Absence of Epstein-Barr virus in the brain and CSF of patients with multiple sclerosis

OBJECTIVE

Epstein-Barr virus (EBV) is a ubiquitous human herpesvirus that becomes latent in B-lymphocytes and has been implicated in the pathogenesis of multiple sclerosis (MS). We searched for latent and active EBV infection in MS brain and CSF.

METHODS

Nested and non-nested real-time PCR were used to detect cell-specific and EBV-specific transcripts in 15 fresh-frozen and 5 formalin-fixed paraffin-embedded MS plaques and in single MS CSF B-lymphocytes and plasma cells. Intrathecal anti-EBV antibody synthesis was measured by ELISA. Immunocytochemistry was used to detect binding of MS CSF and recombinant antibodies (rAbs) generated from clonally expanded plasma cells in MS CSF to EBV-infected cells.

RESULTS

No EBV RNA was found in MS CSF B-lymphocytes or plasma cells. In active MS plaques, EBV-encoded RNA (EBER)-1 was the only and rarely detected transcript. The frequency of detected intrathecal anti-EBV antibody synthesis in patients with MS did not differ from that in non-MS inflammatory CNS disease control patients. Anti-EBV antibodies were detected in the CSF of patients with MS, but MS rAbs did not react with EBV.

CONCLUSIONS

Application of real-time PCR to multiple sclerosis brain and single B-lymphocytes in CSF did not reveal any evidence of active Epstein-Barr virus infection.

Fatal human rabies caused by European bat Lyssavirus type 2a infection in Scotland

We wish to report the first recorded case of indigenous human rabies caused by a bat bite in the United Kingdom in 100 years. This instructive case report highlights a number of key lessons: first, bites from insectivorous bats indiginous to the United Kingdom can cause rabies in humans; second, rabies immunization is essential for bat-handlers, and postexposure treatment for rabies is essential for patients bitten by bats; third, patients able to give a history who present with acute flaccid paralysis and/or presumptive viral encephalitis should be asked if they have been bitten by bats, irrespective of travel history, or this history should be obtained from family or friends; fourth, antemortem diagnosis of bat rabies (EBLV type 2a infection) in humans is possible using RT-PCR.

Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit

BACKGROUND

Few studies have examined mortality rates in relation to the workload of hospital staff. We investigated this issue in one adult intensive-care unit (ICU) in the UK.

METHODS

We measured ICU workload per shift during each patient's stay for all admissions between 1992 and 1995 that met criteria for adjustment of mortality risk by the APACHE II equation (n=1050). APACHE II data were validated by one observer. Measures of workload in each patient's stay included occupancy, total ICU nursing requirement as defined by the UK Intensive Care Society, and the ratio of occupied to appropriately staffed beds. Over the period, staffing was appropriate for between 4.1 and 5.3 occupied beds (1.3 nurses per patient).

FINDINGS

There were 337 deaths, 49 more (95% CI 34-65) than predicted by the APACHE II equation. Median occupancy was 5.8 beds, and median nursing requirement was 1.6 per patient. On multiple logistic regression analysis, adjusted mortality was more than two times higher (odds ratio 3.1 [1.9-5.0]) in patients exposed to high than in those exposed to low ICU workload, defined by average nursing requirement per occupied bed and peak occupancy; the unadjusted odds ratio for this comparison was 4.0 (2.6-6.2). After exclusion of measures of nursing requirement, adjusted mortality increased with the ratio of occupied to appropriately staffed beds during each patient's stay. All logistic regression models fitted the data satisfactorily.

INTERPRETATION

Variations in mortality may be partly explained by excess ICU workload. This methodology may have implications for planning and clinical governance.

Why do patients die on general wards after discharge from intensive care units?

The aim of this study was to determine the cause of death of those patients who died on general hospital wards after discharge from an intensive care unit. Of 1700 patients admitted over a 5-year period, 341 (20%) died in intensive care but a further 153 (9%) died on general wards. From data recorded at discharge from intensive care, 54.2% of those who died on the wards were considered at risk of death, 25.5% were expected to die but 20.3% were expected to survive. The main causes of death were pneumonia, hypoxic or structural brain damage, cerebrovascular accident, malignancy, myocardial infarction, renal or multi-organ failure and sepsis. Some of these may have been preventable with further intensive care or improved care on the wards.

Althesin, ketamine and methohexitone at pressure--duration of action of a single i.v. dose

General anaesthesia for emergency surgery in a pressurized habitat is likely to involve the use of i.v. agents. The anaesthetic property of such agents is known to be antagonized by pressure, but the effect on their duration of action is not easily predicted. The recovery of mice from a single i.v. dose of Althesin, ketamine or methohexitone was estimated by their ability to remain upright in a rotating drum. At 35 atm abs. duration of action was significantly reduced: P less than 0.05 for Althesin; P less than 0.01 for ketamine and methohexitone. A number of animals in each group, however, displayed recovery times that were comparable to control. The convulsion rate with methohexitone was 60% at 35 atm abs., whereas at 1 atm abs. it was 20%. The clinical implications of these findings are discussed.