Prosthetic joint infections

Objectives: To review the available literature on prosthetic joint infections and provide recommendations on management particularly the importance of identifying the causative organism and starting the most appropriate antimicrobial therapy. Methods: The medical literature was searched using PubMed, employing the key words prosthetic joint infections. There appears to be no UK consensus guidelines on the management of prosthetic joint infections or the use of prophylactic antibiotics to prevent them. There is however a number of key documents and trust policies which deal with the subject extensively. We also made use of ‘The Sanford Guide to Antimicrobial therapy 2012’ for the latest recommendations on the correct antimicrobial therapy. Conclusion: Although diagnosis is often difficult, there are a number of investigations which can help us identify the organism. We recommend that the local prevalence of such infections is studied together with identification of the commonest organisms. Work is already underway between the infectious disease team and orthopaedic surgeons to devise locally adapted protocols for the identification and management of such infections. They should work in close liaison to implement the correct treatment which often involves a combination of both surgical and antimicrobial therapy.peer-reviewe

A study on the management of corticosteroid side effects in cancer patients

Background Systemic corticosteroids lead to many adverse effects especially in cancer patients. Preventive measures and treatment options are essential to minimise such side effects. Objectives The aims of the study included the evaluation of the prescribers’ management of corticosteroid induced hyperglycaemia, dyspepsia, oral candidiasis and proximal myopathy, the discussion of possible reasons for non-adherence to guidelines, and the recommendation of interventions to reduce their risk of occurrence. Method A retrospective review of the medical records for 156 consecutive patients at oncology out-patients and in oncology wards of Boffa Hospital between the 1st and the 14th September 2014 was performed. Only patients who were on long term corticosteroids (>2 weeks’ duration) were considered. Patients younger than 12 years of age or those that were prescribed corticosteroids for antiemetic purposes were excluded from the study. For each of the sampled patients, any management aimed at reducing corticosteroid side effects was compared to the guidelines as stated in an article published in a prominent international journal. Results From 156 cancer patients, 55 patients satisfied the inclusion criteria. The mostly addressed side effect was dyspepsia (n=35; 63.6%) followed by proximal myopathy (n=27; 49%), hyperglycaemia (n=24; 43.6%) and lastly oral candidiasis (n=20; 36%). Adherence to guidelines was as follows: hyperglycaemia – haemo-glucose test (HGT) and glycated haemoglobin (HbA1c) (36%); dyspepsia - prescribing of omeprazole (51%) and ranitidine (5%); oral candidiasis - orophargyngeal exam (29%); and proximal myopathy (40% compliance; of which 35% complying with resistance and endurance exercise and 5% complying with steroid dose reduction). Conclusion Improvement is required with regards to the management of corticosteroid side effects especially for hyperglycaemia and oral candidiasis. Possible actions that may be taken include strategies to improve guideline awareness, the prescribing of the lowest effective dose, adequate patient education and the implementation of a steroid card.peer-reviewe

Two-phase distribution in the vertical flow line of a domestic wet central heating system

The theoretical and experimental aspects of bubble distribution in bubbly two-phase flow are reviewed in the context of the micro bubbles present in a domestic gas fired wet central heating system. The latter systems are mostly operated through the circulation of heated standard tap water through a closed loop circuit which often results in water supersaturated with dissolved air. This leads to micro bubble nucleation at the primary heat exchanger wall, followed by detachment along the flow. Consequently, a bubbly two-phase flow characterises the flow line of such systems. The two-phase distribution across the vertical and horizontal pipes was measured through a consideration of the volumetric void fraction, quantified through photographic techniques. The bubble distribution in the vertical pipe in down flow conditions was measured to be quasi homogenous across the pipe section with a negligible reduction in the void fraction at close proximity to the pipe wall. Such a reduction was more evident at lower bulk fluid velocities

MICRO BUBBLE FORMATION AND BUBBLE DISSOLUTION IN DOMESTIC WET CENTRAL HEATING SYSTEMS

16 % of the carbon dioxide emissions in the UK are known to originate from wet domestic central heating systems. Contemporary systems make use of very efficient boilers known as condensing boilers that could result in efficiencies in the 90-100% range. However, research and development into the phenomenon of micro bubbles in such systems has been practically non-existent. In fact, such systems normally incorporate a passive deaerator that is installed as a ‘default’ feature with no real knowledge as to the micro bubble characteristics and their effect on such systems. High saturation ratios are known to occur due to the widespread use of untreated tap water in such systems and due to the inevitable leakage of air into the closed loop circulation system during the daily thermal cycling. The high temperatures at the boiler wall result in super saturation conditions which consequently lead to micro bubble nucleation and detachment, leading to bubbly two phase flow. Experiments have been done on a test rig incorporating a typical 19 kW domestic gas fired boiler to determine the expected saturation ratios and bubble production and dissolution rates in such systems

Two-phase distribution in the vertical flow line of a domestic wet central heating system

The theoretical and experimental aspects of bubble distribution in bubbly two-phase flow are reviewed in the context of the micro bubbles present in a domestic gas fired wet central heating system. The latter systems are mostly operated through the circulation of heated standard tap water through a closed loop circuit which often results in water supersaturated with dissolved air. This leads to micro bubble nucleation at the primary heat exchanger wall, followed by detachment along the flow. Consequently, a bubbly two-phase flow characterises the flow line of such systems. The two-phase distribution across the vertical and horizontal pipes was measured through a consideration of the volumetric void fraction, quantified through photographic techniques. The bubble distribution in the vertical pipe in down flow conditions was measured to be quasi-homogenous across the pipe section with a negligible reduction in the void fraction at close proximity to the pipe wall. Such a reduction was more evident at lower bulk fluid velocities

Bubble shape and breakage events in a vertical pipe at the boiler flow line

The theoretical and experimental aspects concerning the typical bubble shape at the flow line of a standard domestic central heating system are investigated. This is done in support of the on-going research on two-phase flows in domestic central heating systems. Bubble nucleation and detachment at the primary heat exchanger wall of a domestic central heating boiler results in a bubbly two-phase flow in the system pipe work. Bubbly flow results in undesired cold spots at higher points in the system, consequently diminishing system performance. An experimental analysis was done on the bubble shape at the exit of the boiler through the application of photographic techniques. The results are presented in terms of the measured bubble aspect ratios at some principal system operating conditions. The dimensionless Eotvos and bubble Reynolds number were calculated and tabulated with the measured mean diameters. The data was subsequently correlated to the bubble shape regime diagram. Results suggest that most bubbles are quasi-spherical in shape with a noticeable elongation at lower bulk fluid Reynolds numbers

Indoor climate and its impact on atopic conditions in Maltese school children

Several studies on the prevalence of allergic conditions have identified that allergic conditions are on the increase worldwide. The aim of this study was to study the effect of classroom humidity and temperature levels on schoolchildren in Malta. Our cohort included 191 children. Standardised ISAAC health questionnaires were answered by the children’s parents. Lung function tests, acoustic rhinometry, exhaled NO, exhaled CO and nasal lavage were performed on the participating children. School building characteristics were also studied. A significant association was noted between a high relative humidity exposure and nasal cross-sectional areas (p=0.003), and doctor diagnosed allergic rhinitis (p=0.002), indicating the presence of allergic rhinitis, as was increased indoor temperature (p=0.003). Increased indoor temperature was also associated with increased exhaled nitric oxide (FeNO) (p<0.001) indicating uncontrolled asthma. In conclusion, increased classroom temperatures and humidity, both linked to decreased classroom ventilation, were associated with increased incidence of allergic conditions in schoolchildren in Malta. These results emphasize the important need for the introduction of climate control and dehumidifying systems in our schools with the aim of decreasing the prevalence and severity of such conditions in this cohort of patients.peer-reviewe

The impact of school environment on children’s respiratory health

The study was done as part of the European Union SINPHONIE Study commissioned by DG SANCO. The authors received some funding from SINPHONIE (European Commission service contract of the DG Sanco).Abstract Background/Aims: School indoor air quality is important because children spend most of their time outside home within the school environment. This study aimed to investigate the school environment and its impact on the respiratory health of the children. Methods: A total of 191 pupils in the 9- to 11-year age group were selected from 5 primary state schools. Validated school and health questionnaires, spirometry, acoustic rhinometry, nasal lavage, urine for environmental tobacco smoke biomarkers and traffic counts were used. Results: Cumulative (32.98%) and current wheezing (17.8%) were in keeping with the International Study of Asthma and Allergies in Childhood Malta data. Southern schools had the highest prevalence of current wheezers (OR 3.77; p = 0.012), rhinoconjunctivitis (OR 3.59; p = 0.003) and nasal eosinophilic cationic protein levels (p < 0.001). Small openable window areas increased rhinitic symptoms (OR 3.14; p = 0.016). Classes facing roads had increased current wheezers (OR 2.27; p = 0.03) and exhaled carbon monoxide (eCO) levels (p < 0.001). Current wheezing was significantly associated with the number of light and heavy vehicles passing near the school (p < 0.001). The presence of smokers at home was significantly associated with urinary cotinine and 3HC (p < 0.001). Proximity to power plants increased the current wheezers (OR 5.89; p = 0.001) who had impaired spirometry (p = 0.003). Asthma symptoms (OR 5.25; p = 0.001) and elevated eCO levels (p < 0.001) were associated with fuel storage facilities near schools. The accumulation of dust on flat surfaces within classrooms was related to wheezing (OR 5.23; p = 0.001). Conclusions: The school environment had a direct impact on the respiratory health of children, with several factors having a direct impact on the children's health.peer-reviewe

The impact of microbiological pollutants on school indoor air quality

The submitted manuscript has not been previously published in any form and is not currently under consideration for publication elsewhere.Asthma is common in children with allergens and mould influencing the development of the disease. Since children spend most of their time outside their homes within the school environment, school indoor air quality can directly influence their respiratory health. This study aims to identify microbiological contaminants in Maltese schools. The association between contaminants, res-piratory health and school characteristics has been analysed. Five primary schools were selected with 9 to 11 years old students participating. Standardised health questionnaires, lung function tests, and school characterisation were performed. Dust samples were analysed for fungi, bacteria and allergens were performed. Penicillium/Aspergillus/Paecilomyces/Variotii (PenAsp) group had the highest median indoor concentration followed by Mycobacterial and Streptomyces species. There was a significant negative correlation between PenAsp and Mycobacterium spp levels in all the participating schools (r = −0.42; p = 0.03). Cat allergen in classroom dust correlated positively with the number of cat owners (r = 0.43; p = 0.041). High exposure to fungi, bacteria and allergens was significantly associated with upper and lower airway atopy. School/classroom characteristics and cleaning protocols were significantly as-sociated with exposure to these pollutants. In conclusion, fungi, bacteria, en-dotoxin, cat and dog allergens have been found to have a direct influence on school indoor air quality in the Maltese Islands. A significant association was observed between these contaminants and upper and lower airway atopy. Specific school, classroom, cleaning and maintenance characteristics have been identified as having a direct impact on indoor air quality.peer-reviewe