Cervical epidural abscess associated with massively elevated erythrocyte sedimentation rate

We present a case of an elderly woman who presented with neck pain, low-grade fever, bandemia, and a massively elevated erythrocyte sedimentation rate (ESR) who had a cervical epidural abscess. We believe that the selective use of ESR assisted in narrowing the differential diagnosis, as the patient had no neurological deficits and no predisposing factors such as distal infection, immunosuppression, trauma, or recent surgery. Furthermore, in the literature, an elevated ESR is consistently found in patients with epidural abscesses, whereas clinical findings such as fever, leukocytosis, and neurological deficits are only variably present.     

Influence of circadian rhythm on mortality after myocardial infarction: data from a prospective cohort of emergency calls

Myocardial infarction (MI) occurs more frequently in the morning as a result of the concomitant unfavorable timing of several physiological parameters and/or biochemical conditions. However, little is known about the possible influence of this circadian pattern on prognosis. To evaluate whether the time of symptom onset could potentially influence mortality from acute MI, this prospective study considered all consecutive MIs admitted to the ED of Ferrara, Italy, after a call to the Emergency Coordinating Unit from January 1, 1998, to December 31, 2001. The total sample consisted of 442 MIs (mean age, 68.7 years; males, 72%). Eighty patients (males, 82.5%) died in the ED; the remaining 362 were admitted to the hospital. Of these, 50 (males, 60%) died during their hospital stay. Based on the timing of their symptom onset, cases were categorized both into 24 1-hour intervals and four 6-hour intervals (midnight to 5:59 am, 6:00 am to 11:59 am, noon to 5:59 pm, and 6:00 pm to 11:59 pm), and the circadian distributions of fatal versus nonfatal MIs were compared. The circadian variation of MI peaked between 6:00 am and noon (P < .001), and in this period, there was a trend toward a higher frequency of fatal cases (41.5% vs. 35.2%; chi(2) = 1.911, P = .167). To verify whether this higher frequency of fatal events in the morning hours could be related to possible higher severity of cases observed in that hours, a further separate analysis considering age, infarct site, and peak levels of MB was made. Again, no significant temporal differences among the four 6-hour intervals were found between fatal and nonfatal Mis, although a trend toward older age was observed in morning MIs. Not only the frequency, but also the mortality, of acute MI could be increased in the morning hours. This could be of practical interest for emergency doctors and could have significant implications for acute treatment, because several studies have reported a lowered efficacy of thrombolytic drugs in the morning hours.     

Post-Event Processing in Social Anxiety Disorder: Idiosyncratic Priming in the Course of CBT

Post-event processing (PEP) is the cognitive rumination that follows social events for patients with social anxiety. The PEP period was examined in relation to two anxiety provoking tasks in cognitive behavioural group therapy for social anxiety disorder: (1) Attending the first group therapy session (n = 75), and (2) An individually tailored in-session exposure task (n = 50). An assessment of PEP was conducted the week following each task as an indication of the extent of rumination over that event during the subsequent week. Significant PEP occurred after both events, and greater baseline social anxiety predicted greater levels of PEP related to both tasks. Anxiety ratings, as conceptualized by SUDS, were positively correlated with the severity of subsequent PEP related to the exposure task. There was also support for the stability of PEP across the two tasks and for the specificity of the content of PEP as rumination related to social failure, rather than rumination related to depressive symptoms. This study provides additional empirical support for the role of PEP in the cognitive model of social anxiety disorder.     

The practical management of artifact in computerised physiological data

Computerised physiological data contains artifact that needs to be identified and possibly removed. Whilst computers may eventually satisfactorily perform this function, at present only manual removal is possible for the majority of intensive care computer groups. We assessed the effects of artifact and its removal on the physiological data of 3 patients. Artifact was manually removed from 7 days of data in 4 parameters (heart rate, respiratory rate, systolic blood pressure [sbp] and transcutaneous oxygen [tcpO2]) by 3 independent observers. Six hour time periods were analysed. Median and mean values before and after the manual removal of artifact were compared. Overall. 6.5% of data was removed as artifact. This was greatest for tcp02 (9.9%) and sbp (10.6%), with smaller amounts for respiratory rate (2.8%) and heart rate (2.4%). Sbp showed a marked difference in the amount of data removed between patients, whereas tcp02 data contained quite large volumes of artifact, but this was fairly consistent between patients, Removal of artifact affected mean values more than median values. One observer considered that both physiological and non-physiological artifact should be removed, whereas the other two observers removed only non-physiological artifact. Agreement in results between the latter was good. Our results suggest that interobserver variability should have a minimal effect on values, once rules identifying the type of artifact to be removed are agreed. Removal of artifact did not have a clinically significant effect on results, but may be an important consideration in the statistical analysis of computerised physiological data.Abbreviations CPTM computerised physiological trend monitoring - tcp02 transcutaneous pressure of oxygen - sbp systolic blood pressure