Septic Cavernous Sinus Thrombosis: An Unusual and Fatal Disease

BackgroundSeptic cavernous sinus thrombosis (CST) is a rare and fatal disease. Clinical presentations in the early stage are nonspecific, and the sensitivity of cranial axial computed tomography (CT) with thick section is low. This study analyzed the clinical manifestation and neuroimaging findings in patients with septic CST in a medical center in Taiwan.MethodsThis retrospective case series included nine patients with septic CST who had typical symptoms and clinical course, evidence of infection, and imaging studies which demonstrated cavernous sinus lesion, and who were treated between 1995 and 2003 at National Taiwan University Hospital.ResultsSeven (77.8 %) patients were more than 50 years old. Five (55.6%) had diabetes, and three (33.3%) had hematologic diseases. All cases were associated with paranasal sinusitis. The most frequent initial symptom was headache (66.7%), followed by ophthalmic complaints (diplopia or ophthalmoplegia, 55.6%; blurred vision or blindness, 55.6%), and ptosis (44.4%). Initial cranial images failed to identify CTS in all patients. Subsequent magnetic resonance imaging (MRI) or coronal contrast-enhanced CT (CECT) with thin section confirmed the diagnosis. Fungi were the most common pathogens (55.6%). The inhospital case-fatality rate was high (44.4%).ConclusionDue to the high case-fatality rate and low yield rate of blood cultures, fungal CST should be suspected in an immunocompromised patient with ophthalmic complaints that progress from one eye to the other. Coronal thin-section CECT may be a useful alternative to MRI as a diagnostic modality for this condition

Out-of-hospital Cardiac Arrest in the Elderly

SummaryBackgroundTo investigate the characteristics of out-of-hospital cardiac arrest (OHCA) in the elderly, we retrospectively studied a 6-month series of cases in an emergency department (ED) of a medical center in northern Taiwan.MethodsThere were 145 OHCA cases sent to our ED from January 1, 2007 to June 30, 2007. Of these, 28 traumarelated and five pediatric cases were excluded, and 112 cases were eventually enrolled into our study. The 112 cases were divided into an elderly group (≥ 65 years) of 81 cases and a non-elderly group of 31 cases. There were 64 males and 48 females (male/female ratio, 1.33:1) aged 24–99 years. We collected the laboratory data and made comparisons between the elderly and non-elderly group in arterial blood gas, hemoglobin, potassium, glucose, and troponin I. We used the statistical software SPSS version 11.5.0 (SPSS Inc., Chicago, IL, USA) with t test analysis. The clinical significance was set at p < 0.05.ResultsReturn of spontaneous circulation (ROSC) occurred in 46 cases (41%) after standard resuscitation by advanced cardiac life support. The elderly group had a higher ROSC rate than the non-elderly group, but this was not significant (44% vs. 32%; p = 0.335). The elderly group had less acidosis, less hypercapnia, less hyperkalemia, less hyperglycemia and a higher rate of elevated troponin I than the non-elderly group, but the differences were not significant. The elderly group had significantly lower hemoglobin levels than the non-elderly group (10.52 ± 3.04 vs. 12.6 ± 3.32g/dL; p = 0.003). The glucose levels of the ROSC group were significantly higher than the non-ROSC group in the elderly (230.14 ± 130.4 vs. 195.1 ± 147.7mg/dL; p = 0.049). In the group of acute coronary syndrome (ACS)-related OHCA, the ROSC rate in the elderly group was significantly higher than that of the non-elderly (54.2% vs. 40%; p = 0.014). The elderly group had a slightly lower rate of survival than the non-elderly group (7.4% vs. 9.7%; p = 0.159).ConclusionThe elderly OHCA cases had an anemic status. The elderly had a higher ROSC rate in cases with relative hyperglycemia and ACS-related OHCA. This finding provides us with the theory of trialing administration of glucose water during resuscitation in OHCA cases

Pelizaeus-Merzbacher Disease, Easily Misdiagnosed as Cerebral Palsy: A Report of a Three-generation Family

Pelizaeus-Merzbacher disease (PMD) is an X-linked recessive disorder affecting myelination of the central nervous system, and is caused by mutations of the proteolipid protein 1 (PLP1) gene. Clinical manifestations of PMD are variable and major features include progressive nystagmus, spasticity, tremor, ataxia, and psychomotor delay. We describe a classical PMD patient who had been misdiagnosed as cerebral palsy. He had nystagmus and psychomotor delay since infancy and tremor with ataxia developing gradually. Brain MRI revealed demyelination over white matter of the cerebral hemispheres and posterior limbs of the internal capsules. Positive family history led to subsequent mutation analysis, which identified a novel mutation (c.88G>C) in PLP1 in the proband, as well as his affected brother and maternal uncle, and asymptomatic maternal grandmother, mother and two sisters. Therefore, PMD should be considered in a cerebral palsy-like patient with or without positive family history. Mutation analysis is crucial for early diagnosis and further genetic counseling

Ruptured Aortic Aneurysm Presenting as a Stridor

SummaryStridor is an abnormal, high-pitched, whining breathing sound caused by a blockage in the throat or larynx that is usually heard in children. We describe an unusual case of an 81-year-old man brought to our emergency department with sudden onset of dyspnea and shortness of breath. Stridor could be heard without a stethoscope. We found a huge mass over the left upper chest on chest radiography, suggesting an aortic aneurysm. We believed that these symptoms were caused by a huge thoracic aortic aneurysm with trachea/bronchi compression. Chest computed tomography confirmed the diagnosis

A proposal of recommendation function for element fill-in-Blank problems in java programming learning assistant system

Purpose To advance Java programming educations, the authors have developed a Web-based Java programming learning assistant system (JPLAS). It offers the element fill-in-blank problem (EFP) for novice students to study Java grammar and basic programming skills by filling in the missing elements in a source code. An EFP instance can be generated by selecting an appropriate code, and applying the blank element selection algorithm. As it is expected to cover broad grammar topics, a number of EFP instances have been generated. This paper aims to propose a recommendation function to guide a student solving the proper EFP instances among them. Design/methodology/approach This function considers the difficulty level of the EFP instance and the grammar topics that have been correctly answered by the student, and is implemented at the offline answering function of JPLAS using JavaScript so that students can use it even without the Internet connections. Findings To evaluate the effectiveness of the proposal, 85 EFP instances are prepared to cover various grammar topics, and are assigned to a total of 92 students in two universities in Myanmar and Indonesia to solve them using the recommendation function. Their solution results confirmed the effectiveness of the proposal. Originality/value The concept of the difficulty level for an EFP instance is newly defined for the proper recommendation, and the accuracy in terms of the average numbers of answer submission times among the students is verified

Sympathetic-correlated c-Fos expression in the neonatal rat spinal cord in vitro

An isolated thoracic spinal cord of the neonatal rat in vitro spontaneously generates sympathetic nerve discharge (SND) at ~25°C, but it fails in SND genesis at ≤ 10°C. Basal levels of the c-Fos expression in the spinal cords incubated at ≤ 10°C and ~25°C were compared to determine the anatomical substrates that might participate in SND genesis. Cells that exhibited c-Fos immunoreactivity were virtually absent in the spinal cords incubated at ≤ 10°C. However, in the spinal cords incubated at ~25°C, c-Fos-positive cells were found in the dorsal laminae, the white matter, lamina X, and the intermediolateral cell column (IML). Cell identities were verified by double labeling of c-Fos with neuron-specific nuclear protein (NeuN), glial fibrillary acidic protein (GFAP), or choline acetyltransferase (ChAT). The c-Fos-positive cells distributed in the white matter and lamina X were NeuN-negative or GFAP-positive and were glial cells. Endogenously active neurons showing c-Fos and NeuN double labeling were scattered in the dorsal laminae and concentrated in the IML. Double labeling of c-Fos and ChAT confirmed the presence of active sympathetic preganglionic neurons (SPNs) in the IML. Suppression of SND genesis by tetrodotoxin (TTX) or mecamylamine (MECA, nicotinic receptor blocker) almost abolished c-Fos expression in dorsal laminae, but only mildly affected c-Fos expression in the SPNs. Therefore, c-Fos expression in some SPNs does not require synaptic activation. Our results suggest that spinal SND genesis is initiated from some spontaneously active SPNs, which are capable of TTX- or MECA-resistant c-Fos expression

A Retrospective Cohort Study Comparing Stroke Recurrence Rate in Ischemic Stroke Patients With and Without Acupuncture Treatment.

Little was known about the effects of acupuncture on stroke recurrence. The aim of this study is to investigate whether ischemic stroke patients receiving acupuncture treatment have a decreased risk of stroke recurrence. A retrospective cohort study of 30,058 newly diagnosed cases of ischemic stroke in 2000 to 2004 was conducted based on the claims of Taiwan National Health Insurance Research Database. The use of acupuncture treatment and stroke recurrence were identified during the follow-up period from 2000 to 2009. This study compared the risk of stroke recurrence between ischemic stroke cohorts with and without acupuncture treatment by calculating adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of acupuncture associated with stroke recurrence in the Cox proportional hazard model. The stroke recurrence rate per 1000 person-years decreased from 71.4 without to 69.9 with acupuncture treatment (P &lt; 0.001). Acupuncture treatment was associated with reduced risk of stroke recurrence (HR 0.88; 95% CI 0.84-0.91). The acupuncture effect was noted in patients with or without medical treatment for stroke prevention but its impact decreased with aging of stroke patients. Compared with stroke patients without acupuncture treatment and medication therapy, the hazard ratios of stroke recurrence for those had medication therapy only, acupuncture only, and both were 0.42 (95% CI 0.38-0.46), 0.50 (95% CI 0.43-0.57), and 0.39 (95% CI 0.35-0.43), respectively. This study raises the possibility that acupuncture might be effective in lowering stroke recurrence rate even in those on medications for stroke prevention. Results suggest the need of prospective sham-controlled and randomized trials to establish the efficacy of acupuncture in preventing stroke

Spontaneous Dissecting Aneurysm of the Renal Artery: A Case Report

Primary dissecting aneurysms of the renal artery are exceedingly rare. The triad of flank pain, hematuria, and hypertension of acute onset in the absence of urinary obstruction should suggest this rare condition. We report a case of spontaneous dissecting aneurysm of the renal artery treated using conservative medical treatment. The diagnosis, therapeutic management, and outcome are discussed