HIV-assoziierte tuberkulöse Meningoenzephalitis als Ursache abnormen Verhaltens in Haft

Zusammenfassung: Über Art und Häufigkeit psychoorganischer Syndrome bei Inhaftierten ist wenig bekannt. Wir berichten über einen 20-jährigen, HIV-I-positiven Asylbewerber aus Schwarzafrika mit bisher unauffälliger psychiatrischer Anamnese, der in Ausschaffungshaft ein zunehmend bizarres Verhalten entwickelte. Die paranoid-halluzinatorische Verwirrtheit mit tageszeitabhängiger Ausprägung und Desorientierung führte zur Diagnose Delir. Als Ursache hierfür fand sich eine AIDS-definierende tuberkulöse Meningoenzephalitis, die spezifisch und symptomatisch behandelt wurde. Dieser Fall illustriert die Schwierigkeiten der Diagnostik und die Bedeutung der Verhaltensbeobachtung bei eingeschränkten sprachlichen Verständigungsmöglichkeiten. Bei Häftlingen mit Verhaltensauffälligkeiten sollten stets auch somatische Differenzialdiagnosen in Betracht gezogen werden. Pathogenese und Diagnostik der tuberkulösen Meningoenzephalitis werden diskutier

RELATIONSHIP BETWEEN EARLY SOMANTIC, RADIOLOGICAL, CONGNITIVE AND PSYCHOSOCIAL FINDINGS AND OUTCOME DURING A ONE-YEAR FOLLOW-UP IN 117 PATIENTS SUFFERING FROM COMMON WHIPLASH

To analyse the significance of the interply between somatic and psychosocial factors in influencing the course of recovery a non-selected well defined group of 117 whiplash patients was investigated. Initial examination was performed, on average, 7.2±4.2 days after trauma and follo-ups were carried out at 3, 6 and 12 months. At the initial investigation all patients were given a neurological examination, congnitive and psychosocial factor assessment and cervical spine X-rays. At each follow-up stepwise regression was performed to evaluted the relationship between inital findings and the course of recovery. Fifty-one (44%), 36(31%) and 28(24%) patients were symptomatic at 3, 6 and 12 months respectively. Poor improvement at all examiniation was significntly correlated with factors associated with severity of injury such as intial symptoms of radicular irritation and intensity of neck pain. Moreover, results indicate that poor recovery is realted to severity of injury in addition to some pre-traumatic factors(previously history of head trauma and headache). However, Psychosocial factors did not prove predictive at any follow-up examination. These results indiacte that synmptoms suggesting a more severe neck injury appear to be particularly related to delayed recovery from common whiplash. Moreover these results may be of value in the objective evalutuion of potentially difficult claims compensation, which may in some cases be falsely base

Quality of life in survivors after cervical artery dissection

Background and purpose : Little data exists about longterm outcome, quality of life (QOL) and its predictors after spontaneous cervical artery dissections (sCAD). Methods : Clinical and radiological data of 114 patients with sCAD were collected prospectively. Six patients died within 3 months, the remaining 108 were contacted after a mean of 1498 days (range: 379-3455), 99 survivors (92 %) replied. QOL, assessed with the stroke-specific QOL scale (SSQOL), and functional abilities, measured with modified Rankin Scale (mRS) were compared, and predictors of QOL were analyzed. Subgroup analyses were performed for patients with ischemic stroke, those with isolated local symptoms or transient ischemic symptoms and those without significant disabilities (mRS 0-1) at follow-up. Results : Seventy-one of 99 patients (72 %) had no significant disability, but only 53 (54 %) reported a good QOL (SS-QOL ≥ 4). Compared to the self-rated premorbid QOL of all patients, SS-QOL was impaired after sCAD (p 0.5). High National Institute of Health Stroke Scale score on admission and higher age were independent predictors of impaired QOL (p < 0.05). Conclusion : QOL is impaired in almost half of long-term survivors after sCAD, even in patients with local or transient symptoms or without functional disability. Impairment of QOL is a surprisingly frequent long-term sequela after sCAD and deserves attention as an outcome measure in these patient

Efficacy and safety of universal valganciclovir prophylaxis combined with a tacrolimus/mycophenolate-based regimen in kidney transplantation.

BACKGROUND: Immunosuppressive and antiviral prophylactic drugs are needed to prevent acute rejection and infection after transplantation. We assessed the efficacy and safety of the introduction of universal valganciclovir prophylaxis in combination with a tacrolimus/mycophenolate-based regimen in kidney transplantation at our centre. METHODS: We reviewed all consecutive patients who underwent kidney transplantation over a 5.5-year period. Patients transplanted from January 2000 to March 2003 (period 1) were compared to patients from April 2003 to July 2005 (period 2). In period 1 patients were treated with basiliximab, cyclosporine, steroids and mycophenolate (or azathioprine). Prophylaxis with valacyclovir was prescribed in cytomegalovirus (CMV) D+/R- patients, while any R+ patients were managed with a preemptive approach. In period 2, immunosuppression consisted of basiliximab or thymoglobulin induction, tacrolimus, steroids and mycophenolate. Three-month CMV prophylaxis with valganciclovir was used in all at-risk patients. RESULTS: Data analysis included 73 patients (period 1) and 70 (period 2). Acute rejection was more frequent in period 1 than in period 2 (42% vs 7%, p &lt;0.001). Overall, 30% of patients in period 1 were diagnosed with CMV infection/disease requiring antiviral treatment, compared with 11.4% in period 2 (p = 0.003). Late-onset CMV disease remained a problem in D+/R- patients in both periods. There was no difference in incidence of BK virus nephropathy, fungal infections, PTLD, graft loss or mortality. However, 4 cases (5.7%) of delayed transient asymptomatic agranulocytosis were observed in period 2. CONCLUSIONS: The present analysis indicates that the combined regimen introduced in period 2 improved clinical results with a significant decrease in acute rejection and in CMV infection/disease incidence. However, a unique syndrome of delayed transient agranulocytosis probably due to drug myelotoxicity was observed in a subset of patients

Diffusion-weighted MRI in acute spinal cord ischaemia

Abstract : Acute spinal cord ischaemia is often undetectable with conventional MRI. Diffusion-weighted MRI (DWI) has been difficult to use in the spine because of susceptibility artefacts. We assessed the diagnostic value of echoplanar DWI for early confirmation of spinal cord ischaemia. We performed conventional MRI and DWI in two men and three women, aged 54-75years with clinically suspected acute spinal cord ischaemia. Imaging was performed 9-46h after the onset of symptoms, and 2-9days later to assess the extent of ischaemic signal change. Spatial resolution of DWI within the spine using standard equipment was poor, but in all patients, early DWI revealed areas of high signal indicating decreased diffusion, confirmed by measurement of apparent diffusion coefficients. Follow-up MRI showed high signal on T2-weighted images and contrast enhancement at the expected levels. Neurological deficits corresponded with radiological findings in four patients: various syndromes, including isolated bilateral weakness or sensory change and combined deficits, were found. Echoplanar DWI may be helpful for confirmation of spinal cord ischaemia in the acute stage, but follow-up T2-weighted images have superior spatial resolution and correlation with clinical findings and lesion exten

Data Predictive Control for Peak Power Reduction

Decisions on how best to optimize today\u27s energy systems operations are becoming ever so complex and conflicting such that model-based predictive control algorithms must play a key role. However, learning dynamical models of energy consuming systems such as buildings, using grey/white box approaches is very cost and time prohibitive due to its complexity. This paper presents data-driven methods for making control-oriented model for peak power reduction in buildings. Specifically, a data predictive control with regression trees (DPCRT) algorithm, is presented. DPCRT is a finite receding horizon method, using which the building operator can optimally trade off peak power reduction against thermal comfort without having to learn white/grey box models of the systems dynamics. We evaluate the performance of our method using a DoE commercial reference virtual test-bed and show how it can be used for learning predictive models with 90% accuracy, and for achieving 8.6% reduction in peak power and costs

Political institutions and debt crises

This paper shows that political institutions matter in explaining defaults on external and domestic debt obligations. We explore a large number of political and macroeconomic variables using a non-parametric technique to predict safety from default. The advantage of this technique is that it is able to identify patterns in the data that are not captured in standard probit analysis. We find that political factors matter, and do so in different ways for democratic and non-democratic regimes, and for domestic and external debt. In democracies, a parliamentary system or sufficient checks and balances almost guarantee the absence of default on external debt when economic fundamentals or liquidity are sufficiently strong. In dictatorships, high stability and tenure play a similar role for default on domestic debt

Inherited cavernous malformations of the central nervous system: clinical and genetic features in 19 Swiss families

Cavernous malformations (CCMs) are benign, well-circumscribed, and mulberry-like vascular malformations that may be found in the central nervous system in up to 0.5% of the population. Cavernous malformations can be sporadic or inherited. The common symptoms are epilepsy, hemorrhages, focal neurological deficits, and headaches. However, CCMs are often asymptomatic. The familiar form is associated with three gene loci, namely 7q21-q22 (CCM1), 7p13-p15 (CCM2), and 3q25.2-q27 (CCM3) and is inherited as an autosomal dominant trait with incomplete penetrance. The CCM genes are identified as Krit 1 (CCM1), MGC4607 (CCM2), and PDCD10 (CCM3). Here, we present the clinical and genetic features of CCMs in 19 Swiss families. Furthermore, surgical aspects in such families are also discusse

Update of the Swiss guidelines on post-treatment Lyme disease syndrome.

Lyme borreliosis is caused by Borrelia burgdorferi sensu lato infection, which responds well to antibiotic therapy in the overwhelming majority of cases. However, despite adequate antibiotic treatment some patients report persisting symptoms which are commonly summarised as post-treatment Lyme disease syndrome (PTLDS). In 2005, the Swiss Society of Infectious Diseases published a case definition for PTLDS. We aimed to review the scientific literature with a special emphasis on the last 10 years, questioning whether the definitions from 2005 are still valid in the light of current knowledge. Furthermore, we describe the clinical history of infection with Borrelia burgdorferi sensu lato, the estimated prevalence of PTLDS, the possible pathogenesis of PTLDS, and treatment options with an emphasis on clinical studies. In summary, we were unable to find a scientific reason for modification of the PTLDS definitions published in 2005. Thus, the diagnostic criteria remain unchanged, namely documented clinical and laboratory evidence of previous infection with B. burgdorferi, a completed course of appropriate antibiotic therapy, symptoms including fatigue, arthralgia, myalgia, cognitive dysfunction or radicular pain persisting for &gt;6 months, a plausible timely association between documented B. burgdorferi infection and onset of symptoms (i.e., persistent or recurrent symptoms that began within 6 months of completion of a recommended antibiotic therapy for early or late Lyme borreliosis), and exclusion of other somatic or psychiatric causes of symptoms. The main therapeutic options remain cognitive behavioural therapy and low-impact aerobic exercise programmes. Growing and unequivocal evidence confirms that prolonged or repeated antibiotic therapy for PTLDS is not beneficial, but potentially harmful and therefore contraindicated. The Guidelines of the Swiss Society of Infectious Diseases offer an evidence based, diagnostic and therapeutic framework for physicians caring for patients suffering from presumptive PTLDS in Switzerland

Number and cost of claims linked to minor cervical trauma in Europe: results from the comparative study by CEA, AREDOC and CEREDOC

Comparative epidemiological study of minor cervical spine trauma (frequently referred to as whiplash injury) based on data from the Comité Européen des Assurances (CEA) gathered in ten European countries. To determine the incidence and expenditure (e.g., for assessment, treatment or claims) for minor cervical spine injury in the participating countries. Controversy still surrounds the basis on which symptoms following minor cervical spine trauma may develop. In particular, there is considerable disagreement with regard to a possible contribution of psychosocial factors in determining outcome. The role of compensation is also a source of constant debate. The method followed here is the comparison of the data from different areas of interest (e.g., incidence of minor cervical spine trauma, percentage of minor cervical spine trauma in relationship to the incidence of bodily trauma, costs for assessment or claims) from ten European countries. Considerable differences exist regarding the incidence of minor cervical spine trauma and related costs in participating countries. France and Finland have the lowest and Great Britain the highest incidence of minor cervical spine trauma. The number of claims following minor cervical spine trauma in Switzerland is around the European average; however, Switzerland has the highest expenditure per claim at an average cost of €35,000.00 compared to the European average of €9,000.00. Furthermore, the mandatory accident insurance statistics in Switzerland show very large differences between German-speaking and French- or Italian-speaking parts of the country. In the latter the costs for minor cervical spine trauma expanded more than doubled in the period from 1990 to 2002, whereas in the German-speaking part they rose by a factor of five. All the countries participating in the study have a high standard of medical care. The differences in claims frequency and costs must therefore reflect a social phenomenon based on the different cultural attitudes and medical approach to the problem including diagnosis. In Switzerland, therefore, new ways must be found to try to resolve the problem. The claims treatment model known as “Case Management” represents a new approach in which accelerated social and professional reintegration of the injured party is attempted. The CEA study emphasizes the fundamental role of medicine in that it postulates a clear division between the role of the attending physician and the medical expert. It also draws attention to the need to train medical professionals in the insurance business to the extent that they can interact adequately with insurance professionals. The results of this study indicate that the usefulness of the criterion of so-called typical clinical symptoms, which is at present applied by the courts to determine natural causality and has long been under debate, is inappropriate and should be replaced by objective assessment (e.g. accident and biomechanical analysis). In addition, the legal concept of adequate causality should be interpreted in the same way in both third party liability and social security law, which is currently not the case