Fwd: Case: Ear Pain and Mental Status Changes/ECT/Humoral Immunity

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Teaching topics from the New England Journal of Medicine - Vol. 357, No. 19, November 8, 2007

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THIS WEEK'S TEACHING TOPICS 1.  Case of Ear Pain and Mental Status Changes:  What are the leading causes of bacterial meningitis in adults? What are the potential risks of group A streptococcus meningitis? Clinical Pearls | Morning Report Question 2.  Shock Therapy for Depression:  What are the indications, and the potential side effects of electroconvulsive therapy? Clinical Pearls | Morning Report Questions 3.  Duration of Humoral Immunity:  Is there a difference in the persistence of humoral immunity after vaccination versus natural infection? Clinical Pearls | Morning Report Questions also in this e-mail: Images in Clinical Medicine Image Challenge Audio Videos in Clinical Medicine Featured Job of the Week Printer Friendly

Quote of the Week " . . . in the United States, only 10 medicine department chairs are women . . . only 9% of the chairs of all clinical departments are women, and many schools have no female department chairs at all." N.C. Andrews, Perspective, "Climbing through Medicine's Glass Ceiling." top

TEACHING TOPIC 1. Case of Ear Pain and Mental Status Changes CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL, Case 34-2007: A 77-Year-Old Man with Ear Pain, Difficulty Speaking, and Altered Mental Status, M.A. Samuels and Others, Extract | Full Text | PDF | PPT Slide Set A 77-year-old man was admitted to the hospital because of difficulty speaking and altered mental status. He had been well until the day before admission, when pain developed in the right side of his face and in his right ear. Several days earlier, he had fallen on the sidewalk and hit his head. On examination, he was lethargic with incomprehensible speech; dried blood was seen in his right ear canal. CT scanning of his head disclosed pneumocephalus and opacification of the right mastoid ear cells. top Clinical Pearls  Common Organisms in Bacterial Meningitis The most common bacteria causing meningitis in adults are Streptococcus pneumoniae (about half of cases), Neisseria meningitidis (about one fifth of cases), Listeria monocytogenes (about one tenth of cases), and Haemophilus influenzae (about one tenth of cases). The otitic meningitis in this patient (whose ear infection may have caused bony erosion that led to a cerebrospinal fluid fistula) prompted the clinicians to consider more aggressive organisms such as Staphylococcus aureus, gram-negative organisms, and group A streptococcus. In fact, blood and cerebrospinal cultures became positive for group A streptococcus within a few hours.  Group A Streptococcus Meningitis Infections with group A streptococcus are a rare cause of bacterial meningitis, accounting for 0.5 to 1.5% of community-acquired cases; the mortality rate (27%) is similar to that for pneumococcal meningitis (30%). Otitis media due to group A streptococcus is associated with high rates of local invasion, including tympanic perforation and mastoiditis, and this form of otitis media is the most important risk factor for group streptococcal meningitis among adult patients. Most patients with group A streptococcal meningitis do not have the clinical features of septic shock associated with invasive streptococcal disease, and the incidence of group A streptococcal meningitis has not increased, despite an increasing incidence of other forms of invasive disease. top Morning Report Question Q: An important clinical challenge is how to recognize when fluid emanating from the ear or the nose is, in fact, cerebrospinal fluid. How might this be accomplished? A: Otorrhea and rhinorrhea may be recognized as containing cerebrospinal fluid if the fluid has a relatively low protein level (<2 g per liter) and should be clinically suspected when a handkerchief or cloth soaked in the fluid does not stiffen when dry. A fluid glucose level of greater than 40 mg per deciliter ( 2.2 mmol per liter) also suggests that the fluid is cerebrospinal fluid. The most accurate test is a measurement of β2-transferrin, a protein that is found only in cerebrospinal fluid. Of note, cerebrospinal fluid otorrhea may be serosanguineous and mistaken for blood. top TEACHING TOPIC 2. Shock Therapy for Depression CLINICAL THERAPEUTICS, Electroconvulsive Therapy for Depression, S.H. Lisanby, Extract | Full Text | PDF | PPT Slide Set An 82-year-old woman with a history of recurrent unipolar major depression has had several episodes of major depression consisting of depressed mood, crying spells, loss of interest in usual activities, insomnia, loss of appetite and weight, difficulty concentrating, feelings of helplessness and hopelessness, and thoughts of suicide. She has tried various regimens of medications with no response. Is she a candidate for electroconvulsive therapy? Why or why not? top Clinical Pearls  Indications for Electroconvulsive Therapy The primary indications for electroconvulsive therapy (ECT) among patients with depression are lack of a response to or intolerance of antidepressant medications, a good response to previous ECT, and the need for a rapid and definitive response ( e.g., because of psychosis or a risk of suicide). ECT may be used in both unipolar and bipolar disorders. In the United States ECT treatments are usually administered three times weekly for approximately 6 to 12 treatments (two to four weeks), depending on the severity of the patient's symptoms and the rapidity of response. Figure 1. Standard Electrode Placements for Electroconvulsive Therapy.  ECT for Depression ECT for the treatment of depression and other psychiatric disorders involves the application of electric current via the scalp in order to induce seizure activity. ECT has been reported to result in prompt improvement in symptoms of depression in a majority of patients. The Consortium for Research in ECT (CORE) reported a 75% remission rate among 217 patients who completed a short course of ECT during an acute episode of depression; 65% entered remission by the fourth week of therapy. A systematic review of six trials indicated that the effect size for ECT was 0.91 (significantly more effective than sham ECT), and a review of 18 trials showed that the effect size of ECT was 0.80 (more effective than pharmacotherapy). (Lancet, 2003, UK ECT Review Group.) top Morning Report Questions Q: What are the side effects of electroconvulsive therapy (ECT) for depression? A: Retrograde amnesia is the most common persistent adverse effect of ECT. Shortly after ECT, most patients have gaps in the memory of events that occurred before the treatment, and retrograde amnesia may extend back several months or years. The memory of autobiographical information is less often affected by ECT than the memory of events of an impersonal nature. Although retrograde amnesia frequently improves during the first few months after ECT, many patients do not completely recover and have prolonged amnesia regarding events that occurred close to the time of treatment. Other side effects of ECT include headache, muscle aches, nausea, and fatigue. Despite concerns about structural brain injury in ECT, studies in both humans and nonhuman primates have not shown evidence of anatomical damage. Q: What is the lifetime risk of suicide among patients with affective disorders? A: Severe depression can impair the quality of life and lead to death by suicide; the lifetime risk of suicide among patients with affective disorders is 6 to 15%. Severe depression also increases the mortality associated with general medical conditions — most notably, heart disease. top TEACHING TOPIC 3. Duration of Humoral Immunity ORIGINAL ARTICLE, Duration of Humoral Immunity to Common Viral and Vaccine Antigens, I.J. Amanna, N.E. Carlson, and M.K. Slifka, Abstract | Full Text | PDF | PPT Slide Set In this study, researchers performed a longitudinal analysis of antibody titers specific to viral antigens (vaccinia, measles, mumps, rubella, varicella–zoster virus, and Epstein–Barr virus) and nonreplicating antigens (tetanus and diphtheria) in 45 subjects for a period of up to 26 years. The authors determined that antigen-specific antibody responses were measurably boosted through environmental exposure, infection, or vaccination (where it was applicable). The authors observed that antibodies to vaccinia, measles, and mumps were long-lived (estimated half-lives, 50 years), while antibodies against tetanus and diphtheria were shorter-lived (estimated half-lives, 11 and 19 years, respectively). For other results, see table below. Table 2. Duration of Antigen-Specific Serum Antibody Production. top Clinical Pearls  Chronic Viral Infections In contrast to acute viral infections, chronic and latent viral infections may either persist or be reactivated from latency, thereby "boosting" immune responses in the infected person. Unlike antibody responses to Epstein–Barr virus, antibody response to varicella–zoster virus showed frequent fluctuations in this study by Amanna and colleagues. Two subjects described an episode of shingles at or near the time of an observed spike in antibody responses to varicella–zoster virus, one subject may have been exposed to recently vaccinated children. Varicella–zoster virus induced the most short-lived antibody response of the viruses these authors examined. Humoral immunity to infection with Epstein–Barr virus showed no significant decrease and is likely to be maintained for life.  Memory B-Cells and Antibody Titers In this study by Amanna and colleagues, in cases in which multiple exposures or repeated vaccinations were common, memory B-cell numbers did not correlate with antibody titers. The authors believe this suggests that peripheral memory B cells and antibody-secreting plasma cells may represent independently regulated cell populations and may play different roles in the maintenance of protective immunity. top Morning Report Questions Q: Is humoral immunity generally longer after vaccination or natural infection? A: It is unknown whether vaccine-induced immunity is as long-lived as that induced by natural infection. Although the titers of vaccine-induced antibody responses appear to be lower than those reached after natural infection, a longitudinal analysis of immunity against measles, mumps, and rubella suggests that serologic memory may be similar to natural infection. However, according to Amanna and colleagues, this result is based on a very small sample and further studies on antibody maintenance will be required before statistically meaningful comparisons can be made. Q: What triggers memory B cells to divide and differentiate into plasma cells? A: Memory B cells divide and differentiate into plasma cells after stimulation by persistent antigen, reinfection, cross-reactive antigens, or non-antigen-specific polyclonal activation. (One model of antibody maintenance predicts that long-term responses are maintained by non-antigen-specific stimulation, also referred to as "bystander activation" of memory B cells during antigenically unrelated infections.) top

	IMAGES IN CLINICAL MEDICINE				IMAGE CHALLENGE
	Cocaine-Induced Palatal Perforation Get PowerPoint Slide Pulmonary Alveolar Proteinosis Get PowerPoint Slide MORE IMAGES				Question: This 81-year-old woman presented with swelling and pain in the left foot a week after treatment for acute bronchitis. Which one of the following treatments is most likely to have been contributory? Check Your Answer 1. Beta-adrenergic agonist 2. Cephalosporin antibiotic 3. Leukotriene receptor antagonist 4. Guaifenesin expectorant 5. Fluoroquinolone antibiotic ABOUT THE IMAGE CHALLENGE
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	AUDIO				VIDEOS IN CLINICAL MEDICINE
	Listen to this week's Audio Summary Recent Audio Interviews Peter Orszag on the rising cost of health care Senator Charles Grassley on President Bush's veto of the SCHIP reauthorization bill and its implications Jonathan Oberlander on the lessons of the failed Clinton health care plan of 1993 MORE INTERVIEWS				Abscess Incision and Drainage NEW! Chest-Tube Insertion Positive-Pressure Ventilation with a Face Mask and a Bag-Valve Device Pelvic Examination MORE VIDEOS
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