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e19340 Background: Clostridium difficile infection (CDI) is a considerable health burden, and now identified as the leading cause of acquired diarrhea in patients receiving antibiotics. Cancer patients are more prone to acquire CDI, owing to their frequent exposure to risk factors. This study aims to investigate the factors affecting the outcome of Clostridium Difficile Infection in patients with cancer at our community center. Methods: This is a retrospective study that included a total of 59 cancer patients who were hospitalized for clostridium difficile infection. Results: The median age of the study population was 79 years with 39 males and 20 females. The patients were suffering from cancer located at the following sites: Prostate (25), lung (19), colon (7), bladder (4), breast (3) and renal (1). There were 52 cases of 1st and 7 cases of recurrent CDI admissions. 40 patients detected to have CDI at presentation while 19 patients developed CDI during hospitalization. CDI categories were as follows: Non-severe (29), severe (28), and very severe (3). There were 33 and 20 patients on chemotherapy and radiotherapy respectively. 27 patients had a recent history of cancer care-related procedures or interventions. 29 patients were from either rehab or nursing facility. There were 39 recent hospitalizations with 29 patients receiving antibiotics. Almost half of the patients were on PPI (29) and 12 were on steroids (20.3%) at the time of developing CDI. Patients with a high-risk qSOFA Score of 2 or more (p-value = 0.008) or a high white blood cell count of > 15 X 109/L (p-value = 0.016) were found to have higher in-hospital mortality. Critical care data suggested that 9 patients required intensive care, 7 patients required vasopressor support, and 6 needed mechanical ventilation. Patients were treated with either vancomycin alone (13), or metronidazole alone (25), or combination therapy with vancomycin + metronidazole (21). The median duration of hospital stay was 6 days with 11 fatalities (18.64%). Conclusions: CDI causes significant morbidity in cancer patients. Factors like high qSOFA score and leukocytosis can help to prioritize and intensify the care and in prognosticating the patients.

e19365 Background: Along with antitumor effects, Immune Checkpoint Inhibitors (ICPI) have shown great potential in treating chronic infections such as HIV, Hepatitis B, and malaria, in ex-vivo studies. However, several case reports and case series suggested increased infection risk in cancer patients receiving ICPI. The purpose of our study is to assess the risk of infections in cancer patients receiving ICPI. We also attempted to evaluate the role of a multidisciplinary approach (Oncology and Infectious disease specialists) and the cost associated with treatment. Methods: Records on all cancer patients over age ≥18 years old who had received at least one dose of ICPI from 2015 to 2018 at two major community teaching hospitals in the Central Massachusetts region were reviewed. Several risk factors associated with infection were identified. Two-tailed unpaired t-test was used to analyze the association between risk factors and infection. We calculated the average length of stay (LOS) and cost per admission with a multidisciplinary vs. non-multidisciplinary approach. The calculated total average cost per admission was compared with a random set of non-oncologic population admitted with similar infections noted in our study to estimate the economic burden. Results: Thirty-seven (21.8%) patients developed sixty-two episodes of infection. Microbiological confirmation was available in 13 episodes. Risk factors like COPD (P = 0.01), prior chemotherapy (P = 0.03), and steroid use (P = 0.003) were significantly associated with infections. An infection-associated mortality rate was noted to be 2.3%. With the involvement of multidisciplinary team, the average LOS increased from 5.9 to 8.1 days. Yet, the average cost per admission approximately remained the same (52,047$ vs. 54,510$). Upon comparison with a non-oncologic patient, the average cost per admission for an infection in cancer patients receiving ICPI increased from 11,527$ to 35,484$. Conclusions: Surprisingly, a significant incidence of infections and associated health care resource utilization continue to prevail in cancer patients despite the utility of ICPI. Although the economic burden due to the infections in this set of patients is remarkably high when compared to the general population, the multidisciplinary approach did not increase the hospital costs.

Splenic infarction is a rare complication of infectious mononucleosis. We describe 3 cases of splenic infarction attributed to infectious mononucleosis that we encountered within a 2-month period. We underscore the awareness of this potential complication of infectious mononucleosis and discuss the differential diagnosis of splenic infarction, including infectious etiologies. While symptomatic management is usually sufficient for infectious mononucleosis-associated splenic infarction, close monitoring for other complications, including splenic rupture, is mandated.

Vaccination, screening, and linkage to care can reduce the burden of chronic hepatitis B virus (HBV) infection. However, recommendations vary among organizations, and their implementation has been suboptimal. The American College of Physicians' High Value Care Task Force and the Centers for Disease Control and Prevention developed this article to present best practice statements for hepatitis B vaccination, screening, and linkage to care.A narrative literature review of clinical guidelines, systematic reviews, randomized trials, and intervention studies on hepatitis B vaccination, screening, and linkage to care published between January 2005 and June 2017 was conducted.Clinicians should vaccinate against hepatitis B virus (HBV) in all unvaccinated adults (including pregnant women) at risk for infection due to sexual, percutaneous, or mucosal exposure; health care and public safety workers at risk for blood exposure; adults with chronic liver disease, end-stage renal disease (including hemodialysis patients), or HIV infection; travelers to HBV-endemic regions; and adults seeking protection from HBV infection.Clinicians should screen (hepatitis B surface antigen, antibody to hepatitis B core antigen, and antibody to hepatitis B surface antigen) for HBV in high-risk persons, including persons born in countries with 2% or higher HBV prevalence, men who have sex with men, persons who inject drugs, HIV-positive persons, household and sexual contacts of HBV-infected persons, persons requiring immunosuppressive therapy, persons with end-stage renal disease (including hemodialysis patients), blood and tissue donors, persons infected with hepatitis C virus, persons with elevated alanine aminotransferase levels (≥19 IU/L for women and ≥30 IU/L for men), incarcerated persons, pregnant women, and infants born to HBV-infected mothers.Clinicians should provide or refer all patients identified with HBV (HBsAg-positive) for posttest counseling and hepatitis B-directed care.

A 37-year-old woman presented to us for the complaints of pain and swelling over her right side of the neck and high spiking fever for the last 3 days. Her previous medical history was significant for intravenous drug abuse and she reported injecting heroin and methamphetamine by mixing with tap

The existing standard of care for chronic hepatitis C virus (HCV) infection includes the use of pegylated interferon and ribavirin as primary components of treatment, with the addition of a direct-acting antiviral for genotype 1 infection. Sofosbuvir, an oral nucleotide inhibitor of the HCV nonstructural protein 5B RNA-dependent RNA polymerase enzyme, was recently approved for use in combination with ribavirin and/or pegylated interferon for chronic HCV infection, depending on the genotype. Sofosbuvir is orally administered, and peak plasma concentrations are not affected by food. The drug is renally eliminated and does not require adjustment in mild to moderate renal insufficiency or in any degree of hepatic impairment. Sofosbuvir is not metabolized by cytochrome P450 isoenzymes, nor does it induce or inhibit the metabolism of agents that are substrates of these enzymes. Sofosbuvir demonstrates a high barrier to resistance and was well tolerated by patients in clinical trials. Overall efficacy rates vary between 70% and 90%.

Purpose The first published report of the use of triple therapy in a patient with hepatitis C virus (HCV) genotype 6 infection—a treatment that was prescribed due to incorrect HCV genotyping and which ultimately failed—is presented. Summary A 70-year-old male U.S. resident of Vietnamese descent requested treatment for chronic HCV infection acquired decades earlier. He reported experiencing hepatitis C treatment failures twice before—13 years prior (interferon alfa monotherapy for six months) and 7 years prior (standard dual therapy with pegylated interferon alfa-2b and ribavirin for nine months). Initial viral genotyping indicated infection with HCV genotypes 1a and 6c (a form of mixed HCV disease amenable to triple therapy), and treatment with pegylated interferon alfa-2a, ribavirin, and boceprevir was initiated. By week 8 of triple therapy, the patient’s viral load had decreased from 15,700,000 (7.20 log) to 462,882 (5.67 log) IU/mL, but the viral load subsequently rebounded to baseline levels, and treatment was discontinued at week 16. When repeat HCV genotyping was performed, it was discovered that initial genotyping was incorrect and that the man’s infection involved not mixed genotypes but only genotype 6; he was not an appropriate candidate for triple therapy. The case emphasizes the need for clinicians to be cognizant of potential HCV genotyping errors, particularly with regard to patients of Southeast Asian descent. Conclusion Three courses of interferon-based treatment, including triple therapy with boceprevir, failed to produce a sustained therapeutic response in a 70-year-old ethnic Vietnamese man with genotype 6 HCV infection.

With the advent of the direct-acting antiviral agents (DAAs) for chronic hepatitis C infection, the treatment paradigm has dramatically changed, especially the duration, tolerability, and response to therapy. The DAAs fall into several classes and are variously indicated in the treatment of one or more genotypes of infection. All these agents are orally administered and, as they are largely renally eliminated (with exceptions), do not require adjustment in mild to moderate renal insufficiency. Most of these agents demonstrate a high barrier to resistance and are extremely well-tolerated by patients. Overall efficacy rates are ≥90%.

We present a case of a primigravid woman who presented with Plasmodium falciparum nearly 3 years after she last visited a malaria-endemic region. We review the literature to identify case reports of recrudescent P. falciparum malaria during pregnancy, including those with prolonged latency. Reports of recrudescence of P. falciparum during pregnancy are limited. Plasmodium falciparum infection can persist for years. Recrudescence can occur with waning of immunity following departure from endemic areas. Pregnancy, particularly the primigravid state, is a risk factor for severe infection.

Background One in every six adults (16.3% of the U.S. adult population) has high total cholesterol levels, and they are at double the risk of heart disease compared with people with optimal levels. Objective To evaluate compliance of internal medicine residents with the latest National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines in treating patients with hyperlipidemia. Design Retrospective observational study. Setting Ambulatory Clinic, Saint Vincent Hospital, Worcester, Massachusetts. Patients Patients with a diagnosis of hyperlipidemia who attended the clinic during a 1-ear period, from December 2009 to November 2010. Measurements A review of medical records was conducted to evaluate residents' compliance with the NCEP-ATP III guidelines for LDL cholesterol and non-HDL cholesterol management. Results Seven hundred seventy charts were reviewed. Only 212 (27.5%) met the inclusion criteria. Analysis of data revealed better compliance with drug therapy (44%−77%) and therapeutic lifestyle changes (44%−83%) when compared with follow-up recommendations (22%−31%). An increase in compliance also was noted in all areas of intervention when patients had an abnormal lipid profile. Limitations Compliance was assessed on the basis of electronic medical record documentation alone and hence we may be underestimating compliance with therapeutic lifestyle changes and follow-up recommendations. Conclusion Compliance among internal medicine residents in the diagnosis, treatment and follow-up of patients with hyperlipidemia according to NCEP-ATP III guidelines was suboptimal and needs improvement.

Advancements in technology have led to the development of medical applications (apps). Contents of 44 apps related to travel medicine were assessed demonstrating that many were updated infrequently and several developers had no medical background. There is an opportunity for healthcare professionals to develop apps in travel medicine.

This letter provides an update to a case report we previously published in this journal.[1][1] Briefly, a 72-year-old Vietnamese man had not responded to three prior courses of treatment for a genotype 6 hepatitis C virus (HCV) infection, the last treatment being pegylated interferon alfa-2a

Introduction Clostridium difficile infection (CDI) and nontyphoidal Salmonella infection (NSI) have similar clinical manifestations and are seldom seen simultaneously. The decision-making in terms of antibiotic therapy becomes difficult when both the pathogens are isolated from the same patient. Case presentation We describe a case of Clostridium difficile (CD) enterocolitis in a healthcare provider who concomitantly tested positive for nontyphoidal Salmonella. Discussion To the best of our knowledge after extensive literature review (English), this is only the fourth report highlighting this association. Conclusion Although Salmonella is not a risk factor for CDI, it can cause intestinal inflammation and alteration in the intestinal flora. When two pathogens are isolated from the same patient, it is tempting to treat both with antibiotics as highlighted. When it involves healthcare workers, there is no difference in guidelines and should not be prescribed antibiotics with intent of reducing secondary transmission.

Contrast-Induced Nephropathy (CIN) is associated with significant morbidity and mortality after Percutaneous Coronary Intervention (PCI). Very Elderly Patients (VEP) undergoing PCI are at higher risk of CIN because of age and associated multiple comorbidities. Retrospective analysis of Electronic

A retrospective analysis of insurance data was made of 600 individuals claiming compensation for whiplash following motor vehicle accidents. Three hundred randomly selected claimants who had settled their injury claims within 9 months of the accident were compared with 300 who had settled more than 24 months after the accident. We compared the two groups to identify possible risk factors for prolonged recovery, for which settlement time greater than 24 months was a marker. Variables considered included demographic factors, type of collision, degree of vehicle damage, workers compensation, prior claim or neck disability, treatment and time to settlement. Consulting a solicitor was associated with a highly significant, four-fold increase of late settlement of the claim. A concurrent workers’ compensation claim, prior neck disability and undergoing physiotherapy or chiropractic treatment were weakly associated with late settlement. The degree of damage to the vehicle (as indicated by cost of repairs) was not a significant predictor of late settlement. Late settlement may be the direct effect of legal intervention, independent of the severity of the injury. Whilst the financial benefit to the claimant of consulting a solicitor is apparent, the benefit of prolonged disability is not. It may be to the advantage of both insurers and claimants if those likely to proceed to late settlement could be recognised early and their claims settled expeditiously.

SummaryBackground HCV-TARGET is a longitudinal observational study of chronic hepatitis C virus (HCV) patients treated with direct-acting anti-viral agents (DAAs) in a US consortium of 90 academic and community medical centres. Aim To assess utilisation of response-guided therapy (RGT) and sustained virological response (SVR) of a large cohort of patients. Methods Patients received peginterferon (PEG-IFN), ribavirin and either telaprevir or boceprevir. Demographical, clinical and virological data were collected during treatment and follow-up. RGT and treatment futility stopping rules was assessed at key time points. Results Of 2084 patients, 38% had cirrhosis and 56% had received prior treatment for HCV. SVR rates were 31% (95% CI: 24–40) and 50% (95% CI: 44–56) in boceprevir patients with and without cirrhosis, respectively. SVR rates were 46% (95% CI: 42–50) and 60% (95% CI: 57–64) in telaprevir patients with and without cirrhosis, respectively. Early clearance of virus, IL28B genotype, platelet counts and diabetes were identified as predictors of SVR among boceprevir patients, while early clearance of virus, IL28B, cirrhosis, HCV subtype, age, haemoglobin, bilirubin and albumin levels were identified as predictors of SVR for telaprevir patients. Conclusions In academic and community centres, triple therapy including boceprevir or telaprevir led to SVR rates somewhat lower than those noted in large phase 3 clinical trials. Response rates were consistently higher among patients without cirrhosis compared to those with cirrhosis regardless of DAA used and prior treatment response. Trial registration clinicaltrials.gov NCT01474811.

ecently, travel to underdeveloped and exotic desti-nations has increased substantially. Internationaltravel is a multi-billion dollar industry exceeding$900 billionUS dollars (600 euros) in 2008. By the year2020, it is expected that the number of internationaltravelers willexceed1 billion,halfbeingforleisurepur-posesandapproximately15%businessrelated.

Infections of the adrenal glands remain an important cause of adrenal insufficiency, especially in the developing world. Indeed, when Thomas Addison first described the condition that now bears his name over 150 years ago, the vast majority of cases were attributable to tuberculosis. Here we describe a classic, but relatively uncommon, presentation in the United States of adrenal insufficiency followed by a review of the current literature pertaining to adrenal infections.

Peritoneal mesothelioma is a rare malignancy with a poor prognosis. Etiology is unclear and presentation of this disease is often atypical. There are very few cases of long-term survival in patients with peritoneal mesothelioma. We report the case of a patient with peritoneal mesothelioma of 19 years' duration. To the best of our knowledge, there have been no reports of recurrent peritoneal mesothelioma with such long-delayed recurrence and survival. Recurrent peritoneal mesothelioma in the current patient was confirmed by comparing the biopsies of omentum taken in 1979 with that taken in 1997. An extensive literature search was undertaken to look for previous reports of recurrent peritoneal mesothelioma. Aggressive and intensive chemotherapy appeared to provide a longer survival time. Our patient had paraneoplastic manifestations that included paraneoplastic hepatopathy and a wasting syndrome. Peritoneal mesothelioma is a rare malignancy with one to two cases per million in the United States. It is known to exhibit unusual paraneoplastic manifestations, including paraneoplastic hepatopathy. Treatment is often unsuccessful, with a median survival time of approximately 18 months from diagnosis. A better understanding and aggressive management of this disease appear to help prolong survival.

People who travel to areas with high rabies endemicity and have animal contact are at increased risk for rabies exposure. We examined characteristics of international travelers queried regarding rabies vaccination during pretravel consultations at Global TravEpiNet (GTEN) practices during 2009-2010.We performed bivariate and multivariable analyses of data collected from 18 GTEN clinics. Travel destinations were classified by strength level of rabies vaccination recommendation.Of 13,235 travelers, 226 (2%) reported previous rabies vaccination, and 406 (3%) received rabies vaccine at the consultation. Common travel purposes for these 406 travelers were leisure (26%), research/education (17%), and nonmedical service work (14%). Excluding the 226 who were previously vaccinated, 8070 (62%) of 13,009 travelers intended to visit one or more countries with a strong recommendation for rabies vaccination; 1675 (21%) of these 8070 intended to travel for 1 month or more. Among these 1675 travelers, 145 (9%) were vaccinated, 498 (30%) declined vaccination, 832 (50%) had itineraries that clinicians determined did not indicate vaccination, and 200 (12%) remained unvaccinated for other reasons. In both bivariate and multivariate analyses, travelers with trip durations6 months versus 1-3 months (adjusted odds ratio [OR]=4.9 [95% confidence interval [CI] 2.1, 11.4]) and those traveling for "research/education" or to "provide medical care" (adjusted OR=5.1 [95% CI 1.9, 13.7] and 9.5 [95% CI 2.2, 40.8], respectively), compared with leisure travelers, were more likely to receive rabies vaccination.Few travelers at GTEN clinics received rabies vaccine, although many planned trips 1 month long or more to a strong-recommendation country. Clinicians often determined that vaccine was not indicated, and travelers often declined vaccine when it was offered. The decision to vaccinate should take into account the strength of the vaccine recommendation at the destination country, duration of stay, availability of postexposure prophylaxis, potential for exposure to animals, and likelihood of recurrent travel to high-risk destinations.

A 28-year-old woman with a history of snorting heroin and cocaine was admitted with facial cellulitis secondary to a dental phlegmon. She reported rhinolalia, occasional nasal regurgitation of food and a burning sensation in her nose and throat while eating. She self-medicated with a topical application of crushed acetaminophen and oxycodone tablets to her throat to prevent discomfort while eating. Physical examination revealed poor dentition, palatal destruction, absent soft palate and a white …

Summary The objective of this study was to study the spectrum of neurological manifestations in patients with dengue infection. This was a prospective study undertaken at the Departments of Medicine and Neurology, Christian Medical College, Ludhiana, India. All patients diagnosed with dengue fever during an epidemic (1 September 2010–31 December 2010) were screened for neurological manifestations. There were a total of 799 patients with dengue infection. Neurological manifestations were present in 21 (2.63%),19 of whom were men with a mean age of 33.7 ± 13.9 years. The neurological diagnoses were hypokalaemia with: quadriparesis (7); myositis (4); encephalopathy (4); Guillain–Barre syndrome (2); acute disseminated encephalomyelitis (2); lumbosacral plexopathy (1); and intracranial haemorrhage (1). Three of these patients died. Clinicians should be aware that neurological manifestations in dengue fever are not uncommon.

The objectives of treating open knee joint injuries with disruption of the distal quadriceps mechanism are to ensure rapid wound healing and to restore joint function. For this it is necessary to provide soft tissue cover, control infection, restore full extension of the knee by reconstruction of the extensor apparatus and prevent joint stiffness by early mobilisation. Two cases are presented where the gastrocnemius (medial half) musculotendinous unit has been used to reconstruct, in one stage, the extensor apparatus and at the same time to provide soft tissue cover.

Anticoagulants are one of the drug classes most frequently cited in reports of medication errors or adverse drug reactions, and their improper use often results in emergency department visits, hospitalizations, or both.[1][1]–[3][2] In order to minimize the risks and standardize practices within

Implantable cardioverter defibrillators (ICD), despite an unequivocal clinical benefit, are known to have a complex psychosocial impact on the patients. ICD shocks and the resultant psychobiological changes are known to contribute to increased levels of anxiety, depression, and post-shock stress symptoms in these patients. Phantom shock is a patient-reported perception of an ICD shock in the absence of any actual shock; however, its pathophysiological understanding is poor.A retrospective chart review of the University hospital ICD patients' database from June 2006 to April 2010 was conducted. A total of 38 patients with documented phantom shocks as cases and 76 age- and sex-matched patients with no phantom shocks as controls were selected from the database. Patient characteristics were analyzed for their potential association with the occurrence of phantom shocks.Phantom shock patients had higher prevalence of documented depression (31.6%), anxiety (23.7%), and cocaine use (42.1%). Additionally, patients who had previous ICD shock storms were more likely to have phantom shocks (39.5%; p = 0.001). More importantly, no phantom shocks were reported in patients who did not receive defibrillation threshold testing or past ICD shock storms.Phantom shocks are primarily observed in ICD patients who had prior exposure to traumatic device shocks and are more common in patients with a history of depression, anxiety, or substance abuse. A pathophysiological mechanism is proposed as a guide to potential prevention.

This study compares the effects of two polymers currently being marketed on commercially available drug-eluting stents, PVDF-HFP fluorinated copolymer (FP) and phosphorylcholine polymer (PC), on re-endothelialization, acute thrombogenicity, and monocyte adhesion and activity. Rabbit iliac arteries were implanted with cobalt-chromium stents coated with FP or PC polymer (without drug) and assessed for endothelialization at 14 days by confocal and scanning electron microscopy (SEM). Endothelialization was equivalent and near complete for FP and PC polymer-coated stents (>80% by SEM). Acute thrombogenicity was assessed in a Chandler loop model using porcine blood. Thrombus adherence was similar for both polymers as assessed by clot weight, thrombin-antithrombin III complex, and lactate dehydrogenase expression. In vitro cell adhesion assays were performed on FP and PC polymer-coated glass coupon surfaces using HUVECs, HCAECs, and THP-1 monocytes. The number of ECs adhered to FP and control surfaces were equivalent and significantly greater than on PC surfaces (p

Objective: To report a case of a patient who experienced acute renal and hepatic toxicity following administration of daptomycin and review previously published case reports of renal and hepatic dysfunction with daptomycin. Case Summary: A 35-year-old man receiving daptomycin 4 mg/kg (275 mg) intravenously once daily (started 5 wk prior to presentation for presumed osteomyelitis) presented to the emergency department with elevations in serum creatinine and hepatic transaminase levels. He did not experience creatine kinase (CK) elevation or rhabdomyolysis. Following discontinuation of daptomycin, his renal and hepatic function improved. Discussion: To our knowledge, this is the first case of daptomycin-induced hepatotoxicity with acute renal failure in the absence of rhabdomyolysis and CK abnormalities. Previously published case reports described patients with a variety of elevations in liver function tests, serum creatinine, and CK with daptomycin. In our patient, the acute renal and hepatic toxicity was probable according to the Naranjo probability scale. Conclusions: Although daptomycin is a well-tolerated antibacterial agent, clinicians should consider periodic monitoring of liver function and renal function tests to identify potential adverse effects.

Limited information is available from India and other developing countries regarding the various factors that contribute to a delay in hospital admission after stroke. The stroke unit of the Christian Medical College, Ludhiana, in Northwest India prospectively studied the various factors contributing to delay in hospital admission during a 15-month period ending September 2003. Patients or their relatives were interviewed within 48 hours of admission using a structured questionnaire. Of the 147 patients interviewed, 99 (67%) were men and the mean age was 59.7 +/- 14.1 years. A total of 43 (29%) patients presented within 3 hours of stroke onset. Only 12% of patients came by ambulance. Directly reaching the stroke department (P.001, odds ratio [OR] 4.2, confidence interval [CI] 3.13-8.45), distance 10 km or less from the hospital (P.03, OR 4.0, CI 1.12-9.24), and presence of aphasia (P.03, OR 3.7, CI 1.47-7.92) were the factors associated with an early arrival. We found a considerable delay in the early arrival of patients to our stroke department. Both local physicians and the public should be educated about the importance of an early referrals and presentation to the stroke centers.

Background and Purpose— This study assessed public awareness of warning symptoms, risk factors, and treatment of stroke in Ludhiana, Punjab, North West India. Methods— A hospital-based survey was conducted between February 2002 and September 2002 by the Stroke section of Christian Medical College. The study subjects were relatives of patients without history of stroke, attending the outpatient department of the hospital. Trained medical students, interns, and a nurse interviewed subjects using a structured, pretested, open-ended questionnaire. Results— Nine hundred forty-two individuals were interviewed during the study period (56.4% men, mean age 40.1 years, age range 15 to 80 years). Forty-five percent of the subjects did not recognize the brain as the affected organ in stroke. In the multivariate analysis, higher education ( P P Conclusions— This hospital-based survey reveals a better awareness of stroke warning signs and risk factors. However, knowledge regarding the organ involved, etiology, and treatment of stroke is lacking. Considerable education is needed to increase public awareness in modern concepts of stroke treatment.

Reports of accessory soleus muscle are rare, perhaps as a result of it often remaining unrecognized. It presents as a swelling behind the ankle and may be mistaken for a tumour or inflammatory lesion, as occurred in the first of a series of three cases. The other two were incidental findings, one in a 30 year old man with an open tibial fracture and the other in a 9 month old child with a club foot. Patients present with either pain or a diagnostic problem. When large, it may make wearing of footwear difficult. Computerized tomography with electromyography enables confirmation of the diagnosis. Pain is relieved by epimysiotomy and when encountered incidentally during surgery, incision of the epimysium is all that is needed. Excision of the muscle may be considered only if wearing of footwear is difficult. The significance of its presence in a case of club foot is unknown. Disinsertion of its insertion was all that was required to obtain surgical correction of the deformity in the present case. Awareness of the condition will prevent unnecessary surgery in asymptomatic cases.

A 46-year-old man came to the emergency room with a nail in his head after the accidental fi ring of a nail gun at home. His only symptom was a mild frontal headache. Physical examination showed no focal neurological defi cits. A skull radiograph and CT scan of the brain revealed a 6·35 cm nail that had entered the calvarium through the right frontal bone with approximately 4·1 cm of parenchymal penetration, and a small intraparenchymal haemorrhage and air consistent with pneumocephalus (fi gure). The nail was removed successfully with minor bleeding in the tract seen on postoperative imaging. He had an uneventful recovery and was discharged home. An accidental foreign body insertion through the calvarium can have variable consequences, dependent on the velocity, chemical composition, shape, and location of the object. Frameless stereotactic systems greatly facilitate localisation of deep-seated intraparenchymal foreign bodies. Given the increasing use of pneumatic and cartridge-activated nail guns, the addition of a sequential trigger should be required in such equipment, especially for the protection of construction workers, who may be at highest risk for such injuries.

This letter provides an update to a case report and follow-up letter we previously published in AJHP .[1][1],[2][2] Briefly, a now-75-year-old Vietnamese man did not respond to 4 prior courses of interferon-based treatment for a hepatitis C virus (HCV) genotype 6 infection, the last treatment being

Study Design Efficacy of the percutaneous biopsy of the spine under computed tomographic guidence was investigated, Seventy-five patients, ranging in age from 7 to 72 years, underwent this procedure. Objectives To determine the usefulness of computed tomographically guided biopsies in the treatment of patients with spinal disorders. Summary of Background Data The results of 68 biopsies (90.6%) were judged to be accurate insofar as the samples of tissue obtained could be diagnosed as specific types of enoplasm, infective lesions, reactive lesions of nonspecific type, or noramal bone. Methods Biopsies that yielded a specific abnormality were categorized as true positives. The “normal” biopsies were followed for 6–8 months and were than deemed true negatives. Nondiagnostic ones were considered false negatives. Results The results are acceptable with an accuracy rate of 90.6%. It is a safe and simple procedure with a short learning curve. Conclusions Computed tomographically guided biopsy of the spine is recommended as a procedure of choice, especially in cervical and thoracic lesions. Computed tomography is superior to fluiorascopy when dealing with small, deep-seated lesions especially in the cervical and thoracic regions and with lesions picked up on bone scan only, radiographs being negative. Needle biopsy under computed tomographic guidance is safe and precise.

We have used the extensor digitorum brevis musculotendinous unit elevated on its neurovascular pedicle and transposed it to reconstruct the Achilles tendon in a case of neglected rupture.