Brainstem encephalitis caused by Coxsackie A16 virus in a rituximab-immunosuppressed patient.

Rituximab and other B cell depleting agents are increasingly used for haematological, immunological and neurological diseases. In a small minority, immunosuppression leads to increased virulence of normally mild infections. Brainstem encephalitis has been described occurring after infection from enteroviruses, more commonly in the paediatric population, but also in immunosuppressed adults. In this paper, we describe an enteroviral brainstem encephalitis in a rituximab-immunosuppressed patient. The enterovirus identified was Coxsackie A16, which has never yet been reported to cause brainstem encephalitis in an adult.

The Program Without Walls: innovative approach to state agency vocational rehabilitation of persons with traumatic brain injury.

OBJECTIVE: To describe the Program Without Walls (PWW), a person-centered, community-based approach for state rehabilitation counselors to provide vocational rehabilitation (VR) services to people with traumatic brain injury (TBI). DESIGN: Nonrandomized posttest only matched control group design using existing state VR data. SETTING: Community-based within 2 district offices of the state-federal VR program in New York State. PARTICIPANTS: VR consumers with TBI (N=42); 21 received PWW services, and 21 matched controls received traditional VR services. INTERVENTION: All participants experienced the initial VR process: eligibility determination and the development of an individualized employment plan. Participants receiving the traditional approach were referred to various organizations for services and monitored by their state VR counselor. Those receiving PWW services were never "handed off" to outside agencies. Instead, they received person-centered, community-based services from a team of freelance consultants who were recruited, trained, and supervised by the state VR counselor overseeing the PWW team. MAIN OUTCOME MEASURES: Data were gathered from VR central files for all consumers with a primary or secondary disability of TBI. Outcome variables were case status at closure, weekly earnings at closure, hours working at closure, and cost of case services. RESULTS: The PWW successfully placed more consumers who worked a greater number of hours per week and earned more per week than those who received traditional VR services without increasing the cost of case services. CONCLUSIONS: The PWW showed promise as a systems change effort to improve VR services for people with TBI.