Knowledge synthesis of benefits and adverse effects of measles vaccination: the Lasbela balance sheet

<p>Abstract</p> <p>Background</p> <p>In preparation for a cluster-randomized controlled trial of a community intervention to increase the demand for measles vaccination in Lasbela district of Pakistan, a balance sheet summarized published evidence on benefits and possible adverse effects of measles vaccination.</p> <p>Methods</p> <p>The balance sheet listed: 1) major health conditions associated with measles; 2) the risk among the unvaccinated who contract measles; 3) the risk among the vaccinated; 4) the risk difference between vaccinated and unvaccinated; and 5) the likely net gain from vaccination for each condition.</p> <p>Results</p> <p>Two models revealed very different projections of net gain from measles vaccine. A Lasbela-specific combination of low period prevalence of measles among the unvaccinated, medium vaccination coverage and low vaccine efficacy rate, as revealed by the baseline survey, resulted in less-than-expected gains attributable to vaccination. Modelled on estimates where the vaccine had greater efficacy, the gains from vaccination would be more substantial.</p> <p>Conclusion</p> <p>Specific local conditions probably explain the low rates among the unvaccinated while the high vaccine failure rate is likely due to weaknesses in the vaccination delivery system. Community perception of these realities may have had some role in household decisions about whether to vaccinate, although the major discouraging factor was inadequate access. The balance sheet may be useful as a communication tool in other circumstances, applied to up-to-date local evidence.</p

Risk adjusted mortality of critical illness in a defined geographical region

Aims: To evaluate the performance of the Paediatric Risk of Mortality (PRISM) score in a population of UK children and to use this score to examine severity of illness adjusted mortality of critically ill children <16 years old in a defined geographical region. Methods: Observational study of a defined population of critically ill children (<16 years old) admitted to hospitals in the South West Region between 1 December 1996 and 30 November 1998. Results: Data were collected from 1148 eligible admissions. PRISM was found to perform acceptably in this population. There was no significant difference between the overall number of observed deaths and those predicted by PRISM. Admissions with mortality risk 30% or greater had significantly greater odds ratio for death in general intensive care units compared with the tertiary paediatric intensive care unit. Conclusions: Children with a high initial risk of mortality based on PRISM score were significantly more likely to survive in a tertiary paediatric intensive care unit than in general intensive care units in this region. However, there was no evidence from this study that admissions with lower mortality risk than 30% had significantly worse mortality in non-tertiary general units than in tertiary paediatric intensive care units

Anaphylaxis Refractory to intra-muscular adrenaline during in-hospital food challenges: a case series and proposed management.

BACKGROUND: Anaphylaxis is a severe, systemic hypersensitivity reaction, that can be potentially life threatening. Anaphylaxis during oral food challenge is not uncommon and can usually be effectively managed with intramuscular adrenaline as first line treatment. Although very rare, fatal anaphylaxis during in-hospital food challenge has been reported. OBJECTIVE: We describe our experience of cases of refractory anaphylaxis at in-hospital challenge and propose a framework for escalation of treatment in such cases using intravenous infusion of adrenaline which has been adopted for widespread use elsewhere. METHODS: We present 4 patients who all experienced severe life-threatening anaphylaxis, refractory to intramuscular adrenaline treatment, during supervised oral food challenges. Patient data were collected from contemporaneous notes and patient consent was obtained. RESULTS: In all 4 cases, the anaphylaxis reactions were amenable to treatment with low dose intravenous adrenaline, with no reported adverse effects. CONCLUSION AND CLINICAL RELEVANCE: These cases demonstrate the need for clinicians undertaking higher risk allergen challenges to be able to manage cases of severe anaphylaxis refractory to intramuscular adrenaline, and to consider a framework for managing these reactions. Whilst peripheral intravenous adrenaline infusions should always be initiated only in conjunction with expert input, the protocol suggested is simple enough to be undertaken within the hospital environment while more experienced support is obtained

Congenital disseminated neurofibromatosis type 1: a clinical and molecular case report

Neurofibromatosis type 1 (NF1) is an autosomal dominant condition with a birth incidence of 1/3,500. Around 50% of cases are due to new mutations. The NF1 gene maps to 17q11.2 and encodes neurofibromin. NF1 is a “classical” tumor suppressor gene. Congenital disseminated NF1 is rare with just two cases previously reported. We present a deceased baby with congenital disseminated NF1 in whom we performed molecular studies. A germline mutation (R461X) in exon 10a of the NF1 gene was found. A 2 bp deletion (3508delCA) in codon 1170 of exon 21 was identified in DNA derived from some tumor tissue. Loss of heterozygosity in NF1 and TP53 was observed in other tumor samples. No microsatellite instability was observed in the tumor samples. This is the first report of molecular analysis of the NF1 locus in a patient with disseminated congenital neurofibromatosis. This case had a de novo germline mutation in NF1 and three documented somatic mutations in the NF1 and TP53 genes in tumor specimens

Human activity facilitates altitudinal expansion of exotic plants along a road in montane grassland, South Africa

Question: Do anthropogenic activities facilitate the distribution of exotic plants along steep altitudinal gradients? Location: Sani Pass road, Grassland biome, South Africa. Methods: On both sides of this road, presence and abundance of exotic plants was recorded in four 25-m long road-verge plots and in parallel 25 m × 2 m adjacent land plots, nested at five altitudinal levels: 1500, 1800, 2100, 2400 and 2700 m a.s.l. Exotic community structure was analyzed using Canonical Correspondence Analysis while a two-level nested Generalized Linear Model was fitted for richness and cover of exotics. We tested the upper altitudinal limits for all exotics along this road for spatial clustering around four potential propagule sources using a t-test. Results: Community structure, richness and abundance of exotics were negatively correlated with altitude. Greatest invasion by exotics was recorded for adjacent land at the 1500 m level. Of the 45 exotics, 16 were found at higher altitudes than expected and observations were spatially clustered around potential propagule sources. Conclusions: Spatial clustering of upper altitudinal limits around human inhabited areas suggests that exotics originate from these areas, while exceeding expected altitudinal limits suggests that distribution ranges of exotics are presently underestimated. Exotics are generally characterised by a high propagule pressure and/or persistent seedbanks, thus future tarring of the Sani Pass may result in an increase of exotic species richness and abundance. This would initially result from construction-related soil disturbance and subsequently from increased traffic, water run-off, and altered fire frequency. We suggest examples of management actions to prevent this