Herpes simplex virus type 2 encephalitis in an elderly immunocompetent male

An 85-year-old immunocompetent man was hospitalized following the development of increasing confusion and intermittent disorientation over a 48-hour period. Within 48 hours of hospitalization, he was oriented to person only and was unable to follow commands. There were no focal neurologic deficits. Magnetic resonance imaging of the brain showed extensive perivascular demyelination. Lumbar puncture was performed and showed normal opening pressure. Cerebrospinal fluid analysis showed 8 leukocytes (7 lymphocytes), as well as normal glucose and protein levels. Polymerase chain reaction evaluation of cerebrospinal fluid was positive for herpes simplex virus type 2. He was diagnosed with herpes simplex type 2 encephalitis and is to the authors' knowledge the first elderly immunocompetent patient to be reported with this disorder.     

Spontaneous cholesterol crystal embolization to bone marrow

Cholesterol crystal embolization is a well-established complication of arterial trauma and anticoagulation which may involve multiple organs including the skin and muscle, producing clinical features such as livedo reticularis, cyanosis and gangrene of the toes and intense myalgias. Cholesterol crystal embolization to bone marrow has been described in postmortem studies, but has been previously reported premortem in only two patients, both of whom had characteristic risk factors and clinical features. We report herein a case of spontaneous cholesterol crystal embolization to bone marrow in a patient with atypical clinical manifestations.     

Evaluation of emergency medical dispatch in out-of-hospital cardiac arrest in Taipei

INTRODUCTION: Emergency medical dispatchers are the entry points to the emergency medical services (EMS). The overall performances of the dispatchers are imperative determinants of the emergency medical services dispatching system. There is little data on the cultural and language impacts on emergency medical dispatch. OBJECTIVE: This study examined the emotional content and cooperation score (ECCS) among Mandarin Chinese speaking callers for cardiac arrests, and evaluated the performances of emergency medical services dispatching system in Taipei. METHODS: This retrospective, observational study examined dispatching audio recordings obtained from the Taipei City Fire Department Dispatching Center between January 2004 to April 2004. The tapes of call relating to adult (age >or=18 years), non-traumatic cases with a presumed or field diagnosis of out-of-hospital cardiac arrest (OHCA) underwent systemic review. The caller's ECCS and the dispatcher's performances, including interview skills, provision of telephone-assisted cardiopulmonary resuscitation (T-CPR), and dispatcher's ability to identify OHCA were examined. Interrater reliability for determining ECCS and interview skills were assessed using kappa statistic. RESULTS: A total of 199 audio recordings were reviewed. A mean ECCS of 1.42+/-0.64 (95% CI: 1.33-1.51) demonstrated that most callers were emotionally stable and cooperative when calling for help, even when facing cardiac arrest patients. There was a good association between ECCS and the sex of the callers (male 1.32 versus female 1.49; p<0.05). In 82% of interviews, the interview skills of the dispatchers was high (4 or 5 points); while in one fifth the interview skills were suboptimal. About one third of the cases were provided with T-CPR by the dispatchers. The sensitivity and positive predictive value (PPV) for predicting OHCA by dispatchers were 96.9% and 97.9%, respectively. A kappa value of 0.65 and 0.68 were obtained for the interrater reliability of ECCS and interview skills. CONCLUSION: Most callers were found to be emotional stable and cooperative with dispatcher's interrogations when calling for cardiac arrest victims in this Mandarin speaking population. The dispatchers have shown satisfactory interview skills in approaching emergency calls and a good ability to identify OHCA. There is a low rate of T-CPR offered to the callers in the investigation. Efforts should be made to address the deficiencies in order to maximise the function of the EMS.     

Increasing vigilance on the medical/surgical floor to improve patient safety

AIM: This paper reports a study designed to assess an automated non-invasive, patient vigilance system, the (L)G(1TM) system, for determining heart rate and respiration rate. The study uses collected data to optimize the (L)G(1TM)'s alert management scheme for medical/surgical wards. BACKGROUND: Thousands of patients die unnecessarily each year because of compromised patient safety in hospitals. Economic pressures to reduce hospitalization costs, exacerbated by increasing nursing shortages, have created a need for new approaches to patient vigilance. Advanced technologies may help nurses to provide high-quality care while controlling costs and improving patient safety. METHODS: Heart and respiration waveforms from 287 patients were captured by sensor arrays embedded in the mattress coverlets of their beds. No real-time monitoring was performed. Raw data were processed by proprietary algorithms and compared with data captured by a standard reference device. Alert performance was verified by hand-scoring the signal data and matching it against clinical events observed through a systematic review of each patient's medical record. The data were collected between June 2004 and February 2005. RESULTS: Experimental algorithms for heart rate had an accuracy of -1.47 (sd 1.90) and a precision of 4.60 (sd 2.46). Respiration rate algorithms showed an accuracy of -0.94 (sd 1.26) and a precision of 4.02 (sd 1.17). Algorithms identified 178 true-positive physiological alerts on 15 patients. None of the events was deemed clinically significant at chart review. The combined false-positive alert rate for the algorithms was 0.007 events per hour. CONCLUSION: This study demonstrates the accuracy and precision of the signal processing algorithms in the (L)G(1TM) system. Future work will focus on assessing the system's impact on patient outcomes and its integration into the nursing workflow.     

Conservative aesthetic techniques for discoloured teeth: 2. Microabrasion and composite

The first article in this series discussed the minimal intervention approach to discoloured teeth, starting with dental bleaching. This second article goes on to explain the technique of microabrasion and the use of direct composite techniques. CLINICAL RELEVANCE: Microabrasion and composite can provide minimally invasive treatments for discoloured teeth.     

Dominant-negative effect of the heterozygous C104R TACI mutation in common variable immunodeficiency (CVID)

B cells from patients with common variable immunodeficiency (CVID) who are heterozygous for transmembrane activator and CAML interactor (TACI) mutation C104R, which abolishes ligand binding, fail to produce Igs in response to TACI ligand. It is not known whether this is due to haploinsufficiency or dominant interference. Using in vitro transfection assays, here we demonstrate that C104R and the corresponding murine TACI mutant, C76R, which also does not bind ligand, dominantly interfere with TACI signaling. This effect was dependent on preassociation of the mutants with WT TACI in the absence of ligand. The mutants did not interfere with ligand binding by WT TACI, suggesting that they may act by disrupting ligand-induced receptor rearrangement and signaling. This work demonstrates that TACI preassembles as an oligomeric complex prior to ligand binding and provides a mechanistic insight into how the heterozygous C104R TACI mutation can potentially lead to CVID.