Updated French guidelines for diagnosis and management of pelvic inflammatory disease

BACKGROUND

Pelvic inflammatory disease (PID) is commonly encountered in clinical practice.

OBJECTIVES

To provide up-to-date guidelines on management of PID.

SEARCH STRATEGY

An initial search of the Cochrane database, PubMed, and Embase was performed using keywords related to PID to identify reports in any language published between January 1990 and January 2012, with an update in May 2015.

SELECTION CRITERIA

All identified reports relevant to the areas of focus were included.

DATA COLLECTION AND ANALYSIS

A level of evidence based on the quality of the data available was applied for each area of focus and used for the guidelines.

MAIN RESULTS

PID must be suspected when spontaneous pelvic pain is associated with induced adnexal or uterine pain (grade C). Pelvic ultrasonography is necessary to exclude tubo-ovarian abscess (grade B). Microbiological diagnosis requires vaginal and endocervical sampling for molecular and bacteriological analysis (grade B). First-line treatment for uncomplicated PID combines ofloxacin and metronidazole for 14days (grade B). Treatment of tubo-ovarian abscess is based on drainage if the collection measures more than 3cm (grade B), with combined ceftriaxone, metronidazole, and doxycycline for 14-21days.

CONCLUSIONS

Current management of PID requires easily reproducible investigations and treatment, and thus can be applied worldwide.

A new ER-specific photosensitizer unravels (1)O2-driven protein oxidation and inhibition of deubiquitinases as a generic mechanism for cancer PDT

Photosensitizers (PS) are ideally devoid of any activity in the absence of photoactivation, and rely on molecular oxygen for the formation of singlet oxygen ((1)O2) to produce cellular damage. Off-targets and tumor hypoxia therefore represent obstacles for the use of PS for cancer photodynamic therapy. Herein, we describe the characterization of OR141, a benzophenazine compound identified through a phenotypic screening for its capacity to be strictly activated by light and to kill a large variety of tumor cells under both normoxia and hypoxia. This new class of PS unraveled an unsuspected common mechanism of action for PS that involves the combined inhibition of the mammalian target of rapamycin (mTOR) signaling pathway and proteasomal deubiquitinases (DUBs) USP14 and UCH37. Oxidation of mTOR and other endoplasmic reticulum (ER)-associated proteins drives the early formation of high molecular weight (MW) complexes of multimeric proteins, the concomitant blockade of DUBs preventing their degradation and precipitating cell death. Furthermore, we validated the antitumor effects of OR141 in vivo and documented its highly selective accumulation in the ER, further increasing the ER stress resulting from (1)O2 generation upon light activation.

Rhabdomyolysis with Acute Renal Failure and Deep Vein Thrombosis Induced by Antipsychotic Drugs: A Case Report

Atypical antipsychotics, the first line therapy for schizophrenia, have already been reported as causing rhabdomyolysis or isolated elevation in serum creatine kinase (SCK). This case report dealing with rhabdomyolysis in a 25-year-old man treated with antipsychotics is particularly unusual, due to the extremely high elevation in SCK and the ensuing acute renal failure. He was treated with loxapine 400 mg/day and risperidone 4 mg/day for 4 days and then loxapine was replaced by levomepromazine 300 mg/day. A series of laboratory examinations showed: SCK 43 650 UI/L, creatinine 392 µmol/L. An acute renal failure (acute tubular necrosis) after iatrogenic rhabdomyolysis was diagnosed, requiring hemodialysis. Furthermore, the patient also developed a deep vein thrombosis (DVT) attributed to his antipsychotic treatment. This case underlines the importance of taking rhabdomyolysis and DVT risk factors into account in patients treated with antipsychotics. Indeed, in this case we note that rhabdomyolysis was probably promoted by the interruption and the reintroduction of the treatment more than by possible dehydration, because no other risk factor could be identified.

Impact on obstetric outcome of third-trimester screening for small-for-gestational-age fetuses

OBJECTIVES

To evaluate the performance of screening for small-for-gestational-age (SGA) fetuses by ultrasound biometry at 30-35 weeks' gestation, and to determine the impact of screening on obstetric and neonatal outcomes.

METHODS

For this prospective cohort study, pregnant women were recruited from two French university maternity centers between 2003 and 2006. Performance measures of third-trimester biometry for the prediction of SGA, defined as estimated fetal weight < 10(th) centile, were analyzed. Obstetric outcomes and neonatal health status were compared, first, between SGA neonates diagnosed correctly at ultrasound examination (true positive (TP); n = 45) and SGA neonates that went undiagnosed (false negative (FN); n = 110) and, second, between non-SGA neonates identified as normal at ultrasound examination (true negative (TN); n = 1641) and non-SGA neonates diagnosed incorrectly as SGA (false positive (FP); n = 101).

RESULTS

In the prediction of SGA, third-trimester ultrasound had a sensitivity of 29.0% (95% CI, 22.5-36.6%) and specificity of 94.2% (95% CI, 93.0-95.2%). Positive and negative predictive values were 30.8% (95% CI, 23.9-38.7%) and 93.7% (95% CI, 92.5-94.8%), respectively. One hundred and ten SGA neonates went undiagnosed at ultrasound. Compared to the TN neonates considered as of normal weight at ultrasound, planned preterm delivery (before 37 weeks) and elective Cesarean section for a fetal growth indication were 2.4 (P = 0.01) and 2.85 (P = 0.003) times more likely to occur, respectively, in the FP group of non-SGA neonates, diagnosed incorrectly as SGA during the antenatal period. There was no statistically significant difference in 5-min Apgar score < 7, cord blood pH at birth < 7.15 and need for neonatal resuscitation between the two subgroups (TN vs FP and TP vs FN).

CONCLUSIONS

The performance of third-trimester ultrasound screening for SGA seems poor, as it misses the diagnosis of a large number of SGA neonates. The consequences of routine screening for SGA in a low-risk population may lead to unnecessary planned preterm deliveries and elective Cesarean sections in FP pregnancies, without improved neonatal outcome in the FN pregnancies.

Cyclosporine in acute ischemic stroke

OBJECTIVES

We examined whether IV administration of cyclosporine in combination with thrombolysis might reduce cerebral infarct size.

METHODS

Patients aged 18 to 85 years, presenting with an anterior-circulation stroke and eligible for thrombolytic therapy, were enrolled in this multicenter, single-blinded, controlled trial. Fifteen minutes after randomization, patients received either an IV bolus injection of 2.0 mg/kg cyclosporine (Sandimmune, Novartis) or placebo. The primary endpoint was infarct volume on MRI at 30 days. Secondary endpoints included infarct volume according to the site (proximal/distal) of arterial occlusion and recanalization after thrombolysis.

RESULTS

From October 2009 to July 2013, 127 patients were enrolled. The primary endpoint was assessed in 110 of 127 patients. The reduction of infarct volume in the cyclosporine compared with the control group was overall not significant (21.8 mL [interquartile range, IQR 5.1, 69.2 mL] vs 28.8 mL [IQR 7.7, 95.0 mL], respectively; p = 0.18). However, in patients with proximal occlusion and effective recanalization, infarct volume was significantly reduced in the cyclosporine compared with the control group (14.9 mL [IQR 1.3, 23.2 mL] vs 48.3 mL [IQR 34.5, 118.2 mL], respectively; p = 0.009).

CONCLUSIONS

Cyclosporine was generally not effective in reducing infarct size. However, a smaller infarct size was observed in patients with proximal cerebral artery occlusion and efficient recanalization.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that in patients with an acute anterior-circulation stroke, thrombolysis plus IV cyclosporine does not significantly decrease 30-day MRI infarct volume compared with thrombolysis alone.

[Type 2 diabetes and pregnancy: epidemiology and obstetrical consequences. A 97 women continuous series]

OBJECTIVES

To update the epidemiologic data of pregnant women with type 2 diabetes and to assess obstetrical outcomes.

PATIENTS AND METHODS

The pregnant women with type 2 diabetes who delivered between 2002 and 2010 were systematically involved in an observational study. Maternal and fetal outcomes were reviewed, as well as the potential impact of preconceptional management. The presented data were compared with those from the 2010 French perinatal study.

RESULTS

A rise in the incidence of type 2 diabetes was observed during the study period (from 0.19% to 0.35% between 2002 and 2010). Women with diabetes (n=97) were older and had a higher BMI than the general population (>35years: 49% vs 19%, P<0.00001, BMI>25: 86% vs 27.2, P<0.00001). The delivery mode was, for half of these women with diabetes, a C-section. Pregnancy was scheduled in only 4% of cases. Compared to the general population, prematurity rate was multiplied by 6 (28.7% vs 4.7%, P<0.0001) and the malformation rate by 3.2 (7.22% vs 2.2%, P<0.00001).

CONCLUSION

Obstetrical complications were more frequent than in the general population. Preconception care was almost inexistent, despite its potential benefits for the mother and child.

Posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) is a recently proposed cliniconeuroradiologic entity with several well-known causes, such as hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressive drugs, as well as some causes more recently described. PRES is characterized by neuroimaging findings of reversible vasogenic subcortical edema without infarction. The pathogenesis is incompletely understood. Two opposing hypotheses are commonly cited, but the issue is controversial: (1) the current more popular theory suggests that severe hypertension exceeds the limits of autoregulation, leading to breakthrough brain edema; (2) the earlier original theory suggests that hypertension leads to cerebral autoregulatory vasoconstriction, ischemia, and subsequent brain edema. The clinical syndrome of PRES typically involves headache, encephalopathy, visual symptoms, and seizures. The clinical presentation is often nonspecific, and therefore the diagnosis of PRES has come to increasingly rely on magnetic resonance imaging (MRI) abnormalities consistent with PRES with documented recovery clinically and on repeated neuroimaging. The diagnosis has important therapeutic and prognostic implications because the reversibility of the clinical and radiologic abnormalities is contingent on the prompt control of blood pressure and/or discontinuing the offending drug.

[Anticoagulant treatment in patients with atrial fibrillation, according to risk factors for stroke]

Atrial fibrillation (AF) is a common and serious condition in the elderly, concerning about 10% of people over 80. AF is a predictive factor for mortality in the elderly and a major risk factor for stroke. Approximately 15% of patients admitted for ischemic stroke have AF and the proportion increases with age, reaching about 40% in people over 80. Compared to patients with stroke unrelated to AF, patients with AF-associated stroke suffer from more severe strokes with an increased risk of remaining disabled after the event and have a higher risk of stroke recurrence. Although most ischemic strokes in AF patients are probably cardioembolic, due to migration of thrombi originating from the left atrial appendage, many elderly patients will be found to have other potential causes of stroke, such as extracranial or intracranial atherosclerotic stenosis, aortic arch atheroma, or small vessel disease. The absolute risk of stroke in patients with AF varies widely depending on associated risk factors, the most important being age over 75 and previous stroke or transient ischemic attack. Several scoring systems have been developed to help clinicians estimate the stroke risk on an individual basis and to guide the choice of the most appropriate preventive therapy. The management of AF in the elderly should involve a detailed evaluation of the patient's functional status and social situation. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. The benefits of VKAs have been largely shown in patients with AF and appear to be even more important among elderly people. Anticoagulants are recommended in patients with AF aged 75 years or above after assessing the bleeding risk. Novel oral anticoagulants (NOACs) are promising treatments, especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal and cognitive functions.

Treatment of acute decompensation of maple syrup urine disease in adult patients with a new parenteral amino-acid mixture

BACKGROUND

Acute decompensation of maple syrup urine disease (MSUD) is usually treated by enteral feeding with an amino-acid mixture without leucine (Leu), valine or isoleucine. However, its administration is ineffective in cases of gastric intolerance and some adult patients refuse enteral feeding via a nasogastric tube. We developed a new parenteral amino-acid mixture for patients with MSUD.

METHODS

Seventeen decompensation episodes in four adult patients with MSUD treated with a parenteral amino-acid mixture (group P) were compared to 18 previous episodes in the same patients treated by enteral feeding (group E).

RESULTS

The mean Leu concentration at presentation was similar in the groups P and E (1196.9 μmol/L and 1212.2 μmol/L, respectively). The mean decrease in the Leu concentration during the first 3 days of hospitalisation was significantly higher in group P than group E (p = 0.0026); there were no side effects. The mean duration of hospitalisation was similar (4 vs. 4.5 days, p = NS). No patient in group P deteriorated whereas one patient in group E required dialysis.

CONCLUSION

This new parenteral amino-acid mixture is safe and allows efficient Leu concentration decrease during acute MSUD decompensation episodes in adults. Its use avoids the need for nasogastric tube insertion.

[Symptomatic giant Virchow-Robin spaces]

INTRODUCTION

Perivascular spaces, known as Virchow-Robin spaces (VRS), may become massively enlarged but are usually an incidental finding. However, a few reports on patients with unusually large VRS have mentioned association with neurological symptoms. We report a series of three symptomatic patients with extremely wide Virchow-Robin spaces documented on brain magnetic resonance imaging (MRI).

METHODS

We retrospectively analyzed the medical records and brain MRI of three symptomatic patients, who had been diagnosed with VRS widening.

CASE REPORTS

In all three patients, the unusual widening of the VRS was located within the subcortical white matter with asymmetric distribution. Their neurological symptoms were epilepsy and neurological deficits which correlated well with the lesions seen on the MRI. Two patients had associated white matter hyperintensities: in the first case associated gliosis and in the second case, with vascular leukoencephalopathy.

CONCLUSIONS

Enlarged symptomatic VRS are rare. The underlying pathophysiological mechanisms remain uncertain. We report three cases with symptomatic giant dilatation of the Virchow-Robin spaces.

Impaired sexual activity in young ischaemic stroke patients: an observational study

BACKGROUND AND PURPOSE

The present study sought to determine the impact of stroke on sexual function and well-being in a cohort of young ischaemic stroke patients and identify factors associated with impairment.

METHODS

Over a 2-year period, all patients aged 60 or under with ischaemic stroke or transient ischaemic attack (n = 156) were included. Information on sexual function and well-being was obtained by means of a paper questionnaire mailed to participants 1 year after their stroke. Impaired sexual activity (ISA) was defined as a decline in sexual function and/or satisfaction. Psychological well-being was evaluated on the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The response rate was 67% (n = 104). Thirty of these responders (29%) reported ISA. Patients with ISA had a higher HADS score (19.7 vs. 11.2 in patients with no impairment; P < 0.001), anxiety score (10.0 vs. 6.3; P < 0.001) and depression score (8.7 vs. 4.8; P < 0.001) and were more likely to have left brain lesions (70% vs. 30%; P < 0.001) and use angiotensin-converting enzyme (ACE) inhibitors (73% vs. 31%; P < 0.001) and diuretics (50% vs. 19%; P = 0.003). In a stepwise logistic regression, depression (odds ratio 9.1, 95% confidence interval 2.45-33.46; P = 0.001) and ACE inhibitor use (odds ratio 6.0, 95% confidence interval 2.11-17.28; P = 0.001) were associated with ISA.

CONCLUSIONS

Impaired sexual activity was reported by almost one-third of younger patients 1 year after ischaemic stroke. Factors associated with post-stroke ISA may include specific medications and depression rather than the characteristics of the stroke per se.

Magnetic Resonance Imaging-DRAGON Score

Background and Purpose—

The DRAGON score, which includes clinical and computed tomographic scan parameters, showed a high specificity to predict 3-month outcome in patients with acute ischemic stroke treated by intravenous tissue plasminogen activator. We adapted the score for patients undergoing MRI as the first-line diagnostic tool.

Methods—

We reviewed patients with consecutive anterior circulation ischemic stroke treated ≤4.5 hour by intravenous tissue plasminogen activator between 2003 and 2012 in our center, where MRI is systematically implemented as first-line diagnostic work-up. We derived the MRI-DRAGON score keeping all clinical parameters of computed tomography-DRAGON (age, initial National Institutes of Health Stroke Scale and glucose level, prestroke handicap, onset to treatment time), and considering the following radiological variables: proximal middle cerebral artery occlusion on MR angiography instead of hyperdense middle cerebral artery sign, and diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI ASPECTS) ≤5 instead of early infarct signs on computed tomography. Poor 3-month outcome was defined as modified Rankin scale >2. We calculated c-statistics as a measure of predictive ability and performed an internal cross-validation.

Results—

Two hundred twenty-eight patients were included. Poor outcome was observed in 98 (43%) patients and was significantly associated with all parameters of the MRI-DRAGON score in multivariate analysis, except for onset to treatment time (nonsignificant trend). The c-statistic was 0.83 (95% confidence interval, 0.78–0.88) for poor outcome prediction. All patients with a MRI-DRAGON score ≤2 (n=22) had a good outcome, whereas all patients with a score ≥8 (n=11) had a poor outcome.

Conclusions—

The MRI-DRAGON score is a simple tool to predict 3-month outcome in acute stroke patients screened by MRI then treated by intravenous tissue plasminogen activator and may help for therapeutic decision.

NDMA formation in secondary wastewater effluent

Concern over prospective levels of N-nitrosodimethylamine (NDMA) in waters has increased in recent years due to its disinfection byproduct formation potential from chloramination. It has been mooted that this is promoted by organic precursors from municipal wastewaters, such that there is a more significant risk of excessive levels in water reuse applications. Experiments conducted on chloramination and chlorination of secondary wastewater have confirmed that that significant NDMA formation arises only from chloramination, with its concentration varying with test conditions used. A full factor analysis revealed all parameters studied (temperature, pH, monochloramine dose and contact time), both individually and synergistically, to have a statistically significant impact on NDMA formation with contact time being the most important. At raw water temperatures below 10 °C, the NDMA concentration can be minimised to below the 10 ng L(-1) threshold by not exceeding a monochloramine dose of 2 mg L(-1) as Cl(2). However, at higher water temperatures other measures are required to suppress NDMA formation, such as reducing the contact time (which could prove impractical in most applications) or maintaining a pH below 6. Further trials are required to fully develop the operating envelope to ensure NDMA concentrations do not exceed the 10 ng L(-1) threshold, or else to identify effective pretreatment methods for removing the NDMA precursors.