Determination of professional competency in a rapidly changing environment

The recently published American College of Cardiology/American Heart Association/American College of Physicians Clinical Competency Statement for cardiac computed tomography/cardiac magnetic resonance (CCT/CMR) will be of great value to hospital medical staff organizations that grant privileges in the exciting new fields of CCT/CMR. More evidence is needed to document the number of hours of continuing medical education (CME) and minimum case loads required to maintain competence. This ongoing experience should be integrated into comprehensive imaging and clinical education, including vascular imaging as well as cardiac. Mandating hours of CME and minimum case loads does not, by itself, assure quality. Assessment of competency should employ measurable performance standards, identify areas needing improvement, and emphasize continuous quality improvement principles.     

Abbreviated duration of superheat-and-flush and disinfection of taps for Legionella disinfection: lessons learned from failure

One medical center in southern Taiwan faced an outbreak of nosocomial Legionnaires' disease; a total of 81 suspected cases were detected during an 8-month period. Baseline environmental surveillance showed that 80% of the distal sites in intensive care units (ICUs) were positive for Legionella pneumophila. Superheat-and-flush was selected for hospital water supply disinfection because it required no special equipment, and it can be initiated expeditiously. We conducted 2 episodes of superheat-and-flush based on the published recommendations from the Department of Health, Taiwan; US Centers for Disease Control and Prevention; and American Society of Heating, Refrigerating, and Air-Conditioning Engineers. Both flushes failed to control colonization of Legionella in the hospital water supply. The rate of distal sites positive for Legionella in wards and ICUs was 14% and 66%, respectively, 10 days after the second flush. The effect of replacement of faucets and showerheads in ICUs appeared to be insignificant in colonization of Legionella. The application of superheat-and-flush for flush duration of 5 minutes was ineffective. Superheat-and-flush may not be economic for a large medical center because it could be costly and labor intensive.     

Mechanism of paradoxical early diastolic septal motion in patients with mitral stenosis: A cross-sectional echocardiographic study

Paradoxical motion of the interventricular septum in early diastole has been observed in patients with mitral stenosis. To evaluate the cause of this septal motion abnormality M mode and cross-sectional echocardiograms were performed in 36 patients with mitral stenosis and 20 normal subjects. Cross-sectional studies in the normal subjects (Group I) and 9 of 11 patients with minimal septal motion abnormality (Group IIA) showed normal left ventricular diastolic shape and relaxation pattern. In 23 of 25 patients with more severe septal motion abnormality (Group IIB) there was a distinct change in initial diastolic left ventricular shape, characterized by motion of the interventricular septum away from the right ventricle and in toward the left ventricular cavity.     

Colon perforation with peritonitis in an acquired immunodeficiency syndrome patient due to cytomegalovirus and amoebic colitis.

Invasive amoebiasis is rarely seen in human immunodeficiency virus (HIV)-infected individuals, even in endemic areas. By contrast, cytomegalovirus (CMV) disease is recognized as a major clinical problem in acquired immunodeficiency syndrome patients. A 34-year-old HIV-infected man with amoeba colitis, disseminated Mycobacterium avian complex and CMV infection with cecum perforation, presented with the initial symptoms of fever, shortness of breath and painful sensation when swallowing. He was treated with fluconazole, trimethoprim-sulfamethoxazole and hydrocortisone under the impression of esophageal candidiasis and Pneumocystis jiroveci pneumonia. However, diarrhea and abdominal pain developed on day 6 of hospitalization. Invasive amoebiasis and CMV colitis was diagnosed after examination of colon pathological specimens. Emergent laparotomy was performed. Right hemicolectomy with double barrel ileostomy and colostomy was done due to perforation of the cecum. Iodoquinol was given, followed by metronidazole 14 days afterwards. He underwent closure of double barrel ileostomy and colostomy 5 months later. This case illustrates the diagnostic challenge of caring for acquired immunodeficiency syndrome persons with multiple illnesses and medication use. CMV infection, amoebic colitis and possibly corticosteroid may have played a role in colon perforation in our patient.     

Streptococcus suis meningitis with ventriculoperitoneal shunt infection and spondylodiscitis.

Streptococcus suis is a zoonotic pathogen which causes meningitis, bacteremia, and endocarditis in pigs. Human infection is rare and often presents as meningitis with the sequela of permanent deafness and endocarditis. Previous cases were reported from pig-rearing countries such as Holland and Hong Kong. We report a 55-year-old bedridden man with S. suis meningitis complicated with ventriculoperitoneal shunt infection and lumbar spine spondylodiscitis. He presented with fever, delirium, neck stiffness, lower leg weakness and sudden onset hearing loss for several days. He was successfully treated with intravenous antibiotics, ventriculoperitoneal shunt replacement, lumbar spinal laminotomy and discectomy. Cerebrospinal fluid culture initially misidentified the organism as Streptococcus acidominimus, and S. suis was later identified by 16S rRNA sequencing. Misidentification of the microbiological findings may lead to a failure to correctly diagnose this disease. S. suis meningitis should be included in the differential diagnosis of patients with meningitis and sudden hearing loss.