Listeria meningitis warning
A CASE of meningitis caused by Listeria monocytogenes in a healthy young patient has prompted infectious diseases specialists to recommend a low threshold for empiric prescription of benzylpenicillin (or co-trimoxazole with penicillin allergy) in patients with lymphocytic meningitis, regardless of underlying risk factors for listeria infection. The case, reported in the MJA, involved a 22-year-old woman who was well, apart from controlled coeliac disease, and presented to hospital with 3 days of fever, headache, photophobia and neck stiffness, preceded by 2 days of diarrhoea. After undergoing a series of tests including lumbar puncture, she was started on ceftriaxone, co-trimoxazole and aciclovir. Cerebrospinal fluid (CSF) culture was positive after 2 days, showing catalase-positive, β-haemolytic colonies with gram-positive bacilli, identified as L. monocytogenes susceptible to ampicillin and co-trimoxazole. Antibiotics were rationalised to co-trimoxazole alone, and treatment ceased on Day 19 of 21, due to co-trimoxazole-related myelosuppression. Four weeks later, the patient had fully recovered. The authors wrote that L. monocytogenes meningitis accounted for 5%–10% of bacterial meningitis, with a mortality rate of up to 62%. “In our patient, differentiating factors were her high CSF opening pressure, low glucose level, and degree of elevated lymphocyte count and protein concentration”, they wrote. Other differential diagnoses considered included partially treated bacterial, cryptococcal and tuberculous meningitis.
Insulin errors have big impact on the elderly
RESEARCHERS have called on doctors to take a cautious approach to starting insulin treatment in elderly patients with diabetes after finding that insulin-related hypoglycaemia and errors (IHEs) are clinically significant causes of emergency department (ED) visits and hospitalisations for adverse drug events. The research, published in JAMA Internal Medicine, found there were nearly 100 000 ED visits and 30 000 hospitalisations annually for IHEs in the US, demonstrating “the high frequency and significant health effects of these adverse events”. The researchers found severe neurological sequelae in more than 60% of ED visits for IHEs, and blood glucose levels of 50 mg/dL (2.7 mmol/L) or less were recorded in more than half of cases. Insulin-treated patients aged 80 years or older were more than twice as likely to visit the ED and nearly five times as likely to be subsequently hospitalised for IHEs than those aged 45–64 years. “The most commonly identified IHE precipitants were reduced food intake and administration of the wrong insulin product”, the researchers wrote. They said that based on previous cost estimates of ED visits for hypoglycaemia, ED visits for IHEs could have cost more than US$600 million during the 5-year study period. An accompanying commentary said the pharmaceutical industry had shaped the current widespread belief in tight glycaemic control, leading to aggressive prescribing of glucose-lowering agents including insulin. “We should not accept the current rates of hypoglycemia as inevitable. Rather, we should begin using a multipronged approach to decrease the overuse of insulin and minimize the risk of hypoglycaemia”, the commentary said.
“Unexpected” liver transplant outcome
DESCRIBED by doctors as an “unexpected” outcome, a liver transplant (LT) in a young girl with lathosterolosis — a defect of cholesterol biosynthesis characterised by high lathosterol levels associated with progressive cholestasis, multiple congenital anomalies and mental retardation — has resulted in a return to “every day life albeit with limitations” at 5-year follow-up. The case, published in the American Journal of Transplantation, reported on a child born at term with jaundice and microcephaly, and several physical abnormalities. Brain magnetic resonance imaging (MRI) at age 1 year was reported as normal with adequate myelinisation. Neurodevelopmental delay became increasingly evident with age and axial hypotonia was severe. Social smiling and interactions were extremely poor, suggesting autistic spectrum disorder. Abnormal liver enzymes were first documented at 14 months of age and by age 7 years liver disease had progressed to the stage that her paediatrician referred her for possible LT. After much “soul searching” by a multidisciplinary team she received a left split liver graft at age 8 years from an adult deceased donor. At 5-year follow up she had normal liver function. “Her parents view LT as life-changing, in that she now thrives on a normal diet, no longer suffers episodes of drowsiness or semi-coma, and has hitherto escaped hospital admissions”, the authors wrote. “She is alert, interacts with her environment and carers, her posture improved as her contractures regressed and she is able to walk.” They wrote that, while established structural lesions could not be reversed, it was possible that the normalisation of cholesterol and lathosterol levels following healthy liver graft had benefited the patient’s still developing central nervous system. “One cannot but wonder what the evolution of her disease might have been if her metabolic imbalance had been corrected at age 1, when her brain MRI was reported as ‘normal’.”
Similar outcomes from vaginal prolapse surgeries
A RANDOMISED trial comparing two surgeries for pelvic organ prolapse has found neither was significantly superior to the other for anatomical, functional or adverse event outcomes. The research, published in JAMA, also found that perioperative behavioural therapy with pelvic floor muscle training (BPMT) did not improve urinary symptoms or prolapse. The study included 374 women randomly allocated to sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (ULS), described by the study authors as two widely used procedures for correcting apical prolapse. The “success” of the surgery was based on the absence of four primary outcomes descent of the vaginal apex into the vaginal canal by more than a third; anterior or posterior vaginal wall descent beyond the hymen; bothersome vaginal bulge symptoms; and retreatment for prolapse by surgery or pessary. The researchers found that at 2-year follow-up, there was no statistically significant difference in surgical success rates (ULS, 59.2% [93/157], v SSLF, 60.5% [92/152]) between the groups and no clinically significant differences in any of the primary or secondary outcome measures. “This study provides evidence for patients and their surgeons about the benefits, risks, and complications of 2 widely used native tissue vaginal approaches for apical prolapse, as well as the role of perioperative BPMT”, the authors wrote. Another randomised trial, published in Ultrasound in Obstetrics and Gynecology, comparing Prolift Total and unilateral vaginal sacrospinous colpopexy with native tissue vaginal repair (sacrospinous fixation, SSF) for posthysterectomy vaginal vault prolapse in 70 women found SFF had a higher anatomical failure rate than Prolift Total at 1-year follow-up.
Proactive care helps smokers quit
A LARGE randomised clinical trial of more than 5000 smokers aged 18–80 years has shown proactive, population-based tobacco cessation care can have a significant impact on long-term population quit-smoking rates. The Veterans Victory Over Tobacco Study, published in JAMA Internal Medicine, randomly allocated smokers to receive the usual care offered by all US Veterans Affairs services (screening for tobacco use, advising users to quit and offering treatment such as pharmacotherapy and counselling) or proactive care (combined proactive outreach by mail and telephone and a choice of smoking cessation services via telephone or in-person). The primary outcome — 6-month prolonged smoking cessation at 1 year — was achieved by 13.5% of those in the proactive group and 10.9% in the usual care group (P = 0.02). The researchers found that proactive care was effective for increasing use of telephone counselling combined with medications. They wrote that the observed 2.6% increase in population-level cessation in the proactive group was an important absolute reduction in the smoking rate (2600 per 100 000 smokers) with relatively small intervention activities and little effect on medical care costs. “The proactive care intervention evaluated in this study consisted of a single episode to engage smokers in evidence-based treatment”, they wrote. “Future studies are needed to test the effect of proactive care using a chronic disease model to ensure delivery of evidence-based tobacco treatment to those who do not quit with a single episode of care.” The researchers said it was important to note that the usual care offered was also very successful, achieving a population-level cessation rate that was much higher than the 6.2% rate of the total US population.
Glucosamine no help in knee pain
RESEARCH using magnetic resonance imaging (MRI) to assess the benefits of glucosamine hydrochloride on joint health in adults with mild to moderate knee pain has shown it is no more effective than placebo. The randomised, double-blind, placebo-controlled trial, published in Arthritis & Rheumatology, included 201 participants aged 35–65 years with frequent pain typical of knee osteoarthritis, who took 1500 mg of glucosamine in beverage form or a placebo beverage for 24 weeks. In both groups, 88% of knees had prevalent cartilage damage in at least one subregion at baseline. The primary outcome was decreased worsening of cartilage damage in the knees based on MRI scan. The researchers wrote that the results of the study “suggest that administration of glucosamine hydrochloride in a beverage for 24 weeks is not associated with less deterioration in knee cartilage damage, less worsening of BMLs [bone marrow lesions], improvement of BMLs in the knee, decreased urinary excretion of CTX-II [a molecular marker of tissue degradation], and/or decreased pain and functioning in individuals from the community with chronic knee pain”.