Infraorbital nerve involvement on magnetic resonance imaging in European patients with IgG4-related ophthalmic disease: a specific sign.

OBJECTIVES: To measure the frequency of infraorbital nerve enlargement (IONE) on magnetic resonance imaging (MRI) in European patients suffering from an IgG4-related ophthalmic disease (IgG4-ROD) as compared to patients suffering from non-IgG4-related ophthalmic disease (non-IgG4-ROD). METHODS: From January 2006 through April 2015, 132 patients were admitted for non-lymphoma, non-thyroid-related orbital inflammation. Thirty-eight had both pre-therapeutic orbital MRI and histopathological IgG4 immunostaining. Fifteen patients were classified as cases of IgG4-ROD and 23 patients as cases of non-IgG4-ROD. Two readers performed blinded analyses of MRI images. The main criterion was the presence of an IONE, defined as the infraorbital nerve diameter being greater than the optic nerve diameter in the coronal section. RESULTS: IONE was present in 53% (8/15) of IgG4-ROD cases whereas it was never present (0/23) in cases of non-IgG4-ROD (P < 0.0001). IONE was only present in cases where, on MRI, the inflammation of the inferior quadrant was present and in direct contact with the ION canal. CONCLUSIONS: In European patients suffering from orbital inflammation, the presence of IONE on an MRI is a specific sign of IgG4-ROD. Recognition of this pattern may facilitate the accurate diagnosis for clinicians and allow for the adequate management and appropriate care of their patients. KEY POINTS: • IONE on an MRI is a specific sign of IgG4-ROD. • IONE recognition allows for a quicker diagnosis and appropriate management. • IONE appears when inflammation is in direct contact with the ION canal.

Usefulness of colour Doppler flow imaging in the management of lacrimal gland lesions.

OBJECTIVE: To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions. METHODS: Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003-2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination. RESULTS: The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p < 0.001), hypoechogenicity (p < 0.001), high vascular intensity (p < 0.001), both central and peripheral vascularization (p < 0.001), tree-shape vascularization (p < 0.05) and a low resistance index (RI) (p < 0.0001). EL were significantly more likely to present with the presence of cysts (p < 0.001), and a higher RI. Receiver operating characteristic curves identified a RI value of 0.72 as the best cut-off to differentiate NEL from EL, with a sensitivity and specificity of 100 %. CONCLUSION: CDFI is a valuable tool in the differential diagnosis of lacrimal fossa lesions. Resistance index measurement enables substantial distinction between EL and NEL, thus providing crucial data for surgical management. KEY POINTS: • CDFI is a valuable tool in lacrimal fossa lesions. • Resistance Index measurement enables substantial distinction between epithelial and non-epithelial lesions. • Management of patients becomes more appropriate.

[Results of the French cohort of the European observational study FINDER: quality of life of patients treated with antidepressants]. / Résultats de la cohorte française de l'étude observationnelle européenne FINDER : qualité de vie de patients traités par antidépresseurs.

OBJECTIVES: To describe health-related quality of life (HRQoL), pain, clinical outcomes and treatment patterns in French patients with depression treated by general practitioners and psychiatrists. METHODS: Factors Influencing Depression Endpoints Research (FINDER) is a European longitudinal observational, naturalistic, multicentre study to determine the HRQoL (SF-36 and EQ-5D) and to assess outcomes of depression and anxiety (Hospital Anxiety and Depression Scale [HADS]), and pain (VAS) in a population of depressed patients initiating antidepressant treatment. Clinical diagnosis of depression was based on physician's clinical judgment. Physicians decided at their own discretion and clinical practice to initiate pharmacological treatment for depression. Adult patients with a first or new episode of depression were enrolled between May 2004 and September 2005, and followed up for 6 months. Across Europe, 437 physicians observed 3468 patients. RESULTS: In France, 606 patients (approximately 17% of the whole sample) were enrolled by 57 psychiatrists and 46 general practitioners. These patients were (mean ± SD) 45.6 ± 13.0 years old, 69% female and 39% having had a previous depressive episode in the last 2 years. According to the patient-rated HADS score greater or equal to 11, most patients (75%) were classified as cases of depression as well as cases of anxiety (84%); 51% of patients rated their overall pain severity (based on VAS cut-off of 30 mm) as moderate/severe, with 65% of these patients reporting no medical explanation for their pain. The majority (81%) of the patients were prescribed selective serotonin reuptake inhibitors (SSRI). During the 6-month follow-up, the majority of the patients (73%) remained on the same antidepressant at the same dose during the course of treatment. Between baseline and 6-month endpoint, French patients improved their mean scores (SD) on the SF-36 physical score by+3.5 (9.0) (P<0.001) and mental score by+20.6 (14.2) (P<0.001); on the EQ-5D Health State Index by+0.37 (0.32) (P<0.001) and the EQ-5D VAS by+32.3 (25.0) (P<0.001); on the HADS depression score by-8.1 (6.0) (P<0.001) and HADS anxiety score by-6.9 (5.0) (P<0.001). Patients with moderate/severe pain at baseline improved their overall pain on a mean VAS score by-34.1 (28.7) (P<0.001). CONCLUSIONS: More than half of the French patients enrolled in the study experienced pain associated with depression. During follow-up, patients improved all of their outcome measurements (physical and mental SF-36 scores, depression and anxiety HADS scores, pain VAS, EQ-5D Health State Index and VAS) and most patients remained on the same antidepressant at the same dose.

[Switch antidepressants: when? How? Why?]. / Changer d'antidépresseur: quand, comment, pourquoi?

BACKGROUND: The switch is generally admitted as one of the available options in the event of non-response to an antidepressant treatment, despite uncertainties about its implementation in current practice: what time window before switching? Is it necessary to proceed with a direct or with a gradual switch? Is it necessary to change for a different pharmacotherapeutic class? How to minimize interaction risks? If a treatment fails because of poor compliance due to intolerance, it is possible to remain within the same therapeutic class and select another treatment with a more favourable safety profile for the patient. In the remaining non-response cases, changing therapeutic class is the more logical course and may be slightly more efficacious than the switch within the same class. LITERATURE FINDINGS: A review of the literature shows that it is recommended to wait 4 to 8 weeks before changing treatment if the response is insufficient. However, an early switch is possible in case of non-response at 2-4 weeks. Direct switch is possible and well tolerated in most instances, except for situations implicating a monoamine oxidase inhibitor (MAOI) or a tricyclic antidepressant. Direct switch is easy and, therefore, compliance issues associated with the complexity of treatment tapering can be avoided. DISCUSSION: From the pharmacologic standpoint, the lack of effect on the cytochrome P450 isoenzymes, the absence of active metabolites, and the poor binding to plasmatic proteins are all important elements to be identified in order to minimize the risk of interaction. Current research on physiopathology of depression and mechanisms of action of drugs both support expectations for new perspectives for patients' care. The switch increases the chances for a treatment to be successful with response rates of 20 to 70% in the open-labelled clinical studies. It also has the advantage of minimizing adverse effects compared to polytherapy. CONCLUSION: A great number of depressed patients require more than one treatment protocol to obtain or maintain a response. Switching is part of the therapeutic pattern of depression and is recommended by the French authorities. The available data allow the specification of switch modalities as function of the evolution of the initial treatment.

Optimizing 3D FLAIR to detect MS lesions: pushing past factory settings for precise results.

BACKGROUND: To assess the diagnostic value of three 3D FLAIR sequences with differing repetition-times (TR) at 3-Tesla when detecting multiple sclerosis (MS) lesions. METHODS: In this prospective study, approved by the institutional review board, 27 patients with confirmed MS were prospectively included. One radiologist performed manual segmentations of all high-signal intensity lesions using three 3D FLAIR data sets with different TR of 4800 ms ("FLAIR4800"), 8000 ms ("FLAIR8000") and 10,000 ms ("FLAIR10,000") and two radiologists double-checked it. The main judgment criterion was the overall number of lesions; secondary objectives were the assessment of lesion location, as well as measuring contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR). A non-parametric Wilcoxon's test was used to compare the differing FLAIR. RESULTS: The FLAIR8000 and FLAIR10,000 detected significantly more overall lesions per patient as compared with the FLAIR4800 [116.1 (± 61.7) (p = 0.02) and 115.8 (± 56.3) (p = 0.03) versus 99.2 (± 66.9), respectively]. The FLAIR8000 and FLAIR10,000 detected four and eight times more cortical or juxta-cortical lesions per patient as compared with FLAIR4800 [1.6 (± 2.2) (p = 0.001) and 4.1 (± 5.9) (p = 6 × 10-5) versus 0.4 (± 1.1), respectively]. CNR was significantly correlated to the TR value. It was significantly higher with FLAIR10,000 than it was with FLAIR8000 and FLAIR4800 [16.3 (± 3.5) versus 15 (± 2.4) (p = 0.01) and 12 (± 2.2) (p = 2 × 10-6), respectively] CONCLUSION: An optimized 3D FLAIR with a long TR significantly improved both overall lesion detection and CNR in MS patients as compared to a 3D FLAIR with factory settings.

TIPIC Syndrome: Beyond the Myth of Carotidynia, a New Distinct Unclassified Entity.

BACKGROUND AND PURPOSE: The differential diagnosis of acute cervical pain includes nonvascular and vascular causes such as carotid dissection, carotid occlusion, or vasculitis. However, some patients present with unclassified vascular and perivascular changes on imaging previously reported as carotidynia. The aim of our study was to improve the description of this as yet unclassified clinico-radiologic entity. MATERIALS AND METHODS: From January 2009 through April 2016, 47 patients from 10 centers presenting with acute neck pain or tenderness and at least 1 cervical image showing unclassified carotid abnormalities were included. We conducted a systematic, retrospective study of their medical charts and diagnostic and follow-up imaging. Two neuroradiologists independently analyzed the blinded image datasets. RESULTS: The median patient age was 48 years. All patients presented with acute neck pain, and 8 presented with transient neurologic symptoms. Imaging showed an eccentric pericarotidian infiltration in all patients. An intimal soft plaque was noted in 16 patients, and a mild luminal narrowing was noted in 16 patients. Interreader reproducibility was excellent. All patients had complete pain resolution within a median of 13 days. At 3-month follow-up, imaging showed complete disappearance of vascular abnormalities in 8 patients, and a marked decrease in all others. CONCLUSIONS: Our study improved the description of an unclassified, clinico-radiologic entity, which could be described by the proposed acronym: TransIent Perivascular Inflammation of the Carotid artery (TIPIC) syndrome.

[Piercing and its infectious complications. A public health issue in France]. / Le piercing et ses complications infectieuses. Un enjeu de santé publique en France.

CHARACTERISTIC FEATURES: Piercing, an act that modifies the body, has progressed considerably in France over the last few years. The population involved has grown and become more diversified. Performed with a solid needle or a catheter, a wide variety of anatomic localizations are concerned, particularly the nose, ears, and navel. The shape of the "rings", generally made of surgical steel, niobium or titanium, varies greatly. Wound healing by epithelialisation can take up to several months. INFECTIOUS RISK: Between 10% and 20% of all piercings lead to a local infection. The most commonly found causal agests are Staphylococcus aureus, group A Streptococcus and Pseudomonas sp. These germs can cause severe life-threatening complications even in common localizations (earlobe). Viral transmission is another risk (hepatitis B, hepatitis C, hepatitis delta, HIV). A few cases of fatal fulminant hepatitis have been described immediately after piercing. SAFETY MEASURES: Generally performed under less than desirable sanitary conditions, safety measures are needed for piercing. Among professional "piercers", a certain number have emphasized the need for providing their clients with safer services. The prevention of infection risk should be a priority for all. Work along this line has been done in the United States and Canada. In light of the impact on public health, it is important to rapidly develop guidelines and regulations for piercing in France. Both professional piercers and health care workers should participate in developing these safety measures in order to assure their implementation.

[Evaluation of the population received and cared for in France in the "Doctors of the World" Health Centers]. / Présentation de la population accueillie et soignée en France dans les Centres de soins de "Médecins du Monde".

For 11 years now, Médecins du Monde's Mission to France has tried to respond to the needs of a part of marginalized population, which has no access to health care. In 1996, 72,000 consultations have been given throughout the 31 free Health centers based in 31 cities in France. Who is this population? Basically young people (more than half are under the age of 30 and 10% are underaged), men in 213 of the cases, living alone, in 80% of the cases. How do they live? Almost 65% live with less than 20 francs per day (given by social care); 54% are officially jobless. As far as housing is concerned, only 1/4 have a home (women in particular). The others live in hostels, self-made shelters, hotels, or with relatives; 13% admit living on the street. Why do they come to health centers? Almost all diseases observed are identical to the ones detected in regular Health care centers, i.e., Ear--Nose and Throat, respiratory and gynecological infections. What makes them particular is the fact they are diagnosed later than usual, which makes them more serious than usual. The living conditions of this marginalized population explain the high frequency of skin problems (12%) and neuropsychologic disorders. Why do they come to Médecins du Monde? 1/4 of the patients do benefit from social welfare, but are unable to advance the payment of medical costs, or support the difference between the actual cost and the reimbursement by the Social security. 40% have no social coverage whatsoever. However, other motives (1 to 7%) such as administrative problems, rights outside their district, refusal to start the administrative procedures, ignorance of their rights ... are rarely put forward. The population with no access to health care is still unknown. This is why the information gathered is so important. It allows a better qualification of the patients' requests and, consequently, a better comprehension of the social exclusion phenomenon, particularly in the area of health.

Monitoring pancreatin supplementation in cystic fibrosis patients with the 13C-Hiolein breath test: evidence for normalized fat assimilation with high dose pancreatin therapy.

BACKGROUND: 13C-Hiolein is a randomly 13C-labeled mixture of long chain triglycerides synthesized by algae. METHODS: Because the 13C-Hiolein breath test is a suitable noninvasive tool to detect and monitor pancreatic steatorrhea, we used this new breath test for monitoring the effect of enzyme replacement therapy with an acid resistant enteric coated polydisperse pancreatin preparation (1.500 U/kg d) in children with cystic fibrosis. RESULTS: Administration of 1.5 mg/kg 13-C-Hiolein together with a physiological mixed meal (1.5 g/kg rice cookies, containing 25% fat and 37% starch) resulted in significantly higher breath 13CO2/12CO2 ratios in controls than in cystic fibrosis children (maximal delta over baseline responses (DOBmax) 39.2 +/- 18.1% vs. 13.1 +/-13.9%; p < 0.001). With pancreatin, DOBmax in the cystic fibrosis patients responses returned completely to normal (39.2 +/- 29.2% DOBmax). A breath hydrogen increase indicating the malassimilation of starch was noticed in one patient with severe pancreatic insufficiency only. CONCLUSION: In contrast to fecal fat analysis, the 13C-Hiolein breath test reflects postprandial fat assimilation immediately after a given, labeled meal. Monitoring the oxidative fate of physiological test meal with a stable isotope breath test, this study shows that fat assimilation in cystic fibrosis patients can be normalized with high dose pancreatin.