Neonatal enteroviral sepsis/meningoencephalitis and hemophagocytic lymphohistiocytosis: diagnostic challenges

We present the clinical course of three neonates with proven enteroviral infection and an initial clinical picture suggestive of hemophagocytic lymphohistiocytosis (HLH). After a complete workup, only one was treated for HLH. Of particular interest, the first newborn presented with hemophagocytic cells in the cerebrospinal fluid (CSF) and proved to have enteroviral meningoencephalitis but was ultimately not diagnosed with HLH. A fourth infant, who fulfilled the diagnostic criteria for HLH but did not have enteroviral infection, is included for comparison. We suggest that severe neonatal enteroviral infection and HLH are difficult to distinguish. Careful assessment is recommended, as prognosis and treatment differ between these two entities. Literature regarding neonatal enteroviral infection and HLH is reviewed, to demonstrate the continuum between the inflammation triggered by enteroviral infection and the occurrence of HLH, as well as their comparable CSF findings.     

A Systematic Review of Pharmacologic Treatments of Pain After Spinal Cord Injury

Teasell RW, Mehta S, Aubut JL, Foulon B, Wolfe DL, Hsieh JTC, Townson AF, Short C, the Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of pharmacologic treatments of pain after spinal cord injury.

Objective

To conduct a systematic review of published research on the pharmacologic treatment of pain after spinal cord injury (SCI).

Data Sources

MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for articles published 1980 to June 2009 addressing the treatment of pain post SCI. Randomized controlled trials (RCTs) were assessed for methodologic quality using the Physiotherapy Evidence Database (PEDro) assessment scale, whereas non-RCTs were assessed by using the Downs and Black (D&B) evaluation tool. A level of evidence was assigned to each intervention by using a modified Sackett scale.

Study Selection

The review included RCTs and non-RCTs, which included prospective controlled trials, cohort, case series, case-control, pre-post studies, and post studies. Case studies were included only when there were no other studies found.

Data Extraction

Data extracted included the PEDro or D&B score, the type of study, a brief summary of intervention outcomes, the type of pain, the type of pain scale, and the study findings.

Data Synthesis

Articles selected for this particular review evaluated different interventions in the pharmacologic management of pain after SCI. Twenty-eight studies met inclusion criteria; there were 21 randomized controlled trials; of these, 19 had level 1 evidence. Treatments were divided into 5 categories: anticonvulsants, antidepressants, analgesics, cannabinoids, and antispasticity medications.

Conclusions

Most studies did not specify participants' types of pain, making it difficult to identify the type of pain being targeted by the treatment. Anticonvulsant and analgesic drugs had the highest levels of evidence and were the drugs most often studied. Gabapentin and pregabalin had strong evidence (5 level 1 RCTs) for effectiveness in treating post-SCI neuropathic pain as did intravenous analgesics (lidocaine, ketamine, and morphine), but the latter only had short-term benefits. Tricyclic antidepressants only showed benefit for neuropathic pain in depressed persons. Intrathecal baclofen reduced musculoskeletal pain associated with spasticity; however, there was conflicting evidence for the reduction in neuropathic pain. Studies assessing the effectiveness of opioids were limited and revealed only small benefits. Cannabinoids showed conflicting evidence in improving spasticity-related pain. Clonidine and morphine when given together had a significant synergistic neuropathic pain-relieving effect.     

Effect of Clinician Feedback Versus Video Self-Assessment in 5th-Year Chiropractic Students on an End-of-Year Communication Skills Examination

Purpose:

To compare the effect of two learning opportunities, clinician feedback and video self-assessment, on 5th-year chiropractic students'' patient communication skills, specifically those required for history taking.

Methods:

A cohort of 51 final-year students was divided into two groups. The first group received immediate feedback from a clinical supervisor following a history-taking encounter with a patient. The second group performed self-assessments of their videotaped history-taking encounter. An end-of-year Viva Voce examination was used to measure the effectiveness of the students'' history-taking skills, using two subscores, one for behavior and another for content, as well as an overall total score. An unpaired t-test was performed to determine whether any significant difference occurred between the two groups of students. Each group was then subdivided into two subgroups based on gender, and a two-way analysis of variance was performed to determine whether the type of feedback or the students'' gender had any significant effect on the outcome of the Viva Voce.

Results:

There were no significant differences between the two groups of students in terms of their final scores in the Viva Voce. After dividing each group into their gender subgroups and further analysis of the results, neither the mode of feedback nor the students'' gender had any significant effect on the outcome of the Viva Voce.

Conclusion:

This study suggests that, for a mixed cohort, video self-assessment and clinician feedback are equivalent in their ability to enhance students'' communication skills relating to history taking.Key Indexing Terms: Chiropractic, Clinical Competence, Communication, Education     

EXERTION LEVEL AND THE INTENSITY OF ASSOCIATED MOVEMENTS

Associated movements in the contralateral limbs were measured quantitatively for 42 seven- to eight-year-old children who wrote with the right hand. Associated movements of the contralateral homologous muscles systematically increased as a function of the intensity of contraction of the active hand. The associated movements were more intense when the left hand was active. The order of hand use markedly affected the lateral asymmetry, indicating that the right and left hands were affected differentially by previous activity. Associated movements of the contralateral antagonist muscles were also observed, and their frequency varied as a function of active hand and exertion level.     

Fluorodeoxyglucose positron emission tomography for detection of tumor recurrence following radiofrequency ablation in retrospective cohort of stage I lung cancer

Purpose: The goal of this study was to define patterns for tumor recurrence on PET following RFA, compare time to imaging recurrence by PET versus CT, evaluate whether pre-treatment tumor uptake predicts recurrence and propose an optimal post-RFA surveillance strategy.

Materials and methods: A retrospective cohort study was performed of biopsy confirmed primary stage I lung cancers treated with RFA. FDG PET and near contemporaneous diagnostic CT imaging pre-ablation, within 30?days post-ablation, and beyond 6?months were independently and retrospectively evaluated for features supportive of recurrence. Time to imaging recurrence by PET (TTR_PET) and by CT (TTR_CT) were determined and compared. FDG avidity of untreated tumors was compared between recurrent and non-recurrent groups.

Results: Thirteen recurrences after 72 RFA treatments were confirmed by diagnostic CT. All recurrences were associated with focally intense and increasing FDG uptake beyond 6?months (sensitivity 100%; specificity 98.5%). Mean TTR_PET was 14?months compared to mean TTR_CT of 17?months (not statistically significant). Normalized SUVmax and total lesions glycolysis of lung cancers that recurred after RFA was 4.0 and 6.0, respectively compared to 2.8 and 5.0, respectively for cancers that did not recur (p?=?.068).

Conclusion: A pattern of focally intense and increasing FDG PET uptake has high sensitivity and specificity for detecting recurrent lung cancer following RFA. Surveillance after RFA should include a contrast enhanced diagnostic CT at 1?month to diagnose procedural complications, PET at 6?months as a post-treatment metabolic baseline (with diagnostic CT if PET is abnormal) and alternating diagnostic CTs or PET every 6?months for 2?years.     

Improving rapid response systems: progress, issues, and future directions

"Detect the emergency and respond to it right at the patient's bedside" sums up the focus of the recent Third International Conference on Rapid Response Systems.