Active case finding for carbapenemase-producing Enterobacteriaceae in a teaching hospital: prevalence and risk factors for colonization.

BACKGROUND: Over the past decade, the prevalence of carbapenemase-producing Enterobacteriaceae (CPE) has increased. Whilst basic infection prevention and control practices reduce the risk of transmission, cases of unrecognized carriage pose a potential risk of transmission. AIM: To estimate the prevalence of CPE and explore risk factors associated with colonization within a large teaching hospital with an established CPE outbreak. METHODS: All inpatients that had not previously tested positive for CPE were offered testing. Demographic and hospital episode data were also collected, together with antibiotic and proton pump inhibitor (PPI) use in the preceding 24h. FINDINGS: This study identified 70 CPE-positive cases (26 newly identified and 44 previously known) and 592 CPE-negative cases, giving a combined prevalence of 11% [95% confidence interval (CI) 8-13]. Medication (antibiotic and PPI use), previous admission, ethnicity and length of stay were assessed as risk factors for colonization, and none were found to be independently associated with CPE colonization. Using logistic regression, age [odds ratio (OR) 1.03, 95% CI 1.01-1.07] and antibiotic use (OR 2.55, 95% CI 1.08-6.03) were the only risk factors significantly associated with CPE colonization. CONCLUSION: This study has added to the evidence base by estimating the prevalence of CPE among inpatients in an acute hospital with an established CPE outbreak. A case-finding exercise was feasible and identified a number of new cases. Despite a small sample size, increasing age and prescription of an antibiotic on the day of testing were significantly associated with CPE colonization.

Evaluation of patient-held carbapenemase-producing Enterobacteriaceae (CPE) alert card.

Public Health England recommends patient-held cards for those colonized with carbapenemase-producing Enterobacteriaceae (CPE). Alert cards were provided to 104 CPE-positive inpatients, with follow-up at six months. Excluding those who died, the response rate was 39%. Sixteen patients (46%) recalled receiving the card; 13 (81%) of these retained it, most (64%) of whom reported using it. This is the first evaluation of a patient-held alert card for any antimicrobial-resistant (AMR) bacteria in the UK. This study demonstrated that, when retained, CPE alert cards can be an effective communication tool. Further work is required to evaluate effectiveness and improve retention.

Central calcifying epithelial odontogenic tumour in the posterior maxilla: a case report.

The calcifying epithelial odontogenic tumour (CEOT), or Pindborg tumour, is a rare, benign odontogenic tumour. CEOT is usually asymptomatic and an incidental radiological finding, often presenting as a mandibular radiolucency with flecks of calcific material. We report an unusual case of CEOT in the left posterior maxilla of a 46-year-old male that was associated with an unerupted tooth. The tumour in this case caused non-specific sinus symptoms and appeared radiographically similar to an odontoma or ossifying fibroma due to its dense calcific contents. Diagnosis was confirmed histologically following surgical removal of the lesion, which showed classic CEOT histomorphology. We report this case to highlight the unusual clinico-radiologic presentation and illustrate the diagnostic difficulties that can occur with radiolucent and/or radiopaque lesions in the jaws.

Digital display monitor performance in general dental practice.

BACKGROUND: The performance of computer displays represents an important factor influencing the quality of digital radiographs. The aim of this study was to evaluate the performance of computer displays used for the purposes of diagnostic radiology in a sample of dental practices in one Australian state. METHODS: Twelve dental practices comprising 29 displays elected to participate in a detailed performance evaluation of their computer displays according to the AAPM TG18 and DICOM part 14 GSDF standards. RESULTS: None of the 29 displays tested passed the primary or secondary acceptance criteria developed by the AAPM TG18. The greatest contributor to display failure, both prior to and following calibration, were specular and diffuse reflection. When the parameter of display reflection was ignored, the most frequent parameters contributing to display failure following calibration included the primary grade acceptance criteria of noise (n = 29, 100%), contrast ratio (n = 9, 31%) and maximum luminance (n = 12, 41%). However, display calibration resulted in a significant improvement in the parameter of contrast response. CONCLUSIONS: This study demonstrated significant problems concerning the performance of display monitors in the population surveyed. In recognition of the growing utilization of digital imaging in dentistry the importance of the computer display should be considered.

Unilateral Intraparotid Swelling: A Case Report of Kimura's Disease and Review of Differential Diagnosis.

An interesting case of Kimura's disease was described in the 42-year-old patient manifesting itself as a unilateral parotid swelling, albeit the disease usually affects both parotid glands. Furthermore, first pathohistological finding was not suggestive of the disease, revealing only fatty tissue, but on the repeated biopsy together with CT the correct diagnosis was established. It should be emphasized that Kimura's disease has to be taken into account while making differential diagnosis in parotid gland swellings, especially in people of Oriental origin.

Myeloid neoplasms associated with eosinophilia and rearrangement of PDGFRA, PDGFRB, and FGFR1: a review.

Myeloid and lymphoid neoplasms with eosinophilia and abnormalities of platelet-derived growth factor receptor alpha (PDGFRA), platelet-derived growth factor receptor beta (PDGFRB), and fibroblast growth factor receptor-1 (FGFR1) are a group of hematologic neoplasms resulting from the formation of abnormal fusion genes that encode constitutively activated tyrosine kinases. These entities are now separated into their own major category in the 2008 World Health Organization classification of hematolymphoid tumors. Although eosinophilia is characteristic of these diseases, the clinical presentation of the three entities is variable. Conventional cytogenetics (karyotyping) will detect the majority of abnormalities involving PDGFRB and FGFR1, but florescence in situ hybridization (FISH)/molecular studies are required to detect factor interacting with PAP (FIP1L1)-PDGFRA as the characteristic 4q12 interstitial deletion is cryptic. Imatinib mesylate (imatinib) is the first-line therapy for patients with abnormalities of PDGFRA/B, whereas patients with FGFR1 fusions are resistant to this therapy and carry a poor prognosis. The discovery of novel gene rearrangements associated with eosinophilia will further guide our understanding of the molecular pathobiology of these diseases and aid in the development of small-molecule inhibitors that inhibit deregulated hematopoiesis.

The impact of computer display performance on the quality of digital radiographs: a review.

Radiography makes an essential contribution to the processes of examination, diagnosis and treatment planning in dentistry. While the use of film-based imaging still predominates in dentistry, digital imaging is gaining wider acceptance and the use of this modality is anticipated to expand in the future. Two concerns associated with this transition have been raised in the literature. The first of these is the dissatisfaction experienced by many dental professionals with quality of digital radiographs when compared to plain film. In addition, there are indications that practitioners feel limited in their understanding of those factors impacting on digital image quality. One key area highlighted in the literature as having a significant influence on digital radiographic quality and interpretation concerns the performance of the display device. Within the last decade, research derived from the fields of medical radiology and physics have demonstrated that suboptimally performing displays degrade image quality, thereby increasing the potential for compromised diagnostic outcomes. In the field of medicine, this has resulted in the establishment of standards applicable to computer displays used in diagnostic radiology. Conversely, limited guidelines exist in the field of dentistry. The aim of this review is to provide an outline of these standards and highlight the important relationship between computer display performance and digital image quality.

Computed tomography appearance of mandibular para-radicular third molar radiolucencies.

OBJECTIVES: Mandibular para-radicular third molar radiolucencies (MPRs) were first described in 2004 by Bohay et al (Bohay RN, Mara TW, Sawula KW, Lapointe HJ. A preliminary radiographic study of mandibular para-radicular third molar radiolucencies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98: 97-101) as a well-defined oval radiolucency surrounded by a thin sclerotic border located immediately distal to the mandibular third molar roots. Bohay et al's analysis was undertaken using panoramic radiographs. The purpose of this study was to confirm Bohay et al's findings on panoramic radiographs and to identify and document the appearance of MPRs on cross-sectional CT. METHODS: Panoramic films and CT images of the lower third molar regions from 143 patients were reviewed. RESULTS: MPR was identified on panoramic film in 12 patients with a total of 14 MPRs. A number of factors were recorded from panoramic films and CT. CONCLUSIONS: This study confirmed the findings of Bohay et al and concluded that the relative lucent appearance on panoramic radiographs can be explained by the presence of one or a combination of factors: (i) an area of decreased density in trabecular bone, (ii) thinning of the inner surface of the buccal cortex, (iii) thinning of the inner surface of the lingual cortex or (iv) a depression in the external surface of the lingual cortex.

Biopsy and diagnostic histopathology in dental practice in Brisbane: usage patterns and perceptions of usefulness.

BACKGROUND: Biopsy procedures and diagnostic histopathology are rarely used by general dental practitioners (GDPs) compared with dental specialists. The aim of this study was to investigate the usage patterns and views of GDPs and specialists in Brisbane on these procedures. METHODS: An analysis was carried out on 1027 oral biopsy accessions at a private pathology laboratory. A survey was distributed to 200 GDPs and dental specialists inquiring about their use of and views on biopsy and diagnostic histopathology. An analysis was carried out on 327 and 95 biopsies performed at a private oral medicine practice and at the University of Queensland School of Dentistry, respectively. RESULTS: The majority (76.2%) of GDPs surveyed referred all oral lesions requiring biopsy to a specialist, rather than undertaking biopsy themselves. Although most GDPs recognized the importance of biopsy, a large proportion (58.1%) did not feel competent in undertaking the procedure due to concerns of inadequate experience and practical skills. CONCLUSIONS: Many dental practitioners believe that GDPs should be able to undertake simple biopsies of benign lesions, however more undergraduate and postgraduate training in biopsy and diagnostic histopathology is necessary to promote a greater use of these procedures.

Oral medicine in Australia 2000-2010. A publications overview.

Specialties within health care are often identified by the public profile provided by members within the private clinical practice arena. This is clearly important but often the real activity of a specialty discipline exists within the training institutions. This is an unseen area for most, both members of the public as well as professional colleagues, as papers reporting developments of all kinds are delivered to highly specific target audiences and publications reporting research are published in journals again targeting specific audiences. Publication in national journals is important and provides a glimpse of research activities and a wealth of clinical material in the form of reviews and case reports directed again to a specific target audience. This paper addresses the profile of oral medicine in Australia by presenting the papers published in the Australian Dental Journal within a 10-year bracket.

Gingival enlargements and localized gingival overgrowths.

Gingival enlargements are a common clinical finding and most represent a reactive hyperplasia as a direct result of plaque related inflammatory gingival disease. These generally respond to conservative tissue management and attention to plaque control. However, a small group are distinct from these and whilst they also represent a reactive tissue response, this occurs at the level of the superficial fibres of the periodontal ligament. These epulides grow from under the free gingival margin and not as a result of a primary inflammatory gingival enlargement. This distinct aetiopathogenesis separates this group of lesions both in terms of their specific clinical presentation and behaviour and their propensity for recurrence if managed inadequately.

Actinic cheilitis in dental practice.

Actinic cheilitis is a potentially premalignant condition involving predominantly the vermilion of the lower lip. The aim of the current paper was to review the clinical presentation of actinic cheilitis and demonstrate the development of management plans using a series of cases. These are designed to provide immediate treatment where required but also to address the medium and long-term requirements of the patient. The authors suggest that the clinical examination of lips and the assessment of actinic cheilitis and other lip pathology become a regular part of the routine soft tissue examination undertaken as a part of the periodic examination of dental patients. Early recognition of actinic cheilitis can allow the development of strategies for individual patients that prevent progression. These are based on past sun exposure, future lifestyle changes and the daily use of emollient sunscreens, broad-brimmed hats and avoidance of sun exposure during the middle of the day. This is a service that is not undertaken as a matter of routine in general medical practice as patients are not seen with the regularity of dental patients and generally not under the ideal examination conditions available in the dental surgery.

Burning mouth syndrome and psychological disorders.

Burning mouth syndrome (BMS) is an oral dysaesthesia that causes chronic orofacial pain in the absence of a detectable organic cause. The aetiology of BMS is complex and multifactorial, and has been associated in the literature with menopause, trigger events and even genetic polymorphisms. Other studies have found evidence for mechanisms such as central and peripheral nervous system changes, with clinical and laboratory investigations supporting a neuropathologic cause. These physiological explanations notwithstanding, there is still much evidence that BMS aetiology has at least some psychological elements. Somatoform pain disorder has been suggested as a mechanism and factors such as personality, stress, anxiety, depression and other psychological, psychosocial and even psychiatric disorders play a demonstrable role in BMS aetiology and symptomatology. In order to treat BMS patients, both physiological and psychological factors must be managed, but patient acceptance of possible components of psychological disease basis is a major hurdle. Clinical signs of patient stress, anxiety or depression are a useful reinforcement of clinical discussions. The current paper proposes a number of clinical signs that may be useful for both clinical assessment and subsequent patient discussions by providing visible supportive evidence of the diagnosis.

Multiple, large sialoliths of the submandibular gland duct: a case report.

This paper reviews the major clinical and radiographic features of sialoliths and illustrates these with an unusual case of multiple sialoliths within the submandibular gland duct. The differential diagnosis of other calcific structures both within and outside the salivary gland that may mimic a sialolith is also presented.

Comparison of treatment modalities in burning mouth syndrome.

BACKGROUND: Burning mouth syndrome (BMS) is characterized by a spontaneous burning pain in the oral mucosa without known organic cause or standardized treatment. The aims of this study were to assess and compare the efficacy of clonazepam and diazepam in relieving the symptoms associated with BMS and evaluate for which patients this treatment might be effective by correlating treatment efficacy with underlying psychological status. METHODS: The medical records of BMS patients attending an oral medicine private practice (1999-2004) were reviewed. The patients were then contacted and asked to complete a short questionnaire regarding their response to diazepam/clonazepam drug therapies. A second group of patients attending the above clinic (n = 30) were asked to fill out a hospital anxiety and depression assessment form in an attempt to correlate treatment success with underlying psychological status. RESULTS: A total of 71.4 per cent of patients treated with clonazepam had partial or complete resolution of their oral symptoms, while 55.1 per cent of patients treated with diazepam had improvement of their oral symptoms. There was no correlation between underlying anxiety or depression and efficacy of benzodiazepine medication. CONCLUSIONS: A greater percentage of patients taking clonazepam reported either partial or complete relief of symptoms compared to diazepam. However, the differences were not statistically significant. There was no correlation found between underlying psychopathology and treatment success with benzodiazepines.

Scope of practice, referral patterns and lesion occurrence of an oral medicine service in Australia.

AIM: The purpose of this study was to examine the scope of practice, lesion occurrence and utilisation of referral-based hospital and private practice oral medicine and oral pathology (OMP) services in Australia. MATERIALS AND METHODS: Clinical records of patients referred to a hospital (n=500) and private (nbequals;1104) OMP clinic were audited. For each patient, the following parameters were recorded: age, gender, source of referral, reason for referral, site of lesion/condition if applicable, medical and drug history, diagnostic services utilised, clinical and histopathological diagnoses rendered, medications prescribed and further treatment required. RESULTS: A majority of the referrals were generated by general dental practitioners. The most commonly seen problems were epithelial hyperplasia/hyperkeratosis, oral candidosis, oral lichen planus, xerostomia, recurrent aphthous ulcers and burning mouth syndrome. OMP specialists requested diagnostic imaging for 13% of hospital and 9.42% of private patients, diagnostic biopsies were required for 18.4% of hospital and 19.3% of private patients, blood tests were ordered for 14.4% of hospital and 12.13% of private patients, while medications were prescribed for approximately 36% of hospital and 51% of private patients. CONCLUSIONS: This study is the first to detail the scope of practice, lesion occurrence and utilisation of services offered by OMP specialists in Australia. The demand for OMP services is strong.

Supernumerary tooth with associated dentigerous cyst in an infant. A case report and review of differential diagnosis.

This paper reviews the topic of dental structures present at birth or erupting prior to the deciduous incisor teeth. A literature review shows a prevalence of one in every 2000 live births. At this rate of occurrence it is likely that the general dental practitioner may be called upon to offer advice. This review is supported by the presentation of an unusual case of a supernumerary maxillary incisor tooth with the hallmarks of a neonatal tooth and the development of a soft tissue dentigerous cyst. The differential diagnosis of soft and hard tissue swellings in infants is also presented together with rare syndromal associations of natal and neonatal teeth.

Recurrent aphthous ulcerative disease: presentation and management.

Recurrent aphthous ulceration (RAU) is the second most common type of ulceration seen in the oral cavity. Notwithstanding an extensive literature and numerous proposed aetiologies, the cause of the disease remains obscure. In addition to the current conservative management of RAU lesions with corticosteroids, new treatment options are available and some have proven successful in open trials. This paper reviews patient work-up and management.