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

There are times doctors get pretty confused and frustrated by the research that is produced, particularly when it is not within their own specialty. What chance therefore do patients have?

Here is a paper telling us that too much fructose is bad for you. Now this upsets me because I have always considered I eat a healthy diet that contains vast amounts of fruit, which of course is teeming with fructose. Do I now need to reconsider that what I am eating? Is my high fruit intake unhealthy?

Although they are addressing the fructose content of corn syrup as an additive added as a sweetener by the food industry, what are the implications for those of us who do not eat many packaged foods but eat a diet full of fruits and vegetables where fruits predominate over vegetables?

I have just read the abstract of this paper. I suppose I’m going to have to study the whole paper in more detail and any subsequent follow-up papers too.

FRUCTOSE, INSULIN RESISTANCE AND METABOLIC DYSLIPIDEMIA

COUNTRY : CANADA

“Abstract
Obesity and type 2 diabetes are occurring at epidemic rates in the United States and many parts of the world. The “obesity epidemic” appears to have emerged largely from changes in our diet and reduced physical activity. An important but not well-appreciated dietary change has been the substantial increase in the amount of dietary fructose consumption from high intake of sucrose and high fructose corn syrup, a common sweetener used in the food industry. A high flux of fructose to the liver, the main organ capable of metabolizing this simple carbohydrate, perturbs glucose metabolism and glucose uptake pathways, and leads to a significantly enhanced rate of de novo lipogenesis and triglyceride (TG) synthesis, driven by the high flux of glycerol and acyl portions of TG molecules from fructose catabolism. These metabolic disturbances appear to underlie the induction of insulin resistance commonly observed with high fructose feeding in both humans and animal models. Fructose-induced insulin resistant states are commonly characterized by a profound metabolic dyslipidemia, which appears to result from hepatic and intestinal overproduction of atherogenic lipoprotein particles. Thus, emerging evidence from recent epidemiological and biochemical studies clearly suggests that the high dietary intake of fructose has rapidly become an important causative factor in the development of the metabolic syndrome. There is an urgent need for increased public awareness of the risks associated with high fructose consumption and greater efforts should be made to curb the supplementation of packaged foods with high fructose additives. The present review will discuss the trends in fructose consumption, the metabolic consequences of increased fructose intake, and the molecular mechanisms leading to fructose-induced lipogenesis, insulin resistance and metabolic dyslipidemia.”

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

.

© Dreamstime.com

Analysis of data indicates that if you happen to be admitted, whether as an emergency or elective patient, to a UK hospital over the weekend, then you are more likely to be dead within 30 days of that admission than if you were admitted on say a Wednesday.

On the other hand, you are less likely to die in hospital over the weekend than, say, on a Wednesday.

While this is an interesting observation, the question arises “Why might this be?”

The original study was published this week in the Journal of the Royal Society of Medicine.

WEEKEND HOSPITALISATION AND ADDITIONAL RISK OF DEATH : AN ANALYSIS OF INPATIENT DATA.

COUNTRY : UK

Conclusion

We have found clear evidence of an excess of mortality associated with admission to hospital on weekend days in the National Health Service in England and in not-for-profit hospitals in the USA. Although being admitted at the weekend is associated with increased risk of subsequent death, we also found corresponding evidence of a reduced risk of death occurring among patients already in hospital on weekend days versus week days.

It may be that reorganized services providing 7-day access to all aspects of care could improve outcomes for higher risk patients currently admitted at the weekend. However, the economics for such a change need further evaluation to ensure that such reorganization represents an efficient use of scarce resources.

It is very easy to hypothesise on numerous reasons for this, however each hypothesis still needs to be proven. It will be interesting to see if the UK government picks up on this paper for commercial reasons and uses it make changes in the way hospitals work. i.e premature changes that are not evidence based.

A medical blogger has some astute thoughts on the matter:

NATURE COOKS THE BOOKS

COUNTRY : UK

“But – and is a big but – this nicely baked epidemiological cake is only good so far as it goes. One can’t go around layering it with speculative icing, and expect the icing to look good. And yet that is just what Prof Cough did: he leapt from an established association, via a speculative (he himself described the situation as “complex”) causation (not enough senior doctors around at weekends), to an imaginary solution: the 24/7 hospital.”

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

.

© Dreamstime.com

Any medicine, any surgical procedure, carries with it a degree of risk. The skill is deciding whether that risk is worth taking and whether the net result of the intervention is likely to be of significant benefit to the individual patient.

Sometimes though, the risk becomes more of a roller coaster ride and things go seriously wrong. Some breast implants are filled with industrial material or some hip implants do not perform the way they were expected to and unexpectedly release harmful chemicals into the circulation.

The Medicines and Healthcare Products Regulatory Agency (MHRA) is the government agency which is responsible for ensuring that medicines and medical devices work, and are acceptably safe. The MHRA is an executive agency of the Department of Health in the UK.

This link to their website gives up to date information about medicines and products that have been recalled as well as much more.

MHRA

COUNTRY:UK

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

.

© Dreamstime.com

Sometimes life can be very difficult for the parents of a crotchety baby. What’s wrong? Teething is one of first things that springs to mind. All sorts of people might give all sorts of advice, and that advice might turnout to be right, of course. Sometimes though it could be wrong. Very wrong.

The chances are, without examining the baby, if the advice given turns out to be correct, then it is just by chance, based on the probability that most babies, most of the time are not seriously ill. However, teething is a diagnosis of exclusion.

DOES A TEETHING CHILD NEED SERIOUS ILLNESS EXCLUDING

COUNTRY: UK

We also identified one paper highlighting the risks of attributing relevant medical symptoms to teething. This review suggests that there is no evidence that teething can be “identified” as the source of symptoms in a child. We agree with previous authors and recommend that this is a diagnosis of exclusion, to be made with caution. We acknowledge that this message may conflict with many firmly held beliefs of our patients’ parents and of other colleagues, but this review has shown that if a child is ill enough to be admitted to hospital, other organic causes need to be excluded, so that the child is managed appropriately. We also suggest that visualisation of the gums should be part of the clinical examination of the mouth and pharynx in young children to deal with the possible parental concerns, as teething has often been diagnosed on the basis of symptoms alone.

Clinical Bottom Line

No evidence is available to suggest that there are any symptoms or signs specific to teething that allow a diagnosis to be made confidently in a child without excluding other organic pathology (grade B).

It seems then, if a teething child is giving a parent or other carer (the one who knows the child best) real cause for concern, eg, inactivity, poor feeding, diarrhoea, fever, unusual cry, unusual rash, then that concern should be taken seriously. The baby should be examined by a GP or paediatrician to rule out other causes of a sick child, before the diagnosis of “teething” is made.

Remember, grannys, aunties, friends, nursery nurses, health visitors etc are not trained in the diagnosis of an ill child. Only doctors are and some of them who do not see a lot of children, are sometimes not good at it either.

Fortunately the parent who spends most time with their child usually becomes pretty good at knowing when it is appropriate to get worried, and their worries should never be dismissed as “anxiety” or “neuroticism” even if in some situations this may turn this is the case.

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

.

Hypertension or high blood pressure is common particularly as an individual gets older. It can eventually lead to strokes, heart attacks, heart failure, a type of dementia and kidney disease. It is a cause both of long term chronic disease and premature death. Unless the blood pressure is exceptionally high, most people are unaware there is any problem. The only way to diagnose hypertension is to measure the blood pressure.

And that is where there can be a problem.

Generations of medical students have been made aware of “The White Coat Syndrome.” i.e some individuals have a labile blood pressure that goes up when it is formally measured in a health care setting or even in their own home. The technique of inflating a cuff around the upper arm until it tightens is not a pleasant feeling and this sensation alone can even put the blood pressure up even when an individual is measuring their own blood pressure and there is not a white coat is site! The secret then is to take several readings until you get used to the cuff tightening and record the lowest of these. But the same phenomenon may recur next time you measure. You might call it “Blood Pressure Cuff Tightening Syndrome” but I don’t ever remember hearing that term being used.

Guidelines were issued in England and Wales yesterday by NICE regarding the diagnosis and management of hypertension. They have become aware that hypertension may be over-diagnosed and therefore over-treated because of this problem and the new guidelines make recommendations for home monitoring of BP if it is found to be high in the health care setting.

HYPERTENSION : CLINICAL MANAGEMENT OF PRIMARY HYPERTENSION IN ADULTS -UPDATE

COUNTRY: ENGLAND AND WALES

KEY PRIORITIES FOR IMPLEMENTATION
The following recommendations have been identified as priorities for implementation.
Diagnosing hypertension
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011] When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00).
Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension. [new 2011] When using home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension, ensure that:
for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated and blood pressure is recorded twice daily, ideally in the morning and evening and
blood pressure recording continues for at least 4 days, ideally for 7 days. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension. [new 2011]

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

© Tommaso79 | Dreamstime.com

.

I once worked with a doctor who was mildly obsessional. Well, maybe he was moderately obsessional. It was long before the days of mobile phones. One of his obsessions was to use baby wipes to clean his phone. When he used the phone he held it in his hand but never let it touch his ear, face or mouth. He washed his hands immediately afterwards. We all thought he was a bit loopy, but loveable.

I can also remember when everyone in hospitals became obsessed with infection control. It was probably about the time MRSA first appeared. Infection control nurses went around inspecting wards, taking swabs and chastising everyone for not washing their hands enough. There were many meetings. But in the midst of this, no-one gave much thought to computer keyboards as a source of contamination. Then it eventually dawned and some research was done demonstrating the obvious i.e. they were communal honey pots contaminated with all sorts of organisms. So that was taken care of.

This paper identifies the micro-organisms found on the mobile phones and the hands of health care workers in an operating room and in an Intensive Care Unit.

CONTAMINATION OF MOBILE PHONES WITH PATHOGENS

COUNTRY : TURKEY

The rate of bacterial contamination of mobile phones is 94.5%. The isolated microorganisms from mobile phones and hands were similar (Table 1). Some of them are known to cause nosocomial infections. Hand contamination rates of HCWs and their personal mobile phones are shown in Table 2. It was found that 49.0% of phones grew one bacterial species, 34.0% two different species, 11.5% three or more different species and no bacterial growth were identified in 5.5% of phones.

Those S. aureus strains isolated from mobile phones of 52.0% and those strains isolated from hands of 37.7% were methicillin resistant. The gram negative strains were isolated from mobile phones of 31.3% and the ceftazidime resistant strains from the hands were 39.5%. At the study period our nosocomial isolates at ICU were: 33.3% staphylococci, 21.4% non-fermentative gram negatives, 21.4% coliforms, 7.1% enterococci, 11.9% yeasts.

The rate of routine cleaning of HCW’s mobile phones was 10. 5%, which means 89.5% of the participants never cleaned their mobile phones. Although the assistant doctors’ phones have higher colony count there was no significant difference in the rates of specific types of bacterial growth and colony counts isolated on all groups’ mobile phones (Table 2).

25.5% of the entire study population had one or more rings. The mean colony count was higher in ring using staff’s phones but there was no significant difference between rate of contamination and colony count (Table 2) (p > 0.05).

Considering the number of people employed in the health care sector, there will be loads of phones taken home and so there is a possibility they may be a means of transferring multiple resistant microorganisms from hospital into the community. Mobile phones are usually each only used by a single person within the household, however the main household phone and remote controls for TVs are likely to be used by everyone in the family and are likely to be contaminated by the mobile phone flora of the household. It seems logical then to have a cleaning routine for all phones and remote controls as well as computer keyboards. Maybe the obsessional doctor I worked with all these years ago was not loopy after all!

CONTAMINATION OF MOBILE PHONES WITH PATHOGENS

COUNTRY : TURKEY

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

© Draiochtanois | Dreamstime.com

.

The prestigious group of scientific journals from the “Nature” stable generally require a subscription or purchase per individual article. However, “Nature” also produces some excellent educational material which can be accessed freely.

One of these educational eBooks is on genetics.

The topics covered answer the following questions:

What Is DNA? What Does DNA Do?
How Does DNA Move from Cell to Cell?
How Is Genetic Information Passed between Organisms?
How Do Scientists Study and Manipulate the DNA inside Cells?
How Does Inheritance Operate at the Level of Whole Populations?

ESSENTIALS OF GENETICS

COUNTRY : USA

“Why does a commercial dairy cow produce four times as much milk as most other mammals? Why do we look like our cousins? Why do roses come in so many different colors? The answers to these and other questions about the diversity of living things involve processes that occur at the level of genes.

Essentials of Genetics is a brief guide through the core concepts of how genes are structured and how they drive biological diversity. This course can be used as a guide for introductory biology students, as a reference for advanced students, or as a self-guided exploration for general science enthusiasts. Topics covered include the nature of DNA and its relationship to the physical characteristics of organisms; the passage of DNA from organism to organism; and the variation of DNA within and across populations of organisms. Essentials of Genetics also connects these core concepts to the scientific process by discussing the key tools used to study DNA in the laboratory. Alongside each concept are links to biographies of scientists who made major contributions to the field, as well as to a broad set of detailed readings on advanced topics in modern genetics. Finally, Essentials of Genetics combines its descriptions of various core concepts with high-quality video animations of molecular processes to stimulate an intuitive physical understanding of genetics.

About the Authors

Lead Editors: Ilona Miko, Ph.D. and Lorrie LeJeune

Writers: Heidi Chial, Ph.D., Carrie Drovdlic, Maggie Koopman, Ph.D., Sarah Catherine Nelson, Ph. D., Angela Spivey, Robin Smith, Ph. D., WilliamsTown Communications.

Animations and Illustrations: Arkitek

Citation

Please cite this book as:

Miko, I. & LeJeune, L., eds. Essentials of Genetics. Cambridge, MA: NPG Education, 2009.”

Please read DISCLAIMER by clicking on LEGAL tab above

DISCOVER THE MEANING OF THE ICONS

© Dawn Hudson | Dreamstime.com