Introduction. Lactobacillus prosthetic valve endocarditis is a rare infection caused by Lactobacillus bacteria. This bacterium is found in the normal flora of the human mouth, gastrointestinal tract and female genital tract. While there have been isolated cases of Lactobacillus bacteraemia and endocarditis, the infections are associated with comorbidities, immune deficiency, dental manipulation procedures and other medical history. This case of bioprosthetic valve endocarditis caused by Lactobacillus paracasei is unusual, as the patient was immune-competent and treated with pre-procedural antibiotics. Case. We present a case of a 65-year-old male who underwent a dental extraction. He presented after 3 months of fever, chills and fatigue. On initial presentation, blood cultures were positive for alpha-haemolytic streptococcus bacteraemia. He was treated with IV penicillin and underwent aortic valve replacement with a bioprosthetic valve and excision of the mitral vegetation with repair of the mitral valve. Two years later, he had a tooth extraction after being treated properly with antibiotics. Three months later he presented with difficulty speaking, left leg weakness and increased drooling. All testing was normal. Three months later he presented with left side lower extremity weakness and expressive aphasia. He was diagnosed with bioprosthetic aortic valve endocarditis and was treated with IV penicillin and gentamicin for 6 weeks and then switched to oral penicillin. He remained stable. Conclusions. L. paracasei can potentially be a cause of complicated endocarditis in patients with prosthetic heart valves undergoing dental procedures. Timely culture-guided antibiotic therapy is critical and may obviate the need for valve surgery.
Background: Interns experience challenges in their transition from medical school to residency. Orientation is traditionally delivered by faculty and administrators and often does not address the intern’s daily duties.Objectives: Address traditional orientation gaps and improve incoming interns’ experience.Methods: We identified opportunities with our intern orientation using a quality improvement methodology. Plan Do Study Act (PDSA) cycle 1 consisted of a pilot boot camp. PDSA cycle 2 was conducted over two weeks, June 9-23, 2021, at the Detroit Medical Center, in Detroit, MI. Participation was voluntary. Residents were assigned incoming interns on a 1:1 basis. Five virtual sessions were conducted addressing: daily workflow, documentation, presentation skills, and utilization of the Electronic Health Records (EHR). All participants received pre- and post-program surveys.Results: 22 rising second-year and third-year residents (26%) and 22 incoming interns (58%) participated. There was a significant improvement in the understanding of daily workflow (mean improved by 0.957, p=0.003), and most tasks associated with EHR including comfort with the sign-out process (mean improved by 1.21; p=0.002), accessing specific team lists (mean improved by 1.75, p=0.001), writing orders (mean improved by 1.41; p=0.002), composing documentation (mean improved by 1.23; p=0.001). Writing notes improved significantly (mean improved by 0.52; p=0.04). Nearly all (93.2%) stated the program effectively achieved its overall goals and believed (92.9%) the program should be continued for each incoming class of interns.Conclusion: A targeted orientation boot camp led by near peers positively impacted the intern experience improving understanding of day-to-day responsibilities and comfort utilizing the electronic health record.
Figure 1. a-Spiration Valve in place (endoscopic image) b-TEF before treatment (fluoroscopic image) c-Spiration valve in situ controlling the leak (fluoroscopic image).
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