A seroprevalence study to determine the frequency of hantavirus infection in people exposed to wild and pet fancy rats in England.

Recent cases of acute kidney injury due to Seoul hantavirus infection from exposure to wild or pet fancy rats suggest this infection is increasing in prevalence in the UK. We conducted a seroprevalence study in England to estimate cumulative exposure in at-risk groups with contact with domesticated and wild rats to assess risk and inform public health advice. From October 2013 to June 2014, 844 individual blood samples were collected. Hantavirus seroprevalence amongst the pet fancy rat owner group was 34.1% (95% CI 23·9-45·7%) compared with 3·3% (95% CI 1·6-6·0) in a baseline control group, 2·4% in those with occupational exposure to pet fancy rats (95% CI 0·6-5·9) and 1·7% with occupational exposure to wild rats (95% CI 0·2-5·9). Variation in seroprevalence across groups with different exposure suggests that occupational exposure to pet and wild rats carries a very low risk, if any. However incidence of hantavirus infection among pet fancy rat owners/breeders, whether asymptomatic, undiagnosed mild viral illness or more severe disease may be very common and public health advice needs to be targeted to this at-risk group.

Short- and long-term outcomes for patients with variceal haemorrhage in a tertiary hospital.

BACKGROUND/AIM: To determine short- and long-term outcomes among a cohort of patients with variceal haemorrhage at a tertiary referral centre, and to determine the predictive value of the model for end-stage liver disease (MELD) score for mortality in these patients. METHODS: Prospective database hospital audit that captured patients who presented with or were transferred with variceal haemorrhage between 2004 and 2008, and a retrospective review of long-term outcomes. Patients who presented to or were transferred to John Hunter Hospital, a tertiary referral hospital, with confirmed variceal bleeding were included. The main outcome measures were in-hospital, 6 weeks and end-of-audit mortality. We also recorded cause, location and degree of planning surrounding the deaths in this patient group. We analysed the MELD score for patients with complete survival data. RESULTS: We recorded 93 episodes of variceal haemorrhage from 78 unique patients during the initial study period. The in-hospital mortality, 6 weeks mortality and end-of-audit mortality were 2.6, 9.0 and 59, respectively, and median survival time was 3.2 years (95% confidence interval 0.0, 6.1). The most frequent cause of death was related to complications of end-stage liver disease at 74%, followed by variceal bleeding (19%) and unknown (6%). A Cox proportional hazard model showed that the risk of mortality is increased by 1.06 (1.01-1.11) for each unit increase in MELD score. CONCLUSIONS: Short-term outcomes for patients with variceal bleeding continue to improve, but long-term prognosis remains guarded and should prompt further emphasis on advanced care planning to optimise patient care.

Blood transfusion: old blood, new blood or no blood.

Vigorous blood transfusion has long been regarded as having an essential role in the management of acute gastrointestinal haemorrhage. Two new studies, one a nationwide audit of acute gastrointestinal haemorrhage in the UK and another, a complex physiological study of stored blood from the USA, offer new insights.

Bleeding peptic ulcer: characteristics and outcomes in Newcastle, NSW.

BACKGROUND: Peptic ulcer disease risk factors have changed, as has the impact of treatment on morbidity and mortality. Recent data on clinical presentation and outcome are sparse in Australia. AIM: To determine the characteristics and outcome of patients presenting with a bleeding peptic ulcer to a tertiary referral centre. METHODS: We evaluated patients diagnosed with peptic ulcer bleeding between 2004 and 2008 at a tertiary referral hospital. Variables assessed included demographic data, comorbidities, medication use and Rockall score. Outcomes of interest were the time to endoscopy, peptic ulcer treatment, transfusion requirements, urgent surgery and survival. RESULTS: Peptic ulcers were confirmed in 265 patients (55% male), of which 145 were gastric and 119 duodenal. The mean age was 71 years. On admission 38% of patients had haemodynamic instability and 92% had one or more comorbidity. Consumption of ulcerogenic medications at the time of admission was frequent (non-steroidal anti-inflammatory drugs (NSAIDs) 22%, aspirin 41%, clopidogrel or warfarin 10%) and proton pump inhibitors infrequent (15%). A gastroenterologist managed all patients according to their usual practice. Only a minority of patients received over three units of packed red cells. Few patients were referred for surgery (3%) or died (3%), but both events were significantly higher for the duodenal ulcer group. CONCLUSION: The characteristics and outcomes in patients with peptic ulcer bleeding have changed. Peptic ulcer disease remains a public health problem with modifiable risk factors, such as Helicobacter pylori infection and NSAIDs, which should be targeted to reduce the burden of illness.

Personal view: crystalloid transfusion in acute gastrointestinal haemorrhage: is it beneficial? An historical perspective.

The conventional management of acute gastrointestinal haemorrhage mandates early repletion of blood volume with crystalloids and blood, as part of the initial management, where there is evidence of hypovolaemia. Meanwhile there is a major trend towards a restrained use of fluid to raise blood pressure to near normal for the bleeding patient in trauma and similar emergencies. This divergence of view requires analysis. An Ovid/MEDLINE, Google and extensive literature search focused on the resuscitation and transfusion of bleeding trauma patients was performed. In addition to clear evidence from animal experiments that early restoration of blood volume perpetuates bleeding, there is considerable evidence in humans - both in war and civilian life - that rapid crystalloid infusion is harmful. I also report a personal series of benefit from restricted transfusion in acute upper gastrointestinal haemorrhage in humans. Given the lack of evidence of benefit for rapid blood volume repletion in acute gastrointestinal haemorrhage, there is need for controlled studies of the most appropriate approach to crystalloid transfusion in acute gastrointestinal bleeding.

Systematic review: the liver in coeliac disease.

BACKGROUND: For over a decade isolated reports have noted liver histology and biochemistry changes in patients with coeliac disease. The prevalence and response to treatment is clinically important. AIM: To outline the frequency and significance of liver abnormalities in coeliac disease. METHODS: A Medline search using Ovid-Coeliac/Coeliac (exp) and liver disease (exp) was completed of English references published during 1966-June 2003. Bibliographic references and other appropriate sources were also searched. RESULTS: Six studies reported liver biochemistry in 591 patients; 248 patients had abnormal results. Elevated transaminases were the most frequently reported abnormality. A gluten-free diet produced resolution of elevated transaminases in 115 of 130 patients. There was a greater than expected association with primary biliary cirrhosis and advanced liver disease. CONCLUSIONS: Mildly abnormal liver biochemistry is frequent in untreated coeliac disease and may provide a key to the diagnosis. Routine investigations for undiagnosed liver disease should include tissue transglutaminase testing. Left untreated, coeliac-induced hepatitis may rarely progress to end-stage liver disease. Primary biliary cirrhosis is clearly linked to coeliac disease. The full story of these linkages is yet to be written.

Resource allocation and bioethics: the Patti Hearst dilemma.

Abstract Medicine has entered an era of high technology, accompanied by expensive investigation and management. Simultaneously, there is increasing recognition of the gap between the costs of medical technology and society's willingness to pay. It is debatable whether medicine recognizes that it is a hostage in thrall to the medical-industrial complex or whether it has wittingly entered the compact to pursue the high-cost, high-technology course. The situation is reminiscent of the events surrounding the kidnap of Patti Hearst - a wealthy heiress who was much later arrested with the gang of robbers. Whether she was hostage or willing accomplice still remains obscure. It is necessary that a body, such as the Cochrane Collaboration, pursues these issues in medicine.

Isolation of single-chain antibody fragments against Venezuelan equine encephalomyelitis virus from two different immune sources.

Venezuelan equine encephalomyelitis (VEE) virus is an important human and veterinary pathogen of Central and South America. The virus can cause widespread epidemics, affecting hundreds of thousands of horses, and thousands of humans. Detection of the virus early in infection and in mosquito populations may allow epidemics to be predicted such that suitable prophylaxis, such as vaccination, can be used to reduce disease severity and transmission. The sensitivity and specificity of current immunoassays, based on conventional monoclonal and polyclonal antibodies, needs to be improved for the diagnosis of infection. We have examined phage display libraries expressing single-chain antibodies (scFv) produced from two different immune sources, a hybridoma cell line and an immunized mouse spleen. The libraries were panned against VEE virus to select for specific scFvs. scFvs isolated from both libraries were specific for the same epitope on the VEE virus and sequence analysis showed that the scFvs were almost identical apart from the CDR3 region of the heavy chain. The data presented in this article suggest that although scFvs may be useful tools for the detection of viruses, there are serious limitations with the use of phage display as a tool for the isolation of specific antibodies.

Review article: transfusion in gastrointestinal haemorrhage--if, when and how much?

Despite the conventional wisdom that blood transfusion is of use in acute upper gastrointestinal haemorrhage, this review proposes that there is considerable doubt about the optimal timing and intensity of transfusion of blood and crystalloids in this setting. It advocates the need for controlled trials to identify the most appropriate timing and intensity of transfusion of patients with acute gastrointestinal haemorrhage.

Accuracy of provisional diagnoses of dyspepsia in patients undergoing first endoscopy.

BACKGROUND: This study assessed agreement between provisional and endoscopic diagnoses for patients with dyspepsia undergoing initial endoscopy, and examined variation between clinicians at 2 hospitals. METHODS: This was a retrospective review of 423 consecutive patients. RESULTS: Crude percentage agreement ranged from 55% to 97%. Kappa scores revealed poor agreement: peptic ulcers (0.11: 95% CI [0.05, 0.17]); gastroesophageal reflux disease (0.29: 95% CI [0.20, 0.38]); benign esophageal stricture (0.33: 95% CI [0.08, 0.58]); and cancer (0.12: 95% CI [-0.12, 0.36]). Positive and negative predictive values for cancer and benign esophageal stricture showed that agreement for a negative diagnosis was almost perfect, whereas agreement for a positive diagnosis was low. Only 17% of patients with cancer were given an accurate provisional diagnosis. Accuracy of diagnosis did not vary substantially between hospitals. CONCLUSIONS: Crude percentage agreement is misleading. Emphasis should be placed on better prediction of cancer, benign esophageal stricture, and peptic ulcer disease. Accuracy of provisional diagnosis in everyday practice is no worse than that found in prospective studies in which clinicians knew a priori that diagnoses would be scrutinized. The difficulty of predicting diagnoses supports increased reliance on endoscopy.

Group B streptococcal prosthetic joint infections.

We report 6 cases of group B streptococcal prosthetic joint infections seen in our institution and review 8 previously reported cases. These 14 patients (6 men and 8 women) had an average age of 69. Seven hip joints and 7 knee joints were affected. Only 4 patients had risk factors for prosthetic joint infection (diabetes mellitus in 2, cancer in 1, and myelodysplasia in 1). The average time from surgery to onset of symptoms was approximately 4 years (range, 5 months to 10 years). Pain in the affected joint was the chief complaint. Six patients had bacteremia. Seven patients had known or suspected foci of infection, which were genitourinary tract (1), skin and soft tissue trauma sites (1), gastrointestinal tract (1), and oropharynx (1). Nine patients required prosthesis removal in addition to antibiotic therapy. Two patients had apparent cure of the infection with retention of the prosthesis. Group B streptococcal prosthetic joint infections appear to be a late complication of prosthetic joint replacement surgery.

Group C streptococcal infection in a prosthetic joint.

We present possibly the first reported case of prosthetic joint infection due to group C Streptococcus in a 53-year-old man. The patient was treated with surgical debridement along with extended intravenous antibiotics and long-term oral penicillin therapy. He was able to retain the prosthesis and at 4-year follow-up had no symptoms or evidence of recurrent clinical infection.

Long-term survival among patients operated upon for peptic ulcer disease.

BACKGROUND: Although surgery has been used widely for treating peptic ulcer disease, there is conflicting evidence with respect to subsequent life expectancy and the determinants of mortality. Our aim was to compare long-term survival in a large, population-based cohort of operated patients with that expected in the general population. METHODS: We followed 471 Rochester, Minnesota residents who had surgery for peptic ulcer at the Mayo Clinic during 1956-85 for a total of 6174 person-years. Patients were followed through their complete (inpatient and outpatient) medical records in the community until death or last clinical contact and death certificates were obtained for all who succumbed. We compared observed survival and cause-specific death rates in this cohort with expected values and identified the determinants of short (30 day) and long-term mortality. RESULTS AND CONCLUSIONS: Survival was worse than expected, but excess deaths were confined to those with perforated ulcers (42 deaths observed; 18.8 expected). Independent predictors of death included age, male gender, emergency operation, gastric ulcer and cigarette smoking. Most deaths were due to heart disease and cancer, but only those due to digestive diseases (standardized mortality ratio (SMR) 3.8, 95% CI 2.4-5.7) and respiratory diseases (SMR 1.9, 95% CI 1.3-2.7) were increased compared to expected figures. Overall survival was reduced in this cohort but was normal among those whose ulcers were not perforated. However, the data suggest an adverse role for alcohol and smoking in these patients.

Quality in healthcare in the United Kingdom: lessons for Australia.

The United Kingdom has a strong emphasis on quality in healthcare and clinical audit. Many quality activities are funded by the government but managed by professional bodies, a model that should be trialed in Australia.

Agreement between medical record data and patients' accounts of their medical history and treatment for dyspepsia.

We examined agreement between data abstracted from medical records and interview data for patients with dyspepsia admitted to hospital for endoscopy, to determine the extent to which health records could be used to validate self-reports of dyspepsia and the management of this condition. Results from the sample of 220 patients showed that there was poor agreement between data sources for information about duration of dyspepsia (k=0.34) and previous barium meal examination (k=0.34). Patients reported significantly longer dyspepsia histories (Wilcoxon sign test Z=4.13, p<0.0001) and significantly more barium meals (sign test Z=8.43, p<0.0001) than were documented in their records. There was also disagreement between data sources regarding the number of drugs taken before and after endoscopy (k=0.28 and k=0.31, respectively). Where there was disagreement for number of drugs there was no significant difference in the direction of the disagreement. There was moderate agreement regarding the name of pre-endoscopy medication (k=0.55) and substantial agreement for the name of medication used post-endoscopy (k=0.62). There was very poor agreement regarding diagnosis. The medical record was the gold standard for this information. Choice of data source, medical records or self-reports, will in many instances provide significantly different results and it is likely that this may also be true for other variables of interest to researchers. Thus in the case where no gold standards are available researchers need to consider carefully the implication of choice of data source on their results.