patients from January 2012 to July 2017. Data collected included patient demographics, operative details, length of stay (LOS) and postoperative complications. Results The average age was 64 years (range 25-88 years) and 10 had a body mass index (BMI) ≥25 kg/m2. Pre-operative methicillin-resistant Staphylococcus aureus (MRSA) screening was performed in 17 patients (n=4 positive). Surgical antimicrobial prophylaxis (SAP) continued longer than 24 hours in 25. Surgical site infection (SSI) was the most common complication (n=10) and associated with female gender (p= 0.039), high BMI (p=0.017), shorter preoperative (p=0.039) and longer postoperative LOS (p=0.022). Three of 46 patients and four of 38 had graft occlusion at 30 days and one year respectively. Conclusion Pre-operative co-morbidity (e.g., BMI reduction), and MRSA screening optimization and SAP are areas identified for improvement.

Microbial biosurfactants: current trends and applications in agricultural and biomedical industries.

Synthetic surfactants are becoming increasingly unpopular in many applications due to previously disregarded effects on biological systems and this has led to a new focus on replacing such products with biosurfactants that are biodegradable and produced from renewal resources. Microbially derived biosurfactants have been investigated in numerous studies in areas including: increasing feed digestibility in an agricultural context, improving seed protection and fertility, plant pathogen control, antimicrobial activity, antibiofilm activity, wound healing and dermatological care, improved oral cavity care, drug delivery systems and anticancer treatments. The development of the potential of biosurfactants has been hindered somewhat by the myriad of approaches taken in their investigations, the focus on pathogens as source species and the costs associated with large-scale production. Here, we focus on various microbial sources of biosurfactants and the current trends in terms of agricultural and biomedical applications.

Food fraud and the perceived integrity of European food imports into China.

BACKGROUND/AIMS: Persistent incidents of food fraud in China have resulted in low levels of consumer trust in the authenticity and safety of food that is domestically produced. We examined the relationship between the concerns of Chinese consumers regarding food fraud, and the role that demonstrating authenticity may play in relieving those concerns. METHODS: A two-stage mixed method design research design was adopted. First, qualitative research (focus groups n = 7) was conducted in three Chinese cities, Beijing, Guangzhou and Chengdu to explore concerns held by Chinese consumers in relation to food fraud. A subsequent quantitative survey (n = 850) tested hypotheses derived from the qualitative research and theoretical literature regarding the relationship between attitudinal measures (including risk perceptions, social trust, and perceptions of benefit associated with demonstrating authenticity), and behavioral intention to purchase "authentic" European products using structural equation modelling. RESULTS: Chinese consumers perceive food fraud to be a hazard that represents a food safety risk. Food hazard concern was identified to be geographically influenced. Consumers in Chengdu (tier 2 city) possessed higher levels of hazard concern compared to consumers in Beijing and Guangzhou (tier 1). Structural trust (i.e. trust in actors and the governance of the food supply chain) was not a significant predictor of attitude and intention to purchase authenticated food products. Consumers were shown to have developed 'risk-relieving' strategies to compensate for the lack of trust in Chinese food and the dissonance experienced as a consequence of food fraud. Indexical and iconic authenticity cues provided by food manufacturers and regulators were important elements of product evaluations, although geographical differences in their perceived importance were observed. CONCLUSIONS: Targeted communication of authenticity assurance measures, including; regulations; enforcement; product testing; and actions taken by industry may improve Chinese consumer trust in the domestic food supply chain and reduce consumer concerns regarding the food safety risks associated with food fraud. To support product differentiation and retain prestige, European food manufactures operating within the Chinese market should recognise regional disparities in consumer risk perceptions regarding food fraud and the importance of personal risk mitigation strategies adopted by Chinese consumers to support the identification of authentic products.

Interspecies transfer of vancomycin, erythromycin and tetracycline resistance among Enterococcus species recovered from agrarian sources.

BACKGROUND: Enterococci are now well recognised for their ability to transfer antibiotic resistance and for their association with nosocomial infections, but less is known regarding their relevance in the wider environment. Enterococcus faecalis and Enterococcus faecium were isolated from a range of agrarian associated sources (low-flow water, septic tank, poultry litter, high flow water, slurry/soil) and were assessed for latent ability to transfer antimicrobial resistance. RESULTS: The isolates were tested for phenotypic clumping in the presence of cell-free supernatant from other isolates. Some isolates were identified which demonstrated clumping, indicating that they possessed peptide sex pheromone conjugal machinery. All isolates were also tested for antibiotic resistance phenotypes using both disc diffusion and minimum inhibitory concentration (MIC) assays. These tests revealed that the enterococci demonstrated both phenotypic clumping and antibiotic resistance phenotypes. Based on these selection criteria, the isolates were identified as having the potential for horizontal gene transfer and were used to investigate the transfer of multiple antibiotic resistance phenotypes. Conjugal transfer of antibiotic resistance phenotypes was determined using a solid agar mating method followed by a standard antibiotic selection test resulting in different transfer patterns. An interspecies conjugal transfer of vancomycin resistance from E. faecalis to E. faecium was identified while the remaining reactions were within the same species. Transfer efficiencies ranging from 2 × 10-1 to 2.3 × 10-5 were determined based on the reactions of three donor isolates (MF06036, MF0410 and MF06035) and two recipient isolates (MW01105Rif and ST01109Rif), with the transfer of vancomycin, erythromycin and tetracycline resistance genes. CONCLUSIONS: The conjugation reactions and selection conditions used in this study resulted in a variety of co-transferred resistance phenotypes suggesting the presence of different mobile elements in the set of natural isolates. This study highlights the potential for extensive horizontal gene transfer in a previously neglected reservoir for enterococci.

The Use of Arteriovenous Fistulae as an Adjunct to Peripheral Arterial Bypass: A Systematic Review and Meta-analysis.

BACKGROUND: Peripheral arterial bypass is an effective procedure for the management of patients with critical limb ischaemia. However, it is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below-knee arterial segment. A number of studies have suggested that an arteriovenous fistula (AVF) sited at the distal anastomosis may reduce afterload, improve graft patency, and boost subsequent limb salvage. The aim of this study was to assess the effects of adjuvant AVF on the outcomes of peripheral arterial bypass. METHODS: The following databases were searched up to May 2015: Medline through Pubmed; the Cochrane Library; EMBASE; and reference lists of articles. STUDY ELIGIBILITY: All randomised controlled and observational studies that assessed the role of AVF as an adjunct to peripheral arterial bypass were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two reviewers with any disagreements adjudicated on by the senior author. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed. RESULTS: Two randomised controlled trials and seven retrospective cohort studies comprising 966 participants were included. Pooled standardized data showed no difference in primary graft patency (pooled RR = 1.25, 95% CI 0.73-2.16), secondary patency (pooled RR = 1.16, 95% CI 0.82-1.66), or limb salvage at 12-months (pooled RR = 1.13, 95% CI 0.80-1.60) for the peripheral bypass with AVF group compared with peripheral bypass alone. Subgroup analysis indicated a reduction in reintervention rates associated with AVF when performed in conjunction with a synthetic graft (pooled RR = 0.55, 95% CI 0.30-0.98). CONCLUSION: Although adjuvant AVF is not associated with additional operative complication there is little evidence to support its use. The evidence assessing its merits is weakened by small, retrospective studies with heterogeneous cohorts.

Radiofrequency ablation: an assessment of clinical and cost efficacy.

BACKGROUND: Varicose veins are common and frequently cause patient distress. In recent years, Radiofrequency ablation (RFA) has emerged as a minimally invasive alternative to traditional open venous ligation surgery. AIMS: The aim of this study was to directly compare RFA and open saphenofemoral ligation. METHODS: This was a single-centre retrospective cohort study. Consecutive patients undergoing surgical management over a 2-year period commencing from January 2011 were studied. Radiological success, peri-operative serological testing and hospital length of stay were documented. Procedural cost was calculated. A focused cohort analysis was undertaken to compare the initial 50 RFA procedures performed with the last 50. RESULTS: During the study period, 296 patients underwent surgical intervention. A total of 204 patients underwent RFA. Sixty-six percent of all patients were female. RFA was associated with a reduction in overnight hospital stay (18 vs. 78 %, P = <0.001) when compared with open ligation with a success rate of 98 %. No significant inter-group difference was noted for 30-day readmission (p = 0.203). Focused cohort analysis identified an increase in hospital day case activity (74 vs. 90 %, p = 0.002), which contributed to a reduction in procedural cost (€1,024 vs. €971, p = 0.003) over the study period. CONCLUSIONS: Radiofrequency ablation is a viable alternative to open repair offering excellent efficacy. It is however associated with a higher procedural cost than the open surgical option.

Endovascular versus open repair of ruptured abdominal aortic aneurysm.

INTRODUCTION: Endovascular aneurysm repair (EVAR) is a comparatively less invasive technique than open repair (OR). Debate remains with regard to the benefit of EVAR for patients with ruptured abdominal aortic aneurysm (RAAA). We sought to evaluate and report outcomes of EVAR for RAAA in an Irish tertiary vascular referral centre. METHODS: Patients undergoing emergency surgery for ruptured or symptomatic AAA were identified from theatre logbooks and HIPE database. Retrospective chart review was undertaken. Data were exported to IBM SPSS version 21 for statistical analysis with p < 0.05 considered significant. RESULTS: A total of 41 patients underwent surgery for RAAA. The mean age was 74 years old with a range from 55 to 89 years. The majority (n = 25, 61%) were baseline American Society of Anaesthesiology (ASA) grade 3-4. Of these 56% underwent EVAR with the remaining 44% repaired open. Mortality rate in those undergoing emergency EVAR was 34.8%, compared with 38.9% in those undergoing open surgery. This difference was not statistically significant. The mean overall length of stay was 13 days. With regard to prognostic indicators of patient outcome, increasing patient age was noted to be significantly associated with increased mortality (p = 0.013), as was increased ASA score at time of surgery (p = 0.029). CONCLUSIONS: Mortality rates in those undergoing EVAR for RAAA are comparable with those undergoing open repair. Increasing age and ASA score are significant predictors of mortality in patients with RAAA undergoing intervention.

Perforated closed-loop obstruction secondary to gallstone ileus of the transverse colon: a rare entity.

Introduction. Gallstone ileus (GSI) of the colon is an extremely rare entity with potentially serious complications including perforation. Case Presentation. An 88-year-old man presented to the emergency department with abdominal pain and distension. Clinical exam revealed signs of peritonism. Computed tomography (CT) revealed GSI of the transverse colon with a closed-loop large bowel obstruction (LBO) and caecal perforation. The patient underwent emergency laparotomy. A right hemicolectomy was performed, the gallstone was removed, and a primary bowel anastomosis was undertaken. A Foley catheter was sutured into the residual gallbladder bed to create a controlled biliary fistula. The patient recovered well postoperatively with no complications. He was discharged home with the Foley catheter in situ. Discussion. Gallstone ileus is a difficult diagnosis both clinically and radiologically with only 50% of cases being diagnosed preoperatively. Most commonly it is associated with impaction at the ileocaecal valve and small bowel obstruction. Gallstone ileus should also be considered as a rare but potential cause of LBO. This is the first reported case of caecal perforation secondary to gallstone ileus of the transverse colon. Successful operative management consisted of a one-stage procedure with right hemicolectomy and formation of a controlled biliary fistula.

Carotid artery reconstruction for infected carotid patches.

OBJECTIVES: Infected carotid prosthetic patches (ICPP) are a rare but catastrophic complication of carotid endarterectomy (CEA). Prevention and appropriate surgical management is essential. We report our experience of carotid artery reconstruction for ICPP. DESIGN: Single-center retrospective study. METHODS: 10-year review of the surgical treatment of ICPP. RESULTS: Twelve patients presented with patch infection following CEA. Three patients presented acutely with an expanding hematoma, eight with chronic complications (abscess/discharging sinus n = 5, carotid pseudoaneurysm n = 3). Mean age was 75 years. Replacement conduits included superficial femoral artery (n = 6), cadaveric homograft (n = 3), long saphenous vein (n = 2) and one patient had primary closure. Five patients had muscle flaps fashioned for carotid artery protection. Operative complications included hypoglossal nerve injury (1 patient), superficial skin infection (2 patients) and one patient was returned to the operating room for a neck haematoma. Five surgical specimens were culture positive for: Staphylococcus aureus (n = 3), Corynebacterium propionibacterium (n = 1) and Streptococcus anginous (n = 1). There were no 30-day mortalities. Mean hospital stay was 6 days. Median follow-up was 16 months (range 3-108 months). CONCLUSION: Carotid artery reconstruction in a contaminated wound represents a significant surgical challenge. Unlike previous reports that used venous conduits, this is the first series where cadaveric or autologous arterial conduits were preferred. Arterial conduits achieved durable short term follow-up.

Concurrent colorectal malignancy and abdominal aortic aneurysm: a multicentre experience and review of the literature.

OBJECTIVES: There is lack of consensus regarding concurrent vs. staged approaches, and the prioritisation of staged procedures in cases presenting with colorectal carcinoma (CRC) and abdominal aortic aneurysm (AAA) synchronously. We aim to present our experience, review the literature on this therapeutic dilemma and examine the role of endovascular aortic repair (EVAR). DESIGN, MATERIALS AND METHODS: An observational study of the experience of two centres and a systematic review of the published literature. RESULTS: Twenty-four patients were identified from the prospective databases of two tertiary referral centres between 2001 and 2006. Intervention for both malignancy and aneurysm was performed in 13 patients. In 10 patients, cancer resection was performed initially and was followed by open aneurysm repair (n=3) or EVAR (n=7). Two patients (AAA diameters: 7.0 and 8.0cm) underwent EVAR prior to colonic resection. One patient was selected for synchronous surgery. There were no interval AAA ruptures, graft infection or postoperative mortalities. Literature review identified 269 such cases; of these 101 were treated by combined surgery. In staged surgery, there were nine interval aneurysmal ruptures and one aortic graft infection. CONCLUSIONS: In our experience, staged management can be undertaken, without interval aneurysmal rupture. EVAR has an evolving role in preventing delay in CRC management, in high-risk patients, and during combined intervention.

Virtual reality simulation in endovascular surgical training.

BACKGROUND: Shortened trainingtimes duetothe European Working Time Directive (EWTD) and increased public scrutiny of surgical competency have led to a move away from the traditional apprenticeship model of training. Virtual reality (VR) simulation is a fascinating innovation allowing surgeons to develop without the need to practice on real patients and it may be a solution to achieve competency within a shortened training period. METHOD: A Medline search was performed to identify studies and commentaries on the use of VR simulators in endovascular training. FINDINGS: Three studies on carotid stenting and four on peripheral vascular angioplasty demonstrate that simulator training is a valid, feasible and acceptable training tool. One randomised study reports that these skills learned on simulators are transferable to the operating room. CONCLUSION: VR simulators have a role in competency based, structured training of vascular interventionalists and should improve patient safety.

Traumatic inferior gluteal artery pseudoaneurysm and arteriovenous fistula managed with emergency transcatheter embolization.

We present a case of blunt trauma to the buttock resulting in an inferior gluteal artery pseudoaneurysm and arteriovenous fistula. The characteristic diagnostic features on CT angiography and digital subtraction angiography (DSA), along with the emergency percutaneous management of this traumatic vascular injury, are described. A review of the literature demonstrates inferior gluteal artery pseudoaneurysm is a rare condition, while successful treatment with glue embolization is previously unreported.

Relationship between dietary-induced changes in intestinal commensal microflora and duodenojejunal myoelectric activity monitored by radiotelemetry in the rat in vivo.

Interdigestive intestinal motility, and especially phase III of the migrating myoelectric/motor complex (MMC), is responsible for intestinal clearance and plays an important role in prevention of bacterial overgrowth and translocation in the gut. Yet previous results from gnotobiotic rats have shown that intestinal microflora can themselves affect the characteristics of the myoelectric activity of the gut during the interdigestive state. Given that the composition of the intestinal microflora can be altered by dietary manipulations, we investigated the effect of supplementation of the diet with synbiotics on intestinal microflora structure and the duodenojejunal myoelectric activity in the rat. To reduce animal distress caused by restraint and handling, which can itself affect GI motility, we applied radiotelemetry for duodenojejunal EMG recordings in conscious, freely moving rats. Thirty 16-month-old Spraque-Dawley rats were used. The diet for 15 rats (E group) was supplemented with chicory inulin, Lactobacillus rhamnosus and Bifidobacterium lactis. The remaining 15 rats were fed control diet without supplements (C group). Three rats from each group were implanted with three bipolar electrodes positioned at 2, 14 and 28 cm distal to the pylorus. After recovery, two 6 h recordings of duodenojejunal EMG were carried out on each operated rat. Subsequently, group C rats received feed supplements and group E rats received only control diet for 1 week, and an additional two 6 h recordings were carried out on each of these rats. Non-operated C and E rats were killed and samples of GI tract were collected for microbiological analyses. Supplementation of the diet with the pro- and prebiotics mixture increased the number of bifidobacteria, whereas it decreased the number of enterobacteria in jejunum, ileum, caecum and colon. In both caecum and colon, the dietary supplementation increased the number of total anaerobes and lactobacilli. Treatment with synbiotics increased occurrence of phase III of the MMC at all three levels of the small intestine. The propagation velocity of phase III in the whole recording segment was also increased from 3.7 +/- 0.2 to 4.4 +/- 0.2 cm min(-1) by dietary treatment. Treatment with synbiotics increased the frequency of response potentials of the propagated phase III of the MMC at both levels of the jejunum, but not in the duodenum. In both parts of the jejunum, the supplementation of the diet significantly decreased the duration of phase II of the MMC, while it did not change the duration of phase I and phase III. Using the telemetry technique it was demonstrated that changes in the gastrointestinal microflora exhibited an intestinal motility response and, more importantly, that such changes can be initiated by the addition of synbiotics to the diet.

Spontaneous coronary artery dissection.

Spontaneous coronary artery dissection is a rare cause of myocardial ischaemia or sudden death, predominantly affecting young women with no known risk factors for cardiovascular disease. The case described emphasises the benefit of early diagnosis and the need to individualise management based on patient response to treatment.

Effect of feed particle size and feed processing on morphological characteristics in the small and large intestine of pigs and on adhesion of Salmonella enterica serovar Typhimurium DT12 in the ileum in vitro.

A 2 x 2 factorial experiment with pigs was undertaken to investigate the effect of particle size (fine and coarse) and feed processing (pelleted and nonpelleted) on morphological characteristics in the small intestine, cecum, and colon of pigs and on the adhesion of Salmonella enterica serovar Typhimurium DT12 to the ileum in vitro. Ninety-six pigs (average BW = 33 +/- 7 kg) were fed the experimental diets. After 4 wk, 24 pigs were selected (six pigs per diet) and euthanized, and tissue samples were taken from the mid and distal small intestine, cecum, and distal colon. The effects of particle size and feed processing on villus height and crypt depth in the small intestine were minor. Feeding coarse diets increased (P = 0.05) the crypt depth in the colon. The crypt depth was 420 +/- 12 and 449 +/- 12 microm in pigs fed finely and coarsely ground feed, respectively. Pigs fed pelleted diets had a larger (P = 0.01) staining area for neutral mucins, as well as for acidic and sulfomucins on the villi of the distal small intestine than pigs fed nonpelleted diets. The area was 41, 46, and 33% larger for neutral, acidic, and sulfomucins, respectively. The mucin-staining areas of the crypts in the cecum and the colon were not affected by the experimental diets. Examination of lectin binding characteristics of the distal small intestine and the cecum did not reveal any differences between the experimental diets. Using a pig intestine organ culture model, Salmonella adhered less (P < 0.05) to the ileal tissue of pigs fed the nonpelleted diets than to those fed pelleted diets; the adherence was 60% less in these pigs. Results of this study suggest that pigs fed pelleted diets secrete mucins that are capable of binding Salmonella enterica serovar Typhimurium DT12 and thereby allowing for colonization. Therefore, pigs fed a nonpelleted diet are better protected against Salmonella infections than pigs fed a pelleted diet.