Wayne L. Gold

Herpes zoster, caused by varicella zoster virus, most commonly presents as a unilateral dermatomal, vesicular eruption. A sensory prodrome, ranging from minor tingling to severe pain, precedes the rash by 1–5 days.1^,2 Typically, the rash involves a single dermatome and does not cross the midline. The presence of the characteristic rash (Figure 1) is sufficient to allow for clinical diagnosis.1^,2

Prospective analysis of 301 adults who had clinically suspected meningitis found that those most likely to have abnormal computed tomography (CT) scans were 60 years or older, were immunocompromised, had a prior history of neurologic disease or had new-onset seizure, papilledema, focal neurologic deficits or abnormalities on neurologic examination, including altered level of consciousness.² The absence of these findings had a 97% negative predictive value for identifying patients with normal CT scans of the brain. In patients without any of these findings, the Infectious Diseases Society of America recommends proceeding to immediate lumbar puncture without prior CT, provided there are no other contraindications.²

In-hospital mortality associated with community-acquired pneumonia is comparable to that with acute myocardial infarction.¹ Patients with suspected community-acquired pneumonia require urgent assessment and therapy; however, overemphasis on time to first dose of antibiotics may lead to unnecessary administration of antibiotics for noninfectious diseases.² Because of a lack of convincing evidence, guidelines no longer specify a four-hour window for starting antibiotics for patients who require admission to hospital but instead recommend that the first dose be given in the emergency department.^2,3

A 64-year-old man presented with a three-week history of a tender suprapubic mass. His medical history included superficial (stage T1) transitional cell carcinoma of the bladder for which he had undergone transurethral resection of the tumour 10 months earlier. At the time of surgery, he had

An 80-year-old man presented with a one-week history of constant epigastric pain and left-sided exertional chest pain. On the day of presentation, he had experienced four episodes of nonbilious vomiting, but had no other gastrointestinal symptoms. He did not report fever, chills or sweats. There was

Tongue piercing has become an increasingly popular form of body art. However, this procedure can occasionally be complicated by serious bacterial infections. The present article reports a case of prosthetic valve endocarditis caused by a Gemella species in a patient with a pierced tongue, and reviews 18 additional cases of local and systemic bacterial infections associated with tongue piercing. Infections localized to the oral cavity and head and neck region included molar abscess, glossal abscess, glossitis, submandibular lymphadenitis, submandibular sialadenitis, Ludwig’s angina and cephalic tetanus. Infections distal to the piercing site included eight cases of infective endocarditis, one case of chorioamnionitis and one case of cerebellar abscess. Oropharyngeal flora were isolated from all cases. While bacterial infections following tongue piercing are rare, there are reports of potentially life‐threatening infections associated with the procedure. Both piercers and their clients should be aware of these potential complications, and standardized infection prevention and control practices should be adopted by piercers to reduce the risk.

Background. The clinical presentation of severe acute respiratory syndrome (SARS) resembles that of other etiologies of community-acquired pneumonia,

During the recent global outbreak of severe acute respiratory syndrome (SARS), thousands of patients received treatments of uncertain efficacy and known toxicity such as ribavirin and corticosteroids. Despite this, no controlled clinical trials assessing the efficacy of these agents were conducted. If a second global SARS outbreak occurred, clinicians would not have controlled data on which to base therapeutic decisions. We discuss the unique methodologic and logistical challenges faced by researchers who attempt to conduct controlled trials of therapeutic agents during an outbreak of a novel or unknown infectious pathogen. We draw upon our own experience in attempting to conduct a randomized controlled trial (trial) of ribavirin therapy for SARS and discuss the lessons learned. Strategies to facilitate future clinical trials during outbreaks of unknown or novel pathogens are also presented.

OBJECTIVE. This study was performed to evaluate the prognostic significance of the radiographic pattern of disease in probable cases of severe acute respiratory syndrome (SARS). MATERIALS AND METHODS. A retrospective review of 439 radiographs was performed for 51 patients with a final diagnosis of probable SARS. Forty-nine patients were followed up for a mean interval of 23 days (range, 2–63 days). RESULTS. Abnormal findings on a chest radiograph were noted at presentation in 80.4% (41/51) of patients. Four radiographic patterns were seen: normal (group 1) in 19.6% (10/51), focal opacity (group 2) in 39.2% (20/51), multifocal opacities (group 3) in 27.5% (14/51), and diffuse air-space opacification (group 4) in 13.7% (7/51). Radiographic progression of disease occurred in 38.8% (19/49) of the patients in groups 1–4. There were no deaths in groups 1 and 2. In group 3, one (7.7%) of the 13 patients died. Five (71.4%) of the seven patients in group 4 died. Overall, 12.2% (6/49) of the patients died, all of whom had diffuse air-space opacification on the last chest radiograph. In these patients, medical comorbidity was present in 66.7% (4/6), and the exposure history was known in 83.3% (5/6). Death occurred at a mean interval of 18.2 days (range, 9–36 days) from the initial exposure. CONCLUSION. Patients presenting with normal findings or focal air-space opacity on chest radiographs had a good clinical outcome. Patients with multifocal opacities that progressed to diffuse air-space opacification and patients presenting with diffuse air-space opacification had a high fatality rate, but patients in this group were also older and more likely to have comorbid conditions. Patients with SARS present with recognizable patterns of disease that have prognostic significance.

Whether medical school faculty should be provided with assessments of students made by previous teachers remains controversial. To document which schools have implemented policies that address this issue and to characterize the specific features of these policies, in 1998 the authors conducted a direct mail survey of deans of student affairs and medical education at 144 medical schools in the United States, Canada, and Puerto Rico. Replies were received from 129 (90%) of the 144 medical schools. Of those schools, 72 (56%) reported having policies that address this issue. The policies permit the sharing of information in 38 (53%) of the 72 schools that had policies; therefore, at the time of this study, 29% of the 129 medical schools that responded to the survey had a policy that permits the sharing of assessment information. The policies permit the sharing of information related to problems with academic performance (35%), professional conduct (35%), physical health (25%), and miscellaneous circumstances, such as learning disability (5%). Information may be shared with clerkship coordinators (44%), course directors (35%), faculty mentors (11%), clinical faculty supervisors (8%), and resident supervisors (3%). The findings show that there is considerable diversity in the format and content of policies that address the issue of whether medical school faculty should be provided with information about students' assessments made by previous teachers. The authors explain why policies that require the provision of such information are helpful to medical school faculty, and offer recommendations based on the survey findings.