Work-related carpal tunnel syndrome treatment: a cross-sectional study among 106 patients.

The objective is to assess the influence of sociodemographic, professional and clinical variables on the choice of treatment of work-related carpal tunnel syndrome (CTS). An exhaustive and trans-sectional study was conducted over a period of eight years, from 1st January 2006 to 31 December 2013 in the Department of Occupational Medicine at University Hospital of Mahdia, Tunisia. The study population was represented by patients with work-related carpal tunnel syndrome. Data collection was based on a questionnaire sheet, describing social, occupational and medical characteristics of patients. The study population was characterized by a large female dominance, representing 95.3% with an average age of 42±7.8 years. Patients medically treated represented 38.7% and 61.3% had had surgical treatment. After binary logistic regression, surgical indication of CTS was significantly correlated to diabetes (p=0.017), other musculoskeletal disorders (p=0.02), functional signs of CTS (acrocyanosis p=0.05; muscle weakness p=0.015; radiating pain p=0.01; painful discomfort of the hand, the forearm or arm p=0.027) and to the atrophy of thenar muscles (p=0.018). According to this study, the choice of therapy for occupational CTS depends only on clinical data. More detailed studies will be needed to refine these results.

Risk Assessment of Hepatocellular Carcinoma with Aflatoxin B1 Exposure in Edible Oils.

Contamination of edible oils with aflatoxins (AFs) is a universal issue due to the detrimental effects of aflatoxins on human health and the fact that edible oils are a major source of fungal growth, particularly storage fungi (Aspergillus sp.). The objective of this study was to assess aflatoxin B1 (AFB1) in edible oil used in fried food in order to determine the risk of cancer from AFB1 exposure through cooked food using the FAO/WHO's and EFSA's margin of exposure (MOE) quantitative liver cancer risk approaches. Using Mycosep 226 columns and HPLC-FLD, 100 samples of cooking oils (soybean, canola, and sunflower oil) from different food points were analyzed for contamination with aflatoxins. Of all the samples tested, 89% were positive for total aflatoxins and AFB1, with 65% indicating AF concentrations beyond permitted levels. Canola oil was found to contain higher levels of AFB1 and AFs than soybean and sunflower oil. Almost 71 percent of canola oil samples (range of 54.4-281.1 µg/kg) were contaminated with AF levels higher than the proposed limits of the European Union (20 µg/kg). The consumption of canola oil samples used in fried foods had MOE values that were significantly lower as compared to sunflower and soybean oils, indicating that risk reduction is feasible. Additionally, compared to soybean and sunflower oil, canola oil exhibited a greater threat of liver cancer cases linked to AFB1 exposure (17.13 per 100,000 males over 35 and 10.93 per 100,000 females over 35). Using a quantitative liver cancer approach, health risk valuation demonstrated that males and females over the age of 35 are at significant risk of developing liver cancer. The health risk assessment exposed that the males and female over the age of 35 are at considerable risk of liver cancer by using a quantitative liver cancer approach. The innovation of this study lies in the fact that no such study is reported related to liver cancer risk evaluation accompanied with AFB1 exposure from consumed edible oil. As a result, a national strategy must be developed to solve this problem so that edible oil products are subjected to severe regulatory examination.

[Vocal cord dysfunction in athletes: Interest of rehabilitation to effort]. / Dysfonction des cordes vocales chez le sportif : intérêt du reconditionnement à l'effort.

INTRODUCTION: Vocal Cord Dysfunction (VCD) is a syndrome characterized by paradoxical adduction of the vocal folds during breathing. Its non-specific clinical manifestations frequently lead to misdiagnosis and delay in its treatment. The treatment of VCD is not pharmacological but rehabilitative and remains poorly appreciated. OBSERVATION: In this clinical case we describe a 16-year-old female judoka who presented with effort intolerance associated with occasional dyspnea, which had suddenly worsened over the preceding few months so that in now produced sudden respiratory difficulty, mainly during intense and sudden efforts. After a period where her symptoms were confused with asthma, she was diagnosed with exercise-induced VCD. Her treatment was aimed to: (a) rehabilitate respiratory mechanics in order to eliminate abdominal-thoracic asynchrony, (b) rehabilitate naso-nasal breathing, (c) train her to control abdominal-diaphragmatic breathing at rest and then during effort, (d) train her to use ventilatory control as soon as prodromal symptoms appear in order to prevent the development of stridor or complete closure of the vocal folds (at rest and then progressively during exercise). CONCLUSION: Following the implementation of these rehabilitation strategies to correct her ventilatory and dyskinetic issues, the patient no longer develops respiratory discomfort during exercise, including during judo competitions.

Polymorphisms of the human platelet alloantigens HPA-1, HPA-2, HPA-3, and HPA-4 in ischemic stroke.

Polymorphism in human platelet antigen (HPA)-1 and HPA-3 (GPIIb/IIIa), HPA-2 (GPIb/IX), HPA-4 (GPIIIa), and HPA-5 (GPIa/IIa) was investigated in 329 stroke patients and 444 matched control subjects. HPA genotyping was done by PCR-SSP method. Lower HPA-1a (P < 0.001) and higher HPA-1b (P < 0.001) allele frequencies were seen in patients than control subjects, and homozygosity for HPA-1b (P < 0.001) alleles was more prevalent in stroke cases than in controls. The allele and genotype distributions of the other HPA polymorphic variants were similar between cases and controls. Select HPA combined genotypes comprising the 2121 (Pc = 0.008) and 2221 (Pc = 0.018) genotypes, which were positively associated, and the 1111 (Pc < 0.001), which was negatively associated with stroke, thereby conferred a disease susceptibility and protective nature to these genotype combinations. Multivariate analysis confirmed the negative association of the 1111 (P < 0.001) and the positive association of the 2121 (P = 0.017) combined genotypes with stroke, after adjustment for a number of covariates. This is the first evidence demonstrating differential association of the common 4 HPA gene variants and specific HPA genotype combinations with stroke.

Association of human platelet alloantigen 1 through 5 polymorphisms with ischemic stroke.

Polymorphisms in human platelet alloantigen (HPA)-1 and HPA-3 (GPIIb/IIIa), HPA-2 (GPIb/IX), HPA-4 (GPIIIa) and HPA-5 (GPIa/IIa) were investigated in 216 stroke patients and 318 matched control subjects. HPA genotyping was done by the polymerase chain reaction method using sequence-specific primers. Higher frequencies of the HPA-1 a/b (p < 0.001) and HPA-5 a/b (p < 0.001) allele, together with HPA-1 b/b, HPA-5 a/b and HPA-5 b/b genotypes were seen in patients, which was confirmed by regression analysis after controlling for a number of confounding variables. Furthermore, HPA-1 b/b and HPA-5 b/b were significantly associated with the extent of neurological symptoms, and with the recurrence of stroke. Both susceptible (1a/ b -2a/a-3a/ b -4a/a-5a/ b ) and protective (1a/a-2a/a-3a/a-4a/a-5a/a; 1a/a-2a/a-3a/ b -4a/a-5a/a; 1a/ b -2a/a-3a/a-4a/a-5a/a; 1a/ b -2a/a-3a/ b -4a/a-5a/a) HPA genotypes were identified. This is the first evidence demonstrating differential association of the common 5 HPA gene variants with stroke, with HPA-1b and HPA-5b representing strong genetic risk factors.

Association of PAI-1 4G/5G and -844G/A gene polymorphism and changes in PAI-1/tPA levels in stroke: a case-control study.

Mutations in the plasminogen activator inhibitor-1 (PAI-1) gene, along with altered PAI-1 and tissue-type plasminogen activator (tPA) levels, have been implicated in stroke pathogenesis. We investigated the association of PAI-1 and tPA levels with stroke as a function of PAI-1 4G/5G and -844G/A genotypes, as well as the link between these PAI-1 gene variants and stroke risk, in a case-control study of 135 ischemic stroke patient, diagnosed according to clinical and radiologic findings and confirmed by computed tomography scan. Controls (n = 118) were age- and sex-matched and had no personal/family history of stroke. PAI-1 4G/5G and -844G/A genotyping were done by polymerase chain reaction-restriction fragment length polymorphism, and PAI-1 and tPA levels were measured by enzyme immunoassay. Significant elevation in PAI-1 and marked reduction in tPA levels were seen in stroke patients and were correlated with 4G/5G, but not with -844G/A, PAI-1 variants. Whereas the frequencies of 4G or -844A alleles were comparable between patients and controls, 4G/4G carriers had reduced risk of stroke compared with other genotypes (odds ratio [OR] = 0.54; 95% confidence interval [CI] = 0.31-0.95). The 4G/-844A haplotype also was more closely associated with reduced stroke risk (OR = 0.43; 95% CI = 0.20-0.97) than 5G/-844A or 4G/-844G haplotypes. Regression analysis demonstrated that 4G homozygosity (OR = 0.176), hypertension (OR = 6.288), and body mass index (OR = 1.325) were independent predictors of stroke. The protective effect of 4G allele against stroke suggests involvement of PAI-1 4G/5G polymorphism in stroke through a mechanism not related to fibrinolysis, possibly involving altered plaque stabilization, and/or through antagonism of tPA effects.

Association of apolipoprotein E gene polymorphism with ischemic stroke involving large-vessel disease and its relation to serum lipid levels.

A relationship between apolipoprotein E (Apo E) genotype and stroke was previously suggested, but with inconsistent results. We investigated the relationships among serum lipid levels, Apo E alleles and genotypes, and stroke risk factors in 216 stroke patients and 282 age- and sex-matched controls. Fasting blood samples were collected for total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride level determination and for genomic DNA extraction. Apo was genotyped by polymerase chain reaction-restriction fragment length polymorphism (Cfo I) analysis. Increasing levels of total cholesterol, LDL-C, HDL-C, and triglycerides were associated with elevated stroke risk and was more pronounced in Apo E4-carrying subjects than in E3- and/or E2-carrying subjects. Apo 3 was significantly lower (0.546 vs 0.736; P < .001), whereas Apo 4 was higher in the stroke patients (0.370 vs 0.181; P < .001); Apo 2 was present at low but comparable frequencies. The prevalence of E3/E3 was lower and that of E4-containing phenotypes (E3/E4 and homozygous E4/E4) was higher in the stroke patients. The prevalence of the E4-containing phenotypes were significantly higher in ischemic versus hemorrhagic (P < .001) and in small-vessel versus large-vessel stroke cases (P < .001), and was associated with increased need for statin drugs (P = .040). Logistic regression models, after adjusting for potentially confounding variables including lipid profile, age, and sex, showed an significant association of apo 4 genotype with risk of stroke (P = .033). Our findings indicate that Apo 4 is an independent risk factor associated with an altered lipid profile in this study population.

Changes in severity and organ failure scores as prognostic factors in onco-hematological malignancy patients admitted to the ICU.

OBJECTIVE: To determine whether severity and organ failure scores over the first 3 days in an ICU predict in-hospital mortality in onco-hematological malignancy patients. DESIGN AND SETTING: Retrospective study in a 22-bed medical ICU. PATIENTS: 92 consecutive patients with onco-hematological malignancies including 20 hematopoietic stem cell transplantation (HSCT) patients (11 with allogenic HSCT). MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, Organ Dysfunction and/or Infection (ODIN) score, Logistic Organ Dysfunction System (LODS), and Sequential Organ Failure Assessment (SOFA) score were recorded on admission. The change in each score (Delta score) during the first 3 days in the ICU was calculated as follows: severity or organ failure score on day 3 minus severity or organ failure score on day 1, divided by severity or organ failure score on day 1. RESULTS: In-hospital mortality was 58%. Using multivariate analysis in-hospital mortality was predicted by all scores on day 1 and all Delta scores. Areas under the receiver operating characteristics curves were similar for SAPS II (0.78), ODIN (0.78), LODS (0.83), and SOFA (0.78) scores at day 1. They were also similar for DeltaSAPS II, DeltaODIN, DeltaLODS, and DeltaSOFA. Similar results were observed when excluding patients with allogenic HSCT. CONCLUSION: Severity and three organ failure scores on day 1 and Delta scores perform similarly in predicting in-hospital mortality in ICU onco-hematological malignancy patients but do not predict individual outcome. Decision to admit such patients to the ICU or to forgo life-sustaining therapies should not be based on these scores.

[Cardiopulmonary interactions in the course of mechanical ventilation]. / Interactions cœur­poumons au cours de la ventilation mécanique.

INTRODUCTION: The haemodynamic consequences of ventilation are multiple and complex and may affect all the determinants of cardiac performance such as heart rate, preload, contractility and afterload. These consequences affect both right and left ventricle and are also related to the biventricular interdependence. STATE-OF-THE-ART: Ventilation modifies the lung volume and also the intrathoracic pressure. Variations in lung volume have consequences on the pulmonary vascular resistance, hypoxic pulmonary vasoconstriction and ventricular interdependence. Variations in intrathoracic pressure have a major impact and affect systemic venous return, right ventricular preload, left ventricular preload, right ventricular afterload, left ventricular afterload and myocardial contracility. The haemodynamic consequences of positive pressure ventilation depend on the underlying chronic cardiopulmonary pathologies leading to the acute respiratory failure that was the indication for ventilation. CONCLUSION: In this review, we will focus on severe COPD exacerbation, acute left heart failure and weaning from ventilation.

Postoperative cognitive dysfunction after cardiac surgery.

Prolonged postoperative cognitive dysfunction (POCD) is reported to occur frequently after cardiac surgery. However, it is rarely assessed in routine clinical practice and receives little attention. Although the cerebral consequences of cardiopulmonary bypass have been measured clinically, insights into the resulting molecular and pathologic events within the brain have only begun to be investigated. POCD is likely to impair quality of life and constitutes a large burden on society when elderly patients prematurely lose their independence. Numerous studies have reported that neurocognitive deficit is associated with heightened mortality, increased length of hospital stay, and discharge to a nursing home. This is linked with a tremendous demand for health-care resources. Because of the magnitude of the clinical problem, serious consideration must be directed toward understanding its etiology and the development of neuroprotective strategies. Clearly identifying the mechanisms of POCD is challenging. The purpose of this review is to discuss recent developments in our understanding of the pathophysiologic mechanisms, prevention, and treatments that have been designed to ameliorate brain dysfunction after cardiac surgery.

Rapid and beneficial hemodynamic effects of activated protein C in septic shock patients.

OBJECTIVE: Because recombinant human activated protein C (rhAPC) reduces NO production during sepsis, it could improve the vascular tone. We tested whether rhAPC reduces the dose of norepinephrine required to maintain mean arterial pressure (MAP) in septic shock patients. DESIGN AND SETTING: Retrospective study in intensive care unit of two university hospitals. PATIENTS: Twenty-two septic shock patients with at least two organ failures were retrospectively investigated for MAP and the required dose of norepinephrine before and 24 h after rhAPC administration. A control group of 22 septic shock patients with at least two organ failures who did not receive rhAPC was matched on age, SAPS II, MAP, and norepinephrine dose at the time of the theoretical start of rhAPC. MEASUREMENTS AND RESULTS: The MAP remained stable and similar in the two groups (86+/-16 vs. 89+/-9 mmHg at 24 h). The required dose of norepinephrine increased in the control group (+38%, from -41% to +38%) but decreased in the treated group (-33%, from -74% to +11%). CONCLUSIONS: rhAPC rapidly improved the vascular tone in septic shock patients as assessed by a decrease in the norepinephrine dose required to maintain arterial pressure.

[Bickerstaff's brainstem encephalitis]. / La rhombencéphalite postinfectieuse: le syndrome de Bickerstaff.

INTRODUCTION: Bickerstaff's brainstem encephalitis represents a differential diagnostic that must be discuss with meningoencephalitis with ophtalmoplegia, ataxia and confusion. EXEGESE: A 26 year-old woman presented a Bickerstaff syndrome. A severe disturbance of consciousness had lead to admission in intensive care unit with mechanical ventilation. Electrophysiological tests and the brain magnetic resonance were normal. We have not observed systemic anti-G1Qb antibody in our patient. Nevertheless, 66% of patients with Bickerstaff syndrome have anti-GQ1b antibody during the acute phase period. We observed a beneficial effect of IV Ig treatment although no significant improvement was observed with corticosteroids. CONCLUSION: Controlled clinical trials are needed to established the efficacy of IV Ig or plasmapheresis as a specific therapy for this pathology.

[Acute respiratory failure due to Mycoplasma pneumonia]. / Détresse respiratoire aiguë due à Mycoplasma pneumoniae.

INTRODUCTION: Respiratory infections due to Mycoplasma pneumoniae are typically mild and subacute. We report the case of a 40-year-old man hospitalized for acute respiratory distress in the context of an acute infection with Mycoplasma pneumoniae. Radiological and pulmonary function test were consistent with an acute infectious bronchiolitis. CASE REPORT: The patient presented with isolated respiratory failure with profound hypoxemia requiring oxygen delivered at high concentration by face mask. The CT appearance of the lesions corresponded to a spread of bilateral micro-connected pulmonary nodules (a "tree-in-bud" pattern) associated with obstructive ventilatory disorder. The only pathogen identified by PCR on BAL and serology was Mycoplasma pneumoniae. The evolution was favorable with antibiotic therapy combined with corticosteroids. CONCLUSION: Mycoplasma pneumoniae may be responsible for severe respiratory illness in the form of bronchiolitis. In the setting of severe acute community pneumoniae antibiotic treatment which is also effective against Mycoplasma pneumonia should be considered. In this case, corticosteroids may be an effective adjunct by their action on the small airways.

[A multi-centre randomized controlled trial of domiciliary non-invasive ventilation vs long-term oxygen therapy in survivors of acute hypercapnic respiratory failure due to COPD. Non-invasive ventilation in obstructive lung disease (NIVOLD) study]. / Bénéfices de la ventilation non invasive à domicile au décours d'une insuffisance respiratoire aiguë hypercapnique chez les patients BPCO. Étude contrôlée randomisée multicentrique. Étude Non Invasive Ventilation in Obstructive Lung Disease (Nivold).

BACKGROUND: Patients with chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease (COPD) are very likely to develop acute exacerbations. Non-invasive ventilation is often used to treat acute respiratory failure but little information is available about the benefits of domiciliary non-invasive ventilation in COPD patients with chronic hypercapnic respiratory failure who survive an acute episode. The purpose of this study is to determine whether domiciliary non-invasive ventilation can reduce the incidence of recurrent acute hypercapnic respiratory failure in COPD patients who survived an episode of acute hypercapnic respiratory failure (AHRF). METHODS: A multi-center randomized controlled trial including patients with COPD who survived an episode of AHRF. Patients will be randomly assigned to receive long-term oxygen therapy (LTOT) (no intervention) or domiciliary non-invasive ventilation (active comparator) in addition to LTOT. In France, three university hospitals: Rouen, Caen and Amiens and three general hospitals: Dieppe, Le Havre and Elbeuf are recruiting. INCLUSION CRITERIA: Age above 18 years; patients with COPD who have survived an episode of AHRF; patients weaned from non-invasive or mechanical ventilation for at least seven days following an acute episode; with stable arterial blood gases for at least two days: PaCO(2) greater than 55mmHg and pH greater than 7.35. Exclusion criteria are: age above 85 years, other causes of respiratory failure, obstructive sleep apnoea, adverse psychosocial status, serious co-morbidity. Primary outcome is the frequency of episodes of acute hypercapnic respiratory failure (time frame: up to 102 weeks), secondary outcome is mortality (time frame: 1 month and every 6 months for 2 years). EXPECTED RESULTS: A decreased rate of episodes of acute hypercapnic respiratory failure in the group of patients receiving non-invasive ventilation in addition to long term oxygen therapy.

[Non-invasive ventilation era: is there still a place for long-term tracheostomy?]. / Place de la trachéotomie au long cours dans l'insuffisance respiratoire chronique sévère à l'ère de la ventilation non invasive.

INTRODUCTION: At a time when non-invasive ventilation (NIV) is commonly used in acute as well as chronic respiratory failure, it is important to consider the current place, if any, of long-term tracheostomy. BACKGROUND: Except in emergency situations where tracheostomy is mandatory to ensure safe access to the airway, long-term ventilation with tracheostomy (LTVT) is generally considered in the case of inability to wean from NIV after an episode of acute respiratory failure requiring endotracheal ventilation or because of the development of bulbar signs (swallowing, phonation) in advanced neuromuscular disease. It is also appropriate when ventilatory dependence on NIV exceeds 20 hours per day. Historical retrospective studies confirmed the feasibility of LTVT, but this has to be seen in perspective with the results obtained 20 years later with NIV. VIEWPOINT AND CONCLUSION: Even if the indications for LTVT have diminished considerably since the emergence of NIV, tracheostomy remains mandatory in some situations of respiratory distress and it should be considered as a potential resource, possibly temporary in some cases in the light of recent work on the possibility of decanulation after LTVT.

[The French translation and cultural adaptation of the SRI questionnaire. A questionnaire to assess health-related quality of life in patients with chronic respiratory failure and domiciliary ventilation]. / Traduction française et adaptation culturelle du questionnaire SRI. Questionnaire de qualité de vie liée à la santé des patients insuffisants respiratoires chroniques traités par ventilation à domicile.

INTRODUCTION: We performed the French translation and cross-cultural adaptation of the Severe Respiratory Insufficiency (SRI) questionnaire. Written and validated in German, this questionnaire evaluates health-related quality of life in patients treated with domiciliary ventilation for chronic respiratory failure. METHODS: Four bilingual German-French translators and a linguist were recruited to produce translations and back-translations of the questionnaire constituted of 49 items in seven domains. Two successive versions were generated and compared to the original questionnaire. The difficulty of the translation and the naturalness were quantified for each item using a 1-10 scale and their equivalence to their original counterpart was graded from A to C. The translated questionnaire was finally tested in a pilot study, which included 15 representative patients. RESULTS: The difficulty of the first translation and the first back-translation was respectively quantified as 2.5 (range 1-5.5) and 1.5 (range 1-6) on the 10-point scale (P=0.0014). The naturalness and the equivalence of 8/49 items were considered as insufficient, which led to the production of a second translation and a second back-translation. The meanings of two items needed clarification during the pilot study. CONCLUSION: The French translation of the SRI questionnaire represents a new instrument for clinical research in patients treated with domiciliary ventilation for chronic respiratory failure. Its validity needs to be tested in a multicenter study.

Interaction of angiotensin-converting enzyme and apolipoprotein E gene polymorphisms in ischemic stroke involving large-vessel disease.

A relationship between apolipoprotein E (Apo E) genotype and angiotensin-converting enzyme (ACE) insertion-deletion (Ins-Del) mutation and stroke was suggested. We investigated the association of Apo E4 and ACE Ins/Del genotypes with stroke risk and changes in serum lipids in 228 consecutive Tunisian stroke patients, and 323 age-and gender-matched controls. Comparable frequencies of ACE Ins/Del alleles were seen between patients and controls. The prevalence of Apo epsilon3 allele and Apo E3/E3 were lower (P < 0.001), while the frequency of Apo epsilon4 allele and epsilon4-containing genotypes (E3/E4 and E4/E4) were elevated (P < 0.001) among patients. Higher proportion of Apo E4-carrying + ACE Del/Del positive cases were seen in young (<50 years) patients (P = 0.012), and was associated with large vessel stroke (P = 0.035). Mean serum cholesterol, LDL, HDL, and triglycerides were comparable between E4-containing and no E4-containing and ACE Del/Del-positive patients. Apo E4 and ACE Del/Del genotype combination substantially increase stroke risk, supporting the notion that interactions of multiple gene variants influence stroke pathogenesis.

Meaning of arterio-venous PCO2 difference in circulatory shock.

The arterovenous difference in carbon dioxide tension (DeltaPCO2) can be calculated after simultaneous sampling of arterial blood (PaCO2) and of mixed venous blood from the distal of a pulmonary artery catheter (PvCO2). Under physiological conditions, DeltaPCO2 ranges from 2 to 5 mmHg. The DeltaPCO2 depends on carbon dioxide and cardiac output by a complex fashion. In this article, we detail the influence of these factors on DeltaPCO2 in normoxic conditions and in hypoxic conditions. We bring evidence that DeltaPCO2 cannot serve as a marker of tissue hypoxia contrary to what was initially thought. However, DeltaPCO2 can be considered as a marker of the adequacy of venous blood flow (i.e. cardiac output) to remove the total CO2 produced by the peripheral tissues. In this regard, the knowledge of DeltaPCO2 should help the clinicians for the decision of giving therapy aimed at increasing cardiac output.