An ecological approach to clinically assess nightmares in military service members with severe PTSD.

BACKGROUND: Trauma-related nightmares (TRNs) are distressing events which contribute to insomnia severity, chronicity and treatment resistance of PTSD. Therefore, recording TRNs is a crucial technical challenge in order to understand their physiopathological patterns and their impact on sleep. However, TRNs are difficult to record during a single night in a sleep laboratory, which, moreover, is likely to be considered by patients as a protective sleep environment that is therefore not representative of home sleep conditions. METHOD: In the present study, we investigate if objective sleep measures acquired at-home using two ambulatory devices is of clinical value by correlating with PTSD patients' complaints about sleep and nightmares. A secondary objective is to relate awakenings associated with TRNs to sleep stages and to provide new insights into the use of electrodermal activity (EDA) as a potential physiological marker of TRNs. Sixty veterans and active-duty service members were assessed by questionnaires and recorded for 5 consecutive nights in their homes. RESULTS: Our approach firstly identified positive correlations between subjective and objective sleep parameters (total sleep time, sleep-onset latency and TRNs frequency). We also developed a method of synchronization between the two ambulatory devices that allowed us to match 200 TRNs (reported by event marker push button) with sleep stages corresponding to 91 nights and 37 patients. Most awakenings associated with TRNs occurred during NREM sleep (65.5% versus 34.5% during REM sleep). Our results also reveal significant differences in the frequency of EDA peaks 10 min before the reported events, with a lower frequency in REM (13.7 peaks) than in NREM (24.8 peaks) awakenings associated with TRNs. This EDA peaks frequency in REM sleep is not statistically different from that in REM sleep preceding awakenings that are not associated with TRNs. CONCLUSION: The development of wearable devices to collect physiological parameters is of interest in clinical practice to improve our knowledge of sleep and trauma-related nightmares in patients with PTSD.

Translation, Cross-Cultural Adaptation and Preliminary Validation of a French Version of the Trauma-Related Nightmare Survey (TRNS-FR) in a PTSD Veteran Population.

INTRODUCTION: In the military population, trauma-related nightmares (TRNs) are highly associated with deployments and combat-related events. Trauma-related nightmares are also correlated with severity, treatment resistance, and chronicity of Post-Traumatic Stress Disorder (PTSD). However, to date, no specific measure of TRNs has been validated for use in the French language. This study aimed to translate and culturally adapt the English version of the Trauma-Related Nightmare Survey into French and to evaluate the psychometric properties of the translation on veterans. MATERIALS AND METHODS: After the translation and cultural adaptation process, we evaluated the reliability and validity of the French version of the questionnaire (TRNS-FR) in a population of veterans suffering from PTSD with nightmare complaints (n = 56 patients for test-retest and n = 60 for internal consistency), recruited from five French military hospitals. RESULTS: Analyses demonstrated that TRNS-FR has good test-retest reliability (r = 0.59) and good internal consistency with PTSD symptoms, insomnia symptoms, and subjective sleep parameters assessed at home. This questionnaire provides a rapid and comprehensive assessment of sleep disturbance and a specific description of TRNs in the population of veterans with severe PTSD. Our results allowed us to propose a valid and reliable French adaptation of the questionnaire. CONCLUSION: Because sleep disturbances and TRNs require specific therapeutic management, the psychometric qualities of TRNS-FR make it a tool of choice for assessing TRNs in future clinical research settings.

Pulmonary nodules associated with pulmonary embolism: A rare and misleading presentation of amyloidosis.

Amyloidosis is a rare disease especially the localized form involving pulmonary parenchyma. We report the case of a 74 years old woman who presented with chest pain and dyspnoea. CT scan showed pulmonary embolism and bilateral nodules. Laboratory examinations highlighted circulating Kappa IgM. 18F-FDG PET/CT showed intense activity of the nodules. Histological investigation supported the diagnosis of nodular pulmonary amyloidosis. There were no sign of systemic amyloidosis or autoimmune disease. No treatment was initiated: the patient remains asymptomatic after one year. Localized pulmonary amyloidosis related to MGUS was the most likely diagnosis. Malignancy, a differential diagnosis of pulmonary amyloidosis, must be excluded: histological examinations are overriding. Difference between systemic and localized amyloidosis conditions treatment and prognosis. This observation emphasizes the difficulty to establish the diagnosis of pulmonary nodular amyloidosis and the complex relationship between amyloidosis and thromboembolism.

Clinical Features of Mycobacterium canettii Infection: A Retrospective Study of 20 Cases Among French Soldiers and Relatives.

BACKGROUND: Mycobacterium canettii forms part of the Mycobacterium tuberculosis complex. Mycobacterium canettii infections are mainly described in the Horn of Africa. The permanent presence of French soldiers in Djibouti raises the question of the risk of being infected with M. canettii. Here, we describe M. canettii infections among French military and their families between 1998 and 2015. METHODS: This retrospective study relied on 3 sources of data: the reference center for mycobacteria in the Biology Department at Percy Military Hospital in Paris, the French Military Center for Epidemiology and Public Health, and the scientific literature. After an exhaustive census of the strains, we studied the epidemiological data on 20 cases among French soldiers and their families. RESULTS: Twenty cases of M. canettii infections are reported, including 5 unpublished cases. Adenitis predominates (n = 15), especially in the cervico facial area and among children; 1 case was observed 1 month after dental care in Djibouti. The pulmonary forms were less frequent (n = 6), and 3 atypical forms are described. All patients had stayed in Djibouti. CONCLUSIONS: Cases of M. canettii infection among the French military consisted mainly of adenitis; disseminated forms were possible with immunodeficiency. Their evolution under specific treatments was comparable to that of tuberculosis. The presumed origin of the infection seemed to be environmental, possibly a water reservoir, and not due to human-to-human contagion.

Failure of dihydroartemisinin plus piperaquine treatment of falciparum malaria by under-dosing in an overweight patient.

BACKGROUND: Artemisinin-based combination therapy (ACT) introduced in the mid-1990s has been recommended since 2005 by the World Health Organization as first-line treatment against Plasmodium falciparum in all endemic countries. In 2010, the combination dihydroartemisinin-piperaquine (DP) was recommended for the treatment of uncomplicated P. falciparum malaria. DP is one of the first-line treatments used by the French army since 2013. CASE PRESENTATION: A case of P. falciparum clinical failure with DP at day 20 was described in a 104 kg French soldier deployed in Djibouti. He was admitted to hospital for supervision of oral treatment with DP [40 mg dihydroartemisinin (DHA) plus 320 mg piperaquine tetraphosphate (PPQ)]. This corresponded to a cumulative dose of 4.6 mg/kg DHA and 37 mg/kg PPQ in the present patient, which is far below the WHO recommended ranges. No mutation was found in the propeller domain of the Kelch 13 (k13) gene, which is associated with artemisinin resistance in Southeast Asia. Pfmdr1 N86, 184F, S1034 and N1042 polymorphisms and haplotype 72-76 CVIET for the pfcrt gene were found in the present case. There was no evidence of resistance to DP. CONCLUSION: This case confirms the risk of therapeutic failure with dihydroartemisinin-piperaquine by under-dosing in patients weighing more than 100 kg. This therapeutic failure with DP by under-dosing highlighted the importance of appropriate dosing guidelines and the need of research data (efficacy, pharmacokinetics and pharmacodynamics) in over-weight patient group.

Clinical Survey of Dengue Virus Circulation in the Republic of Djibouti between 2011 and 2014 Identifies Serotype 3 Epidemic and Recommends Clinical Diagnosis Guidelines for Resource Limited Settings.

Dengue virus is endemic globally, throughout tropical and sub-tropical regions. While the number of epidemics due to the four DENV serotypes is pronounced in East Africa, the total number of cases reported in Africa (16 million infections) remained at low levels compared to Asia (70 million infections). The French Armed forces Health Service provides epidemiological surveillance support in the Republic of Djibouti through the Bouffard Military hospital. Between 2011 and 2014, clinical and biological data of suspected dengue syndromes were collected at the Bouffard Military hospital and analyzed to improve Dengue clinical diagnosis and evaluate its circulation in East Africa. Examining samples from patients that presented one or more Dengue-like symptoms the study evidenced 128 Dengue cases among 354 suspected cases (36.2% of the non-malarial Dengue-like syndromes). It also demonstrated the circulation of serotypes 1 and 2 and reports the first epidemic of serotype 3 infections in Djibouti which was found in all of the hospitalized patients in this study. Based on these results we have determined that screening for Malaria and the presence of the arthralgia, gastro-intestinal symptoms and lymphopenia < 1,000cell/ mm3 allows for negative predictive value and specificity of diagnosis in isolated areas superior to 80% up to day 6. This study also provides evidence for an epidemic of Dengue virus serotype 3 previously not detected in Djibouti.

Nocardia veterana: disseminated infection with urinary tract infection

Nocardia spp. are a group of aerobic actinomycetes widely distributed in soil, and associated with severe opportunistic infections, essentially pulmonary infections. We report the first case of disseminated infection associated with urinary tract infection caused by Nocardia veterana. The diagnosis was difficult; despite the presence of pulmonary nodules, the lung biopsies remained negative while only one aerobic blood culture and the urine culture were positive for N. veterana, identified after a 16S rDNA gene sequence analysis. Few cases of clinical importance due to N. veterana have been published since its characterization. The bacteriological diagnosis of nocardiosis can be difficult to establish because of the delayed growth and the specific techniques that are required. This case illustrates the necessity of performing specific investigations in immunocompromised patients who present with infectious disease because the severity of this infection requires early diagnosis and quick initiation of appropriate antibiotic therapy.

Nocardia veterana: disseminated infection with urinary tract infection.

Nocardia spp. are a group of aerobic actinomycetes widely distributed in soil, and associated with severe opportunistic infections, essentially pulmonary infections. We report the first case of disseminated infection associated with urinary tract infection caused by Nocardia veterana. The diagnosis was difficult; despite the presence of pulmonary nodules, the lung biopsies remained negative while only one aerobic blood culture and the urine culture were positive for N. veterana, identified after a 16S rDNA gene sequence analysis. Few cases of clinical importance due to N. veterana have been published since its characterization. The bacteriological diagnosis of nocardiosis can be difficult to establish because of the delayed growth and the specific techniques that are required. This case illustrates the necessity of performing specific investigations in immunocompromised patients who present with infectious disease because the severity of this infection requires early diagnosis and quick initiation of appropriate antibiotic therapy.