Evaluating new paralysis, mortality, and readmission among subgroups of patients with spinal epidural abscess: A latent class analysis.

BACKGROUND: Spinal epidural abscess (SEA) is increasing in incidence; this not-to-miss diagnosis can cause significant morbidity and mortality, particularly if diagnoses are delayed. While some risk factors for SEA and subsequent mortality have been identified, the SEA patient population is clinically heterogeneous and sub-populations have not yet been characterized in the literature. The primary objective of this project was to identify characteristics of subgroups of patients with SEA. The secondary objective was to identify associations between subgroups and three clinical outcomes: new onset paralysis, in-hospital mortality, and 180-day readmission. METHODS: Demographics and comorbid diagnoses were collected for patients diagnosed with SEA at an academic health center between 2015 and 2019. Latent class analysis was used to identify clinical subgroups. Chi-squared tests were used to compare identified subgroups with clinical outcomes. RESULTS: We identified two subgroups of patients in our analysis. Group 1 had a high rate of medical comorbidities causing immunosuppression, requiring vascular access, or both. Group 2 was characterized by a high proportion of people with substance use disorders. Patients in Group 2 were more likely to be readmitted within 6 months than patients in Group 1 (p = 0.03). There was no difference between groups in new paralysis or mortality. DISCUSSION: While prior studies have examined the SEA patient population as a whole, our research indicates that there are at least two distinct subgroups of patients with SEA. Patients who are younger, with substance use disorder diagnoses, may have longer hospital courses and are at higher risk of readmission within six months. Future research should explore how to best support patients in both groups, and additional implications for subgroup classification on health outcomes, including engagement in care.

The impact of surgical timing on neurological outcomes and survival in patients with complete paralysis caused by spinal tumours: evaluation of surgery on patients with complete paralysis due to neoplastic epidural spinal cord compression.

AIMS: The aim of this study was to explore the prognostic factors for postoperative neurological recovery and survival in patients with complete paralysis due to neoplastic epidural spinal cord compression. PATIENTS AND METHODS: The medical records of 135 patients with complete paralysis due to neoplastic cord compression were retrospectively reviewed. Potential factors including the timing of surgery, muscular tone, and tumour characteristics were analyzed in relation to neurological recovery using logistical regression analysis. The association between neurological recovery and survival was analyzed using a Cox model. A nomogram was formulated to predict recovery. RESULTS: A total of 52 patients (38.5%) achieved American Spinal Injury Association Impairment Scale (AIS) D or E recovery postoperatively. The timing of surgery (p = 0.003) was found to be significant in univariate analysis. In multivariate analysis, surgery within one week was associated with better neurological recovery than surgery within three weeks (p = 0.002), with a trend towards being associated with a better neurological recovery than surgery within one to two weeks (p = 0.597) and two to three weeks (p = 0.055). Age (p = 0.039) and muscle tone (p = 0.018) were also significant predictors. In Cox regression analysis, good neurological recovery (p = 0.004), benign tumours (p = 0.039), and primary tumours (p = 0.005) were associated with longer survival. Calibration graphs showed that the nomogram did well with an ideal model. The bootstrap-corrected C-index for neurological recovery was 0.72. CONCLUSION: In patients with complete paralysis due to neoplastic spinal cord compression, whose treatment is delayed for more than 48 hours from the onset of symptoms, surgery within one week is still beneficial. Surgery undertaken at this time may still offer neurological recovery and longer survival. The identification of the association between these factors and neurological recovery may help guide treatment for these patients. Cite this article: Bone Joint J 2019;101-B:872-879.

Critical West Nile Neuroinvasive Disease.

BACKGROUND: Data to guide neurointensivists seeing patients with West Nile Neuroinvasive disease (WNND) are lacking. We present a comparatively large series of patients with WNND admitted to the intensive care unit (ICU) and provide data on their early diagnosis, triage to the ICU and predictors of short-term outcomes. METHODS: We retrospectively identified patients aged ≥ 18 years old with WNND from January 1999 to November 2016. Demographic and clinical data, the modified Rankin Scale at discharge and disposition were collected. Univariate analysis was performed to find predictors of ICU admission and to assess the impact of ICU admission on the short-term outcomes. P values < 0.05 were considered significant. RESULTS: Among 26 patients, 16 were admitted to the ICU. Age < 60 years and the presentation with encephalitis and acute flaccid paralysis predicted ICU admission (P = 0.044 and 0.0007). Among patients requiring ICU admission, four died and no one was discharged home. ICU admission predicted longer hospital stay (P = 0.021), inhospital death (P = 0.034), survival with inability to walk independently (P = 0.0094), and discharge disposition other than home (P = 0.007). In the ICU group, older age was associated with longer hospital stay (P = 0.0001) and inhospital death (P = 0.035). CONCLUSION: WNND requiring ICU care has a high morbidity and mortality, especially among older patients. Survivors are highly disabled at discharge, but many improve over time. Therefore, more data on the long-term prognosis of survivors are needed to guide the goals of care in the acute setting.

Factors affecting survival of patients in the acute phase of upper cervical spine injuries.

INTRODUCTION: In recent years, on the one hand, the mortality rates of upper cervical spine injuries, such as odontoid fractures, were suggested to be not so high, but on the other hand reported to be significantly high. Furthermore, it has not been well documented the relationship between survival rates and various clinical features in those patients during the acute phase of injury because of few reports. This study aimed to evaluate survival rates and acute-phase clinical features of upper cervical spine injuries. METHODS: We conducted a retrospective review of all patients who were transported to the advanced emergency medical center and underwent computed tomography of the cervical spine at our hospital between January 2006 and December 2015. We excluded the patients who were discovered in a state of cardiopulmonary arrest (CPA) and could not be resuscitated after transportation. Of the 215 consecutive patients with cervical spine injuries, we examined 40 patients (18.6%) diagnosed with upper cervical spine injury (males, 28; females, 12; median age, 58.5 years). Age, sex, mechanism of injury, degree of paralysis, the level of cervical injury, injury severity score (ISS), and incidence of CPA at discovery were evaluated and compared among patients classified into the survival and mortality groups. RESULTS: The survival rate was 77.5% (31/40 patients). In addition, complete paralysis was observed in 32.5% of patients. The median of ISS was 34.0 points, and 14 patients (35.0%) presented with CPA at discovery. Age, the proportion of patients with complete paralysis, a high ISS, and incidence of CPA at discovery were significantly higher in the mortality group (p = 0.038, p = 0.038, p < 0.001, and p < 0.001, respectively). CONCLUSIONS: Elderly people were more likely to experience upper cervical spine injuries, and their mortality rate was significantly higher than that in injured younger people. In addition, complete paralysis, high ISS, a state of CPA at discovery, was significantly higher in the mortality group.

Preoperative palsy score has no significant association with survival in non-small-cell lung cancer patients with spinal metastases who undergo spinal surgery.

BACKGROUND: Survival is a key factor physicians consider when selecting a treatment modality for the treatment of spinal metastases. Various assessment systems can predict length of survival and facilitate selection of the most appropriate treatment. Spinal palsy is a prognostic parameter in the Tokuhashi scoring system but not in the Tomita scoring system. A limitation of these scoring systems is that studies of them have included different tumor types. The aim of this study was to evaluate the usefulness of preoperative neurological status as a prognostic factor in non-small-cell lung cancer patients with spinal metastases who underwent surgical treatment. METHODS: From November 2000 to March 2010, 50 patients with symptomatic metastatic spinal cord compression secondary to non-small-cell lung cancer underwent palliative surgery. Data collected included patient age and sex, tumor histology, date of surgery, death or last follow-up, preoperative and postoperative ambulatory status according to the Frankel grading system, body mass index (BMI), number of vertebra involved, number of other bone metastasis, visceral metastasis, and preoperative Karnofsky performance status. Log-rank test and multivariate Cox proportional hazard regressions were used to evaluate possible prognostic factors. RESULTS: The mean patient age was 61.6 years (range, 20-87 years), and 34 were male and 16 were female. The median postoperative survival time was 7.5 months. The median survival was 2.5 months (95% confidence interval (CI): 1.22-16.3 months) in the Frankel A + B group and 8.0 months (95% CI: 5.52-9.89 months) in the Frankel C + D group (p = 0.87). Multivariate Cox proportional hazard regressions showed that preoperative performance status was significantly associated with survival. Preoperative palsy score had no statistically significant association with survival. CONCLUSIONS: Preoperative palsy score had no statistically significant association with survival in non-small-cell lung cancer patients with spinal metastases who underwent spinal surgery in this study.

A 14-year experience with blunt thoracic aortic injury.

OBJECTIVE: This study reviewed the natural history of blunt thoracic aortic trauma (BTAT) over a 14-year period at our level 1 trauma center and compared open vs endovascular treatment. METHODS: All patients with BTAT presenting to a level 1 trauma center from 1998 to 2011 were included in a retrospective analysis. Multiple data points and short-term and midterm outcomes were ascertained through a retrospective record review. RESULTS: We identified 129 patients with BTAT. Of these, 32 (25%) were dead on arrival, 38 (29%) underwent a resuscitative thoracotomy and died, 33 (26%) underwent open repair, 14 (11%) underwent endovascular repair, 9 (7%) underwent simultaneous procedures, and 3 (2%) were managed nonoperatively. Mean Injury Severity Scores and Revised Trauma Scores were similar (P = .484, P = .551) between the open repair group (n = 36) and the endovascular repair group (n = 14). In the open repair group, there were 14 deaths (42%) ≤ 30 days of injury, 3 strokes (9%), 2 patients (6%) with paralysis, 2 myocardial infarctions (MIs; 6%), and 3 patients (9%) who required hemodialysis. In the endovascular group, there was 1 death (7%) ≤ 30 days of injury, 1 (7%) stroke, and 1 (7%) stent collapse. No paralysis, MI, or renal failure requiring hemodialysis was noted in the endovascular group. The average length of stay was 15 days for patients treated with endovascular repair vs 24 days for those treated with open repair (P = .003). CONCLUSIONS: The incidence of BTAT is low but the mortality associated with it is significant. During the 14-year period studied, there was a clear change in management preference from open repair to endovascular repair at our level 1 trauma center. Outcomes, including stroke, MI, renal failure, paralysis, length of stay, and death, appear to be reduced in the endovascular group.

Effect of comorbidity on length of hospital stay and in-hospital mortality among unintentionally injured patients.

OBJECTIVES: Because comorbidity is a crucial issue in medical practice and research, this study evaluated the effect of comorbidity on the length of hospital stay and mortality among unintentionally injured patients. METHODS: Korea National Hospital Discharge In-depth Injury Survey 2005 data were used, and the odds ratios for in-hospital mortality and long hospital stay were estimated for injured patients with and without comorbidity. The factors evaluated were the injury mechanisms; patient age, sex and residence; and hospital size. RESULTS: In general, pre-existing diseases were associated with longer hospital stays after injury and increased the risk of death. Controlling for age, sex, residence, cause of injury and hospital size indicated that unintentionally injured patients with comorbidity experienced higher in-hospital mortality (OR=2.23) and longer hospital stays (OR=1.90). The greatest risk of death was associated with coagulopathy (OR=18.5) and fluid and electrolyte disorder (OR=13.8); the greatest risk of a long hospital stay was associated with Alzheimer's disease (OR=10.3) and paralysis (OR=5.8). The prognosis for cases involving drowning, traffic accidents and poisoning was most often affected by comorbidity (OR=15.1, 2.5, 2.5 for mortality). Comorbid patients injured in falls and fires were hospitalized 6.2 and 4.0 times longer, respectively, than those who did not have comorbid conditions. CONCLUSIONS: It is necessary to identify and manage pre-existing disease among unintentional injury patients, and collaboration with other health care providers is important to the prognosis of injured patients.

[Long-term prognosis of patients with primary myelitic manifestation of tick-borne encephalitis: a trend analysis covering 10 years]. / Langzeitprognose bei primär myelitischer Manifestation der FSME : Eine Verlaufsanalyse über 10 Jahre.

BACKGROUND: While some studies have been published about the prognosis of the meningitic and encephalitic course of tick-borne encephalitis (TBE), only few data exist about the long-term prognosis of TBE myelitis. The aim of the present prospective study therefore was to investigate such patients over a period of 10 years. METHOD: In Baden-Württemberg between 1994 and 1999, 731 patients fell ill with TBE. Of them 81 (11%) suffered from encephalomyelitis. All patients were asked to participate in this study, 57 of whom agreed. Individual impairments were measured by allocating single scores for the paresis of the extremities or cranial nerves, ataxia, impaired consciousness, respiratory paralysis and defective hearing. The total impairment was measured at follow-up investigations at 1, 3, 5 and 10 years. RESULTS: A total of 11 patients (19%) recovered, 29 (51%) suffered from persisting pareses or other impairments and 17 (30%) died 1-10 years after the acute disease. The most important ameliorations occurred during the first year after the acute disease; thereafter, improvements were lesser and more seldom. The clinical findings after 5 and 10 years correlated well with the status of the acute disease (r=0.8, p<0.01) allowing one to hazard a prognosis at the first presentation. The best restitution was seen for ataxia, impairment of consciousness, double vision, urinary retention and mild paresis of only one extremity (4/5). Patients with tetraparesis and simultaneous occurrence of respiratory paralysis and/or dysphagia, dysarthria or paresis of the neck muscles had the worst prognosis. CONCLUSION: A myelitic course of TBE is associated with the chance to recover in only about 20% of patients. Clinical deficits do not always correlate to findings in magnetic resonance tomography but to observations in postmortem studies.

[Anaesthics incidents - Injuries caused by regional anaesthesia - closed claims of the North German Arbitration Board]. / Anästhesiezwischenfälle - Schäden durch Regionalanästhesie - "closed claims" der Norddeutschen Schlichtungsstelle.

Injuries caused by regional anaesthesia are the second most common reason for a patient to apply to the North German Arbitration Board. Part of the reported injuries are mild and transient, while others are severe and permanent, e.g. a paraplegia after regional anaesthesia. In the majority of the reported cases, the Arbitration Board did not find a medical error as cause of the injury. Nevertheless, every possible effort needs to be made to reduce the number and the severity of the injuries due to regional anaesthesia. In order to reach that goal, medical treatment has to be applied with the appropriate care, including the strict adherence to the height of puncture for epidural and spinal anaesthesia below the Conus medullaris and the use of assisting devices like nerve stimulator and ultrasound-guided puncture. Using these measures, the frequency of injuries caused by regional anaesthesia will be reduced.

Puffer fish poisoning in Bangladesh: clinical and toxicological results from large outbreaks in 2008.

Poisoning after eating puffer fish containing highly lethal tetrodotoxin (TTX) is widespread in Asia. In 2008, naïve inland populations in Bangladesh were exposed to cheap puffer fish sold on markets. In three outbreaks, 141 patients with history of puffer fish consumption were hospitalized. Symptoms of poisoning included perioral paraesthesia, tingling over the entire body, nausea and vomiting, dizziness, headache, abdominal pain and muscular paralysis of the limbs. Seventeen patients (12%) died from rapidly developing respiratory arrest. Blood and urine samples from 38 patients were analyzed using a TTX-specific enzyme-linked immunoassay (ELISA). Medium to high TTX levels were detected (1.7-13.7 ng/ml) in the blood of 27 patients. TTX was below detection level (< 1.6 ng/ml) in 11 blood samples but the toxin was detected in urine. Ten patients had blood levels above 9 ng/ml and developed paralysis; seven of these died. The remaining patients recovered with supportive treatment. High concentrations of TTX and its analogues 4-epiTTX and 4,9-anhydroTTX were also found in cooked puffer fish by post-column liquid chromatography-fluorescence detection. To prevent future instances of puffer fish poisoning of this magnitude, measures should be implemented to increase awareness, to control markets and to establish toxicological testing. To improve the management of this and other poisoning in Bangladesh, facilities for life-saving assisted ventilation and related training of healthcare personnel are urgently needed at all levels of the health system.

Misfolded mutant SOD1 directly inhibits VDAC1 conductance in a mouse model of inherited ALS.

Mutations in superoxide dismutase (SOD1) cause amyotrophic lateral sclerosis (ALS), a neurodegenerative disease characterized by loss of motor neurons. With conformation-specific antibodies, we now demonstrate that misfolded mutant SOD1 binds directly to the voltage-dependent anion channel (VDAC1), an integral membrane protein imbedded in the outer mitochondrial membrane. This interaction is found on isolated spinal cord mitochondria and can be reconstituted with purified components in vitro. ADP passage through the outer membrane is diminished in spinal mitochondria from mutant SOD1-expressing ALS rats. Direct binding of mutant SOD1 to VDAC1 inhibits conductance of individual channels when reconstituted in a lipid bilayer. Reduction of VDAC1 activity with targeted gene disruption is shown to diminish survival by accelerating onset of fatal paralysis in mice expressing the ALS-causing mutation SOD1(G37R). Taken together, our results establish a direct link between misfolded mutant SOD1 and mitochondrial dysfunction in this form of inherited ALS.

The impact of age on mortality, impairment, and disability among adults with acute traumatic spinal cord injury.

Given the potential effects of age on mortality, impairment, and disability among individuals with traumatic spinal cord injury [(SCI), we examined these issues using a large, prospectively accrued clinical database. This study includes all patients who were enrolled in the Third National Spinal Cord Injury Study (NASCIS 3). Motor, sensory, and pain outcomes were assessed using NASCIS scores. Functional outcome was evaluated using the Functional Independence Measure (FIM). Data analyses included regression models adjusted for major potential confounders (i.e., sex, ethnicity, Glasgow Coma Scale [GCS] score, blood alcohol concentration on admission, drug protocol, cause, and level and severity of SCI). Mortality rates among older people (> or =65 years) were significantly greater than those of younger individuals at 6 weeks, at 6 months, and at 1 year following SCI (38.6% versus 3.1%; p < 0.0001). Among survivors, age was not significantly correlated with motor recovery or change in pain scores in the acute and chronic stages after SCI based on regression analyses adjusted for major confounders. However, older individuals experienced greater functional deficit (based on FIM scores) than younger individuals, despite experiencing similar rates of sensorimotor recovery (based on NASCIS scores). Our results suggest that older individuals have a substantially increased mortality rate during the first year following traumatic SCI in comparison with younger patients. Among survivors, the potential of older patients with SCI to neurologically improve within the first year post-injury does not appear to translate into similar functional recovery compared to that seen in younger individuals. Given this fact, rehabilitation protocols that are more focused on functional recovery may reduce disability among older people with acute traumatic SCI.

Review of the significance of various low force fractures in the elderly.

The elderly are more prone to sustain fractures with low force injury because they have an increased incidence of falls, and because their bones are often more fragile secondary to osteoporosis and other conditions. Cases with fracture are routinely reported to medical examiner and coroner offices because fracture reflects traumatic injury. If a fracture is judged to be a significant factor in a person's death, then the manner of death must reflect how the injury was sustained, which is "accidental" in most of these cases. Often times the best information on the significance of a fracture is obtained from the deceased's physician, nurse, family, or close acquaintance. However, this valuable clinical information is not always available. When this is the situation, it would be helpful to know generally what fractures are likely to be associated with increased mortality, and for how long any excess mortality might be expected to persist. With this in mind, a search of the literature was performed to clarify clinically which fractures in the elderly population were associated with excess mortality and the duration that any excess mortality tended to persist.

Elevated maternal corticosterone during lactation hinders the neonatal adaptive immune response to herpes simplex virus (HSV) infection.

The neonate's immune system is relatively immature. For short-term protection against pathogens the neonate is reliant primarily on maternally derived antibodies delivered via the mother's milk. However, neonates soon acquire the ability to generate adaptive immune responses for long-term protection. Products of the nervous and endocrine systems that are elicited by psychological stress are known to modulate a variety of immune responses. Additionally, psychological stressors are well recognized for their ability to increase corticosterone levels. The studies described herein examined the effects of increases in maternally derived corticosterone on the neonatal cell-mediated immune response to, and pathogenicity of, herpes simplex virus (HSV) infection. Water containing corticosterone was made available to nursing mothers for a period of 6 consecutive days beginning on either the day of or 6 days post-delivery. At 12 days of age, neonates were infected with HSV-1 in the rear footpads. These neonates exhibited a decrease in the proliferative ability of splenic-derived cells due to the reduction of IL-2 production and IL-2 receptor alpha subunit (IL-2R alpha) expression by these cells. These neonates also exhibited a decrease in the number and function of popliteal lymph node-resident HSV-1 gB(498-505) peptide-specific CD8(+) T cells as measured by tetramer analysis, CTL lytic activity, expression of CD107a, cytokine production, and proliferation. Additionally, these HSV-infected neonates exhibited increased morbidity and mortality. Together, these studies indicate that exposure of neonates to maternally derived corticosterone via the milk hinders their ability to generate an adaptive cell-mediated immune response to a viral infection and illustrate the potential importance of maternal stress in neonatal resistance to infectious pathogens.

wasted away, a Drosophila mutation in triosephosphate isomerase, causes paralysis, neurodegeneration, and early death.

To identify genes required for maintaining neuronal viability, we screened our collection of Drosophila temperature-sensitive paralytic mutants for those exhibiting shortened lifespan and neurodegeneration. Here, we describe the characterization of wasted away (wstd), a recessive, hypomorphic mutation that causes progressive motor impairment, vacuolar neuropathology, and severely reduced lifespan. We demonstrate that the affected gene encodes the glycolytic enzyme, triosephosphate isomerase (Tpi). Mutations causing Tpi deficiency in humans are also characterized by progressive neurological dysfunction, neurodegeneration, and early death. In Tpi-deficient flies and humans, a decrease in ATP levels did not appear to cause the observed phenotypes because ATP levels remained normal. We also found no genetic evidence that the mutant Drosophila Tpi was misfolded or involved in aberrant protein-protein associations. Instead, we favor the hypothesis that mutations in Tpi lead to an accumulation of methylglyoxal and the consequent enhanced production of advanced glycation end products, which are ultimately responsible for the death and dysfunction of Tpi-deficient neurons. Our results highlight an essential protective role of Tpi and support the idea that advanced glycation end products may also contribute to pathogenesis of other neurological disorders.

Isolation, partial purification and characterization of active polypeptide from the sea anemone Bartholomea annulata.

In the sea anemone Bartholomea annulata, four different types of cnidocysts, basitrichous isorhizas, microbasic p-mastigophores, microbasic amastigophores and spirocysts were identified. In relation to the efficacy of different substances to induce discharge of nematocysts we observe that distilled water induced more than 70% of microbasic p-mastigophores to discharge, whereas spirocysts were discharged in a lesser extent (approximately 20%). The median lethal dose (LD50) in mice was found after injection of 700.7 mg protein per kg of body weight from the crude extract. The protein with neurotoxic effect was isolated using low-pressure liquid chromatography. The neurotoxic activity was determined using sea crabs (Ocypode quadrata), injecting 15 microg of crude extract or isolated fraction into the third walking leg, and violent motor activity followed by progressive loss of sensibility to external stimuli, further leading to full paralysis were observed. The active fraction (called V) eluted at 43.9 min.

Deaths in children during an outbreak of hand, foot and mouth disease in Peninsular Malaysia--clinical and pathological characteristics.

From July through December 1997, 11 previously healthy children in Peninsular Malaysia succumbed to an illness clinically characterised by an acute severe refractory left-ventricular failure, following a brief prodromal illness, in the midst of an outbreak of hand, foot and mouth disease (HFMD), similar to the reported experience in Sarawak and Taiwan. Retrospective reviews of the clinical features and results of laboratory, pathological and virological investigations of cases were conducted. The median age of the 11 case-patients was 31 months (range, 13 to 49 months); 6 were males. A brief prodromal illness of 3 days (range, 2 to 5 days) was characterised by fever (axillary temperature > 38 degrees C) (100%), oral ulcers (72%), extremity rashes (45%) and significant vomiting (55%). Upon hospitalisation, 7 of 11 case-patients had features suggestive of cardiogenic shock, while 4 of 11 case-patients developed shock during hospitalisation as evidenced by marked sustained tachycardia (heart rate > or = 180 beats per minute), poor peripheral pulses and peripheral perfusion, mottled extremities, pulmonary oedema (haemorrhagic pulmonary secretions in 8 of 11 cases during tracheal intubation, often precipitated by conservative crystalloid boluses, and radiographic evidence of acute pulmonary oedema in 5 of 7 cases) and markedly impaired left ventricular function on echocardiographic examination (7 of 7 cases). Three of 4 case-patients had aseptic meningitis while one case-patient also had an acute flaccid paraparesis. Despite supportive therapy, death occurred within a median of 13.4 hours following hospitalization. Post-mortem findings (all 8 specimens examined) consistently demonstrated brain-stem encephalitis with foci of neuronal necrosis and micro-abscesses. None of the 11 specimens examined revealed histological evidence of myocarditis. Enterovirus 71 (EV71) was detected in 10 of 11 case-patients, many (7) from various sterile tissue sites (5 from central nervous tissues). No other viruses were isolated or identified. Clinical features and pathological studies closely paralleled the reported experience in Sarawak and Taiwan. The uniform necropsy findings of necrotizing brain-stem encephalitis coupled with essentially normal myocardial histology, in concert with the concurrent and consistent detection of EV71 points to a primary EV71 encephalitis; as yet unclear neurogenic mechanisms may account for the cardiovascular manifestations.

Parasitoid wasp affects metabolism of cockroach host to favor food preservation for its offspring.

Unlike predators, which immediately consume their prey, parasitoid wasps incapacitate their prey to provide a food supply for their offspring. We have examined the effects of the venom of the parasitoid wasp Ampulex compressa on the metabolism of its cockroach prey. This wasp stings into the brain of the cockroach causing hypokinesia. We first established that larval development, from egg laying to pupation, lasts about 8 days. During this period, the metabolism of the stung cockroach slows down, as measured by a decrease in oxygen consumption. Similar decreases in oxygen consumption occurred after pharmacologically induced paralysis or after removing descending input from the head ganglia by severing the neck connectives. However, neither of these two groups of cockroaches survived more than six days, while 90% of stung cockroaches survived at least this long. In addition, cockroaches with severed neck connectives lost significantly more body mass, mainly due to dehydration. Hence, the sting of A. compressa not only renders the cockroach prey helplessly submissive, but also changes its metabolism to sustain more nutrients for the developing larva. This metabolic manipulation is subtler than the complete removal of descending input from the head ganglia, since it leaves some physiological processes, such as water retention, intact.

Variations in injury patterns, treatment, and outcome for spinal fracture and paralysis in adult versus geriatric patients.

STUDY DESIGN: Retrospective cohort analysis of hospital discharge and mortality data for spinal fracture and spinal cord injury patients in a single state from 1990 to 1995. OBJECTIVES: Population-based review of preinjury patient factors, injury and treatment patterns, and in-hospital versus 60-day mortality in adult and geriatric spinal injury patients. SUMMARY OF BACKGROUND DATA: While population-based analyses of hospitalized injured patients indicate that geriatric patients are at higher risk for adverse outcome, less is known about the specific subset of patients with spinal fracture and spinal cord injury. A specific knowledge gap exists regarding factors that influence survival after hospital discharge of spine-injured patients. METHODS: Patients with cervical, thoracic, or lumbar spinal fracture were identified by ICD-9-CM discharge diagnosis codes. Age, gender, preexisting conditions, and injury severity were determined, and patients were divided into adult (ages 16-64 years; n = 6,029) and geriatric (ages >or=65 years; n = 3,973) groups. In-hospital and 60-day mortality rates and odds ratios of 60-day mortality were calculated relative to patient and injury characteristics, level of treating hospital, and surgical treatment. RESULTS: Increased 60-day mortality was associated with preexisting medical conditions, increased injury severity, and paralysis but reduced with surgical treatment. Geriatric patients had fewer cervical injures, lower force injuries, less severe overall injuries, decreased paralysis, increased preexisting conditions, decreased treatment at level 1 and 2 treatment centers, and decreased odds of surgical treatment. Geriatric patients also had increased 60-day versus in-hospital mortality and increased mortality associated with cervical spine injury. DISCUSSION: Differences exist in preinjury patient factors, injury and treatment patterns, and mortality between adult and geriatric patients following spinal injuries. The increased 60-day versus in-hospital mortality for the geriatric population suggests that 60-day mortality may be a better measure of outcome for these patients. While the possibility of selection bias exists, both geriatricand adult patients had reduced 60-day mortality associated with surgical intervention.