Prevention and treatment of venous thromboembolism--International Consensus Statement

The aim of this document is to provide a clear and concise account of the evidence regarding efficacy or harm for various methods available to prevent and manage venous thromboembolism (VTE).

A rare case of hypopituitarism with psychosis

A 46-year-old woman presented multiple times in a 4-month period with hypotension, sepsis, hypoglycaemia and psychosis. A low random cortisol in combination with her presenting complaint made adrenal insufficiency the likely diagnosis. Fluid resuscitation and i.v. steroid therapy led to clinical improvement; however, a short synacthen test (SST) demonstrated an apparently satisfactory cortisol response. The test was repeated on a later admission and revealed a peak cortisol level of 25 nmol/l (>550 nmol/l). Concurrent treatment with i.v. hydrocortisone had led to a false-negative SST. ACTH was <5 ng/l (>10 ng/l), indicating secondary adrenal failure. We discuss the challenges surrounding the diagnosis of adrenal insufficiency and hypopituitarism, the rare complication of psychosis and a presumptive diagnosis of autoimmune lymphocytic hypophysitis (ALH).

LEARNING POINTS

Adrenocortical insufficiency must be considered in the shocked, hypovolaemic and hypoglycaemic patient with electrolyte imbalance. Rapid treatment with fluid resuscitation and i.v. corticosteroids is vital.Polymorphic presentations to multiple specialities are common. Generalised myalgia, abdominal pain and delirium are well recognised, psychosis is rare.A random cortisol can be taken with baseline bloods. Once the patient is stable, meticulous dynamic testing must follow to confirm the clinical diagnosis.The chronic disease progression of ALH is hypothesised to be expansion then atrophy of the pituitary gland resulting in empty sella turcica and hypopituitarism.If hypopituitarism is suspected, an ACTH deficiency should be treated prior to commencing thyroxine (T4) therapy as unopposed T4 may worsen features of cortisol deficiency.

Learning Disability Liaison Nursing Services in south-east Scotland: a mixed-methods impact and outcome study

BACKGROUND

There have been significant concerns about the care and treatment of people with intellectual disabilities (ID) when attending general hospitals, which have led to inquiries that highlight service and systems failures. One response has been the development of Learning Disability Liaison Nursing (LDLN) Services across the UK that aim to ensure that additional, specialist support is available for patients, their carers and general healthcare professionals.

METHODS

A mixed-methods study to investigate the impact of LDLN Services across four Scottish NHS boards was undertaken. In total, 323 referrals made over 18 months were analysed along with qualitative data drawn from interviews and focus groups with a sample of 85 participants including patients with ID (n = 5), carers (n = 16), primary care healthcare professionals (n = 39) and general hospital professionals (n = 19) and learning disability liaison nurses (n = 6).

RESULTS

The referral patterns to the four liaison nursing services closely matched the known health needs of adults with ID, with common admissions being due to neurological, respiratory and gastrointestinal issues. The LDLN role was seen to be complex and impacted on three key areas: (i) clinical patient care; (ii) education and practice development; and (iii) strategic organisational developments. Specific patient outcomes were linked to issues relating to capacity and consent to treatment, fostering person-centred adjustments to care, augmenting communication and the liaison nurses acting as positive role models and ambassadors for people with ID.

CONCLUSIONS

The LDLN Services were valued by stakeholders by achieving person-centred outcomes. With their expert knowledge and skills, the liaison nurses had an important role in developing effective systems and processes within general hospital settings. The outcomes highlight the importance of supporting and promoting LDLN Services and the challenges in delivering the multifaceted elements of the role. There is a need to take account of the complex and multidimensional nature of the LDLN role and the possible tensions between achieving clinical outcomes, education and practice developments and organisational strategic initiatives.

Developing a new syndromic surveillance system for the London 2012 Olympic and Paralympic Games

Syndromic surveillance is vital for monitoring public health during mass gatherings. The London 2012 Olympic and Paralympic Games represents a major challenge to health protection services and community surveillance. In response to this challenge the Health Protection Agency has developed a new syndromic surveillance system that monitors daily general practitioner out-of-hours and unscheduled care attendances. This new national system will fill a gap identified in the existing general practice-based syndromic surveillance systems by providing surveillance capability of general practice activity during evenings/nights, over weekends and public holidays. The system will complement and supplement the existing tele-health phone line, general practitioner and emergency department syndromic surveillance systems. This new national system will contribute to improving public health reassurance, especially to meet the challenges of the London 2012 Olympic and Paralympic Games.

Natural disease course and genotype-phenotype correlations in Complex I deficiency caused by nuclear gene defects: what we learned from 130 cases

Mitochondrial complex I is the largest multi-protein enzyme complex of the oxidative phosphorylation system. Seven subunits of this complex are encoded by the mitochondrial and the remainder by the nuclear genome. We review the natural disease course and signs and symptoms of 130 patients (four new cases and 126 from literature) with mutations in nuclear genes encoding structural complex I proteins or those involved in its assembly. Complex I deficiency caused by a nuclear gene defect is usually a non-dysmorphic syndrome, characterized by severe multi-system organ involvement and a poor prognosis. Age at presentation may vary, but is generally within the first year of life. The most prevalent symptoms include hypotonia, nystagmus, respiratory abnormalities, pyramidal signs, dystonia, psychomotor retardation or regression, failure to thrive, and feeding problems. Characteristic symptoms include brainstem involvement, optic atrophy and Leigh syndrome on MRI, either or not in combination with internal organ involvement and lactic acidemia. Virtually all children ultimately develop Leigh syndrome or leukoencephalopathy. Twenty-five percent of the patients died before the age of six months, more than half before the age of two and 75 % before the age of ten years. Some patients showed recovery of certain skills or are still alive in their thirties . No clinical, biochemical, or genetic parameters indicating longer survival were found. No clear genotype-phenotype correlations were observed, however defects in some genes seem to be associated with a better or poorer prognosis, cardiomyopathy, Leigh syndrome or brainstem lesions.

First Report of the Cucurbit Yellow Vine Disease Caused by Serratia marcescens in Watermelon and Yellow Squash in Alabama

More than 3,000 acres of watermelon were planted in Alabama in 2010 with a production value more than $4 million (J. Kemble, personal communication). Symptoms typical of cucurbit yellow vine disease (CYVD) were observed in a 2-ha watermelon field in Crawford, AL on 8 June 2010. Watermelon, cv. Jubilee, exhibited a yellow appearance and some plants were completely wilted. Incidence of affected plants was estimated at 25%. On 24 June, plant samples were collected from a 1-ha watermelon (cv. Jubilee) field near Dadeville, AL. Approximately 30% of the plants exhibited yellowing and wilting, which is symptomatic of CYVD. Samples were also collected from a small planting of yellow crooked-neck squash at the same location. Approximately 20% of the squash plants had symptoms typical of CYVD. Cross-sections of belowground stem and primary root revealed a honey-brown phloem discoloration and a healthy appearing xylem, symptoms consistent with CYVD caused by the phloem-colonizing bacterium, Serratia marcescens Bizio (1). Isolations were made from the crown on four symptomatic watermelon and two squash plants. Approximately 2.5-mm3 tissue pieces from the phloem were excised, surface sterilized in 10% sodium hypochlorite, and ground in 1-ml PBS (phosphate buffer with saline). A 10-μl aliquot of slurry was plated onto nutrient agar (NA) (Difco, Detroit, MI) and the plates were stored at room temperature for 4 days. Individual colonies were selected and purified by serial dilution plating. Isolates from watermelon and squash were consistent with S. marcescens in colony morphology, color, and texture. Three isolates obtained from watermelon were grown on NA and suspended in sterile water at 10⁸ cells per ml for mechanical transmission experiments on 'Lemondrop' squash. Sterile water served as a negative control. After 28 days, plants were cross-sectioned at the juncture of the root and stem and observed for phloem discoloration. Of the 56, 58, and 62 plants inoculated in three replicate studies, 78.6, 56.9, and 62.9% developed CYVD symptoms, respectively, while none of the controls were positive. Cultured bacteria from six of the symptomatic, greenhouse-inoculated plants representing the three watermelon isolates were subjected to multiplex end-point PCR using primer sets YV1/YV4, specific for the species S. marcescens, and a79F/R, which amplifies only the CYVD strains of S. marcescens (3). All six bacteria cultures along with the positive control (reference isolate W01 obtained from watermelon in Texas) were positive, while the negative PBS control was negative. Although rhizosphere-inhabiting and plant growth promoting endophytic strains of S. marcescens have been reported from Alabama (2), to our knowledge, this is the first known report of CYVD and phytopathogenic S. marcescens in Alabama cucurbits. References: (1) B. D. Bruton et al. Plant Dis. 87:937, 2004. (2) J. A. McInroy and J. W. Kloepper. Plant Soil 173:333, 1995. (3) Q. Zhang et al. Appl. Environ. Microbiol. 71:7716, 2005.

Screening for abdominal aortic aneurysm: does it affect men’s quality of life?

A prospective study investigated the psychological wellbeing and quality of life of older rural men after a community-based screening for abdominal aortic aneurysm (AAA). Five hundred and sixteen men aged 65–74 years attended the screening program; 53 had an abnormal aorta detected. These and a subsample of men with a normal aorta were followed up 6 months post-screening. All men completed a pre-screening questionnaire including the Medical Outcomes Short Form 36v 2 (MOSF36) and Hospital Anxiety and Depression Scale (HADS). Six months after screening all 53 men with an abnormal and 130 with a normal aorta were sent a questionnaire including MOSF36 and HADS. Baseline and 6 month scores for both MOSF36 and HADS scores were compared between the two groups and within each group. Baseline scores for both MOSF36 and HADS were not significantly different between men who were subsequently diagnosed with an abnormal aorta and those with a normal aorta. After 6 months there was no difference in HADS scores but a significant increase in the MOSF36 dimension of general health. Those with a normal aorta reported better general health, social functioning andgreater freedom from bodily pain. AAA screening appears highly acceptable to men in the target age group and future research should focus on implementation, cost effectiveness and collateral benefits of AAA screening.

Regional paediatric asthma centre: An intervention model

OBJECTIVE

To evaluate the effectiveness of a multidisciplinary paediatric asthma clinic in reducing the morbidity associated with paediatric asthma.

METHODS

An initial survey of need was undertaken in the community of Orillia, Ontario and the surrounding area. The clinic was established as a separate entity from the adult model. The multidisciplinary nature of the clinic was a priority. The effectiveness of the clinic was assessed with patient/parent reports and objectively analyzed by assessing the frequency of asthma visits to the emergency room and hospital admissions.

RESULTS

Comparison was undertaken between the first year and third year of clinic operation. The number of paediatric asthma visits to the emergency room was reduced by 20%. The number of paediatric asthma inpatient visits was reduced by 12%. At the same time, the number of paediatric asthma visits to the asthma clinic increased by 200%.

CONCLUSIONS

This multidiscipline paediatric asthma clinic model is community friendly and reduces the morbidity of asthma as evidenced by declining visits to the emergency room.