When I was a young doctor rotating through paediatrics (and before I had children of my own) I realised I was gradually becoming aware of identifying serious illness in a child almost intuitively and that this poorly understood phenomenon was sometimes independent of what the medical examination of the child was telling me. This was probably the result of working closely with experienced paediatricians, paediatric nurses, the children’s parents as well as observing many children with various conditions.

This intuitive ability was later discovered when looking after adult patients. It was a kind of raised awareness that “something serious was going on” even if patients minimised their symptoms and physical examination didn’t point to anything in particular. It often required adequate time to talk and observe the patient but not always.

Most doctors who see a lot of patients probably develop this ability over time in much the same way that observant parents get to know when something is amiss with their own children. It is one of the reasons why a good, permanent family doctor who sees their patients over time in the context of their home circumstances is well placed to make decisions about when it is important to take investigations further, even if clinical examination reveals nothing that raises concerns.

A paper, just published in this weeks BMJ investigates these “gut feelings” in the context of paediatric infections.

CLINICIANS’ GUT FEELING ABOUT SERIOUS INFECTIONS IN CHILDREN : OBSERVATIONAL STUDY

Introduction

The early recognition of serious infection in children can be difficult but life saving. Although the incidence of serious childhood infection is falling in Europe, associated with the introduction of vaccination programmes,1 2 serious infection remains an important cause of morbidity and mortality in children.3 Early recognition is also important for those clinicians who daily see large numbers of children with minor self limiting infections every day. For example, in Belgium children aged 0-3 years see a general practitioner on average four times a year, mainly with self limiting viral illnesses.4 The diagnostic task is not as difficult as “finding a needle in the haystack” but identifying a condition with an incidence of 4-5 per 1000 population is not straightforward.5 6 It is therefore not surprising that missed cases are common—for example, an audit of children with meningococcal disease in the United Kingdom reported that half the cases had been missed at first contact.7

A lot of research has been published recently that seeks to make the diagnostic task in acutely ill children easier. The diagnostic performance of individual clinical symptoms and laboratory tests has been clarified.8 9 A wide variety of clinical features have been tested for inclusion in clinical prediction rules.10 The evidence base has been improved for the interpretation of vital signs.11 However, primary care clinicians often see patients at a stage in the course of the illness when characteristic symptoms and signs have yet to develop. In this situation, clinicians sometimes report a “gut feeling of something serious” without being able to explain why. A recent systematic review identified this gut feeling as having greater diagnostic value than most symptoms and signs and suggested it should be seen as an important diagnostic red flag in itself.8

Before this gut feeling can be taught about and applied in practice, however, there is a need to understand what is meant by the term and whether it can be characterised with sufficient clarity to be useful. One study classified it as an intuitive feeling that something is wrong, even if the clinical assessment may be reassuring.12 This intuition is therefore conceptually separate from clinical impression—a mode of clinical assessment requiring a holistic judgment but necessarily explicable in terms of defined symptoms and signs.13 14 As the intuition must to some extent arise from the clinical history and examination we clarified the added value that gut feeling provides in addition to clinical assessment for diagnosing serious infections and identified the associated features of the clinical consultation.

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

.

© Dreamstime.com

Legionnaires’ disease historically was first associated with travel. However, an outbreak can occur in your home town (as in Edinburgh right now) or even in a hospital setting.

This term “legionnaires’ disease” was first used in 1977 following an outbreak of pneumonia in the USA the previous year where 234 people were affected and 34 died.

This was not a usual type of pneumonia and carried with it a high mortality. Many of these people, when diagnosed, were scattered throughout different states. However after some time, it became apparent that there was a common factor – each patient had attended a convention of the American Legion in Philadelphia in July 1976 and had stayed in the same hotel.

Although first identified in the USA in the 1976-77, it existed unrecognised prior to this. In 2007 the Wellcome Trust funded some research to investigate the history of legionnaire’s disease in the UK.

A summary is here:

FEATURE : A HISTORY OF LEGIONNAIRES DISEASE IN THE UK

COUNTRY : UK

Benidorm
The advent of cheaper flights and package tours during the 1970s made it possible for more Britons to holiday abroad. One of the most popular destinations was Spain, where new hotels were springing up. In July 1973, four tourists who stayed at the Rio Park Hotel in Benidorm contracted a mysterious form of pneumonia and died. “There was an Agatha Christie-like investigation: all the drinks and food at the hotel were tested for toxins but no one could find the cause,” says Professor Macfarlane.

DISCOVER THE MEANING OF THE ICONS

© Dreamstime.com

Norovirus, sometimes called Norwalk virus or small round structured virus causes winter vomiting disease. Although commoner in the winter months, it can occur at any time of the year. It is the commonest cause of vomiting and diarrhoea in the UK and is highly infectious. Indeed if it appears in the hospital setting it frequently leads to ward closure since this is often the only way to contain the infection.

Hand-washing alone often is not enough to contain the virus. It is not, however, a hospital acquired infection as such and is brought in by a member of staff, visitor or patient who has acquired it in the community. It is important, therefore not to visit patients if you have recently suffered from a brief episode of diarrhoea because of the havoc this virus can cause to the everyday running of a hospital. Usually you are no longer infectious after being symptom free for 48 hours.

Norovirus is transmitted very easily in the following ways:

Not washing hands after using the toilet

Being exposed to the virus when cleaning up vomit or diarrhoea of infected person

By breathing in virus from the air e.g. after projectile vomiting

Touching surfaces that have virus on them eg toilet seats, furniture, door handles, keyboards etc.

By eating contaminated food eg oysters contaminated from sewage in sea water

Here are some commonly asked questions regarding Norovirus infection:

NOROVIRUS : FREQUENTLY ASKED QUESTIONS

COUNTRY : ENGLAND

What are the symptoms?

The most common symptoms are nausea, vomiting and diarrhoea. Symptoms often start with the sudden onset of nausea followed by projectile vomiting and watery diarrhoea. However, not all of those infected will experience all of the symptoms. Some people may also have a raised temperature, headaches and aching limbs.

Symptoms usually begin around 12 to 48 hours after becoming infected. The illness is self-limiting and the symptoms will last for 12 to 60 hours. Most people make a full recovery within 1-2 days, however some people (usually the very young or elderly) may become very dehydrated and require hospital treatment.

DISCOVER THE MEANING OF THE ICONS

Please read DISCLAIMER by clicking on LEGAL tab above

© GrahamColm at en.wikipedia

Botulism is very rare, but nevertheless important because of the severity of the disease caused by the powerful toxin produced by the bacteria Clostridium botulinum.

This bacterium has developed the ability to form spores. It transforms into the spore like state when it doesn’t like the conditions surrounding it. The spore state offers protection to the bacteria. Spores are also a clever kind of fancy dress that some bacteria use to conceal they are present. In the spore form, these bacteria can be regarded as “resting” and inactive. Their presence is not noticed in food unless they emerge from their spore state and become real bacteria again, and then the food will spoil.

Honey is an interesting food. It is said it does not spoil and in fact claims have been made that edible honey has been found in the tombs of ancient Egypt! Have you ever seen fungus growing on top of a jar of honey as it does on top of a pot of jam?

HONEY AND SPOILAGE

COUNTRY : USA

However, honey carries with it a danger for infants. It may have spores of Clostridium botulinum hiding within it.

So the advice is:

Play safe. Botulism is an extrememly rare but very serious condition. Don’t give honey to infants. Don’t even dip a pacifier in honey.

DON’T GIVE HONEY TO BABIES

COUNTRY : UK

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

© Dreamstime.com

In Scotland last week, two children from the same family were admitted to hospital with the very serious but rare condition of botulism.

Botulism is a type of food poisoning resulting from the ingestion of a toxin produced from a bacterium know as Clostridium botulinum. The toxin is known as botulinum toxin and is one of the most lethal known to man.

Botulism can also occur by entry of the toxin via contaminated wounds.

In this case the toxin was thought to originate from a jar of curry.

PUBLIC URGED TO BE AWARE OF BOTULISM SYMPTOMS

COUNTRY : SCOTLAND

Investigations are continuing into the possible cause, but botulism is often food borne. Botulism is caused by toxins produced by the bacterium Clostridium botulinum, which attacks the nervous system and can affect people of any age. The infection is not contagious and cannot be spread from person to person. Symptoms of foodborne botulism typically begin between 12 and 36 hours after ingestion of contaminated food, but may present in as little as six hours.

The bacteria that produce this toxin can exist in a dormant spore form. Great care must be take in the preparation of certain canned or bottled food in the home. This is why adequate sterilisation of jars used for storage is so important. Even minute amounts of the toxin can be fatal.

The following link to the U.S. National Library of Medicine give practical advice on botulism:

BOTULISM

COUNTRY : USA

Prevention

NEVER give honey or corn syrup to infants younger than 1 year old — not even just a little taste on a pacifier.

Prevent infant botulism by breastfeeding only, if possible.

Always throw away bulging cans or foul-smelling preserved foods. Sterilizing home-canned foods by pressure cooking them at 250 degrees Fahrenheit for 30 minutes may reduce the risk for botulism.

Keep foil-wrapped baked potatoes hot or in the refrigerator, not at room temperature.

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

.

The viral disease known as hand foot and mouth disease in the human is completely unrelated to the disease of the same name in animals. It is generally a mild condition and can affect any age but is predominantly seen in children aged under 10 years. Most adults will have already been exposed to the virus in childhood.

It is caused by an enterovirus, usually coxacki A16.

The link below is to Clinical Knowledge Summaries formerly linked to National Institute for Health and Clinical Excellence (NICE), but note important information about this service.

HAND FOOT AND MOUTH DISEASE – CLINICAL KNOWLEDGE SUMMARIES

COUNTRY : UK

Non-polio enteroviruses (including coxsackie A and B, echoviruses, and other enteroviruses) are among the most common viral infections in humans, second only to common cold viruses [Essex Health Protection Unit, 2009].
This group of viruses is most active in the late summer or early autumn in temperate climates [Frydenberg and Starr, 2003].
Hand, foot, and mouth disease (HFMD) occurs worldwide. It appears sporadically as well as in regular epidemics. However, many cases are asymptomatic and go undetected [CDC, 2008].

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

.

Many years ago general practitioners, nurses, and often mothers and grandmothers were well acquainted with the rashes of the then common infectious diseases such as measles, rubella (German measles), scarlet fever and chicken pox. For example, doctors would have been well trained in distinguishing the rash of chicken pox from the dreaded smallpox rash. The doctors of today have only seen the rash of smallpox in a textbook because this infection is now virtually extinct although most doctors will still be taught about it.

Chicken pox is still common but the other infectious diseases much less so, but other rashes are seen that are much less typical than those of the common infectious diseases of yester-year.

The pre-school child in particular has a real knack of producing weird skin rashes associated with viral infections.

Hand, foot and mouth disease is one of these viral infections. The disease in the human is highly infectious but generally takes a mild course. It is completely unrelated to the condition of the same name that affects animals.

HAND, FOOT AND MOUTH DISEASE

COUNTRY : UK

Hand, foot and mouth disease is usually a short mild illness that mainly affects children. Most children fully recover within a week. Serious complications occur rarely. This disease is NOT related to the disease with a similar name which affects animals.

WHAT ARE THE RISKS OF HAND FOOT AND MOUTH DISEASE DURING PREGNANCY?

COUNTRY: UK

Hand, foot and mouth disease is rare in healthy adults, so the risk of infection during pregnancy is very low.
If a pregnant woman gets hand, foot and mouth disease, the risk of complications is also very low.

DISCOVER THE MEANING OF THE ICONS

Please read DISCLAIMER by clicking on LEGAL tab above

© Popa Sorin | Dreamstime.com