Dengue or Kokobera? A case report from the top end of the Northern Territory

In early April 1998, the Centre for Disease Control in Darwin was notified of a possible case of dengue which appeared to have been acquired in the Northern Territory. Because dengue is not endemic to the Northern Territory, locally acquired infection has significant public health implications, particularly for vector identification and control to limit the spread of infection. Dengue IgM serology was positive on two occasions, but the illness was eventually presumptively identified as Kokobera infection. This case illustrates the complexity of interpreting flavivirus serology. Determining the cause of infection requires consideration of the clinical illness, the incubation period, the laboratory results and vector presence. Waiting for confirmation of results, before the institution of the public health measures necessary for a true case of dengue, was ultimately justified in this case. This is a valid approach in the Northern Territory, but may not be applicable to areas of Australia with established vectors for dengue. Commun Dis Intell 1998;22:105-107.

Engaging paramedic students in research: A case report

The use of volunteer undergraduate students to support simulated training for peers is common in Paramedic Science. However, there are limited examples of engaging paramedic student-volunteers in research as compared to that reported in cognate disciplines such as Medicine and Nursing. This case report shares our experience with engaging a penultimate year paramedic student in evaluation research. This information we hope will start the dialogue on the epistemology and pedagogies for effective engagement of undergraduate paramedic students as future researchers.

Making sense of inconsistencies in psycho-educational assessment: A case report

The case is presented of an 8-year-old young boy who was referred for psycho-educational assessment because of difficulties with writing. The paper provides an example of the way in which a case unfolds as further assessment data become available, and describes a number of challenging aspects of the assessment process. In this case, dilemmas arose when test results were inconsistent at different time points, and when the results were inconsistent with clinical observations. The case report illustrates the ways in which practitioners can collaborate to make sense of such discrepancies, with each contributing a slightly different perspective or set of skills that, in combination, assist to better understand a child’s difficulties.

Dapsone-induced agranulocytosis. The role of xenobiotic-metabolizing enzymes demonstrated by a case report [Dapson-induzierte Agranulozytose]

A 34-year-old female patient with a three year history of generalized granuloma annulare was treated systemically with dapsone (DADPS). Six weeks after the onset of treatment, the patient developed an extensive tonsillitis of the base of the tongue with fever and malaise. Routine laboratory work showed a leukocytopenia with agranulocytosis. Further investigation revealed a marked decrease of the enzyme activity of N-acetyltransferase 2, which plays an important role in dapsone metabolism. Treatment included the cessation of dapsone, antibiotic coverage, and G-CSF leading to the rapid improvement of symptoms and normalization of leukocyte counts. Dapsone-induced angina agranulocytotica is a rare event and is interpreted as an idiosyncratic reaction. Depending on genetic polymorphisms of various enzymes, dapsone can be metabolized to immunologically or toxicologically relevant intermediates. Because of the risk of severe hematologic reactions, dapsone should only be employed for solid indications and with appropriate monitoring. [Article in German]

Smell and taste dysfunction following minor stroke: A case report

Smell (olfactory) and taste (gustatory) are key senses in the regulation of nourishment and individual safety. Olfactory and gustatory dysfunctions have been infrequently reported together in patients following stroke (Landis et al., 2006; Leopold et al., 2006). This case report details two patients who experienced smell and taste dysfunction following minor stroke events. Symptoms reported included hyposmia (diminished sense of smell) and anosmia (complete loss of smell), and dysgeusia (distorted taste). Patients' sense of smell and taste were assessed in an ambulatory care stroke prevention clinic eight months following their strokes. Patient A presented with minor stroke due to a lesion in the anterior circulation, patient B with a lesion in the posterior circulation. Both patients reported intense olfactory and gustatory dysfunction immediately following their strokes. Examination revealed a general inability to detect subtle odours and the ability to identify only 'sweet' tastes for both patients. In addition, both patients reported heavily salting or sweetening their food to mask the distorted and unpleasant taste, which also impacted comorbid conditions such as hypertension and diabetes. Patients and their spouses reported a decrease in their appreciation of family-related activities due to the patients' olfactory and gustatory dysfunction. Patients reported weight loss, lack of energy and strength, likely due to poor nutrition. Olfactory and gustatory dysfunctions are potentially deleterious outcomes following minor stroke and should be assessed by health care professionals prior to patient discharge. Assistance may be required to promote the health and well-being of patients and their carers if smell and taste are impacted by the stroke event.

Editorial: Structure of the case report

The CJNN is one of only two international nursing journals with a focus on neuroscience nursing. We at CJNN (the editorial staff and CANN board of directors) have had to make the difficult decision to reduce publication frequency from quarterly (four times per year) down to three editions per year. The reason behind this decision relates to the current lack of submitted articles for peer review and potential publication in the journal; it is difficult to put out a quality edition with only one or two new manuscripts. We would like to encourage Canadian neuroscience nurses to share their insights and expertise with colleagues by writing about challenges and achievements in patient care, experiences encountered on a daily basis, or about unique/interesting cases that may inform others in their practice.

Non-invasive MR imaging of inflammation in a patient with both asymptomatic carotid atheroma and an abdominal aortic aneurysm: A case report

Inflammation is a recognized risk factor for the vulnerable atherosclerotic plaque. USPIO-enhanced MRI imaging is a promising non-i nvasive method to identify high-risk atheromatous plaque inflammation in vivo in humans, in which areas of focal signal loss on MR images have been shown to correspond to the location of activated macrophages, typically at the shoulder regions of the plaque. This is the first report in humans describing simultaneous USPIO uptake within atheroma in two different arterial territories and again emphasises that atherosclerosis is a truly systemic disease. With further work, USPIO-enhanced MR imaging may be useful in identifying inflamed vulnerable atheromatous plaques in vivo, so refining patient selection for intervention and allowing appropriate early aggressive pharmacotherapy to prevent plaque rupture.

Multi-victim sexual assault : a case study in rural Australia

Objective: There is a paucity of information regarding cases of multi-victim sexual assault of children. The reported incidence suggests that these cases are rare. The aim of this paper is to provide practitioners with information about effective intervention strategies arising out of the direct experience of managing a case of multi-victim sexual assault in an Australian rural community. --------- Method: A descriptive, case-report methodology summarizing the investigation and intervention in a case of multi-victim sexual assault is reported. A community based intervention arising out of the disclosures of 21 male children is described. The intervention occurred at an individual, group, and community level using a coordinated multi-disciplinary team and natural helping networks. ---------- Results: The coordination of police and welfare services increased the communication flow to victims, their families, and the community. The case also demonstrated the utility in regularly briefing political and bureaucratic authorities as well as local officials about emergent issues. Coordinating political and bureaucratic responses was essential in obtaining ongoing support and sufficient researching to enable the effective delivery of services. ---------- Conclusions: Interventions were focused at an individual, group, and community level using a coordinated multi-disciplinary team and natural helping networks. This provided a choice of services which were sensitive to the case setting. Recommendations are offered for practitioners who are confronted with similar events. While this paper describes an approach for intervening in a case of multi-victim sexual assault, further empirical research is needed to enable service deliverers to efficaciously target interventions which offer choice to victims and their families.

Phytophotodermatitis : case reports of children presenting with blistering after preparing lime juice

Letter to the Editor We read with interest the case report entitled ‘‘Contact with fig tree sap: An unusual cause of burn injury’’ by Mandalia et al. [1] and would like to report our similar experience with phytophotodermatitis caused by lime juice. Phototoxic dermatitis is understandably easily confused with a burn, particularly when a patient presents with large blisters of unknown mechanism. At the Royal Children’s Hospital Burns Centre, this injury was treated in the same manner as a burn and is described here...

Pulmonary embolism in the emergency department : a Singaporean nursing case review

Introduction The presentation of pulmonary embolism to the emergency department (ED) can prove challenging because of the myriad of potential disease processes that mimic its signs and symptoms. The incidence of pulmonary embolism and indeed the mortality associated with it is relatively high. Early diagnosis and treatment is crucial in off-setting the potential deleterious effects associated with this condition. The aim of this article is to present a nursing case review of a patient presenting to the ED with a diagnosis of pulmonary embolism. Method We chose to use a case review to highlight the nursing and medical care that was provided for a patient who presented to the emergency department acutely with dyspnoea, chest pain and pyrexia. The use of case reviews are useful in reporting unusual or rare cases and this format is typically seen more in medicine than in nursing. They can naturally take one of two formats—a single case report or a series of case reports; in this case we opted to report on a single case. Discussion The gentleman in question was an ambulance admissionto the ED with a three day history of chest pain, shortness of breath and one episode of syncope which brought him to the ED. Over the course of his admission a variety of treatment modalities were used successfully to alleviate the problem. More notable from a nursing perspective was the use of diagnostic tools as an interpretation to guide his care and provide a platform from which a deeper understanding and appreciation of the intricacies the critically ill patient often presents. Conclusion We found the use of case review very enlightening in understanding the disease process and the decision-making that accompanies this. Whilst our patient was successfully rehabilitated home, we learnt a lot from the experience which has been most beneficial in supporting our understanding of pulmonary embolism.

A novel ACVR1 mutation in the glycine/serine-rich domain found in the most benign case of a fibrodysplasia ossificans progressiva variant reported to date

Fibrodysplasia Ossificans Progressiva (FOP) is a rare, autosomal dominant condition, classically characterised by heterotopic ossification beginning in childhood and congenital great toe malformations; occurring in response to a c.617 G>A ACVR1 mutation in the functionally important glycine/serine-rich domain of exon 6. Here we describe a novel c.587 T>C mutation in the glycine/serine-rich domain of ACVR1, associated with delayed onset of heterotopic ossification and an exceptionally mild clinical course. Absence of great toe malformations, the presence of early ossification of the cervical spine facets joints, plus mild bilateral camptodactyly of the 5th fingers, together with a novel ACVR1 mutation, are consistent with the 'FOP-variant' syndrome. The c.587 T>C mutation replaces a conserved leucine with proline at residue 196. Modelling of the mutant protein reveals a steric clash with the kinase domain that will weaken interactions with FKBP12 and induce exposure of the glycine/serine-rich repeat. The mutant receptor is predicted to be hypersensitive to ligand stimulation rather than being constitutively active, consistent with the mild clinical phenotype. This case extends our understanding of the 'FOP-variant' syndrome.

Resolving painful emotional experience during psychodrama

Unresolved painful emotional experiences such as bereavement, trauma and disturbances in core relationships, are common presenting problems for clients of psychodrama or psychotherapy more generally. Emotional pain is experienced as a shattering of the sense of self and disconnection from others and, when unresolved, produces avoidant responses which inhibit the healing process. There is agreement across therapeutic modalities that exposure to emotional experience can increase the efficacy of therapeutic interventions. Moreno proposes that the activation of spontaneity is the primary curative factor in psychodrama and that healing occurs when the protagonist (client) engages with his or her wider social system and develops greater flexibility in response to that system. An extensive case-report literature describes the application of the psychodrama method in healing unresolved painful emotional experiences, but there is limited empirical research to verify the efficacy of the method or to identify the processes that are linked to therapeutic change. The purpose of this current research was to construct a model of protagonist change processes that could extend psychodrama theory, inform practitioners’ therapeutic decisions and contribute to understanding the common factors in therapeutic change. Four studies investigated protagonist processes linked to in-session resolution of painful emotional experiences. Significant therapeutic events were analysed using recordings and transcripts of psychodrama enactments, protagonist and director recall interviews and a range of process and outcome measures. A preliminary study (3 cases) identified four themes that were associated with helpful therapeutic events: enactment, the working alliance with the director and with group members, emotional release or relief and social atom repair. The second study (7 cases) used Comprehensive Process Analysis (CPA) to construct a model of protagonists’ processes linked to in-session resolution. This model was then validated across four more cases in Study 3. Five meta-processes were identified: (i) a readiness to engage in the psychodrama process; (ii) re-experiencing and insight; (iii) activating resourcefulness; (iv) social atom repair with emotional release and (v) integration. Social atom repair with emotional release involved deeply experiencing a wished-for interpersonal experience accompanied by a free flowing release of previously restricted emotion and was most clearly linked to protagonists’ reports of reaching resolution and to post session improvements in interpersonal relationships and sense of self. Acceptance of self in the moment increased protagonists’ capacity to generate new responses within each meta-process and, in resolved cases, there was evidence of spontaneity developing over time. The fourth study tested Greenberg’s allowing and accepting painful emotional experience model as an alternative explanation of protagonist change. The findings of this study suggested that while the process of allowing emotional pain was present in resolved cases, Greenberg’s model was not sufficient to explain the processes that lead to in-session resolution. The protagonist’s readiness to engage and activation of resourcefulness appear to facilitate the transition from problem identification to emotional release. Furthermore, experiencing a reparative relationship was found to be central to the healing process. This research verifies that there can be in-session resolution of painful emotional experience during psychodrama and protagonists’ reports suggest that in-session resolution can heal the damage to the sense of self and the interpersonal disconnection that are associated with unresolved emotional pain. A model of protagonist change processes has been constructed that challenges the view of psychodrama as a primarily cathartic therapy, by locating the therapeutic experience of emotional release within the development of new role relationships. The five meta-processes which are described within the model suggest broad change principles which can assist practitioners to make sense of events as they unfold and guide their clinical decision making in the moment. Each meta-process was linked to specific post-session changes, so that the model can inform the development of therapeutic plans for individual clients and can aid communication for practitioners when a psychodrama intervention is used for a specific therapeutic purpose within a comprehensive program of therapy.

Unilateral pseudogerontoxon

Peripheral corneal opacities are a common clinical finding. In this case report we describe the routine presentation of a young adult male patient with unilateral opacities in the peripheral cornea resembling a corneal arcus. These opacities were confined to the level of the anterior corneal stroma. The patient also exhibited bilateral signs of mild keratoconus and reported a history of vernal keratoconjunctivitis as a child. A diagnosis of unilateral pseudogerontoxon was made. Pseudogerontoxon is an opacity of the peripheral cornea resembling corneal arcus that typically occurs in patients with a history of allergic eye disease. The clinical features and differential diagnoses of this relatively uncommon cause of peripheral corneal opacity are discussed.