Tension Pneumocephalus: An Uncommon Cause of Altered Mental Status
Published online: 16 April 2012
Joshua Simmons, Andrew M. Luks
Journal of Emergency Medicine, The,
“[A]n 89-year-old man who presented to the Emergency Department with declining mental status 9h after endoscopic sinus surgery. He was subsequently found to have tension pneumocephalus and underwent emergent burr hole evacuation……”
Debt Collector Is Faulted for Tough Tactics in Hospitals
By JESSICA SILVER-GREENBERG
“Hospital patients waiting in an emergency room or convalescing after surgery are being confronted by an unexpected visitor: a debt collector at bedside.
This and other aggressive tactics……. like embedding debt collectors as employees in emergency rooms and demanding that patients pay before receiving treatment, were outlined in hundreds of company documents released by the attorney general. And they cast a spotlight on the increasingly desperate strategies among hospitals to recoup payments as their unpaid debts mount……”
US warns terrorists could avenge bin Laden on anniversary of his death
Last Updated: 5:30 PM, April 26, 2012
Posted: 12:11 AM, April 26, 2012
“…..In an intelligence bulletin issued late Wednesday, the FBI, Department of Homeland Security and US Northern Command note that terrorist groups such as al Shabaab in Somalia, northern Africa’s al Qaeda in the Islamic Maghreb and the Pakistani Taliban have called for revenge against the United States for killing bin Laden during the May 1, 2011 raid on his hideout in Pakistan……”
Statement by USDA Chief Veterinary Officer John Clifford Regarding a Detection of Bovine Spongiform Encephalopathy (BSE) in the United States
Assures Consumers That Existing Safeguards Protected Food Supply; Reiterates Safety of Consuming Beef Products
WASHINGTON, April 24, 2012 – USDA Chief Veterinary Officer John Clifford today released the following statement on the detection of BSE in the United States:
“As part of our targeted surveillance system, the U.S. Department of Agriculture’s (USDA) Animal and Plant Health Inspection Service (APHIS) has confirmed the nation’s fourth case of bovine spongiform encephalopathy (BSE) in a dairy cow from central California. The carcass of the animal is being held under State authority at a rendering facility in California and will be destroyed. It was never presented for slaughter for human consumption, so at no time presented a risk to the food supply or human health. Additionally, milk does not transmit BSE.
“The United States has had longstanding interlocking safeguards to protect human and animal health against BSE. For public health, these measures include the USDA ban on specified risk materials, or SRMs, from the food supply. SRMs are parts of the animal that are most likely to contain the BSE agent if it is present in an animal. USDA also bans all nonambulatory (sometimes called “downer”) cattle from entering the human food chain. For animal health, the Food and Drug Administration (FDA) ban on ruminant material in cattle feed prevents the spread of the disease in the cattle herd.
“Evidence shows that our systems and safeguards to prevent BSE are working, as are similar actions taken by countries around the world. In 2011, there were only 29 worldwide cases of BSE, a dramatic decline and 99% reduction since the peak in 1992 of 37,311 cases. This is directly attributable to the impact and effectiveness of feed bans as a primary control measure for the disease.
“Samples from the animal in question were tested at USDA’s National Veterinary Services Laboratories in Ames, Iowa. Confirmatory results using immunohistochemistry and western blot tests confirmed the animal was positive for atypical BSE, a very rare form of the disease not generally associated with an animal consuming infected feed.
“We are sharing our laboratory results with international animal health reference laboratories in Canada and England, which have official World Animal Health (OIE) reference labs. These labs have extensive experience diagnosing atypical BSE and will review our confirmation of this form of the disease. In addition, we will be conducting a comprehensive epidemiological investigation in conjunction with California animal and public health officials and the FDA.
“BSE is a progressive neurological disease among cattle that is always fatal. It belongs to a family of diseases known as transmissible spongiform encephalopathies. Affected animals may display nervousness or aggression, abnormal posture, difficulty in coordination and rising, decreased milk production, or loss of body weight despite continued appetite.
“This detection in no way affects the United States’ BSE status as determined by the OIE. The United States has in place all of the elements of a system that OIE has determined ensures that beef and beef products are safe for human consumption: a mammalian feed ban, removal of specified risk materials, and vigorous surveillance. Consequently, this detection should not affect U.S. trade.
“USDA remains confident in the health of the national herd and the safety of beef and dairy products. As the epidemiological investigation progresses, USDA will continue to communicate findings in a timely and transparent manner.”
Statement by U.S. Agriculture Secretary Tom Vilsack Regarding a Detection of Bovine Spongiform Encephalopathy (BSE) in the United States
“The beef and dairy in the American food supply is safe and USDA remains confident in the health of U.S. cattle. The systems and safeguards in place to protect animal and human health worked as planned to identify this case quickly, and will ensure that it presents no risk to the food supply or to human health. USDA has no reason to believe that any other U.S. animals are currently affected, but we will remain vigilant and committed to the safeguards in place.”Please visit www.USDA.gov/BSE to learn more about BSE and to find updates as USDA continues to investigate this incident and share information as it becomes available. Video of an interview with USDA’s Chief Veterinary Officer John Clifford on the BSE case is available HERE.
Lassa virus electron micrograph. Image courtesy, C.S. Goldsmith and M. Bowen (CDC).
Lassa fever is an acute viral illness that occurs in West Africa. The illness was discovered in 1969 when two missionary nurses died in Nigeria, West Africa. The cause of the illness was found to be Lassa virus, named after the town in Nigeria where the first cases originated. The virus, a member of the virus family Arenaviridae, is a single-stranded RNA virus and is zoonotic, or animal-borne.
In areas of Africa where the disease is endemic (that is, constantly present), Lassa fever is a significant cause of morbidity and mortality. While Lassa fever is mild or has no observable symptoms in about 80% of people infected with the virus, the remaining 20% have a severe multisystem disease. Lassa fever is also associated with occasional epidemics, during which the case-fatality rate can reach 50%.
Where is Lassa fever found?
Lassa fever is an endemic disease in portions of West Africa. It is recognized in Guinea, Liberia, Sierra Leone, as well as Nigeria. However, because the rodent species which carry the virus are found throughout West Africa, the actual geographic range of the disease may extend to other countries in the region.
How many people become infected?
The number of Lassa virus infections per year in West Africa is estimated at 100,000 to 300,000, with approximately 5,000 deaths. Unfortunately, such estimates are crude, because surveillance for cases of the disease is not uniformly performed. In some areas of Sierra Leone and Liberia, it is known that 10%-16% of people admitted to hospitals have Lassa fever, which indicates the serious impact of the disease on the population of this region.
In what animal host is Lassa virus maintained?
Mastomys rodent, also known as the “multimammate rat”. Note the hairless tail.
The reservoir, or host, of Lassa virus is a rodent known as the “multimammate rat” of the genus Mastomys. It is not certain which species of Mastomys are associated with Lassa; however, at least two species carry the virus in Sierra Leone. Mastomys rodents breed very frequently, produce large numbers of offspring, and are numerous in the savannas and forests of West, Central, and East Africa. In addition, Mastomys generally readily colonize human homes. All these factors together contribute to the relatively efficient spread of Lassa virus from infected rodents to humans.
How do humans get Lassa fever?
There are a number of ways in which the virus may be transmitted, or spread, to humans. The Mastomys rodents shed the virus in urine and droppings. Therefore, the virus can be transmitted through direct contact with these materials, through touching objects or eating food contaminated with these materials, or through cuts or sores. Because Mastomys rodents often live in and around homes and scavenge on human food remains or poorly stored food, transmission of this sort is common. Contact with the virus also may occur when a person inhales tiny particles in the air contaminated with rodent excretions. This is called aerosol or airborne transmission. Finally, because Mastomys rodents are sometimes consumed as a food source, infection may occur via direct contact when they are caught and prepared for food.
Lassa fever may also spread through person-to-person contact. This type of transmission occurs when a person comes into contact with virus in the blood, tissue, secretions, or excretions of an individual infected with the Lassa virus. The virus cannot be spread through casual contact (including skin-to-skin contact without exchange of body fluids). Person-to-person transmission is common in both village and health care settings, where, along with the above-mentioned modes of transmission, the virus also may be spread in contaminated medical equipment, such as reused needles (this is called nosocomial transmission).
What are the symptoms of Lassa fever?
Signs and symptoms of Lassa fever typically occur 1-3 weeks after the patient comes into contact with the virus. These include fever, retrosternal pain (pain behind the chest wall), sore throat, back pain, cough, abdominal pain, vomiting, diarrhea, conjunctivitis, facial swelling, proteinuria (protein in the urine), and mucosal bleeding. Neurological problems have also been described, including hearing loss, tremors, and encephalitis. Because the symptoms of Lassa fever are so varied and nonspecific, clinical diagnosis is often difficult.
How is the disease diagnosed in the laboratory?
Lassa fever is most often diagnosed by using enzyme-linked immunosorbent serologic assays (ELISA), which detect IgM and IgG antibodies as well as Lassa antigen. The virus itself may be cultured in 7 to 10 days. Immunohistochemistry performed on tissue specimens can be used to make a post-mortem diagnosis. The virus can also be detected by reverse transcription-polymerase chain reaction (RT-PCR); however, this method is primarily a research tool.
Are there complications after recovery?
The most common complication of Lassa fever is deafness. Various degrees of deafness occur in approximately one-third of cases, and in many cases hearing loss is permanent. As far as is known, severity of the disease does not affect this complication: deafness may develop in mild as well as in severe cases. Spontaneous abortion is another serious complication.
What proportion of people die from the illness?
Approximately 15%-20% of patients hospitalized for Lassa fever die from the illness. However, overall only about 1% of infections with Lassa virus result in death. The death rates are particularly high for women in the third trimester of pregnancy, and for fetuses, about 95% of which die in the uterus of infected pregnant mothers.
How is Lassa fever treated?
Ribavirin, an antiviral drug, has been used with success in Lassa fever patients. It has been shown to be most effective when given early in the course of the illness. Patients should also receive supportive care consisting of maintenance of appropriate fluid and electrolyte balance, oxygenation and blood pressure, as well as treatment of any other complicating infections.
What groups are at risk for getting the illness?
Individuals at risk are those who live or visit areas with a high population of Mastomys rodents infected with Lassa virus or are exposed to infected humans. Hospital staff are not at great risk for infection as long as protective measures are taken.
How is Lassa fever prevented?
Wearing protective clothing — an important part of practicing barrier nursing methods.
Primary transmission of the Lassa virus from its host to humans can be prevented by avoiding contact with Mastomys rodents, especially in the geographic regions where outbreaks occur. Putting food away in rodent-proof containers and keeping the home clean help to discourage rodents from entering homes. Using these rodents as a food source is not recommended. Trapping in and around homes can help reduce rodent populations. However, the wide distribution of Mastomys in Africa makes complete control of this rodent reservoir impractical.
When caring for patients with Lassa fever, further transmission of the disease through person-to-person contact or nosocomial routes can be avoided by taking preventive precautions against contact with patient secretions (together called VHF isolation precautions or barrier nursing methods). Such precautions include wearing protective clothing, such as masks, gloves, gowns, and goggles; using infection control measures, such as complete equipment sterilization; and isolating infected patients from contact with unprotected persons until the disease has run its course.
What needs to be done to address the threat of Lassa fever?
Further educating people in high-risk areas about ways to decrease rodent populations in their homes will aid in the control and prevention of Lassa fever. Other challenges include developing more rapid diagnostic tests and increasing the availability of the only known drug treatment, ribavirin. Research is presently under way to develop a vaccine for Lassa fever.
This information is current as of today, April 25, 2012 at 17:35 EDT
Released: April 25, 2012
What Is the Current Situation?
The Nigerian Federal Ministry of Health has reported an increased number of cases of Lassa fever. Nineteen of the country’s 36 states have reported cases since the beginning of 2012. As of April 13, 2012, there were reports of 818 suspected cases, including 84 deaths. At this time, 131 cases have been confirmed by laboratory testing. Seven deaths have also been reported among health care workers. Cases have occurred in the states of Edo, Bauchi, Plateau and Taraba. The number of reported cases of Lassa fever in Nigeria is greater this year than in previous years. However, cases in previous years could have been underestimated due to the lack of laboratory and disease investigation systems.
The Nigerian government is responding to the outbreak by improving the disease investigation, treatment of patients, and conducting awareness campaigns among affected populations. Security and availability of resources are proving to be a major challenge. WHO does not advise or recommend any restrictions on travel or trade with Nigeria.
What Is Lassa Fever?
Lassa fever is a viral illness that is spread by rats. People get the disease through direct contact with rat droppings or urine and through touching objects or eating food contaminated with rat droppings or urine. Lassa fever may also spread though person-to-person contact. This happens when a person comes into contact with an infected person’s blood, tissue, or body fluids. The symptoms include fever, pain behind the chest, sore throat, back pain, cough, abdominal pain, vomiting, diarrhea , and bleeding from the mouth or nose. People with Lassa fever may also experience hearing loss, tremors, swelling of the face and eyelids, and swelling of the brain. Pregnant women with Lassa fever often have bleeding from the genitals and miscarriage and may die from the illness.
Lassa fever is seen in West Africa. Cases have been documented in Guinea, Liberia, Sierra Leone, and Nigeria. However, the rats that spread Lassa fever also live in other countries in Africa. The number of Lassa virus infections per year in West Africa is estimated at 100,000 to 300,000, with approximately 5,000 deaths. These numbers are estimates because cases are not investigated everywhere. In some areas of Sierra Leone and Liberia, 10%-16% of people admitted to hospitals have Lassa fever, which indicates the serious impact of the disease on the population of this region. Lassa fever can occur all year long, but most cases occur from January to May.
How Can Travelers Protect Themselves?
Avoid contact with rats, especially rat urine and feces.
Put food away in rodent-proof containers.
Keep the home clean and rodent proof.
Trap rats in and around homes.
Do not eat rats.
Stay away from germs:
Wash hands well and often with soap, and teach children to wash their hands, too.
Do not share eating or drinking utensils.
Clean surfaces that are frequently touched (such as toys, doorknobs, tables, and counters) regularly with soap and water or with cleaning wipes.
Avoid close contact with sick people.
Seek Medical Care:
If you have traveled to the area and develop symptoms of fever, headache, sore throat, muscle pain, chest pain, nausea, vomiting, diarrhea, and abdominal pain, see a doctor or healthcare provider right away. Be sure to tell your doctor or healthcare provider that you have recently traveled to Nigeria.
Lassa fever is most often diagnosed by using reverse transcription-polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent serologic assays (ELISA), which detect IgM and IgG antibodies as well as Lassa antigen. The virus itself may be cultured in 7 to 10 days. Immunohistochemistry performed on tissue specimens can be used to make a post-mortem diagnosis.
Ribavirin, an antiviral drug, has been used with success in Lassa fever patients. It has been shown to be most effective when given early in the course of the illness. Patients should also receive supportive care consisting of maintenance of fluid and electrolyte balance, oxygenation, and blood pressure, as well as treatment of any other complicating infections.
“Pittsburgh paramedics have set a city record for the resuscitation of patients in cardiac arrest, and now officials are weighing strategies for further boosting the survival rate.
Mayor Luke Ravenstahl said one possibility is encouraging bystanders to start CPR before rescue workers arrive at a call, something believed to have helped Seattle post high resuscitation rates.
For the 12-month period that ended Sept. 30, city paramedics responded to more than 300 calls for patients whose hearts had stopped beating. In 16.4 percent of those cases, the patients were resuscitated and ultimately discharged from the hospital…”