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A case series of shared delusional infestation: folie à deux revisited.
No full textDelusional infestation (DI) describes the unshakeable belief that one's skin is infected or infested with an external organism or inanimate material, in the absence of supportive medical evidence. It has been found that 5-26% of patients with DI will report similar symptoms in a close relative, which is known as shared DI or folie à deux. In some cases, more than one close relation may be affected. Shared psychotic disorder (SPD) appears as a distinct entity in the Classification of Mental and Behavioural Disorders (ICD-10)
External Validation Of The Updated ADO Score In COPD Patients From The Birmingham COPD Cohort.
No full textBackground
Reviews suggest that the ADO score is the most discriminatory prognostic score for predicting mortality among chronic obstructive pulmonary disease (COPD) patients, but a full evaluation and external validation within primary care settings is critical before implementation.
Objectives
To validate the ADO score in prevalent and screen-detected primary care COPD cases at 3 years and at shorter time periods.
Patients and methods
One thousand eight hundred and ninety-two COPD cases were recruited between 2012 and 2014 from 71 United Kingdom general practices as part of the Birmingham COPD Cohort study. Cases were either on the practice COPD register or screen-detected. We validated the ADO score for predicting 3-year mortality with 1-year and 2-year mortality as secondary endpoints using discrimination (area-under-the-curve (AUC)) and calibration plots.
Results
One hundred and fifty-four deaths occurred within 3 years. The ADO score was discriminatory for predicting 3-year mortality (AUC= 0.74; 95% CI: 0.69-0.79). Similar performance was found for 1- (AUC= 0.73; 0.66-0.80) and 2-year mortality (0.72; 0.67-0.76). The ADO score showed reasonable calibration for predicting 3-year mortality (calibration slope 0.95; 0.70-1.19) but over-predicted in cases with higher predicted risks of mortality at 1 (0.79; 0.45-1.13) and 2-year (0.79; 0.57-1.01) mortality.
Discussion
The ADO score showed promising discrimination in predicting 3-year mortality in a primary care population including screen-detected cases. It may need to be recalibrated if it is used to provide risk predictions for 1- or 2-year mortality since, in these time-periods, over-prediction was evident, especially in cases with higher predicted mortality risks
Exercise induced hypoglycaemia in type 1 diabetes.
No full textNEW FINDINGS
What is the topic of this review? Hypoglycaemia is a commonly cited barrier to exercise in T1D. Knowledge of approaches to prevent or manage exercise induced hypoglycaemia can support patients to exercise and help clinicians to give advice. This review presents a number of evidence-based strategies to prevent exercise induced hypoglycaemia in T1D. What advances does it highlight? This review highlights a number of approaches which can be used before, during and after exercise which can mitigate the risk of hypoglycaemia. Approaches include: timing of exercise; type of exercise; adjustments to insulin and carbohydrate; use of novel technology; and education ABSTRACT: Exercise is a key component for the management of type 1 diabetes (T1D) and is associated with reduced risk of cardiovascular disease, decreased daily insulin requirements and improved quality of life. Because of these benefits people with T1D are recommended to undertake regular physical activity, 150 minutes per week for adults and 60 minutes per day for children and adolescents. Despite recommendations, many do not meet these targets. One of the commonly cited barriers to exercise is fear of hypoglycaemia along with limited knowledge of effective preventative strategies. Hypoglycaemia can be difficult to predict, and symptoms are often masked during exercise or stress of competition. For athletes with T1D hypoglycaemia can also limit sporting success. Hypoglycaemia prior to an event increases the risks of hypoglycaemia during competition and can reduce performance. To avoid hypoglycaemia, people with T1D may avoid exercise altogether, or consume excessive amounts of carbohydrates, which mitigates many of the health benefits of exercise. Increased understanding of approaches to prevent or manage hypoglycaemia are therefore important to help increase levels of physical activity in people with T1D, as well as supporting athletes with T1D to compete at the highest level. This review outlines the prevalence of exercise related hypoglycaemia, its underlying physiology as well as the strategies that can be used to prevent and manage exercise induced hypoglycaemia in T1D. The hope of the authors is that this knowledge will be used by people with T1D and their clinicians to find individual approaches to manage exercise related hypoglycaemia. This article is protected by copyright. All rights reserved
Tuberculosis disease in children and adolescents on therapy with anti-tumor necrosis factor-alpha agents: a collaborative, multi-centre ptbnet study.
No full textBACKGROUND
In adults, anti-tumor-necrosis-factor (TNF)-α therapy is associated with progression of latent tuberculosis infection (LTBI) to tuberculosis (TB) disease. The existing paediatric data are very limited.
METHODS
Retrospective multi-centre study within the Paediatric Tuberculosis Network European Trials Group, capturing patients <18 years who developed TB disease during anti-TNF-α therapy.
RESULTS
Sixty-six tertiary healthcare institutions providing care for children with TB participated. Nineteen cases were identified; Crohn´s disease (n=8;42%) and juvenile idiopathic arthritis (n=6;32%) were the commonest underlying conditions. Immune-based TB screening (tuberculin skin test and/or interferon-gamma release assay) was performed in 15 patients before commencing anti-TNF-α therapy, but only identified one LTBI case; 13 patients were already receiving immunosuppressants at the time of screening. The median interval between starting anti-TNF-α therapy and TB diagnosis was 13.1 (IQR:7.1-20.3) months. All cases presented with severe disease, predominately miliary TB (n=14;78%). One case was diagnosed post-mortem. TB was microbiologically confirmed in 15 cases (79%). The median duration of anti-TB treatment was 50 (IQR:46-66) weeks. Five of 15 (33%) cases who had completed TB treatment had long-term sequelae.
CONCLUSIONS
The data indicate that LTBI screening is frequently false-negative in this patient population, likely due to immunosuppressants impairing test performance. Therefore, patients with immune-mediated diseases should be screened for LTBI at the point of diagnosis, before commencing immunosuppressive medication. Children on anti-TNF-α therapy are prone to severe TB disease, and significant long-term morbidity. Those observations underscore the need for robust LTBI screening programs in this high-risk patient population, even in low TB prevalence settings
Encephalitis secondary to nitrous oxide and vitamin B deficiency.
No full textA 27-year-old woman presented with confusion, agitation and fever. Having initially been treated as an infective encephalitis case her initial and subsequent lumbar punctures revealed cerebrospinal fluid with a worsening pleocytosis and elevated protein. It was initially felt she had been suffering from tuberculous meningitis and started on treatment it later became apparent that she had a severe vitamin B deficiency related to recreational nitrous oxide use. She also was noted to have a peripheral neuropathy. After replacing her vitamin B and later stopping her tuberculous medication once cultures were negative her cognition and peripheral neuropathy continued to improve
The clinical significance of a pathologically positive lymph node at the circumferential resection margin in rectal cancer.
No full textBACKGROUND
This study aimed to determine if the nature of circumferential resection margin (CRM) involvement, either by tumour or lymph nodes, had an impact upon local recurrence and survival in rectal cancer.
METHODS
A retrospective analysis of a prospectively collected database was performed. Consecutive patients with stage I-III rectal cancer having curative surgery were included. All specimens were analysed by a single histopathologist. Statistical analysis was performed using chi-squared test and Kaplan-Meier.
RESULTS
Of 265 patients, 29 (11%) had a positive CRM. Compared to patients with a negative CRM, a positive margin due to tumour was associated with a higher 5-year cumulative incidence of local recurrence (43.7% versus 8.8%, p = 0.001) and distant metastases (62% versus 13.6%, p = 0.001) with poorer 5-year cancer-specific survival (32% versus 87.8%, p = 0.001). Although patients with margin positivity due to lymph nodes had a higher rate of distant metastases (41.3% versus 13.6%, p = 0.004) and poorer 5-year cancer-specific survival (59.3% versus 87.8%, p = 0.038), the rate of local recurrence was comparable to that of patients with negative margins (8.3% versus 8.8%, p = 0.694).
CONCLUSIONS
Our findings suggest that the nature of CRM involvement may be important in determining prognosis in rectal cancer. Local recurrence is higher only when there is tumour present at the margin. Lymph node involvement of the margin confers similar risk of local recurrence to patients with CRM-negative, node-positive disease. These results need further evaluation in multicentre, prospective studies
Evaluation of the Psychiatric Decisions Unit (PDU): effect on emergency department presentations and psychiatric inpatient admissions.
No full textBACKGROUND
Busy emergency departments (EDs) are not the optimum environment for assessment of patients in mental health crisis. The Psychiatric Decisions Unit (PDU) was developed by the Birmingham and Solihull Mental Health Foundation Trust as an enhanced assessment service to ensure patients in mental health crisis receive optimal care.
AIMS
To evaluate the activities of the PDU and its impact on the frequency of ED presentations and inpatient admissions, and to explore patient satisfaction.
METHODS
Data were collected over a 6-month period during 2015 regarding patient demographics, referral sources, length of stay, and frequency of mental health-related ED presentations and inpatient psychiatric admissions. Comparison group data were used to evaluate the impact of the PDU. Patient satisfaction was measured using the 'Friends and Family Test' and structured feedback forms.
RESULTS
In total, 385 patients were referred to the PDU during the study period. Implementation of the PDU was associated with a 39% decrease in the number of patients taken to the ED by Street Triage and a 26% fall in inpatient psychiatric admissions via the Trusts' in-hospital liaison psychiatry team. Ninety-eight per cent of patients surveyed felt that they were treated with respect and understanding, and 94% reported that they were likely or extremely likely to recommend the service to friends and family.
CONCLUSIONS
Implementation of the PDU was associated with a reduction in the frequency of ED presentations and inpatient psychiatric admissions. This study suggests that patients are satisfied with the care provided at the PDU
Repair or Prevent - What is the real impact of normothermic machine perfusion in liver transplantation?
No full textWe read with great interest the paper by Jassem et al(1), which provides detailed gene expression profiles of human livers during normothermic machine perfusion (NMP), compared to conventional cold storage. Authors should be congratulated to this extensive analysis, which shows for the first time transcriptional changes during any form of reperfusion under normothermic conditions(1). However, we would like to add a few critical comments. This article is protected by copyright. All rights reserved
Mendelian randomisation: A powerful and inexpensive method for identifying and excluding non-genetic risk factors for colorectal cancer.
No full textColorectal cancer (CRC) is the third most common cancer in economically developed countries and a major cause of cancer-related mortality. The importance of lifestyle and diet as major determinants of CRC risk is suggested by differences in CRC incidence between countries and in migration studies. Previous observational epidemiological studies have identified associations between modifiable environmental risk factors and CRC, but these studies can be susceptible to reverse causation and confounding, and their results can therefore conflict. Mendelian randomisation (MR) analysis represents an approach complementary to conventional observational studies examining associations between exposures and disease. The MR strategy employs allelic variants as instrumental variables (IVs), which act as proxies for non-genetic exposures. These allelic variants are randomly assigned during meiosis and can therefore inform on life-long exposure, whilst not being subject to reverse causation. In previous studies MR frameworks have associated several modifiable factors with CRC risk, including adiposity, hyperlipidaemia, fatty acid profile and alcohol consumption. In this review we detail the use of MR to investigate and discover CRC risk factors, and its future applications
Glutamate Receptor Antibodies in Autoimmune Central Nervous System Disease: Basic Mechanisms, Clinical Features, and Antibody Detection.
No full textImmune-mediated inflammation of the brain has been recognized for more than 50 years, although the initial descriptions were mainly thought to be secondary to an underlying neoplasm. Some of these paraneoplastic encephalitides express serum antibodies, but these were not thought to be pathogenic but instead have a T-cell-mediated pathophysiology. Over the last two decades, several pathogenic antibodies against neuronal surface antigens have been described in autoimmune encephalitis, which are amenable to immunotherapy. Several of these antibodies are directed against glutamate receptors (GluRs). NMDAR encephalitis (NMDARE) is the most common of these antibodies, and patients often present with psychosis, hallucinations, and reduced consciousness. Patients often progress on to develop confusion, seizures, movement disorders, autonomic instability, and respiratory depression. Although initially described as exclusively occurring secondary to ovarian teratoma (and later other tumors), non-paraneoplastic forms are increasingly common, and other triggers like viral infections are now well recognized. AMPAR encephalitis is relatively less common than NMDARE but is more likely to paraneoplastic. AMPAR antibodies typically cause limbic encephalitis, with patients presenting with confusion, disorientation, memory loss, and often seizures. The syndromes associated with the metabotropic receptor antibodies are much rarer and often can be paraneoplastic-mGluR1 (cerebellar degeneration) and mGluR5 (Ophelia syndrome) being the ones described in literature.With the advance in molecular biology techniques, it is now possible to detect these antibodies using cell-based assays with high sensitivity and specificity, especially when coupled with brain tissue immunohistochemistry and binding to live cell-based neurons. The rapid and reliable identification of these antibodies aids in the timely treatment (either in the form of identifying/removing the underlying tumor or instituting immunomodulatory therapy) and has significantly improved clinical outcome in this otherwise devastating group of conditions