Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension.

BACKGROUND: Early Mobilization in Intensive Care Units (ICUs) enhances patients' evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS. METHODS: This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria. RESULTS: Patients' conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended. CONCLUSIONS: Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated. TRIAL REGISTRATION: ClinicalTrials database (ID: NCT04300491).

The Frontal Bone Window for Transcranial Doppler Ultrasonography in Critically Ill Patients: Validation of a New Approach in the ICU.

BACKGROUND AND OBJECTIVE: The temporal bone window (TBW) for transcranial Doppler (TCD) often fails to insonate the anterior cerebral artery (ACA). The frontal bone window (FBW) has never been evaluated in intensive care units (ICU). The main objective was to determine the ability of the FBW to assess ACA velocities in critically ill patients. METHODS: A prospective study was conducted in two ICUs of the Montpellier University Hospital (France), between November 2014 and September 2016. Adult patients admitted to ICU for brain injury, with a Glasgow Coma Scale score ≤ 13, were enrolled within 3 days after admission. A first TCD examination was carried out bilaterally through the TBW and FBW by an intensivist expert in TCD, repeated by the same examiner, and 15 min later by an intensivist certified in TCD, designated as non-expert, blinded. The success of the FBW examinations was defined by the ability to measure the ACA velocities. Intra- and interobserver agreements were analyzed according to the Bland and Altman method. RESULTS: A total of 147 patients were analyzed. The FBW succeeded in insonating the ACA in 66 patients [45%, CI (37-53)], 45 bilaterally and 21 unilaterally. For 16 patients (11%), the FBW was the only way to measure ACA velocities. By combining the two techniques, the ACA success rate increased from 62% CI (54-70) to 73% CI (65-79) (P = 0.05). Intra- and interobserver mean biases and 95% limits of agreement for ACA systolic velocity measurements through the FBW were 1 (- 33 to 35) and 2 (- 34 to 38) cm s-1, respectively. For paired TBW and FBW measures of ACA velocities, mean biases (± SD) for ACA systolic, and mean and diastolic velocities were relatively close to zero, but negatives (- 7 ± 33, - 2 ± 19, - 1 ± 15 cm s-1, respectively), highlighting that ACA velocities were lower with the FBW (A2 segment) than TBW (A1 segment). The correlation coefficient for ACA systolic velocities measured by the FBW and TBW was R = 0.47, CI (0.28-0.62). No risk factors for failure of the FBW were identified. CONCLUSIONS: In ICU, the FBW was able to insonate the ACA in 45% of patients admitted for brain injury, without the use of contrast agents. The FBW could improve the detection of ACA vasospasms.

Deep brain stimulation treated dystonia-trajectory via status dystonicus.

BACKGROUND: Status dystonicus (SD) is a life-threatening condition. OBJECTIVE AND METHODS: In a dystonia cohort who developed status dystonicus, we analyzed demographics, background dystonia phenomenology and complexity, trajectory previous to-, via status dystonicus episodes, and evolution following them. RESULTS: Over 20 years, 40 of 328 dystonia patients who were receiving DBS developed 58 status dystonicus episodes. Dystonia was of pediatric onset (95%), frequently complex, and had additional cognitive and pyramidal impairment (62%) and MRI alterations (82.5%); 40% of episodes occured in adults. Mean disease duration preceding status dystonicus was 10.3 ± 8 years. Evolution time to status dystonicus varied from days to weeks; however, 37.5% of patients exhibited progressive worsening over years. Overall, DBS was efficient in resolving 90% of episodes. CONCLUSION: Status dystonicus is potentially reversible and a result of heterogeneous conditions with nonuniform underlying physiology. Recognition of the complex phenomenology, morphological alterations, and distinct patterns of evolution, before and after status dystonicus, will help our understanding of these conditions. © 2018 International Parkinson and Movement Disorder Society.

Prevalence of Migraine Disease in Electrohypersensitive Patients.

BACKGROUND: The vast majority of electrohypersensitive (EHS) patients present headaches on contact with an electromagnetic source. Clinical features suggest that the headaches of these patients could be a variant of the migraine disease and could be treated as such. We aimed to assess the prevalence of migraine disease in EHS patients using a validated questionnaire. METHODS: Patients with EHS defined according to WHO criteria were contacted through EHS patient support associations. They were required to answer a self-questionnaire including clinical data and the extended French version of the ID Migraine questionnaire (ef-ID Migraine) to screen for the migraine disease. Migraine prevalence and its 95% confidence interval (CI) were reported. Patients' characteristics, symptoms (rheumatology, digestive, cognitive, respiratory, cardiac, mood, cutaneous, headache, perception, genital, tinnitus and tiredness) and impact on daily life were compared between migraineur and non-migraineur patients. RESULTS: A total of 293 patients were included (97% women, mean age 57 ± 12 years). Migraine was diagnosed in 65% (N = 191; 95% CI: 60-71%) with the ef-ID Migraine. The migraine diagnosis was accompanied by nausea/vomiting in 50% of cases, photophobia in 69% or visual disturbances in 38%. All of the 12 symptoms assessed were of higher intensity in migraineurs than in non-migraineurs. The symptoms prevented social life in 88% of migraineurs and 75% of non-migraineurs (p < 0.01). CONCLUSIONS: Our work encourages us to consider the headaches of these patients as a possible variant of the migraine disease and, possibly, to manage them according to the current recommendations.

Transcranial sonographic assessment of the third ventricle in neuro-ICU patients to detect hydrocephalus: a diagnostic reliability pilot study.

BACKGROUND: Transcranial sonography is a point-of-care tool recommended in intensive care units (ICU) to monitor brain injured patients. Objectives of the study was to assess feasibility and reliability of the third ventricle (V3) diameter measurement using transcranial sonography (TCS) compared to brain computed-tomography (CT), the gold standard measurement, and to measure the TCS learning curve. DESIGN: prospective study, in a 16-bed neurological ICU in an academic hospital. Every consecutive brain injured adult patient, who required a brain CT and TCS monitoring were included. The V3 diameter was blindly measured by TCS and CT. Intraclass correlation coefficient (ICC) and Bland-Altman plot were used to assess the reliability and agreement between TCS and CT V3 measurements. Diagnosis performance of the V3 diameter using TCS to detect hydrocephalus was measured. Absolute difference between V3 measurement by residents and experts was measured consecutively to assess the learning curve. RESULTS: Among the 100 patients included in the study, V3 diameter could be assessed in 87 patients (87%) from at least one side of the skull. Both temporal windows were available in 70 patients (70%). The ICC between V3 diameter measured by TCS and CT was 0.90 [95% CI 0.84-0.93] on the right side, and 0.92 [0.88-0.95] on the left side. In Bland-Altman analysis, mean difference, standard deviation, 95% limits of agreement were 0.36, 1.52, - 2.7 to 3.3 mm, respectively, on the right side; 0.25, 1.47, - 2.7 to 3.1 mm, respectively, on the left side. Among the 35 patients with hydrocephalus, V3 diameters could be measured by TCS in 31 patients (89%) from at least one side. Hydrocephalus was, respectively, excluded, confirmed, or inconclusive using TCS in 35 (40%), 25 (29%) and 27 (31%) of the 87 assessable patients. After 5 measurements, every resident reached a satisfactory measurement compared to the expert operator. CONCLUSION: TCS allows rapid, simple and reliable V3 diameter measurement compared with the gold standard in neuro-ICU patients. Aside from sparing irradiating procedures and transfers to the radiology department, it may especially increase close patient monitoring to detect clinically occult hydrocephalus earlier. Further studies are needed to measure the potential clinical benefit of this method. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02830269.

Technical Assessment of Ultrasonic Cerebral Tomosphygmography and New Scientific Evaluation of Its Clinical Interest for the Diagnosis of Electrohypersensitivity and Multiple Chemical Sensitivity.

Ultrasonic cerebral tomosphygmography (UCTS), also known as "encephaloscan", is an ultrasound-based pulsatile echoencephalography for both functional and anatomical brain imaging investigations. Compared to classical imaging, UCTS makes it possible to locate precisely the spontaneous brain tissue pulsations that occur naturally in temporal lobes. Scientific publications have recently validated the scientific interest of UCTS technique but clinical use and industrial development of this ancient brain imaging technique has been stopped notably in France, not for scientific or technical reasons but due to a lack of financing support. UCTS should be fundamentally distinguished from transcranial Doppler ultrasonography (TDU), which, although it also uses pulsed ultrasounds, aims at studying the velocity of blood flow (hemodynamics) in the cerebral arteries by using Doppler effect, especially in the middle cerebral artery of both hemispheres. Instead, UCTS has the technical advantage of measuring and locating spontaneous brain tissue pulsations in temporal lobes. Recent scientific work has shown the possibility to make an objective diagnosis of electrohypersensitivity (EHS) and multiple chemical sensitivity (MCS) by using UCTS, in conjunction with TDU investigation and the detection of several biomarkers in the peripheral blood and urine of the patients. In this paper, we independently confirm the clinical interest of using UCTS for the diagnosis of EHS and MCS. Moreover, it has been shown that repetitive use of UCTS in EHS and/or MCS patients can contribute to the objective assessment of their therapeutic follow-up. Since classical CT scan and MRI are usually not contributive for the diagnosis and are poorly tolerated by these patients, UCTS should therefore be considered as one of the best imaging technique to be used for the diagnosis of these new disorders and the follow-up of patients.

Deep brain stimulation is effective in pediatric patients with GNAO1 associated severe hyperkinesia.

BACKGROUND: Exacerbation of hyperkinesia is a life-threatening complication of dyskinetic movement disorders, which can lead to multi-organ failure and even to death. GNAO1 has been recently identified to be involved in the pathogenesis of early infantile epileptic encephalopathy and movement disorders. Patients with GNAO1 mutations can present with a severe, progressive hyperkinetic movement disorder with prolonged life-threatening exacerbations, which are refractory to most anti-dystonic medication. OBJECTIVE: The objective was to investigate the evolution of symptoms and the response to deep brain stimulation of the globus pallidus internus (GPi-DBS) in patients with different GNAO1 mutations. METHODS: We report six patients presenting with global motor retardation, reduced muscle tone and recurrent episodes of severe, life-threatening hyperkinesia with dystonia, choreoathetosis, and ballism since early childhood. Five of them underwent GPi-DBS. RESULTS: The genetic workup revealed mutations in GNAO1 for all six patients. These encompass a new splice site mutation (c.723+1G>T) in patient 1, a new missense mutation (c.610G>C; p.Gly204Arg) in patient 2, a heterozygous mutation (c.625>T; p.Arg209Cys) in patients 3 and 4, and a heterozygous mutation (c.709G>A; p.Glu237Lys) in patients 5 and 6. By intervention with GPi-DBS the severe paroxysmal hyperkinetic exacerbations could be stopped in five patients. One patient is still under evaluation for neuromodulation. CONCLUSION: In complex movement disorders of unsolved etiology clinical WES can rapidly streamline pathogenic genes. We identified two novel GNAO1 mutations. GPi-DBS can be an effective and life-saving treatment option for patients with GNAO1 mutations and has to be considered early.

Study of rabies virus by Differential Scanning Calorimetry.

Differential Scanning Calorimetry (DSC) has been used in the past to study the thermal unfolding of many different viruses. Here we present the first DSC analysis of rabies virus. We show that non-inactivated, purified rabies virus unfolds cooperatively in two events centered at approximately 62 and 73 °C. Beta-propiolactone (BPL) treatment does not alter significantly viral unfolding behavior, indicating that viral inactivation does not alter protein structure significantly. The first unfolding event was absent in bromelain treated samples, causing an elimination of the G-protein ectodomain, suggesting that this event corresponds to G-protein unfolding. This hypothesis was confirmed by the observation that this first event was shifted to higher temperatures in the presence of three monoclonal, G-protein specific antibodies. We show that dithiothreitol treatment of the virus abolishes the first unfolding event, indicating that the reduction of G-protein disulfide bonds causes dramatic alterations to protein structure. Inactivated virus samples heated up to 70 °C also showed abolished recognition of conformational G-protein specific antibodies by Surface Plasmon Resonance analysis. The sharpness of unfolding transitions and the low standard deviations of the Tm values as derived from multiple analysis offers the possibility of using this analytical tool for efficient monitoring of the vaccine production process and lot to lot consistency.

Characterization of the structural modifications accompanying the loss of HBsAg particle immunogenicity.

The aim of this work was to further understand the relationship between the immunogenicity and the structure of Hepatitis B surface antigen (HBsAg) particles used in Hepatitis B vaccines. To reach this aim, we compared by using a large range of techniques, the structure and properties of untreated particles with those of particles stored for 3 weeks at +60°C, a treatment which resulted in a loss of HBsAg antigenicity (toward RF-1 mAb) and immunogenicity (in mice). While untreated particles imaged by electron microscopy and atomic force microscopy appeared as isolated nanoparticles of ∼ 20nm, heated particles appeared as long chains of particle aggregates with a partial loss of their protein protrusions. Moreover, infrared spectroscopy and circular dichroism revealed that the secondary structure of the S proteins was significantly affected, with a loss of 10% of their α-helix content. Steady-state and time-resolved fluorescence data further revealed strong modifications of the most emitting Trp residues at the particle surface, confirming significant changes in the conformation of the S proteins. Moreover, modifications in the organization of both the lipid core and lipid membrane surface of the heated particles were evidenced by environment-sensitive 3-hydroxyflavone probes. Taken together, our data evidenced a clear relationship between the bona fide S protein structure and lipid organization notably at the particle surface and the particle immunogenicity.

Successful rescue thrombolysis in massive pulmonary embolism with intracerebral hemorrhage.

We report the case of a man with a massive pulmonary embolism, which lead to cardiac arrest. After ruptured aneurysm clipping, he was successfully treated by rescue thrombolysis administered as compassionate treatment despite the risk of cerebral bleeding. The patient was discharged from the intensive care unit; his initial neurological, cardiac, and pulmonary conditions restored. In case of life-threatening pulmonary embolism, the risk-benefit ratio of thrombolysis therapy should be systematically evaluated and the decision adapted to each patient.

The structure of HBsAg particles is not modified upon their adsorption on aluminium hydroxide gel.

Current Hepatitis B vaccines are based on recombinant Hepatitis B surface antigen (HBsAg) virus-like particles adsorbed on aluminium (Al) gel. These particles exhibit a lipoprotein-like structure with about 70 protein S molecules in association with various types of lipids. To determine whether the adsorption on Al gel affects HBsAg structure, we investigated the effect of adsorption and mild desorption processes on the protein and lipid parts of the particles, using various techniques. Electron microscopy showed that the size and morphology of native and desorbed HBsAg particles were comparable. Moreover, infrared and Raman spectroscopy revealed that the secondary structure of the S proteins was not affected by the adsorption/desorption process. Affinity measurements with Surface Plasmon Resonance showed no difference between native and desorbed HBsAg for HBsAg-specific RF-1 monoclonal antibody. Steady-state and time-resolved fluorescence data of the intrinsic fluorescence of the S proteins further indicated that the adsorption/desorption of HBsAg particles on Al gel did not modify the environment of the most emitting Trp residues, confirming that the conformation of the S proteins remains intact. Moreover, using environment-sensitive 3-hydroxyflavone probes, no significant changes of the lipid core and lipid membrane surface of the HBsAg particles were observed during the adsorption/desorption process. Finally, the ratio between lipids and proteins in the particles was found to be similar before and after the adsorption/desorption process. Taken together, our data show that adsorption on Al gel does not affect the structure of the HBsAg particles.

The use of microcalorimetry to characterize tetanus neurotoxin, pertussis toxin and filamentous haemagglutinin.

Tetanus neurotoxin (TeNT), pertussis toxin (PT) and pertussis filamentous haemagglutinin (FHA) are major virulence factors of Clostridium tetani and Bordetella pertussis, which are the causative agents of tetanus and whooping cough respectively. Inactivated forms of these virulence factors are the protein components of vaccines against these diseases. Here we report microcalorimetric studies to characterize these proteins. The microcalorimetric titration curves of TeNT with micelles of gangliosides GD1b, GT1b and GQ1b were biphasic. For these gangliosides a high-affinity binding site (KD 45-277 nM) can be distinguished from a lower-affinity binding event (KD 666-1190 nM). This is direct evidence for multiple binding sites for gangliosides of the 1b series at TeNT as proposed by Emsley et al. [Emsley, Fotinou, Black, Fairweather, Charles, Watts, Hewitt and Isaacs (2000) J. Biol. Chem. 275, 8889-8894]. In agreement with previous reports, no binding was observed for gangliosides GM1, GM2, GM3 and GD2. The thermal denaturation of TeNT was characterized by two unfolding transitions centred around 57.4 and 62.4 degrees C. The conversion of TeNT into the toxoid form by formaldehyde treatment was accompanied by a large increase in Tm (the midpoint of protein unfolding transition, that is, the temperature at which half the protein is denatured and the other half is still present in its native form). Fetuin and asialofetuin bound to PT with similar affinities (KD 420 and 335 nM respectively). Binding was largely enthalpy-driven and counterbalanced by an unfavourable entropy change, indicating a loss of conformational flexibility. The latter could account for the observed inhibition of ATP binding after binding to fetuin. Furthermore, the molecular limits of mature PT subunit S5 were defined by MS and N-terminal peptide sequencing. The differential-scanning-calorimetry thermogram of FHA shows four well-resolved unfolding transitions, a finding consistent with the sequential denaturation of four structural domains.

HIV-1 gp41 and gp160 are hyperthermostable proteins in a mesophilic environment. Characterization of gp41 mutants.

HIV gp41(24-157) unfolds cooperatively over the pH range of 1.0-4.0 with T(m) values of > 100 degrees C. At pH 2.8, protein unfolding was 80% reversible and the DeltaH(vH)/DeltaH(cal) ratio of 3.7 is indicative of gp41 being trimeric. No evidence for a monomer-trimer equilibrium in the concentration range of 0.3-36 micro m was obtained by DSC and tryptophan fluorescence. Glycosylation of gp41 was found to have only a marginal impact on the thermal stability. Reduction of the disulfide bond or mutation of both cysteine residues had only a marginal impact on protein stability. There was no cooperative unfolding event in the DSC thermogram of gp160 in NaCl/P(i), pH 7.4, over a temperature range of 8-129 degrees C. When the pH was lowered to 5.5-3.4, a single unfolding event at around 120 degrees C was noted, and three unfolding events at 93.3, 106.4 and 111.8 degrees C were observed at pH 2.8. Differences between gp41 and gp160, and hyperthermostable proteins from thermophile organisms are discussed. A series of gp41 mutants containing single, double, triple or quadruple point mutations were analysed by DSC and CD. The impact of mutations on the protein structure, in the context of generating a gp41 based vaccine antigen that resembles a fusion intermediate state, is discussed. A gp41 mutant, in which three hydrophobic amino acids in the gp41 loop were replaced with charged residues, showed an increased solubility at neutral pH.