Autoimmune hemolytic anemia in an infant with giant cell hepatitis.

Autoimmune hemolytic anemia (AIHA) associated with giant cell hepatitis (GCH) is a rare disorder in infants. AIHA usually precedes the development of liver disease by months to years. Early recognition of the disease and prompt institution of immunosuppressive therapy results in clinical remission and prevents liver disease progression.

Institutional risk factors for outbreaks of nosocomial gastroenteritis: survival analysis of a cohort of hospital units in South-west England, 2002-2003.

Nosocomial outbreaks of gastroenteritis are a major burden on hospital inpatient services, costing an estimated pound115 million annually to the English National Health Service. We actively followed-up 171 inpatient units from four major acute hospitals and 11 community hospitals in South-west England for one year. Outbreaks of gastroenteritis were ascertained through an active surveillance network using standard clinical definitions. Survival analysis Cox regression models using an outbreak of gastroenteritis as the endpoint were fitted to identify institutional and operational attributes related to increased outbreak rates at the level of the care unit. Greater number of beds in unit [hazard ratio (HR) 1.22 (per 10 additional beds), 95% confidence intervals (CI) 0.96-1.55] was associated with increased hazard, as were geriatric (HR 2.6, 95%CI 1.6-4.3) and general medical (HR 1.7, 95%CI 1.1-2.6) care units. The average length of stay on a unit was inversely associated with outbreak incidence [HR=0.89 (per additional week of stay), 95%CI 0.80-0.99]. Larger care units and those with higher throughput have increased rates of gastroenteritis outbreaks. These results should guide infection control policy and support the design of hospitals with smaller care units.

Outbreak of a new Salmonella phage type in South West England: alternative epidemiological investigations are needed.

An outbreak of Salmonella Typhimurium DT193a occurred in South West England in April-May 2003. Preliminary investigation suggested an association with the consumption of ham. A matched case-control study was implemented, together with an environmental investigation and a geographic information system (GIS) analysis. Thirty-seven cases and 38 controls were enrolled in the study. Matched analysis was based only on 23 cases, as the other cases did not nominate controls. Eighty per cent of cases and 51% of controls had eaten ham (odds ratio = 3.5, p = 0.03). Cases did not differ from controls in terms of distance from outlets providing ham. All environmental samples collected were negative. The epidemiological evidence indicated an association between this outbreak and consumption of ham, but the environmental investigation was inconclusive. Alternative methods should be considered in support of traditional epidemiological investigation.

Cluster of meningococcal disease in rugby match spectators.

Four adults among three unconnected groups of spectators at a rugby match developed invasive meningococcal disease four to five days after the match. Two died. All four cases were caused by serogroup C serotype 2a strains, genotype P1.5, P1.2. Although the route of transmission remains uncertain, the most likely explanation is that an asymptomatic carrier disseminated meningococci to at least four others in the course of an afternoon. Clusters among spectators at an event without other links between cases are very unusual.

Invasive Haemophilus influenzae disease in adults.

We reviewed retrospectively all invasive Haemophilus influenzae (Hi) infections in adults ascertained from reference laboratory records and notifications from five NHS regions over the 5 years from 1 October 1990, a period encompassing the introduction of routine Hib childhood immunization (October 1992). A total of 446 cases were identified, a rate of 0.73 infections per 10(5) adults per annum. Though numbers of Hib infections in adults fell after the introduction of Hib vaccines for children (P = 0.035), and there was no increase in infections caused by other capsulated Hi serotypes, total numbers of invasive Hi infections increased due to a large rise in infections caused by non-capsulated Hi (ncHi) strains (P = 0.0067). There was an unexpectedly low rate of infections in those aged 75 years or more (P < 0.0001). The commonest clinical presentations were pneumonia with bacteraemia (227/350, 65%) and bacteraemia alone (62/350, 18%) and the highest rates of disease were in the 65-74 years age group (P < 0.0001). Clinical presentation was not influenced by the capsulation status of the invading Hi strain. 103/350 cases (29%) died within 1 month, and 207/350 (59%) within 6 months of their Hi infection. Case fatality rates were high in all age groups. Pre-existing diseases were noted in 220/350 cases and were associated with a higher case fatality rate (82% vs. 21%, P < 0.0001). After the introduction of Hib immunization in children, invasive Hib infections in unimmunized adults also declined, but the overall rate of invasive Hi disease in adults increased, with most infections now caused by non-capsulated strains. Physicians and microbiologists should be aware of the changing epidemiology, the high associated mortality and high risk of underlying disease. Invasive haemophilus infections in adults should be investigated and treated aggressively.

Management of menorrhagia in primary care-impact on referral and hysterectomy: data from the Somerset Morbidity Project.

OBJECTIVE: To investigate the management of menorrhagia in primary care and its impact on referral and hysterectomy rates. DESIGN: Prospective observational study. SETTING: 11 general practices from the Somerset Morbidity Project. SUBJECTS: 885 women consulting their general practitioner with menorrhagia over four years. MAIN OUTCOME MEASURES: Proportions of these women investigated and treated with drugs in primary care, referred to a gynaecologist and undergoing operative procedures. The relation between investigation and prescribing in primary care and referral to and surgery in secondary care. RESULTS: Less than half of women had a vaginal examination (42%, 95% CI 39% to 45%), or a full blood count (39%, 95% CI 36% to 43%). Almost a quarter of women, 23% (95% CI 20% to 26%), received no drugs and 37% (95% CI 34% to 40%) received norethisterone. Over a third, 38% (95% CI 34% to 40%), of women were referred, and once referred 43% (95% CI 38% to 48%) of women were operated on. Women referred to a gynaecologist were significantly more likely to have received tranexamic acid and/or mefenamic acid in primary care (chi(2)=16.4, df=1, p<0.001). There were substantial between practice variations in management, for example in prescribing of tranexamic acid and/or mefenamic acid (range 16% to 72%) and referral to gynaecology (range 24% to 52%). There was a significant association between high referral and high operative rates (Spearman's correlation coefficient=0.86, p=0.001). CONCLUSIONS: Substantial differences in management exist between practices when investigating and prescribing for menorrhagia in primary care. Rates of prescribing of effective medical treatment remain low. The decision to refer a woman impacts markedly on her chances of subsequently being operated on. Effective management in primary care may not reduce referral or hysterectomy rates.

Prevention of post splenectomy sepsis: a population based approach.

BACKGROUND: The aim of the study was to prevent the occurrence of serious, overwhelming infection following splenectomy, by a district based initiative. Subjects were residents of Plymouth and Torbay District Health Authority (DHA) who had undergone splenectomy in the past and general practitioners (GPs) within the District. METHODS: District guidelines on the prevention of post splenectomy sepsis were developed and disseminated among local GPs and hospital doctors. Patients who had undergone operative splenectomy were actively traced through GP and hospital information systems so that they could be offered sepsis preventive measures in accordance with the guidelines. Data capture-recapture was used as an ascertainment adjustment method to estimate the district prevalence of alive patients who have had an operative splenectomy. A postal questionnaire of district GPs was undertaken after one year to determine their awareness and use of the guidelines. RESULTS: Eight-eight alive patients who had undergone splenectomy were not previously identified be their GP as being asplenic. They were traced so that they could be offered sepsis preventive measures in line with the local guidelines. The estimated district prevalence of individuals who had had an operative splenectomy after ascertainment adjustment using data capture-recapture is p = 9.75 per 10,000 population [95 per cent confidence interval (CI) (7.87, 11.64) per 10,000]. Out of 367 district GPs, 201 used the local guidelines after one year. CONCLUSIONS: Effective prevention of overwhelming infection following splenectomy requires an active population based approach.

Essential skills for purchasing--the views of directors of public health and health authority chief executives.

Since the NHS reforms, health authorities have been purchasing health care and have been advised that public health considerations must inform all NHS activities, and that the Director of Public Health must be supported by a team of qualified support staff. This survey of directors of public health and health authority chief executives in England shows the skills currently available to support health authority purchasing, and the perceived importance of this wide range of skills to the purchasing process. Future models of purchasing will need to ensure access by purchasers to public health and multi-disciplinary advice.

General practitioner registrars' views about a career in general practice.

BACKGROUND: Current low morale in general practice and the fall in the number of general practitioner registrars (trainees) has led to concern about the decline in popularity of general practice as a career. AIM: A study was performed to evaluate the career intentions of general practitioner registrars and the factors underlying their decisions. METHOD: An anonymous postal questionnaire seeking both quantitative and qualitative data was sent to 138 registrars during June 1993. All were registrars at practices in the south west region of England. Outcome measures used were the popularity of different types of general practice work and identification of variables and emergent themes considered important in career choice. RESULTS: A total of 101 registrars returned questionnaires (73%). Of the respondents, 96% expressed an interest in general practice as a career. However, registrars expressed considerable uncertainty about the future of general practice and therefore their career. Continuity of care and a holistic approach were considered valued aspects of work in general practice. Increased workload, increased out-of-hours work and erosion of professional autonomy emerged as negative aspects of a career in general practice. Of the respondents, 91% considered time for leisure activities an important factor when considering future career, 72% would have been glad to do away with 24-hour cover and 99% agreed that general practitioners increasingly fear litigation. CONCLUSION: Although registrars were interested in general practice as a career they had many concerns and expressed uncertainties. The future popularity of general practice is likely to depend on addressing these concerns and on the clarification of the future direction of the profession.

Responsibilities and resources of on-call public health doctors.

We investigated the resource available for public health doctors to carry out statutory responsibilities out-of-hours by a postal questionnaire survey of consultants in communicable disease control (CsCDC) in England and Wales. The questionnaire requested details of local District Health Authority (DHA) population profile, major incident and outbreak policies, the background of the CCDC, out-of-hours communication, access and resources, reference materials and medical equipment carried by the public health doctor on duty. The CsCDC from 96% (121/126) DHAs in England and Wales responded. Whilst 85% (101/119) of public health doctors carried policies on infectious disease when on duty, only 28% (32/116) carried policies on dealing with chemical incidents and 25% (28/111) carried the District policy to deal with radiation hazards. Twenty-six per cent (32/121) of public health physicians had no access to their District headquarters. There is a wide variation in the standard of resources available to on-call public health doctors in England and Wales; following Department of Health and Department of the Environment guidance, Health Authorities need to ensure that they have adequate arrangements in the event of any major incident or outbreak.