Behavioral, Hormonal, Inflammatory, and Metabolic Effects Associated with FGF21-Pathway Activation in an ALS Mouse Model

In amyotrophic lateral sclerosis (ALS), motor neuron degeneration occurs simultaneously with systemic metabolic dysfunction and neuro-inflammation. The fibroblast growth factor 21 (FGF21) plays an important role in the regulation of both phenomena and is a major hormone of energetic homeostasis. In this study, we aimed to determine the relevance of FGF21 pathway stimulation in a male mouse model of ALS (mutated SOD1-G93A mice) by using a pharmacological agonist of FGF21, R1Mab1. Mice (SOD1-WT and mutant SOD1-G93A) were treated with R1Mab1 or vehicle. Longitudinal data about clinical status (motor function, body weight) and biological parameters (including hormonal, immunological, and metabolomics profiles) were collected from the first symptoms to euthanasia at week 20. Multivariate models were performed to identify the main parameters associated with R1Mab1 treatment and to link them with clinical status, and metabolic pathways involving the discriminant metabolites were also determined. A beneficial clinical effect of R1Mab1 was revealed on slow rotarod (p = 0.032), despite a significant decrease in body weight of ALS mice (p < 0.001). We observed a decrease in serum TNF-α, MCP-1, and insulin levels (p = 0.0059, p = 0.003, and p = 0.01, respectively). At 16 weeks, metabolomics analyses revealed a clear discrimination (CV-ANOVA = 0.0086) according to the treatment and the most discriminant pathways, including sphingolipid metabolism, butanoate metabolism, pantothenate and CoA biosynthesis, and the metabolism of amino acids like tyrosine, arginine, proline, glycine, serine, alanine, aspartate, and glutamate. Mice treated with R1Mab1 had mildly higher performance on slow rotarod despite a decrease on body weight and could be linked with the anti-inflammatory effect of R1Mab1. These results indicate that FGF21 pathway is an interesting target in ALS, with a slight improvement in motor function combined with metabolic and anti-inflammatory effects.

New Insights in the Pharmacotherapy of Psychosis: The Example of Parkinson's Disease Psychosis

Introduction

With 10 million of patients across the world, Parkinson's disease is the second most common form of neurodegeneration, after Alzheimer's. Among half of patients develop psychotic symptoms, such as visual hallucinations and delusions, which are correlated with higher rate of placement in nursing home, are difficult to treat and severely affect quality of life, making Parkinson's disease psychosis (PDP) a major public health issue.

Objectives

The aim of this study is to identify treatment options that could be used to treat PDP and clarify underlying pathophysiology.

Method

We conducted a literature review on Pubmed, Goggle scholar and Cochrane library, using a combination of the following: “Parkinson's disease Psychosis” “visual hallucinations” “Pimavanserin” “Clozapine” “atypical anti-psychotics” 120 articles were screened.

Results

Considering that hallucinations arise from overactivation of dopaminergic receptors, treatment options include reducing the dopaminergic drugs used to control motor symptoms; using atypical anti-psychotics such as Risperidone, Olanzapine, Quetiapine, which often results in the worsening of extra-pyramidal symptoms. Another option is the use of low doses of Clozapine, which has been proven efficient with no worsening of non-motor symptoms, suggesting the implication of other pathways, such as serotonin. Finally, Pimavanserin, a 5-HT2A receptor inverse agonist, without any dopaminergic activity, has been demonstrated to be effective in the treatment of PDP, well tolerated and easy to use.

Conclusion

Serotonin inverse agonists represent a major breakthrough in the pharmacotherapy of PDP, and may lead the way to changes in the treatment of schizophrenia and other psychotic disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Image of Psychiatric Hospitals Among General Population in 2015, Views From Four Countries

Introduction

In recent years, numerous studies about the image of psychiatry have been conducted. However, to our knowledge, a significant part of psychiatry has been very little explored: the vision of psychiatric hospitals (PsH). For instance, “PsH” on google images reveals a long list of frightening pictures of ravaged places.

Objectives/Aims

With such an image spread by the medias, we wanted to evaluate the vision of PsH and treatment modalities among general population in 2015, in 4 countries: France, Spain, England, and Brazil.

Methods

An online survey in 4 languages has been sent via facebook and emails. Two hundred and fifteen responses were collected during September 2015: 178 French, 11 Spanish, 17 Brazilians, 9 English.

Results

Thirty-nine percent of participants consider PsH as a place of care, and 16% as an asylum. There were differences among countries: for example, asylum is more represented in France than Spain. Regarding patients admitted in PsH, they are not all dangerous (90%), nor all irresponsible (94%) and have specifics rights (66%). Concerning diseases: delirium, bipolar disorders, and perversity are to be treated in PsH, while depression, addiction, and autism are to be cured in psychiatric structures other than hospital. Moreover, 2% of participants believe abuses are common practice, whereas a majority consider therapeutic activities instead.

Conclusions

These results are quite different from the studies based on the perception of mental illness and patients. Here, on the overall, they are quite encouraging. So, PsH could lead the path on the improvement of the image of psychiatry.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Mosquito salivary gland protein preservation in the field for immunological and biochemical analysis

Mosquito salivary proteins are involved in several biological processes that facilitate their blood feeding and have also been reported to elicit an IgG response in vertebrates. A growing number of studies have focused on this immunological response for its potential use as a biological marker of exposure to arthropod bites. As mosquito saliva collection is extremely laborious and inefficient, most research groups prefer to work on mosquito salivary glands (SGs). Thus, SG protein integrity is a critical factor in obtaining meaningful data from immunological and biochemical analysis. Current methodologies rely on an immediate freezing of SGs after their collection. However, the maintenance of samples in a frozen environment can be hard to achieve in field conditions. In this study, SG proteins from two mosquito species (Aedes aegypti and Anopheles gambiae s.s.) stored in different media for 5 days at either +4°C or room temperature (RT) were evaluated at the quantitative (i.e., ELISA) and qualitative (i.e., SDS-PAGE and immunoblotting) levels. Our results indicated that PBS medium supplemented with an anti-protease cocktail seems to be the best buffer to preserve SG antigens for 5 days at +4°C for ELISA analysis. Conversely, cell-lysis buffer (Urea-Thiourea-CHAPS-Tris) was best at preventing protein degradation both at +4°C and RT for further qualitative analysis. These convenient storage methods provide an alternative to freezing and are expected to be applicable to other biological samples collected in the field.

Development of leptomeningeal carcinomatosis (LC) in advanced prostate cancer patients: Characteristics of six cases in a single institution

218

Background: In the past months, we have noticed an increasing number of leptomeningeal carcinomatosis (LC) in patients known for advanced prostate cancer (PC). This complication has only been reported in a few patients.

Methods: We identified and reviewed the charts of all patients known for advanced PC who later developed LC. We report their characteristics as well as survival.

Results: Between March 2009 and April 2010, we identified 6 patients known for advanced PC that showed evidence of LC (median time from diagnosis of prostate cancer to development of LC, 55.8 months). Disease was already metastatic to other sites in all of them, and all had previously showed evidence of castrate refractory prostate cancer (CRPC). All patients maintained LHRH agonist therapy and were treated with prednisone once they showed evidence of CRPC. Most had also been treated with docetaxel (n=5), zoledronic acid (n=4; the remaining 2 patients received either zoledronic acid or denosumab as part of a protocol) and/or other (dasatinib/placebo as part of a protocol, n=1; sunitinib as part of a protocol, n=1). LC was diagnosed a median of 21.2 months after evidence of CRPC, based on clinical findings (cranial nerve[s] involvement [n=6] and nausea and/or ataxia [n=2]) and magnetic resonance imaging (MRI). 2 patients underwent lumbar puncture (negative results). Treatment administered for LC included dexamethasone (n=1), radiation therapy (n=1), or both (n=2). Two patients with poor performance status did not receive any treatment. All patients assessable for response (n=3) showed a partial improvement in their symptoms, but not complete resolution. Median overall survival from development of CRPC and from diagnosis of LC is 23.9 months and 2.7 months, respectively.

Conclusions: LC is a newly described site of metastasis in patients with advanced CRPC. It is associated with a late onset and a very poor prognosis.

[Table: see text]

[Post-transplant renal tumors: a report of three cases]

We report three cases of primary renal tumors occurring on post-transplant kidneys, after a delay of 4, 8 and 12 years respectively following transplantation in a population of 1134 post kidney transplant followed at our institution. All three tumors underwent early detection because of the yearly ultrasound evaluation recommended for all post kidney transplant patients. The diagnosis was suggested by CT in all three cases but confirmed by preoperative percutaneous biopsy in two cases. The final pathology results confirmed two cases of clear cell renal carcinomas and one case of oncocytoma. Tumorectomy was undertaken for all three patients with successful results in two cases and return to hemodialysis in the third patient with a 4 cm tumor with mass effect on the collecting system.

PCBs and PCDD/FS in fish and fish products and their impact on the human body burden in Belgium

The concentrations of marker PCBs (28, 52, 101, 118, 138, 153, 180) in fish have been assessed with GC-MS: an average concentration of 540 ng-PCB g(-1) fat (5.02 ng-PCB g(-1) wet weight) was observed. The average concentration of PCDD/Fs, assessed with the CALUX bioassay, amounted to 64 pg-CALUX-TEQ g(-1) fat (0.58 pg-CALUX-TEQ g(-1) wet weight) and that of PCDD/Fs + dioxin-like PCBs amounted to 131 pg-CALUX-TEQ g(-1) fat (1.18 pg-CALUX-TEQ g(-1) wet weight). Results of the PCB congeners analyses show that PCB-153 is the most abundant congener in almost all samples, with also main contributions of the 138- and 180-congeners. For some species such as the sand sole and lemon sole, a fairly constant PCB content, independent of the fat percentage, was observed. For a second group of species such as whelks, cod, and whiting, a positive correlation was observed between their PCB concentration (ng g(-1) fat) and their % of fat. The relationship between marker PCBs and PCDD/Fs concentrations, when plotted on a log scale, fits a straight line (correlation coefficient r = 0.83). With our results on fish and literature data for other food products, intake of marker PCBs and PCDD/Fs could be calculated for the adult population in Belgium (19-60 years old). The Total Daily Intake (TDI) of marker PCBs (ng-PCB day(-1)) ranges between 1690 and 2210. The TDI of PCDD/Fs (pg-CALUX day(-1)) ranges between 80.5 and 122, that of PCDD/Fs + dioxin-like PCBs amounts to 151. When PCDD/Fs in fish are assessed with GC-HRMS, the TDI can be lower. The relative importance of fish regarding marker PCB intake amounts to 15-19%, while regarding PCDD/Fs intake it amounts to 34-51%. Using TDI, the body burden evolution of marker PCBs and PCDD/Fs, with age has been calculated.

[Proteomic analysis and parasitosis: principles and applications]

O'Farrel described a method allowing two-dimensional (2D) protein separation more than 30 years ago. Since then the original technique has made enormous progress. This progress has been accompanied by advances in mass spectrometry technology as well as various genome-sequencing programs. Today 2D electrophoresis has become the workhorse of proteomics, allowing resolution of complex structures containing thousands of proteins and providing a global view of the state of a proteome. This article presents the different steps and limitations of proteomic analysis: preparation of biological material, 2D electrophoresis, protein detection systems, and available tools for protein identification. Alternative proteomic approaches to 2D electrophoresis are also presented. A few applications are described as examples to illustrate the utility of proteomic analysis for studying the mechanisms underlying virulence, resistance to antimalarial therapies and immune response against pathologic agents.

Effectiveness of written guidelines on the appropriateness of thromboprophylaxis prescriptions for medical patients: a prospective randomized study

OBJECTIVE

To assess the effectiveness of providing doctors with written thromboprophylaxis prescription aids based on current recommendations.

DESIGN

A prospective trial of specific anticoagulant prescription forms: a 1-day survey before and after the intervention in each centre.

SETTING

30 Internal Medicine departments of Assistance Publique-Hôpitaux de Paris.

SUBJECTS

All inpatients were included, except those who were either admitted or discharged on the day of the survey, and those receiving curative anticoagulant treatment.

INTERVENTIONS

The study included three parts: (i) a 1-day baseline survey; (ii) over the following 3-month period, departments were randomized into two groups: all practitioners in wards allocated to the intervention group were required to systematically use specific anticoagulant prescription forms, whilst doctors in the control group continued prescribing according to their usual practices and (iii) a 1-day postintervention survey.

MAIN OUTCOME MEASURE

The proportion of prescriptions in accordance with the recommendations.

RESULTS

1,469 patients were included. The intervention produced a significant reduction in the frequency of over-prescriptions, from 25% to 14% of the patients who did not meet the guideline criteria (adjusted OR: 0.3; 95% CI: 0.1-0.8). Using specific forms did not improve under-prescription of anticoagulants. A little over 60% of the patients who met guideline criteria for thromboprophylaxis were prescribed anticoagulants in both intervention and control wards, either at baseline or after intervention.

CONCLUSIONS

Multitargeted interventions using a variety of means and strategies should still be considered to improve prescriptions that may have a significant impact on health expenses and, most importantly, on patients outcomes.

[Pigment dispersion and Artisan implants: crystalline lens rise as a safety criterion]

PURPOSE

To validate the theoretical notion of a crystalline lens rise as a safety criterion for ARTISAN implants in order to prevent the development of pigment dispersion in the implanted eye.

MATERIAL AND METHOD

Crystalline lens rise is defined by the distance between the crystalline lens's anterior pole and the horizontal plane joining the opposite iridocorneal recesses. We analyzed the biometric measurements of 87 eyes with an Artisan implant. A comparative analysis of the crystalline lens rise was carried out on the nine eyes having developed pigment dispersion and 78 eyes with no problems. Among the modern anterior segment imaging devices (Artemis, Scheimpflug photography, optical coherence tomography, radiology exploration, magnetic resonance imaging, TDM), an anterior chamber optical coherence tomography (AC-OCT) prototype was used.

RESULTS

This working hypothesis was confirmed by this study: the crystalline lens rise must be considered as a new safety criterion for implanting Artisan phakic lenses. Indeed, the higher the crystalline lens's rise, the greater the risk of developing pigment dispersion in the pupil area. This complication is more frequent in hyperopes than in myopes. We can consider that there is little or no risk of pigment dispersion if the rise is below 600 microm; however, at 600 microm or greater, there is a 67% rate of pupillary pigment dispersion. In certain cases, when the implant was loosely fixed, there was no traction on the iris root. This is a complication that can be avoided or delayed.

CONCLUSIONS

The crystalline lens rise must be part of new safety criteria to be taken into consideration when inserting an Artisan implant. This notion must also be applied to other types of phakic implants. The distance remaining between the crystalline lens rise and a 600-micromm theoretical safety level allows one to calculate a safety time interval.

[Multifocal phakic intraocular lens implant to correct presbyopia]

INTRODUCTION

Presbyopic surgery is considered as the new frontier in refractive surgery. Different solutions are proposed: myopization of one eye, insertion of an accommodative crystalline lens, scleral surgery, the effects of which are still unknown, and finally multifocal phakic implants. We therefore decided to undertake a prospective study under the Huriet law to determine its efficacy and specify the conditions required for an anterior chamber multifocal phakic implant.

MATERIAL AND METHOD

Fifty-five eyes of 33 patients received an anterior chamber foldable multifocal phakic implant. Twenty-one females and 12 males underwent surgery. Initial refraction was between -5D and +5D. The implant's single addition was +2.50. Recuperating a distant uncorrected visual acuity of 0.6 or better and near uncorrected vision of Parinaud 3 or better can be considered a very good postoperative result.

RESULTS

Average follow-up was 42.6+/-18 weeks. Mean postoperative refraction was -0.12+/-0.51 D. Mean postoperative uncorrected visual acuity was 0.78+/-0.20. Postoperative uncorrected visual acuity was Parinaud 2.3+/-0.6. Eighty-four percent of eyes operated on recuperated 0.6 or better without correction and Parinaud 3 or better without correction. Lenses in four eyes were explanted for different reasons, essentially optical, and no severe anatomical complications were observed.

CONCLUSIONS

Placing an anterior chamber multifocal phakic implant to correct presbyopia is an effective technique with good predictability and has the advantage of being reversible in case of intolerance, optical parasite effects or undesired complications. Considering the particularity of this surgery, it is imperative to respect very strict inclusion criteria: anterior chamber depth equal to or above 3.1 mm, open angle, endothelial cell count equal to or above 2000 cells/mm2, absence of an incipient cataract or the slightest evidence of macular alteration.

[Evaluating the effectiveness of child lead poisoning prevention programs]

PROBLEM

A multi annual screening and prevention program against lead poisoning was implemented in a suburb of the Paris area. We attempted to assess the effectiveness of this program based on data available from children screening and follow-up.

METHODS

Indicators of effectiveness included the evolution of blood lead levels at screening and the frequency of secondary increases in blood lead levels. Buildings inclusion dates were used to control for the increasing selection of less exposed children.

RESULTS

A total of 3,660 children were screened between 1992 and 2000. We observed a regular decrease in blood lead levels at screening, in the highest blood lead levels obtained for each child and in the proportion of children whose blood lead levels increased after screening: the proportion of children with initial blood lead levels >=15 micro g/dl fell from 17.4% in the 1992-1996 period to 4.1% in the 1997-2000 period. A multivariate analysis taking into account the first year that children were screened in a given building showed that less exposed children were included over time, but found also an additional independent decrease in blood lead levels that can be related to the effectiveness of prevention efforts. A "building by building" analysis of 30 buildings where more than 20 children were located over the whole study period confirmed that the incidence of lead poisoning decreased within most of these buildings.

CONCLUSIONS

Taking into account buildings'inclusion dates makes it possible to distinguish program effectiveness from the consequences of including less exposed children The effectiveness of preventive actions is associated with several interacting factors, including the participation of families and the active involvement of local technical staff and policy makers. The finding that the decrease in blood lead levels leveled off after 1997 calls for further actions.

Anatomical study of the blood supply of the coxal bone: radiological and clinical application

The aim of this work was to study the arterial blood supply of the coxal bone in order to optimize radiological embolization and to minimize the risk of postoperative osteonecrosis. Ten fresh cadavers were dissected after intra-arterial injection of colored resin. All the collateral vessels running to this bone were described and counted. On 25 dry bones, the vascular foramina were measured with the aid of a millimetric gauge and a vascular map was created. The posterior part of the ilium appears to be twice as well vascularized as the anterior part. Fractures of the posterior arch of the pelvis are theoretically more hemorrhagic. The presence of the iliolumbar artery in contact with the sacroiliac joint increases the risk with open book or shearing fractures. The artery of the ischium, a collateral of the pudendal artery, supplies the posterior and lateral parts of the acetabulum and the artery of the roof of the acetabulum, its superior and lateral parts. The branches of the anterior and posterior divisions of the obturator artery supply the superior part of the surroundings of the obturator foramen and the antero-inferior and postero-inferior parts of the acetabulum. The Kocher approach may injure the artery of the ischium. Letournel's extended lateral approach and Mears' triradiate approach may injure the artery of the ischium and the artery of the roof of the acetabulum. The risk of osteonecrosis appears to be theoretically increased if one adds an endopelvic approach. The anterior approach to the acetabulum appears to be that which theoretically leads to the least devascularization. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server located at http://dx.doi.org/10.1007/s00276-002-0029-2.

Element-selective nanosecond magnetization dynamics in magnetic heterostructures

We have developed a new original technique to study the magnetization reversal dynamics of thin films with element selectivity in the nanosecond time scale. X-ray magnetic circular dichroism measurements in pump-probe mode are carried out taking advantage of the time structure of synchrotron radiation. The dynamics of the magnetization reversal of each of the layers of complex heterostructures (like spin valves or tunnel junctions) can be probed independently. The interlayer coupling in the studied systems has been shown to play a key role in the determination of the magnetization reversal of each individual layer.

Ehlers-Danlos syndrome mimicking mesenteric vasculitis: therapy, then diagnosis

The etiology of acute intraabdominal bleeding is often unclear at the time emergent arteriography is performed. During localization and embolization, the arteriogram may suggest the diagnosis of vasculitis. However, controlling the bleeding remains the priority. Connective tissue diseases such as Ehlers-Danlos syndrome (EDS) may also cause bleeding and mimic vasculitis and must be included in the differential diagnosis. We present such a case in which the initial findings were misleading.

X-ray magnetic circular dichroism in FeZrB amorphous alloys: the influence of the tensile stress

We present X-ray Magnetic Circular Dichroism experiments (XMCD) on the Fe K edge of FeZrB metallic glasses performed under tensile stress. In these compounds the application of tensile stresses produces a large increase of the Curie Temperature. The XMCD signal presents the features expected for a weak ferromagnet but a gradual enhancement of the ferromagnetism is observed as boron and zirconium concentrations increase. The main effect of the tensile stress is to increase the density of states at the Fermi level as deduced from the increment of the amplitude of the XMCD signal with the stress.

CT-guided transfemoral portocaval shunt creation

A patient with superior vena cava (SVC) occlusion presented with severe ascites and urgent transjugular intrahepatic portosystemic shunt (TIPS) was requested. The patient had a chronically occluded SVC. An alternative to classic TIPS was employed using CT guidance to traverse the left portal vein to the inferior vena cava with a small gauge needle. Fluoroscopic guidance was then used to snare a wire placed through the needle and then work from the femoral vein to create a portocaval shunt that passed through the caudate lobe. This procedure was a technical success and improved the patient's ascites.

Integrating particle image velocimetry and laser Doppler velocimetry measurements of the regurgitant flow field past mechanical heart valves

This study investigates the transient regurgitant flow downstream of a prosthetic heart valve using both laser Doppler velocimetry (LDV) and particle image velocimetry (PIV). Until now, LDV has been the more commonly used tool in investigating the flow characteristics associated with mechanical heart valves. The LDV technique allows point-by-point velocity measurements and provides enough information about the temporal variations in the flow. The main drawback of this technique is the time consuming nature of the data acquisition process in order to assess an entire flow field area. The PIV technique, on the other hand, allows measurement of the entire flow field in space in a plane at a given instant. In this study, PIV with spatial resolution of 0 (1 mm) and LDV with a temporal resolution of 0 (1 ms) were used to measure the regurgitant flow proximal to the Björk-Shiley monostrut (BSM) valve in the mitral position. With PIV, the ability to measure 2 velocity components over an entire plane simultaneously provides a very different insight into the flow field compared to a more traditional point-to-point technique like LDV. In this study, a picture of the effects of occluder motion on the fluid flow in the atrial chamber is interpreted using an integration of PIV and LDV measurements. Specifically, fluid velocities in excess of 3.0 m/s were recorded in the pressure-driven jet during valve closure, and a 1.5 m/s sustained regurgitant jet was observed on the minor orifice side. Additionally, the effects of the impact and subsequent rebound of the occluder on the flow also were clearly recorded in spatial and temporal detail by the PIV and LDV measurements, respectively. The PIV results provide a visually intuitive way of interpreting the flow while the LDV data explore the temporal variations and trends in detail. This analysis is an integrated flow description of the effects of valve closure and leakage on the pulsatile regurgitation flow field past a tilting-disc mechanical heart valve (MHV). It further reinforces the hypothesis that the planar flow visualization techniques, when integrated with traditional point-to point techniques, provide significantly more insight into the complex pulsatile flow past MHVs.

[Undergraduate medical education. Students' perspective and medical school policy]

OBJECTIVES

Student attendance to lectures in French medical schools is often poor. We surveyed undergraduate medical students in our medical school, repeating a similar survey conducted ten years earlier. The results are presented with the conclusions of the faculty seminar that followed this survey.

METHODS

A closed item questionnaire was distributed in June, 1998, through the hospital wards where the students were posted. After two reminders, the final response rate was 71% (247/348).

RESULTS

Overall, 71% of the students declared that they never, or only occasionally, attended lectures in the medical school. Reasons included lack of time (75%), the curriculum diverging from the program of the selective examination that gives access to graduate specialization programs (59%), or insufficient practical clinical content (36%); 46% believed that this teaching prepared them to practice family medicine (11% some specially), and 92% that the way it was organized was not compatible with preparing for the selective examination. On the other hand, 75% of the students in the final two years of the curriculum declared that attending regularly special preparation seminars for the selective examination, to succeed at this test (91%), but also to prepare for family practice (25%). Respectively, 75%, 68% and 66% declared that undergraduate medical courses should, ideally, prepare them for the selective examination, but also for the practice of family medicine, and for graduate medical education.

CONCLUSIONS

These results echoed the difficulties of the faculty of the medical school to reconcile preparing students both for their future medical practice and for the selective examination. Two working groups were asked to identify independently appropriate educational objectives according to each perspective: their conclusions appeared to be quite compatible. Based on these conclusions, institutional objectives were ratified to guide the educational policy of our medical school, including the following: to reinforce the consistency and progressiveness of the curriculum; to promote active and autonomous student learning approaches; to develop faculty teaching skills, curriculum evaluation and recognition of teaching activities.

MRI analysis of brain atrophy after severe closed-head injury: relation to clinical status

The purpose of this study was to determine the clinical correlates of supratentorial ventricular dilations and of corpus callosal atrophy at the subacute stage after a severe closed-head injury (CHI). Thirty-three CHI patients underwent MRI 2 months or more after injury. Morphometric measures were compared to clinical data (coma score, coma duration and Glasgow Outcome Scale). There were numerous significant correlations between clinical data and mid-third ventricle and frontal horns measurements. Fewer significant correlations were found with the lateral ventricle bodies and the corpus callosal body. There was no significant correlation with the posterior part of the corpus callosum and of the ventricles. Corpus callosum atrophy correlated significantly with anterior and deep ventricular dilatation. In conclusion, the best indicator of clinical status was ventriculomegaly, and particularly third ventricle enlargement, which probably reflects the extent of both anterior and deep white matter lesions.

Multicenter prospective study of ventilator-associated pneumonia during acute respiratory distress syndrome. Incidence, prognosis, and risk factors. ARDS Study Group

We investigated the incidence, risk factors for, and outcome of ventilator-associated pneumonia (VAP) in patients with acute respiratory distress syndrome (ARDS). We compared 134 patients with ARDS with 744 patients without ARDS on mechanical ventilation. Fiberoptic bronchoscopic examination and quantitative bacterial cultures (protected brush or catheter sampling [threshold: 10(3) cfu/ml], or bronchoalveolar lavage [threshold: 10(4) cfu/ml]) were used to diagnose pneumonia. VAP occurred in 49 patients (36.5%). The incidence of pneumonia was 23% (173 of 744 patients) among patients without ARDS (p < 0.002). Nonfermenting gram-negative rods caused significantly more pneumonia in ARDS patients. Mortality rates were identical in ARDS patients with (28 of 49 patients, 57%) and without (50 of 85 patients, 59%) pulmonary infection (p = 0.8). VAP resulted in a considerable increase in attributable time on mechanical ventilation of both the overall population of ARDS patients and of survivors. Both the use of sucralfate (adjusted odds ratio [OR]: 4. 42; 95% confidence interval [CI]: 2.01 to 9.7, p = 0.0002) and the duration of exposure to sucralfate (adjusted OR: 1.206; 95% CI: 1. 095 to 1.328, p = 0.0002) were associated with an increased risk of VAP during ARDS. VAP considerably prolongs the time on mechanical ventilation without affecting survival. Patients given sucralfate may be at greater risk of developing pulmonary infection during ARDS.

Fluid dynamics of a pediatric ventricular assist device

The number of pediatric patients requiring some form of mechanical circulatory assistance is growing throughout the world because of new surgical procedures and the success of pediatric cardiac transplantation. However, the salvage rate for those patients requiring circulatory support may be as low as 25%. Despite the fact that Penn State's 70 cc pneumatic ventricular assist device has been used with a success rate of over 90% in more than 250 patients worldwide, efforts to scale down the pump have encountered difficulties. Animal experiments with a 15 cc version were unsuccessful, with explanted pumps showing extensive thrombus deposition within the pumping chamber. The materials used to fabricate the smaller pump as well as the basic operating principles are identical to the successful adult-sized version. It is therefore believed that reducing the size of the pump altered the internal flow field, and that fluid dynamic factors were responsible for the high degree of thrombus observed with the implanted devices. A dimensional analysis was conducted that revealed significant differences in both Reynolds (Re) and Strouhal (St) numbers between the successful and unsuccessful pumps. Two component laser Doppler velocimetry was then used to characterize the internal flow field quantitatively. Comparison with data from the 70 cc pump showed a reduction in wall shear stress and turbulence levels in the 15 cc pump that would yield an environment conducive to clot formation.

Flow visualization in mechanical heart valves: occluder rebound and cavitation potential

High density particle image velocimetry, with spatial resolution of O(1 mm), was used to measure the effect of occluder rebound on the flow field near a Bjork-Shiley Monostrut tilting-disk mitral valve. The ability to measure two velocity components over an entire plane simultaneously provides a very different insight into the flow compared to the more traditional point to point techniques (like Laser Doppler Velocimetry) that were utilized in previous investigations of the regurgitant flow. A picture of the effects of occluder rebound on the fluid flow in the atrial chamber is presented. Specifically, fluid velocities in excess of 1.5 m/s traveling away from the atrial side were detected 3 mm away from the valve seat in the local low pressure region created by the occluder rebound on the major orifice side where cavitation has been observed. This analysis is the first spatially detailed flow description of the effects of occluder rebound on the flow field past a tilting-disk mechanical heart valve and further reinforces the hypothesis that the rebound effect plays a significant role in the formation of cavitation, which has been implicated in the hemolysis and wear associated with tilting-disk valves in vivo.

[Length of stay in maternity wards after normal delivery: diverging point of views]

OBJECTIVES

To compare maternity ward professionals' and patients' views regarding the length of stay in the maternity after a normal delivery and to explore working relationships with ambulatory health professionals.

METHODS

Three surveys

RESULTS

General professional agreement on a minimum of 4 days; few contacts with ambulatory health professionals. One third of the women found their length of stay excessive. Most did not appear to gain new skills after 3 days, nor to encounter major difficulties once they returned to their home.

DISCUSSION

and conclusion. It will be essential to organize effective working relationships between the maternity ward and ambulatory health professionals to ensure appropriate follow-up after an earlier discharge from the hospital, in agreement with the capabilities and expectations of a majority of women.

Functional anatomy of neuropsychological deficits after severe traumatic brain injury

BACKGROUND

Neurobehavioral disorders after severe traumatic brain injury (TBI) are poorly correlated with focal lesions detected by structural neuroimaging techniques such as CT scan or MRI.

OBJECTIVE

To explore the relationships between regional cerebral glucose metabolism at rest, as measured by PET, and neurobehavioral status after severe TBI at the subacute stage.

METHODS

Thirteen patients without focal structural lesion on MRI were studied. Neuropsychological assessment included tests of memory, attention and speed of information processing, and executive functions, and a global neurobehavioral assessment. Regional cerebral glucose metabolism at rest was measured with (18F)-fluorodeoxyglucose and PET.

RESULTS

A close link was found between cognitive and behavioral disorders and decreased cortical metabolism in prefrontal and cingulate cortex. Tests of memory and executive functions significantly correlated with regional metabolism in the mesial and lateral prefrontal cortex and the cingulate gyrus. Behavioral disorders correlated significantly with mesial prefrontal and cingulate metabolisms.

CONCLUSION

These results suggest a predominant role of prefrontal and cingulate dysfunction in cognitive and behavioral disorders of patients with severe traumatic brain injury, even in the absence of focal structural lesion of the brain. Further cognitive functional activation research using PET or functional MRI might help clarify the relative contributions of both areas to dysfunction.

Physicians' recognition of the symptoms experienced by HIV patients: how reliable?

To assess how well physicians recognize common symptoms in HIV patients and identify factors associated with symptom recognition, a multicenter cross-sectional survey was performed in a random sample of 118 hospitalized and 172 ambulatory HIV patients, and their attending physicians. Patients' reports of 16 different symptoms were compared to physicians' reports of whether each symptom was present and/or specific treatments prescribed. Overall, fatigue, anxiety, skin problems, fever, and weight loss were more often recognized by physicians than other symptoms. Agreement between patients and physicians was poor to moderate, with Kappa statistics ranging from 0.17 (dry mouth) to 0.58 (fever). Recognition was independently more likely for ambulatory patients (adjusted odds ratio 1.69, P < 0.001) and for patients seen as sicker (adjusted odds ratio 1.88, P < 0.001). Appropriate symptom management requires improved symptom recognition. More systematic clinical examinations, including attentive patient interview, are needed.

Evolution of the French public's knowledge and attitudes regarding postoperative pain, cancer pain, and their treatments: two national surveys over a six-year period

Pain management has become a notable feature of public health policy and mass media communication in France over the past few years. To assess the evolution of the knowledge and attitudes of the French population with respect to pain management and morphine use, telephone surveys using similar questionnaires were conducted in 1990 (n = 1001) and 1996 (n = 1006). The proportion of respondents who would take pain management adequacy into consideration when selecting a surgical facility increased from 52% to 81% (P < 0.001), as did the proportion who associated morphine with pain treatment (from 44% to 80%; P < 0.001) or who would not be afraid of becoming addicted to morphine after it had been prescribed for pain relief (from 26% to 69%; P < 0.001). However, the proportion of respondents who agreed that morphine can be prescribed to patients with pain increased only slightly. In 1996, 58% of the respondents believed that their knowledge had improved over the past 5 yr and associated this improvement first with television, followed by written press articles and by interaction with physicians. Increased awareness of pain management possibilities among the public may generate increased demand on health professionals to provide adequate and precise information addressing each patient's needs.

IMPLICATIONS

The results of two representative surveys conducted over a 6-yr interval show significant improvements of knowledge and attitudes regarding pain and its management in the French general population. However, these results point to the need for additional specific information that should be provided through patient-physician interactions.

Diurnal variations in keratometry and refraction with intracorneal ring segments

PURPOSE

To study refraction variations during the day in eyes with intrastromal corneal ring segments (ICRS) to correct low myopia.

SETTING

Monticelli Clinic, Marseille, France.

METHODS

Thirteen eyes with ICRS were included in the study; the ICRS was explanted from 3 eyes because of undercorrection. The minimum follow-up in all eyes was 1 year. The same observer measured refraction and keratometry at 9:00 AM, 1:00 PM, and 7:00 PM with the same autokeratorefractometer. To validate the analysis method, these eyes were compared with a group of emmetropic control eyes that had not had surgery and with a group of eyes that had photorefractive keratectomy for a similar degree of myopia. All measurements were done under the same conditions.

RESULTS

After 1 year, the ICRS eyes showed a tendency toward an evening myopic shift. This was confirmed by the objective keratometry study, which showed variations closely correlated with the myopia observed. These phenomena were not observed in the other groups.

CONCLUSION

The ICRS had satisfactory predictability in eyes with up to -3.50 diopters of myopia. However, the evening myopic shift appeared similar to that observed after radial keratotomy.

[Access to health services: difficulties encountered by refugees residing on Ile-de-France. Charity and full-coverage health care: two divergent concepts?]

Theoretically, since 1992, 100% of socially underprivileged persons residing in France have unlimited access to health care. However, before they become fully integrated into the society, many refugees in various legal situations do not have access to health care. The mechanisms behind this exclusion unmask the difficulties the health care system has in managing the underprivileged population. This work was conducted at the Comede health care facility specially designed to care for refugees. According to the current French legislation, health care protection and medical insurance coverage is a right of all persons living in France. Although the establishment of a large number of centers specifically designated for the underprivileged population has improved access to health care, repeat visits and uninterrupted care cannot be assured unless the patient has been awarded 100% free health care status. There are several obstacles to acquiring this status: complexity of the legal procedures, recipients unaware of their rights and the procedures of the health care system, information limited to specialized journals, restrictive or illegal action by the health protection services. All of these obstacles can be overcome if the patients are given precise information, notably by their physician. Instead of effectively applying the procedures concerning patients rights to health care, the system has developed free health care facilities which do not necessarily provide uninterrupted care. To provide the universal health care coverage promised by the legislators, the only criteria for access to care must be residence in France. Acquiring this status should be considerably simplified and requires the active participation of the entire health care community.