Clinical epidemiology, determinants, and outcomes of viral encephalitis in Ghana; a cross-sectional study

Viral encephalitis is a rare, yet severe neurological disorder. It poses a significant public health threat due to its high morbidity and mortality. Despite the disproportionate burden of the disease in impoverished African countries, the true extent of the problem remains elusive due to the scarcity of accurate diagnostic methods. The absence of timely and effective diagnostic tools, particularly Real-time Polymerase Chain Reaction, has led to misguided treatment, and an underestimation of the disease burden in Ghana. We conducted a prospective cross-sectional study to determine the viral aetiologies of encephalitis among patients presenting to a major referral hospital in Ghana from May 2019 and August 2022. The study aimed at providing a comprehensive information on the clinical epidemiology, and outcomes of viral encephalitis in Ghana. Clinical samples were collected from patients presenting with signs and symptoms of encephalitis and tested for viral agents using real-time polymerase chain reaction. We assessed the clinical epidemiology, risk factors and outcome of individuals using descriptive and logistic regression analysis. Seventy-seven (77) patients were enrolled unto the study. The participants frequently presented with fever (85.7%), seizures (80.5%), lethargy (64.9%) and headache (50.6%). Viruses were detected in 40.3% of the study participants in either cerebrospinal fluid, rectal or oral swab samples. The most frequently detected viruses were cytomegalovirus (48.4%), enteroviruses (38.7%) and HSV (29.0%). Twenty-one (27.3%) of the patients died while on hospital admission. Gender (OR = 5.70 (1.536-1.172), p = 0.01), and negative polymerase chain reaction test results were identified as significant factors associated with death. Antiviral treatment increased the chance of survival of viral encephalitis patients by 21.8%. Our results validate the crucial role of molecular tools as essential for the rapid diagnosis of viral encephalitis, enabling effective treatment and improved patient outcomes. This study contributes valuable epidemiological and clinical insight into viral encephalitis in Ghana.

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

Investment in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing in Africa over the past year has led to a major increase in the number of sequences that have been generated and used to track the pandemic on the continent, a number that now exceeds 100,000 genomes. Our results show an increase in the number of African countries that are able to sequence domestically and highlight that local sequencing enables faster turnaround times and more-regular routine surveillance. Despite limitations of low testing proportions, findings from this genomic surveillance study underscore the heterogeneous nature of the pandemic and illuminate the distinct dispersal dynamics of variants of concern-particularly Alpha, Beta, Delta, and Omicron-on the continent. Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve while the continent faces many emerging and reemerging infectious disease threats. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century.

Genetic characterization of varicella-zoster and HIV-1 viruses from the cerebrospinal fluid of a co-infected encephalitic patient, Ghana

BACKGROUND

Encephalitis is a serious disease of the brain characterized by prodromal and specific neurological symptoms. HIV infections offer opportunistic viruses, such as Varicella-zoster virus (VZV), the chance to cause encephalitis in patients. There is a lack of information on the genetic diversity of VZV in Ghana and other parts of Africa which requires sequencing and characterization studies to address. The active evolution of HIV-1 in West Africa also requires continuous surveillance for the emergence of new genetic forms.

CASE PRESENTATION

VZV was detected in the CSF sample of an 11-year-old patient presenting with symptoms of encephalitis by real-time PCR diagnostics. To identify possible unknown aetiological pathogens, next-generation sequencing was performed, and revealed an HIV-1 co-infection. Alignments of concatenated HIV-1 genome fragments in the gag, pol, vif, env and nef regions and a near-complete VZV genome were analyzed by Bayesian inference, and phylogenetic trees were generated. The VZV sequence belongs to clade 5 and the HIV-1 sequence is a member of the CRF02_AG predominant circulating recombinant form in Ghana.

CONCLUSIONS

Diagnostic tests for CSF HIV would be useful where possible in patients presenting with encephalitis due to VZV and other opportunistic viruses in Kumasi to shed light on the role of HIV in encephalitis cases in Ghana. This report reaffirms the role of the CRF02_AG circulating recombinant form in HIV infections in Ghana and also gives a preliminary genetic characterization of VZV in Kumasi, Ghana.

Using drones to transport suspected COVID-19 samples; experiences from the second largest testing centre in Ghana, West Africa

BACKGROUND

The declaration of COVID-19 as a pandemic on March 11 2020, by the World Health Organisation prompted the need for a sustained and a rapid international response. In a swift response, the Government of Ghana, in partnership with Zipline company, launched the use of Unmanned Automated Vehicles (UAV) to transport suspected samples from selected districts to two foremost testing centres in the country. Here, we present the experiences of employing this technology and its impact on the transport time to the second largest testing centre, the Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR) in Kumasi, Ghana.

METHODS

Swab samples collected from suspected COVID-19 patients were transported to the Zipline office by health workers. Information on the samples were sent to laboratory personnel located at KCCR through a WhatsApp platform to get them ready to receive the suspected COVID-19 samples while Zipline repackaged samples and transported them via drone. Time of take-off was reported as well as time of drop-off.

RESULTS

A total of 2537 COVID-19 suspected samples were received via drone transport from 10 districts between April 2020 to June 2021 in 440 deliveries. Ejura-Sekyedumase District Health Directorate delivered the highest number of samples (765; 30%). The farthest district to use the drone was Pru East, located 270 km away from KCCR in Kumasi and 173 km to the Zipline office in Mampong. Here, significantly, it took on the average 39 minutes for drones to deliver samples compared to 117 minutes spent in transporting samples by road (p<0.001).

CONCLUSION

The use of drones for sample transport during the COVID-19 pandemic significantly reduced the travel time taken for samples to be transported by road to the testing site. This has enhanced innovative measures to fight the pandemic using technology.

Rabies is still a fatal but neglected disease: a case report

Background

Rabies, caused by a lyssavirus, is a viral zoonosis that affects people in many parts of the world, especially those in low income countries. Contact with domestic animals, especially dogs, is the main source of human infections. Humans may present with the disease only after a long period of exposure. Nearly half of rabies cases occur in children <15 years old. We report on a fatal case of rabies in a Ghanaian school child 5 years after the exposure incident, and the vital role of molecular tools in the confirmation of the diagnosis.

Case presentation

The patient, an 11-year-old junior high school Ghanaian student from the Obuasi Municipality in Ghana, presented with aggressive behavior, which rapidly progressed to confusion and loss of consciousness within a day of onset. Her parents reported that the patient had experienced a bite from a stray dog on her right leg 5 years prior to presentation, for which no antirabies prophylaxis was given. The patient died within minutes of arrival in hospital (within 24 hours of symptom onset). Real-time polymerase chain reaction testing of cerebrospinal fluid obtained after her death confirmed the diagnosis of rabies. Subsequent phylogenetic analysis showed the virus to belong to the Africa 2 lineage of rabies viruses, which is one of the predominant circulating lineages in Ghana.

Conclusion

The incubation period of rabies is highly variable so patients may only present with symptoms long after the exposure incident. Appropriate molecular testing tools, when available as part of rabies control programmes, are vital in confirming cases of rabies.

A year of genomic surveillance reveals how the SARS-CoV-2 pandemic unfolded in Africa

The progression of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in Africa has so far been heterogeneous, and the full impact is not yet well understood. In this study, we describe the genomic epidemiology using a dataset of 8746 genomes from 33 African countries and two overseas territories. We show that the epidemics in most countries were initiated by importations predominantly from Europe, which diminished after the early introduction of international travel restrictions. As the pandemic progressed, ongoing transmission in many countries and increasing mobility led to the emergence and spread within the continent of many variants of concern and interest, such as B.1.351, B.1.525, A.23.1, and C.1.1. Although distorted by low sampling numbers and blind spots, the findings highlight that Africa must not be left behind in the global pandemic response, otherwise it could become a source for new variants.

Transmission of SARS-CoV-2 in northern Ghana: insights from whole-genome sequencing

Following the detection of the first imported case of COVID-19 in the northern sector of Ghana, we molecularly characterized and phylogenetically analysed sequences, including three complete genome sequences, of severe acute respiratory syndrome coronavirus 2 obtained from nine patients in Ghana. We performed high-throughput sequencing on nine samples that were found to have a high concentration of viral RNA. We also assessed the potential impact that long-distance transport of samples to testing centres may have on sequencing results. Here, two samples that were similar in terms of viral RNA concentration but were transported from sites that are over 400 km apart were analyzed. All sequences were compared to previous sequences from Ghana and representative sequences from regions where our patients had previously travelled. Three complete genome sequences and another nearly complete genome sequence with 95.6% coverage were obtained. Sequences with coverage in excess of 80% were found to belong to three lineages, namely A, B.1 and B.2. Our sequences clustered in two different clades, with the majority falling within a clade composed of sequences from sub-Saharan Africa. Less RNA fragmentation was seen in sample KATH23, which was collected 9 km from the testing site, than in sample TTH6, which was collected and transported over a distance of 400 km to the testing site. The clustering of several sequences from sub-Saharan Africa suggests regional circulation of the viruses in the subregion. Importantly, there may be a need to decentralize testing sites and build more capacity across Africa to boost the sequencing output of the subregion.

Osteomyelitis of the ulnar head in a presumed "pulled elbow"

The "pulled elbow" is a common emergency department diagnosis that presents with a classic history and examination. A differential diagnosis should be sought in all children with atypical clinical features or in those in whom manipulation is unsatisfactory. The importance of follow-up should also be highlighted in the atypical pulled elbow. An unusual presentation of osteomyelitis of the ulnar head initially diagnosed as a pulled elbow in a 9-month-old boy is discussed. This case was further complicated by the lack of inflammatory response to infection and the manifestation clinically of signs apparently within the elbow rather than the osteomyelitic inferior radioulnar joint.

Choice of antenatal testing significantly effects a patient's work obligations

OBJECTIVE

We sought to compare two approaches to antenatal testing for their impact on the workforce.

STUDY DESIGN

This is a prospective observational study of women who presented for antenatal testing. All women were given a survey upon presentation. As per hospital protocol, nonstress testing (NST) was performed semiweekly and biophysical profile (BPP) was performed weekly. The choice of testing was determined by the attending physician. chi2- and Student's t-tests were performed where appropriate. A P-value of <0.05 was considered significant.

RESULT

A total of 195 women were surveyed. Among them, 94 women had an NST and 101 had a BPP. Overall, 59.2% were multiparous, 33.1% had to arrange for child care and 97.2% felt reassured by the testing. There were no differences in demographic characteristics, education, type of insurance or employment status between the groups. Women who had NSTs were more likely to lose time from work than those who had BPPs (218.4 versus 68.9 min; P<0.001). Of the women who had semiweekly NSTs, 80.6% would have preferred weekly testing. If the 94 women who received semiweekly testing had weekly testing, a total of 534.4 h would have been available for the workforce.

CONCLUSION

Twice-weekly NST results in a significant increase in time lost from the workforce compared with weekly BPP.

An evaluation of five preservation techniques and conventional freezing temperatures of -20oC and -85oC for long-term preservation of Campylobacter jejuni

AIMS

This study aimed to identify a simple, inexpensive preservation technique that will allow a quick and reliable recovery of Campylobacter jejuni following long-term periods of preservation.

METHODS AND RESULTS

Preservation techniques include (i) Cryobank microbial preservation system using hypertonic 'cryopreservative solution' and glass beads, (ii) Cryobank microbial preservation system using defibrinated lysed horse blood and glass beads, (iii) FBP medium, (iv) 15% glycerol/85% nutrient broth no. 2 culture, and (v) 50% glycerol/50% nutrient broth no. 2 culture. Each preservation technique was evaluated over a 1-year period at conventional freezing temperatures of -20 degrees C and -85 degrees C. Replacement of 'cryopreservative fluid' in commercially prepared vials of glass beads with lysed horse blood increased the duration of preservation of Camp. jejuni by up to 6 months.

CONCLUSIONS

FBP medium proved the most successful preservation technique with 100 and 80% recovery after 1 year at -85 degrees C and -20 degrees C, respectively.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrated a simple inexpensive preservation method for long-term storage of Camp. jejuni.

Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery

BACKGROUND

Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta.

METHODS

One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones.

RESULTS

Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups.

CONCLUSIONS

In patients undergoing surgery of the abdominal aorta, thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia, offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia.

Low-amplitude, extremely low frequency magnetic fields for the treatment of osteoarthritic knees: a double-blind clinical study

CONTEXT

Noninvasive magnetotherapeutic approaches to bone healing have been successful in past clinical studies.

OBJECTIVE

To determine the effectiveness of low-amplitude, extremely low frequency magnetic fields on patients with knee pain due to osteoarthritis.

DESIGN

Placebo-controlled, randomized, double-blind clinical study.

SETTING

4 outpatient clinics.

PARTICIPANTS

176 patients were randomly assigned to 1 of 2 groups, the placebo group (magnet off) or the active group (magnet on).

INTERVENTION

6-minute exposure to each magnetic field signal using 8 exposure sessions for each treatment session, the number of treatment sessions totaling 8 during a 2-week period, yielded patients being exposed to uniform magnetic fields for 48 minutes per treatment session 8 times in 2 weeks. The magnetic fields used in this study were generated by a Jacobson Resonator, which consists of two 18-inch diameter (46-cm diameter) coils connected in series, in turn connected to a function generator via an attenuator to obtain the specific amplitude and frequency. The range of magnetic field amplitudes used was from 2.74 x 10(-7) to 3.4 x 10(-8) G, with corresponding frequencies of 7.7 to 0.976 Hz.

OUTCOME MEASURES

Each subject rated his or her pain level from 1 (minimal) to 10 (maximal) before and after each treatment and 2 weeks after treatment. Subjects also recorded their pain intensity in a diary while outside the treatment environment for 2 weeks after the last treatment session (session 8) twice daily: upon awakening (within 15 minutes) and upon retiring (just before going to bed at night).

RESULTS

Reduction in pain after a treatment session was significantly (P < .001) greater in the magnet-on group (46%) compared to the magnet-off group (8%).

CONCLUSION

Low-amplitude, extremely low frequency magnetic fields are safe and effective for treating patients with chronic knee pain due to osteoarthritis.

Relationship of disability prevention to patient health status and satisfaction with primary care provider

A sample of 625 patients aged 18 to 65 with primary care visits was used to explore the relationship of disability prevention to patient health status and satisfaction with health care provider. Disability prevention and the patient-provider relationship, the latter a potential mediating factor, were measured using reliable and valid scales. The joint effects of disability prevention and a strong patient-provider relationship were associated with decreased risks for poor physical health, as measured by the Medical Outcomes Study 12-item short-form health survey, decreased restricted activity days, and overall satisfaction with their primary care provider. Patient-provider relationship was independently associated with increased patient satisfaction with the provider overall and endorsement of the provider to family or friends. The evidence questions the conventional wisdom among some primary care providers that incorporating disability prevention principles into their daily practice jeopardizes patient satisfaction. These results suggest that primary care providers with strong patient-provider relationships can successfully add disability prevention to their practice.

Immaturity or starvation? Longitudinal study of leptin levels in premature infants

OBJECTIVE

Leptin, the protein product of the ob gene, is a potential placental growth factor and is integral to the body's system of energy regulation as shown in animal models. Premature infants are especially vulnerable to changes in energy regulation, and several studies have demonstrated a rapid fall in leptin values at birth. The purpose of the present investigation was to measure leptin levels in premature infants throughout hospitalization.

METHODS

Eligible infants were less than 32 weeks' gestation, appropriate for gestational age, and hospitalized at Christiana Hospital Special Care Nursery. Serum samples for leptin analysis were drawn within 24 h of birth and twice a week thereafter until discharge. Concurrent growth measurements were obtained with each leptin sample. Body mass index, ponderal index, and midarm circumference/head circumference ratios were calculated to assess growth.

RESULTS

Leptin levels were low and remained low for the duration of the premature infants' hospitalization (mean +/- SD = 1.35 +/- 0.63 ng/ml/ml, range 0-3.06). After controlling for weight, there was a small (r(2) = 0.1, p < 0.00001) but significant correlation between leptin and postnatal age after 4 days of age. Despite an increase in caloric intake during the study period, there was no relationship between leptin and caloric intake. There were significant negative correlations between measurements of growth and both leptin and the leptin/weight ratio. Maternal diabetes and the use of steroids had small but significant effects on the leptin/weight ratio.

CONCLUSION

In this population of predominantly female premature infants, leptin levels were very low as compared to term infants, children and adults, and did not change appreciably over the study period. The low leptin levels seen in these premature infants are similar to those levels seen in malnourished adults, anorexics, and in animal models of starvation. We speculate that a critical adipose store needs to be reached before increased amounts of leptin can be adequately produced. Persistently low leptin levels may also reflect an immaturity in the hypothalamic-pituitary-adrenal axis.

Disability prevention principles in the primary care office

The simple request for a sick note can disguise important medical, psychologic or social issues. Disability may be influenced by social and cultural factors as well as by patient expectations. Assessment of impairment and subsequent disability is best made on the basis of objective data by use of a biopsychosocial model to ensure that the expression of disability does not mask other unaddressed psychologic or social issues. Enabling prolonged disability in such a situation can be a dysfunctional physician response to a maladaptive process. The physician's role is to treat the condition, to fulfill the appropriate role of patient advocate, to facilitate health (including resumption of activity), to offer proactive advice on the basis of prognosis, to be familiar with the patient's social obligations and resources and to provide education about the therapeutic benefits of returning to optimal function. This factual, medical-based approach offers an effective preventive strategy that will save many patients from unnecessary disability and morbidity.

Adjustment of birth weight standards for maternal and infant characteristics improves the prediction of outcome in the small-for-gestational-age infant

OBJECTIVE

Birth weight is a function of gestational age. Various maternal and infant characteristics also affect birth weight. This study sought to adjust for these factors to better define abnormal growth.

STUDY DESIGN

Maternal and infant characteristics from normal pregnancies were correlated with birth weight. A formula was developed and applied to a second group in which we compared perinatal outcomes in normally grown infants with those who were small for gestational age. We compared outcomes between small-for-gestational-age infants defined by the formula with those defined by conventional tables.

RESULTS

Infants defined by the formula as small-for-gestational-age were more likely to have morbidity and mortality than those who were normally grown (p < 0.001). Small-for-gestational-age infants defined by the formula had more deaths and adverse outcomes than those defined by gestational age.

CONCLUSION

Adjusting birth weight standards for maternal and infant characteristics may improve the prediction of adverse outcomes.

Expert system for management of urinary incontinence in women

The purpose of this nursing informatics and outcomes research study was to determine the effectiveness of an expert system for disseminating knowledge to ambulatory women health care consumers with urinary incontinence. Clinical knowledge from the Agency for Health Care Policy and Research (AHCPR) patient guideline for urinary incontinence and research literature for behavioral treatments provided the knowledge base for the expert system. Two experimental groups (booklet and expert system) and one control group were utilized. Study results suggest the use of an expert system as one effective communication means for disseminating clinical information in an advisory capacity to ambulatory women with urinary incontinence.

Colonization of intestinal bacteria in the normal neonate: comparison between mouth and rectal swabs and small and large bowel specimens

Seventy-four New Zealand white rabbit pups were divided into four groups: group I, 2 days of age (n = 9); group II, 3 to 5 days of age (n = 24); group III, 6 to 8 days of age (n = 27); and group IV, 10 to 13 days of age (n = 14). Mouth swabs (MS), rectal swabs (RS), small bowel specimens (SB), and large bowel specimens (LB) were obtained from each rabbit, incubated for 24 hours in thioglycolate broth, and plated on blood agar in aerobic and anaerobic environments. After 24 hours, growth on blood agar plates were observed. All MS specimens and all but one RS specimen showed positive growth. Growth of both LB and SB specimens increased significantly with age (P < .04). In addition, SB growth was significantly less than RS or MS growth in groups I, II, and III (P < .05). LB growth was significantly less than RS or MS growth in group I (P < .01) and tended to be less in groups II and III (62.5% v 100% and 93% v 100%, respectively). These data show that nearly half of normal rabbits under 6 days of age have sterile small and large intestines despite almost 100% growth from rectal and mouth swabs. These findings partially explain the absence of spontaneous bacterial translocation in young rabbit pups (under 4 days of age) and have important implications for the prophylaxis and treatment of neonatal sepsis.

Research priorities of VA nurses: a Delphi study

The purpose of this study was to conduct a Delphi survey of a sample of Gainesville Veterans Affairs Medical Center staff and head nurses. The study consisted of three rounds of questionnaires completed by the nurses as they identified and narrowed the most pressing nursing research questions. Results indicated that in five of the six clinical settings, despite investigators' instructions to identify clinical nursing research questions, administrative research questions were identified and ranked consistently higher in priority than clinical research questions. The single exception was in home care, where clinical questions received the highest priority. This phenomena may suggest that institutional constraints interfere with nurses' full expression of their clinical practice.

Decline in spindle support to alpha-motoneurones during sustained voluntary contractions

1. To address whether the muscle spindle support to alpha-motoneurones is maintained during prolonged isometric voluntary contractions, the discharge of eighteen muscle spindle afferents, originating in the dorsiflexors of the ankle or toes, was recorded from the common peroneal nerve in eight subjects. Isometric contractions were generally sustained for 1 min, usually below 30% of the maximal voluntary dorsiflexion force. 2. Once the afferent had been identified, subjects were instructed to dorsiflex the foot slowly to recruit the spindle ending, to continue the ramp contraction until a predetermined target force was reached, and then to hold that force until requested to relax. 3. Five muscle spindle afferents maintained a constant discharge frequency during the hold phase of the isometric contraction. Following relaxation of the contraction two spindle afferents from tibialis anterior, exhibited a post-contraction discharge despite the absence of detectable electromyographic activity (EMG). 4. The discharge frequency of most of the spindle afferents (72%) declined progressively during the isometric contraction. The mean firing rates had declined to two-thirds of those at the onset of the contraction by 30 s, and to half after 1 min. The decline in spindle firing rate commenced during the ramp phase of the contraction and was statistically significant by 10 s, when force was held constant. The extent of the decline was greater for those units with the higher initial firing rates and for those units studied after many preceding contractions. 5. In the same contractions a progressive increase in EMG was required to maintain force and consequently the change in EMG was inversely related to the change in spindle discharge. While many mechanisms may contribute to the decline in spindle discharge during a sustained isometric contraction, it is argued that the result will be a progressive disfacilitation of alpha-motoneurones, which may contribute to the decline in motor unit firing rates during a sustained contraction.

Interference of automated electroencephalographic processing by an endocardial pacemaker

This article reports a patient with an endocardial pacemaker undergoing a carotid endarterectomy in whom cerebral function was monitored by using processed electroencephalography (EEG). The EEG was processed by means of aperiodic analysis. The pacemaker generated an artifact that was identified on the processed EEG display and on the raw EEG display. During the time of carotid cross-clamping, a loss of EEG activity was noted on careful examination of the processed EEG and confirmed by referring to the raw EEG. Nevertheless, because of the presence of the artifact, the activity edge remained essentially constant despite the change in underlying EEG activity. The cross-clamp was released based on the observed change in EEG activity, yielding a return to baseline EEG activity. The surgeon elected to shunt the patient. The patient awoke without neurologic sequelae. This case serves to demonstrate the importance of referring to the raw EEG signal and the limitations of the activity edge in the presence of artifact.

Toluidine blue in the corroboration of rape in the adult victim

Objective physical evidence to corroborate a claim of rape is frequently absent. Genital lacerations are considered evidence that rape has occurred. In this study, toluidine blue dye, a nuclear stain, was used to detect vaginal lacerations. The detection of vaginal lacerations in reported rape victims increased from one in 24 to 14 in 24 with toluidine application. Toluidine blue increases the detection of perineal lacerations in adult rape victims and the presence of lacerations is supportive of the documentation of rape.

Relationship of thromboxane generation to the aggregation of platelets from humans: effects of eicosapentaenoic acid

A non-linear relationship between the percent aggregation of human platelets and the amount of TXB2 generated requires investigators to use caution when using the data to assess antiplatelet regimens. The relationship approximates a hyperbola with a roughly linear relationship from 0 to 70% aggregation and 0 to 50 ng TXB2 per ml of platelet-rich plasma. Above these values, the amount of TXB2 produced may increase up to 500 ng per ml of platelet-rich plasma with no clear relationship to the observed platelet function of aggregation. Also, appreciable inhibition of TXB2 formation can occur at high TXB2 levels with no detectable decrease in aggregation. Thus, assessment of antiplatelet regimens using TXB2 formation alone are unlikely to be interpretable without reference to this non-linear property of platelet function. We applied this concept when evaluating a study of forty subjects with dietary supplements of 1.8 g or 2.7 g of ethyl eicosapentaenoate (20:5n-3) for four weeks. There was a moderate, but statistically significant decrease in average values for the percent aggregation (60 +/- 15 to 45 +/- 30) and thromboxane production (51 +/- 30 to 33 +/- 31 ng/ml). Although the differences in mean values were slight relative to the overall standard deviations, reductions of platelet function were clearly evident in 31 of 40 subjects when paired results were examined relative to the recognized hyperbolic relationship.

Development of a gas chromatographic-mass spectrometric method using a stable isotope internal standard for quantitation of thromboxane B2

Tetradeuterated 19, 19',20,20'-2H4-thromboxane B2 was synthesized and used as a stable isotope internal standard for the development of a gas chromatographic/mass spectrometric (GC/MS) method to quantitate thromboxane B2. Quantitation was based on the detection of fragment ions at m/z 301 for thromboxane B2 and m/z 305 for the corresponding tetradeuterated internal standard. At m/z 301/305 a response equivalent to a protium/deuterium ratio of 0.2% thromboxane B2 could be measured with a standard deviation of 15% when 100 nanograms of the tetradeuterated internal standard was analyzed. For measurement of cellular biosynthesis of thromboxane B2 in whole blood or platelet rich plasma, the internal standard and naturally occurring thromboxane B2 were i) isolated by solvent extraction, or sequestration to XAD-2 columns; ii) purified by reversed phase high performance liquid chromatography; and iii) converted to methoxime methyl ester trimethylsilyl ethers prior to analysis. A limited comparison was made using both radioimmunological and mass spectrometric quantitation of thromboxane B2.

Outbreak of meningococcal disease in a family

An outbreak of three cases of meningococcal disease occurring in a family of 14 is presented. Three of the children, between the ages of 10 months to 10 years, were hospitalized. Two of them showed positive signs of meningitis, and one had evidence of bacteremia. Neisseria meningitidis was isolated from a blood sample of one patient and a CSF sample of another. The organism was also recovered from the nasopharyngeal secretion of four other adult members of the family. All three hospitalized children were treated with parenteral penicillin and responded well to therapy. The rest of the family was treated with oral rifampin, and subsequent cultures of the nasopharynx were negative.

9,11-Iminoepoxyprosta-5,13-dienoic acid is a selective thromboxane A2 synthetase inhibitor

9,11-Iminoepoxyprosta-5,13-dienoic acid inhibits the thromboxane A2 synthetase in platelet and lung microsomal enzyme preparations and in intact platelets. It does not inhibit the protaglandin I2 synthetase in aorta or lung microsomes and intact Balb 3T3 fibroblasts. In lung microsomes, which contain both enzymes, 9,11-iminoepoxyprosta-5,13-dienoic acid inhibits only thromboxane A2 formation and augments prostaglandin I2 formation. This inhibitor is more selective than other reported prostaglandin endoperoxide analogs which inhibit the platelet thromboxane synthetase.