Marked increase in severe neurological disorders after nitrous oxide abuse: a retrospective study in the Greater Paris area.

BACKGROUND: Recreational nitrous oxide (N2O) use has become more widespread worldwide, leading to an increase in myelopathies and peripheral neuropathies. The aim of this study was to describe clinical and socioeconomical characteristics of severe N2O-induced (NI) neurological disorders (NI-NDs), to determine its incidence in the Greater Paris area and to compare it with that of similar inflammatory neurological disorders. METHODS: We performed a retrospective multicentric cohort study of all adult patients with severe NI-NDs in the neurology and general internal medicine departments of the Greater Paris area from 2018 to 2021. The incidence was compared with that of non-NI-myelitis and Guillain-Barré syndrome (GBS) using a sample of 91,000 hospitalized patients sourced from health insurance data. RESULTS: Among 181 patients, 25% had myelopathy, 37% had peripheral neuropathy and 38% had mixed disease. Most were aged between 20 and 25 years, lived in socially disadvantaged urban areas, and exhibited high rates of unemployment (37%). The incidence of NI-NDs increased during 2020 and reached a peak mid-2021. The 2021 incidence in 20-25-year-olds was 6.15 [4.72; 8.24] per 100,000 persons for NI-myelopathy and 7.48 [5.59; 9.37] for NI-peripheral neuropathy. This was significantly higher than for non-NI-myelitis (0.35 [0.02; 2.00]) and GBS (2.47 [0.64; 4.30]). The incidence of NI-NDs was two to three times higher in the most socially disadvantaged areas. CONCLUSION: The recent increase in recreational N2O use has led to a rise in the incidence of severe NI-NDs, particularly in young adults with low socioeconomic status for whom NI-NDs strongly outweigh similar neurological disorders.

Commentary on "Prognostic effect of carcinoma in situ in muscle-invasive urothelial carcinoma patients receiving neoadjuvant chemotherapy."

BACKGROUND: Carcinoma in situ (CIS) is a poor prognostic finding in urothelial carcinoma. However, its significance in muscle-invasive urothelial carcinoma (MIUC) treated with neoadjuvant chemotherapy (NAC) is uncertain. We assessed the effect of CIS found in pretreatment transurethral resection of bladder tumor (TURBT) biopsies on the pathologic and clinical outcomes. MATERIALS AND METHODS: Subjects with MIUC treated with NAC before cystectomy were identified. The pathologic complete response (pCR) rates stratified by TURBT CIS status were compared. The secondary analyses included tumor response, progression-free survival (PFS), overall survival (OS), and an exploratory post hoc analysis of patients with pathologic CIS only (pTisN0) at cystectomy. RESULTS: A total of 137 patients with MIUC were identified. TURBT CIS was noted in 30.7% of the patients. The absence of TURBT CIS was associated with a significantly increased pCR rate (23.2% vs. 9.5%; odds ratio = 4.08; 95% CI: 1.19-13.98; P = 0.025). Stage pTisN0 disease was observed in 19.0% of the TURBT CIS patients. TURBT CIS status did not significantly affect the PFS or OS outcomes. Post hoc analysis of the pTisN0 patients revealed prolonged median PFS (104.5 vs. 139.9 months; P = 0.055) and OS (104.5 vs. 152.3 months; P = 0.091) outcomes similar to those for the pCR patients. CONCLUSION: The absence of CIS on pretreatment TURBT in patients with MIUC undergoing NAC was associated with increased pCR rates, with no observed differences in PFS or OS. Isolated CIS at cystectomy was frequently observed, with lengthy PFS and OS durations similar to those for pCR patients. Further studies aimed at understanding the biology and clinical effect of CIS in MIUC are warranted.

Novel Pharmacological Interventions to Maintain Sinus Rhythm after DC Cardioversion.

Despite the availability of potentially curative interventions for atrial fibrillation, there remains an important role for conventional anti-arrhythmic therapy and anti-coagulation combined with direct current cardioversion. Unfortunately, the latter approach is disturbed by high recurrence rates of atrial fibrillation. In recent years, several adjunctive therapies have emerged which may facilitate the maintenance of sinus rhythm. These novel therapies and their potential mechanisms of action are reviewed in this article.

Heart rate deceleration after exercise predicts patients most likely to respond to cardiac resynchronisation therapy.

OBJECTIVE: This study examines the relationship between heart rate recovery following exercise and subsequent response to cardiac resynchronisation therapy (CRT). BACKGROUND: Blunted heart rate recovery is an adverse prognostic marker in heart failure and has been shown to correlate with disease severity. METHODS: 37 patients receiving biventricular pacemakers for conventional indications underwent functional assessments; cardiopulmonary exercise test, 6-min walk test and quality-of-life assessment, together with echo analyses, before and at 3 months following implant. Heart rate deceleration (HRD) gradients were calculated at 30-, 60-, 90- and 120-s intervals following cessation of the baseline exercise test and compared with subsequent markers of response to CRT. Functional response was defined as > or =20% improvement in any two of the three functional assessments, and echo response defined as > or =5% increase in ejection fraction. RESULTS: Functional responders demonstrated steeper HRD gradients than non-responders at 30, 60 and 90 s. Echo responders also demonstrated steeper HRD at 30 and 60 s from the cessation of exercise. Receiver-operating curve analysis demonstrates area under the curve of 0.87 and 0.82, respectively, for HRD30 to predict functional and echo response to CRT. A cut-off value of 3 for HRD30, equating to a 5% reduction in HR between peak exercise and 30 s into recovery, demonstrates the optimal sensitivity/specificity profile to perform this function. CONCLUSIONS: HRD following exercise correlates with functional and echocardiographic response to CRT. Application of this parameter in addition to standard criteria may provide valuable supplementary information in the evaluation of prospective CRT candidates.

The use of low-glycaemic index diets in diabetes control.

The aim of diabetes management is to normalise blood glucose levels since improved blood glucose control is associated with fewer complications. Food affects blood glucose levels; however, there is no universal approach to the optimal diabetic diet and there is controversy about the usefulness of the low-glycaemic index (GI) diet. To assess the effects of low-GI diets on glycaemic control in diabetes, we conducted electronic searches of the Cochrane Library, MEDLINE, EMBASE and CINAHL. We assessed randomised controlled trials (RCT) with interventions >4 weeks that compared a low-GI diet with a higher-GI diet for type 1 or type 2 diabetes. Twelve RCT (n 612) were identified. There was a significant decrease in glycated Hb (HbA1c) with low-GI diet than with the control diet, indicating improved glycaemic control (seven trials, n 457, weighted mean difference (WMD) - 0.4 % HbA1c, 95% CI - 0.7, - 0.20, P = 0.001). In four studies reporting the results for glycaemic control as fructosamine, three of which were 6 weeks or less in duration, pooled data showed a decrease in fructosamine (WMD - 0.23 mmol/l, 95% CI - 0.47, 0.00, P = 0.05), n 141, with low-GI diet than with high-GI diet. Glycosylated albumin levels decreased significantly with low-GI diet, but not with high-GI diet, in one study that reported this outcome. Lowering the GI of the diet may contribute to improved glycaemic control in diabetes.

A qualitative investigation of individuals' experiences and expectations before and after completing a trial of commercial weight loss programmes.

OBJECTIVES: To investigate the previous dieting experiences and expectations of individuals enrolled in a randomized trial of four commercial weight loss programmes and post-intervention to compare experiences across the diet groups. AIM: The purpose of this study was to enhance the understanding of why subjects volunteered to take part in a weight loss trial and also to ascertain their views on each of the diets tested. METHODS: Focus groups containing both men and women were undertaken at baseline prior to randomization, and diet specific focus groups were held post-intervention. All group discussions were recorded and transcribed verbatim and analysed for emerging themes using the long-table approach. RESULTS: The main intrinsic motivators to enroling in the study were a current lack of self-esteem and confidence. The opportunity to take part in an academic study was also a motivator. Motivation and increasing efficacy were cited commonly among those who had successfully lost (or at least not gained) weight. The 'pros' identified for each of the commercial diets tested in the trial were in line with each of the diet's promotional materials; the 'cons' varied between groups. CONCLUSION: In this study, reducing health risks was not the main motivator for people deciding to lose weight. Increasing intrinsic sense of worth gained by losing weight and continued motivation appear to be related to success. The differing experiences of people undertaking each of the four diets suggest that matching diet regimen to individual is important.

Low glycaemic index or low glycaemic load diets for overweight and obesity.

BACKGROUND: Obesity is increasingly prevalent, yet the nutritional management remains contentious. It has been suggested that low glycaemic index or load diets may stimulate greater weight loss than higher glycaemic index or load diets or other weight reduction diets. OBJECTIVES: To assess the effects of low glycaemic index or load diets for weight loss in overweight or obese people. SEARCH STRATEGY: Trials were identified through The Cochrane Library, MEDLINE, EMBASE, CINAHL and manual searches of bibliographies. SELECTION CRITERIA: Randomised controlled trials comparing a low glycaemic index or load diet (LGI) with a higher glycaemic index or load diet or other diet (Cdiet) in overweight or obese people. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed quality and extracted data, including any information provided on adverse effects. MAIN RESULTS: We identified six eligible randomised controlled trials (total of 202 participants). Interventions ranged from five weeks to six months duration with up to six months follow-up after the intervention ceased. The decrease in body mass (WMD -1.1 kg, 95% confidence interval (CI) -2.0 to -0.2, P < 0.05) (n = 163), total fat mass (WMD -1.1 kg, 95% CI -1.9 to -0.4, P < 0.05) (n =147) and body mass index (WMD -1.3, 95% CI -2.0 to -0.5, P < 0.05) (n = 48) was significantly greater in participants receiving LGI compared to Cdiets. The decrease in total cholesterol was significantly greater with LGI compared to Cdiets (WMD -0.22 mmol/L, 95% CI -0.43 to -0.02, P < 0.05), as was the change in LDL-cholesterol (WMD -0.24 mmol/L, 95% CI -0.44 to -0.05, P < 0.05). No study reported adverse effects, mortality or quality of life data. AUTHORS' CONCLUSIONS: Overweight or obese people on LGI lost more weight and had more improvement in lipid profiles than those receiving Cdiets. Body mass, total fat mass, body mass index, total cholesterol and LDL-cholesterol all decreased significantly more in the LGI group. In studies comparing ad libitum LGI diets to conventional restricted energy low-fat diets, participants fared as well or better on th LGI diet, even though they could eat as much as desired. Lowering the glycaemic load of the diet appears to be an effective method of promoting weight loss and improving lipid profiles and can be simply incorporated into a person's lifestyle. Further research with longer term follow-up will determine whether improvement continues long-term and improves quality of life.

Exercise for type 2 diabetes mellitus.

BACKGROUND: Exercise is generally recommended for people with type 2 diabetes mellitus. However, some studies evaluate an exercise intervention including diet or behaviour modification or both, and the effects of diet and exercise are not differentiated. Some exercise studies involve low participant numbers, lacking power to show significant differences which may appear in larger trials. OBJECTIVES: To assess the effects of exercise in type 2 diabetes mellitus. SEARCH STRATEGY: Trials were identified through the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and manual searches of bibliographies. Date of last search was March 3, 2005. SELECTION CRITERIA: All randomised controlled trials comparing any type of well-documented aerobic, fitness or progressive resistance training exercise with no exercise in people with type 2 diabetes mellitus. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed trial quality and extracted data. Study authors were contacted for additional information. Any information on adverse effects was collected from the trials. MAIN RESULTS: Fourteen randomised controlled trials comparing exercise against no exercise in type 2 diabetes were identified involving 377 participants. Trials ranged from eight weeks to twelve months duration. Compared with the control, the exercise intervention significantly improved glycaemic control as indicated by a decrease in glycated haemoglobin levels of 0.6% (-0.6 % HbA(1c), 95% confidence interval (CI) -0.9 to -0.3; P < 0.05). This result is both statistically and clinically significant. There was no significant difference between groups in whole body mass, probably due to an increase in fat free mass (muscle) with exercise, as reported in one trial (6.3 kg, 95% CI 0.0 to 12.6). There was a reduction in visceral adipose tissue with exercise (-45.5 cm(2), 95% CI -63.8 to -27.3), and subcutaneous adipose tissue also decreased. No study reported adverse effects in the exercise group or diabetic complications. The exercise intervention significantly increased insulin response (131 AUC, 95% CI 20 to 242) (one trial), and decreased plasma triglycerides (-0.25 mmol/L, 95% CI -0.48 to -0.02). No significant difference was found between groups in quality of life (one trial), plasma cholesterol or blood pressure. AUTHORS' CONCLUSIONS: The meta-analysis shows that exercise significantly improves glycaemic control and reduces visceral adipose tissue and plasma triglycerides, but not plasma cholesterol, in people with type 2 diabetes, even without weight loss.

Knowledge and use of evidence-based nutrition: a survey of paediatric dietitians.

OBJECTIVE: To survey paediatric dietitians' knowledge and use of evidence-based nutrition (EBN). DESIGN: Cross-sectional survey using reply-paid questionnaires. SUBJECTS: Paediatric dietitians in Australian teaching hospitals. MAIN OUTCOME MEASURES: Age, sex, appointment, clinical practice, research activities; attitudes to, training in and use of EBN; and perceived barriers to use of EBN. STATISTICAL ANALYSIS: Data were analysed using descriptive statistics (SPSS). RESULTS: Fifty-nine (86%) of 69 questionnaires were returned. Most (97%) dietitians were women working full-time (63%), mean age 37 years (+/-9 SD). Most (75%) dietitians encountered knowledge gaps less than five times per week and most (87%) questions related to therapy. The majority (95%) performed their own literature searches, less than five times per month. All had access to >or=1 electronic literature databases including Medline (n = 58, 98%), Cochrane Library (n = 44, 75%) and CINAHL (n = 35, 59%). Information sources used most often were Medline and consultation with colleagues. Reported barriers to using EBN were lack of time (n = 53, 90%) or lack of skills for critical appraisal of published articles (n = 51, 86%) or literature searching (n = 48, 81%). While 53 (90%) believed in an evidence-based approach, 43 (73%) either did not practise EBN or rated themselves as beginners. CONCLUSION: Most dietitians favoured evidence-based practice, but reported lack of time, skills or rapid access to electronic databases as barriers to its practice.

Preparation of monoclonal antibodies using the electrophoresis separation instrument, Gradiflow.

Gradiflow, a preparative electrophoresis separation device, was utilized to develop and test generic protocols for the preparation of monoclonal antibodies (MAbs) from tissue culture supernatant and ascites fluid. The charge based protocol separated the high pI antibodies from the lower isoelectric points (pI) contaminants by either moving the antibody (ascites fluid) or contaminants (tissue culture supernatant) through a polyacrylamide separation membrane. A total of 60 separations were performed with tissue culture supernatant, and a further 30 separations with ascites fluid. The Gradiflow procedure resulted in higher yields, equivalent functionality and similar purity compared with affinity chromatography antibody preparation on protein A and G. The results suggest that the Gradiflow protocols may be an alternative method of antibody preparation for these samples.

Referrals to a hospital-based child abuse committee: a comparison of the 1960s and 1990s.

OBJECTIVE: Although reports of child maltreatment have increased yearly since national data were first collected in 1976, little information is available about changes in the characteristics of children reported. Therefore, to examine changes over time in recognition and reporting in a medical setting, we compared referrals to a hospital-based child abuse committee in the late 1960s and early 1990s. DESIGN: Retrospective, cross-sectional review of medical records and logs of the hospital's child abuse committee. SETTINGS: Ambulatory, emergency, and inpatient services at Yale-New Haven Hospital. PATIENTS: Medical records were reviewed for 101 of the 165 children referred to the child abuse committee in 1968-1969 (early group) and 107 of the 843 children referred in 1990-1991 (late group). Cases of sexual abuse were excluded. RESULTS: Referrals for nonsexual abuse cases increased from 80 children per year in the early group to 181.5 per year in the late group; the late group was characterized by a larger number of newborn referrals (1% vs. 52%, p < .001). When non-newborns were compared, the two groups were similar with respect to gender and race, but the late group had fewer patients with private insurance (31% vs. 12%, p < .05). The late group also had more female-headed households (32% vs. 67%, p < .05) and more parents with a history of substance abuse (4% vs. 49%, p < .001). Excluding newborns, who were all classified as "at-risk," the types of problems were classified as abuse (41% early vs. 29% late), neglect (41% vs. 35%), and "at-risk" (16% vs. 35%). Although the types of injuries were similar: superficial injuries (20% vs. 16%), burns (9% vs. 8%), and fractures (6% vs. 4%), fewer maltreated children suffered physical injuries in the late group (71% vs. 49%, p < .05). CONCLUSIONS: A substantial change has occurred in referrals to the hospital's child abuse committee for abuse or neglect. Most referrals have become socially high-risk newborns and children or children with minimal injuries. This shift is likely due to broader definitions of maltreatment and earlier recognition of troubled families.

Evaluation of the iScreen digital screening system for amblyogenic factors.

BACKGROUND: A digital photoscreener, the iScreen screening system, is now available to detect amblyogenic factors. We carried out a prospective study to evaluate the accuracy of the device in detecting anisometropia, significant refractive error, strabismus and opacities of the ocular media. METHODS: A total of 449 consecutive patients (median age 7 years) from a private pediatric ophthalmology practice underwent screening with the iScreen photoscreener operated by a minimally trained technician. The results were compared to the masked clinical examination of a pediatric ophthalmologist. RESULTS: The iScreen device had a sensitivity of 92.4%, specificity of 89.1%, positive predictive value of 94.1% and false-negative rate of 13.8%. Of the 21 patients with a false-negative result, 12 had myopia of less than -1.50 dioptres. High hyperopia was missed in two patients, high astigmatism in one, unequal cylindrical error in one and strabismus in five. INTERPRETATION: The iScreen digital photoscreener produced accurate and timely screening for potentially amblyogenic defects in the study population.

A cross-sectional survey of the opinions on weight loss treatments of adult obese patients attending a dietetic clinic.

OBJECTIVE: To investigate the views and opinions on weight loss treatments of adult obese patients attending a dietetic clinic. DESIGN: Cross-sectional survey. SUBJECTS: 161 adults attending dietetic outpatients clinics in Portsmouth for obesity with a body mass index of at least 30 kg/m2. MEASUREMENTS: Self-administered questionnaire developed from a series of focus groups with obese adults. Key topics were previous attempts to lose weight, methods used, the role of physical activity and patients' views about treatment from health professionals. RESULTS: The preferences and usefulness of different methods to lose weight varied according to the number of attempts to lose weight, gender, age, body mass index and medical condition of the patient. Men were less likely to use special slimming products, attend slimming groups and swimming than women (odds ratios (95% confidence interval), 0.1 (0.03-0.6) for slimming groups other than Weight Watchers, 0.3 (0.1-0.80) for special slimming products and 0.3 (0.1-0.6) for swimming). Men were more likely to use physical activity (2.6 (1.1-6.2)) and in particular walking (3.7 (1.0-13.6)) and cycling (2.8 (1.0-7.6)) and were more likely to see the dietitian (3.8 (1.4-9.9)) than women. Those with more than 10 attempts to lose weight were more likely to see the dietitian (3.6(1.6-8.2)), use Weight Watchers (2.5 (1.1-5. 6)) and newspapers and magazines (4.4 (1.8-10.9)) than those with fewer attempts. The younger age group were more likely to use more vigorous forms of exercise (4.2 (1.6-11.2) for keep fit and 3.7 (1. 5-9.6) for cycling) than the older subjects. The most obese were more likely to have negative views on their treatment by health professionals (4.4 (1.9-9.8) 'chairs are never big enough' and 4.0 (1.8-8.8) 'I am regarded as a second class citizen') than those who were less obese. Those without a medical condition were more likely to exercise (2.8 (1.3-6.3)) and use books (4.8 (2.0-11.2)) than those with a medical condition. CONCLUSION: The views of obese people should be considered when planning services for the treatment of obesity and a variety of options should be available. International Journal of Obesity (2000) 24, 164-170

Reuse of single-use medical devices: informed consent and physician liability.

This overview addresses the controversial practice of reuse and reprocessing of single-use medical devices and the issues this practice raises for physician liability. Specifically, we describe the health risks associated with medical device reprocessing, analyze the market costs arising from the reuse and reprocessing of single-use medical devices, and discuss physician liability for failure to obtain informed consent of the patient for the use of reprocessed single-use medical devices.

Hepatic artery aneurysm rupture: case report, imaging findings, and literature review.

Hepatic artery aneurysm rupture is a rare condition that requires urgent diagnosis and treatment in order to avoid a potentially fatal outcome. The clinical presentation is often non-specific. The classic triad of abdominal pain, gastrointestinal hemorrhage, and obstructive jaundice occurs in less than one-third of cases. Physical examination is rarely helpful since bruits, masses or pulsations are infrequent. Radiologic imaging provides the best tool to early diagnosis. Angiography has historically been the gold standard of diagnosis and is needed prior to radiologic intervention. Computerized tomography, doppler ultrasound and even magnetic resonance imaging have all demonstrated visceral artery aneurysms with success. Conventional treatment has included surgical ligation and resection. More recently transcatheter embolization or even percutaneous transhepatic injection of thrombin has been successfully performed by the interventional radiologist. This article discusses the clinical presentation, imaging findings, and review of the literature of this elusive entity.

Elevated in vivo expression of the costimulatory molecule B7-BB1 (CD80) on antigen presenting cells from a patient with SLE.

The CD28/CTLA4-B7-family plays an important role in T-cell costimulation and is crucial for IL-2 production and tolerance induction. The costimulatory molecule B7-BB1 (CD80) is expressed on activated antigen presenting cells, but its expression on peripheral blood mononuclear cells is very low. Here we report a patient with untreated SLE whose peripheral blood antigen presenting cells expressed increased amounts of B7-BB1.

Modulation of human T-lymphocyte plasma membrane Ca2+ permeability by imidazole antimycotics.

The role of cytochrome P-450 in the regulation of plasma membrane Ca+2 permeability of human peripheral T-lymphocytes by intracellular Ca+2 was examined. We assessed the effect of imidazole inhibitors of cytochrome P-450 on the intracytoplasmic free Ca+2 ([Ca+2]i) response generated using the microsomal ATPase inhibitor thapsigargin (THG) to deplete the intracellular Ca+2 stores. Econazole, miconazole and clotrimazole dramatically inhibited the THG mediated increase in [Ca+2]i and induced an increase in [Ca+2]i themselves. This inhibitory effect was previously observed in other cell systems and was attributed to inhibition of cytochrome P-450 by these agents. However, we evaluated a variety of structurally dissimilar P-450 inhibitors and found that none affected [Ca+2]i, indicating that the mechanism of imidazole action does not involve P-450.

Plasma glucose levels after prolonged strenuous exercise correlate inversely with glycemic response to food consumed before exercise.

It was hypothesized that slowly digested carbohydrates, that is, low glycemic index (GI) foods, eaten before prolonged strenuous exercise would increase the blood glucose concentration toward the end of exercise. Six trained cyclists pedaled on a cycle ergometer at 65-70% VO2max 60 min after ingestion of each of four test meals: a low-GI and a high-GI powdered food and a low-GI and a high-GI breakfast cereal, all providing 1 g of available carbohydrate per kilogram of body mass. Plasma glucose levels after more that 90 min of exercise were found to correlate inversely with the observed GI of the foods (p < .01). Free fatty acid levels during the last hour of exercise also correlated inversely with the GI (p < .05). The findings suggest that the slow digestion of carbohydrate in the prevent food favors higher concentrations of fuels in the blood toward the end of exercise.