Viral aetiology in paediatric age group patients admitted with acute febrile encephalopathy in Western Rajasthan

PurposeIn this study, we are trying to find out viral aetiology in paediatric age group patients from 1 month to 15 years of age in Western Rajasthan region.MethodsA total of 105 patients from 1 month to 15 years were recruited into this study. CSF samples were collected and were processed by multiplex real-time PCR for detection of various predefined panels of viral agents. ELISA was also done for all samples for detection of dengue, JE, measles and mumps.ResultsA total of 32 samples out of 105 were tested positive for viral agents. Viral aetiology detected in this study were Adenovirus (n ?= ?2), EBV (n ?= ?1), HHV-1 (n ?= ?10), HHV-6 (N ?= ?5), Parechovirus (n ?= ?1), Parvovirus B19 (n ?= ?7), Dengue (n ?= ?2) and Measles (n ?= ?1). Mixed infections were also detected, HHV-1 and HHV-6 (n ?= ?2), HHV-1 and Parvovirus B19 (n ?= ?1). In 73 patients no viral aetiology could be detected.ConclusionsParvovirus B19 is sporadically prevalent in this geographical region. In this study, HHV-6 was also found which has not been reported earlier from India.     

BSACI guideline for the diagnosis and management of peanut and tree nut allergy

Peanut nut and tree nut allergy are characterised by IgE mediated reactions to nut proteins. Nut allergy is a global disease. Limited epidemiological data suggest varying prevalence in different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE‐mediated symptoms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisation, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥ 8 mm or sIgE ≥ 15 KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food challenges are usually not necessary but may be used to confirm or refute a conflicting history and test result. As nut allergy is likely to be a long‐lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehensive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medication. Regular re‐training is required.     

Risk factors for venous thrombosis – current understanding from an epidemiological point of view

Epidemiological research throughout the last 50 years has provided the long list of risk factors for venous thrombosis that are known today. Although this has advanced our current understanding about the aetiology of thrombosis, it does not give us all the answers: many people have several of these risk factors but never develop thrombosis; others suffer from thrombosis but have none. In this review, we discuss how risk factors for venous thrombosis can be interpreted with use of several epidemiological models. We comment on how to explain why risk factors for first venous thrombosis differ from recurrent venous thrombosis, and use a causal model to better understand risk of first and recurrent venous thrombosis.     

Septicaemia in a population‐based HIV clinical cohort in rural Uganda, 1996–2007: incidence,aetiology, antimicrobial drug resistance and impact of antiretroviral therapy

Objectives To describe the incidence and aetiology of septicaemia, and antimicrobial drug resistance in HIV‐infected and uninfected individuals, and the impact of antiretroviral therapy (ART) on septicaemia. Methods Between 1996 and 2007, we followed up a rural population–based cohort of HIV‐infected and uninfected participants. The aetiology and incidence of septicaemia, and antimicrobial drug resistances were determined. ART became available in 2004, and its impact on the incidence of septicaemia was examined. Results The overall septicaemia incidence (per 1000 pyrs) was 32.4 (95% CI 26.2–40.6) but was only 2.6 (95% CI 1.3–6.2) in HIV‐negative patients and 67.1 (95% CI 53.4–85.4) in HIV‐positive patients not on ART. Among those on ART, the overall incidence was 71.5 (95% CI 47.1–114.3), although it was 121.4 (95%CI 77.9–200.4) in the first year on ART and 37.4 (95%CI 18.9–85.2) in the subsequent period. Septicaemia incidence was significantly associated with lower CD4 counts. The commonest isolates were Streptococcus pneumoniae (SPN, n = 68) and Non‐typhi salmonellae (NTS, n = 42). Most SPN isolates were susceptible to ceftriaxone and erythromycin, while resistance to cotrimoxazole and penicillin was common. All NTS isolates were susceptible to ciprofloxacin, but resistance to cotrimoxazole and chloramphenicol was common. Conclusions Septicaemia incidence was higher in HIV‐infected than in HIV‐uninfected participants, and it remained high for some time among those who started ART. Starting ART earlier at higher CD4 counts is likely to lead to lower septicaemia incidence. Both SPN and NTS, the commonest isolates, were resistant to most commonly available antimicrobials. Blood culture laboratory surveillance systems to monitor antibiotic susceptibility and inform treatment guidelines are needed in Africa.     

Prevalence of diabetes in liver cirrhosis: A systematic review and meta‐analysis

An association between diabetes mellitus (DM) and liver cirrhosis is well‐known, but estimates of the prevalence of DM in patients with liver cirrhosis vary widely. A systematic review was undertaken to determine the prevalence of DM in adult patients with liver cirrhosis. The Medline, EMBASE, and Cochrane Library databases were searched for peer‐reviewed studies published in English (1979‐2017) that investigated the prevalence of diabetes in adult patients with cirrhosis. Pooled estimates of prevalence of DM were determined for all eligible patients and according to aetiology and severity of liver disease. Fifty‐eight studies satisfied criteria for inclusion, with 9705 patients included in the pooled prevalence analysis. The overall prevalence of DM was 31%. The prevalence of DM was highest in patients with nonalcoholic fatty liver disease (56%), cryptogenic (51%), hepatitis C (32%), or alcoholic (27%) cirrhosis. For assessing prevalence of DM as a function of severity of liver disease, evaluable data were available only for hepatitis C and hepatitis B cirrhosis. DM may be more prevalent in cirrhosis than previously thought. This has implications for prognosis and treatment in these patients.     

Natural history of severe eosinophilia with uncertain aetiology and proposals on a practical approach to its management

Background: Eosinophilia is commonly encountered during clinical practice. Some can be attributed to well‐defined causes while others cannot. Optimal management of hypereosinophilia with unknown aetiology is uncertain as the natural history is not well described. Methods: We retrospectively studied patients with hypereosinophilia (>5 × 10⁹/L) and described the characteristics, natural history and treatment of those with eosinophilia of uncertain aetiology. Results: There were 141 patients with hypereosinophilia: 87 with well‐defined causes, 54 with uncertain aetiology. The latter was managed as hypereosinophilic syndrome (HES) (n= 5), idiopathic hypereosinophilia (IH) (n= 11), presumptive helminthic infection (n= 11) and reactive eosinophilia (n= 5), while 22 were insufficiently investigated and did not have definite working diagnoses. Their median age and peak eosinophil count were 64 (22 to 94) years and 10.0 (5.2–33.9) × 10⁹/L respectively. Forty‐six per cent had symptoms attributable to eosinophilia, with the HES and insufficiently investigated groups having the highest (100%) and lowest (27%) percentages respectively. HES and IH patients were most extensively investigated. All 14 HES or IH patients who received steroids responded. All presumptive helminthic infection patients received mebendazole: nine responded, and two had unassessable responses. For the remaining patients, seven received steroids and all responded; one received mebendazole but defaulted; 19 were not treated:11 resolved spontaneously. No non‐HES patients developed eosinophilia‐related organ dysfunction. No mortality was caused by hypereosinophilia. Conclusions: Patients with hypereosinophilia of uncertain aetiology can be empirically managed according to working diagnoses derived from history taking, examination and selective investigations. Most patients have benign short‐term outcomes, but longer monitoring is required to assess long‐term outcomes from untreated hypereosinophilia.     

Effect of Lower Oesophageal Sphincter on Oesophageal Varices

Portographic studies of six patients with cirrhosis of the liver and submucosal oesophageal varices showed that metoclopramide, which raises lower oesophageal sphincter pressure (LESP), decreased the flow to the varices in five, whereas butylscopolamine, which reduces LESP, increased the flow. These results support the hypothesis that pharmacological increase of LESP might be of value in the treatment of oesophageal varices.     

Thrombocytosis in adults: analysis of 777 patients

A total of 777 patients with thrombocytosis, defined as a platelet count of greater than 500 x 10(9)l-1, seen in a University hospital over a 1-year period, were studied prospectively for aetiology. The most frequent causes of thrombocytosis were infection (21.9%), rebound thrombocytosis (19.4%), tissue damage (17.9%), chronic inflammatory disorders (13.1%) and malignancy (5.9%). Thrombocytosis associated with multiple causative factors, occurring simultaneously, was seen in 6.1% of cases. Thrombocytosis of greater than or equal to 1 million x 10(9)l-1 was found most frequently in patients with multiple aetiological factors occurring at the same time, in myeloproliferative disorders, or in postsplenectomy patients.     

Does the skin heat up before it breaks down in diabetic foot ulceration?

Aims

Most diabetic foot ulcers are caused by tissue stress from being ambulatory in people without protective sensation. These ulcers are suggested to be preceded by local skin temperature increase due to inflammation of the underlying tissue, a so-called hotspot. Evidence to support this mechanism of ulcer development is meagre at best. We investigated if foot ulcers are preceded by increased skin temperature in people with diabetes and foot ulcer history.

Material and Methods

Participants measured temperature at 6–8 plantar foot locations each day for 18 months and identified a hotspot with a temperature difference >2.2°C between corresponding foot locations for two consecutive days.

Results

Twenty-nine of 151 participants developed a non-traumatic ulcer while adhering to temperature measurements. In the 2 months prior to ulceration, 8 (28%) had a true hotspot (i.e. at/adjacent to the ulcer location) and the hotspot was on average no longer present 9 days before ulceration. Seven (24%) participants had a false hotspot (i.e. at another location) and 14 (48%) had no hotspot.

Conclusions

The skin of the majority of the ulcers does not heat up before it breaks down or, when it does, not directly before breakdown, questioning the foot temperature increase—uslcer association.