Stephen T Green

Successful treatment of molluscum contagiosum with topical imiquimod in a severely immunocompromised HIV-positive patient.

Molluscum contagiosum is a common viral infection in the immuno-compromised HIV-positive patient where it is often severe and affecting the face and neck. It is frequently resistant to conventional, locally destructive therapies. Anecdotal evidence suggests that the immunomodulatory drug imiquimod might be a valid therapeutic option in this group of patients. We report the case of a severely immunocompromised HIV-positive patient with resistant facial molluscum contagiosum lesions that responded to topical imiquimod. The response to therapy and the possible implications for pathogenesis are discussed.

Automated exchange transfusion for life-threatening plasmodium falciparum malaria—Lessons relating to prophylaxis and treatment

We report a case of traveller to Kenya who contracted severe plasmodium falciparum malaria complicated by disseminated intravascular coagulation and acute renal failure. She had taken no antimalarial prophylaxis in view of concerns in the media regarding the adverse effects of mefloquine. There was a protracted delay before the diagnosis of malaria was made. Clinical recovery occurred following treatment with intravenous quinine, haemofiltration and manual/automated red-cell exchange transfusions. Automated red-cell exchange transfusion resulted in a marked decrease in the parasitaemia, before a response to quinine therapy would have been anticipated, leading to a successful outcome thereafter. In conjunction with other groups we therefore feel that exchange transfusions should be considered in seriously ill patients with falciparum malaria, multiorgan complications and parasitaemias greater than 10%.

Are there implications for quality of care for patients who participate in international medical tourism

Expert Rev. Pharmacoeconomics Outcomes Res. 11(2), 133–136 (2011) “As with all medical treatments, an element of risk can exist to the patient’s health, which is mitigated and outweighed by the benefits resulting from the surgery. Medical tourism adds a new dynamic to this element of risk, owing to the overseas travel involved.” Medical tourism is now an established feature of the international healthcare landscape and is a burgeoning commercial industry attracting increasing numbers of people willing to fund their own treatment overseas. Although medical tourism spans the full spectrum of health services, most travel is restricted to a limited range of medical procedures, including cosmetic surgery, dental procedures, orthopedic surgery, cardiac surgery, fertility treatment, and organ and cellular transplantation [1,2].

Hepatitis B: Report of prevalence and access to healthcare among Chinese residents in Sheffield UK

UNLABELLED Overall prevalence of hepatitis B (HBV) in the UK is low. However, among migrants from endemic areas, prevalence has been shown to be high. Furthermore, timely diagnosis and/or referral are required prevent serious health consequences through early institution of treatment. METHODS We identified locations that would be familiar to Chinese members of the community with the objective of facilitating testing. Dried blood spot samples were collected from 229 Chinese subjects and tested for HBV and also for hepatitis C virus (HCV) infection--offering complete chronic viral hepatitis screening. RESULTS HBsAg was positive in 20/229 (8.7%) participants, (10 F, 10 M). Five women and one man were aware of their condition, but only one man and none of the women were under specialist care. The average length of residence in the UK for positive patients was 15 years (range 2-40). Evidence of HBV past infection, HBcAb(+)/HBsAg(-), was seen in 28/229 participants (12.2%). HCV antibody testing produced negative results in all participants. The methodology of testing was well accepted, 139/144 (95%) responded to a feedback questionnaire declaring no discomfort and 100% finding the information session useful. CONCLUSION This model of outreach testing is helpful for addressing health inequalities afflicting the UKs Chinese community.

United Kingdom and Republic of Ireland renal physicians' experiences of patients undergoing renal transplants abroad: A questionnaire-based cross-sectional survey

BACKGROUND Due to ongoing poor availability of organs, increasingly patients from developed countries are reported to be travelling abroad for renal transplants. We aimed to assess the extent and characteristics of this trend across the UK and Republic of Ireland. METHODS A questionnaire-based cross-sectional survey; 397 renal consultants from 33 hospitals with renal units across the UK and the Republic of Ireland were contacted through email and 62 replied (16%). RESULTS Fifty-seven out of 62 (93%) renal consultants managed transplant patients, and of these 36/57 (63%) had managed at least one patient who had undergone a transplant abroad. The most popular reason reported for doing this was being on the UK or Republic of Ireland transplant list but seeking a shorter wait. Respondents reported commencement by overseas doctors of appropriate routine post-transplant prophylaxis with the following medications in all cases they had encountered as follows: co-trimoxazole 12%, isoniazid 3%, anti-fungals 0%, and Cytomegalovirus prophylaxis or treatment 0%. Fourty-four percent of renal consultants reported having some prior warning of a patient undergoing a renal transplant abroad. CONCLUSIONS Renal transplant tourism has become widely established in the UK and the Republic of Ireland, and care for these patients is often suboptimal. Furthermore, the opportunity exists for pre-transplant counselling.

Zanamivir, influenza, and meningococcal disease. Zanamivir may help to fight potential flu epidemic.

Editor—The zanamivir issue described by Yamey in his news article1 and the whole subject of treating influenza have ramifications apart from the potential expense to the British taxpayer (who can easily turn into a patient). I am keen on any development that might help to reduce the burden of disease in hospital wards. If I were asked to state which single condition will fill up my inpatient beds and send healthcare staff home ill most efficiently, I would always choose influenza. Although it is true that influenza is often a mild illness, its association with the development of potentially lethal sequelae is well recognised. It has been described as the best known model of bacterial-viral coinfection.2 Influenza is a powerful predisposing factor for invasive meningococcal disease3 one of the few bacterial conditions still regularly killing otherwise normal healthy young people in the United Kingdom. Hubert et al have stated that when an epidemic of influenza-like syndrome is identified, medical practitioners should be informed of the likelihood of an increased incidence and severity of meningococcal disease.4 We cannot currently vaccinate against Neisseria meningitidis type B. Zanamivir has the potential to be useful here. This certainly needs further investigation. Influenza epidemics result in increased hospital admission rates for bacterial pneumonia,2 and I have come across many patients who have known the pain and misery of having to have chest drains inserted for the drainage of empyemas as a consequence of having suffered a bout of “not very serious” influenza. The zanamivir issue merits a broader debate, which should not centre exclusively upon whether or not it will be a helpful agent for groups at high risk. At a recent meeting in Geneva, to mark the 50th anniversary of WHO influenza surveillance, the Director General, Gro Harlem Brundtland, said that, “time to react may be very short—from the first recognition of a new subtype and the onset of a full-blown pandemic, it may be too short to prepare a vaccine and to use it.”5 We have time to plan now but may not later. Like the little Dutch boy, we may need a finger to stick in the dyke to stop everyone drowning—perhaps zanamivir and similar drugs are that finger.

Undergraduate teaching on biological weapons and bioterrorism at medical schools in the UK and the Republic of Ireland: results of a cross-sectional study

Objective To determine if individual undergraduate schools of medicine in the UK and the Republic of Ireland provide any teaching to medical students about biological weapons, bioterrorism, chemical weapons and weaponised radiation, if they perceive them to be relevant issues and if they figure them in their future plans. Design A cross-sectional study utilising an internet-based questionnaire sent to key figures responsible for leading on the planning and delivery of undergraduate medical teaching at all schools of medicine in the UK and Ireland. Setting All identified undergraduate schools of medicine in the UK and Ireland between August 2012 and December 2012. Outcome measures Numerical data and free text feedback about relevant aspects of undergraduate teaching. Results Of the 38 medical schools approached, 34 (28 in UK, 6 in Ireland) completed the questionnaire (89.47%). 4 (all in UK) chose not to complete it. 6/34 (17.65%) included some specific teaching on biological weapons and bioterrorism. 7/34 (20.59%) had staff with bioterrorism expertise (mainly in microbiological and syndromic aspects). 4/34 (11.76%) had plans to introduce some specific teaching on bioterrorism. Free text responses revealed that some felt that because key bodies (eg, UKs General Medical Council) did not request teaching on bioterrorism, then it should not be included, while others regarded this field of study as a postgraduate subject and not appropriate for undergraduates, or argued that the curriculum was too congested already. 4/34 (11.76%) included some specific teaching on chemical weapons, and 3/34 (8.82%) on weaponised radiation. Conclusions This study provides evidence that at the present time there is little teaching at the undergraduate level in the UK and Ireland on the subjects of biological weapons and bioterrorism, chemical weapons and weaponised radiation and signals that this situation is unlikely to change unless there were to be high-level policy guidance.

Missed opportunities to diagnose Plasmodium falciparum malaria: results of a regional service evaluation.

Plasmodium falciparum malaria (PFM) is a potentially fatal infection, and despite the reduction of malaria risk in some parts of the world and the introduction of new drugs, the number of people travelling continues to increase and malaria reports in the United Kingdom (UK) are not decreasing e indeed, malaria accounts for approximately 10 deaths per annum in the UK. There is a growing body of evidence highlighting shortcomings in the care provided by health services in the UK, including inadequate use of chemoprophylaxis and public education, and recent guidelines from the British Infection Society have reasserted that early consideration of malaria as a possible diagnosis is vital for successful management. In addition, there is anecdotal evidence of significant delays in the referral pathway. A regional retrospective service evaluation was undertaken in an attempt to assess this objectively. Confirmed cases of PFM were identified from records at Sheffield Teaching Hospitals during the period January 2000 to December 2005. All records relating to the episode were obtained including those from peripheral district hospital departments, and questionnaires were sent to the patient’s registered General Practitioner (GP). Records were systematically audited for details regarding demographics, chemoprophylaxis, referral pathways, diagnosis and management. PFM was diagnosed in 53 adults during the period evaluated and reliable information for further analysis was available for 39 of these (73.6%). 22 (56.4%) patients originated from countries endemic with PFM, and 17 (43.6%) had travelled for the purpose of visiting friends or relatives in an endemic region (VFR). 34 (87.2%) cases of PFM were acquired in Sub-Saharan Africa, with the majority of cases from West Africa. Of the 39 patients, only 15 (38.5%) tookany form of malaria chemoprophylaxis during their travel abroad. Of the 15, 5 were taking appropriate prophylaxis for their destination, according to recommendations in the British National Formulary. Overall, only 2 patients (5.1%) took appropriate prophylaxisat a sufficientdose for anadequateperiodof time. The majority of patients (79%) first presented to NHS health-care services within 2 weeks of arrival in the UK (mean, 11.3; range, 1e61 days). Points of initial contact varied and included the patient’s own GP (46.2%), emergency departments (38.5%), GP Co-operative (5.1%), Primary Care HCA (Health-Care Assistant e non-medically trained) (5.1%), and Primary Care Practice Nurse (2.6%). 8 (20.5%) patients had presented to health professionals on an occasion when, in retrospect, they were symptomatic for malaria without a referral to hospital or a diagnostic test being performed (ranging from 1 to 6 such encounters). The majority of patients had a first blood-smear taken for malaria diagnosis within 6 h of their initial presentation to a health professional; in 6 cases (15.4%) it was taken over 24 h after initial presentation. 17 (43.6%) patients had complicated malaria, as defined by the BIS UK Malaria treatment guidelines. Of these 17 patients, 1 (5.9%) died and 5 (29.4%) required a period of treatment on intensive-care. The average length of hospital stay for surviving patients was 5.45 days (range, 1e28 days). This evaluation was able to describe the complete patient journey for a significant proportion of the identified cases. An almost complete record was available for all the patients included, with the exception of NHS Direct data. This information was sought but was not made available to us. The demographic results reflect similar findings to that of a recent Health Protection Agency study, most noticeably VFR accounting for the majority of cases, and West Africa being the most common origin of imported infections. With increasing media attention following several highprofile cases, more pressure is being placed on health-care services not to miss a PFM diagnosis. This is a difficult and controversial area to evaluate, however, this evaluation highlighted several failures by health-care services where improvements are possible:

Acute painless hepatitis in pregnancy—a cause for concern?

A 26 year old woman, who was 19 weeks’ pregnant, was referred by her general practitioner with acute onset hepatitis and painless jaundice. She described a four week history of lethargy and palpitations on exertion. She also reported febrile episodes over the past three days, with no other clinical features on systems inquiry. Her medical history included pre-eclampsia in her first pregnancy, which resulted in induction at 40+1 weeks and a caesarean section. She was taking aspirin at presentation but no other drugs. She had a history of allergy to penicillin and latex, which both caused a rash. She was married with a 2 year old son and worked as a pharmacy dispenser. She reported no recent travel outside the UK, no unusual hobbies, no risk factors for acquiring blood borne viruses, and no contacts with similar symptoms. Baseline bloods tests showed alanine aminotransferase 1779 U/L (reference range 0-41; 1 U/L=0.02 µkat/L), total bilirubin 65 µmol/L (0-21), albumin 33 g/L (35-50), and prothrombin time of 11.4 s (9.7-11.5). Her full blood count was normal. During admission her transaminases rose and her prothrombin time increased. ### 1. What are the viral causes of hepatitis in pregnancy and which are of greatest concern? #### Short answer Viral causes include hepatitis A, B, C, D, and E, as well as cytomegalovirus and Epstein-Barr virus. These infections can occur during any trimester. Cytomegalovirus is associated with congenital infection and hepatitis E virus is associated with fulminant hepatitis in pregnancy. In rare cases herpes simplex and varicella zoster viruses can cause hepatitis and are associated with congenital and perinatal infection. #### Long answer Common causes of acute viral …

Aspergillus fumigatus in sputum during acute EBV infection

Murayama et al 1recently suggested that Aspergillus fumigatus may possess the ability to inhibit phagocyte function. We report a patient with transient neutropenia in whom A fumigatus was present in the sputum. She had a productive cough of two months’ duration and presented with seven days of fever, sweats, myalgia, fatigue, and right supraclavicular swelling. There was no significant past history except smoking. Apart from supraclavicular lymphadenopathy the examination was normal. She was leukopenic (2.3 × 109/1) and neutropenic (0.96 × 109/1). The CD4 count was normal (1.44 × 109/1) and levels of …