NUTRISEP: Assessment of the nutritional status of patients with multiple sclerosis and link to fatigue.

BACKGROUND: Fatigue is a common complaint in patients with multiple sclerosis (PwMS) and reduces quality of life. Several hypotheses for the pathogenesis of fatigue in MS are proposed ranging from neurological lesions to malnutrition, but none has been conclusively validated through clinical research. OBJECTIVES: The goal of this study was to examine the correlation between fatigue and nutritional status and dietary habits in PwMS. METHODS: This was a cross-sectional, multicenter study conducted at 10 French MS centers and enrolling PwMS with an Expanded Disability Status Scale (EDSS) score between 0 and 7. Plasma level of albumin, magnesium, calcium, iron, vitamin D and B12 evaluated nutritional status. A semi-structured eating behavior questionnaire has been developed to evaluate dietary habits. Evaluation of fatigue used specific questionnaire (EMIF-SEP). Quality of sleep was evaluated by visual analogue scale (VAS), depression with Beck Depression Inventory (BDI-II); dysphagia by DYsphagia in MUltiple Sclerosis questionnaire (DYMUS) and taste disorders by gustometry. Association between nutritional deficiencies and different data such as socio-demographic data, disease characteristics, swallowing and taste disorders, food intake, depression and sleep quality was investigated. RESULTS: A total of 352 patients mean age: 48.1±10.1 years, mean duration of MS: 15.3±9.1 years and median EDSS: 4 were analyzed. Bivariate and multivariate analyses showed a statistically significant correlation between fatigue and depression and use of sleeping pills, while none of the variables related to dietary habits or nutritional status correlated significantly with fatigue. CONCLUSIONS: Dietary habits and nutritional status have little impact on fatigue and general population nutrition recommendations remain the rule for PwMS. In cases of fatigue, specific attention should be paid to depression and use of sleeping pills.

How reproducible are classical and new CT-pelvimetry measurements?

PURPOSE: The objective of this study was to assess the reliability and reproducibility of existing and new computed tomography (CT)-pelvimetry measurements. MATERIAL AND METHODS: A retrospective cohort study of 63 women with a mean age of 33.9±5.2 (SD) years (range: 19-49 years) was conducted. Classical pelvimetry measurements were collected including the obstetric conjugate (OC), median transverse diameter (MTD), and interspinous diameter (ISD). Additionally, we used multiplanar reconstruction (MPR) mode to define two oblique planes: inlet pelvic plane (IPP) and mid-pelvic plane (MPP) and measure new pelvic parameters, including anteroposterior (APD), transverse diameters and circumference of both IPP and MPP (inletAPD, inletMTD, inletCIRC and midAPD, ISD, midCIRC, respectively). The reproducibility (intra- and inter-observer) of our results were assessed. Multivariate analyses using principal component analysis and clustering methods were conducted to analyze the association between pelvimetry measurements and identify patient sub-groups. RESULTS: All linear measurements (OC, inletAPD, MTD, inletMTD, midAPD, and ISD) showed statistically "almost perfect" intra- and inter-observer correlation coefficients (range: 0.924-0.980). Circumferences (inletCIRC and midCIRC) showed statistically "almost perfect" intra- (range: 0.847-0.857) and inter-observer correlation coefficients (range: 0.923-0.957). The measurement of 6 pelvimetric parameters allowed determining three groups of pelvis size. CONCLUSION: New pelvic measurements have excellent reproducibility and are similar to the classical measurements, based on the MPR analysis of CT planes adjusted to the inner bony pelvis.

Inaugural tumor-like multiple sclerosis: clinical presentation and medium-term outcome in 87 patients.

BACKGROUND: Tumefactive demyelinating lesions of the central nervous system can be the initial presentation in various pathological entities [multiple sclerosis (the most common), Balo's concentric sclerosis, Schilder's disease and acute disseminated encephalomyelitis] with overlapping clinical presentation. The aim of our study was to better characterize these patients. METHODS: Eighty-seven patients (62 women and 25 men) from different MS centers in France were studied retrospectively. Inclusion criteria were (1) a first clinical event (2) MRI showing one or more large demyelinating lesions (20 mm or more in diameter) with mass-like features. Patients with a previous demyelinating event (i.e. confirmed multiple sclerosis) were excluded. RESULTS: Mean age at onset was 26 years. The most common initial symptoms (67% of the patients) were hemiparesis or hemiplegia. Aphasia, headache and cognitive disturbances (i.e. atypical symptoms for demyelinating diseases) were observed in 15, 18 and 15% of patients, respectively. The mean largest diameter of the tumefactive lesions was 26.9 mm, with gadolinium enhancement in 66 patients (81%). Twenty-one patients (24%) had a single tumefactive lesion. During follow-up (median time 5.7 years) 4 patients died, 70 patients improved or remained stable and 12 worsened. 86% of patients received initial corticosteroid treatment, and 73% received disease-modifying therapy subsequently. EDSS at the end of the follow-up was 2.4 ± 2.6 (mean ± SD). CONCLUSION: This study provides further evidence that the clinical course of MS presenting with large focal tumor-like lesions does not differ from that of classical relapsing-remitting MS, once the noisy first relapsing occurred.

Anterior lumbar sagittal alignment after anterior or lateral interbody fusion.

PURPOSE: Anterior or lateral interbody fusion is a treatment option for lumbar disc disease. A segmental change occurs after such surgery. This study was designed to evaluate the changes in the lumbar regional alignment after a single or two-level standalone anterior or lateral interbody fusion (ALIF or LLIF). METHODS: Data from patients referred to our institution between March 2013 and November 2015 for standalone ALIF or LLIF for low-grade isthmic spondylolisthesis or degenerative discopathy were retrospectively included in our analysis. Patients with a history of spinal fusion were excluded. Global and regional alignments were analyzed pre- and postoperatively. Pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), lumbar lordosis (LL), index segmental lordosis (ISL) and L4S1 lordosis were compared. Three groups according to the pelvic incidence (PI) (low, normal and high) were separately analyzed then compared. RESULTS: Forty-one women and 27 men (mean age was 46 years; range 25-66) were included. The mean follow-up was 10.8 (range 3-34 months). The patients were globally well balanced preoperatively and remained after surgery (SVA stagnated from 16.76±28.42mm to 15.97±28.20mm, P=0.75). PT and LL did not vary. L4S1 lordosis, and ISL were significantly increased respectively from 30.56±8.59 to 34.58±7.47 (P=0.0026) and from 5.94±5.25 to 12.99±5.87 (P<0.0001) at latest follow-up. CONCLUSION: Despite effective changes in the segmental lordosis at the index levels, our findings suggest that one or two-levels standalone ALIF or LLIF had no effect on the global balance and the lumbar lordosis. The three groups behaved similarly, the regional lordosis was redistributed in a better harmony (L4S1/LL ratio went up from 55% to 61%, P=0.01). STUDY TYPE: Retrospective study. LEVEL OF EVIDENCE: 4.

["Heart, arteries and women" an innovative care pathway for women at high risk: First evaluation at one year]. / Le circuit « cœur, artères et femmes ¼ chez la femme à haut risque cardiovasculaire : première évaluation à un an.

INTRODUCTION: Cardiovascular diseases remain the first cause of death in women. To improve women's health cardiologists and gynaecologists should work together on women's specific cardiovascular risk factor. METHOD: Our study evaluated a care pathway named "heart, arteries and women". One hundred and ninety-one women were included for vascular (n=55) or hypertensive (n=136) explorations from January the first to December the 31st of 2013. We studied their clinical presentation and medical management. RESULTS: All women were at high cardiovascular risk (38% of them at very high risk). The average age was 52 years old. A woman on three had experienced high blood pressure or diabetes during pregnancy. One on two was postmenopausal woman. We stopped twelve estrogen-progesterone contraceptions; 60% didn't have gynaecological follow-up; 146 had high blood pressures (73% at night, 50% had no dipping blood pressure profile and 15 were newly diagnosed for hypertension). Sleep apnoea syndrome was suspected in half women. Medical therapies were optimized especially for women with atheroma in which 30 to 46% were properly treated (P=0.0005). Only 18% of the gynecologists received conclusive reports. CONCLUSION: At one year, our care pathway "heart, arteries and women" allowed to optimize medical therapy and clinical management. Everyone should be aware of this program.

First data on Pneumocystis jirovecii colonization in patients with respiratory diseases in North Lebanon.

Pneumocystis colonization may play a role in transmission and local inflammatory response. It was explored in patients with respiratory diseases in North Lebanon. Overall prevalence reached only 5.2% (95% CI 2.13-10.47) but it was higher (17.3%) in the subpopulation of patients with chronic obstructive pulmonary disease (COPD). COPD was the only factor associated with a significantly increased risk of colonization. mtLSU genotyping revealed predominance of genotype 2, identified in five patients (71.4%), including one patient who had co-infection with genotype 3. These first data in North Lebanon confirm Pneumocystis circulation among patients with respiratory diseases and the potential for transmission to immunocompromised patients.

Tumor necrosis after preventive embolization of large renal angiomyolipomas.

OBJECTIVES: The purpose of this study was to retrospectively evaluate tumor necrosis following preventive embolization in patients with renal angiomyolipoma (RAML) at high risk of bleeding. PATIENTS AND METHODS: Arterial embolization was performed in 24 patients (22 women, 2 men; mean age, 43±13 years) with a total of 30 RAMLs (mean volume, 137 cm(3)±163) between 1996 and 2012. Two sub-groups of patients were identified and further compared based on the presence or not of necrosis following arterial embolization. RESULTS: The technical and clinical success rates of arterial embolization of RAMLs were 97% and 87%, respectively. The mean initial volume of RAMLs differed between the two sub-groups with 331 cm(3) in the group with tumor necrosis and 88 cm(3) in the group without tumor necrosis (P=0.0047). High-fat content RAMLs were predominantly observed in the necrosis group and the mean volume reduction observed for high-fat RAMLs was 65% whereas it was 36% for low-fat content RAMLs. The six patients who developed RAML necrosis had arterial embolization using microspheres (one patient with microspheres alone and five with a combination of microspheres and metallic coils). All necrotic RAMLs displayed arterial dysplasia. CONCLUSION: The risk of tumor necrosis is higher for larger RAMLs. The role of distal arterial embolization with microspheres in tumor necrosis in RAML is suggested by the results of our study but could not be definitely demonstrated statistically due to the limited sample size.

[Pudendal nerve block for perineo-vulvar surgery: monocentered prospective and randomised study]. / Bloc du nerf pudendal en chirurgie périnéo-vulvaire : étude monocentrique prospective randomisée.

OBJECTIVES: Evaluation of pudendal nerve block on the quality of analgesia in perineal or vulvar surgery. PATIENTS AND METHODS: We realised a monocentered, prospective and randomised study of all patients undergoing perineo-vulvar surgery. Two groups of patients were evaluated: general anaesthesia alone (GA group, 41 patients) and both general anaesthesia and bilateral nerve stimulator-guided pudendal nerve block (15 mL of Ropivacaïne 5 mg.mL(-1)+0,5 µg.kg(-1) of Clonidine) (PB group, 42 patients). Evaluation of pain was realised with per- and post-surgical prescription of hypnotics and antalgics was noted. The primary outcome measure was the Visual Analogic Scale (VAS) pain means scores in the first postoperative 24 hours. RESULTS: There was no difference in the VAS pain means scores in the first 24 hours, but it seemed to have a decrease in VAS pain at 2 hours in the PB group. Analgesic consumption during surgery was decreased in the same group. No complication of the pudendal block has been reported. DISCUSSION AND CONCLUSION: The nerve stimulator-guided pudendal nerve block is a simple and useful method which can, when associated with general anesthesia, reduce per-operative antalgics consumption and a decrease in the immediate postoperative pain in perineal or vulvar surgery, without complication or lengthening operating time. Further studies are needed to confirm the effectiveness of this technique and evaluate the costs and potential complications.

[Systematic screening of masked hypertension in patients with peripheral arterial disease: a pilot study]. / Dépistage systématique de l'hypertension artérielle masquée chez les patients ayant une artériopathie des membres inférieurs: une étude pilote.

AIM: Masked hypertension (MH) is defined by a normal office blood pressure (BP) and a high ambulatory BP. MH is characterized by high prevalence and poor cardiovascular prognosis. The aim of this study was to evaluate the usefulness of routine MH screening, using 24-h blood pressure monitoring (BPM), among patients with peripheral arterial disease (PAD). METHODS: Between 2011 and 2013, 54 patients with PAD were included in the Hypertension and Vascular Medicine Unit of the Lille Hospital. They had normal office BP (< 140/90mmHg). A 24 h-BPM device was set on each patient. MH diagnosis was established if the BP average over 24 hours was ≥ 130/80 mmHg and/or the daytime average ≥ 135/85 mmHg and/or the nighttime average ≥ 120/70 mmHg. RESULTS: MH prevalence was about 42.6% (23 patients). It was significantly more frequent in diabetic patients (odds ratio: 3.8 [1.1-12.8]), in patients with known hypertension (odds ratio: 5 [1.5-16.9]) or with high normal office BP (<140/90 mmHg but ≥ 130/85 mmHg) (odds ratio: 5.6 [1.7-18.2]). By multivariate analysis, only known hypertension and high normal office BP were associated with masked hypertension. CONCLUSION: The high prevalence of MH in patients with PAD shows us the importance of a careful screening of MH in this population, especially in diabetic patients, in patients with known hypertension or with a high normal office BP.

Scoring of medical publications with SIGAPS software: Application to orthopedics.

SIGAPS is a bibliometric software tool developed in France to identify and analyze Medline-indexed publications that are produced by a researcher or research group. This measurement takes into account the author's ranking on the paper along with the journal's prestige according to its impact factor within the research field. However, use of this impact factor is the primary limitation of SIGAPS. SIGAPS analysis results are used to assign a financial value to hospital facilities. The impact of the journal Revue de Chirurgie Orthopédique and its successor-Orthopaedics & Traumatology: Surgery & Research-was compared using the Medline-based ISI (SIGAPS) and SCOPUS-based SCImago journal rankings.

[Limiting a Medline/PubMed query to the "best" articles using the JCR relative impact factor]. / Limiter une requête Medline/PubMed aux articles publiés dans les revues les plus citées de chaque discipline.

BACKGROUND: Medline/PubMed is the most frequently used medical bibliographic research database. The aim of this study was to propose a new generic method to limit any Medline/PubMed query based on the relative impact factor and the A & B categories of the SIGAPS score. MATERIAL AND METHODS: The entire PubMed corpus was used for the feasibility study, then ten frequent diseases in terms of PubMed indexing and the citations of four Nobel prize winners. The relative impact factor (RIF) was calculated by medical specialty defined in Journal Citation Reports. The two queries, which included all the journals in category A (or A OR B), were added to any Medline/PubMed query as a central point of the feasibility study. RESULTS: Limitation using the SIGAPS category A was larger than the when using the Core Clinical Journals (CCJ): 15.65% of PubMed corpus vs 8.64% for CCJ. The response time of this limit applied to the entire PubMed corpus was less than two seconds. For five diseases out of ten, limiting the citations with the RIF was more effective than with the CCJ. For the four Nobel prize winners, limiting the citations with the RIF was more effective than the CCJ. CONCLUSION: The feasibility study to apply a new filter based on the relative impact factor on any Medline/PubMed query was positive.

[SIGAPS: a software package for the evaluation of medical publications]. / Modèle de valorisation des publications médicales scientifiques: le logiciel SIGAPS.

The "système d'interrogation, de gestion et d'analyse des publications scientifiques" (System for Identification, Management and Analysis of Scientific Publications), or SIGAPS, is an innovative tool of French design that enables the identification and analysis of bibliographic references produced by a given researcher or unit using the Medline database (PubMed). This evaluation takes into account the author's rank of signature and the impact factor of the journal of publication within the discipline in question. The limits are those of the impact factor. Analyses produced by SIGAPS enable financial assessment to be made by hospitals.

Rate of intravenous thrombolysis for acute ischaemic stroke in the North-of-France region and evolution over time.

The proportion of patients with ischaemic stroke treated by intravenous (i.v.) recombinant tissue plasminogen activator (rt-PA) is an indicator of quality of stroke care. The objective of the study is to evaluate the rate of i.v. thrombolysis in the North-of-France region and its evolution over time. We determined the proportion of inhabitants treated by i.v. rt-PA in 2009-2010 (period A; 8 stroke units, no telemedicine) and 2012 (period B; population campaigns, 12 stroke units with telemedicine in 5). We used hospital registries from the 12 stroke units, and population-based data were collected in a subpopulation of 226,827 inhabitants (5.6% of the whole population). 1,563 inhabitants received i.v. rt-PA for stroke (period A: 835 in 24 months; period B: 728 in 12 months). Hospital and population data were similar. Annual rates of thrombolysis increased from 103 per million inhabitants [95% confidence interval (CI) 85-125] to 181 (95% CI 157-209; relative increase 76%, 95% CI 67-83%). This rate increased in 12 districts (significantly in 6), but the increase was greater in districts where new stroke units, telemedicine, or both were implemented. In conclusion, although the proportion of patients treated was already high in period A, there was still place for improvement. Implementation of new stroke units, extension of the telemedicine network and new population campaigns are necessary to improve the rate of thrombolysis in several areas, to ensure an equal access to treatment over the whole territory. The next step is now to determine whether this high rate of i.v. rt-PA delivery at the population level translates into clinical results.

[Anemia in the critically ill child and adult: a narrative review]. / L'anémie aux soins intensifs pédiatriques et adultes: revue narrative.

Anemia is frequent in the pediatric and adult intensive care unit. Anemia decreases oxygen transport which can be harmful in the critically ill patient; it is independently associated with a poor prognosis. The major prophylactic measure against anemia is the limitation of blood draws: several approaches can be used to limit phlebotomy overdraw without harming the patient. Red blood cell transfusion is the quickest way to increase the hemoglobin level, but it is not without risk. It is therefore important to promote the use of evidence-based transfusion strategies. Iron could be useful in case of iron deficiency, but this condition is difficult to diagnose in the critically ill patient. Erythropoietin is no longer relevant in the intensive care unit in the era of restrictive transfusion practice, at least for its hematological effects. Several questions remain to be addressed in order to improve anemia management in the intensive care unit.

[A specific questionnaire to evaluate therapeutic inertia in hypertensive patients: a pilot study]. / Évaluation de l'inertie thérapeutique chez des patients hypertendus à l'aide d'un questionnaire ciblé : étude pilote.

BACKGROUND: Therapeutic inertia (TI) is a recent concept still unknown by many physicians. In chronic diseases such as hypertension, it is defined as the tendency of physicians not to increase or change antihypertensive medications when the target blood pressure is not reached. Acting on TI could improve blood pressure control in France. METHOD: This was a single-center prospective pilot study conducted by hypertension specialist physicians at the University Cardio-Vascular Center in Lille (France). It was conducted between March and June 2011. Data was collected from 161 hypertensive patients (mean age: 61.64±11.18 years; 98 (60.9%) male; 75 secondary prevention patients). Each physician completed a questionnaire on therapeutic inertia. TI was defined as a consultation in which treatment change was indicated (systolic blood pressure [BP]≥140 and/or diastolic BP≥90mmHg in all patients), but did not occur, with absence of an adapted justification of this choice. We considered as an adapted justification: a white coat effect demonstrated by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring; scheduled reassessment of the BP by ABPM; recent change in antihypertensive treatment (less than 4 weeks); hospitalization needed for complete evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage in patients with grade 1 or 2 hypertension. Our study aimed to evaluate rates of TI, to identify factors associated with TI, and to test the TI questionnaire. RESULTS: Therapeutic inertia as defined in this study occurred in 11 consultations (8.3%) of the 133 hypertensive patients having uncontrolled BP above or equal to 140 and/or 90mmHg. Significant factors associated with TI were older age (Z=2.35, P<0.05) and sleep apnea syndrome (χ(2)=8.33, P<0.05). The absence of ambulatory blood pressure monitoring before the consultation (χ(2)=4.28, 0.1>P>0.05) and the number of consultations (Z=1.92, 0.1>P>0.05) exhibited a significant trend to be associated with TI. CONCLUSIONS: Although the rate of TI was low in our study conducted in a specialized center, a well-accepted definition of therapeutic inertia would be useful for further study. The feasibility of using the questionnaire tested with this study shows that this measurement tool could help physicians become more aware of TI, both in the hospital and primary care setting. Further multicenter studies are needed for validation.