Delayed awakening in neurocritical care.

Delayed awakening is defined as a persistent disorder of arousal or consciousness 48 to 72h after sedation interruption in critically ill patients. Delayed awakening is either a component of coma or delirium. It results in longer hospital stays and increased mortality. It is therefore a diagnostic, therapeutic and prognostic emergency. In severe brain injured patients, delayed awakening may be related to the primary neurological injury or to secondary systemic insults related to organ failure associated with intensive care. In the present review, we propose diagnostic, therapeutic and prognostic algorithms for managing delayed awaking in neuro-ICU brain injured patients.

Free-standing interconnected carbon nanofiber electrodes: new structural designs for supercapacitor application.

This work aims to develop and characterize a new design of free-standing interconnected carbon nanofiber electrodes for supercapacitor application. The fibers are obtained via carbonization of three components of electrospun nanofiber mats based on a polyacrylonitrile polymer (as a carbon backbone precursor), polyvinylalcohol (as a sacrificial copolymer), and 0-1.0 wt% multi-walled carbon nanotubes. Carbonizing these ternary composites results in fibers with about twice as large in surface area and one order of magnitude higher in electrical conductivity than those obtained by the carbonization of neat polyacrylonitrile and/or binary polyacrylonitrile-0-1.0 wt% carbon nanotube mats. The carbonized polyacrylonitrile-polyvinylalcohol-0.3 wt% carbon nanotube mat reveals the highest surface area and electrical conductivity and best capacitive performance. It exhibits energy and power densities of 27.8 Wh kg-1 and 110.59 kW kg-1, respectively, and cyclic stability of 95% after 2000 charge-discharge cycles at a charging current of 1.0 Ag-1. The nanotubes' alignment along the fiber's axis, the formation of fiber-fiber interconnected morphology with more mesopore pollution, and changes in the graphitization degree and defect features of fiber crystallites are the reasons for the observed increase in the electrical conductivity, surface area, and capacitive performance of the carbon fibers. Therefore, the new design represents a potential free-standing carbon nanofiber electrode for future electrochemical double layer capacitor (EDLC) device fabrication.

Life-threatening lactic acidosis occurring in adults with mitochondrial disorders.

Although relatively common in children, severe acute lactic acidosis is rare in adults with mitochondrial myopathies. We report here three cases, aged 27, 32 and 32 years, who developed life-threatening metabolic crisis with severe lactic acidosis, requiring hospitalisation in intensive care unit. Plasma lactates were elevated 10 to 15 fold normal values, necessitating extra-renal dialysis. By contrast CK levels were moderately increased (3 to 5N). No triggering factor was identified, but retrospectively all patients reported long-lasting mild muscle fatigability and weakness before their acute metabolic crisis. All of them recovered after prolonged intensive care but resting lactate levels remained elevated. Muscle biopsy showed ragged-red and COX-negative fibers in two patients and mild lipidosis in the third one. Heteroplasmic pathogenic point mutations were detected in MT-TL1 (m.3280G>A;m.3258C>T) and MT-TK (m.8363A>G). Life-threatening lactic acidosis may thus be a major inaugural clinical manifestation in adults with mitochondrial myopathies. Prolonged intensive care may lead to a dramatic and sustained improvement and is mandatory in such cases.

Mismatch negativity to predict subsequent awakening in deeply sedated critically ill patients.

BACKGROUND: Mismatch negativity (MMN) is the neurophysiological correlate of cognitive integration of novel stimuli. Although MMN is a well-established predictor of awakening in non-sedated comatose patients, its prognostic value in deeply sedated critically ill patients remains unknown. The aim of this prospective, observational pilot study was to investigate the prognostic value of MMN for subsequent awakening in deeply sedated critically ill patients. METHODS: MMN was recorded in 43 deeply sedated critically ill patients on Day 3 of ICU admission using a classical 'odd-ball' paradigm that delivers rare deviant sounds in a train of frequent standard sounds. Individual visual analyses and a group level analysis of recordings were performed. MMN amplitudes were then analysed according to the neurological status (awake vs not awake) at Day 28. RESULTS: Median (inter-quartile range) Richmond Assessment Sedation Scale (RASS) at the time of recording was -5 (range, from -5 to -4.5). Visual detection of MMN revealed a poor inter-rater agreement [kappa=0.17, 95% confidence interval (0.07-0.26)]. On Day 28, 30 (70%) patients had regained consciousness while 13 (30%) had not. Quantitative group level analysis revealed a significantly greater MMN amplitude for patients who awakened compared with those who had not [mean (standard deviation) = -0.65 (1.4) vs 0.08 (0.17) µV, respectively; P=0.003). CONCLUSIONS: MMN can be observed in deeply sedated critically ill patients and could help predict subsequent awakening. However, visual analysis alone is unreliable and should be systematically completed with individual level statistics.

Assessment of elemental and NROM/TENORM hazard potential from non-nuclear industries in North Sinai, Egypt.

Non-nuclear industries use raw materials containing significant levels of naturally occurring radioactive material (NORM). The processing of these materials may expose workers engaged in or even people living near such sites to technologically enhanced naturally occurring radioactive material (TENORM) above the natural background. Inductively coupled plasma and gamma ray spectrometry have been used to determine major and trace elements and radionuclide concentrations in various samples, respectively, in order to investigate the environmental impact of coal mining and cement plant in North Sinai, Egypt. Generally, very little attention was directed to the large volumes of waste generated by either type of industrial activities. Different samples were analyzed including various raw materials, coal, charcoal, Portland and white cement, sludge, and wastes. Coal mine and cement plant workers dealing with waste and kaolin, respectively, are subjected to a relatively high annual effective dose. One of the important finding is the enhancement of all measured elements and radionuclides in the sludge found in coal mine. It may pose an environmental threat because of its large volume and its use as combustion material. The mine environment may have constituted Al, Fe, Cr, and V pollution source for the local area. Higher concentration of Al, Fe, Mn, B, Co, Cr, Mn, Ni, Sr, V, and TENORM were found in Portland cement and Zn in white cement. Coal has higher concentrations of Al, Fe, B, Co, Cr, and V as well as (226)Ra and (232)Th. The compiled results from the present study and different worldwide investigations demonstrate the obvious unrealistic ranges normally used for (226)Ra and (232)Th activity concentrations in coal and provided ranges for coal, Portland and white cement, gypsum, and limestone.

Increased incidence of Campylobacter jejuni-associated Guillain-Barré syndromes in the Greater Paris area.

The role of Campylobacter jejuni as the triggering agent of Guillain-Barré syndrome (GBS) has not been reassessed since the end of the 1990s in France. We report that the number of C. jejuni-related GBS cases increased continuously between 1996 and 2007 in the Paris region (mean annual increment: 7%, P = 0·007).

Home-based exercise in autoimmune myasthenia gravis: A randomized controlled trial.

The tolerance of exercise and its effects on quality of life in myasthenia gravis are not currently backed up by strong evidence. The aim of this study was to determine whether exercise as an adjunct therapy is well tolerated and can improve health-related quality of life (HRQoL) in stabilized, generalized autoimmune myasthenia gravis (gMG). We conducted a parallel-group, multi-center prospective RCT using computer-generated block randomization. Adults with stabilized, gMG, and no contra-indication to exercise, were eligible. Participants received usual care alone or usual care and exercise. The exercise intervention consisted of 3-weekly 40 min sessions of an unsupervised, moderate-intensity home rowing program over 3 months. The primary endpoint was the change in HRQoL from randomization to post-intervention. Assessor-blinded secondary endpoints were exercise tolerance and effects on clinical, psychological and immunological status. Of 138 patients screened between October 2014 and July 2017, 45 were randomly assigned to exercise (n = 23) or usual care (n = 20). Although exercise was well tolerated, the intention-to-treat analysis revealed no evidence of improved HRQoL compared to usual care (MGQOL-15-F; mean adjusted between-groups difference of -0.8 points, 95%CI -5.4 to 3.7). Two patients hospitalized for MG exacerbation were from the usual care group.

Immunosuppressant drugs for myasthenia gravis.

Along with corticosteroids, immunosuppressant drugs are mainstays of disease-modifying therapy for myasthenia gravis (MG). However, their efficacies and optimum use are unclear. We identified seven randomised controlled trials (RCT) of immunosuppressants in generalised MG that qualified for Cochrane Review: (1) azathioprine plus initial prednisolone versus prednisolone; (2) azathioprine plus prednisolone versus prednisolone plus placebo; (3) ciclosporin versus placebo (4) ciclosporin plus prednisolone versus prednisolone plus placebo; (5) cyclophosphamide plus prednisolone versus prednisolone plus placebo; (6) mycophenolate mofetil (MMF) alone or plus either ciclosporin or prednisolone versus placebo alone or plus either ciclosporin or prednisolone; (7) tacrolimus plus corticosteroids with or without plasma exchange versus corticosteroids with or without plasma exchange. All trials were small (14 to 41 participants) and their designs heterogeneous. The RCT evidence, albeit limited, was that ciclosporin (alone or with corticosteroids) or cyclophosphamide (with corticosteroids) improved MG significantly within 1 year compared with placebo. There was no clear evidence of benefit for azathioprine, MMF, or tacrolimus within 1 year. Larger, better-designed, longer trials are needed.

Tongue weakness is associated with respiratory failure in patients with severe Guillain-Barré syndrome.

OBJECTIVE: Swallowing impairment may worsen respiratory weakness and conduct to respiratory complications such as aspiration pneumonia in Guillain-Barré syndrome (GBS). We prospectively evaluate how tongue weakness could be associated to bulbar dysfunction and respiratory weakness in severe GBS patients. MEASUREMENTS AND MAIN RESULTS: Tongue strength, dysphagia and respiratory parameters were measured in 16 GBS patients at intensive care unit (ICU) admission and discharge and in seven controls. Tongue strength was decreased in the GBS patients compared with the controls. At admission, patients with dysphagia and those requiring mechanical ventilation (MV) had greater tongue weakness. All the patients with initial tongue strength <150 g required MV during ICU stay. Tongue strength correlated significantly with respiratory parameters. CONCLUSION: This study confirms the strong association between bulbar and respiratory dysfunction in GBS admitted to ICU. Tongue weakness may be present in GBS, especially during the phase of increasing paralysis, and resolves during the recovery phase. Tongue strength and indices of global and respiratory strength vary in parallel throughout the course of GBS. Further studies are needed to assess if, when used in combination with other respiratory tests, tongue strength measurement could contribute to identify patients at high risk for respiratory complications.

Immunosuppressive agents for myasthenia gravis.

BACKGROUND: The benefits of different immunosuppressants for myasthenia gravis (MG) are unclear. OBJECTIVES: Assessment of immunosuppressant drug efficacy in MG. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to July 2007), EMBASE (from January 1980 to July 2007), review and trial bibliographies and contacted trial authors. SELECTION CRITERIA: Types of studies: Randomised and quasi-randomised controlled trials. TYPES OF PARTICIPANTS: Any age, any type or severity of MG regardless of concomitant treatment. Types of interventions: Any immunosuppressive agent. Types of outcome measures: Primary: (1) Improvement or not at six months. Secondary: (1) Improvement or not at one year (2) Need for other treatment, for example corticosteroid dose, at six months (3) Number of exacerbations during the first year (4) Acetylcholine receptor antibody titre after at least six months (5) Occurrence of one or more adverse events at any time after the introduction of treatment. DATA COLLECTION AND ANALYSIS: One author extracted and two checked the data. MAIN RESULTS: Seven trials are included but few reported the outcomes selected for this review. A meta-analysis of ciclosporin versus placebo from two trials (59 participants) - one as monotherapy (20 participants) and the other with corticosteroids (39 participants) - showed that it resulted in improvement of participants in the ciclosporin group compared with those in the placebo group, with a relative rate of improvement of 2.44 (95% confidence interval (CI) 1.13 to 5.27). In addition the weighted mean difference in QMG score between the ciclosporin and placebo groups was -0.34 (95% CI -0.52 to -0.17). Azathioprine (plus prednisolone for first month) had no significant benefit over prednisolone alone (41 participants). The effects of azathioprine plus prednisolone versus prednisolone plus placebo were similar (34 participants). Cyclophosphamide was reported to be statistically more efficacious than placebo at 12 months in corticosteroid-dependent participants (23 participants), but no raw data were available. Trials of mycophenolate mofetil and tacrolimus did not provide relevant endpoint data for this review. All trials had low numbers of participants. Adverse event reporting was variable. Trial protocol heterogeneity prevented comparison of the different immunosuppressants. AUTHORS' CONCLUSIONS: In generalised MG, limited evidence from small RCTs suggests that ciclosporin, as monotherapy or with corticosteroids, or cyclophosphamide with corticosteroids, significantly improve MG.Limited evidence from RCTs shows no significant benefit from azathioprine (as monotherapy or with steroids), mycophenolate mofetil (as monotherapy or with either corticosteroids or ciclosporin) or tacrolimus (with corticosteroids or plasma exchange). Bigger, better-designed, longer trials are needed.

Distribution of gamma-ray emitting radionuclides in the environment of Burullus Lake: I. Soils and vegetations.

The concentrations and distribution of gamma-ray emitting isotopes in Burullus Lake were investigated with the aim of evaluating the environmental radioactivity. Particularly in wetlands, natural properties of the environment can cause the actual inventory to be different from the activity originally deposited. The mean concentrations of (226)Ra, (232)Th and (40)K were 14.3, 15.5 and 224 Bq/kg, respectively, in the coastal soils. On the other hand, soil samples from the islands had mean concentrations of 13.5, 17.4 and 341 Bq/kg for (226)Ra, (232)Th and (40)K, respectively. Samples from coast and islands show evidence of possible transfer and accumulation of the (137)Cs radionuclide. The mean (137)Cs activity concentrations in the soil samples were 1.2 and 15.1 Bq/kg in the coast and islands, respectively. The vertical migration of (137)Cs was studied based on its content in the consequently located three soil layers down to 30 cm depth. The radium equivalent, dose rate in air and annual dose equivalent from the terrestrial natural gamma-radiation were evaluated. The mean activity concentrations of the gamma-ray emitting radionuclides in vegetation were relatively low.

Optical and positron annihilation spectroscopic studies on PMMA polymer doped by rhodamine B/chloranilic acid charge transfer complex: Special relevance to the effect of γ-ray irradiation.

Polymeric sheets of poly (methylmethaclyerate) (PMMA) containing charge transfer (CT) complex of rhodamine B/chloranilic acid (Rho B/CHA) were synthesized in methanol solvent at room temperature. The systematic analysis done on the Rho B and its CT complex in the form of powder or polymeric sheets confirmed their structure and thermal stability. The IR spectra interpreted the charge transfer mode of interaction between the CHA central positions and the terminal carboxylic group. The polymer sheets were irradiated with 70 kGy of γ radiation using (60)Co source to study the enhanced changes in the structure and optical parameters. The microstructure changes of the PMMA sheets caused by γ-ray irradiation were analyzed using positron annihilation lifetime (PAL) and positron annihilation Doppler broadening (PADB) techniques. The positron life time components (τ(i)) and their corresponding intensities (I(i)) as well as PADB line-shape parameters (S and W) were found to be highly sensitive to the enhanced disorder occurred in the organic chains of the polymeric sheets due to γ-irradiation.

Titin antibodies in "seronegative" myasthenia gravis--A new role for an old antigen.

Myasthenia gravis (MG) is an autoimmune disease caused by antibodies targeting the neuromuscular junction of skeletal muscles. Triple-seronegative MG (tSN-MG, without detectable AChR, MuSK and LRP4 antibodies), which accounts for ~10% of MG patients, presents a serious gap in MG diagnosis and complicates differential diagnosis of similar disorders. Several AChR antibody positive patients (AChR-MG) also have antibodies against titin, usually detected by ELISA. We have developed a very sensitive radioimmunoprecipitation assay (RIPA) for titin antibodies, by which many previously negative samples were found positive, including several from tSN-MG patients. The validity of the RIPA results was confirmed by western blots. Using this RIPA we screened 667 MG sera from 13 countries; as expected, AChR-MG patients had the highest frequency of titin antibodies (40.9%), while MuSK-MG and LRP4-MG patients were positive in 14.6% and 16.4% respectively. Most importantly, 13.4% (50/372) of the tSN-MG patients were also titin antibody positive. None of the 121 healthy controls or the 90 myopathy patients, and only 3.6% (7/193) of other neurological disease patients were positive. We thus propose that the present titin antibody RIPA is a useful tool for serological MG diagnosis of tSN patients.

Characteristics, spatial distribution and vertical profile of gamma-ray emitting radionuclides in the coastal environment of North Sinai.

Radionuclide concentrations of beach and dune sand from various sites in Al-Arish city and surrounding area, North Sinai, Egypt, were measured. The sampling sites included locations in the local harbor, Al-Arish valley and Zaranik protected area. The results indicate that the activities of the products of (232)Th and (226)Ra series in samples from the harbor and along the beach were higher than those from non-coastal sites. The activity concentrations of (232)Th for beach sand ranged from 2.3 to 506.5 Bq/kg with an average of 83.4 Bq/kg, while that for dune sand ranged from 2.2 to 15.1 Bq/kg with an average of 6.4 Bq/kg. The average activity concentration of (226)Ra for beach sand was 56.0 Bq/kg (2.9-261.5 Bq/kg), while that for dune sand was 6.5 Bq/kg (3.0-14.7 Bq/kg). The average activity concentrations of (40)K for beach and dune sand were 88.1 Bq/kg and 178.4 Bq/kg, respectively. Six depth profiles in the harbor area were measured up to a depth of 1m within more than two years. These sets of measurements allowed the determination of the migration rate of black sand to be 0.094 cm/day. Samples with the smallest grain size (<0.2 mm) were found to have the highest level of activities, which were attributed to their high content of black sand. No risk exists for public health based on the calculated effective dose equivalent and the recommended limit of 5 mSv/y. On the other hand, local children and adults may receive doses higher than this recommended limit in two locations in the Zaranik protected area according to a model developed in this study.

[Neuromuscular abnormalities in critical illness]. / Neuvièmes Journées des Maladies du Système Nerveux Périphérique.

Critical illness neuromuscular abnormalities (CINMA) are found in 25 percent of ITU patients who recover consciousness and are characterized by a bilateral and symmetric weakness that involves the four limbs but spares the facial muscles. Electrophysiological testing shows an axonal sensory motor polyneuropathy and/or myopathy. The main risk factors of CINMA are prolonged durations of multiple organ failure and mechanical ventilation, use of corticosteroids and hyperglycaemia. CINMA contribute also to increase the duration of mechanical ventilation, this effect being mediated by diaphragm weakness. The median duration of limb weakness is 21 days, although it can exceed several months in some patients. Few preventive measures have been assessed. Whether the benefit of strict blood glucose control in ITU patients recovering from heart surgery on CINMA incidence can be extended to medical ICU patients needs to be determined.

[Long term domiciliary mechanical ventilation in patients with neuromuscular disease (indications, establishment and follow up)]. / Ventilation mécanique a domicile et au long cours des patients neuromusculaires (indication, mise en place et surveillance).

UNLABELLED: Neuromuscular diseases represent a heterogeneous group of pathologies which common feature is the development of a restrictive ventilatory failure. BACKGROUND: Respiratory insufficiency of neuromuscular origin manifests itself by functional symptoms that must be carefully searched for in the history, such as headaches, sleep disorders, or dyspnoea of effort, sometimes very mild, or in severe cases associated with orthopnoea. Follow up should be multi-disciplinary. On the respiratory level regular measurement of blood gases, vital capacity, maximum inspiratory and expiratory pressures as well as sleep studies, will detect the criteria for mechanical ventilation (hypercarbia > 45 mm Hg, nocturnal desaturation < 88%, vital capacity < 60%, PImax < 60 cm H2O). STATE OF THE ART: The establishment of mechanical ventilation is a major decision for patients with neuromuscular disease because of the important physical, psychological, social and sometimes financial consequences. The patients and their family must be instructed precisely in order to obtain the best possible observation and compliance. The establishment requires a stay in hospital of several days to optimise the choice of ventilator, its settings, and connections. The link with the organisation managing the domiciliary ventilation is fundamental in ensuring follow up after discharge from hospital. Techniques of cough assistance must be taught to each neuromuscular patient requiring mechanical ventilation. CONCLUSION: Ventilation of neuromuscular patients requires careful evaluation of the indications and rigorous follow up by a multidisciplinary team with wide experience of this type of disease.

Study of chemical bonding, physical and biological effect of metformin drug as an organized medicine for diabetes patients with chromium(III) and vanadium(IV) ions.

New vanadium(IV) and chromium(III) complexes of metformin (MFN) were synthesized upon the chemical interaction between vanadyl(II) sulfate monohydrate or chromium(III) chloride hexahydrate with metformin diabetic drug in the media of a pure grade of methanol solvent. The [(VO)2(MFN)2(SO4)2]2H2O and [Cr(MFN)3]·Cl3·6H2O complexes were discussed using microanalytical measurements, molar conductance, spectroscopic (infrared, ESR, XRD, and UV-vis), effective magnetic moment, scanning electron microscopy (SEM), and thermal analyses (TG/DTG). The elemental analysis shows that VO(II) and Cr(III) complexes were associated with 1:1 and 1:3M ratios, respectively. The infrared spectroscopic results data received from the comparison between free MFN free ligand and their vanadyl(II) and chromium(III) complexes were proven that metformin reacted with respected metal ions as a bidentate ligand through its two imino groups. The kinetic thermodynamic parameters were estimated from the DTG curves. The microstructure changes of the VO(II) and Cr(III) complexes have been probed using positron annihilation lifetime (PAL) and positron annihilation Doppler broadening (PADB) techniques. The PAL and PADB line-shape parameters were found to be dependent on the structure, electronic configuration and molecular weight of metal complexes. Antimicrobial activity of the metformin free ligand and its vanadyl(II) and chromium(III) complexes were evaluated against the gram negative and gram positive bacteria strains and different fungal strains. Moderate antimicrobial activity recorded by disk diffusion inhibition growth zone method in vanadyl(II) and chromium(III) complexes compared to metformin free ligand.

Sepsis induces long-term metabolic and mitochondrial muscle stem cell dysfunction amenable by mesenchymal stem cell therapy.

Sepsis, or systemic inflammatory response syndrome, is the major cause of critical illness resulting in admission to intensive care units. Sepsis is caused by severe infection and is associated with mortality in 60% of cases. Morbidity due to sepsis is complicated by neuromyopathy, and patients face long-term disability due to muscle weakness, energetic dysfunction, proteolysis and muscle wasting. These processes are triggered by pro-inflammatory cytokines and metabolic imbalances and are aggravated by malnutrition and drugs. Skeletal muscle regeneration depends on stem (satellite) cells. Herein we show that mitochondrial and metabolic alterations underlie the sepsis-induced long-term impairment of satellite cells and lead to inefficient muscle regeneration. Engrafting mesenchymal stem cells improves the septic status by decreasing cytokine levels, restoring mitochondrial and metabolic function in satellite cells, and improving muscle strength. These findings indicate that sepsis affects quiescent muscle stem cells and that mesenchymal stem cells might act as a preventive therapeutic approach for sepsis-related morbidity.

MuSK autoantibodies in myasthenia gravis detected by cell based assay--A multinational study.

Seronegative myasthenia gravis (MG) presents a serious gap in MG diagnosis and understanding. We applied a cell based assay (CBA) for the detection of muscle specific kinase (MuSK) antibodies undetectable by radioimmunoassay. We tested 633 triple-seronegative MG patients' sera from 13 countries, detecting 13% as positive. MuSK antibodies were found, at significantly lower frequencies, in 1.9% of healthy controls and 5.1% of other neuroimmune disease patients, including multiple sclerosis and neuromyelitis optica. The clinical data of the newly diagnosed MuSK-MG patients are presented. 27% of ocular seronegative patients were MuSK antibody positive. Moreover, 23% had thymic hyperplasia suggesting that thymic abnormalities are more common than believed.