An approach to a patient with infective endocarditis.

Although infective endocarditis (IE) is relatively uncommon, it remains an important clinical entity with a high in-hospital and 1-year mortality. It is most commonly caused by viridans streptococci. Staphylococcus aureus is responsible for a malignant course of IE and often requires early surgery to eradicate. Other rarer causes are various bacilli, including the HACEK (Haemophilus, Actinobacillus,Cardiobacterium, Eikenella and Kingella spp.) group of organisms and fungi. The clinical presentation varies. Patients may present with a nonspecific illness, valve dysfunction, heart failure (HF) and symptoms due to peripheral embolisation. The diagnosis is traditionally based on the modified Duke criteria and rests mainly on clinical features and to a lesser extent on certain laboratory findings,microbiological assessment and cardiovascular imaging. Identification of the offending micro-organism is not only important from a diagnostic point of view, but also makes targeted antibiotic treatment possible and provides useful prognostic information. A significant proportion of microbiological cultures are negative, frequently owing to the administration of antibiotics prior to appropriate culture.Blood-culture-negative IE poses significant diagnostic and treatment challenges. The course of the disease is frequently complicated, and sequelae include HF, local intracardiac extension of infection (abscess, fistula, pseudoaneurysm), stroke and intracranial haemorrhage due to septic emboli or mycotic aneurysm formation as well as renal injury. Management includes prolonged intravenous antibiotics and consideration for early surgery with removal of infective tissue and valve replacement in patients who have poor prognostic features or complications. Antibiotic administration for at-risk patients to prevent bacteraemia during specific procedures (particularly dental) is recommended to prevent IE. The patient population who would benefit from antibiotic prophylaxis has become increasingly restricted,and guidelines recommend prophylaxis only for patients with cyanotic congenital heart disease, prosthetic heart valves and a previous episode of IE. The management of a patient with IE is challenging and often requires multidisciplinary input from an IE heart team,which includes cardiologists

Kounis syndrome.

Kounis syndrome is characterised by a group of symptoms that manifest as unstable vasospastic or non-vasospastic angina secondary to a hypersensitivity reaction. It was first described by Kounis and Zavras in 1991 as the concurrence of an allergic response with an anaphylactoid or anaphylactic reaction and coronary artery spasm or even myocardial infarction. Since then, this condition has evolved to include a number of mast cell activation disorders associated with acute coronary syndrome. There are many triggering factors, including reactions to multiple medications, exposure to radiological contrast media, poison ivy, bee stings, shellfish and coronary stents. In addition to coronary arterial involvement, Kounis syndrome comprises other arterial systems with similar physiologies, such as mesenteric and cerebral circulation resulting in ischaemia/infarction of the vital organs. The incidence of this condition is difficult to establish owing to the number of potential instigating factors and its relatively infrequent documentation in the literature.We report the case of an HIV-negative 39-year-old man with no coronary risk factors or family history of premature coronary artery disease, who developed Kounis syndrome after the administration of fluoroquinolone for dysuria. However, to the best of our knowledge,no data on the incidence and prevalence of Kounis syndrome in South Africa have ever been reported in the literature. The recent understanding of Kounis syndrome has led to the condition being classified into three syndrome variants.

The image of the nursing profession as perceived by the community members of three adjacent residential areas of Empangeni in KwaZulu-Natal.

The study was undertaken out of concern that nurses and the nursing profession project a negative image to the public they serve. Diverse aspects of nursing examined in this study included standards or quality of nursing care and its influence on encouraging clients to utilise health care services, communication, attitudes, expertise, availability at all times and patients'/clients' participation in decision-making. Nurses are part of the communities they serve. The rationale for the study was that nurses should be alert to perceptions of the communities about the service they provide, whether expressed formally or informally. Survival of nursing as a profession is dependent upon the positive impact it has on consumers in the past, present and the future. The aim of the study was to discover, through a systematic, scientific inquiry, the positive and negative perceptions that communities have about nursing. An exploratory, descriptive study was done in KwaZulu-Natal on a sample of 50 participants from three adjacent historically Black residential areas (townships) using questionnaires. Findings of the study were contrary to the assumption that nursing has a negative image. All aspects except one were rated very good or good by the majority of the participants. Those who had negative perceptions, though in the minority, highlighted important reasons directed at both the authorities and the nurses. These were used as a basis for recommendations for further improvement of the image of nursing. The area of gross dissatisfaction among the majority was feeling unsafe with nurses getting increasingly involved in unionism, which would lead to abandonment of patients in times of industrial action.