13 research outputs found
Phylogenetic Analysis of the VP1 Gene of Human Echovirus 30 Isolates from Sarawak Reveals An Emerging Genotype
Identification and validation of clinical predictors for the risk of neurological involvement in children with hand, foot, and mouth disease in Sarawak
Background: Human enterovirus 71 (HEV71) can cause Hand, foot, and mouth disease (HFMD) with neurological
complications, which may rapidly progress to fulminant cardiorespiratory failure, and death. Early recognition of children
at risk is the key to reduce acute mortality and morbidity.
Methods: We examined data collected through a prospective clinical study of HFMD conducted between 2000 and 2006
that included 3 distinct outbreaks of HEV71 to identify risk factors associated with neurological involvement in children
with HFMD.
Results: Total duration of fever ≥ 3 days, peak temperature ≥ 38.5°C and history of lethargy were identified as
independent risk factors for neurological involvement (evident by CSF pleocytosis) in the analysis of 725 children
admitted during the first phase of the study. When they were validated in the second phase of the study, two or more
(≥ 2) risk factors were present in 162 (65%) of 250 children with CSF pleocytosis compared with 56 (30%) of 186 children
with no CSF pleocytosis (OR 4.27, 95% CI2.79–6.56, p < 0.0001). The usefulness of the three risk factors in identifying
children with CSF pleocytosis on hospital admission during the second phase of the study was also tested. Peak
temperature ≥ 38.5°C and history of lethargy had the sensitivity, specificity, positive predictive value (PPV) and negative
predictive value (NPV) of 28%(48/174), 89%(125/140), 76%(48/63) and 50%(125/251), respectively in predicting CSF
pleocytosis in children that were seen within the first 2 days of febrile illness. For those presented on the 3rd or later day
of febrile illness, the sensitivity, specificity, PPV and NPV of ≥ 2 risk factors predictive of CSF pleocytosis were 75%(57/
76), 59%(27/46), 75%(57/76) and 59%(27/46), respectively.
Conclusion: Three readily elicited clinical risk factors were identified to help detect children at risk of neurological
involvement. These risk factors may serve as a guide to clinicians to decide the need for hospitalization and further
investigation, including cerebrospinal fluid examination, and close monitoring for disease progression in children with
HFMD
Practice advisory on the appropriate use of NSAIDs in primary care
Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks
Enterovirus 71 encephalomyelitis and Japanese encephalitis can be distinguished by topographic distribution of inflammation and specific intraneuronal detection of viral antigen and RNA
Aims: To investigate if two important epidemic viral
encephalitis in children, Enterovirus 71 (EV71)e ncephalomyelitis and Japanese encephalitis (JE) whose clinical and pathological features may be nonspecific and overlapping, could be distinguished.
Methods: Tissue sections from the central nervous system of infected cases were examined by light microscopy, immunohistochemistry and in situ hybridization. Results: All 13 cases of EV71 encephalomyelitis collected from Asia and France invariably showed stereotyped distribution of inflammation in the spinal cord, brainstem, hypothalamus, cerebellar dentate nucleus and, to a lesser extent, cerebral cortex and meninges. Anterior pons, corpus striatum, thalamus, temporal lobe, hippocampus and cerebellar cortex were always uninflamed. In contrast, the eight JE cases studied showed inflammation involving most neuronal areas of the central nervous system, including the areas that were uninflamed in EV71 encephalomyelitis. Lesions in both infections were nonspecific, consisting of perivascular and parenchymal infiltration by inflammatory cells,
oedematous/necrolytic areas, microglial nodules and neuronophagia. Viral inclusions were absent.
Conclusions:
Immunohistochemistry and in situ hybridization assays
were useful to identify the causative virus, localizing viral antigens and RNA, respectively, almost exclusively to neurones. The stereotyped distribution of inflammatory
lesions in EV71 encephalomyelitis appears to be very
useful to help distinguish it from JE
Convenient and versatile DNA extraction using agarose plugs for ribotyping of problematic bacterial species.
We describe a convenient, versatile and safe method for preparing bacterial DNA for ribotyping analysis. In this method, extraction of bacterial DNA from Salmnonella typhi and Burkholderia pseudomallei. and subsequent restriction endonuclease digestion, was performed in agarose blocks/plugs thus minimizing shearing and loss of DNA, problems commonly associated with liquid phase phenol extraction. Digested DNA in the plugs was then electrophoresed directly, transferred to nylon membranes and hybridized with labeled rDNA probes in the usual manner to provide reproducible restriction patterns. This method is particularly useful for bacterial species where standard DNA extraction in the liquid phase using phenol has been problematic (e.g. B. pseudomallei) but can be used for any bacterial species. The DNA extracted within the agarose plugs can be stored for long periods and can be used in other, widely-used typing methods such as pulsed-field gel electrophoresis (PFGE) and PCR-based techniques. Embedding live cells directly in agarose plugs also minimizes the risk of exposure to these virulent human pathogens among laboratory workers
Disability after encephalitis: development and validation of a new outcome score
Objective To develop a simple tool for assessing the severity of disability
resulting from Japanese encephalitis and whether, as a result, a child is likely
to be dependent.
Methods A new outcome score based on a 15-item questionnaire was
developed after a literature review, examination of current assessment tools,
discussion with experts and a pilot study. The score was used to evaluate 100
children in Malaysia (56 Japanese encephalitis patients and 44 controls) and
95 in India (36 Japanese encephalitis patients, 41 patients with encephalitis of
unknown etiology and 18 controls). Inter- and intra-observer variability in the
outcome score was determined and the score was compared with full clinical
assessment.
Findings There was good inter-observer agreement on using the new
score to identify likely dependency (κ = 0.942 for Malaysian children;
κ = 0.786 for Indian children) and good intra-observer agreement (κ = 1.000
and 0.902, respectively). In addition, agreement between the new score and
clinical assessment was also good (κ = 0.906 and 0.762, respectively). The
sensitivity and specificity of the new score for identifying children likely to be
dependent were 100% and 98.4% in Malaysia and 100% and 93.8% in India.
Publication: Bulletin of the World Health Organization; Type: Research
Article DOI: 10.2471/BLT.09.071357
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Positive and negative predictive values were 84.2% and 100% in Malaysia
and 65.6% and 100% in India.
Conclusion The new tool for assessing disability in children after
Japanese encephalitis was simple to use and scores correlated well with
clinical assessment
Adenovirus type 21-associated acute flaccid paralysis during an outbreak of hand-foot-and-mouth disease in Sarawak, Malaysia
We report the virological and clinical features of 8 children who presented with adenovirus-associated acute flaccid paralysis (AFP) during an epidemic of enterovirus type 71 (EV71)-associated hand-foot-and-mouth disease (HFMD) in Sarawak, Malaysia, in 1997. Neutralization tests and phylogenetic analysis revealed adenovirus type 21 (Ad21), although DNA restriction digests suggested that this virus was different from the prototype Ad21. Four children had upper-limb monoparesis, 2 had lower-limb monoparesis (one of whom had changes in the anterior spinal cord noted on magnetic resonance imaging), and 2 had flaccid paraparesis. At follow-up, 4 children were noted to have made full recoveries and 3 had residual flaccid weakness and wasting. Neurophysiological investigation revealed a mixture of axonal and demyelinating features in motor and sensory nerves, with denervation. These findings suggest that Ad21 might cause AFP by anterior horn cell damage or neuropathy of the brachial or lumbosacral plexus. The occurrence of these unusual adenovirus infections during an outbreak of EV71-associated HFMD suggests that an interaction between the 2 viruses may have occurred