Association between brain metabolism and clinical course of motor functional neurological disorders.

Features of resting brain metabolism in motor functional neurological disorder are poorly characterized. This study aimed to investigate the alterations of resting brain metabolism in a cohort of patients experiencing a first episode of motor functional neurological disorder with recent symptom onset and their association with persistent disability after 3 months. Patients eligible for inclusion were diagnosed with first episode of motor functional neurological disorder, were free from bipolar disorder, substance use disorder, schizophrenia, psychogenic non-epileptic seizure or any chronic or acute organic neurological disorder. Exclusion criteria included current suicidal ideation, antipsychotic intake and previous history of functional neurological disorder. Nineteen patients were recruited in Psychiatry and Neurology departments from two hospitals. Resting brain metabolism measured with 18F-fluorodeoxyglucose positron emission computed tomography at baseline and 3 months was compared to 23 controls without neurological impairment. Disability was scored using Expanded Disability Status Scale and National Institutes of Health Stroke Scale score at baseline and 3 months. Correlations were calculated with Spearman correlation coefficient. Hypometabolism was found at baseline in bilateral frontal regions in patients versus controls, disappearing by 3 months. The patients with Expanded Disability Status Scale score improvement showed greater resting state activity of prefrontal dorsolateral cortex, right orbito-frontal cortex and bilateral frontopolar metabolism at 3 months versus other patients. The resting state metabolism of the right subgenual anterior cingular cortex at baseline was negatively correlated with improvement of motor disability (measured with Expanded Disability Status Scale) between inclusion and 3 months (r = -0.75, P = 0.0018) and with change in motor symptoms assessed with the National Institutes of Health Stroke Scale (r = -0.81, P = 0.0005). The resting state metabolism of the left subgenual anterior cingular cortex at baseline was negatively correlated with improvement in Expanded Disability Status Scale and National Institutes of Health Stroke Scale scores between inclusion and 3 months (r = -0.65, P = 0.01 and r = -0.75, P = 0.0021, respectively). The negative association between the brain metabolism of the right subgenual anterior cingular cortex at baseline and change in National Institutes of Health Stroke Scale score remained significant (r = -0.81, P = 0.0414) after correction for multiple comparisons. Our findings suggest the existence of metabolic 'state markers' associated with motor disability and that brain markers are associated with motor recovery in functional neurological disorder patients.

Cross-Calibration Study of The Stratos And Hologic QDR 4500A Dual-Energy X-Ray Absorptiometers to Assess Bone Mineral Density And Body Composition.

The objective of the study was to assess the agreement between the Stratos (DMS) and QDR 4500A (Hologic) DXAs in determining whole body and regional aBMD, as well as whole body composition. Fifty-five individuals (46 women: 84%) with a mean age of 41 ± 13.0 years (range: 20 to 64) and a mean BMI of 31.9 ± 10 kg/m² (range: 12.2 to 49.5) were consecutively scanned on the same day using the two devices. Predictive equations for areal bone mineral density (aBMD) and whole body composition (WBC) were derived from linear regression of the data. The two DXAs were highly correlated (p<0.001 for all parameters) with a correlation coefficient (r) ranging from 0.89 to 0.99 for aBMD (r=0.89 for whole body, r=0.92 for radius, r=0.95 for femoral neck, r=0.96 for total hip, and r=0.99 for L1-L4). For WBC, the r value was 0.98 for lean tissue mass (LTM) and 1.0 for fat mass (FM). Paired t-tests indicated a statistically significant bias between the two DXAs for the majority of measurements, requiring the determination of specific cross-calibration equations. Compared to QDR 4500A, Stratos underestimated whole body aBMD and LTM and overestimated neck and hip aBMD and whole body FM. Conversely, no significant bias was demonstrated for mean aBMD at L1-L4 and radius. For whole body aBMD and FM, the concordance between the two DXAs was influenced by BMI. Despite a high concordance between the two DXAs, the systematic bias for aBMD and WBC measurements illustrates the need to define cross-calibration equations to compare data across systems.

S100B serum level: A relevant biomarker for the management of non-traumatic headaches in emergency care?

BACKGROUND: The diagnostic of primary or secondary headaches in emergency units is mostly based on brain imaging, which is expensive and sometimes hardly accessible. An increase in serum S100B protein has already been found in several neurological conditions inducing brain damage. The objective of this study was to assess the diagnostic performance of S100B serum assay to distinguish primary and secondary headaches among patients with non-traumatic headaches in the emergency department. METHODS: This was a phase 2, prospective, monocentric diagnostic study. Eighty-one adult patients with non-traumatic headaches in the emergency department were included. In addition to the usual management, a blood assay of the S100B protein was performed in the emergency department, as well as a brain MRI between 48 and 96 h if not performed during the initial management. The primary or secondary headache diagnosis was made at one month by an expert committee, blindly of the results of the S100B assay. The primary outcome was the blood assay of the S100B protein. RESULTS: There was 63 patients for analysis in the primary headache group and 17 in the secondary headache group. The S100B protein assay was significantly higher in secondary headaches than primary headaches, with an AUC of the ROC curve of 0.67. The optimal threshold of 0.06 µg.L-1 allowed to obtain those diagnostic characteristics: sensitivity 75% [48; 93], specificity 62% [48; 74], PPV 35% [20; 54] and NPV 90% [76; 97]. The association between the S100B protein level and the onset of pain was significantly higher for patients with headaches <3 h. CONCLUSION: The assay of the S100B protein could be useful in the management of this pathology in emergencies. Future studies taking into account dosing time and etiologies could be conducted in order to refine its use in practice.

Comparison of interface pressures in two dynamic pressure ulcer prevention supports (NIMBUS 3 and SUMMIT): A randomized controlled trial.

BACKGROUND: Pressure ulcers are a risk for bedridden patients and various supports exist to prevent them. The Pressure Relief Index (PRI) evaluates pressure relief of dynamic mattresses over time. This study compared the PRI of the SUMMIT mattress (AKS-France) and the NIMBUS 3 (HNE Medical). METHODS: In this non-blinded, randomized, crossover, non-inferiority study, patients aged ≥60 with a BMI of 16-35 kg/m2, predominantly confined to bed, able to walk with aid and with pelvic symmetry were recruited from a hospital rehabilitation department from March-April 2012. Exclusion criteria included past or present pressure ulcers, inability to remain supine and deep vein thrombosis. Peak pressures of the sacrum were recorded at 0.1 Hz during a single complete 10-min inflating cycle on both mattresses, with the order determined via electronic randomization allocation. RESULTS: Thirty-one subjects were included and randomized; with 14 finally analyzed in the SUMMIT-NIBMUS 3 order group and 16 in the NIMBUS 3-SUMMIT group. The difference in PRI <30 mmHg between the two mattresses was 13.2% [0.3-26.1] (p < 0.05), allowing a non-inferiority - superiority switch. The SUMMIT mattress demonstrated a significantly higher percentage of time <30 mmHg (p = 0.0454). No significant difference in mean minimal pressure was seen (p = 0.3231) and mean maximal pressure was in favor of SUMMIT mattress (p = 0.0096). BMI did not affect pressure profile. There were no adverse events. CONCLUSIONS: Evaluated by the PRI, the SUMMIT mattress had a better interface pressure profile than the NIMBUS 3 in older patients. The PRI is a promising tool for clinical decision-making and research, warranting validation.

French validation of the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA revised (PISQ-IR).

INTRODUCTION AND HYPOTHESIS: The aim of this study was to clinically validate the French-translated PISQ-IR in a French-speaking population of women with pelvic floor disorders. METHODS: We aimed to recruit 300 women to account for potential attrition secondary to failure to respond or loss to follow-up. Women were enrolled as part of an RCT and from a separate specific study. Both studies included surgically managed patients. Data were collected at recruitment, visit 1 (V1), V2 (9-12 months postoperatively) and V3 (V2 + 5-15 days). Participants also completed a PFDI 20, ICI-Q and FSFI and were assessed by POP-Q. RESULTS: A total of 297 women were recruited between 18 January 2013 and 18 January 2016. Data were available for 291, 148 and 110 participants at V1, V2 and V3, respectively. The non-response rate for the NSA items varied from 5% to 30%, while for SA women, the non-response rate for the items varied from 0% to 15%. The tool was deemed reliable for five domains of the summary score. We also identified that several sections demonstrated acceptable to good temporal stability. A statistically significant score change was identified in different domains in the participants categorized as improved on either PGI-I or POP-Q. We also identified moderate to strong correlations between PISQ-IR and FSFI. CONCLUSIONS: The French translated PISQ-IR has several strengths in support of its validity. Our findings confirm the validity of the summary scores in addition to the item-based initial scoring system.

Post-operative opioid-related adverse events with intravenous oxycodone compared to morphine: A randomized controlled trial.

BACKGROUND: The value of intravenous oxycodone compared to morphine remains controversial. The purpose of this trial was to compare opioid-related adverse events (ORAES) of intravenous oxycodone and morphine after total hip arthroplasty. METHODS: Patients scheduled for total hip arthroplasty were enrolled in this study of post-operative pain treatment with intravenous oxycodone or intravenous morphine (ratio 1:1). After surgery, patients received similar drug regimens for titration in the post-operative care unit followed by intravenous patient-controlled analgesia (PCA). The primary outcome was the number of patients with ≥1 ORAEs within the first 24 hours defined as either nausea, vomiting, respiratory depression, pruritus, urinary retention requiring evacuation, allergy, hallucinations. Secondary outcomes included pain scores and opioid consumption. RESULTS: The analysis included 238 patients with similar characteristics. There were 55 patients with at least one ORAEs in the oxycodone group vs 46 in the morphine group: 48% vs 40%, P = .19; relative risk = 1.22 (0.91:1.63). Intravenous oxycodone vs intravenous morphine requirements were respectively (median, IQR): 6 (0-11) vs 8 (0-12) mg (P = .06) for titration, 15 (8-26) vs 8 (5-16) mg (P = .001) for PCA, and 22 (12-37) mg vs 19 (11-28) mg for cumulated intravenous consumption (P = .048). During the first 24 hours, there was no difference in secondary outcomes (oxycodone vs morphine, respectively, in %): nausea (15 vs 13), vomiting (5 vs 5), urinary retention (20 vs 12) or pain scores. CONCLUSION: This study demonstrates that IV oxycodone did not significantly reduce ORAEs within the first 24 hours compared to similar ratio of IV morphine.

Evaluation of the effect of multipoint intra-mucosal vaginal injection of a specific cross-linked hyaluronic acid for vulvovaginal atrophy: a prospective bi-centric pilot study.

BACKGROUND: Vulvo-vaginal atrophy (VVA) is one of the common consequences of estrogen deficiency especially after the menopause. Several studies have assessed the effects of Hyaluronic acid (HA) on physical and sexual symptoms associated with VVA with promising results. However, most of these studies have focused on subjective assessment of symptom response to topically administered preparations. Nonetheless, HA is an endogenous molecule and it is logical that its effects are best realized if injected in the superficial epithelial layers. Desirial® is the first crosslinked HA that is administered by injection in the vaginal mucosa. The aim of this study was to explore the effect of multipoint vaginal intra-mucosal injections of specific cross-linked hyaluronic acid (DESIRIAL®, Laboratoires VIVACY) on several clinical and patient reported core outcomes. METHODS: A cohort bi-centric pilot study. The chosen outcomes included change in vaginal mucosa thickness, biological markers for collagen formation, vaginal flora, vaginal pH, vaginal health index, vulvo-vaginal atrophy symptoms and sexual function 8 weeks post Desirial® injection. Patients' satisfaction was also assessed using the patient global impression of improvement (PGI-I) scale. RESULTS: A total of 20 participants were recruited between 19/06/2017 and 05/07/2018. At the end of the study, there was no difference in the median total thickness of the vaginal mucosa or in procollagen I, III or Ki67 fluorescence. However, there was a statistically significant increase in COL1A1 and COL3A1 gene expression (p = 0.0002 and p = 0.0010 respectively). There was also a significant reduction in reported dyspareunia, vaginal dryness, vulvar pruritus, vaginal chafing and significant improvement in all female sexual function index dimensions. Based on PGI-I, 19 patients (95%) reported varying degrees of improvement where, 4 (20%) felt slightly better; 7 (35%) better and 8 (40%) much better. CONCLUSIONS: Multi-point vaginal intra-mucosal injections, of Desirial® (a crosslinked HA) was significantly associated with the expression of CoL1A1 and CoL3A1 suggesting stimulation of collagen formation. Furthermore, there was a significant reduction in VVA symptomatology and a significant improvement in patient satisfaction and sexual function scores. However, there was no demonstrable change in the total vaginal mucosal thickness. Study registration ID-RCB: 2016-A00124-47, Protocol code number: LOCAL/2016/PM-001.

Unilateral versus bilateral sacral neuromodulation test in the treatment of refractory idiopathic overactive bladder: A randomized controlled pilot trial.

AIM: To compare treatment success rate in terms of improvement of bladder overactivity between unilateral and bilateral sacral neuromodulation testing. METHODS: A multicentric, parallel, randomized, open pilot trial (October 2012-September 2017) was conducted. Participants presented primary overactive bladder resistant to first-line treatments. Patients were excluded in case of secondary bladder, pelvic, or neurological condition. Patients were randomized between bilateral testing (n = 28) or unilateral testing (n = 27), to determine the best functional response before final implantation. The primary outcome was the rate of patients presenting at least 50% of clinical improvement at 1 month on urinary frequency, number of urge incontinence episodes or number of urinary urgency episodes. Symptom severity, implantation success rate, uroflowmetry, device tolerance, complications, and quality of life were also assessed. RESULTS: Fifty-five patients have been included. The rate of patients presenting at least one significant clinical improvement at month 1 was 62% in the bilateral group versus 84% in the unilateral group (P = .0891), RR = 0.74 (0.51; 1.07). There was no significant difference between bilateral and unilateral groups in terms of improvement of urinary frequency (0% and 17%; P = .1115), number of urge incontinence episodes (52% and 63%; P = .4929) or number of urinary urgency episodes (57% and 74%; P = .2411). More complications were reported in the bilateral group than in the unilateral group (9 [47%] vs 4 [16%], respectively; P = .0239). CONCLUSION: Systematic bilateral sacral neuromodulation testing before final implantation did not appear to increase success rate compared with unilateral stimulation in the treatment of overactive bladder.

Long-term outcomes of a randomized controlled trial comparing trans-obturator vaginal mesh with native tissue repair in the treatment of anterior vaginal wall prolapse.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to report the long-term subjective and objective outcomes after transvaginal mesh (TVM) or native tissue repair. METHODS: Prospective, randomized, multicenter study conducted between April 2005 and December 2009 comparing anterior colporrhaphy with trans-obturator vaginal mesh (Pelvitex/Ugytex®, Sofradim, Trevoux, France) for the treatment of anterior vaginal wall prolapse. The primary endpoint was functional recurrence rate 5-8 years after surgery. Secondary endpoints consisted of anatomical results, mesh-related morbidity and patient satisfaction measured through validated questionnaires. RESULTS: Of the 147 women originally included, 75 (51%) were successfully re-contacted a median of 7 years after the initial surgery. The primary outcome, subjective recurrence of prolapse, was similar between the TVM and the anterior colporrhaphy groups (31 vs 34% respectively). Anatomical recurrence was less likely in the TVM group (67 vs 24%, p = 0.004). Mesh exposure occurred in 4 of the 39 patients (13%) during follow-up, 2 of which had a surgical reintervention. Reintervention for prolapse took place in 7 patients (9%). CONCLUSION: Seven-year follow-up showed similar functional outcomes for mesh and native tissue repair in anterior vaginal wall prolapse. TVM did not reduce repeat surgery in the long term; it did, however, reduce anatomical recurrence. Mesh exposure rates were relatively high, but no difference in outcome of pain or dyspareunia was noted.

Impact of mode of delivery of twins on the pelvic floor 3 and 12 months post-partum-part II.

INTRODUCTION AND HYPOTHESIS: To compare the impact of vaginal delivery (VD) versus cesarean section (CS) on the pelvic floor in twin primiparae at 3 and 12 months postpartum. METHODS: This comparative multicenter prospective cohort from a large French national cohort study consisted of primiparas who gave birth to live twins after 34 weeks of gestation. The primary end point was the postnatal urinary incontinence rate 3 months postpartum. The secondary end points were the pelvic floor dysfunction (PFD) at 3 and 12 months based on PFDI-20, PFIQ-7, PISQ-12, and SF-12 responses. RESULTS: A total of 2812 patients in 172 French maternity units were recruited between February 2014 and March 2015: 1076 (38%) responded at 3 and 12 months (61% at 3 months); 1155 were analyzed at 3 months (556 VD and 599 CS) and 800 at 12 months (394 VD and 406 CS). VD was associated with more symptoms at 3 months [median PFDI-20 score 25/300 (8-50) vs. 17/300 (4-36) after CS; p < 0.0001]. Vaginal bulge was more frequently reported after VD (9 vs. 4%; p = 0.0015). Abdnormal PFD-related quality-of-life scores (scores > 0) were more frequent after VD at 3 months (58 vs. 42%; p < 0.0001) and 12 months (57 vs. 43%; p = 0.0020), indicating greater discomfort. However, SF-12 scores were higher after VD [56 (53-59) vs. 55 (51-58)] at 12 months, indicating better general quality of life. CONCLUSIONS: Mode of delivery is significantly associated with pelvic organ prolapse symptoms 3 months postpartum, which regress by 12 months, probably because of the known spontaneous postnatal improvement of PFDs.

Risk of new-onset urinary incontinence 3 and 12 months after vaginal or cesarean delivery of twins: Part I.

INTRODUCTION AND HYPOTHESIS: Our purpose was to compare the prevalence of urinary incontinence (UI) 3 and 12 months after vaginal vs cesarean delivery of twins after 34 weeks of gestation. METHODS: This was a multicenter prospective cohort study conducted at 172 French maternity units and included 2812 primiparous women with twins with no prior history of UI. Participants were enrolled at the time of delivery and followed up to 12 months postpartum. The primary outcome was the prevalence of UI, both stress and urge, 3 months postpartum, based on the patient reporting any frequency of urine leakage to the first question of the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF). The Pelvic Floor Distress Inventory - Short Form 20 (PFDI-20), Pelvic Floor Impact Questionnaire - Short Form 7 (PFIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and Medical Outcome Study Short Form-12 (SF-12) were also used. RESULTS: The ICIQ-SF was completed by 1155 (39.8%) and 800 (27.5%) women, respectively, at 3 and 12 months postpartum; 556 (48%) had delivered vaginally and 599 (52%) by cesarean section. The prevalence of UI at 3 months was 26% overall and was significantly higher in the vaginal delivery group at both 3 months (35% vs 17% in the cesarean group, p < 0.0001) and 12 months postpartum (38% vs 24%, p < 0.0001). UI was predominantly stress or mixed. The risk factors for UI at 3 months, determined by multivariate modeling, were vaginal delivery [odds ratio (OR) 3.073, 95% confidence interval (CI) 2.3-4.105, p < 0.0001) and body mass index >25 in early pregnancy (OR 1.620, 95% CI 1.188-2.209, p = 0.0023). CONCLUSIONS: Vaginal delivery is a risk factor for UI at 3 months after twin birth.

Assessment of agreement and time in therapeutic range of capillary versus venous international normalised ratio in frail elderly people in a nursing home.

Vitamin K antagonists are widely used, yet have a slim therapeutic margin and high iatrogenicity. Patients are monitored through international normalised ratio (INR) by venipuncture, but coagulometers could measure INR by capillary puncture. This prospective study evaluated the clinical concordance of capillary INR versus venous INR in 31 nursing home patients. Concordance was good and mean time in therapeutic range (TTR) markedly increased. Capillary INR is thus reliable, could improve TTR and decrease iatrogenicity.

Performances of Four Real-Time PCR Assays for Diagnosis of Pneumocystis jirovecii Pneumonia.

Pneumonia due to Pneumocystis jirovecii (PCP) is a frequent infection among HIV-positive or other immunocompromised patients. In the past several years, PCR on pulmonary samples has become an essential element for the laboratory diagnosis of PCP. Nevertheless, very few comparative studies of available PCR assays have been published. In this work, we evaluated the concordance between four real-time PCR assays, including three commercial kits, AmpliSens, MycAssay, and Bio-Evolution PCR, and an in-house PCR (J. Fillaux et al. 2008, J Microbiol Methods 75:258-261, doi:http://dx.doi.org/10.1016/j.mimet.2008.06.009), on 148 pulmonary samples. The results showed concordance rates ranging from 81.6% to 96.6% (kappa, 0.64 to 0.93). Concordance was excellent between three assays: the in-house assay, AmpliSens, and the MycAssay PCR (kappa, >0.8). The performances of these PCR assays were also evaluated according to the classification of the probability of PCP (proven, probable, possible, or no final diagnosis of PCP) based on clinical and radiological signs as well as on the direct examination of bronchoalveolar lavage samples. In the proven PCP category, Pneumocystis jirovecii DNA was detected with all four assays. In the probable PCP category, the in-house PCR, AmpliSens, and the MycAssay PCR were positive for all samples, while the Bio-Evolution PCR failed to detect Pneumocystis jirovecii DNA in two samples. In the possible PCP category, the percentage of positive samples according to PCR varied from 54.5% to 86.4%. Detection of colonized patients is discussed. Finally, among the four evaluated PCR assays, one was not suitable for colonization detection but showed good performance in the proven and probable PCP groups. For the three other assays, performances were excellent and allowed detection of a very low fungal burden.

Influence of Diaphragmatic Motion on Inferior Vena Cava Diameter Respiratory Variations in Healthy Volunteers.

BACKGROUND: The collapsibility index of inferior vena cava (cIVC) is widely used to decide fluid infusion in spontaneously breathing intensive care unit patients. The authors hypothesized that high inspiratory efforts may induce false-positive high cIVC values. This study aims at determining a value of diaphragmatic motion recorded by echography that could predict a high cIVC (more than or equal to 40%) in healthy volunteers. METHODS: The cIVC and diaphragmatic motions were recorded for three levels of inspiratory efforts. Right and left diaphragmatic motions were defined as the maximal diaphragmatic excursions. Receiver operating characteristic curves evaluated the performance of right diaphragmatic motion to predict a cIVC more than or equal to 40% defining the best cutoff value. RESULTS: Among 52 included volunteers, interobserver reproducibility showed a generalized concordance correlation coefficient (ρc) above 0.9 for all echographic parameters. Right diaphragmatic motion correlated with cIVC (r = 0.64, P < 0.0001). Univariate analyses did not show association between cIVC and age, sex, weight, height, or body mass index. The area under the receiver operating characteristic curves for cIVC more than or equal to 40% was 0.87 (95% CI, 0.81 to 0.93). The best diaphragmatic motion cutoff was 28 mm (Youden Index, 0.65) with sensitivity of 89% and specificity of 77%. The gray zone area was 25 to 43 mm. CONCLUSIONS: Inferior vena cava collapsibility is affected by diaphragmatic motion. During low inspiratory effort, diaphragmatic motion was less than 25 mm and predicted a cIVC less than 40%. During maximal inspiratory effort, diaphragmatic motion was more than 43 mm and predicted a cIVC more than 40%. When diaphragmatic motion ranged from 25 to 43 mm, no conclusion on cIVC value could be done.

Diaphragmatic excursion measurement in emergency patients with acute dyspnea: toward a new diagnostic tool?

INTRODUCTION: During acute dyspnea (AD), respiratory exhaustion is mainly due to diaphragm fatigue. The primary objective was to validate interobserver reproducibility of diaphragmatic excursion (DE) in emergency department (ED) patients admitted for AD. The secondary objectives were to assess the feasibility of DE measurement and intraobserver reproducibility. Finally, we examined whether the DE value was associated with a need for noninvasive ventilation (NIV). MATERIALS: This was a monocentric, prospective, technical reproducibility study. Adult patients in spontaneous ventilation admitted for AD were included. Two operators carried out 2 consecutive diaphragm excursion measurements each on the right and left hemidiaphragms. RESULTS: Twenty-four patients were analyzed. The feasibility was 96% on the right and 67% on the left. The interobserver concordance between the 2 measures was 0.80 (95% confidence interval [CI], 0.59-0.91) (average difference, -0.07±0.48 cm) on the right and 0.59 (95% CI, 0.19-0.82) (average difference, 0.30±0.91 cm) on the left. For right DE values inferior to 2.3 cm, the interobserver concordance between measures was 0.92 (95% CI, 0.78-0.97). The intraobserver concordance was 0.89 (95% CI, 0.81-0.94) (average difference, 0.02±0.35 cm) on the right and 0.90 (95% CI, 0.82-0.95) (average difference,-0.06±0.45 cm) on the left. When the DE was greater than 2 cm, no patient required NIV. CONCLUSION: Diaphragmatic excursion measurement of the right diaphragm is feasible, with good interobserver and intraobserver reproducibility in ED patients admitted for AD. When the DE value is greater than 2 cm at admission, no subsequent NIV is required.

Assessment of neutrophil gelatinase-associated lipocalin in the brain-dead organ donor to predict immediate graft function in kidney recipients: a prospective, multicenter study.

BACKGROUND: Delayed graft function is a major determinant of long-term renal allograft survival. Despite considerable efforts to improve donor selection and matching, incidence of delayed graft function remains close to 25%. As neutrophil gelatinase-associated lipocalin (NGAL) has been shown to predict acute renal failure, the authors tested the hypothesis that NGAL measurement in brain-dead donors predicts delayed graft function in kidney recipients. METHODS: In a prospective, multicenter, observational study, serum NGAL was measured in donors at the time of transfer to operating room. The primary endpoint was the delayed graft function, defined as the need for renal replacement therapy during the first week posttransplantation. RESULTS: Among 159 included brain-dead donors, 146 were analyzable leading to 243 renal transplantations. Of these, 56 (23%) needed renal replacement therapy. Donors' NGAL values were similar in case of both delayed and normal graft function in recipients. The area under the receiver-operating curve for NGAL to predict the need for renal replacement therapy before day 8 was 0.50 (95% CI, 0.42 to 0.59). The area under curve for NGAL to predict failure to return to a normal graft function at day 8 was 0.51 (95% CI, 0.44 to 0.59). Using multivariate analysis, NGAL was not associated to the need for renal replacement therapy (odds ratio, 0.99; 95% CI, 0.98 to1.00) or failure to return to a normal graft function at day 8 (odds ratio, 1.00; 95% CI, 0.99 to 1.00). CONCLUSION: NGAL measurement in brain-dead donors at the time of recovery failed to predict delayed or normal graft function in kidney recipients.

Critical norepinephrine dose to predict early mortality during circulatory shock in intensive care: a retrospective study in 3423 ICU patients over 4-year period.

INTRODUCTION: The maximal norepinephrine (NE) dose >1 µg/kg/min during circulatory shock apparently is associated with higher mortality, but this threshold needs confirmation. This study aimed at investigating whether NE infusion at a dose >1 µg/kg/min could predict early intensive care unit (ICU) mortality (first 5 days). The secondary objective was to assess the day-by-day relationship between NE dose during the first four days of ICU stay and subsequent mortality. METHODS: We conducted a retrospective analysis of data from ICU patients receiving NE for circulatory shock at the Nimes University Hospital (France) from January/2016 to December/2019. RESULTS: 5,735 patients were admitted, 3,693 were screened and 3,423 were analyzed. NE infusion at a dose >1 µg/kg/min was associated with day-5 mortality (Hazard Ratio: 7.40, p < 0.0001). The area under the receiver operating characteristic was 0.79 to predict day-5 mortality in ICU for maximal NE > 1 µg/kg/min. The calculated threshold of 1.13 µg/kg/min for maximal NE was the best prognostic value (Sensitivity: 67%, Specificity: 80%, positive predictive value: 45%). When the 1.2 µg/kg/min threshold was crossed either on the first, second, third or fourth day of ICU stay, the probability of subsequent death was 47%, 49%, 60% and 40%, respectively. Along the first four days of ICU stay, the risk of death increased with increasing NE infusion dose. CONCLUSIONS: A NE infusion rate > 1.13 µg/kg/min predicts day-5 mortality in ICU patients with circulatory shock. The time to reach maximal NE infusion rate was shorter in survivors than in non-survivors.

The value of ultrasound-guidance of nerves and muscles for patient tolerance and parameters electrodiagnostic studies.

Objective: To assess impact of ultrasound guidance (USG) on patient's perception of nerve conduction studies (NCS). Methods: In this single-center, randomized, sham-controlled, parallel, single-blind trial, we evaluated ultrasound (US) in identifying NCS stimulation site. Consecutive adults (18-80 old) without neuropathy referred for NCS were electronically randomized 1:1 to USG or Sham US. The primary outcome was sensory supramaximal intensity (SSMI) for each site/nerve; motor supramaximal intensity (MSMI), amplitudes, number of non-routine muscle punctured, Visual Analogue Scale (VAS), satisfaction were secondary outcomes. Results: 290 participants were randomized, with 145 in the USG and 144 Sham US groups, respectively. No difference in SSMI, CMAP or SNAP, VAS, satisfaction was recorded. With USG, the median at the elbow and fibular MMSI were lower (p = 0.04; p = 0.02). With normal NCS or overweight and obese subgroups patients had lower median SSMI (p = 0.05/ p = 0.02), higher median and sural SNAP with normal NCS (p = 0.04; p = 0.007) and the sural SNAP for the expert US subgroup (p = 0.02). Conclusions: USG is useful for nerves, that are anatomically variable or in obesity. The sural SNAP gain with US in the normal NCS subgroup could facilitate routine NCS. Significance: In standard NCS the USG does not modify the patient's tolerance.Trial Registration: clinicaltrials.gov (NCT03868189).

Dementia and glaucoma: Results from a Nationwide French Study between 2006 and 2018.

PURPOSE: Glaucoma is the leading cause of irreversible blindness worldwide. The brain and eye share many characteristics, so the eye may provide an easy-access window on brain processes. The aim of the study was to evaluate the link between glaucoma as well as intraocular pressure (IOP)-lowering drops load and all-cause dementia. METHODS: This was a nested case-control study based on the French national healthcare database from 1 January 2006 to 31 December 2018in individuals aged ≥60 years. We compared cases of incident all-cause dementia with 1:5 controls matched by date of case diagnosis (index date), age, sex, and income. We set a 5-year exposure to glaucoma period ending 2 years before the index date (lag-time period to avoid protopathic bias). The main outcome was glaucoma defined with hospitalization related to POAG and/or dispensations of IOP-lowering drops. The secondary outcome was the IOP-lowering drops load. RESULTS: In total, 4810 incident all-cause dementia and 24 050 matched controls were analysed (median [IQR] age 82 [10] years; 66.6% women). The prevalence of glaucoma was 14.0% in controls and cases. Risk of all-cause dementia was not associated with glaucoma (crude OR, 1.02; 95% CI [0.93-1.11]; p = 0.7; adjusted OR, 0.99; 95% CI [0.91-1.09]; p = 0.9) or IOP-lowering drops load (p = 0.2). CONCLUSION: The present study in general population ≥60 years old in France did not find any association between glaucoma and incident all-cause dementia.

Diagnosis challenges in inception cohorts in axial spondyloarthritis: the case of the French national DESIR cohort.

BACKGROUND: Inception cohorts aim to describe chronic diseases from diagnosis and over years of follow-up. Axial spondyloarthritis (axSpA) diagnosis might be challenging during the first years of the disease. Thus, identifying the features that will be associated with a confirmed diagnosis over time is key. OBJECTIVES: To assess the frequency and the predisposing factors for a change of an initial diagnosis in an inception axSpA cohort. METHODS: DESIR is an ongoing national multicentre inception axSpA cohort with currently 12.5 years of follow-up. At the entry visit and confirmed at each visit, the diagnosis of axSpA was based on the opinion of the treating rheumatologist. Follow-up was interrupted in case of a change in this initial diagnosis. Multiple imputation was used to estimate the probability of a change in the initial diagnosis of axSpA for each patient lost to follow-up. Factors predisposing to an unchanged diagnosis of axSpA were then assessed using a multivariate logistic regression model on the imputed data sets. RESULTS: Of the 708 patients included, over 10 years of follow-up, 45 (6.4%) were excluded due to a diagnosis change and 300 (42.4%) patients were lost to follow-up. Based on the imputation of these 300 patients, a change in their initial axSpA diagnosis was estimated in 42 (14.0%). Factors predisposing to an unchanged initial axSpA diagnosis during follow-up were (ORs (95% CIs)): radiographic sacroiliitis: 17.0 (4.1 to 71.0); psoriasis: 5.3 (2.0 to 14.3); CRP≥6 mg/L: 2.7 (1.3 to 5.3); good NSAID response: 2.5 (1.5 to 4.2); HLA B27+: 2.0 (1.3 to 3.3); anterior chest wall pain: 2.0 (1.2 to 3.3) and female sex: 1.9 (1.2 to 3.0). CONCLUSION: These data suggest that a change in diagnosis in recent onset axSpA exists, but is not frequent, and is less likely to occur in the presence of objective features at baseline.