Interhospital Sepsis Code in Catalonia (Spain): Territorial model for initial care of patients with sepsis. / Código Sepsis Interhospitalario en Catalunya: modelo organizativo territorial para la atención inicial al paciente con sepsis.

Sepsis is a syndromic entity with high prevalence and mortality. The management of sepsis is standardized and exhibits time-dependent efficiency. However, the management of patients with sepsis is complex. The heterogeneity of the forms of presentation can make it difficult to detect and manage such cases, in the same way as differences in training, professional competences or the availability of health resources. The Advisory Commission for Patient Care with Sepsis (CAAPAS), comprising 7 scientific societies, the Emergency Medical System (SEM) and the Catalan Health Service (CatSalut), have developed the Interhospital Sepsis Code (CSI) in Catalonia (Spain). The general objective of the CSI is to increase awareness, promote early detection and facilitate initial care and interhospital coordination to attend septic patients in a homogeneous manner throughout Catalonia.

[Meningism]. / Meningismus.

A thorough neurological examination in emergency situations requires the evaluation of meningeal signs. Even though in most settings, evaluation of meningism is technically not very demanding, the interpretation of findings may prove difficult. As opposed to a widely held belief, clinical signs of meningism are neither specific nor highly sensitive for detection of meningitis or subarachnoid hemorrhage. A meaningful evaluation of meningeal signs, therefore, requires careful consideration of both clinical findings and other accessory symptoms.

URGENT DIAGNOSTICS OF CEREBRAL VENOUS TROMBOSIS.

Investigations were carried out in 24 patients in order to evaluate information value of the data of clinical, laboratory, neuroradiological methods of research and develop the diagnostic algorithm in case of cerebral venous thrombosis (CVT). The main group consisted of 11 patients (7 male, 4 female, average age 49,1±4,3) with CVT. The comparison group included 13 patients (6 male, 7 female; average age 68,1±9,5) with ischemic stroke (IS) of moderate severity. There were revealed changes in blood and cerebrospinal fluid (CSF) as form of leukocytosis of blood and moderately increased cell count with elevated protein in CSF and blood in case of CTV. The authors noted an elevated protein in CSF and blood and leukocytosis with predominant lymphopenia in blood and neurophilic predominance in CSF within the reference range of CSF in patient with ischemic stroke. The epileptic attacks, meningeal syndromes, headaches were more often among clinical syndromes at CTV than in case of ischemic stroke. The algorithm of neuroimaging research methods and modes of MRI were determined and allowed an effective diagnostics of damages of venous sinuses, superficial and deep cerebral veins in case of urgent hospitalization of patients. It was possible to suggest the venous pathology in 7 (63,6%) cases due to SKT (without contrast) and in case of application of MR venography (2D TOFmode), there were revealed 100% of cases.

Meningismus in children with chronic headache is most likely due to streptococcal infection.

We previously found that 97% of children diagnosed with chronic tension-type headaches had meningismus. In the present study, we investigate the relationship between streptococcal infection and meningismus in children suffering from chronic headaches. Six hundred and forty children suffering from idiopathic chronic headaches were examined by a neurologist in an outpatient setting. Antistreptolysin titer (ASOT) was determined from blood samples taken from all the children. Meningismus was diagnosed in 337 patients. Patients were divided into two groups: 337 children (Group 1) with meningismus with an increased ASOT (200-1790 IU/ml) in 264 children (78%), and 303 children (Group 2) without meningismus with an increased ASOT (200-1030 IU/ml) in 117 children (39%). We report herein that a majority of children with headaches associated with meningismus, had evidence of a streptococcal infection when compared to a non-meningismus group. We postulate that streptococcal infection may play an important role in the etiology of meningismus-positive chronic headaches in children.

Meningitis.

Meningitis is defined as inflammation of the meninges, in almost all cases identified by an abnormal number of white blood cells in the cerebrospinal fluid and specific clinical signs/symptoms. Onset may be acute or chronic, and clinical symptoms of acute disease develop over hours to days. This article reviews the epidemiology, pathophysiology, clinical manifestations, diagnosis, and management of acute meningitis, and provides a list of key points for primary care practitioners. Aseptic and bacterial meningitis vary significantly and are discussed separately.

Meningite asséptica / Aseptic meningitis

JUSTIFICATIVA E OBJETIVOS: As meningites assépticas (MA) representam a grande maioria das meningites presentes em nosso meio. Os principais causadores dessa doença são os enterovírus. O quadro clínico caracteriza-se por cefaleia, fotofobia, sinais de irritação meníngea, náuseas, vômitos e febre. A grande dificuldade diagnóstica é que estes mesmos sintomas são encontrados nos quadros de meningites bacterianas, mais graves, demandando condutas mais agressivas. O objetivo deste estudo foi rever o assunto, destacando o manuseio dos casos suspeitos bem como suas etiologias e fisiopatologias. CONTEÚDO: Conceitos de MA, suas etiologias virais e não virais, incluindo àquelas causadas pela utilização de medicamentos. CONCLUSÃO: Devido às sobreposições sintomatológicas, introduziu-se empiricamente a antibioticoterapia intra-hospitalar no momento da suspeita de infecção meníngea, observando a evolução clínico-laboratorial do paciente.

BACKGROUND AND OBJECTIVES: The aseptic meningitis (AM) representing the vast majority of meningitis in our society. The main cause of this disease is the enteroviruses. The clinical picture is characterized by headache, photophobia, and signs of meningeal irritation, nausea, vomiting and fever. The diagnostic difficulty is that these same symptoms are found in the tables of bacterial meningitis, the most serious, demanding more aggressive treatment. This article aims to review the issue, emphasizing the management of suspected cases as well as its etiology and pathophysiology. CONTENTS: Address the concept of AM, its viral and nonviral etiologies, including those caused by medication use. CONCLUSION: Due to the overlap of the symptoms, we introduced an empirical intrahospital antibiotic treatment at the moment we suspect meningeal infection, observing the evolution of clinical and laboratory signs.

Tripod sign.

"Tripod Sign" or "Amoss's Sign" is a sign of meningeal irritation. Although useful in diagnosing meningitis, it is not pathognomic and may be seen in a variety of clinical conditions. Infants < 1 year of age and immunocompromised individuals may not demonstrate signs of meningeal irritation. Since elicitation of the sign requires voluntary sitting up, it is of limited use in patients with marked altered sensorium and young infants.

Review of meningococcal infection in children at a United Kingdom hospital.

Sixty-nine children were identified and evaluable. Forty-one (60%) presented with hypotension and/or abnormal neurological signs. In 34 (49%) a petechial rash was present on admission. Of note, 13 (19%) had a non-petechial rash, and rash was absent in 19 (28%). Twenty-one (30%) presented with meningism or meningitis. In one child the illness was so mild that the child was discharged prior to making a diagnosis. Five children died (7%). Sixty-three cases (91%) were diagnosed by blood or cerebrospinal fluid culture; these investigations remain the mainstay of diagnosis.

Lymphomatous meningitis in primary central nervous system lymphoma.

Lymphomatous meningitis (LM) due to primary central nervous system (CNS) lymphoma is an uncommon problem in neurooncology and can occur at time of diagnosis or recurrence. Notwithstanding frequent focal signs and symptoms, LM is a disease affecting the entire neuraxis, and therefore staging and treatment need to encompass all cerebrospinal fluid (CSF) compartments. Central nervous system staging of LM includes contrast agent-enhanced cranial computed tomography (CT) or Gd-enhanced magnetic resonance (MR) imaging, Gd-enhanced spinal MR imaging, CT myelography, and radionuclide CSF flow study. Treatment of LM includes involved-field radiotherapy of bulky or symptomatic disease sites and intra-CSF drug therapy. The inclusion of concomitant systemic therapy can benefit patients with LM and can obviate the need for intra-CSF chemotherapy. At present, intra-CSF drug therapy is confined to three chemotherapeutic agents (methotrexate, cytosine arabinoside, and thiotepa) administered by a variety of schedules either by intralumbar or intraventricular drug delivery. Although treatment of LM is palliative and the expected median survival of patients is 4 to 6 months, it often provides stabilization and protection from further neurological deterioration. In patients with primary CNS lymphoma, CNS prophylaxis has been recommended (using a combination of high-dose systemic chemotherapy and intra-CSF chemotherapy), but the strategy remains controversial because high-dose systemic methotrexate is commonly used as an adjuvant therapy. Patients with primary CNS lymphoma at high risk as defined by positive CSF cytology or neuroradiography consistent with LM may benefit from the inclusion of intra-CSF chemotherapy.

Adult meningism and viral meningitis, 1997-2004: clinical data and cerebrospinal fluid cytokines.

OBJECTIVE: Although meningism manifesting acute headache has been observed to be associated with common viral and bacterial infections, its definition and pathogenesis have not been clarified. Clinical findings and cerebrospinal fluid (CSF) cytokines in adult patients with meningism were investigated and compared with those in viral meningitis. PATIENTS AND METHODS: Among the adult inpatients in our hospital from 1997 to 2004, 5 with meningism and 17 with viral meningitis were identified according to the criteria described in this study, and their clinical data were analyzed. In the CSF samples of the 5 patients with meningism and the 17 with viral meningitis, the concentrations of interferon-gamma (IFN-gamma), tumor necrosis factor-alpha (TNF-alpha), interleukin-2 (IL-2), IL-4, IL-6, and IL-10 were determined using a cytometric bead array. RESULTS: The five patients with meningism all showed fever and meningeal signs such as severe headache and nuchal stiffness without CSF pleocytosis (<5 cells/mm3). Four patients were associated with herpetic Kaposi's eczema, herpes simplex, or herpes zoster, and all five patients had favorable outcomes. The levels of all CSF cytokines in patients with meningism were below normal values, whereas IFN-gamma and IL-6 in patients with viral meningitis were moderately elevated. CONCLUSION: The normal cytokine levels in meningism may possibly reflect the lack of direct viral infection and may be helpful in differentiating both meningism and viral meningitis at an early stage.

Meningismus is a commonly overlooked finding in tension-type headache in children and adolescents.

At present, both migraine and tension-type headaches in children are believed to be chronic primary headaches. Meningeal signs in both cases are ignored or not examined, and the neurologic status is considered normal. This is the first study that focuses on meningeal signs in children with chronic headaches. The study population comprised 1738 patients aged 5 to 17 years who were examined in an outpatient neurologic clinic over a 6-year period. Particular attention was paid to examination of meningeal signs, including nuchal rigidity, Kernig's sign, Brudzinski's three signs (upper, middle, and lower), the "tripod" sign, and Guillain's and facial signs; the presence of these signs was regarded as meningismus syndrome. Some meningeal signs were found in 12% of 1007 children suffering from migraine, whereas 97% of 731 children with tension-type headaches had the whole set of meningeal signs. This suggested that meningismus is the major clinical syndrome in chronic tension-type headaches in children and adolescents. Chronic mild sterile (possibly autoimmune) inflammation of meninges (dura mater) can be caused by a preceding infection, as well as minor trauma of the head and/or back. Prolonged rest in a recumbent position usually resulted in relief or complete disappearance of both headache and meningeal signs. Monitoring of the meningeal signs is helpful for evaluation of the patient's condition in the course of treatment.

A diagnostic decision rule for management of children with meningeal signs.

In a previous study we devised a diagnostic decision rule to improve management of children with meningeal signs, suspected of having bacterial meningitis. The decision rule aimed to guide decisions on (1) whether a lumbar puncture is necessary in children with meningeal signs, and (2) which children need hospitalisation and empirical antibiotic treatment for bacterial meningitis. In this study we assessed the validity of this rule in an external population of four (paediatric) hospitals in The Netherlands. The decision rule included two scoring algorithms using symptoms, signs and quickly available blood and cerebrospinal fluid (CSF) laboratory tests. To evaluate the discriminative value of both algorithms, the absolute numbers of correctly diagnosed patients and the area under the receiver operator characteristic curve were estimated, and compared with the results from the original population (n = 360). In a 18 month period, we included 226 children, median age 2.2 years, who visited the emergency department with meningeal signs. Bacterial meningitis was present in 25 (11%). Using the scoring algorithms patients could be categorised in groups of increasing risk of bacterial meningitis. The discriminative values of the clinical and CSF algorithm in this new population were similar to those in the original population. In the total population of 586 children with meningeal signs, the rule selected 205 children (35%) who did not need a lumbar puncture and 366 children who did not need empirical treatment (62%). In conclusion, this diagnostic rule performed well in a new population of children with meningeal signs. This diagnostic decision rule is a valuable tool for the clinician when deciding to treat these children for bacterial meningitis and thus improving their management.

[Acute headache with meningism and xanthochromic cerebrospinal fluid.An unusual manifestation of cervical epidural abscess]. / Akute Zephalgie mit Meningismus und xanthochromem Liquor. Ungewöhnliche Manifestation eines zervikalen epiduralen Abszesses.

We report on a 70-year-old female with acute onset of headache, meningism, xanthochromic cerebrospinal fluid, and developing laboratory parameters indicating a systemic infection. Initially, a subarachnoidal hemorrhage was assumed. However, magnetic resonance imaging showed upper cervical osteomyelitis and extending spinal epidural abscess. After application of broad systemic antibiotics, secluded abscess formation was achieved and successful neurosurgical debridement performed. The unusual cranial concentration of the complaints is probably due to the involvement of the craniocervical transition. Cervical epidural spinal abscess represents a potentially dangerous bacterial infection of the upper spine. Inadequate treatment can lead to irreversible neurological deficits. Cervical magnetic resonance imaging is an effective tool for diagnosis, since early diagnosis is important for good prognosis.