Management of suspected viral encephalitis in adults--Association of British Neurologists and British Infection Association National Guidelines

In the 1980s the outcome of patients with herpes simplex encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 h after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to day clinical practice appears to be limited. The emergency management of meningitis in children and adults was revolutionised by the introduction of a simple algorithm as part of management guidelines. In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.

Regional survey of tuberculosis risk assessment in rheumatology outpatients commencing anti-TNF-alpha treatment in relation to British Thoracic Society guidelines

The aim of this study was to analyse tuberculosis (TB) risk assessment for rheumatology patients commencing anti-tumour necrosis factor-alpha (anti-TNF-alpha) therapy using the British Thoracic Society (BTS) guidelines. Data were obtained retrospectively on 856 outpatients regionally receiving anti-TNF-alpha. Prior to commencing treatment, patients had the following assessments documented: respiratory examination, 47.4%; chest X-ray, 84.5%; TB history, 92.9%; and advice about TB risk, 45.8%. Of the 856 patients, 94.3% were on immunosuppressives but 27% had a tuberculin test; 12.6% had > or =1 high-risk factors for TB. In total, 3.4% were referred to a TB specialist and of these, 24.1% had no risk factors for TB. Of patients with > or =1 risk factor, 76.9% were not referred. Only 4/28 patients at high risk for TB due to ethnicity or birthplace received chemoprophylaxis. Marked inter-unit variation was demonstrated and it was evident that patients require improved screening for TB. Greater awareness is necessary of patients with risk factors, particularly ethnicity, to facilitate more appropriate targeting of chemoprophylaxis. Multi-centre audit is a valuable clinical governance tool.

Selecting sanitation systems for sustainability in developing countries

This paper presents a methodology for systematically incorporating multi-dimensional sustainability considerations into the selection of wastewater options for developing countries and the evaluation and comparison of these options. Appropriate technologies for developing countries were screened based on their function and their use of operational sustainability features; this list of technologies can then be used to elaborate design options. Sustainability indicators are used to enable a parallel comparison of the options from environmental, economic, and socio-cultural perspectives. For illustration, the indicator approach is applied to a case study of the sanitation options for peri-urban/rural areas of the eThekwini Municipality in South Africa.

Experience with highly purified porcine factor VIII in a patient with haemophilia A and a factor VIII inhibitor

Highly purified porcine factor VIII has been advocated for the treatment of bleeding episodes in patients with haemophilia who have inhibitors to factor VIII. This approach has been successful in a patient with an intermediate potency inhibitor showing little cross-reactivity to porcine material. As in some other reported cases, a severe allergic reaction occurred on one occasion but did not preclude the subsequent use of the porcine concentrate in carefully controlled conditions.

Challenges with up-scaling dry sanitation technologies

The acceleration of sanitation delivery towards meeting the South African Government's target of completely eradicating the existing backlogs by 2010, has led to a surge of activities. As part of its strategy for ensuring that basic sanitation is provided, the policy has recommended that a ventilated improved pit latrine (VIP) is considered as the basic minimum requirement in the form of a sanitation technology. The up-scaling and delivering of sanitation in many cases in the form of VIPs and its derivatives, as well as urine diversion technology are beginning to pose many technical challenges. The principles on which they have been designed are not always being observed in practice. As a result, some systems are filling up much faster than expected. Research has found that the breakdown in the faeces is not happening as would be expected in an anaerobic reactor, and that the drying of faeces in humid conditions, even with the use of drying agents, is not optimum. These problems, which are being experienced in the field, will have long term repercussions on the sustainability of sanitation provision. This paper aims to share these experiences and findings of research, and the impact it may have on the Sanitation MDG goals.

Etanercept: effective in the management of hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic suppurative condition which is poorly responsive to treatment and is characterized by significant morbidity. Successful treatment of HS in patients treated with infliximab for concomitant Crohn's disease has been reported. More recent reports of positive responses to infliximab [an antitumour necrosis factor (TNF)-alpha agent] in patients who have HS but not Crohn's disease are encouraging.

OBJECTIVES

TNF-alpha is implicated in many inflammatory disorders and we wished to determine the efficacy of subcutaneous etanercept, a competitive inhibitor of TNF-alpha in the control of HS symptoms.

METHODS

We commenced six patients with severe, recalcitrant HS on etanercept (25 mg subcutaneously twice weekly in all cases). All patients had a normal chest X-ray and negative purified protein derivative test prior to treatment and were closely monitored throughout the treatment period for signs of infection. Patients self-assessed their disease activity and completed Dermatology Life Quality Index (DLQI) questionnaires immediately before the introduction of therapy and 24 weeks later in the case of four patients, and 12 weeks later in the case of two others. All patients were asked to estimate the time lapse between commencement of treatment and initial response.

RESULTS

Treatment was well tolerated by all patients with no reported adverse reactions. A marked reduction in self-reported disease activity (mean reduction of 61% at 24 weeks), in DLQI scores (mean reduction of 64% at 24 weeks) and in relapse rates occurred. All patients rated etanercept as their most effective treatment to date.

CONCLUSIONS

Our results show the effectiveness of etanercept in this group of patients with particularly challenging disease. Etanercept, unlike infliximab, may be administered subcutaneously, rendering costly day-case admissions unnecessary.

Mutation analysis in Irish families with glomuvenous malformations

BACKGROUND

Glomuvenous malformations (GVMs) are rare bluish lesions that can affect the skin and mucosal surfaces. They represent defects in vasculogenesis. Lesions can occur sporadically or in an autosomal dominant mode of inheritance. Recent studies have shown that mutations in the glomulin gene (GLMN) on chromosome 1p21-22 are responsible for familial GVMs.

OBJECTIVES

To search for mutations in GLMN in Irish families with GVMs.

METHODS

We identified four Irish families with GVMs and confirmed linkage to chromosome 1p21-22 in these cases. We sequenced the glomulin gene in all affected and unaffected members of the families. Results Linkage analysis showed that affected individuals from the families shared a common haplotype. Mutation analysis revealed a delAAGAA mutation in exon 3 of the glomulin gene in all four families with GVMs.

CONCLUSIONS

We confirm that mutations in the glomulin gene are responsible for GVMs and suggest a founder Irish mutation in the glomulin gene in four Irish families.

Microbiological studies of an anaerobic baffled reactor: microbial community characterisation and deactivation of health-related indicator bacteria

This WRC funded project has studied the appropriateness of the ABR (anaerobic baffled reactor) for on-site primary sanitation in low-income communities. A 3,000 L pilot reactor was located at the Kingsburgh wastewater treatment plant south of Durban, South Africa. Feed to the reactor was raw domestic wastewater containing a significant proportion of particulate organic matter. The compartments of the ABR were routinely monitored for pH, COD, and gas production, among other physical-chemical determinants. The microbial population in each compartment was analysed by fluorescent in situ hybridisation, using general oligonucleotide probes for eubacteria and archeae and a suite of 10 genera or family specific probes. Scanning electron microscopy was conducted on the sludge fraction of each compartment. Mixed fractions from each compartment were also analysed for health-related indicator bacteria (total coliforms and E. coli). Results indicated that methanogenesis was not occurring to the expected extent in the latter compartments, and that this was probably due to a hydraulic load limitation. This contrasted with earlier studies on industrial effluent, for which the organic load was exclusively in soluble form. Inactivation of health-related indicator bacteria was less than 1 log, indicating the need for an additional post-treatment of the effluent to protect community health.

Non spiral and spiral (helical) flow patterns in stenoses. In vitro observations using spin and gradient echo magnetic resonance imaging (MRI) and computational fluid dynamic modeling

AIM

Physiological blood flow patterns are themselves poorly understood despite their impact on arterial disease. Stable spiral (helical) laminar flow (SLF) has been observed in normal subjects. The purpose of the present study is to develop a method of magnetic resonance (MR) flow pattern visualization and to analyze spiral and non-spiral flow patterns with and without luminal narrowing in vitro. The flow conditions were then modeled using computational fluid dynamics (Star-CD).

METHODS

Laminar integrity was examined in a flow-rig using spin and gradient echo magnetic resonance imaging (MRI) in non-stenosed and stenosed conduits in the presence of non-spiral and spiral flow.

RESULTS

No difference was observed in a non-stenosed conduit between non-spiral and spiral flow. In the presence of a stenosis spiral flow preserves flow velocity coherence whereas non-spiral flow increasingly lost coherence beginning proximal to the stenosis. Computational fluid dynamic modeling of the in vitro experiment showed marked differences between the 2 flow patterns. Non-spiral flow produced greater inwardly directed forces just beyond the stenosis and greater outward pressures at more distal sites. The near wall turbulent energy was up to 700% less with spiral flow over non-spiral flow beyond the stenosis.

CONCLUSIONS

Spiral flow appears to offer clear flow profile stabilizing advantages over non-spiral flow, by significantly reducing the turbulence caused by a stenosis. Spiral flow also produces lower forces acting on the vessel wall.

Fast emulsion droplet sizing using NMR self-diffusion measurements

Emulsion droplet sizing using pulsed field gradient (PFG) nuclear magnetic resonance (NMR) is a well-established technique. Traditionally these measurements require total acquisition times of typically 5-20 min per sample, which severely limits our ability to use this method to study dynamic processes. Here we present the application and verification of an NMR pulse sequence, Difftrain, which enables emulsion droplet size distributions to be measured in 3-10 s. We have previously introduced applications of Difftrain (C. Buckley, K.G. Hollingsworth, A.J. Sederman, D.J. Holland, M.L. Johns, L.F. Gladden, J. Magn. Reson. 161 (2003) 112-117), including the droplet sizing of a single unimodal emulsion sample. In this paper, several model emulsions containing different oils are measured and the results compared directly with sizing provided by laser scattering. In this manner, the Difftrain method is verified and its possibilities and limitations are explored. Guidelines are proposed for the range of droplet sizes for which accurate results can be produced. The Difftrain technique opens up the possibility of studying non-equilibrium emulsions; a study of the in situ emulsification of a 21% v/v water-in-silicone oil emulsion is presented.