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Each year, the Nuffield Department of Medicine awards prizes to its graduate research students for various achievements, including success in terms of discoveries and published work, significant achievements in establishing infrastructure, success in strongly collaborative projects, and involvement in public engagement and other departmental activities.
Tetanus.
Tetanus is a vaccine-preventable disease that still commonly occurs in many low-income and middle-income countries, although it is rare in high-income countries. The disease is caused by the toxin of the bacterium Clostridium tetani and is characterised by muscle spasms and autonomic nervous system dysfunction. Global vaccination initiatives have had considerable success but they continue to face many challenges. Treatment for tetanus aims to control spasms and reduce cardiovascular instability, and consists of wound debridement, antitoxin, antibiotics, and supportive care. Recent research has focused on intravenous magnesium sulphate and intrathecal antitoxin administration as methods of spasm control that can avoid the need for ventilatory support. Nevertheless, without access to mechanical ventilation, mortality from tetanus remains high. Even with such care, patients require several weeks of hospitalisation and are vulnerable to secondary problems, such as hospital-acquired infections.
Catastrophic health care expenditure due to septic shock and dengue shock in Vietnam
Abstract Background The cost of treatment for infectious shock in intensive care in Vietnam is unknown. Methods We prospectively investigated hospital bills for adults treated for septic and dengue shock in Vietnam and calculated the proportion who faced catastrophic health care expenditures. Results The median hospital bills were US$617 for septic shock (n=100) and US$57 for dengue shock (n=88). Catastrophic payments were incurred by 47% (47/100) and 13% (11/88) of patients with septic shock and dengue shock, respectively, and 56% (25/45) and 84% (5/6) fatal cases of septic shock and dengue shock respectively. Conclusions Further advocacy is required to moderate insurance co-payments for costly critical care interventions.
Urinary catecholamine excretion in tetanus
Summary Imperfect understanding of the pathophysiology of tetanus has limited therapeutic advances. Autonomic disturbance is a major cause of mortality and is believed to be associated with catecholamine release, predominantly norepinephrine. We measured epinephrine and norepinephrine concentrations in 24‐h urine collections from tetanus and critically ill patients suffering from other severe diseases. In patients with severe tetanus, mean (SD) epinephrine was 164.18 (129.37) nmol.day −1 compared with 45.18 (37.74) nmol.day −1 in mild‐moderate disease (p = 0.008). In the severe group, mean (SD) norepinephrine was 411.64 (208.5), and 121.00 (81.81) nmol.day −1 in moderately ill patients (p < 0.001). Compared with critically ill control patients, median epinephrine was 331.77 in tetanus patients and 89.70 nmol.day −1 in controls (p < 0.001). Median norepinephrine concentration was 788.02 nmol.day −1 in tetanus and 300.05 nmol.day −1 in control patients, p = 0.006. The study finds a novel result of increased epinephrine excretion in tetanus and confirms that catecholamine excretion in tetanus exceeds that in other critically ill patients. These results should be considered in designing more effective therapeutic strategies.
Predicting the clinical outcome of tetanus: the tetanus severity score
SummaryObjectives To create a new tetanus score and compare it with the Phillips and Dakar scores.Methods We used prospectively acquired data from consecutive patients admitted to the Hospital for Tropical Diseases, Ho Chi Minh City, to create the Tetanus Severity Score (TSS) with multivariate logistic regression. We compared the new score with Phillips and Dakar scores by means of resubstituted and prospective data, assessing performance in terms of sensitivity, specificity and area under receiver operator characteristic curves.Results Resubstitution testing yielded a sensitivity of 77% (298/385) and a specificity of 82% (1183/1437) for the TSS; 89% (342/385) and 20% (281/1437) for the Phillips score; and 13% (49/385) and 98% (1415/1437) for the Dakar score. The TSS showed greatest discrimination with 0.89 area under the receiver operator characteristic curve (95% CI 0.88–0.90); this was 0.74 for the Dakar score and (95% CI 0.71–0.77) and 0.66 for the Phillips score (95% CI 0.63–0.70; P values <0.001). Prospective testing showed 65% (13/20) sensitivity and 91% (210/230) specificity for the TSS; 80% (16/20) and 51% (118/230) for the Phillips score; and 25% (5/20) and 96% (221/230) for the Dakar score. The TSS achieved the greatest area under TSS of 0.89 (95% CI 0.82–0.96), significantly greater than the Phillips score [0.74 (0.6–0.88), P = 0.049] but not the Dakar score [0.80, (0.71–0.90), P = 0.090].Conclusions The TSS is the first prospectively developed classification scheme for tetanus and should be adopted to aid clinical triage and management and as a basis for clinical research.
Tetanus in Southern Vietnam: Current Situation
In Vietnam, there are no accurate data on tetanus incidence to allow assessment of disease burden or vaccination program efficacy. We analyzed age structure of 786 tetanus cases admitted to a tertiary referral center in Vietnam for three separate years during an 18-year period to examine the impact of tetanus prevention programs, namely the Expanded Program on Immunization (EPI) and the Maternal and Neonatal Tetanus (MNT) initiative. Most cases were born before the initiation of EPI. Median age increased from 33 (interquartile range: 20–52) in 1994, to 46 (32–63) in 2012 (P < 0.001). Birth-year distribution was unchanged, indicating the same birth cohorts presented with tetanus in 1994, 2003, and 2012. Enzyme-linked immunosorbent assay measurements in 90 men and 90 women covered by MNT but not EPI showed 73.3% (95% confidence interval [CI]: 62.9–82.1%) of women had anti-tetanus antibody compared with 24.4% (95% CI: 15.9–34.7%) of men, indicating continued tetanus vulnerability in older men in Vietnam.