Disseminated varicella-zoster virus (VZV) infection has devastating impacts on patients’ quality of life, with increasing morbidity and mortality. Thus, it is imperative that a diagnosis be made early. This case description illustrates a unique and dramatic presentation of disseminated VZV infection with important clinical implications.

Une femme de 68 ans s’est présentée au centre hospitalier à la suite d’une chute. Elle avait subi une thyroïdectomie totale plus de 20 ans auparavant. Son examen neurologique était normal. Des images tomodensitométriques de la tête, réalisées pour exclure la présence de saignements

A 68-year-old woman presented to hospital after a fall. She had undergone a total thyroidectomy more than 20 years previously. Her neurologic examination was normal. Computed tomography scans of her head, done to exclude intracranial bleed, showed symmetric parenchymal calcification in the basal

A 54-year-old man who had recently immigrated to Canada presented to the emergency department afraid that “spirits” possessed him. He had long-standing beliefs in a spirit world, rooted in his childhood in Cameroon. In the past few months, he began experiencing command hallucinations from his

Balen and colleagues imply that insulin resistance and hyperinsulinaemia are not usually present in lean …

The case: A 21-year-old university student presented to hospital with a 1-week history of swelling and discomfort in his right calf. Compression ultrasonography revealed occlusive thrombi in the right superficial femoral and popliteal veins. Investigations, including complete blood count,

I had a feeling of great comfort and pride when I read the commentaries by Ben Hoyt1 and by Sacha Bahtia and Adam Natsheh:2 if the opinions expressed by these authors reflect the attitudes of young physicians to health care in Canada for the future, we are in safe hands. The medical establishment should heed their message. I have practised under systems of no health insurance and of multiple insurers in addition to our current national system. I would never want to see us return to some version of the former 2 systems or to adopt a costly, confused, limited scheme like that in the United States. I hope our current medical leaders and those they represent can see past their desire for immediate financial gratification with a long-term view of what is best for the average Canadian.

C-reactive protein (CRP) is an acute phase reactant that increases during the host response to tissue injury, including that caused by infection, trauma, malignant disease and chronic inflammatory conditions.[1][1] In recent years, increasing attention has been paid to elevated levels of CRP as a

Consider the following scenario. You are perusing your favourite clinical journal and flip to an advertisement for a new drug. The left frame shows a sad looking fellow who seems older than his years. On the right panel, he looks much better and is smiling as he gazes up at a man wearing a white

Writing Team for the Diabetes Control and Complications Trial/ Epidemiology of Diabetes Interventions and Complications Research Group. Sustained effect of intensive treatment of type I diabetes mellitus on development and progression of diabetic nephropathy. JAMA 2003;290:2159-67. Background: The

In man, total glucose uptake is the sum of insulin mediated glucose uptake and non-insulin mediated glucose uptake. The latter pathway has not been examined in Type 1 (insulin-dependent) diabetes mellitus. In order to assess non-insulin mediated glucose uptake in Type 1 diabetes, we measured steady-state rates of glucose uptake during glucose clamps at 5.27, 9.71 and 12.5 mmol/l using low (0.25 mU· kg−1·min−1), intermediate (0.75 mU·kg−1·min−1) and high (1.50 mU·kg−1·min−1) insulin infusion rates in 10 subjects with Type 1 diabetes. For insulin infusion rates of 0.25, 0.75 and 1.50 mU·kg−1·min−1 as plasma glucose rose from 5.27 to 9.71 mmol/l, total glucose uptake increased by 35, 43 and 52 percent respectively (p<0.05 for each insulin infusion rate). For all three insulin infusion rates, there was no significant increase in total glucose uptake as plasma glucose increased from 9.71 to 12.5 mmol/l. At each glycaemic level, glucose uptake correlated significantly with plasma free insulin (r=0.81, p<0.01 at 5.71 mmol/l; r=0.84, p<0.01 at 9.71 mmol/l; r=0.73, p<0.02 at 12.5 mmol/l). Linear regression analysis to a point corresponding to plasma free insulin equalling zero, yielded values for non-insulin mediated glucose uptake (mmol·kg−1·min−1) of 0.11,0.14,0.18 at plasma glucose of 5.27, 9.7 and 12.5 mmol/l respectively. Thus, increasing plasma glucose concentrations were associated with increasing rates of non-insulin mediated glucose uptake. For each insulin infusion rate used, the percent of total glucose uptake accounted for by non-insulin mediated glucose uptake remained independent of plasma glucose concentration, but decreased as insulin infusion rate increased. During the insulin infusion at 0.25 mU·kg−1·min−1, this percentage ranged from 83.7 to 91.4%. Analysis of glucose uptake data derived for theoretical plasma insulin levels of 0, 40, 80 and 160 μU/ml yielded linear Eadie-Hofstee plots (r=− 0.83 to − 0.99), suggesting that insulin increased Vmax but did not alter Km. Hence, in these subjects with Type 1 diabetes, glucose uptake, both insulin mediated and non-insulin mediated can be described by Michaelis-Menten kinetics. Comparison of values obtained for Vmax and Km in the present studies of Type 1 diabetes with those obtained from non-diabetic subjects indicates that non-insulin dependent glucose uptake in Type 1 diabetes is quantitatively similar to that of non-diabetic subjects.

Pretend you're all alone and no one is watching. Ever get tempted to read a medical editorial? Editorials are abundant. In 2001, CMAJ published 4 times as many of them as randomized trials. Their mystique has lasted more than a century because they can tackle issues where science is lacking. No

Cryptococcus neoformans commonly causes opportunistic infection in immunocompromised patients, especially in patients with AIDS. The CD4+ T-lymphocyte count is measured in patients with HIV infection, because it signals an increased risk of opportunistic infection and a decline in immunological function. We report a case of cryptococcal meningitis in a patient with persistently low CD4+ cell counts without evidence of HIV infection. The patient's underlying immunocompromised state was attributed to idiopathic CD4+ T-lymphocytopenia (ICL), a recently described syndrome characterized by depletions in the CD4+ T-cell subsets without evidence of HIV infection. Immunodeficiency can exist in the absence of laboratory evidence of HIV infection, highlighting the importance of evaluating T-cell subsets in patients who present with unusual infections.

Physicians receive little instruction on how to interact with colleagues, and even less guidance on what to do when their colleagues are poorly informed. Eight techniques are presented here that may be of use in dealing with colleagues who have clearly not read the literature and are unable to maintain the facade that they have. If employed properly and used judiciously, these techniques may help avoid embarrassment for all and may also improve the exchange of valuable information between professionals.

Tough times at American medical centers have motivated some to ask whether clinician-teachers are a luxury they can no longer afford. Many health maintenance organizations, for example, have reduced their commitment to teaching activities under the belief that they cause a drag on profits or a loss in care.1 Of course, academic medical centers are not immune to economic forces, and several prominent organizations now pressure faculty to focus on research, patient care, to other activities that produce large revenues.2 Self-interested administrators seem to recognize the importance of medical education, but suggest that it not be located in their own backyards. Advocates for clinician-teachers need strong defenses against these pressures, and two such defenses are described in this issue. Investigators in Ohio document a clear plan for allocating discretionary teaching dollars according to teaching effort.3 Investigators in Michigan describe the range of incentives that are being offered to nonsalaried faculty.4 Together, these two articles document that some institutions are serious about supporting clinician-teachers, and they show how support for individual clinician-teachers can be made both fair and imaginative. Hence, the pie can be sliced in an equitable and innovative manner. However, neither of these studies says much about the absolute magnitude of support. That is, how big should the pie be? We answer this question by describing reasons for increasing support for all clinician-teachers. The most direct argument is that teaching hospitals provide better clinical care than nonteaching hospitals, at least for some patients.5,6 the superior outcomes are somewhat surprising, given that trainees most likely make more errors than experienced physicians. Perhaps, however, a greater frequency of error is more than offset by a far greater frequency of double-checking, thereby resulting in more mistakes but fewer egregious mistakes. Alternatively, perhaps the academic environment encourages more striving for excellence. If so, truly outstanding care might be more frequent at teaching hospitals. Whatever explanation, an institution that values patient care may wish to retain its teaching status. A durable health care institution must also consider how teaching affects recruiting. The back pages of this and other medical journals indicate how much money institutions spend advertising to fill vacancies. These visible activities usually are accompanied by other, less visible activities such as consulting headhunters or entertaining lavishly, undertakings that incur cost without providing care. Furthermore, unfilled vacancies are inherently unproductive. Hence, a health care institution may be more efficient if it can recruit from a steady stream of its own trainees. Thoughtful planning also entails thinking about referrals. All else being equal, physicians tend to refer patients to professionals they know and respect. And rightly or wrongly, clinician-teachers leave powerful impressions on trainees that may last a long time and reach into diverse areas where trainees are dispersed. These early impressions can be especially important for cases involving rare disorders, for example, when a psychiatrist diagnoses a patient with Wilson’s disease and can remember only one previous patient seen during training. Eliminating clinician-teachers may eliminate these referrals. Optimizing patient care also requires continually updating staff about advances in medicine. Like other successful businesses, successful health care organizations must provide intramural, staff-enhancing activities like weekly grand rounds.7 Yet, finding individuals willing to present in such venues can be a problem. Clinician-teachers are uniquely qualified, and they may have special incentives if they are expected to have full teaching dossiers. Moreover, clinician-teachers are less likely to be absent because they are presenting at scientific meetings or reviewing grants at study-section meetings. Having fewer clinician-teachers means spending more elsewhere on staff development. Some claim that the biggest cost of a clinician-teacher derives from the inevitable association with trainees. According to this theory, trainees are inefficient clinicians who cause excessive testing, unnecessary treatments, wasted time, general chaos, and other economic losses. The available evidence confirms that the direct costs of care at teaching hospitals are marginally higher than they are at nonteaching hospitals.8,9 However, this is not an argument against clinician-teachers, but rather an argument against one type of teaching. Some institutions believe that trainees create indirect profits by allowing, for example, the hiring of fewer nursing staff. Whether trainees are profitable or not depends on the balance between their service contributions and other aspects of their educational program, and that varies from place to place. Generous donations from grateful individuals provide one small, yet pleasant source of revenue for many health care institutions. Some donors are specifically interested in teaching excellence, and forgoing a teaching program means sacrificing these donations. In addition, donors who are interested in promoting research excellence are sometimes more enthusiastic if they see that the institution is successful at attracting trainees. Moreover, donors who are interested in clinical care usually appreciate the importance of education. Together, these arguments suggest that a drop in teaching activity may eventually lead to a drop in donor activity. And, of course, grateful alumni can be another source of donations. Perhaps the most pernicious attack on clinician-teachers is the claim that a small reduction in support can be absorbed without any loss in performance. Such a belief presupposes a gain in efficiency, a supposition not generally supported by observation in any type of education.10,11 To be sure, practitioners of medicine have enjoyed large gains in efficiency recently because of advances in technology; however, teachers of medicine draw much smaller benefits from computers, biotechnology, and other such marvels. Education still takes about the same amount of time because the human brain has changed little in the past century. Moreover, technology cannot replace human interactions because nothing substitutes for the clinician-teacher’s inspiration, praise, and encouragement. The most compelling argument for supporting clinician-teachers is not mercenary but altruistic. The practice of medicine survives only by being taught to others. An institution that supports clinician-teachers identifies itself as an institution that supports other humanitarian efforts.12 Moreover, such an institution provides an environment that prevents burnout by using keen young minds to recharge its practitioners. In this time of economic uncertainty, the theory of rationality dictates that all decision makers should follow high moral principles. Teaching others is one such principle.

OBJECTIVE: To describe the design of the HOPE (Heart Outcomes Prevention Evaluation) Study.DESIGN: Description of the key design features of HOPE, a large, simple randomized trial of two widely applicable treatments - ramipril, an angiotensin-converting enzyme inhibitor; and vitamin E, a naturally occurring antioxidant vitamin - in the prevention of myocardial infarction, stroke or cardiovascular death.SETTING: Two-hundred and sixty-seven hospitals, physician offices and clinics in Canada, the United States, Mexico, Europe and South America.PATIENTS: Over 9000 women and men aged 55 years and above at high risk for cardiovascular events such as myocardial infarction and stroke were recruited over 18 months.INTERVENTIONS: A 2x2 factorial design with ramipril and vitamin E with follow-up for up to four years.CONCLUSIONS: HOPE will be one of the largest trials of two new interventions to prevent myocardial infarction, stroke or cardiovascular death in high risk patients. The results of HOPE will have direct public health impact and are likely to be readily incorporated into clinical practice. Key design features of HOPE are inclusion of individuals at high risk of cardiovascular disease, inclusion of a substantial proportion of patients with diabetes (36%) and women (27%), and detailed substudies to provide data on mechanisms of benefit.