Weil's Disease from a Local New Orleans Bar.

INTRODUCTION: Leptospirosis is a zoonotic infection that typically presents with fever, myalgias, nausea, and vomiting after contact with contaminated waters or infected animals (typically rodents); and their excrements. Conditions favorable to the transmission of leptospirosis are common in LA and, without treatment, leptospirosis can lead to both liver and renal failure, meningitis, pulmonary hemorrhage and ultimately death. CASE: A 56 year old woman with no past medical history presented to the Emergency Department with weakness, myalgias, jaundice and decreased urine output for one week. On arrival, she appeared septic with a heart rate of 130 and fever. Her exam was significant for significant jaundice and diffuse abdominal pain. Laboratory studies were notable for WBC 14, hemoglobin of 12 and platelet count of 63. Creatinine was 8.5mg/dL with a blood-urea nitrogen of 96mg/dl. Total bilirubin was 19.4mg/dL and direct bilirubin was 13.7mg/dL. AST/ALT were 69/38 U/L, respectively and the alkaline phosphate was 160U/L. The patient was admitted to the hospital medicine wards for sepsis and multi-organ failure. She was started on broad spectrum antibiotics but her clinical condition continued to worsen with progressive decline in her hemoglobin and thrombocytopenia and worsening liver failure. She quickly became anuric necessitating dialysis and developed respiratory distress with bilateral pulmonary infiltrates and hemoptysis. Additional history was obtained from her employer that she works at a local New Orleans bar and had been cleaning out rats from the kitchen. Leptospirosis antibody was sent, which returned as positive. Her antibiotics were de-escalated to IV Ceftriaxone. She made a slow recovery over the next two-week period. DISCUSSION: Since 1987, there has been an average of 3 cases of Leptospirosis diagnosed per year, most of which have been from southeast LA. This case illustrates the importance of considering the diagnosis of Leptospirosis and Weil's Disease in patients in the southeast region of LA who present with multi-organ failure. In addition, our patient's occupational exposure was key to her diagnosis which emphasizes the importance of a detailed history in clinical decision making and patient outcomes.

NEVER SEEMS TO GROW PAINS: A CASE OF SUSPECTED PSEUDOSEPTIC ARTHRITIS.

Pseudoseptic arthritis is an acute inflammatory arthritis found in association with a sterile synovial fluid culture despite white blood cell (WBC) counts >100,000 and >75% polymorph neutrophils. This arthritis occurs most frequently in patients with underlying inflammatory or immune disorders. Early distinction from true septic arthritis can decrease the need for unnecessary antibiotics and improve patient outcomes.

Gene expression alterations at baseline and following moderate exercise in patients with Chronic Fatigue Syndrome and Fibromyalgia Syndrome.

OBJECTIVES: To determine mRNA expression differences in genes involved in signalling and modulating sensory fatigue, and muscle pain in patients with chronic fatigue syndrome (CFS) and fibromyalgia syndrome (FM) at baseline, and following moderate exercise. DESIGN: Forty-eight patients with CFS only, or CFS with comorbid FM, 18 patients with FM that did not meet criteria for CFS, and 49 healthy controls underwent moderate exercise (25 min at 70% maximum age-predicted heart rate). Visual-analogue measures of fatigue and pain were taken before, during and after exercise. Blood samples were taken before and 0.5, 8, 24 and 48 h after exercise. Leucocytes were immediately isolated from blood, number coded for blind processing and analyses and flash frozen. Using real-time, quantitative PCR, the amount of mRNA for 13 genes (relative to control genes) involved in sensory, adrenergic and immune functions was compared between groups at baseline and following exercise. Changes in amounts of mRNA were correlated with behavioural measures and functional clinical assessments. RESULTS: No gene expression changes occurred following exercise in controls. In 71% of patients with CFS, moderate exercise increased most sensory and adrenergic receptor's and one cytokine gene's transcription for 48 h. These postexercise increases correlated with behavioural measures of fatigue and pain. In contrast, for the other 29% of patients with CFS, adrenergic α-2A receptor's transcription was decreased at all time-points after exercise; other genes were not altered. History of orthostatic intolerance was significantly more common in the α-2A decrease subgroup. FM-only patients showed no postexercise alterations in gene expression, but their pre-exercise baseline mRNA for two sensory ion channels and one cytokine were significantly higher than controls. CONCLUSIONS: At least two subgroups of patients with CFS can be identified by gene expression changes following exercise. The larger subgroup showed increases in mRNA for sensory and adrenergic receptors and a cytokine. The smaller subgroup contained most of the patients with CFS with orthostatic intolerance, showed no postexercise increases in any gene and was defined by decreases in mRNA for α-2A. FM-only patients can be identified by baseline increases in three genes. Postexercise increases for four genes meet published criteria as an objective biomarker for CFS and could be useful in guiding treatment selection for different subgroups.

Myalgic encephalomyelitis: International Consensus Criteria.

The label 'chronic fatigue syndrome' (CFS) has persisted for many years because of the lack of knowledge of the aetiological agents and the disease process. In view of more recent research and clinical experience that strongly point to widespread inflammation and multisystemic neuropathology, it is more appropriate and correct to use the term 'myalgic encephalomyelitis' (ME) because it indicates an underlying pathophysiology. It is also consistent with the neurological classification of ME in the World Health Organization's International Classification of Diseases (ICD G93.3). Consequently, an International Consensus Panel consisting of clinicians, researchers, teaching faculty and an independent patient advocate was formed with the purpose of developing criteria based on current knowledge. Thirteen countries and a wide range of specialties were represented. Collectively, members have approximately 400 years of both clinical and teaching experience, authored hundreds of peer-reviewed publications, diagnosed or treated approximately 50 000 patients with ME, and several members coauthored previous criteria. The expertise and experience of the panel members as well as PubMed and other medical sources were utilized in a progression of suggestions/drafts/reviews/revisions. The authors, free of any sponsoring organization, achieved 100% consensus through a Delphi-type process. The scope of this paper is limited to criteria of ME and their application. Accordingly, the criteria reflect the complex symptomatology. Operational notes enhance clarity and specificity by providing guidance in the expression and interpretation of symptoms. Clinical and research application guidelines promote optimal recognition of ME by primary physicians and other healthcare providers, improve the consistency of diagnoses in adult and paediatric patients internationally and facilitate clearer identification of patients for research studies.

Applied technologies in humanitarian assistance: report of the 2009 Applied Technology Working Group.

Information and communication technologies, especially in the forms of mobile telecommunications, satellite imaging, and geographical information systems, promise to significantly improve the practice of humanitarian relief. A working group convened at the Humanitarian Action Summit 2009, has begun investigating the challenges to implementing these technologies in field operations, keeping in mind the ethical considerations of linking people to place, and pledging to build a community of practice among academics, practitioners, and developers.

Chemoproteomics-enabled covalent ligand screen reveals a cysteine hotspot in reticulon 4 that impairs ER morphology and cancer pathogenicity.

Chemical genetics has arisen as a powerful approach for identifying novel anti-cancer agents. However, a major bottleneck of this approach is identifying the targets of lead compounds that arise from screens. Here, we coupled the synthesis and screening of fragment-based cysteine-reactive covalent ligands with activity-based protein profiling (ABPP) chemoproteomic approaches to identify compounds that impair colorectal cancer pathogenicity and map the druggable hotspots targeted by these hits. Through this coupled approach, we discovered a cysteine-reactive acrylamide DKM 3-30 that significantly impaired colorectal cancer cell pathogenicity through targeting C1101 on reticulon 4 (RTN4). While little is known about the role of RTN4 in colorectal cancer, this protein has been established as a critical mediator of endoplasmic reticulum tubular network formation. We show here that covalent modification of C1101 on RTN4 by DKM 3-30 or genetic knockdown of RTN4 impairs endoplasmic reticulum and nuclear envelope morphology as well as colorectal cancer pathogenicity. We thus put forth RTN4 as a potential novel colorectal cancer therapeutic target and reveal a unique druggable hotspot within RTN4 that can be targeted by covalent ligands to impair colorectal cancer pathogenicity. Our results underscore the utility of coupling the screening of fragment-based covalent ligands with isoTOP-ABPP platforms for mining the proteome for novel druggable nodes that can be targeted for cancer therapy.

Nutrition support improves patient outcomes, treatment tolerance and admission characteristics in oesophageal cancer.

AIMS: Patients with oesophageal cancer undergoing chemoradiation with curative intent are at high risk of malnutrition and its complications, including increased side effects of treatment. We have developed a nutrition pathway (NP), involving the early then periodic nutrition assessment of all patients presenting to the multidisciplinary oesophageal clinic who were planned to receive definitive chemoradiation. MATERIALS AND METHODS: Patients were assessed as at 'low', 'moderate' or 'severe' nutrition risk, and were provided with appropriate nutrition intervention ranging from preventative advice (low risk), oral nutrition support (moderate risk) to enteral feeding (severe risk). Outcomes for 24 patients treated before implementation of the NP were compared with those of 24 patients treated using the NP. RESULTS: Patients managed using the NP experienced less weight loss (mean weight change -4.2 kg +/-6.4 cf. -8.9 kg +/- 5.9, P = 0.03), greater radiotherapy completion rates (92% cf. 50%, P = 0.001), fewer patients had an unplanned hospital admission (46% cf. 75%, P = 0.04), and those that did had a shorter length of stay (3.2 days +/- 5.4 cf. 13.5 days +/- 14.1, P = 0.002). CONCLUSION: Early and regular nutrition assessment/intervention and a multidisciplinary approach to nutrition care results in improved treatment tolerance for patients with oesophageal cancer receiving chemoradiation.

Experiences of injectable contraceptive users in an urban setting.

OBJECTIVE: To examine method-related experiences and acceptability of depot medroxyprogesterone acetate (DMPA) among women using this contraceptive for the first time. METHODS: Five hundred thirty-six women who received an injection of DMPA from any of seventeen clinical settings in southeast Texas, United States, were followed for 1 year. At each follow-up visit, patients were asked about their experiences with DMPA during the past 3 months and their plans to use this method in the future. RESULTS: Amenorrhea, irregular bleeding, and weight gain were the conditions reported most frequently. Reports of amenorrhea, weight gain, and acne or skin problems increased over time, but complaints of longer periods decreased (P < .001). Two pregnancies occurred during the study period. However, of these, one existed before the first injection. Depot medroxyprogesterone acetate's continuation rate at 1 year was 28.6%. Heavier and more frequent bleeding, increased cramping, amenorrhea, weight gain, headaches, depression, and nervousness were more frequent complaints of women who discontinued DMPA (P < .05), whereas lighter and less frequent bleeding were reported more often by those who continued to use this method (P <.05). Women who discontinued use of DMPA were more likely to be married and have a concern about injectable contraceptives than those who continued to use this method. CONCLUSION: Intolerable side effects and changes in menstrual pattern are the most frequently indicated reasons for discontinuing DMPA use. Our results suggest that DMPA's 1-year continuation rate may be lower than previously reported.

Characteristics and experiences of American women electing for early removal of contraceptive implants.

The study describes the experiences of 430 women who had Norplant(R) contraceptive implants removed prior to the five years of method effectiveness. Each subject was surveyed when the implants were inserted and again at the time of removal. Descriptive data are presented concerning perceptions of the method before insertion and after removal, reactions to the contraceptive and experiences associated with the removal procedure. Subjects' use of Norplant implants ranged from 14 days to 40 months, with a mean of 13.3 and median of 13 months. Over 95% reported changes in menstrual bleeding patterns and 95% experienced other non-bleeding related side effects. Non-bleeding side effects were the most frequently indicated reasons for removal, followed by bleeding changes. The mean removal time was 34 minutes with a median of 25 minutes. Over 48% reported experiencing significant pain during the removal procedure, and 27% stated that the pain was greater than expected. Despite electing for early removal of implants,the majority of women surveyed indicated satisfaction with all aspects of the method save its effect on their overall health. Although method-related side effects were intolerable for most subjects, their overall perception of the method was generally satisfactory.

PIP: 430 women enrolled at the time of acceptance in a longitudinal study of Norplant acceptability elected to have their implants removed between May 13, 1991 and September 8, 1994 (within 40 months of insertion). 225 of these women were surveyed immediately after removal, and 205 were identified during the follow-up study. The study provided information sociodemographic characteristics of the women and on 1) contraceptive method used before and after Norplant; 2) concerns about Norplant which were expressed prior to insertion; 3) reasons indicated for having implants removed; 4) changes in bleeding patterns; 5) side effects unrelated to menstrual bleeding; 6) significant pain reported during each of six stages of the removal process; and 7) user satisfaction in terms of comfort, convenience, cost, health effect, insertion, removal, and medical care. Most of the women chose early removal because they were unable to tolerate the side effects, but 13% chose removal because of discomfort at the implantation site and 10% because they no longer desired contraception. Removal was related to a pregnancy in three women (not method failure), and five others were acting on their physicians' advice. 48% of the women reported significant pain during removal, which was a larger number than expected. Since the cost-effectiveness of Norplant depends upon longterm use, it will be helpful to identify women who might be better served by a shorter term contraceptive. Despite the desire for removal, more than 25% of the women stated that they would consider Norplant use again in the future. Because side effects caused most women to discontinue, it is important that patients be properly counseled on the disadvantages of a longterm method.

One-year experience with subdermal contraceptive implants in the United States.

Women who received Norplant contraceptive implants from any of fifteen clinical settings in southeast Texas, U.S.A., were followed for one year to determine their reactions to the method. Of 1,385 who enrolled to receive Norplant implants, 1,253 had implants inserted. Side effects were reported by 78% of those receiving implants and 70% described changes in bleeding patterns. Spotting or irregular bleeding, weight gain and headaches were the conditions reported most frequently. Nine pregnancies were reported during the study period. Six of these, however, existed before the implants were inserted. At the one year anniversary, 143 of women receiving implants had had them removed. Those who discontinued method use were less satisfied, reported more side effects and were more likely to have planned to have another child, thus using the method for spacing, or to have had a change in their marital status while they were using the contraceptive. Providers should counsel patients to focus attention on plans for the future in selecting their contraceptive method. In addition, we recommend, as does the product's distributor, that providers confirm that patients are not pregnant prior to inserting implants.

Comparison of three types of ultrasound transducers in evaluating the amniotic fluid index.

The purpose of this study was to determine whether there was good correlation between amniotic fluid index measurements obtained with different types of ultrasound transducer. Women undergoing obstetric ultrasonography for multiple indications between 26 and 40 weeks' gestation had the four-quadrant amniotic fluid index measured with three ultrasound transducers: 3.5-MHz linear, 3.5-MHz sector and 3.5-MHz convex. Pearson product-moment correlation and linear regression analysis were utilized to compare the amniotic fluid index values. Sixty-five women participated in the study. A statistically significant correlation was noted between the three ultrasound transducers evaluated (P < .001). Placental location did not appear to affect the results. Amniotic fluid index values obtained with the sector or convex transducers were as reliable as those obtained with the "gold standard" linear transducer and may be interpreted in the same manner.

[Subcutaneous emphysema and pneumomediastinum after dental drilling]. / Emphysème sous-cutané et pneumo-médiastin suite au fraisage dentaire.

Subcutaneous emphysema and pneumomediastinum is a rare complication of dental treatment. Our case report describes a case secondary to dental drilling with a high-speed air drill, and diffusion of the compressed air. Our case had the classical clinical features of sudden subcutaneous emphysema starting in the face, and subsequently extending into the neck and thorax, accompanied by severe pain and dyspnoea. Rapid medical treatment for this emergency avoided the surgical decompression.

The prevalence and characteristics of battered women in a primary care setting.

Estimates are that 2 million women are battered each year by their male partner. To prevent battering and promote physical safety, Planned Parenthood of Houston and Southeast Texas added four abuse-assessment questions to the standard intake form for all initial and annual-visit clients. To establish the prevalence of battering, all intake forms completed at four clinics during a one-month period were analyzed. A total of 793 forms were reviewed. The prevalence of physical battering was 8.2 percent. When the characteristics of the battered women were compared with the non-battered, statistically significant differences existed. Information on the health consequences of battering are presented along with suggested assessment questions.

Fluctuating hearing loss with otorrhoea in Hughes syndrome.

We present an unusual case of bilateral aural symptoms in a 34-weeks pregnant woman with Hughes syndrome. This report underscores the unpredictable nature of this syndrome and its ENT complications. No previous case of fluctuating hearing loss and otorrhoea in Hughes syndrome has been described.

Sensorineural hearing loss with brainstem auditory evoked responses changes in homozygote and heterozygote sickle cell patients in Guadeloupe (France).

This prospective study involved 79 homozygote and heterozygote sickle cell anaemia patients (16 to 50 years old) and a control group of 40 people.All patients underwent ENT, audiological and brainstem auditory evoked responses (BSER) examinations in order to evaluate the incidence of sensorineural hearing loss (SNHL), to identify the changes at the level of the cochlear nerve and the central pathways, and to determine the most vulnerable group, in order to intervene with early prevention and rehabilitation for this condition.A hearing loss of greater than 20 dB at two or more frequencies was found in 36 (45.57 per cent) sickle cell patients (19 (47.22 per cent) HbSC patients and 17 (43.59 per cent) HbSS patients) and three (7.5 per cent) members of the control group. Homozygote and heterozygote patients, as well as both sexes, were equally affected. Bilateral hearing loss occurred in 19 (52.78 per cent) patients, unilateral right-sided hearing loss in five (13.89 per cent) patients and unilateral left-sided hearing loss in 12 (33.33 per cent) patients. Brainstem auditory evoked potential demonstrated a prolonged I-V (III-V) interpeak latency in 13 (25.35 per cent) sickle cell patients (11 men (eight with HbSS) and two women). The hearing loss in HbSS patients was neural in nature and of earlier onset; the hearing loss in HbSC patients was usually cochlear in nature and of later onset. Despite high medical standards and 100 per cent social security cover, the high incidence of SNHL in our sickle cell affected patients (the majority with the Benin haplotype) was probably due to their specific haematological profile and to the original geographical distribution of the disease in the tropics. Our results highlight the necessity for early and regular hearing assessment of sickle cell patients, including BSER examination, especially in male patients with SNHL.

Control stimuli in investigations of the acute-angled and obtuse-angled Müller-Lyer illusions.

Over the past decade, attention has been drawn to the importance of intertip distance (the distance between the tips of the arrowheads or featherheads) as a possible determinant of the Müller-Lyer illusion. Investigation of this stimulus property for the arrowhead and featherhead components of the Müller-Lyer figure has indicated that the two components exhibit a lack of symmetry, a conclusion supported by other studies using rather different approaches to the investigation of symmetry. This article argues that the control stimuli used in previous investigations are inadequate. It is proposed that in addition to the conventional straight-line control stimulus, in which the standard shaft is stripped of the oblique inducing lines. H-shaped figures in which the inducing lines are vertical should be included. Results are reported of an experiment in which both types of control stimuli are used to investigate the effects of intertip distance, and the spatial separation of that distance from the standard shaft, upon the arrowhead and featherhead figures.

A correlational analysis of symmetry between the arrowhead and featherhead Müller-Lyer illusions.

Correlational methods were used to investigate symmetry of effect for the arrowhead and featherhead versions of the Müller-Lyer figure. Two control figures were compared in the determination of baseline levels for measurement of the illusions: a shaft presented without any inducing context, and a shaft with vertical inducing lines attached. In addition, results based on difference-score measures of the illusions were contrasted with results obtained by partial-correlation techniques. Overall, when one considers the results for either one of the arrowhead or featherhead versions, the evidence favours a common underlying mechanism. However, results across the two versions suggest that the mechanisms for the two versions differ fundamentally. In weighting the different kinds of evidence contributing to this conclusion, methodological issues were raised. By obtaining two judgments for each stimulus figure from a large number of subjects, it was possible to demonstrate not only that conventional difference-score measures of illusions are highly unreliable, but also that they can yield biased results.

Factors associated with the choice of Norplant by women attending subsidized clinics in the US.

US women attending family planning clinics in Texas, were surveyed to determine which characteristics, experiences, behavior and specific needs were associated with the selection of the contraceptive Norplant. Race, ethnic origin, age and education were unrelated to choice of method. Increased numbers of previous pregnancies, familiarity with the method, dissatisfaction with previous methods, and sources of information about Norplant were associated with its selection. There was significant variation among the clinics in the proportion of patients to which they dispensed the method. Therefore, clinic selection may have influenced the outcomes of contraceptive decisions.