Allergy in the elderly: A case note review of referrals to an adult allergy clinic.

The UK population is ageing and we can expect more referrals to allergy clinics for this age group. 16% of patients to our clinic are aged >60. Compared to younger patients, 3 times as many referrals were for angioedema. Overall, allergy was excluded in 79% of cases. 15% were diagnosed with previously unrecognised allergies, while allergic disease was confirmed in 6%, enabling optimised management. While the differential diagnosis of allergic conditions is wider in older people, assessment in the allergy clinic is helpful and adds value.

Neuropsychological presentation and adaptive skills in high-functioning adolescents with visual impairment: A preliminary investigation.

Studies in infants and young children with congenital visual impairment (VI) have indicated early developmental vulnerabilities, conversely research with older children and adults have highlighted areas of cognitive strength. A minimal amount is known, however, about the possible combination of strengths and weaknesses in adolescence, and this present study therefore aims to explore the neuropsychological presentation and adaptive behavior profile in high-functioning adolescents with congenital VI. Participants completed a battery of commonly used neuropsychological measures assessing memory, executive function, and attention. The measures utilized focused on auditory neuropsychological function, because only subtests that could be completed with auditory administration were suitable for this sample. Parents completed standardized measures of adaptive behavior, executive function, and social communication. Compared to aged-based norms for normal sight, adolescents with VI demonstrated strengths in aspects of working memory and verbal memory. Furthermore, performance across the neuropsychological battery was within or above the average range for the majority of the sample. In contrast, parent-report measures indicated areas of weakness in adaptive functioning, social communication, and behavioral executive functioning. Overall, this study provides preliminary evidence that relative to fully sighted peers, high-functioning adolescents with VI present with an uneven profile of cognitive and adaptive skills, which has important implications for assessment and intervention.

Summer indoor heat exposure and respiratory and cardiovascular distress calls in New York City, NY, U.S.

Most extreme heat studies relate outdoor weather conditions to human morbidity and mortality. In developed nations, individuals spend ~90% of their time indoors. This pilot study investigated the indoor environments of people receiving emergency medical care in New York City, NY, U.S., from July to August 2013. The first objective was to determine the relative influence of outdoor conditions as well as patient characteristics and neighborhood sociodemographics on indoor temperature and specific humidity (N = 764). The second objective was to determine whether cardiovascular or respiratory cases experience hotter and more humid indoor conditions as compared to controls. Paramedics carried portable sensors into buildings where patients received care to passively monitor indoor temperature and humidity. The case-control study compared 338 respiratory cases, 291 cardiovascular cases, and 471 controls. Intuitively, warmer and sunnier outdoor conditions increased indoor temperatures. Older patients who received emergency care tended to occupy warmer buildings. Indoor-specific humidity levels quickly adjusted to outdoor conditions. Indoor heat and humidity exposure above a 26 °C threshold increased (OR: 1.63, 95% CI: 0.98-2.68, P = 0.056), but not significantly, the proportion of respiratory cases. Indoor heat exposures were similar between cardiovascular cases and controls.

Oral nystatin prophylaxis and neonatal fungal infections.

BACKGROUND: The value of antifungal prophylaxis depends partly on the incidence of neonatal fungal infection. We compared the incidence of fungal infection in babies in neonatal units which do and do not give antifungal prophylaxis using oral nystatin. METHODS: Prospective, multi-centre surveillance study from 1993 to 2006 of invasive fungal infection, defined as positive blood or cerebrospinal fluid culture, in babies <1500 g birth weight in neonatal units in Australia and New Zealand. RESULTS: There were 118 episodes of invasive fungal infection in 14 778 babies <1500 g, an incidence of 0.80% (95% confidence interval (CI) 0.66 to 0.94%). All infections were due to Candida species, mostly C. albicans (74, 62.7%) and C. parapsilosis (39, 33.1%). The mortality was 16.5%. The incidence was 0.54% (0.38 to 0.70%) for babies <1500 g in units using selective or universal oral nystatin prophylaxis and 1.23% (0.84 to 1.62%) in units using no prophylaxis (p<0.001). The incidence of infection in babies <1000 g was 1.78% (106/5948) (95% CI 1.44 to 2.12%). The incidence was 1.23% (0.92 to 1.54%) for babies <1000 g in units using nystatin prophylaxis and 2.67% (1.97 to 3.37%) in units using no prophylaxis (p<0.001). CONCLUSIONS: The incidence of neonatal fungal infection was low in Australia and New Zealand, even without antifungal prophylaxis. Antifungal prophylaxis with oral nystatin was associated with a significantly lower incidence of fungal infection compared with no prophylaxis.

Neonatal infections in Asia.

OBJECTIVE: To study the epidemiology (including incidence, antibiotic sensitivity and mortality) of neonatal unit infections in countries in Asia. METHODS: One year prospective study of neonatal infections in eight neonatal units in Asia. RESULTS: There were 453 episodes of sepsis affecting 394 babies. Mortality from neonatal sepsis was 10.4%, with an incidence of 0.69 deaths/1000 live births. Group B streptococcus was the most common early-onset organism causing 38% of episodes of early-onset (<48 h old) sepsis, with a rate of 0.51 episodes per 1000 live births and a mortality of 22%. Gram-negative bacillary early-onset sepsis occurred at a rate of 0.15 episodes per 1000 live births with a mortality of 12%. There were 406 episodes of late-onset sepsis. The incidence was high at 11.6 per 1000 live births, and mortality was 8.9%. Coagulase-negative staphylococcus caused 34.1% of episodes, whereas Staphylococcus aureus caused only 5.4%. Gram-negative bacilli caused 189 episodes (46.6%). Only 44% of Gram-negative bacilli were sensitive to both gentamicin and a third-generation cephalosporin, whereas 30% were resistant to both antibiotics. Meningitis occurred in 17.2% of episodes of late sepsis, with a mortality of 20%. CONCLUSIONS: The incidence of late-onset sepsis was higher in Asia than in resource-rich countries, but the organisms isolated and mortality were similar. Over half of all Gram-negative bacilli were antibiotic resistant.

Guidelines for the prevention of sepsis in asplenic and hyposplenic patients.

Asplenic or hyposplenic patients are at risk of fulminant sepsis. This entity has a mortality of up to 50%. The spectrum of causative organisms is evolving as are recommended preventive strategies, which include education, prophylactic and standby antibiotics, preventive immunizations, optimal antimalarial advice when visiting endemic countries and early management of animal bites. However, there is evidence that adherence to these strategies is poor. Consensus-updated guidelines have been developed to help Australian and New Zealand clinicians and patients in the prevention of sepsis in asplenic and hyposplenic patients.

Increased mortality among patients sustaining hip fractures requiring surgery in a district general hospital.

Fractures of the femoral neck are a common condition the incidence of which continues to rise. Associated mortality remains very high and knowledge of factors contributing to this high mortality is crucial in understanding outcome for both patient and surgeon. A retrospective review of 1254 patients operated on for fracture neck of femur was conducted to identify mortality at 30 days, 90 days and one year. Age, type of fracture, sex and waiting time for surgery were evaluated along with mortality for 47 patients who sustained their fracture while already inpatients with other concurrent illnesses. Those patients who sustained an inpatient fracture were found to have significantly higher mortality at 30 days, 90 days and one year. We concluded that these patients represent a very high-risk group that needs special consideration in management of their fracture and concurrent medical condition to reduce their high mortality.

Unnatural selection: reducing antibiotic resistance in neonatal units.

Antibiotic use selects for antibiotic resistant bacteria. This is an example of rapid Darwinian natural selection in action. It occurs in neonatal intensive care units with the use of parenteral antibiotics, and in the community with oral antibiotic use. A 10 point plan is put forward to reduce antibiotic resistance in neonatal units.

Early onset neonatal meningitis in Australia and New Zealand, 1992-2002.

OBJECTIVES: To study the epidemiology of early onset neonatal bacterial meningitis (EONBM) in Australasia. DESIGN: Prospective surveillance study, 1992-2002, in 20 neonatal units in Australia and New Zealand. EONBM was defined as meningitis occurring within 48 hours of delivery. RESULTS: There were 852 babies with early onset sepsis, of whom 78 (9.2%) had EONBM. The incidence of early onset group B streptococcal meningitis fell significantly from a peak of 0.24/1000 live births in 1993 to 0.03/1000 in 2002 (p trend = 0.002). There was no significant change over time in the incidence of Escherichia coli meningitis. The rate of EONBM in very low birthweight babies was 1.09/1000 compared with the rate in all infants of 0.11/1000. The overall rate of EONBM was 0.41/1000 in 1992 and 0.06 in 2001, but this trend was not significant (p trend = 0.07). Case-fatality rates for EONBM did not change significantly with time. Birth weight <1500 g (odds ratio (OR) 7.2 (95% confidence interval (CI) 4.8 to 10.9)) and Gram negative bacillary meningitis (OR 3.3 (95% CI 2.2 to 4.9)) were significant risk factors for mortality. Sixty two percent of the 129 babies who died from early onset sepsis or suspected sepsis did not have a lumbar puncture performed. CONCLUSION: The incidence of early onset group B streptococcal meningitis has fallen, probably because of maternal intrapartum antibiotic prophylaxis, without a corresponding change in E. coli meningitis. Gram negative bacillary meningitis still carries a worse prognosis than meningitis with a Gram positive organism.

Recurrent parotitis of childhood.

BACKGROUND: Recurrent parotitis (RP) of childhood is a rare condition of unknown aetiology, probably immunologically mediated. OBJECTIVE: To review the clinical presentation, diagnosis and management of RP of childhood. METHODS: Retrospective study from 1983 to 2004 of children diagnosed with RP of childhood at a tertiary children's hospital. RESULTS: We identified 53 children, 37 (70%) male and 16 (30%) female. The age of onset was biphasic, with peaks at 2-5 years of age and at 10 years. The commonest symptoms were swelling (100%), pain (92.5%) and fever (41.5%). Symptoms usually lasted 2-7 days with a median of 3 days. The mean frequency was 8 episodes per year. The diagnosis was often delayed, >1 year in 70% of patients, maximum 8 years. The most common diagnoses, before the definitive diagnosis of RP, were mumps (21%), 'infection' (15%) and stones (11%). Sialogram (57%) and/or ultrasound (41%) showed sialectasis in 81% of patients. Over half the patients (54%) were given antibiotics at least once to treat the parotitis. Two children had hypogammablobulinaemia, one child had human immunodeficiency virus infection, and one child had Sjogren's syndrome. Two children had high titre antinuclear antibodies. CONCLUSIONS: Recurrent parotitis had a biphasic age distribution. The major clinical features that distinguish it from other causes of parotid swelling are the lack of pus and recurrent episodes. A clinical diagnosis can often be confirmed by ultrasound. Antibiotics do not have a role in treatment. Affected children should be screened for Sjogren's syndrome and immune deficiency.

Mycoplasma pneumoniae infections in Australian children.

OBJECTIVES: To describe the epidemiology, clinical features and outcome of Mycoplasma pneumoniae infection in children presenting to a tertiary children's hospital. METHODS: Sixty-three month retrospective review of serologically diagnosed M. pneumoniae infections. RESULTS: There were 76 children, 42 boys and 34 girls, mean age 6.3 +/- 3.5 years. The age group most commonly affected was 5-9 years, followed by children 1-5 years. More than half of the patients had failed to respond to antibiotics before referral. The commonest presentation was with cough and fever. Coryza, diarrhoea, vomiting, tachypnoea and recession were significantly more common in children less than 5 years than in children 5-15 years. Hospitalized patients were more likely than non-hospitalized patients to have respiratory distress with recession and wheeze. Radiographic findings were non-specific. Thrombocytosis was found in 29 (41.4%) of 70 children studied. CONCLUSION: The clinical features of M. pneumoniae infection were different in children less than 5 years than in children aged 5-9 years. The presence of thrombocytosis in 40% of the cases has not previously been reported in children.

Comprehensive health assessment for newly arrived refugee children in Australia.

Providing appropriate and responsive care to refugees from diverse backgrounds and with unique health needs is challenging. Refugee children may present with a wide range of conditions, which may be unfamiliar to health professionals in developed countries. Additionally, refugees may experience unfamiliarity with the Australian health system and distrust of authority figures and/or medical practitioners. This article provides an overview of the priority areas in health and health management for paediatric refugee patients for paediatricians as well as other relevant health care providers caring for this group. Specific issues covered include general health assessment, infectious diseases, immunization, growth and nutrition, oral health, development and disability, mental health and child protection. Comprehensive health assessment can assist in identifying children at risk of poor health and to provide them with timely and effective care, advocacy and appropriate referral.

Should routine childhood immunizations be compulsory?

Routine childhood immunizations are compulsory in a small number of countries, including the United States of America. Arguments used to justify making immunizations compulsory include enhancing the health of the community and treating as paramount the rights of the child to be protected against vaccine-preventable diseases. But compulsory immunization infringes the autonomy of parents to make choices about child rearing, an autonomy which we generally respect unless doing so seriously endangers the child's health. We present a historical review and ethics discussion on whether routine childhood immunizations should be compulsory. We conclude that, for both ethical and practical reasons, routine immunization should not be compulsory if adequate levels of immunization can be achieved by other means.

Staphylococcus aureus infections in Australasian neonatal nurseries.

OBJECTIVE: To study the incidence and outcome of systemic infections with methicillin sensitive (MSSA) and methicillin resistant Staphylococcus aureus (MRSA) infections in Australasian neonatal nurseries. METHODS: Prospective longitudinal study of systemic infections (clinical sepsis plus positive cultures of blood and/or cerebrospinal fluid) in 17 Australasian neonatal nurseries. RESULTS: The incidence of early onset sepsis with S aureus, mainly MSSA, was 19 cases per 244 718 live births or 0.08 per 1000. From 1992 to 1994, MRSA infections caused only 8% of staphylococcal infections. From 1995 to 1998, there was an outbreak of MRSA infection, in two Melbourne hospitals. The outbreak resolved, after the use of topical mupirocin and improved handwashing. Babies with MRSA sepsis were significantly smaller than babies with MSSA sepsis (mean birth weight 1093 v 1617 g) and more preterm (mean gestation 27.5 v 30.3 weeks). The mortality of MRSA sepsis was 24.6% compared with 9.9% for MSSA infections. The mortality of early onset MSSA sepsis, however, was 39% (seven of 18) compared with 7.3% of late onset MSSA infection presenting more than two days after birth. CONCLUSIONS: S aureus is a rare but important cause of early onset sepsis. Late onset MRSA infections carried a higher mortality than late onset MSSA infections, but babies with early onset MSSA sepsis had a particularly high mortality.

Should Australia introduce a vaccine injury compensation scheme?

At least a dozen countries or states in the world have introduced vaccine injury compensation schemes. This paper argues that the Australian Government should introduce such a scheme, which may reduce litigation, and may improve consumer and provider confidence. The most important justification, however, is an ethical argument from justice and equity: introduction of a vaccine injury compensation scheme acknowledges the unique situation that routine childhood immunization is a public health measure, given and accepted in good faith, that may occasionally damage the recipient.