Effect of Sublay Preventive Mesh for Terminal Colostomy on Symptoms and Quality of Life in Patients With Parastomal Hernia: A Post Hoc Analysis of the GRECCAR 7 Cohort.

BACKGROUND: Recent randomized clinical trials and meta-analyses confirm that the use of a prophylactic mesh does not significantly reduce the parastomal hernia rate. Data about the benefits of these meshes concerning the symptoms of parastomal hernia are lacking in the existing literature. OBJECTIVE: The aim of this study was to perform a post hoc analysis of the patients presenting parastomal hernia from the GRECCAR 7 (Groupe de recherche sur la chirurgie du cancer du rectum) randomized clinical trials cohort on whether the presence or the absence of the mesh influenced the symptoms, the quality of life, and complications of patients with parastomal hernias. DESIGN: We studied the parastomal hernia-related symptoms among the 2 groups of the GRECCAR 7 randomized clinical trial, with or without prophylactic mesh at the time of the index surgery. SETTINGS: Data were retrospectively extracted and analyzed from the GRECCAR 7 database. PATIENTS: Patients diagnosed with a parastomal hernia during the 2 years of the GRECCAR 7 study. MAIN OUTCOME MEASURES: Several prospectively collected data about the symptoms were studied among this population. We also studied the average interval between parastomal hernia repair surgery and both index surgery and diagnosis of parastomal hernia. RESULTS: Among the 199 patients included in the GRECCAR study, 36 patients (35.6%) in the nonmesh group and 33 patients (33.7%) in the mesh group were diagnosed with clinical and/or radiological parastomal hernia at 2-year follow-up, without a statistically significant difference ( p = 0.89). None of the studied symptoms showed any statistically significant difference between the groups. LIMITATIONS: This study relies on a relatively small number of patients, and although data were prospectively collected, we lacked some details about the categorization of parastomal hernias. CONCLUSIONS: We believe that the use of a prosthetic mesh in a sublay position to prevent parastomal hernia in terminal end colostomy patients should no longer be recommended. See Video Abstract . EFECTO DE LA MALLA PREVENTIVA RETROMUSCULAR PARA COLOSTOMA TERMINAL CON RESPECTO A LOS SNTOMAS Y LA CALIDAD DE VIDA EN PACIENTES CON HERNIA PARAESTOMAL UN ANLISIS POSTHOC DE LA COHORTE GRECCAR: ANTECEDENTES:Los recientes metaanálisis y ensayos clínicos aleatorizados confirman que el uso de una malla profiláctica no reduce significativamente la tasa de hernia paraestomal. En la literatura existente faltan datos sobre los beneficios de estas mallas en relación con los síntomas de la hernia paraestomal.OBJETIVO:El objetivo de este estudio fue realizar un análisis post-hoc de los pacientes que presentaron hernia paraestomal de la cohorte de 7 ensayos clínicos aleatorizados GRECCAR sobre si la presencia o ausencia de la malla influyó en los síntomas, la calidad de vida y las complicaciones de los pacientes con hernias paraestomales.DISEÑO:Estudiamos los síntomas relacionados con la hernia paraestomal entre los dos grupos del ensayo clínico aleatorizado GRECCAR 7, con o sin malla profiláctica en el momento de la cirugía índice.AJUSTES:Los datos fueron extraídos y analizados de manera retrospectiva de la base de datos GRECCAR 7.PACIENTES:Pacientes diagnosticados con hernia paraestomal durante los dos años del estudio GRECCAR 7.PRINCIPALES MEDIDAS DE RESULTADO:Se estudiaron varios datos recopilados de manera prospectiva sobre los síntomas en esta población. También estudiamos el intervalo promedio entre la cirugía reparadora de la hernia paraestomal así como también la cirugía índice como el diagnóstico de la hernia paraestomal.RESULTADOS:De entre los 199 pacientes incluidos en el estudio GRECCAR, 36 pacientes (35,6%) fueron diagnosticados con hernia paraestomal de manera clínica y/o radiológica en el grupo sin malla a los 2 años de seguimiento y 33 (33,7%) en el grupo con malla, sin diferencia estadísticamente significativa ( p = 0,89). Ninguno de los síntomas estudiados mostró diferencias estadísticamente significativas entre los grupos.LIMITACIONES:Este estudio se basa en un número relativamente pequeño de pacientes y, aunque los datos fueron recopilados de forma prospectiva, nos faltaron algunos detalles sobre la categorización de las hernias paraestomales.CONCLUSIONES:Creemos que ya no se debe recomendar el uso de una malla protésica en posición retromuscular para prevenir la hernia paraestomal en pacientes con colostomía terminal. (Traducción-Dr. Osvaldo Gauto ).

A multidisciplinary and structured investigation of three suspected clusters of transverse upper limb reduction defects in France.

INTRODUCTION: Between 2019-2021, facing public concern, a scientific expert committee (SEC) reanalysed suspected clusters of transverse upper limb reduction defects (TULRD) in three administrative areas in France, where initial investigations had not identified any risk exposure. We share here the national approach we developed for managing suspicious clusters of the same group of congenital anomalies occurring in several areas. METHODS: The SEC analysed the medical records of TURLD suspected cases and performed spatiotemporal analyses on confirmed cases. If the cluster was statistically significant and included at least three cases, the SEC reviewed exposures obtained from questionnaires, environmental databases, and a survey among farmers living near to cases' homes concerning their plant product use. RESULTS: After case re-ascertainment, no statistically significant cluster was observed in the first administrative areas. In the second area, a cluster of four children born in two nearby towns over two years was confirmed, but as with the initial investigations, no exposure to a known risk factor explaining the number of cases in excess was identified. In the third area, a cluster including just two cases born the same year in the same town was confirmed. DISCUSSION: Our experience highlights that in the event of suspicious clusters occurring in different areas of a country, a coordinated and standardised approach should be preferred.

Direct Determination rather than Oscillometric Estimation of Systolic Blood Pressure in Patients with Severe Chronic Kidney Disease.

INTRODUCTION: Although arterial hypertension is a major concern in patients with chronic kidney disease (CKD), obtaining accurate systolic blood pressure (SBP) measurement is challenging in this population for whom automatic oscillometric devices may yield erroneous results. METHODS: This cross-sectional study was conducted in 89 patients with stages 4, 5, and 5D CKD, for whom we compared SBP values obtained by the recently described systolic foot-to-apex time interval (SFATI) technique which provides direct SBP determination, the standard technique (Korotkoff sounds), and oscillometry. We investigated the effects of age, sex, diabetes, CKD stage, and pulse pressure to explain measurement errors defined as biases or misclassification relative to the SBP thresholds of 110-130-mm Hg. RESULTS: All 3 techniques showed satisfactory reproducibility for SBP measurement (CCC > 0.84 and >0.91, respectively, in dialyzed and nondialyzed patients). The mean ± SD from SBP as determined via Korotkoff sounds was 1.7 ± 4.6 mm Hg for SFATI (CCC = 0.98) and 5.9 ± 9.3 mm Hg for oscillometry (CCC = 0.88). Referring to the 110-130-mm Hg SBP range outside which treatment prescription or adaptation is recommended for CKD patients, SFATI underestimated SBP in 3 patients and overestimated it in 1, whereas oscillometry underestimated SBP in 12 patients and overestimated it in 3. Higher pulse pressure was the main explanatory factor for measurement and classification errors. DISCUSSION/CONCLUSION: SFATI provides accurate SBP measurements in patients with severe CKD and paves the way for the standardization of automated noninvasive blood pressure measurement devices. Before prescribing or adjusting antihypertensive therapy, physicians should be aware of the risk of misclassification when using oscillometry.

Sutureless socket technique after removal of third molars: a multicentric, open, randomized controlled trial.

BACKGROUND: Although wisdom-tooth extraction is a routine intervention, the postoperative period remains marked by local inflammation classically manifesting as pain, edema and trismus. Furthermore, there is no consensus on the best operative techniques, particularly for the mucosal closure stage on impacted mandibular wisdom teeth. METHODS: This parallel, randomized, non-blinded study compared pain following removal of impacted third molars, with and without sutures. Patients were electronically allocated 1:1 to extraction with versus without sutures. Patients ≥ 14 years' old scheduled for extraction of four impacted wisdom teeth under general anesthesia at three French hospitals were eligible for inclusion. Exclusion criteria included taking antiplatelet agents or anticoagulants, coagulation disorders or immunosuppression, and planned orofacial surgical procedures or emergency pain/infection. The primary objective was pain evaluated by Visual Analogue Scale on Day 3. Secondary outcomes were edema, trismus, healing, complications, painkiller consumption and quality of life on Day 3 and 31. RESULTS: Between June 2016 and November 2018, 100 patients were randomized. Finally, 44 patients in the Suture group and 50 patients in the Without Suture group were analyzed. Mean age was 16.5 years and 66.6% of patients were female. After adjustment on center, age and smoking, no statistical difference was seen between groups for pain on Day 3 (p = 0.904). No differences were seen for swelling, trismus, consumption of painkillers, healing, complications or quality of life. Smokers had a 3.65 times higher complications rate (p = 0.0244). CONCLUSIONS: Sutureless removal of third molars is thus a reliable technique without negative consequence on outcomes, and allows shorter operating time. Smoking is a risk factor for postoperative complications. Trial registration www. CLINICALTRIALS: gov (NCT02583997), registered 22/10/2015.

End Colostomy With or Without Mesh to Prevent a Parastomal Hernia (GRECCAR 7): A Prospective, Randomized, Double Blinded, Multicentre Trial.

OBJECTIVE: To evaluate whether systematic mesh implantation upon primary colostomy creation was effective to prevent PSH. SUMMARY OF BACKGROUND DATA: Previous randomized trials on prevention of PSH by mesh placement have shown contradictory results. METHODS: This was a prospective, randomized controlled trial in 18 hospitals in France on patients aged ≥18 receiving a first colostomy for an indication other than infection. Participants were randomized by blocks of random size, stratified by center in a 1:1 ratio to colostomy with or without a synthetic, lightweight monofilament mesh. Patients and outcome assessors were blinded to patient group. The primary endpoint was clinically diagnosed PSH rate at 24 months of the intention-to-treat population. This trial was registered at ClinicalTrials.gov, number NCT01380860. RESULTS: From November 2012 to October 2016, 200 patients were enrolled. Finally, 65 patients remained in the no mesh group (Group A) and 70 in the mesh group (Group B) at 24 months with the most common reason for drop-out being death (n = 41). At 24 months, PSH was clinically detected in 28 patients (28%) in Group A and 30 (31%) in Group B [P = 0.77, odds ratio = 1.15 95% confidence interval = (0.62;2.13)]. Stoma-related complications were reported in 32 Group A patients and 37 Group B patients, but no mesh infections. There were no deaths related to mesh insertion. CONCLUSION: We failed to show efficiency of a prophylactic mesh on PSH rate. Placement of a mesh in a retro-muscular position with a central incision to allow colon passage cannot be recommended to prevent PSH. Optimization of mesh location and reinforcement material should be performed.

Prospective ultrasonographic follow-up of transvaginal lightweight meshes: a 1-year multicenter study.

INTRODUCTION AND HYPOTHESIS: The use of new lightweight meshes in pelvic organ prolapse (POP) surgery may reduce complications related to mesh retraction (chronic pain, dyspareunia, and mesh exposure). The aim of this study was to investigate changes in the area and position of Uphold Lite™ mesh 6 weeks and 12 months after anterior and/or apical prolapse repair. METHODS: This observational prospective multicenter study included patients who had undergone transvaginal surgery for symptomatic POP-Q stage ≥ II anterior and/or apical compartment prolapse with placement of Uphold Lite mesh. The dimensions and position of the mesh were evaluated at 6 weeks and 12 months by ultrasonography. Correlations between ultrasonographic mesh characteristics and POP recurrence were analyzed. RESULTS: Fifty evaluable women with an average age of 66.8 years were included. No statistically significant difference in mesh area was found between week 6 and month 12 postoperatively, either at rest (1746.92 vs. 1574.48 mm2; p = 0.15) or on Valsalva (1568.81 vs. 1542.98 mm2; p = 0.65). The ROC-AUC of the distance between the mesh and the bladder neck (M-BN) at 6 weeks for predicting cystocele recurrence at 12 months was 0.764 (95% CI 0.573-0.955) at rest and 0.724 (95% CI 0.533-0.916) on Valsalva. An M-BN distance > 12.5 mm could predict cystocele recurrence at month 12 with a sensitivity of 80% and a specificity of 69%. CONCLUSIONS: Ultrasonographic measurements of the Uphold Lite™ mesh appear to remain stable between 6 weeks and 12 months postoperatively. M-BN distance correlates with cystocele recurrence. These results appear to confirm the value of ultrasound in mesh evaluation.

Clinical evaluation of a dose management system-integrated 3D skin dose map by comparison with radiochromic films.

OBJECTIVES: To validate the performance of an automatic tool to estimate a patient's peak skin dose (PSD) and a skin dose map from data collected by a radiation dose management system (RDMS) during interventional procedures. METHODS: In total, 288 eligible consecutive patients undergoing abdominopelvic embolisation or planned coronary angioplasty using radiochromic films were screened between June 2018 and March 2019. For 98 included patients, PSD was measured using radiochromic films (PSDFilm) and computed by RDMS (PSDRDMS) using one flat and two anthropomorphic phantoms. Statistical concordance between PSDFilm and PSDRDMS was computed with Lin's concordance correlation coefficient and clinical concordance with the Bland and Altman graphic; values were compared using the paired Mann-Whitney-Wilcoxon test. RESULTS: In total, 190/288 patients were excluded and 98 patients were analysed (69 men, mean age 66 ± 14 years). The PSDFilm median (1st; 3rd quartile) was 0.59 Gy (0.40; 1.08). PSDRDMS was 0.62 Gy (0.43; 1.22) for the flat phantom and 0.62 Gy (0.42; 1.19) for anthropomorphic phantoms. The concordance between PSDFilm and PSDRDMS was good for both phantoms (flat: 0.94 [0.91; 0.95]; anthropomorphic 0.94 [0.91; 0.96]). Compared with the values of PSDFilm, the values of PSDRDMS were significantly increased by 5% (- 4%; 16%) for flat phantom (p = 0.001) and 7% (- 6%; 22%) for anthropomorphic phantoms (p = 0.002) for vascular procedures and 9% (- 4%; 26%, p = 0.01) and 6% (- 4%; 23%, p = 0.02) for cardiac procedures, respectively. Dose map representations matched for most patients. The gaps identified were due to table displacement during fluoroscopy events and the use of a wedge filter. CONCLUSIONS: The RDMS skin dose map tool allowed the computation of the PSD and skin dose distribution for all patients with fewer constraints than radiochromic films. However, the computed PSD was overestimated, increasing the number of patients requiring follow-up. KEY POINTS: • A good concordance correlation was identified between the peak skin dose (PSD) values measured with radiochromic films and estimated with the radiation dose management system (RDMS) skin dose map tool. • Differences were related to table displacement during fluoroscopy events and the use of a wedge filter, which are not accounted in the Digital Imaging and Communications in Medicine Radiation Dose Structured Reports. • For all procedures, the estimated PSDs were significantly higher than the measured PSDs by 5% (- 4%; 18%) for flat phantom (p < 0.001) and 6% (- 5%; 22%) for anthropomorphic phantoms (p < 0.001).

Cerebrospinal fluid chitinase-3-like protein 1 level is not an independent predictive factor for the risk of clinical conversion in radiologically isolated syndrome.

BACKGROUND: Younger age, male sex and presence of spinal cord lesion(s) increase the risk of conversion from radiologically isolated syndrome (RIS) to relapsing-remitting multiple sclerosis (RRMS). Elevated cerebrospinal fluid (CSF) chitinase-3-like protein 1 (CHI3L1) levels predict conversion from clinically isolated syndrome (CIS) to RRMS. OBJECTIVE: To evaluate the prognostic value of CSF CHI3L1 in RIS patients for conversion to RRMS. METHODS: We compared CSF CHI3L1 concentrations in RIS, CIS, RRMS and symptomatic controls (SCs). We analysed the influence of epidemiological, radiological and CSF parameters on the risk of clinical event. RESULTS: A total of 211 patients (71 RIS, 48 CIS, 50 RRMS and 42 SC) were included. CSF CHI3L1 levels were lower in RIS than in RRMS and higher in RIS with positive CSF versus negative CSF and SC. The presence of at least one spinal cord lesion was the only independent predictor of faster conversion to RRMS. Association of high CSF CHI3L1 levels, positive CSF (presence of oligoclonal bands and/or an elevated IgG index) or four Barkhof criteria with any spinal cord lesion showed a tendency for reduced mean conversion time. CONCLUSION: CSF CHI3L1 correlates with positive CSF but is not an independent predictor of the risk of conversion from RIS to RRMS.

Small obliquely oriented cortical cerebellar infarctions are associated with cardioembolic stroke.

BACKGROUND: A revised classification of cerebellar infarctions (CI) may uncover unrecognized associations with etiologic stroke subtypes. We hypothesized that obliquely oriented small cortical cerebellar infarction (SCCI) representing end zone infarctions on MRI would be associated with cardiac embolism. METHODS: We retrospectively analyzed consecutive stroke patients recruited between January-December 2016 in our center. Analyzed baseline characteristics: sex, age, cardiovascular risk factors, history of stroke or atrial fibrillation (AF). TOAST classification was used for determining stroke subtype. Acute infarction location (anterior/posterior/mixed anterior-posterior circulation), acute uni- or multiterritorial infarction, and acute or chronic CI/SCCI/non-SCCI were assessed by MRI, and vertebrobasilar stenosis/occlusion by vessel imaging. Pre-specified analysis was also performed in patients without known high cardioembolic risk (known AF history or acute multiterritorial infarction). RESULTS: We included 452 patients (CI in 154, isolated SCCI in 55, isolated non-SCCI in 50, and mixed SCCI/non-SCCI in 49). Both SCCI and non-SCCI were associated with AF history (SCCI, p = 0.021; non-SCCI, p = 0.004), additional acute posterior circulation infarction (p < 0.001 both CI-subtypes), multiterritorial infarctions (SCCI, p = 0.003; non-SCCI, p < 0.001) and cardioembolic more frequent than large-artery atherosclerosis origin (p < 0.001 for both CI-subtypes). SCCI was associated with older age (p < 0.001), whereas non-SCCI was associated with stroke history (p = 0.036) and vertebrobasilar stenosis/occlusion (p = 0.002). SCCI were older (p = 0.046) than non-SCCI patients, had less frequently prior stroke (p < 0.001), and more frequent cardioembolic infarction (p = 0.025). In patients without known high cardioembolic risk (n = 348), SCCI was strongly associated with subsequent cardioembolism diagnosis (OR 3.00 [CI 1.58-5.73, p < 0.001]). No such association was present in non-SCCI. CONCLUSIONS: Acute or chronic SCCI are strongly associated with a cardioembolic origin.

Clinical evaluation of the Uphold LITE mesh for the surgical treatment of anterior and apical prolapse: A prospective, multicentre trial.

AIMS: To evaluate the safety and efficacy of the Uphold LITE mesh in the treatment of pelvic organ prolapse at 12-month follow-up. METHODS: Women undergoing a mesh surgery due to an anterior prolapse plus a symptomatic anterior prolapse (classed as pelvic organ prolapse quantification stage ≥2) were included in this prospective, multicentre, observational study. The primary endpoint was a composite outcome including a good anatomical correction, no prolapse symptoms, and no reintervention for an anterior or apical recurrent prolapse within 12 months of surgery. Secondary outcomes included safety, improvements in quality of life (QoL), and risk factor for recurrence. This study was registered with ClinicalTrials.gov, number NCT01559168. RESULTS: A total of 121 patients were included. Symptomatic and anatomic cure rates were 94% (95 of 101) and 76.8% (76 of 99), respectively. The composite success rate was 72.4% (71 of 98). The rate of reoperation for apical or anterior recurrent prolapse was 3.9% (4 of 103). Anatomical anterior or apical recurrence occurred in 18.2% (18 of 97) and 7.2% (7 of 97) of patients, respectively. The composite success rate was significantly higher in centres where more than 30 patients had been treated (80% vs 50%; P = .045). The rate of serious complication was 5.4% (6 of 111). Improvements were recorded in QoL including sexual function. CONCLUSIONS: The Uphold LITE mesh procedure provides satisfactory outcomes in the treatment of anterior and apical prolapse, particularly in high-volume centres. The rates of adverse effects and reintervention for recurrent prolapse were acceptable.

Time course of fluid responsiveness in sepsis: the fluid challenge revisiting (FCREV) study.

BACKGROUND: Fluid challenge (FC) is one of the most common practices in Intensive Care Unit (ICU). The present study aimed to evaluate whether echocardiographic assessment of the response to FC at the end of the infusion or 20 min later could affect the results of the FC. METHODS: This is a prospective, observational, multicenter study including all ICU patients in septic shock requiring a FC of 500 mL crystalloids over 10 min. Fluid responsiveness was defined as a > 15% increase in stroke volume (SV) assessed by velocity-time integral (VTI) measurements at baseline (T0), at the end of FC (T10), then 10 (T20) and 20 min (T30) after the end of FC. RESULTS: From May 20, 2014, to January 7, 2016, a total of 143 patients were enrolled in 11 French ICUs (mean age 64 ± 14 years, median IGS II 53 [43-63], median SOFA score 10 [8-12]). Among the 76/143 (53%) patient responders to FC at T10, 37 patients were transient responders (TR), i.e., became non-responders (NR) at T30 (49%, 95%CI = [37-60]), and 39 (51%, 95%CI = [38-62]) patients were persistent responders (PR), i.e., remained responders at T30. Among the 67 NR at T10, 4 became responders at T30, (6%, 95%CI = [1.9-15.3]). In the subgroup analysis, no statistical difference in hemodynamic and echocardiographic parameters was found between groups. CONCLUSIONS: This study shows that 51.3% of initial responders have a persistent response to fluid 30 min after the beginning of fluid infusion and only 41.3% have a transient response highlighting that fluid responsiveness is time dependent. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02116413 . Registered on April 16, 2014.

Sacroiliac radiographic progression in recent onset axial spondyloarthritis: the 5-year data of the DESIR cohort.

OBJECTIVE: To estimate sacroiliac joint radiographic (X-SIJ) progression in patients with axial spondyloarthritis (axSpA) and to evaluate the effects of inflammation on MRI (MRI-SIJ) on X-SIJ progression. METHODS: X-SIJ and MRI-SIJ at baseline and after 2 and 5 years in patients with recent onset axSpA from the DESIR cohort were scored by three central readers. Progression was defined as (1) the shift from non-radiographic (nr) to radiographic (r) sacroiliitis (by modified New York (mNY) criteria) or alternative criteria, (2) a change of at least one grade or (3) a change of at least one grade but ignoring a change from grade 0 to 1. The effects of baseline inflammation on MRI-SIJ on 5-year X-SIJ damage (mNY) were tested by generalised estimating equations. RESULTS: In 416 patients with pairs of baseline and 5-year X-SIJ present, net progression occurred in 5.1% (1), 13.0% (2) and 10.3% (3) respectively, regarding a shift from nr-axSpA to r-axSpA (1), a change of at least one grade (2) or a change of at least one grade but ignoring a change from grade 0 to 1 (3). Baseline MRI-SIJ predicted structural damage after 5 years in human leukocyte antigen-B27 (HLA-B27) positive (OR 5.39 (95% CI 3.25 to 8.94)) and in HLA-B27 negative (OR 2.16 (95% CI 1.04 to 4.51)) patients. CONCLUSIONS: Five-year progression of X-SIJ damage in patients with recent onset axSpA is limited but present beyond measurement error. Baseline MRI-SIJ inflammation drives 5-year radiographic changes.

Characterizing Deep White Matter Hyperintensities in Patients with Symptomatic Isolated Cortical Superficial Siderosis.

BACKGROUND: In patient with cerebral amyloid angiopathy (CAA) presenting with lobar hemorrhage (LH), magnetic resonance imaging (MRI) white matter hyperintensities (WMH) tend to be predominant in posterior regions with the "multiple subcortical spots" WMH pattern as the most frequent topographical WMH pattern. Our aim was to analyze WMH severity and topographical distribution in patients with cortical superficial siderosis (CSS). METHODS: We retrospectively analyzed MRIs from consecutive symptomatic isolated (i.e., without LH) CSS and LH-CAA (with or without associated CSS) patients. We analyzed baseline clinical characteristics including age, history of hypertension, diabetes, hypercholesterolemia, and pre-existing cognitive deficit. The presence of lobar microbleeds (MB) was scored on T2*. FLAIR (fluid-attenuated inversion recovery) WMH severity (using the Fazekas scale) and topographical distribution (using [slightly modified] earlier described WMH patterns) were analyzed and compared between both groups. RESULTS: Twenty CSS and 63 LH-CAA patients were analyzed. Baseline clinical characteristics were similar between both groups, except for hypercholesterolemia less frequently present in the CSS group (P = .026). Lobar MB were significantly less frequently present in the CSS group (P < .01), and CSS was more frequently focal in the CSS group compared with LH-CAA patients with associated CSS (P = .03). Mean Fazekas scale was significantly lower in CSS patients (P = .011). WMH patterns did not differ between both groups, with the multiple subcortical spots pattern as the most frequently observed pattern. CONCLUSIONS: Relative severe WMH scores and similar topographical distribution in CSS patients argue for WMH as a CAA-related feature in these patients with isolated CSS, adding level of evidence that isolated CSS could correspond to early manifestations of CAA.

The impact of emergency department segmentation and nursing staffing increase on inpatient mortality and management times.

BACKGROUND: The aim of our study was to investigate the impact of a new organization of our emergency department (ED) on patients' mortality and management delays. METHODS: The ED segmentation consisted of the development of a new patient care geographical layout on a pre-existing site and changing the organization of patient flow. It took place on May 10, 2012. We did a before-after study in the ED of a university hospital, "before" (winter 2012) and "after" (summer 2012) reorganization by segmentation into sectors. All ED patients were included. RESULTS: Eighty-three thousand three hundred twenty-two patient visits were analyzed, 61,118 in phase "before", 22,204 during the phase "after". The overall inpatient mortality was 1.5 % during summer 2011 ("before" period), 1.8 % during winter 2012 ("before" period), 1.3 % during summer 2012 ("after" period) period (summer 2012 vs. winter 2012, OR = 0.72; 95 % CIs [0.61, 0.85], and summer 2012 vs. summer 2011, OR = 0.85; 95 % CIs [0.72, 0.99]). The mean (SD) time to first medical contact was 129 min (±133) during winter 2012 and 104 min (± 95) during summer 2012 (p < .05). CONCLUSIONS: Our study showed a decrease in mortality and improvement in time to first medical contact after the segmentation of our ED and nursing staffing increase, without an increase in medical personnel. Improving patient care through optimizing ED segmentation may be an effective strategy.

Clinical predictive factors and trajectories of suicidal remission over 6 weeks following intravenous ketamine for suicidal ideation.

BACKGROUND: Ketamine is efficient for short-term reduction of suicidal ideas. Predictive factors and outcome trajectories are poorly characterized. METHODS: Secondary analyses were conducted on the KETIS study (Abbar et al. BMJ 2022): 156 suicidal patients were randomized to two intravenous infusions of racemic ketamine (0.5 mg/kg) or placebo. Response or remission was assessed over six weeks based on the Beck Scale for Suicidal Ideation (SSI). We calculated i) predictive values of 12 baseline variables on remission ii) outcome courses, and iii) positive (PPV) and negative predictive values. RESULTS: In multivariate analyses, bipolar disorder, lower patient-rated suicidal ideas, and higher physical pain were predictive of suicidal remission at day 3. No clinical factor predicted remission at week 6. Twenty and 24 different clinical courses were identified in early (day 3) and later (week 6) follow-up, respectively, including around 40 % sustained remission, 50 % fluctuating course and 10 % no response. Suicidal remissions at day 1 and day 3 were highly predictive of remissions at day 3 and week 6 (PPV = 96.8 and 92.6 %). LIMITATIONS: SSI may not be adapted for rapid variations and repeated measures. CONCLUSIONS: Clinical factors were poorly predictive of remission. Fluctuations in suicidal ideas were frequent, even after ketamine (although less than placebo), necessitating vigilance and multimodal care. Remission at day 1 after one infusion was highly predictive of future remission. The benefits of a second infusion will have to be tested.

CD138 as a Specific CSF Biomarker of Multiple Sclerosis.

BACKGROUND AND OBJECTIVES: The aim of this study was to identify novel biomarkers for multiple sclerosis (MS) diagnosis and prognosis, addressing the critical need for specific and prognostically valuable markers in the field. METHODS: We conducted an extensive proteomic investigation, combining analysis of (1) CSF proteome from symptomatic controls, fast and slow converters after clinically isolated syndromes, and patients with relapsing-remitting MS (n = 10 per group) using label-free quantitative proteomics and (2) oligodendrocyte secretome changes under proinflammatory or proapoptotic conditions using stable isotope labeling by amino acids in cell culture. Proteins exhibiting differential abundance in both proteomic analyses were combined with other putative MS biomarkers, yielding a comprehensive list of 87 proteins that underwent quantification through parallel reaction monitoring (PRM) in a novel cohort, comprising symptomatic controls, inflammatory neurologic disease controls, and patients with MS at various disease stages (n = 10 per group). The 11 proteins that passed this qualification step were subjected to a new PRM assay within an expanded cohort comprising 158 patients with either MS at different disease stages or other inflammatory or noninflammatory neurologic disease controls. RESULTS: This study unveiled a promising biomarker signature for MS, including previously established candidates, such as chitinase 3-like protein 1, chitinase 3-like protein 2, chitotriosidase, immunoglobulin kappa chain region C, neutrophil gelatinase-associated lipocalin, and CD27. In addition, we identified novel markers, namely cat eye syndrome critical region protein 1 (adenosine deaminase 2, a therapeutic target in multiple sclerosis) and syndecan-1, a proteoglycan, also known as plasma cell surface marker CD138 and acting as chitinase 3-like protein 1 receptor implicated in inflammation and cancer signaling. CD138 exhibited good diagnostic accuracy in distinguishing MS from inflammatory neurologic disorders (area under the curve [AUC] = 0.85, CI 0.75-0.95). CD138 immunostaining was also observed in the brains of patients with MS and cultured oligodendrocyte precursor cells but was absent in astrocytes. DISCUSSION: These findings identify CD138 as a specific CSF biomarker for MS and suggest the selective activation of the chitinase 3-like protein 1/CD138 pathway within the oligodendrocyte lineage in MS. They offer promising prospects for improving MS diagnosis and prognosis by providing much-needed specificity and clinical utility. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that CD138 distinguishes multiple sclerosis from other inflammatory neurologic disorders with an AUC of 0.85 (95% CI 0.75-0.95).

Autoantibodies to citrullinated fibrinogen compared with anti-MCV and anti-CCP2 antibodies in diagnosing rheumatoid arthritis at an early stage: data from the French ESPOIR cohort.

OBJECTIVES: To compare the performance of anticitrullinated peptides/protein antibodies (ACPA) detected by three immunoassays in the French ESPOIR cohort of patients with early rheumatoid arthritis (RA) and undifferentiated arthritis (UA) and to study the relationship between ACPA and disease activity. METHODS: A diagnosis of RA (1987 American College of Rheumatology (ACR) criteria) was established at baseline in 497 patients and after a 2-year follow-up in 592 patients. At baseline, antibodies to citrullinated fibrinogen (AhFibA), antimutated citrullinated vimentin (anti-MCV) and anticyclic citrullinated peptide (anti-CCP2) were assayed and the individual and combined diagnostic sensitivities and predictive values of the tests were determined. Relationships between ACPA positivity and the 28-joint disease activity score and Health Assessment Questionnaire scores were analysed. RESULTS: At a diagnostic specificity of at least 98%, the three tests exhibited similar diagnostic sensitivities (47-48.5%). When considering as positive patients with at least one positive test, the sensitivity increased to 53.5% with a probable loss of specificity. Among the patients classified as having UA at baseline, 30% were positive for one ACPA, the positive predictive values for RA of the three tests ranging from 73% to 80% but increasing when two tests were associated. Whatever the test used, the addition of ACPA positivity to the 1987 criteria enhanced their sensitivity by 6%, close to that of the 2010 ACR/European League Against Rheumatism (EULAR) criteria. CONCLUSIONS: In early arthritis, AhFibA, anti-MCV and anti-CCP2 showed similar diagnostic sensitivity with a high diagnostic specificity and a similar high positive predictive value for RA. Adding ACPA to the 1987 ACR criteria significantly increased the number of patients classified as having RA, confirming the validity of the recent inclusion of the serological criterion in the ACR/EULAR criteria.

Deforestation, agriculture and farm jobs: a good recipe for Plasmodium vivax in French Guiana.

BACKGROUND: In a malaria-endemic area the distribution of patients is neither constant in time nor homogeneous in space. The WHO recommends the stratification of malaria risk on a fine geographical scale. In the village of Cacao in French Guiana, the study of the spatial and temporal distribution of malaria cases, during an epidemic, allowed a better understanding of the environmental factors promoting malaria transmission. METHODS: A dynamic cohort of 839 persons living in 176 households (only people residing permanently in the village) was constituted between January 1st, 2002 and December 31st, 2007.The information about the number of inhabitants per household, the number of confirmed cases of Plasmodium vivax and house GPS coordinates were collected to search for spatial or temporal clustering using Kurlldorff's statistical method. RESULTS: Of the 839 persons living permanently in the village of Cacao, 359 persons presented at least one vivax malaria episode between 2002 and 2007. Five temporal clusters and four spatial clusters were identified during the study period. In all temporal clusters, April was included. Two spatial clusters were localized at the north of the village near the Comté River and two others localized close to orchards. CONCLUSION: The spatial heterogeneity of malaria in the village may have been influenced by environmental disturbances due to local agricultural policies: deforestation, cultures of fresh produce, or drainage of water for agriculture. This study allowed generating behavioural, entomological, or environmental hypotheses that could be useful to improve prevention campaigns.

Precision of estimates of local stability of repetitive trunk movements.

PURPOSE: Local dynamic stability of trunk movements quantified by means of the maximum Lyapunov exponent (λmax) can provide information on trunk motor control and might offer a measure of trunk control in low-back pain patients. It is unknown how many repetitions are necessary to obtain sufficiently precise estimates of λmax and whether fatigue effects on λmax can be avoided while increasing the number of repetitions. METHOD: Ten healthy subjects performed 100 repetitions of trunk movements in flexion, of trunk rotation and of a task combining these movement directions. λmax was calculated from thorax, pelvis and trunk (thorax relative to pelvis) kinematics. Data series were analyzed using a bootstrap procedure; ICC and coefficient of variation were used to quantify precision as a function of the number of cycles analyzed. ANOVA was used to compare movement tasks and to test for effects of time. RESULTS: Trunk local stability reached acceptable precision level after 30 repetitions. λmax was higher (indicating lower stability) in flexion, compared to rotation and combined tasks. There was no time effect (fatigue). λmax of trunk movement was lower and less variable than that of thorax and pelvis movements. CONCLUSIONS: The data provided allow for an informed choice of the number of repetitions in assessing local dynamic stability of trunk movements, weighting the gain in precision against the increase in measurement effort. Within the 100 repetitions tested, fatigue did not affect results. We suggest that increased stability during asymmetric movement may be explained by higher co-activation of trunk muscles.

Neuromuscular adaptations after a rehabilitation program in patients with chronic low back pain: case series (uncontrolled longitudinal study).

BACKGROUND: To investigate the impact of a short-term multimodal rehabilitation program for patients with low back pain (LBP) on trunk muscle reflex responses and feedforward activation induced by postural perturbations. METHODS: Case series (uncontrolled longitudinal study). Thirty chronic patients with LBP (21 women and 19 men, mean age 42.6 ± 8.6 years, mean weight 73 ± 14 kg, mean height 174 ± 10 cm) were included. The intervention consisted in a 5-day program including therapeutic education sessions (360 min), supervised abdominal and back muscle strength exercises (240 min), general aerobic training (150 min), stretching (150 min), postural education (150 min) and aqua therapy (150 min). Feedforward activation level and reflex amplitude determined by surface electromyographic activity triggered by postural perturbations were recorded from abdominal and paraspinal muscles in unexpected and expected conditions. Subjects were tested before, just after and again one month after the rehabilitation program. RESULTS: No main intervention effect was found on feedforward activation levels and reflex amplitudes underlining the absence of changes in the way patients with LBP reacted across perturbation conditions. However, we observed a shift in the behavioral strategy between conditions, in fact feedforward activation (similar in both conditions before the program) decreased in the unexpected condition after the program, whereas reflex amplitudes became similar in both conditions. CONCLUSIONS: The results suggest that a short-term rehabilitation program modifies trunk behavioral strategies during postural perturbations. These results can be useful to clinicians for explaining to patients how to adapt to daily life activities before and after rehabilitation.