How well do patients obtain short-term follow-up after discharge from the emergency department?

STUDY OBJECTIVE

We sought to determine the follow-up rate of discharged emergency department patients who were instructed to obtain reevaluation within 48 hours at our ED, a clinic, or a private physician's office and to determine the reasons why patients do not obtain short-term follow-up when instructed.

METHODS

Emergency physicians prospectively enrolled a convenience sample of patients discharged from a university hospital ED who were believed to be at risk for clinical deterioration. Patients were instructed to obtain reevaluation within 48 hours at a public clinic, private physician's office, or our ED (without charge). A telephone interview was conducted after 48 hours had elapsed.

RESULTS

Three hundred twenty-five patients were enrolled, 300 were included in data analysis, and 203 (67.7%) of these obtained follow-up as instructed. Those referred to the ED had a higher follow-up rate (105/127 [82.7%]) than those referred to clinics (59/99 [59.6%]) or private physicians (39/74 [52.7%]). Inability to obtain an appointment was cited by 34.3% of those who did not obtain follow-up care as instructed.

CONCLUSION

Many patients discharged from the ED who were believed to be at risk for clinical deterioration did not obtain medical follow-up within 48 hours when so instructed. Free ED follow-up resulted in a better rate of short-term follow-up than that for clinics and private physicians and may be especially useful if a patient's ability to obtain follow-up is uncertain or if timely reevaluation is particularly imperative.

Evolution of abstracts presented at the annual scientific meetings of academic emergency medicine

There has been a general trend in medicine towards greater sophistication in research design. In order to assess this trend in emergency medicine we compared the characteristics of abstracts presented at the 1974, 1983, 1989, and 1997 annual scientific meetings of academic emergency medicine. All 870 abstracts were reviewed by 1 of 3 investigators who determined research design attributes using a standardized classification scheme that has good interrater reliability. Over the last 25 years the following trends were noted: more surveys (0% v1% v3% v8%, P = 0.002), more randomized studies (0% v10% v12% v15%, P = 0.05), and more blinded studies (0% v7% v5% v11%, P = 0.01). Tests of statistical significance were reported with increasing frequency (8% v26% v59% v69%, P < 0.001) as were power calculations (0% v0% v1% v3%, P = 0.02). During the study period there were also increases in the median number of authors, proportion of foreign lead authors, and the proportion of studies involving human subjects. These results reflect considerable improvement in the degree of research design sophistication reported in selected abstracts of academic emergency medicine over the study period. Further strategies to assure continued enhancement of emergency medicine research should be explored.

Evolution of abstracts presented at the annual scientific meetings of academic emergency medicine

There has been a general trend in medicine toward greater sophistication in research design. To assess this trend in emergency medicine, we compared the characteristics of abstracts presented at the 1974, 1983, 1989, and 1997 annual scientific meetings of Academic Emergency Medicine. All 870 abstracts were reviewed by 1 of 3 investigators who determined research design attributes using a standardized classification scheme that has good interrater reliability. Over the last 25 years, the following trends were noted: more surveys (0% v1% v3% v8%, P=.002), more randomized studies (0% v10% v12% v15%, P=.05), and more blinded studies (0% v7% v5% v11%, P=.01). Tests of statistical significance were reported with increasing frequency (8% v26% v59% v 69%, P < .001), as were power calculations (0% v0% v1% v3%, P=.02). During the study period, there were also increases in the median number of authors, proportion of foreign lead authors, and the proportion of studies involving human subjects. These results reflect considerable improvement in the degree of research design sophistication reported in selected abstracts of academic emergency medicine over the study period. Further strategies to assure continued enhancement of emergency medicine research should be explored.

Alterations in hepatic gluconeogenesis, prostanoid, and intracellular calcium during sepsis

OBJECTIVE

The metabolic alterations observed during sepsis may be associated with changes in local concentrations of intracellular calcium (Ca2+) and prostanoid synthesis in the liver. The authors studied hepatocyte intracellular Ca2+ and the release of glucose and prostanoid in an in-vivo murine liver perfusion model.

METHODS

Sepsis was induced in anesthetized, fasted rats by cecal ligation and puncture (CLP, n = 42). Hepatic glucose release was studied in control (n = 10) and CLP (n = 10) groups using a non-recirculating liver perfusion model with and without lactate as gluconeogenic substrate. Hepatocyte intracellular Ca2+ (n = 11) was measured using the selective indicator Fura-2 under basal and epinephrine (10(-5) M) stimulated conditions. 6-Keto-prostaglandin F1alpha (6-Keto) and thromboxane B2 (TxB2) were determined from liver perfusate by radioimmunassay (n = 11). Data were analyzed using t-tests and repeated-measures ANOVA.

RESULTS

Plasma glucose was significantly lower in CLP groups compared with controls (74.9+/-6.6 vs 115.7+/-4.6 mg/dL, p < 0.05). Plasma lactate was significantly higher in CLP vs controls (3.7+/-0.4 vs 1.4+/-0.1 mM, p < 0.05). Glucose release in isolated perfused livers was significantly lower in CLP vs controls (8.5 vs 16+/-1.2 microM/g/hr, p < 0.001). With the addition of lactate + pyruvate to the perfusate, glucose output in CLP livers was significantly lower following 5 (9.9+/-0.7 vs 17.7+/-1.1 microM/g/hr, p < 0.05) and 10 (11.9+/-1.2 vs 20.6+/-1.3 microM/g/hr, p < 0.001) minutes of perfusion. The basal level of intracellular calcium ([Ca2+]i) in CLP rats (460.1+/-91.6 nM) was significantly higher than in control rats (196.3+/-35.5 nM) (p < 0.05). A significant increase (p < 0.05) in [Ca2+]i occurred after the addition of epinephrine in hepatocytes in control (196.3+/-35.5 vs 331.8+/-41.4 nM) but not CLP (460.1+/-91.6 vs 489.4+/-105 nM) rats. 6-Keto was significantly lower in CLP compared with controls at 30 minutes (25.7+/-3.9 vs 33.4+/-5.5 pg/mL, p < 0.05), whereas TxB2 was not significantly altered (52.1+/-34.7 vs 87.5+/-43.2 pg/mL).

CONCLUSION

These results demonstrate that CLP sepsis is associated with an increase in hepatocyte intracellular free Ca2+ concentration along with attenuation of hormone-mediated Ca2+ mobilization and hepatic gluconeogenesis.

Thermal characteristics of neutralization therapy and water dilution for strong acid ingestion: an in-vivo canine model

OBJECTIVE

To determine whether in-vivo neutralization therapy for acid ingestions will superimpose a thermal injury upon tissue already damaged by acid.

METHODS

An in-vivo canine model was used with repeated measures of tissue and luminal temperatures. All dogs were placed under halothane general anesthesia. The stomach was exteriorized and temperature probes were placed in the lumen and mucosa. 25 mL of 0.5 N HCl (25 degrees C) was placed in the gastric lumen followed 5 minutes later by 75 mL of either 8% NaHCO3 neutralization (25 degrees C, n = 10) or water dilution (25 degrees C, n = 10). Temperature measurements were recorded at specified intervals for 5 minutes post HCl acid exposure and for 30 minutes post treatment. Temperature profiles were analyzed by repeated-measures ANOVA. Post-treatment changes were evaluated using signed-rank tests.

RESULTS

In both treatment groups, treatment resulted in significant decreases in initial mucosa and intraluminal temperatures. Both the mucosa and intraluminal temperatures decreased immediately after treatment with HCO3 by an average of 1.6 degrees C (p = 0.05). In the water dilution treatment group, both temperatures decreased by 1.1 degrees C (p = 0.05). Ensuing post-treatment temperatures increased but did not reach baseline temperatures at any time up to 30 minutes post treatment.

CONCLUSIONS

In the in-vivo setting, there is no evidence of hazardous temperature elevation when a weak alkali or dilution therapy is used to neutralize strong acid-induced injury. Contraindication of this form of emergency treatment should not be based on the preconceived idea that a resultant exothermic reaction will cause a superimposed thermal injury. Further clinical study is needed to determine the clinical utility of this emergency therapeutic modality.

Low-frequency sonophoresis: pathologic and thermal effects in dogs

OBJECTIVE

Low-frequency sonophoresis has recently been shown to significantly facilitate transdermal permeability of various substances (e.g., insulin) in animal models, thus eliminating the need to inject such agents. Prior to human trials, the authors studied the safety profile of low-frequency sonophoresis in dogs by evaluating microscopic and temperature changes in the skin after sonophoresis.

METHODS

An evaluator-blinded canine study of sonophoresis using different energy intensities and probe diameters was performed. Low-frequency ultrasound was applied for 60 seconds to the clipped abdominal skin of 3 anesthetized adult mongrel dogs using a sonicator operating at a frequency of 20 KHz with a maximal energy output of 400 W. The sonicator was immersed in normal saline, and intensities of 4%, 10%, 20%, 30%, and 50% were applied during 600 msec of every second (pulsed mode). Three probes, 1-cm cylindrical, 5-cm cylindrical, and 10-cm disc-shaped, were evaluated. Each experimental condition was performed twice. Subcutaneous temperatures were measured by temperature probe before and after sonophoresis. At 30 minutes post-sonophoresis, full-thickness skin biopsies were taken for blinded histopathologic evaluation.

RESULTS

Minimal urticarial reactions were noted with the 1-cm probe at intensities of < or = 20% and with the 5-cm probe at 4% intensity. With higher intensity, thermal injuries were observed grossly with erythema and vesicles. The microscopic correlates were papillary and dermal edema with neutrophils and telangiectasia. The conditions producing vesicles grossly had foci of epidermal necrosis, subepidermal vesicles, and degeneration of papillary dermal collagen. With still higher intensities, confluent epidermal necrosis became apparent. Use of the 10-cm probe did not result in any injury.

CONCLUSIONS

Low-frequency ultrasound at low intensities appears safe for use to enhance the topical delivery of medications, producing only minimal urticarial reactions. Higher-intensity conditions resulted in second-degree burns, most likely attributable to localized heating.

Comparison of types of research articles published in emergency medicine and non-emergency medicine journals

INTRODUCTION

As the specialty of emergency medicine (EM) matures, its journals should be publishing research of a quality similar to that which appears in other premier journals.

OBJECTIVE

To compare the types of original research published in 4 EM vs 3 non-EM journals.

METHODS

Retrospective review of all 1995 articles published in Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, Journal of Emergency Medicine, Annals of Internal Medicine, JAMA, and New England Journal of Medicine. Research articles were classified as longitudinal vs cross-sectional, prospective vs retrospective, and interventional vs observational. Other characteristics noted were number of subjects, randomization, blinding, control, and power calculations. Journals were reviewed by 4 investigators who received specific training in research classification, adhering to previously reported criteria for retrospective reviews. Interobserver reliability was independently validated.

RESULTS

The authors reviewed 3,524 articles, of which 874 (24.8%) were original research. Compared with research reported in non-EM journals, EM journals contained fewer longitudinal studies (40.5% vs 60.4%, p < 0.0001) and fewer prospective studies (70.8% vs 78.7%, p = 0.008). Fewer EM journals had studies that were blinded (13.7% vs 18.9%, p = 0.047) or controlled (36.3% vs 50.0%, p = 0.003). Studies reported in EM journals had fewer subjects (138 vs 300, p < 0.001). Research reports in EM journals were less likely to have been funded, even after adjustment for the differences in study designs (adjusted odds ratio 7.0, 95% CI 5.1-9.7).

CONCLUSION

Significant differences in types of research published in EM and non-EN journals were identified.

Thermal effects of neutralization therapy and water dilution for acute alkali exposure in canines

OBJECTIVE

To evaluate the change in temperature of the gastric mucosa and lumen contents when a weak acid or water is used to manage acute alkali exposure.

METHODS

A prospective in-vivo canine model was used in a university-based animal laboratory setting. Eighteen adult canines weighing 20-25 kg were placed under a surgical plane of anesthesia and a laparotomy was performed. A gastrotomy was then made later ligation of the distal esophagus and proximal duodenum. Separate mucosa and lumen temperature probes were placed. Then 25 mL of room-temperature (24-26 degrees C) 50% sodium hydroxide (NaOH) was instilled in the gastric lumen. After 5 minutes, each canine was given treatment. Group 1 (n = 10) was treated with 75 mL of room-temperature orange juice. Group 2 (n = 8) was treated with 75 mL of room-temperature water. Continuous mucosa and lumen temperatures were observed and recorded at baseline and at specified intervals for 35 minutes after the alkali insult. Repeated-measures analysis of variance was used to evaluate the overall temperature profile. Signed-rank tests were used to compare the changes in temperature immediately following neutralization treatment.

RESULTS

Significant temperature decreases of 1.1 degrees C and 2.1 degrees C were observed for both mucosa (p = 0.002) and lumen (p < 0.001) temperature, respectively, following neutralization therapy with room-temperature orange juice. In the group treated with room-temperature water, significant temperature decreases of 2.1 degrees C for mucosa (p = 0.01) and 2.4 degrees C for lumen (p = 0.01) were observed. Posttreatment temperatures did not exceed baseline for the entire observation period.

CONCLUSION

Neutralization therapy with room-temperature orange juice or water dilution for acute gastric injuries by liquid alkali does not cause a rise in mucosal or intraluminal temperatures in an in-vivo canine model.

Renal gluconeogenesis and blood flow during endotoxic shock

OBJECTIVES

To determine whether endotoxic shock decreases the renal gluconeogenic capacity and the renal artery blood flow.

METHODS

An in-vivo, murine, nonrecirculating kidney perfusion model was studied in a trauma research laboratory. Each of 12 fasted, male Holtzman rats (shock n = 6, control n = 6) was injected with 1 mL of normal saline or endotoxin (20 mg/kg). Five hours after the injection, all the rats were anesthetized and blood samples were obtained for the determination of the plasma glucose. Right renal artery blood flow was measured by an ultrasonic small-animal flow meter. The kidney was then perfused via the renal artery with 37 degrees C, oxygenated, glucose-free Krebs-Henseleit solution in the presence of 100 mumol of phloridzin to inhibit the cellular uptake of glucose. Renal glucose production was determined by measuring glucose in both renal vein effluent and urine. After 30 minutes of equilibration, 5 mmol of lactate and 0.5 mmol of pyruvate were added to the perfusate as a gluconeogenic substrate. Renal vein and ureteral effluent samples were collected after 5, 10, and 15 minutes.

RESULTS

The endotoxic shock group showed hypoglycemia (p < 0.05) as well as a decrease in renal artery blood flow (p < 0.05). Gluconeogenic stimulation was demonstrable in both the control and the endotoxic shock groups after 15 minutes of perfusion with substrate (p < 0.05). However, renal gluconeogenesis was significantly attenuated in the endotoxic shock group compared with the control.

CONCLUSIONS

Renal glucose production in response to a gluconeogenic substrate is significantly attenuated during the hypoglycemic phase of endotoxic shock. Endotoxic shock also causes a significant decrease of renal artery blood flow.

In vivo tissue temperature comparison of cryotherapy with and without external compression

STUDY OBJECTIVE

To compare the tissue-cooling efficiency of external cryotherapy with and without adjunctive compression.

METHODS

We conducted an experimental repeated-measures study in which each of the 11 anesthetized subject dogs served as its own control. A chemical instant cold pack was applied to each subject's ventral thighs. One pack was held in position by gravity, and the other was compressed against the musculature with a tubular elastic wrap. Baseline and subsequent temperature measurements were taken every 10 minutes for 1 hour with the use of an IM temperature probe percutaneously inserted into each subject's hind legs.

RESULTS

IM temperatures were not significantly different at baseline and were coldest at 20 minutes; they increased slowly thereafter. The recorded temperature was lower under the compressed cold pack (P = .003), and changes over time for both groups were also significant (P = .005). The instantaneous temperature difference at 10, 30, 40, 50, and 60 minutes was also significant.

CONCLUSION

Externally applied instant cold packs in a dog model caused local tissue hypothermia that peaked by 20 minutes, persisted for at least 1 hour, and was significantly augmented by adjunctive compression. Further research is needed to evaluate the clinical efficacy and safety of these interventions in the management of acute soft-tissue injuries.

Effective treatment for acute alkali injury to the esophagus using weak-acid neutralization therapy: an ex-vivo study

OBJECTIVE

1) To evaluate whether neutralization therapy with weak acid is effective in reducing observed histopathologic esophageal tissue injury secondary to liquid alkali, 2) to quantify the temperature change of the neutralizing agent, and 3) to determine the effect of interval to therapy on injury severity.

METHODS

Harvested Sprague-Dawley rat esophagi were catheterized and placed in an oxygenated saline bath (37 degrees C) for 60 minutes and then fixed in 10% formalin. Nine groups (n = 10) were perfused with 50% sodium hydroxide (NaOH). Six of the groups were treated by neutralization with cooled orange juice (OJ) or cola that was maintained between 2 degrees C and 4 degrees C. This was performed at 0, 5, or 30 minutes after injury. In addition, two positive control groups were exposed to OJ or cola at time 0 and were not exposed to strong alkali. A third control group was exposed to strong alkali but was not administered any subsequent treatment. The temperature of the neutralizing agent was recorded prior to instillation and after exiting the esophagus. Blinded pathologic scoring of 0 (no injury) to 3 (severe) was recorded performed for six histopathologic categories: epithelial cell viability, cornified epithelial cell differentiation, granular cell differentiation, epithelial cell nuclei, muscle cells, and muscle cell nuclei. Comparisons were made among treatment times using the Kruskal-Wallis test and linear trend analysis.

RESULTS

For each histopathologic category and each treatment mode, the Kruskal-Wallis test showed significant differences between the groups (p < 0.002) over time. Trend analyses showed more severe injury with delayed neutralization therapy (p < 0.05) for each treatment mode and histopathologic category.

CONCLUSION

Early neutralization therapy with OJ or cola reduces acute esophageal alkali injury. Additional in-vivo study is needed before neutralization therapy is adopted for clinical use.

Histopathologic evaluation of the therapeutic efficacy of water and milk dilution for esophageal acid injury

OBJECTIVE

To determine whether acid-induced injury to the esophagus is decreased by early dilutional therapy with water or milk.

METHODS

A controlled in-vitro animal model for acid injury to the esophagus was carried out using esophagi harvested from 70 Sprague-Dawley rats of both sexes and weighing 250-350 g. One control and six experimental groups each containing ten esophagi were instilled with 1 mL of 0.5 normal solution of hydrogen chloride (N HCl). Dilution with water or milk was performed at 0, 5, or 30 minutes postinjury in the experimental groups. No dilution was performed with the control group. Specimens were maintained in an oxygenated saline bath for a 60-minute experimental period and then fixed in 10% formalin for histologic evaluation. Injury severity was rated by blinded histopathologic examination using scores of 0 (no injury), 1 (minor), 2 (moderate), and 3 (severe) for the histopathologic categories: cornified epithelial cells (CEs), granular cells (GCs), granular cell nuclei (GNs), and basal cells (BCs). Red blood cells were scored as positive or negative for lysis.

RESULTS

The controls showed the most severe outcomes. Significant differences in injury occurred for all time periods and histopathologic categories, except for the GN/water and BC/milk histopathologic category/treatment groups. However, a linear trend analysis was significant for all histopathologic categories except BC. These analyses support decreased injury in the earlier treated groups. Injury severity was highest in the most superficial cell layer (CE).

CONCLUSIONS

Emergency therapy with water or milk reduces acute acid injury to the esophagus. Earlier treatment is associated with decreased injury severity. This research supports the use of dilutional therapy with water or milk for acute acid injury to the esophagus.

Evaluation of an emergency-procedure teaching laboratory for the development of proficiency in tube thoracostomy

OBJECTIVE

Emergency-procedure laboratories are not a standardized part of the curriculum for emergency medicine residency programs. The authors evaluated the efficacy of an emergency-procedure laboratory to teach medical students and residents the performance of tube thoracostomy.

METHODS

A prospective repeated-measures study of tube thoracostomy placement training was performed in an animal-laboratory setting. Participants were six first-postgraduate-year emergency medicine residents and six fourth-year medical students. Each participant was given a written pretest on tube thoracostomies followed by lectures on tube thoracostomy, venous cutdown, peritoneal lavage, and surgical airway. The procedure laboratory, using an anesthetized canine model (20-25 kg), was then conducted. Tube thoracostomies were timed from skin incision to passage of the tube into the thoracic cavity with subsequent tube fogging. Four attempts per participant were documented. Eighteen days later, an identical procedure laboratory was conducted for the same students including a written posttest identical to the pretest.

RESULTS

The written test scores improved for every participant (p < 0.0001). Mean times for procedures completion improved from 121 sec to 39 sec (p = 0<.001) during the first session and improved from 58 sec to 28 sec (p = 0.005) during the second session. Retention of skills was indicated by significant shortening of the time to completion from the first attempt of the first session to that of the second session (121 sec to 58 sec, p = 0.002).

CONCLUSION

This procedure laboratory, which emphasized skill repetition, led to improvement in procedural speed and retention of tube thoracostomy skills over time. This approach to teaching clinical procedures should be considered for emergency medicine residency programs and for continuing medical education courses that emphasize acquisition of clinical procedural skills.

Therapeutic effects of water and milk for acute alkali injury of the esophagus

STUDY BACKGROUND

Alkali ingestions cause progressive and devastating injury to the esophagus by liquefaction necrosis. However, the therapeutic efficacy of water or milk dilution for alkali-induced esophageal injury has not been determined. This study used our previously reported model of alkali-induced esophageal injury to evaluate the effectiveness of water and milk dilution.

HYPOTHESIS

Early dilution with water or milk is efficacious in decreasing esophageal damage from alkali exposure.

METHODS

The esopgagi of 75 Sprague-Dawley rats were harvested, and each end was cannulated with a 20-gauge catheter. Specimens were maintained in an oxygenated saline solution (at 37 degrees C) during a 60-minute experimental period and then fixed immediately in 10% Formalin solution for histologic examination. Esophagi from six experimental groups (total of 60) were perfused with 50% NaOH solution at time 0. Water or milk dilution was performed immediately at 0 minutes, 5 minutes after injury, and 30 minutes after injury. Blinded pathologic examination was performed using a score of 0 (no injury), 1 (minimal), 2 (moderate), or 3 (severe) for the following six histologic categories: epithelial viability, cornified epithelial cell differentiation, granular cell differentiation, epithelial cell nuclei, muscle cells, and muscle cell nuclei.

RESULTS

Positive and negative controls showed expected outcomes. Significant progressions of injury over time were seen for every histologic category for both water and milk dilution. The injury scores for the milk-treated group at 0 minutes were less than or equal to the injury score for the water-treated group for all categories. However, these differences were significant only for the cornified epithelial cells.

CONCLUSION

Early dilution therapy with water or milk reduces acute alkali injury of the esophagus and supports use of these forms of emergency treatment.

Effective treatment of acute alkali injury of the rat esophagus with early saline dilution therapy

BACKGROUND

Controversy persists regarding the appropriate treatment of acute alkali injury to the esophagus. The current study establishes a controlled model of alkali esophageal injury and examines the efficacy of saline dilution therapy.

STUDY HYPOTHESIS

Early saline dilution therapy effectively reduces esophageal injury resulting from acute alkali exposure.

METHODS

The esophagi were harvested from 60 Sprague-Dawley rats. Each end was cannulated with a 20-gauge catheter. Specimens were maintained in an oxygen-perfused saline bath (37 C) during a 60-minute experimental period and then fixed immediately in 10% formalin solution for histologic examination. Three experimental groups (A, B, and C) were perfused with 50% NaOH solution at time zero. Treatment with saline perfusion was performed immediately in group A, five minutes after injury in group B, and 30 minutes after injury in group C. The positive control group D was perfused with saline at time zero. A negative control, group E, was perfused with 50% NaOH at time zero. This group did not receive subsequent treatment with saline. Pathologic examination was performed in a blinded fashion using a score of 0 to 3 (0, no injury; 1, minimal; 2, moderate; 3, severe) for seven histologic criteria: epithelial viability, extent of injury, cornified epithelial cell differentiation, granular cell differentiation, epithelial cell nuclei, muscle cells, and muscle cell nuclei.

RESULTS

The positive control group demonstrated scores of zero. Nonparametric analysis showed a significant difference among treatment groups for each injury category. Trend analysis revealed a significant progression of injury for each category associated with time to treatment. Discriminant analysis indicated that the muscle cells category was the most useful category with which to distinguish injury among groups.

CONCLUSION

In our model, saline lavage decreased objective evidence of esophageal injury after a severe alkaline exposure, and early therapy enhanced this beneficial effect.

The enlarging clinical spectrum of Lyme disease: Lyme cerebral vasculitis, a new disease entity

The case of a patient with cerebral vasculitis with a right thalamic infarct associated with cerebral spinal fluid Lyme disease is presented. This entity has not been described in the United States, and only one similar case in the world literature could be found. The patient presented with a progressive headache and subsequent development of grand mal seizure activity. Lyme disease has been associated with cranial nerve palsies, peripheral and cranial radiculopathies, aseptic meningitis, encephalitic symptoms, chorea, and demyelinating polyneuropathy presenting like Guillain-Barré syndrome. These syndromes can occur separately or in combination. Stroke and strokelike syndromes have been attributed to Lyme disease. The literature concerning the neurologic manifestations of Lyme disease is reviewed.