Remote neurological evaluation reliably identifies patients eligible to endovascular therapy while non-eligible to intravenous thrombolysis.

INTRODUCTION/BACKGROUND: Early identification of suspected stroke patients who might be eligible for a reperfusion strategy is a daily challenge in the management of patient referrals. The aim of this study was to evaluate the performance of a remote medical assessment in identifying patients eligible for endovascular therapy (EVT) while not eligible for intravenous thrombolysis (IVT), compared with a decision based on bedside clinico-radiological data. METHODS: Patients admitted to the emergency department for acute neurological symptoms lasting for less than 24h were prospectively included. Assessment of the clinical severity and medical history was performed simultaneously by two vascular neurologists (VNs), one remotely using a mobile telemedicine solution (NOMADEEC), the other at the bedside. RACE score was calculated from the NIHSS score. At the end of the evaluation, both VNs quoted their treatment convictions (IVT/EVT). Final therapeutic decision following brain and vascular imaging was recorded and compared to remote and bedside predictions. The performances of three different conditions were evaluated: complete medical evaluation (NIHSS+medical history), NIHSS score alone, and RACE score alone. Remote and bedside performances were also compared. Diagnostic accuracy parameters (sensitivity, specificity, positive and negative predictive values) of each condition were estimated, along with their two-sided 95% binomial confidence intervals. RESULTS: Out of 215 enrolled patients, 186 had a complete evaluation, 91 (54.3%) were diagnosed with an ischemic stroke or transient ischemic attack and 46 (24.7%) had an intracranial occlusion. Considering the three conditions evaluated remotely, RACE score-based decision provided the best sensitivity 54.6% [95% CI 23.4; 83.2]/specificity 80.6% [73.9; 86.2] combination. However, the complete medical evaluation had the best specificity (88.6% [82.9; 92.9] compared to RACE scores alone (P=0.038). Remote and bedside performances did not differ (κ=0.68 [0.59; 0.77]). DISCUSSION/CONCLUSION: This real-life study performed in the setting of emergency demonstrates that remote medical evaluations including recording of extensive medical information and NIHSS examination to address patient's eligibility to revascularization treatment is swiftly feasible and is as effective as bedside prediction to EVT and/or IVT. Remote standardized medical evaluation might improve the decision of patients' primary orientation and avoid overcrowding of comprehensive stroke centres.

Important oral care needs of older French people: A cross-sectional study.

BACKGROUND: Older persons comprise a growing proportion of the European population and may have a distinct epidemiological oral profile requiring specific preventive and curative care poorly documented. The objectives of this study were to assess the oral health status of people ≥90 years of age in France, to compare their perceived and observed oral care needs and to investigate the oral problems associated with a low oral health-related quality-of-life (OHRQoL). METHODS: An oral cross-sectional study was performed during the 25th follow-up of a cohort of older persons being followed up prospectively for screening of dementia over a 15-year period in Gironde and Dordogne, France. Clinical oral indices were determined by oral examinations conducted at the participants' place of living. Cohen's Kappa coefficient was used to assess the agreement between perceived and observed oral care needs. Oral problems associated with a low OHRQoL, measured with the Geriatric Oral Health Assessment Index (GOHAI<50) were investigated with logistic regression. Odds ratios (OR) were estimated with their 95% confidence intervals (CI). RESULTS: Data from 90 persons were analysed (76% female; median age=93 years; 20% living in an institution). Plaque and calculus were present in 93% and 58% respectively, of the 74 dentate participants. The mean number of decayed, missing, and filled teeth was 26.5 (±5.3); 66% of the participants had at least one untreated decayed tooth. Among the 85 participants with tooth loss not replaced by a fixed denture, two thirds had a removable dental prosthesis; 84% of these prostheses were considered to be maladapted. Among the 39 participants who felt unable to consult a dentist (43%), lack of transportation was the most frequently cited reason. Although 88% of the participants needed oral care, only 26% perceived that they had such a need (Kappa=0.06). Oral problems associated with a GOHAI<50 were the absence of posterior occluding teeth (OR=7.15; 95%CI=1.53-33.35; P=0.012), feeling of dry mouth (OR=11.94; 95%CI=3.21-44.39; P=0.0002) and oral pain (OR=9.06; 95%CI=1.91-69.00; P=0.033). CONCLUSIONS: Persons ≥90 years of age have considerable preventive and curative dental care needs that impact their quality-of-life but they are rarely aware and lack transportation. NCT04065828.

Liver-related deaths in HIV-infected patients between 1995 and 2010 in France: the Mortavic 2010 study in collaboration with the Agence Nationale de Recherche sur le SIDA (ANRS) EN 20 Mortalité 2010 survey.

OBJECTIVES: The aim of this study was to describe the proportion of liver-related diseases (LRDs) as a cause of death in HIV-infected patients in France and to compare the results with data from our five previous surveys. METHODS: In 2010, 24 clinical wards prospectively recorded all deaths occurring in around 26 000 HIV-infected patients who were regularly followed up. Results were compared with those of previous cross-sectional surveys conducted since 1995 using the same design. RESULTS: Among 230 reported deaths, 46 (20%) were related to AIDS and 30 (13%) to chronic liver diseases. Eighty per cent of patients who died from LRDs had chronic hepatitis C, 16.7% of them being coinfected with hepatitis B virus (HBV). Among patients who died from an LRD, excessive alcohol consumption was reported in 41%. At death, 80% of patients had undetectable HIV viral load and the median CD4 cell count was 349 cells/µL. The proportion of deaths and the mortality rate attributable to LRDs significantly increased between 1995 and 2005 from 1.5% to 16.7% and from 1.2‰ to 2.0‰, respectively, whereas they tended to decrease in 2010 to 13% and 1.1‰, respectively. Among liver-related causes of death, the proportion represented by hepatocellular carcinoma (HCC) dramatically increased from 5% in 1995 to 40% in 2010 (p = 0.019). CONCLUSIONS: The proportion of LRDs among causes of death in HIV-infected patients seems recently to have reached a plateau after a rapid increase during the decade 1995-2005. LRDs remain a leading cause of death in this population, mainly as a result of hepatitis C virus (HCV) coinfection, HCC representing almost half of liver-related causes of death.

Risk factors for colonization and infection by Pseudomonas aeruginosa in patients hospitalized in intensive care units in France.

OBJECTIVE: To assess the role of environment, medical care and individual risks factors for P. aeruginosa colonization and infection. STUDY DESIGN AND SETTING: A French multicentric prospective study involved ten ICUs for a five months period. Every adult patient newly hospitalized in ICUs with no P. aeruginosa carriage up to 48 hours after admission was included and weekly screened before discharge or death. Screening swabs were either rectal, sputum or oropharyngeal samples. Hydric environment was also sampled each week. Data on patient clinical features, environmental and device exposures, and antibiotics supports were regularly collected. Multivariate analysis was performed with a multistate model. RESULTS: The overall prevalence of P. aeruginosa carriage was 15.3% (201/1314). Risk factors associated with patient colonization were: use of inactive antibiotics against P. aeruginosa (HR = 1.60 [1.15-2.21] p<0.01), tap water contamination at the entry in the room (HR = 1.66 [1.01-2.27] p<0.05) and mechanical invasive ventilation (HR = 4.70 [2.66-8.31] p<0.0001). Active antibiotics prevented from colonization (HR = 0.67 [0.48-0.93] p = 0.02) and from infection (HR = 0.64 [0.41-1.01] p = 0.05). Interaction between hydric environment antibiotics support was not statistically associated with patient colonization. CONCLUSION: Hydric contamination and antibiotics pressure seem to remain key independent risk factors in P. aeruginosa colonization. These results advocate the need to carry on preventive and targeted interventions toward healthcare associated infections.

Narcolepsy associated with arteriovenous malformation of the diencephalon.

Narcolepsy associated with localized brain lesions is rare, and few reports of well-documented cases have been published. We describe the case of a 20-year-old male (HLA DQw1 negative) who fulfilled clinical and polygraphic criteria of symptomatic narcolepsy. Narcolepsy in this patient was associated with an arteriovenous malformation involving the structures around the third ventricle. Clinical symptoms improved after embolization and radiosurgery. These findings support the hypothesis that lesions in the vicinity of the third ventricle can cause symptomatic narcolepsy.

Benign intracranial hypertension and disorders of CSF absorption.

Sixteen patients suffering from benign intracranial hypertension were studied by a continuous measurement of intraventricular pressure, a simultaneous recording of intraventricular and sagittal sinus pressures, and a measurement of the cerebrospinal fluid (CSF) resistance to drainage. Isotope cisternography was performed and the patency of the dural sinuses verified by direct sinography or phlebography or both. The same procedure was used to study 6 other patients suffering from disorders leading to the same type of intracranial hypertension. In 16, our results confirm a defect in CSF absorption mechanisms linked to an abolition of the pressure gradient between CSF and sagittal sinus in 6 patients, as well as an important increase in CSF resistance to drainage in 10 others. Despite this defect, the CSF circulation was normal in most patients (10 of 12) as demonstrated by isotope cisternography.

Intracranial pressure with intracerebral hemorrhages.

Intracranial pressure was recorded continuously during an average of 15 days in 17 patients suffering from primary intracerebral hemorrhage. In 12 cases the highest pressures were recorded just after the stroke; then the intracranial pressure decreased and became normal in an average of 20-30 days. Other patterns of evolution were less often observed: a rapid and lethal elevation of pressure in one case, a constantly low pressure in two, and a stagnant evolution with moderate hypertension in two others. Secondarily developing intracranial hypertension was never observed during the monitoring period. Evacuation of the clots was performed in six patients. This only slightly shortened the course of the increased intracranial pressure. It is concluded that intracerebral hematoma appears as an expanding lesion only during the time of its formation. The prognosis depends more upon the destructions by the hemorrhage than upon the increased pressure. Nevertheless, true hypertension is possible. Knowledge of intracranial pressure in the course of intracerebral hemorrhage is important in deciding whether the treatment is to be surgical or conservative. Measurements of the intracranial pressure in our practice has reduced the number of interventions, with identical or slightly improved results.

[Resistance in cerebrospinal fluid flow in normal pressure hydrocephalus]. / La résistance à l'écoulement du liquide céphalo-rachidien dans l'hydrocéphalie à pression normale

C.S.F. resistance to flow (Rf) was measured in 24 patients by the mean of a constant infusion manometric test, and the results were compared with those of pneumo-encephalography and isotope cisternography. It is concluded that Rf is constantly elevated in patients with normal pressure hydrocephalus, is at least as reliable as the two other tests and therefore provides a really valuable aid to the identification of the patients to be shunted.

[Dissection of the vertebral arteries after manipulation of the cervical spine. Apropos of a case]. / Dissection des artères vertébrales après manipulation du rachis cervical. A propos d'un cas.

Dissecting aneurysm of the vertebral arteries following chiropractic manipulation of the spine. A thirty-five years old man had a Wallenberg Syndrome following chiropractic manipulation of the spine. Plain films and hypocycloidal tomography showed a foramen arcuale on both side. Arteriography lead to the diagnosis of dissecting aneurysm of the vertebral arteries. The favourable course point to the value of the posterior communicating arteries and the spinal artery as collateral pathways of the vertebro-basilar circulation.

[Neurologic manifestations of basal cell nevomatosis. A case]. / Manifestations neurologiques de la naevomatose baso-cellulaire. Un cas.

The naevoid basal cell syndrome, also called Gorlin's syndrome, is a dysembryoplasia akin to the phakomatoses and which may affect the skin, the bones, the nervous system, the eyes, the endocrine glands and the genitalia. A case with numerous tumours and malformations is presented, together with a review of the literature.

[Benign paralysis of the last 4 cranial nerves. Arguments in favor of an ischemic mechanism]. / Paralysie bénigne des quatre derniers nerfs crâniens. Arguments en faveur d'un mécanisme ischémique.

The last four cranial nerves are fed by the ascending pharyngeal artery, a branch of the external carotid artery. The fact that paralysis of these nerves may occur immediately after arteriography of the external carotid artery demonstrates that ischaemic truncular neuropathies do exist. The deficit is sudden and usually regressive. Ischaemia may account for regressive paralysis of these nerves reported in diabetes, herpes zoster and after some traumas. Apparently idiopathic and benign paralysis might be due to the same mechanism. All 4 nerves may be affected, or only the IXth, Xth and XIth nerves, or the XIth nerve may be spared, being fed by two arteries. Apart from the obvious case of arteriographic accident, the diagnosis of paralysis of ischaemic origin can only be made after other causes, notably compression, have been excluded, since direct evidence of arterial obstruction is exceptionally obtainable; regression at follow-up is a major argument in favour of ischaemia.

Benign intracranial hypertension. A clinical evaluation of the CSF absorption mechanisms.

Fifteen patients suffering from Benign Intracranial Hypertension due to various causes were investigated by measuring the CSF resistance to flow, and the pressure difference between the CSF and the sagittal sinus. Isotope cisternography was also performed, and the patency of the dural sinuses was checked by both sinography and phlebography. In twelve the results confirm a defect in the resorption mechanism, the nature of which proved to be venous in six, and linked to impairment of subarachnoid villi in six others. Three patients could not be classified. The significance of normal isotope cisternography is discussed.

Primary empty sella turcica in children. Report of two familial cases.

The authors describe cranio-facial deformities found in two sisters and associated with spinal anomalies, short stature and delayed skeletal maturation. The principal radiological features were an enlarged J-shaped sella turcica and intrasellar cisternal herniation. Enlargement of optic foramina and internal acoustic canals were also present. These asymptomatic cases of "empty sella" seem to be part of a general dysplastic syndrome rather than a local disease.

[Acute parasellar compression syndrome disclosing hypophyseal adenoma. 3 cases]. / Syndrome de compression parasellaire brutale révélateur d'adénome hypophysaire. Trois observations.

Three cases of acute necrosis of a hypophyseal adenoma are reported with a review of the medical literature. The clinical presentation as an acute parasellar compression syndrome was the result of aseptic meningitis in 2 cases and of cavernous sinus thrombosis in the other; the usual symptoms of headaches, oculomotor paralysis and impairment of consciousness were observed. The diagnosis was suspected on clinical grounds, by the radiological changes of the pituitary fossa and confirmed by computerised axial tomography. All three patients had a favourable outcome. Surgery was only required in one case with threatening visual complications. Dissociated anterior pituitary deficiency persisted in all cases; two patients also had diabetes insipidus. In one case, the pituitary necrosis stabilised an acromegaly for a two year period.