Recurrent confusion and ataxia triggered by pyrexia in a case of occult multiple sclerosis It has long been known that an increase in body temperature may worsen reversibly the signs and symptoms of multiple sclerosis, probably by the production of conduction block in partially demyelinated nerve axons. We present the case of a man whom we believe has multiple sclerosis, who has a nine year history of brief episodes of profound neurological dysfunction, always in association with pyrexial illnesses. The unusual feature of this case is that, until recently, between these attacks our patient remained subjectively well, and that there was no history suggesting episodes of acute demyelination.A 44 year old man was admitted in May 1992 with a 12 hour history of increasing confusion, blurring of vision, and ataxia, associated with a fever. On admission he was pyrexial at 39°C, but there were no signs of localised infection or any features of meningism. He was drowsy and mildly confused. The cranial nerves were normal apart from bilateral failure of adduction with ataxic nystagmus of the abducting eyes typical of an internuclear ophthalmoplegia, down-beat nystagmus on down-gaze, and up-beat nystagmus on up-gaze. There was a mild bilateral ptosis and a slight left upper motor neuron facial weakness. Bulbar function was intact. In the limbs power was normal, but tone was slightly increased generally and the reflexes were exaggerated, particularly on the left. The left plantar reflex was extensor, the right flexor. There was pronounced cerebellar ataxia in all four limbs, again more pronounced on the left, and he was unable to walk unassisted. Sensation was normal. The only abnormal investigations were a noticeable peripheral neutrophilia (granulocyte count 11 -6 x 109/1), and a raised C reactive protein concentration of 77 mg/l (normal range 0-10). Cerebrospinal fluid contained 1 white blood cell/mm', 0-21 g/l protein, and 4-7 mmol/l glucose.The Further analysis of the CSF collected on his admission showed the presence of oligoclonal IgG bands that were absent from plasma, although the CSF IgG:albumin ratio was normal at 0-20 (normal range 0-0 25). An MRI of the brain two days after his discharge showed the presence of multiple areas of increased signal intensity in the periventricular regions, the corpus callosum, the base of the fourth ventricle, the left cerebellar peduncle, and the lower medulla. The appearances were typical of widespread demyelination caused by multiple sclerosis. Repeat MRI five months later appeared identical. Visual evoked responses recorded eight months after his admission were of grossly increased latency.In

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Homologues of the bacterial mutS and mutL genes involved in DNA mismatch repair have been found in organisms from bacteria to humans. Here, we describe the structure and function of a newly identified Schizosaccharomyces pombe gene that encodes a predicted amino acid sequence of 794 residues with a high degree of homology to MutL related proteins. On the basis of its closer relationship to the eukaryotic “PMS” genes than to the “MLH” genes, we have designated the S. pombe homologue pms1. Disruption of the pms1 gene causes a significant increase of spontaneous mutagenesis as documented by reversion rate measurements. Tetrad analyses of crosses homozygous for the pms1 mutation reveal a reduction of spore viability from >92% to 80% associated with a low proportion (∼50%) of meioses producing four viable spores and a significant, allele-dependent increase of the level of post-meiotic segregation of genetic marker allele pairs. The mutant phenotypes are consistent with a general function of pms1 in correction of mismatched base pairs arising as a consequence of DNA polymerase errors during DNA synthesis, or of hybrid DNA formation between homologous but not perfectly complementary DNA strands during meiotic recombination.

Methods, Intervention, & Analysis: Assist staff to provide care that accommodates HCT patients with geriatric specific needs with education materials as well as identify and utilize a geriatric assessment tool to determine if the patient would benefit from a formal geriatric assessment. The geriatric NP would perform the assessment and provide specific recommendations in order to provide the best possible care to the older adults being treated with HCT. Findings & Interpretation: Patient education material was revised in order to meet the needs of the older adult and has been implemented on the HCT inpatient unit. The RN staff will be educated to complete a functional assessment on all admissions that are greater than 65 years old and what criteria would deem a patient appropriate for a consultation from the geriatric nurse practitioner. Discussion & Implications: Considering the specific needs of the older adult can lead to better outcomes and ensure age appropriate care is provided to this patient population.