Longitudinally extensive transverse myelitis as the sole presentation of neuro-Behçet's disease responding to infliximab

Context

Isolated involvement of the spinal cord is an uncommon presentation of neuro-Behçet''s disease (NBD) and it is associated with a poor prognosis for functional recovery.

Method

A case report of an 18-year-old Turkish man who presented with a progressive paraparesis and bladder dysfunction secondary to a longitudinally extensive transverse myelitis as the sole presentation of NBD.

Findings

Examination revealed a spastic paraparesis and a T7 sensory level. Magnetic resonance imaging revealed multiple enhancing lesions throughout the thoracic cord and cerebrospinal fluid showed intense neutrophilia. On further enquiry a family history of Behçet''s disease was elicited. The patient subsequently reported a history of recurrent oral ulceration and intermittent occular inflammation. A diagnosis of NBD was made and intravenous high-dose steroids commenced with poor response. In view of the poor prognosis for functional recovery associated with spinal NBD the patient was treated with infliximab, an anti-tumour necrosis factor-alpha monoclonal antibody, leading to excellent recovery of function.

Conclusion/clinical relevance

Early treatment with infliximab may facilitate a favourable functional recovery and should be considered in cases of NBD with spinal cord involvement.     

Medical conditions among Iraqi refugees in Jordan: data from the United Nations Refugee Assistance Information System

Objective

To determine the range and burden of health services utilization among Iraqi refugees receiving health assistance in Jordan, a country of first asylum.

Methods

Medical conditions, diagnosed in accordance with the tenth revision of the International classification of diseases, were actively monitored from 1January to 31December 2010 using a pilot centralized database in Jordan called the Refugee Assistance Information System.

Findings

There were 27 166 medical visits by 7642 Iraqi refugees (mean age: 37.4 years; 49% male; 70% from Baghdad; 6% disabled; 3% with a history of torture). Chronic diseases were common, including essential hypertension (22% of refugees), visual disturbances (12%), joint disorders (11%) and type II diabetes mellitus (11%). The most common reasons for seeking acute care were upper respiratory tract infection (11%), supervision of normal pregnancy (4%) and urinary disorders (3%). The conditions requiring the highest number of visits per refugee were cerebrovascular disease (1.46 visits), senile cataract (1.46) and glaucoma (1.44). Sponsored care included 31 747 referrals or consultations to a specialty service, 18 432 drug dispensations, 2307 laboratory studies and 1090 X-rays. The specialties most commonly required were ophthalmology, dentistry, gynaecology and orthopaedic surgery.

Conclusion

Iraqi refugees in countries of first asylum and resettlement require targeted health services, health education and sustainable prevention and control strategies for predominantly chronic diseases.     

Estimating the Burden of Maternal and Neonatal Deaths Associated With Jaundice in Bangladesh: Possible Role of Hepatitis E Infection

Objectives. We estimated the population-based incidence of maternal and neonatal mortality associated with hepatitis E virus (HEV) in Bangladesh.Methods. We analyzed verbal autopsy data from 4 population-based studies in Bangladesh to calculate the maternal and neonatal mortality ratios associated with jaundice during pregnancy. We then reviewed the published literature to estimate the proportion of maternal deaths associated with liver disease during pregnancy that were the result of HEV in hospitals.Results. We found that 19% to 25% of all maternal deaths and 7% to 13% of all neonatal deaths in Bangladesh were associated with jaundice in pregnant women. In the published literature, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV.Conclusions. Jaundice is frequently associated with maternal and neonatal deaths in Bangladesh, and the published literature suggests that HEV may cause many of these deaths. HEV is preventable, and studies to estimate the burden of HEV in endemic countries are urgently needed.Hepatitis E virus (HEV) infection is endemic in Asia and many parts of Africa, where it is a leading cause of sporadic and epidemic acute hepatitis.1–3 HEV is primarily transmitted through the fecal–oral route, and outbreaks in endemic areas are typically associated with contaminated drinking water sources.4–13 Clinically, it is indistinguishable from other causes of acute viral hepatitis, and jaundice, the yellowing of the eyes and skin, is the most common clinical feature.14 Jaundice is caused by a buildup of bilirubin, a product of dying red blood cells, in the blood. The healthy liver removes bilirubin from the blood, but when the liver’s ability to process bilirubin is impaired, the buildup occurs. Additional clinical signs and symptoms include anorexia, malaise, fever, dark urine, vomiting, and stomach pain.14 Adults are more likely to have HEV disease and antibodies to HEV than are children in endemic areas, which is unexpected given the young ages at which most people are exposed to other enteric pathogens in low-income countries.15In general, fewer than 1% of patients with clinical HEV die, but case fatality ratios among pregnant women have been reported to be as high as 6% to 20%.12,14,16–18 A high case fatality rate among pregnant women is a characteristic feature of HEV that has not been observed for other etiologies of acute viral hepatitis.19 Pregnant women whose deaths are associated with HEV typically die of hemorrhage or hepatic neuropathy.20,21 The few studies that investigated vertical transmission of HEV noted that neonates born to mothers with HEV infections were frequently infected and often died from complications such as prematurity, liver failure, hypothermia, or hypoglycemia.21–25Hepatitis is not considered to be an important cause of maternal or neonatal mortality globally,26–28 but some data suggest that acute hepatitis might significantly contribute to maternal mortality in HEV endemic countries. A retrospective, community-based study of maternal mortality from southern India reported that 11% of maternal deaths were attributable to infectious hepatitis, resulting in a maternal mortality ratio of 8 per 1000 live births.29 Another record review of maternal mortality from Ethiopia concluded that 15% of maternal deaths were the result of infectious hepatitis.30 An autopsy study from India found that the most common cause of maternal deaths at 1 large hospital was acute viral hepatitis, which accounted for 42% of all maternal deaths.31 Notably, none of these studies provided evidence about the etiology of these hepatitis illnesses, so it is not known if they were caused by HEV. However, given that HEV is a particularly fatal cause of acute hepatitis among pregnant women,19 the possibility that HEV could meaningfully contribute to maternal mortality in these countries should be considered.However, to our knowledge, no studies have attempted to quantify the burden of HEV-associated maternal and neonatal mortality. In low-income countries in Asia and Africa where HEV is commonly found,1–3 population-based estimates of mortality usually come from verbal autopsy studies that use structured questionnaires to interview relatives of the deceased about signs and symptoms of illness before death, and then use coding algorithms to determine cause of death based on the interview data.32 The verbal autopsy questionnaires include questions about new onset of jaundice before death in pregnant women, or new onset of jaundice in the mother as a complication of pregnancy for neonatal deaths. Thus, data from verbal autopsy studies can be used to calculate population-based estimates of maternal and neonatal mortality associated with jaundice. However, the nature of these data precludes conclusions about deaths from specific infectious etiologies, such as HEV. Hospital-based studies can provide important information about etiologic causes of maternal and neonatal deaths associated with jaundice that occur in hospital settings of HEV endemic countries. We investigated the possible contribution of HEV to maternal and neonatal mortality by analyzing data from 4 population-based verbal autopsy studies in Bangladesh and comparing these data with the published literature from hospital-based studies of the etiologic causes of jaundice-associated deaths during pregnancy.     

Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh

Started in 2007, the Sanitation Hygiene Education and Water Supply in Bangladesh (SHEWA-B) project aims to improve the hygiene, sanitation and water supply for 20 million people in Bangladesh, and thus reduce disease among this population. This paper assesses the effectiveness of SHEWA-B on changing behaviors and reducing diarrhea and respiratory illness among children < 5 years of age. We assessed behaviors at baseline in 2007 and after 6 months and 18 months by conducting structured observation of handwashing behavior in 500 intervention and 500 control households. In addition we conducted spot checks of water and sanitation facilities in 850 intervention and 850 control households. We also collected monthly data on diarrhea and respiratory illness from 500 intervention and 500 control households from October 2007 to September 2009. Participants washed their hands with soap < 3% of the time around food related events in both intervention and control households at baseline and after 18 months. Washing both hands with soap or ash after cleaning a child's anus increased from 22% to 36%, and no access to a latrine decreased from 10% to 6.8% from baseline to 18 months. The prevalence of diarrhea and respiratory illness, among children <5 years of age were similar in intervention and control communities throughout the study. This large scale sanitation, hygiene and water improvement programme resulted in improvements in a few of its targeted behaviors, but these modest behavior changes have not yet resulted in a measurable reduction in childhood diarrhea and respiratory illness.     

Antibacterial resistance and their genetic location in MRSA isolated in Kuwait hospitals, 1994-2004

Background  

Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a major cause of serious infections in hospitals and in the community worldwide. In this study, MRSA isolated from patients in Kuwait hospitals were analyzed for resistance trends and the genetic location of their resistance determinants.     

Patient doses from computed tomography in Manitoba from 1977 to 1987

The number of patients undergoing computed tomographic (CT) examinations in the province of Manitoba is reported for the period 1977-1987. The annual patient throughput has increased from 4.2 per 10(3) population in 1978 to 18.2 per 10(3) population in 1987. Over the same period, the per capita population dose from CT has increased from 4.2 to 81.0 microSv. This substantial rise has occurred because of an increase in patient throughput, higher radiation doses associated with modern CT scanners and an increasing proportion of (higher dose) body CT studies. The mean patient dose on a second generation (EMI 5005) scanner was about 1.4 mSv, whereas the corresponding doses on third generation scanners operating in Manitoba were 3.9 mSv (GE 9800) and 5.6 mSv (Siemens DRH).     

Contribution of the Ventral Subiculum to Inhibitory Regulation of the Hypothalamo-Pituitary-Adrenocortical Axis

Anatomical studies indicate that the ventral subiculum is in a prime position to mediate hippocampal inhibition of the hypothalamo-pituitary-adrenocortical (HPA) axis. The present study evaluated this hypothesis by assessing HPA function following ibotenic acid lesion of the ventral subiculum region. Rats with lesions of the ventral subiculum (vSUB) or ventral hippocampus (vHIPPO) did not show changes in basal corticosterone (CORT) secretion at either circadian peak or nadir time points when compared to sham-lesion rats (SHAM) or unoperated controls. However, rats with vSUB lesions exhibited a prolonged glucocorticoid stress response relative to all other groups. Baseline CRH mRNA levels were significantly increased in the medial parvocellular paraventricular nucleus (PVN) of the vSUB group relative to controls. CRH mRNA differences were particularly pronounced at caudal levels of the nucleus, suggesting topographic organization of vSUB interactions with PVN neurons. Notably, the vHIPPO group, which received large lesions of ventral CA1, CA3 and dentate gyrus without significant subicular damage, showed no change in stress-induced CORT secretion, suggesting that the ventral subiculum proper is principally responsible for ventral hippocampal actions on the HPA stress response. No differences in medial parvocellular PVN AVP mRNA expression were seen in either the vSUB or vHIPPO groups. The results indicate a specific inhibitory action of the ventral subiculum on HPA activation. The increase in CRH biosynthesis and stress-induced CORT secretion in the absence of changes in baseline CORT secretion or AVP mRNA expression suggests that the inhibitory actions of ventral subicular neurons affect the response capacity of the HPA axis.     

The fibroblast growth factor system and mood disorders.

Recent evidence now suggests the involvement of the fibroblast growth factor (FGF) system in mood disorders. Specifically, several members of the FGF family have been shown to be dysregulated in individuals with major depression. In this review, we will introduce the FGF system in terms of structure and function during development, in adulthood, and in various regions and cell types. We will also review the FGF system as a mediator of neural plasticity. Furthermore, this review will summarize animal as well as human studies. The majority of animal studies have focused on stress, environmental enrichment, pharmacological manipulations, and the hippocampus. By contrast, human studies have focused on volumetric measurements, antidepressant literature, and, most recently, post-mortem microarray experiments. In summary, a reduced tone in the FGF system might alter brain development or remodeling and result in a predisposition or vulnerability to mood disorders, including major depression.