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We describe the case of a 67-year-old African American woman with multiple medical problems who presented with septic shock resulting from Sphingobacterium multivorum bacteraemia. S. multivorum, a Gram-negative bacillus, is ubiquitous in nature and is rarely involved in human infections. However, it is intrinsically resistant to many commonly administered antibiotics and can be a life-threatening microorganism.

Intravenous drug use and sexual practices account for 60% of hepatitis C (HCV) and B (HBV) infection. Disclosing these activities can be embarrassing and reduce risk reporting, blood testing and diagnosis. In diagnosed patients, linkage to care remains a challenge. Audio-computer-assisted survey interview (Audio-CASI) was used to guide HCV and HBV infection testing in urban clinics. Risk reporting, blood testing and serology results were compared to historical controls. A patient navigator (PN) followed up blood test results and provided patients with positive serology linkage to care (LTC). Of 1932 patients surveyed, 574 (30%) were at risk for chronic viral hepatitis. A total of 254 (44.3%) patients were tested, 34 (13.5%) had serology warranting treatment evaluation, and 64% required HBV vaccination. Of 16 patients with infection, seven HCV and three HBV patients started treatment following patient LTC. Of 146 HBV-naive patients, 70 completed vaccination. About 75% and 49% of HCV antibody and HBV surface antigen-positive patients were born between 1945 and 1965. Subsequently, automated HCV testing of patients born between 1945 and 1965 was built into our hospital electronic medical records. Average monthly HCV antibody testing increased from 245 (January-June) to 1187 (July-October). Patient navigator directed LTC for HCV antibody-positive patients was 61.6%. In conclusion, audio-CASI can identify patients at risk for HCV or HBV infection and those in need of HBV vaccination in urban medical clinics. Although blood testing once a patient is identified at risk for infection needs to increase, a PN is useful to provide LTC of newly diagnosed patients.

Objective To assess the prevalence of impairments and evaluate the relationships between impairments, activity limitations and participation restrictions in people affected by leprosy living in The Netherlands. Design A cross-sectional study. Subjects Eighty-two people affected by leprosy living in The Netherlands. Methods A postal questionnaire was performed. Impairments were inventoried with the Total Impairment Score. Activity limitations were assessed with the World Health Organization Disability Schedule II (WHODAS-II) and participation restrictions with the Impact on Participation and Autonomy (IPA) questionnaire. Results A high prevalence of impairments was found (83%), mostly in hands and feet. Activity limitations were substantial, and highest for the WHODAS-II domains "household/work" and "getting around". The severity of impairments correlated significantly with activity limitations. Eye and foot impairments independently contributed to the domains "household/work" and "getting around", explaining 34% and 40% of variance. Poor or very poor participation (IPA) was reported by 13-32% of persons, mostly in the "autonomy outdoors" and "family role" domains. These domains were associated with activity limitations and hand impairments Conclusions People affected by leprosy in The Netherlands encounter limitations in activities and participation restrictions, which are related to the severity of impairments. The high prevalence of disability suggests rehabilitation care should be considered for a substantial proportion of people affected by leprosy.

Conventional techniques, such as plain radiography and bone-scintigraphy, were used in the past to evaluate skeletal changes in patients with leprosy. More recent publications focus on radiological imaging of affected nerves, and involve advanced modalities such as Computed Tomography (CT-scan), Ultrasonography (US), and Magnetic Resonance Imaging (MRI). US and MRI can play an especially important role in the evaluation of nerve involvement in newly diagnosed patients, and also during leprosy reactions. This is important, because when nerve involvement is diagnosed in time, it may be reversible with adequate treatment. Radiological modalities can also play an important role during the followup of patients with leprosy with nerve function impairment. Skeletal and soft-tissue abnormalities occur, even after treatment. The so-called neuropathic foot is a well known consequence. Because of nerve function impairment, there is a constant risk of developing ulcers and subsequent osteomyelitis, or neuro-osteoarthropathy (Charcot foot or tarsal disintegration), which can lead to the amputation of the affected limb. Different radiological modalities can be used during the evaluation and follow-up of patients with leprosy with a neuropathic foot. With this up-to-date review, we highlight the importance and potential role of radiological imaging techniques in leprosy.

OBJECTIVES: An MRI study done in 2000 on 10 leprosy patients with neuropathic feet, without clinical complications such as ulcerations, osteomyelitis or Charcot deformities revealed abnormalities in nine patients, with degradation, interruption of subcutaneous fat and effusion/synovitis, all located in the first metatarsophalangeal (MTP) region. Since these MRI abnormalities may precede clinical complications of the foot, a follow-up study was performed. DESIGN: A new evaluation was based on a clinical examination and an MRI of the same patients who participated in the initial study. RESULTS: Four patients were lost to follow-up. Average follow-up period was 4-6 years. MRI abnormalities in the MTP 1 region in the first study were no longer visible in three patients, but were still present in two patients. In six patients new MRI findings were found, without clinical evidence of ulceration, osteomyelitis or Charcot deformity. No relationship was found between MRI findings in the MTP 1 region at the start of the study and the development of foot ulcers, callus or skin fissures in the MTP 1 region during follow-up. CONCLUSION: MRI findings of interruption and infiltration of the subcutaneous fat in leprosy patients with uncomplicated neuropathic feet do not necessarily have any clinical implication for the development of future foot problems

This paper presents the conceptualization, design and simulation of a hybrid multi-frequency antenna system for Radio Frequency (RF) hyperthermia and Magnetic Resonance Imaging (MRI) applications with ultra-sharp hotspot. Two different bowtie antenna arrays have been designed, simulated and integrated. The first antenna array is designed as an RF coil for MR imaging. It is optimized to generate a highly homogeneous transmit equation field and is intended for 3 T MRI systems. This corresponds to a frequency of 128 MHz. The second array aims to induce heat by accumulating the electromagnetic energy at one location thereby forming a hotspot. The operating frequency of the second system is 600 MHz. The computed homogeneity of the B1+ field generated by the imaging antennas shows similar values compared to a birdcage coil at the same frequency. The size of the hotspot generated by the heating subsystem was 26 × 26 × 93mm3. The heating produced by the MR imaging antennas was negligible, compared to the RF hyperthermia applicator.

Sustained virologic response rates for hepatitis C virus are difficult to achieve in patients infected with human immunodeficiency virus, especially if they have other poor predictors of response. Rates of sustained virologic response for hepatitis C virus genotype 1 in patients with end stage kidney disease are lower than patients with normal renal function. We present the first case report of a co-infected African American man with end stage kidney disease, who was haemodialysis dependant, and an interferon non-responder with advanced liver fibrosis, who achieved sustained virologic response on a telaprevir-based regimen.

Not only plantar pressure but also weight-bearing activity affects accumulated mechanical stress to the foot and may be related to foot ulceration. To date, activity has not been accounted for in leprosy. The purpose was to compare barefoot pressure, in-shoe pressure and daily cumulative stress between persons affected by leprosy with and without previous or current foot ulceration. Nine persons with current plantar ulceration were compared to 15 with previous and 15 without previous ulceration. Barefoot peak pressure (EMED-X), in-shoe peak pressure (Pedar-X) and daily cumulative stress (in-shoe forefoot pressure time integral×mean daily strides (Stepwatch™ Activity Monitor)) were measured. Barefoot peak pressure was increased in persons with current and previous compared to no previous foot ulceration (mean±SD=888±222 and 763±335 vs 465±262kPa, p

Diabetic peripheral neuropathy can cause changes in foot structures and function as well as gait abnormalities, which subsequently can lead to abnormal mechanical loading of the foot. Foot deformities, such as prominent MTHs, clawed toes and Charcot neuroarthropathy, are strongly associated with and predictive of increased plantar pressure and foot ulceration. Limited joint mobility of the foot and ankle has also been suggested to increase foot pressure and to be related to foot ulceration. Additionally, changes in quantity and quality of plantar subcutaneous fat cushioning are indicators of abnormal foot loading during walking, thereby causing high plantar foot pressure. Excessive and/or repetitive pressure applied to the plantar surface of the foot appears to be the main causative factor for development of skin breakdown. However, often, it is the combination of footwear characteristics, lifestyle factors, soft tissue characteristics, plantar foot pressures and level of physical activity that contribute to the development of foot ulceration.

Objective: To explore the relationships between perceived limitations in walking-related daily activities, walking ability (capacity), and the amount of daily walking (performance) in persons affected by leprosy and to identify their determinants. Design: A cross-sectional study. Subjects: Thirty-nine persons affected by leprosy. Methods: Perceived limitations were assessed with the World Health Organization Disability Schedule 11, domain "getting around". Walking capacity was assessed as covered distance in 6 min. Walking performance was recorded as mean strides/day with the Stepwatch(TM) 3 Activity Monitor. Potential determinants were sensory function, foot deformities, joint mobility, ankle muscle strength and co-morbidity. Results: Perceived limitations in walking-related activities were significantly correlated with walking capacity (r=-0.47; p < 0.01) but not with walking performance, although walking capacity significantly correlated with walking performance (r=0.38; p < 0.05). Various foot impairments independently contributed to reduced walking capacity and, to a lower degree, to perceived limitations in activities and performance. Conclusion: People affected by leprosy perceive limitations in walking-related activities that are determined by a reduced walking ability and the severity of foot impairments. Since perceived limitations in walking-related activities were not related to walking performance, perceived limitations are apparently weighted against the individual's needs

Charcot neuro-osteoarthropathy is a significant problem with a rapid devastating nature. If not recognized it may lead to progressive foot deformity, ulceration or osteomyelitis, or eventually to amputation. The diagnosis is challenging, and imaging plays a pivotal role. Rapid and accurate diagnosis and early intervention is important to prevent progressive and destructive Charcot deformity of the foot. The imaging workup of the warm swollen Charcot foot is presented. The advantages and disadvantages of different imaging modalities are discussed. This review provides the consulting radiologists with tools to cautiously differentiate Charcot's neuro-osteoarthropathy from osteomyelitis. It is crucial to look beyond radiological features and integrate the location of pathology and presence of ulcer in the reading process. Because imaging plays a pivotal role in arriving at the definitive diagnosis and adequate treatment, the radiologist "makes the difference"-can be a friend or a foe.

A magnetic resonance imaging (MRI) protocol was performed in leprosy patients with a neuropathic foot and superficial ulcers and/or localized cellulitis but no clinical suspicion of osteomyelitis. The aim of the study was to determine if unsuspected osteomyelitis was present in this defined group of leprosy patients. A total of 15 neuropathic feet from 9 patients were included. Clinically and on MRI, the forefoot was predominantly affected. MRI findings of osteomyelitis were found in 4 feet. In feet with osteomyelitis, 3 had a superficial ulcer and 3 had clinical signs of localized cellulitis. A clinical diagnosis of cellulitis was confirmed on MRI in 2 feet.A striking discrepancy between clinical and MRI findings was found.This study shows that, compared with clinical evaluation, MRI is a sensitive method for the detection of unsuspected osteomyelitis in neuropathic feet with superficial ulcers and/or cellulitis. MRI findings in this group of patients may influence clinical decision making and may prevent further complications, because osteomyelitis requires more aggressive medical treatment. This preliminary communication should pave the wave for designed controlled studies so that patients with Hansen’s neuropathy may get the best medical care.

Case report.To examine the unusual and unknown, severe side effect of a therapeutic dose of oral Baclofen on cardiac function.Spinal Cord Unit, Rehabilitation Centre Amsterdam, Amsterdam, The Netherlands.Review of relevant literature.A 53-year-old patient with an incomplete C2 tetrapareses (ASIA B) developed severe and painful muscle spasms together with respiratory failure and autonomic dysreflexia. Spasmolytic treatment was started. After the first admission of 5 mg of oral Baclofen, he collapsed in bed with extreme bradycardia, hypotension, hyperventilation and decreased oxygen saturation. A second dosage of 5 mg Baclofen resulted in the same complications. After implantation of a pacemaker, restarting oral Baclofen induced a pacemaker rhythm with episode of hypotension and respiratory failure and also a delirium. Intrathecal Baclofen also resulted in a pacemaker rhythm with hypotension and a decreased cardiac output. To our knowledge, this is the first time a severe heart conduction problem was induced in a spinal cord injury patient after a single therapeutic dose of Baclofen.In this case therapeutic oral Baclofen has caused serious cardiac conduction problems.

SUMMARY. 1. The filtration rate of Dreissena polymorpha Pallas measured in the field in three shallow Dutch lakes shows an inverse exponential relationship with the dry matter content of the water. 2. Temperature seems to set only a gross level to the filtration rate in summer and winter season respectively; within a season no clear relation between the filtration rate and temperature exists. 3. Under laboratory conditions the risk of measuring abnormal behaviour of Dreissena polymorpha is shown to be substantial; hence field-measurements of the filtration rate are preferable. 4. The clearing capacity of the Dreissena polymorpha populations in Lakes IJsselmeer and Markermeer is sufficient to filter both lakes at least once or twice a month. This indicates the potential importance of this species for restoration of turbid, eutrophic lakes by means of biomanipulation.