Unusual presentation of rheumatic fever in a 3-year-old child in the UK

In the developed world, acute rheumatic fever (ARF) is rare. When it does arise, symptoms commonly include fever, arthralgia and rash. We describe a presentation of a 3-year-old child with ARF in a UK District General Hospital. The patient had a 6-week history of diarrhoea, rash and intermittent right hip arthralgia. This was initially thought to be a viral illness until she re-presented with shortness of breath and fever with a pan-systolic murmur. A throat-culture was negative, but an anti-streptolysin titre was elevated, with a bedside echocardiogram demonstrating moderate to severe mitral regurgitation. The young child was transferred to the local tertiary centre for further management; however, she went on to develop acute left ventricular failure. This case illustrates the need to be vigilant for the presentation of a rare illness, such as rheumatic fever, as there can be significant impacts on the quality of life of young patients.

What is the optimum method of weaning intra-aortic balloon pumps?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is weaning an intra-aortic balloon pump by volume superior to ratio reduction in terms of failure of weaning, inotropic support and haemodynamic parameters? A total of 667 papers were identified as a result of the search described below. Six papers were relevant to the question asked. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. Little published evidence exists, although weaning by ratio is more common particularly in high-volume centres. The published data highlight the heterogeneity of weaning protocols not only between countries but also between hospitals in the same country. Current evidence is unable to establish any difference in clinical outcomes including mortality, reinsertion of intra-aortic balloon pumps and requirement for inotropic support between weaning by ratio, volume weaning and abrupt cessation. Despite this, the only randomized trial demonstrates improved haemodynamic profiles in those weaned by volume weaning. In addition, given the difficulty in obtaining clear clinical outcomes, N-terminal pro-brain natriuretic peptide and central venous oxygen saturation may be useful as surrogate markers for successful weaning.

Non elective re-admissions to an acute hospital in people with diabetes: Causes and the potential for avoidance. The WICKED project

INTRODUCTION

Managing people with diabetes is a health priority worldwide. Cost benefit attempts at avoiding non elective admissions (NEA) have had some success. To develop an NEA avoidance service, we audited multiple NEA in those with diabetes.

METHOD

All people with diabetes who had ≥3 NEA to our hospital over 12 months were identified (n=418); 104 (1 in 4) patients were randomly selected and retrospective data collected in 98 subjects on their index (latest, 3rd) admission.

RESULTS

Of 98 subjects (50 males, 60 Caucasians, 86 type 2 diabetes, aged 69±16 years).Conditions contributing to admission included: Significant co-morbidities in 95 patients (≥2 in 57, ≥4 in 24). Only 14 admission were directly due to diabetes: hypoglycaemia (5); hyperglycaemia (6); DKA (2), Infected foot ulcer (1).97 admissions were justified at the time of presentation. However whilst 78 were unavoidable, 19 were deemed avoidable amongst whom 10 were diabetes related.

CONCLUSION

The majority of re-admissions were due to multi-morbidity and were often non-diabetes related. The concept of avoidability must be distinguished from point justification at the time of acute need. This would allow the prospective identification of high risk patients and requires an integrated working process to avoid NEA.

Lifetime costs and outcomes of repair of Tetralogy of Fallot compared to natural progression of the disease: Great Ormond Street Hospital cohort

Background

Tetralogy of Fallot is a congenital heart disease that requires surgical repair without which survival through childhood is extremely rare. The aim of this paper is to use data from the mandatory follow-up of patients with Tetralogy of Fallot to model the health-related costs and outcomes over the first 55-years of life.

Method

A decision analytical model was developed to establish costs and outcomes for patients up to 55 years after diagnosis and first repair of Tetralogy of Fallot compared to natural progression. Data from Adult Congenital Heart Disease (ACHD) centres that follow up Tetralogy of Fallot patients and Great Ormond Street Hospital (GOSH), London, United Kingdom (UK) medical records was used to establish the cost and effectiveness of current interventions. Data from a Czech cohort was used for the natural, no intervention condition.

Results

The average cost per patient of a repair for Tetralogy of Fallot was £26,938 (SE = £4,140). The full life time cost per patient, with no discount rate, was £65,310 (95% CI £64,981–£65,729); £56,559 discounted (95% CI £56,159–£56,960). Patients with a repair had an average of 35 Quality Adjusted Life Years (QALYs) per patient over 55 years undiscounted and 20.16 QALYs discounted. If the disorder was left to take its natural course, patients on average had a total of 3 QALYs per patient with no discount rate and 2.30 QALYs discounted.

Conclusion

A model has been developed that provides an estimate of the value for money of an expensive repair of a congenital heart disease. The model could be used to test the cost-effectiveness of making amendments to the care pathway.

Plasticity of autonomic nerves: differential effects of long-term guanethidine sympathectomy on the sensory innervation of the rat uterus during maturation

The sensory nerves, containing substance P and calcitonin gene-related peptide, and noradrenaline-containing sympathetic nerves of the rat uterus were analyzed following long-term sympathectomy with guanethidine in prepubertal (four weeks), young adult (eight weeks) and fully adult animals (18 weeks). Immunohistochemical and histochemical methods were used in association with nerve density measurements and biochemical assays. The main findings were as follows: (1) long-term guanethidine treatment completely abolished the noradrenergic innervation of the uterine horn and parametrial tissue and markedly reduced the tissue levels of noradrenaline in both regions at the three ages analysed; (2) in the uterine horn guanethidine treatment had no effect on the tissue levels of either calcitonin gene-related peptide or substance P or on the density of calcitonin gene-related peptide-containing nerves, at any of the three ages studied; (3) in the parametrial tissue increased levels of calcitonin gene-related peptide were observed at 8 and 18 weeks of age, together with a significant increase in the density of calcitonin gene-related peptide-containing nerves. Substance P levels showed a transient increase in this tissue at eight weeks. In conclusion, long-term sympathectomy with guanethidine resulted in an increase in calcitonin gene-related peptide and substance P in sensory nerves in the parametrial tissue, but not in the uterine horn. The changes in the parametrial tissue only occurred after puberty. It is suggested that sensory nerves in the uterine horn may be less responsive to sympathetic denervation since loss of sympathetic nerves occurs as part of a normal physiological process during pregnancy in this region.

Maturational changes in sympathetic and sensory innervation of the rat uterus: effects of neonatal capsaicin treatment

The plasticity of the sympathetic and sensory innervation of the rat uterus was examined, before and after puberty, in controls and in animals where primary sensory nerves had been destroyed by neonatal capsaicin treatment. Immunohistochemical and histochemical methods were used in association with nerve density measurements and biochemical assays. The main findings were as follows: (1) Puberty was associated with a marked increase in the weight of the uterine horn, uterine cervix and parametrial tissue. This was unaffected by capsaicin treatment. (2) The sympathetic innervation of the uterine horn and parametrial tissue was reduced following puberty as revealed by a decrease in the density of noradrenaline-containing nerves and a marked decrease in the tissue concentration of noradrenaline. Sympathetic nerves supplying the uterine cervix and the blood vessels of the uterus appeared to be unaffected by puberty. (3) In contrast, the sensory supply of the uterus by substance P and calcitonin gene-related peptide-containing nerves increased in parallel with uterine growth during puberty resulting in no change in nerve density and only a slight reduction in peptide concentration. (4) Neonatal capsaicin treatment caused a long-lasting depletion of substance P- and calcitonin gene-related peptide-containing nerves. In the uterine horn and parametrial tissue, capsaicin-resistant calcitonin gene-related peptide, but not substance P, still increased with tissue weight during puberty, indeed, in the uterine horn, the relative increase was greater than in controls. (5) Sensory denervation resulted in an increase in the non-vascular sympathetic supply of the uterus, although there was a regional variation in the time course of the response. Perivascular sympathetic nerves were unaffected by capsaicin treatment. The pattern of change in non-vascular noradrenaline-containing nerves associated with puberty was similar in nature to controls. Thus, there is considerable plasticity in the innervation of the uterus both during puberty and following sensory denervation. A complex pattern of change occurs with differential responses in vascular and nonvascular nerves and in different regions of the uterus. Such differences may be due in part to the different origins of individual nerve populations and/or to their relative sensitivities to sex hormones.

Postnatal development of noradrenaline-containing nerves of the rat uterus

The postnatal development of noradrenaline (NA)-containing nerves of the rat uterus and its associated blood vessels was investigated using histochemical and biochemical methods. These studies were carried out in conjunction with examination of the morphology of the uterus and the density of blood vessels at the prepubertal, peripubertal and adult stages. It was demonstrated that: (1) the rat uterus is innervated at birth; (2) the innervation of blood vessels develops earlier than that of the myometrium and the density of NA-containing perivascular nerves is not affected by puberty; (3) between birth and day 30 (prepubertal) there was a progressive increase in the innervation of the myometrium which was accompanied by a progressive increase in the total NA content of the organ; (4) at the first oestrus there was a marked increase in the weight of the uterus and isolated myometrial and parametrial tissue. Both muscle cell size and number were also increased. The density of myometrial innervation by NA-containing nerves was markedly reduced, although the total NA content did not change at this stage. This indicates a 'dilution' of myometrial NA-containing nerves in a greater amount of non-neuronal tissue; and (5) between the peripubertal and adult stages there was a further increase in uterine weight together with an increase in the number of smooth muscle cells and a reduction in the density of myometrial NA-containing nerves. Although the density of perivascular nerves was unaffected by puberty, the number of blood vessels supplying the uterus increased during the transition to the adult stage. This was reflected by a significant increase in the total NA content of the uterine horn and of isolated myometrial and parametrial preparations.

Gap junctions of the muscles of the small and large intestine

The distribution of gap junctions (nexuses) in various parts of the small and large intestines of the guinea-pig was studied using the freeze-fracture technique and in thin sections. The percentage area of smooth muscle cell surface occupied by gap junctions varies from 0.50% in the circular muscle of the duodenum to zero in the longitudinal muscle of the ileum. In the circular muscle of the jejunum and ileum the area occupied by nexuses is 0.22% (or about 11 micrometers 2 per cell). The sizes of junctions range from less than 0.01 micrometer 2 to 0.20 micrometer 2, with two-thirds of them being smaller than 0.05 micrometer 2. In the colon, gap junctions are rare, very small and confined to the circular muscle layer. Even the smallest aggregates of intramembrane particles correspond to areas of close apposition between the membranes of adjacent cells; it is therefore justified to interpret them as being gap junctions. Some gap junctions are formed between a smooth muscle cell and an interstitial cell. Gap junctions are not found in the longitudinal muscle of the small intestine; this is in sharp contrast to the abundance of gap junctions in the adjacent circular layer. In the small intestine of cats and rabbits, gap junctions are abundant in the circular muscle layer, whereas they are very small in size and very few in number in the longitudinal muscle layer.

Nexuses between the smooth muscle cells of the guinea-pig ileum

The circular musculature of the guinea-pig ileum has been studied by freeze-fracture to analyze quantitatively the gap junctions (nexuses) between its smooth muscle cells. The average cell surface area and cell volume are 5,074 micron 2 and 3,260 micron 3. The packing density of nexuses is 48/1,000 micron 2 of cell surface or approximately 244/muscle cell. Nexuses range in area from less than 0.1 to approximately 1.5 micron 2 and they occupy 0.212% of the cell surface. The average packing density of intramembrane particles or pits in nexuses is approximately 7,200/micron 2 of nexal surface, indicating that there may be approximately 77,000 intercellular channels in the full complement of nexuses of one muscle cell.

Effect of stretch and contraction on caveolae of smooth muscle cells

The number of caveolae present at the surface of smooth muscle cells of guinea-pig taenia coli and visualized by freeze-fracture is about 35 per micron2. (By comparison, endothelial cells of intramuscular capillaries have about 73 caveolae per micron2). The packing density of smooth muscle caveolae is not significantly different in muscle strips isotonically contracted with carbachol or stretched and relaxed in a calcium-free solution, under a range of loads varying from 1 to 15 g. Also the diameter of the fractured necks of the caveolae appears unchanged in all the experimental conditions tested. The plasma membrane of smooth muscle cells often shows a ring of intramembranous particles rimming the opening of a caveola; on the other hand, particles are rare in the membrane of the caveolae themselves. The close relation between caveolae and sarcoplasmic reticulum is readily visualized in freeze-fracture preparations. Characteristic changes of the cell surface shape accompany the contraction and relaxation of the muscle. On rare occasions small aggregates of intramembranous particles are found and it is possible that they represent punctate gap junctions. However, the characteristic clusters of particles found in the circular musculature of the caecum and ileum are not seen in taenia coli.