Diagnostic Pathways as Social and Participatory Practices: The Case of Herpes Simplex Encephalitis

Herpes simplex virus (HSV) encephalitis is a potentially devastating disease, with significant rates of mortality and co-morbidities. Although the prognosis for people with HSV encephalitis can be improved by prompt treatment with aciclovir, there are often delays involved in the diagnosis and treatment of the disease. In response, National Clinical Guidelines have been produced for the UK which make recommendations for improving the management of suspected viral encephalitis. However, little is currently known about the everyday experiences and processes involved in the diagnosis and care of HSV encephalitis. The reported study aimed to provide an account of the diagnosis and treatment of HSV encephalitis from the perspective of people who had been affected by the condition. Thirty narrative interviews were conducted with people who had been diagnosed with HSV encephalitis and their significant others. The narrative accounts reveal problems with gaining access to a diagnosis of encephalitis and shortfalls in care for the condition once in hospital. In response, individuals and their families work hard to obtain medical recognition for the problem and shape the processes of acute care. As a consequence, we argue that the diagnosis and management of HSV encephalitis needs to be considered as a participatory process, which is co-produced by health professionals, patients, and their families. The paper concludes by making recommendations for developing the current management guidelines by formalising the critical role of patients and their significant others in the identification, and treatment of, HSV encephalitis

Care beyond the hospital ward: understanding the socio-medical trajectory of herpes simplex virus encephalitis

Background Herpes simplex virus (HSV) encephalitis is a life-threatening infection of the brain, which has significant physical, cognitive and social consequences for survivors. Despite increasing recognition of the long-term effects of encephalitis, research and policy remains largely focused on its acute management, meaning there is little understanding of the difficulties people face after discharge from acute care. This paper aims to chart the problems and challenges which people encounter when they return home after treatment for HSV encephalitis. Methods The paper reports on data from 30 narrative interviews with 45 people affected by HSV encephalitis and their significant others. The study was conducted as part of the ENCEPH-UK programme grant on Understanding and Improving the Outcome of Encephalitis. Results The findings show the diverse challenges which are experienced by people after treatment for HSV encephalitis. We first chart how peoples’ everyday lives are fragmented following their discharge from hospital. Second, we document the social consequences which result from the longer-term effects of encephalitis. Finally, we show how the above struggles are exacerbated by the lack of support systems for the post-acute effects of encephalitis, and describe how people are consequently forced to devise their own care routines and strategies for managing their problems. Conclusion The paper argues that in order to improve long-term outcomes in encephalitis, it is vital that we develop pathways of support for the condition beyond the acute hospital setting. We conclude by making recommendations to enhance communication and care for the post-acute consequences of encephalitis, to ensure those affected are fully supported through the chronic effects of this devastating disease

Leigh syndrome mimicking neuromyelitis optica spectrum disorder (NMOSD)

We report two children with molecularly confirmed mitochondrial disease mimicking Neuromyelitis Optica Spectrum Disorder (NMOSD). The first patient presented at the age of 15 months with acute deterioration following a pyrexial illness with clinical features localising to the brainstem and spinal cord. The second patient presented at 5 years with acute bilateral visual loss. In both cases, MOG and AQP4 antibodies were negative. Both patients died within a year of symptoms onset from respiratory failure. Arriving at an early genetic diagnosis is important for redirection of care and avoiding potentially harmful immunosuppressant therapies

The role of lumbar puncture in children with suspected central nervous system infection

BACKGROUND: The use of the lumbar puncture in the diagnosis of central nervous system infection in acutely ill children is controversial. Recommendations have been published but it is unclear whether they are being followed. METHODS: The medical case notes of 415 acute medical admissions in a children's hospital were examined to identify children with suspected central nervous system infection and suspected meningococcal septicaemia. We determined whether lumbar punctures were indicated or contraindicated, whether they had been performed, and whether the results contributed to the patients' management. RESULTS: Fifty-two children with suspected central nervous system infections, and 43 with suspected meningococcal septicaemia were identified. No lumbar punctures were performed in patients with contraindications, but only 25 (53%) of 47 children with suspected central nervous system infection and no contraindications received a lumbar puncture. Lumbar puncture findings contributed to the management in 18 (72%) of these patients, by identifying a causative organism or excluding bacterial meningitis. CONCLUSION: The recommendations for undertaking lumbar punctures in children with suspected central nervous system infection are not being followed because many children that should receive lumbar punctures are not getting them. When they are performed, lumbar puncture findings make a useful contribution to the patients' management

Ornamental plants, 1988: a summary of research

Follow-up evaluation of Cyanazine, Terbacil and Metolachlor slow-release herbicide tablets on woody landscape crops / E. M. Smith and S. A. Treaster -- Tolerance of daylily and peony to Surflan, Devrinol and Treflan / E. M. Smith and S. A. Treaster -- Growth response of euonymus, juniper and azalea treated with differing rates of Osmocote 18-6-12 / E. M. Smith and S. A. Treaster -- Evaluation of Ronstar wettable powder on woody landscape crops / E. M. Smith and S. A. Treaster -- An evaluation of Ronstar plus Diflufenican on container-grown landscape crops / E. M. Smith and S. A. Treaster -- Prodiamine evaluation in container-grown landscape / E. M. Smith and S. A. Treaster -- Evaluation of flowering crabapple susceptibility to apple scab in Ohio-1987 / E. M. Smith and S. A. Treaster -- Field study of root zone heating systems in greenhouses / M. F. Brugger and R. H. Zondag -- Costs of producing field rapid-growing evergreens (]uniperus) in Ohio / R. D. Taylor, H. H. Kneen, E. M. Smith, D. E. Hahn and S. Uchida -- Costs of producing field ornamental trees (Malus) in Ohio / R. D. Taylor, H. H. Kneen, E. M. Smith, D. E. Hahn and S. Uchid

Understanding parental perspectives on outcomes following paediatric encephalitis: A qualitative study

Background Encephalitis, characterised as inflammation of the brain tissue, is an important cause of acquired brain injury in children. Objective clinical outcomes vary significantly between affected patients, however they do not always correlate with quality of life as reported by parents. The aim of this study was to explore how parents experience and interpret outcomes in relation to their child who has been affected by encephalitis. Methods Data were derived from in-depth, semi-structured interviews, with 15 parents of 12 children and young people affected by encephalitis. Paediatric cases were identified from the retrospective arm of the research programme ‘ENCEPH-UK-Understanding and Improving the Outcome of Encephalitis’, and from the prospective UK childhood meningitis and encephalitis cohort study (UK-ChiMES, 2012 to 2016). Data were analysed thematically. Results Parents’ perspectives on important outcomes for their child and family changed during the different stages of the encephalitis illness trajectory: from acute illness, recovery and rehabilitation, then reintegration into everyday life. Parents’ understanding of their children’s overall outcome was informed by their own experiences, involving comparisons with other children and reflections on their child’s problems before, during and after the acute illness. Conclusion Outcomes in paediatric encephalitis need to be understood in terms of the context of the patient and family experience as well as the timeframe of recovery. The research highlights the need to include more patient, parent and/or carer reported outcome measures during patient assessment, and that assessment should be repeated during recovery as family concerns change. In the longer term, these parameters could be included in clinical and rehabilitation practice to further support child recovery

A Feasibility Study of Quantifying Longitudinal Brain Changes in Herpes Simplex Virus (HSV) Encephalitis Using Magnetic Resonance Imaging (MRI) and Stereology.

OBJECTIVES: To assess whether it is feasible to quantify acute change in temporal lobe volume and total oedema volumes in herpes simplex virus (HSV) encephalitis as a preliminary to a trial of corticosteroid therapy. METHODS: The study analysed serially acquired magnetic resonance images (MRI), of patients with acute HSV encephalitis who had neuroimaging repeated within four weeks of the first scan. We performed volumetric measurements of the left and right temporal lobes and of cerebral oedema visible on T2 weighted Fluid Attenuated Inversion Recovery (FLAIR) images using stereology in conjunction with point counting. RESULTS: Temporal lobe volumes increased on average by 1.6% (standard deviation (SD 11%) in five patients who had not received corticosteroid therapy and decreased in two patients who had received corticosteroids by 8.5%. FLAIR hyperintensity volumes increased by 9% in patients not receiving treatment with corticosteroids and decreased by 29% in the two patients that had received corticosteroids. CONCLUSIONS: This study has shown it is feasible to quantify acute change in temporal lobe and total oedema volumes in HSV encephalitis and suggests a potential resolution of swelling in response to corticosteroid therapy. These techniques could be used as part of a randomized control trial to investigate the efficacy of corticosteroids for treating HSV encephalitis in conjunction with assessing clinical outcomes and could be of potential value in helping to predict the clinical outcomes of patients with HSV encephalitis

Ornamental plants, 1987: a summary of research

Wound healing in street trees / James M. Martin and T. Davis Sydnor -- Evaluation of flowering crabapple susceptibility to apple scab in Ohio—1986 / Elton M. Smith and Sharon A. Treaster -- Fertilizing trees in the landscape: a 15 year evaluation / Elton M. Smith and Sharon A. Treaster -- Juniper injury from Poast / Elton M. Smith and Sharon A. Treaster -- Pre-emergence herbicides for Canna / Elton M. Smith and Sharon A. Treaster -- An evaluation of Cyanazine and Terbacil and metolachlor slow-release herbicide tablets on woody landscape crops / Elton M. Smith and Sharon A. Treaster -- Tolerance of landscape vines to selected pre-emergence herbicides / Elton M. Smith and Sharon A. Treaster -- Influences of supplementary high intensity discharge lighting upon the growth of 'Ringo' geranium and 'Scarletta' begonia plug propagated plants / John C. Peterson and Richard P. Vetanovetz -- Fixed costs of operating field nurseries in Ohio by size of firm and species of plant / Reed D. Taylor, Harold H. Kneen, Elton M. Smith, David E. Hahn and Stanley Uchida -- Costs of producing slow-growing evergreens (Taxus) in the field by size of firm in Ohio / Harold H. Kneen, Reed D. Taylor, Elton M. Smith, David E. Hahn and Stanley Uchida -- Costs of producing deciduous shrubs (Viburnum) in the field by size of firm in Ohio / Reed D. Taylor, Harold H. Kneen, Elton M. Smith, David E. Hahn and Stanley Uchida -- Costs of producing shade trees (Acer rubrum) in the field by size of firm in Ohio / Reed D. Taylor, Harold H. Kneen, Elton M. Smith, David E. Hahn and Stanley Uchid