A French observational study of botulinum toxin use in the management of children with cerebral palsy: BOTULOSCOPE.

BACKGROUND: Dystonia and spasticity are common symptoms in children with Cerebral Palsy (CP), whose management is a challenge to overcome in order to enable the harmonized development of motor function during growth. AIM: To describe botulinum toxin A (BTX-A) use and efficacy as a treatment of focal spasticity in CP children in France. METHODS: This prospective observational study included 282 CP children mostly administered according to French standards with BTX-A in lower limbs. Realistic therapeutic objectives were set with parents and children together before treatment initiation and assessed using the Visual Analogue Scale (VAS). Child management was recorded and the efficacy of injections was assessed during a 12-month follow-up period by physicians (Modified Ashworth Scale, joint range of motion, Physician Rating Scale, Gillette Functional Assessment Questionnaire and Gross Motor Function Measure-66) and by patients/parents (Visual Analogue Scale). RESULTS: BTX-A treatment was administered in different muscle localizations at once and at doses higher than those recommended by the French Health Authorities. Children were treated in parallel by physiotherapy, casts and ortheses. Injections reduced spasticity and improved joint range of motion, gait pattern and movement capacity. Pain was reduced after injections. BTX-A administration was safe: no botulism-like case was reported. The log of injected children who were not included in the study suggested that a large population could benefit from BTX-A management. CONCLUSIONS: We showed here the major input of BTX-A injections in the management of spasticity in CP children. The results are in favor of the use of BTX-A as conservative safe and efficient treatment of spasticity in children, which enables functional improvement as well as pain relief.

Evaluation of in-stent restenosis in proximal coronary arteries with multidetector computed tomography (MDCT).

The purpose of this study was to assess the ability of 16-slice computed tomography (CT) to detect in-stent restenosis of proximal coronary arteries. From November 2002 to April 2004, 134 consecutive patients with proximal stents (3.25 +/- 0.47 mm) were prospectively studied. Multidetector CT (MDCT) was performed 24 h (baseline) and 6 months after angioplasty and analysed by two radiologists blinded to the results of the coronary angiography. Sensitivity, specificity, positive and negative predictive values for in-stent restenosis were compared with conventional quantitative coronary angiography (QCA). Stenosis with a diameter >or=50% was considered diagnostic of in-stent restenosis. The CT analysis was performed in 131 and 114 patients at baseline and 6 months, respectively. The in-stent lumen was evaluable in 111 (121 stents) and 99 patients (108 stents) at baseline and 6 months, respectively. The prevalence of in-stent restenosis was 22.5%. Restenoses were correctly identified in 91.7 and 87.5% by the two radiologists. The sensitivity, specificity, positive and negative predictive values for the assessment of significant in-stent restenosis were 92, 67, 43, 97% and 87, 66, 41, 95% for the radiologists, respectively. MDCT is a potential non-invasive technique for the screening of in-stent restenosis of proximal coronary arteries that needs further improvements.

[Percutaneous embolisation of a iatrogenic fistula between the internal mammary artery and the coronary vein]. / Embolisation percutanée d'une fistule iatrogène entre l'artère mammaire interne et la veine coronaire. Revue de la littérature à propos d'une observation.

Latrogenic fistula between the aorta and coronary vein is a rare complication of coronary bypass surgery due to accidental venous or arterial graft onto a coronary vein. The authors report a case of a patient admitted to hospital 2 months after coronary bypass surgery for cardiac failure due to a iatrogenic fistula by implantation of the left internal mammary artery on the great coronary vein. This presentation led to the choice of percutaneous embolisation of the fistula by the release of 6 coils. Based on a review of the literature, this clinical case illustrates the feasibility and value of percutaneous embolisation of iatrogenic fistulae.

[Coronary-bronchial artery fistula and two-vessel coronary disease treated by embolisation of the anastomosis and coronary angioplasty]. / Fistule coronaro-bronchique et lesions coronaires bitronculaires, traitées par embolisation de l'anastomose puis par angioplastie coronaire.

Coronary-bronchial artery fistulae are rare and may present with broncho-pulmonary haemorrhage and myocardial ischaemia. The authors report the case of a coronary-bronchial artery fistula associated with bronchiectasis responsible for haemoptysis and discovered at coronary angiography performed during an acute coronary syndrome. Radical treatment by embolisation of this fistula allowed the use of platelet inhibitors and anticoagulants for the coronary angioplasty performed secondarily. This method is an interesting alternative to surgical ligature.

[Inadequate management of dyslipidaemic patients in France. Results of the Odyssée study]. / Insuffisance de la prise en charge des patients dyslipidémiques en France. Résultats de l'étude Odyssée.

The objective of this study was to compare the results of the management of dyslipidaemic patients in the community with the objectives fixed by the AFSSAPS recommendations. An observational epidemiological study was set up among 4 000 general practitioners and 527 cardiologists. This study included 22 323 patients (average age 60.6 years) affected by a documented primary dyslipidaemia. The average number of associated risk factors, according to the AFSSAPS criteria, was 1.8. The prevalence of secondary prevention in patients was 17.5%. More than 80% of patients were being treated by a lipid lowering agent (fibrate or statin) combined or not with lifestyle guidelines. In primary prevention, although the target levels of LDL-C fixed by the AFSSAPS were attained in 94.4% and 82.6% respectively for patients with no other risk factor or with one associated risk factor, the objectives were reached in only 55.4% of patients with two other risk factors and in 29.6% of patients with more than two other risk factors. In secondary prevention, the AFSSAPS objectives were attained in only 45.2% of patients. Following this lipid result, 34.8% of patients underwent therapeutic adjustment, principally the use of medication in the patients receiving lifestyle advice or reinforcement of pharmacological treatment. This study underlines the inadequate management in France of dyslipidaemic patients in the community.

Modulation of the transmission in group II heteronymous pathways by tizanidine in spastic hemiplegic patients.

OBJECTIVE: To investigate the effect of tizanidine (an alpha(2) noradrenergic agonist) on transmission in the interneuronal pathway coactivated by group I and group II afferents in post-stroke patients with spastic hemiplegia. METHODS: Early and late facilitation of the quadriceps H reflex elicited in the common peroneal nerve--attributed to non-monosynaptic group I and group II excitation, respectively--was investigated in 14 spastic hemiplegic patients. All received a single dose of tizanidine (150 microg/kg) or placebo in randomised order at 10 day intervals. Repeated measurements were made at baseline (T0), 45-90 min, and 120 min after drug intake. Spasticity was assessed by modified Ashworth score in the quadriceps muscle and by a leg tone score calculated by the sum of the modified Ashworth score in five muscle groups. RESULTS: On the spastic side a decrease in late group II and, to a lesser extent, early group I common peroneal nerve induced quadriceps H reflex facilitation occurred with tizanidine (group II, mean (SEM) difference T0-T90: 34.3 (10.2)%, p<0.001; group I, T0-T120: 19.8 (9)%, p<0.05), but not with placebo (group II, difference T0-T90: 12.5 (8)%, NS; group I, T0-T120: 3.2 (7)%, NS). Tizanidine but not placebo decreased the quadriceps muscle and global lower limb Ashworth scores (2.9 (0.2) to 1.9 (0.3), p<0.001; and 12 (0.7) to 9.5 (0.8), p<0.0001, respectively). CONCLUSIONS: Enhancement of group II-group I facilitation of the quadriceps motor neurones on the spastic side of hemiplegic patients is modulated by alpha(2) noradrenergic agonists. This strengthens the view that late facilitation of quadriceps motor neurones is mediated by group II afferents and suggests that group II pathways may be involved in lower limb spasticity.

[Medical treatment of spasticity]. / Traitements médicamenteux de la spasticité.

Spasticity is one of the clinical signs observed after a lesion of the pyramidal tract. Clinical manifestations are polymorphous and depend on the location of the lesion on the pre-motoneuron. Functional consequences are also variable. Only negative effects such as painful spasms, stiffness, distortions, are to be treated. Three different categories of drugs are available: GABA-like (baclofen, benzodiazepine), central alpha 2 agonists (tizanidine, clonidine) and peripheral anti-spastics (dantrolene). Baclofen remains the most commonly used anti-spastic. The preferential indication is spasticity from spinal cord disease, especially when the aetiology is multiple sclerosis. Efficacy of benzodiazepines (diazepam, tetrazepam, clonazepam) is comparable with baclofen; however, side effects (drowsiness) are more frequent. Benzodiazepines are indicated when spasticity is associated with anxiety. Tizanidine is an efficient and well tolerated antispastic. In France, prescription requires a temporary authorization of use. Dantrolen has a peripheral mechanism of action and can be prescribed in the different forms of spasticity. There are other compounds with anti-spastic properties (gabapentine, cyproheptadine, piracetam). Their advantage is rather limited when used alone. Generally, they are administrated in combinaison with usual anti-spastic drugs.

[Revascularization of acute myocardial infarction. Doing better and doing more]. / Revascularisation de l'infarctus du myocarde aigu. Faire mieux et faire plus.

Effectiveness, safety, moderation, complementary, network, consensus, strategy and evaluation are the key words in the therapeutic management of acute myocardial infarction. They focus the development of pharmacological and interventional tools of recanalisation, and the decisions for those who use them. In order to cover a condition for which the patient and doctor alike choose neither time nor place, they lead to linking methods and disciplines together for a united approach. They take account of practice in order to adapt scientific data to the realities of exercise, to justify the given means, and to propose clear, realistic and useful management guidelines to first contact doctors. They deliver the best to the greatest number of patients.

Functional asymmetries of the lower limbs. A comparison between clinical assessment of laterality, isokinetic evaluation and electrogoniometric monitoring of knees during walking.

We used bilateral electrogoniometric gait monitoring of the knees to demonstrate the existence of an angular asymmetry between the two legs in healthy subjects. We also searched for correlations between this asymmetry and handedness, footedness and ocular laterality and isokinetic strength of the flexor-extensor muscles of the two knees. Among the 40 subjects studied, 25 (62.5%) showed an asymmetric maximal knee flexion: the difference being superior or equal to 5 degrees between the knees. There was no correlation between this asymmetry and the lateralities studied. We termed this type of asymmetry 'angular preponderance' to differentiate it from the laterality defined by clinical tests. Isokinetic strength of the knee flexors and extensors was correlated with the gender and speed, but not with side or laterality. Appropriate interpretation of lower limb examination should take into consideration angular gait asymmetry in the healthy subject.

[Feasability of a back school assessment programme]. / Etude de faisabilité dun programme dévaluation de lécole du dos.

OBJECTIVES: Testing the feasability of a back school assessment programme in two populations of people suffering with chronic low back pain. MATERIAL: Twenty-nine patients were randomly included in a chronic low back pain assessment programme (15 patients waiting for back school and 14 patients after back school). METHODS: The programme was made of the measure of the age, the sex, the body mass index, the pain (VAS, St Antoine Hospitals Pain Questionnaire - SAPQ), the anxiety, the depression, the RIII nociceptive reflex, the fingertip-floor distance, the strength of the flexors and of the extensors of the lumbar spine (CybexR 6000 isocinetic dynamometer), the lumbar function (EIFEL, Dougados), the Dallas self-questionnaire. The Back School Education programme was made of five sessions (information, ergonomics, extension exercises). RESULTS: Comparing the two populations we did not observe significant differences concerning the age, the body mass index, the anxiety and depression levels, the pain (VAS, SAPA, RIII nociceptive reflex), the lumbar stiffness, the lumbar disability, the quality of life; the patients who had achieved back school had a peak torque of the flexors and a ratio flexors/extensors significantly lower. Comparing men and women we observed significant differences in the SAPQ and the muscles strength. The SAPQ was correlated with the depression and anxiety levels, the lumbar disability, the peak torque of the flexors. The VAS was correlated with the age, the lumbar stiffness, the depression level, the peak torque of the flexors. The RIII nociceptive reflex was correlated with the ratio flexors/extensors. CONCLUSION: This study present some biases but this objective assessment of chronic low back pain appeared as feasible. The pain must be investigated in term of intensity, expression, alleviation. The impairment of the flexors muscles in women and after back school has to be confirmed. The different tests are relevant to determinate the efficiency of the back school programmes.

[Prognostic value of the assessment of ischemic status at admission to the coronary care unit after pre-hospital thrombolysis]. / Intérêt pronostique de l'évaluation du statut ischémique à l'arrivée en USIC après une thrombolyse préhospitalière.

The object of this study was to assess and analyse TIMI (Thrombolysis in Myocardial Infarction) grade and secondary major cardiac events of patients with acute myocardial infarction benefiting from pre-hospital thrombolysis according to their predefined clinical and electrical "ischaemic status" (Active, Inactive, Intermediate) on admission to the coronary care unit and at the end of thrombolysis (90th minute). This single centre study was undertaken from March 1994 to August 1999 on 161 patients treated by thrombolysis by the emergency ambulance service for acute myocardial infarction (< or = 6 hours). The mean age was 56.2 +/- 11.3 years with 8.7% of women. On admission to the coronary care unit. 30.8% were classified as Inactive and 51.6% as Active. At the end of thrombolysis, 62.3% were classified as Inactive and 27.7% as Active. Nearly 93% of TIMI 3 flow was observed in Inactive patients at the 90th minute and 76.7% of TIMI < or = 2 flow in Active patients (p < 0.0001). Global hospital mortality was 2.48% but it was zero in the Inactive group at the end of thrombolysis. With an average follow-up of 26.9 +/- 15.8 months, the incidence of major cardiac events was 34.1%, including 16.1% of revascularisation of the target lesion. In multivariate analysis, predictive factors for TIMI < or = 2 at the end of thrombolysis included persistent pain, the number of leads with ST elevation and the absence of regression of ST elevation on admission to the coronary care unit. The only predictive factor for secondary major cardiac events was persistent ST elevation at the 90th minute of thrombolysis.

Omapatrilat, a dual angiotensin-converting enzyme and neutral endopeptidase inhibitor, prevents fatty streak deposit in apolipoprotein E-deficient mice.

Angiotensin-converting enzyme (ACE) is mainly responsible for converting angiotensin I (AI) to angiotensin II (AII), and ACE inhibitors prevent atherosclerosis in animal models. Neutral endopeptidase 24.11 (NEP) degrades substance P, kinins and atrial natriuretic peptide (ANP), and aortic wall NEP activity was found to be increased in atherosclerosis. In the present study, we have evaluated the effect of candoxatril, a NEP inhibitor, and of omapatrilat, a dual ACE and NEP inhibitor, on the development of fatty streak in apolipoprotein E (apoE)-deficient mice. Groups of ten male apoE-deficient mice were given either placebo, candoxatril 50 mg/kg per day, or omapatrilat 10, or 100 mg/kg per day for 4 months. None of the treatments influenced body weight, serum total or HDL-cholesterol. Compared with the placebo, candoxatril did not protect the mice from fatty streak deposit. In contrast, omapatrilat dose dependently inhibited the constitution of fatty streak in apoE-deficient mice. The precise advantages of the dual ACE and NEP inhibition versus the inhibition of only ACE should now be considered in the prevention of atherosclerosis as well as in the occurrence of its complications.

Facilitation of transmission in heteronymous group II pathways in spastic hemiplegic patients.

OBJECTIVE: A potent heteronymous group II excitation of quadriceps motor neurons has been recently demonstrated in normal subjects. The present study was undertaken to investigate whether this heteronymous group II excitation also contributes to spasticity in hemiplegic patients. METHOD: The early and late facilitations of the quadriceps H reflex elicited by a conditioning volley to the common peroneal nerve at three times motor threshold, attributed to non-monosynaptic group I and group II excitations respectively, were investigated. The comparison was drawn between results obtained in 20 patients after stroke, with hemiplegia due to a vascular lesion in the territory of the middle cerebral artery, and 20 age and sex matched normal subjects. RESULTS: A significant increase in the group I as well as in the group II common peroneal nerve induced facilitation of the quadriceps H reflex was seen on the spastic side of the patients (group I: 159 (SEM 10)% of control H reflex; group II: 165 (SEM 8)%) compared with their unaffected side (group I: 126 (SEM 4)%; group II: 128 (SEM 5)%) (Wilcoxon signed rank test, p<0. 01), or to the right (group I: 132 (SEM 4)%; group II: 131 (SEM 5)%) or left (group I: 130 (SEM 3)%; group II: 135 (SEM 6)%) side of controls (Mann-Whitney U test, p<0.01). No significant correlation (Spearman rank test) was found between the degree of group I and group II induced facilitations on the spastic side of the patients and the degree of clinically assessed spasticity (Ashworth scale). CONCLUSION: These results reflect a facilitation of the transmission in the interneuronal pathway coactivated by group I and group II afferents, probably resulting from a change in their descending control in spastic hemiplegic patients.

Asymmetric leg activity in healthy subjects during walking, detected by electrogoniometry.

AIM: To show asymmetric leg activity during walking in healthy subjects. DESIGN: Two electrogoniometers were used to measure the amplitude of the flexion-extension movements of both knees during walking. BACKGROUND: Walking is considered to be a symmetrical activity. Quantitative studies of walking often only consider one side of the body or remove differences between individuals by averaging results. METHODS: The handedness, lateral eye dominance and footedness of 31 healthy subjects were determined. A strain gauge electrogoniometer was then fitted to the outside of each knee to analyze the flexion-extension movements. The results were recorded automatically. The subject walked a distance of 30 m three times, with different attention levels: free walking (with no other task assigned), walking with attention diverted (whilst performing a mental task), and focused walking (walking as straight as possible in a straight line). RESULTS: 51.6% of the subjects tested displayed asymmetry of the total flexion-extension movement of more than 5 degrees between the two knees during free walking. The side favored (preponderance) by this asymmetry was not related to the handedness or other lateral dominance. The different attention levels did not significantly affect the characteristics of motion of the sub-groups studied (symmetric, right-favoring and left-favoring). CONCLUSIONS: The origin of this asymmetry, which is independent of handedness or attention level, could be the spinal stepping generator for which there is evidence in both animals and humans. Walking should not be considered to be a strictly symmetrical phenomenon. RELEVANCE: The demonstration of asymmetric leg activity during walking may lead to a better understanding of the way in which walking controlled. The presence of such asymmetry is normal, and it should be borne in mind during explorations of walking in both healthy and pathologic individuals.