Late Functional Changes Post-Severe Traumatic Brain Injury Are Related to Community Reentry Support: Results From the PariS-TBI Cohort.

OBJECTIVES: To explore late functional changes after a traumatic brain injury and their relation to patients' characteristics and reentry support. DESIGN: Prospective follow-up of an inception cohort of adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France. One and 4-year assessments were performed by trained neuropsychologists. One-to-4-year change in the Glasgow Outcome Scale-Extended defined 3 groups: "improvement," "stability," and "worsening." Relationships between these groups and patients' characteristics were analyzed. RESULTS: Among 504 recruited patients and 245 four-year survivors, 93 participated in both evaluations. Overall Glasgow Outcome Scale-Extended improved by 0.4. Forty percent of the sample improved, 44% were stable, and 16% worsened. Being in a more unfavorable group was related to preinjury alcohol abuse and to higher anxiety and depression at 4 years. Attendance to a specialized community reentry unit was related to higher chances of being in the "improvement" group in univariate analyses and after adjustment for age, time to follow command, preinjury alcohol and occupation, and mood disorders (adjusted odds ratio [OR] = 4.6 [1.1-20]). CONCLUSION: Late functional changes were related to psychosocial variables and to reentry support. The effect of reentry support on late recovery needs to be confirmed by further investigations.

Prevalence of traumatic brain injury and epilepsy among prisoners in France: Results of the Fleury TBI study.

OBJECTIVE: The first aim of this study was to estimate the prevalence of TBI and epilepsy in a French prison population and to study variables known to be associated with TBI. The second aim was to compare prisoners with and without a history of TBI. PARTICIPANTS: All offenders (females, males and juveniles) admitted consecutively to Fleury-Mérogis prison over a period of 3 months were included in the study. DESIGN: During the admission procedure, offenders were interviewed by healthcare staff using a self-reported questionnaire. RESULTS: In all, 1221 prisoners were included. The rates of TBI and epilepsy were high, with a prevalence of 30.6% and 5.9%, respectively. Psychiatric care, anxiolytic and antidepressant treatment, use of alcohol and cannabis were all significantly higher among offenders with a history of TBI. Moreover, the number of times in custody and the total time spent in jail over the preceding 5 years were significantly higher among offenders with a history of TBI. CONCLUSIONS: These results provide further evidence that specific measures need to be developed such as, first of all, screening for TBI upon arrival in prison.

[Muscle, tendon and joint injections : What is the evidence?]. / Injektionen an Muskeln, Sehnen und Gelenken : Was ist die Evidenz?

Injections at tendon insertions, in muscles and in joints are an important instrument in the conservative treatment of musculoskeletal diseases, for acute injuries as well as for chronic degenerative diseases. Local anesthetic agents and glucocorticoids are well-established medications; however, severe side effects, such as chondrolysis have sometimes been reported, particularly for local anesthetic agents. In addition platelet rich plasma (PRP) and hyaluronic acid are also widely used; however, the clinical effectiveness has not always been proven. This article gives an overview on the most commonly used medications for injections and the mechanisms of action. The indications for treatment and the evidence for the clinical adminstration of muscle, tendon and joint injections are described based on the currently available literature.

[Antiplatelet therapy after acute coronary syndrome. Therapeutic strategies and treatment duration]. / Antithrombozytäre Therapie nach akutem Koronarsyndrom. Differenzialtherapie und Dauer.

Besides percutaneous coronary interventions, antiplatelet drugs are of overwhelming importance for patients with acute coronary syndrome (ACS). For ACS patients, the guidelines recommend treatment with acetylsalicylic acid and a P2Y12 receptor antagonist. The third generation P2Y12 receptor antagonists prasugrel and ticagrelor provide stronger platelet inhibition than clopidogrel and improve the clinical outcome in patients with ACS; however, it is still under discussion which P2Y12 antagonist fits best to which subgroup of ACS patients. This article summarizes current guidelines and antiplatelet treatment strategies for patients with non-ST-segment elevation (NSTE) ACS or ST-segment elevation myocardial infarction (STEMI). The information is mainly based on the recently published guidelines of the European Society of Cardiology on myocardial revascularization.

[Conservative treatment of chronic tendinopathies]. / Konservative Therapie der chronischen Enthesiopathien.

The majority of insertional and noninsertional tendinopathy cases are associated with repetitive or overuse injuries. Certain tendons are particularly vulnerable to degenerative pathology; these include the Achilles and patella tendon, the rotator cuff, and forearm extensors/flexors. Disorders of these tendons are often chronic and can be difficult to manage successfully in the long term. Eccentric exercise has the strongest evidence of therapeutic efficacy. Extracorporeal shock wave treatment, sclerosing agents as well as nitric oxide patches show promising early results but require long-term studies. Corticosteroid and nonsteroidal antiinflammatory medications have not been shown to be effective except for temporary pain relief for rotator cuff tendinopathy. Platelet-rich plasma injections show encouraging short-term results.

Predictive factors for 1-year outcome of a cohort of patients with severe traumatic brain injury (TBI): results from the PariS-TBI study.

OBJECTIVES: To assess outcome and predicting factors 1 year after a severe traumatic brain injury (TBI). METHODS: Multi-centre prospective inception cohort study of patients aged 15 or older with a severe TBI in the Parisian area, France. Data were collected prospectively starting the day of injury. One-year evaluation included the relatives-rating of the Dysexecutive Questionnaire (DEX-R), the Glasgow Outcome Scale-Extended (GOSE) and employment. Univariate and multivariate tests were computed. RESULTS: Among 257 survivors, 134 were included (mean age 36 years, 84% men). Good recovery concerned 19%, moderate disability 43% and severe disability 38%. Among patients employed pre-injury, 42% were working, 28% with no job change. DEX-R score was significantly associated with length of education only. Among initial severity measures, only the IMPACT prognostic score was significantly related to GOSE in univariate analyses, while measures relating to early evolution were more significant predictors. In multivariate analyses, independent predictors of GOSE were length of stay in intensive care (LOS), age and education. Independent predictors of employment were LOS and age. CONCLUSIONS: Age, education and injury severity are independent predictors of global disability and return to work 1 year after a severe TBI.

[Conservative therapy of osteoarthritis]. / Konservative Therapie der Gonarthrose.

Osteoarthritis of the knee is a degenerative joint disease with progressive degradation of articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking and joint effusion depending on the stage of the disease. In an effort to delay major surgery, patients with knee osteoarthritis are offered a variety of nonsurgical modalities, such as weight loss, exercise, physiotherapy, bracing, orthoses, nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular viscosupplementation or corticosteroid injection. In general, the goals of these therapeutic options are to decrease pain and improve function. Some of these modalities may also have a disease-modifying effect by altering the mechanical environment of the knee. Chondroprotective substances, such as lucosamine, chondroitin sulphate and hyaluronic acid are safe and provide short-term symptomatic relief while the therapeutic effects remain uncertain.

[Approach to painful hip resurfacing]. / Vorgehen bei schmerzhafter Kappenprothese.

Hip resurfacing in young patients has been increasingly performed within the last decade. In comparison to standard total hip arthroplasty the failure rate remains high. Age and implant size have a significant effect on the risk of revision for primary total resurfacing and the risk of revision increases with increasing age. At 7 years the cumulative revision rate for patients is 5% and females have more than twice the cumulative revision rate as males. Even in hip resurfacing arthroplasty which has been performed in a perfect manner, a certain percentage of patients suffer from persistent pain for various reasons, such as neck fracture, iliopsoas tendinopathy, metal hypersensitivity, such as aseptic lymphocytic vasculitis associated lesions (ALVAL) and aseptic loosening. Diagnostic work-up of the painful hip resurfacing is challenging even for experienced surgeons. Recommendations for the diagnostic procedure are described.

[Calcific tendinitis of the shoulder]. / Die Kalkschulter - Tendinosis calcarea.

Calcific tendinitis of the shoulder is a process involving crystal calcium deposition in the rotator cuff tendons, which mainly affects patients between 30 and 50 years of age. The etiology is still a matter of dispute. The diagnosis is made by history and physical examination with specific attention to radiologic and sonographic evidence of calcific deposits. Patients usually describe specific radiation of the pain to the lateral proximal forearm, with tenderness even at rest and during the night. Nonoperative management including rest, nonsteroidal anti-inflammatory drugs, subacromial corticosteroid injections, and shock wave therapy is still the treatment of choice. Nonoperative treatment is successful in up to 90% of patients. When nonsurgical measures fail, surgical removal of the calcific deposit may be indicated. Arthroscopic treatment provides excellent results in more than 90% of patients. The recovery process is very time consuming and may take up to several months in some cases.

Light and electron microscopy studies of the midgut and salivary glands of second and third instars of the horse stomach bot, Gasterophilus intestinalis.

A morphological study of the midgut and salivary glands of second and third instars of Gasterophilus intestinalis (De Geer) (Diptera: Oestridae) was conducted by light, scanning and transmission electron microscopy. The midgut is anteriorly delimited by a proventriculus, without caeca, and is composed of posterior foregut and anterior midgut tissue from which a double-layered peritrophic matrix is produced. The midgut can be divided into anterior, median and posterior regions on the basis of the structural and physiological variations of the columnar cells which occur along its length. Two other types of cell were identified: regenerative cells scattered throughout the columnar cells, and, more rarely, endocrine cells of two structural types (closed and open). Different secretion mechanisms (merocrine, apocrine and microapocrine) occur along the midgut epithelium. Abundant microorganisms are observed in the endoperitrophic space of the anterior midgut. The origin and nature of these microorganisms remain unknown. No structural differences are observed between the second and third instar midguts. The salivary glands of G. intestinalis second and third instars consist of a pair of elongated tubular structures connected to efferent ducts which unite to form a single deferent duct linked dorsally to the pharynx. Several intermediate cells, without cuticle, make the junction with the salivary gland epithelium layer. Cytological characteristics of the gland epithelial cells demonstrate high cellular activity and some structural variations are noticed between the two larval stages.

Neurological sequelae after cerebral anoxia.

PRIMARY OBJECTIVE: Cardiac arrest can cause neurological impairment. The aim of this study is to confirm the disability and the predominant part of executive and behavioural impairments after cardiac arrest. RESEARCH DESIGN: A retrospective study is proposed. METHODS AND PROCEDURES: All consecutive patients admitted to the Department of Rehabilitation for Neurological Impairments following cerebral anoxia after cardiac arrest between 1995-2007 were included. Clinical and neuropsychological assessment was proposed. MAIN OUTCOMES AND RESULTS: Thirty patients, 19 men, were examined. Ages ranged from 16-58 (mean = 39.5). Fourteen patients presented with severe disability and 16 patients presented with moderate disability. In the first group (severe disability) no patients were autonomous for daily life activities. They presented with dysexecutive syndrome and behavioural disorders associated with amnesia syndrome; 64% of them presented with motor disorders. In the second group, patients with moderate disability were autonomous in daily life but not for the complex activities or functioning. They had no motor impairment but suffered from executive and memory impairments. Behavioural changes were noted. Medical history or demographic data did not differ between the two groups. CONCLUSION: The study confirms the predominant part of executive, memory and behavioural impairments after cardiac arrest. This retrospective study cannot provide prognosis factors and further prognosis studies are needed.

Arbuscular mycorrhizal infection in two morphological root types of Araucaria araucana (Molina) K. Koch.

Araucaria araucana (Molina) K. Koch is a conifer distributed in the Andean-Patagonian forests in the south of Argentina and Chile. The main objective of this work was to relate the different root classes appearing in A. araucana to mycorrhizal behavior. Samples were collected in three different sites in the Lanín National Park (NW Patagonia, Argentina). Two different root classes were present in A. araucana: longitudinal fine roots (LFR) and globular short roots (GSR). Both had extensive mycorrhizal arbuscular symbiosis (AM) and presented abundant hyphae and coils in root cells, a characteristic of the anatomical Paris-type. Dark septate fungal endophytes were also observed. Values of total AM colonization were high, with similar partial AM% values for each root class. Seasonal differences were found for total and partial colonization, with higher values in spring compared to autumn. Regarding the percentage of fungal structures between root classes, values were similar for vesicles and arbuscules, but higher coil percentages were observed in GSR compared to LFR. The percentages of vesicles increased in autumn, whereas the arbuscule percentages increased in spring, coinciding with the plant growth peak. Results show that both root classes of A. araucana in Andean-Patagonian forests are associated with AM fungi, which may have ecological relevance in terms of the importance of this symbiosis, in response to soil nutrient-deficiencies, especially high P-retention.

[Cognitive rehabilitation]. / La rééducation cognitive.

During these last 30 years, cognitive rehabilitation has accomplished dramatic improvement. In this paper, we review progress in four main domains: the development of pragmatic and ecological approaches in neuropsychological rehabilitation; the development of computerised rehabilitation; rehabilitation of executive functions; cognitive rehabilitation in degenerative dementia. Finally, we present a single-case study, recently published elsewhere, showing the effectiveness of rehabilitation of verbal working memory in a patient with left hemisphere stroke. In addition, future issues for rehabilitation research are presented. The development of bottom-up rehabilitation strategies as well as the use of inter-hemispheric interactions appears as future promising tracks for clinical rehabilitation.

[Sensory syndrome and aphasia after left insular infarct]. / L'insula, une île oubliée? Troubles sensitifs et troubles du langage après infarctus insulaire gauche.

INTRODUCTION: Sensorial impairment without hemiplegia is usually caused by a thalamic lesion. CASE REPORT: A 28-year-old woman presented with hemianesthesia associated with aphasia following a left insular lesion, subsequent to subarachnoid hemorrhage. Brain MRI Flair sequence revealed a high intensity signal in the left insular and frontal subcortical regions. Insular infarct was diagnosed, associated with hemorrhagic sequelae. DISCUSSION/CONCLUSION: Study of the normal and pathologic insular cortex suggest several implications of the region in somatosensory and language functions. However, the insular cortex has been mainly associated with central pain. Lasting objective hypoesthesia has been very rarely documented. The left insular cortex has also been implicated in speech apraxia but our patient presented with fluent aphasia mostly affecting the rhythm of speech, as it has been observed in thalamic aphasia.

[The effect of age on executive functioning after acquired brain injury in adults]. / Effet de l'âge sur le fonctionnement exécutif après lésion cérébrale chez l'adulte.

INTRODUCTION: Executive functioning deficits have often been described in normal aging. They are also known to be a frequent sequel of traumatic brain injury, where patients may exhibit severe long-standing impairments in instrumental activities of daily living. One could therefore expect that cerebral lesions affecting executive functioning would result in more severe impairments in older patients. We previously developed an ecological assessment of executive functions, consisting of a cooking task, requiring multitasking abilities and known to be sensitive to a dysexecutive syndrome [Cortex 36 (2000) 649-669]. The aim of this study was to analyze the effect of age on the cognitive and ecological assessments of executive functions in a group of patients with acquired brain injury (ABI) resulting in a dysexecutive syndrome. Studies in this area usually focus on patients older than 60 or 65, but we chose to analyze the effect of age in a younger population. We hypothesized that older patients would have poorer performances on the cognitive and ecological tests of executive functioning, when compared to younger patients. METHODS: Forty-five patients with ABI resulting in frontal lesions and a dysexecutive syndrome participated in this study. Patients underwent a comprehensive battery of cognitive tests assessing executive functioning, as well as the cooking task. We also studied a group of 12 control subjects who performed the cooking task. RESULTS: No effect of age was found on performance in the cooking task in the control group. Age was not related to demographic parameters or injury severity in the ABI group. Although the ABI group was relatively young (mean age: 40.3 years (S.D.=12.5), ranging from 17 to 63), results indicated a significant deleterious effect of age on the cognitive tests of executive functioning in the ABI group. We also highlighted a significant worsening of patients' performance in the cooking task with age, and this effect was found on several variables of task analysis: the number of errors and occurrence of dangerous behaviors. CONCLUSION: Our study demonstrates the deleterious effect of aging on cognitive and ecological assessment of executive functioning after ABI. The strength of this study is that it deviated from the traditional age considered in studies of elderly populations and focused on younger patients. It is therefore important to consider the implication that this may have on a patient's rehabilitation program and postinjury discharge.

[The role of microparticles in vascular diseases]. / Die Bedeutung von Mikropartikeln bei vaskulären Erkrankungen.

Microparticles (MP) are small cell vesicles that are released by activated or apoptotic cells and that are amenable to quantification in peripheral blood. MP consist of the cytoplasm and the cell membrane of their cell of origin, which allows for their assignment to these cells. By the detection of the respected MP one can conclude to the functional status of the cell of origin. It is known that MP confer specific information between cells and contribute to inflammatory and coagulatory processes. They are detectable in many acute and chronic vascular diseases as a surrogate marker for disease activity but also play a role in the pathophysiology of vascular diseases.

[Ecological assessment of executive functions in a patient with acquired brain injury]. / Evaluation écologique des fonctions exécutives chez un patient traumatisé crânien.

UNLABELLED: Dysexecutive syndrome is one of the most frequent sequel of severe traumatic brain injury. It causes severe disabilities and it is incompletely assessed by the classical "paper and pencil" neuropsychological tests. We developed an ecological assessment conducted in a naturalistic situation, consisting of a cooking task, and we described a classification of errors. This assessment is very sensitive, even to a mild dysexecutive syndrome. OBJECTIVE: To describe the disabilities in activities of daily living of a traumatic brain-injured patient and to demonstrate the sensitivity of an ill-structured ecological assessment. METHOD: We report a single case study illustrating how the ecological assessment by the cooking task helped better understand and characterize the patient's disabilities. RESULTS: The patient presented severe disabilities in daily life activities, which were well described by his family. His cognitive disorders were mild in the cognitive tests, even those supposed to be more ecological, such as the Six Elements Task or script generation. He exhibited very severe disorders in the cooking task, with a very high number of errors. Moreover, duration of the cooking task was very long; he did not achieve the goal and exhibited dangerous behaviour. DISCUSSION AND CONCLUSION: The cooking task involves abilities to deal with multitasking, which particularly involve executive functions. The most severe disorders were observed during the patient's interaction with the environment while conducting a complex goal-directed action plan, indicating control disorders. This type of naturalistic assessment provides very useful information to help patients organise their familial, social or professional reintegration.

[Fantastic confabulations or delusion?]. / Confabulations fantastiques ou délire ?

INTRODUCTION: Confabulations are inaccurate narratives purporting to convey information about the world or the self. Fantastic utterances from brain-injured patients are difficult to interpret as confabulation or delusion. METHODS: Starting from two clinical observations, we analyse the terms "spontaneous confabulations" and "delusion". RESULTS: Two brain-injured patients presented with fantastic utterances; the adhesion was complete for both patients. They also suffered from amnesic and executive disorders. Clinical interviews with neuropsychologist and psychopathologist could not distinct between spontaneaous confabulations and delusion. DISCUSSION: Neuropsychological interpretations of spontaneous confabulations are (1) the deficient strategic retrieval process arising from executive failures and (2) confusion of the temporal order of information within memory. These hypotheses cannot explain the fantastic utterances described. Are spontaneous fantastic confabulations a specific entity or did these patients present a morbid association of neurological and psychiatric disorders? Fantastic confabulations are very scarcely described and the association of neurological and psychiatric impairments enables us to better describe the clinical observations. Spontaneous confabulations reported after amnesic and executive disorders are indeed typically composed of the patient's past experiences and do not usually comprehend fantastic utterances. CONCLUSION: Neurological and psychological analyses of the fantastic utterances from two brain-injured patients do not respond to the definition of spontaneous confabulation. Fantastic confabulations are a rare entity and we propose another explanation consisting of the association of neurological and psychiatric disorders.

[Cognitive rehabilitation of amusia]. / Vers une rééducation cognitive de l'amusie.

INTRODUCTION: The cognitive model of music processing has a modular architecture with two main pathways (a melody pathway and a time pathway) for processing the musical "message" and thus enabling music recognition. It also features a music-specific module for tonal encoding of pitch which stands apart from all other known cognitive systems (including language processing). To the best of our knowledge, rehabilitation therapy for amusia has not yet been reported. OBJECTIVE: We developed a therapeutic method (inspired by work on word deafness) in order to determine whether specific rehabilitation based on melody discrimination could prompt the regression of amusia. METHOD: We report the case of a patient having developed receptive, acquired amusia four years previously. His tone deafness disorder was assessed using the Montreal Battery of Evaluation of Amusia (MBEA), which revealed impairment of the melody pathway but no deficiency in the time pathway. A computer-assisted rehabilitation method was implemented; it used melody discrimination tasks and an errorless learning paradigm with progressively fading visual cues. RESULTS: After therapy, we noted an improvement in the overall MBEA score and its component subscores which could not be explained by spontaneous recovery (in view of the number of years since the neurological accident). The improvement was maintained at seven months post-therapy. Although post-therapy improvement in daily life was not systematically assessed, the patient started listening to his favourite music again. CONCLUSION: Specific amusia therapy has shown efficacy.

[Is stent thrombosis the new Achilles heel of interventional cardiology? State of the Art clinical trials, causes and approaches for prevention]. / Ist die Stentthrombose die neue Achillesferse der interventionellen Kardiologie? Aktuelle Studienlage, Ursachen und Ansätze zur Prävention.

Coronary stents are the mainstay of percutaneous coronary intervention. Stent thrombosis is a potentially catastrophic and often life-threatening complication. If it occurs it presents in up to 80% as myocardial infarction, about half of the affected patients die from this complication. The dual antiplatelet therapy has markedly reduced its occurrence. Today, stent thrombosis occurs in <1%, usually as a delayed event; but compared to bare metal stents the overall incidence has not increased in meta-analyses of randomized trials. The advent of drug-eluting stents (DES) has raised concerns regarding the occurrence of delayed stent thrombosis. Delayed arterial wall healing as well as prothrombotic characteristics of the drug eluting stent itself may contribute to stent thrombosis. In order to prevent stent thrombosis a standardized fixed dose antiplatelet therapy with ASA and clopidogrel is recommended. But, their efficacy depends on patient's individual characteristics such drug metabolism. Therefore, individual determination of platelet function in each patient undergoing stent implantation may help to avoid prothrombotic as well as bleeding complications.