Birthdays Birthdays

We celebrate 2 birthdays today, Jenny's and Miles

After work, we went to Jenny's, should have gone for a BBQ but i was late leaving work, so they had one without us, but we spent an hour at Jenny's and had a drink with them.

Then i went and picked up Jude, Miles and Charlotte and we went to the hospital, where we went to see Steven, Kira was also there, luckily Steven was feeling a little better, Miles opened some Birthday presents with his daddy, and we had some birthday cake.  After 15 mins Jude and Charlotte took Miles downstairs so as not to tire Steven, while i spent time with Steven, then i went downstairs and took over and Jude saw Steven.  It seemed to work rather well.

Update on Steven

Steven has not had a good week, it has been quite worrying, he has not eaten and slept a lot of the time.

During the week, Steven went to Theatre and had a PICC Line inserted

Peripherally inserted central catheter is a form of IV access. The catheter is inserted in a vein usually located in the arm with the catheter tip terminating in a large vein close to the heart. While in the hospital, nurses will care for the PICC line. They will assess the insertion site, inspect the dressing, check for leakage, perform flushing maintenance and act according to the outcomes. The PICC can be a long term IV access device and patients may be discharged home with the PICC in place to continue with treatments instead of requiring additional hospitalization. Therefore, the patient must be informed of general PICC line care so he is comfortable with it and is aware of circumstances that require alerting healthcare professionals of possible complication.

this is where he now has his antibiotic.

He has also come off of the antibiotics

Vancomycin
Gentamicin

And he has now been put on the antibiotic

Daptomycin

This medication is an antibiotic used to treat serious bacterial infections. It works by stopping the growth of bacteria.

 SIDE EFFECTS: Nausea, vomiting, constipation, diarrhea, headache, dizziness, trouble sleeping, anxiety, or pain/redness/swelling at the injection site may occur.

The reason for this change in medication is that Steven has High Renal Levels which could mean Kidney problems.

Steven has seen a Dental surgeon and hopefully will get his dental problems sorted while in hospital.


Steven was looking and sounding so much better tonight, i felt a lot happier.

I think I love you by Stephanie Bond

Wow, what a surprise, a free kindle book, murder, romance, humour, what more could you ask for, a good pleasant easy read.

So there's some bad blood and bruised egos among the Metcalf sisters. At least they're reuniting. A cause to celebrate? Not for Justine, Regina, and Mica. Their parents are splitting up and the family business is going on the auction block--just a little reminder of how much they really have in common...

Take the local bad boy who proposed to Justine, seduced Regina, and ran off with Mica. Add the unsolved murder they witnessed when they were young girls, and their vow to keep it a secret. Toss in their knack for being drawn to shady men, and there's only one thing left for them to do--put the bonds of family loyalty to the test.

But it takes courage to outsmart a murderer, know-how to avenge the cad who betrayed them, and patience to bring their parent back together. Three talents. Three sisters. And who knows? Maybe even three new chances to fall in love when Justine, Regina, and Mica discover how much they're willing to risk--and forgive--in the name of sisterhood...

The Nightmare Stone by Finian Black

An different, unusual book, which was slow to start but improved.

The ultimate lucky break gives John Harris and his family the opportunity to fulfill their wildest dreams. But all dreams have a darker side, and John's past is never far away, ready to reach through to cast its shadow.
One hundred years ago, their new home was the scene for strange events that cannot easily be explained.
As John feels his past draw ever nearer, he knows that he must face up to his deepest fears if he is to prevent history repeating itself.
And as the past and present collide, a force beyond his control or comprehension is looking for one, final battle.

Holiday at The Oakes

Sophie, my 12 year old grandaugher, has Dyspraxia, including verbal Dyspraxia, and so with the support of Jean and Andrew we encouraged her to go to The Oakes Holiday Centre, with me going as her carer and support network.


Monday 27^th August

This morning I went to work, I left early at 2pm, to get ready to take Sophie to the Oakes Holiday Centre.

Andrew and Jean Holland, collected us at 3.30pm in the Docking Community mini bus, with Courtney  (Monica Burtons Granddaughter) and Jude and our only boy JJ, we stopped at Wisbech to pick up another girl Lucy.

After an uneventful journey we arrived at The Oakes just past 7pm.   We were shown our room,  Sophie had a bunk in a 6 bed en suite room with Courtney and Jude.  I was the only person in a twin bedded en suite room complete with kettle, mugs, tea, coffee, hot chocolate and biscuits, as well as ear plugs.

We unpacked and the girls introduced themselves to other room mates, then we went to the dining room  and enjoyed Pizza for tea.

The theme of the holiday is the Olympics, surprise surprise, where they could win Bronze, Silver and Gold Medals, they were put into teams.

There were 4 teams

Spain

Brazil

Australia

Canada

Sophie was in Spain, they were given lanyards with their ID on.   The leader of their team was Chloe and Holly.

After tea, they got into their groups to get to know each other, then followed an Olympic quiz. I thought quiz was a quiet activity but oh no, the noise you wouldn’t believe.

It seems the tradition during meal times that they all sing a song to a team leader, changing the name each time,

Sing a song Chloe

Sing a song

Sing a song Chloe

Sing a song

We won’t shut up

Till you stand up

Sing a song Chloe

Sing a song

This gets louder and louder, until the leader in question stands up and sings a short song, if the song is a popular one they chant

Encore

At 10.30 I went up and said good night to Sophie.

Tuesday 28^th August

The day started with CBS (Campers Bible Study), complete with hot chocolate to go with it.

Then we had Breakfast of cereal and Bonus Breakfast Pain au Chocolat.

We then had a bible meeting with Andy, which was very noisy and vibrant, where there were bible readings, songs and prayer.

They then split into five activity groups, 

Beijing

 Sydney

Barcelona

Athens

Atlanta

 Sophie was in Beijing.

They then went off to take part in 5 activities

Rope Course

Climbing Wall

Rafting

 Archery

Craft

Sophies first activity was the rope course, I didn’t stay with her , because I felt she needed the challenge, I later learned that she took part in some of the course and was so proud that her trainers got muddy.  Sophie was introduced to a young man named Pete who was a volunteer, and he had dyspraxia, dyslexia and was blind in one eye, and he told Sophie he had done all the  activities.

After a short period of free time we had lunch of  Wraps, chicken, salad, and crisps, with a chocolate bar.

This after noon they had Dorm Time which is where the dormitorys got together in a group to fill in a workbork called Jesus Lives discuss and ask questions of the bible.

Then came Activity Two this time Sophie’s activity was the Climbing Wall, when I spoke to her later, she said it wasn’t too high and she did some and enjoyed it.

Then they played a game David and Goliath, which consists of them running around and avoided being hit by soft frisbys, it was nice to watch Sophie joining in.

Then we had Tuck Shop in the Cellar, where they could spend pocket money on sweets and drink.

Shortly after that we had tea of Fish Fingers, peas and chips followed by ice cream sundae.

Then there was another bible meeting time, with some more noisy bible study, followed by Water Balloon Volleyball, and a variation of the game, rock, paper,  scissors.  We then had a bonfire with songs and stories, accompanied by hot chocolate and marshmellows, it was a lovely night for a bonfire, a clear sky, full moon, and bright shiny stars.

Camper of the day’s prize was to choose 4 leaders, who knelt on the grass in a row , the winner had a bucket of water and a cup and from behind could pour water on the leaders by sprinkling with fingers, using the cup or the bucket.

Then at 9.45pm it was bedtime.

Wednesday 29^th August

We started off with CBS (Camper Bible Study), then we had breakfast of cereal and Bonus Breakfast of Pancakes and Toffee Sauce.

It was then time for the Bible Meeting, then was supposed to be Activity 3 which for Sophie was Rafting, but because of torrential rain this was halted, and substituted with indoor games.

We then had lunch of DIY Sandwiches and yoghurt.

This afternoon we had Dorm time to discuss and ask questions of the bible.

Followed by the postponed Activity 3, where Sophie  took part in Rafting, she wasn’t keen on the canoeing, so paddled in the pond and was proud of getting wet.

Then the game Diving 4 Gold was played, there were 4 paddling pools with gold medals in that they had to try to get, and they all got extremely wet.

However, after rafting, Sophie disappeared, apparently she was having a shower and couldn’t get out.

Then came FREE Time  with Tuck Shop and Ice Cream for sale.

This was followed by Workshops, there was a choice of 5 sessions

2 Ways 2 Live

Suffering

Bible Overview

Active 4 Christ

Peer Pressure

Sophies choice was 2 ways to Live, which explained about Why to follow God, they were given a booklet Who will be King,  after the session Sophie went into question mode and was asking one of the leaders, how can she speak to God and hear him, then somehow it moved to what Heaven and Hell is like.

Then we had Dinner which was Pasta Bolognese and Mars Bar Mousse.

Then being our last night this followed with Party Games and a Cocktail Bar, with fruit drink concoctions.  They went to bed about 11pm, and then had a Midnight Feast!!!!

Thursday 30^th August

Once again the day started with CBS (Camper Bible Study), then we had breakfast of Cereal, Toast and Breakfast Bonus Chocolate Donuts!!!

Then we had our Final Bible Meeting.

And moved on to Activity 4, which for Sophie was Archery, which she had looked forward to doing, and she managed to hit the target.

Then it was time to clean up, pack our bags and take downstairs.

We then had lunch of Hot Dogs, Potatoes and Salad followed by Ice Lolly.

After lunch, the children all filled in a postcard, which asked them to fill in,

Who to pray for (Sophie said Uncle Steven)
What did they like best (Sophie said Food and Rafting)
What did they learn about the Bible (Sophie said That Jesus is King)
What friends did they make

This postcard will be posted in about a month to Sophie.

Then they had another Dorm Time, followed by Looney Olympics Competition.

Then came the time for Goodbye, the competition winners were

Australia

Spain (Sophies Team)

Brazil

Canada

We visited the shop and Sophie bought a Purple T shirt and a book called Sophie’s World.

And another safe journey home with thanks to Andrew and Jean.

We got home at about 8.15pm.

During the holiday i decided to give Sophie some space and interfere as little as possible thus challenging her out of her comfort zone, Sophie succeeded in tackling some of her gremlins while i caught up with lots of cross stitch and did some reading

It was a good holiday all the children including Sophie thoroughly enjoyed it, and i have to sincerely thank Andrew and Jean for making it all possible.

About 9.15pm this was posted on Facebook by Sophies Mum - Sophie Smith has just got back from the oakes i think she may have enjoyed herself she hasn't stopped talking yet.

The Oakes

Background

The Oakes Holiday Centre is a 36 roomed Georgian house with 7 acres of grounds. The site lies within 90 acres of parkland in Norton, Sheffield. The Oakes Trust, a registered charity, purchased the property in May 1998 and an extensive programme of renovation work followed. This was funded by donations and carried out almost entirely by volunteers. The centre opened on 1^st July 2000.

Aim

The Oakes is an interdenominational Christian charity, whose aim is to provide a holiday centre where 8-18 year olds can:

• hear the Christian message
• be encouraged in their faith
• enjoy a great holiday

The Need

There is no church contact with 86% of children and young people in Britain. Many

• know little about the Christian faith
• don't understand its significance

The Holidays (Camps)

The focus of most camps is to present a clear, exciting and relevant explanation of the Gospel message. Some camps are geared towards the encouragement of young Christians and aim to develop and strengthen their faith. Other camps are for school groups and complement R.E. curriculums and the Qualifications and Curriculum Development Agency (QCDA) units of work.

http://www.oakes.org.uk/

Busy Busy Day

Well Miles, went to sleep about 11pm and woke up about 7.20pm, that is acceptable.

This morning when Jude came home from work she stayed at our had a couple of hours sleep while i was at church, then we had a roast dinner, Jude and Jenny washed up,  we went to leave the children with mum and wish Dad a Happy Birthday.

Then we went to see Steven, not too good to day, this morning he passed out in the toilet, he also threw up, and then he slept most of the day.

Then i went home to tea made by Andy and Jenny.  As we went to the hospital this afternoon i was able to watch some TV this evening.

CSI: Crime Scene Investigation

Series 6 - 20. Poppin' Tags

20/24. Grissom and Stokes are called in to investigate the fatal shooting of three teenagers, and discover they were murdered while putting up posters to promote hip-hop star Dollar - who is later found bound and gagged in the boot of his car. Evidence initially suggests that competition between rival rappers has taken on a deadly dimension, but inquiries soon take the team in a new direction.

Volcano

Disaster thriller starring Tommy Lee Jones and Anne Heche. When an underground explosion kills several construction workers who are building a tunnel in Los Angeles, a team of seismologists investigates and discovers that volcanic activity is threatening to destroy the city.

 

Shattered

This morning i went to work, towards the end there was an enormous thunder storm, lightning lit up everywhere, and the thunder made everywhere shake.

After work absolutely shattered.

As i was working Jenny ran a stall at a craft fair for me she sold 2 kits, 2 cards and 5 threads, not brilliant, but ticking over.

I later went to collect Jude from Mums who were having the children, and went to see steven, he wasn't as good today, he was very tired and didn't look as well, i think it is because he over exerted himself when he went down to see Miles last night.

A quieter day as things go...................

Well, i slept like a log right through the alarm.

But i did make it to work on time phew, work was not too bad, got home had a rest, collected Jude and we took Miles and Charlotte upto see Steven, as Miles is not allowed on the ward, Steven came down stairs to see us.

Not Another One...................................

Just after 10.30pm last night, just after turning off my computer to go to bed I got a call from Jude, Miles was lethargic and had a temperature of about 40C,  he had had some medicine about 6pm.  I told her give it a while and see how he gets on, then after discussing it with Bob and having a rethink, i called Jude back asked a few more questions, and told her to call NHS Direct, who advised her to take him to the a&e, to which i was not totally surprised, that seems to be what they do.

So off me and Bob went, thinking we both needed to go because of Charlotte, which turned out she was having a sleepover, so Bob could have stayed home.  We ended up with us all going to the hospital, after seeing Miles, i wasn't too concerned, and anticipated them getting his temperature down and send him home.

I was irritated that Jude had stressed Steven out by informing him, but whats done is done.

We initially got seen very fast and he had his blood pressure and temperature taken and given some calpol, then we waited and waited and waited, eventually we saw the doc who gave him an exam, he said (we think), that he go home after a urine sample, and we waited and waited and waited, eventually they gave up and sent us home, we got home about 3am.

Steven came down to spend time with us and see Miles, but after a while felt he had had enought and went back to the ward, which was good that he recognised and acted on his symptoms.

This morning felt like death warmed up, i started my new job properly with my first lady in Heacham, of course it had to be Mrs Marsh, and old time customer, however she was expecting me at 11am and  and i had down 12 noon, but i did an hour and we got on ok.

Then i popped into Mums, and had a sandwich and continued on to see Steven,  Kira was there complete with boyfriend and blue hair.  Steven seemed ok but fed up, the lady from PALS Tonianne Shand

came along at Stevens request

E mail: Tonianne.Shand@qehkl.nhs.uk

Patient Advice and Liaison Service

We’re here to help you

Patient Advice and Liaison Service (PALS) is confidential and can help when you need advice, don’t know where to turn to or have concerns about your healthcare at The Queen Elizabeth Hospital.
As a patient, relative or carer sometimes you may need to turn to someone for on-the-spot help, advice and support. This is where the Patient Advice and Liaison Service comes in.

About us

The Patient Advice and Liaison Service focuses on improving the service to NHS patients.
The service aims to:

• Advise and support patients, their families and carers
• Provide information on NHS services
• Listen to your concerns, suggestions or queries
• Help sort out problems quickly on your behalf

We act on your behalf when handling patient and family concerns, liaising with staff, managers and, where appropriate, relevant organisations to negotiate immediate or prompt solutions and to help bring about changes to the way that services are delivered. We will also refer patients and families to local or national based support agencies as appropriate.

http://www.qehkl.nhs.uk/section-index.asp?s=advice&p=advice

She advised us about a parking pass, keeping a wellbeing appointment and she will contact someone about benefits for him, so altogether useful.

I got home and felt shattered, not long after getting home, Micheal and Hana turned up to collect Iliana, and Bob turned up with Iliana, we fed Iliana then they left for home.

Streptococcus Infective Endocarditis

Stevens diagnosis is confirmed as  Streptococcus Infective Endocarditis.

What is endocarditis?

Endocarditis is a serious infection of one of the four heart valves.(It is on Stevens Mitral Valve, his artificial valve)

What causes endocarditis?

Endocarditis is caused by a growth of bacteria on one of the heart valves, leading to an infected mass called a "vegetation". The infection may be introduced during brief periods of having bacteria in the bloodstream, such as after dental work, colonoscopy, and other similar procedures.

What are the symptoms of endocarditis?

Patients with endocarditis can develop:

• fever,
• fatigue,
• chills,
• weakness
• aching joints and muscles,
• night sweats,
• edema (fluid collection) in the leg(s), foot (feet), and abdomen,
• malaise,
• shortness of breath, and
• occasionally, scattered small skin lesions.

In endocarditis, blood cultures can often detect the bacteria causing the endocarditis. Patients can also develop anemia, blood in urine, elevated white blood cell count, and a new heart murmur.

Who is at risk for endocarditis?

People with existing diseases of the heart valves (aortic stenosis, mitral stenosis, mitral regurgitation, etc.) and people who have undergone heart valve replacements are at an increased risk of developing endocarditis. These people are usually given antibiotics prior to any procedure which may introduce bacteria into the bloodstream. This includes routine dental work, minor surgery, and procedures that may traumatize body tissues such as colonoscopy and gynecologic or urologic examinations. Examples of antibiotics used include oral amoxicillin (Amoxil) and erythromycin (Emycin, Eryc,PCE), as well as intramuscular or intravenous ampicillin, gentamicin, and vancomycin.

How is endocarditis diagnosed?

The infection on the valve can cause build up of nodules on the valves called "vegetations". These valve vegetations can be detected by echocardiography (an ultrasound examination of the heart). The most accurate method of detecting valve vegetations is with a procedure called transesophageal echocardiography (TEE). In this procedure an echo-transducer is placed on the tip of a flexible endoscope. The endoscope is inserted through the mouth into the esophagus. The transducer at the tip of the endoscope is then able to take sound wave "pictures" of the heart valves located adjacent to the lower esophagus. It is important to realize that endocarditis may exist without visible vegetations on the heart valve; the exact diagnosis is made by the identification of bacteria in a blood culture, in the appropriate clinical setting.

How is endocarditis treated?

The mainstay of treatment is aggressive antibiotics, generally given intravenously, usually for 4-6 weeks. The duration and intensity of treatment depends on the severity of the infection and the type of bacterial organism responsible. In cases where the valve has been severely damaged by the infection, resulting in severe valve dysfunction, surgical replacement of the valve may be necessary. Response to treatment is indicated by a reduction in fever, negative blood bacterial cultures, and findings on echocardiography.

http://www.medicinenet.com/endocarditis/article.htm


Infective Endocarditis (IE)


IE produces both intracardiac effects, eg valvular insufficiency and a wide variety of systemic effects, both from emboli (sterile and infected) and a variety of immunological mechanisms.

It is a disease that is easily overlooked or misdiagnosed and clinicians should be vigilant and well versed in the manifestations of IE to avoid missing the diagnosis.

Epidemiology

The incidence of infective endocarditis is approximately 1.7-6.2 cases per 100,000 patient years, although rates are higher in at-risk cohorts such as intravenous drug users.^[1] Incidence has remained constant for 50 years despite changes in the factors affecting incidence.^[2]

Figures for incidence are similar between countries. It is 3 times more common in men and increasing in elderly patients (25-50% of cases occur in the over 60s) often associated with other disease, eg diabetes, cancer, alcoholism.

Risk factors

• Previous IE with valvular damage
• Invasive vascular procedures
• Recreational drug abuse
• Rheumatic heart disease (fewer than 20% of cases of IE)
• Elderly patients with calcific aortic stenosis
• Congenital heart disease accounts for 15% of cases (bicuspid aortic valve being the most common)
• Prosthetic valve implants

Pathogenesis

All cases have a nonbacterial thrombotic endocarditis (a sterile fibrin-platelet vegetation) as the prerequisite for adhesion and invasion. The site of this thrombus is influenced by the Venturi effect, with deposition of thrombus on the low pressure side.
There are differences in the different clinical situations:

• Acute IE:
  The thrombus may be produced either by the invading organism or by valvular trauma (pacing wires, catheters, etc.).
• Subacute IE:
  Sufficient inoculum of bacteria required to allow invasion of the thrombus, bacteria clumping with production of agglutinating antibodies.
• Nonbacterial thrombotic endocarditis:
  This can result from, for example, renal failure, neoplasia, systemic lupus erythematosus (SLE) or malnutrition.

The valves most commonly affected by infective endocarditis are (in decreasing order of frequency):

• Mitral valve
• Aortic valve
• Combined mitral and aortic valve
• Tricuspid valve
• Pulmonary valve - rare

Note: mechanical and bioprosthetic valves are affected equally.

The organisms responsible for infective endocarditis

• Staphylococcus aureus:
  The most common cause of IE overall (acute and subacute); most common with prosthetic valves, acute IE, and IE related to intravenous drug abuse. High mortality rate.
  Coagulase negative S. aureus: causes subacute disease similar to Streptococcus viridans. Accounts for 30% of IE associated with prosthetic valves.
• Streptococci:
  • S. viridans:
    50-60% of subacute IE cases.
  • Group D streptococci:
    Usually subacute and the third most common cause of IE.
  • Streptococcus intermedius:
    Acute and subacute infection. Causes 15% of all cases of IE.
  • Group A, C and G streptococci:
    Acute IE is similar to that with S. aureus. High mortality (up to 70%).
  • Group B streptococci:
    Acute disease, high mortality often requiring valve replacement. Occurs in pregnancy and the elderly particularly.
• Pseudomonas aeruginosa:
  Usually acute IE and requires surgery for cure.
• HACEK organisms (Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae):
  Usually subacute disease and about 5% of all IE.
• Fungi:
  Cause subacute disease.
• Enterococci.

Presentation

• Early disease subtle and nonspecific
• Indolent process which may include:
  • Fatigue
  • Low-grade fever
  • Flu-like illness
  • Polymyalgia-like symptoms
  • Loss of appetite
  • Back pain
  • Pleuritic pain
  • Abdominal symptoms (may be pain, vomiting and appendicitis-like symptoms)
  • Symptoms akin to rheumatic fever
  • Weight loss
• Cerebrovascular accident - less common
• Congestive cardiac failure - less common
• May be history of:
  • Invasive procedures (see above)
  • Recreational drug use
  • Dental disease
  • Gingivitis - most cases caused by transient bacteraemia from this
  • Symptoms usually arise 2 weeks after invasive procedures but diagnosed after 6 weeks
  • Fewer than half of patients have previously-diagnosed valvular disease
• Developing disease produces a myriad of further clinical features of embolic or immunological origin when treatment/diagnosis delayed for weeks/months:
  • Acute meningitis - signs and symptoms but with sterile CSF
  • Hemiplegia from emboli in the middle cerebral artery (50% of patients may be first manifestation; has high mortality)
  • Renal infarcts causing painless haematuria
  • Splenic infarction causing pain
  • Blindness from retinal artery occlusion
  • Myocardial infarction from emboli in the coronary artery
  • Pulmonary emboli
  • Interstitial nephritis or proliferative glomerulonephritis from deposition of circulating immune complexes
  • Renal failure may result
  • Musculoskeletal symptoms (nearly half of patients) often from immunologically mediated synovitis
  • Immune-mediated vasculitis (causing Osler's nodes and Roth's spots)
  • Palpitations from immune-mediated myocarditis
  • Back pain (15% of patients) may have origin in immune complex deposition in disc spaces

Examination

• Fever: elderly, chronically ill patients with subacute IE may not have fever, but the majority do
• Heart murmurs:
  • Most patients have a murmur
  • Exception is right-sided IE where one third have murmurs
  • Only 15% have the classic 'changing murmur'
  • Most common murmur is aortic regurgitation
• Petechiae:
  • Conjunctivae
  • Hands and feet (dorsum)
  • Chest and abdominal wall
  • Oral mucosae and soft palate
• Splinter or subungual haemorrhages: Linear and red
• Osler's nodes: small tender red-to-purple nodules pulp of terminal phalanges fingers and toes
• Clubbing: only 10% of cases and usually in longstanding subacute IE
• Roth's spots: retinal haemorrhages with pale centres
• Janeway's lesions: irregular painless erythematous macules on the thenar and hypothenar eminence (usually with acute IE and S. aureus)
• Arthritis:
  • With subacute IE usually asymmetric and up to 3 joints affected (fluid sterile)
  • Acute IE can give acute septic monoarticular arthritis
• Splenomegaly: most often observed in longstanding subacute disease and often persists after treatment
• Meningism/meningitis: purulent disease occurs in acute IE and aseptic variety in subacute IE

Differential diagnosis

The differential diagnosis could include all those conditions which occur as a complication or with progression of the disease.

Some of the more unusual diseases which may also have similar complex and varied manifestations are:

• SLE
• Atrial myxoma and other cardiac neoplasms
• Lyme disease
• Antiphospholipid syndrome
• Polymyalgia rheumatica
• Reactive arthritis

Investigations

Blood cultures

• Blood cultures are used to demonstrate bacteraemia of 30 minutes or more duration
• Draw 3 to 5 sets of blood cultures over 24 hours
• In acute IE, 3 sets drawn from different venepuncture sites over 30 minutes demonstrates continuous bacteraemia
• If cultures are negative 24 hours after stopping antibiotics, repeat after 7 days and, if still negative, reconsider IE diagnosis
• Blood should not be drawn from IV lines (unless diagnosing line infection when simultaneous line and peripheral vein sampling may be used)
• Prior use of antibiotics commonly gives false negative results
• Probably 50% of culture results are estimated to be falsely positive
• Fastidious organisms may require special culture media or prolonged incubation
• HACEK organisms may require 3 weeks of culture and brucella organisms up to 6 weeks

Serological tests

These may be necessary to detect some organisms, eg legionella, chlamydia, brucella and coxiella species.

Imaging studies

Echocardiography is the indirect investigative method of choice. Note in general terms that:

• Echocardiography is particularly useful in the elderly
• Echocardiography is especially of use when clinical picture of IE but negative cultures
• Echocardiography is useful to predict complications such as embolisation:
  • Larger vegetations (>10 mm diameter)
  • Multiple vegetations
  • Pedunculated vegetations
  • Prolapsing vegetations
• Diagnosis of IE can never be excluded with negative echocardiogram (of whatever type)
• Echocardiography should not be used to screen for IE because of high (15% plus) false positive rate (caused by thickened valves, etc.)

Transthoracic echocardiography (TTE):

• TTE is the initial technique of choice for investigating infective endocarditis.^[1]
• Can detect vegetations in 60% of native valve endocarditis but much less often in prosthetic valves
• TTE is good enough for most cases of IE

Transoesophageal echocardiography (TEE):

• In high risk groups, TEE, with its higher sensitivity and specificity, may be needed if the TTE is normal and suspicion of infective endocarditis remains high^[1]
• Was developed to visualise prosthetic valves and right-sided pathology
• It detects over 90% of all vegetations
• TEE is better at detecting myocardial abscesses and vegetations on pacemaker leads

Two dimensional cardiac ultrasound Doppler studies have been a helpful advance providing more information on vegetations:

• This may help in diagnosis but also in predicting risk of embolisation
• Useful for visualising jet lesions and cusp perforation

Radionucleotide studies are of little value except for detecting splenic abscesses which are refractory to antibiotic treatment.
Electrocardiogram is useful to detect the 10% of patients who will develop conduction defects.

Diagnostic criteria

The Duke criteria - for definitive clinical diagnosis requires either 2 major or 1 major and 3 minor or 5 minor criteria from the list below:^[3]

• Major blood culture criteria:
  • 2 positive blood cultures for typical IE organisms
  • Persistently positive cultures for such organisms drawn >12 hours apart
  • 3 or more positive cultures drawn at least 1 hour apart
• Major echocardiographic criteria:
  • Positive result and no alternative explanation
  • Myocardial abscess
  • Partial dehiscence of prosthetic valve
  • New valvular regurgitation
• Positive molecular assays for specific gene targets
• Positive serology for Coxiella burnetii, Bartonella spp., or Chlamydophila psittaci
• Minor criteria:
  • Predisposing cardiac condition
  • Intravenous drug use
  • Fever (38°C or over)
  • Elevated C-reactive protein or erythrocyte sedimentation rate
  • Vascular lesions
  • Immunological phenomenon
  • Positive cultures less than 'major'
  • Positive echocardiographic results but insufficient for major criteria
• Definitive pathological diagnosis from tissue

Management

Have a high index of suspicion:

• Admit the patient to hospital for full investigation:
  • Blood cultures
  • Temperature records
  • Basic haematology and biochemistry investigations
  • ECG and CXR
  • Comprehensive TTE
• Blood cultures:
  • With a sick patient (acute IE) take 3 sets of cultures at >1 hour intervals.
  • Less obvious IE (sub-acute presentation) requires 6 sets of cultures over 24-48 hours.
  • Cultures negative for the commoner organisms should be checked for unusual slow-growing organisms and fungi.
• Referral:
  • When blood cultures are positive to a cardiologist.
  • At the outset to a microbiologist.
• TTE or TEE:
  • If TTE difficult or suboptimal.
  • In order further to assess vegetations, abscesses or valvular perforations.
  • In all patients with prosthetic valve endocarditis (PVE).
• Serological testing:
  • If the diagnosis is still suspected but cultures negative after 7 days.
  • Tests for Coxiella burnetii, Bartonella spp. and chlamydial organisms are available and should be performed.
• Testing of biopsied tissue with special techniques to identify bacteria and fungi are being developed.

Antimicrobial therapy

Stevens antibiotic treatment is Vancomycin, Gentamicin, Rifampicin, lasting for 6 weeks, in hospital via drip.

Guidelines have been produced for treating IE.^[

Treatment of infective endocarditis: guidelines from the RCP.
Type or variety of IE/ organism	Antibiotic	Dose/route	Duration of treatment
IE due to penicillin-sensitive viridans streptococci and S. bovis (MIC*<0.1 mg/l) in adults	Benzylpenicillin and gentamicin (b)	Benylpenicillin: 7.2-12 g iv/24 hours in 4-6 divided doses Gentamicin: 3-5 mg/kg iv daily in 2-3 divided doses (max 240 mg/day)	4-6 weeks (a) 2 weeks
As above but allergic to penicillin	Vancomycin and gentamicin (b)	Vancomycin: 30 mg/kg iv in 24 hours infused in 2 divided doses over 2 hours Gentamicin: as above	4 weeks 2 weeks
IE due to penicillin-relative resistant viridans streptococci and S. bovis (MIC*>0.1 mg/l) in adults	Benzylpenicillin and gentamicin (b)	Benzylpenicillin: 12-14 g iv/24 hours in 4-6 divided doses Gentamicin as above	4-6 weeks (a) 2 weeks(a)
As above but allergic to penicillin	Vancomycin and gentamicin (b)	Vancomycin and gentamicin as above	Vancomycin and gentamicin as above
IE due to staphylococci on native valve: penicillin-sensitive (non-beta-lactamase producers)	Benzylpenicillin and gentamicin (b)	Benzylpenicillin: 12-14 g regime as above. Gentamicin as above	6 weeks benzylpenicillin 3-5 days of gentamicin only
IE due to staphylococci on native valve: methicillin-sensitive staphylococci (beta-lactamase producer)	Flucloxacillin and gentamicin (b)	Flucloxacillin: 8-12 g iv/24 hours in 4 divided doses Gentamicin as above	6 weeks flucloxacillin 3-5 days of gentamicin only
IE due to staphylococci on native valve: methicillin-resistant staphylococci (c)	Vancomycin (d) and gentamicin (b)	Vancomycin: 30 mg/kg iv in 24 hours in 2 divided doses (infused over 2 hours) Gentamicin as above	6 weeks vancomycin 3-5 days of gentamicin only
As above but allergic to penicillin	Vancomycin (d) and gentamicin (b)	As above for V and G	As above for V and G
IE due to enterococci in adults: gentamicin-sensitive or low level resistant organism (MIC*<500 mg/l)	Benzylpenicillin or ampicillin or amoxicillin and gentamicin (f), (b)	Benzylpenicillin: 10-12 g iv/24 hours in 4-6 divided doses Amp/amox: 12 g iv/24 hours in 4-6 divided doses Gentamicin as above	All 4-6 weeks with 6 weeks if symptoms for more than 3 months of amox and amp (e)
As above but allergic to penicillin	Vancomycin (d) and gentamicin (b)	As above for V and G	As above for V and G
(a) Adjust duration according to response and microbiologist advice. (b) Check gentamicin levels regularly. (c) Linezolid or Synercid® may be used with MRSA. (d) Monitor peak and trough levels with advice. (e) 6 weeks for symptoms over 3 months. (f) Strains highly resistant to gentamicin seek microbiology advice. *MIC = minimum inhibitory concentration.

Surgical care

Surgery is needed in approximately 50% of patients who develop infective endocarditis and careful timing is essential to ensure a good outcome:^[1]

• In most stable patients surgery is best delayed until antibiotics are completed to reduce the risk of perioperative complications and early prosthetic valve endocarditis.
• Unstable patients with haemodynamic or perivalvular complications have a poor prognosis and are best transferred to a specialist centre at the earliest opportunity.

Complications

These are an inherent part of the progression of the disease. Patients should be monitored for:

• Valve dysfunction
• Myocardial abscesses
• Embolic phenomena
• Heart failure
• Metastatic infection
• Immunological disease and organ dysfunction
• Complications even after bacteriological cure
• Conduction defects (patients with IE should have daily ECGs)

Prognosis

This varies markedly according to a variety of factors. The following outlines the range of prognosis when managed appropriately:

• Native valve endocarditis:
  • S. viridans 98% cure rate
  • S. aureus 60-90% cure rate with worse results in occurring in those NOT abusing intravenous drugs
  • Fungal infections - cure rate less than 50%
• PVE:
  • Cure rates at least 10% lower than above for each variety
  • Surgery needed more often
  •  
  http://www.patient.co.uk/doctor/infective-endocarditis
  
  
  Streptococci are the commonest causes of bacterial endocarditis. However, Streptococcus mutans, a member of this group associated with dental caries which might be expected to be commonly associated with endocarditis, has only rarely been reported. This is possibly because of difficulties in isolation and identification. Differing blood culture media may affect the chances of isolation of these organisms, and, though brain-heart infusion, thiol, tryptic soy, and glucose-brain infusion broths have all proved satisfactory, subcultures may require increased CO2 concentrations for growth. Plemorphism in the resultant colonies and in the individual organisms may give rise to a hazardous misinterpretation of this appearance as contamination. Strep. mutans and the similarly penicillin sensitive Strep. bovis may be differentiated from the penicillin resistant enterococci by their lincomycin sensitivity and intolerance of 6-3 per cent sodium chloride. Precise differentiation of streptococci in bacterial endocarditis is of value both epidemiologically and in the management of the disease.
• 
  
  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC483257/
  
  

Docking Market

Today we went to Docking Market, Charlene (who runs the cafe) wasn't there as she had a tummy bug, so Bob ended up serving Teas and Coffees.

My stall didn't do too badly, a lot of interest was shown, and some sales.

Today Steven has his TOE

What is a transoesophaegal echo (TOE)?

A transoesophaegal echo (TOE) is a special type of heart ultrasound that involves taking pictures inside your oesophagus, which is the tube connecting your mouth to your stomach. As your oesophagus is close to the back of your heart this allows your doctor to see clear pictures of your heart.

He got back late morning Groggy and Sore.

Steven seemed in good spirits and the confirmed results are Streptocococcus Infective Endocarditis, Please see blog Infective Endocarditis for more details of the condition.

The TOE showed definite vegetation, it is going to be a prolonged hospital stay i am afraid :(

The Morning after the Night Before

Well Miles started off sleeping fine, sleeping with Charlotte, then at 1.30 heard him grumbling, eventually i gave up and went and got him, and he screamed solid for about 45 mins, then he dropped off, and he woke several times, the one he wanted was Grandad :(.

On top of that Bob wasn't well, he was aching and couldn't breathe properly so all in all not a good night at all.

I spent the morning catching up with jobs and doing housework.

Then at lunchtime, i left to go to Norwich for my job induction, I first met up with Tina Neil from Human Resources, where we discussed the contract and filled in loads of forms, she also gave me the Employee Handbook, this lasted about 30 minutes.  Then i had a meeting with Sam Woods Household Helpers Line Manager, she told me about my uniform, and my first customers, went through the risk assessment with me, this lasted about 3/4 hour.

We got home about 6pm and Kevin and Kinga came round and made us a Polish meal, it was Pork Roulade, which is Pork rolled and stuffed with a vegetable mixture, salad and New Potatoes, it was most delicious followed by Triple Chocolate Gateaux, served with wine.  It was a delicious satisfying spread.

Steven's INR is back at 3 so he is now back on Warfarin, other than that a quiet day.

Hospital and Work

This morning i worked it was hard but a fairly good day.

After a break, i took Jude to see Steven, while Bob had the children, he bought them back home, because as Jude is working tonight, they can stay round home, be interesting, see how we get on. When Jude left for work, Miles cried constantly for a while, he only wanted Grandad, eventually Bob went outside, his breathing was bad, and he wasn't well at all.

Steven is not too bad, he saw Dr Kumar today, who said it was suspected encarditis and that he will be in for a while.

He is to have a TOE exam on Wednesday

What is a transoesophaegal echo (TOE)?

A transoesophaegal echo (TOE) is a special type of heart ultrasound that involves taking pictures inside your oesophagus, which is the tube connecting your mouth to your stomach. As your oesophagus is close to the back of your heart this allows your doctor to see clear pictures of your heart.

Lets go fly a kite

This morning we headed off to Hunstanton Kite Festival, as i have a stall booked in the craft fair for my cross stitch kits.

It was another hot hot day, but trade was disappointing only sold 1 kit, but quite a few people looked and leaflets went.  However, we did design, sew and made a cross stitch key ring, during the day.

It was a pleasant day till they end. when Sophie refused to take Dylan to his mum, he got upset, then she got angry and violent, Andy and Jenny ended up packing up the Rainbow Stall earlier than they would have.

Jude went to see steven on the bus with charlotte while mum had Miles. This seemed to go ok, Jude says steven is ok and in good spirits.  Having spoken to mum, she is struggling with Miles he has grizzled and cried all afternoon.

On speaking to steven this evening he is fed up and the day has been very long.

This evening I watched

 X-Factor

Series 9 - Episode 1

 It’s the first of several weeks of auditions and the press has already run stories of diva-ish behaviour from a few contestants, despite the change in rules that is presumably aimed at turning The X Factor into a more serious singing contest like The Voice. This time anyone over the age of 16 can enter, even if he or she is already an amateur artist and currently has (or has had) a management deal.

New girl joining Gary Barlow, Tulisa and Louis Walsh on the judging panel
is gorgeous Nicole Scherzinger, onetime Pussycat Doll, although in the pre-boot camp stages there is a succession of guests including Geri Halliwell. 

 Countryfile

On a visit to Grizedale Forest in the Lake District, Julia Bradbury discovers why the area is a haven for mountain bikers and John Craven witnesses the end of a project to release red kites into the countryside. He also explores the legacy of artist and social commentator John Ruskin, while Tom Heap assesses the future of dairy farmers and Adam Henson learns whether he stands to make a profit on his harvest. 

Silent Witness

Series 15 - 11. And Then I Fell in Love - Part One

11/12. Part one of two. Nikki sees a barefoot girl being knocked over by a car, marking the beginning of a case that takes the team into the harrowing world of sex grooming and teenage prostitution. The police know the girl has been abused and suspicion soon falls on her stepfather. Meanwhile, an early-morning bath saves Harry's life, and two puzzling corpses are brought in to the centre - a heavily tattooed man and a decomposed body found at the airport. Guest starring Sanjeev Bhaskar (The Indian Doctor), Elyes Gabel (Casualty) and Madeline Duggan (EastEnders). 

 

Phew a hot one

This is the hottest day of the year so far, it has been a gruelling day.

This morning i worked which was so hard.

This afternoon i collapsed outside with something to eat, i left about 5pm and went to collect Jude to go and see Steven, he was looking so much better, bright and bubbly today, still not eating properly yet though.

Bob was late home, didn't get home untill 10.30pm, as he was looking at CCTV as they  had had a theft of fuel, someone stole £30 by filling up a large petrol can.

Another hectic day

This morning i worked, which was hard, then we went to Jude's Bob held the babies while we went to the hospital, Steven is now on the Tilney Ward.

Kevin and Micheal both rang up to see how Steven was, Kevins comments, he is lucky they sent him in hospital, they normally say take a couple of paracetymol and come back in 2 weeks, ummm welllllllllll.....

He is much better this afternoon he had an Echo, his colour is better and he is brighter, I am much happier tonight.

After Bob went work Mum had the children.

We got back about 8.30pm.

I found this an extremely hard day, i ache so so much.

Stevens Medications

Steven has been put on the following antibiotics through his IV

Vancomycin INN ( /væŋkɵˈmaɪsɨn/) is a glycopeptide antibiotic used in the prophylaxis and treatment of infections caused by Gram-positive bacteria. Vancomycin has traditionally been reserved as a drug of "last resort", used only after treatment with other antibiotics had failed.

Gentamicin is an aminoglycoside antibiotic, used to treat many types of bacterial infections, particularly those caused by Gram-negative organisms

Rifampicin (INN) ( /rɪˈfæmpəsɪn/) or rifampin (USAN) is a bactericidal antibiotic drug of the rifamycin group.[

Unplanned day

Well today was interesting certainly not boring.

Me and Bob being tired had a lie in, we were just getting up and the phone rang, it was Jude, Steven had just been to the Doctors and they were referring him to the Hospital with possible CCF (after googling it i found it meant oh help "congestive heart failure," ) or heart failure.


Symptoms for past 3 weeks include

• Headaches, severe
• Tiredness and Fatigue including no energy
• Unable to sleep
• Loss of appetite
• Tremor in left hand
•  Chest pains
• Fever (especially at night, burning up and sweating while claiming he is frozen)

We dashed down to Steven's Bob took control of children and I took them to the hospital.   We first went to A and E and then to MAU (Medical Assessment Unit), during the course of the day Steven has had 2 ECG's and Chest X Ray and loads of Blood taken in 4 different places both arms and hands.

He saw 3 sets of different doctors during the day, each time rising in hierarchy, the end result was they suspect he has an infection in his Artificial Heart Valve (see below Infective endocarditis)

To find out definitely they need to grow some blood cultures which takes 3-4 days, so he will be in over the weekend.

They are talking about referring him to cardiac department, where they will probably put a camera in, so they can have a look at the valve.

If the culture is positive, he will need to go on high dose of anti biotics, which would mean an extended stay in hospital.

We eventually got home about 7pm.

Stevens Temperature was recorded as 39C.

Normal human body temperature varies slightly from person to person and by the time of day. Consequently, each type of measurement has a range of normal temperatures. The range for normal human body temperatures, taken orally, is 37.0±0.5 °C (98.6±0.9 °F). This means that any oral temperature between 36.5 and 37.5 °C (97.7 and 99.5 °F) is likely to be normal.

From  http://www.patient.co.uk/health/Endocarditis-Infective.htm

Infective Endocarditis

Infective endocarditis is an infection that can seriously damage heart valves and cause other serious complications if it is not treated quickly with antibiotics.

Who gets infective endocarditis?

Endocarditis is uncommon. In the UK it occurs in about 20 in a million people each year. It can occur in anybody, but the risk of developing it is increased in people who have:

• Heart valve problems or an artificial heart valve. Heart valves that are already damaged or abnormal are more likely to become infected.
• Had surgery to a heart valve.
• Certain congenital heart defects.
• A heart condition called hypertrophic cardiomyopathy.
• Had a previous episode of infective endocarditis.
• Been injecting street drugs such as heroin, with dirty or contaminated needles.
• A poor immune system. For example, people with AIDS.

What are the symptoms and signs of infective endocarditis?

Slowly developing infection

In many cases the infection develops quite slowly. This is sometimes called subacute bacterial endocarditis (SBE). Symptoms can develop gradually, over weeks or months, and can be vague at first. You tend to feel generally unwell and may have general aches and pains, tiredness, and be off your food. A fever (a high temperature) develops at some stage in most cases. As these first symptoms can be caused by a lot of other conditions, the cause of the symptoms may not be diagnosed for some time.

Heart murmurs tend to develop. These are sounds that can be heard by a doctor listening to your heart with a stethoscope. Murmurs are caused by abnormal flow of blood through faulty or damaged valves. If you already have a heart murmur from an existing valve problem, the murmur may change or become more intense. A new or changing murmur is often what alerts a doctor to suspect infective endocarditis.

Reading the above Steven has got classic symptoms of the condition.


Finished the day with a lager shandy and watched

There's No Business Like Show Business (1954)

Molly and Terry Donahue, plus their three children, are The Five Donahues. Son Tim meets hat-check girl Vicky and the family act begins to fall apart. 

It was supposed to be a feel good film, but got too close to heart and i got tearful at times.