West Park Hospital

A case of chickenpox in a 94-year-old female is described. Serological tests for Varicella zoster virus (VZV) performed on early and late serum samples confirmed primary VZV infection. The patient recovered but seventeen days after presentation she developed a stroke from which she subsequently died. Chickenpox in older people is relatively rare—this case may be the oldest case of laboratory-proven chickenpox described—but it is a life-threatening illness. The varicella vaccine is licensed for use in immunocompetent persons of 12 months of age or older but in the UK is only offered to susceptible healthcare workers and close contacts of immunocompromised patients. In the US, the vaccine is recommended for all susceptible adolescents and adults. The same recommendation should be made in the UK.

Abstract Background: Aromatase inhibitors (AI) are accepted as adjuvant endocrine therapy for hormone receptor-positive (HR+) postmenopausal early breast cancer (EBC) with superior efficacy to tamoxifen. However, because of the increased bone loss associated with the use of AI, three international randomised studies Z-FAST, ZO-FAST and E-ZO-FAST were performed to evaluate the bone protective effects of zoledronic acid (ZOL). These studies showed that the bone mineral density (BMD) loss associated with AI therapy can effectively be prevented by ZOL. In addition, these studies included disease-free survival (DFS) as a secondary endpoint, although the studies were not powered to detect a difference between treatment arms. Following the results from ABCSG 12 indicating a powerful effect of ZOL in premenopausal women receiving endocrine therapy, exploratory analyses of the individual trials have been done. However, this is the first report of DFS outcome for all three studies.Materials and Methods: Across the three studies 2194 patients(pts) with HR+ EBC were randomised to either immediate ZOL 4mg every 6 months or delayed ZOL where bone protection was started if either the BMD T-score fell below < -2.0 SD or a non-traumatic fracture occurred. DFS was defined as time to first appearance of breast cancer recurrence or death from any cause. Pts in ZO-FAST and E-ZO-FAST, but not in Z-FAST, were followed for recurrence and survival after stopping study drug. DFS was summarized by the Kaplan-Meier method and compared between the two groups using the log-rank test, stratified by baseline BMD and adjuvant chemotherapy. A Gail-Simon test was performed to assess interactions between treatment and study on DFS.Results: Median follow up times for this analysis are 54, 48 and 36 months respectively for Z-FAST, ZO-FAST and E-ZO-FAST. The proportion of pts with a follow-up lag time of ≥ 6 months was 29.7% Z-FAST, 8.3% ZO-FAST and 8.7% E-ZO-FAST. The pt-years of time on study for both arms combined were calculated; Z-FAST 2709; ZO-FAST 4260 and E-ZO-FAST 1580. The percent of pts starting ZOL in the delayed ZOL arm was: Z-FAST 26%, ZO-FAST 25%, and E-ZO-FAST 17%. The Gail-Simon test was statistically significant for a quantitative interaction between studies (p-value 0.047). Therefore, combining the results was not considered statistically appropriate. Numbers of recurrences and individual trial hazard ratios are shown below.Table 1 No of PatientsImmediateDelayedHR (95% CI)p valueZ-FAST60222260.80 (0.45-1.41)NSZO-FAST106532530.59 (0.38-0.92)0.0176E-ZO-FAST52719111.76 (0.83-3.69)NS Conclusion: This exploratory analysis of DFS has several limitations: a small number of pt events, differences between trials in the method of collecting pt follow up data on DFS and length of median follow-up times, a wide range of pt-years on study, and a statistically significant interaction between studies, reflecting the heterogeneity of results. Also, the use of a ZOL delayed arm as active control limits a direct assessment to that of no ZOL. Additional analyses are planned when the studies are completed. Results from ongoing appropriately powered randomised studies are awaited to determine the true role of adjuvant ZOL in EBC. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4082.

Four trainees describe their expectations, experiences and learning from their clinical placement with older people as part of their doctoral course in clinical psychology.

A fatal case of myocarditis in a neonate is described. The clinical features were evident at birth, and enteroviral RNA was detected in the blood of the baby on the day of birth and again 10 days later by a generic enterovirus nested reverse transcription-polymerase chain reaction (RT-PCR) assay. The enterovirus RNA was subsequently retested by a separate, newly developed nested RT-PCR assay yielding a PCR product within the VP1 coding region suitable for sequencing. Identical 239-base pair sequences were obtained from the RNA of the two blood samples and this sequence most closely resembled coxsackievirus B3 (94% identity). The baby's mother was pyrexial immediately postpartum and an early antenatal serum and a serum sample collected 10 days postpartum tested in parallel for enterovirus IgM antibody showed negative to strong-positive seroconversion. Infection of the mother was the likely primary event with in utero transfer of the virus to the fetus in the last few days of pregnancy. Neonatal blood is a valuable specimen for enterovirus diagnosis by RT-PCR. A newly developed nested RT-PCR assay was successful in typing the enterovirus from stored RNA extracted directly from the blood samples. Serology for enterovirus IgM antibody can be useful for convalescent diagnosis of enterovirus infection in the mother, especially with earlier serum for comparison.

In order to review the literature on children's consent, we need to be clear about the concepts involved. This paper attempts to define some of these concepts, and to point out the need to distinguish legal from clinical use of terms. It will review the sparse recent empirical research in this area, and also highlight two important papers describing new approaches to children's consent. The authors suggest that children's competence is not all-or-nothing, but is gradually developed. They suggest using both individual and systemic models in concert when obtaining consent from children. There is a need for more empirical research into children's consent, particularly in the field of mental health.

There has been a steady increase in referrals of patients with multidrug-resistant tuberculosis (MDR-TB) who are human immunodeficiency virus (HIV) negative. Between 1986 and 1999, 40 patients were admitted to the authors' institution, eight of whom were admitted between January and June 1999. The management of such individuals is difficult. Although they are a clinically and epidemiologically important group of patients, few reports detail their management. To review the demographics, clinical management and long term outcome of 40 non-HIV-infected individuals with MDR-TB referred to the only specialized TB inpatient service in Ontario. Clinical hospital records were reviewed. Twenty-one men and 19 women (mean age 41+/-18 years) were admitted between January 1986 and June 1999 with MDR-TB and negative serology for HIV. Thirty-eight patients (95%) were born outside of Canada. Twenty-six patients (65%) had a history of previous TB. All were symptomatic with productive cough and positive sputum smears for acid-fast bacilli. There was a delay of 4.5 months between the initial diagnosis of TB and the recognition of the presence of MDR-TB. Four patients (10%) had TB resistant to isoniazid and rifampin only. Over 50% of patients had TB with additional resistance to streptomycin, and over 40% had additional resistance to ethambutol. Coexisting resistance was also found in significant numbers for pyrazinamide, ethionamide, para-aminosalicylic acid and cycloserine. Bacteriological conversion was achieved in 34 patients (85%). Six patients underwent surgical resection for localized lung disease. Twenty-four patients completed treatment and have remained free of disease for 33+/-25 months. All five patients (12%) who died had longstanding disease before their referral. MDR-TB is most frequently seen among immigrants with a previous history of TB, especially if they come from countries in which TB is highly prevalent. Outcome can be improved by a more timely recognition of MDR-TB.

In 1986 Spain became a member of the European Economic Community. Since then an increasing number of Spanish doctors have come to the UK seeking specialist training. This article gives a brief account of their experience.