Proctalgia

=anal pain.

Rule out anal fissure (may be hard to see but bleeding or sentinel pile are clues, typically caused by constipation), thrombosed haemorrhoid, infection.

After that, functional (see Rome criteria)- often triggered by defaecation or sitting.

Classifed as acute (less than 20 mins – “fugax”) or chronic (greater than 20 mins episodes). Latter thought to be due to paradoxical pelvic floor contraction.

Biofeedback has best evidence but consider tricyclic antidepressants, Botox, and sacral nerve stimulation (!).

Testosterone

Should be only low levels until puberty kicks in.

Most of the research into testosterone and aggression comes from adults.

Some small studies have found a link between testosterone levels in children and aggression, particularly in boys, but not all. Similarly some studies have suggested low cortisol in association with aggression, but other studies have found links to high cortisol.

A small study of pre pubertal and pubertal children (boys and girls) found testosterone levels were associated with high moodiness and low attachment. Testosterone was also associated with low sociability, but only in the prepubertal group. 

One study suggested that the influence of these hormones can modulate the balance of aggressive tendencies and empathy, with cortisol being relevant only to boys and testosterone only to girls.

All these studies at high risk of bias.

Primum non nocere

“First do no harm” – fundamental of medical ethics.

Except dubious origins… The Latin makes people think it’s Hippocrates and in the Hippocratic oath – but Hippocrates was Greek and it’s not in the oath. He does say something pretty similar in the Epidemics.

Not in the Oxford English Dictionary. Well known in America in the 1930s.

1860 Medical Textbook by Inman says it comes from Thomas Sydenham, but not found in his work, and no one else confirms this. But Sydenham did like Latin.

Florence Nightingale says it in English in the preface to her book on hospitals but not in Latin.

Jack Eckert reckons it was the Latin versions of Hippocrates that started to circulate as printed versions that gave rise to the expression. But still odd that rarely used in either English or Latin until second half of 20th century.

Of course, it isn’t a great principle in any case. Most of medicine is a risk:benefit calculation, rather than avoidance of any possible harm.

Lots more discussion in Cedric Smith’s article.

Scabies

Serpiginous burrows between the fingers, in the flexures of the wrist, genitalia etc characteristic but rare. More usually papules, pustules – pruritus often on unaffected skin and esp at night. In infants, lesions on head, nappy area, occ palms and soles.

Caused by the mite sarcoptes scabiei, which does not fly or jump – direct skin contact, mostly. Infection by contact with fomites is very rare.

Rash is partly hypersensitivty so not related to number of mites, may take several weeks after inital infestation to appear – on reinfection just a few days. Cross reaction with related house dust mite.

Topical steroids will mask rash/itch. Superinfection common. Differential is contact dermatitis, animal scabies (do not form burrows, do not complete life cycle so self limited), lichen planus.

Rarely, nodular form (esp groin, axillae) – hypersensivity reaction. 

Norwegian or crusted scabies esp immunosuppressed (but not necessarily) – psoriaform, not always itchy, very infectious.

Treat with Permethrin 5% (=Lyclear) dermal cream [Permethrin 1% rinse cream ineffective in scabies cf head lice]. Safe in infants (rarely CNS side effects). An alternative treatment is Malathion (safe in pregnancy). All household members should be treated simultaneously. After treatment the itching from scabies can take weeks to settle. Treatment should be extended to the scalp, neck, face and ears in children up to the age of 2 years. All skin surfaces should have the agent applied for 24 hours for malathion and for 8-12 hours for Permethrin 5% and have treatment repeated at 7 days.

Oral ivermectin in single dose is effective in over 70%, given twice 2 weeks apart 95% effective. Use for crusted (along with keratolytics), epidemics. Lancet Infectious Diseases Volume 6, Number 12, December 2006

HACEK organisms

Group of similar gram negative, low pathogenicity organisms – not actually related to each other, but cause similar infections:

  • Haemophilus (usually parainfluenzae, not H. influenzae which rarely causes endocarditis)
  • Aggregatibacter actinomycetemcomitans (prev Actinobacillus)
  • Cardiobacterium hominis
  • Eikenella corrodens
  • Kingella kingae

Commensals of the mouth – usually just cause dental infections but can cause endocarditis (gram positives are the usual cause) and osteomyelitis (esp Kingella – named after Elizabeth King – can be spread by respiratory route, so outbreaks of septic arthritis!).

May grow on chocolate agar but not the McConkey you usually use for gram negatives. Some beta-lactamase but most susceptible to cefalosporins.

Cowden syndrome

Autosomal dominant, PTEN gene (10q23). See OMIM.

Clinically –

  • Macrocephaly
  • Skin lesions – esp hamartomatous. Eg trichilemmomas (smooth, skin coloured, warty or dome like lesions, esp face), acral keratoses (ie on hands), papillomatous papules)
  • Increased risk for the development of breast, thyroid, and endometrial carcinoma

In some cases intestinal polyps, papilloedema, immunodeficiency.

LTP allergy

Lipid transfer protein. One of the allergen families. Cross reactions therefore seen with fruit (stoned fruit but also raspberry), nuts, seeds (eg linseed/flaxseed), pulses, even cereals, tomatoes, vegetables (lettuce! Cabbage!). You may also see reactions only to composite foods eg pizza, curry, due to multiple allergens being present, but only producing reaction due to co-factors.

A less common cause of Pollen food syndrome than PR10 allergy. Thought of as a Mediterranean thing but increasing reports from Northern and Western Europe. Plane tree and mugwort have LTP but not thought to be the usual cause for sensitisation (except maybe in China). In N/W Europe, often birch sensitised too but not to be confused with PR10 type PFS!

Important to identify because heat stable (so not affected by heat, processing, digestion etc in the way PR10 allergens are) and potential for severe reactions.

So do component testing if atypical (eg unusually severe) reactions to fruit.

LTP allergy also seems to be more likely to cause reactions of varying severity, compared with primary food allergy, with co-factors perhaps more important. Eating multiple different plant foods at the same time seems to be the most likely cause of co-factor associated severe reactions. Of course, co-factors can co-exist too (alcohol and dancing, for example). So some would advise:

  • Avoid exercise for 2 hours before (more in same cases) and 4 hours after eating
  • Avoid NSAIDs for 2 hours before and 2 hours after
  • Avoid alcohol with food or after
  • Eat cautiously if not had for many months
  • (sleep deprivation, cannabis, stress, fasting, anti-reflux medication…)

Diagnosis

Danger that with LTP allergy you show sensitisation to multiple foods, and then you end up on a restricted diet without knowing whether there is allergy or not.

Peach allergen Pru p 3 is a good surrogate for LTP allergy, even if peach hasn’t been a problem! If not available, you could test with SPT reagent for peach that is rich in pru p 3 (but might be false positive due to other components being present. London plane and mugwort allergy would also support.

Wheat is a bit tricky – the wheat LTP Tri a 14 is only 45% homologous with Pru p 3 so may get missed. Given the co-factor issue, probably good to do Tri a 19 (omega 5 gliadin, as in exercise induced anaphylaxis) as well.

Where hay fever and atypical reactions to nuts, do the LTPs Ara h 9 (peanut), Cor a 8 (hazelnut), Jug r 3 (walnut). You would do the other components to exclude primary food allergy which can co-exist with LTP sensitisation.

Food challenges have limited use in this situation – if positive, unclear whether LTP is the cause, and if negative, perhaps because of co-factor issue! Exercise challenge?? May just need a bigger dose!

Management

Individualize, to balance risk of reaction against dietary restriction.

Safest fruit/veg appear to be potato, carrot/root vegetables, beans, peas, melon, cashew and pistachio. Avoid pips and skin. Banana is hit and miss.

Good results with Pru p 3 sublingual and oral peach juice immunotherapy in Spain and Portugal.

McCulloch case

Clarifies an aspect of the Montgomery decision in a way that supports healthcare professionals getting consent. The decision can be found here.

In Montgomery, the Supreme Court said that a doctor ‘is under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments’. In the McCulloch case, the Supreme Court was asked to decide what legal test was applicable when assessing whether an alternative treatment was ‘reasonable’. Was it the Montgomery test or was it the Hunter –v- Hanley test? Put another way, was the decision about whether to discuss an alternative treatment with a patient one of clinical judgement, or was it one for the Court to assess and determine?

The decision was that a doctor (or other healthcare professional) who has decided that a treatment is not a ‘reasonable alternative treatment’ for a particular patient will not be negligent in failing to inform the patient of that alternative treatment if the doctor’s view is supported by a responsible body of medical opinion. In other words, this decision involves an exercise of clinical judgement and any challenge to that decision by a patient is therefore to be determined by the Hunter –v- Hanley test. In the circumstances of the McCulloch case, the application of that legal test resulted in the claim being rejected by the Court.

The court said this:

“Taking a hypothetical example – say that there are ten possible treatment options; the doctor, exercising his or her clinical judgment, decides that only four of them are reasonable and that decision to rule out six is supported by a responsible body of medical opinion. The doctor is not negligent by failing to inform the patient about the other six even though they are possible alternative treatments.

“The narrowing down from possible alternative treatments to reasonable alternative treatments is an exercise of clinical judgment to which the professional practice test should be applied. The duty of reasonable care would then require the doctor to inform the patient not only of the treatment option that the doctor is recommending but also of the other three reasonable alternative treatment options (plus no treatment if that is a reasonable alternative option) indicating their respective advantages and disadvantages and the material risks involved in each treatment option.”

[Michael Stewart, Central Legal Office]