Clinical Case of the Month: A 49-Year-Old Man with Fever, Headache and Leg Weakness.

A 49-year-old man with an unremarkable past medical history presented to an outside hospital with a five-day history of fever, left leg weakness, myalgia and headache. The patient reported that the illness started as a fever and sore throat and he was originally diagnosed with streptococcal pharyngitis and prescribed antibiotics. The day after his initial diagnosis, his fever had progressed to include a headache, myalgia, a rash on his upper torso and right shoulder and sudden-onset left leg weakness with preserved sensation. With progressively worsening symptoms, he eventually presented to a local emergency department (ED), five days after his symptoms first started. He was experiencing continued left leg weakness, an inability to ambulate, persistent fevers to 103ºF, muscle aches, an intense band-like headache and confusion. The patient denied neck stiffness, photophobia, loss of sensation or any additional muscle weakness. He denied any recent travel aside from work, any sick contacts, recent tick/insect bites, history of sexually transmitted diseases or contact with animals. He reported no history of illicit drug use as well as no recent weight loss, trauma or radiation exposure. The patient had approximately a 10-pack-year tobacco smoking history. For the last ten years he drank about a six-pack of beer daily while onshore (roughly two weeks out of every month). He works on an offshore oil platform. He was not taking any home medications besides his recently prescribed antibiotics. He lived alone at home in a moderately rural area of South Louisiana. His family history was non-contributory.

Antigen recognition is facilitated by invadosome-like protrusions formed by memory/effector T cells.

Adaptive immunity requires that T cells efficiently scan diverse cell surfaces to identify cognate Ag. However, the basic cellular mechanisms remain unclear. In this study, we investigated this process using vascular endothelial cells, APCs that possess a unique and extremely advantageous, planar morphology. High-resolution imaging revealed that CD4 memory/effector T cells dynamically probe the endothelium by extending submicron-scale, actin-rich "invadosome/podosome-like protrusions" (ILPs). The intimate intercellular contacts enforced by ILPs consistently preceded and supported T cell activation in response to endothelial MHC class II/Ag. The resulting calcium flux stabilized dense arrays of ILPs (each enriched in TCR, protein kinase C-θ, ZAP70, phosphotyrosine, and HS1), forming what we term a podo-synapse. Similar findings were made using CD8 CTLs on endothelium. Furthermore, careful re-examination of both traditional APC models and professional APCs suggests broad relevance for ILPs in facilitating Ag recognition. Together, our results indicate that ILPs function as sensory organelles that serve as actuators of immune surveillance.

Changes in breast density associated with initiation, discontinuation, and continuing use of hormone replacement therapy.

CONTEXT: Initiation of hormone replacement therapy (HRT) has been shown to increase breast density. Evidence exists that increased breast density decreases mammographic sensitivity. The effects on breast density of discontinuing and continuing HRT have not been studied systematically. OBJECTIVE: To examine the effects of initiation, discontinuation, and continued use of HRT on breast density in postmenopausal women. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 5212 naturally postmenopausal women aged 40 to 96 years and enrolled in a large health maintenance organization in western Washington State who had 2 screening mammograms between 1996 and 1998. MAIN OUTCOME MEASURES: Breast density, assessed using the clinical radiologists' BI-RADS 4-point scale, compared among women who did not use HRT before either mammogram (nonusers); who used HRT before the first but not before the second mammogram (discontinuers); who used HRT before the second but not before the first mammogram (initiators); and who used HRT prior to both mammograms (continuing users). RESULTS: Relative to nonusers, women who initiated HRT were more likely to show increases in breast density (relative risk [RR], 2.57; 95% confidence interval [CI], 2.12-3.08), while women who discontinued HRT use were more likely to show decreases in density (RR, 1.81; 95% CI, 1.06-2.98) and women who continued to use HRT were more likely to show both increases in density (RR, 1.33; 95% CI, 1.13-1.55) and sustained high density (RR, 1.45; 95% CI, 1.33-1.58). CONCLUSIONS: These results indicate that breast density changes associated with HRT are dynamic, increasing with initiation, and decreasing with discontinuation.

Development and implementation of novel community outreach methods in women's health issues: the National Centers of Excellence in Women's Health.

Numerous outreach efforts have been employed to educate both lay and professional communities about many medical issues. As part of our contracts with the Public Health Service, Office of Women's Health, Department of Health and Human Services, the National Centers of Excellence (CoEs) in Women's Health have been charged with creating innovative and effective methods of educating these audiences about the major issues involved in women's health. This mission is particularly critical in the arena of women's health, as women are responsible for approximately 75% of the healthcare decisions made by and for American families, and past efforts to provide them with good, evidence-based information have been fraught with difficulties ranging from financial to cultural. We report herein some of our successful novel outreach efforts. A common thread throughout this account is that among the most successful of the outreach activities are those that involve or incorporate existing community groups committed to women's health.

Shigellosis: más allá de la enterocolitis / Shigellosis: more to the enterocolitis

Con el fin de estudiar la frecuencia de bacteremias en niños con diarrea producidas por Shigella y sus características clínicas, se revisaron 9.833 hemocultivos realizados en el Hospital de Niños "J. M. de los Ríos", entre 1995 y Agosto 1998, así como las historias clínicas de los pacientes cuyos hemocultivos resultaron positivos a Shigella. Se encontró que 4 de los niños (0,4 por ciento) presentaron bacteremia a Shiguella flexneri, de los cuales, 3 (75 por ciento) evolucionaron tórpidamente y 1 (25 por ciento) sufrió meningitis con secuelas neurológicas permanentes. Se identificó déficit nutricional en uno de ellos (25 por ciento). El 100 por ciento de las cepas fueron Shigella flexneri resistentes in vitro a ampicilina y sulfatrimetropin y sensibles a cefalosporinas de tercera generación. Una (25 por ciento) prsentó sensibilidad disminuida al cloranfenicol

Resistencia bacteriana a los antimicrobianos en el Hospital de Niños "J. M de los Ríos" 1991-1993 / Bacterial resistance to antibiotics in Hospital Niños \"J. M de los Ríos\" 1991-1993

Se presentan los primeros datos publicados de Resistencia Bacteriana a los antimicrobianos en el Hospital "J.M. de los Ríos" en los años 1991 a 1993 y las cartillas bacteriológicas clínicas. Se analizan los resultados de las siguientes bacterias: Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus sp, Eschericha coli, Klebsiella pneumoniae, Enterobacter cloacae, Enterobacter aerogenes, Proteus vulgaris, Acinetobacter sp, Pseudomona aeruginosa

Effect of estrogen replacement therapy on the specificity and sensitivity of screening mammography.

BACKGROUND: Previous studies have demonstrated that mammographic breast density increases following the initiation of estrogen replacement therapy (ERT). The effect, if any, that this increase in density has on the specificity (related to false-positive readings) and the sensitivity (related to false-negative readings) of screening mammography is unknown. PURPOSE: Using a retrospective cohort study design, we assessed the effects of ERT on the specificity and the sensitivity of screening mammography. METHODS: Participants (n = 8779) were postmenopausal women, aged 50 years or older, who were enrolled in a health maintenance organization located in western Washington state and who entered a breast cancer screening program between January 1988 and June 1993. Two-view mammography was performed as part of a comprehensive breast cancer screening visit. Menopausal status, as well as demographic and risk-factor information, was recorded via self-administered questionnaires. Hormonal replacement therapy type and use were determined from questionnaire data and from an automated review of pharmacy records. Individuals diagnosed with breast cancer within 12 months of their first screening-program mammograms were identified through use of a regional cancer registry. Risk ratios (RRs) plus 95% confidence intervals (CIs) of false-positive as well as false-negative examinations among current and former ERT users (with never users as the reference group) were calculated. Reported P values are two-sided. RESULTS: The specificity of mammographic screening was lower for current users of ERT than for never users or former users. Defining a positive mammographic reading as any non-normal reading (either suspicious for cancer or indeterminate), the adjusted RR (95% CI) of a false-positive reading for current users versus never users was 1.33 (1.15-1.54) (P < .001); for former users versus never users, the RR (95% CI) was 1.00 (0.87-1.15). The adjusted mammographic specificities (95% CIs) for never users, former users, and current users of ERT were 86% (84%-88%), 86% (84%-87%), and 82% (80%-84%), respectively. Defining a positive reading more rigorously (i.e., as suspicious for cancer only), the adjusted RRs (95% CIs) of false-positive readings for current users and former users (versus never users) were 1.71 (1.37-2.14) (P < .001) and 1.16 (0.93-1.45), respectively. Sensitivity was also lower in women currently receiving ERT. The unadjusted RR (95% CI) of a false-negative reading for current users versus never users was 5.23 (1.09-25.02) (P = .04); for former users versus never users, the RR (95% CI) was 1.06 (0.10-10.87). The unadjusted mammographic sensitivities (95% CI) for never users, former users, and current users of ERT were 94% (80%-99%), 94% (69%-99%), and 69% (38%-91%), respectively. CONCLUSIONS AND IMPLICATIONS: Current use of ERT is associated with lower specificity and lower sensitivity of screening mammography. Lower specificity could increase the cost of breast cancer screening, and lower sensitivity may decrease its effectiveness.

Effect of postmenopausal hormonal replacement therapy on mammographic density and parenchymal pattern.

PURPOSE: To measure changes and predictors of change in mammograms obtained in postmenopausal women undergoing continuous combined hormonal replacement therapy (HRT). MATERIALS AND METHODS: Mammograms of 41 postmenopausal women obtained before and 1 year after the initiation of HRT were evaluated blindly according to the quantitative density percentage method and the Wolfe classification system. RESULTS: Mammographic densities increased compared with baseline values in 73% of subjects (mean increase, 6.7%; 95% confidence interval, 2.5%, 11.0%; P = .003). A shift in Wolfe classification from lower to greater parenchymal density was noted in 24% of subjects (P = .016). Multivariate analysis results indicated that the lower the tissue density percentage before treatment, the greater the increase in density percentage after treatment. CONCLUSION: An increase in mammographic density was demonstrated in most subjects undergoing continuous combined HRT and was most pronounced in subjects with a lower baseline density percentage.

Lethal pulmonary embolism in a patient with primary antiphospholipid syndrome and a vena caval filter.

A 61-year old Hispanic woman with a history of primary antiphospholipid syndrome with pulmonary emboli and who was status post a vena caval filter placement to prevent recurrent pulmonary emboli, presented with acute onset of right upper quadrant abdominal pain. Acute cholecystitis was diagnosed and she underwent a surgically uncomplicated cholecystectomy. The postoperative course was complicated by new, massive pulmonary emboli despite prophylactic treatment with aspirin and low-dose heparin. Patient died en route to surgery for emergency embolectomy. This case suggests that a regimen of low-dose heparin and aspirin therapy in patients with primary antiphospholipid syndrome and a previously placed vena caval filter is not effective in preventing postoperative thromboembolic complications; more aggressive anticoagulation therapy is required.

Primary antiphospholipid syndrome and chronic disseminated intravascular coagulation: the differences and the similarities.

A middle aged woman with a medical history of recurrent spontaneous abortions and chronic leg ulcers presented with a pulmonary embolism and inferior vena caval thrombosis. Primary antiphospholipid syndrome (PAPS) was diagnosed by evidence of extremely high titers of anticardiolipin IgG and IgM, typical clinical features and the absence of other autoimmune diseases. Multiple coagulation parameters suggested chronic disseminated intravascular coagulation (DIC). It is important to distinguish PAPS from true chronic DIC as the underlying causes, treatment and prognosis differ greatly. In describing this case of PAPS presenting hematologically as a chronic DIC, we offer a discussion of the means to distinguish between these two coagulopathies and briefly discuss their treatments.

Malignant fibrous histiocytoma of the heart. A case report and review of the literature.

A case report of a 28-year-old woman with malignant fibrous histiocytoma (MFH) of the left atrium is presented, and the six previous reports of this rare cardiac tumor are reviewed. A tendency for malignant fibrous histiocytoma of the heart to occur in the left atrium of young women is suggested; this sarcoma's usual location is in the soft tissue of elderly men. The apparent predilection for the left atrium is unique among cardiac malignancies. Careful pathologic study is necessary to differentiate the uniformly fatal MFH of the heart from the more common benign atrial myxoma.