Toxic-metabolic encephalopathy in adults: Critical discussion and pragmatical diagnostic approach

Toxic-metabolic encephalopathy (TME) results from an acute cerebral dysfunction due to different metabolic disturbances including medications or illicit-drugs. It can lead to altered consciousness, going from delirium to coma, which may require intensive care and invasive mechanical ventilation. Even if it is a life-threatening condition, TME might have an excellent prognosis if its etiology is rapidly identified and treated adequately. This review summarizes the main etiologies, their differential diagnosis, and diagnostic strategy and management of TME with a critical discussion on the definition of TME.

Vector-apodizing phase plate coronagraph: design, current performance, and future development [Invited]

Over the last decade, the vector-apodizing phase plate (vAPP) coronagraph has been developed from concept to on-sky application in many high-contrast imaging systems on 8 m class telescopes. The vAPP is a geometric-phase patterned coronagraph that is inherently broadband, and its manufacturing is enabled only by direct-write technology for liquid-crystal patterns. The vAPP generates two coronagraphic point spread functions (PSFs) that cancel starlight on opposite sides of the PSF and have opposite circular polarization states. The efficiency, that is, the amount of light in these PSFs, depends on the retardance offset from a half-wave of the liquid-crystal retarder. Using different liquid-crystal recipes to tune the retardance, different vAPPs operate with high efficiencies (${\gt}96\%$) in the visible and thermal infrared (0.55 µm to 5 µm). Since 2015, seven vAPPs have been installed in a total of six different instruments, including Magellan/MagAO, Magellan/MagAO-X, Subaru/SCExAO, and LBT/LMIRcam. Using two integral field spectrographs installed on the latter two instruments, these vAPPs can provide low-resolution spectra (${\rm{R}} \sim 30$) between 1 µm and 5 µm. We review the design process, development, commissioning, on-sky performance, and first scientific results of all commissioned vAPPs. We report on the lessons learned and conclude with perspectives for future developments and applications.

Use, timing and factors associated with tracheal intubation in septic shock: a prospective multicentric observational study

Background

No recommendation exists about the timing and setting for tracheal intubation and mechanical ventilation in septic shock.

Patients and methods

This prospective multicenter observational study was conducted in 30 ICUs in France and Spain. All consecutive patients presenting with septic shock were eligible. The use of tracheal intubation was described across the participating ICUs. A multivariate analysis was performed to identify parameters associated with early intubation (before H8 following vasopressor onset).

Results

Eight hundred and fifty-nine patients were enrolled. Two hundred and nine patients were intubated early (24%, range 4.5–47%), across the 18 centers with at least 20 patients included. The cumulative intubation rate during the ICU stay was 324/859 (38%, range 14–65%). In the multivariate analysis, seven parameters were significantly associated with early intubation and ranked as follows by decreasing weight: Glasgow score, center effect, use of accessory respiratory muscles, lactate level, vasopressor dose, pH and inability to clear tracheal secretions. Global R-square of the model was only 60% indicating that 40% of the variability of the intubation process was related to other parameters than those entered in this analysis.

Conclusion

Neurological, respiratory and hemodynamic parameters only partially explained the use of tracheal intubation in septic shock patients. Center effect was important. Finally, a vast part of the variability of intubation remained unexplained by patient characteristics.

Trial registration Clinical trials NCT02780466, registered on May 23, 2016. https://clinicaltrials.gov/ct2/show/NCT02780466?term=intubatic&draw=2&rank=1.

[Metabolic encephalopathies]

Metabolic encephalopathies (ME) are a common cause of admission to emergency rooms, to hospitalization wards or to intensive care units. They could account for 10 to 20% of causes of comatose states in ICU and could be associated to a poor outcome especially in older patients. Nevertheless, they are often reversible and are associated with a favorable outcome when diagnosed and rapidly treated. They correspond to an altered brain functioning secondary to the deficiency of a substance that is mandatory for the normal brain functioning or to the accumulation of a substance that can be either endogenous or exogenous. It preferably occurs in co-morbid patients, complicating its diagnosis and its management. Altered brain functioning, going from mild neuropsychological impairment to coma, movement disorders especially myoclonus and the absence of any obvious differential diagnosis are highly suggestive of the diagnosis. Whereas some biological samplings and brain MRI are essential to rule out differential diagnosis, some others, such as electroencephalogram, may be able to propose important clues in favor of the diagnosis. Once simple symptomatic measures are introduced, the treatment consists mainly in the correction of the cause. Specific treatment options are only seldom available for ME; this is the case for hepatic encephalopathy and some drug-induced encephalopathies. We will successively describe in this review the main pathophysiological mechanisms, the main causes, favoring circumstances of ME, the differential diagnosis to rule out and the etiological work-up for the diagnosis. Finally, a diagnostic and therapeutic strategy for the care of patients with ME will be proposed.

Bacterial pathogens associated with lung lesions in slaughter pigs from 125 herds

Relationships between macroscopic lesions and Polymerase Chain Reaction (PCR) detection of Mycoplasma hyopneumoniae (Mhp), Pasteurella multocida (Pm), Actinobacillus pleuropneumoniae (App), Haemophilus parasuis (Hps) and Streptococcus suis (Ssuis) of the lungs of 3731 slaughter pigs from 125 herds were assessed in France. Pneumonia and pleuritis were the most frequent lesions (69.3% and 15% of the lungs, respectively). Mhp, Pm, App, Ssuis and Hps were detected in 69.3%, 36.9%, 20.7%, 6.4% and 0.99% of the lungs, respectively. Mhp and Pm were associated with pneumonia at both the pig and herd levels. Pleuritis was not associated with any pathogen at the pig level, but was associated with a high percentage of pigs PCR-positive for App at the herd level. Measures focused on control of Mhp, Pm and App should significantly reduce the occurrence of both pneumonia and pleuritis.

Longitudinal study of respiratory infection patterns of breeding sows in five farrow-to-finish herds

A longitudinal study was carried out in five French farrow-to-finish herds differently affected by respiratory diseases to describe the carrying and infection patterns of batches of sows to various respiratory pathogens during gestation and lactation. An entire batch of sows was followed during two successive reproduction cycles. Nasal, tonsillar and oro-pharyngeal swabs and blood samples were taken from each sow 9 and 4 weeks before farrowing and 1 and 4 weeks after farrowing. Mycoplasma hyopneumoniae, Actinobacillus pleuropneumoniae, Pasteurella multocida, Haemophilus parasuis and Streptococcus suis were detected from swab samples using PCR assays. Blood samples were tested for antibodies against M. hyopneumoniae, A. pleuropneumoniae serotypes 1-9-11 and 2, Porcine Circovirus type-2 (PCV-2) and Porcine Reproductive and Respiratory Syndrome virus (PRRSV) by ELISA tests. Antibodies against H₁N₁, H₁N₂ and H₃N₂ Swine Influenza Viruses (SIV) of European lineages were tested by hemagglutination inhibition assay. The results indicated that S. suis is widespread among sows (67.1% of PCR-positive sows). A. pleuropneumoniae, P. multocida, and H. parasuis were detected by PCR in 30.9%, 24.6% and 23.4% of the sows, respectively. Antibodies against M. hyopneumoniae were recovered from more than 55% of the sows in all herds whereas the micro-organism was detected in 2.4% of the sows. Although PCV-2 and SIV infections were highly prevalent, the PRRSV infection patterns ranged from no infection in farms mildly affected by respiratory diseases to active circulation in more severely affected herds. The sow population thus constitutes a reservoir for a continuous circulation of respiratory pathogens and needs to be properly considered in control strategies.

Estimation of the sensitivity of four sampling methods for Mycoplasma hyopneumoniae detection in live pigs using a Bayesian approach

Four sampling techniques for Mycoplasma hyopneumoniae detection, namely nasal swabbing, oral-pharyngeal brushing, tracheo-bronchial swabbing and tracheo-bronchial washing, were compared in naturally infected live pigs. In addition, a quantitative real-time PCR assay for M. hyopneumoniae quantification was validated with the same samples. 60 finishing pigs were randomly selected from a batch of contemporary pigs on a farm chronically affected by respiratory disorders. Each pig was submitted to nasal swabbing, oral-pharyngeal brushing, tracheo-bronchial swabbing and tracheo-bronchial washing. Nested-PCR and real-time PCR assays were performed on all samples. A Bayesian approach was used to analyze the nested-PCR results of the four sampling methods (i.e. positive or negative) to estimate the sensitivity and specificity of each method. M. hyopneumoniae was detected by nested-PCR in at least one sample from 70% of the pigs. The most sensitive sampling methods for detecting M. hyopneumoniae in live naturally infected pigs were tracheo-bronchial swabbing and tracheo-bronchial washing, as compared to oral-pharyngeal brushing and nasal swabbing. Swabbing the nasal cavities appeared to be the least sensitive method. Significantly higher amounts of M. hyopneumoniae DNA were found at the sites of tracheo-bronchial sampling than in the nasal cavities or at the oral-pharyngeal site (p<0.001). There was no difference between the tracheo-bronchial washing and the tracheo-bronchial swabbing results (p>0.05). Our study indicated that tracheo-bronchial swabbing associated with real-time PCR could be an accurate diagnostic tool for assessing infection dynamics in pig herds.

Development of a quantitative Real-Time TaqMan PCR assay for determination of the minimal dose of Mycoplasma hyopneumoniae strain 116 required to induce pneumonia in SPF pigs

AIMS

A triplex real-time PCR assay to quantify Mycoplasma hyopneumoniae in specimens from live and dead pigs was developed and validated. The minimal dose of Myc. hyopneumoniae required to induce pneumonia in specific pathogen-free pigs was determined.

METHODS AND RESULTS

This TaqMan test simultaneously detected three genes encoding the proteins P46, P97 and P102. All Myc. hyopneumoniae strains analysed were detected, including strains isolated in three countries (France, England and Switzerland) and from several pig farms (n = 33), and the test was specific. The estimated detection thresholds were 1.3 genome equivalents (microl(-1)) for the targets defined in p97 and p102 genes and 13 genome equivalents (microl(-1)) for the segment defined in the p46 gene. This test was used to quantify Myc. hyopneumoniae in specimens sampled from experimentally infected pigs. In live pigs, c. 10(7), 10(8) and 10(10) genome equivalents (ml(-1)) of Myc. hyopneumoniae were detected in the nasal cavities, tonsils and trachea samples, respectively. In dead pigs, 10(8)-10(10) genome equivalents (ml(-1)) of Myc. hyopneumoniae were detected in the lung tissue with pneumonia. The estimated minimal dose of Myc. hyopneumoniae required to induce pneumonia was 10(5) colour-changing units (CCU) per pig (corresponding to 10(8) mycoplasmas).

CONCLUSION

The triplex RT-PCR test was validated and can be used for testing samples taken on the pig farms.

SIGNIFICANCE AND IMPACT OF THE STUDY

This test should be a very useful tool in pig herds to control enzootic pneumonia or healthy carrier pigs and to study the dynamics of Myc. hyopneumoniae infections.

Isolation of Mycoplasma hyopneumoniae from different sampling sites in experimentally infected and contact SPF piglets

The purpose of this study was to determine the optimal route of infection and the optimal sampling sites for the recovery of M. hyopneumoniae, the etiological agent of enzootic porcine pneumonia. Virulence of two strains, BQ 14 and 116, isolated in France in 1975 and 2003, respectively, was also compared. Groups of specific pathogen free piglets were experimentally infected by the intratracheal or intranasal route. One non-inoculated pig was placed in each group of infected pigs to study direct transmission. Two groups were kept uninfected. Coughing was recorded daily. Blood samples, nasal, tonsillar and tracheal swabs and tracheobronchiolar washings were collected weekly. Pigs were killed 27-37 days post-infection. Lung lesions were scored and swabs were collected from nasal cavities, tonsils, trachea, lung, liver and spleen. All the samples, collected from live and dead pigs, were cultured for M. hyopneumoniae recovery. Results showed that both experimentally infected pigs and contact pigs developed enzootic pneumonia, whatever the route of infection and the strain tested. Direct contact transmission occurred quickly. No difference between the two routes of infection or between the two strains tested was evidenced, but high individual variations were observed between pigs. Tracheal swabs and tracheobronchiolar washings were the most effective samples to detect M. hyopneumoniae compared to nasal or tonsillar swabs. Our results also suggested that tracheobronchiolar washings could have an influence on the lesion extent observed at necropsy. M. hyopneumoniae could be re-isolated from liver and spleen of experimentally infected pigs and contact pigs.

Multiplex PCR assay for detection of Streptococcus suis species and serotypes 2 and 1/2 in tonsils of live and dead pigs

A PCR assay was developed for the detection of Streptococcus suis serotypes 2 and 1/2. This multiplex PCR is based on the amplification of the gene coding for 16S rRNA of S. suis and on the amplification of the cps2J gene coding for the capsule of S. suis serotypes 2 and 1/2. An internal control was constructed and added in this test to monitor the efficiency of amplification in each reaction. To evaluate the specificity of the test, 31 strains of other bacterial species related to S. suis or isolated from pigs and 42 strains of S. suis serotypes 1 and 3 to 34 were analyzed. The detection threshold of the test was 28 S. suis CFU/ml. The specificity and the sensitivity of the multiplex PCR test and the presence of an internal control allowed the analysis of biological samples without a culture step. The PCR assay was then applied to the detection of 14 S. suis serotype 1/2 strains, 88 S. suis serotype 2 strains isolated from pigs, and 25 S. suis serotype 2 strains isolated from humans. This test was also applied to analyze tonsil samples of pigs experimentally infected and carrier pigs without any symptoms.

A reverse transcription-PCR assay to detect viable Mycoplasma synoviae in poultry environmental samples

In order to study horizontal transmission of Mycoplasma synoviae an avian pathogen, a reverse transcription-polymerase chain reaction (RT-PCR) assay was developed to detect viable Mycoplasma in environment. The test was based on the RT-PCR of the 16S ribosomal RNA (rRNA) of Mycoplasma genus. Results showed that Mycoplasma 16S rRNA was stable up to 23 h after cell death. Therefore, the test allowed detection of viable or very recently (less than 23 h) dead mycoplasmas. M. synoviae survival in artificially contaminated water, food and soil and in the environment of M. synoviae experimentally infected turkeys was estimated by culture and RT-PCR. The RT-PCR method was then applied in a naturally infected laying hen farm showing problems of recurrent mycoplasmosis in the hens. Results confirmed the usefulness of RT-PCR in checking the efficiency of biosecurity measures and in improving cleaning and disinfection protocols.

Molecular differentiation of Mycoplasma gallisepticum and Mycoplasma imitans strains by pulsed-field gel electrophoresis and random amplified polymorphic DNA

Pulsed-field gel electrophoresis (PFGE) and random amplified polymorphic DNA (RAPD) analysis were used to compare 21 Mycoplasma gallisepticum strains and five M. imitans strains. Each strain of M. gallisepticum typed by PFGE and RAPD methods was genetically quite unique and RAPD and PFGE fingerprinting enabled strain characterization. Relationships between the M. gallisepticum and M. imitans strains were established and dendrograms were drawn from PFGE and RAPD patterns. PFGE group A and RAPD group D were significantly associated with M. imitans strains (P < 0.05). Three M. imitans strains shared the same PFGE and RAPD patterns. The two M. gallisepticum vaccine strains had singular PFGE and RAPD patterns. Thus, PFGE and RAPD can be used to investigate disease outbreaks in vaccinated flocks or for epidemiological tracking. For M. gallisepticum, the RAPD and PFGE discriminatory powers were superior to 0.95 and the in vitro, in ovo and in vivo reproducibility of RAPD and PFGE was 100%. The RAPD drawback was the inconsistent band intensity complicating the interpretation of patterns, while the PFGE limit was its low typeability (86%). Thus, these two molecular typing methods seemed complementary for M. gallisepticum epidemiological studies.

Comparison of pulsed-field gel electrophoresis with random amplified polymorphic DNA for typing of Mycoplasma synoviae

Pulsed-field gel electrophoresis (PFGE) analysis was developed and compared with random amplified polymorphic DNA (RAPD) method to type 18 Mycoplasma synoviae (MS) strains. All analysed strains were typeable by RAPD but only 89% of MS strains were typeable by PFGE because of DNA degradation. The discriminatory power of RAPD was greater than that of PFGE but the two techniques had a discriminatory index superior to 0.95, the threshold value for interpreting typing results with confidence. The in vitro, in ovo and in vivo reproducibility of both typing techniques was 100%. However, the interpretation of RAPD patterns was complicated because of inconsistent band intensity. Thus, these molecular typing techniques should be helpful for epidemiological studies of avian mycoplasma infections.

Detection of Mycoplasma synoviae in poultry environment samples by culture and polymerase chain reaction

Successful detection of Mycoplasma synoviae (MS) by culture and PCR from samples collected in the environment of experimentally infected chickens and turkeys, or under field conditions, is described. Results showed that in the experimental infection, 10/96 and 46/96 samples of food, drinking water, feathers, droppings or dust were positive by culture and Mycoplasma-PCR. In field conditions, the number of positive results for environmental samples were respectively 7/28 and 17/28. These observations highlight the high disseminating capacities of this mycoplasma and show the usefulness of the PCR method for epidemiological studies.

Genetic features of Streptococcus agalactiae strains causing severe neonatal infections, as revealed by pulsed-field gel electrophoresis and hylB gene analysis

A collection of 114 independent Streptococcus agalactiae strains, including 54 strains isolated from the cerebrospinal fluid (CSF) samples of neonates and 60 strains from asymptomatic patients, was characterized by pulsed-field gel electrophoresis (PFGE) of DNA restricted with SmaI and by PCR analysis of the hylB gene. All strains were previously studied by multilocus enzyme electrophoresis (MLEE) (R. Quentin, H. Huet, F.-S. Wang, P. Geslin, A. Goudeau, and R. K. Selander, J. Clin. Microbiol. 33:2576-2581, 1995). Among these 114 strains, there were 92 PFGE patterns. Eleven genetic groups (A to K) were identified with 38% divergence. A more homogeneous group (PFGE group A) was defined, consisting of 73% of the strains previously identified as belonging to a particular MLEE phylogenetic group. A 162-kb fragment was identified as a marker of strains that invaded the central nervous system of neonates. It was detected in 69% of the PFGE patterns obtained with CSF isolates and in only 1.8% of the PFGE patterns obtained with carrier strains. The hylB gene encoding hyaluronate lyase was amplified for all strains in our collection. Ten of 15 isolates belonging to an MLEE subgroup, previously described as being likely to cause invasive infection, had an insertion in the hylB gene (IS1548).

[Ipsilateral adrenalectomy in the surgical treatment of renal carcinoma]

OBJECTIVES

To assess the value of ipsilateral adrenalectomy during radical nephrectomy for the treatment of renal cell carcinoma as a function of preoperative computed tomography findings.

METHODS

Between May 1985 and June 1994, 194 patients underwent radical nephrectomy for renal cell carcinoma in our institution. Preoperative radiological reports and postoperative pathological reports were reviewed for 185 patients.

RESULTS

148 patients underwent abdominal computed tomography before surgery. 94 adrenalectomies were performed in this group of patients. None of the 77 patients in whom computed tomography showed a normal adrenal gland had adrenal metastasis on the definitive histological examination. 17 patients had an adrenal mass on computed tomography, 3 of which proved to be neoplastic. Preoperative CT had a sensitivity of 100%, a specificity of 82%, a positive predictive value of 18% and a negative predictive value of 100%. The 185 files reviewed included 114 adrenalectomies, including 4 adrenal glands invaded by renal cell carcinoma (3.5%). In these 4 cases, the smallest diameter of the renal tumour was 4 cm and the minimum pathological stage was T3.

CONCLUSIONS

It therefore appears justified not to perform adrenalectomy during nephrectomy, in the presence of a renal tumour and negative adrenal computed tomography.

Biochemical reactions involved in pancreatic enzyme secretion. I. Activation of the adenylate cyclase complex

Pancreatic amylase secretion was studied using an in vitro system. Secretion was increased by urecholine and cholecystokinin–pancreozymin (CCK–PZ). Addition of tetracaine and dibucaine to the medium abolished secretion stimulated by urecholine and decreased by 75% that stimulated by CCK–PZ. In contrast, an increase in enzyme secretion was observed after dibutyryl cyclic AMP; this was potentiated by tetracaine added to the medium. Oxygen uptake by pieces of pancreatic tissue was not affected by tetracaine. Adenylate cyclase activity, increased in vitro when CCK–PZ was added to a pancreas homogenate, was inhibited by 15% by tetracaine at 2 mM and by 67.5% at the 10 mM concentration.From data known on biochemical reactions associated with the process of secretion and the results described in the present paper, we propose a model for the activation of the pancreatic adenylate cyclase complex. Associated to the depolarization of the acinar cell plasma membrane by urecholine and CCK–PZ and an inward movement of sodium and calcium, there is an immediate rise in adenylate cyclase activity within 10 s which is timed with the initiation of amylase secretion.