Semi-recumbent body position fails to prevent healthcare-associated pneumonia in Vietnamese patients with severe tetanus

Healthcare-associated pneumonia (HCAP) is a common complication in patients with severe tetanus. Nursing tetanus patients in a semi-recumbent body position could reduce the incidence of HCAP. In a randomised controlled trial we compared the occurrence of HCAP in patients with severe tetanus nursed in a semi-recumbent (30°) or supine position. A total of 229 adults and children (aged ≥1 year) with severe tetanus admitted to hospital in Vietnam, were randomly assigned to a supine (n=112) or semi-recumbent (n=117) position. For patients maintaining their assigned positions and in hospital for>48h there was no significant difference between the two groups in the frequency of clinically suspected pneumonia [22/106 (20.8%) vs 26/104 (25.0%); p=0.464], pneumonia rate/1000 intensive care unit days (13.9 vs 14.6; p=0.48) and pneumonia rate/1000 ventilated days (39.2 vs 38.1; p=0.72). Mortality in the supine patients was 11/112 (9.8%) compared with 17/117 (14.5%) in the semi-recumbent patients (p=0.277). The overall complication rate [57/112 (50.9%) vs 76/117 (65.0%); p=0.03] and need for tracheostomy [51/112 (45.5%) vs 69/117 (58.9%); p=0.04) was greater in semi-recumbent patients. Semi-recumbent body positioning did not prevent the occurrence of HCAP in severe tetanus patients.     

Etoposide (VP 16-213) induced hepatitis. Report of three cases following standard-dose treatments

Acute hepatitis is a potential, although rare, complication following administration of high doses of Etoposide (VP 16-213). We report three cases of severe hepatocellular necrosis following administration of standard doses of this antineoplastic agent.     

Evolutionarily divergent herpesviruses modulate T cell activation by targeting the herpesvirus entry mediator cosignaling pathway

The herpesvirus entry mediator (HVEM), a member of the TNF receptor (TNFR) superfamily, can act as a molecular switch that modulates T cell activation by propagating positive signals from the TNF-related ligand LIGHT (TNFR superfamily 14), or inhibitory signals through the Ig superfamily member B and T lymphocyte attenuator (BTLA). Competitive binding analysis and mutagenesis reveals a unique BTLA binding site centered on a critical lysine residue in cysteine-rich domain 1 of HVEM. The BTLA binding site on HVEM overlaps with the binding site for the herpes simplex virus 1 envelope glycoprotein D, but is distinct from where LIGHT binds, yet glycoprotein D inhibits the binding of both ligands, potentially nullifying the pathway. The binding site on HVEM for BTLA is conserved in the orphan TNFR, UL144, present in human CMV. UL144 binds BTLA, but not LIGHT, and inhibits T cell proliferation, selectively mimicking the inhibitory cosignaling function of HVEM. The demonstration that distinct herpesviruses target the HVEM-BTLA cosignaling pathway suggests the importance of this pathway in regulating T cell activation during host defenses.     

Safety and efficacy of digital rectal examination in patients with acute myocardial infarction

OBJECTIVE: Digital rectal examination (DRE) is often ignored or deferred in acute myocardial infarction (AMI). The aim of this study was to determine the safety and efficacy of DRE in patients with AMI. METHODS: This was a prospective, comparative, stratified study in an inner-city teaching hospital. A total of 480 patients from intensive care and telemetry units were stratified into three groups. Group I included 160 patients with AMI in whom a DRE was performed and electrocardiographic (EKG) recordings were obtained. Group II included 155 patients with AMI in whom DRE was not done, but EKG recordings were made. Group III consisted of 165 patients without AMI in whom DRE was performed and EKG recordings were obtained. Sustained arrhythmias and vital signs were measured. RESULTS: None of the patients developed sustained arrhythmias and there was no change in vital signs. DRE resulted in the detection of several clinically significant findings. CONCLUSION: DRE was found to be safe in our stable patients with AMI.