Depression and routinization following stroke.

OBJECTIVE: Post-stroke depression is a frequent complication of stroke that has detrimental consequences for quality of life and functional outcomes. Daily life routines may increase feelings of security for some individuals confronted with age-related health concerns, but little information is available concerning their role following stroke. The aim of this investigation was to examine the association of depression and other psychological variables at hospitalization for stroke and behavioral routines and mood symptoms three months later using Ecological Momentary Assessment (EMA). METHODS: Forty-four patients with minor ischemic stroke were consecutively enrolled in the study. Stroke severity, handicap, depression and anxiety symptoms were assessed at baseline. EMA data acquired three months later were coded for the repetition of specific activities or behaviors occurring within the same time period across days. RESULTS: Higher baseline depression and anxiety symptom severity were significantly associated with increased behavioral routines three months after stroke. The occurrence of routines was associated with a higher level of depressive symptomatology over subsequent hours of the day. CONCLUSION: The findings demonstrate a general correlation between baseline psychological vulnerability and routines three months later, but within-day analyses suggest that routines may increase the risk of negative affect in this vulnerable population.

Ecological Assessment Battery for Numbers (EABN) for brain-damaged patients: standardization and validity study.

OBJECTIVES: Number-processing may be altered following brain injury and might affect the everyday life of patients. We developed the first ecological tool to assess number-processing disorders in brain-injured patients, the Ecological Assessment Battery for Numbers (EABN; in French, the BENQ). The aim of the present study was to standardize and validate this new tool. MATERIAL AND METHODS: Standardization included 126 healthy controls equally distributed by age, sex and sociocultural level. First, 17 patients were evaluated by the EABN; then scores for a subgroup of 10 were compared with those from a French analytical calculation test, the Évaluation Clinique des Aptitudes Numériques (ECAN). The concordance between the EABN and the ECAN was analyzed to determine construct validity. Discrimination indexes were calculated to assess the sensitivity of the subtests. RESULTS: Standardization highlighted a major effect of sociocultural level. In total, 9 of 17 patients had a pathological EABN score, with difficulties in telling time, making appointments and reading numerical data. The results of both the EABN and ECAN tests were concordant (Kendall's w=0.97). Finally, the discriminatory power was good, particularly for going to the movies, cheque-writing and following a recipe: scores were>0.4. CONCLUSION: The EABN is a new tool to assess number-processing disorders in adults. This tool has been standardized and has good psychometric properties for patients with brain injury.

[Acute posterior multifocal placoid pigment epiteliopathy and neurological involvement in an elderly patient: case report and review]. / Epiteliopatia acuta multifocale posteriore a placche di pigmento e coinvolgimento neurologico in un paziente anziano: caso clinico e revisione della letteratura.

We report a rare case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) in an elderly patient and a review of the recent scientific literature. A 65-year-old Caucasian man, forty-five days after return from tropical travel he developed right-sided facial palsy with right hemiplegia, dysarthria and a positive Babinski sign. He started prednisone 90 mg/day. Clinical, laboratory and imaging examinations were reported. Five months later there was a complete neurological and ophthalmological recovery. Although APMPPE was described primarily in young adults, we report the first case of APMPPE associated with neurological involvement in an older patient with a complete restitutio ad integrum.

The PRRT2 mutation c.649dupC is the so far most frequent cause of benign familial infantile convulsions.

PURPOSE: Mutations in the PRRT2 gene have been recently described as a cause of paroxysmal kinesigenic dyskinesia, infantile convulsions with choreoathetosis syndrome and, less often, infantile convulsions. We have analysed the frequency of PRRT2 mutations in families with benign familial infantile convulsions without paroxysmal kinesigenic dyskinesia. METHODS AND RESULTS: Direct sequencing of the coding region identified the PRRT2 mutation c.649dupC in 5/5 families with infantile convulsions. The mutation was present in 23 family members, of which 18 were clinically affected and 2 were obligate carriers. The affected carriers of this mutation presented with different types of epileptic seizures during early childhood but did not develop additional neurological symptoms later in life. CONCLUSION: Our data demonstrate that the PRRT2 mutation c.649dupC is a frequent cause of benign familial infantile convulsions.

[Infectious complications in patients treated with anti-TNF-alpha: two cases of leishmaniasis]. / Complications infectieuses liées au traitement par anti-TNFα : à propos de deux cas de leishmaniose.

UNLABELLED: We report the cases of two patients treated with anti-TNF-alpha for uveitis. The first patient developed visceral leishmaniasis and the second cutaneous leishmaniasis. FIRST CASE: an 8-year-old girl was treated with corticosteroids and intravenous infliximab for juvenile idiopathic arthritis with bilateral anterior uveitis. After 12 months of treatment, she presented with fever, hepatosplenomegaly and thrombocytopenia. Visceral leishmaniasis was diagnosed, and she was treated successfully with parenteral liposomal Amphotericin-B (Ambisome(®)). Upon resolution, we re-instituted her treatment with infliximab. Second case: a 48-year-old man consulted us for severe panuveitis of the left eye with a serous retinal detachment. He was diagnosed with seronegative ankylosing spondylitis. His uveitis and arthritis were treated successfully with infliximab for 20 months, after which two cutaneous lesions appeared. The diagnosis of cutaneous leishmaniasis without visceral involvement was based on the presence of Leishmania in the skin scraping of a lesion. Intravenous infusions of infliximab were discontinued, and local treatment consisting of intralesional injections of meglumine antimonate salts (Glucantime(®)) was initiated, leading to rapid improvement. Anti-TNFα drugs are used frequently now. They appear promising in terms of efficacy, but one must carefully monitor patients for possible side effects, including infection.

[Acute diplopia after the age of 50; always look for giant cell arteritis]. / Diplopie brutale après l'âge de 50 ans, toujours rechercher une maladie de Horton.

Although giant cell arteritis (GCA) is a rare cause of ophthalmoplegia, swift diagnosis and treatment are necessary to avoid other complications. We report here a case of GCA in a 59-year-old woman with a history of hypertension and thyroid lobectomy. Diagnosis resulted from binocular diplopia, although classical GCA symptoms had been present a few days before. Oral corticotherapy led to a rapid disappearance of headaches and normal ocular motility in 1 month. We discuss the ophthalmological signs of the disease and the place of temporal artery biopsy and treatment.

[Tolerance to fixed combinations]. / Tolérance des combinaisons fixes.

Four classes of drugs are mainly used for glaucoma medical therapy: beta-blockers, prostaglandin analogs, alpha-2 agonists, and carbonic anhydrase inhibitors. Clinicians can prescribe fixed combinations that associate two drugs from two different classes that have been available for a long time. Tolerance of fixed combinations seems to be better than the separate instillation of drugs, but it is interesting to review the adverse events and the contraindications of these drugs.

[Retinal atrophy using optical coherence tomography (OCT) in 15 patients with multiple sclerosis and comparison with healthy subjects]. / Etude de la perte axonale optique en tomographie en cohérence optique (OCT) chez 15 patients atteints de sclérose en plaques et comparaison avec une population de témoins appariés.

INTRODUCTION: Multiple sclerosis is a common disabling progressive neurological disorder. Axonal loss is thought to be a likely cause of persistent disability after a multiple sclerosis relapse. Retinal nerve fiber layer (RNFL) imaging by optical coherence tomography (OCT) seems to be a non-invasive way of detecting optical axonal loss following optic neuritis. OBJECTIVE: To determine whether multiple sclerosis affects retinal nerve fiber layer measurements obtained with optical coherence tomography (OCT3-Carl Zeiss Meditec, Dublin, California, USA). MATERIAL AND METHODS: Diagnosis of MS was based on the MacDonald criteria. The cohort was divided into two groups based on their clinical course (multiple sclerosis with [n=8; 16 eyes] or without [n=7; 14 eyes] optic neuritis antecedents). The disease-free controls were matched for age and gender (n=15; 30 eyes). Retinal nerve fiber layer thickness was measured using optical coherence tomography (OCT; fastRNFL and RNFL thickness software protocol). Visual acuity, visual field, color vision were also noted. RESULTS: There were highly significant reductions (p<0.001) of retinal nerve fiber layer thickness in affected patients (with or without optic neuritis antecedents) compared with control eyes (fastRNFL and RNFL procedures). Visual acuity, visual field and color vision were globally less altered than OCT. There were no significant relationships among RNFL thickness and visual acuity, visual field, or color vision. CONCLUSION: This study has demonstrated the anatomic changes of the retinal nerve fiber layer of patients with multiple sclerosis with optic neuritis antecedents. Thus axonal loss following optic neuritis can be detected with OCT. But the retinal nerve fiber layer of patients without optic neuritis is also thinner than disease-free controls so that chronic optic axonal loss can be frequent in multiple sclerosis. Additionally, OCT was more sensitive than the common ophthalmological explorations to detect optical nerve impairment during multiple sclerosis. Finally, we demonstrated that two procedures fastRNFL and RNFL could be used to detect optic nerve impairment.

[Risk factors for primary open-angle glaucoma]. / Les facteurs de risque du glaucome primitif à angle ouvert.

AIMS: To review the literature for risk factors involved in primary open-angle glaucoma (POAG). MATERIALS AND METHODS: Articles and reviews studying the epidemiology and assessment of risk factors in POAG were collected from PubMed. RESULTS: The literature findings were divided into three categories: (1) What are the risks of developing POAG in healthy subjects? Significant factors include advancing age, family history of glaucoma, African origin, and elevated intraocular pressure; (2) What are the risks of developing POAG in ocular hypertensive patients? Significant factors include age, family history of glaucoma, reduced central corneal thickness, pronounced elevated IOP, and IOP fluctuations; and (3) What are the risks for progression in known cases of POAG? Significant factors include advancing age, elevated IOP fluctuations, IOP, elevated cup-over-disk ratio, disc asymmetry, and disk hemorrhages. DISCUSSION: A working knowledge of the risk factors for developing POAG and disease progression is essential to good clinical practice. Therefore, one could ideally concentrate resources on populations at risk for developing the disease as well as more actively treat those patients at risk for progression.

Hair analysis to document a clinical case of TCDD over-exposure.

Dioxins and related compounds (furans) are persistent environmental contaminants that cause adverse biological effects. Their influence on humans is still unclear, except for accidental high-dose exposure. Chronic exposure to these compounds seems to be involved in cancer, endocrine disruption and neurobehavioral effects. For several years, a large concern about the potential health risks of dioxins is emerging in Europe and United States. The case of a 50-year-old man victim of an acute over-exposure to tetrachloro dibenzo-p-dioxin (TCDD or Seveso dioxin) is reported here with particular focus on hair investigations. The developed method involved the decontamination of the hair strand using picograde level methylene chloride, the homogenization of hair segments with scissors and their extraction in presence of 13C12-marked dioxin congeners under reflux of toluene using a Soxhlet, 8h at 130 degrees C. After reduction of the toluene fraction to 1 ml and addition of purification marker (37Cl4-2,3,7,8-TCDD), dioxins purification was achieved using three successive columns: silica, alumina/sodium sulfate and carbon/Celite columns. Finally, the toluene eluent was evaporated and the extract injected in the analytical system. After chromatographic separation, detection was achieved in single ion monitoring mode using a high resolution mass spectrometer operating in electron impact ionization mode (40 eV, minimal resolution of 10,000). The analysis of the first hair segment (0-6 cm) revealed the presence of 2,3,7,8-TCDD at 65 fg/mg when the distal one remained negative (LOQ=0.3 fg/mg). All other congeners (n=16) were in the range of those determined in the general population (0.62 and 0.89 fg/mg in the two hair segments, respectively). The extremely low dioxin levels generally found in hair specimens (low fg/mg range) lead us to analyze them using the very sensitive and specific gas chromatography-high resolution mass spectrometry apparatus. From the best of our knowledge, this is the first case of over-exposure to Seveso dioxin through hair analysis reported in the literature.

[The French glaucoma and ocular hypertension 1-day study]. / Enquête Française Glaucome et Hypertonie 1 Jour.

PURPOSE: The purpose of this study was to describe the distribution and characteristics (age, duration, type, treatment, etc.) of ocular hypertension and glaucoma in French ophthalmologic practices. METHODS: The French glaucoma and ocular hypertension 1-day study is a descriptive cross-sectional "1-day" type survey, conducted among all ophthalmologists of mainland France. They had to include all patients aged 18 years and over with ocular hypertension or glaucoma who were seen on November 25th 2003. The participation rate was 24.0% (1.173 ophthalmologists). Among the 3.919 patients included, 3.896 subjects (99%) had usable data for the statistical analyses. RESULTS: The ophthalmologists reported treating 16 patients with ocular hypertension or glaucoma on average per week. Among the patients, 29.5% had ocular hypertension, 61.7% had open-angle glaucoma, 3.4% had normal tension glaucoma, and 5.5% angle-closure glaucoma. The ophthalmologists used surgery or laser treatment for 74.1% of angle-closure glaucoma, while for other pathologies, treatment with drugs only was preponderant. More than 87% of patients received one or several ocular treatments: beta-blockers (59.3%), prostaglandins (50.1%), carbonic anhydrase inhibitors (21.6%), or mydriatic sympathomimetics (6.3%). CONCLUSIONS: The characteristics of glaucoma and ocular hypertension (type of glaucoma, age, duration, etc.) correspond to those of other Western populations. The therapeutic habits of French ophthalmologists is in line with current international guidelines.

[The epidemiology of glaucoma]. / Epidémiologie du glaucome.

The epidemiology of glaucoma studies the incidence and prevalence of the disease, searches for risk factors, evaluates screening procedures, and compares therapies. The epidemiology of glaucoma faces several problems: the diversity of glaucoma types, patient-dependent disease progression, and the cost of epidemiological studies. We detail the epidemiological data useful for the ophthalmologist's practice.

Identification of alprazolam in hair in two cases of drug-facilitated incidents.

The use of a drug to modify a person's behaviour for criminal gain is not a recent phenomenon. However, the recent increase in reports of drug-facilitated crimes (sexual assault, robbery) has caused alarm by the general public. Among the drugs that can be used, alprazolam (Xanax), an anxiolytic benzodiazepine, has been seldom observed. To document two cases involving this drug, we have developed an approach based on hair testing by LC-MS/MS. After pH 8.4 buffer incubation and extraction with methylene chloride/diethyl ether (80/20, v/v), hair extracts were separated on a XTerra MS C18 column using a gradient of acetonitrile and formate buffer. Alprazolam and diazepam-d5, used as internal standard, were detected by electrospray tandem mass spectrometry. In the first criminal case, alprazolam tested positive in two consecutive 2 cm hair segments at 4.9 and 2.4 pg/mg, from a 12-year-old girl, assaulted by her father who had sedated her three or four times. In the other case, alprazolam was detected in four consecutive 1cm hair segments at 3.1-0.4 pg/mg, obtained from an adolescent who had been forced to prostitute herself.

Evidence of addiction by anesthesiologists as documented by hair analysis.

Chemical dependency is a disease that can affect all professions. Among the health care professionals, anesthesiologists represent a specific group. Numerous factors have been proposed to explain the high incidence of drug abuse among anesthesiologists. These include: easy access to potent drugs, particularly narcotics, highly addictive potential of agents with which they are in contact, and easy diversion of these agents since only small doses will initially provide an effect desired by the abuser. Opioids are the drugs of choice for anesthesiologists, and among them fentanyl and sufentanil are the most commonly used. Alcohol is mostly abused by older anesthesiologists. Propofol, ketamine, thiopental and midazolam are also abused. In fact, all but quaternary ammonium drugs can be observed. Signs and symptoms of addiction in the hospital workplace include: unusual changes in behavior, desire to work alone, refusal of lunch relief or breaks, volunteer for extra cases, call, come in early and leave late, frequent restroom breaks, weight loss and pale skin, malpractice, behind on charts .... Toxicological investigations are difficult, as the drugs of interest are difficult to test for. In most cases, half-lives of the compounds are short, and the circulating concentrations weak. It is, therefore, necessary to develop tandem mass spectrometry procedures to satisfy the criteria of identification and quantitation. In most cases, blood and/or urine analyses are not useful to document impairment, as these specimens are collected at inadequate moments. Hair analysis appears, therefore, as the unique choice to evidence chronic exposure. Depending the length of the hair shaft, it is possible to establish an historical record, associated to the pattern of drug use, considering a growth rate of about 1cm/month. An original procedure was developed to test for fentanyl derivatives. After decontamination with methylene chloride, drugs are extracted from the hair by liquid/liquid extraction after incubation in pH 8.4 phosphate buffer. Fentanyl derivatives are analyzed by GC-MS/MS. The following cases are included in this paper: Case 1: 50-year-old anesthetist, positive for fentanyl (644 pg/mg); Case 2: 42-year-old anesthetist, positive for fentanyl (101 pg/mg) and sufentanil (2 pg/mg); Case 3: 40-year-old anesthetist, positive for codeine (210 pg/mg), alfentanil (30 pg/mg) and midazolam (160 pg/mg); Case 4: 46-year-old nurse, found dead, positive for alfentanil (2 pg/mg) and fentanyl (8 pg/mg). In these cases, the combination of an alternative specimen (hair) and hyphenated analytical techniques (tandem mass spectrometry) appears to be a pre-requisite.