High prevalence of infections in non-COVID-19 patients admitted to the Emergency Department with severe lymphopenia.

BACKGROUND: In the Emergency Department (ED), early and accurate recognition of infection is crucial to prompt antibiotic therapy but the initial presentation of patients is variable and poorly characterized. Lymphopenia is commonly associated with bacteraemia and poor outcome in intensive care unit patients. The objective of this retrospective study was to assess the prevalence of community-acquired infection in a cohort of unselected patients admitted to the ED with undifferentiated symptoms and severe lymphopenia. METHODS: This is a retrospective single-center study conducted over a 1 year-period before the COVID-19 pandemic. Consecutive adult patients admitted to the ED with severe lymphopenia (lymphocyte count < 0.5 G/L) were studied. Patients with hematological or oncological diseases, HIV infection, hepato-cellular deficiency, immunosuppression, or patients over 85 years old were excluded. Diagnoses of infection were validated by an independent adjudication committee. The association between various parameters and infection was assessed using a multivariate logistic regression analysis. RESULTS: Of 953 patients admitted to the ED with severe lymphopenia, 245 were studied (148 men; mean age: 63 ± 19 years). Infection was confirmed in 159 patients (65%) (bacterial: 60%, viral: 30%, other: 10%). Only 61 patients (25%) were referred to the ED for a suspected infection. In the univariate analysis, SIRS criteria (OR: 5.39; 95%CI: 3.04-9.70; p < 0.001) and temperature ≥ 38.3 °C (OR: 10.95; 95%CI: 5.39-22.26; p < 0.001) were strongly associate with infection. In the multivariate analysis, only SIRS criteria (OR: 2.4; 95%CI: 1.48-3.9; p < 0.01) and fever (OR: 3.35; 95%CI: 1.26-8.93; p = 0.016) were independently associated with infection. CONCLUSIONS: The prevalence of underlying infection is high in patients admitted to the ED with lymphopenia, irrespective of the reason for admission. Whether lymphopenia could constitute a valuable marker of underlying infection in this clinical setting remains to be confirmed prospectively in larger cohorts. TRIAL REGISTRATION: No registration required as this is a retrospective study.

Continuous hemoglobin and plethysmography variability index monitoring can modify blood transfusion practice and is associated with lower mortality.

To determine the effect of implementing an algorithm of fluid and blood administration based on continuous monitoring of hemoglobin (SpHb) and PVI (plethysmography variability index) on mortality and transfusion on a whole hospital scale. This single-center quality program compared transfusion at 48 h and mortality at 30 days and 90 days after surgery between two 11-month periods in 2013 and 2014 during which all the operating and recovery rooms and intensive care units were equipped with SpHb/PVI monitors. The entire team was trained to use monitors and the algorithm. Team members were free to decide whether or not to use devices. Each device was connected to an electronic wireless acquired database to anonymously acquire parameters on-line and identify patients who received the monitoring. All data were available from electronic files. Patients were divided in three groups; 2013 (G1, n = 9285), 2014 without (G2, n = 5856) and with (G3, n = 3575) goal-directed therapy. The influence of age, ASA class, severity and urgency of surgery and use of algorithm on mortality and blood use were analyzed with cox-proportional hazard models. Because in 2015, SpHb/PVI monitors were no longer available, we assessed post-study mortality observed in 2015 to measure the impact of team training to adjust vascular filling on a patient to patient basis. During non-cardiac surgery, blood was more often transfused during surgery in G3 patients as compared to G2 (66.6% vs. 50.7%, p < 0.001) but with fewer blood units per patient. After adjustment, survival analysis showed a lower risk of transfusion at 48 h in G3 [OR 0.79 (0.68-0.93), p = 0.004] but not in G2 [OR 0.90 (0.78-1.04) p = 0.17] as compared to G1. When adjusting to the severity of surgery as covariable, there was 0.5 and 0.7% differences of mortality at day 30 and 90 whether patients had goal directed therapy (GDT). After high risk surgery, the mortality at day 30 is reduced by 4% when using GDT, and 1% after intermediate risk surgery. There was no difference for low risk surgery. G3 Patients had a lower risk of death at 30 days post-surgery [OR 0.67 (0.49-0.92) p = 0.01] but not G2 patients [OR 1.01, (0.78-1.29), p = 0.96]. In 2015, mortality at 30 days and 90 days increased again to similar levels as those of 2013, respectively 2.18 and 3.09%. Monitoring SpHb and PVI integrated in a vascular filling algorithm is associated with earlier transfusion and reduced 30 and 90-day mortality on a whole hospital scale.

Relevance of emergency head CT scan for fall in the elderly person.

OBJECTIVES: Fall of the elderly person is a public health problem. The objectives of our study were to evaluate the relevance of systematically performing in emergency a computed tomography (CT) scan for fall in the elderly person, to identify specific criteria predicting the appearance of lesions. MATERIAL AND METHODS: We performed a retrospective analysis of 500 consecutive patients aged 65 and over, who underwent an emergency head CT scan for fall from their height. Outcome at the end of the acute care, clinico-biological data and delays between trauma an d CT were collected, and crossed with a detection of head lesion on the CT scan. RESULTS: Of 500 patients, 38 (7.6%) had traumatic lesions depicted on the CT scan and 267 (53.4%) were hospitalized after the CT scan. Three (0.6%) had been operated for urgent head surgery. Nine of the 38 (23.6%) patients with traumatic lesion returned home. Presence of a lesion depicted on the CT scan was not correlated with the orientation of the patient (P < 0.0001). Post-traumatic injury was significantly associated with male sex (RR = 2.19, P = 0.0217), consciousness impairment (RR = 1.56, P < 0.0001), focal neurological deficit (RR = 6.36, P = 0.0362) and past history of post-traumatic brain injury (RR = 7.17, P = 0.0027). Anticoagulant therapy was not associated with increased risk of traumatic lesions (P = 0.3315). ROC analysis determined that a 5-hours time-interval between head trauma and CT allowed optimal detection of lesions. CONCLUSION: The systematic indication of an emergency head CT scan for fall in elderly patients presents a low diagnostic and therapeutic yield and is not relevant. Male sex, consciousness impairment, focal neurological deficit, past history of post-traumatic brain injury and time-interval between head trauma and CT are statistically related to the presence of lesions and should therefore be taken into account.

MRI in chronic groin pain: sequence diagnostic reliability compared to systematic surgical assessment.

OBJECTIVE: To determine the diagnostic reliability of magnetic resonance imaging (MRI) sequences in chronic groin pain (CGP) compared to surgery and try to propose a suitable MRI protocol. MATERIALS AND METHODS: Forty-three consecutive patients with resistant clinical CGP underwent a pre-surgical pelvis MRI. Eight MRI sequences were acquired: axial fast spin-echo T1-weighted (FSE T1), coronal FSE T1, axial-oblique (in symphysis plane) proton density weighted with fat saturation (PDFS), coronal PDFS, sagittal PDFS, axial FSE T1 with fat saturation and gadolinium enhancement (FSGE), coronal FSE T1 FSGE and axial FSE T1 with Valsalva maneuver (VM). These sequences were reviewed for pubic symphysis assessment, adductor longus (AL) tendon and abdominal wall (AW) injuries. The same surgeon operated on all of these patients (26 AL and 49 AW). Sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative prospective value (NPV) and accuracy of each sequence and combinations for AL or AW injuries were calculated in comparison to surgical findings. RESULTS: One hundred ninety-two sequences were obtained. Coronal T1 FSGE and axial T1 VM proved to be the most reliable sequences (accuracy: 91.67% in AL and 83.33% in AW). The best sequence combination was coronal T1, axial PDFS, sagittal PDFS and axial T1 VM (accuracy: 77.78%; Se: 100.00%, Sp: 69.23%, PPV: 55.56%, NPV: 100.00%). CONCLUSION: MRI has 77.78% accuracy, 100.00% sensitivity, 69.23% specificity, 55.56% PPV and 100.00% NPV in evaluating CGP, with coronal T1-axial PDFS-sagittal PDFS-axial T1 VM as the optimal protocol in terms of diagnostic performance within a reasonable scan time. Diagnostic performance of MRI was examined in the evaluation of CGP using surgery as reference standard.

Isometric Characteristics of the Anterolateral Ligament of the Knee: A Cadaveric Navigation Study.

PURPOSE: To measure the variations in length during flexion and internal tibial rotation of the 3 different femoral insertions of the anterolateral ligament (ALL) while maintaining a fixed tibia insertion. METHODS: Twelve fresh-frozen cadaver knees were analyzed using a navigation system. Maximal distance variations of the 3 different anatomic femoral insertions of the ALL were measured during knee flexion and internal tibial rotation at 20° (IR20°) and 90° (IR90°). The 3 different femoral attachments were, as published, at the center of the lateral epicondyle, distal and anterior from this position, and proximal and posterior. Each of these 3 femoral insertions was coupled to the same tibial insertion at the tibial margin, halfway between the tip of the fibular head and the prominence of the Gerdy tubercle. RESULTS: During IR20°, variation in the distance between paired points is not different between the proximal-posterior, epicondyle, and distal-anterior femoral insertions. These variations were statistically different during IR90° for the 3 different femoral locations. In increasing degrees of flexion, there was a length decrease between paired points observed with the proximal-posterior position. A length increase was observed for both the epicondyle location and the distal-anterior location. CONCLUSIONS: The ALL did not reveal an isometric behavior at any of the femoral insertion locations but had different length change patterns during knee flexion and internal tibial rotation at 90°. The proximal and posterior to epicondyle femoral position is the only position with a favorable isometry, as shown by being tight in extension and in internal rotation at 20° and then relaxed when the knee goes to flexion at 120° and during internal rotation at 90°. CLINICAL RELEVANCE: Clinical relevance is significant with respect to optimizing the femoral position of an ALL reconstruction.

Impact of epilepsy on children and parents in Gabon.

Children with epilepsy and their parents face many social and psychological difficulties that remain insufficiently studied in sub-Saharan Africa. The aim here was to assess the quality of life of children with epilepsy and their parents. A community-based cross-sectional survey was conducted in two urban areas and four rural areas of Gabon. Children were screened through key informants, medical sources, and a door-to-door survey. They were clinically selected based on their medical history and a clinical exam conducted by the investigating physician. Electroencephalography had not been carried out because of a lack of material and financial resources. The quality of life of children and their parents was assessed by a structured interview of parents using a questionnaire. Of 317 suspected cases on screening, 83 children with epilepsy were identified. Their mean age was 11.9±4.4years. Twelve percent of the children had neurosensory abnormalities on clinical exam. Sixty-three percent of them attended school; factors associated with schooling were higher score on the sociability subscale, specialized medical advice, and antiepileptic drug treatment. Sociability difficulties, anxiety, cognitive impairment, and behavioral disorders were suspected in 39.8%, 45.8%, 49.4%, and 42.2% of children, respectively. A total of 48.2% of parents expressed a poor quality of life related to their children's illness. A higher score on the cognition subscale, urban residence, specialized medical advice, and a stable income in the household were predictive of poor parental quality of life. Epilepsy influences many aspects of a child's life and the life of the child's parents. Care should incorporate a cognitive assessment of the child and emphasize information for patients and their relatives.

Brain-derived neurotrophic factor serum levels in alcohol-dependent subjects 6 months after alcohol withdrawal.

BACKGROUND: Diagnosing alcohol dependence is based on clinical signs and on the measured levels of biological markers of alcohol consumption. However, these markers are neither sufficiently sensitive and nor specific enough to definitively determine alcohol dependence. The neuroadaptive changes associated with alcohol dependence involve markers such as brain-derived neurotrophic factor (BDNF), which regulate neuronal plasticity. Serum levels of BDNF have been reported to decrease during alcohol dependence and may be restored to normal soon after alcohol is withdrawn. However, the long-term relationship between serum BDNF levels and abstinence status is unknown. METHODS: We investigated serum BDNF levels in 101 abstinent and relapsing alcohol-dependent subjects at the moment of hospitalization for alcohol withdrawal (M0) and 6 months later (M6) and compared them to the serum BDNF levels of 41 nondependent subjects. The BDNF levels of the alcohol-dependent subjects were compared to their serum gamma glutamyl transferase (GGT) levels, mean corpuscular volume (MCV) values, and their score on the Beck Depression Inventory (BDI) questionnaire. RESULTS: Forty-four percent of the alcohol-dependent participants remained abstinent during the 6 months following alcohol detoxification. Serum BDNF levels of the abstinent group at M6 were significantly higher than those of the original group of alcohol-dependent subjects at M0 (p = 0.034). Only the abstinent group had higher BDNF levels than the control group (p < 0.001). Serum BDNF levels increased to a greater extent in the abstinent group than in the nonabstinent group (p = 0.016). No correlations were found between serum BDNF levels and GGT level, MCV value, or BDI score. CONCLUSIONS: Our data confirm that serum BDNF levels do not correlate with either chronic alcohol consumption or peripheral toxicity but may be linked to neuronal aspects of alcohol consumption and dependence. The increased serum levels of BDNF may reflect the concomitant activation of BDNF synthesis that accompanies the neuronal remodeling triggered by alcohol withdrawal and suggests that BDNF synthesis may have a role in the long-term maintenance of abstinence. Monitoring the serum BDNF levels of alcoholics undergoing treatment could help to characterize alcohol dependence profiles and predict relapse.

Is prehospital endobronchial intubation a risk factor for subsequent ventilator associated pneumonia? A retrospective analysis.

More than half of patients under mechanical ventilation in the intensive care unit (ICU) are field-intubated, which is a known risk factor for ventilator associated pneumonia (VAP). We assessed whether field endobronchial intubation (EBI) is associated with the development of subsequent VAP during the ICU stay. This retrospective, nested case-control study was conducted in a cohort of field-intubated patients admitted to an ICU of a teaching hospital during a three-year period. Cases were defined as field-intubated patients with EBI and controls corresponded to field-intubated patients with proper position of the tracheal tube on admission chest X-ray. Primary endpoint was the development of early VAP. Secondary endpoints included the development of early ventilator associated tracheo-bronchitis, late VAP, duration of mechanical ventilation, length of stay and mortality in the ICU. A total of 145 patients were studied (mean age: 54 ± 19 years; men: 74%). Reasons for field intubation were predominantly multiple trauma (49%) and cardiorespiratory arrest (38%). EBI was identified in 33 patients (23%). Fifty-three patients (37%) developed early or late VAP. EBI after field intubation was associated with a nearly two-fold increase of early VAP, though not statistically significant (30% vs. 17%: p = 0.09). No statistically significant difference was found regarding secondary outcomes. The present study suggests that inadvertent prehospital EBI could be associated with a higher incidence of early-onset VAP. Larger studies are required to confirm this hypothesis. Whether strategies aimed at decreasing the incidence and duration of EBI could reduce the incidence of subsequent VAP remains to be determined.

Development of Giant Cell Arteritis after Treating Polymyalgia or Peripheral Arthritis: A Retrospective Case-control Study.

OBJECTIVE: We investigated the development of giant cell arteritis (GCA) in patients with prior diagnoses of isolated polymyalgia rheumatica and/or peripheral arthritis (PMR/PA), and the potentially relevant characteristics of both illnesses in such patients. METHODS: We retrospectively compared the features of 67 patients at the onset of PMR/PA, and their outcomes, to those of a random group of 65 patients with PMR/PA who did not develop late GCA. We also compared the features and outcomes of patients with late GCA to those of a random sample of patients with more usual GCA (65 with concurrent PMR/PA and 65 without). RESULTS: Patients with late GCA represented 7.4% of all patients with GCA included in a large hospital-based inception cohort. PMR/PA preceded overt GCA by 27 months on average. Permanent visual loss developed in 10 patients, including 8 of 48 (17%) patients featuring cranial arteritis. A questionable female predominance was the only distinguishing feature of PMR/PA evolving into GCA; late GCA more often featured subclinical aortitis (OR 6.42, 95% CI 2.39-17.23; p < 0.001), headache (OR 0.44, 95% CI 0.19-1.03; p = 0.06), and fever (OR 0.29, 95% CI 0.13-0.64; p = 0.002) less often compared to the more usual form of GCA. Patients with either form of GCA experienced similar outcomes. CONCLUSION: A cranial arteritis pattern of late GCA is associated with a significant risk for ischemic blindness. However, compared to the usual form of GCA, late GCA is often less typical, with a higher frequency of silent aortitis. Patients with relapsing/refractory PMR may not be at increased risk for late GCA.

Acceleration of the learning curve for mastering basic critical care echocardiography using computerized simulation.

PURPOSE: To assess the impact of computerized transthoracic echocardiography (TTE) simulation on the learning curve to achieve competency in basic critical care echocardiography (CCE). METHODS: In this prospective bicenter study, noncardiologist residents novice in ultrasound followed either a previously validated training program with adjunctive computerized simulation on a mannequin (two 3 h-sessions; Vimedix simulator, CAE Healthcare) (interventional group; n = 12) or solely the same training program (control group; n = 12). All trainees from the same institution were assigned to the same study group to avoid confusion bias. Each trainee was evaluated after 1 (M1), 3 (M3) and 6 (M6) months of training using our previously validated scoring system. Competency was defined by a score ≥ 90% of the maximal value. RESULTS: The 24 trainees performed 965 TTE in patients with cardiopulmonary compromise during their 6-month rotation. Skills assessments relied on 156 TTE performed in 106 patients (mean age 53 ± 14 years; mean Simplified Acute Physiologic Score 2: 55 ± 19; 79% ventilated). When compared to the control group, trainees of the interventional group obtained a significantly higher mean skills assessment score at M1 (41.5 ± 4.9 vs. 32.3 ± 3.7: P = 0.0004) and M3 (45.8 ± 2.8 vs. 42.3 ± 3.7: P = 0.0223), but not at M6 (49.7 ± 1.2 vs. 50.0 ± 2.7: P = 0.6410), due to higher practical and technical skills scores. Trainees of the control group required significantly more supervised TTE to obtain competency than their counterparts (36 ± 7 vs. 30 ± 9: p = 0.0145). CONCLUSIONS: Adjunctive computerized simulation accelerates the learning curve of basic CCE in improving practical and technical skills and reduces the number of TTE examinations required to reach competency.

Updated evidence of the association between toxocariasis and epilepsy: Systematic review and meta-analysis.

OBJECTIVE: To gain further insight on the association between human toxocariasis and epilepsy in light of the new evidence in the last years. METHODS: A systematic review was conducted without date and language restriction in the following electronic databases: MEDLINE (PubMed), Ingenta Connect, Science Direct (Elsevier), RefDoc, Scopus, HighWire, Scielo and the database of the Institute of Neuroepidemiology and Tropical Neurology of the Limoges University (IENT). Two investigators independently conducted the search up to November 2017. A pooled odds ratio (OR) was estimated using a random effects model. Meta-regression was conducted to investigate potential sources of heterogeneity. RESULTS: Database search produced 204 publications. Eleven case-control studies were included that were carried out in 13 countries worldwide. A total number of 4740 subjects were considered (2159 people with epilepsy and 2581 people without epilepsy). The overall pooled OR was 1.69 (95% CI 1.42-2.01) for the association between epilepsy and Toxocara spp. seropositivity. A positive association was constantly reported in the restricted analysis (WB as confirmatory or diagnostic test, younger population, and population-based studies). Meta-regression showed no statistically significant association between covariates and outcome. CONCLUSION: The updated meta-analysis provides epidemiological evidence of a positive association between Toxocara seropositivity and epilepsy. New surveys supported the association, mainly population-based studies. On this basis, health strategies to reduce the impact of Toxocara spp are strongly advised. Further research should be performed to understand the physiopathological mechanisms of toxocara-associated epileptogenesis.

Long-Term Results After Sleeve Gastrectomy for Gastroesophageal Reflux Disease: a Single-Center French Study.

BACKGROUND: Many studies have analyzed the impact of sleeve gastrectomy (SG) on weight loss and/or the evolution of obesity-related comorbid conditions, but few have reported the long-term outcomes after surgery. The objective of this study was to investigate the outcomes after SG on weight loss, obesity-related comorbid conditions, quality of life (QoL), and GERD symptoms (GERDS) beyond 5 years. METHODS: A prospective database was retrospectively searched for the following factors: gender, age, anthropometrics, presence of comorbid conditions, QoL (BAROS questionnaire), and presence of GERDS. The data were analyzed before and at 1 and 6 years after surgery. RESULTS: Of the 64 patients included, 32.8% were lost to follow-up (76% during the first postoperative year). A complete follow-up of >5 years was obtained for 41 patients. Before surgery, mean excess BMI was 22 ± 7 kg/m2, and 26.8% of patients had GERDS. Percent excess BMI loss was 55 ± 30% at 1 year and 48 ± 27% at 6 years. Preoperative BMI and absence of type 2 diabetes (T2D) before surgery were the only independent variables for long-term failure. Six years after SG, remission from metabolic comorbidities was as follows: 50% for T2D, 28% for blood hypertension, 58% for dyslipidemia, and 33% for sleep-apnea syndrome. Thirty percent of patients with preoperative GERD had resolution of symptoms at 6 years whereas 9 patients (32%) had de novo GERD. QoL was improved for 62% of patients at 6 years. CONCLUSION: The benefits of SG on weight loss, resolution of comorbidities, and QoL were maintained in the long term for most patients.

Dietary sodium and potassium intakes: Data from urban and rural areas.

OBJECTIVES: Hypertension is highly prevalent in West African populations, but little data is available on salt and potassium intake in these populations. We assumed in this study that sodium and potassium intake might be high and low, respectively, in the Beninese population in view of the emerging nutritional transition. The aim of this study was to estimate dietary sodium and potassium intakes based on 24-h urine collections. METHODS: We selected 420 individuals (ages 25-64 y), representative of the population, from urban and rural areas in Benin. Urine was collected over 24 h, and sodium, potassium, and creatinine were quantified. Blood pressure was measured on the left arm using a validated electronic oscillometric monitor. RESULTS: Adequate data were available for 354 participants. Mean dietary intake of sodium and potassium were 4.4 ± 2.1 and 1.8 ± 0.9 g/24 h, respectively. High intake of sodium was associated with urban area, age <44 y, administrative occupation, higher income, body mass index (BMI) ≥25 kg/m2, and a large waist circumference. High potassium intake was associated with male sex, administrative occupation, BMI ≥25 kg/m2, and large waist circumference. Sodium intake was associated with high systolic and diastolic blood pressures. In multivariate analysis, only age <44 y and, marginally, BMI ≥25 kg/m2 were associated with high sodium intake, whereas male sex and a BMI ≥25 kg/m2 were associated with high potassium intake. CONCLUSION: Large proportions of the population had sodium intake higher, and potassium intake lower, than dietary recommendations. These results suggest that interventions to reduce salt consumption and promote potassium-rich foods, including fruits and vegetables, are needed in Benin.

Venous thrombosis in patients with giant cell arteritis: Features and outcomes in a cohort study.

OBJECTIVES: To describe the features and outcomes of patients with giant cell arteritis who developed venous thrombosis. METHODS: Inception cohort study including 428 newly diagnosed patients of giant cell arteritis from 1976 to 2014. Clinical and biological data and outcomes were analysed by comparing patients with and without venous thrombosis. RESULTS: Twenty-six patients (6%) developed venous thrombosis, 12 of whom presented with pulmonary embolism. The mean time between the onset of giant cell arteritis symptoms and venous thrombosis occurrence was 248.8±215.0 days. No difference was observed between the two groups in clinical or laboratory data collected at diagnosis. The mean time from the start of prednisone to venous thrombosis diagnosis was 187.7±217.0 days. The average dose of prednisone at venous thrombosis onset was 21.5mg/day. The venous thrombosis group had a higher number of glucocorticoid-related adverse effects (mean, 3.1 vs 1.1; P<0.0001), a higher mortality rate (58% vs 33%, P=0.01) and a higher proportion of deaths occurring during glucocorticoid treatment (31% vs 14%, P=0.03). Death was related to venous thrombosis in four patients. DISCUSSION: The occurrence of overt venous thrombosis is more than anecdotal among patients treated for giant cell arteritis. Venous thrombosis does not rely on the active phase of giant cell arteritis, but could be associated with long-term use of glucocorticoids. Because venous thrombosis may be associated with an increased mortality risk in patients with giant cell arteritis, a high index of suspicion should be applied in appropriate settings, especially in patients experiencing multiple glucocorticoid-related adverse effects.

The Involvement of the Anterolateral Ligament in Rotational Control of the Knee.

BACKGROUND: Rotational control of the knee is crucial for knee stability. The anterolateral ligament (ALL) has been identified as a potentially important structure involved in rotational control of the knee. PURPOSE/HYPOTHESIS: The purpose of this study was to determine, utilizing a navigation system, the involvement of the anterior cruciate ligament (ACL), the iliotibial band (ITB), and the ALL in tibial internal rotational control of the knee. The hypothesis was that the ALL would be involved in rotational control of the knee at varying degrees of knee flexion. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve fresh-frozen cadaveric knees were tested in internal rotation at 20° and 90° of flexion and then subsequently tested using a simulated pivot-shift test consisting of coupled axial rotation at 30° of flexion. Serial sectioning of the ACL, ALL, and ITB was performed. On the contralateral knee, sectioning was performed in the reverse order. Measurements were collected using a surgical navigation system before and after each sectioning. RESULTS: After ACL sectioning, an incision of the ALL induced a significant increase in internal rotation (+19.2% [P = .0002] at 20°; +21.8% [P = .0029] at 90°) and in coupled axial rotation (+43.0%; P = .0035) compared with the intact knee as well as a significant increase in internal rotation at 90° (+13.4%; P = .009) and in coupled axial rotation (+30.8%; P = .0124) compared with the ACL-deficient knee. After ITB sectioning, an additional ALL section caused a significant increase in internal rotation (+39.0% [P = .002] at 20°; +63.0% [P = .0147] at 90°) and in coupled axial rotation (+59.7%; P = .0003) compared with the intact knee as well as a significant increase in internal rotation at 90° (+14.8%; P = .0067) in comparison to the ITB-deficient knee. CONCLUSION: The ALL is involved in rotational control of the knee at varying degrees of knee flexion and during a simulated pivot shift. Concomitant to an ACL or ITB transection, sectioning the ALL further increased rotational laxity. CLINICAL RELEVANCE: This laboratory study demonstrated that the ALL provides rotational control of the knee in combination with the ACL and/or ITB.

Risk Factors for Permanent Visual Loss in Biopsy-proven Giant Cell Arteritis: A Study of 339 Patients.

OBJECTIVE: To determine the risk factors for permanent visual loss (PVL) in patients with biopsy-proven giant cell arteritis (GCA) and the usefulness of the factors in clinical practice. METHODS: From 1976 through 2015, the clinical charts and laboratory results of 339 patients with biopsy-proven GCA were recorded prospectively at the time of diagnosis. We used multivariable logistic regression analysis to determine which of 24 pretreatment characteristics were associated with PVL. RESULTS: Visual ischemic manifestations occurred in 108 patients, including PVL in 53 (16%), bilaterally in 15 patients (28%). The independent predictors associated with an increased risk of PVL were age (OR 1.06, 95% CI 1.01-1.12, p = 0.01), a history of transient visual ischemic symptoms (OR 2.62, 95% CI 1.29-5.29, p < 0.01), and jaw claudication (OR 2.11, 95% CI 1.09-4.10, p = 0.03). The presence of fever (OR 0.30, 95% CI 0.14-0.64, p < 0.01) and rheumatic symptoms (OR 0.23, 95% CI 0.10-0.57, p = 0.001) were associated with a markedly reduced risk of developing visual loss (3.7% if features were both present). No laboratory variables were independently associated with PVL. CONCLUSION: The visual ischemic risk of untreated GCA can be readily estimated upon simple clinical findings, but not laboratory variables. However, we did not identify a subgroup of patients carrying no risk of developing visual loss. Glucocorticoid treatment remains, therefore, urgent for any patient with a high clinical suspicion index.

Estimation of Daily Sodium and Potassium Excretion Using Spot Urine and 24-Hour Urine Samples in a Black Population (Benin).

The 24-hour urine collection method is considered the gold standard for the estimation of ingested potassium and sodium. Because of the impracticalities of collecting all urine over a 24-hour period, spot urine is often used for epidemiological investigations. This study aims to assess the agreement between spot urine and 24-hour urine measurements to determine sodium and potassium intake. A total of 402 participants aged 25 to 64 years were randomly selected in South Benin. Spot urine was taken during the second urination of the day. Twenty-four-hour urine was also collected. Samples (2-mL) were taken and then stored at -20°C. The analysis was carried out using potentiometric dosage. The agreement between spot urine and 24-hour urine measurements was established using Bland-Altman plots. A total of 354 results were analyzed. Daily sodium chloride and potassium chloride urinary excretion means were 10.2±4.9 g/24 h and 2.9±1.4 g/24 h, respectively. Estimated daily sodium chloride and potassium chloride means from the spot urine were 10.7±7.0 g/24 h and 3.9±2.1 g/24 h, respectively. Concordance coefficients were 0.61 at d=-0.5 g, (d±2SD=-11 g and 10.1 g) for sodium chloride and 0.61 at d=-1 g, (d±2SD=-3.8 g and 1.8 g) for potassium chloride. Spot urine method is acceptable for estimating 24-hour urinary sodium and potassium excretion to assess sodium and potassium intake in a black population. However, the confidence interval for the mean difference, which is too large, makes the sodium chloride results inadmissible at a clinical level.

Prognostic impact of left ventricular diastolic function in patients with septic shock.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is highly prevalent in the general population and associated with a significant morbidity and mortality. Its prognostic role in patients sustaining septic shock in the intensive care unit (ICU) remains controversial. Accordingly, we investigated whether LV diastolic function was independently associated with ICU mortality in a cohort of septic shock patients assessed using critical care echocardiography. METHODS: Over a 5-year period, patients hospitalized in a Medical-Surgical ICU who underwent an echocardiographic assessment with digitally stored images during the initial management of a septic shock were included in this retrospective single-center study. Off-line echocardiographic measurements were independently performed by an expert in critical care echocardiography who was unaware of patients' outcome. LV diastolic dysfunction was defined by the presence of a lateral E' maximal velocity <10 cm/s. A multivariate analysis was performed to determine independent risk factors associated with ICU mortality. RESULTS: Among the 540 patients hospitalized in the ICU with septic shock during the study period, 223 were studied (140 men [63 %]; age 64 ± 13 years; SAPS II 55 ± 18; SOFA 10 ± 3; Charlson 3.5 ± 2.5) and 204 of them (91 %) were mechanically ventilated. ICU mortality was 35 %. LV diastolic dysfunction was observed in 31 % of patients. The proportion of LV diastolic dysfunction tended to be higher in non-survivors than in their counterparts (28/78 [36 %] vs. 41/145 [28 %]: p = 0.15). Inappropriate initial antibiotic therapy (OR 4.17 [CI 95 % 1.33-12.5]: p = 0.03), maximal dose of vasopressors (OR 1.38 [CI 95 % 1.16-1.63]: p = 0.01), SOFA score (OR 1.16 [CI 95 % 1.02-1.32]: p = 0.02) and lateral E' maximal velocity (OR 1.12 [CI 95 % 1.01-1.24]: p = 0.02) were independently associated with ICU mortality. After adjusting for the SAPS II score, inappropriate initial antibiotic therapy and maximal dose of vasopressors remained independent factors for ICU mortality, whereas a trend was only observed for lateral E' maximal velocity (OR 1.11 [CI 95 % 0.99-1.23]: p = 0.07). CONCLUSION: The present study suggests that LV diastolic function might be associated with ICU mortality in patients with septic shock. A multicenter prospective study assessing a large cohort of patients using serial echocardiographic examinations remains required to confirm the prognostic value of LV diastolic dysfunction in septic shock.

Evaluation of iodine intake and status using inductively coupled plasma mass spectrometry in urban and rural areas in Benin, West Africa.

OBJECTIVE: Iodine deficiency has severe pathological repercussions. The aim of this study was to evaluate iodine intake and status in adults in Benin, West Africa. METHODS: We randomly selected 420 participants ages 25 to 64 y and free of visible goiter from urban and rural settings of South Benin. The participants had a diet based on carbohydrates and fish. Urine was collected over a 24-h period and samples were assayed for iodine analysis using inductively coupled plasma mass spectrometry. RESULTS: We studied 401 urinary iodine samples. The overall median urinary iodine concentration (UIC) in 24-h urine was 62.9 µg/L (interquartile range: 40-96.2 µg/L). UIC was significantly lower in women than men (56.5 versus 78.6 µg/L; P < 0.001) and in rural versus urban areas (54.7 versus 77.8 µg/L; P < 0.001). In multivariate analysis, low UIC (<100 µg/L) was positively associated with women (odds ratio, 2.48; 95% confidence interval, 1.44-4.26; P = 0.001) and body mass index <25 kg/m(2) (odds ratio, 2.06; 95% confidence interval, 1.20-3.54; P = 0.008). CONCLUSION: Iodine intake appeared to be fairly low in the Beninese population, according to World Health Organization criteria, and factors associated with low iodine intake were identified. Public health interventions to increase iodine intake, such as iodization of commercial salt and/or fortification of selected nutrients, should be strengthened at the national level.

Steroid-sparing effect and toxicity of dapsone treatment in giant cell arteritis: A single-center, retrospective study of 70 patients.

Although a glucocorticoid (GC)-sparing strategy is needed for patients with giant cell arteritis (GCA) suffering from refractory disease or serious treatment-related complications, evidence of efficacy in this setting of immunosuppressive drugs and biotherapies is lacking. Herein, we evaluated the GC-sparing effects and tolerability of addition of dapsone (DDS) to prednisone therapy in patients with GCA. We retrospectively assessed data on 18 GCA patients who received DDS as a first-line treatment (DDS-1 group) and 52 patients who received it as a second- or third-line treatment for refractory GCA, with or without excessive GC-related toxicity (DDS-2 group). Of these 70 patients, 63 belonged to an inception cohort of 478 patients, whereas the remaining 7 were referred to our department for resistant GCA. In all, 52 patients were assessable for DDS efficacy. The baseline characteristics of the DDS-1 patients were similar to those of 395 GCA patients (control group) who received prednisone alone. DDS-1 patients had a more sustained decrease in GC dose with a lower mean prednisone dose at 12 months, and they comprised higher proportions who achieved GC withdrawal within the first year, who stopped prednisone treatment, and who recovered from GCA (P < 0.001 for each variable). Patients in the DDS-2 group achieved a mean rate of prednisone reduction of 65% and a prednisone dose reduction of 16.9 ±â€Š13.3 mg/d. The monthly decreases in the prednisone dose were 2.4 and 1.25 mg in DDS-1 and DDS-2 patients, respectively. DDS-induced side effects were recorded in 44 (64%) assessable patients. These side effects led to lowering of the DDS dose by 25 mg/d in 11 (16%) patients and permanent cessation of DDS in 14 patients (20%), due to allergic skin rash in 7, agranulocytosis in 2, icteric hepatitis in 2, and excessive hemolysis in 2 patients. DDS is a potent GC-sparing agent in GCA that should be evaluated in prospective studies. However, DDS use should be restricted to refractory GCA patients due to its toxicity, and close clinical and laboratory monitoring for 3 months is necessary.